Clinical prediction rule for delayed hemothorax after minor thoracic injury: a multicentre derivation and validation study.

BACKGROUND: About 75% of patients with minor thoracic injury are discharged after an emergency department visit. However, complications such as delayed hemothorax can occur. We sought to derive and validate a clinical decision rule to predict hemothorax in patients discharged from the emergency department. METHODS: We conducted a 6-year prospective cohort study in 4 university-affiliated emergency departments. Patients aged 16 years or older presenting with a minor thoracic injury were assessed at 5 time points (initial visit and 7, 14, 30 and 90 d after the injury). Radiologists' reports were reviewed for the presence of hemothorax. We used log-binomial regression models to identify predictors of hemothorax. RESULTS: A total of 1382 patients were included: 830 in the derivation phase and 552 in the validation phase. Of these, 151 (10.9%) had hemothorax at the 14-day follow-up. Patients 65 years of age or older represented 25.3% (210/830) and 23.7% (131/552) of the derivation and validation cohorts, respectively. The final clinical decision rule included a combination of age (> 70 yr, 2 points; 45-70 yr, 1 point), fracture of any high to mid thorax rib (ribs 3-9, 2 points) and presence of 3 or more rib fractures (1 point). Twenty (30.8%) of the 65 high-risk patients (score ≥ 4) experienced hemothorax during the follow-up period. The clinical decision rule had a high specificity (90.7%, 95% confidence interval 87.7%-93.1%) in this high-risk group, thus guiding appropriate post-emergency care. INTERPRETATION: One patient out of every 10 presented with delayed hemothorax after discharge from the emergency department. Implementation of this validated clinical decision rule for minor thoracic injury could guide emergency discharge plans.

Comparison of functional outcomes in elderly who have sustained a minor trauma with or without head injury: a prospective multicenter cohort study.

OBJECTIVES: The consequences of minor trauma involving a head injury (MT-HI) in independent older adults are largely unknown. This study assessed the impact of a head injury on the functional outcomes six months post-injury in older adults who sustained a minor trauma. METHODS: This multicenter prospective cohort study in eight sites included patients who were aged 65 years or older, previously independent, presenting to the emergency department (ED) for a minor trauma, and discharged within 48 hours. To assess the functional decline, we used a validated test: the Older Americans' Resources and Services Scale. The cognitive function of study patients was also evaluated. Finally, we explored the influence of a concomitant injury on the functional decline in the MT-HI group. RESULTS: All 926 eligible patients were included in the analyses: 344 MT-HI patients and 582 minor trauma without head injury. After six months, the functional decline was similar in both groups: 10.8% and 11.9%, respectively (RR=0.79 [95% CI: 0.55-1.14]). The proportion of patients with mild cognitive disabilities was also similar: 21.7% and 22.8%, respectively (RR=0.91 [95% CI: 0.71-1.18]). Furthermore, for the group of patients with a MT-HI, the functional outcome was not statistically different with or without the presence of a co-injury (RR=1.35 [95% CI: 0.71-2.59]). CONCLUSION: This study did not demonstrate that the occurrence of a MT-HI is associated with a worse functional or cognitive prognosis than other minor injuries without a head injury in an elderly population, six months after injury.

Correlates of cognitive functioning in independent elderly patients discharged home from the emergency department after a minor injury.

BACKGROUND: The objective of this study was to explore correlates of cognitive functioning of older adults visiting the emergency department (ED) after a minor injury. METHODS: These results are derived from a large prospective study in three Canadian EDs. Participants were aged ≥ 65 years and independent in basic activities of daily living, visiting the ED for minor injuries and discharged home within 48 hours (those with known dementia, confusion, and delirium were excluded). They completed the Montreal Cognitive Assessment (MoCA). Potential correlates included sociodemographic and injury variables, and measures of psychological and physical health, social support, mobility, falls, and functional status. RESULTS: Multivariate analyses revealed that male sex, age ≥ 85 years, higher depression scores, slower walking speed, and self-reported memory problems were significantly associated with lower baseline MoCA scores. CONCLUSIONS: These characteristics could help ED professionals identify patients who might need additional cognitive evaluations or follow-ups after their passage through the ED. Obtaining information on these characteristics is potentially feasible in the ED context and could help professionals alter favorably elderly's trajectory of care. Since a significant proportion of elderly patients consulting at an ED have cognitive impairment, the ED is an opportunity to prevent functional and cognitive decline.

Frail older adults with minor fractures show lower health-related quality of life (SF-12) scores up to six months following emergency department discharge.

BACKGROUND: Minor fractures (e.g. wrist, ankle) are risk factors for lower physical health-related quality of life (HRQoL) in seniors. Recent studies found that measures of frailty were associated with decreased physical and mental HRQoL in older people. As most people with minor fractures go to emergency departments (EDs) for treatment, measuring their frailty status in EDs may help stratify their level of HRQoL post-injury and provide them with appropriate health care and services after discharge. This study thus examines the HRQoL of seniors visiting EDs for minor fractures at 3 and 6 months after discharge, according to their frailty status. METHODS: This prospective sub-study was conducted within the larger Canadian Emergency Team Initiative (CETI) cohort. Independent seniors (≥65 years) were recruited in 7 Canadian EDs after treatment for various minor fractures. Frailty status in the ED phase was assessed by the Canadian Study of Health and Aging--Clinical Frailty Scale (CSHA-CFS). The SF-12 questionnaire was completed at 3 and 6 months after ED discharge to ascertain HRQoL. Demographic and clinical data were collected. Linear mixed models were used to test for differences between frailty levels and HRQoL outcomes, controlling for confounding variables and repeated measures over time. RESULTS: The sample comprised 334 participants with minor fractures. Prevalence of frailty was as follows: 56.6 % very fit-well; 32.3 % well with treated comorbidities-apparently vulnerable; and 11.1 % mildly-moderately frail. After adjusting for confounding variables, the frailest group showed significantly lower mean HRQoL scores than the fittest group on the physical scale at 3 months (49.3 ± 3.7 vs 60.9 ± 2.0) and 6 months (48.7 ± 3.8 vs 61.1 ± 1.8), as well as on the mental scale at 3 months (59.5 ± 4.4 vs 69.6 ± 1.9). Analyses exploring differences in proportion of patients with HRQoL < 50/100 between the three groups produced similar results. CONCLUSIONS: Older adults with minor fractures who were frail had lower physical and mental HRQoL scores at 3 and 6 months after ED discharge than their fittest counterparts. Measuring the frailty status of older adults who suffered a minor fracture in ED might help clinical decision-making at the time of discharge by providing them with appropriate health care and services to improve their HRQoL in the following months.

Decline in activities of daily living after a visit to a Canadian emergency department for minor injuries in independent older adults: are frail older adults with cognitive impairment at greater risk?

OBJECTIVES: To compare functional decline in activities of daily living (ADLs) of older adults visiting emergency departments (EDs) for minor injuries according to frailty and cognitive status. DESIGN: Prospective cohort study. SETTING: Seven Canadian EDs. PARTICIPANTS: Individuals aged 65 and older who were independent in ADLs at baseline were recruited between March 2011 and March 2013 (N=1,114). MEASUREMENTS: The Older American Resources and Services (OARS) questionnaire was completed during the ED visit or within 7 days and 3 and 6 months after a minor injury to ascertain functional decline (≥1-point drop in ADL score). Participants were considered frail based on the Canadian Study of Health and Aging Clinical Frailty Scale (≥Level 4, vulnerable). Cognitive impairment was defined as performing below cutoffs on the Montreal Cognitive Assessment (<23/30) or Telephone Interview for Cognitive Status (≤31/50). Four subgroups were created: frail with cognitive impairment, frail without cognitive impairment, nonfrail with cognitive impairment, nonfrail without cognitive impairment. Sociodemographic and health data were also collected. RESULTS: Information on OARS, frailty, and cognitive impairment were available for 850 at 3 months and 728 at 6 months; 19.9% of participants showed declining function at 3 months and 25.3% at 6 months. After adjusting for age, number of comorbidities, and instrumental activity of daily living disability at baseline, frail participants with cognitive impairment were at significantly greater risk of functional decline at 3 (adjusted risk ratio (aRR)=1.89; 95% confidence interval (CI)=1.38-2.59) and 6 (aRR=2.09; 95% CI=1.45-3.00) months than nonfrail participants without cognitive impairment. CONCLUSION: Easy-to-administer frailty and cognitive screening tools should be included in ED assessments to identify independent older adults at high risk of functional decline after minor injury so that appropriate services may be provided to prevent deterioration in ADLs.

Is cognitive function a concern in independent elderly adults discharged home from the emergency department in Canada after a minor injury?

OBJECTIVES: To describe the cognitive functioning of independent community-dwelling elderly adults visiting the emergency department (ED) for minor injuries and at 3- and 6-month follow-up assessments and to document the occurrence of falls, return to the ED, and hospital visits over time according to cognitive level. DESIGN: Prospective cohort study. SETTING: Three Canadian EDs. PARTICIPANTS: Individuals aged 65 and older who were independent in basic activities of daily living, visiting the ED for minor injuries, and discharged home within 48 hours (N = 320). MEASUREMENTS: Participants completed the Montreal Cognitive Assessment (MoCA). New falls involving pain and ED or hospital visits were documented at 3 and 6 months. RESULTS: At baseline, 62.4% of participants scored below the recommended cutoff of 26 on the MoCA, suggesting cognitive dysfunction, and 22.9% scored below a more-stringent cutoff of 21. MoCA scores had improved significantly at 3 and 6 months. Items showing the most improvement were delayed recall and verbal fluency. Persons with MoCA scores of less than 21 reported significantly more new falls and hospital visits 3 to 6 months after injury. CONCLUSION: Cognition is not optimal in many community-dwelling elderly adults visiting an ED for a minor injury, which may affect their capacity to comprehend, recall, and adhere to medical recommendations after their injury and put them at risk of further negative health events such as falls.

Cohort study on the prevalence and risk factors for delayed pulmonary complications in adults following minor blunt thoracic trauma.

OBJECTIVES: The objectives of this study are to determine the prevalence, risk factors, and time to onset of delayed hemothorax and pneumothorax in adults who experienced a minor blunt thoracic trauma. METHOD: A prospective cohort of 450 consecutive patients was recruited. Eligible patients had to be over 16 years of age, consulted within 72 hours for a trauma, and available for outpatient follow-up at 2, 7, and 14 days posttrauma. The clinical outcome investigated was the presence of delayed pneumothorax or hemothorax on the follow-up chest x-ray. OUTCOMES: Delayed hemothorax occurred in 11.8% (95% CI 8.8-14.8), and delayed pneumothorax occurred in 0.9% (95% CI 0.2-2.3) of participants. During the 14-day follow-up period, 87.0% of these delayed complications developed in the first week. In the multivariate analysis, the only statistically significant risk factor for delayed complications was the location of fractures on the x-ray of the hemithorax. The adjusted odds ratio was 1.52 (95% CI 0.62-3.73) for the lower ribs (tenth to twelfth rib), 3.11 (95% CI 1.60-6.08) for the midline ribs (sixth to ninth rib), and 5.05 (95% CI 1.80-14.19) for the upper ribs (third to fifth rib) versus patients with no fractures. CONCLUSION: The presence of at least one rib fracture between the third and ninth rib on the x-ray of the hemithorax is a significant risk factor for delayed hemothorax and pneumothorax.

[Cohort study on the prevalence and risk factors of late pulmonary complications in adults following a closed minor chest trauma]. / Étude de cohorte sur la prévalence et les facteurs de risque de complications pulmonaires tardives chez les adultes à la suite d'un traumatisme thoracique mineur fermé.

OBJECTIVES: The objectives of this study are to determine the prevalence, risk factors, and time to onset of delayed hemothorax and pneumothorax in adults who experienced a minor blunt thoracic trauma. METHOD: A prospective cohort of 450 consecutive patients was recruited. Eligible patients had to be over 16 years of age, consulted within 72 hours for a trauma, and available for outpatient follow-up at 2, 7, and 14 days posttrauma. The clinical outcome investigated was the presence of delayed pneumothorax or hemothorax on the follow-up chest x-ray. OUTCOMES: Delayed hemothorax occurred in 11.8% (95% CI 8.8-14.8), and delayed pneumothorax occurred in 0.9% (95% CI 0.2-2.3) of participants. During the 14-day follow-up period, 87.0% of these delayed complications developed in the first week. In the multivariate analysis, the only statistically significant risk factor for delayed complications was the location of fractures on the x-ray of the hemithorax. The adjusted odds ratio was 1.52 (95% CI 0.62-3.73) for the lower ribs (tenth to twelfth rib), 3.11 (95% CI 1.60-6.08) for the midline ribs (sixth to ninth rib), and 5.05 (95% CI 1.80-14.19) for the upper ribs (third to fifth rib) versus patients with no fractures. CONCLUSION: The presence of at least one rib fracture between the third and ninth rib on the x-ray of the hemithorax is a significant risk factor for delayed hemothorax and pneumothorax.

Cumulative incidence of functional decline after minor injuries in previously independent older Canadian individuals in the emergency department.

OBJECTIVES: To estimate the cumulative incidence of functional decline in independent older adults 3 and 6 months after a minor injury treated in the emergency department (ED) and to identify predictors of this functional decline. DESIGN: Prospective cohort study. SETTINGS: Three Canadian teaching EDs. PARTICIPANTS: Individuals aged 65 and older who were independent in basic activities of daily living before their injury and were evaluated in the ED for minor injuries (N = 335). MEASUREMENTS: Functional decline was defined as a loss of 2 or more out of 28 points on the self-reported Older Americans Resources Services scale. Sociodemographic, mobility, and clinical risk factors for functional decline in non-ED studies were measured at the ED visit and 3 and 6 months after the injury. Generalized linear mixed models were used to explore differences in functional decline between groups determined according to the different factors. RESULTS: The cumulative incidence of decline was 14.9% (95% confidence interval (CI) = 7.6-29.1%) at 3 months and 17.3% (95% CI = 9.7-30.9%) at 6 months. Predictors of functional decline were occasional use of a walking aid (relative risk (RR)=2.4, 95% CI = 1.4-4.2), needing help in instrumental activities of daily living (IADLs) before the injury (RR = 3.1, 95% CI=1.7-5.5), taking five or more daily medications (RR = 1.8, 95% CI = 1.0-3.2), and the emergency physicians' assessment of functional decline (RR = 2.8, 95% CI = 1.5-5.3). CONCLUSION: Minor injuries in independent older adults treated in EDs are associated with a 15% cumulative incidence of functional decline 3 months after the injury that persisted 6 months later. Simple-to-measure factors such as occasional use of a walking aid, daily medication, need for help with IADLs, and physician assessment of decline may help identify independent older adults at risk of functional decline during their consultation. These results confirm the need to improve risk assessment and management of this population in EDs.

Patients with rib fractures do not develop delayed pneumonia: a prospective, multicenter cohort study of minor thoracic injury.

STUDY OBJECTIVE: Patients admitted to emergency departments (EDs) for minor thoracic injuries are possibly at risk of delayed pneumonia. We aimed to evaluate the incidence of delayed pneumonia post-minor thoracic injury and the associated risk factors. METHODS: A prospective, multicenter cohort study was conducted in 4 Canadian EDs, from November 2006 to November 2010. All consecutive patients aged 16 years and older with minor thoracic injury who were discharged from the ED were screened for eligibility. Uniform clinical and radiologic evaluations were performed on the initial ED visit and were repeated at weeks 1 and 2. Relative risk analyses quantified incidence with comparison by age, sex, smoking status, alcohol intoxication, pulmonary comorbidity, ability to cough atelectasis, pain level, and number of rib fractures. RESULTS: Of the 1,057 participants recruited, 347 (32.8%) had at least 1 rib fracture, 87 (8.2%) had asthma, and 36 (3.4%) had chronic obstructive pulmonary disease. Only 6 patients (0.6%; 95% confidence interval 0.24% to 1.17%) developed pneumonia during the follow-up period. The relative risk for patients with preexistent pulmonary disease and radiologically proven rib fractures was 8.6 (P=.045; 95% confidence interval 1.05 to 70.9). Sex, smoking habit, initial atelectasis, ability to cough, and alcohol intoxication were not significantly associated with delayed pneumonia. CONCLUSION: This prospective cohort study of nonhospitalized patients with minor thoracic injuries revealed a low incidence of delayed pneumonia. Nonetheless, our results support tailored follow-up for asthmatic or chronic obstructive pulmonary disease patients with rib fracture.

Does training family physicians in shared decision making promote optimal use of antibiotics for acute respiratory infections? Study protocol of a pilot clustered randomised controlled trial.

BACKGROUND: In North America, although it varies according to the specific type of acute respiratory infections (ARI), use of antibiotics is estimated to be well above the expected prevalence of bacterial infections. The objective of this pilot clustered randomized controlled trial (RCT) is to assess the feasibility of a larger clustered RCT aiming at evaluating the impact of DECISION+, a continuing professional development (CPD) program in shared decision making, on the optimal use of antibiotics in the context of ARI. METHODS/DESIGN: This pilot study is a cluster RCT conducted with family physicians from Family Medicine Groups (FMG) in the Quebec City area, Canada. Participating FMG are randomised to an immediate DECISION+ group, a CPD program in shared decision making, (experimental group), or a delayed DECISION+ group (control group). Data collection involves recruiting five patients consulting for ARI per physician from both study groups before (Phase 1) and after (Phase 2) exposure of the experimental group to the DECISION+ program, and after exposure of the control group to the DECISION+ program (Phase 3). The primary outcome measures to assess the feasibility of a larger RCT include: 1) proportion of contacted FMG that agree to participate; 2) proportion of recruited physicians who participate in the DECISION+ program; 3) level of satisfaction of physicians regarding DECISION+; and 4) proportion of missing data in each data collection phase. Levels of agreement of the patient-physician dyad on the Decisional Conflict Scale and physicians' prescription profile for ARI are performed as secondary outcome measures. DISCUSSION: This study protocol is informative for researchers and clinicians interested in designing and/or conducting clustered RCT with FMG regarding training of physicians in shared decision making. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00354315.

Pythium attrantheridium sp. nov.: taxonomy and comparison with related species.

Pythium attrantheridium sp. nov. is a new species isolated from cavity spot lesions of carrots as well as apple and cherry seedlings from various locations widely distributed in Canada and the USA. This fungus is closely related to the heterothallic P. intermedium, but is distinguished by: (1) unique molecular characteristics; (2) unique morphological characteristics; and (3) mating incompatibility with P. intermedium. The ITS region of the nuclear rDNA of all strains of P. attrantheridium studied is different from that of all other known Pythium spp. The oogonia attract a large number of antheridia when compatible mating types contact each other. The positive mating type produces zoospores unlike those of P. intermedium. Thus, biological, morphological and molecular data support the recognition of a new species.