bluuebunny/crossref_metadata_2025 huggingface dataset:
LO07: Procainamide for the acute management of atrial fibrillation and flutter in the emergency department: a systematic review
Authors: Tran F. , Junqueira D. , Tan M. , Rowe B.
Published: May 2020

Introduction: Management of acute atrial fibrillation or flutter (AFF) in the emergency department (ED) can be performed with chemical or electrical cardioversion. Procainamide is the most common chemical agent used in Canada; however, there is substantial practice variation. The objective of this systematic review was to provide comparative evidence on return to normal sinus rhythm (NSR) and adverse events to better support clinical decisions. Methods: Systematic search of five electronic databases and grey literature. Randomized controlled trials (RCTs) and prospective controlled cohort studies including adults (≥17 years) with recent-onset of AFF comparing intravenous procainamide with other cardioversion strategies (e.g., electrical cardioversion, placebo or other antiarrhythmic drugs) were eligible. Two independent reviewers performed study selection and data extraction. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. The protocol was registered with PROSPERO (CRD42019142080). Results: From 4060 potentially relevant citations, 7 studies were considered eligible and three RCTs and two cohort studies included in the analysis. Procainamide was less effective in promoting return to NSR at 1st attempt compared to other chemical (RR 0.76; 95% CI: 0.65 to 0.90) and electrical (RR 0.58; 95% CI: 0.53 to 0.64) options. Electrical cardioversion was more effective in restoring NSR compared to procainamide when used as 2nd attempt in one RCT (RR 0.46; 95% CI: 0.23 to 0.92). Pre-specified serious adverse events were assessed and reported by two studies showing that hypotension was more common in patients receiving procainamide in comparison with electrical cardioversion (RR 20.57; 95% CI: 1.59 to 265.63). Treatment discontinuation due to adverse events was infrequently reported with only two studies reporting that no patients withdrew from the study following treatment with procainamide. The remaining studies provided incomplete data reporting on adverse events. Conclusion: Shared decision-making for patients with acute AFF in the ED requires knowledge of the effectiveness and safety of comparative interventions. Overall, procainamide is less effective than other chemical options and electrical cardioversion strategies to restore NSR. Evidence shows that hypotension is a concern when procainamide is administered; however, the overall adverse events information provided from the studies is suboptimal.
LO09: Role of hospitalization for detection of serious adverse events among emergency department patients with syncope: a propensity-score matched analysis of a multicenter prospective cohort
Authors: Krishnan R. , Mukarram M. , Ghaedi B. , Sivilotti M. , Le Sage N. , Yan J. , Huang P. , Hegdekar M. , Mercier E. , Nemnom M. , Calder L. , McRae A. , Rowe B. , Wells G. , Thiruganasambandamoorthy V.
Published: May 2020

Introduction: Selecting appropriate patients for hospitalization following emergency department (ED) evaluation of syncope is critical for serious adverse event (SAE) identification. The primary objective of this study is to determine the association of hospitalization and SAE detection using propensity score (PS) matching. The secondary objective was to determine if SAE identification with hospitalization varied by the Canadian Syncope Risk Score (CSRS) risk-category. Methods: This was a secondary analysis of two large prospective cohort studies that enrolled adults (age ≥ 16 years) with syncope at 11 Canadian EDs. Patients with a serious condition identified during index ED evaluation were excluded. Outcome was a 30-day SAE identified either in-hospital for hospitalized patients or after ED disposition for discharged patients and included death, ventricular arrhythmia, non-lethal arrhythmia and non-arrhythmic SAE (myocardial infarction, structural heart disease, pulmonary embolism, hemorrhage). Patients were propensity matched using age, sex, blood pressure, prodrome, presumed ED diagnosis, ECG abnormalities, troponin, heart disease, hypertension, diabetes, arrival by ambulance and hospital site. Multivariable logistic regression assessed the interaction between CSRS and SAE detection and we report odds ratios (OR). Results: Of the 8183 patients enrolled, 743 (9.0%) patients were hospitalized and 658 (88.6%) were PS matched. The OR for SAE detection for hospitalized patients in comparison to those discharged from the ED was 5.0 (95%CI 3.3, 7.4), non-lethal arrhythmia 5.4 (95%CI 3.1, 9.6) and non-arrhythmic SAE 6.3 (95%CI 2.9, 13.5). Overall, the odds of any SAE identification, and specifically non-lethal arrhythmia and non-arrhythmia was significantly higher in-hospital among hospitalized patients than those discharged from the ED (p < 0.001). There were no significant differences in 30-day mortality (p = 1.00) or ventricular arrhythmia detection (p = 0.21). The interaction between ED disposition and CSRS was significant (p = 0.04) and the probability of 30-day SAEs while in-hospital was greater for medium and high risk CSRS patients. Conclusion: In this multicenter prospective cohort, 30-day SAE detection was greater for hospitalized compared with discharged patients. CSRS low-risk patients are least likely to have SAEs identified in-hospital; out-patient monitoring for moderate risk patients requires further study.
LO11: STAR-EM: An innovative summer research program for medical students in an urban Canadian academic emergency department
Authors: Friedman S. , Porplycia D. , Lexchin J. , Hayman K. , Masood S. , O'Connor E. , Xie E. , Bryan J. , Smith-Gorvie T. , Lim D. , Leung J. , Sheikh H.
Published: May 2020

Innovation Concept: Research training programs for students, especially in emergency medicine (EM), may be difficult to initiate due to lack of protected time, resources, and mentors (Chang Y, Ramnanan CJ. Academic Medicine 2015). We developed a ten-week summer program for medical students aimed at cultivating research skills through mentorship, clinical enrichment, and immersion in EM research culture through shadowing and project support. Methods: Five second year Ontario medical students were recruited to participate in the Summer Training and Research in Emergency Medicine (STAR-EM) program at University Health Network, Toronto, from June - Aug, 2019. Program design followed review of existing summer research programs and literature regarding challenges to EM research (McRae, Perry, Brehaut et al. CJEM 2018). The program had broad emergency physician (EP) engagement, with five EP research project mentors, and over ten EPs delivering academic sessions. Curriculum development was collaborative and iterative. All projects were approved by the hospital Research Ethics Board (REB). Curriculum, Tool or Material: Each weekly academic morning comprised small group teaching (topics including research methodology, manuscript preparation, health equity, quality improvement, and wellness), followed by EP-led group progress review of each student's project. Each student spent one half day per week in the emergency department (ED), shadowing an EP and identifying patients for recruitment for ongoing mentor-initiated ED research projects. Remaining time was spent on independent student project work. Presentation to faculty and program evaluation occurred in week 10. Scholarly output included one abstract submitted for publication per student. Program evaluation by students reflected a uniform impression that course material and mentorship were each excellent (100%, n = 5). Interest in pursuing academic EM as a career was identified by all students. Faculty researchers rated the program as very effective (80%, n = 4) or somewhat effective (20%, n = 1) in terms of enhancing productivity and scholarly output. Conclusion: The STAR-EM program provides a transferable model for other academic departments seeking to foster the development of future clinician investigators and enhance ED research culture. Program challenges included delays in REB approval for student projects and engaging recalcitrant staff to participate in research.
LO12: ClerkCast: a novel online free open access emergency medicine curriculum for medical students
Authors: Forestell B. , Beals L. , Chan T.
Published: May 2020

Innovation Concept: Canadian medical students completing their Emergency Medicine (EM) clerkship rotations must develop approaches to undifferentiated patients. Increasingly used in postgraduate EM education, Open Educational Resources (OERs) are a convenient and flexible solution to meeting medical student educational needs on their EM rotation. We hoped to supplement Canadian medical student EM education through the development of ‘ClerkCast’, a novel OER and podcast-based curriculum on CanadiEM.org. Methods: We utilized the Kern Six Step approach to curriculum development for ‘ClerkCast’. A general needs assessment involved a review of available OERs and identified a lack of effective EM OERs specific for medical students. A specific online needs assessment was used to determine which EM topics required further education for medical students. The survey was shared directly with key Canadian medical student and undergraduate medical educator stakeholder groups, and distributed globally through the CanadiEM social media networks. Results of the needs assessment highlighted shared perceptions of educational needs for medical students, with an emphasis on increased need for education on critical care and common EM presentations. We used the topics determined to be highest priority for the development of our first ten episodes of ‘ClerkCast’. Curriculum, Tool or Material: Podcast episodes are released from CanadiEM biweekly. Episodes are 30 to 45 min in length, and focus on cognitive approaches to a common EM presentation for medical students. Content is anchored on medical student interactions with a staff or resident EM co-host. Podcasts are supplemented by infographics and blog posts highlighting the key points from each episode. Learners are also encouraged to interact with the content through review quizzes on a provided question bank. Quality assurance of the content is provided by physician co-hosts who review episode scripts both prior to recording. Post-production feedback is elicited via comments on the curriculum's host website, CanadiEM.org, and through direct email correspondence to the ClerkCast address. Conclusion: With an ever increasing number of OERs in EM and critical care, the systematic development of new resources is important to avoid redundancies in content and medium while also addressing unmet learner needs. We describe the successful use of the Kern Six Steps for curriculum development for the creation of our novel EM OER for Canadian medical students, ‘ClerkCast’.
LO14: Interdepartmental program to improve outcomes for acute heart failure patients seen in the emergency department
Authors: Stiell I. , Taljaard M. , Forster A. , Mielniczuk L. , Wells G. , Hebert G. , Clark H. , Clement C. , Brinkhurst J. , Sheehan C. , Brown E. , Nemnom M. , Perry J.
Published: May 2020

Introduction: An important challenge physicians face when treating acute heart failure (AHF) patients in the emergency department (ED) is deciding whether to admit or discharge, with or without early follow-up. The overall goal of our project was to improve care for AHF patients seen in the ED while avoiding unnecessary hospital admissions. The specific goal was to introduce hospital rapid referral clinics to ensure AHF patients were seen within 7 days of ED discharge. Methods: This prospective before-after study was conducted at two campuses of a large tertiary care hospital, including the EDs and specialty outpatient clinics. We enrolled AHF patients ≥50 years who presented to the ED with shortness of breath (<7 days). The 12-month before (control) period was separated from the 12-month after (intervention) period by a 3-month implementation period. Implementation included creation of rapid access AHF clinics staffed by cardiology and internal medicine, and development of referral procedures. There was extensive in-servicing of all ED staff. The primary outcome measure was hospital admission at the index visit or within 30 days. Secondary outcomes included mortality and actual access to rapid follow-up. We used segmented autoregression analysis of the monthly proportions to determine whether there was a change in admissions coinciding with the introduction of the intervention and estimated a sample size of 700 patients. Results: The patients in the before period (N = 355) and the after period (N = 374) were similar for age (77.8 vs. 78.1 years), arrival by ambulance (48.7% vs 51.1%), comorbidities, current medications, and need for non-invasive ventilation (10.4% vs. 6.7%). Comparing the before to the after periods, we observed a decrease in hospital admissions on index visit (from 57.7% to 42.0%; P <0.01), as well as all admissions within 30 days (from 65.1% to 53.5% (P < 0.01). The autoregression analysis, however, demonstrated a pre-existing trend to fewer admissions and could not attribute this to the intervention (P = 0.91). Attendance at a specialty clinic, amongst those discharged increased from 17.8% to 42.1% (P < 0.01) and the median days to clinic decreased from 13 to 6 days (P < 0.01). 30-day mortality did not change (4.5% vs. 4.0%; P = 0.76). Conclusion: Implementation of rapid-access dedicated AHF clinics led to considerably increased access to specialist care, much reduced follow-up times, and possible reduction in hospital admissions. Widespread use of this approach can improve AHF care in Canada.
LO16: Predicting survival from out-of-hospital cardiac arrest
Authors: Drennan I. , Thorpe K. , Cheskes S. , Mamdani M. , Scales D. , Morrison L.
Published: May 2020

Introduction: Prognostication is a significant challenge early in the post-cardiac arrest period. Common prognostic factors for neurological survival are unreliable (high false positive rates) until 72 hours post-cardiac arrest. It is not known whether there are a combination of factors that can be utilized earlier in the post-cardiac arrest period to accurately predict patient outcome. Our objective was to predict neurological outcome utilizing a novel combination of patient factors early in the post-cardiac arrest period. Methods: We conducted a retrospective cohort study using data from our local cardiac arrest registry. We included adult patients who obtained a return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). We excluded patients who did not survive for at least 24 hours post-ROSC and those who had a do not resuscitate (DNR) order within 2 hours of ROSC. We performed an ordinal regression analysis using the proportional odds model to predict neurological outcome (modified rankin score (mRS)). We included a good neurological outcome (mRS 0-2), poor neurological outcome (mRS 3-5), and dead (mRS 6) as an ordinal outcome. We included a number of patient demographics, intra- and post-cardiac arrest factors as covariates in our model. The predictive performance of our model was analyzed using receiver operating characteristic (ROC) curves for discrimination and Brier statistic for calibration. Results: We included 3448 patients in our analysis. We found that an initial shockable rhythm (odds ratio (OR) 4.1; 95% confidence interval (CI) 3.6, 5.4), the absence of pupillary reflexes (OR 3.5; 95% CI 2.4,4.8) and maximum motor score on the Glasgow Coma Scale (GCS) (OR 1.5; 95% CI 1.4,1.6) had the greatest association with improved neurologic outcome. Longer duration of resuscitation was associate with worse outcomes (OR 0.84, 95% CI 0.82,0.87). The overall performance of our model was excellent with an area under the ROC curve of 0.89 and a Brier statistic of 0.13. Conclusion: Our model predicted good neurological outcome with a high rate of accuracy, however external validation of the model is required. This model may be useful in providing initial risk stratification of patients in clinical practice and future research on post-cardiac arrest care.
LO18: The state of the evidence for emergency medical services (EMS) care of prehospital hypoglycemia: an analysis of appraised research from the Prehospital Evidence-based Practice Program
Authors: Greene J. , Goldstein J. , Brown R. , Swain J. , Fidgen D. , Leroux Y. , McVey J. , Jensen J. , Carter A.
Published: May 2020

Introduction: The Prehospital Evidence-based Practice (PEP) program is an online, freely accessible, continuously updated repository of appraised EMS research evidence. This report is an analysis of published evidence for EMS interventions used to assess and treat patients suffering from hypoglycemia. Methods: PubMed was systematically searched in June 2019. One author screened titles, abstracts and full-texts for relevance. Trained appraisers reviewed full text articles, scored each on a three-point Level of Evidence (LOE) scale (based on study design and quality) and three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings for each intervention's primary outcome), abstracted the primary outcome, setting and assigned an outcome category (patient or process). Second party appraisal was conducted for all included studies. The level and direction of each intervention was plotted in an evidence matrix, based on appraisals. Results: Twenty-nine studies were included and appraised for seven interventions: 5 drugs (Dextrose 50% (D50), Dextrose 10% (D10), glucagon, oral glucose and thiamine), one assessment tool (point-of-care (POC) glucose testing) and one call disposition (treat-and-release). The most frequently reported study primary outcomes were related to: clinical improvement (n = 15, 51.7%), feasibility/safety (n = 8, 27.6%), and diagnostics (n = 6, 20.7%). The majority of outcomes were patient focused (n = 18, 62.0%). Conclusion: EMS interventions for treating hypoglycemia are informed by high-quality supportive evidence. Both D50 and D10 are supported by high-quality evidence; suggesting D10 may be an effective alternative to the standard D50. “Treat-and-release” practices for hypoglycemia are supported by moderate-quality evidence for the patient related outcomes of relapse, patient preference and complications. This body of evidence is high-quality, patient-focused and conducted in the prehospital setting thus generalizable paramedic practice.
LO21: Consistency of CTAS scores by presenting complaint pre and post eCTAS implementation in 35 emergency departments across Ontario
Authors: McLeod S. , Thompson C. , Borgundvaag B. , Thabane L. , Ovens H. , Scott S. , Ahmed T. , Grewal K. , McCarron J. , Filsinger B. , Mittmann N. , Worster A. , Agoritsas T. , Guyatt G.
Published: May 2020

Introduction: eCTAS is a real time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The tool dynamically calculates a recommended CTAS score based on the presenting complaint, vital signs and selected clinical modifiers. The primary objective was to assess consistency of CTAS score distributions across 35 emergency departments (EDs) by 16 presenting complaints pre and post eCTAS implementation. Methods: This retrospective cohort study used population-based administrative data from January 2016 to December 2018 from all hospital EDs in Ontario that had implemented eCTAS with at least 9 months of data. Following a 3-month stabilization period, we compared data for 6 months post-eCTAS implementation to the same 6-month period the previous year (pre-implementation) to account for potential seasonal variation, patient volume and case-mix. We included triage encounters of adult (≥18 years) patients if they had one of 16 pre-specified high-volume, presenting complaints. A paired-samples t-test was used to determine consistency by estimating the absolute difference in CTAS distribution for each presenting complaint, by each hospital, pre and post eCTAS implementation, compared to the overall average of the 35 EDs. Results: There were 183,231 triage encounters in the pre-eCTAS cohort and 179,983 in the post-eCTAS cohort from 35 EDs across the province. Triage scores were more consistent with the overall average after eCTAS implementation in 6 (37.5%) presenting complaints: chest pain (cardiac features) (p < 0.001), extremity weakness/symptoms of cerebrovascular accident (p < 0.001), fever (p < 0.001), shortness of breath (p < 0.001), syncope (p = 0.02), and hyperglycemia (p = 0.03). Triage consistency was similar pre and post eCTAS implementation for the presenting complaints of altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication or vertigo. Conclusion: A standardized, electronic approach to performing triage assessments increased consistency in CTAS scores across many, but not all, high-volume CEDIS complaints. This does not reflect triage accuracy, as there are no known benchmarks for triage accuracy. Improvements in consistency were greatest for sentinel presenting complaints with a minimum allowable CTAS score.
LO23: Do point of care ultrasound findings of left ventricular dysfunction predict cardiogenic shock in undifferentiated hypotensive patients?
Authors: Atkinson P. , Fraser J. , Lewis D. , Pham C. , Lamprecht H. , Stander M. , French J. , Sibley A. , Henneberry R.
Published: May 2020

Introduction: Patients presenting to the emergency department (ED) with hypotension have a high mortality rate and require careful yet rapid resuscitation. The use of cardiac point of care ultrasound (PoCUS) in the ED has progressed beyond the basic indications of detecting pericardial fluid and activity in cardiac arrest. We examine if finding left ventricular dysfunction (LVD) on emergency physician performed PoCUS reliably predicts the presence of cardiogenic shock in hypotensive ED patients. Methods: We prospectively collected PoCUS findings performed in 135 ED patients with undifferentiated hypotension as part of an international study. Patients with clearly identified etiologies for hypotension were excluded, along with other specific presumptive diagnoses. LVD was defined as identification of a generally hypodynamic LV in the setting of shock. PoCUS findings were collected using a standardized protocol and data collection form. All scans were performed by PoCUS-trained emergency physicians. Final shock type was defined as cardiogenic or non-cardiogenic by independent specialist blinded chart review. Results: All 135 patients had complete follow up. Median age was 56 years, 53% of patients were male. Disease prevalence for cardiogenic shock was 12% and the mortality rate was 24%. The presence of LVD on PoCUS had a sensitivity of 62.50% (95%CI 35.43% to 84.80%), specificity of 94.12% (88.26% to 97.60%), positive-LR 10.62 (4.71 to 23.95), negative-LR 0.40 (0.21 to 0.75) and accuracy of 90.37% (84.10% to 94.77%) for detecting cardiogenic shock. Conclusion: Detecting left ventricular dysfunction on PoCUS in the ED may be useful in confirming the underlying shock type as cardiogenic in otherwise undifferentiated hypotensive patients.
LO30: Optimizing diagnostic testing processes to improve emergency department throughput: a systematic review
Authors: Grant K. , Bayley C. , Lang E. , Innes G.
Published: May 2020

Introduction: Emergency Department (ED) crowding is an intensifying crisis. While input, throughput, and output factors all contribute to crowding, throughput factors are the most dependent on ED staff and process. Diagnostic testing is a fundamental ED process that has not been systematically evaluated. We present a systematic review of interventions designed to reduce ED length of stay (LOS) by optimizing laboratory or imaging turnaround time, or by introducing point-of-care testing (POCT). Methods: We conducted systematic database searches in Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials without filters or language restrictions, of all interventions on diagnostic technology that affected ED throughput (PROSPERO:CRD42019125651). Studies were screened by two independent reviewers. Study quality was assessed using the Cochrane ROB-2 tools for randomized controlled trials (RCTs), and the National Heart, Lung, and Blood Institute tool for all other study designs. Results: 18 studies met inclusion criteria (Cohen's kappa = 0.69). Study results were not pooled due to high statistical heterogeneity as assessed by chi-squared and I-squared statistics. 12 POCT intervention studies reported LOS changes ranging from -114 to + 8 minutes (-26.8% to + 3.8%), although three were non-significant findings. Four studies that initiated POCT or lab-ordering at triage reported LOS reductions ranging from 22 to 174 minutes, but only one of these, at 29 minutes (16%), was statistically significant. One study of improved laboratory troponin processing reported a LOS reduction of 43 minutes (12.3%). Another, which allowed triage nurses to order ankle x-rays using the Ottawa ankle rules, reported a non-significant LOS reduction of 28 minutes for patients with ankle injuries. LOS improvements reflected the population of patients who underwent the testing modality, rather than overall ED LOS. Seven studies had low risk of bias, 11 studies had some risk of bias, and no studies had high risk of bias (Cohen's kappa = 0.58). Conclusion: Eleven of 18 diagnostic testing studies reported LOS reductions. POCT was the most common intervention type, and usually reduced EDLOS within relevant patient subsets, while triage-initiated testing generally did not. To aid widespread adoption, future research should focus on interrupted time series or RCT designs, and more comprehensive descriptions of the contextual factors affecting implementation of these interventions.
LO43: First Nations emergency care visits in Alberta: Descriptive results of a retrospective cohort study
Authors: McLane P. , Barnabe C. , Holroyd B. , Colquhoun A. , Bill L. , Fitzpatrick K. , Rittenbach K. , Healy C. , Bull H. , Crawler M. , Firth L. , Jacobs T. , Twin D. , Rosychuk R.
Published: May 2020

Introduction: Emergency care serves as an important health resource for First Nations (FN) persons. Previous reporting shows that FN persons visit emergency departments at almost double the rate of non-FN persons. Working collaboratively with FN partners, academic researchers and health authority staff, the objective of this study is to investigate FN emergency care patient visit statistics in Alberta over a five year period. Methods: Through a population-based retrospective cohort study for the period from April 1, 2012 to March 31, 2017, patient demographics and emergency care visit characteristics for status FN patients in Alberta were analyzed and compared to non-FN statistics. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage Acuity Scale (CTAS)). Means and standard deviations (medians and interquartile ranges (IQR)) describe continuous variables (e.g., distances) as appropriate for the data distribution. These descriptions are repeated for the FN and non-FN populations, separately. Results: The data set contains 11,686,288 emergency facility visits by 3,024,491 unique persons. FN people make up 4.8% of unique patients and 9.4% of emergency care visits. FN persons live further from emergency facilities than their non-FN counterparts (FN median 6 km, IQR 1-24; vs. non-FN median 4 km, IQR 2-8). FN visits arrive more often by ground ambulance (15.3% vs. 10%). FN visits are more commonly triaged as less acute (59% CTAS levels 4 and 5, compared to non-FN 50.4%). More FN visits end in leaving without completing treatment (6.7% vs. 3.6%). FN visits are more often in the evening – 4:01pm to 12:00am (43.6% vs. 38.1%). Conclusion: In a collaborative validation session, FN Elders and health directors contextualized emergency care presentation in evenings and receiving less acute triage scores as related to difficulties accessing primary care. They explained presentation in evenings, arrival by ambulance, and leaving without completing treatment in terms of issues accessing transport to and from emergency facilities. Many factors interact to determine FN patients’ emergency care visit characteristics and outcomes. Further research needs to separate the impact of FN identity from factors such as reasons for visiting emergency facilities, distance traveled to care, and the size of facility where care is provided.
Legal implications of antibiotic stewardship programs
Authors: Maliha George , Nepps Mary Ellen , Tamma Pranita D , Dodds Ashley Elizabeth , Szymczak Julia E , Kolesar Emma , Hamilton Keith W
Published: May 2020

Infectious diseases professional societies, public health agencies, and healthcare regulatory agencies call for antibiotic stewardship programs (ASP) in many healthcare settings. However, medical legal implications of these programs remain largely uncharted territory. Although there is no legal precedent addressing issues of liability and standards of care on this subject, anticipating how the courts may assess questions of medical liability with respect to the various components of ASPs is important to define best practices in ASP operations, not only to manage the potential risk but also to improve patient care. This article seeks to address some of the common processes and interventions involved in antibiotic stewardship and the potential professional liability implications of these activities.
A new geography of civil war: a machine learning approach to measuring the zones of armed conflicts
Authors: Kikuta Kyosuke
Published: May 2020

Where do armed conflicts occur? In applied studies, we may take ad hoc approaches to answer this question. In some regression studies, for instance, a single conflict event can cause an entire province to be classified as a conflict zone. In this paper, I fill this void of knowledge by developing a machine learning method that is less dependent on the areal-unit assumptions and can flexibly estimate conflict zones. I apply the method to a conflict event dataset and create a new dataset of conflict zones. A replication of Daskin and Pringle (2018, Nature 553, 328–332) with the new dataset indicates that the effect of civil war on mammal populations is much smaller than the original estimate.
The Cannero Castle (Italy): Development of Radiocarbon Dating Methodologies in the Framework of the Layered Double Hydroxide Mortars
Authors: Ricci Giulia , Secco Michele , Marzaioli Fabio , Terrasi Filippo , Passariello Isabella , Addis Anna , Lampugnani Paolo , Artioli Gilberto
Published: May 2020

The mortar samples of the Castle of Cannero (Lake Maggiore, Italy) have been characterized and radiocarbon (14C) dated. The presence of LDH phases was identified. The hydraulic reaction was evaluated by a multi-analytical approach. Careful extraction, preparation and purification of the binder fraction have been performed. Contaminations due to LDH phases have been removed allowing reliable absolute dating of the structures.

Non-hydraulic lime-based mortars represent only part of the binding materials found in archaeological and historical structures, and a new challenge is the application of 14C dating techniques on mortars that feature hydraulic reactions. This research work aims at 14C dating a series of Mg-rich hydraulic mortars from the Castle of Cannero (Lake Maggiore, Italy), from which both charcoals and mortar samples were collected. A multi-analytical approach employing X-ray powder diffraction (XRPD), optical microscopy (OM), and scanning electron microscopy/energy-dispersive microanalysis (SEM-EDS) was adopted in order to carefully characterize the samples. A wet gravimetric separation for the extraction of the fine fraction mainly composed by the mortar binder was carried out and the binder fraction was characterized by XRPD in order to investigate the presence of contaminants. The binding fractions are characterized by the widespread occurrence of hydrotalcite-type minerals, considered contaminants in 14C dating of mortars because of their capability to exchange carbonate anions even after the hardening process. A further purification treatment by thermal decomposition was performed before 14C dating by AMS. The obtained dates were consistent with archaeological expectations, confirming the potential of the developed purification methodology for hydraulic mortars dating.
State First? A Disaggregation and Empirical Interrogation
Authors: Andersen David , Doucette Jonathan
Published: May 2020

This letter is the first to systematically scrutinize the multifaceted claim that a strong state promotes democratic development. It analyzes new Varieties of Democracy data from 1789 to 2015 to specify and examine eight different versions of this ‘state-first’ argument in analyses that span the entire era of modern democracy. The authors document that high levels of bureaucratic quality at the time of the first democratic transition and during democratic spells are positively associated with democratic survival and deepening. By contrast, state capacity has no robust effects on democratic survival or deepening and does not condition the impact of bureaucratic quality. These findings underline the importance of particular features of a strong state as well as the importance of a disaggregated approach. They imply that democratic development is better aided by strengthening the impartiality of bureaucratic organizations than by building capacity for territorial control.
AN EXTENSION OF A RESULT OF ERDŐS AND ZAREMBA
Authors: WEBER MICHEL JEAN GEORGES
Published: May 2020

Erdös and Zaremba showed that
$ \limsup_{n\to \infty} \frac{\Phi(n)}{(\log\log n)^2}=e^\gamma$
, γ being Euler’s constant, where
$\Phi(n)=\sum_{d|n} \frac{\log d}{d}$
.

We extend this result to the function
$\Psi(n)= \sum_{d|n} \frac{(\log d )(\log\log d)}{d}$
and some other functions. We show that
$ \limsup_{n\to \infty}\, \frac{\Psi(n)}{(\log\log n)^2(\log\log\log n)}\,=\, e^\gamma$
. The proof requires a new approach. As an application, we prove that for any
$\eta>1$
, any finite sequence of reals
$\{c_k, k\in K\}$
,
$\sum_{k,\ell\in K} c_kc_\ell \, \frac{\gcd(k,\ell)^{2}}{k\ell} \le C(\eta) \sum_{\nu\in K} c_\nu^2(\log\log\log \nu)^\eta \Psi(\nu)$
, where C(η) depends on η only. This improves a recent result obtained by the author.
Technological properties of beneficial bacteria from the dairy environment and development of a fermented milk with the beneficial strain Lactobacillus casei MRUV6
Authors: Colombo Monique , Todorov Svetoslav D. , Carvalho Antonio F. , Nero Luís A.
Published: May 2020

In this research paper we describe the technological properties of beneficial lactic acid bacteria (LAB) obtained from a dairy production chain and the development of a fermented milk produced with Lactobacillus casei MRUV6. Fifteen LAB isolates (Lactobacillus sp., Pediococcus sp. and Weissela sp.) presented acidifying abilities (pH ranges from 0.73 to 2.11), were able to produce diacetyl (except by 5 isolates) and exopolysaccharides, and two were proteolytic. L. casei MRUV6 was selected for producing a fermented milk, stored up to 35 d at 4 and 10°C. Counts on MRS agar with added vancomycin (10 mg/l) and MRS agar with added bile salts (1.5% w/v) ranged from 9.7 to 9.9 log CFU/g, independently of the tested conditions, indicating stability and intestinal resistance of L. casei MRUV6, despite some significant differences (P < 0.05). The study demonstrated the technological potential of a potential probiotic candidate strain, L. casei MRUV6, to be used as a starter culture in the dairy industry.
The onset of electron-only reconnection
Authors: Mallet Alfred
Published: May 2020

Motivated by recent observations of ‘electron-only’ magnetic reconnection, without an ion-scale sheet or ion outflows, in both the Earth’s magnetosheath and in numerical simulations, we study the formation and reconnection of electron-scale current sheets at low plasma

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. We first show that ideal sheets collapse to thicknesses much smaller than the ion scales, by deriving an appropriate analogue of the Chapman–Kendall collapse solution. Second, we show that, in practice, reconnection onset happens in these collapsing sheets once they reach a critical aspect ratio, because the tearing instability then becomes faster than their collapse time scale. We show that this can happen for sheet thicknesses larger than the ion scale or at only a few times the electron scale, depending on plasma parameters and the aspect ratio of the collapsing structure, thereby unifying the usual picture of ion-coupled reconnection and the new regime of electron-only reconnection. We derive relationships between plasma

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, ion-to-electron temperature ratio, the aspect ratio, electron outflow velocity and the final thickness of the sheets, and thus determine under what circumstances electron-scale sheets form and reconnect.
Bringing the World to the Classroom: Using FBIS Reports in the Int'l Politics Course
Authors: Merrill John
Published: May 2020

Many recent reports have voiced alarm at the decline of international and area studies in the United States. Symptomatic of this problem is the disturbing fact that only 15 percent of American high school students study a foreign language. This inadequate background is also apparent among students in introductory international politics courses. Few have traveled or lived overseas. Most have only a nodding acquaintance with foreign opinion garnered secondhand from newspapers and news weeklies — and not all can be supposed even to read these regularly. In this situation, the results obtained by assigning research papers are likely to be disappointing: many students simply lack the background to do a credible job. They feel put upon by the paper, postpone it until the last minute, and then cobble together a hasty paraphrase of a few stories and articles.
A Moot Court for Constitutional Issues
Authors: Claude Richard , Parker Paul E.
Published: May 2020

According to the syllabus of “Civil Rights and the Constitution“—an undergraduate public law course at the University of Maryland—we study Supreme Court cases, and we “do constitutional law.” The phrase—“doing law“—is intended to capture Sheldon Wolin's notion of “doing political theory.” That is, public law, like political theory, should be an active pursuit, not a passive process of ingestion. Law and theory are rich in pedagogical opportunities to involve students with issues of recurrent public importance, and to do so in a creative manner that develops critical, principled, analytical skills. In public law, this can be done by reliance on structured role-playing, involving judicial problem solving, and focusing on a normatively exciting hypothetical issue over which participants might reasonably differ.
The College Textbook Acquisitions Review
Authors: Rockwood Irving E.
Published: May 2020

While there is considerable variation among college publishers with respect to the type of projects they are willing to consider, the process by which such projects are evaluated is remarkably similar from house to house. Invariably, that process involves the use of “outside” reviewers to whom proposals being given serious consideration are sent for evaluation. Thus, unlike trade publishers, who rely heavily on their own instincts when considering projects for publication, college textbook publishers seldom publish materials that have not first been reviewed, and by and large approved, by a group of potential adopters.

There are two major types of reviews commissioned by textbook publishers: developmental reviews and acquisitions reviews. The former are commissioned after a manuscript has been contracted for publication but before it has actually been published. Developmental reviews are intended to help an author (and publisher) “develop” a manuscript deemed sufficiently promising to warrant publication.
Using the Concept "Development" to Teach Contemporary Issues
Authors: Seitz John L.
Published: May 2020

Why don't political science teachers teach their students about many of the important policy issues that political systems face today? Why is it uncommon in undergraduate political science classes to find discussions of the population explosion and famine in the Third World, and of acid rain and toxic wastes in the First and Second worlds? Why aren't our students knowledgeable about the arguments for and against nuclear power and acquainted with the problems the world faces as it moves from a reliance on oil to a reliance on renewable fuels? And why do we often ignore such awesome issues as those connected with the greenhouse effect and nuclear war? I believe that the answer to these questions is that political science teachers often don't know how to deal with these subjects in a respected, scholarly way — in a manner that will prevent the class from just becoming a forum for the discussion of current events. I believe also that we have a concept — development — which can serve as the necessary tool we need to allow us to approach these issues in a responsible manner.
Laboratory Education in Political Science and Public Administration
Authors: Segal Morley , Fishel Jeff
Published: May 2020

In the past 25 years, an old social science task — management training and education for the public and private sectors — has spawned a variety of innovative approaches and created a new educational speciality. This new field, usually labeled Human Resources Development (HRD) or Organizational Development (OD), challenges conventional political science and public administration education in a number of important respects. HRD in the 1980s reflects the convergence of two contemporary approaches to learning and management. The first stems from humanistic psychology and its various applications in education; the second from the “behavioral science revolution” in management and organizational theory.
The First Telecasts of Congress
Authors: Swain Susan M.
Published: May 2020

When C-SPAN began satellite-transmitted telecasts of the U.S. House of Representaives in March 1979, three million cable homes were wired to receive its service. Weekdays, between the hours of 10:00 a.m. and 6:00 p.m. live Congressional debates could be piped into the livingrooms of interested cable subscribers. Four C-SPAN employees labored on the project and when the House was dark, they typed up the text for video billboards that announced their next Congressional telecast.

Over the next eight years, C-SPAN grew dramatically. Today, 135 employees work for C-SPAN in fields as diverse as programming, marketing, accounting, and newsletter publication. C-SPAN is on the air 24 hours a day with two channels of public affairs programming. The core of C-SPAN's fare is still the U.S. House debates; C-SPAN II, created in 1986, offers live coverage of Senate debates.
A Note to Students About C-SPAN
Authors: Frantzich Stephen E.
Published: May 2020

The courses outlined below are designed to analyze various aspects of the American political process utilizing the capabilities of C-SPAN, the cable coverage of the U.S. Congress. Before exclaiming “Gee, goody, we get to watch T.V.,” a few words of explanation are necessary. Until recently, most students of public policy and particularly the Congress were limited to studying it from afar. Woodrow Wilson wrote his classic book Congressional Government (1888) without ever coming to Washington D.C. Many contemporary scholars and journalists interview the participants in the political process and rely on written records, but most cannot base their research on viewing Congress in action. The serious student has had to rely on selective and limited news coverage or wait for a number of years while a select group of events percolated through the academic publishing process to become part of “the literature”. Students often come away from political science courses with the impression that the discipline is solely retrospective and lack a feeling for how the tools of political science can be applied to the here and now.
Teaching Citizens to be Policy Analysts or Policy Analysts to be Citizens
Authors: Oakerson Ronald S.
Published: May 2020

This essay may be considered a brief report to the discipline on a three year project designed to integrate citizenship and public policy education. Supported by the Fund for the Improvement of Postsecondary Education (FIPSE), an agency of the U.S. Department of Education, the project established an on-going “Workshop in Citizenship and Public Policy” in the Department of Political Science at Marshall University. Although students enroll in “workshop” as for any other course, traditional classroom methods are abandoned in an effort to engage students actively in field research related to policy problems in West Virginia. The highlight of the project is a workshop product — the West Virginia Citizens’ Almanac, to be published annually as a guide to citizen participation in the Mountain State. The almanac is intended to give direction and focus to workshop activity, bring students into an effective working relationship with current issues of citizenship and public policy, and at the same time reach out to citizens in a way that might foster greater interaction between higher education and the wider, less formal, processes of learning in a democratic society.
Nebraska Documents and Sources
Authors: Miewald Robert , Sittig Robert
Published: May 2020

If the American states are political laboratories, then Nebraska has performed its share of experiments, the most impressive, as the following bibliography indicates, being the unicameral, nonpartisan legislature. There are other notable features, also worthy of comparative study. For example, the state is just now ending a sixteen-year trial of setting state sales and income tax rates by members of the executive branch rather than by the legislature. The ways in which Nebraskans resolve their grievances with state administrators, manage their water resources, impeach their public officials, and provide their electrical power are also out of the ordinary.

Nebraskans can be unpredictable and the political life of the state continues to bewilder the careful observer. Superficially, it might appear that the turmoil of the early years, from the battles over statehood through the Populist movement, has reached a condition of placidity approaching dullness.
Teaching Political Communications as a Skill
Authors: Kaid Lynda Lee
Published: May 2020

Undergraduate students in most disciplines hope to gain some practical experience in applying the principles they learn in the classroom. It is sometimes difficult to provide students with such opportunities for practical experience, but courses in political communication offer abundant possibilities of this type.

The political communication course described here is entitled “Mass Media and Politics,” and it seeks to blend both theory and research in political campaigns with mass media skills. Although this particular course is taught in the Radio-Television-Film sequence at the University of Oklahoma, it could easily be adapted to political science courses at any university. In addition to providing an integration of political theory and practical experience in politics, the course has several subsidiary goals: (1) to give students a broader understanding of the modern electoral process, (2) to make students better consumers of political information, (3) to make students more aware of the problems and responsibilities involved in direct participation in the electoral process, and (4) to give students an opportunity to apply political organizational and communication skills in a realistic setting.