Analysis of Firework-Related Injuries to the Upper Extremity in the United States: 2011-2020.

INTRODUCTION: The purpose of this study is to examine and characterize patterns of injury to the upper extremity caused by fireworks in a nationally representative sample of emergency department patients from 2011 to 2020. METHODS: The National Electronic Injury Surveillance System was queried for upper-extremity injuries caused by fireworks between 2011 and 2020. RESULTS: One thousand two hundred fifty-one injuries were identified from the database representing 47,235 national cases that presented to emergency departments in the United States. Case frequency was stable during the period until 2020, which was nearly 70% higher than the previous 9-y average. Patients were generally young and male, with most cases in the 10-29-y age group and males over three times as likely to be injured as females. The most common injury was burn, and the week of July 4th accounted for 53% of cases alone. Diagnosis was also significantly associated with device type. CONCLUSIONS: These data can be used to target prevention measures and campaigns to specific patient populations most at risk of injury, specifically young males. They may also be used to highlight the impact of policy changes on availability of fireworks, the need for public health education coinciding with injury incidence peaks, and secondary pandemic effects.

Symptom resolution following a repeat concussion within the same athlete.

INTRODUCTION: Repeat sport-related concussion (SRC) is anecdotally associated with prolonged recovery. Few studies have examined repeat concussion within the same athlete. We sought to explore differences in symptom burden and recovery outcomes in an individual athlete's initial and repeat SRC. METHODS: A retrospective within-subject cohort study of athletes aged 12-23 years diagnosed with two separate SRCs from 11/2017-10/2020 was conducted. Primary outcomes were initial symptom severity and time-to-symptom-resolution. Secondary outcomes included return-to-learn (RTL) and return-to-play (RTP) duration. RESULTS: Of 868 athletes seen, 47 athletes presented with repeat concussions. Median time between concussions was 244 days (IQR 136-395). Comparing initial to repeat concussion, no differences were observed in time-to-clinic (4.3 ± 7.3vs.3.7 ± 4.6 days, p = 0.56) or initial PCSS (26.2 ± 25.3 vs. 30.5 ± 24.1, p = 0.32). While a difference was observed in time-to-symptom resolution between initial/repeat concussion (21.2 ± 16.3 vs. 41.7 ± 86.0 days, p = 0.30), this did not reach statistical significance. No significant differences were observed in time-to-RTL (17.8 ± 60.6 vs. 6.0 ± 8.3 days, p = 0.26) and RTP (33.2 ± 44.1 vs. 29.4 ± 39.1 days, p = 0.75). Repeat concussion was not associated with symptom resolution on univariate (HR 1.64, 95% CI 0.96-2.78, p = 0.07) and multivariable (HR 0.85, 95% CI 0.49-1.46, p = 0.55) Cox regression. CONCLUSION: No significant differences in symptom duration and RTP/RTL were seen between initial/repeat concussion.

Traumatic chest wall pyomyositis presenting with mediastinitis.

Pyomyositis is an acute bacterial infection of the skeletal muscle that is commonly associated with localized abscess formation. It is estimated that pyomyositis accounts for up to 4% of all hospital admissions throughout Asia, tropical Africa, Oceania and the Caribbean Islands. However, there has been an increasing emergence of pyomyositis in temperate climates and high-income countries. Staphylococcus aureus is the most common organism implicated. Management requires a high index of clinical suspicion, prompt diagnosis and early management to prevent sequalae that can be fatal if left untreated. We describe an interesting case of pyomyositis in an otherwise fit and immunocompetent individual causing mediastinitis; a rare sequalae of the disease. Percutaneous drainage of his left pectoral abscess and a prolonged course of antibiotics provided complete clinical and radiological resolution of the disease despite mediastinal extension. Here we discuss aetiology, associations, pathophysiology and epidemiology of pyomyositis with associated sequalae of the disease.

Use of acute cognitive symptom cluster to predict return-to-learn duration following a sport-related concussion.

OBJECTIVE: Adolescents sustaining sport-related concussion often experience difficulties with the return-to-learn (RTL) process. Whereas the initial symptom burden has predicted prolonged RTL, no studies have established a relationship between acute cognitive symptoms and RTL duration. The authors sought to evaluate the relationship between initial cognitive symptoms and RTL duration. METHODS: A retrospective single-institution cohort study of adolescent athletes aged 12-23 years who were evaluated within 5 days of a diagnosed sport-related concussion between November 2017 and October 2020 was conducted. Athletes missing cognitive symptom ratings and RTL data were excluded. The primary exposure variable was the Cognitive Symptom Ratio (CSR), defined as total cognitive symptom cluster score divided by total Post-Concussion Symptom Scale (PCSS) score from the initial clinic visit. Primary and secondary outcomes were time to RTL and total length of care, respectively. Multivariable Cox proportional hazards modeling was used to assess the effect of CSR on RTL duration. RESULTS: Of 653 athletes evaluated within 5 days of injury, 346 patients were included in the final cohort. Athletes reported a median initial PCSS score of 21 (interquartile range [IQR] 6-37) and a median cognitive symptom score of 4 (IQR 0-9). Most patients endorsed some degree of difficulty concentrating (n = 212, 61.3%). The median CSR was 0.18 (IQR 0.00-0.27). On multivariable regression analysis, a higher CSR was associated with prolonged RTL duration (HR 0.30, 95% CI 0.13-0.69, p = 0.004). When initial PCSS score was added to the model, the previously significant association between CSR and RTL was no longer significant (HR 0.67, 95% CI 0.29-1.59, p = 0.367). When dichotomized based on frequency distribution, a higher proportion of patients with low CSR achieved RTL by 7 days postinjury (82.2% vs 69.9%, p = 0.007), a difference not seen at 14 days (92.2% vs 87.3%, p = 0.133). CONCLUSIONS: An acute ratio of cognitive symptoms may predict patients at increased risk for prolonged RTL and those with normal PCSS scores who may experience difficulties once resuming school activities.

Which Recommendations Are You Using? A Survey of Emergency Physician Management of Paroxysmal Atrial Fibrillation.

Background: Both the Canadian Cardiovascular Society (CCS) and the Canadian Association of Emergency Physicians (CAEP) have published documents to guide atrial fibrillation (AF) management. In 2021, the CAEP updated its AF checklist. Prior to this update, the recommendations of the 2 organizations differed in several key areas, including the suggested cardioversion timeframe, the factors determining cardioversion eligibility, and anticoagulant initiation after cardioversion. Whether emergency physicians (EPs) are aware of, or adhering to, one, both, or neither of these documents is unknown. Methods: We assessed document awareness, adherence, and EP practice using a piloted questionnaire administered to EPs at 5 emergency departments in 3 provinces. Results: Of 166 survey recipients, 123 (74.1%) responded. The majority (64.7%) worked at an academic site, 38.8% identified as female, and median years in practice was 10.0. Most (93.1%) were aware of at least one of the documents; 45.7% were aware of both. Reported awareness was higher for the CCS (77.6%) vs the CAEP (61.2%) guidelines. Respondents varied in their adherence, with 40.5% using parts of both documents. Considerable practice variability occurred when recommendations conflicted. Despite its use not being recommended by either organization, half of respondents (50.0%) reported using the CHA2DS2-VASc score as their stroke-risk assessment tool. Conclusions: Although most surveyed EPs were aware of at least one organization's AF documents, many reported using parts of both. When recommendations conflicted, EPs were divided in their decision-making. These findings emphasize the need to improve consensus between organizations and further improve knowledge translation.

Introduction: La Société canadienne de cardiologie (SCC) et l'Association canadienne des médecins d'urgence (ACMU) ont publié des documents pour orienter la prise en charge de la fibrillation auriculaire (FA). En 2021, l'ACMU a actualisé sa liste de vérification sur la FA. Avant cette actualisation, les recommandations des deux organismes différaient sur plusieurs points importants, notamment le laps de temps suggéré avant la cardioversion, les facteurs qui déterminent l'admissibilité à la cardioversion, et l'amorce du traitement anticoagulant après la cardioversion. On ignore si les médecins d'urgence (MU) connaissent ou adhère à un, à deux ou à aucun de ces documents. Méthodes: Nous avons évalué la connaissance qu'ont les MU de ces documents, leur adhésion et leur pratique grâce à un questionnaire pilote soumis aux MU de cinq services des urgences de trois provinces. Résultats: Parmi les 166 participants à l'enquête, 123 (74,1 %) y ont répondu. La majorité (64,7 %) travaillait dans un établissement universitaire, 38,8 % étaient des femmes, et le nombre médian d'années de pratique était de 10,0. La plupart (93,1 %) connaissaient au moins un des documents; 45,7 % connaissaient les deux. La connaissance rapportée était plus élevée pour les lignes directrices de la SCC (77,6 %) que pour les lignes directrices de l'ACMU (61,2 %). L'adhésion des répondants variait, mais 40,5 % utilisaient des parties des deux documents. La variabilité considérable de la pratique était observée lorsque les recommandations étaient contradictoires. Bien que son utilisation ne soit pas recommandée par l'un ou l'autre de ces organismes, la moitié des répondants (50,0 %) signalaient utiliser le score CHA2DS2-VASc comme outil d'évaluation du risque d'accident vasculaire cérébral. Conclusions: Bien que la plupart des MU interrogés connaissaient au moins un document sur la FA des organismes, plusieurs signalaient utiliser des parties des deux documents. Lorsque les recommandations étaient contradictoires, les MU étaient divisés sur la prise de décision. Ces résultats confirment la nécessité d'améliorer le consensus entre les organismes et d'améliorer davantage l'application des connaissances.

Thiamine increases resident endoglin positive cardiac progenitor cells and atrial contractile force in humans: A randomised controlled trial.

BACKGROUND: The heart has an intrinsic ability to regenerate, orchestrated by progenitor or stem cells. However, the relative complexity of non-resident cardiac progenitor cell (CPC) therapy makes modulation of resident CPCs a more attractive treatment target. Thiamine analogues improve resident CPC function in pre-clinical models. In this double blinded randomised controlled trial (identifier: ACTRN12614000755639), we examined whether thiamine would improve CPC function in humans. METHODS AND RESULTS: High dose oral thiamine (one gram twice daily) or matching placebo was administered 3-5 days prior to coronary artery bypass surgery (CABG). Right atrial appendages were collected at the time of CABG, and CPCs isolated. There was no difference in the primary outcome (proliferation ability of CPCs) between treatment groups. Older age was not associated with decreased proliferation ability. In exploratory analyses, isolated CPCs in the thiamine group showed an increase in the proportion of CD34-/CD105+ (endoglin) cells, but no difference in CD34-/CD90+ or CD34+ cells. Thiamine increased maximum force developed by isolated trabeculae, with no difference in relaxation time or beta-adrenergic responsiveness. CONCLUSION: Thiamine does not improve proliferation ability of CPC in patients undergoing CABG, but increases the proportion of CD34-/CD105+ cells. Having not met its primary endpoint, this study provides the impetus to re-examine CPC biology prior to any clinical outcome-based trial examining potential beneficial cardiovascular effects of thiamine.

Long-chain acylcarnitine 18:1 acutely increases human atrial myocardial contractility and arrhythmia susceptibility.

Long-chain acylcarnitines (LCACs) are known to directly alter cardiac contractility and electrophysiology. However, the acute effect of LCACs on human cardiac function is unknown. We aimed to determine the effect of LCAC 18:1, which has been associated with cardiovascular disease, on the contractility and arrhythmia susceptibility of human atrial myocardium. Additionally, we aimed to assess how LCAC 18:1 alters Ca2+ influx and spontaneous Ca2+ release in vitro. Human right atrial trabeculae (n = 32) stimulated at 1 Hz were treated with LCAC 18:1 at a range of concentrations (1-25 µM) for a 45-min period. Exposure to the LCAC induced a dose-dependent positive inotropic effect on myocardial contractility (maximal 1.5-fold increase vs. control). At the 25 µM dose (n = 8), this was paralleled by an enhanced propensity for spontaneous contractions (50% increase). Furthermore, all LCAC 18:1 effects on myocardial function were reversed following LCAC 18:1 washout. In fluo-4-AM-loaded HEK293 cells, LCAC 18:1 dose dependently increased cytosolic Ca2+ influx relative to vehicle controls and the short-chain acylcarnitine C3. In HEK293 cells expressing ryanodine receptor (RyR2), this increased Ca2+ influx was linked to an increased propensity for RyR2-mediated spontaneous Ca2+ release events. Our study is the first to show that LCAC 18:1 directly and acutely alters human myocardial function and in vitro Ca2+ handling. The metabolite promotes proarrhythmic muscle contractions and increases contractility. The exploratory findings in vitro suggest that LCAC 18:1 increases proarrhythmic RyR2-mediated spontaneous Ca2+ release propensity. The direct effects of metabolites on human myocardial function are essential to understand cardiometabolic dysfunction.NEW & NOTEWORTHY For the first time, the fatty acid metabolite, long-chain acylcarnitine 18:1, is shown to acutely increase the arrhythmia susceptibility and contractility of human atrial myocardium. In vitro, this was linked to an influx of Ca2+ and an enhanced propensity for spontaneous RyR2-mediated Ca2+ release.

Outcomes of out of hospital cardiac arrest in First Nations and non-First Nations patients in Saskatoon.

INTRODUCTION: One in nine (11.7%) people in Saskatchewan identify as First Nations. It is known that First Nations people have a higher burden of cardiovascular disease, but not whether outcomes of out of hospital cardiac arrest are different. METHODS/METHODOLOGY: We reviewed pre-hospital and inpatient records of patients with out of hospital cardiac arrest between January 1st, 2015 and December 31st, 2017. The population consisted of patients aged 18 years or older with out of hospital cardiac arrest of presumed cardiac origin occurring in the catchment area of Saskatoon's emergency medical services (EMS). Variables of interest included age, gender, First Nations status, EMS response times, bystander cardiopulmonary resuscitation (CPR), and shockable rhythm. Outcomes of interest included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge. RESULTS: In all, 372 patients sustained out of hospital cardiac arrest, of which 27 were status First Nations. There were no differences between First Nations and non-First Nations patients in terms of shockable rhythms (24% vs 26%; p = 0.80), ROSC (42% vs 41%; p = 0.87), survival to hospital admission (27% vs 33%; p = 0.53), and survival to hospital discharge (15% vs 12%; p = 0.54). First Nations patients with out of hospital cardiac arrest were significantly younger (mean age 46 vs. 65 years; p < 0.0001) and had shorter EMS response times (median times 5.3 vs. 6.2 min; p = 0.01) when compared to non-First Nations patients. CONCLUSIONS: In Saskatoon, First Nations patients with out of hospital cardiac arrest appear to have similar survival rates when compared with non-First Nations patients. However, First Nations patients sustaining out of hospital cardiac arrest were significantly younger than their non-First Nations counterparts. This highlights a significant public health issue.

RéSUMé: INTRODUCTION: Une personne sur neuf (11,7 %) en Saskatchewan s'identifie comme membre des Premières Nations. On sait que le fardeau des maladies cardiovasculaires est plus lourd pour les membres des Premières Nations, mais on ne sait pas si les résultats d'un arrêt cardiaque en dehors de l'hôpital sont différents. MéTHODES/MéTHODOLOGIE: Nous avons examiné les dossiers pré-hospitaliers et les dossiers des patients hospitalisés ayant subi un arrêt cardiaque hors hôpital entre le 1er janvier 2015 et le 31 décembre 2017. La population était composée de patients âgés de 18 ans ou plus ayant subi un arrêt cardiaque hors de l'hôpital d'origine cardiaque présumée survenu dans la Territoire des services médicaux d'urgence (SMU) de Saskatoon. Les variables d'intérêt comprenaient l'âge, le sexe, le statut des Premières Nations, les temps de réponse des SMU, la réanimation cardiorespiratoire (RCR) des témoins et le rythme choquant. Les résultats d'intérêt comprenaient le retour de la circulation spontanée (RCS), la survie à l'admission à l'hôpital et la survie la sortie de l'hôpital. RéSULTATS : Au total, 372 patients ont subi un arrêt cardiaque hors de l'hôpital, dont 27 étaient des Premières Nations inscrites. Il n'y avait aucune différence entre les patients des Premières Nations et les patients non membres des Premières Nations en termes de rythmes choquants (24 % contre 26 %; p = 0.80), RCS (42% contre 41% ; p = 0.87), survie à l'admission à l'hôpital ( 27% contre 33%; p = 0.53) et la survie à la sortie de l'hôpital (15 % contre 12%; p = 0.54). Les patients des Premières Nations ayant subi un arrêt cardiaque hors hôpital étaient significativement plus jeunes (âge moyen 46 ans contre 65 ans ; p < 0.0001)) et avaient des temps de réponse plus courts aux SMU (temps médian 5,3 contre 6,2 minutes ; p = 0.01) par rapport aux patients des autres nations. CONCLUSIONS: À Saskatoon, les patients des Premières Nations ayant subi un arrêt cardiaque hors de l'hôpital semblent avoir des taux de survie similaires à ceux des patients non autochtones. Cependant, les patients des Premières Nations qui ont subi un arrêt cardiaque hors de l'hôpital étaient beaucoup plus jeunes que leurs homologues des autres nations. Cela met en évidence un problème de santé publique important.

Human Atrial Fibrillation Is Not Associated With Remodeling of Ryanodine Receptor Clusters.

The release of Ca2+ by ryanodine receptor (RyR2) channels is critical for cardiac function. However, abnormal RyR2 activity has been linked to the development of arrhythmias, including increased spontaneous Ca2+ release in human atrial fibrillation (AF). Clustering properties of RyR2 have been suggested to alter the activity of the channel, with remodeling of RyR2 clusters identified in pre-clinical models of AF and heart failure. Whether such remodeling occurs in human cardiac disease remains unclear. This study aimed to investigate the nanoscale organization of RyR2 clusters in AF patients - the first known study to examine this potential remodeling in diseased human cardiomyocytes. Right atrial appendage from cardiac surgery patients with paroxysmal or persistent AF, or without AF (non-AF) were examined using super-resolution (dSTORM) imaging. Significant atrial dilation and cardiomyocyte hypertrophy was observed in persistent AF patients compared to non-AF, with these two parameters significantly correlated. Interestingly, the clustering properties of RyR2 were remarkably unaltered in the AF patients. No significant differences were identified in cluster size (mean ∼18 RyR2 channels), density or channel packing within clusters between patient groups. The spatial organization of clusters throughout the cardiomyocyte was also unchanged across the groups. RyR2 clustering properties did not significantly correlate with patient characteristics. In this first study to examine nanoscale RyR2 organization in human cardiac disease, these findings indicate that RyR2 cluster remodeling is not an underlying mechanism contributing to altered channel function and subsequent arrhythmogenesis in human AF.

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.

RéSUMé: OBJECTIF: Développer des recommandations pragmatiques pour lancer, établir et soutenir un programme de recherche en médecine d'urgence (MU) au Canada dans des sites avec une infrastructure et / ou une expérience de recherche antérieure limitée. MéTHODES: Sous la direction de la section académique de l'Association canadienne des médecins d'urgence (ACMU), nous avons réuni un comité d'experts de 10 chercheurs en MU possédant de l'expérience dans le développement des programmes de recherche. En utilisant une approche Delphi modifiée, notre comité a mis en place des recommandations initiales pour 1) lancer, 2) établir et 3) soutenir un programme de recherche en MU. Ces recommandations ont été examinées par des médecins d'urgence et des chercheurs appartenant aux établissements d'origine des chacun des membres de comité et ont été testées pour leur validité apparente et conceptuelle, ainsi que leur facilité de compréhension. Les recommandations ont ensuite été fréquemment révisées en fonction des commentaires et suggestions de l'examen des pairs et modifiées à nouveau après avoir été présentées au symposium académique 2020 de l'ACMU. RéSULTATS: Notre comité a créé 15 recommandations pragmatiques pour ceux qui ont l'intention de lancer (formation formelle en recherche, trouver des mentors, soutien local, développer un créneau, débuter à petite échelle), d'établir (financer, constituer une équipe, collaborer, publier, s'attendre à l'échec) et de soutenir (devenir un mentor, obtenir des rôles de leadership, diriger des études nationales, gagner en influence, prioriser le bien-être) un programme de recherche en MU dans des centres sans culture de la recherche établie. De plus, nous suggérons 4 recommandations aux responsables de département visant à promouvoir un programme de recherche au sein de leur département. CONCLUSION: Ces recommandations servent de guide aux centres qui souhaitent établir un programme de recherche en MU.

Elevated myocardial fructose and sorbitol levels are associated with diastolic dysfunction in diabetic patients, and cardiomyocyte lipid inclusions in vitro.

Diabetes is associated with cardiac metabolic disturbances and increased heart failure risk. Plasma fructose levels are elevated in diabetic patients. A direct role for fructose involvement in diabetic heart pathology has not been investigated. The goals of this study were to clinically evaluate links between myocardial fructose and sorbitol (a polyol pathway fructose precursor) levels with evidence of cardiac dysfunction, and to experimentally assess the cardiomyocyte mechanisms involved in mediating the metabolic effects of elevated fructose. Fructose and sorbitol levels were increased in right atrial appendage tissues of type 2 diabetic patients (2.8- and 1.5-fold increase respectively). Elevated cardiac fructose levels were confirmed in type 2 diabetic rats. Diastolic dysfunction (increased E/e', echocardiography) was significantly correlated with cardiac sorbitol levels. Elevated myocardial mRNA expression of the fructose-specific transporter, Glut5 (43% increase), and the key fructose-metabolizing enzyme, Fructokinase-A (50% increase) was observed in type 2 diabetic rats (Zucker diabetic fatty rat). In neonatal rat ventricular myocytes, fructose increased glycolytic capacity and cytosolic lipid inclusions (28% increase in lipid droplets/cell). This study provides the first evidence that elevated myocardial fructose and sorbitol are associated with diastolic dysfunction in diabetic patients. Experimental evidence suggests that fructose promotes the formation of cardiomyocyte cytosolic lipid inclusions, and may contribute to lipotoxicity in the diabetic heart.

Inotropic and lusitropic, but not arrhythmogenic, effects of adipocytokine resistin on human atrial myocardium.

The adipocytokine resistin is released from epicardial adipose tissue (EAT). Plasma resistin and EAT deposition are independently associated with atrial fibrillation. The EAT secretome enhances arrhythmia susceptibility and inotropy of human myocardium. Therefore, we aimed to determine the effect of resistin on the function of human myocardium and how resistin contributes to the proarrhythmic effect of EAT. EAT biopsies were obtained from 25 cardiac surgery patients. Resistin levels were measured by ELISA in 24-h EAT culture media (n = 8). The secretome resistin concentrations increased over the culture period to a maximal level of 5.9 ± 1.2 ng/mL. Coculture with ß-adrenergic agonists isoproterenol (n = 4) and BRL37344 (n = 13) had no effect on EAT resistin release. Addition of resistin (7, 12, 20 ng/mL) did not significantly increase the spontaneous contraction propensity of human atrial trabeculae (n = 10) when given alone or in combination with isoproterenol. Resistin dose-dependently increased trabecula-developed force (maximal 2.9-fold increase, P < 0.0001), as well as the maximal rates of contraction (2.6-fold increase, P = 0.002) and relaxation (1.8-fold increase, P = 0.007). Additionally, the postrest potentiation capacity of human trabeculae was reduced at all resistin doses, suggesting that the inotropic effect induced by resistin might be due to altered sarcoplasmic reticulum Ca2+ handling. EAT resistin release is not modulated by common arrhythmia triggers. Furthermore, exogenous resistin does not promote arrhythmic behavior in human atrial trabeculae. Resistin does, however, induce an acute dose-dependent positive inotropic and lusitropic effect.

Acute interaction between human epicardial adipose tissue and human atrial myocardium induces arrhythmic susceptibility.

Epicardial adipose tissue (EAT) deposition has a strong clinical association with atrial arrhythmias; however, whether a direct functional interaction exists between EAT and the myocardium to induce atrial arrhythmias is unknown. Therefore, we aimed to determine whether human EAT can be an acute trigger for arrhythmias in human atrial myocardium. Human trabeculae were obtained from right atrial appendages of patients who have had cardiac surgery (n = 89). The propensity of spontaneous contractions (SCs) in the trabeculae (proxy for arrhythmias) was determined under physiological conditions and during known triggers of SCs (high Ca2+, ß-adrenergic stimulation). To determine whether EAT could trigger SCs, trabeculae were exposed to superfusate of fresh human EAT, and medium of 24 h-cultured human EAT treated with ß1/2 (isoproterenol) or ß3 (BRL37344) adrenergic agonists. Without exposure to EAT, high Ca2+ and ß1/2-adrenergic stimulation acutely triggered SCs in, respectively, 47% and 55% of the trabeculae that previously were not spontaneously active. Acute ß3-adrenergic stimulation did not trigger SCs. Exposure of trabeculae to either superfusate of fresh human EAT or untreated medium of 24 h-cultured human EAT did not induce SCs; however, specific ß3-adrenergic stimulation of EAT did trigger SCs in the trabeculae, either when applied to fresh (31%) or cultured (50%) EAT. Additionally, fresh EAT increased trabecular contraction and relaxation, whereas media of cultured EAT only increased function when treated with the ß3-adrenergic agonist. An acute functional interaction between human EAT and human atrial myocardium exists that increases the propensity for atrial arrhythmias, which depends on ß3-adrenergic rather than ß1/2-adrenergic stimulation of EAT.

Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis.

OBJECTIVES: Performing an extended Focused Assessment with Sonography in Trauma (eFAST) exam is common practice in the initial assessment of trauma patients. The objective of this study was to systematically review the published literature on diagnostic accuracy of all components of the eFAST exam. METHODS: We searched Medline and Embase from inception through October 2018, for diagnostic studies examining the sensitivity and specificity of the eFAST exam. After removal of duplicates, 767 records remained for screening, of which 119 underwent full text review. Meta-DiSc™ software was used to create pooled sensitivities and specificities for included studies. Study quality was assessed using the Quality in Prognostic Studies (QUADAS-2) tool. RESULTS: Seventy-five studies representing 24,350 patients satisfied our selection criteria. Studies were published between 1989 and 2017. Pooled sensitivities and specificities were calculated for the detection of pneumothorax (69% and 99% respectively), pericardial effusion (91% and 94% respectively), and intra-abdominal free fluid (74% and 98% respectively). Sub-group analysis was completed for detection of intra-abdominal free fluid in hypotensive (sensitivity 74% and specificity 95%), adult normotensive (sensitivity 76% and specificity 98%) and pediatric patients (sensitivity 71% and specificity 95%). CONCLUSIONS: Our systematic review and meta-analysis suggests that e-FAST is a useful bedside tool for ruling in pneumothorax, pericardial effusion, and intra-abdominal free fluid in the trauma setting. Its usefulness as a rule-out tool is not supported by these results.

OBJECTIF: Le recours à l'évaluation ciblée par échographie étendue en traumatologie (eFAST : sigle anglais) est pratique courante dans l'évaluation initiale des patients ayant subi un trauma. L'étude avait donc pour but une revue systématique de la documentation publiée sur l'exactitude du diagnostic reposant sur tous les éléments constitutifs de l'eFAST. MÉTHODE: Les chercheurs ont effectué une recherche d'études sur les examens de diagnostic ayant pour objets la sensibilité et la spécificité de l'eFAST, dans les bases de données Medline et Embase, depuis leur début respectif jusqu'à octobre 2018. Après le retrait des doubles, il restait 767 documents aux fins de sélection, dont 119 ont été soumis à un examen en texte intégral. Le logiciel Meta-DiScMC a servi à établir la sensibilité et la spécificité globales des études retenues. Quant à la qualité des études, elle a été évaluée à l'aide de l'instrument Quality in Prognostic Studies (QUADAS-2). RÉSULTATS: Au total, 75 études totalisant 24 350 patients et publiées entre 1989 et 2017 répondaient aux critères de sélection. La sensibilité et la spécificité globales ont été calculées pour la détection des pneumothorax (69% et 99% respectivement), des épanchements péricardiques (91% et 94% respectivement) et de liquide libre intra-abdominal (74% et 98% respectivement). Il y a eu également analyse de sous-groupes en vue de la détection de liquide libre intra-abdominal chez les patients hypotendus (sensibilité : 74%; spécificité : 95%), les adultes normotendus (sensibilité : 76%; spécificité : 98%) et les enfants (sensibilité : 71%; spécificité : 95%). CONCLUSION: D'après les résultats de la revue systématique et de la méta-analyse, l'eFAST au chevet se montre utile pour confirmer la présence de pneumothorax, d'épanchement péricardique ou de liquide libre intra-abdominal en traumatologie, mais pas pour en écarter la présence.

Risk factors for adverse outcomes in older adults with blunt chest trauma: A systematic review.

OBJECTIVES: The objective of this study was to systematically review the published literature for risk factors associated with adverse outcomes in older adults sustaining blunt chest trauma. METHODS: EMBASE and MEDLINE were searched from inception until March 2017 for prognostic factors associated with adverse outcomes in older adults sustaining blunt chest trauma using a pre-specified search strategy. References were independently screened for inclusion by two reviewers. Study quality was assessed using the Quality in Prognostic Studies tool. Where appropriate, descriptive statistics were used to evaluate study characteristics and predictors of adverse outcomes. RESULTS: Thirteen cohort studies representing 79,313 patients satisfied our selection criteria. Overall, 26 prognostic factors were examined across studies and were reported for morbidity (8 studies), length of stay (7 studies), mortality (6 studies), and loss of independence (1 study). No studies examined patient quality of life or emergency department recidivism. Prognostic factors associated with morbidity and mortality included age, number of rib fractures, and injury severity score. Although age and rib fractures were found to be associated with adverse outcomes in more than 3 studies, meta-analysis was not performed due to heterogeneity amongst included studies in how these variables were measured. CONCLUSIONS: While blunt chest wall trauma in older adults is relatively common, the literature on prognostic factors for adverse outcomes in this patient population remains inadequate due to a paucity of high quality studies and lack of consistent reporting standards.

Optimum Accuracy of Massive Transfusion Protocol Activation: The Clinician's View.

Background Massive transfusion protocols (MTP) aid in the efficient delivery of blood components to rapidly exsanguinating patients. Unfortunately, clinical gestalt and currently available clinical scoring systems lack the optimal accuracy to prevent blood product wastage (through over-activation), as well as individual patient morbidity and mortality (through under-activation). In order to help refine the MTP activation criteria and protocols, we surveyed clinicians on acceptable over- and under-activation rates for massive transfusions. Methods We surveyed Canadian content experts in their respective fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 was comprised of trauma and acute care specialists (TACS), while Group 2 was comprised of clinical and laboratory medicine specialists (CLMS). Between-group differences were examined using Fisher's exact test and the likelihood ratio. Statistical significance was set at p < 0.05. Results We received responses from 35 clinicians in the TACS group and 10 clinicians in the CLMS group. About half (45.7%) of respondents in the TACS group considered an MTP overactivation rate of 5% - 10% acceptable (vs. 60% of the CLMS group; not significant (NS)). Approximately one-third (34.2%) of the respondents in the TACS group considered an MTP under-activation rate of less than 5% acceptable, whereas the majority (60%) of respondents in the CLMS group considered an under-activation rate of less than 5% acceptable (NS). A significantly greater proportion of respondents in the TACS group felt that an anticipated need for > 20 units of packed red blood cells within the next 24 hours was an acceptable criterion for MTP activation. Respondents in the CLMS group were more likely to consider "poor communication" as a reason for blood component wastage. Conclusion Similarities in acceptable MTP over- and under-activation rates were noted across specialties. Collaboration between involved parties is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage.

Antibiotic use among older adults on an acute care general surgery service.

BACKGROUND: Antibiotics play an important role in the treatment of many surgical diseases that affect older adults, and the potential for inappropriate use of these drugs is high. Our objective was to describe antibiotic use among older adults admitted to an acute care surgery service at a tertiary care teaching hospital. METHODS: Detailed data regarding diagnosis, comorbidities, surgery and antibiotic use were retrospectively collected for patients 70 years and older admitted to an acute care surgery service. We evaluated antibiotic use (perioperative prophylaxis and treatment) for appropriateness based on published guidelines. RESULTS: During the study period 453 patients were admitted to the acute care surgery service, and 229 underwent surgery. The most common diagnoses were small bowel obstruction (27.2%) and acute cholecystitis (11.0%). In total 251 nonelective abdominal operations were performed, and perioperative antibiotic prophylaxis was appropriate in 49.5% of cases. The most common prophylaxis errors were incorrect timing (15.5%) and incorrect dose (12.4%). Overall 206 patients received treatment with antibiotics for their underlying disease process, and 44.2% received appropriate first-line drug therapy. The most common therapeutic errors were administration of second- or third-line antibiotics without indication (37.9%) and use of antibiotics when not indicated (12.1%). There was considerable variation in the duration of treatment for patients with the same diagnoses. CONCLUSION: Inappropriate antibiotic use was common among older patients admitted to an acute care surgery service. Quality improvement initiatives are needed to ensure patients receive optimal care in this complex hospital environment.

CONTEXTE: Les antibiotiques jouent un rôle important dans de nombreux cas de chirurgie chez les adultes âgés, et le risque d'utilisation inappropriée de ces médicaments est élevé. Notre objectif était de décrire l'utilisation des antibiotiques chez les patients âgés admis au service chirurgical d'urgence d'un centre hospitalier universitaire de soins tertiaires. MÉTHODES: Nous avons recueilli de manière rétrospective les données détaillées sur le diagnostic, les comorbidités, la chirurgie et l'utilisation d'antibiotiques chez les patients de 70 ans et plus admis dans un service chirurgical d'urgence. Nous avons évalué le bien-fondé du recours aux antibiotiques (prophylaxie et traitement périopératoire) en fonction des lignes directrices publiées. RÉSULTATS: Durant la période de l'étude, 453 patients ont été admis au service chirurgical d'urgence et 229 ont subi une chirurgie. Les diagnostics les plus fréquents étaient : occlusion de l'intestin grêle (27,2 %) et cholécystite aigüe (11,0 %). En tout, 251 interventions abdominales urgentes ont été effectuées et l'antibioprophylaxie périopératoire était justifiée dans 49,5 % des cas. Les erreurs les plus fréquentes en matière de prophylaxie ont été : moment mal choisi (15,5 %) et dose incorrecte (12,4 %). En tout, 206 patients ont reçu une antibiothérapie pour un processus pathologique sous-jacent et 44,2 % ont reçu un traitement antibiotique de première intention approprié. Les erreurs thérapeutiques les plus fréquentes concernaient l'administration d'antibiotiques de deuxième ou de troisième intention sans indication (37,9 %) et l'utilisation d'antibiotiques lorsque cela n'était pas indiqué (12,1 %). On a noté une variation considérable de la durée des traitements chez des patients porteurs de diagnostics semblables. CONCLUSION: L'utilisation inappropriée des antibiotiques a été fréquente chez les patients adultes admis dans un service chirurgical d'urgence. Des initiatives s'imposent sur le plan de l'amélioration de la qualité pour s'assurer ainsi que les patients reçoivent des soins optimaux dans cet environnement hospitalier complexe.

How Robust Are Studies in the American Board of Emergency Medicine Maintenance of Certification Lifelong Learning and Self-assessment? An Examination of Fragility and Bias of Included Randomized Controlled Trials.

OBJECTIVE: Critics have raised concerns regarding the validity of maintenance of certification (MOC) programs. We sought to examine the quality of the randomized controlled trials (RCTs) selected for the lifelong learning and self-assessment (LLS) component of the American Board of Emergency Medicine (ABEM) MOC program. METHODS: We systematically reviewed the ABEM LLS reading lists from 2004 to 2017 to identify RCTs with dichotomous outcomes and superiority designs. A fragility index (FI) was calculated using Fisher's exact test for all statistically significant dichotomous outcomes. Bivariate correlation was performed to examine associations between the FI and RCT study characteristics. Each included study was evaluated with the Cochrane Collaboration risk-of-bias (ROB) tool. RESULTS: Thirteen superiority RCTs with dichotomous outcomes were included in the 2004-2017 LLS reading lists. Ten had a statistically significant outcome, and the majority were robust and at low ROB. The median trial size was 511 patients (interquartile range [IQR] = 251-1,517), and the median FI was 10 (IQR = 7-18); i.e., if 10 patients in the treatment arm had not had events, the results would not have been statistically significant. CONCLUSIONS: The majority of RCTs included in the LLS are robust and at low ROB.