Thapsigargin was originally isolated from the roots of the Mediterranean umbelliferous plant Thapsia garganica in order to characterize the skin irritant principle. Characteristic chemical properties ...and semi-syntheses are reviewed. The biological activity was related to the subnanomolar affinity for the sarco/endoplasmic reticulum calcium ATPase. Prolonged inhibition of the pump afforded collapse of the calcium homeostasis and eventually apoptosis. Structure-activity relationships enabled design of an equipotent analogue containing a linker. Conjugation of the analogue containing the linker with peptides, which only are substrates for either prostate specific antigen (PSA) or prostate specific membrane antigen (PSMA) enabled design of prodrugs targeting a number of cancer diseases including prostate cancer (G115) and hepatocellular carcinoma (G202). Prodrug G202 has under the name of mipsagargin in phase II clinical trials shown promising properties against hepatocellular carcinoma.
Objective: To explore parental perceptions of psychosocial screening in the paediatric emergency department and identify post-screening barriers to accessing mental health care. Methods: We conducted ...a qualitative study during the 30-day follow-up period of a larger prospective cohort study. Eligible youth and their accompanying parent/guardian first completed psychosocial self/proxy-screening using the MyHEARTSMAP tool and then received a standardized clinical mental health assessment. If the MyHEARTSMAP assessment provided youth with mental health resources recommendations, their parents were invited to a follow-up session. Thirty days (±5 days) after their ED visit, parents participated in a virtual interview to reflect and share their attitudes, perceptions and thoughts around the screening and mental health care-seeking process. Results: Of the 171 participants who received resource recommendations during their ED visit, 124 parents (72.5%; 95% CI 65.2–79.1%) completed the follow-up interview. Most parents endorsed positive perceptions of the screening process, describing it as an ‘eye-opening’ process that ‘sparked conversation’. Most participants (74.2%; 95% CI 65.6–81.6) agreed with the resource recommendations they received. In terms of resources-seeking, only 41 participants (33.1%; 95% CI 24.9–42.1) attempted to access recommended supports. Families generally felt identified concerns were mild and ‘not serious enough’ to warrant resource-seeking, though many expressed an intention to seek care if concerns escalated. Conclusion: Perceptions of psychosocial screening in the ED were favourable and encouraging among participating parents of youth screened positive for psychosocial issues. Despite positive attitudes, only a fraction of the families invited to follow-up attempted to access care. Mental health may be perceived as low priority for many families, signifying the need for improved education and awareness building on the importance of early intervention.
Objective To describe trends in utilization of pediatric emergency department (PED) resources by patients with mental health concerns over the past 10 years at a tertiary care hospital. Study design ...We conducted a retrospective cohort study of tertiary PED visits from 2003 to 2012. All visits with chief complaint or discharge diagnosis related to mental health were included. Variables analyzed included number and acuity of mental health-related visits, length of stay, waiting time, admission rate, and return visits, relative to all PED visits. Descriptive statistics were used to summarize the results. Results We observed a 47% increase in the number of mental health presentations compared with a 9% increase in the number of total visits to the PED over the study period. Return visits represented a significant proportion of all mental health-related visits (31%-37% yearly). The proportion of mental health visits triaged to a high acuity level has decreased whereas the proportion of visits triaged to the mid-acuity level has increased. Length of stay for psychiatric patients was significantly longer than for visits to the PED in general. We also observed a 23% increase in the number of mental health-related visits resulting in admission. Conclusion Mental health-related visits represent a significant and growing burden for the emergency department at a tertiary care PED. These results highlight the need to reassess the allocation of health resources to optimize acute management, risk assessment, and linkage to mental health services upon disposition from the PED.
Background
Pediatric acute respiratory infections (ARIs) represent a significant burden on pediatric Emergency Departments (EDs) and families. Most of these illnesses are due to viruses. However, ...investigations (radiography, blood, and urine testing) to rule out bacterial infections and antibiotics are often ordered because of diagnostic uncertainties. This results in prolonged ED visits and unnecessary antibiotic use. The risk of concurrent bacterial infection has been reported to be negligible in children over three months of age with a confirmed viral infection. Rapid viral testing in the ED may alleviate the need for precautionary testing and antibiotic use.
Objectives
To determine if the use of a rapid viral detection test for children with an acute respiratory infection (ARI) in Emergency Departments (EDs) changes patient management and resource use in the ED, compared to not using a rapid viral detection test. We hypothesized that rapid viral testing reduces antibiotic use in the ED as well as reduces the rate of ancillary testing and length of ED visits.
Search methods
We searched CENTRAL (2014, Issue 6), MEDLINE (1950 to July week 1, 2014), MEDLINE In‐Process & Other Non‐Indexed Citations (15 July 2014), EMBASE.com (1988 to July 2014), HealthStar (1966 to 2009), BIOSIS Previews (1969 to July 2014), CAB s (1973 to July 2014), CBCA Reference (1970 to 2007) and ProQuest Dissertations and Theses (1861 to 2009).
Selection criteria
Randomized controlled trials (RCTs) of rapid viral testing for children with ARIs in the ED.
Data collection and analysis
Two review authors used the inclusion criteria to select trials, evaluate their quality, and extract data. We obtained missing data from trial authors. We expressed differences in rate of investigations and antibiotic use as risk ratios (RRs), and expressed difference in ED length of visits as mean differences (MDs), with 95% confidence intervals (CIs).
Main results
No new trials were identified in this 2014 update. We included four trials (three RCTs and one quazi‐RCT), with 759 children in the rapid viral testing group and 829 in the control group. Three out of the four studies were comparable in terms of young age of participants, with one study increasing the age of inclusion up to five years of age. All studies included either fever or respiratory symptoms as inclusion criteria (two required both, one required fever or respiratory symptoms, and one required only fever). All studies were comparable in terms of exclusion criteria, intervention, and outcome data. In terms of risk of bias, one study failed to utilize a random sequence generator, one study did not comment on completeness of outcome data, and only one of four studies included allocation concealment as part of the study design. None of the studies definitively blinded participants.
Rapid viral testing resulted in a trend toward decreased antibiotic use in the ED, but this was not statistically significant. We found lower rates of chest radiography (RR 0.77, 95% CI 0.65 to 0.91) in the rapid viral testing group, but no effect on length of ED visits, or blood or urine testing in the ED. No study made mention of any adverse effects related to viral testing.
Authors' conclusions
There is insufficient evidence to support routine rapid viral testing to reduce antibiotic use in pediatric EDs. Rapid viral testing may or may not reduce rates of antibiotic use, and other investigations (urine and blood testing); these studies do not provide enough power to resolve this question. However, rapid viral testing does reduce the rate of chest X‐rays in the ED. An adequately powered trial with antibiotic use as an outcome is needed.
Prediction of pediatric emergency department (PED) workload can allow for optimized allocation of resources to improve patient care and reduce physician burnout. A measure of PED workload is thus ...required, but to date no variable has been consistently used or could be validated against for this purpose. Billing codes, a variable assigned by physicians to reflect the complexity of medical decision making, have the potential to be a proxy measure of PED workload but must be assessed for reliability. In this study, we investigated how reliably billing codes are assigned by PED physicians, and factors that affect the inter-rater reliability of billing code assignment. A retrospective cross-sectional study was completed to determine the reliability of billing code assigned by physicians (n = 150) at a quaternary-level PED between January 2018 and December 2018. Clinical visit information was extracted from health records and presented to a billing auditor, who independently assigned a billing code-considered as the criterion standard. Inter-rater reliability was calculated to assess agreement between the physician-assigned versus billing auditor-assigned billing codes. Unadjusted and adjusted logistic regression models were used to assess the association between covariables of interest and inter-rater reliability. Overall, we found substantial inter-rater reliability (AC.sub.2 0.72 95% CI 0.64-0.8) between the billing codes assigned by physicians compared to those assigned by the billing auditor. Adjusted logistic regression models controlling for Pediatric Canadian Triage and Acuity scores, disposition, and time of day suggest that clinical trainee involvement is significantly associated with increased inter-rater reliability. Our work identified that there is substantial agreement between PED physician and a billing auditor assigned billing codes, and thus are reliably assigned by PED physicians. This is a crucial step in validating billing codes as a potential proxy measure of pediatric emergency physician workload.
Pediatric emergency departments are overcrowded, in part due to many non-emergent visits. We aimed to assess the proportion of parents interested in leaving the pediatric emergency department (ED) ...prior to physician assessment if they could be offered a scheduled community healthcare appointment. We explored differences in care children received in the ED stratified by interest in a community healthcare appointment and parents' reasons when they were not interested.
We conducted a 14-item survey within the pediatric ED at a Canadian tertiary care teaching hospital to assess parents' interest if a program offered community healthcare appointments and we determined preferred appointment characteristics. All parents presenting with children triaged as CTAS 2-5 who met eligibility criteria were approached by a research assistant prior to physician assessment. Surveys were paired with the medical chart outlining the care received. Descriptive statistics and a regression model were used to describe characteristics of families and care received among those who were and were not interested in a community healthcare appointment.
In total, 403 surveys were completed. Overall, 236 participants (58.6%; 95% CI 53.8-63.4) were interested in a community healthcare appointment. In general, parents who were interested in a community healthcare appointment were younger and presented with younger children compared to those who were not interested. Among those interested, there was a preference to have the appointment with a pediatrician or family physician, timely access to an appointment, and appointments scheduled outside of regular business hours.
Our study provides evidence that there is interest in an alternative care access model positioned to reduce pediatric ED congestion. We found that parents would be interested in leaving the pediatric ED in favor of a community healthcare appointment, provided it was with a physician and available in a timely manner.
To validate the two-factor structure (i.e., cognitive and somatic) of the Health and Behaviour Inventory (HBI), a widely used post-concussive symptom (PCS) rating scale, through factor analyses using ...bifactor and correlated factor models and by examining measurement invariance (MI).
PCS ratings were obtained from children aged 8-16.99 years, who presented to the emergency department with concussion (n = 565) or orthopedic injury (OI) (n = 289), and their parents, at 10-days, 3-months, and 6-months post-injury. Item-level HBI ratings were analyzed separately for parents and children using exploratory and confirmatory factor analyses (CFAs). Bifactor and correlated models were compared using various fit indices and tested for MI across time post-injury, raters (parent vs. child), and groups (concussion vs. OI).
CFAs showed good fit for both a three-factor bifactor model, consisting of a general factor with two subfactors (i.e., cognitive and somatic), and a correlated two-factor model with cognitive and somatic factors, at all time points for both raters. Some results suggested the possibility of a third factor involving fatigue. All models demonstrated strict invariance across raters and time. Group comparisons showed at least strong or strict invariance.
The findings support the two symptom dimensions measured by the HBI. The three-factor bifactor model showed the best fit, suggesting that ratings on the HBI also can be captured by a general factor. Both correlated and bifactor models showed substantial MI. The results provide further validation of the HBI, supporting its use in childhood concussion research and clinical practice.
Evidence suggests emergency department (ED) overcrowding is associated with poor health outcomes. Children comprise 20–25% of general ED visits, yet few studies have examined the differential impact ...of ED overcrowding on pediatric and adult populations.
The primary objective of this study was to compare flow measures, such as wait time to see a physician, length of stay (LOS), and rate of patients leaving without being seen by a physician (LWBS) between adults and children in British Columbia and Ontario, clustered by province, and then stratified by acuity level during the study period.
We conducted a retrospective, repeated cross-sectional study using administrative data from all community EDs in Ontario and 10 EDs in the Vancouver Lower Mainland, British Columbia. Visits from January 1, 2008 and December 31, 2012 were included.
Visit volumes increased 13.9% per year in British Columbia and 2.2% per year in Ontario, with a more pronounced rise in adult visits. Both groups displayed a shift toward higher-acuity presentations. Adults spent more time in the ED compared to children (36 to 53 min longer), and were more likely to be admitted. Children consistently spent a greater portion of their visit awaiting assessment compared to adults.
In the context of system incentives to reduce overcrowding, ED LOS and the LWBS rate did not significantly change for either children or adults, despite increased visit volume and acuity. Our findings suggest that measures to improve patient flow might have provided EDs with the means to meet increased demands on departmental resources.
Emergency department overcrowding has been associated with increased odds of hospital admission and mortality after discharge from the emergency department in predominantly adult cohorts. The ...objective of this study was to evaluate the association between crowding and the odds of several adverse outcomes among children seen at a pediatric emergency department.
We conducted a retrospective cohort study involving all children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014. We analyzed the association between mean departmental length of stay for each index visit and hospital admission within 7 days or death within 14 days of emergency department discharge, as well as hospital admission at index visit and return visits within 7 days, using mixed-effects logistic regression modelling.
A total of 1 931 465 index visits occurred across study sites over the 5-year period, with little variation in index visit hospital admission or median length of stay. Hospital admission within 7 days of discharge and 14-day mortality were low across provinces (0.8%-1.5% and < 10 per 100 000 visits, respectively), and their association with mean departmental length of stay varied by triage categories and across sites but was not significant. There were increased odds of hospital admission at the index visit with increasing departmental crowding among visits triaged to Canadian Triage and Acuity Scale (CTAS) score 1-2 (odds ratios ORs ranged from 1.01 to 1.08) and return visits among patients with a CTAS score of 4-5 discharged at the index visit at some sites (ORs ranged from 1.00 to 1.06).
Emergency department crowding was not significantly associated with hospital admission within 7 days of the emergency department visit or mortality in children. However, it was associated with increased hospital admission at the index visit for the sickest children, and with return visits to the emergency department for those less sick.
PDF
