An interphase actin wave promotes mitochondrial content mixing and organelle homeostasis.

Across the cell cycle, mitochondrial dynamics are regulated by a cycling wave of actin polymerization/depolymerization. In metaphase, this wave induces actin comet tails on mitochondria that propel these organelles to drive spatial mixing, resulting in their equitable inheritance by daughter cells. In contrast, during interphase the cycling actin wave promotes localized mitochondrial fission. Here, we identify the F-actin nucleator/elongator FMNL1 as a positive regulator of the wave. FMNL1-depleted cells exhibit decreased mitochondrial polarization, decreased mitochondrial oxygen consumption, and increased production of reactive oxygen species. Accompanying these changes is a loss of hetero-fusion of wave-fragmented mitochondria. Thus, we propose that the interphase actin wave maintains mitochondrial homeostasis by promoting mitochondrial content mixing. Finally, we investigate the mechanistic basis for the observation that the wave drives mitochondrial motility in metaphase but mitochondrial fission in interphase. Our data indicate that when the force of actin polymerization is resisted by mitochondrial tethering to microtubules, as in interphase, fission results.

Simulation as an educational tool to teach emergency medicine residents about unconscious bias.

Medical training embraces simulation-based education. One important topic that has recently been added to the simulation curriculum at the University of Toronto is unconscious bias. This educational innovation project evaluates a simulation that could be used as a novel instructional design strategy to teach unconscious bias. The simulation involved two resuscitation scenarios with a similar clinical trajectory. Each resuscitation was led by standardized physicians of different binary genders, followed by a debrief with highly trained facilitators. Tangible educational takeaways on team dynamic variation between different gendered team leaders were discussed following the simulation, highlighting its benefit to resident education on bias awareness and response. Limitations include inevitable unconscious bias in facilitators and unequal gender representation in the learner participants, which may impact simulation effectiveness. The findings support translating this simulation to other forms of bias education in future simulation development.

RéSUMé: La formation médicale englobe l'éducation basée sur la simulation. Un sujet important qui a récemment été ajouté au programme de simulation de l'Université de Toronto est celui des préjugés inconscients. Ce projet d'innovation éducative évalue une simulation qui pourrait être utilisée comme une nouvelle stratégie de conception pédagogique pour enseigner les préjugés inconscients. La simulation a impliqué deux scénarios de réanimation avec une trajectoire clinique similaire. Chaque réanimation a été menée par des médecins standardisés de sexe binaire différent, suivis d'un débriefing avec des facilitateurs hautement qualifiés. Après la simulation, on a discuté de points concrets à retenir sur la variation de la dynamique d'équipe entre les différents chefs d'équipe selon le sexe, en soulignant les avantages pour l'éducation des résidents sur la sensibilisation aux préjugés et la réponse. Les limites comprennent des préjugés inconscients inévitables chez les animateurs et une représentation inégale des sexes chez les apprenants participants, ce qui peut avoir une incidence sur l'efficacité de la simulation. Les résultats appuient la traduction de cette simulation à d'autres formes de formation sur les préjugés dans le développement futur de la simulation.

Origin and arrangement of actin filaments for gliding motility in apicomplexan parasites revealed by cryo-electron tomography.

The phylum Apicomplexa comprises important eukaryotic parasites that invade host tissues and cells using a unique mechanism of gliding motility. Gliding is powered by actomyosin motors that translocate host-attached surface adhesins along the parasite cell body. Actin filaments (F-actin) generated by Formin1 play a central role in this critical parasitic activity. However, their subcellular origin, path and ultrastructural arrangement are poorly understood. Here we used cryo-electron tomography to image motile Cryptosporidium parvum sporozoites and reveal the cellular architecture of F-actin at nanometer-scale resolution. We demonstrate that F-actin nucleates at the apically positioned preconoidal rings and is channeled into the pellicular space between the parasite plasma membrane and the inner membrane complex in a conoid extrusion-dependent manner. Within the pellicular space, filaments on the inner membrane complex surface appear to guide the apico-basal flux of F-actin. F-actin concordantly accumulates at the basal end of the parasite. Finally, analyzing a Formin1-depleted Toxoplasma gondii mutant pinpoints the upper preconoidal ring as the conserved nucleation hub for F-actin in Cryptosporidium and Toxoplasma. Together, we provide an ultrastructural model for the life cycle of F-actin for apicomplexan gliding motility.

Application of the Modified Early Obstetrical Warning System (MEOWS) in postpartum patients in the emergency department.

INTRODUCTION: Over the last two decades, there has been a steady rise in severe maternal morbidity and pregnancy-related deaths in Canada and the USA. The Modified Early Obstetric Warning System (MEOWS) is a risk stratification tool designed to predict severe maternal morbidity and mortality and has been validated for use in obstetrical wards. The objective of this study was to determine if MEOWS could accurately identify patients at risk of severe maternal morbidity and mortality in the ED setting. METHODS: This was a chart review of patients presenting to an academic tertiary care centre (annual ED census 65,000) with a postpartum complaint within 6 weeks of delivery between May 2020 and March 2022. The exposure was the presence of a trigger, defined as one severely abnormal (red) or two mildly abnormal (yellow) physiological measurements during the ED visit. The diagnostic accuracy of the tool to identify patients at risk of severe maternal morbidity severe maternal morbidity or mortality was estimated by calculating the sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: Two hundred and sixty-seven patients were included, of which 21 (7.9%) met the criteria for severe maternal morbidity. There were no maternal deaths. Overall, the sensitivity of the MEOWS tool was 85.7% (95% CI 63.7-97.0%), specificity was 67.9% (95% CI 61.7-73.7%), positive predictive value was 18.6% (95% CI 15.1-22.7%), and negative predictive value was 98.2% (95% CI 95.1-99.4%). Severe preeclampsia and eclampsia were the most common outcome category of severe maternal morbidity, representing 16 (76.2%) cases. Most patients (86.5%) were discharged directly from the ED, and 90.0% did not return within 30 days. CONCLUSIONS: This study is the first to explore the utility of MEOWS in postpartum ED patients. The presence of a MEOWS trigger at ED triage or the first ED nursing assessment was associated with severe maternal morbidity. Thus, MEOWS may be a valuable tool to identify postpartum patients at risk of severe outcomes early in an ED visit.

RéSUMé: INTRODUCTION: Au cours des deux dernières décennies, la morbidité maternelle grave et les décès liés à la grossesse ont connu une augmentation constante au Canada et aux États-Unis. Le système d'alerte précoce en obstétrique modifié (Modified Early Obstetric Warning System, MEOWS) est un outil de stratification des risques conçu pour prédire la morbidité et la mortalité maternelles graves. Il a été validé pour être utilisé dans les services d'obstétrique. L'objectif de cette étude était de déterminer si le MEOWS pouvait identifier avec précision les patientes présentant un risque de morbidité et de mortalité maternelles graves dans le contexte des urgences. MéTHODES: Il s'agit d'une étude des dossiers des patientes qui se sont présentées dans un centre de soins tertiaires universitaires (recensement annuel des urgences : 65 000) avec une plainte post-partum dans les six semaines suivant l'accouchement, entre mai 2020 et mars 2022. L'exposition était la présence d'un facteur déclenchant, défini comme une mesure physiologique gravement anormale (rouge) ou deux mesures légèrement anormales (jaune) au cours de la visite au service des urgences. La précision diagnostique de l'outil pour identifier les patientes à risque de morbidité maternelle grave morbidité maternelle grave ou de mortalité a été estimée en calculant la sensibilité, la spécificité, la valeur prédictive positive et la valeur prédictive négative. RéSULTATS: 267 patientes ont été incluses, dont 21 (7,9 %) répondaient aux critères de morbidité maternelle sévère. Il n'y a pas eu de décès maternel. Globalement, la sensibilité de l'outil MEOWS était de 85,7 % (IC 95 % : 63,7 %-97,0 %), la spécificité de 67,9 % (IC 95 % : 61,7 %-73,7 %), la valeur prédictive positive de 18,6 % (IC 95 % : 15,1 %-22,7 %) et la valeur prédictive négative de 98,2 % (IC 95 % : 95,1 %-99,4 %). La pré-éclampsie sévère et l'éclampsie étaient la catégorie d'issue la plus fréquente de la morbidité maternelle sévère, représentant 16 (76,2 %) cas. La plupart des patients (86,5 %) sont sortis directement des urgences et 90,0 % ne sont pas revenus dans les 30 jours. CONCLUSIONS: Cette étude est la première à explorer l'utilité du MEOWS chez les patientes des urgences post-partum. La présence d'un déclencheur MEOWS lors du triage aux urgences ou de la première évaluation infirmière aux urgences était associée à une morbidité maternelle grave. Ainsi, le MEOWS peut être un outil précieux pour identifier les patientes du post-partum qui risquent d'avoir des conséquences graves dès le début d'une visite aux urgences.

Myo19 tethers mitochondria to endoplasmic reticulum-associated actin to promote mitochondrial fission.

Mitochondrial homeostasis requires a dynamic balance of fission and fusion. The actin cytoskeleton promotes fission, and we found that the mitochondrially localized myosin, myosin 19 (Myo19), is integral to this process. Myo19 knockdown induced mitochondrial elongation, whereas Myo19 overexpression induced fragmentation. This mitochondrial fragmentation was blocked by a Myo19 mutation predicted to inhibit ATPase activity and strong actin binding but not by mutations predicted to affect the working stroke of the motor that preserve ATPase activity. Super-resolution imaging indicated a dispersed localization of Myo19 on mitochondria, which we found to be dependent on metaxins. These observations suggest that Myo19 acts as a dynamic actin-binding tether that facilitates mitochondrial fragmentation. Myo19-driven fragmentation was blocked by depletion of either the CAAX splice variant of the endoplasmic reticulum (ER)-anchored formin INF2 or the mitochondrially localized F-actin nucleator Spire1C (a splice variant of Spire1), which together polymerize actin at sites of mitochondria-ER contact for fission. These observations imply that Myo19 promotes fission by stabilizing mitochondria-ER contacts; we used a split-luciferase system to demonstrate a reduction in these contacts following Myo19 depletion. Our data support a model in which Myo19 tethers mitochondria to ER-associated actin to promote mitochondrial fission.

Demographic characteristics, outcomes and experience of patients using virtual urgent care services from 14 emergency department led sites in Ontario.

INTRODUCTION: As part of the COVID-19 pandemic response, the Ontario Ministry of Health funded a virtual care pilot program intended to support emergency department (ED) diversion of patients with low acuity complaints and reduce the need for face-to-face contact. The objective was to describe the demographic characteristics, outcomes and experience of patients using the provincial pilot program. METHODS: This was a prospective cohort study of patients using virtual care services provided by 14 ED-led pilot sites from December 2020 to September 2021. Patients who completed a virtual visit were invited by email to complete a standardized, 25-item online survey, which included questions related to satisfaction and patient-reported outcome measures. RESULTS: There were 22,278 virtual visits. When patients were asked why they contacted virtual urgent care, of the 82.7% patients who had a primary care provider, 31.0% said they could not make a timely appointment with their family physician. Rash, fever, abdominal pain, and COVID-19 vaccine queries represented 30% of the presenting complaints. Of 19,613 patients with a known disposition, 12,910 (65.8%) were discharged home and 3,179 (16.2%) were referred to the ED. Of the 2,177 survey responses, 94% rated their overall experience as 8/10 or greater. More than 80% said they had answers to all the questions they had related to their health concern, believed they were able to manage the issue, had a plan they could follow, and knew what to do if the issue got worse or came back. CONCLUSIONS: Many presenting complaints were low acuity, and most patients had a primary care provider, but timely access was not available. Future work should focus on health equity to ensure virtual care is accessible to underserved populations. We question if virtual urgent care can be safely and more economically provided by non-emergency physicians.

RéSUMé: INTRODUCTION: Dans le cadre de la réponse à la pandémie de COVID-19, le ministère de la Santé de l'Ontario a financé un programme pilote de soins virtuels visant à soutenir la réorientation vers les services d'urgence des patients présentant des problèmes de faible acuité et à réduire le besoin de contact en personne. L'objectif était de décrire les caractéristiques démographiques, les résultats et l'expérience des patients utilisant le programme pilote provincial. MéTHODES: Il s'agissait d'une étude de cohorte prospective de patients utilisant des services de soins virtuels fournis par 14 sites pilotes dirigés par des services d'urgence, de décembre 2020 à septembre 2021. Les patients qui ont effectué une visite virtuelle ont été invités par courriel à répondre à une enquête en ligne standardisée de 25 questions, qui comprenait des questions relatives à la satisfaction et aux résultats rapportés par les patients. RéSULTATS: Il y a eu 22 278 visites virtuelles. Lorsqu'on a demandé aux patients pourquoi ils avaient contacté les soins urgents virtuels, sur les 82,7 % de patients qui avaient un prestataire de soins primaires, 31,0 % ont répondu qu'ils n'avaient pas pu obtenir un rendez-vous en temps voulu avec leur médecin de famille. Les éruptions cutanées, la fièvre, les douleurs abdominales et les interrogations sur le vaccin COVID-19 représentaient 30 % des plaintes présentées. Sur les 19 613 patients dont la disposition était connue, 12 910 (65,8 %) ont été renvoyés chez eux et 3 179 (16,2 %) ont été orientés vers les urgences. Sur les 2 177 réponses à l'enquête, 94 % ont attribué une note de 8/10 ou plus à leur expérience globale. Plus de 80 % d'entre eux ont déclaré avoir obtenu des réponses à toutes les questions qu'ils se posaient sur leur problème de santé, se croire capables de le gérer, avoir un plan qu'ils pouvaient suivre et savoir quoi faire si le problème s'aggravait ou revenait. CONCLUSIONS: De nombreuses plaintes présentées étaient de faible acuité, et la plupart des patients avaient un fournisseur de soins primaires, mais l'accès en temps opportun n'était pas disponible. Les travaux futurs devraient se concentrer sur l'équité en matière de santé pour s'assurer que les soins virtuels sont accessibles aux populations mal desservies et nous nous demandons si ces services peuvent être fournis en toute sécurité et de manière plus économique par des médecins non urgentistes.

Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis.

OBJECTIVE: Anterior shoulder dislocations are commonly treated in the emergency department (ED). Analgesia for reduction is provided by intra-articular lidocaine (IAL) injection or intravenous sedation (IV sedation). The objective of this systematic review and meta-analysis was to compare IAL versus IV sedation for closed reduction of acute anterior shoulder dislocation in the ED. METHODS: Electronic searches of MEDLINE and EMBASE (1946-September 2021) were completed and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing IAL and IV sedation for reduction of acute anterior shoulder dislocations among patients ≥ 15 years old in the ED were included. Outcomes of interest included a successful reduction, adverse events, ED length of stay, pain scores, procedure time, ease of reduction, patient satisfaction, and cost. Two reviewers independently screened abstracts, assessed study quality and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RR) with 95% confidence intervals (CIs). RESULTS: 12 RCTs were included with a total of 630 patients (IAL = 327; IV sedation = 303). There was no difference in reduction success between IAL and IV sedation (RR 0.93; 95% CI 0.86-1.01, I2 = 69%), significantly lower adverse events with IAL (RR 0.16; 95% CI 0.07-0.33, I2 = 0%), shorter ED length of stay with IAL (mean difference - 1.48; 95% CI - 2.48 to - 0.47, I2 = 93%), no difference in pain scores post-analgesia and no difference in ease of reduction. CONCLUSIONS: Intra-articular lidocaine may have similar effectiveness as IV sedation in the successful reduction of anterior shoulder dislocations in the ED with fewer adverse events, shorter ED length of stay, and no difference in pain scores or ease of reduction. Intra-articular lidocaine may be an effective alternative to IV sedation for reducing anterior shoulder dislocations, particularly when IV sedation is contraindicated or not feasible.

RéSUMé: OBJECTIF: Les luxations antérieures de l'épaule sont couramment traitées au service des urgences (SU). L'analgésie pour la réduction est fournie par une injection intra-articulaire de lidocaïne (IAL) ou par une sédation intraveineuse (sédation IV). L'objectif de cette revue systématique et méta-analyse était de comparer la sédation IAL par rapport à la sédation IV pour la réduction fermée de la luxation antérieure aiguë de l'épaule aux urgences. MéTHODES: Des recherches électroniques ont été effectuées sur MEDLINE et EMBASE (1946-septembre 2021) et les listes de références ont été consultées manuellement. Les essais contrôlés randomisés (ECR) comparant la sédation IAL et IV pour la réduction des luxations antérieures aiguës de l'épaule chez les patients ≥ 15 ans aux urgences ont été inclus. Les résultats d'intérêt comprenaient une réduction réussie, les effets indésirables, la durée de séjour aux urgences, les scores de douleur, la durée de la procédure, la facilité de réduction, la satisfaction du patient et le coût. Deux examinateurs ont indépendamment passé en revue les résumés, évalué la qualité des études et extrait les données. Les données ont été regroupées à l'aide de modèles à effets aléatoires et présentées sous forme de différences moyennes et de rapports de risque (RR) avec des intervalles de confiance (IC) à 95 %. RéSULTATS: 12 ECR ont été inclus avec un total de 630 patients (IAL = 327 ; sédation IV = 303). Il n'y avait pas de différence dans le succès de réduction entre la sédation IAL et la sédation IV (RR = 0,93; IC à 95 % : 0,86 à 1,01, I2 = 69 %), événements indésirables significativement plus faibles avec IAL (RR = 0,16; IC à 95 % : 0,07 à 0,33, I2 = 0 %), durée de séjour plus courte avec IAL (différence moyenne = -1,48; IC à 95 % : -2,48 à -0,47, I2 = 93 %), aucune différence dans les scores de douleur après l'analgésie et aucune différence dans la facilité de réduction. CONCLUSIONS: La lidocaïne intra-articulaire peut avoir une efficacité similaire à celle de la sédation IV dans la réduction réussie des luxations antérieures de l'épaule aux urgences avec moins d'effets indésirables, une durée de séjour aux urgences plus courte et aucune différence dans les scores de douleur ou la facilité de réduction. La lidocaïne intra-articulaire peut être une alternative efficace à la sédation IV pour réduire les luxations antérieures de l'épaule, en particulier lorsque la sédation IV est contre-indiquée ou impossible.

Antibiotic prescribing and outcomes for patients with uncomplicated purulent skin and soft tissue infections in the emergency department.

INTRODUCTION: Current guidelines suggest adjuvant antibiotics after incision and drainage (I&D) of small, uncomplicated abscesses may improve patient outcomes, minimize pain, and prevent recurrence. The objective was to explore antibiotic prescribing at ED discharge and describe patient outcomes. METHODS: This was a health records review of adult patients (≥ 18 years) discharged from an academic hospital ED (annual census 65,000) over a 2-year period with diagnosis of an uncomplicated skin abscess. Outcomes included any unplanned return ED visits within 30 days, repeat I&D, and escalation to intravenous (IV) antibiotics. RESULTS: Of 389 ED visits, 85.6% patients underwent I&D, of which 62.2% were prescribed antibiotics at discharge. Of these patients, 36.7% received guideline recommended antibiotics (TMP-SMX or clindamycin). Of all patients who underwent I&D, 13.2% had an unplanned return ED visit within 30 days, 6.9% required repeat I&D, and 0.6% patients were escalated to IV antibiotics. Patients treated with cefalexin were more likely to have an unplanned return ED visit within 30 days (20.0 vs 5.3%; Δ14.7, 95% CI 4.6-24.4), and were more likely to have a repeat I&D within 30 days (13.7 vs 0%; Δ13.7, 95% CI 6.4-22.0), compared to patients prescribed guideline recommended antibiotics. Treatment with guideline recommended antibiotics reduced treatment failure significantly in MRSA positive patients (0.0 vs 44.4%; Δ44.4, 95% CI 13.4-73.3). CONCLUSIONS: Antibiotics were prescribed for most abscesses that underwent I&D. Less than half of the patients received antibiotics that were guideline recommended. Compared to those who received cefalexin, patients prescribed TMP-SMX or clindamycin had fewer return ED visits and were less likely to have a repeat I&D within 30 days. However, adjuvant antibiotic use did not significantly improve outcomes overall, with most patients not requiring a change in management irrespective of antibiotic use.

RéSUMé: OBJECTIFS: Les lignes directrices actuelles suggèrent que les adjuvants aux antibiotiques après l'incision et le drainage (I&D) des petits abcès simples peuvent améliorer les résultats pour les patients, réduire la douleur et prévenir la récidive. L'objectif était d'explorer la prescription d'antibiotiques à la sortie des urgences et de décrire les résultats pour les patients. MéTHODES: Il s'agissait d'une étude des dossiers médicaux des patients adultes (≥ 18 ans) sortis des urgences d'un hôpital universitaire (recensement annuel 65 000) sur une période de deux ans avec un diagnostic d'abcès cutané non compliqué. Les résultats comprenaient toutes les visites de retour non planifiées aux urgences dans les 30 jours, la répétition de l'I&D et l'escalade vers des antibiotiques intraveineux (IV). RéSULTATS: Sur 389 visites aux urgences, 85,6 % des patients ont subi une I&D, dont 62,2 % se sont vu prescrire des antibiotiques à la sortie. Parmi ces patients, 36,7 % ont reçu les antibiotiques recommandés par les directives (TMP-SMX ou clindamycine). Sur l'ensemble des patients ayant subi une I&D, 13,2 % ont eu une visite non planifiée aux urgences dans les 30 jours, 6,9 % ont dû subir une nouvelle I&D et 0,6 % des patients ont eu recours à une antibiothérapie IV. Les patients traités par la céfalexine étaient plus susceptibles d'avoir une visite de retour imprévue à l'urgence dans les 30 jours 20,0 % vs 5,3 % ; Δ14,7, IC 95 % : 4,6 à 24,4), et étaient plus susceptibles d'avoir une I&D répétée dans les 30 jours (13,7 % vs 0 % ; Δ13,7, IC 95 % : 6,4 à 22,0), par rapport aux patients auxquels on a prescrit des antibiotiques recommandés par les lignes directrices. Le traitement avec les antibiotiques recommandés par les lignes directrices a réduit de manière significative l'échec thérapeutique chez les patients positifs au SARM (0,0 % vs 44,4 % ; Δ44,4, IC 95 % : 13,4 à 73,3). CONCLUSIONS: Des antibiotiques ont été prescrits pour la plupart des abcès ayant fait l'objet d'une I&D. Moins de la moitié des patients ont reçu des antibiotiques recommandés par les lignes directrices. Par rapport à ceux qui ont reçu de la céfalexine, les patients à qui l'on a prescrit du TMP-SMX ou de la clindamycine ont eu moins de visites de retour aux urgences et étaient moins susceptibles de subir une nouvelle I&D dans les 30 jours. Toutefois, l'utilisation des adjuvants aux antibiotiques n'a pas amélioré de façon significative les résultats dans l'ensemble, la plupart des patients n'ayant pas besoin d'un changement de prise en charge, quelle que soit l'utilisation d'antibiotiques.

Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures: A Population-Based Cohort Study.

STUDY OBJECTIVE: Temporary lower limb immobilization may be a risk for venous thromboembolism. The purpose of this study was to examine the 90-day incidence of venous thromboembolism among patients discharged from an emergency department (ED) with ankle fractures requiring temporary immobilization. Secondary objectives were to examine individual factors associated with venous thromboembolism in this population and to compare the risk of venous thromboembolism in patients with ankle fractures against a priori-selected control groups. METHODS: This was a retrospective cohort study using province-wide health datasets from Ontario, Canada. We included patients aged 16 years and older discharged from an ED between 2013 and 2018 with closed ankle fractures requiring temporary immobilization. We estimated 90-day incidence of venous thromboembolism after ankle fracture. A Cox proportional hazards model was used to evaluate risk factors associated with venous thromboembolism, censoring at 90 days or death. Patients with ankle fractures were then propensity score matched to 2 control groups: patients discharged with injuries not requiring lower limb immobilization (ie, finger wounds and wrist fractures) to compare relative hazard of venous thromboembolism. RESULTS: There were 86,081 eligible patients with ankle fractures. Incidence of venous thromboembolism within 90 days was 1.3%. Factors associated with venous thromboembolism were older age (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39), venous thromboembolism or superficial venous thrombosis history (HR: 5.18; 95% CI: 4.33 to 6.20), recent hospital admission (HR: 1.33; 95% CI: 1.05 to 1.68), recent nonankle fracture surgery (HR: 1.58; 95% CI: 1.30 to 1.93), and subsequent surgery for ankle fracture (HR: 1.80; 95% CI: 1.48 to 2.20). In the matched cohort, patients with ankle fractures had an increased hazard of venous thromboembolism compared to matched controls with finger wounds (HR: 6.31; 95% CI: 5.30 to 7.52) and wrist fractures (HR: 5.68; 95% CI: 4.71 to 6.85). CONCLUSION: The 90-day incidence of venous thromboembolism among patients discharged from the ED with ankle fractures requiring immobilization was 1.3%. These patients had a 5.7- to 6.3-fold increased hazard compared to matched controls. Certain patients immobilized for ankle fractures are at higher risk of venous thromboembolism, and this should be recognized by emergency physicians.

A new giant keelback slug of the genus Limax from the Balkans, described by citizen scientists.

Background: Despite their large size, striking colouration and genital extravagance, the taxonomy of the European giant keelback slugs of the genus Limax is still poorly understood. Preliminary morphological and molecular data suggest that many unnamed or unrecognised species exist, especially in the Alps, the Mediterranean and the Balkans. New information: We organised a citizen science expedition to Durmitor National Park in Montenegro and discovered a new species, genetically distinct, but morphologically similar to the sympatric L.cinereoniger Wolf 1803 and describe it as L.pseudocinereoniger.

The Effect of a Nurse Initiated Therapeutic Conversation Compared to Standard Care for Patients With Acute Pain in the ED: A Randomized Controlled Trial.

Acute pain is a common presenting complaint in the emergency department (ED) and is most often treated with opioid or nonopioid analgesia. However, studies have shown that receiving analgesia alone does not always influence patient satisfaction with pain management in the ED. Pain anxiety and catastrophizing have been shown to affect pain intensity and patients' response to analgesia. The objective of this study was to determine whether a brief therapeutic conversation would improve patient satisfaction with pain management compared with standard care for adult patients presenting to the ED with moderate to severe acute pain. Adult (18 years or older) patients presenting to the ED with moderate to severe acute pain were randomized to either the standard care group or the intervention group. Patients in the intervention group participated in a brief therapeutic conversation with an ED nurse to discuss their perceived cause of pain, level of anxiety, and expectations of their pain management. Prior to discharge, all patients were asked to complete a self-reported, 9-item questionnaire to assess their level of satisfaction with their overall ED experience. A total of 166 patients (83 in each group) were enrolled. Patient satisfaction with ED pain management and the proportion of patients who received analgesia in the ED were similar in both the control (n = 57; 68.7%) and intervention (n = 58; 69.9%) groups (Δ 1.2%; 95% CI [12.6, 15]). Qualitative findings demonstrate that patients place high importance on acknowledgment from ED staff and worry about the unknown cause of pain. This study suggests that patient satisfaction with pain management in the ED is multifactorial and complex. Further research should investigate additional methods of integrating nurse-led interventions into the care of patients in acute pain.

Antibiotic prescribing and use of corticosteroids for the emergency department management of acute uncomplicated pharyngitis.

BACKGROUND: Acute pharyngitis is common in the ambulatory setting. The Modified Centor score uses five criteria to predict Group A Streptococcus (GAS) infection and can be used to guide management. OBJECTIVE: The objective of this study was to describe the emergency department (ED) management (throat cultures, antibiotics and corticosteroids) of acute, uncomplicated pharyngitis by Centor score. METHODS: This was a retrospective chart review of adult (>17 years) patients with an ED discharge diagnosis of acute pharyngitis from January 2016 to December 2018. RESULTS: Of 638 patients included, 286 (44.8%) had a Centor score of 0-1, 328 (51.4%) had a score of 2-3 and 24 (3.8%) had a score of ≥4. Of those with a Centor score of 0-1, 83 (29.0%) had a throat culture, 88 (30.8%) were prescribed antibiotics, 15 (5.2%) were positive for GAS and 74 (25.9%) received corticosteroids. Of those with a Centor score of 2-3, 156 (47.6%) had a throat culture, 220 (67.1%) were prescribed antibiotics, 44 (13.4%) were positive for GAS and 145 (44.2%) received corticosteroids. Of those with a Centor score ≥4, 14 (58.3%) had a throat culture, 18 (75.0%) were prescribed antibiotics, 7 (29.2%) were positive for GAS and 12 (50.0%) received corticosteroids. CONCLUSIONS: A higher Centor score was associated with a higher risk of GAS infection, increased antibiotic prescribing and use of corticosteroids. Many patients with low Centor scores were prescribed antibiotics and had throat cultures. Further work is required to understand clinical decision-making for the management of acute pharyngitis.

Influence of electronic triage decision-support on hospital admission, left without being seen and time to physician initial assessment in the emergency department.

OBJECTIVE: To explore the impact of the implementation of eCTAS, a real-time electronic decision-support tool, on hospital admission, rate of left without being seen, and time from triage to physician initial assessment. METHODS: We conducted a cohort study using population-based administrative data from all Ontario emergency departments (EDs) that had implemented eCTAS for 9 months. We compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥ 18 years) patients if they had one of 16 pre-specified, high-volume presenting complaints. Multivariable logistic regression and quantile regression models informed the effect of eCTAS on outcomes. RESULTS: We included data from 354,176 triage encounters from 31 EDs. There was a change in the distribution of triage scores post-eCTAS, with fewer patients classified as CTAS 2 and CTAS 3, and more patients classified as CTAS 1 and CTAS 4. Overall, hospital admission decreased post-eCTAS (adjusted OR: 0.98; 95% CI: 0.97 to 1.00), with fewer CTAS 2 and more CTAS 3 and CTAS 4 patients admitted post-eCTAS. The rate of left without being seen increased (2.8% vs. 3.0%; adjusted OR: 1.07; 95% CI: 1.03 to 1.11) post-eCTAS, while time to physician initial assessment proved similar pre and post-eCTAS. CONCLUSIONS: eCTAS implementation had little impact on admission, rate of left without being seen and time to physician initial assessment. eCTAS appears to reclassify patients from higher to lower acuity scores, resulting in higher admission rates for CTAS 3 and CTAS 4 patients. It remains unknown if this reclassification is appropriate.

RéSUMé: OBJECTIF: Étudier l'impact de la mise en œuvre de l'eCTAS, un outil électronique d'aide à la décision en temps réel, sur l'admission à l'hôpital, le taux de personnes qui ne sont pas vues et le délai entre le triage et l'évaluation initiale du médecin. LES MéTHODES: Nous avons mené une étude de cohorte en utilisant les données administratives basées sur la population de tous les services d'urgence (SU) de l'Ontario qui avaient mis en place l'eCTAS depuis 9 mois. Nous avons comparé les données de six mois après l'eCTAS aux mêmes données de six mois de l'année précédente (avant l'eCTAS). Nous avons inclus les rencontres de triage des patients adultes (≥ 18 ans) s'ils présentaient l'une des 16 plaintes pré-spécifiées à haut volume. Des modèles de régression logistique multivariable et de régression quantile ont permis d'évaluer l'effet de l'eCTAS sur les résultats. RéSULTATS: Nous avons inclus les données de 354 176 rencontres de triage provenant de 31 services d'urgence. Il y a eu un changement dans la distribution des scores de triage après l'eCTAS, avec moins de patients classés comme CTAS 2 et CTAS 3, et plus de patients classés comme CTAS 1 et CTAS 4. Dans l'ensemble, les admissions à l'hôpital ont diminué après l'eCTAS (RC ajusté: 0,98 ; 95 % IC 0,97 à 1,00), avec moins de patients CTAS 2 et plus de patients CTAS 3 et CTAS 4 admis après eCTAS. Le taux de personnes laissées sans surveillance a augmenté (2,8 % contre 3,0 % ; RC ajusté : 1,07 ; 95 % IC 1,03 à 1,11) après l'eCTAS, tandis que le délai avant l'évaluation initiale par le médecin s'est avéré similaire avant et après l'eCTAS. CONCLUSIONS: La mise en œuvre de l'eCTAS a eu peu d'impact sur l'admission, le taux de patients laissés sans consultation et le temps nécessaire à l'évaluation initiale par le médecin. L'eCTAS semble reclasser les patients des scores d'acuité supérieurs aux scores d'acuité inférieurs, ce qui entraîne des taux d'admission plus élevés pour les patients CTAS 3 et CTAS 4. On ignore encore si ce reclassement est approprié.

Illuminating the planktonic stages of salmon lice: A unique fluorescence signal for rapid identification of a rare copepod in zooplankton assemblages.

Monitoring of planktonic salmon louse (Lepeophtheirus salmonis salmonis) abundance and parameterization of key life-history traits has been hindered by labour-intensive and error-prone quantification using traditional light microscopy. Fluorescence illumination has been proposed as a means of improving visualization, but prior to this study adequate investigation of the relevant fluorescence profiles and measurement conditions has not been undertaken. We investigated the fluorescence profiles of L. salmonis and non-target copepod spp. with excitation and emission matrices (200-600 nm) and identified unique fluorescence signals. Fluorescence microscopy using excitation wavelengths of 470 ± 40 nm, and emission wavelengths of 525 ± 50 nm, showed that after 90 days of formalin storage salmon lice have a mean fluorescence intensity that is 2.4 times greater than non-target copepods (copepodid and adult stages). A 7-day heat treatment of 42°C in formalin increased the difference between salmon louse copepodids and non-target copepods to a factor of 3.6, eliminating the need for prolonged storage. Differences in the fluorescence signal and endogenous fluorophores were investigated with respect to variation in sea lice species, age, stage and host fish origin. Under the conditions outlined in this paper, the fluorescence signal was found to be a reliable means of visualizing and differentiating salmon lice from non-target zooplankters. Adaptation of the fluorescence signal would greatly expedite traditional methods of enumerating salmon louse larvae in plankton samples and could provide a means of automated detection.

Hydraena (s.str.) dinarica, new species (Coleoptera: Hydraenidae) along with further records of Hydraena spp. from Durmitor National Park, Montenegro and comments on the DNA barcoding problem with the genus.

BACKGROUND: Long-palped Water Beetles were collected during a taxon expedition in Montenegro which involved citizen scientists, students and taxonomists. The material was collected from springs, brooks, fens and the Tara River, at altitudes between 600 m and 1450 m above sea level, using fine-meshed hand-nets and by manual checking of submerged substrates. The morphological species delimitation was supplemented and congruent with mtDNA sequences mainly obtained in the field using the newly-developed MinION-based ONTrack pipeline. NEW INFORMATION: The new species Hydraena dinarica Freitag & de Vries, sp. n. from Durmitor Mt. is described, illustrated and compared in detail to closely-related congeners of the H. saga d'Orchymont, 1930/H. emarginata Rey, 1885 species complex. Five additional species and female specimens of two unidentified morphospecies of the genus were also recorded in the vicinity of Durmitor National Park. New records and the first DNA barcodes for Hydraena biltoni Jäch & Díaz, 2012 (endemic to Montenegro) and H. morio Kiesenwetter, 1849 are provided. Further records of H. nigrita Germar, 1824, H. minutissima Stephens, 1829, H. subintegra Ganglbauer, 1901 and females of two unidentified morphospecies are commented upon. The resulting inter- and intraspecific genetic distances and some observations of low or zero sequence divergence between recently-diverged species of Hydraena Kugelann, 1794 are briefly discussed.

Predictors of persistent concussion symptoms in adults with acute mild traumatic brain injury presenting to the emergency department.

OBJECTIVE: To identify risk factors associated with persistent concussion symptoms in adults presenting to the emergency department (ED) with acute mild traumatic brain injury (TBI). METHODS: This was a secondary analysis of a randomized controlled trial conducted in three Canadian EDs whereby the intervention had no impact on recovery or healthcare utilization outcomes. Adult (18-64 years) patients with a mild TBI sustained within the preceding 48 h were eligible for enrollment. The primary outcome was the presence of persistent concussion symptoms at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire. RESULTS: Of the 241 patients who completed follow-up, median (IQR) age was 33 (25 to 50) years, and 147 (61.0%) were female. At 30 days, 49 (20.3%) had persistent concussion symptoms. Using multivariable logistic regression, headache at ED presentation (OR: 7.7; 95% CI 1.6 to 37.8), being under the influence of drugs or alcohol at the time of injury (OR: 5.9; 95% CI 1.8 to 19.4), the injury occurring via bike or motor vehicle collision (OR: 2.9; 95% CI 1.3 to 6.0), history of anxiety or depression (OR: 2.4; 95% CI 1.2 to 4.9), and numbness or tingling at ED presentation (OR: 2.4; 95% CI 1.1 to 5.2), were found to be independently associated with persistent concussion symptoms at 30 days. CONCLUSIONS: Five variables were found to be significant predictors of persistent concussion symptoms. Although mild TBI is mostly a self-limited condition, patients with these risk factors should be considered high risk for developing persistent concussion symptoms and flagged for early outpatient follow-up.

RéSUMé: OBJECTIFS: Identifier les facteurs de risque associés aux symptômes persistants consécutifs à une commotion cérébrale chez les adultes se présentant au service des urgences avec un traumatisme cranio-cérébral aiguë. MéTHODES: Il s'agissait d'une analyse secondaire d'un essai contrôlé randomisé mené dans trois services d'urgence Canadien, dans lequel l'intervention n'a eu aucun impact sur le rétablissement ou les conséquences d'utilisation des soins de santé. L'essai clinique a été effectuée sur les patients adultes (âgés de 18 à 64 ans) avec un traumatisme cranio-cérébral léger (TCCL) soutenu dans les 48 heures précédentes. Le critère principal de jugement était la présence des symptômes de traumatisme crânien 30 jours après la commotion, définie comme la présence d'au moins 3 symptômes dans le questionnaire Rivermead sur les symptômes post-commotionnels. RéSULTATS: Parmi les 241 patients qui ont terminé le suivi, l'âge médian (EI) était de 33 ans (25 à 50) et 147 (61,0 %) étaient des femmes. À 30 jours, 49 (20,3 %) présentaient des symptômes persistants. En utilisant une régression logistique multivariée, des maux de tête à la présentation aux services d'urgence (OR: 7,7; IC à 95 % : 1,6 à 37,8), être sous l'influence de drogues ou d'alcool au moment de la commotion (OR : 5,9; IC à 95 % : 1,8 à 19,4), la blessure survenue à la suite d'une collision à vélo ou à moteur (OR : 2,9; IC à 95 %: 1,3 à 6,0), des antécédents d'anxiété ou de dépression (OR : 2,4; IC à 95 % : 1,2 à 4,9) et un engourdissement ou des picotements lors de la présentation aux services d'urgence (OR : 2,4; IC à 95 % : 1,1 à 5,2), se sont avérés être indépendamment associés aux symptômes persistants consécutifs à une commotion cérébrale à 30 jours CONCLUSIONS: Cinq variables se sont révélées être des indicateurs significatifs des symptômes persistants consécutifs à une commotion cérébrale. Bien que le TCCL soit principalement une condition auto-limitée, les patients présentant ces facteurs de risque doivent être considérés comme à haut risque de développer des symptômes persistants et signalés pour un suivi ambulatoire précoce.

A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury.

BACKGROUND: There is a paucity of effective management strategies to prevent prolonged symptoms following mild traumatic brain injury (mTBI), and emerging evidence suggesting possible benefits of exercise. The objective of this trial was to determine whether adult patients presenting to the emergency department (ED) with a diagnosis of acute mTBI prescribed light exercise were less likely to develop persistent postconcussion symptoms (PCS). METHODS: This was a randomized controlled trial conducted in three Canadian EDs. Consecutive, adult (18-64 years) ED patients with an mTBI sustained within the preceding 48 hours were eligible for enrollment. The intervention group received discharge instructions prescribing 30 minutes of daily light exercise, and the control group was given standard mTBI instructions advising gradual return to exercise following symptom resolution. The primary outcome was the proportion of patients with PCS at 30 days, defined as the presence of three or more symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ). RESULTS: A total of 367 patients were enrolled (control group, n = 184; intervention, n = 183). Median age was 32 years and 201 (57.6%) were female. There was no difference in the proportion of patients with PCS at 30 days (control, 13.4% vs intervention, 14.6%; ∆1.2%, 95% confidence interval [CI] = -6.2 to 8.5). There were no differences in median change of RPQ scores, median number of return health care provider visits, median number of missed school or work days, or unplanned return ED visits within 30 days. Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35; ∆5, 95% CI = 2 to 15). CONCLUSION: In this trial of prescribed early light exercise for acute mTBI, there were no differences in recovery or health care utilization outcomes. Results suggest that early light exercise may be encouraged as tolerated at ED discharge following mTBI, but this guidance is not sufficient to prevent PCS.

Consistency of triage scores by presenting complaint pre- and post-implementation of a real-time electronic triage decision support tool.

OBJECTIVE: eCTAS is a real-time electronic decision-support tool designed to standardize the application of the Canadian Triage and Acuity Scale (CTAS). This study addresses the variability of CTAS score distributions across institutions pre- and post-eCTAS implementation. METHODS: We used population-based administrative data from 2016-2018 from all emergency departments (EDs) that had implemented eCTAS for 9 months. Following a 3-month stabilization period, we compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥17 years) patients who presented with 1 of 16 pre-specified, high-volume complaints. For each ED, consistency was calculated as the absolute difference in CTAS distribution compared to the average of all included EDs for each presenting complaint. Pre-eCTAS and post-eCTAS change scores were compared using a paired-samples t-test. We also assessed if eCTAS modifiers were associated with triage consistency. RESULTS: There were 363,214 (183,231 pre-eCTAS, 179,983 post-eCTAS) triage encounters included from 35 EDs. Triage scores were more consistent (P < 0.05) post-eCTAS for 6 (37.5%) presenting complaints: chest pain (cardiac features), extremity weakness/symptoms of cerebrovascular accident, fever, shortness of breath, syncope, and hyperglycemia. Triage consistency was similar pre- and post-eCTAS for altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication, and vertigo. Use of eCTAS modifiers was associated with increased triage consistency. CONCLUSIONS: eCTAS increased triage consistency across many, but not all, high-volume presenting complaints. Modifier use was associated with increased triage consistency, particularly for non-specific complaints such as fever and general weakness.

Lumbosacral Spinal Imaging for Patients Presenting to the Emergency Department With Nontraumatic Low Back Pain.

BACKGROUND: Choosing Wisely Canada (CWC) guidelines recommend that in the absence of clinical indicators suggestive of serious underlying pathology, physicians should not order radiological imaging for patients presenting with nonspecific low back pain (LBP). OBJECTIVE: Our aim was to determine how many patients presenting to the emergency department (ED) with nontraumatic LBP had spinal imaging before and after the release of the CWC guideline. METHODS: We conducted a retrospective medical record review for patients aged 18-70 years presenting to an academic tertiary care ED with nontraumatic LBP from April 1, 2014 to March 31, 2015 (pre-guideline) and April 1, 2017 to March 31, 2018 (post-guideline). RESULTS: One-thousand and sixty (545 pre-guideline, 515 post-guideline) patients were included. Pre-guideline, 45 patients (8.3%) had spinal imaging compared to 39 (7.6%) post-guideline (Δ 0.7%; 95% confidence interval [CI] -2.6% to 4.0%). Of the 84 patients (7.9%) who had spinal imaging, 4 (8.9%) had pathologic findings pre-guideline compared to 11 patients (28.2%) post-guideline (Δ 19.3%; 95% CI 2.7% to 35.8%). CONCLUSIONS: CWC guidelines did not appear to alter the rate of imaging for patients presenting to the ED with nontraumatic LBP. Future clinical recommendations should consider active knowledge dissemination and education strategies to help facilitate guideline adoption.