Cost analysis and economic evaluation of a virtual pediatric emergency department pilot program.

OBJECTIVES: The Children's Hospital of Eastern Ontario launched Canada's first virtual pediatric emergency department (ED) from May 2020 through November 2021 to deliver accessible care during the COVID-19 pandemic. The objective of this study was to (i) conduct a cost analysis of the virtual pediatric ED, and (ii) compare the virtual costs to in-person ED costs to inform future resource allocation decisions. METHODS: We calculated costs from a health system perspective in 2021 Canadian dollars. Using a decision tree model, we compared expected costs with and without the virtual pediatric ED, and calculated overall and per patient cost savings of implementing the virtual ED. RESULTS: The virtual ED provided care to 7394 patients. In the base case, virtual care saved $890,000 ($120 per patient). One-way sensitivity analyses suggest overall cost savings were most sensitive to the proportion of virtual care patients who would have received in-person care had the virtual option not been available (range $300,000-$1,700,000), followed by ED overhead costs (range $640,000-$1,140,000). Multivariate sensitivity analyses demonstrated robust cost savings of $920,000 (95% CI 850,000-990,000) in a scenario using billing codes to calculate costs, and savings of $1,040,000 (95% CI 960,000-1,120,000) if physician salaries were used instead. CONCLUSIONS: These findings suggest the virtual pediatric ED reduced costs per patient. Virtual care may represent a financially valuable pediatric emergency department service.

ABSTRAIT: OBJECTIFS: Le Centre hospitalier pour enfants de l'Est de l'Ontario a lancé le premier service d'urgence pédiatrique (SU) virtuel du Canada de mai 2020 à novembre 2021 pour offrir des soins accessibles pendant la pandémie de COVID-19. L'objectif de cette étude est de i) effectuer une analyse des coûts du DE pédiatrique virtuel et ii) comparer les coûts virtuels aux coûts du DE, en personne pour éclairer les décisions futures en matière d'affectation des ressources. MéTHODES: Nous avons calculé les coûts du point de vue du système de santé en dollars canadiens de 2021. À l'aide d'un modèle d'arbre décisionnel, nous avons comparé les coûts prévus avec et sans le service d'urgence pédiatrique virtuel et calculé les économies globales et par patient découlant de la mise en œuvre du service d'urgence virtuel. RéSULTATS: Le service d'urgence virtuel a fourni des soins à 7 394 patients. Dans le cas de base, les soins virtuels ont permis d'économiser 890 000 $ (120 $ par patient). Les analyses de sensibilité unidirectionnelles donnent à penser que les économies de coûts globales étaient plus sensibles à la proportion de patients en soins virtuels qui auraient reçu des soins en personne si l'option virtuelle n'avait pas été disponible (fourchette de 300 000 $ à 1 700 000 $), suivie des frais généraux du SU (fourchette de 640 000 $ à 1 140 000 $). Les analyses de sensibilité à variables multiples ont démontré de solides économies de coûts de 920 000 $ (IC à 95 %, 850 000 à 990 000) dans un scénario utilisant des codes de facturation pour calculer les coûts, et des économies de 1 040 000 $ (IC à 95 %, 960 000 à 1 120 000) si les salaires des médecins étaient utilisés à la place. CONCLUSIONS: Ces résultats suggèrent que le SU pédiatrique virtuel a réduit les coûts par patient. Les soins virtuels peuvent représenter un service d'urgence pédiatrique financièrement utile.

Concurrent versus terminal feedback: The effect of feedback delivery on lumbar puncture skills in simulation training.

INTRODUCTION: Simulation-based medical education (SBME) is widely used to teach bedside procedural skills. Feedback is crucial to SBME but research on optimal timing to support novice learners' skill development has produced conflicting results. METHODS: We randomly assigned 32 novice medical students to receive feedback either during (concurrent) or after (terminal) trialing lumbar puncture (LP). Participants completed pre- and post-acquisition tests, as well as retention and transfer tests, graded on a LP checklist by two blinded expert raters. Cognitive load and anxiety were also assessed, as well as learners' perceptions of feedback. RESULTS: Participants who received concurrent feedback demonstrated significantly higher LP checklist scores (M = 91.54, SE = 1.90) after controlling for baseline levels, than those who received terminal feedback (M = 85.64, SE = 1.90), collapsed across post, retention, and transfer tests. There was no difference in cognitive load and anxiety between groups. In open-ended responses, participants who received concurrent feedback more often expressed satisfaction with their learning experience compared to those who received terminal feedback. DISCUSSION AND CONCLUSIONS: Concurrent may be superior to terminal feedback when teaching novice learners complex procedures and has the potential to improve learning if incorporated into SBME and clinical teaching. Further research is needed to elucidate underlying cognitive processes to explain this finding.

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.

Are 2 Radiographic Views As Good as 3 Views to Diagnose Ankle Fractures in Children and Adolescents?

OBJECTIVES: Ankle radiographs are among the most commonly obtained trauma images in the pediatric population, with the standard 3 views (AP/mortise [M]/lateral [L]) routinely ordered in the emergency department. The purpose of this study was to compare the diagnostic accuracy, sensitivity, and specificity of sets of 2 views (AP/L or M/L) with the standard 3 views. METHODS: One hundred twenty sets of ankle radiographs of skeletally immature patients obtained in the emergency department of a level 1 pediatric trauma center were used. These included sets with and without fractures. Sets of 3 and 2 views were reviewed by pairs of pediatric-trained orthopedic surgeons, radiologists, and emergency physicians. Each completed 3 randomized viewing sessions where all possible combinations for each set of radiographs were reviewed. Diagnoses for the 3 sets of views were compared for accuracy, sensitivity, and specificity. RESULTS: Overall accuracy, sensitivity, and specificity for all reviewers were as follows: AP/M/L 74%, 94%, and 90%, AP/L 71%, 90%, and 94%, as well as M/L 69%, 90%, and 91%. P values for accuracy, sensitivity, and specificity of AP/L and M/L compared with 3 views were 0.34, 0.04, and 0.52, as well as 0.04, 0.004, and 1.00, respectively. CONCLUSIONS: In skeletally immature patients, statistically significant differences in accuracy were obtained when comparing the standard 3 AP/M/L views with more limited M/L views, suggesting that this set of 2 views is not as accurate. Differences in sensitivity of limited views were also statistically significant. Conversely, differences in accuracy between the standard 3 views and AP/Lateral views were not statistically significant. While more limited AP/L views may be comparable in accuracy and specificity and lead to dramatically decreased radiation and costs, this can be at the expense of less diagnostic sensitivity and increased risk of misdiagnosing or missing certain fractures. LEVEL OF EVIDENCE: Level III.

How safe are paediatric emergency departments? A national prospective cohort study.

BACKGROUND: Despite the high number of children treated in emergency departments, patient safety risks in this setting are not well quantified. Our objective was to estimate the risk and type of adverse events, as well as their preventability and severity, for children treated in a paediatric emergency department. METHODS: Our prospective, multicentre cohort study enrolled children presenting for care during one of 168 8-hour study shifts across nine paediatric emergency departments. Our primary outcome was an adverse event within 21 days of enrolment which was related to care provided at the enrolment visit. We identified 'flagged outcomes' (such as hospital visits, worsening symptoms) through structured telephone interviews with patients and families over the 21 days following enrolment. We screened admitted patients' health records with a validated trigger tool. For patients with flags or triggers, three reviewers independently determined whether an adverse event occurred. RESULTS: We enrolled 6376 children; 6015 (94%) had follow-up data. Enrolled children had a median age of 4.3 years (IQR 1.6-9.8 years). One hundred and seventy-nine children (3.0%, 95% CI 2.6% to 3.5%) had at least one adverse event. There were 187 adverse events in total; 143 (76.5%, 95% CI 68.9% to 82.7%) were deemed preventable. Management (n=98, 52.4%) and diagnostic issues (n=36, 19.3%) were the most common types of adverse events. Seventy-nine (42.2%) events resulted in a return emergency department visit; 24 (12.8%) resulted in hospital admission; and 3 (1.6%) resulted in transfer to a critical care unit. CONCLUSION: In this large-scale study, 1 in 33 children treated in a paediatric emergency department experienced an adverse event related to the care they received there. The majority of events were preventable; most were related to management and diagnostic issues. Specific patient populations were at higher risk of adverse events. We identify opportunities for improvement in care.

About time! A scoping review of public-facing emergency department wait time displays in Canada.

PURPOSE: Waiting is a common experience for patients during an emergency department (ED) visit. While high acuity patients are seen with little delay, low acuity patients may experience dissatisfaction from prolonged wait times. One strategy to improve patient experience involves changing the perception of the wait by providing realistic expectations of wait times using public-facing wait time displays. The primary objective of this study is to quantify the number of Canadian EDs with online wait time displays and describe the features and type of information provided. METHODS: A systematic online search of all Canadian EDs was completed to identify EDs with public-facing wait time displays. A scoping review was then performed to assess their message characteristics, translations offered, availability of multi-site information, and accessibility features. Data were summarized using descriptive statistics. RESULTS: Sixty (9.3%) of the 647 Canadian EDs identified provide public-facing real-time wait time displays. Thirteen of these (21.7%) were associated with a single proprietary system. Distribution of wait time displays differs across Canada, with a range of zero to 100% of EDs within each province utilizing this communication tool. Common characteristics include "average" wait time (95%), graphical trend data (32%), number of patients waiting (33%), longest wait time (12%), and expected length of stay (10%). Sixty-two percent of wait time displays provide a combination of these methods to inform wait times. Important accessibility features include language translation, compliance with Canadian National Institute for the Blind (CNIB) accessibility guidelines and availability on a mobile application. CONCLUSION: Currently, there is emerging use of wait time displays in Canada with considerable variability in the information communicated through these tools. Effectiveness of these displays and their content needs to be determined.

RéSUMé: OBJECTIF: L'attente est une expérience courante pour les patients lors d'une visite au service des urgences (SU). Alors que les patients avec un niveau d'acuité élevé sont vus dans les plus brefs délais, les patients à faible degré d'acuité peuvent éprouver de l'insatisfaction à cause des temps d'attente prolongés. Une stratégie visant à améliorer l'expérience des patients consiste à modifier la perception de l'attente en fournissant des attentes réalistes en matière de temps d'attente au moyen d'affichages de temps d'attente destinés au public. L'objectif principal de la présente étude est de quantifier le nombre de services d'urgence canadiens qui affichent les temps d'attente en ligne et de décrire les caractéristiques et le type d'information fournie. MéTHODES: Une recherche systématique en ligne de tous les services d'urgence canadiens a été effectuée afin d'identifier les services d'urgence qui affichent les temps d'attente à l'intention du public. Un examen de la portée a ensuite été effectué pour évaluer les caractéristiques de leurs messages, les traductions offertes, la disponibilité d'informations multisites et les caractéristiques d'accessibilité. Les données ont été résumées à l'aide de statistiques descriptives. RéSULTATS: Soixante (9,3 %) des 647 urgences canadiennes recensées offrent au public un affichage en temps réel des temps d'attente. Treize d'entre eux (21,7 %) étaient associés à un seul système propriétaire. La répartition des affichages sur les temps d'attente varie d'un bout à l'autre du Canada, avec une fourchette de zéro à 100 % des services d'urgence dans chaque province utilisant cet outil de communication. Les caractéristiques communes comprennent le temps d'attente « moyen ¼ (95 %), les données de tendance graphique (32 %), le nombre de patients en attente (33 %), le temps d'attente le plus long (12 %) et la durée prévue du séjour (10 %). Soixante-deux pour cent des affichages des temps d'attente fournissent une combinaison de ces méthodes pour informer les temps d'attente. Les fonctionnalités d'accessibilité importantes incluent la traduction linguistique, la conformité aux directives d'accessibilité de l'Institut national canadien pour les aveugles (INCA) et la disponibilité sur une application mobile. CONCLUSION: À l'heure actuelle, l'utilisation des présentoirs sur les temps d'attente au Canada est de plus en plus répandue, et l'information communiquée au moyen de ces outils varie considérablement. L'efficacité de ces affichages et de leur contenu doit être déterminée.

Virtual care in the pediatric emergency department: a new way of doing business?

OBJECTIVES: To understand the feasibility, utilization rate, and satisfaction of the first Virtual Pediatric ED (V-PED) in Canada. METHODS: We conducted a prospective cohort study examining the feasibility and impact of virtual care as an adjunct to in-person emergency care at a tertiary pediatric hospital from May to July 2020. Children (< 18 years) from Ontario and Quebec seeking V-PED care were included. A secure, encrypted, video platform within the hospital's electronic medical record was used. Caregivers self-determined appropriateness of V-PED using a standardized online triage questionnaire to request their appointment. The V-PED is directly launched from the patient's chart and the family joins the portal via hyperlink. Outcome measures included the number of V-PED visits, hospital admission rates, and caregiver satisfaction using a 10-item voluntary post-visit online survey. RESULTS: A total of 1036 V-PED visits were seen of which 176 (17.0%) were referred for further in-person ED assessment, and 8 (0.8%) required hospital admission. Of the 107 completing patient experience surveys (10% response), most respondents (69%) endorsed they "very likely" or "definitely" would have presented in-person to the ED if V-PED were unavailable. Overall satisfaction was rated as excellent (9 or 10 out of 10) in 87% of respondents. CONCLUSION: Our novel V-PED is feasible, has high caregiver satisfaction, and can reduce the burden of in-person ED visits. Future work must ensure the safety of emergency virtual care and examine how to increase capacity and integrate V-PED within traditional emergency medicine.

RéSUMé: OBJECTIFS: Comprendre la faisabilité, le taux d'utilisation et la satisfaction du premier service d'urgence pédiatrique virtuel (V-PED) au Canada. MéTHODES: Nous avons mené une étude de cohorte prospective examinant la faisabilité et l'impact des soins virtuels comme complément aux soins d'urgence en personne dans un hôpital pédiatrique tertiaire de mai à juillet 2020. Les enfants (< 18 ans) de l'Ontario et du Québec cherchant à bénéficier d'une prise en charge par la V-PED ont été inclus. Une plateforme vidéo sécurisée et cryptée a été utilisée dans le dossier médical électronique de l'hôpital. Les soignants ont autodéterminé la pertinence du V-PED à l'aide d'un questionnaire de triage en ligne normalisé pour demander leur rendez-vous. Le V-PED est directement lancé à partir du dossier du patient et la famille rejoint le portail via un lien hypertexte. Les mesures des résultats comprenaient le nombre de visites de V-PED, les taux d'admission à l'hôpital et la satisfaction des soignants à l'aide d'une enquête en ligne volontaire en 10 points après la visite. RéSULTATS: Au total, 1036 visites de DEP-V ont été effectuées, dont 176 (17,0 %) ont fait l'objet d'une évaluation approfondie en personne aux urgences, et 8 (0,8 %) ont nécessité une hospitalisation. Sur les 107 répondants aux enquêtes sur l'expérience des patients (10 % de réponses), la plupart (69 %) ont déclaré qu'ils se seraient "très probablement" ou "certainement" présentés en personne aux urgences si la V-PED n'était pas disponible. La satisfaction globale a été jugée excellente (9 ou 10 sur 10) par 87 % des répondants. CONCLUSION: Notre nouveau V-PED est réalisable, donne une grande satisfaction aux soignants et peut réduire le fardeau des visites en personne aux urgences. Les travaux futurs doivent garantir la sécurité des soins virtuels d'urgence et examiner comment augmenter la capacité et intégrer la V-PED dans la médecine d'urgence traditionnelle.

Adverse events in the paediatric emergency department: a prospective cohort study.

BACKGROUND: Understanding adverse events among children treated in the emergency department (ED) offers an opportunity to improve patient safety by providing evidence of where to focus efforts in a resource-restricted environment. OBJECTIVE: To estimate the risk of adverse events, their type, preventability and severity, for children seen in a paediatric ED. METHODS: This prospective cohort study examined outcomes of patients presenting to a paediatric ED over a 1-year period. The primary outcome was the proportion of patients with an adverse event (harm to patient related to healthcare received) related to ED care within 3 weeks of their visit. We conducted structured telephone interviews with all patients and families over a 3-week period following their visit to identify flagged outcomes (such as repeat ED visits, worsening symptoms) and screened admitted patients' health records with a validated trigger tool. For patients with flagged outcomes or triggers, three ED physicians independently determined whether an adverse event occurred. RESULTS: Of 1567 eligible patients, 1367 (87.2%) were enrolled and 1319 (96.5%) reached in follow-up. Median patient age was 4.34 years (IQR 1.5 to 10.57 years) and most (n=1281; 93.7%) were discharged. Among those with follow-up, 33 (2.5%, 95% CI 1.8% to 3.5%) suffered an adverse event related to ED care. None experienced more than one event. Twenty-nine adverse events (87.9%, 95% CI 72.7% to 95.2%) were deemed preventable. The most common types of adverse events (not mutually exclusive) were management issues (51.5%), diagnostic issues (45.5%) and suboptimal follow-up (15.2%). CONCLUSION: One in 40 children suffered adverse events related to ED care. A high proportion of events were preventable. Management and diagnostic issues warrant further study.

Keeping busy learners informed: email is most useful for medical residents!

BACKGROUND: Educators need to ensure trainees have access to the rotation orientation information they need in the most effective way possible. We wanted to find the best method to distribute this information. METHODS: We provided post-graduate medical trainees rotating through the Pediatric Emergency Medicine program at the Children's Hospital of Eastern Ontario in Ottawa, Canada, the regular rotation information package three ways: email, online, and paper. We surveyed them to find out which method(s) they used and which they found most useful. RESULTS: All trainees were able to access the electronic orientation package via email and most found this method useful. Most also found the paper package distributed at the orientation helpful. Few accessed the online wiki site. CONCLUSION: Using email is efficient and effective and can save both the time and cost of producing paper packages. The wiki site was not used frequently in our cohort, but may be worth future exploration.

Education in the Waiting Room: Description of a Pediatric Emergency Department Educational Initiative.

OBJECTIVE: The aim of this study was to understand parents' awareness of and reactions to a slide presentation based waiting-room educational initiative. METHODS: This was a prospective observational study at a Canadian tertiary-care pediatric emergency department (ED) with an annual census of 68,000 visits. An anonymous parental survey was developed de novo, and parents were asked to complete the survey during their low-acuity ED visit over a 2-week study period. Descriptive statistics were used to describe responses and themes. RESULTS: Parents completed 520 surveys (733 approached, 70.9% response rate). Eighty-three percent of respondents had previously sought care in the ED. Most parents (68.9%) were aware of the slide presentation, but only 33.7% were able to watch it in its entirety (20 minutes' duration). Of those who watched the whole presentation, 62.9% understood that lower-acuity cases are assessed in the ambulatory zone of the ED, and sicker children are assessed in the acute zone (89.4%), 79.9% felt the presentation helped them to understand how the ambulatory zone functions, and 83.2% appreciated the current wait-time information. General questions about common health concerns were answered correctly in 58.3% (fever), 56.0% (gastroenteritis), 50.5% (abdominal pain/constipation), 35.7% (earache), and 17.0% (head injury). CONCLUSIONS: The majority of parents were aware of this waiting-room educational initiative, but there was variable uptake of information. Parents watching the entire presentation appreciated the information provided, especially wait-time information, and felt it improved their experience. Knowledge of common health conditions was low; novel methods of knowledge transfer must be utilized and evaluated.

A qualitative exploration of which resident skills parents in pediatric emergency departments can assess.

BACKGROUND: Residents must strive for excellence in their nontechnical skills (NTS). However, NTS have not traditionally been well-assessed in pediatric emergency departments (EDs). One underutilized assessment strategy is to have parents assess the residents caring for their children. Prior to involving parents in resident assessment, it is essential to identify which NTS parents in pediatric EDs can assess. AIM: To explore which resident NTS parents in pediatric EDs can assess. METHODS: An exploratory qualitative study design was used. It included interviews with faculty members involved in the supervision and assessment of residents in a pediatric ED and residents who had experience working in a pediatric ED, as well as focus groups with parents who had visited a pediatric ED at least twice in the past year. RESULTS: Participants in this study suggested that parents, if provided with the opportunity, can assess residents' communication skills, comfort in a pediatric setting, adaptability, and collaboration. CONCLUSIONS: This study demystifies how parents can become involved in the assessment of residents' NTS. The findings will inform the development of assessment strategies and could be used to develop assessment instruments that enable parents to become actively involved in the assessment of residents in pediatric EDs.

KDM4B is a master regulator of the estrogen receptor signalling cascade.

The importance of the estrogen receptor (ER) in breast cancer (BCa) development makes it a prominent target for therapy. Current treatments, however, have limited effectiveness, and hence the definition of new therapeutic targets is vital. The ER is a member of the nuclear hormone receptor superfamily of transcription factors that requires co-regulator proteins for complete regulation. Emerging evidence has implicated a small number of histone methyltransferase (HMT) and histone demethylase (HDM) enzymes as regulators of ER signalling, including the histone H3 lysine 9 tri-/di-methyl HDM enzyme KDM4B. Two recent independent reports have demonstrated that KDM4B is required for ER-mediated transcription and depletion of the enzyme attenuates BCa growth in vitro and in vivo. Here we show that KDM4B has an overarching regulatory role in the ER signalling cascade by controlling expression of the ER and FOXA1 genes, two critical components for maintenance of the estrogen-dependent phenotype. KDM4B interacts with the transcription factor GATA-3 in BCa cell lines and directly co-activates GATA-3 activity in reporter-based experiments. Moreover, we reveal that KDM4B recruitment and demethylation of repressive H3K9me3 marks within upstream regulatory regions of the ER gene permits binding of GATA-3 to drive receptor expression. Ultimately, our findings confirm the importance of KDM4B within the ER signalling cascade and as a potential therapeutic target for BCa treatment.

Does postural stability affect the performance of eye-hand coordination in stroke survivors?

OBJECTIVE: The aim of this study was to investigate eye-hand coordination in stroke survivors while sitting and standing and its relationship with sensorimotor performance. DESIGN: This was a cross-sectional study conducted at university-based rehabilitation center. Fifteen stroke survivors performed a fast finger-pointing task toward a visual target moving at 10 cm/sec from the contralateral side toward the moving arm in sitting and standing positions. Reaction time, movement time, and pointing accuracy were measured. Anteroposterior, medial-lateral, and total sway were also measured during the standing trials. Several sensorimotor impairments were also measured to correlate with the eye-hand coordination performance. RESULTS: A significantly shorter reaction time was found in the nonparetic than the paretic side when standing, but not when sitting. The movement time of the paretic side was significantly faster when standing when compared with sitting. Fast pointing with the paretic arm significantly increased the total sway path and anteroposterior displacement while standing compared with pointing with the nonparetic arm. Movement time of the paretic arm was negatively correlated with handgrip strength and the strength of the elbow flexors and wrist extensors. CONCLUSIONS: The movement time of eye-hand coordination of stroke survivors was affected by postural stability. Correlations were found between pointing performance and several sensorimotor impairments.