bluuebunny/crossref_metadata_2025 huggingface dataset:
Calcium scoring: a personalized probability assessment predicts the need for additional or alternative testing to coronary CT angiography
Authors: Simon Judit , Száraz Lili , Szilveszter Bálint , Panajotu Alexisz , Jermendy Ádám , Bartykowszki Andrea , Boussoussou Melinda , Vattay Borbála , Drobni Zsófia Dóra , Merkely Béla , Maurovich-Horvat Pál , Kolossváry Márton
Published: May 2020

Objective

To assess whether anthropometrics, clinical risk factors, and coronary artery calcium score (CACS) can predict the need of further testing after coronary CT angiography (CTA) due to non-diagnostic image quality and/or the presence of significant stenosis.

Methods

Consecutive patients who underwent coronary CTA due to suspected coronary artery disease (CAD) were included in our retrospective analysis. We used multivariate logistic regression and receiver operating characteristics analysis containing anthropometric factors: body mass index, heart rate, and rhythm irregularity (model 1); and parameters used for pre-test likelihood estimation: age, sex, and type of angina (model 2); and also added total calcium score (model 3) to predict downstream testing.

Results

We analyzed 4120 (45.7% female, 57.9 ± 12.1 years) patients. Model 3 significantly outperformed models 1 and 2 (area under the curve, 0.84 [95% CI 0.83–0.86] vs. 0.56 [95% CI 0.54–0.58] and 0.72 [95% CI 0.70–0.74], p < 0.001). For patients with sinus rhythm of 50 bpm, in case of non-specific angina, CACS above 435, 756, and 944; in atypical angina CACS above 381, 702, and 890; and in typical angina CACS above 316, 636, and 824 correspond to 50%, 80%, and 90% probability of further testing, respectively. However, higher heart rates and arrhythmias significantly decrease these cutoffs (p < 0.001).

Conclusion

CACS significantly increases the ability to identify patients in whom deferral from coronary CTA may be advised as CTA does not lead to a final decision regarding CAD management. Our results provide individualized cutoff values for given probabilities of the need of additional testing, which may facilitate personalized decision-making to perform or defer coronary CTA.

Key Points

• Anthropometric parameters on their own are insufficient predictors of downstream testing. Adding parameters of the Diamond and Forrester pre-test likelihood test significantly increases the power of prediction.

• Total CACS is the most important independent predictor to identify patients in whom coronary CTA may not be recommended as CTA does not lead to a final decision regarding CAD management.

• We determined specific CACS cutoff values based on the probability of downstream testing by angina-, arrhythmia-, and heart rate–based groups of patients to help individualize patient management.
Onco-Cardiology: Consensus Paper of the German Cardiac Society, the German Society for Pediatric Cardiology and Congenital Heart Defects and the German Society for Hematology and Medical Oncology
Authors:   Committee for Clinical Cardiovascular Medicine of the German Cardiac Society, Rassaf Tienush , Totzeck Matthias , Backs Johannes , Bokemeyer Carsten , Hallek Michael , Hilfiker-Kleiner Denise , Hochhaus Andreas , Lüftner Diana , Müller Oliver J. , Neudorf Ulrich , Pfister Roman , von Haehling Stephan , Lehmann Lorenz H. , Bauersachs Johann
Published: May 2020

The acute and long-lasting side effects of modern multimodal tumour therapy significantly impair quality of life and survival of patients afflicted with malignancies. The key components of this therapy include radiotherapy, conventional chemotherapy, immunotherapy and targeted therapies. In addition to established tumour therapy strategies, up to 30 new therapies are approved each year with only incompletely characterised side effects. This consensus paper discusses the risk factors that contribute to the development of a potentially adverse reaction to tumour therapy and, in addition, defines specific side effect profiles for different treatment groups. The focus is on novel therapeutics and recommendations for the surveillance and treatment of specific patient groups.
Three-year audiological outcomes of the latest generation middle ear transducer (MET) implant
Authors: Skarżyński Henryk , Dziendziel Beata , Włodarczyk Elżbieta , Skarżyński Piotr H.
Published: May 2020

Purpose

To evaluate the long-term audiological outcomes and safety of the latest generation of middle ear transducer (MET) among a group of Polish patients.

Methods

Ten patients aged 48–72 years with bilateral sensorineural hearing loss (n = 8) and mixed hearing loss (n = 2) were included in this study. Pure tone audiometry, sound thresholds, word recognition scores in quiet and speech reception thresholds in noise were assessed. Medical and technical complication information was gathered.

Results

All the patients underwent unilateral implantation with the latest generation Cochlear MET between 2014 and 2016. Mean length of follow-up was 3.7 years. Compared to the unaided condition, the implant provided significant functional gain (mean M = 26.1 dB) at 12 months follow-up. Compared to before surgery, average word recognition in quiet at 65 dB and at 80 dB SPL, as well as speech reception threshold in noise, were significantly better at 12 months. However, postoperative air conduction thresholds 6 months after implantation worsened by 10.3 dB (standard deviation SD = 5.8 dB). Postoperatively, three patients had skin problems around the processor, and one of them completely resigned from using the device 5 months after activation. Technical failures occurred in 4 cases. There were 9 out of 10 patients who still used the MET, but only 5 of them used the processor regularly (every day).

Conclusion

Despite changes in the transducer implemented by the manufacturer, we observed a significant number of adverse events in users of the latest generation of MET.
Modellierung vergangener und zukünftiger Abflüsse und Sedimentfrachten mit freier Software – Einblicke am Beispiel des Schöttlbach (Niedere Tauern)
Authors: Peßenteiner Stefanie , Gegenleithner Sebastian , Kamp Nicole , Krenn Paul
Published: May 2020

Rezent häufigere Hochwasserereignisse und die besondere Vulnerabilität des Alpenraums gegenüber dem Klimawandel erhöhen die gesellschaftliche und politische Nachfrage nach robusten Informationen über mögliche zukünftige Entwicklungen. Ergebnisse numerischer Modellierungen in Verbindung mit Expertenmeinungen stellen ein wichtiges Instrument zur Abschätzung zukünftiger Veränderungen dar und ermöglichen die Untersuchung von Gebieten, in denen es nur wenige oder gar keine Sediment- bzw. Abflussmessungen gibt. Die Verwendung von quelloffenen (Open Source) und frei verfügbaren Modellen trägt dabei wesentlich zu Transparenz und wissenschaftlicher Nachvollziehbarkeit bei. Im vorliegenden Beitrag möchten wir eine Modellkette aus frei verfügbaren bzw. Open-Source-Modellen zur Simulation von Abflüssen und Sedimentfrachten am Beispiel des Schöttlbachs (Niedere Tauern) vorstellen und Einblicke in erste Ergebnisse geben.
Comparison of thermally and chemically reduced graphene oxides by thermal analysis and Raman spectroscopy
Authors: Farah Shereen , Farkas Attila , Madarász János , László Krisztina
Published: May 2020

Graphene oxide (GO) is not only an intermediate in top-down graphene preparation, but it is also acknowledged for its convenient application when the hydrophobicity of graphene is a drawback. Its preparation through the wet exfoliation of graphite inevitably leads to a product lacking several of the outstanding features of graphene. The destroyed graphene structure can be at least partially reconstructed by thermal and/or wet chemical reduction. Thermally reduced graphene oxide (TRGO) was obtained by mild heat treatment (300 °C) in argon, while chemically reduced graphene oxide (CRGO) was prepared by using a green reagent, ascorbic acid (AA). The parent GO and the two GO derivatives were compared by thermogravimetric analysis coupled with mass spectroscopy and Raman spectroscopy. Both reductive treatments resulted in enhanced thermal stability and higher C/O ratio. Although the chemical reduction with AA was more efficient in the elimination of the O functionalities, it also resulted in significant fragmentation of the graphene-like platelets.
Detection of pharmaceuticals in wastewater effluents—a comparison of the performance of Chemcatcher® and polar organic compound integrative sampler
Authors: Gravell Anthony , Fones Gary R. , Greenwood Richard , Mills Graham A.
Published: May 2020

Chemcatcher® and POCIS passive sampling devices are widely used for monitoring polar organic pollutants in water. Chemcatcher® uses a bound Horizon Atlantic™ HLB-L sorbent disk as receiving phase, whilst the POCIS uses the same material in the form of loose powder. Both devices (n = 3) were deployed for 21 days in the final effluent at three wastewater treatment plants in South Wales, UK. Following deployment, sampler extracts were analysed using liquid chromatography time-of-flight mass spectrometry. Compounds were identified using an in-house database of pharmaceuticals using a metabolomics workflow. Sixty-eight compounds were identified in all samplers. For the POCIS, substantial losses of sorbent (11–51%) were found during deployment and subsequent laboratory analysis, necessitating the use of a recovery factor. Percentage relative standard deviations varied (with 10 compounds exceeding 30% in both samplers) between individual compounds and between samplers deployed at the three sites. The relative performance of the two devices was evaluated using the mass of analyte sequestered, measured as an integrated peak area. The ratio of the uptake of the pharmaceuticals for the POCIS versus Chemcatcher® was lower (1.84x) than would be expected on the basis of the ratio of active sampling areas (3.01x) of the two devices. The lower than predicted uptake may be attributable to the loose sorbent material moving inside the POCIS when deployed in the field in the vertical plane. In order to overcome this, it is recommended to deploy the POCIS horizontally inside the deployment cage.
New Criteria for Lupus
Authors: Aringer Martin , Leuchten Nicolai , Johnson Sindhu R.
Published: May 2020

Purpose of the Review

Classification criteria define the patient population for clinical trials and translational studies, but also influence current understanding of the disease. This review attempts to delineate the development from the American College of Rheumatology (ACR) 1982 to the European League Against Rheumatism (EULAR)/ACR 2019 classification criteria for systemic lupus erythematosus (SLE).

Recent Findings

The new EULAR/ACR classification criteria use antinuclear antibodies (ANA) as an entry criterion. (Non-infectious) fever is the one new criterion. All criteria items now have individual weights (from 2 to 10) and are structured in domains, within which only the highest item is counted. There is one common attribution rule, counting criteria only if there is no more likely alternative explanation. Ten points are sufficient for classification. The new criteria have reached a sensitivity of 96.1% and a specificity of 93.4%.

The new EULAR/ACR 2019 classification criteria for SLE build on the previous criteria sets, adding fever only as a new criteria item. The new structure is reflective of the current diagnostic approach and has led to improved statistical performance.
Standard hypothyroid treatment did not restore proper metabolic response to carbohydrate
Authors: Kozacz Agnieszka , Assis Gilmara Gomes de , Sanocka Urszula , Ziemba Andrzej Wojciech
Published: May 2020

Purpose

Hypothyroidism is associated with a lower metabolic rate, impaired glucose tolerance, and increased responsiveness of sympathetic nervous system to glucose ingestion. The Levothyroxine (LT4) monotherapy is the standard treatment for hypothyroidism; however to what extent this treatment restores the patients’ metabolism has not been verified. The aim of this study was to test the hypothesis that standard LT4 therapy may not restore proper metabolic response to carbohydrate ingestion.

Methods

Energy expenditure, glucose tolerance, and catecholamine response to glucose ingestion were compared in 18 subjects with pharmacologically compensated hypothyroidism (PCH) and controls, at baseline and during oral glucose tolerance test conditions.

Results

Metabolic rate was significantly lower in PCH (P < 0.0001). Glucose tolerance was decreased in this group with no differences in insulin resistance indicators between both groups. Adrenergic activity (P < 0.05) as well as adrenergic reaction to glucose ingestion (P < 0.001) were stronger in PCH.

Conclusions

Standard treatment for hypothyroidism does not restore the normal metabolic reaction to carbohydrate which is observed in healthy people.
The Effect of Chronic Mild Stress and Venlafaxine on the Expression and Methylation Levels of Genes Involved in the Tryptophan Catabolites Pathway in the Blood and Brain Structures of Rats
Authors: Wigner Paulina , Synowiec Ewelina , Jóźwiak Paweł , Czarny Piotr , Bijak Michał , Białek Katarzyna , Szemraj Janusz , Gruca Piotr , Papp Mariusz , Śliwiński Tomasz
Published: May 2020

A growing body of evidence suggests that depression may be associated with impairment of the tryptophan catabolites (TRYCATs) pathway. The present study investigated the effects of the chronic administration of venlafaxine on the expression and methylation status of Katl, Tph1/2, Ido1, Kmo and Kynu in the brain and blood of rats exposed to the CMS model of depression. The rats were subjected to the CMS procedure for 2 or 7 weeks and administered venlafaxine (10 mg/kg/day, IP) for 5 weeks. mRNA and protein expression and the methylation status of gene promoters in PBMCs and six brain structures were evaluated and analysed using the TaqMan Gene Expression Assay and Western blotting, and methylation-sensitive high-resolution melting (MS-HRM), respectively. We found that the CMS procedure increased KatI expression in the midbrain and KatII expression in the midbrain and the amygdala, while venlafaxine administration decreased KatII expression in the hypothalamus and the cerebral cortex. The methylation status of the Tph1 and Kmo promoters in peripheral blood mononuclear cells (PBMCs) was significantly increased in the stressed group after antidepressant therapy. The protein levels of Tph1 and Ido1 were decreased following venlafaxine administration. Our results confirmed that CMS and venlafaxine modulate the expression levels and methylation status of genes involved in the TRYCATs pathway.
Long-Term Venovenous Connection for Extracorporeal Carbon Dioxide Removal (ECCO2R)–Numerical Investigation of the Connection to the Common Iliac Veins
Authors: Steuer N. B. , Hugenroth K. , Beck T. , Spillner J. , Kopp R. , Reinartz S. , Schmitz-Rode T. , Steinseifer U. , Wagner G. , Arens J.
Published: May 2020

Purpose

Currently used cannulae for extracorporeal carbon dioxide removal (ECCO2R) are associated with complications such as thrombosis and distal limb ischemia, especially for long-term use. We hypothesize that the risk of these complications is reducible by attaching hemodynamically optimized grafts to the patient’s vessels. In this study, as a first step towards a long-term stable ECCO2R connection, we investigated the feasibility of a venovenous connection to the common iliac veins. To ensure its applicability, the drainage of reinfused blood (recirculation) and high wall shear stress (WSS) must be avoided.

Methods

A reference model was selected for computational fluid dynamics, on the basis of the analysis of imaging data. Initially, a sensitivity analysis regarding recirculation was conducted using as variables: blood flow, the distance of drainage and return to the iliocaval junction, as well as the diameter and position of the grafts. Subsequently, the connection was optimized regarding recirculation and the WSS was evaluated. We validated the simulations in a silicone model traversed by dyed fluid.

Results

The simulations were in good agreement with the validation measurements (mean deviation 1.64%). The recirculation ranged from 32.1 to 0%. The maximum WSS did not exceed 5.57 Pa. The position and diameter of the return graft show the highest influence on recirculation. A correlation was ascertained between recirculation and WSS. Overall, an inflow jet directed at a vessel wall entails not only high WSS, but also a flow separation and thereby an increased recirculation. Therefore, return grafts aligned to the vena cava are crucial.

Conclusion

In conclusion, a connection without recirculation could be feasible and therefore provides a promising option for a long-term ECCO2R connection.
Een onbekende procedure: double-barreled wet colostomy
Authors: Yildirim Hilin , Tanis Pieter J. , de Reijke Theo M. , Beerlage Harrie P. , Hompes Roel , Oddens Jorg R.
Published: May 2020

Samenvatting

Een 62-jarige vrouw onderging een double barreled wet colostomy (DBWC) na een bekkenexenteratie. De DBWC is een relatief onbekende ingreep, waarbij een colostoma wordt aangelegd met twee openingen, waardoor urine en ontlasting via gescheiden compartimenten naar buiten worden geleid. Het doel van dit artikel is de DBWC te vergelijken met een gescheiden urostoma en colostoma aan de hand van een casus en een review van de beschikbare literatuur. Er werden drie retrospectieve studies gevonden die een DWBC vergeleken met een gescheiden uro- en colostoma, met in totaal 267 patiënten. Daaruit bleek geen verhoogde mortaliteit en morbiditeit bij een DBWC ten opzichte van een gescheiden urinestoma en colostoma. De conclusie luidt dat een DBWC kan worden overwogen na een bekkenexenteratie.
Synanthropic spider fauna of the Carpathian Basin in the last three decades
Authors: Szinetár Csaba , Kovács Gábor , Urák István , Gajdoš Peter
Published: May 2020

This paper reviews the scientific literature published on synanthropic spiders in three Carpathian Basin countries—Hungary, Slovakia and Romania. A total number of 204 spider species have been reported from human constructions. Most of the 204 spider species (165 species) found in buildings were only occasional visitors, so-called asynanthropic species with typically low abundance. On average, eusynanthropic (23 species) and hemisynanthropic (16 species) species accounted for 80% of the specimen number. We have discovered that the number of hemisynanthropic faunal elements have remained unchanged in the past three decades. At the same time 14 new eusynanthropic species have been observed in the region, roughly one new species in every 2 years. Some of them have been introduced from the tropics, but some species originates from southern Europe, which may be related to climate change. This hypothesis was also confirmed by the seasonal summer outdoor appearance of these eusynanthropic species. True tropical spiders could only be settled permanently in greenhouses with special climate (such as botanical gardens). We still do not have data of any synanthropic species posing a health risk in this region.
Procurement to shop floor – the importance of PPE
Authors: Matenaers Chris
Published: May 2020

Chris Matenaers, marketing director of Zoro UK stresses why it is important that SMEs must have confidence in PPE suppliers to have the right stock when they need it.
Impacts of synoptic-scale cyclones on Arctic sea-ice concentration: a systematic analysis
Authors: Schreiber Erika A. P. , Serreze Mark C.
Published: May 2020

The role of synoptic-scale cyclones in the trends and variability of Arctic sea ice conditions has remained uncertain. In recognition, we conduct a systematic investigation of how sea-ice concentration (SIC) changes with cyclone passage, including all individual storms that pass over any part of the region's ice pack. For all seasons, especially summer and autumn, we find a pattern of higher ice concentration after a region is influenced by a cyclone compared to when it is not, primarily due to thermodynamic effects. During warm months, cyclones appear to slow the general day-to-day decline in concentration; in cold months, cyclones augment the day-to-day increase. These relationships are changing over time, with cyclone-associated concentration changes becoming less distinct from overall changes. Cyclone effects on ice divergence are spatially variable; computed fields are noisy. In summer, these dynamic effects of cyclone passage generally decrease SIC, but are outweighed by the thermodynamic effects (e.g., reductions in air temperature, shortwave radiation). In autumn, cyclone-associated concentration changes are not as easily explained by observed cyclone conditions. Key questions remain regarding the extent to which our findings are influenced by artifacts of surface melt and weather effects on the passive microwave retrievals.
LO48: Pediatric cannabinoid hyperemesis syndrome in the emergency department: a 5-year retrospective review
Authors: Foster D. , Aarsen K. Van , Yan J. , Teefy J. , Lynch T.
Published: May 2020

Introduction: Cannabinoid Hyperemesis Syndrome (CHS) in pediatric patients is poorly characterized. Literature is scarce, making identification and treatment challenging. This study's objective was to describe demographics and visit data of pediatric patients presenting to the emergency department (ED) with suspected CHS, in order to improve understanding of the disorder. Methods: A retrospective chart review was conducted of pediatric patients (12-17 years) with suspected CHS presenting to one of two tertiary-care EDs; one pediatric and one pediatric/adult (combined annual pediatric census 40,550) between April 2014-March 2019. Charts were selected based on discharge diagnosis of abdominal pain or nausea/vomiting with positive cannabis urine screen, or discharge diagnosis of cannabis use, using ICD-10 codes. Patients with confirmed or likely diagnosis of CHS were identified and data including demographics, clinical history, and ED investigations/treatments were recorded by a trained research assistant. Results: 242 patients met criteria for review. 39 were identified as having a confirmed or likely diagnosis of CHS (mean age 16.2, SD 0.85 years with 64% female). 87% were triaged as either CTAS-2 or CTAS-3. 80% of patients had cannabis use frequency/duration documented. Of these, 89% reported at least daily use, the mean consumption was 1.30g/day (SD 1.13g/day), and all reported ≥6 months of heavy use. 69% of patients had at least one psychiatric comorbidity. When presenting to the ED, all had vomiting, 81% had nausea, 81% had abdominal pain, and 30% reported weight loss. Investigations done included venous blood gas (30%), pregnancy test in females (84%), liver enzymes (57%), pelvic or abdominal ultrasound (19%), abdominal X-ray (19%), and CT head (5%). 89% of patients received treatment in the ED with 81% receiving anti-emetics, 68% receiving intravenous (IV) fluids, and 22% receiving analgesics. Normal saline was the most used IV fluid (80%) and ondansetron was the most used anti-emetic (90%). Cannabis was suspected to account for symptoms in 74%, with 31% of these given the formal diagnosis of CHS. 62% of patients had another visit to the ED within 30 days (prior to or post sentinel visit), 59% of these for similar symptoms. Conclusion: This study of pediatric CHS reveals unique findings including a preponderance of female patients, a majority that consume cannabis daily, and weight loss reported in nearly one third. Many received extensive workups and most had multiple clustered visits to the ED.
LO50: Pain free laceration repairs using intra-nasal ketamine: DosINK 2 clinical trial
Authors: Rached-Dastous S. , Trottier E. D. , Finkelstein Y. , Bailey B. , Marquis C. , Lebel D. , Desjardins M.
Published: May 2020

Introduction: Lacerations are common in children presenting to the emergency department (ED). They are often uncooperative when sutures are needed and may require procedural sedation. Few studies have evaluated intranasal (IN) ketamine for procedural sedation in children, with doses from 3 to 9 mg/kg used mostly for dental procedures. In a previous dose escalation trial, DosINK-1, 6 mg/kg was found to be the optimal IN ketamine dose for procedural sedation for sutures in children. In this trial, we aim to further evaluate the efficacy of this dose. Methods: We conducted a multicentre single-arm clinical trial. A convenience sample of 30 uncooperative children between 1 and 12 years (10 to 30 kg) with no cardiac or kidney disease, active respiratory infection, prior administration of opioid or sedative agents received 6 mg/kg of IN ketamine using an atomizer for their laceration repair with sutures in the ED. The primary outcome was defined as the proportion (95% CI) of patients who achieved an adequate procedural sedation evaluated with the PERC/PECARN consensus criteria. Results: Thirty patients were recruited from April 2018 to November 2019 in 2 pediatric ED. The median age was 3.2 (interquartile range(IQR), 1.9 to 4.7) years-old with laceration of more than 2 cm in 20 (67%) patients and in the face in 21 (70%) cases. Sedation was effective in 18 out of 30 children 60% (95%CI, 45 to 80), was suboptimal in 6 patients (20%) with a procedure completed with minimal difficulties, and unsuccessful in the remaining 6 (20%), all without serious adverse event. Similarly, 21/30 (70%) physicians were willing to reuse IN ketamine at the same doses and 25 parents (83%) would agree to the same sedation in the future. Median time to return to baseline status was 58 min (IQR, 33 to 73). One patient desaturated during the procedure and required transitory oxygen and repositioning. After the procedure, 1 (3%) patient had headache, 1 (3%) patient had nausea, and 2 (7%) patients vomited. Conclusion: A single dose of 6 mg/kg of IN Ketamine for laceration repair with sutures in uncooperative children is safe and facilitated the procedure in 60% (95%CI, 45 to 80) of patients, was suboptimal in 20% and unsuccessful in 20% of patients. As seen with IV ketamine, an available additional dose of IN ketamine for some children if needed could potentially increase proportion of successful sedation. However, the safety and efficacy of repeated doses needs to be addressed.
LO62: Cannabis-induced psychotic disorder at a Canadian tertiary care emergency department
Authors: Skoblenick K. , Rumley A. , Gauri A. , Marsh-Joyal M.
Published: May 2020

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.
LO68: Kelowna emergency department buprenorphine/naloxone for opioid use disorder: a program evaluation study
Authors: Jones M. , Bailey B. , Nevers W. , Hill M. , Lappalainen L. , Williams D.
Published: May 2020

Introduction: Emergency department (ED) buprenorphine/naloxone inductions for opioid use disorder are an effective and safe way to initiate addictions care in the ED. Kelowna General Hospital's ED buprenorphine/naloxone (KEDSS) program was implemented in September 2018 in order to respond to a community need for accessible and evidence-based addictions care. The objective of our program evaluation study was to examine the implementation of the first five months of the KEDSS program through evaluating patient characteristics and service outcomes. Methods: The KEDSS treatment pathway consists of a standardized protocol (pre-printed order set) to facilitate buprenorphine/naloxone induction and stabilization in the acute care setting (ED and inpatient wards) at Kelowna General Hospital, a community academic hospital. All patients referred to the outpatient addictions clinic via the order set during September 2018-January 2019 (the first 5 months) were included in the study population. A retrospective descriptive chart review was completed. Outcome measures included population characteristics (sociodemographic information, clinical characteristics) and service outcomes (number of patients initiated, patient follow-up). Descriptive statistics and bivariate analyses using t-tests or Pearson's χ2 statistic, as appropriate, were conducted to compare the ED-initiated group with the inpatient-initiated group. Results: During the first five months of the KEDSS program, a total of 35 patients (26% female, mean age 36.6 years, 54% homeless) were started on the treatment pathway, 16 (46%) in the ED. Compared to the inpatient-initiated group, the ED-initiated group were less likely to have psychiatric comorbidities (ED 1.0 vs. inpatient 1.5, p = 0.002), require methadone or sustained-release oral morphine (ED 13% vs. inpatient 37%, p = 0.048), and have attended follow-up (ED 56% vs. inpatient 84%, p = 0.004). Conclusion: This study provides a preliminary look at a new opioid agonist therapy (OAT) treatment pathway (KEDSS) at Kelowna General Hospital, and provides insight into the population that is accessing the program. We found that the majority of patients who are started on buprenorphine/naloxone in the ED are seen in follow-up at the addictions clinic. Future work will examine ongoing follow-up and OAT adherence rates in the study population to quantify the program's impact on improving access to addictions treatment within this community hospital setting.
LO69: Haloperidol versus ondansetron for hyperemesis due to cannabis (HaVOC): a randomized, controlled clinical trial
Authors: Ruberto A. , Sivilotti M. , Forrester S. , Hall A. , Crawford F. , Day A.
Published: May 2020

Introduction: One of the most common adverse effects of habitual cannabis use is hyperemesis—recurrent bouts of protracted vomiting, retching and abdominal pain superimposed on a baseline of daily nausea and anorexia. Largely anecdotal evidence supports the use of haloperidol, benzodiazepines or topical capsaicin over traditional antiemetics, yet little is known about the cause or optimal treatment of this newly recognized disorder. We report the results of one of the first clinical trials on so-called cannabis hyperemesis syndrome (NCT03056482). Methods: We approached adults with a working diagnosis of hyperemesis due to cannabis, provided they had ongoing emesis for >2 hours, a cyclic pattern of 3+ episodes in the last 2 years, and near daily use of cannabis by inhalation. We excluded those who were pregnant, deemed unreliable, or using opioids. Subjects provided written consent to be randomized during the index or any subsequent visit to either haloperidol (with a nested randomization to either 0.05 mg/kg or 0.1 mg/kg) or ondansetron 8 mg intravenously in a quadruple-blind fashion, and to be followed for 7 days. The primary outcome was the average reduction from baseline in abdominal pain and nausea (each measured on a 10-cm VAS) at 2 hours. While the original trial design allowed for crossover, the primary analysis used only the first treatment period since fewer than the prespecified threshold of 20% of subjects crossed over. Results: We enrolled 33 subjects, of whom 30 (16 men, 29+/-11 years old, using 1.5+/-0.9 g/day since age 19+/-2 years) were treated at least once (haloperidol 13, ondansetron 17). Haloperidol at either dose was superior to ondansetron (difference 2.3 cm [95%CI 0.6, 4.0]; p = 0.01), with similar improvements in both pain and nausea, as well as less rescue antiemetics (27% vs 61%; p = 0.04), and shorter time to ED departure (3.1+/-1.7 vs 5.6+/-4.5 hours; p = 0.03 Wilcoxon rank sum). There were two (haloperidol) vs six (ondansetron) return visits for ongoing nausea/vomiting, as well as two return visits for acute dystonia, both in the higher dose haloperidol group. Conclusion: Haloperidol is superior to ondansetron for the acute symptomatic treatment of patients with ongoing hyperemesis attributed to habitual cannabis use. The efficacy of this agent over ondansetron provides insight into the mechanism of this new disorder, now almost a daily diagnosis in many Canadian emergency departments.
LO70: Emergency department use and migration patterns of people experiencing homelessness
Authors: Hossain R. , Burcul I. , Dai J. , Hossain R. , Strobel S. , Ma Z. , Jamani S.
Published: May 2020

Introduction: Understanding how homeless patients interact with healthcare systems can be challenging. The nature of the population is such that identifying and following these persons can be severely limited by data. Previous studies have used survey data which relies on self-reporting and selected samples such as those persons admitted to homeless shelters (Gray et al. 2011). Other studies have been able to leverage administrative data but only for selected local geographic areas (Somers et al. 2016, Tompkins et al 2003). It is possible that the current literature has not examined a large proportion of homeless persons and their healthcare use. This is concerning because this population can have higher associated medical costs and greater medical resource utilization especially with regards to psychiatric and emergency department (ED) resources (Tulloch et al. 2012, Forchuk et al, 2015). Methods: Administrative health data (2010 to 2017) is used to analyze ambulatory care records for homeless individuals in Ontario, Canada. Uniquely, we are able to use ED contacts as a way of identifying homeless migrations from region to region within Ontario. Using a network analysis we identify high impact ED nodes and discrete hospital networks where homeless patients congregate. We are also able to more fully characterize this population's demographics, health issues, and disposition from the ED. Results: We provide a more complete understanding of migration patterns for homeless individuals, across Ontario and their concomitant ED use and hospitalizations. The three most frequented regions in Ontario (n = 640,897) were Toronto Central (35.96%), Hamilton Niagara Halimand Brant (8.9%) and Champlain (7.84%). In subsequent visits, the majority of patients presented to different EDs, however a subgroup who always presented to the same site was present. Over the 7 year period, migration between visits occurred most often between urban areas, and increased as a whole. Conclusion: The results of the study allow for the enhancement care coordination for vulnerable populations and enhance the availability and delivery of services for sub-groups of homelessness whose care needs may differ based on migration patterns. Services can be coordinated between jurisdictions for homeless individuals, and appropriate referrals can be made across the health care system. Further evidence is provided for a novel method of mapping migration among the homeless and its associations and effects on ED use.
LO71: The effect of boarding time in ED on length of stay for psychiatric patients
Authors: Lane D. , Lang E. , Roberts L.
Published: May 2020

Introduction: The Emergency Departments (ED) is a gateway to the health care system for many psychiatric patients. As a consequence of hospital administrative factors and overcrowding, admitted psychiatric patients are often boarded in the ED while waiting for an inpatient bed. There is currently a lack of evidence to quantify the effect that ED boarding has on psychiatric patients. The primary objective of this study is to determine whether a patient's length of stay is related to longer ED boarding time. Methods: This study is a retrospective cohort using data from an administrative source, which was obtained from patient records captured in the Sunrise Clinical Manager EMR used across Calgary, Alberta EDs from 2014-2018. A hierarchical Bayesian regression analysis was used to model the several patient-level and hospital-level factors. The mean and variance was defined by the exposure of interest, namely hours in the Emergency Department after admission to psychiatry unit expressed as a continuous variable. An interaction between this exposure and patient-level confounders was used to model the changing effect of a patient's severity in the ED on their boarding time. Results: The median boarding time for patients in our study was 6.6 hours (standard deviation 17.3), while the average was 13.6 hours. Patients who were boarded for greater than 6 hours more frequently required an antipsychotic (37% vs 11%; SMD 0.651), sedative (52% vs 29%; SMD 0.483) or restraints (18% vs. 14%; SMD 0.102). In crude analysis there was no difference in median length of stay for patients that were boarding more than 6 hours compared to those boarded for less than 6 hours (8 days vs 9 days; SMD 0.012).The rate ratio for length of stay is 1.05 with 95% posterior interval 1.04 - 1.06 for each 24 hour increase in boarding time. This means that for each 1 day worth of boarding time, the length of stay (in days) increases 1.05 times (or 0.05 days/day boarding time). Conclusion: Boarding time is associated with a small but absolute increase in length of stay for psychiatric patients. Decreasing boarding time could have ripple effects for ED efficiency and overall patient outcomes.
LO72: Spotting potential opportunities for teachable moments
Authors: Alrimawi H. , BCh MB , Sample S. , Chan T.
Published: May 2020

Introduction: With the transition of Emergency Medicine into competency based medical education (CBME), entrustable professional activities (EPAs) are used to evaluate residents on performed clinical duties. This study aimed to determine if implementing a case-based orientation, designed to increase recognition of available EPAs, into CBME orientation would help residents increase the number of EPAs completed. Methods: We designed an intervention consisting of clinical cases that were reviewed by national EPA experts who identified which EPAs could be assessed from each case. A case-based session was incorporated into the 2019 CBME orientation for The McMaster Emergency Medicine Program. Postgraduate Year (PGY)1 residents read the cases and discussed which EPAs could be obtained with PGY2/faculty facilitators. The number of EPAs completed in the first two blocks of PGY1 was determined from local program data and Student's t-test was used to compare averages between cohorts. Results: We analyzed data from 22 trainees (7 in 2017, 8 in 2018, and 7 in 2019). In the first two blocks of PGY1, the intervention cohort (2019) had a significantly higher average number of EPAs completed per trainee (47.4 [SD 11.8]) than the historical cohort (25.3 [SD 6.7]) (p < 0.001) (Cohen's d = 2.3). No significant difference existed in the number EPAs obtained between the 2017/2018 cohorts, with averages of 24.3 [SD 6.8] and 26.1 [SD 7.0] per trainee respectively (p = 0.6). Conclusion: Implementation of a case-based orientation led by CBME-experienced facilitators nearly doubled the EPA acquisition rate of our PGY1s. The consistent EPA acquisition by the 2017/2018 cohorts suggest that the post-intervention increase was not solely due to developed familiarity with the CBME curriculum.
LO75: Does the Ottawa emergency department shift observation tool give more useful information – assessing the utility of transitioning to a novel, entrustability based assessment tool in the emergency department
Authors: Dewhirst S. , Cheung W. , Dudek N. , Wood T. , Frank J.
Published: May 2020

Introduction: The Ottawa Emergency Department Shift Observation Tool (O-EDShOT) was recently developed to assess a resident's ability to safely run an ED shift and is supported by multiple sources of validity evidence. The O-EDShOT uses entrustability scales, which reflect the degree of supervision required for a given task. It was found to discriminate between learners of different levels, and to differentiate between residents who were rated as able to safely run the shift and those who were not. In June 2018 we replaced norm-based daily encounter cards (DECs) with the O-EDShOT. With the ideal assessment tool, most of the score variability would be explained by variability in learners’ performances. In reality, however, much of the observed variability is explained by other factors. The purpose of this study is to determine what proportion of total score variability is accounted for by learner variability when using norm-based DECs vs the O-EDShOT. Methods: This was a prospective pre-/post-implementation study, including all daily assessments completed between July 2017 and June 2019 at The Ottawa Hospital ED. A generalizability analysis (G study) was performed to determine what proportion of total score variability is accounted for by the various factors in this study (learner, rater, form, pgy level) for both the pre- and post- implementation phases. We collected 12 months of data for each phase, because we estimated that 6-12 months would be required to observe a measurable increase in entrustment scale scores within a learner. Results: A total of 3908 and 3679 assessments were completed by 99 and 116 assessors in the pre- and post- implementation phases respectively. Our G study revealed that 21% of total score variance was explained by a combination of post-graduate year (PGY) level and the individual learner in the pre-implementation phase, compared to 59% in the post-implementation phase. An average of 51 vs 27 forms/learner are required to achieve a reliability of 0.80 in the pre- and post-implementation phases respectively. Conclusion: A significantly greater proportion of total score variability is explained by variability in learners’ performances with the O-EDShOT compared to norm-based DECs. The O-EDShOT also requires fewer assessments to generate a reliable estimate of the learner's ability. This study suggests that the O-EDShOT is a more useful assessment tool than norm-based DECs, and could be adopted in other emergency medicine training programs.
LO77: Performance enhancing psychological skills in clinical simulation
Authors: Johannessen E. , Davies T. , Valeriano A. , Blackmore E. , Belyea A. , Gilic F.
Published: May 2020

Introduction: Clinical simulations in are designed to evoke feelings of stress and uncertainty in order to mimic challenges that learners will face in the real world. When not managed properly, these sources of extraneous cognitive load cause a burden on working memory, leading to a hindered ability to acquire new information. The “Beat the Stress Fool” (BTSF) protocol is a performance-enhancing tool designed to reduce cognitive overload during acute care scenarios. It involves breathing exercises, positive self-talk, visualization, and deliberate articulations. This study aims to validate the BTSF protocol as a method for reducing cognitive load using both psychometric and physiologic measures. Methods: Data collection took place during the Queen's University “Nightmares-FM” course. This clinical simulation program involves team-based scenarios designed to teach the fundamentals of acute care to first-year family medicine residents. Participants were divided equally into experimental and control groups based on pre-existing cohorts. Participants completed a baseline state-trait anxiety inventory and a demographics survey. The experimental group was guided through the BTSF protocol prior to each of 16 simulations; in both groups, physiologic and psychometric cognitive load measurements were collected for the alternating team leader. Galvanic skin response (GSR) and heart rate (HR) were collected during a 15-second baseline and throughout each simulation using a Shimmer 3 GSR+ wearable sensor. Self-reported cognitive load was assessed after each scenario using the 9-point Paas scale. Results: The mean Paas scores for the BTSF group were significantly lower than the control group (6.2 vs 6.9, p < 0.05), indicating lower subjective cognitive load. GSR signal magnitude (p = 0.086), spike amplitude (p = 0.066), and spike density (p = 0.584) were also lower in the BTSF group. There was no difference in HR between groups. There was not a significant correlation between self-reported cognitive load and the normalized physiologic measures. Conclusion: The results demonstrate the effectiveness of the BTSF protocol in lowering the amount of perceived mental effort required to perform clinical simulation tasks. These findings were mirrored in the galvanic skin response signal, though our study was likely underpowered for significance. This is the first study to validate a proof-of-concept for the BTSF protocol in learners during simulated training.