Search

Objectives: To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture., Design: A substudy of a prospective multicenter cohort study., Setting: 12 Canadian academic emergency departments, from November 2000 to December 2009., Participants: Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage., Main Outcome Measure: Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death., Results: Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with >1 × 10(6)/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000 × 10(6)/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%)., Conclusion: No xanthochromia and red blood cell count <2000 × 10(6)/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache., (© Perry et al 2015.)

Objective: To document the scope of the teaching and evaluation of ethics and professionalism in Canadian family medicine postgraduate training programs, and to identify barriers to the teaching and evaluation of ethics and professionalism., Design: A survey was developed in collaboration with the Committee on Ethics of the College of Family Physicians of Canada. The data are reported descriptively and in aggregate., Setting: Canadian postgraduate family medicine training programs., Participants: Between June and December of 2008, all 17 Canadian postgraduate family medicine training programs were invited to participate., Main Outcome Measures: The first part of the survey explored the structure, resources, methods, scheduled hours, and barriers to teaching ethics and professionalism. The second section focused on end-of-rotation evaluations, other evaluation strategies, and barriers related to the evaluation of ethics and professionalism., Results: Eighty-eight percent of programs completed the survey. Most respondents (87%) had learning objectives specifically for ethics and professionalism, and 87% had family doctors with training or interest in the area leading their efforts. Two-thirds of responding programs had less than 10 hours of scheduled instruction per year, and the most common barriers to effective teaching were the need for faculty development, competing learning needs, and lack of resident interest. Ninety-three percent of respondents assessed ethics and professionalism on their end-of-rotation evaluations, with 86% assessing specific domains. The most common barriers to evaluation were a lack of suitable tools and a lack of faculty comfort and interest., Conclusion: By far most Canadian family medicine postgraduate training programs had learning objectives and designated faculty leads in ethics and professionalism, yet there was little curricular time dedicated to these areas and a perceived lack of resident interest and faculty expertise. Most programs evaluated ethics and professionalism as part of their end-of-rotation evaluations, but only a small number used novel means of evaluation, and most cited a lack of suitable assessment tools as an important barrier.

Objective: To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset., Design: Prospective cohort study., Setting: 11 tertiary care emergency departments across Canada, 2000-9., Participants: Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage., Main Outcome Measures: Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography., Results: Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%)., Conclusion: Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.