bluuebunny/crossref_metadata_2025 huggingface dataset:
A learning progression should address regression: Insights from developing non‐linear reasoning in ecology
Authors: Hovardas Tasos
Published: June 2016

Although ecological systems at varying scales involve non‐linear interactions, learners insist thinking in a linear fashion when they deal with ecological phenomena. The overall objective of the present contribution was to propose a hypothetical learning progression for developing non‐linear reasoning in prey–predator systems and to provide empirical evidence for one part of this progression. Pre‐service teachers followed three teaching units that involved a game simulation of the prey–predator system. Participants predicted how wolf and deer populations would evolve in a hypothetical forest, and then they used the simulation to generate data, construct a graph, describe their graph, and compare their predictions with graph description. A new learning context was introduced and new predictions were requested to investigate whether participants would transfer former learning experiences in the new setting. Analysis of learning products revealed the “messy” character of learners' intermediate steps. Some participants succeeded in identifying aspects of metamodeling knowledge, but this was not used in their new predictions. Graph description could either perpetuate or challenge linear heuristics depending on the strategy participants followed. There were a number of participants who misrepresented prey and predator population trends as “inversely proportional,” which indicated that there is a possibility of regression to the lower anchor. Linearity and proportionality might have re‐surfaced during the learning activity sequence and linear heuristics could have been so powerful as to distract learners' attention from axes labels. Learning products constructed by learners during learning activities included crucial benchmarks to diagnose learner performance and indicated proper timing for feedback provision. Overall, the implications of the study highlight the importance of using learning products to enact formative assessment. Directions for future research are discussed. © 2016 Wiley Periodicals, Inc. J Res Sci Teach 53: 1447–1470, 2016
Impacts of drought and responses of rural populations in West Africa: a systematic review
Authors: Gautier Denis , Denis David , Locatelli Bruno
Published: June 2016

In West Africa, climate variations and droughts have always affected livelihoods but have also triggered adaptation strategies. A better understanding of the impacts of drought and the responses of West African populations is indispensable for researchers and decision makers in the current and future context of multiple socioeconomic and environmental changes, including climate change. We conducted a systematic review of the literature on drought in West Africa. In this paper, we highlight controversial issues and identify knowledge gaps. Although drought has been widely considered as a major problem in West Africa, there is a need to frame it within a set of multiple threats faced by local populations and to understand how droughts act as a trigger in economic, societal, and environmental contexts. The literature on responses to drought focuses on agricultural and individual responses, while diversification, migration, and tree‐based or livestock‐based responses are less frequently addressed. More research is needed on the effectiveness and on the unexpected effects of responses of populations, states, and NGOs, as well as on the interactions between different responses. To understand the complexity of impacts and responses, the context in which they occur and how individual and collective actions interact within households or communities needs to be taken into account. Ecosystems and agriculture offer many goods and services that are suitable for adaptation and the different landscape components should be analyzed together. Such historical, contextual, and integrated analyses would better inform new policies and projects for adaptation to climate change. WIREs Clim Change 2016, 7:666–681. doi: 10.1002/wcc.411

This article is categorized under:

Vulnerability and Adaptation to Climate Change > Learning from Cases and Analogies

Climate and Development > Sustainability and Human Well‐Being
Maternal AP determinants in the Drosophila oocyte and embryo
Authors: Ma Jun , He Feng , Xie Gengqiang , Deng Wu‐Min
Published: June 2016

An animal embryo cannot initiate its journey of forming a new life on its own. It must rely on maternally provided resources and inputs to kick‐start its developmental process. In Drosophila, the initial polarities of the embryo along both the anterior–posterior (AP) and dorsal–ventral (DV) axes are also specified by maternal determinants. Over the past several decades, genetic and molecular studies have identified and characterized such determinants, as well as the zygotic genetic regulatory networks that control patterning in the early embryo. Extensive studies of oogenesis have also led to a detailed knowledge of the cellular and molecular interactions that control the formation of a mature egg. Despite these efforts, oogenesis and embryogenesis have been studied largely as separate problems, except for qualitative aspects with regard to maternal regulation of the asymmetric localization of maternal determinants. Can oogenesis and embryogenesis be viewed from a unified perspective at a quantitative level, and can that improve our understanding of how robust embryonic patterning is achieved? Here, we discuss the basic knowledge of the regulatory mechanisms controlling oogenesis and embryonic patterning along the AP axis. We explore properties of the maternal Bicoid gradient in relation to embryo size in search for a unified framework for robust AP patterning. WIREs Dev Biol 2016, 5:562–581. doi: 10.1002/wdev.235

This article is categorized under:

Establishment of Spatial and Temporal Patterns > Regulation of Size, Proportion, and Timing

Gene Expression and Transcriptional Hierarchies > Quantitative Methods and Models

Early Embryonic Development > Development to the Basic Body Plan
The Two‐Dimensional Anion [Sb6Se10]2–: Solvothermal Synthesis, Crystal Structure, and Properties of an Iron ­Selenidoantimonate(III) [Fe(phen)3]Sb6Se10
Authors: Shen Yali , Liu Yun , Liu Shuzhen , Sun Peipei , Tang Chunying , Han Jingyu , Jia Dingxian
Published: June 2016

The iron selenidoantimonate(III) [Fe(phen)3]Sb6Se10 (1) (phen = 1, 10‐phenanthroline) was prepared by reaction of Fe, Sb, Se, phen, and 1, 4‐diazabicyclo[2.2.2]octane in MeOH and H2O mixed solvent under solvothermal conditions. 1 consists of a [Fe(phen)3]2+ cation and a two dimensional [Sb6Se10]2– anion. The [Sb6Se10]2– anion is constructed by SbSe3, SbSe4, and SbSe6 primary building blocks by corner‐ and edge‐sharing, resulting Sb4Se4, Sb5Se5, and Sb6Se6 heterorings and a semi‐cubic Sb4Se6 motif, which act as secondary building units. The octahedral SbSe6 primary unit and semi‐cubic Sb4Se6 motif make compound 1 quite different from the thioantimonates(III). Compound 1 exhibits steep bandgap (Eg) of 1.56 eV, indicating potential semiconducting property. The thermal stability of 1 was also investigated.
Outcomes of Percutaneous Cholecystostomy for Acute Cholecystitis
Authors: Pang Khang Wen , Tan Chun Han Nigel , Loh Stanley , Chang Kin Yong Stephen , Iyer Shridhar Ganpathi , Madhavan Krishnakumar , Kow Wei Chieh Alfred
Published: June 2016

Background

Acute cholecystitis (AC) is an important cause of emergency admissions among the elderly. The use of percutaneous cholecystostomy (PC) as bridging therapy among high‐risk patients is widely accepted. However, the use of PC as definitive treatment is controversial.

Aim

To determine the characteristics, clinical outcomes and predictors of recurrence of AC among patients who underwent PC.

Methods

A retrospective case series of 71 consecutive patients [73 (38–96) years, 43/71 males] treated with PC for AC at a tertiary hospital from 2007 to 2013, with data collected from case records.

Results

Patients were followed up for 37.0 (0.1–110.8) months after PC. Mortality rate was 8.5 % (6/71) during the index admission and 32.4 % (23/71) at the end of follow‐up. Recurrence rate for AC was 11.9 % (7/59). Median time to recurrence was 62 (13–464) days. PC was definitive treatment in 33/59. Predictors of recurrence were higher serum alkaline phosphatase (ALP) at diagnosis (OR = 1.01, 95 % CI 1.00–1.02, p = 0.021) and acute myocardial infarction (AMI) during index admission (OR = 8.00, 95 % CI 1.19–54.0, p = 0.033). Fifteen patients (26.3 %, 15/71) had post‐procedural complications including dislodgement (14 %, 10/71), tube obstruction (7.0 %, 5/71), bile leaks (2.8 %, 2/71), gallbladder perforation (1.4 %, 1/71), bowels perforation (1.4 %, 1/71) and severe post‐procedural haemorrhage (1.4 %, 1/71).

Conclusion

PC is effective and relatively safe in high‐risk patients with AC. However, patients with higher ALP or AMI during index admission have higher risk of recurrence and might benefit from definitive cholecystectomy.
Nicotine inhibits activation of microglial proton currents via interactions with α7 acetylcholine receptors
Authors: Noda Mami , Kobayashi AI
Published: June 2016

Alpha 7 subunits of nicotinic acetylcholine receptors (nAChRs) are expressed in microglia and are involved in the suppression of neuroinflammation. Over the past decade, many reports show beneficial effects of nicotine, though little is known about the mechanism. Here we show that nicotine inhibits lipopolysaccharide (LPS)-induced proton (H+) currents and morphological change by using primary cultured microglia. The H+ channel currents were measured by whole-cell patch clamp method under voltage-clamp condition. Increased H+ current in activated microglia was attenuated by blocking NADPH oxidase. The inhibitory effect of nicotine was due to the activation of α7 nAChR, not a direct action on the H+ channels, because the effects of nicotine was cancelled by α7 nAChR antagonists. Neurotoxic effect of LPS-activated microglia due to inflammatory cytokines was also attenuated by pre-treatment of microglia with nicotine. These results suggest that α7 nAChRs in microglia may be a therapeutic target in neuroinflammatory diseases.
Suicidal ideation and suicide attempts among youth who report bully victimization, bully perpetration and/or low social connectedness
Authors: Arango Alejandra , Opperman Kiel J. , Gipson Polly Y. , King Cheryl A.
Published: June 2016

The current study examined characteristics of bullying involvement and social connectedness in relation to suicide ideation and attempts in a sample of youth who report bully victimization, bully perpetration, and/or low social connectedness. The sample was comprised of 321 youth (67% female), ages 12–15 years (M = 13.6), recruited from an emergency department in the Midwest region of the United States. Results indicated that lower levels of social connectedness and higher levels of bully victimization and perpetration were significantly associated with suicide ideation and attempts. Level of social connectedness did not moderate the relationship between bullying involvement and suicide risk. The associations between the severity of subtypes of bully victimization and perpetration (verbal, relational, physical), electronic bullying involvement, and suicide risk were examined. Results highlight a continuum in severity of bullying involvement and social connectedness associated with suicide risk. Implications of these results are discussed.
Antimicrobial Stewardship: The Role of Vascular Access Teams
Authors: Carrico Ruth , Wiemken Timothy
Published: June 2016

Interventions that address the increasing threat of multidrug resistance are the responsibility of all health care disciplines. Vascular access teams ensure that vascular access needs are met, facilitating antimicrobial agent administration. Competent vascular access practice includes participation on interprofessional teams and provision of expert knowledge that enables medication administration and process monitoring.
A 10-Year Review of a Vascular Access Service for Patients Receiving Hemodialysis: Analysis of Procedural Modifications and Service Innovations
Authors: Lancashire John F. , Steele Michael , Swinbank Amy , Toit Dianne Du , Jackson Mark J.
Published: June 2016

Objective: We aimed to identify trends in vascular access modalities for renal hemodialysis and to evaluate the influence of service modifications on service performance and patient outcomes.

Methods: Retrospective analysis of incident and prevalent hemodialysis patients treated by the Gold Coast Hospital and Health Service, Queensland, Australia, between January 2004 and December 2013 was conducted. A comparison of patient demographic characteristics and analysis of trends in access modality and outcomes was performed for each group over the study period. Modifications to service structure and practice changes were also evaluated.

Results: A total of 1787 patients (456 incident and 1331 prevalent) and 1671 procedures were examined. The proportion of patients starting hemodialysis on a catheter decreased from 79.2% to 63.6%. Patients starting hemodialysis on a fistula increased from 16.7% to a peak of 61.5% but fell to 27.3% in 2003. Catheter use in prevalent patients decreased from 11.7% to 6.1%, whilst fistula use increased from 60.6% to 88.5%. Graft access remained low for the incident group (0.0%–9.1%) and was reduced in prevalent patients from 27.7% to 4.9%. Bloodstream infection rates were reduced from 1.88 to 1.60 per 1000 dwelling-days. Endovascular and surgical revision of arteriovenous access was increased.

Conclusions: Coordinated and multidisciplinary access service provided earlier referral for planned incident access with fewer catheters and increased fistulas with reduced bloodstream infection rates. Modifications to this vascular access service are associated with improved permanent access rates for incident and prevalent patients. There was an overall improvement of service performance and patient outcomes.
Global re‐wiring of p53 transcription regulation by the hepatitis B virus X protein
Authors: Chan Cheryl , Thurnherr Thomas , Wang Jingbo , Gallart-Palau Xavier , Sze Siu Kwan , Rozen Steve , Lee Caroline G.
Published: June 2016

Background

The tumour suppressor p53 is a central player in transcription regulation and cell fate determination. By interacting with p53 and altering its sequence‐specific binding to the response elements, the hepatitis B virus X protein (HBx) was reported to re‐direct p53 regulation of some genes.

Results

Coupling massively parallel deep sequencing with p53 chromatin immunoprecipitation, we demonstrate that HBx modulates global p53 site selection and that this was strongly influenced by altered interaction with transcription co‐factors/co‐regulators as well as post‐translational modifications. Specifically, HBx attenuated p53‐TBP‐RB1 transcription complex recruitment and interaction and this was associated with hyper‐phosphorylation of p53 at serine 315 by HBx. Concurrently, HBx enhanced p53 DNA occupancy to other response elements either alone by displacing specific transcription factors such as CEBPB and NFkB1, or in complex with distinct interacting co‐factors Sp1, JUN and E2F1. Importantly, re‐wiring of p53 transcription regulation by HBx was linked to the deregulation of genes involved in cell proliferation and death, suggesting a role of HBx in errant cell fate determination mediated by altered p53 site selection of target genes.

Conclusions

Our study thus presents first evidence of global modes of p53 transcription alteration by HBx and provides new insights to understand and potentially curtail the viral oncoprotein.
LO064: Simulation in Canadian postgraduate emergency medicine training — a national survey
Authors: Russell E. , Hagel C. , Petrosoniak A. , Howes D. , Dagnone D. , Hall A.K.
Published: June 2016

Introduction: Simulation-based medical education (SBME) is an important training strategy in emergency medicine (EM) postgraduate programs yet the extent of its use is variable. This study sought to characterize the use of simulation in FRCP-EM residency programs across Canada. Methods: A national survey was administered to residents (PGY2-5) and program representatives (PR), either a program director or simulation lead at all Canadian FRPC-EM programs. Residents completed either paper or electronic versions of the survey, and PR surveys were conducted by telephone. Results: The resident and PR response rates were 60% (187/310) and 100% (16/16), respectively. All residency programs offer both manikin-based high fidelity and task trainer simulation modalities. Residents reported a median of 20 (range 0-150) hours participating in simulation training annually, spending a mean of 16% of time in situ, 55% in hospital-based simulation laboratories, and 29% in off-site locations. Only 52% of residents indicated that the time dedicated to simulation training met their training needs. All PRs reported having a formal simulation curriculum with a frequency of simulation sessions ranging from weekly to every 6 months. Only 3/16 (19%) of programs linked their simulation curriculum to their core teaching. Only 2/16 programs (13%) used simulation for resident assessment, though 15/16 (93%) PRs indicated they would be comfortable with simulation-based assessment. The most common PR identified barriers to administering simulation by were a lack of protected faculty time (75%) and a lack of faculty experience with simulation (56%). Both PRs and residents identified a desire for more simulation training in neonatal resuscitation, pediatric resuscitation, and obstetrical emergencies. Multidisciplinary involvement in simulations was strongly valued by both residents and PRs, with 76% of residents indicating that they would like greater multidisciplinary involvement. Conclusion: Among Canadian FRCP-EM residency programs, SBME is a frequently used training modality, however, there exists considerable variability in the structure, frequency and timing of simulation exposure for residents. Several common barriers were identified that impact SBME implementation. The transition to competency-based medical education will require a national, standardized approach to SBME that includes a unified strategy for training and assessment.
LO066: H1-antihistamine administration is associated with a lower likelihood of progression to anaphylaxis among emergency department patients with allergic reactions
Authors: Kawano T. , Grunau B.E. , Gibo K. , Scheuermeyer F.X. , Stenstrom R.
Published: June 2016

Introduction: H1-antihistamines are often used to treat allergic reactions, however, the influence of H1-antihistamines on progression to anaphylaxis remains unclear. Among patients initially presenting with allergic reactions, we investigated whether H1-antihistamines were associated with a lower proportion of patients progressing to anaphylaxis during observation. Methods: This was a retrospective cohort study conducted at two urban EDs from 2007 to 2012. We included adult patients with allergy and excluded those who met criteria of anaphylaxis at first evaluation by medical professionals and/or received antihistamines before the evaluation. Primary outcomes of interest were the number of patients who developed anaphylaxis during observation at ED and/or transportation by EMS. Secondary outcomes were the number of biphasic reactions and severe anaphylaxis (defined as sBP<90; SpO2<92%; and/or confusion, collapse, loss of conscious, or incontinence). Logistic regression was performed comparing primary and secondary outcomes between H1-antihistamine treated and non-treated groups with propensity score adjustment of the baseline covariates. Number needed to treat (NNT) was calculated by adjusted absolute risk reduction of H1-antihistamine compared to non H1-antihistamine use on primary outcome. Results: This study included 1717 patients with allergic reactions, of whom 1228 were treated with H1-antihistamines. In the H1-antihistamine group 1.0% and 0.2% developed anaphylaxis and severe anaphylaxis, respectively; in the non-H1-antihistamine group 2.6% and 0.6% developed anaphylaxis and severe anaphylaxis, respectively. There were no biphasic reactions (0%, 95% confidence interval [CI] 0 to 0.17%). Administration of H1-antihistamines was associated with a lower incidence of subsequent anaphylaxis (adjusted odds ratio [OR] 0.23, 95% CI 0.10 to 0.53; NNT to benefit 49.1, 95% CI 41.6 to 83.3). There were no significant associations between H1-histamines administration and secondary outcomes. Conclusion: Among ED patient with allergic reactions, H1-antihistamine administration was associated with a lower likelihood of progression to anaphylaxis. These findings suggest that H1-antihistamines should be administered early in the care of patients with allergic reactions.
LO068: Physician adherence to Antimicrobial Guidelines for Community Acquired Pneumonia in the St. Michael’s Hospital Emergency Department
Authors: Atlin C.R. , McGowan M. , Toma A.
Published: June 2016

Introduction: The Toronto Central Local Health Integration Network released new antimicrobial guidelines for the treatment of community acquired pneumonia (CAP) in August 2013. These deemphasized antimicrobial coverage for atypical organisms and use amoxicillin-clavulanic acid (AMC) as first-line for low risk CAP. The purpose of this study was to assess physician adherence to these guidelines in St. Michael’s Hospital (SMH) Emergency Department (ED). Methods: A retrospective chart review was conducted from April 1 to May 31 in 2013, 2014 and 2015. All adult patients who were discharged home from the ED with a diagnosis of pneumonia were included. Severity of pneumonia was graded based on the CRB-65 score as per the CAP guidelines. Primary outcome was type of antibiotic prescribed by the ED physician. Data was analyzed using simple descriptive statistics. Results: There were a total of 141 patients analyzed during the study period (N=46 in 2013, N=59 in 2014, N=36 in 2015). Demographics and relevant comorbidities were similar across the years: age (2013: median=53 years, range 20-92 years; 2014: 56, 21-83; 2015: 54, 20-81); preexisting lung disease (30%, 27%, 25% respectively); HIV positive status (9%, 7%, 17%). CRB-65 score was: low risk (0 points)=70% in 2013, 66% in 2014, 75% in 2015; intermediate risk (1-2 points)=30%, 34%, 25%; high risk (3-4 points)=0% in all years. Percentage of patients discharged home with a documented prescription was 83%, 85%, and 94% respectively. In 2013, patients received azithromycin (AZM) (n=17, 43% of antibiotic prescriptions that year); levofloxacin (LVX) (n=10, 25%); AMC (n=5, 13%); clarithromycin (CLR) (n=5, 13%); trimethoprim-sulfamethoxazole (SXT) (n=2, 5%); doxycycline (DOX) (n=1, 3%). In 2014: AMC (n=26, 51%); AZM (n=12, 24%); LVX (n=9, 18%); CLR (n=2, 4%); DOX (n=1, 2%); erythromycin (ERY) (n=1, 2%). In 2015: AMC (n=17, 47%); AZM (n=12, 33%); LVX (n=4, 11%); CLR (n=1, 3%); SXT (n=1, 3%); DOX (n=1, 3%). Number of return ED visits within 2 weeks were: n=16 (35%); n=11 (19%); and n=10 (28%) respectively. Conclusion: The results of this study show that there has been a change in antibiotic prescribing practices in the SMH ED since dissemination of the CAP guidelines, with AMC accounting for nearly half of antibiotic prescriptions. Further antimicrobial stewardship efforts will focus on evaluating factors influencing prescribing practices.
LO069: Current management of pharyngitis in the emergency department: a retrospective multicenter observational study
Authors: Butler M.B. , Nason A. , Patrick L. , MacDonald S. , Dong A.X. , McIsaac W. , Smith D. , Gillis J.
Published: June 2016

Introduction: Pharyngitis is a common presenting complaint at the emergency department (ED). Historically, acute pharyngitis has been overdiagnosed as the result of a bacterial etiology, leading to over-prescription of antibiotics, and overuse of throat culturing. This study attempts to quantify the current management of acute pharyngitis in the ED, and compare to the theoretical management using a modified Centor score. Methods: This was a retrospective chart review of 1640 patients who presented to four EDs in the central zone of the Nova Scotia Health Authority that received a diagnosis of pharyngitis, bacterial pharyngitis or tonsillitis. The primary outcome was the observed rate of each diagnosis in the study population, the rate of antibiotic prescription, and the rate of throat swab cultures performed. The secondary outcomes were the rate of antibiotics and throat swabs ordered using a modified Centor score. Antibiotics as first-line treatment were indicated if the Centor score was three or greater, and throat cultures were indicated if the Centor score was two or greater. Results: A total of 1596 patients were included in the analysis. Antibiotics were given in 893 patients (0.559; 95% CI: {0.535, 0.584}). Cultures were sent on 863 patients (0.541 CI: {0.516, 0.565}). Using the modified Centor thresholds, we would have prescribed antibiotics as the first-line treatment in 77 cases (0.048 CI: {0.038, 0.060}), potentially saving 786 prescriptions, and ordered throat swabs on 502 patients (0.315, CI: {0.292, 0.338}), saving 361 cultures. The most commonly prescribed antibiotic was penicillin, and the least prescribed was metronidazole. Conclusion: Over half of patients that present with acute pharyngitis receive an antibiotic, and over half have a throat swab culture performed. Utilizing a modified Centor score would result in decreased antibiotic prescription rate, and a diminished rate of throat cultures. Incorporation of these Centor criteria could result in diminished antibiotic prescription rates for acute pharyngitis in the ED.
LO073: Implementation of an ED atrial fibrillation and atrial flutter pathway decreases ED length of stay
Authors: Barbic D. , Harris D.R. , Stenstrom R. , Dewitt C. , Marsden J. , Kalla D. , Wu C. , Vadeanu C. , Heilbron B. , Tung S. , Grafstein E. , Rogers J. , Scheuermeyer F.X.
Published: June 2016

Introduction: Atrial fibrillation and flutter (AFF) are the most common arrhythmias presenting to the emergency department. A coordinated ED AFF electronic order-set and management pathway was developed in collaboration with cardiologists at our institution. The primary objective of this study was to compare the ED length of stay pre and post pathway implementation. Secondary objectives included comparison of the following outcomes pre and post-pathway (PRE & POST): AFF Clinic referral rates, ED return rates, and mortality. Methods: This was a retrospective case series of patients presenting to our quarternary care ED with AFF pre and post AFF pathway implementation. Cases were identified using an administrative database covering 120 000 annual ED visits. Trained research assistants and the primary investigator extracted data from the electronic medical record. 20% of all charts were double collected to ensure accuracy (k=0.85). Descriptive variables were described using counts, means, medians and confidence intervals. Chi-square statistics of dependent samples were calculated for the primary outcome. Results: We examined 307 cases of AFF presenting to our ED (n=130 PRE; n=177 POST). Demographic variables were similar PRE and POST: mean age (66.0 [95%CI 63.8-68.3] PRE; 65.0 [63.0-67.0] POST), % male (59.2% PRE; 59.3% POST), presenting rhythm (66.2% A.fib [58.0-74.3] A. flutter 29.2% [21.4-37.0] PRE; 61.0% A.fib [53.8-68.1] A. flutter 17.5% [11.9-23.1] POST), and CHADS2VASC score (2.1 [1.8-2.4] PRE; 1.9 [1.7-2.1] POST). The mean ED LOS decreased by 72.5 minutes (95% CI -22.9 to -122.1; P < 0.001). AFF clinic referral rates increased from 16.9% PRE to 25.4% POST (not significant). ED return rates within 30 days for AFF, CHF, major bleeding and CVA were unchanged. 30 day mortality rates were not statistically different (1.5% PRE vs. 2.8% POST). Conclusion: A coordinated ED AFF pathway was associated with a significant reduction in ED LOS without significant changes in ED return rates or mortality.
LO074: Point of care ultrasound for lung B-lines in the early diagnosis of acute decompensated heart failure in the emergency department: a systematic review
Authors: McGivery K. , Atkinson P.R. , Lewis D. , Taylor L. , Gadd K.
Published: June 2016

Introduction: Dyspnea is a common presenting problem in the emergency department (ED) that frequently creates a diagnostic challenge for physicians. Acute decompensated heart failure (ADHF) represents a common cause that requires prompt diagnosis and management. Recent studies on dyspneic patients have suggested a potential role for point-of-care ultrasound (PoCUS). The objective of this systematic review was to assess the sensitivity and specificity of early bedside lung ultrasound in patients presenting to the ED with dyspnea. Methods: A search of the literature was conducted using PubMed, EMBASE, the Cochrane Library, bibliographies of previous systematic reviews, and abstracts from major emergency medicine conferences. We included prospective studies that assessed the diagnostic accuracy of B-lines from bedside lung ultrasound in the ED patients compared to a clinical diagnosis of ADHF at hospital discharge. The final diagnosis included at least one of CXR, computed tomography, or BNP. Two reviewers independently screened all titles and abstracts for possible inclusions. Two separate content experts full text-reviewed selected studies and performed quality analysis using a modified Critical Appraisal Skills Program (CASP) questionnaire. Extracted data was assessed with summary receiver operator characteristics curve (SROC) analysis with pooled sensitivity and specificity. Heterogenity was tested. Results: The electronic search yielded 3674 articles of which six met the inclusion criteria and fulfilled CASP requirements for methodological quality. The total number of patients in these studies was 1911. Heterogeneity was noted; due to poorer performance by novice users. Meta-analysis of the data showed that in detecting ADHF, bedside lung ultrasound had a pooled sensitivity of 89.6% (95% CI 69.5 to 97.0%) and a pooled specificity of 88.4% (95% CI 75.0 to 95.1%). The positive likelihood ratio was 6.01 (95% CI 2.93 to 12.32) and negative likelihood ratio was 0.13 (95% CI 0.06 to 0.30). Conclusion: This study suggests that in patients presenting to the ED with undifferentiated dyspnea, early point of care lung ultrasound may be used to confirm the diagnosis of ADHF, which may facilitate earlier appropriate management. Test performance may vary according to experience.
LO078: The immigrant effect: a barrier to accessing primary and emergency department care - a Canadian population cross-sectional study
Authors: Ohle R. , Bleeker H. , Perry J.J.
Published: June 2016

Introduction: In 2011, Canada had a foreign-born population of about 6,775,800 people. They represented 20.6% of the total population, the highest proportion among the G8 countries. Immigrants encounter significant barriers to accessing primary healthcare. This is thought to be due to lower education level, employment status and the healthy immigrant effect. Our objective was to assess in an immigrant population without a primary care physician, would similar socioeconomic barriers also prevent access to the emergency department. Methods: Data regarding individuals’ ≥12 years of age from the Canadian Community Health Survey, 2007 to 2008 were analyzed (N=134,073, response rate 93%). Our study population comprised 15,554 individuals identified without a primary care physician who used emergency department care. Socioeconomic variables included employment, health status, and education. Covariates included chronic health conditions, mobility, gender, age, and mental health. Prevalence estimates and confidence intervals for each variable were calculated. Weighted logistic regression models were constructed to evaluate the importance of individual risk factors and their interactions after adjustment for relevant covariates. Model parameters were estimated by the method of maximum likelihood. The Wald statistic was employed to test the significance of individual variables or interaction terms in relation to ED choice. Results: Our study population included 1,767 immigrants and 13,787 Canadian born respondents from across Canada without a primary care physician (57.3% male). Immigrants were less likely to use the emergency department then Canadian born respondents (Odds Ratio 0.4759 (95%CI 0.396-0.572). Adjusting for health, education or employment had no effect on this reduced access (Odds Ratio 0.468 (95%CI 0.378-0.579). Conclusion: In a Canadian population without a primary care physician, immigrants access the emergency department less then Canadian born respondents. However this effect is independent of previously reported social and economic barriers. Immigration status is an important but complex component of racial and ethnic disparity in access to care. Specific policy and system development targeting this at risk population are required to allow for equal access to healthcare.
LO082: EMS response to police use of force events: periods of personal and professional risk in prehospital care
Authors: Hall C.A. , Votova K. , Randhawa G. , Andrusiek D. , Carter A. , MacDonald S. , Eramian D.
Published: June 2016

Introduction: This study provides an estimate of the number of EMS calls related to police use of force events that involve struggling, intoxicated and/or emotionally distressed patients. We hypothesized there would be under-reporting of EMS risk by paramedic agencies due to lack of standardized reporting of police events by EMS services and lack of a common linked case number between prehospital agencies in Canada. Methods: Data were collected during a multi-site, prospective, consecutive cohort study of police use of force in 4 Canadian cities using standardized data forms. Use of force was defined a priori and the application of handcuffs was not considered a force modality. Inclusion criteria: all subjects ≥ 18 years of age involved in a use of force police-public encounter. We defined risk to EMS as the presence of police- and/or paramedic- assessments of violent or struggling subjects on the scene. Three separate data forms (police-report of use of force, EMS encounter, and Emergency Department (ED) visit) were linked in the study by unique ID. When police-reported EMS was activated, investigators hand searched the EMS service reports at the relevant agencies for matching call sheets. Results: From Jan 2010 to Dec 2012, we studied 3310 consecutive public-police interactions involving use of force above simple joint lock application. Subjects were male (86%) with a mean age of 33 yrs; 85% were assessed by police as emotionally disturbed, intoxicated with drugs and/or alcohol or a combination of those. 45% were violent at the scene. Police-reported EMS attendance in 24% (809/3310) of use of force events, of which only 43% (349/809) of EMS run sheets were available. In events with violent subjects, EMS transported 51% to ED compared to 35% by police transport (chi=79.7, p=0.00). Conclusion: We identified periods of professional and physical risk to paramedics attending police use of force events and found that risk significantly underrepresented in EMS data. Paramedical training would benefit from policy and procedures for response to police calls and the violent patient, the majority of whom are struggling. A common linked case number in prehospital care would enable more specific quantification of the risk for EMS providers involved in police events.
LO091: Non-urgent presentations to the emergency department: patients’ reasons for presentation
Authors: Krebs L. , Chetram R. , Kirkland S.W. , Nikel T. , Voaklander B. , Davidson A. , Holroyd B. , Cross E. , Villa-Roel C. , Crick K. , Couperthwaite S. , Alexiu C. , Cummings G. , Voaklander D. , Rowe B.H.
Published: June 2016

Introduction: Some low acuity Emergency Department (ED) presentations are considered non-urgent or convenience visits and potentially avoidable with improved access to primary care. This study explored self-reported reasons why non-urgent patients presented to the ED. Methods: Patients, 17 years and older, were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada during weekdays (0700 to 1900). A 47-item questionnaire was completed by each consenting patient, which included items on whether the patient believed the ED was their best care option and the rationale supporting their response. A thematic content analysis was performed on the responses, using previous experience and review of the literature to identify themes. Results: Of the 2144 eligible patients, 1408 (65.7%) questionnaires were returned, and 1402 (65.4%) were analyzed. For patients who felt the ED was their best option (n = 1234, 89.3%), rationales included: safety concerns (n = 309), effectiveness of ED care (n = 284), patient-centeredness of ED (n = 277), and access to health care professionals in the ED (n = 204). For patients who felt the ED was not their best care option (n = 148, 10.7%), rationales included a perception that: access to health professionals outside the ED was preferable (n = 39), patient-centeredness (particularly timeliness) was lacking in the ED (n = 26), and their health concern was not important enough to require ED care (n = 18). Conclusion: Even during times when alternative care options are available, the majority of non-urgent patients perceived the ED to be the most appropriate location for care. These results highlight that simple triage scores do not accurately reflect the appropriateness of care and that understanding the diverse and multi-faceted reasons for ED presentation are necessary to implement strategies to support non-urgent, low acuity care needs.
MP001: Low acuity emergency department access: are other options available?
Authors: MacKay J. , Atkinson P.R. , Howlett M. , Palmer E. , Fraser J. , Vaillancourt E.
Published: June 2016

Introduction: Patients with low-acuity (CTAS level IV and V) complaints often use the emergency department (ED) to access care. This has often been attributed to lack of a primary care (PC) provider. However, simply being registered with a primary care practitioner may not prevent low acuity ED presentation. There is some evidence that a lack of timely access to primary care may contribute to low acuity ED presentations. The Wait Time Alliance, a group of Canadian physicians and their respective professional associations, has recently set a benchmark of same day access to family doctors. It is unclear if this benchmark has been achieved in all jurisdictions. Methods: We performed linked cross sectional surveys to quantify the number of people presenting to a tertiary hospital ED (with 56,000 annual visits) with non-urgent problems who felt unable to access PC. PC practices were also surveyed to assess access using the metric of time to third next available appointment. Sample size calculations were completed. Descriptive statistics were reported. Results: In the patient survey, 381 of 580 patients consented to participate. Of those, 89 patients met eligibility criteria. 32 (35.9%) reported that the wait to see their PC provider was “too long”. 45 (50.5%) patients did not contact their PC office prior to ED presentation. 46 of 72 PC physician surveys were returned; a response rate of 63.8%. The mean time to third next available appointment in the region was 7.7 (95% CI 4.9-10.5) days (median 5 days, range 0-50 days). Conclusion: Fifty percent of low acuity patients did not attempt to access their PC provider prior to ED presentation. The benchmark of same day access to primary care has not been achieved in many practices in this region. Initiatives to promote primary care access would benefit both patients and providers.
MP006: Review of clinical presentation and trajectory of patients with a diagnosis of primary brain tumour in a pediatric tertiary centre
Authors: Abou-Diab J. , Gouin S. , Bouhout I. , Carret A.
Published: June 2016

Introduction: Recognition of life-threatening conditions, such as brain tumours, remains a challenge among pediatric patients. Few studies have described the implication of initial presentation, clinical evolution and healthcare system factors in diagnosis delay of brain tumours in children. We aimed to determine the clinical presentation patterns and health care trajectory of children with a diagnosis of primary brain tumour. Methods: A retrospective chart review in a pediatric university-affiliated hospital was conducted. Participants were all patients less than 18 years of age diagnosed with a brain tumour by neuroimaging between Jan 2003 and Dec 2014. Data were extracted from an institutional tumour registry and medical records. Results: From the registry, 288 patients were identified. The mean age at time of diagnosis was 7.44 ± 0.29 years. Most tumours were infra-tentorial (55%) and had astrocytic origin (29%). The majority (35%) had consulted only once prior to diagnosis, while 14% had consulted at least 4 times prior to diagnosis. The mean time between the onset of symptoms and diagnosis was 147 ± 19 days. The mean time between symptoms onset and first consultation was 84 ± 14 days. The most frequent symptoms and signs at onset and diagnosis were respectively: headache (44% vs 59%, p<0.01), nausea and vomiting (31% vs 58%, p<0.01) and abnormalities of gait (10% vs 32%, p<0.01). 129 patients (45%) were diagnosed in an Emergency Department (ED). Symptoms and signs that differed significantly for those diagnosed in an ED were: headache (71% vs 42%, p<0.01), nausea and vomiting (73 % vs 32%, p<0.01), lethargy (26% vs 9%, p<0.01), weight loss (15% vs 3%, p<0.01), irritability (9% vs 0%, p<0.01) and endocrine abnormality (2% vs 8%, p=0.02). Clinical presentations of infants up to one year of age (14%) differed from other age groups. They presented mostly with growth abnormality (46%), macrocephaly (40%), irritability (40%), development abnormalities (18%) and sun-setting eyes sign (10%). Conclusion: In this large comprehensive cohort, we have found that the diagnosis of primary brain tumours is most frequently made in the ED. Different clinical presentations have been identified and varied between different settings of diagnosis and different age groups.
MP009: Reliability and interchangeability of measures of two tissue oximeters in healthy volunteers
Authors: Cournoyer A. , Denault A. , Cossette S. , Fortier A. , Chauny J. , Daoust R. , Iseppon M. , Notebaert E.
Published: June 2016

Introduction: Near-infrared spectroscopy (NIRS) is a non-invasive, continuous and painless method of monitoring oxygen saturation of hemoglobin in any given superficial tissue. Given that hemodynamic instability can affect the oxygen saturation, NIRS could prove to be an interesting tool in quantifying tissue oxygenation, consequently guiding clinical management. The aim of this study was to compare the reliability of two commonly used tissue oximeters, the INVOS 5100c from Covidien and the Equanox 7600 from Nonin. We postulated the Equanox (a more recent tissue oximeter) would have a better reliability than the INVOS. As a secondary outcome, we evaluated whether the measures given by the two oximeters were comparable. Methods: The study population was composed of healthy adult volunteers. Three measurements were taken at six different sites on both sides of the body in a randomized order. Two different sensors were used for each measure. From these measures, two intra-class correlations (ICC) - one inter-sensor and the other intra-sensor - were calculated for each device and compared using the Fisher’s r-to-z transformation method. An additional inter-device ICC was also calculated. We considered ICCs over 0.75 as an indicator of good reliability, while ICCs under 0.40 were considered to represent poor reliability. The sample size was calculated based on the calculation of a unidirectional confidence interval for a parametric ICC. Expecting a 0.75 ICC value, we concluded that 53 participants needed to be recruited in order to attain 80% power and a range of 0.1 towards the low values. Results: Fifty-three healthy volunteers (27 men and 26 women) with a mean age of 31 years (standard deviation 10) were recruited. We found no differences between the repeatability of the INVOS and the Equanox for both inter and intra-sensor reliability (ICC=0.94 (95% confidence interval (CI) 0.86-0.97) versus ICC=0.92 (95%CI 0.86-0.95), p=0.42 and ICC=0.94 (95%CI 0.89-0.96) versus ICC=0.96 (95%CI 0.93-0.98), p=0.21, respectively). However, when compared directly, we found that the readings produced by the two oximeters varied considerably (ICC 0.18 (95%CI -0.10 to 0.43). Conclusion: When taken individually, both tissue oximeters displayed good inter and intra-sensor reliability. However, they oximeters displayed poor inter-devices agreement, their readings varying considerably amongst each other.
MP010: Wraparound care for youth injured by violence: a randomized control trial
Authors: Snider C. , Chernomas W. , Cook K. , Jiang D. , Klassen T. , Logsetty S. , Mahmood J. , Mordoch E. , Strome T.
Published: June 2016

Introduction: Youth injured by violence is a major public health concern in Canada. It is the fourth leading cause of death in youth and the foremost reason youth visit an emergency department (ED). In Winnipeg, 20% of youth who visit an ED with an injury due to violence will have an ED visit for a subsequent violent injury within one year. Youth injured by violence are in a reflective and receptive state of mind, rendering the ED setting appropriate for intervention. Methods: We completed a randomized control trial in November 2015 comparing wraparound care for youth age 14 - 24 who were injured by violence to standard ED care. Youth were excluded if their injury was due to child maltreatment, sexual assault or self-harm. An adapted pre-consent randomization methodology was used. The intervention was developed using a community based participatory research approach. Wraparound care was delivered by a support worker with lived experience with violence. Support workers were on call 24/7 in order to start the intervention in the ED and take advantage of the “teachable moment.” Care continued in the community for approximately one year. Results: A total of 133 youth were randomized (68 intervention, 65 control) in one year. There was no difference in age, gender, or severity of injury between the two groups. Patients randomized to the intervention spent a median of 30 minutes less in the ED than those receiving standard care (p=0.22). Youth are safely housed, have enrolled in education opportunities, and are engaged in addictions care. Results of a chart review examining repeat visits to the ED for violent injury, substance use and mental health will be completed in Spring 2016 and will be presented. Conclusion: There were no differences between standard care and intervention groups on baseline characteristics reflecting effective randomization. The introduction of an intervention at bedside in the ED did not have a negative impact on patient length of stay.