2005 CAEP / ACMU Scientific Abstracts - Oral Presentations: 15-29
2005 Scientific Abstracts
CJEM 2005;7(3):176-211
May 29 - June 1, 2005
Edmonton, Alta.
Disclaimer: The large number of abstracts submitted and the short time interval between submission and publication does not permit communication with authors, abstract revision, or CJEM editorial review. The following abstracts are presented, unedited, as they were submitted to the CAEP Research Committee. Abstract authors are from the department or division of emergency medicine of their respective universities unless otherwise specified.
Avertissement : Le grand nombre de résumé soumis et le court délai entre leur réception et la date de publication on empêché la communication avec les auteurs, la révision des résumés, ou l'évaluation par le comité de réduction du JCMU. Les résumés qui suivent sont présentés non édités, tel qu'ils ont été soumis au Comité de Recherche de l'ACMU. Les auteurs des résumés sont rattachés au département de médecine d'urgence de leur université respective, sauf indication contraire.
all abstracts: 1-14, 15-29, 30-44, 45-58, 59-71, 72-84, 85-99, 100-116
indices: author index | keyword index
indices: author index | keyword index
Oral Presentations (Abstracts #1 to #58)
15
Overview of reports on the quality of systematic reviews and meta-analysis in the biomedical literature.
INTRODUCTION: To review the evidence for quality of systematic reviews and/or meta-analyses (SRs/MAs) available in the published biomedical literature. METHODS: Retrospective study of overviews of SRs/MAs published from 1966 to May 2004. A series of comprehensive MEDLINE searches were conducted. One investigator selected potential studies for inclusion. Data on the number of SRs/MAs included per overview, the methods of quality assessment, and the quality of SRs/MAs according to the overview conclusions are described. RESULTS: From 978 citations identified, 36 overviews analyzing the methodological quality of SRs/MAs were included. On average, 67.64 (95% CI: 40.53 to 94.7) SRs/MAs were included per report. The evidence on the methodological quality of SRs/MAs mainly arises from overviews in the areas of anesthesia/pain management (19%), and general medical journals (14%). The Overview Quality Assessment Questionnaire (OQAQ) was the most frequently used instrument to assess the quality of the SRs/MAs (47%). Overviews reporting the OQAQ median (weighted median: 3.47, n = 5) and mean total scores (weighted mean: 3.96, n = 7) found a pattern of major flaws in the methodological quality of included SRs/MAs. Overall, overview authors found methodological and reporting deficiencies in the SRs/MAs for the methods used to avoid selection bias, the reporting of criteria to assess the validity of primary studies, heterogeneity testing and publication bias. CONCLUSIONS: A large number of studies reporting the quality of SRs/MAs have been conducted to date. Although SRs/MAs are considered the "gold standard" for clinical and policy decisions in healthcare, evidence from overviews shows that the pattern of methodological quality varies across several biomedical specialties and is generally "low". The adoption of standardized guidelines for submission and appraisal for publication of higher quality SRs/MAs must be enforced to reach an appropriate level of methodological quality across the biomedical literature. Key words: systematic reviews; research; methodology
16
Medical student skills: effectiveness of core skills teaching in a procedures lab.
INTRODUCTION: Basic procedural skills are an essential ingredient in undergraduate medical education. However, the literature suggests that contemporary education in this area is inadequate. Little has been published on effective methods of helping students acquire such skills. Emergency physicians are well-suited to assist medical students in this area. We set out to measure the effectiveness of a 1-hour mannequin-based procedure lab in improving objective and subjective performance in three skills as part of a new emergency medicine clerkship. METHODS: We gathered prospective observational data as part of a before and after program evaluation design. Participants included all members of initial cohort of medical students in a new emergency medicine clerkship. All students were given hands-on procedural skills training on IV, NG, and Foley catheter insertion. Students were observed by two expert physicians before and after the training sessions, and at the bedside by supervisors. Students were also surveyed before and after training on their self-rated competence, their number of experiences, and their satisfaction with their clerkship training. Educational impact was calculated using Cohen's d. RESULTS: The first 45 students participated. Cohen's d scores were high for objective ratings of all three skills (IV, NG, and Foley): 1.48, 2.69, and 2.14, respectively. Mean differences between pre- and post-objective skills scores (95% confidence interval) were: 21.4 (17.1-25.8) for IV, 26.6 (23.6-29.6) for NG, and 15.1 (13.0-17.2) for Foley. Cohen's d scores were also highly significant for all self-ratings of competence after training: 1.38 for IV, 1.58 for NG, and 1.38 for Foley. Overall satisfaction with the training was 4.67 on a 5-point scale, and 100% of students satisfactorily completed their clinical procedures log during the allotted time. CONCLUSIONS: This procedures lab was effective in assisting medical students in acquiring essential IV, NG, and Foley skills. Key words: medical education; procedures
17
Prospective validation of a termination of resuscitation decision rule for out-of-hospital cardiac arrests managed by primary care paramedics.
INTRODUCTION: A Primary Care Paramedic (PCP) Termination of Resuscitation (TOR) rule for out-of-hospital cardiac arrest has been retrospectively derived, but not validated. Continued PCP resuscitation is indicated when there is any one of the following: 1) return of spontaneous circulation; 2) any shock given prior to transport; 3) arrest witnessed by EMS personnel; otherwise further resuscitation is futile. The objective of this study was to prospectively validate a TOR clinical decision rule for PCPs by comparing the survival rate when the rule suggests termination to the acceptable medical futility rate of 1% for any intervention; and evaluate the diagnostic test characteristics of the rule to predict survival. METHODS: This prospective validation study was conducted in 12 rural and urban communities. Survival was measured as hospital discharge or in-hospital at 6 months. A t-test statistic compared the survival rate when the rule suggested termination to the 1% rate of survivability reflective of medical futility. Diagnostic test characteristics of the rule to predict survival were calculated. RESULTS: A total of 1241 cardiac arrest cases were enrolled over the 25 month study period, with 100% follow-up. The survival rate when the rule indicated termination was 4/776 or 0.5% (95% CI, 0.1%, 0.9%), significantly less than the medical futility rate of 1.0% (p = 0.04). The TOR guideline was 90% (95% CI, 88%, 92%) sensitive in predicting survival; with a specificity of 64% (95% CI, 62%, 37%), a positive predictive value of 8% (95% CI, 7%, 10%), and a negative predictive value of 99% (95% CI, 99%, 100%). CONCLUSIONS: The TOR clinical decision rule suggests termination with a survival rate below that considered to be medically futile and has a strong negative predictive value for survival. Key words: cardiac arrest; emergency medical services; resuscitation termination
18
Designing an effective emergency medicine clerkship -- systematic needs assessment.
INTRODUCTION: There is renewed interest in Canada in enhancing medical student education in emergency medicine (EM). As medical schools expand in an era in which CAEP has identified a shortage of emergency physicians, a number of universities have developed emergency medicine clerkships. However, little has been written about the educational needs of medical students with respect to emergency medicine competencies. In preparation for a new clerkship at the University of Ottawa, we conducted a systematic educational needs assessment to identify the essential EM competencies of contemporary medical students. METHODS: We used a systematic educational planning model to identify four categories of EM educational needs: societal, institutional, observed by experts, and perceived by learners. We conducted a systematic literature search using the search terms medical education, emergency, emergency medicine, acute care, skills, and procedures. Medical students were surveyed about their interests with respect to EM. We used the Google search engine to find descriptions of EM student curriculum needs on the internet. We consulted Canadian medical educators and emergency medicine societies. Competency lists were integrated by iterative consensus and validated via review by EM teachers and medical students. RESULTS: We developed a competency framework for a medical student clerkship that included 20 specific competencies, 9 core procedural skills, and addressed 15 common EM presentations. CONCLUSIONS: This systematic needs assessment identified a framework of core competencies for medical students to acquire in EM. It is suitable for use in planning enhanced EM UGME education such as clerkships. Key words: medical education; emergency medicine
19
A randomized clinical trial comparing efficacy and safety of etomidate versus midazolam for procedural sedation among children.
INTRODUCTION: There are suggestions that etomidate has sedative properties superior to midazolam especially among adults. Our objective was to study the efficacy and safety of etomidate in comparison with midazolam for achieving PSA in children. METHODS: A randomized, double-blind, controlled pediatric emergency department and orthopedic clinic-based, outpatient clinical trial was carried out among patients aged 2 to 18 years undergoing PSA for reduction of displaced limb fractures. Patients were administered 1 mcg/kg of fentanyl and either 0.2 mg/kg of etomidate or 0.1 mg/kg of midazolam. A score of 4 or 5 on the Ramsay sedation scale indicated attainment of adequate sedation. The time taken for induction and recovery was compared using non-parametric COX-proportional hazards modeling. The rates of adverse effects among the treatment arms were also evaluated. RESULTS: From April to August 2004, 100 of 128 eligible patients were enrolled (age: 8.7 ± 3.7 years and 50% male). A higher proportion of patients attained adequate sedation among those who received etomidate: 43/50 (86%) vs. 16/49 (33%) (Δ 53%, 95% CI = 33 - 86). After adjusting for potential confounding variables, time taken for induction (Hazard ratio (HR): 4.98, 95% CI 2.05-12.08), and time taken for recovery (HR: 4.95, 95% CI 2.20-11.08), were lower among those who received etomidate. Eleven (22%) patients receiving etomidate presented with myoclonus compared to none among those receiving midazolam (Δ 22%, 95% CI = 10-35). The rate of transient oxygen desaturation (<93%) was comparable between the groups (20% vs 22%); none required positive pressure ventilation. No other adverse events, including vomiting or hospitalization occurred as a result of PSA. CONCLUSION: At the dosages used for PSA among children, etomidate has higher efficacy in comparison to midazolam. Except for myclonus, the frequency of drug related adverse effects was similar between the comparison groups. Key words: etomidate; midazolam; procedural sedation
20
What is the impact of testing for NT-proBNP in ED patients?
INTRODUCTION: Serum concentrations of B-type natriuretic peptide (BNP) and more recently its precursor N-terminal proBNP (NT-proBNP) are advocated for the emergency diagnosis of congestive heart failure (CHF). We sought to estimate the impact of introducing NT-proBNP into the standard evaluation of ED patients with dyspnea. METHODS: This prospective cohort study enrolled dyspneic patients presenting to a tertiary care academic ED during research nurse hours. We excluded trauma patients or those under 30 years. Patients underwent customary evaluation, including radiography when indicated. At the moment of final ED diagnosis and blinded to the NT-proBNP result, senior ED physicians estimated the likelihood that CHF accounted for the patient's dyspnea (Yes, No or Unsure). NT-proBNP values were classified using the manufacturer-recommended, age-specific cutoff. The primary outcome was the rate of discordance between the clinical impression of CHF and the NT-proBNP assay. RESULTS: 139 visits were enrolled (129 patients, median age 76, 48% admitted). The serum NT-proBNP assay was positive in all but 20 visits (see Table 1, Abstract 20). Notably, NT-proBNP was positive in 75% (95% CI 62%-86%) of CHF No and 86% (95% CI 68%-96%) CHF Unsure visits. While average NT-proBNP concentrations were higher in patients diagnosed with CHF (median 4361 pg/mL; IQR 2386-10877) rather than pneumonia or COPD (1651 pg/mL; IQR 370-4745), these ranges overlapped extensively. CONCLUSIONS: There was high discordance between clinical judgment and NT-proBNP concentrations, particularly in patients felt not to have CHF. While the reference standard of ED diagnosis is imperfect, broad overlap in NT-proBNP concentrations suggests poor diagnostic accuracy in this target patient population. The introduction of routine ED testing for NT-proBNP using the current cutoff would be expected to result in substantial indirect costs from further diagnostic testing. Key words: BNP; congestive heart failure
| Physician | Positive | Negative |
| Yes | 51 | 2 |
| No | 43 | 14 |
| Unsure | 25 | 4 |
21
Does practice make perfect? The volume of acute myocardial infarction patients seen in emergency departments and the risk of missed diagnoses.
INTRODUCTION: Failure to diagnose critical conditions is a common cause of medical error in emergency departments (ED). Our prior study demonstrated wide variation in the rate of missed AMIs across EDs. Since higher volume predicts better outcomes for some medical conditions, we hypothesized that the annual volume of AMI patients seen in an ED was associated with the rate of missed diagnoses. METHODS: As in a previous study, we linked administrative health records for all acute AMI patients admitted to an Ontario hospital from April 2002-March 2003 to all ED visit records in the 7 days preceding the admission. The AMI was defined as missed if the final diagnosis on a prior ED visit matched a pre-specified list. The main predictor was annual volume of admitted AMI patients seen in the ED (grouped as 0-49; 50-99; 100-199; 200-299; 300+). Covariates were age, sex, teaching hospital, comorbidities and AMI severity index. We used GEE for logistic regression to account for clustering. RESULTS: 18,353 AMI patients were identified; 9.4% were seen in the lowest volume group EDs and 29.7% in the highest-volume group EDs. Mean age (69y), sex (63% male), and AMI severity score (mean = 0.21;SD 0.2) were similar across all AMI volume groups. Overall 410 AMIs (2.2%; 95% CI 2.0,2.5) were missed on a prior ED visit; the rate varied from 0-25% across EDs. In adjusted analyses with highest-volume group EDs as reference, the risk of missed AMI was significantly higher in EDs in the lowest (OR 1.9; 95% CI 1.4, 2.7) and second-lowest (OR 1.5; 95% CI 1.1,2.2) AMI volume groups, with similar trends in the remaining 2 volume groups. 61 fewer AMIs would be missed annually if the average rate in all AMI volume groups equaled that of the highest volume group. CONCLUSION: The risk of missed AMI is up to 2-fold higher in lower volume EDs compared with highest-volume EDs, after controlling for patient factors and AMI severity. Interventions to reduce AMI misdiagnosis should target low-volume high-risk EDs. Key words: emergency health services; myocardial infarction; diagnosis
22
Sensitivity of 6 hour Troponin assays in ED patients with chest pain.
INTRODUCTION: The measurement of cardiac troponin is the gold standard for detecting myocardial injury in acute coronary syndromes (ACS). Emergency physicians currently rely on troponin levels sampled 6 hours from chest pain onset to assess for the presence of myocardial injury. The objective of this study was to examine the sensitivity of 6 hour troponin levels in a cohort of ED patients followed for 24 hours. METHODS: This nested descriptive study stems from a cohort of ED patients with symptoms suggestive of an ACS. Serial blood samples were taken at 1, 2, 6, and 18-24 hours from chest pain onset. Troponin I and troponin T were assessed on each sample. RESULTS: 154 patients were enrolled. Troponin I and troponin T samples were positive in 15.6% (n = 24) and 24.7% (n = 38) patients respectively. Six (16.2%) samples positive for troponin I at 18-24 hours were negative at 6 hours. The corresponding numbers for troponin T were 5, or 20.1%. One patient from each troponin assay was deemed a false positive for ACS based on subsequent clinical evaluation. CONCLUSIONS: These findings suggest that while the sensitivity of 6 hour troponin assays are high, an important proportion of patients presenting with chest pain may be discharged home with undetected coronary ischemia were discharge decisions to rely on positive troponin assays alone. Key words: troponin; chest pain; acute coronary syndrome
23
From 911 to balloon: reduction of ischemic time in primary angioplasty by implementation of an expedited transfer pathway.
INTRODUCTION: Recent publications demonstrate that transferring patients to invasive-treatment centre for primary percutaneous coronary intervention (PPCI) is safe and effective in acute ST elevation myocardial infarction (STEMI) compared to on-site fibrinolytic therapy. Yet, the process of triage, diagnosis and transportation to invasive-treatment centre may prolong time to reperfusion hence reducing its efficacy. As part of the regional cardiovascular Quality Improvement and Health Information (QIHI) initiative for the Calgary Health Region (CHR), the cardiology service, emergency medical service (EMS) and emergency department (ED) established a working group with the objective of improving outcomes in acute STEMI patients. METHODS: As phase one of QIHI, an expedited transfer pathway (ETP) was designed and implemented in Jan04 to streamline the process of care in patients who seek medical attention through 911 emergency services. These improvements include preliminary EKG diagnosis of STEMI by EMS, early communication with ED, cath lab and CCU, expedited transportation from home to invasive-treatment centre and shortening ED triage process. RESULTS: Patients (N = 17) enrolled in the ETP from Jan 04 to Mar 04 were compared to matched historical controls (n = 81). Median EMS scene arrival to balloon inflation time is reduced by 62 min (129 vs. 67; p < 0.001). Median door-to-balloon time is reduced by 55 min (95 vs. 40; p < 0.001). Majority of time saved occurred during ED triage to cath lab arrival of 43.5 min (62.5 vs. 19: p < 0.001). CONCLUSION: Early results from the streamlined STEMI pathway showed promising reduction of total ischemic time in patients requiring transfer to invasive-treatment centre. Key words: myocardial infarction; percutaneous coronary intervention; emergency health services
24
Intramuscular versus oral corticosteroids for preventing relapse following acute exacerbations of asthma.
OBJECTIVE: To determine the benefit of intramuscular (IM) and/or oral corticosteroids (CCS) for patients with asthma discharged from the Emergency Department (ED) after an asthmatic exacerbation. METHODS: A comprehensive search was conducted using the "Asthma and Wheez* RCT" register maintained by the Cochrane Airways Group (which includes searches on EMBASE, MEDLINE, CINAHL, and hand searches of the top 20 respiratory care journals). Trials were included if patients with acute asthma were randomized to receive oral or IM CCS versus placebo after discharged from the ED. Two reviewers performed selection, methodological quality, and data extraction independently. The main outcome of the study was relapse to additional care. Results were analyzed using relative risk (RR) with 95% confidence intervals (CI). RESULTS: A search that yielded 821 references identified 68 potentially relevant articles for inclusion. A total of 15 trials produced in the past 15 years were included (Kappa: 0.81). Overall, no significant difference in the relapse rate to additional care between IM and oral CCS (RR (fixed effects) = 0.88; 95% CI: 0.68, 1.14; six studies) was found. This result was consistent both at 7-10 days (RR = 0.73; 95% CI: 0.49, 1.09) and at 11-21 days of follow up (RR = 1.03; 95% CI: 0.73, 1.44). IM CCS did not significantly differ from placebo in the relapse rate (RR = 0.29; 95% CI: 0.09, 1.01; two studies). Oral CCS were more effective than placebo at reducing the relapse rate (RR = 0.50; 95% CI: 0.37, 0.67; eight studies). This effect was consistent both at 7-10 days (RR = 0.65; 95% CI: 0.43, 0.97) and at 11-21 days of follow up (RR = 0.36; 95% CI: 0.20, 0.66); however, seems to be deleterious at 22 days and over (RR = 0.63; 95% CI: 0.32, 1.23). CONCLUSIONS: Oral CCS appear to effective in preventing relapse after ED discharge; IM CCS, while effective, do not appear to be more effective than oral agents at preventing relapse. IM agents are a valuable alternative in selected patients. Key words: asthma; steroids
25
Predicting relapse in acute asthma following discharge from the emergency department: the importance of adhering to oral corticosteroids.
OBJECTIVE: Despite prescription of standard treatment, many asthma patients relapse (defined as need for "additional care" based on worsening of symptoms) following Emergency Department (ED) discharge. Oral and inhaled corticosteroids (OCS and ICS) reduce rates of relapse; however, little is known about other factors associated with relapse. Predictors of relapse were investigated using individual patient data (IPD) from randomized trials conducted for the treatment of acute asthma. METHODS: IPD (N = 456) from 4 comparable trials conducted at Canadian EDs were combined. In all studies, patients received OCS (prednisone 50 mg) for 7 days and short acting beta-agonists. Additional inhaled treatments included placebo (n = 71), low-dose fluticasone (n = 28), high-dose budesonide (n = 82), high-dose fluticasone (n = 107), or high-dose fluticasone/salmeterol (n = 93). All patients were followed until relapse or for 1 month after discharge. Proportional hazards models were used to determine predictors of relapse, presented as adjusted relative risks (RR) with 95% confidence intervals (CI). RESULTS: Overall, relapse occurred in 16% (75/456) of patients. Univariate analyses demonstrated that relapse was associated (p<0.05) with older age (34 vs. 29 yrs), female gender (17 vs. 11%), smoke exposure at home (12 vs. 20%), smaller changes in PEFR during ED stay (94 vs. 134 L/min) and missed prednisone doses (7 vs. 29%). No evidence supported a difference based on the dose or type of inhaled treatments. In the multivariate model, missing prednisone doses (RR = 4.29; 2.49-7.40), smaller changes in PEFR (RR = 0.94; 0.91-0.97) and older age (RR = 1.14; 1.02-1.27) were independently associated with relapse. CONCLUSIONS: Our results indicate that non-adherence with OCS is one of the major determinants of acute asthma relapse following ED discharge. Additional research to improve adherence with OCS and explore other modifiable factors associated with relapse following discharge are warranted. Key words: asthma; steroids
26
Mechanisms of injury associated with brain injury in mild head injury patients.
INTRODUCTION: To identify high-risk mechanisms of injury that are associated with clinically important brain injury in mild head injury patients. METHODS: This secondary data analysis was conducted on patients from the Canadian CT Head rule study, a prospective cohort involving adults with loss of consciousness, amnesia, or confusion and a GCS score of 13-15. The outcome criterion was clinically important brain injury on CT. Study nurses reviewed ambulance, ED, and in-hospital records to classify each case according to 21 mechanisms of injury. A logistic regression model was built by manual stepwise addition of pre-injury characteristics, adding interactions and adjusting for clustering by hospital. RESULTS: Characteristics of the 5,858 patients were: important brain injury 8.4%, urgent neurological intervention 1.5%, male 69%, intoxicated 13.3%, median age 34 years. Odds ratios with 95% CIs for brain injury for each mechanism with MVC as the comparison group were: Motorcycle with speed >100 km/hr 5.8 (1.2, 26.9), Motorcycle 0.9 (0.3, 2.4), and Other motorized vehicle 1.8 (0.8, 4.0), pedestrian struck 3.8 (2.4, 6.2), pedestrian stuck & thrown 4.0 (2.6, 6.3), Bicycle struck un-helmeted 3.0 (1.3, 7.3), Bicycle struck 1.6 (0.6, 4.4), Bicycle collision un-helmeted 6.6 (2.4, 17.7), Bicycle collision 1.2 (0.4, 4.1), Other bicycle 0.4 (0.2, 1.1), Fall onto Head 6.9 (2.6, 18.5), Heavy object on the head 4.1 (1.9, 9.1), Fall <3 feet 1.6 (1.1, 2.3), Fall >3 and <10 feet 4.4 (2.7, 7.3), Fall >10 feet 3.2 (2.1, 4.9), Contact sports 1.5 (0.6, 3.7), Other sports 0.6 (0.3, 1.3), Assault feet or fist 1.3 (0.8, 2.2), Assault blunt object 3.8 (2.4, 5.9), and Hit head on an object 1.3 (0.5, 2.9). Other important pre-injury variables were: age (10-year increments) 1.3 (1.3, 1.4), female 0.7 (0.5, 0.8), and suspected intoxication 1.3 (1.0, 1.6). CONCLUSIONS: Certain injury mechanisms place patients at increased risk of brain injury, and health care providers should carefully ascertain details of the injury when managing mild head injury patients. Key words: head injury; traumatic brain injury; trauma
27
Utility of silver sulfadiaizine in burn management: a systematic review.
INTRODUCTION: This systematic review was undertaken to determine the superiority of silver sulfadiazine (SSD) compared to other topical ointments in the management of superficial partial-thickness second degree burns, for the outcomes of wound healing and wound infection rates. METHODS: Independent search strategies included electronic databases (Medline, EMBASE, CINAHL, Cochrane Collaboration), manual searches of reference lists and core textbooks in emergency and burn medicine. Of the 122 randomized controlled trials identified, 20 met predefined inclusion criteria. Methodological quality was measured independently by the Jadad criteria, and only those with a score of 3+/5 points were included in the analysis. Independent data extraction was performed using standardized forms. Data analysis was performed using the Cochrane Revman 4.0 software. RESULTS: Only 3 of 12 available articles met the required Jadad threshold of 3+/5 for the wound-healing outcome. For wound healing at 10-14 days, the OR (random) was 0.45 (95% CI 0.20-0.99) in favour of SSD. For the wound infection outcome, only 2 studies met the Jadad threshold. For wound infection at 7 days, the OR (random) was 2.98 (95% CI 1.03-8.65) in favour of controls. There was no appreciable difference in effect measures using a random vs. fixed effects model. For either outcome, no study involving outpatient management met the Jadad threshold for inclusion in the analysis. CONCLUSION: This study demonstrates that SSD is not clinically superior to other ointments in outcomes involving wound healing or wound infection rates. The methodologic quality of studies that are published in the burn literature is uniformly poor, as determined by Jadad criteria. There is need for a well-designed randomized controlled trial to establish the utility of SSD in outpatient burn management. Key words: burns; silver sulfadiazine
28
Simple educational intervention for the prevention of chronic whiplash: results of a randomised, controlled trial.
OBJECTIVE: To examine the effectiveness of an educational pamphlet given to emergency department (ED) patients experiencing a grade 1 or 2 whiplash injury. METHODS: Patients aged greater than 17 involved in a motor vehicle collision (MVC) as a passenger or driver who presented to one Alberta ED were approached for participation. Consecutive subjects were randomly allocated to either an educational intervention or usual care. The intervention group received an educational pamphlet based on the current best evidence, while the control group received a standard discharge information sheet. Follow-up interviews were performed at 2 weeks and 3 months. The primary outcome was self-assessed complete recovery from injuries. Additional outcomes concerned severity of symptoms, resource use, litigation, and employment status. RESULTS: Between 12/2002 and 01/2004, 112 subjects were randomised. Demographics, collision parameters and ED treatments were similar between the groups. At 2 weeks post-collision, 7.3% of the intervention group reported recovery compared to 8.8% in the control group (absolute risk difference [ARR]: -1.5%; 95% CI: -12.6% to 9.7%). At 3 months post-collision, 21.8% of the intervention group reported complete recovery compared to 21.0% in the control group (ARR: 0.8%; 95% CI: -14.4% to 16.0%). At 3 months there were no significant differences between groups in severity of symptoms, limitations in daily activities, health resource use, medications used, employment status and lost time from work, or litigation status. CONCLUSIONS: An evidence-based educational pamphlet provided to patients at discharge from the ED is no more effective in relieving pain, reducing time lost from work or reducing litigation than usual care for patients suffering grade 1 or 2 whiplash-associated disorder. More research is required to determine what, if any, interventions may effectively reduce the symptoms associated with chronic pain following MVC. Key words: whiplash; patient education
29
Changes in cyclist helmet wearing following the introduction of helmet legislation in Alberta for those under age 18.
INTRODUCTION: Helmet use is known to protect against head and face injuries in cyclists; however, voluntary use is low, especially in children. The purpose of this study was to determine the changes in helmet wearing in Edmonton, AB cyclists following the introduction of a bicycle helmet law in 2002. METHODS: This study was conducted from June-August 2004 (post-legislation) and data were compared to a similar survey completed at the same locations and days in June-August 2000 (pre-legislation). The assessment of cyclists was made at randomly selected locations in the city by two independent observers. Univariate and bivariate analyses consisted of examining changes in the prevalence of helmet use between observation periods. Logisitc regression analysis with adjustment for clustering was used to relate helmet use to cyclist characteristics, location, average annual income level, and date (2004 vs. 2000). RESULTS: Results: Data were collected for over 270 cyclists in 2004 compared with 699 cyclists in 2000. The overall prevalence of helmet use increased from 43% (95% CI: 39-47) in 2000 to 54% (95% CI: 48-59) in 2004. Helmet use increased in those under 18 (28%, 95% CI: 22%-35% in 2000; 83%, 95% CI: 22%-35% in 2004), but did not change in those 18 and older (49%, 95% CI: 45%-54% in 2000; 48%, 95% CI: 42%-55% in 2004). In the cluster adjusted multivariate logistic regression model, the odds of helmet use increased for those under age 18 (Adjusted Odds Ratio (AOR): 13.73, 95% CI: 6.44-29.29), but did not change for those 18 and older (AOR: 0.95, 95% CI: 0.61-1.48). CONCLUSIONS: Our results clearly show a substantial post-legislation increase in helmet use, but only for those affected by the Alberta helmet law (i.e., those under age 18). These results identify persistent variation in the use of cycling helmets in Edmonton and the extension of the legislation to all age groups should be considered. Future research should focus on cycling rates and cycling injuries. Key words: helmets; head injury; legislation
all abstracts: 1-14, 15-29, 30-44, 45-58, 59-71, 72-84, 85-99, 100-116
indices: author index | keyword index
indices: author index | keyword index
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