Julien Poitras

Treatment for calcium channel blocker poisoning: A systematic review

Abstract Context. Calcium channel blocker poisoning is a common and sometimes life-threatening ingestion. Objective. To evaluate the reported effects of treatments for calcium channel blocker poisoning. The primary outcomes of interest were mortality and hemodynamic parameters. The secondary outcomes included length of stay in hospital, length of stay in intensive care unit, duration of vasopressor use, functional outcomes, and serum calcium channel blocker concentrations. Methods. Medline/Ovid, PubMed, EMBASE, Cochrane Library, TOXLINE, International pharmaceutical abstracts, Google Scholar, and the gray literature up to December 31, 2013 were searched without time restriction to identify all types of studies that examined effects of various treatments for calcium channel blocker poisoning for the outcomes of interest. The search strategy included the following Keywords: [calcium channel blockers OR calcium channel antagonist OR calcium channel blocking agent OR (amlodipine or bencyclane or bepridil or cinnarizine or felodipine or fendiline or flunarizine or gallopamil or isradipine or lidoflazine or mibefradil or nicardipine or nifedipine or nimodipine or nisoldipine or nitrendipine or prenylamine or verapamil or diltiazem)] AND [overdose OR medication errors OR poisoning OR intoxication OR toxicity OR adverse effect]. Two reviewers independently selected studies and a group of reviewers abstracted all relevant data using a pilot-tested form. A second group analyzed the risk of bias and overall quality using the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist and the Thomas tool for observational studies, the Institute of Health Economics tool for Quality of Case Series, the ARRIVE (Animal Research: Reporting In Vivo Experiments) guidelines, and the modified NRCNA (National Research Council for the National Academies) list for animal studies. Qualitative synthesis was used to summarize the evidence. Of 15,577 citations identified in the initial search, 216 were selected for analysis, including 117 case reports. The kappa on the quality analysis tools was greater than 0.80 for all study types. Results. The only observational study in humans examined high-dose insulin and extracorporeal life support. The risk of bias across studies was high for all interventions and moderate to high for extracorporeal life support. High-dose insulin. High-dose insulin (bolus of 1 unit/kg followed by an infusion of 0.5–2.0 units/kg/h) was associated with improved hemodynamic parameters and lower mortality, at the risks of hypoglycemia and hypokalemia (low quality of evidence). Extracorporeal life support. Extracorporeal life support was associated with improved survival in patients with severe shock or cardiac arrest at the cost of limb ischemia, thrombosis, and bleeding (low quality of evidence). Calcium, dopamine, and norepinephrine. These agents improved hemodynamic parameters and survival without documented severe side effects (very low quality of evidence). 4-Aminopyridine. Use of 4-aminopyridine was associated with improved hemodynamic parameters and survival in animal studies, at the risk of seizures. Lipid emulsion therapy. Lipid emulsion was associated with improved hemodynamic parameters and survival in animal models of intravenous verapamil poisoning, but not in models of oral verapamil poisoning. Other studies. Studies on decontamination, atropine, glucagon, pacemakers, levosimendan, and plasma exchange reported variable results, and the methodologies used limit their interpretation. No trial was documented in humans poisoned with calcium channel blockers for Bay K8644, CGP 28932, digoxin, cyclodextrin, liposomes, bicarbonate, carnitine, fructose 1,6-diphosphate, PK 11195, or triiodothyronine. Case reports were only found for charcoal hemoperfusion, dialysis, intra-aortic balloon pump, Impella device and methylene blue. Conclusions. The treatment for calcium channel blocker poisoning is supported by low-quality evidence drawn from a heterogeneous and heavily biased literature. High-dose insulin and extracorporeal life support were the interventions supported by the strongest evidence, although the evidence is of low quality.

Wikis and Collaborative Writing Applications in Health Care: A Scoping Review

Background Collaborative writing applications (eg, wikis and Google Documents) hold the potential to improve the use of evidence in both public health and health care. The rapid rise in their use has created the need for a systematic synthesis of the evidence of their impact as knowledge translation (KT) tools in the health care sector and for an inventory of the factors that affect their use. Objective Through the Levac six-stage methodology, a scoping review was undertaken to explore the depth and breadth of evidence about the effective, safe, and ethical use of wikis and collaborative writing applications (CWAs) in health care. Methods Multiple strategies were used to locate studies. Seven scientific databases and 6 grey literature sources were queried for articles on wikis and CWAs published between 2001 and September 16, 2011. In total, 4436 citations and 1921 grey literature items were screened. Two reviewers independently reviewed citations, selected eligible studies, and extracted data using a standardized form. We included any paper presenting qualitative or quantitative empirical evidence concerning health care and CWAs. We defined a CWA as any technology that enables the joint and simultaneous editing of a webpage or an online document by many end users. We performed qualitative content analysis to identify the factors that affect the use of CWAs using the Gagnon framework and their effects on health care using the Donabedian framework. Results Of the 111 studies included, 4 were experimental, 5 quasi-experimental, 5 observational, 52 case studies, 23 surveys about wiki use, and 22 descriptive studies about the quality of information in wikis. We classified them by theme: patterns of use of CWAs (n=26), quality of information in existing CWAs (n=25), and CWAs as KT tools (n=73). A high prevalence of CWA use (ie, more than 50%) is reported in 58% (7/12) of surveys conducted with health care professionals and students. However, we found only one longitudinal study showing that CWA use is increasing in health care. Moreover, contribution rates remain low and the quality of information contained in different CWAs needs improvement. We identified 48 barriers and 91 facilitators in 4 major themes (factors related to the CWA, users’ knowledge and attitude towards CWAs, human environment, and organizational environment). We also found 57 positive and 23 negative effects that we classified into processes and outcomes. Conclusions Although we found some experimental and quasi-experimental studies of the effectiveness and safety of CWAs as educational and KT interventions, the vast majority of included studies were observational case studies about CWAs being used by health professionals and patients. More primary research is needed to find ways to address the different barriers to their use and to make these applications more useful for different stakeholders.

A descriptive study of access to services in a random sample of Canadian rural emergency departments

Objective To examine 24/7 access to services and consultants in a sample of Canadian rural emergency departments (EDs). Design Cross-sectional study—mixed methods (structured interview, survey and government data bases) with random sampling of hospitals. Setting Canadian rural EDs (rural small town (RST) definition—Statistics Canada). Participants 28% (95/336) of Canadian rural EDs providing 24/7 physician coverage located in hospitals with acute care hospitalisation beds. Main outcome measures General characteristics of the rural EDs, information about 24/7 access to consultants, equipment and services, and the proportion of rural hospitals more than 300 km from levels 1 and 2 trauma centres. Results Of the 336 rural EDs identified, 122 (36%) were randomly selected and contacted. Overall, 95 EDs participated in the study (participation rate, 78%). Hospitals had, on an average, 23 acute care beds, 7 ED stretchers and 13 500 annual ED visits. The proportion of rural hospitals with local access to the following 24/7 services was paediatrician, 5%; obstetrician, 10%; psychiatrist, 11%; internist, 12%; intensive care unit, 17%; CT scanner, 20%; surgeon, 26%; ultrasound, 28%; basic X-ray, 97% and laboratory services, 99%. Forty-four per cent and 54% of the RST EDs were more than 300 km from a level 1 and level 2 trauma centre, respectively. Conclusions This is the first study describing the services available in Canadian rural EDs. Apart from basic laboratory and X-ray services, most rural EDs have limited access to consultants, advanced imaging and critical care services. A detailed study is needed to evaluate the impact of these limited services on patient outcomes, costs and interfacility transport demands.

Comparing Two Brief Psychological Interventions to Usual Care in Panic Disorder Patients Presenting to the Emergency Department with Chest Pain

BACKGROUND There has been considerable acknowledgement in treatment outcome research that, although the assessment of treatment integrity is essential in many respects, it requires great effort as well as resources and is therefore often neglected. AIMS In order to fill this gap, the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP) was developed, based on the Cognitive Therapy Scale, to measure therapist competence in delivering cognitive therapy for social phobia. The aim of the present study was to investigate interrater reliability, internal consistency and retest reliability of the scale. METHOD Raters evaluated therapist competence from 161 videotaped sessions (98 patients) selected from 234 cognitive treatments within a multi-centre study. RESULTS Interrater-reliability was found to be high for the overall score (ICC = .81) and moderate for individual items (ICC = .62-.92). Internal consistency and retest reliability were also found to be high (Cronbachs alpha = .89; (ICCretest = .86). CONCLUSIONS The results indicate that the CTCS-SP is highly reliable. As even individual items yield satisfactory reliability, the scale can be used in various fields of research, including the measurement of changes in skill acquisition and the impact of competence on outcome criteria.BACKGROUND Panic disorder (PD) is a common, often unrecognized condition among patients presenting with chest pain to the emergency departments (ED). Nevertheless, psychological treatment is rarely initiated. We are unaware of studies that evaluated the efficacy of brief cognitive-behavioural therapy (CBT) for this population. AIM Evaluate the efficacy of two brief CBT interventions in PD patients presenting to the ED with chest pain. METHOD Fifty-eight PD patients were assigned to either a 1-session CBT-based panic management intervention (PMI) (n = 24), a 7-session CBT intervention (n = 19), or a usual-care control condition (n = 15). A structured diagnostic interview and self-reported questionnaires were administered at pre-test, post-test, 3- and 6-month follow-ups. RESULTS Statistical analysis showed significant reduction in PD severity following both interventions compared to usual care control condition, but with neither showing superiority compared to the other. CONCLUSIONS CBT-based interventions as brief as a single session initiated within 2 weeks after an ED visit for chest pain appear to be effective for PD. Given the high prevalence of PD in emergency care settings, greater efforts should be made to implement these interventions in the ED and/or primary care setting.

Access to emergency care in rural Canada: should we be concerned?

Approximately 20% of Canadians live in rural areas. Compared to their urban counterparts, rural citizens are in poorer health and are at greater risk for trauma and trauma death. There are great challenges providing and accessing rural emergency care in Canada due to inherent greater distances and limited resources. However, few studies have described the level of resources available in rural emergency departments (EDs) in Canada and the challenge this represents for providing safe patient care. There is minimal information on ED use in Canada, and comparison between provinces is limited by differences in the types of data collected. We present the situation in a rural ED in Nelson, British Columbia, after major service cuts took place. The issue of reasonable access to emergency services is discussed in the context of the Canada Health Act (CHA). We argue that with budgetary constraints and rising costs, service attribution may not be evidence based and outcomes will not be compared to established benchmarks. Considerable variability in access to timely patient care may result; further research is required to determine the impact of service cuts prior to their implementation. In 2001, health care services to BC rural populations were reduced. In the region served by Kootenay Lake Hospital in Nelson, services were centralized in a community 74 km away. The intensive care unit, general surgical service, and inpatient mental health ward were closed, and laboratory and radiography services were reduced. As a result, over 1,500 patients per year required transfer for workups, consultations, or a higher level of care, frequently on an emergency basis. This transfer process resulted in delays in obtaining definitive care. A recent report also suggested that the service cuts coincided with worse outcomes. Using data from the Discharge Abstract Database and the Canadian Institute for Health Information, the Fraser Institute published its British Columbia hospital report card in 2011. For example, residents in Nelson fell from fourth place (4 of 47 municipalities in 2001–2002, prior to health cuts) to last in the province in 2008–2009 with respect to ‘‘failure to rescue,’’ which is considered among the most important health quality indicators and describes mortality from complications that arose while a patient was hospitalized. For many, Canada’s universal health care system is a defining feature of this country. Rural citizens may be tempted to look toward the CHA as a safeguard because one of the central components of the CHA is ‘‘reasonable access’’ to care. The ‘‘intent of accessibility criterion’’ of the CHA is set to ensure that Canadians ‘‘have reasonable access to insured hospital, medical and surgical-dental services on uniform terms and conditions, unprecluded or unimpeded, either directly or indirectly, by charges (user charges or extra-billing) or other means (e.g., discrimination on the basis of age, health status or financial circumstances).’’ Yet reasonable access in terms of physical availability of medical services has been interpreted under the CHA using the ‘‘where and as available’’ rule. Thus, residents of a province or territory are entitled to have access to insured health services at the facility where the services are provided and as the services are available in that setting. Moreover, Canadian emergency medical service systems are not part of the CHA; emergency transportation times and direct costs to patients to where services are available will demonstrate great variation across the country. Hence, the ‘‘where and as available’’ nuance confers significant powers to provinces with respect to service

Hyperbaric oxygen therapy in the management of two cases of hydrogen sulfide toxicity from liquid manure

Hydrogen sulfide is a potent lethal gas. Supportive care, nitrite therapy and hyperbaric oxygen are the treatment modalities reported in the literature in cases of hydrogen sulfide exposure. We describe an industrial exposure in which 6 workers inhaled high concentrations of hydrogen sulfide when they entered a closed spreader tank partially filled with liquid swine manure. Five of the 6 lost consciousness, and 2 were agitated and poorly responsive on arrival to the emergency department despite having already received high-flow oxygen for nearly 1 hour. These 2 patients received nitrite therapy followed by orotracheal intubation and hyperbaric oxygen. All patients were discharged home without sequelae after short stays in hospital. The emergency management of hydrogen sulfide exposure is briefly reviewed.

Portrait of rural emergency departments in Quebec and utilisation of the Quebec Emergency Department Management Guide: a study protocol

Introduction Emergency departments are important safety nets for people who live in rural areas. Moreover, a serious problem in access to healthcare services has emerged in these regions. The challenges of providing access to quality rural emergency care include recruitment and retention issues, lack of advanced imagery technology, lack of specialist support and the heavy reliance on ambulance transport over great distances. The Quebec Ministry of Health and Social Services published a new version of the Emergency Department Management Guide, a document designed to improve the emergency department management and to humanise emergency department care and services. In particular, the Guide recommends solutions to problems that plague rural emergency departments. Unfortunately, no studies have evaluated the implementation of the proposed recommendations. Methods and analysis To develop a comprehensive portrait of all rural emergency departments in Quebec, data will be gathered from databases at the Quebec Ministry of Health and Social Services, the Quebec Trauma Registry and from emergency departments and ambulance services managers. Statistics Canada data will be used to describe populations and rural regions. To evaluate the use of the 2006 Emergency Department Management Guide and the implementation of its various recommendations, an online survey and a phone interview will be administered to emergency department managers. Two online surveys will evaluate quality of work life among physicians and nurses working at rural emergency departments. Quality-of-care indicators will be collected from databases and patient medical files. Data will be analysed using statistical (descriptive and inferential) procedures. Ethics and dissemination This protocol has been approved by the CSSS Alphonse–Desjardins research ethics committee (Project MP-HDL-1213-011). The results will be published in peer-reviewed scientific journals and presented at one or more scientific conferences.

Comparison of access to services in rural emergency departments in Quebec and British Columbia.

INTRODUCTION Although emergency departments (EDs) in Canadas rural areas serve approximately 20% of the population, a serious problem in access to health care services has emerged. OBJECTIVE The objective of this project was to compare access to support services in rural EDs between British Columbia and Quebec. METHODS Rural EDs were identified through the Canadian Healthcare Associations Guide to Canadian Healthcare Facilities. We selected hospitals with 24/7 ED physician coverage and hospitalization beds that were located in rural communities (using the rural and small town definition from Statistics Canada). Data were collected from ministries of health, local health authorities, and ED statistics. A telephone interview was administered to collect denominative user data statistics and determine the status of services. RESULTS British Columbia has more rural EDs (n  =  34) than Quebec (n  =  26). EDs in Quebec have higher volumes (19,310 versus 7,793 annual visits). With respect to support services, 81% of Quebec rural EDs have a 24/7 on-call general surgeon compared to 12% for British Columbia. Nearly 75% of Quebec rural EDs have 24/7 access to computed tomography versus only 3% for British Columbia. Rural EDs in Quebec are also supported by a greater proportion of intensive care units (88% versus 15%); however, British Columbia appears to have more medevac aircraft/helicopters than Quebec. CONCLUSIONS The results suggest that major differences exist in access to support services in rural EDs in British Columbia and Quebec. A nationwide study is justified to address this issue of variability in rural and remote health service delivery and its impact on interfacility transfers and patient outcomes.

Suicidality and panic in emergency department patients with unexplained chest pain

OBJECTIVES The present study aims to document the problem of suicidality in emergency department (ED) patients with unexplained chest pain and to assess the strength and independence of the relationship between panic and suicidal ideation (SI) in this population. METHOD This cross-sectional study included 572 ED patients with unexplained chest pain. SI, history of suicide attempts, history of SI and the presence of thoughts about how to commit suicide were assessed. Logistic regression analyses were used to quantify the relationship between current SI and panic. RESULTS Approximately 15% [95% confidence interval (CI), 12%-18%] of patients reported current SI, and 33% (95% CI, 29%-37%) reported history of SI. Nearly 19% (95% CI, 16%-22%) of patients had thought about a method to commit suicide, and 33% (95% CI, 29%-37%) had a history of a suicide attempt. Panic attacks were diagnosed in 42% (95% CI, 38%-46%) of patients, and 45% (95% CI, 39%-51%) of those had panic disorder. Panic increased the crude likelihood of current SI [odds ratio (OR)=2.53, 1.4-4.5]. This increase in SI risk remained significant after controlling for confounding factors (OR=1.70, 95% CI, 1.0-2.9). CONCLUSIONS Suicidality and SI were common and often severe in our sample of ED patients with unexplained chest pain.

Treatment of panic in chest pain patients from emergency departments: efficacy of different interventions focusing on panic management.

OBJECTIVE The aim was to assess the efficacy of two brief cognitive-behavioral therapy (CBT)-based interventions (7×1-h sessions and 1×2-h session) and a pharmacological treatment (paroxetine), compared to supportive usual care, initiated in the emergency department (ED) for individuals suffering from panic disorder (PD) with a chief complain of noncardiac chest pain (NCCP). We hypothesized that the interventions would be more efficacious than supportive usual care on all outcomes. METHOD A 12-month follow-up study of patients who received a diagnosis of NCCP in the ED and who met diagnostic criteria for PD (n=71) was performed. Assessments included several psychological questionnaires and a structured interview. A series of repeated-measures analyses of variances, using a split-plot design, were conducted, as well as planned comparisons to examine the differences. RESULTS The seven-session CBT (n=19), one-session panic management (n=24) and pharmacotherapy (n=13) led to greater improvements in PD severity (primary outcome) compared to supportive usual care (n=15) at posttest, and no significant difference was noted between the three active interventions. On the other measures, patients improved in all conditions, and the therapeutic gains were maintained up to 1 year following the visit to the ED. CONCLUSIONS These results suggests that early intervention, in particular seven sessions of CBT, one session of PM or pharmacotherapy (generic paroxetine), should be considered for the treatment of PD patients consulting the ED with a discharge diagnosis of NCCP.