Mild Traumatic Brain Injury Is Associated With Increased Dual-Task Cost During Ambulation: A Preliminary Study.

OBJECTIVE: The aim of the study was to determine the impact of dual-task conditions on mobility after mild traumatic brain injury. DESIGN: Eleven adults with mild traumatic brain injury within 1 wk of injury and 10 age- and sex-matched healthy controls completed gait trials with a single-task condition and three separate dual-task conditions: counting by 1 (low), serial subtraction by 3 (medium), and alternating letters and numbers (high). Dual-task cost was calculated as dual-task cost = ([dual-task performance] - [single-task performance]) / [single-task performance] × 100%. RESULTS: Participants with mild traumatic brain injury ambulated slower than control subjects (P < 0.001). Significant differences in dual-task cost were noted for both group (P < 0.001) and dual-task condition (P = 0.005). Dual-task cost was greater for those with mild traumatic brain injury compared with controls with significant group differences for the low and high cognitive loads (P < 0.05). Only 1 of the 11 individuals with mild traumatic brain injury and 1 of the 10 controls demonstrated gait speed less than 80 cm/sec, which is predictive of community mobility, during any dual-task condition. Dual-task cost exceeded 11.9%, previously determined to be the minimal detectable change in healthy adults, for 9 of the 11 individuals with mild traumatic brain injury compared with 3 of the 10 controls. CONCLUSIONS: Dual-task cost may be a more sensitive measure for impairment during dual-task conditions than gait speed after mild traumatic brain injury.

Pediatric Pain Assessment in the Emergency Department: Patient and Caregiver Agreement Using the Wong-Baker FACES and the Faces Pain Scale-Revised.

OBJECTIVE: This study aimed to assess the agreement between patients presenting to the pediatric emergency department (ED) with acute pain and their caregivers when using the Wong-Baker FACES (WBF) and Faces Pain Scale-Revised (FPS-R). METHODS: This was a prospective, observational study examining patients 3 to 7.5 years old presenting to a pediatric ED with acute pain. Participants completed the WBF and FPS-R twice during their ED evaluation. Caregivers rated their child's pain using both the WBF and FPS-R at the same time points. Intraclass correlations (ICCs) were calculated between caregiver and child reports at each time point, and Bland-Altman plots were created. RESULTS: Forty-six subjects were enrolled over 5 months. Mean age was 5.5 ± 1.2 years. Average initial child pain scores were 6.6 ± 2.8 (WBF) and 6.1 ± 3.3 (FPS-R), and repeat scores were 3.3 ± 3.4 (WBF) and 3.1 ± 3.3 (FPS-R). Average initial caregiver pain scores were 6.3 ± 2.4 (WBF) and 6.2 ± 2.3 (FPS-R), and repeat scores were 3.4 ± 2.0 (WBF) and 3.4 ± 2.1 (FPS-R). On initial assessment, ICCs between children and caregivers using the FPS-R and WBF were 0.33 and 0.22, respectively. On repeat assessment, the ICCs were 0.31 for FPS-R and 0.26 for WBF. Bland-Altman plots showed poor agreement but no systematic bias. CONCLUSION: There was poor agreement between caregivers and children when using the WBF and FPS-R for assessment of acute pain in the ED. Caregiver report should not be used as a substitute for self-report of pain if possible.

Assessment of Vessel Density on Non-Contrast Computed Tomography to Detect Basilar Artery Occlusion.

INTRODUCTION: Basilar artery occlusion (BAO) may be clinically occult due to variable and non-specific symptomatology. We evaluated the qualitative and quantitative determination of a hyperdense basilar artery (HDBA) on non-contrast computed tomography (NCCT) brain for the diagnosis of BAO. METHODS: We conducted a case control study of patients with confirmed acute BAO vs a control group of suspected acute stroke patients without BAO. Two EM attending physicians, one third-year EM resident, and one medical student performed qualitative and quantitative assessments for the presence of a HDBA on axial NCCT images. Our primary outcome measures were sensitivity and specificity for BAO. Our secondary outcomes were inter-rater and intra-rater reliability of the qualitative and quantitative assessments. RESULTS: We included 60 BAO and 65 control patients in our analysis. Qualitative assessment of the hyperdense basilar artery sign was poorly sensitive (54%-72%) and specific (55%-89%). Quantitative measurement improved the specificity of hyperdense basilar artery assessment for diagnosing BAO, with a threshold of 61.0-63.8 Hounsfield units demonstrating relatively high specificity of 85%-94%. There was moderate inter-rater agreement for the qualitative assessment of HDBA (Fleiss' kappa statistic 0.508, 95% confidence interval: 0.435-0.581). Agreement improved for quantitative assessments, but still fell in the moderate range (Shrout-Fleiss intraclass correlation coefficient: 0.635). Intra-rater reliability for the quantitative assessments of the two attending physician reviewers demonstrated substantial consistency. CONCLUSION: Our results highlight the importance of carefully examining basilar artery density when interpreting the NCCT of patients with altered consciousness or other signs and symptoms concerning for an acute basilar artery occlusion. If the Hounsfield unit density of the basilar artery exceeds 61 Hounsfield units, BAO should be highly suspected.

Assessment of cardiopulmonary resuscitation knowledge and skills among healthcare providers at an urban tertiary referral hospital in Tanzania.

BACKGROUND: Early and effective CPR increases both survival rate and post-arrest quality of life. In limited resource countries like Tanzania, there is scarce data describing the basic knowledge of CPR among Healthcare providers (HCP). This study aimed to determine the current level of knowledge on, and ability to perform, CPR among HCP at Muhimbili National Hospital (MNH). METHODS: This was a descriptive cross sectional study of a random sample of 350 HCP from all cadres and departments at MNH from October 2015 to March 2016. Each participant completed a with 25 question multiple choice and fill-in-the-blank CPR test and a practical test using a CPR manikin where the participant was videotaped for 1-2 min. Two expert observers independently viewed the videos and rated participant performance on a structured data form. The primary outcome of interest was staff member overall performance on the written and practical CPR testing. RESULTS: We enrolled 350 HCPs from all 12 MNH clinical departments. The median participant age was 35 (IQR 29-43) years, 225 (64%) were female and 138 (39%) had clinical experience of less than 5 years. Only 57 (16%) and 88 (25%) scored above 50% in written and practical tests, respectively according to local minimum passing test score and 13(4%) and 30 (9%) scored above 75% in written and practical tests, respectively according to international minimum passing test score on CPR. The 233(67%) HCP who reported prior experience performing CPR on an adult patient scored higher on testing than those without; 40% (IQR 28-54) versus 26% (IQR 16-42) respectively, but both groups had median scores <50%. CONCLUSION: The level of CPR knowledge and skills displayed by all cadres and in all departments was poor despite the fact that most providers reported having performed CPR in the past. Since MNH is a tertiary referral hospital, it may reflect the performance of resuscitation status of other local health centers in Tanzania and other low-income countries to employ a formal system of training every HCP in CPR. Staff should be certified and assessed regularly to ensure retention of resuscitation knowledge and skills.

Evidence-Based Guidelines for Fatigue Risk Management in EMS: Formulating Research Questions and Selecting Outcomes.

BACKGROUND: Greater than half of Emergency Medical Services (EMS) personnel report work-related fatigue, yet there are no guidelines for the management of fatigue in EMS. A novel process has been established for evidence-based guideline (EBG) development germane to clinical EMS questions. This process has not yet been applied to operational EMS questions like fatigue risk management. The objective of this study was to develop content valid research questions in the Population, Intervention, Comparison, and Outcome (PICO) framework, and select outcomes to guide systematic reviews and development of EBGs for EMS fatigue risk management. METHODS: We adopted the National Prehospital EBG Model Process and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for developing, implementing, and evaluating EBGs in the prehospital care setting. In accordance with steps one and two of the Model Process, we searched for existing EBGs, developed a multi-disciplinary expert panel and received external input. Panelists completed an iterative process to formulate research questions. We used the Content Validity Index (CVI) to score relevance and clarity of candidate PICO questions. The panel completed multiple rounds of question editing and used a CVI benchmark of ≥0.78 to indicate acceptable levels of clarity and relevance. Outcomes for each PICO question were rated from 1 = less important to 9 = critical. RESULTS: Panelists formulated 13 candidate PICO questions, of which 6 were eliminated or merged with other questions. Panelists reached consensus on seven PICO questions (n = 1 diagnosis and n = 6 intervention). Final CVI scores of relevance ranged from 0.81 to 1.00. Final CVI scores of clarity ranged from 0.88 to 1.00. The mean number of outcomes rated as critical, important, and less important by PICO question was 0.7 (SD 0.7), 5.4 (SD 1.4), and 3.6 (SD 1.9), respectively. Patient and personnel safety were rated as critical for most PICO questions. PICO questions and outcomes were registered with PROSPERO, an international database of prospectively registered systematic reviews. CONCLUSIONS: We describe formulating and refining research questions and selection of outcomes to guide systematic reviews germane to EMS fatigue risk management. We outline a protocol for applying the Model Process and GRADE framework to create evidence-based guidelines.

Prospective study of clinician-entered research data in the Emergency Department using an Internet-based system after the HIPAA Privacy Rule.

BACKGROUND: Design and test the reliability of a web-based system for multicenter, real-time collection of data in the emergency department (ED), under waiver of authorization, in compliance with HIPAA. METHODS: This was a phase I, two-hospital study of patients undergoing evaluation for possible pulmonary embolism. Data were collected by on-duty clinicians on an HTML data collection form (prospective e-form), populated using either a personal digital assistant (PDA) or personal computer (PC). Data forms were uploaded to a central, offsite server using secure socket protocol transfer. Each form was assigned a unique identifier, and all PHI data were encrypted, but were password-accessible by authorized research personnel to complete a follow-up e-form. RESULTS: From April 15, 2003-April 15 2004, 1022 prospective e-forms and 605 follow-up e-forms were uploaded. Complexities of PDA use compelled clinicians to use PCs in the ED for data entry for most forms. No data were lost and server log query revealed no unauthorized entry. Prospectively obtained PHI data, encrypted upon server upload, were successfully decrypted using password-protected access to allow follow-up without difficulty in 605 cases. Non-PHI data from prospective and follow-up forms were available to the study investigators via standard file transfer protocol. CONCLUSIONS: Data can be accurately collected from on-duty clinicians in the ED using real-time, PC-Internet data entry in compliance with the Privacy Rule. Deidentification-reidentification of PHI was successfully accomplished by a password-protected encryption-deencryption mechanism to permit follow-up by approved research personnel.