Emergency Departments In Edmonton Research Articles

LO62: Cannabis-induced psychotic disorder at a Canadian tertiary care emergency department

Introduction: Acute psychosis is a disruptive change in mental state that requires the mobilization of significant resources for its immediate treatment and ongoing management in the emergency department (ED). Cannabis-induced psychotic disorder (CIP) is one potential cause; however, the diagnosis may be overlooked due to limited understanding of the etiology of CIP. Methods: This study employed a retrospective cohort analysis of all CIP cases admitted from a tertiary care ED in Edmonton, Alberta between 10/2016 and 10/2018 – the month cannabis was legalized in Canada. Charts were identified based on a most responsible diagnosis of CIP, as defined by ICD-10 code F12.5. Two reviewers abstracted data using a standardized form, which was entered into a database; 10% of charts were analyzed by both reviewers to examine inter-rater reliability. Patients were excluded if there was any documentation of methamphetamine use within the week prior to presentation. Outcomes included management, symptom profile, and length of stay. Results: In total there were 44 cases of CIP identified in 40 unique patients during the two-year period. The largest age group of patients (n = 14, 35%) were between 15-20 years old and the median length of admission was 6 days. A minority of patients (n = 13, 32.5%) had a previous psychiatric diagnosis. A distinct clinical picture evolved during the summation of patient symptoms in the ED with 65% of patients (n = 26) exhibiting persecutory delusions and 52.5% endorsing auditory hallucinations (n = 21). Only four patients were found to have visual hallucinations, three of which also had auditory hallucinations. Most patients (n = 34, 85%) were treated with an antipsychotic medication in the ED and during their time as inpatients, but only 70% of patients were prescribed an antipsychotic medication at the time of discharge (n = 28). Conclusion: This study is the first of its kind describing a cohort of patients with CIP in a Canadian ED setting. The patients presenting to the ED who would later be diagnosed CIP were more likely to be 15-20 years old, experiencing persecutory delusions, and unlikely to be experiencing isolated visual hallucinations. With the recent legalization of cannabis in Canada, further prospective research is required to determine any changes in the characteristics, incidence, and prevalence of CIP, as well as data from other centers to look for any regional differences in the presentation and management of CIP.

Parents' information needs and preferences related to bronchiolitis: a qualitative study.

Bronchiolitis affects more than one-third of children less than age 2 years and can cause substantial anxiety for parents, leading them to seek information on how to care for their sick child. The aim of our qualitative study was to explore the information needs and preferences of parents caring for a child with bronchiolitis. We used a qualitative descriptive approach. Participants were recruited by means of purposive sampling from Oct. 1, 2017, to Mar. 15, 2018 from the Stollery Children's Hospital emergency department, a specialized pediatric emergency department in Edmonton. Individual semistructured interviews were conducted. Fifty-three parents were recruited to participate, of whom 30 could not be reached after 4 contact attempts and 8 refused. Thus, 15 parents participated (16 children). Three major themes were identified: 1) parents' information needs about bronchiolitis, 2) parents' preferred information sources and 3) parents' preferred information delivery formats. Participants indicated that they want and require credible, easy-to-understand information about bronchiolitis in a variety of formats, and especially valued information obtained directly from a health care professional or an evidence-based website. This study provides important information about parents' information needs concerning bronchiolitis in children. Identifying the information that parents want and value in relation to acute pediatric illnesses is imperative to developing innovative educational approaches for parents that reflect patient-centred care.

Management of acute venous thromboembolism among a cohort of patients discharged directly from the emergency department

ObjectiveTo report the proportion of patients discharged directly from the emergency department (ED) on traditional therapy (parenteral anticoagulant±warfarin) or a direct oral anticoagulant (DOAC) for the management of acute venous...

P154: Exploring health care connections and transitions in care for patients presenting to emergency departments with acute wheezing illnesses

Introduction: Asthma and/or chronic obstructive pulmonary disease (COPD) exacerbations often result in emergency department (ED) visits. This study examined the health-related personnel providing regular care to patients with asthma and/or COPD, as well as, explored the coordination of care between the ED and outpatient settings. Methods: Descriptive cross-sectional examination of patients presenting with asthma and/or COPD exacerbations to two EDs in Edmonton between August and December 2017. Using patient interview methods information on demographics, established health care connections and health system use was collected; information on consultations, disposition and referrals was collected through chart review methods. Results: A total of 50 patients were recruited (14 patients with asthma and 36 patients with COPD). Most of the patients with asthma were female (64%) and their median age was 36 years (interquartile range [IQR]: 29, 46); sex was evenly distributed among the patients with COPD and their median age was 68 years (IQR: 61, 78). The majority reported having a family doctor (86% of the patients with asthma and 94% of the patients with COPD). On the day of admission to the ED, 29% of the patients with asthma visited their family doctor while 42% of the patients with COPD visited their Respirologist; these doctors referred >70% of the patients to the ED. While in the ED, consultations were requested in 21% of the patients with asthma (all to Pulmonary) and in 78% of the patients with COPD (evenly divided between Medicine and Pulmonary). Transition coordinators and social workers were involved in the ED care of <15% of the patients with COPD. Most patients with asthma were discharged home (86%) and 64% of the patients with COPD were hospitalized. After discharge, 14% of the patients with asthma and 50% of the patients with COPD were referred to specialized care. Conclusion: While the study patients with asthma and COPD had different health professionals providing regular care to their respiratory conditions, they both sought care before presenting to the ED. More health professionals were involved in the ED care of patients with COPD than of those with asthma. This study provided important information to support further research projects exploring ways to effectively and efficiently improve the delivery, comprehensiveness and utilization of health care services.

LO46: Sex-based differences in concussion symptom reporting and self-reported outcomes in a general adult ED population

Introduction: Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. To-date, study of sex-based concussion differences in general adult populations have been limited. This study examined sex-based differences in concussion outcomes. Methods: Adult (>17 years) patients presenting to one of three urban EDs in Edmonton, Alberta with Glasgow coma scale score 13 within 72 hours of a concussive event were recruited by on-site research assistants. Follow-up calls at 30 and 90 days post ED discharge captured extent of PCS using the Rivermead Post-Concussion questionnaire (RPQ), effect on daily living activities measured by the Rivermead Head Injury Questionnaire (RHIQ), and overall health-related quality of life using the 12-item Short Form Health Survey (SF-12). Dichotomous and categorical variables were compared using Fishers exact test; continuous variables were compared using t-tests or Mann-Whitney tests, as appropriate. Results: Overall, 130/250 enrolled patients were female. The median age was 35 years; men trended towards being younger (median=32 years; IQR: 23, 45) than women (median=40 years; IQR: 22, 52). Compared to women, more men were single (56% vs 38% (p=0.007) and employed (82% vs 71% (p=0.055). Men and women experienced different injury mechanisms (p=0.007) with more women reporting injury due to a fall (44% vs 26%), while more men were injured at work (16% vs 7%) or due to an assault (11% vs. 3%). Men had a higher return to ED rate (13% vs. 5%; p=0.015). Women had higher RPQ scores at baseline (p<0.001) and 30-day follow-up (p=0.001); this difference was not significant by 90 days (p=0.099). While women reported on the RHIQ at 30 days that their injury affected their usual activities significantly more than men (Median=5, IQR: 0, 11 vs. median=0.5, IQR: 0.5, 7; p=0.004), both groups had similar scores on the SF-12 physical composite and mental composite scales at all three measurement points. Conclusion: In a general ED concussion population, demographic differences exist between men and women. Based on self-reported and objective outcomes, womens usual activities may be more affected by concussion and PCS than men. Further analysis of these differences is required in order to identify different treatment options and ensure adequate care and treatment of injury.

LO95: A prospective evaluation of mild traumatic brain injuries in a working population in Edmonton, AB

Introduction: Patients with mild traumatic brain injury (mTBI) frequently present to the emergency department (ED); however, wide variation in diagnosis and management has been demonstrated in this setting. Sub-optimal mTBI management can contribute to post-concussion syndrome (PCS), affecting vocational outcomes like return to work. This study documented the work-related events, ED management, discharge advice, and outcomes for employed patients presenting to the ED with mTBI. Methods: Adult (>17 years) patients presenting to one of three urban EDs in Edmonton, Alberta with Glasgow coma scale score ≥13 within 72 hours of a concussive event were recruited by on-site research assistants. Follow-up calls ascertained outcomes, including symptoms and their severity, advice received in the ED, and adherence to discharge instructions, at 30 and 90 days after ED discharge. Dichotomous variables were analyzed using chi-square testing; continuous variables were compared using t-tests or Mann-Whitney tests, as appropriate. Work-related injury and return to work outcomes were modelled using logistic or linear regression, as appropriate. Results: Overall, 250 patents were enrolled; 172 (69%) were employed at the time of their injury and completed at least one follow-up. The median age was 37 years (interquartile range [IQR]: 24, 49.5), both sexes were equally represented (48% male), and work-related concussions were uncommon (16%). Work-related concussion was related to manual labor jobs and self-reported history of attention deficit disorder. Patients often received advice to avoid sports (81%) and/or work (71%); however, the duration of recommended time off varied. Most employed patients (80%) missed at least one day of work (median=7 days; IQR: 3, 14); 91% of employees returned to work by 90 days, despite 41% reporting persistent symptoms. Increased days of missed work were linked to divorce, history of sleep disorder, and physician’s advice to avoid work. Conclusion: While work-related concussions are uncommon, most employees who sustain a mTBI at any time miss some work. Many patients experience mTBI symptoms past 90 days, which has serious implications for workers’ abilities to fulfill their work duties and risk of subsequent injury. Workers, employers, and the workers compensation system should take the necessary precautions to ensure that workers return to work safely and successfully following a concussion.

P057: Diagnosis for mild traumatic brain injury in three Canadian emergency departments: missed opportunities

Introduction: Patients with mild traumatic brain injury (mTBI) often present to the emergency department (ED). Incorrect diagnosis may delay appropriate treatment and recommendations for these patients, prolonging recovery. Notable proportions of missed mTBI diagnosis have been documented in children and athletes, while diagnosis of mTBI has not been examined in the general adult population. Methods: A prospective cohort study was conducted in one academic (site 1) and two non-academic (sites 2 and 3) EDs in Edmonton, Canada. On-site research assistants enrolled adult (>17 years) patients presenting within 72 hours of the injury event with clinical signs of mTBI and Glasgow comma scale score ≥13. Patient demographics, injury characteristics, and ED flow information were collected by chart review. Physician-administered questionnaires and patient interviews documented the recommendations given by emergency physicians at discharge. Bi-variable comparisons are reported using Pearson’s chi-square tests, Student’s t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. Results: Overall, 130/250 enrolled patients were female, and the median age was 35. Proportions of successfully diagnosed mTBI varied significantly across study sites (Site 1: 89%; Site 2: 73%, Site 3: 53%; p>0.001). Patients without a diagnosis were less likely to receive a recommendation to follow-up with their family physician (OR=0.08; 95% CI: 0.03, 0.21) or advice about return to work (OR=0.17; 95% CI: 0.08, 0.04) or physical activity (OR=0.08; 95% CI: 0.04, 0.17). Patients with missed diagnoses had longer ED stays (median=5.0 hours; IQR: 3.8, 7.0) compared with diagnosed mTBI patients (median=3.9 hours; IQR: 3.0, 5.3). In the adjusted model, patients presenting to non-academic centers had reduced likelihood of mTBI diagnosis (Site 2: OR=0.21; 95% CI: 0.08, 0.58; Site 3: OR=0.07; 95% CI: 0.02, 0.24). Conclusion: The diagnostic accuracy of physicians assessing patients presenting with symptoms of mTBIs to these three EDs is suboptimal. The rates of missed diagnosis vary among EDs and were associated with length of ED stay. Closer examination of institutional factors, including diagnosis processes and personnel factors such as physician training, is needed to identify effective strategies to heighten the awareness of mTBI presentations.

Risk of heart failure after community acquired pneumonia: prospective controlled study with 10 years of follow-up

Objective To determine the attributable risk of community acquired pneumonia on incidence of heart failure throughout the age range of affected patients and severity of the infection.Design Cohort study.Setting Six...

LO087: Emergency department patients’ connection to primary care providers: reasons for lack of connection

Introduction: Some non-urgent/low-acuity Emergency Department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study surveyed patients who presented to the ED and explored their self-reported reasons and barriers for not being connected to a primary care provider (PCP). Methods: Patients aged 17 years and older were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada. Following initial triage, stabilization, and verbal informed consent, patients completed a 47-item questionnaire. Data from the survey were cross-referenced to a minimal patient dataset consisting of ED and demographic information. The questionnaire collected information on patient characteristics, their connection to a PCP, and patients' reasons for not having a PCP. Results: Of the 2144 eligible patients, 1408 (65.7%) surveys were returned and 1402 (65.4%) were completed. The majority of patients (74.4%) presenting to the ED reported having a family physician; however, the ‘closeness’ of the connection to their family physician varied greatly among ED patients with the most recent family physician visit ranging from 1 hour before ED presentation to 45 years prior. Approximately 25% of low acuity ED patients reported no connection with a family physician. Reasons for a lack of PCP connection included: prior physician retired, left, or died (19.8%), they had never tried to find one (19.2%), they had recently moved to Alberta (18.0%), and they were unable to find one (16.5%). Conclusion: A surprisingly high proportion of ED patients (25.6%) have no identified PCP. Patients had a variety of reasons for not having a family physician. These need to be understood and addressed in order for primary care access to successfully contribute to diverting non-urgent, low acuity presentations from the ED.

LO091: Non-urgent presentations to the emergency department: patients’ reasons for presentation

Introduction: Some low acuity Emergency Department (ED) presentations are considered non-urgent or convenience visits and potentially avoidable with improved access to primary care. This study explored self-reported reasons why non-urgent patients presented to the ED. Methods: Patients, 17 years and older, were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada during weekdays (0700 to 1900). A 47-item questionnaire was completed by each consenting patient, which included items on whether the patient believed the ED was their best care option and the rationale supporting their response. A thematic content analysis was performed on the responses, using previous experience and review of the literature to identify themes. Results: Of the 2144 eligible patients, 1408 (65.7%) questionnaires were returned, and 1402 (65.4%) were analyzed. For patients who felt the ED was their best option (n = 1234, 89.3%), rationales included: safety concerns (n = 309), effectiveness of ED care (n = 284), patient-centeredness of ED (n = 277), and access to health care professionals in the ED (n = 204). For patients who felt the ED was not their best care option (n = 148, 10.7%), rationales included a perception that: access to health professionals outside the ED was preferable (n = 39), patient-centeredness (particularly timeliness) was lacking in the ED (n = 26), and their health concern was not important enough to require ED care (n = 18). Conclusion: Even during times when alternative care options are available, the majority of non-urgent patients perceived the ED to be the most appropriate location for care. These results highlight that simple triage scores do not accurately reflect the appropriateness of care and that understanding the diverse and multi-faceted reasons for ED presentation are necessary to implement strategies to support non-urgent, low acuity care needs.

Ten-Year Mortality after Community-acquired Pneumonia. A Prospective Cohort.

Information on the long-term prognosis after community-acquired pneumonia (CAP) is limited. To determine if CAP increases adverse long-term outcomes relative to a control population. Between 2000 and 2002, 6,078 adults with CAP from six hospitals and seven emergency departments in Edmonton (AB, Canada) were prospectively recruited and matched on age, sex, and site of treatment with five control subjects without pneumonia (n = 29,402). Mortality, hospitalizations, and emergency department admissions through 2012 were evaluated using multivariable Cox proportional hazards analyses adjusted for socioeconomic status and comorbidities. Average age was 59 years (2,682 [44%] ≥ 65 yr), 3,214 (53%) were men, and 3,425 (56%) were managed as outpatients. Over a median of 9.8 years, 2,858 patients with CAP died compared with 9,399 control subjects (absolute risk difference, 30 per 1,000 patient years [py]; adjusted hazard ratio [aHR], 1.65; 95% confidence interval, 1.57-1.73; P < 0.001). Patients with CAP who were younger than 25 years old had the lowest absolute rate difference for mortality (4 per 1,000 py; aHR, 2.40), and patients older than 80 years old had the highest absolute rate difference (92 per 1,000 py; aHR, 1.42). Absolute rates of all-cause hospitalization, emergency department visits, and CAP-related visits were all significantly higher in patients with CAP compared with control subjects (P < 0.001 for all comparisons). Our results indicate that an episode of CAP confers a high risk of long-term adverse events compared with the general population who have not experienced CAP, and this is irrespective of age.

Assessing the Use of International Classification of Diseases-10th Revision Codes From the Emergency Department for the Identification of Acute Heart Failure

ObjectivesThe objective of this study was to compare administrative codes with chart review for patients with acute heart failure (AHF). BackgroundAdministrative databases are used in population health research; however, the validity of codes in the emergency department (ED) for AHF compared with chart review is uncertain. MethodsA cohort of 952 patients with suspected AHF were prospectively recruited from 4 EDs in Edmonton, Alberta, Canada, from 2009 to 2012. Patients had their diagnoses adjudicated by expert physicians using a standardized scoring system and detailed chart review. ED and hospital discharge International Classification of Diseases-10th Revision (ICD-10) codes were captured in the main diagnosis or in any diagnostic field. ResultsThe 897 patients had a median age of 77 years (interquartile range: 67 to 85 years), and 806 (90%) were admitted to the hospital. Overall, 809 patients (90.2%) had AHF by adjudication and 660 (73.6%) had ICD-10 code I50.x as a main diagnosis in the ED administrative data, respectively. The positive predictive value of an AHF main diagnosis in the ED administrative data was 93.3% (95% confidence interval [CI]: 92.0% to 94.7%), with sensitivity of 76.1% (95% CI: 75.0% to 77.2%) and specificity of 50.0% (95% CI: 39.8% to 60.1%). The positive predictive value for AHF in any diagnostic field of the ED administrative data was 92.0% (95% CI: 91.1% to 93.0%), with a sensitivity of 89.4% (95% CI: 88.5% to 90.4%) and specificity of 28.4% (95% CI: 20.1% to 37.9%). ConclusionsAn ICD-10 I50.x diagnosis in the ED is highly predictive of AHF compared with chart-level adjudication using a validated score. Thus, the use of these codes in ED administrative databases could identify AHF for clinical and epidemiological studies.

Medication transitions and polypharmacy in older adults following acute care

Background/objectiveMedication changes at transitions of care and polypharmacy are growing concerns that adversely impact optimal drug use. We aimed to describe transitions and patterns of medication use before and 1 year after older patients were hospitalized for community-acquired pneumonia, the second-most common reason for admission in North America.Materials and methodsThis was an analysis of a population-based clinical registry of patients treated in any of the six hospitals or seven emergency departments in Edmonton, Alberta, Canada, comprising 2,105 patients 65 years and older with community-acquired pneumonia who had survived at least 1 year. The prevalence of polypharmacy (five or more unique prescription drugs), as well as new use and persistence of common drug classes were assessed.ResultsThe mean age was 78 years (standard deviation 8 years), 50% were female, 62% were hospitalized, and 58% had severe pneumonia. Among the 2,105 patients, 949 (45%) were using five or more medications prior to hospitalization, increasing to 1,559 (74%) within 90 days postdischarge and remaining over 70% at 1 year. Overall, 1,690 (80%) patients newly started and 1,553 (74%) patients stopped at least one medication in the first 90 days of follow-up. The prevalence of the most common drug classes (ie, cardiovascular, alimentary/metabolism) remained stable, with the exception of anti-infective agents, whereby 25% of patients were dispensed an anti-infective agent 3 months to 1 year after hospitalization.ConclusionMost older patients with pneumonia are subject to polypharmacy, and almost every patient had a medication started or stopped during 1-year follow-up, with 25% using antibiotics again. The period following an episode of pneumonia represents an opportunity potentially to optimize pharmacotherapy.

Hockey-Related Emergency Department Visits After a Change in Minor Hockey Age Groups

To examine ice hockey injury rates presenting to emergency departments (EDs) in 2 separate cohorts of players before and after a policy change for age groups in minor hockey. : Retrospective cross-sectional study. Retrospective review of ice hockey injuries presenting to 2 tertiary care and 5 community care EDs in Edmonton, Alberta. Two cohorts of minor ice hockey players were constructed. The pre-age change cohort consisted of 4215 registered male hockey players. The post-age change cohort consisted of 3811 registered male hockey players. The risk of fracture, head and neck injury (intracranial and nonintracranial), and all other injuries presenting to EDs were compared between the pre-age change and post-age change cohorts. Presentation to an ED with an injury occurring in ice hockey between September 1 and April 31 for the years 1997 through 2010. Overall, significantly lower injury rates were observed in the post-age change cohort for players in the Peewee division; however, no significant differences were observed for the rate of fractures, and intracranial or nonintracranial head and neck injuries. There were no statistically significant differences observed between the pre-age change and post-age change cohorts in the Atom or Bantam divisions. Introducing body checking 1 year earlier than in a previous cohort (11 vs 12 years of age) neither significantly decreased nor increased the rate of serious ice hockey injuries occurring 2 years after the introduction of body checking. Further research is recommended to evaluate the claim that introducing body checking lowers injury rates in older divisions of hockey.

Beliefs and Expectations of Canadian Parents Who Bring Febrile Children for Medical Care

The purpose of this survey was to study the beliefs, expectations, and satisfaction of Canadian parents regarding fever and the treatment of their febrile children. A survey was developed exploring caregiver beliefs and treatment strategies, as well as expectations and satisfaction with medical care. Some items were modeled after previous studies to allow comparison. Caregivers with febrile children were recruited from 2005 to 2007 at 3 urgent care centers and emergency departments in Edmonton, Canada: a pediatric emergency department (n = 376), an urban urgent care center (n = 227), and a suburban urgent care clinic (n = 173). High and rapidly rising temperature, as well as physical symptoms associated with fever, caused concern in most parents surveyed. Seventy-four percent of parents felt that the elevated temperature from fever was dangerous and 90.3% always try to treat it. Forty degrees Celsius was the most commonly sited threshold for danger. Identifying the cause (80.6%) and seriousness (87.4%) of fever were the most com-mon stressors identified. Caregivers expected to receive information about the child's illness and appropriate treatment. The parents most often wanted information about febrile seizures and the potential dangers of febrile illness. Only 16.7% of caregivers expected anti-biotics. Nearly 92% of subjects were usually satisfied with medical care. Fever phobia continues to be a significant issue for Canadian parents. As a result, they treat fever aggressively and often seek medical attention. Good communication is important for medical staff caring for febrile children and typically leads to satisfied parents.

Population-based cohort study of outpatients with pneumonia: rationale, design and baseline characteristics

BackgroundThe vast majority of research in the area of community-acquired pneumonia (CAP) has been based on patients admitted to hospital. And yet, the majority of patients with CAP are treated on an ambulatory basis as outpatients, either by primary care physicians or in Emergency Departments. Few studies have been conducted in outpatients with pneumonia, and there is a paucity of data on short and long term morbidity or mortality and associated clinical correlates in this group of patients.MethodsFrom 2000–2002, all CAP patients presenting to 7 Emergency Departments in Edmonton, Alberta, Canada were prospectively enrolled in a population-based registry. Clinical data, including pneumonia severity index (PSI) were collected at time of presentation. Patients discharged to the community were then followed for up to 5 years through linkage to the provincial administrative databases. The current report provides the rationale and design for the cohort, as well as describes baseline characteristics and 30-day morbidity and mortality.ResultsThe total sample included 3874 patients. After excluding patients who were hospitalized, died or returned to the Emergency Department the same day they were initially discharged (n = 451; 12 %), and patients who could not be linked to provincial administrative databases (n = 237; 6 %), the final cohort included 3186 patients treated according to a validated clinical management pathway and discharged back to the community. Mean age was 51 (SD = 20) years, 53 % male; 4 % resided in a nursing home, 95 % were independently mobile, and 88 % had mild (PSI class I-III) pneumonia. Within 30-days, return to Emergency Department was common (25 %) as was hospitalization (8 %) and 1 % of patients had died.ConclusionsTo our knowledge, this represents the largest clinically-detailed outpatient CAP cohort assembled to date and will add to our understanding of the determinants and outcomes in this under-researched patient population. The rich clinical data along with the long term health care utilization and mortality will allow for the identification of novel prognostic indicators. Given how under studied this population is, the findings should aid clinicians in the routine care of their outpatients with pneumonia and help define the next generation of research questions.

Guideline adherence and macrolides reduced mortality in outpatients with pneumonia

For outpatients with pneumonia, guidelines recommend empiric antibiotics and some suggest macrolides are preferred agents. We hypothesized that both guideline-concordant antibiotics and macrolides would be associated with reduced mortality. All outpatients with pneumonia assessed at 7 Emergency Departments in Edmonton, Alberta, Canada were enrolled in a population-based registry that included clinical-radiographic data, Pneumonia Severity Index (PSI) and treatments. Guideline-concordant regimens included macrolides and respiratory fluoroquinolones; other regimens were "discordant". Main outcome was 30-day all-cause mortality. The study included 2973 outpatients; mean age 51 years, 47% female, most had mild pneumonia (73% PSI Class I-II). Over 30-days, 38 (1%) patients died, 228 (8%) were hospitalized, and 253 (9%) reached the endpoint of death or hospitalization. Most (2845 [96%]) patients received guideline-concordant antibiotics. Compared to patients receiving discordant antibiotics, those receiving guideline-concordant antibiotics were less likely to die within 30-days (8 [6%] versus 30 [1%], adjusted OR 0.23, 95% CI 0.09-0.59, p=0.002). Within the guideline-concordant subgroup, compared to the 947 (33%) patients treated with fluoroquinolones, those receiving macrolides [1847 (64%)] were less likely to die (25 [3%] versus 4 [0.2%], adjusted OR 0.28, 95% CI 0.09-0.86, p=0.03). In outpatients with pneumonia, treatment with guideline-concordant antibiotics and macrolides were both associated with mortality reduction.

A retrospective cohort study of stroke onset: implications for characterizing short term effects from ambient air pollution

BackgroundCase-crossover studies used to investigate associations between an environmental exposure and an acute health response, such as stroke, will often use the day an individual presents to an emergency department (ED) or is admitted to hospital to infer when the stroke occurred. Similarly, they will use patient's place of residence to assign exposure. The validity of using these two data elements, typically extracted from administrative databases or patient charts, to define the time of stroke onset and to assign exposure are critical in this field of research as air pollutant concentrations are temporally and spatially variable. Our a priori hypotheses were that date of presentation differs from the date of stroke onset for a substantial number of patients, and that assigning exposure to ambient pollution using place of residence introduces an important source of exposure measurement error. The objective of this study was to improve our understanding on how these sources of errors influence risk estimates derived using a case-crossover study design.MethodsWe sought to collect survey data from stroke patients presenting to hospital EDs in Edmonton, Canada on the date, time, location and nature of activities at onset of stroke symptoms. The daily mean ambient concentrations of NO2 and PM2.5 on the self-reported day of stroke onset was estimated from continuous fixed-site monitoring stations.ResultsOf the 336 participating patients, 241 were able to recall when their stroke started and 72.6% (95% confidence interval [CI]: 66.9 - 78.3%) experienced stroke onset the same day they presented to the ED. For subjects whose day of stroke onset differed from the day of presentation to the ED, this difference ranged from 1 to 12 days (mean = 1.8; median = 1). In these subjects, there were no systematic differences in assigned pollution levels for either NO2 or PM2.5 when day of presentation rather than day of stroke onset was used. At the time of stroke onset, 89.9% (95% CI: 86.6 - 93.1%) reported that they were inside, while 84.5% (95% CI: 80.6 - 88.4%) reported that for most of the day they were within a 15 minute drive from home. We estimated that due to the mis-specification of the day of stroke onset, the risk of hospitalization for stroke would be understated by 15% and 20%, for NO2 and PM2.5, respectively.ConclusionsOur data suggest that day of presentation and residential location data obtained from administrative records reasonably captures the time and location of stroke onset for most patients. Under these conditions, any associated errors are unlikely to be an important source of bias when estimating air pollution risks in this population.

Incidence, Correlates, and Chest Radiographic Yield of New Lung Cancer Diagnosis in 3398 Patients With Pneumonia

One reason chest radiographs are recommended after pneumonia is to exclude underlying lung cancer. Our aims were to determine the incidence and correlates of new lung cancer and the diagnostic yield of new lung cancer by chest radiography in patients with pneumonia. We conducted a population-based cohort study of patients with chest radiography-confirmed pneumonia, who were discharged alive from hospitals and emergency departments in Edmonton, Alberta, Canada. Patients were enrolled from 2000 through 2002 and followed up for 5 years. We determined incidence of new lung cancer and receipt of chest radiographs within 90 days, 1 year, and 5 years. Multivariable proportional hazards analyses were used to determine independent correlates of lung cancer. There were 3398 patients; 59% were 50 years or older, 52% were male, and 17% were smokers. Half (49%) were admitted to hospital. At 90 days, 36 patients (1.1%) had new lung cancer; at 1 year, 57 patients (1.7%); and over 5 years, 79 patients (2.3%). The median time to diagnosis was 109 days (interquartile range, 27-423 days). Characteristics independently associated with lung cancer included age 50 years or older (adjusted hazard ratio [aHR], 19.0; 95% confidence interval [CI], 5.7-63.6), male sex (aHR, 1.8; 95% CI, 1.1-2.9), and smoking (aHR, 1.7; 95% CI, 1.0-3.0). Of the patients, 1354 (40%) had follow-up chest radiographs within 90 days, and the diagnostic yield of lung cancer was 2.5%; if radiographs were restricted to patients 50 years or older, the yield would have been 2.8%. The incidence of new lung cancer after pneumonia is low: approximately 1% within 90 days and 2% over 5 years. Routine chest radiographs after pneumonia for detecting lung cancer are not warranted, although our study suggests that patients 50 years or older should be targeted for radiographic follow-up.

Case-control study of unemployment and parasuicide

Objective The objective of the study was to estimate the odds ratio for the association between unemployment and parasuicide, controlling for potential confounding variables. Methods A case-control study was conducted involving 507 cases of parasuicide and 200 age- and sex-matched controls presenting to emergency departments in Edmonton, Canada. Subjects were interviewed using an extensive questionnaire developed for a World Health Organization study of parasuicide. The data were analyzed using conditional logistic regression. Results In a crude analysis, the odds ratio for the association between unemployment and parasuicide was 12.0 (95% confidence interval, 6.0-23.9). After controlling for sociodemographic factors, lifetime prevalence of several Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, disorders, previous parasuicide, hopelessness, childhood experiences, and emotional support from family and friends, the odds ratio was 5.2 (95% confidence interval, 2.3-11.4). Conclusions Those who are unemployed have an increased risk of parasuicide, and this association persists after accounting for a wide range of potential confounders.