Tissue informative cell-free DNA methylation sites in amyotrophic lateral sclerosis

Cell-free DNA (cfDNA) is increasingly recognized as a promising biomarker candidate for disease monitoring. However, its utility in neurodegenerative diseases, like amyotrophic lateral sclerosis (ALS), remains underexplored. Existing biomarker discovery approaches are tailored to a specific disease context or are too expensive to be clinically practical. Here, we address these challenges through a new approach combining advances in molecular and computational technologies. First, we develop statistical tools to select tissue-informative DNA methylation sites relevant to a disease process of interest. We then employ a capture protocol to select these sites and perform targeted methylation sequencing. Multi-modal information about the DNA methylation patterns are then utilized in machine learning algorithms trained to predict disease status and disease progression. We applied our method to two independent cohorts of ALS patients and controls (n=192). Overall, we found that the targeted sites accurately predicted ALS status and replicated between cohorts. Additionally, we identified epigenetic features associated with ALS phenotypes, including disease severity. These findings highlight the potential of cfDNA as a non-invasive biomarker for ALS.

Chest Pain Evaluation: Diagnostic Testing

Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice.

Lack of association between four biomarkers and persistent post-concussion symptoms after a mild traumatic brain injury

Approximately 15 % of individuals who sustained a mild Traumatic Brain Injury (TBI) develop persistent post-concussion symptoms (PPCS). We hypothesized that blood biomarkers drawn in the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and PPCS at 90 days post mild TBI. We conducted a prospective cohort study in seven Canadian EDs. Patients aged ≥ 14 years presenting to the ED within 24 h of a mild TBI who were discharged were eligible. Clinical data and blood samples were collected in the ED, and a standardized questionnaire was administered 90 days later to assess the presence of symptoms. The following biomarkers were analyzed: S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial Fibrillary Acidic Protein (GFAP). The primary outcome measure was the presence of PPCS at 90 days after trauma. Relative risks and Areas Under the Curve (AUC) were computed. A total of 595 patients were included, and 13.8 % suffered from PPCS at 90 days. The relative risk of PPCS was 0.9 (95 % CI: 0.5-1.8) for S100B ≥ 20 pg/mL, 1.0 (95 % CI: 0.6-1.5) for NSE ≥ 200 pg/mL, 3.4 (95 % CI: 0.5-23.4) for GFAP ≥ 100 pg/mL, and 1.0 (95 % CI: 0.6-1.8) for C-Tau ≥ 1500 pg/mL. AUC were 0.50, 0.50, 0.51 and 0.54, respectively. Among mild TBI patients, S100B protein, NSE, c-Tau or GFAP do not seem to predict PPCS. Future research testing of other biomarkers is needed to determine their usefulness in predicting PPCS.

Angiotensin-II for vasoplegia following cardiac surgery

INTRODUCTION

The objective of this study was to describe the implementation and outcomes of a protocol outlining angiotensin-II utilization for vasoplegia following cardiac surgery.

METHODS

This was a retrospective chart review at a single-center university hospital. Included patients received angiotensin-II for vasoplegia refractory to standard interventions, including norepinephrine 20 mcg/min and vasopressin 0.04 units/min, following cardiac surgery between April 2021 and April 2022.

RESULTS

30 patients received angiotensin-II for refractory vasoplegia. Adjunctive agents at angiotensin-II initiation included corticosteroids (26 patients; 87%), epinephrine (26 patients; 87%), dobutamine (17 patients; 57%), dopamine (9 patients; 30%), milrinone (2 patients; 7%), and hydroxocobalamin (4 patients; 13%). At 3 hours, the median mean arterial pressure increased from baseline (70 vs 61.5 mmHg, p = .0006). Median norepinephrine doses at angiotensin-II initiation, 1 hour, 3 hours, and angiotensin-II discontinuation were 0.22, 0.16 (p = .0023), 0.10 (p < .0001), and 0.07 (p < .0001) mcg/kg/min. Median dobutamine doses decreased throughout angiotensin-II infusion from eight to six mcg/kg/min (p = .0313). Other vasoactive medication doses were unchanged. Three patients (10%) subsequently received hydroxocobalamin. Thirteen (43.3%) and five (16.7%) patients experienced mortality by day 28 and venous or arterial thrombosis events, respectively.

CONCLUSIONS

The administration of angiotensin-II to vasoplegic patients following cardiac surgery was associated with increased mean arterial pressure, reduced norepinephrine dosages, and reduced dobutamine dosages.

Age-varying effects of repeated emergency department presentations for children in Canada

Objectives

Repeated presentations to emergency departments (EDs) may indicate a lack of access to other health care resources. Age is an important predictor of frequent ED use; however, age-varying effects are not generally investigated. This study examines the age-specific effects of predictors on ED presentation frequency for children in Alberta and Ontario, Canada.

Methods

This retrospective study used population-based data during April 2010 to March 2017. Data were extracted from the National Ambulatory Care Reporting System for children aged <18 who were members of the top 10% of ED users in any one of the fiscal years 2011/2012 to 2015/2016 along with a comparison sample from the bottom 90%. A marginal regression model studied the age-varying associations on the frequency of ED presentations with province, sex, access to primary health care provider (for Ontario only), area of residence and lowest neighbourhood income quintile.

Results

There were 2,481,172 patients who made 9,229,156 ED presentations. The effects of sex, lowest income quintile, rural residence, access to primary health care provider and province on the frequency of presentations varied by age. Notably, boys go from having more frequent presentations than girls when aged ≤5 (i.e. adjusted intensity ratio [IR]=1.04 at age 5, 95% confidence interval [CI] = 1.03,1.06) to less frequent for ages 8–11 years and beyond 14 (i.e. IR = 0.80 at age 15, 95% CI = 0.78,0.81). Adolescents aged ≥15 without access to a primary care provider had more frequent presentations compared to those with a primary care provider.

Conclusions

When examining the frequency of ED presentations in children, age-varying effects of predictors should be considered. Our more nuanced examination of age provides insights into how health services might better target programmes for different ages to potentially reduce unnecessary ED use by providing other health care alternatives.

Characteristics of Pediatric Frequent Users of Emergency Departments in Alberta and Ontario

OBJECTIVES

Emergency department (ED) volumes have drawn attention to frequent users but less attention has been paid to children. This study examined sociodemographic and ED presentation characteristics of pediatric high-system ED users (HSUs) in 2 provinces in Canada.

METHODS

Cohorts of HSUs were created from the National Ambulatory Care Reporting System in 2015/2016 for children with the top 10% of ED presentations. Controls were random samples of non-HSU patients. Factors were explored in multivariable logistic regression models.

RESULTS

There were 151,497 HSUs (51.7% girls, average age, 6.4 years) and 591,545 controls (53.1% girls; average age, 7.4 years). High-system ED users were more likely to be younger (adjusted odds ratio [aOR], 0.89 per 5 years; 95% confidence interval [CI], 0.88-0.89), live in less populated areas (aOR, 1.85; 95% CI, 1.82-1.88), and from lowest income neighborhoods (aOR, 1.51; 95% CI, 1.48-1.54) than controls. High-system ED users had higher proportions of presentations for pediatric complex chronic (aOR, 1.25 per 0.25 increase; 95% CI, 1.21-1.29), respiratory (aOR, 1.14 per 0.25; 95% CI, 1.12-1.15), and mental health (aOR, 1.14 per 0.25; 95% CI, 1.13-1.16) conditions than controls.

CONCLUSIONS

Complex factors underlie pediatric health care utilization decisions. Findings identified conditions to target in interventions to improve health care access and utilization. Future work should engage children and families to design interventions.

Prevalence, management and outcomes of unrecognized delirium in a National Sample of 1,493 older emergency department patients: how many were sent home and what happened to them?

BACKGROUND

Retrospective studies estimate Emergency Department (ED) delirium recognition at <20%; few prospective studies have assessed delirium recognition and outcomes for patients with unrecognized delirium.

OBJECTIVES

To prospectively measure delirium recognition by ED nurses and physicians, document their confidence in diagnosis and disposition, actual dispositions, and patient outcomes.

METHODS

Prospective observational study of people ≥65 years. We assessed delirium using the Confusion Assessment Method, then asked ED staff if the patient had delirium, confidence in their assessment, if the patient could be discharged, and contacted patients 1 week postdischarge. We report proportions and 95% confidence intervals (Cls).

RESULTS

We enrolled 1,493 participants; mean age was 77.9 years; 49.2% were female, 79 (5.3%, 95% CI 4.2-6.5%) had delirium. ED nurses missed delirium in 43/78 cases (55.1%, 95% CI 43.4-66.4%). Nurses considered 12/43 (27.9%) patients with unrecognized delirium safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 7.0/10. Physicians missed delirium in 10/20 (50.0%, 95% CI 27.2-72.8) cases and considered 2/10 (20.0%) safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 8.0/10. Fifteen patients with unrecognized delirium were sent home: 6.7% died at 1 week follow-up vs. none in those with recognized delirium and 1.1% in the rest of the cohort.

CONCLUSION

Delirium recognition by nurses and physicians was sub-optimal at ~50% and may be associated with increased mortality. Research should explore root causes of unrecognized delirium, and novel strategies to systematically improve delirium recognition and patient outcomes.

Transfusions in patients with iron deficiency anemia following release of Choosing Wisely Guidelines

BACKGROUND

In 2016, based on recommendations of the American Association of Blood Banks (AABB), Choosing Wisely Canada released transfusion guidelines for patients with Iron Deficiency Anemia. The goal of the present study was to examine the number of transfusions given in Calgary emergency departments (EDs) before and after the release of these guidelines.

METHODS

We analyzed 11,786 anemia encounters from January 2014 to December 2019. A transfusion was considered potentially avoidable if the patient's hemoglobin was > 70 g/L and if the patient was hemodynamically stable. We used time-series analyses to examine change in rate of total and potentially avoidable transfusions quarterly over the total and pre and post intervention periods.

RESULTS

In total, 1409/11,786 (12.0%) of the encounters received transfusions; 80.0% (1127/1409) were indicated while 19.9% (281/1409) were potentially avoidable. In the pre-intervention period, the rate of potentially avoidable transfusions was 21.5% (133/618) and in the post-intervention period, the rate of potentially avoidable transfusions was 18.7% (148/791). The rate of potentially avoidable transfusions decreased quarterly at a rate of 0.3% which did not reach statistical significance (p = 0.06).

DISCUSSION

Our data suggest that the number of potentially avoidable transfusions has not decreased since the release of Choosing Wisely Canada guidelines and local educational initiatives. This may be due to the fact that there is a pre-existing down trend in the number of transfusions provided.

Characteristics of frequent users of emergency departments in Alberta and Ontario, Canada: an administrative data study

OBJECTIVE

Frequent users to emergency departments (EDs) are a diverse group of patients accounting for a disproportionate number of ED presentations. This study examined sociodemographic and ED visit characteristics of adult high-system users in two Canadian provinces.

METHODS

Cohorts of high-system users were created for Alberta and Ontario including patients with the top 10% of presentations in the National Ambulatory Care Reporting System (April 2015-March 2016). Controls were random samples of non-high-system user patients. Sociodemographic and ED visits data were used to predict high-system user group membership in a multivariable logistic regression model.

RESULTS

There were 579,674 high-system users and 2,115,960 controls. High-system users were more likely to be female [odds ratio (OR) = 1.1, 95% confidence interval (CI) 1.1,1.1], older (OR 1.02 per 5 years, 95% CI 1.02,1.02), from the lowest-income quintile (OR 1.8, 95% CI 1.7,1.8), and more rural (OR 1.6, 95% CI 1.6,1.6) than controls. High-system users had a higher proportion of presentations by ambulance (OR 1.1 per 0.25 increase, 95% CI 1.1,1.1) and disposition was admission/transfer (OR 1.1 per 0.25 increase, 95% CI 1.1,1.1), left without being seen (OR 1.1, 95% CI 1.1,1.1), or left against medical advice (OR 1.1, 95% CI 1.1,1.1) more often than controls.

CONCLUSION

High-system users were more likely to be female, older, live in rural areas and within the lowest-income quintile compared to controls. Their heterogeneity in acuity, comorbid chronic diseases, and limited access to primary care suggests that interventions referring high-system users to primary care may be fruitful in reducing ED utilization by high-system users.

Starting, building and sustaining a program of research in emergency medicine in Canada

OBJECTIVE

To develop pragmatic recommendations for starting, building and sustaining a program of research in emergency medicine (EM) in Canada at sites with limited infrastructure and/or prior research experience.

METHODS

At the direction of the Canadian Association of Emergency Physicians (CAEP) academic section, we assembled an expert panel of 10 EM researchers with experience building programs of research. Using a modified Delphi approach, our panel developed initial recommendations for (1) starting, (2) building, and (3) sustaining a program of research in EM. These recommendations were peer-reviewed by emergency physicians and researchers from each of the panelist's home institutions and tested for face and construct validity, as well as ease of comprehension. The recommendations were then iteratively revised based on feedback and suggestions from peer review and amended again after being presented at the 2020 CAEP academic symposium.

RESULTS

Our panel created 15 pragmatic recommendations for those intending to start (formal research training, find mentors, local support, develop a niche, start small), build (funding, build a team, collaborate, publish, expect failure) and sustain (become a mentor, obtain leadership roles, lead national studies, gain influence, prioritize wellness) a program of EM research in centers without an established research culture. Additionally, we suggest four recommendations for department leads aiming to foster a program of research within their departments.

CONCLUSION

These recommendations serve as guidance for centres wanting to establish a program of research in EM.

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

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

Study design: secondary analysis of a prospective multicentre cohort study conducted between 2013 and 2016 in five Canadian EDs. Inclusion criteria: 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. Data collected: 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. Main outcome: 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.

Frequent users of emergency departments and patient flow in Alberta and Ontario, Canada: an administrative data study

Background

This paper describes and compares patient flow characteristics of adult high system users (HSUs) and control groups in Alberta and Ontario emergency departments (EDs), Canada.

Methods

Annual cohorts of HSUs were created by identifying patients who made up the top 10% of ED users (by count of ED presentations) in the National Ambulatory Care Reporting System during 2011–2016. Random samples of patients not in the HSU groups were selected as controls. Presentation (e.g., acuity) and ED times (e.g., time to physician initial assessment [PIA], length of stay) data were extracted and described. The length of stay for 2015/2016 data was decomposed into stages and Cox models compared time between stages.

Results

There were 20,343,230 and 18,222,969 ED presentations made by 7,032,655 and 1,923,462 individuals in the control and HSU groups, respectively. The Ontario groups had higher acuity than the Alberta groups: about 20% in the Ontario groups were from the emergent level whereas Alberta had 11–15%. Time to PIA was similar across provinces and groups (medians of 60 min to 67 min). Lengths of stay were longest for Ontario HSUs (median = 3 h) and shortest for Alberta HSUs (median = 2.2 h). HSUs had shorter times to PIA (hazard ratio [HR] = 1.03; 95% confidence interval [CI] 1.02,1.03), longer times from PIA to decision (HR = 0.84; 95%CI 0.84,0.84), and longer times from decision to leaving the ED (HR = 0.91; 95%CI 0.91,0.91).

Conclusions

Ontario HSUs had higher acuity and longer ED lengths of stay than the other groups. In both provinces, HSU had shorter times to PIA and longer times after assessment.

Derivation and Internal Validation of a Clinical Risk Prediction Tool for Hyperkalemia-Related Emergency Department Encounters Among Hemodialysis Patients

Background

Approximately 10% of emergency department (ED) visits among dialysis patients are for conditions that could potentially be managed in outpatient settings, such as hyperkalemia.

Objective

Using population-based data, we derived and internally validated a risk score to identify hemodialysis patients at increased risk of hyperkalemia-related ED events.

Design

Retrospective cohort study.

Setting

Ten in-center hemodialysis sites in southern Alberta, Canada.

Patients

All maintenance hemodialysis patients (≥18 years) between March 2009 and March 2017.

Measurements

Predictors of hyperkalemia-related ED events included patient demographics, comorbidities, health-system use, laboratory measurements, and dialysis information. The outcome of interest (hyperkalemia-related ED events) was defined by International Classification of Diseases (10th Revision; ICD-10) codes and/or serum potassium [K⁺] ≥6 mmol/L.

Methods

Bootstrapped logistic regression was used to derive and internally validate a model of important predictors of hyperkalemia-related ED events. A point system was created based on regression coefficients. Model discrimination was assessed by an optimism-adjusted C-statistic and calibration by deciles of risk and calibration slope.

Results

Of the 1533 maintenance hemodialysis patients in our cohort, 331 (21.6%) presented to the ED with 615 hyperkalemia-related ED events. A 9-point scale for risk of a hyperkalemia-related ED event was created with points assigned to 5 strong predictors based on their regression coefficients: ≥1 laboratory measurement of serum K⁺ ≥6 mmol/L in the prior 6 months (3 points); ≥1 Hemoglobin A1C [HbA1C] measurement ≥8% in the prior 12 months (1 point); mean ultrafiltration of ≥10 mL/kg/h over the preceding 2 weeks (2 points); ≥25 hours of cumulative time dialyzing over the preceding 2 weeks (1 point); and dialysis vintage of ≥2 years (2 points). Model discrimination (C-statistic: 0.75) and calibration were good.

Limitations

Measures related to health behaviors, social determinants of health, and residual kidney function were not available for inclusion as potential predictors.

Conclusions

While this tool requires external validation, it may help identify high-risk patients and allow for preventative strategies to avoid unnecessary ED visits and improve patient quality of life.

Trial registration

Not applicable-observational study design.

Temporal trends in emergency department volumes and crowding metrics in a western Canadian province: a population-based, administrative data study

Background

Emergency Department (ED) crowding is a pervasive problem, yet there have been few comparisons of the extent of, and contributors to, crowding among different types of EDs. The study quantifies and compares crowding metrics for 16 high volume regional, urban and academic EDs in one Canadian province.

Methods

The National Ambulatory Care Reporting System (NACRS) provided ED presentations by adults to 16 high volume Alberta EDs during April 2010 to March 2015 for this retrospective cohort study. Time to physician initial assessment (PIA), length of stay (LOS) for discharges and admissions were grouped by start hour of presentation and facility. Multiple crowding metrics were created by taking the means, medians (PIA-M, LOS-M), and 90th percentiles of the hourly, ED-specific values. Similarly, proportion left against medical advice (LAMA) and proportion left without being seen (LWBS) were day and ED aggregated. Calculated based on the start of the presentation and the facility and for PIA and LOS. The mean, median, and 90th percentiles for the date and time ED-specific metrics for PIA and LOS were obtained. Summary statistics were used to describe crowding metrics.

Results

There were 3,925,457 presentations by 1,420,679 adults. The number of presentations was similar for each sex and the mean age was 46 years. Generally, the three categories of EDs had similar characteristics; however, urban and academic/teaching EDs had more urgent triage scores and a higher percentage of admissions than regional EDs. The median of the PIA-M metric was 1 h23m across all EDs. For discharges, the median of the LOS-M metric was 3h21m whereas the median of the LOS-M metric for admissions was 10h08m. Generally, regional EDs had shorter times than urban and academic/teaching EDs. The median daily LWBS was 3.4% and the median daily LAMA was about 1%.

Conclusions

Emergency presentations have increased over time, and crowding metrics vary considerably among EDs and over the time of day. Academic/teaching EDs generally have higher crowding metrics than other EDs and urgent action is required to mitigate the well-known consequences of ED crowding.

A Multicenter Assessment of the Sensitivity and Specificity for a Single High-Sensitivity Cardiac Troponin Test at Emergency Department Presentation for Hospital Admission

Background

Studies have illustrated how a low or undetectable high-sensitivity cardiac troponin (hs-cTn) concentration at emergency department (ED) presentation can rule out myocardial infarction (MI). A problem with using an undetectable hs-cTn cutoff is that this value may be defined differently among hospitals and is also difficult to monitor. In the present study, we assess the diagnostic performance of a clinical chemistry score (CCS) vs hs-cTn alone in the presentation blood sample in the ED for patient hospital admission in a multicenter setting.

Methods

From January 1 to June 30, 2018, consecutive patients with random glucose, creatinine (for an estimated glomerular filtration rate calculation), and hs-cTnI (Abbott, 2 hospitals, Hamilton, Ontario, n = 10496) or hs-cTnT (Roche, 4 hospitals, Calgary, Alberta, n = 25177) were assessed for hospital admission with the CCS (range of scores, 0–5) or hs-cTn alone. Sensitivity, specificity, predicative values, and likelihood ratios were calculated for a CCS of 0 and 5 and for hs-cTn alone (hs-cTnI cutoffs, 5 and 26 ng/L; hs-cTnT cutoffs, 6 and 14 ng/L).

Results

The CCS of 0 (CCS &lt;1) identified approximately 10% of all patients as low risk and had a sensitivity for hospital admission of nearly 98% as compared to &lt;93% when hs-cTnT (&lt;6 ng/L) or hs-cTnI (&lt;5 ng/L) cutoffs alone were used. A CCS ≥5 had a specificity for hospital admission &gt;95%, with approximately 14% of patients at high risk.

Conclusions

An ED disposition (admit or send home) using the presentation blood sample could occur in nearly 25% of all patients by use of the CCS.

Patient classification based on volume and case-mix in the emergency department and their association with performance

Predicting daily patient volume is necessary for emergency department (ED) strategic and operational decisions, such as resource planning and workforce scheduling. For these purposes, forecast accuracy requires understanding the heterogeneity among patients with respect to their characteristics and reasons for visits. To capture the heterogeneity among ED patients (case-mix), we present a patient coding and classification scheme (PCCS) based on patient demographics and diagnostic information. The proposed PCCS allows us to mathematically formalize the arrival patterns of the patient population as well as each class of patients. We can then examine the volume and case-mix of patients presenting to an ED and investigate their relationship to the ED's quality and time-based performance metrics. We use data from five hospitals in February, July and November for the years of 2007, 2012, and 2017 in the city of Calgary, Alberta, Canada. We find meaningful arrival time patterns of the patient population as well as classes of patients in EDs. The regression results suggest that patient volume is the main predictor of time-based ED performance measures. Case-mix is, however, the key predictor of quality of care in EDs. We conclude that considering both patient volume and the mix of patients are necessary for more accurate strategic and operational planning in EDs.

Safe Cardioversion for Patients With Acute-Onset Atrial Fibrillation and Flutter: Practical Concerns and Considerations

In this Viewpoint concerns raised by Canadian emergency physicians regarding recommendations 2 and 6 from the recent Canadian Cardiovascular Society 2018 update for atrial fibrillation are discussed. These recommendations narrow the window for safe cardioversion and suggest 4 weeks of anticoagulation for all patients who undergo urgent cardioversion regardless of their CHADS-65 status. We discuss the implications of Grading of Recommendations, Assessment, Development, and Evaluation weak recommendations on the basis of low-quality evidence.

Emergency Department Use in Patients with Cancer: A Population-Based Study

IntroductionEmergency Department (ED) visits in cancer patients represent a significant burden to both patients and the health care system. Emergency Care of cancer patients is complex compared to the population. There is lack of knowledge regarding the pattern and reasons for ED visits in this population. Objectives and ApproachWe sought to identify factors and patterns associated with ED use among cancer patients, in the first year after diagnosis. Adult cancer patients diagnosed between 2011 and 2013 were identified from the Alberta Cancer Registry. This was linked with cancer related treatments extracted from medical records system at provincial cancer centers. ED visits and outpatient clinics were acquired from National Ambulatory Care Reporting System (NACRS). Databases were linked by unique patient identification number. Previous cancer patients were defined by having at least one cancer related diagnosis in NACRS before. The other patients were treated as non-cancer patients. ResultsCancer patients accounted for 6.7% of ED visits and 10\% of ED hours. They had higher male percentage (53% vs. 49%), higher admission rate (23% vs. 10%), ambulance usage (20% vs. 12%) and longer stay (LOS) (171 vs. 131 mins) compared to non-cancer patients. 24% of cancer patients had 4 or more ED visits/year and accounted for 59% of visits. Lung and liver cancer patients had higher ED utilization than patients with other cancers. Breast cancer patients had more after-treatment-ED-visits (41% within a week vs. 26% in lung cancer). Use of ED was highest within 1 month of diagnosis for all types except breast cancer, which was highest at 2 months after. Differences were observed between urban and rural area for numbers reported above. Conclusion/ImplicationsThese data suggest high ED utilization by cancer patients, and variation in utilization by cancer type. Identifying the timing and risk factors of ED visit for each cancer type, especially on frequent ED users presents opportunities to improve care in oncology clinics and ED.

Moderate sensitivity and high specificity of emergency department administrative data for transient ischemic attacks

Background

Validation of administrative data case definitions is key for accurate passive surveillance of disease. Transient ischemic attack (TIA) is a condition primarily managed in the emergency department. However, prior validation studies have focused on data after inpatient hospitalization. We aimed to determine the validity of the Canadian 10th International Classification of Diseases (ICD-10-CA) codes for TIA in the national ambulatory administrative database.

Methods

We performed a diagnostic accuracy study of four ICD-10-CA case definition algorithms for TIA in the emergency department setting. The study population was obtained from two ongoing studies on the diagnosis of TIA and minor stroke versus stroke mimic using serum biomarkers and neuroimaging. Two reference standards were used 1) the emergency department clinical diagnosis determined by chart abstractors and 2) the 90-day final diagnosis, both obtained by stroke neurologists, to calculate the sensitivity, specificity, positive and negative predictive values (PPV and NPV) of the ICD-10-CA algorithms for TIA.

Results

Among 417 patients, emergency department adjudication showed 163 (39.1%) TIA, 155 (37.2%) ischemic strokes, and 99 (23.7%) stroke mimics. The most restrictive algorithm, defined as a TIA code in the main position had the lowest sensitivity (36.8%), but highest specificity (92.5%) and PPV (76.0%). The most inclusive algorithm, defined as a TIA code in any position with and without query prefix had the highest sensitivity (63.8%), but lowest specificity (81.5%) and PPV (68.9%). Sensitivity, specificity, PPV, and NPV were overall lower when using the 90-day diagnosis as reference standard.

Conclusions

Emergency department administrative data reflect diagnosis of suspected TIA with high specificity, but underestimate the burden of disease. Future studies are necessary to understand the reasons for the low to moderate sensitivity.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2612-6) contains supplementary material, which is available to authorized users.

Limitations of pulmonary embolism ICD-10 codes in emergency department administrative data: let the buyer beware

BACKGROUND

Administrative data is a useful tool for research and quality improvement; however, validity of research findings based on these data depends on their reliability. Diagnoses assigned by physicians are subsequently converted by nosologists to ICD-10 codes (International Statistical Classification of Diseases and Related Health Problems, 10th Revision). Several groups have reported ICD-9 coding errors in inpatient data that have implications for research, quality improvement, and policymaking, but few have assessed ICD-10 code validity in ambulatory care databases. Our objective was to evaluate pulmonary embolism (PE) ICD-10 code accuracy in our large, integrated hospital system, and the validity of using these codes for operational and health services research using ED ambulatory care databases.

METHODS

Ambulatory care data for patients (age ≥ 18 years) with a PE ICD-10 code (I26.0 and I26.9) were obtained from the records of four urban EDs between July 2013 to January 2015. PE diagnoses were confirmed by reviewing medical records and imaging reports. In cases where chart diagnosis and ICD-10 code were discrepant, chart review was considered correct. Physicians' written discharge diagnoses were also searched using 'pulmonary embolism' and 'PE', and patients who were diagnosed with PE but not coded as PE were identified. Coding discrepancies were quantified and described.

RESULTS

One thousand, four hundred and fifty-three ED patients had a PE ICD-10 code. Of these, 257 (17.7%) were false positive, with an incorrectly assigned PE code. Among the 257 false positives, 193 cases had ambiguous ED diagnoses such as 'rule out PE' or 'query PE', while 64 cases should have had non-PE codes. An additional 117 patients (8.90%) with a PE discharge diagnosis were incorrectly assigned a non-PE ICD-10 code (false negative group). The sensitivity of PE ICD-10 codes in this dataset was 91.1% (95%CI, 89.4-92.6) with a specificity of 99.9% (95%CI, 99.9-99.9). The positive and negative predictive values were 82.3% (95%CI, 80.3-84.2) and 99.9% (95%CI, 99.9-99.9), respectively.

CONCLUSIONS

Ambulatory care data, like inpatient data, are subject to coding errors. This confirms the importance of ICD-10 code validation prior to use. The largest proportion of coding errors arises from ambiguous physician documentation; therefore, physicians and data custodians must ensure that quality improvement processes are in place to promote ICD-10 coding accuracy.

Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients

Purpose

The study sought to compare radiologist's ability to 1) visualize the appendix; 2) diagnose acute appendicitis; and 3) diagnose alternative pathologies responsible for acute abdominal pain among adult patients undergoing computed tomography (CT) scan with 3 different protocols: 1) intravenous (IV) contrast only; 2) IV and oral contrast with 1-hour transit time; and 3) IV and oral contrast with 3-hour transit time.

Methods

We collected data of 225 patients; 75 consecutive patients with a clinical suspicion of appendicitis received oral contrast for 3 hours and IV contrast, 75 received oral contrast for 1 hour and IV contrast, and 75 trauma patients received IV contrast only. Three independent reviewers, blinded to final pathology, retrospectively analysed the cases and documented visualization of the appendix, periappendiceal structures, and their confidence in diagnosing appendicitis. Clinical diagnoses were derived from a combination of clinical, surgical, pathologic, or radiologic follow-up.

Results

Frequency of visualizing the appendix within IV group alone was 87.3%, IV with oral for 1 hour was 94.1%, and IV with oral for 3 hours was 93.8%. Both oral contrast groups had 100% sensitivity and negative predictive value in diagnosis of acute appendicitis. Specificity for the 1- and 3-hour oral contrast groups was 94.1% and 96.1%, respectively and positive predictive value for both groups was 92%.

Conclusions

Our findings suggest that reader confidence in visualizing the appendix improved with addition of oral contrast as compared to IV contrast alone. One- and 3-hour oral regimens have a similar diagnostic performance in diagnosing appendicitis.

Evaluation of Wound Healing Activity of Vanda roxburghii R.Br(Orchidacea): A Preclinical Study in a Rat Model

The extract of Vanda roxburghii was administered topically to rats at a dose of 150mgkg – 1 day – 1 for 10daysandwas studied for its effect on wound healing, using the excision wound model. A 60% reduction in wound diameter was observed in the test group rats receiving the extract compared to controls (48%). Significant increases in wet and dry granulation tissue weights (P < .001), hydroxyproline (P < .001), and hexosamine (P < .003) contents were detected. An increase in protein content was also detected in the test group (P > .05, ns). These findings are consistent with wound healing at cellular levels. The pro-healing action may be attributed either to increased collagen deposition or to better alignment and maturation or both. The test wounds (extract-treated wounds) were, on average, fully healed by the 13th day, whereas the control group healed, on average, by the 20th day. These data suggest that the extract ofVanda roxburghii administered topically has wound-healing potential in rats.

Genome-wide autozygosity is associated with lower general cognitive ability

Inbreeding depression refers to lower fitness among offspring of genetic relatives. This reduced fitness is caused by the inheritance of two identical chromosomal segments (autozygosity) across the genome, which may expose the effects of (partially) recessive deleterious mutations. Even among outbred populations, autozygosity can occur to varying degrees due to cryptic relatedness between parents. Using dense genome-wide single-nucleotide polymorphism (SNP) data, we examined the degree to which autozygosity associated with measured cognitive ability in an unselected sample of 4854 participants of European ancestry. We used runs of homozygosity-multiple homozygous SNPs in a row-to estimate autozygous tracts across the genome. We found that increased levels of autozygosity predicted lower general cognitive ability, and estimate a drop of 0.6 s.d. among the offspring of first cousins (P=0.003-0.02 depending on the model). This effect came predominantly from long and rare autozygous tracts, which theory predicts as more likely to be deleterious than short and common tracts. Association mapping of autozygous tracts did not reveal any specific regions that were predictive beyond chance after correcting for multiple testing genome wide. The observed effect size is consistent with studies of cognitive decline among offspring of known consanguineous relationships. These findings suggest a role for multiple recessive or partially recessive alleles in general cognitive ability, and that alleles decreasing general cognitive ability have been selected against over evolutionary time.

Emergency department management of syncope: need for standardization and improved risk stratification

Variations in emergency department (ED) syncope management have not been well studied. The goals of this study were to assess variations in management, and emergency physicians' risk perception and disposition decision making. We conducted a prospective study of adults with syncope in six EDs in four cities over 32 months. We collected patient characteristics, ED management, disposition, physicians' prediction probabilities at index presentation and followed patients for 30 days for serious outcomes: death, myocardial infarction (MI), arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage, or procedural interventions. We used descriptive statistics, ROC curves, and regression analyses. We enrolled 3662 patients: mean age 54.3 years, and 12.9 % were hospitalized. Follow-up data were available for 3365 patients (91.9 %) and 345 patients (10.3 %) suffered serious outcomes: 120 (3.6 %) after ED disposition including 48 patients outside the hospital. After accounting for differences in patient case mix, the rates of ED investigations and disposition were significantly different (p < 0.0001) across the four study cities; as were the rates of 30-day serious outcomes (p < 0.0001) and serious outcomes after ED disposition (p = 0.0227). There was poor agreement between physician risk perception and both observed event rates and referral patterns (p < 0.0001). Only 76.7 % (95 % CI 68.1-83.6) of patients with serious outcomes were appropriately referred. There are large and unexplained differences in ED syncope management. Moreover, there is poor agreement between physician risk perception, disposition decision making, and serious outcomes after ED disposition. A valid risk-stratification tool might help standardize ED management and improve disposition decision making.

Influence of publicly available online wait time data on emergency department choice in patients with noncritical complaints

Objectives:

Increased emergency department (ED) wait times lead to more patients who leave without being seen and decreased patient satisfaction. Many EDs post estimated wait times either online or in the ED to guide patient expectations. The objectives of this study were to assess patients' awareness of online wait time data and to investigate patients' willingness to use this information when choosing between two academic EDs in London, Ontario.

Methods:

A prospective study was conducted over a 2-month period in a tertiary ED with online available wait times. Patients over 18 years of age assigned a Canadian Triage and Acuity Scale (CTAS) score of 3, 4, or 5 were approached by trained research assistants to complete a 15-item paper-based questionnaire. Multivariable logistic regression models were used to determine factors independently associated with the outcomes.

Results:

A total of 1,211 patients completed the survey. Of these, 109 (9%) were aware that ED wait time information was available on the Internet; 544 (45%) reported that they would use the available data to make a decision on which ED to visit, and 536 (44%) indicated that they were more likely to go to the ED with a shorter wait time. Age, gender, household income, education, and Internet access were not associated with awareness of online ED wait times. Participants less than 40 years of age were more likely to use online wait time information.

Conclusion:

There is low awareness of the availability of ED wait time data published online in the study locaton. Future research may include the delivery of a public awareness strategy for ED wait time data and a re-evaluation of ED use and patient satisfaction following this.

Computerized physician order entry and decision support improves ED analgesic ordering for renal colic

OBJECTIVES

Computerized physician order entry (CPOE) offers the potential for safer, faster patient care, as well as greater use of evidence-based therapy via built-in decision support. However, the effectiveness of CPOE in yielding these benefits has shown mixed results in the emergency department (ED) setting. Our objective was to evaluate the impact of CPOE implementation on analgesic prescribing and dosing practices for renal colic presentations.

METHODS

This retrospective pre/post comparative study was conducted in 3 tertiary hospitals that implemented CPOE in 2010. Two patient groups were compared: prior to (pre-CPOE) and after (post-CPOE) CPOE implementation. Each group consisted of 230 randomly selected, high-acuity patients presenting to the ED with renal colic. The primary outcome was the proportion of patients receiving ketorolac in the ED. Secondary outcomes included choice of analgesic and average morphine dose.

RESULTS

The proportion of patients receiving ketorolac significantly increased after CPOE implementation (65.6% pre-CPOE vs 76.5% post-CPOE, P = .015), as did the proportion of patients receiving fentanyl (pre, 9.7%; post, 16.7%; P = .047). Differences in morphine use (pre, 66.0%; post, 69.1%) and average morphine dose (pre, 10.09 mg; post, 12.28 mg) did not reach statistical significance.

CONCLUSIONS

The introduction of CPOE is associated with an increase in ketorolac use for ED renal colic visits. This may reflect the inclusion of ketorolac in the renal colic order set. Computerized physician order entry implementation with condition-specific electronic order sets and decision support may improve evidence-based practice.

Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis

BACKGROUND

Despite several expert panel recommendations and cellulitis treatment guidelines, there are currently no clinical decision rules to assist clinicians in deciding which emergency department (ED) patients should be treated with oral antibiotics and which patients require intravenous (IV) therapy at first presentation of cellulitis amenable to outpatient treatment.

OBJECTIVES

The objective was to determine risk factors associated with adult patients presenting to the ED with cellulitis who fail initial antibiotic therapy as outpatients and require a change of antibiotics or admission to hospital.

METHODS

This was a prospective cohort study of patients 18 years of age or older presenting with cellulitis to one of two tertiary care EDs (combined annual census 140,000). Patients were excluded if they had been treated with antibiotics for the cellulitis before presenting to the ED, if they were admitted to the hospital, or if they had an abscess only. Trained research personnel administered a questionnaire at the initial ED visit with telephone follow-up 2 weeks later. Multivariable logistic regression models determined predictor variables independently associated with treatment failure (failed initial antibiotic therapy and required a change of antibiotics or admission to hospital).

RESULTS

A total of 598 patients were enrolled, 52 were excluded, and 49 were lost to follow-up. The mean (±standard deviation [SD]) age was 53.1 (±18.4) years and 56.4% were male. A total of 185 patients (37.2%) were given oral antibiotics, 231 (46.5%) were given IV antibiotics, and 81 patients (16.3%) received both oral and IV antibiotics in the ED. A total of 102 (20.5%, 95% confidence [CI] = 17.2% to 24.2%) patients had treatment failures. Fever (temperature > 38°C) at triage (odds ratio [OR] = 4.3, 95% CI = 1.6 to 11.7), chronic leg ulcers (OR = 2.5, 95% CI = 1.1 to 5.2), chronic edema or lymphedema (OR = 2.5, 95% CI = 1.5 to 4.2), prior cellulitis in the same area (OR = 2.1, 95% CI = 1.3 to 3.5), and cellulitis at a wound site (OR = 1.9, 95% CI = 1.2 to 3.0) were independently associated with treatment failure.

CONCLUSIONS

These risk factors should be considered when initiating empiric antibiotic therapy for ED patients with cellulitis amenable to outpatient treatment.

Risk stratification of adult emergency department syncope patients to predict short-term serious outcomes after discharge (RiSEDS) study

Background

While Canadian ED physicians discharge most syncope patients with no specific further follow-up, approximately 5% will suffer serious outcomes after ED discharge. The goal of this study is to prospectively identify risk factors and to derive a clinical decision tool to accurately predict those at risk for serious outcomes after ED discharge within 30 days.

Methods/Design

We will conduct a prospective cohort study at 6 Canadian EDs to include adults with syncope and exclude patients with loss of consciousness > 5 minutes, mental status changes from baseline, obvious witnessed seizure, or head trauma prior to syncope. Emergency physicians will collect standardized clinical variables including historical features, physical findings, and results of immediately available tests (blood, ECG, and ED cardiac monitoring) prior to ED discharge/hospital admission. A second emergency physician will evaluate approximately 10% of study patients for interobserver agreement calculation of predictor variables. The primary outcome will be a composite serious outcome occurring within 30 days of ED discharge and includes three distinct categories: serious adverse events (death, arrhythmia); identification of serious underlying disease (structural heart disease, aortic dissection, pulmonary embolism, severe pulmonary hypertension, subarachnoid hemorrhage, significant hemorrhage, myocardial infarction); or procedures to treat the cause of syncope. The secondary outcome will be any of the above serious outcomes either suspected or those occurring in the ED. A blinded Adjudication Committee will confirm all serious outcomes. Univariate analysis will be performed to compare the predictor variables in patients with and without primary outcome. Variables with p-values <0.2 and kappa values ≥0.60 will be selected for stepwise logistic regression to identify the risk factors and to develop the clinical decision tool. We will enroll 5,000 patients (with 125 positive for primary outcome) for robust identification of risk factors and clinical decision tool development.

Discussion

Once successfully developed, this tool will accurately risk-stratify adult syncope patients; however, validation and implementation will still be required. This program of research should lead to standardized care of syncope patients, and improve patient safety.

Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors

Background

Advances in ultrasound imaging technology have made it more accessible to prehospital providers. Little is known about how ultrasound is being used in the prehospital environment and we suspect that it is not widely used in North America at this time. We believe that EMS system characteristics such as provider training, system size, population served, and type of transport will be associated with use or non-use of ultrasound. Our study objective was to describe the current use of prehospital ultrasound in North America.

Methods

This study was a cross-sectional survey distributed to EMS directors on the National Association of EMS Physicians (NAEMSP) mailing list. Respondents had the option to complete a paper or electronic survey.

Results

Of the 755 deliverable surveys we received 255 responses from across Canada and the United states for an overall response rate of 30%. Of respondents, 4.1% of EMS systems (95% CI 1.9, 6.3) reported currently using ultrasound and an additional 21.7% (95% CI 17, 26.4) are considering implementing ultrasound. EMS services using ultrasound have a higher proportion of physicians (p < 0.001) as their highest trained prehospital providers when compared to the survey group as a whole. The most commonly cited current and projected applications are Focused Abdominal Sonography for Trauma (FAST) and assessment of pulseless electrical activity (PEA) arrest. The cost of equipment and training are the most significant barriers to implementation of ultrasound. Most medical directors want evidence that prehospital ultrasound improves patient outcomes prior to implementation.

Conclusions

Prehospital ultrasound is infrequently used in North America and there are a number of barriers to its implementation, including costs of equipment and training and limited evidence demonstrating improved outcomes. A research agenda for prehospital ultrasound should focus on patient-important outcomes such as morbidity and mortality. Two commonly used indications that could be a focus of standardized training programs are the FAST exam, and assessment of PEA arrest.

Reporting of patient consent in healthcare cluster randomised trials is associated with the type of study interventions and publication characteristics

OBJECTIVE

Cluster randomised trial (CRT) investigators face challenges in seeking informed consent from individual patients (cluster members). This study examined associations between reporting of patient consent in healthcare CRTs and characteristics of these trials.

STUDY DESIGN

Consent practices and study characteristics were abstracted from a random sample of 160 CRTs performed in primary or hospital care settings that were published from 2000 to 2008. Multivariable logistic regression was used to examine associations between reporting of patient consent and methodological characteristics, as well as publication features such as date and journal of publication.

RESULTS

82 (53.8%) of 160 studies reported obtaining informed consent from individual patients. Reporting of patient consent was independently and positively associated with: smaller cluster size, the evaluation of experimental interventions targeted at patients, data collection from individual patients, publication later than 2004 and publication in higher-impact journals.

CONCLUSIONS

Reporting of consent practices in published CRTs should be improved. Consent practices in published CRTs appear to be related to the type of interventions under study, as well as journal impact and trends in research ethics practices. These findings will inform best practices in trial conduct and ethics review, remediation of errors in consent practices and ethics review and the development of regulatory guidance for CRTs.

Influence of publicly available online wait time data on emergency department choice in patients with noncritical complaints

OBJECTIVES

Increased emergency department (ED) wait times lead to more patients who leave without being seen and decreased patient satisfaction. Many EDs post estimated wait times either online or in the ED to guide patient expectations. The objectives of this study were to assess patients' awareness of online wait time data and to investigate patients' willingness to use this information when choosing between two academic EDs in London, Ontario.

METHODS

A prospective study was conducted over a 2-month period in a tertiary ED with online available wait times. Patients over 18 years of age assigned a Canadian Triage and Acuity Scale (CTAS) score of 3, 4, or 5 were approached by trained research assistants to complete a 15-item paper-based questionnaire. Multivariable logistic regression models were used to determine factors independently associated with the outcomes.

RESULTS

A total of 1,211 patients completed the survey. Of these, 109 (9%) were aware that ED wait time information was available on the Internet; 544 (45%) reported that they would use the available data to make a decision on which ED to visit, and 536 (44%) indicated that they were more likely to go to the ED with a shorter wait time. Age, gender, household income, education, and Internet access were not associated with awareness of online ED wait times. Participants less than 40 years of age were more likely to use online wait time information.

CONCLUSION

There is low awareness of the availability of ED wait time data published online in the study locaton. Future research may include the delivery of a public awareness strategy for ED wait time data and a re-evaluation of ED use and patient satisfaction following this.

Impact of CONSORT extension for cluster randomised trials on quality of reporting and study methodology: review of random sample of 300 trials, 2000-8

OBJECTIVE

To assess the impact of the 2004 extension of the CONSORT guidelines on the reporting and methodological quality of cluster randomised trials.

DESIGN

Methodological review of 300 randomly sampled cluster randomised trials. Two reviewers independently abstracted 14 criteria related to quality of reporting and four methodological criteria specific to cluster randomised trials. We compared manuscripts published before CONSORT (2000-4) with those published after CONSORT (2005-8). We also investigated differences by journal impact factor, type of journal, and trial setting.

DATA SOURCES

A validated Medline search strategy. Eligibility criteria for selecting studies Cluster randomised trials published in English language journals, 2000-8.

RESULTS

There were significant improvements in five of 14 reporting criteria: identification as cluster randomised; justification for cluster randomisation; reporting whether outcome assessments were blind; reporting the number of clusters randomised; and reporting the number of clusters lost to follow-up. No significant improvements were found in adherence to methodological criteria. Trials conducted in clinical rather than non-clinical settings and studies published in medical journals with higher impact factor or general medical journals were more likely to adhere to recommended reporting and methodological criteria overall, but there was no evidence that improvements after publication of the CONSORT extension for cluster trials were more likely in trials conducted in clinical settings nor in trials published in either general medical journals or in higher impact factor journals.

CONCLUSION

The quality of reporting of cluster randomised trials improved in only a few aspects since the publication of the extension of CONSORT for cluster randomised trials, and no improvements at all were observed in essential methodological features. Overall, the adherence to reporting and methodological guidelines for cluster randomised trials remains suboptimal, and further efforts are needed to improve both reporting and methodology.

Electronic search strategies to identify reports of cluster randomized trials in MEDLINE: low precision will improve with adherence to reporting standards

Background

Cluster randomized trials (CRTs) present unique methodological and ethical challenges. Researchers conducting systematic reviews of CRTs (e.g., addressing methodological or ethical issues) require efficient electronic search strategies (filters or hedges) to identify trials in electronic databases such as MEDLINE. According to the CONSORT statement extension to CRTs, the clustered design should be clearly identified in titles or abstracts; however, variability in terminology may make electronic identification challenging. Our objectives were to (a) evaluate sensitivity ("recall") and precision of a well-known electronic search strategy ("randomized controlled trial" as publication type) with respect to identifying CRTs, (b) evaluate the feasibility of new search strategies targeted specifically at CRTs, and (c) determine whether CRTs are appropriately identified in titles or abstracts of reports and whether there has been improvement over time.

Methods

We manually examined a wide range of health journals to identify a gold standard set of CRTs. Search strategies were evaluated against the gold standard set, as well as an independent set of CRTs included in previous systematic reviews.

Results

The existing strategy (randomized controlled trial.pt) is sensitive (93.8%) for identifying CRTs, but has relatively low precision (9%, number needed to read 11); the number needed to read can be halved to 5 (precision 18.4%) by combining with cluster design-related terms using the Boolean operator AND; combining with the Boolean operator OR maximizes sensitivity (99.4%) but would require 28.6 citations read to identify one CRT. Only about 50% of CRTs are clearly identified as cluster randomized in titles or abstracts; approximately 25% can be identified based on the reported units of randomization but are not amenable to electronic searching; the remaining 25% cannot be identified except through manual inspection of the full-text article. The proportion of trials clearly identified has increased from 28% between the years 2000-2003, to 60% between 2004-2007 (absolute increase 32%, 95% CI 17 to 47%).

Conclusions

CRTs should include the phrase "cluster randomized trial" in titles or abstracts; this will facilitate more accurate indexing of the publication type by reviewers at the National Library of Medicine, and efficient textword retrieval of the subset employing cluster randomization.

Ethical and policy issues in cluster randomized trials: rationale and design of a mixed methods research study

BACKGROUND

Cluster randomized trials are an increasingly important methodological tool in health research. In cluster randomized trials, intact social units or groups of individuals, such as medical practices, schools, or entire communities--rather than individual themselves--are randomly allocated to intervention or control conditions, while outcomes are then observed on individual cluster members. The substantial methodological differences between cluster randomized trials and conventional randomized trials pose serious challenges to the current conceptual framework for research ethics. The ethical implications of randomizing groups rather than individuals are not addressed in current research ethics guidelines, nor have they even been thoroughly explored. The main objectives of this research are to: (1) identify ethical issues arising in cluster trials and learn how they are currently being addressed; (2) understand how ethics reviews of cluster trials are carried out in different countries (Canada, the USA and the UK); (3) elicit the views and experiences of trial participants and cluster representatives; (4) develop well-grounded guidelines for the ethical conduct and review of cluster trials by conducting an extensive ethical analysis and organizing a consensus process; (5) disseminate the guidelines to researchers, research ethics boards (REBs), journal editors, and research funders.

METHODS

We will use a mixed-methods (qualitative and quantitative) approach incorporating both empirical and conceptual work. Empirical work will include a systematic review of a random sample of published trials, a survey and in-depth interviews with trialists, a survey of REBs, and in-depth interviews and focus group discussions with trial participants and gatekeepers. The empirical work will inform the concurrent ethical analysis which will lead to a guidance document laying out principles, policy options, and rationale for proposed guidelines. An Expert Panel of researchers, ethicists, health lawyers, consumer advocates, REB members, and representatives from low-middle income countries will be appointed. A consensus conference will be convened and draft guidelines will be generated by the Panel; an e-consultation phase will then be launched to invite comments from the broader community of researchers, policy-makers, and the public before a final set of guidelines is generated by the Panel and widely disseminated by the research team.

Variations in the branching pattern of the aortic arch in three Trinidadians

In routine anatomical dissections for the purpose of preparation of teaching and museum specimens, it was observed that three cadavers of elderly Trinidadian males (of African descent) showed uncommon origin and variations in the number of branches of the aortic arch.