A Multifaceted Strategy for Implementation of the Ottawa Ankle Rules in Two Emergency Departments

Problem Despite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably. Design Before and after study. Background and setting Emergency departments of a tertiary teaching hospital and a community hospital in Australia. Key measures for improvement Documentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture. Strategies for change Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as “gatekeepers.” Effects of change Documentation of the Ottawa ankle rules improved from 57.5% to 94.7% at the tertiary hospital, and 51.6% to 80.8% at the community hospital (P<0.001 for both). The proportion of patients undergoing radiography fell from 95.8% to 87.2% at the tertiary hospital, and from 91.4% to 78.9% at the community hospital (P<0.001 for both). The proportion of radiographs showing a fracture increased from 20.4% to 27.1% at the tertiary hospital (P=0.069), and 15.2% to 27.2% (P=0.002) at the community hospital. The missed fracture rate increased from 0% to 2.9% at the tertiary hospital and from 0% to 1.6% at the community hospital compared with baseline (P=0.783 and P=0.747). Lessons learnt Assessment of case note documentation has limitations. Clinician groups seem to differ in their capacity and willingness to change their practice. A multifaceted change strategy including a problem specific radiography request form can improve the selection of patients for radiography.

Injury severity of pedestrian crashes in Singapore

Singapore is a highly urbanized city-state country where walking is an important mode of travel. Pedestrians form about 25% of road fatalities every year, making them one of the most vulnerable road user groups in Singapore. Engineering measures like provision of overhead pedestrian crossings and raised zebra crossings tend to address pedestrian safety in general, but there may be occasions where pedestrians are particularly vulnerable so that targeted interventions are more appropriate. The objective of this study is to identify factors and situations that affect the injury severity of pedestrians involved in traffic crashes. Six years of crash data from 2003 to 2008 containing around four thousands pedestrian crashes at roadway segments were analyzed. Injury severity of pedestrians—recorded as slight injury, major injury and fatal—were modeled as a function of roadway characteristics, traffic features, environmental factors and pedestrian demographics by an ordered probit model. Results suggest that the injury severity of pedestrians involved in crashes during night time is higher indicating that pedestrian visibility during night is a key issue in pedestrian safety. The likelihood of fatal or serious injuries is higher for crashes on roads with high speed limit, center and median lane of multi-lane roads, school zones, roads with two-way divided traffic type, and when pedestrians cross the roads. Elderly pedestrians appear to be involved in fatal and serious injury crashes more when they attempt to cross the road without using nearby crossing facilities. Specific countermeasures are recommended based on the findings of this study.

Os livros de viagens medievais

Quando tomados no seu todo, os livros de viagens medievais formam um género multifacetado. São obras de carácter diverso, que têm na sua base propósitos igualmente diferenciados. No entanto, ainda que de forma variável e sem qualquer padrão estabelecido, o recurso comum a um conjunto de procedimentos narrativos garante aos textos que compõem este género diversificado uma forma literária autónoma no panorama da prosa medieva. Uma forma literária que, na essência, oferece uma visão bastante clara da concepção do mundo e da realidade na Idade Média, ao mesmo tempo que constitui uma fonte incontornável para compreender aspectos muito diversos da cultura medieval.

Structuring the pre-search reference interview: a useful technique for handling clinical questions*

Objectives: To explore whether structuring a literature search request form according to an evidence-based medicine (EBM) anatomy elicits more information, improves precision of search results, and is acceptable to participating librarians.

Analytical form of the Probability Density Function of travel times in rectangular zone with Tchebyshev’s metric

Geometrical dependencies are being researched for analytical representation of the probability density function (pdf) for the travel time between a random, and a known or another random point in Tchebyshev’s metric. In the most popular case - a rectangular area of service - the pdf of this random variable depends directly on the position of the server. Two approaches have been introduced for the exact analytical calculation of the pdf: Ad-hoc approach – useful for a ‘manual’ solving of a specific case; by superposition – an algorithmic approach for the general case. The main concept of each approach is explained, and a short comparison is done to prove the faithfulness.