Publications by authors named "Éric Mercier"

80 Publications

Low-value injury admissions in an integrated Canadian trauma system: a multicenter cohort study.

Int J Clin Pract 2021 Jun 9:e14473. Epub 2021 Jun 9.

Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada.

Background: Injury represents 260,000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among ED presentations between countries and providers but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low-value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low-value admissions and assess inter-hospital variation.

Methods: We conducted a retrospective multicenter cohort study based on all injury admissions in the Québec trauma system (2013-2018). Using literature and expert consultation, we developed criteria to identify potentially low-value injury admissions. We used a multilevel logistic regression model to evaluate inter-hospital variation in the prevalence of low-value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+ years).

Results: The prevalence of low-value injury admissions was 16% (n=19,163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12,345) in older adults. Diagnostic groups contributing most to low-value admissions were mild traumatic brain injury in children (48% of low-value pediatric injury admissions; n=922), superficial injuries (14%, n=660) or minor spinal injuries (14%, n=634) in adults aged 16-64, and superficial injuries in adults aged 65+ (22%, n=2771). We observed strong inter-hospital variation in the prevalence of low-value injury admissions (ICC=37%).

Conclusion: One out of six hospital admissions following injury may be of low-value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce health care services overuse. Inter-hospital variation indicates there may be an opportunity to reduce low-value injury admissions with appropriate interventions targeting modifications in care processes.
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http://dx.doi.org/10.1111/ijcp.14473DOI Listing
June 2021

A Delphi study to identify prehospital and emergency department trauma care modifiers for older adults.

Can J Surg 2021 06 4;64(3):E339-E345. Epub 2021 Jun 4.

From the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Yadav); Université Laval, Québec, Que. (Boucher, Le Sage, Mercier, Voyer, Clement, Emond); and McGill University, Montréal, Que. (Malo).

Background: Older patients (age ≥ 65 yr) with trauma have increased morbidity and mortality compared to younger patients; this is partly explained by undertriage of older patients with trauma, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. The objective of this study was to identify modifiers to the prehospital and emergency department phases of major trauma care for older adults based on expert consensus.

Methods: We conducted a modified Delphi study between May and September 2019 to identify major trauma care modifiers for older adults based on national expert consensus. The panel consisted of 24 trauma care professionals from across Canada from the prehospital and emergency department phases of care. The survey consisted of 16 trauma care modifiers. Three online survey rounds were distributed. Consensus was defined a priori as a disagreement index score less than 1.

Results: There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panellists. The panel achieved consensus agreement for 17 of the 19 trauma care modifiers. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate less than 10 or greater than 20 breaths/min or need for ventilatory support. The emergency department modifier with the strongest level of agreement was obtaining 12-lead electrocardiography following the primary and secondary survey.

Conclusion: Using a modified Delphi process, an expert panel agreed on 17 trauma care modifiers for older adults in the prehospital and emergency department settings. These modifiers may improve the delivery of trauma care for older adults and should be considered when developing local and national trauma guidelines.
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http://dx.doi.org/10.1503/cjs.021519DOI Listing
June 2021

Prehospital Decompression of Pneumothorax: A Systematic Review of Recent Evidence.

Prehosp Disaster Med 2021 May 25:1-10. Epub 2021 May 25.

VITAM - Centre de Recherche en Santé Durable de l'Université Laval, Québec, Québec, Canada.

Introduction: Pneumothorax remains an important cause of preventable trauma death. The aim of this systematic review is to synthesize the recent evidence on the efficacy, patient outcomes, and adverse events of different chest decompression approaches relevant to the out-of-hospital setting.

Methods: A comprehensive literature search was performed using five databases (from January 1, 2014 through June 15, 2020). To be considered eligible, studies required to report original data on decompression of suspected or proven traumatic pneumothorax and be considered relevant to the prehospital context. They also required to be conducted mostly on an adult population (expected more than ≥80% of the population ≥16 years old) of patients. Needle chest decompression (NCD), finger thoracostomy (FT), and tube thoracostomy were considered. No meta-analysis was performed. Level of evidence was assigned using the Harbour and Miller system.

Results: A total of 1,420 citations were obtained by the search strategy, of which 20 studies were included. Overall, the level of evidence was low. Eleven studies reported on the efficacy and patient outcomes following chest decompression. The most studied technique was NCD (n = 7), followed by FT (n = 5). Definitions of a successful chest decompression were heterogeneous. Subjective improvement following NCD ranged between 18% and 86% (n = 6). Successful FT was reported for between 9.7% and 32.0% of interventions following a traumatic cardiac arrest. Adverse events were infrequently reported. Nine studies presented only on anatomical measures with predicted failure and success. The mean anterior chest wall thickness (CWT) was larger than the lateral CWT in all studies except one. The predicted success rate of NCD ranged between 90% and 100% when using needle >7cm (n = 7) both for the lateral and anterior approaches. The reported risk of iatrogenic injuries was higher for the lateral approach, mostly on the left side because of the proximity with the heart.

Conclusions: Based on observational studies with a low level of evidence, prehospital NCD should be performed using a needle >7cm length with either a lateral or anterior approach. While FT is an interesting diagnostic and therapeutic approach, evidence on the success rates and complications is limited. High-quality studies are required to determine the optimal chest decompression approach applicable in the out-of-hospital setting.
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http://dx.doi.org/10.1017/S1049023X21000509DOI Listing
May 2021

Early ADAMTS13 testing associates with pre-eclampsia occurrence in antiphospholipid syndrome.

Thromb Res 2021 Apr 27;203:101-109. Epub 2021 Apr 27.

Department of Gynaecology and Obstetrics, First Moscow State Medical University (Sechenov University), Russian Federation; Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; Faculty of Pharmaceutical and Biological Sciences, Montpellier University, Montpellier, France; UA 011 INSERM- Université de Montpellier, Institut Desbrest d'Epidémiologie et de Santé Publique, Montpellier, France. Electronic address:

Introduction: Women with obstetric antiphospholipid syndrome (oAPS) still develop placental diseases, mainly pre-eclampsia (PEcl), which diagnosis is associated with reduced ADAMTS13 levels. Testing ADAMTS13 in newly pregnant oAPS may provide evidence for risk stratification.

Materials And Methods: We retrospectively investigated the prognostic value of ADAMTS13 activity, antigen and antibodies on stored plasma samples obtained prior to beginning low-molecular weight heparin-low dose aspirin treatment in 513 oAPS women.

Results: Some women had evidences of early positive ADAMTS13 antibodies and low ADAMTS13 activity:antigen ratio, suggestive of ADAMTS13 dysfunction. Women with a subsequent PEcl had higher ADAMTS13 antibodies (p < 0.0001), and lower ADAMTS13 activity and activity:antigen ratios (p < 0.0001). In multivariate analysis, these markers were significant risk factors for PEcl and for the most devastating PEcl subgroups (early-onset PEcl, severe PEcl, PEcl with no living child after 28 days). ADAMTS13-related markers showed acceptable discrimination power to predict clinical events, particularly for ADAMTS13 activity:antigen ratio in predicting PEcl cases with no living child after 28 days (AUC: 0.844 (0.712-0.974), p < 0.0001), with excellent negative predictive value (0.990).

Conclusions: The characterization of ADAMTS13 in newly pregnant women with oAPS depicts the risk of PEcl occurrence. ADAMTS13 might help identify pregnant women with oAPS not requiring escalating treatment strategies to prevent PEcl.
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http://dx.doi.org/10.1016/j.thromres.2021.04.021DOI Listing
April 2021

A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter.

CJEM 2021 May 18;23(3):314-324. Epub 2021 Jan 18.

Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.

Background: Acute atrial flutter has one-tenth the prevalence of acute atrial fibrillation in the emergency department (ED) but shares many management strategies. Our aim was to compare conversion from acute atrial flutter to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (Drug-Shock), and electrical cardioversion alone (Shock-Only).

Methods: We conducted a randomized, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary, and placebo infusion followed by electrical cardioversion. We enrolled stable patients with a primary diagnosis of acute acute atrial flutter at 11 academic EDs. The primary outcome was conversion to normal sinus rhythm.

Findings: From July 2013 to October 2018, we enrolled 76 patients, and none were lost to follow-up. Comparing the Drug-Shock to the Shock-Only group, conversion to sinus rhythm occurred in 33 (100%) versus 40 (93%) (absolute difference 7.0%; 95% CI - 0.6 to 14.6; P = 0.25). Median time to conversion from start of infusion in the Drug-Shock group was 24 min (IQR 21-82) but only 9 (27%) cases were converted with IV procainamide. Patients in both groups had similar outcomes at 14 days; there were no strokes or deaths.

Interpretation: This trial found that the Drug-Shock strategy is potentially superior but that either approach to immediate rhythm control in the ED for patients with acute acute atrial flutter is highly effective, rapid, and safe in restoring sinus rhythm and allowing patients to go home and return to normal activities. Unlike the case of atrial fibrillation, we found that IV procainamide alone was infrequently effective.
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http://dx.doi.org/10.1007/s43678-020-00067-7DOI Listing
May 2021

Differentiating between questionable and legitimate trauma journals: A systematic review and evaluation of two sets of criteria.

Injury 2021 Mar 17. Epub 2021 Mar 17.

Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgences - Soins Intensifs, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada.

Background: The sudden increase of questionable or predatory journals has raised concerns in the medical literature. The aims of this study were to identify potentially legitimate and questionable trauma journals and to assess the applicability of criteria previously proposed in the literature to distinguish them.

Methods: A comprehensive search strategy was developed to identify journals using keywords and controlled vocabulary. Presumed legitimate journals were identified using nine databases (Directory of Open Access Journals, PubMed, Web of Science, etc.). Presumed questionable journals were identified using Google Search/Scholar, emails received and former Beall's lists. Scientific active English journals whose titles contained the words injury or trauma were eligible. Two reviewers independently selected journals and extracted information from their websites. Criteria to differentiate journals status were based on two lists proposed by Shamseer et al. (2017; salient characteristics) and Wicherts (2016; transparency of peer review's items) and treated as dichotomous variables. Applicability of criteria to distinguish journal status was assessed using Fisher's exact test.

Results: Following duplicate removal, 54 potentially legitimate and 30 potentially questionable active English journals were included. Among 13 salient characteristics, seven were found to distinguish potentially legitimate from potentially questionable trauma journals: the presence of fuzzy images or spelling and grammar errors on the website, homepages targeting authors, request to submit manuscripts by email, the absence of a retraction policy, promise of rapid publication and copyright claims. However, only 3/14 of Wicherts' items were associated with journal status: journal's website highlights issues of publication ethics, the journal has clear guidelines concerning sharing and availability of research data, and journal allows authors to indicate names of (non-) desired reviewers.

Conclusions: Eighty-four active English trauma journals were identified. Among 27 criteria, 10 were found to determine trauma journals status related to their scientific legitimacy. Though no single criteria is foolproof, these criteria may be helpful to authors, readers, and reviewers when assessing potential legitimacy of scientific trauma journals.
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http://dx.doi.org/10.1016/j.injury.2021.03.031DOI Listing
March 2021

Continuous flow insufflation of oxygen for cardiac arrest: Systematic review of human and animal model studies.

Resuscitation 2021 May 22;162:292-303. Epub 2021 Mar 22.

Faculté de Médecine, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, Canada; VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada. Electronic address:

Objective: To synthetize the evidence regarding the effect of constant flow insufflation of oxygen (CFIO) on the rate of return of spontaneous circulation (ROSC) and other clinical outcomes during cardiac arrest (CA).

Methods: A systematic review was performed using four databases (PROSPERO: CRD42020071960). Studies reporting on adult CA patients or on animal models simulating CA and assessing the effect of CFIO on ROSC or other clinical outcomes were considered.

Results: A total of 3540 citations were identified, of which 16 studies were included. Four studies (two randomized controlled trials (RCT), two cohort studies), reported on humans while 12 studies used animal models. No meta-analysis was performed due to clinical heterogeneity. There were no differences in the ROSC (18.9% vs 20.8%, p = 0.99; 27.1% vs 21.3%, p = 0.51) and sustained ROSC rates (16.1% vs 17.3%, p = 0.81; 12.5% vs 14.9%, p = 0.73) with CFIO compared to intermitant positive pressure ventilation (IPPV) in the two human RCTs. Survival to ICU discharge was similar between CFIO (2.3%) and IPPV (2.3%) in the largest RCT (p = 0.96). Human studies were at serious or high risk of bias. In animal models' studies, ROSC rates were presented in seven RCTs. CFIO was superior to IPPV in one trial, but was associated with similar ROSC rates using different ventilation strategies in the remaining six studies.

Conclusions: No definitive association between CFIO and ROSC, sustained ROSC or survival compared to other ventilation strategies could be demonstrated. Future studies should assess CFIO effect on post-survival neurological functions and patient-important CA outcomes.
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http://dx.doi.org/10.1016/j.resuscitation.2021.03.009DOI Listing
May 2021

Development of the Canadian COVID-19 Emergency Department Rapid Response Network population-based registry: a methodology study.

CMAJ Open 2021 Jan-Mar;9(1):E261-E270. Epub 2021 Mar 17.

Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC.

Background: Emergency physicians lack high-quality evidence for many diagnostic and treatment decisions made for patients with suspected or confirmed coronavirus disease 2019 (COVID-19). Our objective is to describe the methods used to collect and ensure the data quality of a multicentre registry of patients presenting to the emergency department with suspected or confirmed COVID-19.

Methods: This methodology study describes a population-based registry that has been enrolling consecutive patients presenting to the emergency department with suspected or confirmed COVID-19 since Mar. 1, 2020. Most data are collected from retrospective chart review. Phone follow-up with patients at 30 days captures the World Health Organization clinical improvement scale and contextual, social and cultural variables. Phone follow-up also captures patient-reported quality of life using the Veterans Rand 12-Item Health Survey at 30 days, 60 days, 6 months and 12 months. Fifty participating emergency departments from 8 provinces in Canada currently enrol patients into the registry.

Interpretation: Data from the registry of the Canadian COVID-19 Emergency Department Rapid Response Network will be used to derive and validate clinical decision rules to inform clinical decision-making, describe the natural history of the disease, evaluate COVID-19 diagnostic tests and establish the real-world effectiveness of treatments and vaccines, including in populations that are excluded or underrepresented in clinical trials. This registry has the potential to generate scientific evidence to inform our pandemic response, and to serve as a model for the rapid implementation of population-based data collection protocols for future public health emergencies.

Trial Registration: Clinicaltrials.gov, no. NCT04702945.
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http://dx.doi.org/10.9778/cmajo.20200290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096396PMC
March 2021

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study.

JMIR Res Protoc 2021 Feb 22;10(2):e25619. Epub 2021 Feb 22.

Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.

Background: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal.

Objective: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease.

Methods: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness.

Results: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025.

Conclusions: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative.

International Registered Report Identifier (irrid): PRR1-10.2196/25619.
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http://dx.doi.org/10.2196/25619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7939947PMC
February 2021

Post-concussion symptoms in sports-related mild traumatic brain injury compared to non-sports-related mild traumatic brain injury.

CJEM 2021 Mar 29;23(2):223-231. Epub 2021 Jan 29.

Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine, CHU de Québec-Université Laval Research Centre, Hôpital de l'Enfant-Jésus, 1401, 18e rue, H-610, Québec, QC, G1J 1Z4, Canada.

Objectives: To compare post-concussion symptoms in patients who sustained a sports-related mild traumatic brain injury (TBI) to those with non-sports-related mild TBI at 7 and 90 days post-injury.

Methods: This prospective multicentre cohort study took place in seven Canadian Emergency Departments (ED). Non-hospitalized patients aged ≥ 14 years with a documented mild TBI that occurred ≤ 24 h of ED visit and a Glasgow Coma Scale score ≥ 13 were included. Main outcome measure was the presence of ≥ 3 symptoms on the Rivermead Post-concussion Questionnaire at 90 days post-injury. Secondary outcomes were the prevalence of (1) individual Rivermead Post-concussion Questionnaire symptom, (2) total Rivermead Post-concussion Questionnaire score ≥ 21 and (3) return to normal daily activities. Adjusted risk ratios (RR) were calculated.

Results: 1727 patients were included, 363 (21.0%) sustained a sports-related mild TBI. Similar proportions of patients with ≥ 3 symptoms, a Rivermead Post-concussion Questionnaire score ≥ 21 and those who returned to their normal daily activities were observed at 7 and 90 days post-injury. Sports-related mild TBI patients were at higher risk of poor concentration [RR: 1.3 (95% CI 1.05-1.54)] and non-return to sports activities [RR: 2.2 (95% CI 1.69-2.94)] at 7 days post-injury. At 90 days, sports-relate -mild TBI patients reported less fatigue [RR: 0.7 (95% CI 0.51-0.98)] and feeling of dizziness [RR: 0.6 (95% CI 0.35-0.99)].

Conclusion: Patients who sustained sports-related mild TBI could be at lower risk of experiencing symptoms such as fatigue and dizziness 90 days post-injury. Clinicians should be mindful that non-sports-related mild TBI patients may experience more post-concussion symptoms and that the level of physical activity may influence the patient's rehabilitation.
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http://dx.doi.org/10.1007/s43678-020-00060-0DOI Listing
March 2021

NETosis Markers in Pregnancy: Effects Differ According to Histone Subtypes.

Thromb Haemost 2021 Jan 10. Epub 2021 Jan 10.

Department of Haematology, University Hospital, Nîmes, France.

NETosis is an innate immune response occurring after infection or inflammation: activated neutrophils expel decondensed DNA in complex with histones into the extracellular environment in a controlled manner. It activates coagulation and fuels the risk of thrombosis. Human pregnancy is associated with a mild proinflammatory state characterized by circulatory neutrophil activation which is further increased in complicated pregnancies, placenta-mediated complications being associated with an increased thrombotic risk. This aberrant activation leads to an increased release of nucleosomes in the blood flow. The aim of our study was to initially quantify nucleosome-bound histones in normal pregnancy and in placenta-mediated complication counterpart. We analyzed the role of histones on extravillous trophoblast function. Circulating nucleosome-bound histones H3 (Nu.QH3.1, Nu.QH3PanCit, Nu.QH3K27me3) and H4 (Nu.QH4K16Ac) were increased in complicated pregnancies. In vitro using the extravillous cell line HTR-8/SVNeo, we observed that free recombinant H2B, H3, and H4 inhibited migration in wound healing assay, but only H3 also blocked invasion in Matrigel-coated Transwell experiments. H3 and H4 also induced apoptosis, whereas H2B did not. Finally, the negative effects of H3 on invasion and apoptosis could be restored with enoxaparin, a low-molecular-weight heparin (LMWH), but not with aspirin. Different circulating nucleosome-bound histones are increased in complicated pregnancy and this would affect migration, invasion, and induce apoptosis of extravillous trophoblasts. Histones might be part of the link between the risk of thrombosis and pregnancy complications, with an effect of LMWH on both.
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http://dx.doi.org/10.1055/s-0040-1722225DOI Listing
January 2021

S100B protein level for the detection of clinically significant intracranial haemorrhage in patients with mild traumatic brain injury: a subanalysis of a prospective cohort study.

Emerg Med J 2020 Dec 18. Epub 2020 Dec 18.

Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Quebec, Canada

Background: Clinical assessment of patients with mild traumatic brain injury (mTBI) is challenging and overuse of head CT in the ED is a major problem. Several studies have attempted to reduce unnecessary head CTs following a mTBI by identifying new tools aiming to predict intracranial bleeding. Higher levels of S100B protein have been associated with intracranial haemorrhage following a mTBI in previous literature. The main objective of this study is to assess whether plasma S100B protein level is associated with clinically significant brain injury and could be used to reduce the number of head CT post-mTBI.

Methods: secondary analysis of a prospective multicentre cohort study conducted between 2013 and 2016 in five Canadian EDs. non-hospitalised patients with mTBI with a GCS score of 13-15 in the ED and a blood sample drawn within 24 hours after the injury. sociodemographic and clinical data were collected in the ED. S100B protein was analysed using ELISA. All CT scans were reviewed by a radiologist blinded to the biomarker results. the presence of clinically important brain injury.

Results: 476 patients were included. Mean age was 41±18 years old and 150 (31.5%) were women. Twenty-four (5.0%) patients had a clinically significant intracranial haemorrhage. Thirteen patients (2.7%) presented a non-clinically significant brain injury. A total of 37 (7.8%) brain injured patients were included in our study. S100B median value (Q1-Q3) was: 0.043 µg/L (0.008-0.080) for patients with clinically important brain injury versus 0.039 µg/L (0.023-0.059) for patients without clinically important brain injury. Sensitivity and specificity of the S100B protein level, if used alone to detect clinically important brain injury, were 16.7% (95% CI 4.7% to 37.4%) and 88.5% (95% CI 85.2% to 91.3%), respectively.

Conclusion: Plasma S100B protein level was not associated with clinically significant intracranial lesion in patients with mTBI.
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http://dx.doi.org/10.1136/emermed-2020-209583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982939PMC
December 2020

Older Emergency Department Patients: Does Baseline Care Status Matter?

Can Geriatr J 2020 Dec 1;23(4):289-296. Epub 2020 Dec 1.

Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON.

Background: Little is known about the prognostic differences between older emergency department (ED) patients who present with different formal support requirements in the community. We set out to describe and compare the patient profiles and patterns of health service use among three older ED cohorts: home care clients, nursing home residents and those receiving no formal support.

Methods: We conducted a secondary analysis of the Canadian cohort from the interRAI multinational ED study. Data were collected using interRAI ED contact assessment on patients 75 years of age and older (n = 2,274), in eight ED sites across Canada. A series of descriptive statistics were reported. Adjusted associations were determined using logistic regression.

Results: Older adults receiving no formal support services were most stable. However, they were most likely to be hospitalized. Older home care clients were most likely to report depressive symptoms and distressed caregivers. They also had the greatest odds of frequent ED visitation post-discharge (OR=1.9; 95% CI=1.39-2.59). Older adults transferred from a nursing home were the frailest but had the lowest odds of hospital admission (OR=0.14; 95% CI=0.09-0.23).

Conclusion: We demonstrated the importance of inquiring about community-based formal support services and provide data to support decision-making in the ED.
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http://dx.doi.org/10.5770/cgj.23.421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704072PMC
December 2020

Benefit of hospital admission for detecting serious adverse events among emergency department patients with syncope: a propensity-score-matched analysis of a multicentre prospective cohort.

CMAJ 2020 Oct;192(41):E1198-E1205

John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.

Background: The benefit of hospital admission after emergency department evaluation for syncope is unclear. We sought to determine the association between hospital admission and detection of serious adverse events, and whether this varied according to the Canadian Syncope Risk Score (CSRS).

Methods: We conducted a secondary analysis of a multicentre prospective cohort of patients assessed in the emergency department for syncope. We compared patients admitted to hospital and discharged patients, using propensity scores to match 1:1 for risk of a serious adverse event. The primary outcome was detection of a serious adverse event in hospital for admitted patients or within 30 days after emergency department disposition for discharged patients.

Results: We included 8183 patients, of whom 743 (9.1%) were admitted; 658/743 (88.6%) were matched. Admitted patients had higher odds of detection of a serious adverse event (odds ratio [OR] 5.0, 95% confidence interval [CI] 3.3-7.4), nonfatal arrhythmia (OR 5.1, 95% CI 2.9-8.8) and nonarrhythmic serious adverse event (OR 6.3, 95% CI 2.9-13.5). There were no significant differences between the 2 groups in death (OR 1.0, 95% CI 0.4-2.7) or detection of ventricular arrhythmia (OR 2.0, 95% CI 0.7-6.0). Differences between admitted and discharged patients in detection of serious adverse events were greater for those with a CSRS indicating medium to high risk ( = 0.04).

Interpretation: Patients with syncope were more likely to have serious adverse events identified within 30 days if they were admitted to hospital rather than discharged from the emergency department. However, the benefit of hospital admission is low for patients at low risk of a serious adverse event.
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http://dx.doi.org/10.1503/cmaj.191637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588246PMC
October 2020

Contribution of Substance Use in Acute Injuries With Regards to the Intent, Nature and Context of Injury: A CHIRPP Database Study.

Cureus 2020 Sep 6;12(9):e10282. Epub 2020 Sep 6.

Emergency Department, CHU De Québec - Université Laval, Quebec, CAN.

Introduction Using the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) sentinel surveillance system, the objective of this study was to compare intent, circumstances, injury type and patient demographics in patients who used a substance prior to the injury versus those who did not use any substances. Methods Data were retrospectively collected from November 1 2016 to October 31 2017. All patients presenting to the Hôpital de l'Enfant-Jésus ED following trauma were included, aside from those who left without seeing a physician or had no physical injury (e.g., overdose without any trauma was excluded). Patients voluntarily completed a standardised form or agreed to be contacted later. Medical charts of all attendances were reviewed by the CHIRPP's program coordinator. Substance use included illicit drugs, medications for recreational purposes, alcohol or other used either by the patient or another person involved. Results A total of 12,857 patients were included. Substance use was involved in 701 (5.5%) cases and was associated with injuries sustained by males (p < .001). The mean age of patients injured while using substances was 42.8 years, compared to 45.5 years in those who did not use substances (p < .001). Substance use was involved in 3.6% of unintentional injuries, compared to 26.2% of injuries intentionally inflicted by other and 38.9% for self-inflicted injuries (p < 0.0001). When substances were used, the odds of intentional injuries were 7.5 times greater compared to non-intentional injuries (95% CI 6.7, 8.5). Burns, head injuries and polytraumas were more prevalent when drugs or alcohol were involved. Conclusion This study outlines the significant contribution of substance use in intentional injuries, suggesting that it could potentially be beneficial to specifically target patients who present with deliberate physical injuries in preventive and therapeutic interventions offered in the ED.
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http://dx.doi.org/10.7759/cureus.10282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7538210PMC
September 2020

Placenta-mediated complications: Nucleosomes and free DNA concentrations differ depending on subtypes.

J Thromb Haemost 2020 12 18;18(12):3371-3380. Epub 2020 Oct 18.

Department of Haematology, CHU Nimes, Univ Montpellier, Nîmes, France.

Background: Placenta-mediated pregnancy complications generate short- and long-term adverse medical outcomes for both the mother and the fetus. Nucleosomes and free DNA (fDNA) have been described in patients suffering from a wide range of inflammatory conditions.

Objective: The objective of our study was to compare nucleosomes and fDNA circulating levels during pregnancy and particularly in women developing a placenta-mediated complication according to the subtype (preeclampsia or intrauterine growth restriction) (NCT01736826).

Patients/methods: A total of 115 women were prospectively included in the study across three groups: 30 healthy non-pregnant women, 50 with normal pregnancy, and 35 with a complicated pregnancy. Blood samples were taken up to every 4 weeks for several women with normal pregnancy and nucleosomes and fDNA were quantified using enzyme-linked immunosorbent assay and quantitative polymerase chain reaction, respectively.

Results: We show that nucleosomes and fDNA concentrations significantly increase during normal pregnancy, with concentrations at delivery differing between the two groups. Interestingly, we show that concentrations differ according to the type of placenta-mediated complications, with higher levels in preeclampsia compared to intrauterine growth restriction.

Conclusions: These data suggest that nucleosomes and fDNA may be additional actors participating in placenta-mediated pregnancy complications.
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http://dx.doi.org/10.1111/jth.15105DOI Listing
December 2020

Propofol for migraine in the emergency department: A pilot randomised controlled trial.

Emerg Med Australas 2020 08;32(4):542-547

Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.

Objective: To test the administration of intravenous (i.v.) propofol at a procedural sedation dose compared to standard therapy for initial management of migraine in the ED.

Methods: This was an open label, randomised controlled pilot trial. Eligible patients were adults with a diagnosis of migraine and planned for treatment with i.v. medications. Patients were randomised to propofol or standard therapy groups. The primary outcome variable was time to discharge (TTD) defined as time from intervention to discharge from the ED. Secondary outcomes were safety of propofol administration and change in pain scores. A reduction of pain by ≥50% or discharge from the ED was defined as favourable. All analyses were performed on an intention-to-treat basis.

Results: Data from 29 patients were analysed, with 15 patients in the propofol group and 14 patients in the standard therapy group. TTD was significantly lower in the propofol group with median of 290 (interquartile range 162-500) min compared to 554.5 (interquartile range 534-639) min in the standard therapy group (P = 0.021). The hazard ratio for the defined favourable outcome of reduction of pain scores or discharge from the ED was 1.54 (95% CI 0.69-3.41).

Conclusions: Initial management of migraine with i.v. propofol at procedural sedation doses significantly reduced TTD compared to standard therapy. We did not detect any significant safety concerns although the study was not adequately powered to detect safety of the intervention and requires validation.
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http://dx.doi.org/10.1111/1742-6723.13542DOI Listing
August 2020

Clinically significant traumatic intracranial hemorrhage following minor head trauma in older adults: a retrospective cohort study.

Brain Inj 2020 05 14;34(6):834-839. Epub 2020 Apr 14.

Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada.

Objectives: The primary objective of this study was to determine the incidence of clinically significant traumatic intracranial hemorrhage (T-ICH) following minor head trauma in older adults. Secondary objective was to investigate the impact of anticoagulant and antiplatelet therapies on T-ICH incidence.

Methods: This retrospective cohort study extracted data from electronic patient records. The cohort consisted of patients presenting after a fall and/or head injury and presented to one of five ED between 1st March 2010 and 31st July 2017. Inclusion criteria were age ≥ 65 years old and a minor head trauma defined as an impact to the head without fulfilling criteria for traumatic brain injury.

Results: From the 1,000 electronic medical records evaluated, 311 cases were included. The mean age was 80.1 (SD 7.9) years. One hundred and eighty-nine (189) patients (60.8%) were on an anticoagulant (n = 69), antiplatelet (n = 130) or both (n = 16). Twenty patients (6.4%) developed a clinically significant T-ICH. Anticoagulation and/or antiplatelets therapies were not associated with an increased risk of clinically significant T-ICH in this cohort (Odds ratio (OR) 2.7, 95% CI 0.9-8.3).

Conclusions: In this cohort of older adults presenting to the ED following minor head trauma, the incidence of clinically significant T-ICH was 6.4%.
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http://dx.doi.org/10.1080/02699052.2020.1753242DOI Listing
May 2020

Does tranexamic acid reduce traumatic brain injury-related death?

CJEM 2020 05;22(3):297-298

Faculté de médicine, Département de médicine familiale et de médicine d'urgence, Université Laval, Québec, QC.

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http://dx.doi.org/10.1017/cem.2020.19DOI Listing
May 2020

Multicenter Emergency Department Validation of the Canadian Syncope Risk Score.

JAMA Intern Med 2020 05;180(5):737-744

Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.

Importance: The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use.

Objective: To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation.

Design, Setting, And Participants: This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018.

Main Outcomes And Measures: Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated.

Results: A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively.

Conclusions And Relevance: The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
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http://dx.doi.org/10.1001/jamainternmed.2020.0288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7091474PMC
May 2020

Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial.

Lancet 2020 02;395(10221):339-349

Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.

Background: Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion.

Methods: We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058.

Findings: Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68).

Interpretation: Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes.

Funding: Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.
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http://dx.doi.org/10.1016/S0140-6736(19)32994-0DOI Listing
February 2020

Elder Abuse in the Out-of-Hospital and Emergency Department Settings: A Scoping Review.

Ann Emerg Med 2020 02;75(2):181-191

Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia.

This scoping review aimed to synthesize the available evidence on the epidemiology, patient- and caregiver-associated factors, clinical characteristics, screening tools, prevention, interventions, and perspectives of health care professionals in regard to elder abuse in the out-of-hospital or emergency department (ED) setting. Literature search was performed with MEDLINE, EMBASE, the Cumulative Index of Nursing and Allied Health, PsycINFO, and the Cochrane Library. Studies were eligible if they were observational or experimental and reported on elder abuse in the out-of-hospital or ED setting. A qualitative approach, performed independently by 2 reviewers, was used to synthesize and report the findings. A total of 413 citations were retrieved, from which 55 studies published between 1988 and 2019 were included. The prevalence of elder abuse reported during the ED visit was lower than reported in the community. The most commonly detected type of elder abuse was neglect, and then physical abuse. The following factors were more common in identified cases of elder abuse: female sex, cognitive impairment, functional disability, frailty, social isolation, and lower socioeconomic status. Psychiatric and substance use disorders were more common among victims and their caregivers. Screening tools have been proposed, but multicenter validation and influence of screening on patient-important outcomes were lacking. Health care professionals reported being poorly trained and acknowledged numerous barriers when caring for potential victims. There is insufficient knowledge, limited training, and a poorly organized system in place for elder abuse in the out-of-hospital and ED settings. Studies on the processes and effects of screening and interventions are required to improve care of this vulnerable population.
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http://dx.doi.org/10.1016/j.annemergmed.2019.12.011DOI Listing
February 2020

Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: A systematic review.

Injury 2020 Feb 26;51(2):157-163. Epub 2019 Dec 26.

Centre de recherche sur les soins et services de première ligne de l'Université Laval (CERSSPL-UL), Quebec, Quebec, Canada.

Introduction: Seniors who fall are an increasing proportion of the patients who are treated in emergency departments (ED). Falling on level-ground is the most common cause of traumatic intracranial bleeding. We aimed to determine the incidence of intracranial bleeding among all senior patients who present to ED after a fall.

Method: We performed a systematic review. Medline, EMBASE, Cochrane, and Database of Abstracts of Reviews of Effects databases, Google Scholar, bibliographies and conference abstracts were searched for articles relevant to senior ED patients who presented after a ground-level fall. Studies were included if they reported on patients aged 65 or older who had fallen. At least 80% of the population had to have suffered a ground-level fall. There were no language restrictions. We performed a meta-analysis (using the random effects model) to report the pooled incidence of intracranial bleeding within 6 weeks of the fall.

Results: We identified eleven studies (including 11,102 patients) addressing this clinical question. Only three studies were prospective in design. The studies varied in their inclusion criteria, with two requiring evidence of head injury and four requiring the emergency physician to have ordered a head computed tomography (CT). One study excluded patients on therapeutic anticoagulation. Overall, there was a high risk of bias for eight out of eleven studies. The pooled incidence of intracranial bleeding was 5.2% (95% CI 3.2-8.2%). A sensitivity analysis excluding studies with a high risk of bias gave a pooled estimate of 5.1% (95% CI 3.6-7.2%).

Conclusion: We found a lack of high-quality evidence on senior ED patients who have fallen. The available literature suggests there is around a 5% incidence of intracranial bleeding in seniors who present to the ED after a fall.
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http://dx.doi.org/10.1016/j.injury.2019.12.036DOI Listing
February 2020

Examining the relationship between triage acuity and frailty to inform the care of older emergency department patients: Findings from a large Canadian multisite cohort study.

CJEM 2020 01;22(1):74-81

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON.

Background: The 2016 Canadian Triage and Acuity Scale (CTAS) updates introduced frailty screening within triage to more accurately code frail patients who may deteriorate waiting for care. The relationship between triage acuity and frailty is not well understood, but may help inform which supplemental geriatric assessments are beneficial to support care in the emergency department (ED). Our objectives were to investigate the relationship between triage acuity and frailty, and to compare their associations with a series of patient outcomes.

Methods: We conducted a secondary analysis of the Canadian cohort from a multinational prospective study. Data were collected on ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Triage acuity was assigned using the CTAS, whereas frailty was measured using an ED frailty index. Spearman rank and binary logistic regression were used to examine associations.

Results: A total of 2,153 ED patients were analyzed. No association was found between the CTAS and ED frailty index scores assigned to patients (r = .001; p = 0.99). The ED frailty index was associated with hospital admission (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.4-1.6), hospital length of stay (OR = 1.4; 95% CI = 1.2-1.6), future hospitalization (OR = 1.1; 95% CI = 1.05-1.2), and ED recidivism (OR = 1.1; 95% CI = 1.04-1.2). The CTAS was associated with hospital admission (e.g., CTAS 2 v. 5; OR = 6; 95% CI = 3.3-11.4).

Conclusion: Our findings demonstrate that frailty and triage acuity are independent but complementary measures. EDs may benefit from comprehensive frailty screening post-triage, as frailty and its associated geriatric syndromes drive outcomes separate from traditional measures of acuity.
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http://dx.doi.org/10.1017/cem.2019.432DOI Listing
January 2020

The role of haemostasis in placenta-mediated complications.

Thromb Res 2019 Sep;181 Suppl 1:S10-S14

University of Montpellier, France; Department of Vascular Imaging and Vascular Medicine, Nîmes University Hospital, France.

Normal pregnancy is associated with an increasing state of activation of the haemostatic system. This activation state is excessive in women with placenta-mediated pregnancy complications (PMPCs), including preeclampsia (PE). Platelet activation plays a crucial pathophysiological role in PE. The very early activation of coagulation in the intervillous space is mandatory for placental growth and morphogenesis but its excesses and/or inadequate control may participate to the emergence of the trophoblastic phenotype of PE. Extracellular vesicles, of endothelial but also of trophoblastic origin, can favour key cellular reactions of preeclampsia, acting as proactive cofactors. The understanding of this intricate relationship between haemostasis activation and PMPCs may provide interesting keys for new pathophysiological therapeutic developments.
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http://dx.doi.org/10.1016/S0049-3848(19)30359-7DOI Listing
September 2019

What do community paramedics assess? An environmental scan and content analysis of patient assessment in community paramedicine.

CJEM 2019 11;21(6):766-775

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON.

Objectives: Patient assessment is a fundamental feature of community paramedicine, but the absence of a recognized standard for assessment practices contributes to uncertainty about what drives care planning and treatment decisions. Our objective was to summarize the content of assessment instruments and describe the state of current practice in community paramedicine home visit programs.

Methods: We performed an environmental scan of all community paramedicine programs in Ontario, Canada, and used content analysis to describe current assessment practices in home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy.

Results: A total of 43 of 52 paramedic services in Ontario, Canada, participated in the environmental scan with 24 being eligible for further investigation through content analysis of intake assessment forms. Among the 24 services, 16 met inclusion criteria for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Most assessments included some content from each of the domains outlined in the ICF. At the subdomain level, only assessment of impairments of the functions of the cardiovascular, hematological, immunological, and respiratory systems appeared in all assessments.

Conclusion: Although community paramedicine home visit programs may differ in design and aim, all complete multi-domain assessments as part of patient intake. If community paramedicine home visit programs share similar characteristics but assess patients differently, it is difficult to expect that the resulting referrals, care planning, treatments, or interventions will be similar.
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http://dx.doi.org/10.1017/cem.2019.379DOI Listing
November 2019

Differences in the epidemiology of out-of-hospital and in-hospital trauma deaths.

PLoS One 2019 4;14(6):e0217158. Epub 2019 Jun 4.

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

Background: Trauma is a leading cause of mortality. Holistic views of trauma systems consider injury as a public health problem that requires efforts in primary, secondary and tertiary prevention. However, the performance of trauma systems is commonly judged on the in-hospital mortality rate. Such a focus misses opportunities to consider all deaths within a population, to understand differences in in-hospital and out-of-hospital trauma deaths and to inform population-level injury prevention efforts. The aim of this study was to provide an epidemiological overview of out-of-hospital and in-hospital trauma deaths in a geographically-defined area over a 10-year period.

Methods: We performed a population-based review of out-of-hospital and in-hospital trauma deaths over the period of 01 July 2006 to 30 June 2016 in Victoria, Australia, using data from the National Coronial Information System and the Victorian State Trauma Registry. Temporal trends in population-based incidence rates were evaluated.

Results: Over the study period, there were 11,246 trauma deaths, of which 71% were out-of-hospital deaths. Out-of-hospital trauma deaths commonly resulted from intentional self-harm events (50%) and transport events (35%), while in-hospital trauma deaths commonly resulted from low falls (≤1 metre) (50%). The incidence of overall trauma deaths did not change over the study period (incidence rate ratio 0.998; 95%CI: 0.991, 1.004; P = 0.56).

Conclusions: Out-of-hospital deaths accounted for most trauma deaths. Given the notable differences between out-of-hospital and in-hospital trauma deaths, monitoring of all trauma deaths is necessary to inform injury prevention activities and to reduce trauma mortality. The absence of a change in the incidence of both out-of-hospital and in-hospital trauma deaths demonstrates the need for enhanced activities across all aspects of injury prevention.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217158PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548370PMC
February 2020

Low-value clinical practices in injury care: A scoping review and expert consultation survey.

J Trauma Acute Care Surg 2019 06;86(6):983-993

From the Department of Social and Preventative Medicine (L.M., K.M.B., I.F.), Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, Critical Care Medicine (L.M., F.Lauzier, P.-A.T., K.M.B., I.M., E.M., S.B., P.L.B., A.F.T.), Centre de Recherche du CHU de Québec, Université Laval (Hôpital de l'Enfant-Jésus), Department of Anesthesiology and Critical Care Medicine (F.Lauzier, A.F.T.), Population Health and Optimal Health Practices Research Unit (P.A.), Transfert des Connaissances et Évaluation des Technologies et Modes d'Intervention en Santé, Centre de Recherche du CHU de Québec, Université Laval (Hôpital St François d'Assise), Université Laval; Department of Medicine (F.Lamontagne), Université de Sherbrooke, Sherbrooke; Department of Medicine (M.C.), Université de Montréal, Montréal, Québec; Departments of Critical Care Medicine (H.T.S.), Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; School of Public Health and Preventive Medicine (B.G.), Monash University, Melbourne, Australia; Emergency Medicine (F.Lecky), University of Sheffield, Sheffield; Trauma Audit and Research Network, United Kingdom; Department of Surgery (N.Y.), Dalhousie University, Halifax, Nova Scotia; Department of Surgery (H.C.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Surgery (J.K.), University of Calgary, Calgary, Alberta, Canada; The Alfred Hospital (P.C.), Monash University, Melbourne, Australia; Division of Neurosurgery, Department of Surgery (P.L.B., J.P.), Université Laval; Institut National D'Excellence en Santé et en Services Sociaux (C.T.), Québec, Canada.

Background: Tests and treatments that are not supported by evidence and could expose patients to unnecessary harm, referred to here as low-value clinical practices, consume up to 30% of health care resources. Choosing Wisely and other organizations have published lists of clinical practices to be avoided. However, few apply to injury and most are based uniquely on expert consensus. We aimed to identify low-value clinical practices in acute injury care.

Methods: We conducted a scoping review targeting articles, reviews and guidelines that identified low-value clinical practices specific to injury populations. Thirty-six experts rated clinical practices on a five-point Likert scale from clearly low value to clearly beneficial. Clinical practices reported as low value by at least one level I, II, or III study and considered clearly or potentially low-value by at least 75% of experts were retained as candidates for low-value injury care.

Results: Of 50,695 citations, 815 studies were included and led to the identification of 150 clinical practices. Of these, 63 were considered candidates for low-value injury care; 33 in the emergency room, 9 in trauma surgery, 15 in the intensive care unit, and 5 in orthopedics. We also identified 87 "gray zone" practices, which did not meet our criteria for low-value care.

Conclusion: We identified 63 low-value clinical practices in acute injury care that are supported by empirical evidence and expert opinion. Conditional on future research, they represent potential targets for guidelines, overuse metrics and de-implementation interventions. We also identified 87 "gray zone" practices, which may be interesting targets for value-based decision-making. Our study represents an important step toward the deimplementation of low-value clinical practices in injury care.

Level Of Evidence: Systematic Review, Level IV.
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http://dx.doi.org/10.1097/TA.0000000000002246DOI Listing
June 2019

Clinical clearance of the thoracic and lumbar spine: a pilot study.

ANZ J Surg 2019 06 13;89(6):718-722. Epub 2019 May 13.

Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.

Background: In patients who are awake with normal mental and neurologic status, it has been suggested that the thoracolumbar (TL) spine may be cleared by clinical examination, irrespective of the mechanism of injury. The aim of this pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the TL spine during assessment of patients in the emergency department after trauma.

Methods: A prospective interventional study was conducted at two major trauma centres. The intervention of a clinical decision tool for assessment of the TL spine was applied prospectively to all patients with subsequent imaging results acting as the comparator. The primary outcome variable was fracture of the thoracic or lumbar vertebra(e). The clinical decision tool was assessed using sensitivity and specificity for detecting a TL fracture and reported with 95% confidence intervals (CIs).

Results: There were 188 cases included for analysis that all underwent imaging of the thoracic and/or lumbar vertebrae. There were 34 (18%) patients diagnosed with fractures of the thoracic and/or lumbar vertebrae. In this pilot study, sensitivity of the clinical decision tool was 100% (95% CI 87.3-100%) and specificity was 37.0% (95% CI 29.5-45.2%) for the detection of a thoracic or lumbar vertebral fracture.

Conclusions: Feasibility of clinical clearance of the TL spine in two major trauma centres was demonstrated in a clinical study setting. Evaluation of this clinical decision tool in patients following blunt trauma, particularly in reducing imaging rates, is indicated using a larger prospective study.
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http://dx.doi.org/10.1111/ans.15253DOI Listing
June 2019