The Evolution of Board-Certified Emergency Physicians and Staffing of Emergency Departments in Israel.

Introduction: Emergency medicine (EM) was recognized as a specialty in Israel in 1999. Fifty-nine of the 234 (25%) attending physicians working in emergency departments (ED) nationwide in 2002 were board-certified emergency physicians (EP). A 2012 study revealed that 123/270 (45%) of ED attendings were EPs, and that there were 71 EM residents. The EPs primarily worked midweek morning shifts, leaving the EDs mostly staffed by other specialties. Our objective in this study was to re-evaluate the EP workforce in Israeli EDs and their employment status and satisfaction 10 years after the last study, which was conducted in 2012. Methods: We performed a three-part, prospective cross-sectional study: 1) a survey, sent to all EDs in Israel, to assess the numbers, level of training, and specialties of physicians working in EDs; 2) an anonymous questionnaire, sent to EPs in Israel, to assess their demographics, training, employment, and work satisfaction; and 3) interviews of a convenience sample of EPs analyzed by a thematic approach. Results: There were 266 board-certified EPs, 141 (53%) of whom were employed in EDs full-time or part-time. Sixty-two non-EPs also worked in EDs. The EPs were present in the EDs primarily during weekday morning shifts. There were 273 EM residents nationwide. A total of 101 questionnaires were completed and revealed that EPs working part-time in the ED worked fewer hours, received higher salaries, and had more years of experience compared to EPs working full time or not working in the ED. Satisfaction correlated only with working part time. Meaningful work, diversity, and rewarding relationships with patients and colleagues were major positive reasons for working in the ED. Feeling undervalued, carrying a heavy caseload, and having complicated relationships with other hospital departments were reasons against working in the ED. Conclusion: Our study findings showed an increase in the number of trained and in-training EPs, and a decrease in the percentage of board-certified EPs who persevere in the EDs. Emergency medicine in Israel is at a crossroads: more physicians are choosing EM than a decade ago, but retention of board-certified EPs is a major concern, as it is worldwide. We recommend taking measures to maintain trained and experienced EPs working in the ED by allowing part-time ED positions, introducing dedicated academic time, and diversifying EP roles, functioning, and work routine.

Can cardiovascular reserve index (CVRI) on arrival to the trauma unit detects massive hemorrhage and predicts developing hemorrhage? observational prospective cohort study.

BACKGROUND: The detection of haemorrhage in trauma casualties may be delayed owing to compensatory mechanisms. This study aimed to evaluate whether the cardiovascular reserve index (CVRI) on arrival detects massive haemorrhage and predicts haemorrhage development in trauma casualties. METHODS: This was an observational prospective cohort study of adult casualties (≥18 years) who were brought to a single level-1 trauma centre, enroled upon arrival and followed until discharge. Vital signs were monitored on arrival, from which the CVRI and shock index were retrospectively calculated (blinded to the caregivers). The outcome measure was the eventual haemorrhage classification group: massive haemorrhage on arrival (MHOA) (defined by massive transfusion on arrival of ≥6 [O+] packed cells units), developing haemorrhage (DH) (defined by a decrease in haemoglobin >1 g/dl in consecutive tests), and no significant haemorrhage noted throughout the hospital stay. The means of each variable on arrival by haemorrhage group were evaluated using the analysis of variance. The authors evaluated the detection of MHOA in the entire population and the prediction of DH in the remainders (given that MHOA had already been detected and treated) by C-statistic predefined strong prediction by area under the curve (AUC) greater than or equal to 0.8, P less than or equal to 0.05. RESULTS: The study included 71 patients (after exclusion): males, 82%; average age 37.7 years. The leading cause of injuries was road accident (61%). Thirty-nine (54%) patients required hospital admission; distribution by haemorrhage classification: 5 (7%) MHOA, 5 (7%) DH, and 61 (86%) no significant haemorrhage. Detection of MHOA found a strong predictive model by CVRI and most variables (AUC 0.85-1.0). The prediction of DH on arrival showed that only lactate (AUC=0.88) and CVRI (0.82) showed strong predictive model. CONCLUSIONS: CVRI showed a strong predictive model for detection of MHOA (AUC>0.8) as were most other variables. CVRI also showed a strong predictive model for detection of DH (AUC=0.82), only serum lactate predicted DH (AUC=0.88), while all other variables were not found predictive. CVRI has advantages over lactate in that it is feasible in pre-hospital and mass casualty settings. Moreover, its repeatability enables detection of deteriorating trend. The authors conclude that CVRI may be a useful additional tool in the evaluation of haemorrhage.

Social psychological factors drive farmers' adoption of environmental best management practices.

Agriculture is a main driver of land-cover change globally resulting in decreased biodiversity, increased carbon emissions, and land desertification. Environmental best management practices reduce risk to the environment caused by agricultural operations. However, the adoption of environmental best management practices by farmers often is lower than what would be possible. While prior studies have investigated determinants of environmental best management practices, it is not well understood how social psychological drivers of various best management practices may be modified by contextual factors. To help close this knowledge gap, we conducted a large-scale survey of Ontario farmers investigating how social psychological factors and resource constraints combine to determine adoption of farm forests, riparian buffers and windbreaks, and how these relationships are modified by farmer demographics and farm characteristics. We analyzed survey responses of 490 farmers with structural equation modeling using the Theory of Planned Behavior as theoretical framework. Our results suggest that perceived benefits of environmental best management practices are of relatively low impact on best management practice adoption. Beliefs of a personal obligation for adoption and the perception of the capacity for adoption consistently were of higher impact, with lack of labor as main constraint. The relationships of perceived benefits and social norms with adoption were modified by farmer income, education, and age, as well as by the distance between a farm and the nearest settlement. However, the relationship of control beliefs with adoption was not affected by any contextual factors. We conclude that the improvement of programs in support of labor availability may have positive impacts on the adoption of the investigated environmental best management practices.

Host test based on tumor necrosis factor-related apoptosis-inducing ligand, interferon gamma-induced protein-10 and C-reactive protein for differentiating bacterial and viral respiratory tract infections in adults: diagnostic accuracy study.

OBJECTIVES: To assess the performance of a test (called BV), integrating the blood levels of three immune proteins into a score, to differentiate bacterial from viral infection among adults with suspected lower respiratory tract infection (LRTI). METHODS: Prospective diagnostic accuracy study, enrolling febrile adults >18 years with LRTI signs or symptoms for less than 7 days presenting to several hospitals' emergency departments in Israel. The main exclusion criterion was immunodeficiency. Reference standard diagnosis (bacterial/viral/indeterminate) was based on three experts independently reviewing comprehensive patient data including follow-up data. BV generated three results: viral infection or other nonbacterial condition (0 ≤ score < 35), equivocal (35 ≤ score ≤ 65) and bacterial infection including co-infection (65 < score ≤ 100). BV performance was assessed against the reference standard with indeterminate reference standard and equivocal BV cases removed. RESULTS: Of 490 enrolled patients, 415 met eligibility criteria (median age 56 years, interquartile range 35). The reference standard classified 104 patients as bacterial, 210 as viral and 101 as indeterminate. BV was equivocal in 9.6% (30/314). Excluding indeterminate reference standard diagnoses and equivocal BV results, BV's sensitivity for bacterial infection was 98.1% (101/103; 95% confidence interval 95.4-100), specificity 88.4% (160/181; 83.7-93.1) and negative predictive value 98.8% (160/162; 97.1-100). DISCUSSION: BV exhibited high diagnostic performance for febrile adults with suspected LRTI among patients with reference standard diagnoses of bacterial or viral LRTI.

Traumatic Injuries Following Mechanical versus Manual Chest Compression.

Objective: Survival after out-of-hospital cardiac arrest (OHCA) depends on multiple factors, mostly quality of chest compressions. Studies comparing manual compression with a mechanical active compression-depression device (ACD) have yielded controversial results in terms of outcomes and injury. The aim of the present study was to determine whether out-of-hospital ACD cardiopulmonary resuscitation (CPR) use is associated with more skeletal fractures and/or internal injuries than manual compression, with similar duration of cardiopulmonary resuscitation (CPR) between the groups. Methods: The cohort included all patients diagnosed with out-of-hospital cardiac arrest (OHCA) at a tertiary medical center between January 2018 and June 2019 who achieved return of spontaneous circulation (ROSC). The primary outcome measure was the incidence of skeletal fractures and/or internal injuries in the two groups. Secondary outcome measures were clinical factors contributing to skeletal fracture/internal injuries and to achievement of ROSC during CPR. Results: Of 107 patients enrolled, 45 (42%) were resuscitated with manual chest compression and 62 (58%) with a piston-based ACD device (LUCAS). The duration of chest compression was 46.0 minutes vs. 48.5 minutes, respectively (p=0.82). There were no differences in rates of ROSC (53.2% vs.50.8%, p=0.84), cardiac etiology of OHCA (48.9% vs.43.5%, p=0.3), major complications (ribs/sternum fracture, pneumothorax, hemothorax, lung parenchymal damage, major bleeding), or any complication (20.5% vs.12.1%, p=0.28). On multivariate logistic regression analysis, factors with the highest predictive value for ROSC were cardiac etiology (OR 1.94;CI 2.00-12.94) and female sex (OR 1.94;CI 2.00-12.94). Type of arrhythmia had no significant effect. Use of the LUCAS was not associated with ROSC (OR 0.73;CI 0.34-2.1). Conclusion: This is the first study to compare mechanical and manual out-of-hospital chest compression of similar duration to ROSC. The LUCAS did not show added benefit in terms of ROSC rate, and its use did not lead to a higher risk of traumatic injury. ACD devices may be more useful in cases of delayed ambulance response times, or events in remote locations.

Age as a Predictive Factor in Severity of Injuries in Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study.

The growth in worldwide popularity of electric bikes (E-bikes) and powered scooters (P-scooters) has been accompanied by an increase in injuries associated with their use. The aim of this study was to evaluate the contribution of rider age to injury severity, represented by need for hospitalization. A retrospective review of the database of a tertiary medical center yielded 1234 patients (75.7% male) who attended the emergency department (ED) in 2014−2020 for injuries sustained while riding an E-bike or P-scooter. Mean age was 31.52 ± 14.77 years: 23% were aged <20 years; 33%, 21−30 years; 23%, 31−40 years; 10%, 41−50 years; 11%, >51 years. Ninety patients (7.3%) were hospitalized. Older age was significantly associated with the need for hospitalization on univariate analysis (p <.001), but significance was not maintained on binary logistic regression (OR = 1.02, 95%CI 0.99−1.06; p = 0.11). Patients who underwent imaging evaluation in the ED were at lower risk of hospitalization, and patients who had surgery or a relatively long operative procedure were at higher risk of hospitalization. The study shows that older age (>51 years) is not associated with a significantly increased probability of severe injury in E-bike and P-scooter riders. This finding has important implications for insurers and healthcare administrators.

Daily output measures of Emergency Department in association with seasonality and day of the week: A retrospective cohort observational study.

To evaluate the daily output measures of the emergency department (ED) in association with seasonality and the day of the week. A retrospective cohort of ED visits to tertiary medical centers between 2016 and 2020. The research unit was each day during the study period. The independent variables were season and day of the week. The dependent variables were ED visits, admission and dropout rates, and duration of ED discharge. The comparison of means was evaluated using ANOVA. Statistical significance was set at P < .05. There were 1826 days, 792 thousand visits, 58% were female. Admission rate 28%, duration to discharge 3.8 h, dropout rate 2%. The average daily visits by season ranged from 101% of the overall average in autumn to 97% in spring. Average daily visits by day of the week were significantly different, with the highest on Sunday (Israel's first working day of the week), 124% of the overall daily average, and the lowest on Saturday (weekly day off) with 70%. Saturdays had the highest admission rate of 30% and 28% of the overall rate. There was a moderate dependency between the ED duration and discharge, with a dropout rate of r2 = 0.19. The average daily visits were not affected by season but differed considerably by day of the week. Admission rates varied slightly by season but were similar by day of the week apart from Saturdays. This may be attributable to the case mix on Saturdays or less restriction to admit when the number of visits is low. We recommended each Emergency Department to evaluate its daily output measures dependency with seasonality and day of the week for operational optimization.

Trends in the Incidence and Severity of Injuries Sustained by Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study.

Background and Objectives: The worldwide increase in electric bike (E-bike) and powered scooter (P-scooter) use in recent years has been accompanied by an increase in associated injuries to riders. The aim of this study was to evaluate trends in the incidence and types of E-bikes and P-scooter-related injuries in riders evacuated to a tertiary ED. Materials and Methods: A retrospective cross-sectional design was used. The cohort included 1234 patients referred to the emergency department (ED) of a tertiary medical center in 2014-2020 for injuries sustained while riding an E-bike or P-scooter. Demographic, clinical, and injury data were collected from the medical files, and injury rates were evaluated over time. Results: The results showed that the annual number of ED visits by injured E-bike and P-scooter riders increased steadily over the study period concomitant with an increase in ED referrals for hospitalization, indicating severe injury. The upper and lower extremities were the most frequent anatomic sites of injury in every year of the study, with variations among the different age groups. Conclusions: Our findings suggest a need for safety regulations for riders who operate two-wheel powered vehicles, such as licensing requirements and mandatory protective gear, especially for anatomic sites most at risk.

Impact of Drug and Alcohol Use on Hospitalization for Injuries in Riders of Electric Bikes or Powered Scooters: A Retrospective Cross-Sectional Study.

The growing popularity of E-bikes and P-scooters has led to their increasing involvement in injuries. This study sought to evaluate the impact of drug and alcohol consumption on hospitalization rates for electric-vehicle-associated injuries. A retrospective cross-sectional study design was used, including patients evacuated to the emergency department (ED) of a tertiary medical center in 2014−2020 for injuries sustained while riding E-bikes or P-scooters. Data on clinical characteristics were collected from the medical files, including pre-accident usage of alcohol or drugs. Of the 1234 patients (75.7% male) who met the inclusion criteria, 90 (7.3%) were hospitalized. The mean (SD) number of admission days was 5.44 (±0.12). Alcohol consumption was associated with 2.2% of injuries and drug use with 0.6%. Patients who rode under the influence of alcohol were significantly more likely to be hospitalized than discharged (6.7% vs. 1.8%, χ2 (2) =19.25, p < 0.001); the odds ratio was 14.1. A similar association with hospitalization was found for drug use (χ2 (2) = 7.83, p = 0.02). Riding an E-bike or P-scooter under the influence of alcohol or drugs increases the probability of severe injury requiring hospital admission. These results should prompt the relevant authorities to initiate effective legislation of alcohol and drug use.

Sex Differences in Identifying Chest Pain as Being of Cardiac Origin Using the HEART Pathway in the Emergency Department.

Objectives: The HEART Pathway is a diagnostic protocol designed to identify low-risk patients with chest pain who can be safely discharged from the emergency department (ED) without hospitalization. Studies have reported a negative bias in identifying myocardial ischemia in females versus males and a different clinical pattern of cardiac ischemia across genders. This study sought to determine if the HEART Pathway recommendations are affected by negative bias in females. Materials and Methods: A retrospective cohort study was conducted in the ED of an academic tertiary medical center. Admission/discharge decisions made by physicians in male and female patients presenting with chest pain in 4/2014-7/2019 were compared with HEART Pathway protocol predictions. Probabilities were estimated with logistic regression analysis, and odds ratios and 95% confidence intervals were calculated. Results: The cohort included 772 patients, 485 male (63%) and 287 female (37%), of median age 54 years. On the basis of their presenting symptoms, 278 patients (36%) were admitted by the ED physician and 494 (64%) were discharged. Using the HEART Pathway protocol, 227 patients (29.4%) would be expected to be admitted and 545 (70.6%) discharged. The real-life admission rate was higher than possible with the HEART Protocol (p = 0.001). In a regression model, male sex was a significant factor favoring admission among the patients for whom the HEART Pathway predicted admission (p = 0.007). Conclusions: As the HEART Pathway is a validated risk-stratification tool, there is a high likelihood that serious coronary artery disease may be overlooked in women, even those who seek timely medical assistance.

Impact of Comorbidities on Hospitalization for Injuries in Riders of Electric Bikes and Powered Scooters: A Retrospective Cross-Sectional Study.

Background and Objectives: Injuries associated with electric bikes (E-bikes) and powered scooters (P-scooters) have increased yearly worldwide. We aimed to evaluate the impact of pre-existing comorbidities on the probability of hospitalization for injuries in riders of E-bikes and P-scooters. Materials and Methods: A retrospective cross-sectional study design was used. The cohort included patients referred to the emergency department (ED) of a tertiary medical center in 2014-2020 for injuries sustained while riding an E-bike or P-scooter. Data were collected from the medical files on demographics, clinical characteristics including pre-existing comorbidities and permanent use of medications, and injury characteristics. Findings were compared between patients referred for hospitalization from the ED and patients discharged home. Results: Of the 1234 patients who met the inclusion criteria, 202 (16.4%) had a prior medical condition and 167 (13.5%) were taking medication on a permanent basis. A significant relationship was found between hospitalization and having a medical condition (𝜒2(1) = 9.20, p = 0.002) or taking medication on a permanent basis (𝜒2(1) = 6.24, p = 0.01). Hospitalization for injuries was more likely in patients with a comorbidity (27.8%) than those without a comorbidity (15.5%), and in patients who were on permanent drug therapy (22.2%) than in patients who were not (12.9%). Surprisingly, anticoagulant intake specifically had no effect on the probability of hospital admission. Conclusions: Patients with comorbidities have a higher incidence of hospitalization for E-bike- and P-scooter-associated injuries. Therefore, physicians may take into account comorbidities for the effective management of this patient group's injuries.

Trends and predictors of wetland conversion in urbanizing environments.

Wetlands provide critical ecosystem services including flood mitigation and habitat for diverse species, but globally, many wetlands have been destroyed. In urban areas and surrounding urban-rural fringes, many lost wetlands have been indirectly replaced with stormwater management (SWM) ponds. SWM ponds are designed to manage urban stormwater and contaminants, but only provide limited ecosystem services. In our study area, historic extent of wetland loss is partially documented, while more recent losses and SWM pond creation have not been fully reported. We examine wetland loss and SWM pond creation in seven southern Ontario (Canada) municipalities from 2002 to 2010. We then apply a Markov model to project future extent of wetland losses and SWM pond creation, with and without effects of specific land use and land cover types. We find that from 2002 to 2010, 95.5 ha of wetlands were lost, with most being smaller than 2 ha in size. A total area of 111.6 ha of SWM ponds was created, but on average, created SWM ponds were smaller than lost wetlands. Our projections to 2026 suggest wetland losses of 438.1 ha and SWM pond creation of 293.8 ha. We suggest a need for more stringent wetland protection policies to conserve wetlands that still exist in growing municipalities, especially smaller wetlands. Lack of such protection will weaken provisioning of wetland-related ecosystem services, which are more critical than ever in a changing climate.

Quick cell-free DNA testing for the prediction of postconcussion syndrome: a single-center prospective pilot trial.

OBJECTIVE: Mild traumatic brain injury (mTBI) is a major cause of emergency room (ER) admission. Thirty percent of mTBI patients have postconcussion syndrome (PCS), and 15% have symptoms for over a year. This population is underdiagnosed and does not receive appropriate care. The authors proposed a fast and inexpensive fluorometric measurement of circulating cell-free DNA (cfDNA) as a biomarker for PCS. cfDNA is a proven, useful marker of a variety of acute pathological conditions such as trauma and acute illness. METHODS: Thirty mTBI patients were recruited for this prospective single-center trial. At admission, patients completed questionnaires and blood was drawn to obtain cfDNA. At 3-4 months after injury, 18 patients returned for cognitive assessments with questionnaires and the Color Trails Test (CTT). The fast SYBR Gold assay was used to measure cfDNA. RESULTS: Seventeen men and 13 women participated in this trial. The mean ± SD age was 50.9 ± 13.9 years. Of the 18 patients who returned for cognitive assessment, one-third reported working fewer hours, 4 (22.2%) changed their driving patterns, and 5 (27.7%) reduced or stopped performing physical activity. The median cfDNA level of the mTBI group was greater than that of the matched healthy control group (730.5 vs 521.5 ng/ml, p = 0.0395). Admission cfDNA concentration was negatively correlated with performance on the CTT1 and CTT2 standardized tests (r = -0.559 and -0.599), meaning that greater cfDNA level was correlated with decreased cognitive performance status. The performance of the patients with normal cfDNA level included in the mTBI group was similar to that of the healthy participants. In contrast, the increased cfDNA group (> 800 ng/ml) had lower scores on the CTT tests than the normal cfDNA group (p < 0.001). Furthermore, patients with moderate/severe cognitive impairment according to CTT1 results had a greater median cfDNA level than the patients with scores indicating mild impairment or normal function (1186 vs 473.5 ng/ml, p = 0.0441, area under the receiver operating characteristic curve = 0.8393). CONCLUSIONS: The data from this pilot study show the potential to use cfDNA, as measured with a fast test, as a biomarker to screen for PCS in the ER. A large-scale study is required to establish the value of cfDNA as an early predictor of PCS.

Specialized Emergency Department Assessment and Multidisciplinary Intervention After Discharge Improve Management of Patients With Inflammatory Bowel Diseases.

GOAL: The aim was to assess proactive specialized inflammatory bowel diseases (IBD) emergency department (ED) consultation and multidisciplinary IBD team (IBD-MDT) intervention on IBD-related patient outcomes after discharge. BACKGROUND: Despite advances in patient care, IBD-related ED visits have increased and substantially contribute to the IBD burden. METHODS: Consecutive patients with IBD (below 50 y) who visited the ED during November 2017 to April 2018 (intervention group) were compared with patients with IBD that visited the same ED during 2014 to 2017 (standard-care group). The primary outcomes were hospitalization and ED revisits at 30, 90, and 180 days. RESULTS: The intervention group (45 patients, mean age 32.43±8.6 y, 57.8% male) and the standard-care group (237 patients) had comparable baseline characteristics, including age, sex, and IBD type, and similar rates of hospital admissions from the ED (46.7% vs. 38.8%, P=0.32). The intervention group more frequently underwent computed tomography (40% vs. 8%, P<0.001) and surgical interventions (13.3% vs. 0.8%, P<0.001) within the same hospital admission, compared with the standard-care group. In the intervention group, 24 patients were discharged from the ED, of whom 17 patients visited the IBD clinic (median 5 d postdischarge) and the majority were referred to ambulatory IBD-MDT services (dietitian: 46.7%, psychologist: 6.7%, advanced endoscopist: 8.9%, and proctology services: 6.7%). The intervention group had significantly fewer ED revisits than the standard-care group (30 d: 4.4% vs. 19.8%, P=0.013; 90 d: 4.4% vs. 35.9%, P<0.001; 180 d: 6.7% vs. 43%, P<0.001). CONCLUSION: Proactive specialized ED assessments and IBD-MDT interventions after a hospital discharge were preferable; they significantly reduced the ED revisit rate for at least 6 months.

Polymicrobial and monomicrobial necrotizing soft tissue infections: comparison of clinical, laboratory, radiological, and pathological hallmarks and prognosis. A retrospective analysis.

BACKGROUND: Necrotizing soft tissue infection (NSTI) is a life-threatening infection associated with high morbidity and mortality. Treatment consists of surgery and antibiotics. Many studies have addressed NSTI and its subtypes, but few have reviewed the clinical, radiological, and pathological differences between the polymicrobial and monomicrobial diseases. The objective of our study was to evaluate the clinical, radiological, and pathological features of patients with polymicrobial (NSTI I) and monomicrobial (NSTI II) infections and their association with outcome. METHODS: The cohort consisted of patients hospitalized with NSTI at a tertiary medical center in 2002-2019. The medical charts were reviewed for clinical, radiological, and pathological features. Findings were compared between patients in whom blood/tissue bacterial cultures yielded one or more than one pathological isolate. The primary clinical outcome measure of the study was all-cause mortality at 90 days. Secondary outcomes were duration of hospitalization, intensive care unit (ICU) admission, score on the LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis), and need for vasopressor treatment. RESULTS: A total of 81 patients met the inclusion criteria: 54 (66.6%) with monomicrobial NSTI and 27 (33.3%) with polymicrobial NSTI. There were no significant between-group differences in in-hospital and 90-day mortality. On multivariate analysis, the monomicrobial disease group had a significantly higher 90-day mortality rate in addition to higher rates of in-hospital mortality, ICU admission, and vasopressor use than the polymicrobial disease group. CONCLUSION: Our study is the first to compare the clinical, radiological, and pathological differences between the two most common types of NSTI. The results demonstrate better prognosis for polymicrobial NSTI, with minimal ICU stay, lower mortality, and lower use of vasopressors. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

The impact of helmet use on oral and maxillofacial injuries associated with electric-powered bikes or powered scooter: a retrospective cross-sectional study.

BACKGROUND: Electric bikes (E-bikes) and powered scooters (P-scooters) have become increasingly popular modes of public transportation, but they have been associated with injuries of all kinds, including dental trauma. Helmet use is promoted as a means of reducing injuries in accidents involving motorized and unmotorized vehicles. The aim of the study was to evaluate the impact of helmet use on the number and severity of oral and maxillofacial injuries caused by E-bikes and P-scooters. METHODS: A retrospective cross-sectional study design was used. The cohort included all patients referred to the emergency department of a tertiary medical center in 2014-2020 with oral and maxillofacial injuries involving E-bikes or P-scooters. Data were collected from the medical files on demographics, types of injuries, circumstances of occurrence, work-up, treatment, and outcome. Use of a helmet was recorded in each case. RESULTS: Of the total 1417 patients referred to the emergency department for E-bike and P-scooter-related trauma, 62 had oral and maxillofacial injuries, including 57 riders and 5 pedestrians. All had hard- or soft-tissue injuries; 20 (32.2%) had head injuries and 22 (35.5%) had dentoalveolar injuries. Eleven riders had worn a helmet at the time of injury (17.7%). Helmet use was associated with time of injury (weekday/weekend, daytime/night-time), type of motorized vehicle (E-bike or P-scooter), head injury, and number of bone fractures. Head injuries occurred more often on the weekend (57.9%) than during the week (20.9%) and were more likely to occur in riders who were not protected by a helmet (37.3% vs 18.2%). Patients who used helmets also had a lower rate of fractured bones (18.2%) and dentoalveolar injuries (23.7%) than patients who did not (68.8 and 37.3%, respectively). Interestingly, helmet use had no protective effect on soft-tissue injuries. CONCLUSIONS: Helmet use by E-bike and P-scooter riders decreased the probability of head injury and of hard tissue and dentoalveolar injuries. These results may provide guidance for effective legislation and regulation of helmet use and improved treatment protocols for general and dental physicians.

Elevated Plasma Soluble Triggering Receptor Expressed on Myeloid Cells-1 Level in Patients with Acute Coronary Syndrome (ACS): A Biomarker of Disease Severity and Outcome.

BACKGROUND AND AIMS: Plasma levels of soluble triggering receptor expressed on myeloid cells (sTREM-1) reflect innate immune cell activation. We sought to evaluate sTREM-1 levels in patients with acute coronary syndrome (ACS) and their predictive value for disease severity and outcome. METHODS: Plasma sTREM-1 levels were prospectively measured by ELISA in 121 consecutive patients with new-onset (≤24 h) chest pain at arrival to the emergency department (ED) and 73 healthy controls. Secondary endpoints were the association of plasma levels of sTREM-1 with day 30 and month 6 major adverse cardiovascular events (MACE) defined as death, ACS, stroke, and need for coronary revascularization, as well as with CAD severity. The primary endpoint of the study was the association of plasma sTREM-1 level at the time of admission to the ED with a diagnosis of ACS at day 30. RESULTS: Fifty-nine patients (48.7%) were diagnosed with ACS and 62 (51.3%) with nonspecific chest pain (NSCP). Median plasma sTREM-1 level at admission was significantly higher in the ACS group than the NSCP group and the control group (539.4 ± 330.3 pg/ml vs. 432.5 ± 196.4 pg/ml vs. 230.1 ± 85.5 pg/ml, respectively; P < 0.001) and positively correlated with the number of stenosed/occluded coronary arteries on angiography (P < 0.001). On logistic regression analysis, higher sTREM-1 levels predicted definite ACS vs. NSCP determined on day 30 (OR 1.29, 95% CI 1.07-1.54, P = 0.01) as well as with recurrent ACS (P = 0.04) and stroke (P = 0.02) at 6 months. CONCLUSIONS: Plasma sTREM-1 levels are significantly elevated in patients with ACS and might serve as a biomarker differentiating ACS from NSCP in the ED as well as an inflammatory biomarker for coronary artery disease severity and outcome.

Social-psychological Determinants of the Implementation of Green Infrastructure for Residential Stormwater Management.

Climate change effects and increasing levels of imperviousness, cause many urban areas globally to experience larger rainfall runoff volumes that need to be managed to protect property and infrastructure, and avoid environmental pollution. Conventionally engineered, 'grey' stormwater infrastructure often is outdated and unable to control these increased runoff volumes. Green stormwater infrastructure (GSI) can complement grey infrastructure, but public land for its installation is limited. Consequently, municipalities often look to residential properties to install GSI at the lot-level. While many studies have been conducted in the engineering aspects of GSI, less is known about what determines residents' decisions to install GSI on their properties. To help close this knowledge gap, we conducted a survey of social-psychological determinants of residential GSI implementation using the Theory of Planned Behavior as theoretical framework, and analyzing our data with partial least squares path modeling. Results from three neighborhoods of our case study area suggest that residents' decisions to install GSI largely are determined by social norms and perceived control factors such as available finances and time. However, residents' beliefs and attitudes toward the effectiveness and attractiveness of GSI did not seem to play a significant role. Neighborhood characteristics including local flooding history did not seem to affect residents' decisions about GSI installation either. We recommend creation of effective municipal education and outreach programs regarding urban stormwater management that speak to residents' shared responsibility and options for addressing this issue, as well as creation of financial instruments that provide meaningful subsidies for residential GSI adoption.

Thinking relationally about built environments and walkability: A study of adult walking behavior in Waterloo, Ontario.

The majority of research on built form and walking has been approached from a deterministic perspective and does not address the theoretical underpinnings of individual walking behaviour. This paper interrogates the relationship between individual walkers and their local environment in order to illuminate how and why people walk through/with space. Specifically, the paper reports on findings from 20 adult participants in Waterloo, Canada who took part in a participatory walking interview accompanied by a member of the research team. A relational interpretation of the data revealed that the relationship between built form and walking extends beyond the correlates of residential density, mix of land uses and street networks. Our findings reveal that there are blurred boundaries between utilitarian and recreational walking behavior, and that walking decisions were influenced by desires to avoid discomfort, seek pleasure, foster social connection and more-than-human encounters. We conclude with the argument that a relational perspective better captures the dynamics between people and place, and ultimately guides practitioners to design built environments that accommodate the realities of human activity in general and walking behavior in particular.