bluuebunny/crossref_metadata_2025 huggingface dataset:
P143: A prospective cohort study characterizing 30-day recurrent emergency department visits for hyperglycemia
Authors: Yan J. , Azzam D. , Columbus M. , Van Aarsen K.
Published: May 2019

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), often recur in patients who have poorly controlled diabetes. Identification of those at risk for recurrent hyperglycemia visits may improve health care delivery and reduce ED utilization for these patients. The objective of this study was to prospectively characterize patients re-presenting to the emergency department (ED) for hyperglycemia within 30 days of an initial ED visit. Methods: This is a prospective cohort study of patients ≥18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS from Jul 2016-Nov 2018. Trained research personnel collected data from medical records, telephoned patients at 10-14 days after the ED visit for follow-up, and completed an electronic review to determine if patients had a recurrent hyperglycemia visit to any of 11 EDs within our local health integration network within 30 days of the initial visit. Descriptive statistics were used where appropriate to summarize the data. Results: 240 patients were enrolled with a mean (SD) age of 53.9 (18.6) years and 126 (52.5%) were male. 77 (32.1%) patients were admitted from their initial ED visit. Of the 237 patients (98.8%) with 30-day data available, 55 (23.2%) had a recurrent ED visit for hyperglycemia within this time period. 21 (8.9%) were admitted on this subsequent visit, with one admission to intensive care and one death within 30 days. For all patients who had a recurrent 30-day hyperglycemia visit, 22/55 (40.0%) reported having outpatient follow-up with a physician for diabetes management within 10-14 days of their index ED visit. 7/21 (33.3%) patients who were admitted on the subsequent visit had received follow-up within the same 10-14 day period. Conclusion: This prospective study builds on our previous retrospective work and describes patients who present recurrently for hyperglycemia within 30 days of an index ED visit. Further research will attempt to determine if access to prompt follow-up after discharge can reduce recurrent hyperglycemia visits in patients presenting to the ED.
P144: “I wasn't oriented a lot, so I'm essentially learning as I go”: onboarding and transition to practice of new emergency physicians
Authors: Yeung M. , Cheung W. , Hebert G. , Gee A.
Published: May 2019

Introduction: Transition to the attending physician role and onboarding at a new workplace are often stressful. Effective initiation is important to individuals as well as departments, hospitals and universities wishing to retain valuable staff. Our aim was to learn about early experiences from the perspective of new staff and apply these findings to develop a new onboarding program. Methods: Following a pilot study of individual interviews, we surveyed and conducted focus group interviews with all attending physicians who had joined our dual site, urban, academic emergency department within three years. We used a mixed quantitative and qualitative approach to collect and analyze data. We applied the data to develop a new needs-based formal onboarding program. Results: 24/36 participated in the survey, 22/36 in focus groups. 95% were 30-39 years old. Newcomers described the existing orientation as too brief, non-specific, and missing essential elements. We identified six onboarding themes: (1)clinical protocols and reference documents, (2)graduated responsibilities, (3)mentorship, (4)relationship building, (5)department structure and culture, and (6)emotions. We formed a committee to develop and implement these initiatives: (1)a new online platform enables easy access to clinical care and orientation documents, (2)a formal mentorship program matches each newcomer with 2 mentors to coach towards goals, navigate department structure and culture, and provide perspective to mitigate strong emotions, (3)adjusting shift and teaching assignments allows newcomers to ease into clinical and academic responsibilities, and (4)our next priority is to improve clarity around academic opportunities, expectations, and advancement. Conclusion: New emergency physicians are highly engaged and provided many insights on their orientation experiences. Using mixed methods, we identified six themes to guide the design and implementation of a program to promote successful integration of newcomers.
P146: Does a communications skills intervention improve emergency department staff coping skills and burnout?
Authors: Zhou F. , Howlett M. , Talbot J. , Fraser J. , Robinson B. , Atkinson P.
Published: May 2019

Introduction: Emergency department (ED) staff carry a high risk for the burnout syndrome of increased emotional exhaustion, depersonalization and decreased personal accomplishment. Previous research has shown that task-oriented coping skills were associated with reduced levels of burnout compared to emotion-oriented coping. ED staff at one hospital participated in an intervention to teach task-oriented coping skills. We hypothesized that the intervention would alter staff coping behaviors and ultimately reduce burnout. Methods: ED physicians, nurses and support staff at two regional hospitals were surveyed using the Maslach Burnout Inventory (MBI) and the Coping Inventory for Stressful Situations (CISS). Surveys were performed before and after the implementation of communication and conflict resolution skills training at the intervention facility (I) consisting of a one-day course and a small group refresher 6 to 15 months later. Descriptive statistics and multivariate analysis assessed differences in staff burnout and coping styles compared to the control facility (C) and over time. Results: 85/143 (I) and 42/110 (C) ED staff responded to the initial survey. Post intervention 46 (I) and 23(C) responded. During the two year study period there was no statistically significant difference in CISS or MBI scores between hospitals (CISS: (Pillai's trace = .02, F(3,63) = .47, p = .71, partial η2 = .02); MBI: (Pillai's trace = .01, F(3,63) = .11, p = .95, partial η2 = .01)) or between pre- and post-intervention groups (CISS: (Pillai's trace = .01, F(3,63) = .22, p = .88, partial η2 = .01); MBI: (Pillai's trace = .09, F(3,63) = 2.15, p = .10, partial η2 = .01)). Conclusion: We were not able to measure improvement in staff coping or burnout in ED staff receiving communication skills intervention over a two year period. Burnout is a multifactorial problem and environmental rather than individual factors may be more important to address. Alternatively, to demonstrate a measurable effect on burnout may require more robust or inclusive interventions.
PL01: Prospective multicenter validation of the Canadian TIA Score for predicting subsequent stroke within seven days
Authors: Perry J. , Sivilotti M. , Emond M. , Worster A. , Lee J. , Morris J. , Stotts G. , Wells G. , Stiell I. , Cheung K. , Chagnon N. , Murray H. , Sharma M.
Published: May 2019

Introduction: Individualizing risk for stroke following a transient ischemic attack (TIA) is a topic of intense research, as existing scores are context-dependent or have not been well validated. The Canadian TIA Score stratifies risk of subsequent stroke into low, moderate and high risk. Our objective was to prospectively validate the Canadian TIA Score in a new cohort of emergency department (ED) patients. Methods: We conducted a prospective cohort study in 14 Canadian EDs over 4 years. We enrolled consecutive adult patients with an ED visit for TIA or nondisabling stroke. Treating physicians recorded standardized clinical variables onto data collection forms. Given the ability of prompt emergency carotid endarterectomy (CEA) to prevent stroke (NNT = 3) in high risk patients, our primary outcome was the composite of subsequent stroke or CEA ≤7 days. We conducted telephone follow-up using the validated Questionnaire for Verifying Stroke Free Status at 7 and 90 days. Outcomes were adjudicated by panels of 3 local stroke experts, blinded to the index ED data collection form. Based on prior work, we estimated a sample size of 5,004 patients including 93 subsequent strokes, would yield 95% confidence bands of +/− 10% for sensitivity and likelihood ratio (LR). Our analyses assessed interval LRs (iLR) with 95% CIs. Results: We prospectively enrolled 7,569 patients with mean 68.4 +/−14.7 years and 52.4% female, of whom 107 (1.4%) had a subsequent stroke and 74 (1.0%) CEA ≤7 days (total outcomes = 181). We enrolled 81.2% of eligible patients; missed patients were similar to enrolled. The Canadian TIA Score stratified the stroke/CEA ≤7days risk as: Low (probability <0.2%, iLR 0.20 [95%CI 0.091-0.44]; Moderate (probability 1.3%, iLR 0.79 [0.68-0.92]; High (probability 2.6%, iLR 2.2 [1.9-2.6]. Sensitivity analysis for just stroke ≤7 days yielded similar results: Low iLR 0.17 [95%CI 0.056-0.52], Medium iLR 0.89 [0.75-1.1], High iLR 2.0 [1.6-2.4]. Conclusion: The Canadian TIA Score accurately identifies TIA patients risk for stroke/CEA ≤7 days. Patients classified as low risk can be safely discharged following a careful ED assessment with elective follow-up. Patients at moderate risk can undergo additional testing in the ED, have antithrombotic therapy optimized, and be offered early stroke specialist follow-up. Patients at high risk should in most cases be fully investigated and managed ideally in consultation with a stroke specialist during their index ED visit.
LO04: Canadian best practice diagnostic algorithm for acute aortic syndrome
Authors: Ohle R. , McIsaac S. , Yan J. , Yadav K. , Jetty P. , Atoui R. , Fortino N. , Wilson B. , Coffey N. , Scott T. , Cournoyer A. , Rubens F. , Savage D. , Ansell D. , Middaugh J. , Gupta A. , Bittira B. , Callaway Y. , Bignucolo S. , Mc Ardle B. , Lang E.
Published: May 2019

Introduction: Acute aortic syndrome (AAS) is a time sensitive aortic catastrophe that is often misdiagnosed. There are currently no Canadian guidelines to aid in diagnosis. Our goal was to adapt the existing American Heart Association (AHA) and European Society of Cardiology (ESC) diagnostic algorithms for AAS into a Canadian evidence based best practices algorithm targeted for emergency medicine physicians. Methods: We chose to adapt existing high-quality clinical practice guidelines (CPG) previously developed by the AHA/ESC using the GRADE ADOLOPMENT approach. We created a National Advisory Committee consisting of 21 members from across Canada including academic, community and remote/rural emergency physicians/nurses, cardiothoracic and cardiovascular surgeons, cardiac anesthesiologists, critical care physicians, cardiologist, radiologists and patient representatives. The Advisory Committee communicated through multiple teleconference meetings, emails and a one-day in person meeting. The panel prioritized questions and outcomes, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. The algorithm was prepared and revised through feedback and discussions and through an iterative process until consensus was achieved. Results: The diagnostic algorithm is comprised of an updated pre test probability assessment tool with further testing recommendations based on risk level. The updated tool incorporates likelihood of an alternative diagnosis and point of care ultrasound. The final best practice diagnostic algorithm defined risk levels as Low (0.5% no further testing), Moderate (0.6-5% further testing required) and High ( >5% computed tomography, magnetic resonance imaging, trans esophageal echocardiography). During the consensus and feedback processes, we addressed a number of issues and concerns. D-dimer can be used to reduce probability of AAS in an intermediate risk group, but should not be used in a low or high-risk group. Ultrasound was incorporated as a bedside clinical examination option in pre test probability assessment for aortic insufficiency, abdominal/thoracic aortic aneurysms. Conclusion: We have created the first Canadian best practice diagnostic algorithm for AAS. We hope this diagnostic algorithm will standardize and improve diagnosis of AAS in all emergency departments across Canada.
LO06: Évolution du rythme en fonction du délai avant l'initiation des manœuvres de réanimation chez des patients souffrant d'un arrêt cardiaque extrahospitalier
Authors: Cournoyer A. , Cossette S. , Daoust R. , Morris J. , Chauny J. , Potter B. , de Montigny L. , Ross D. , Londei-Leduc L. , Lamarche Y. , Paquet J. , Marquis M. , Notebaert É. , Bernard F. , Albert M. , Piette É. , Cavayas Y. , Denault A.
Published: May 2019

Introduction: Les patients dont l'arrêt cardiaque extrahospitalier (ACEH) n'a pas été témoigné sont généralement exclus des protocoles de réanimation par circulation extracorporelle puisque le délai avant l'initiation de leur réanimation est inconnu. Il a été proposé que la présence d'un rythme initial défibrillable (RD) est fortement suggestif une très courte période avant l'initiation des manœuvres de réanimation. La présente étude vise à décrire l'association entre la durée avant l'initiation de la réanimation et la présence d'un RD chez des patients souffrant d'un ACEH. Methods: Cette étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients dont l'arrêt était témoigné, mais dont les témoins n'ont pas entamé de manœuvres de réanimation, ont été inclus. Nous avons également inclus les patients dont l'arrêt était témoigné par les paramédics comme groupe contrôle (durée avant l'initiation de la réanimation = 0 minute). Les patients avec un retour de circulation spontanée avant l'arrivée des services préhospitaliers ont été exclus, tout comme ceux dont le rythme initial était inconnu. Nous avons décrit l’évolution de la proportion de chacun des rythmes et construit une régression logistique multivariée ajustant pour les variables sociodémographiques et cliniques pertinentes. Results: Un total de 1751 patients (1173 hommes et 578 femmes) d'un âge moyen de 69 ans (±16) ont été inclus dans l'analyse principale, parmi lesquels 603 (34%) avaient un RD. Un total de 663 autres patients ont vu leur ACEH témoigné directement par les paramédics. Un plus court délai avant l'initiation des manœuvres est associé à la présence d'un RD (rapport de cotes ajusté = 0,97 [intervalle de confiance à 95% 0,94-0,99], p = 0,016). Cependant, cette relation n'est pas linéaire et la proportion de RD ne diminue pas avant notablement jusqu’à ce que 15 minutes s’écoulent avant le début de la réanimation (0 min = 35%, 1-5 min = 37%, 5-10 min = 35%, 10-15 min = 34%, +de 15 min = 16%). Conclusion: Bien que la proportion de patients avec un RD diminue lorsque le délai augmente avant l'initiation des manœuvres, cette relation ne semble pas linéaire. La baisse principale de la proportion de patients avec RD semble se produire suite à la quinzième minute de délai avant le début de la réanimation.
LO07: Double sequential external defibrillation improves termination of ventricular fibrillation and return of spontaneous circulation in shock-refractory out-of- hospital cardiac arrest
Authors: Cheskes S. , Wudwud A. , Turner L. , Mcleod S. , Summers J. , Morrison L. , Verbeek R.
Published: May 2019

Introduction: Despite significant advances in resuscitation efforts, there are some patients who remain in ventricular fibrillation (VF) after multiple shocks during out-of-hospital cardiac arrest (OHCA). Double sequential external defibrillation (DSED) has been proposed as a treatment option for patients in shock refractory VF. We sought to compare DSED to standard therapy with regards to VF termination and return of spontaneous circulation (ROSC) for patients presenting in shock refractory VF. Methods: We performed a retrospective review of all treated adult OHCA who presented in VF and received a minimum of three successive shocks over a two year period beginning on Jan 1, 2015 in four Canadian EMS agencies. Using ambulance call reports and defibrillator files, we compared VF termination (defined as the absence of VF at the rhythm check following defibrillation and 2 minutes of CPR) and VF termination into a perfusing rhythm with ROSC between patients who received standard therapy (CPR, defibrillation, epinephrine and antiarrhythmics) and those who received DSED (after on-line medical consultation) for shock refractory VF. Cases of traumatic cardiac arrest and those who presented in VF but terminated VF prior to 3 successive shocks were excluded. Results: Among 197 patients who met the study criteria for shock refractory VF, 161 (81.7%) patients received standard therapy and 36 (18.3%) received DSED. For the primary outcome, VF termination was significantly higher for DSED compared to standard therapy (63.9% vs 18.0%; Δ45.9%; 95% CI: 28.3 to 60.5). For the secondary outcome of VF termination into ROSC, DSED was associated with significantly higher ROSC compared to standard care (33.3% vs 13%; Δ20.3%; 95% CI:13.0 to 33.3). The median (IQR) number of failed standard shocks prior to DSED was 8 (6, 10). When DSED terminated VF, it did so with a single DSED shock in 69.6% of cases. Conclusion: Our observational findings suggest improved VF termination and ROSC are associated with DSED compared to standard therapy for shock refractory VF. An appropriately powered randomized controlled trial is required to assess the impact of DSED on patient-important outcomes.
LO21: One-year mortality of patients treated in the emergency department for an opioid overdose: a single-centre retrospective cohort study
Authors: Jiang A. , Godwin J. , Moe J. , Buxton J. , Crabtree A. , Kestler A. , Scheuermeyer F. , Erdelyi S. , Slaunwhite A. , Rowe A. , Cochrane C. , Ng B. , Risi A. , Ho V. , Brar R. , Brubacher J. , Purssell R.
Published: May 2019

Introduction: Opioid overdoses (OODs) have become a public health emergency, yet little is known about their long-term outcomes following an OD. We determined the one-year all-cause mortality and associated risk factors in a cohort of patients treated in an urban emergency department (ED) for an OOD. Methods: We reviewed records of all patients who visited St. Paul's Hospital ED from January 2013 to August 2017 and had a discharge diagnosis of OOD or had received naloxone in the ED as per pharmacy records. Patients with a suspected OOD were identified on structured chart review. A patient's first visit for an OOD during the study period was used as the index visit, with subsequent visits excluded. The primary outcome was mortality during the year after the index visit. Mortality was assessed by linking patient electronic medical records with Vital Statistics data. Deaths that occurred in the ED on the index visit were excluded. Patients admitted to hospital following ED treatment were included in this study. We described patient characteristics, calculated mortality rates, and used Cox regression to identify risk factors. Results: A total of 2239 patients visited the ED for an OOD during the study period, with a median patient age of 37 years (IQR 29, 49). Males comprised 73% of patients, while 28% had no fixed address, and 21% received take-home naloxone at the index visit. In total, 137 patients (6.1%) died within 1 year of the index visit. Eighty-one deaths (3.6%) occurred within 6 months, including 24 deaths (1.1%) that occurred within 1 month. The highest mortality rate occurred in 2017, with 8.0% of patients entering the cohort that year dying within 1 year. Gender did not significantly impact mortality risk. A Cox regression analysis controlled for gender, housing status, and whether take-home naloxone was provided at the index visit indicated that advancing age (adjusted hazards ratio [AHR] 1.03; 95%CI: 1.01-1.04 for each year increase in age) and the index visit calendar year (AHR 1.30; 95%CI: 1.10-1.54 for each yearly increase in the study period) were significant factors for mortality within 1 year. Conclusion: The mortality rate following an opioid OD treated in the ED is high, with over 6% of patients in our study dying within 1 year. The rising mortality risk with increasing calendar year may reflect the growing harms of fentanyl-related OODs. Patients visiting the ED for an OOD should be considered high risk and offered preventative treatment and referrals prior to discharge.
LO22: Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators
Authors: Atkinson P. , Peach M. , Hunter S. , Kanji A. , Taylor L. , Lewis D. , Milne J. , Diegelmann L. , Lamprecht H. , Stander M. , Lussier D. , Pham C. , Henneberry R. , Howlett M. , Mekwan J. , Ramrattan B. , Middleton J. , van Hoving D. , Richardson L. , Stoica G. , French J.
Published: May 2019

Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.
LO39: Systematic review of emergency department practice change interventions for improving asthma outcomes
Authors: Hurley K. , Fitzpatrick E. , MacEachern L. , Curran J.
Published: May 2019

Introduction: Emergency departments (ED) play a vital role in asthma care for patients of all ages. Our objective was to review and synthesize all practice change interventions in ED settings that focused on improving the health outcomes of adults and children with asthma. Methods: This study was a systematic review adhering to the methods outlined by the Effective Practice and Organization of Care (EPOC) Cochrane Review Group. We developed a search strategy with a library scientist for the following databases: AMED, CINAHL, Embase, ERIC, MEDLINE, HealthStar, CENTRAL, DARE and Cochrane's EPOC and Airways registers. We also hand searched the Journal of Asthma, Pediatrics and Chest. Two reviewers independently reviewed titles, abstracts and full text using predetermined criteria. Data were extracted by two independent reviewers who used a structured abstraction form and assessed risk of bias. All discrepancies were resolved by consensus. Results: Our search strategy yielded 8,878 titles and abstracts for review. A total of 214 studies underwent full text screening and we extracted data from 27 studies. Risk of bias was judged as low in 10 studies, moderate in 8 studies and high in 9 studies. A range of interventions were employed, with education (n = 14) and reminders (n = 8) being the most prevalent. In pediatric settings, most studies targeted changing the behaviour of parents (n = 11). Four studies targeted health care providers and four studies targeted both providers and parents. We identified a major deficit in the use of behaviour change theory to guide intervention design. The most common primary outcomes of interest were unscheduled return visits (n = 14), primary care follow-up (n = 9), quality of life (n = 5) and ED length of stay (n = 4). We were not able to perform a meta-analysis due to heterogeneity in interventions and outcomes. Conclusion: Although we found a range of interventions used to improve asthma care in EDs, there was significant variation in reported primary outcomes. Both unscheduled return visits and primary care follow-ups, the most common primary outcomes, varied in the timeframe and manner in which they were collected. Most interventions were educational and based on an assumption that education would change behaviour. Future research in this ares would benefit from standardized outcome measures and intervention designs based upon models of behaviour change model.
LO43: Simulation curricular content in postgraduate emergency medicine: a multicenter delphi study
Authors: Kester-Greene N. , Hall A. , Walsh C.
Published: May 2019

Introduction: There is increasing evidence to support the integration of simulation into medical training; however, no national emergency medicine (EM) simulation curriculum currently exists. Using Delphi methodology, we aimed to identify and establish content validity evidence for EM curricular content best suited for simulation-based training to inform national postgraduate EM training. Methods: A national panel of experts in EM simulation-related education iteratively rated potential curricular topics, on a 4-point scale, to determine those best suited for simulation-based training. After each round, responses were analyzed and topics scoring <2/4 were removed. Remaining topics were resent to the panel for further ratings until consensus was achieved, defined as Cronbach α ≥ 0.95. At conclusion of the Delphi process, topics that were rated ≥3.5/4 were considered core curricular topics, while those rated 3.0-3.5 were considered extended curricular topics. Results: Forty-four experts from 13 Canadian centres participated. Two hundred and eighty potential curricular topics, in 29 domains, were generated from a systematic review of the literature, analysis of relevant educational documents and a survey of Delphi panelists. Three rounds of Delphi surveys were completed before consensus was achieved, with response rates ranging from 93-100%. Twenty-eight topics, in 8 domains, reached consensus as core curricular topics. An additional 35 topics, in 14 domains, reached consensus as extended curricular topics. Conclusion: Delphi methodology allowed for achievement of expert consensus and content validation of EM curricular content best suited for simulation-based training. These results provide a foundation for improved integration of simulation into postgraduate EM training and can be used to inform a national simulation curriculum to supplement clinical training and optimize learning.
LO48: Similarities and differences between sports and recreation-related concussions and concussions from non-sport activities
Authors: Gaudet L. , Eliyahu L. , Mrazik M. , Beach J. , Cummings G. , Voaklander D. , Rowe B.
Published: May 2019

Introduction: Patients with concussion often present to the emergency department (ED). Although sports and recreation (SR) activities account for less than half of all adult concussions, guidelines developed for management of SR-related concussions (SRC) are widely used for all concussion patients. This study aimed to identify whether there are clinically relevant differences in patient and injury characteristics between SRC and those occurring outside of SR activities. Methods: Adults ( >17 years) presenting from April 2013 to April 2015 with a concussion to one of three EDs with Glasgow coma scale score ≥13 were recruited by on-site research assistants. Data on patient characteristics (i.e., age, sex, employment, lifestyle, relevant medical history), ED presentation (i.e., EMS arrival, hours since injury, CTAS, Glasgow Coma Scale score) and injury characteristics (i.e., activity leading to injury, loss of consciousness [LOC], signs and symptoms [scored using the Rivermead Post-Concussion Questionnaire], and health-related quality of life [from the 12-Item Short Form Health Survey [SF-12]) were collected from structured interviews and the ED chart. Dichotomous and categorical variables were compared using Fisher's exact test; continuous variables were compared using t-tests or Mann-Whitney tests, as appropriate. Results: In total, 248 patients were enrolled (47% male, median [IQR] age: 35 [23, 49]). Patients with SRC were younger (median: 23.5 years vs 35 years; p < 0.001), more likely to be a student (31% vs 8%; p > 0.001), and more likely to exercise regularly (89% vs 66%; p = 0.001). Patients with SRC were less likely to present during the daytime (66% vs. 77%; p = 0.022), less likely to have a history of mental health issues (18% vs 33%; p = 0.011) and had significantly higher median SF-12 physical components scores (55.5 [IQR: 51.4 to 57.8] vs. 53.5 [IQR: 45.5 to 56.7]; p = 0.025). All other characteristics were similar between the two groups. Conclusion: Although differences in demographics and lifestyle have been identified between patients sustaining a SRC and those concussed during other activities, injury characteristics, such as presentation acuity, proxies for severity, and signs and symptoms, were similar in both groups. Further analysis to assess whether the demographic and lifestyle differences affect clinical outcomes, such as time to symptom resolution, between these two groups is required to assess if sport-based treatment guidelines are appropriate for all patients.
LO50: Can clinical examination alone rule out a central cause for acute dizziness?
Authors: Ohle R. , Regis A. , Bodunde O. , LePage R. , Turgeon Z. , Caswell J. , McIsaac S. , Conlon M.
Published: May 2019

Introduction: The vast majority of patients presenting with dizziness to the emergency department (ED) are due to a benign self-limiting process. However, up to 5% have a serious central neurological cause. Our goal was to assess the sensitivity of clinical exam for a central cause in adult patients presenting to the emergency department with dizziness. Methods: At a tertiary care ED we performed a medical records review (Sep 2014- Mar 2018) including adult patients with dizziness (vertigo, unsteady, lightheaded), excluding those with symptoms >14days, recent trauma, GCS < 15, hypotensive, or syncope/loss of consciousness. 5 trained reviewers used a standardized data collection sheet to extract data. Individual patient data were linked with the Institute of Clinical Evaluation Science (ICES) database. Our outcome was a central cause defined as: ischemic stroke (IS), transient ischemic attack (TIA), brain tumour, intra cerebral haemorrhage (ICH), or multiple sclerosis (MS) diagnosed on either neurology assessment, computed tomography, magnetic resonance imaging, or diagnostic codes related to central causes found within ICES. A sample size of 1,906 was calculated based on an expected prevalence of 3% with an 80% power and 95% confidence interval to detect an odds ratio greater than 2. Univariate analysis and logistic regression were performed. Results: 3,109 were identified and 2,307 patients included (mean 57 years SD ± 20, Female 59.1%, Kappa 0.91). 62 central causes (IS 56.5%, TIA 14.5%, Tumour 11.3%, MS 9.7%, ICH 6.5%) of dizziness were identified. Imaging was performed in 945(42%) and neurology assessment in 42 (1.8%). ICES yielded no new diagnoses of a central cause for dizziness. Multivariate logistic regression found 11 high-risk findings associated with a central cause; history of IS/TIA (OR 3.8 95%CI 1.7-8.2), cancer (OR 3.2 95%CI 1.4-7.2), dyslipidemia (OR 2.3 95%CI 1.2-4.4), symptoms of visual changes (OR 2.1 95%CI 1.5-6.3), dysarthria (OR 9.1 95%CI 3-27.4), vomiting (OR 2 95%CI 1-3.7), motor deficit (OR 7.7 95%CI 2.9-20.2), sensory deficit (OR 28.9 95%CI 7.4-112.9), nystagmus (OR 3.3 95%CI 1.6-6.7), ataxia (OR 2.5 95%CI 1.3-4.9) and unable to walk 3 steps unaided (OR 3.4 95%CI 1.4-8.5). Absence of these findings had a sensitivity of 100% (95%CI 92.5-100%) for ICH, IS, Tumour and 95.2% (86.5-98.9) if including TIA and MS. Specificity was 51.5% (95%CI 49.4-53.6%). Conclusion: Clinical exam is highly sensitive for identifying patients without a central etiology for their dizziness.
LO56: Measuring cognitive load on shift: Application of cognitive load theory during clinical work in the emergency department
Authors: Vella K. , Hall A. , van Merrienboer J. , Szulewski A.
Published: May 2019

Introduction: By virtue of the nature of their work, emergency medicine physicians and residents experience high cognitive load and stress, which are known to affect physician performance and patient outcomes. However, the contribution of cognitive load has not previously been measured during the clinical work of emergency physicians. The objectives of this study were to measure cognitive load and stress in emergency physicians and residents during clinical work, evaluate the relative contribution of multiple factors on cognitive load, and to determine the effect of experience on these results. Methods: This observational study was conducted at an academic Canadian Urgent Care Centre from July to August 2018. Emergency medicine residents and staff physicians completed a survey while on shift to evaluate measures of cognitive load and acute stress. Patient acuity and the number of active patients for each physician, hours worked and patients in the waiting room were recorded. Correlational analyses and multivariable linear regression were performed to evaluate the effect of each predictor on measures of overall cognitive load. Results: A total of 131 questionnaires were completed by 42 physicians (87 questionnaires from 26 staff physicians and 44 questionnaires from 16 residents). Results showed that staff physicians carried a significantly higher patient load compared to residents (p < 0.001). There were no differences in mean overall cognitive load (p = 0.25), acute stress (p = 0.17) or measured subcomponents of cognitive load between the two groups. Perceived case difficulty and acute stress were strong predictors of overall cognitive load, while level of distraction did not correlate with the other outcomes. The number of patients in the waiting room predicted acute stress in staff physicians, while the number of higher acuity patients was a significant predictor in residents. Conclusion: Measures of overall cognitive load and acute stress were strongly correlated in the clinical setting. Different factors affect cognitive load and acute stress in staff physicians compared to residents. Appreciating these differences may help medical educators understand the cognitive challenges faced by learners in a clinical context, and aid in the design of cognitive and educational strategies to help mitigate these challenges and reduce stress.
Hydroelastic effects during the fast lifting of a disc from a water surface
Authors: Vega-Martínez P. , Rodríguez-Rodríguez J. , Khabakhpasheva T. I. , Korobkin A. A.
Published: May 2019

Here we report the results of an experimental study where we measure the hydrodynamic force acting on a plate which is lifted from a water surface, suddenly starting to move upwards with an acceleration much larger than gravity. Our work focuses on the early stage of the plate motion, when the hydrodynamic suction forces due to the liquid inertia are the most relevant ones. Besides the force, we measure as well the acceleration at the centre of the plate and the time evolution of the wetted area. The results of this study show that, at very early stages, the hydrodynamic force can be estimated by a simple extension of the linear exit theory by Korobkin (J. Fluid Mech., vol. 737, 2013, pp. 368–386), which incorporates an added mass to the body dynamics. However, at longer times, the measured acceleration decays even though the applied external force continues to increase. Moreover, high-speed recordings of the disc displacement and the radius of the wetted area reveal that the latter does not change before the disc acceleration reaches its maximum value. We show in this paper that these phenomena are caused by the elastic deflection of the disc during the initial transient stage of water exit. We present a linearised model of water exit that accounts for the elastic behaviour of the lifted body. The results obtained with this new model agree fairly well with the experimental results.
Non-Boussinesq gravity currents and surface waves generated by lock release in a circular-section channel: theoretical and experimental investigation
Authors: Chiapponi L. , Ungarish M. , Petrolo D. , Di Federico V. , Longo S.
Published: May 2019

We present a combined theoretical and experimental study of lock-release inertial gravity currents (GCs) propagating in a horizontal channel of circular cross-section with open-top surface in the non-Boussinesq regime. A two-layer shallow-water (SW) model is developed for a generic shape of the cross-section with open top, and then implemented in a finite difference numerical code for the solution in a circular-cross-section channel of the type used in the experiments. The model predicts propagation with (almost) constant speed for a fairly long distance, accompanied by a depression of the ambient free open-top surface behind the front of the current. Sixteen experiments were conducted with a density ratio $r=0.587{-}0.939$ in full-depth and part-depth release conditions, measuring the front speed and the free-surface time series at four cross-sections. The channel was a circular tube 409 cm long, with a radius of 9.5 cm; the lengths of the locks were 52 and 103.5 cm. Density contrast was obtained by adding sodium chloride and dipotassium phosphate to fresh water. The theoretical values of the front speed and of the depression overestimate the experimental values, but they predict correctly their trend for varying parameters and provide reliable insights into the underlying mechanisms. In particular, we demonstrate that the circular cross-section increases the speed of propagation as compared to the standard rectangular cross-section case (for the same initial height and density ratio). The discrepancies between the SW predictions and the present experiments are of the same order of magnitude as those of previously published results for simpler systems (Boussinesq, rectangular). In addition to the depression, which is a wave bound to, and following the front of, the GC, the system also displays two kinds of free-surface waves, namely the initial bump (its amplitude is of the same order as the depression) and some short-length and low-amplitude waves in the tail of the bump. These free waves propagate with a celerity well predicted by the ‘fast’ eigenvalues of the mathematical model. Comparison is provided with the celerity of a solitary wave. It is expected that discrepancies between theory and experiments can be partly attributed to the presence of these waves. The reported insights and SW prediction method can be applied to a variety of cross-sections of practical interest (triangles, trapezoids, etc.).
The Geneva Boomerang: The Military Commissions Act of 2006 and U.S. Counterterror Operations
Authors: Beard Jack M.
Published: May 2019

Over five years have passed since President George W. Bush issued the much-criticized order making an obscure device, military commissions, the primary tool for the United States to bring accused Qaeda terrorists to justice. Some legal scholars suggested in the wake of the issuance of that order that military commissions were the only practicable method available to address many of the problems presented by the trial of accused terrorists in civilian U.S. courts. True or not, it is clear that the decision to approach the problem of terrorists primarily in terms of war rather than crime continues to have far-reaching legal consequences. Following the Supreme Court’s decision in Hamdan v. Rumsfeld, which found that the military commissions designed by the Bush administration were inconsistent with the requirements of both the Uniform Code of Military Justice (U.C.M.J.) and the law of war as incorporated in that statute, the U.S. Congress attempted to fashion a compliant charter for these commissions through the Military Commissions Act of 2006 (MCA).
Barbados/Trinidad and Tobago. Award on Jurisdiction and Merits
Authors: Bodansky Daniel , Kwiatkowska Barbara
Published: May 2019

Barbados/Trinidad and Tobago. Award on Jurisdiction and Merits. At , available at 45 ILM 800 (2006).

UN Convention on the Law of the Sea Annex VII Arbitral Tribunal, April 11, 2006.

The dispute addressed in the Barbados/Trinidad and Tobago arbitration emerged during nine rounds of negotiations concerning delimitation of die maritime boundary in the western, central, and eastern sectors of their overlapping claims to the continental shelf and 200-mile exclusive economic zone (EEZ) in the Caribbean Sea (five rounds), along with associated questions posed by the continuing access for Barbadian fisherfolk to flying fish stocks south of a prospective equidistance line in the western sector (four rounds). In February 2004, according to Barbados, the prime minister of Trinidad and Tobago declared the issue of the maritime boundary “intractable” (para. 56) and invited Barbados to proceed, if it so wished, with arbitration. Barbados then invoked the compulsory arbitration provisions of Part XV, Section 2, of the UN Convention on the Law of the Sea (LOS Convention). Upon its establishment, the Annex VII Barbados/Trinidad and Tobago Arbitral Tribunal [Tribunal], which comprised President Stephen M. Schwebel and arbitrators Ian Brownlie, Vaughan A. Lowe, Francisco Orrego Vicuña, and Sir Arthur Watts, adopted its Rules of Procedure and issued four orders by year's end. After joining Trinidad and Tobago's preliminary objections to the merits phase, the Tribunal held hearings in London on October 17-28,2005. The vital interests of the two states in valuable oil and fishery resources were reflected in the high intensity of the factual and legal (both procedural and substantive) contentions forcefully disputed by the parties as represented by leading international counsel, and a number of procedurally incidental issues arose in the context of the proceedings’ confidentiality and the treatment of evidence.
Cooperation with international tribunals—binding orders directed at states and international organizations—intelligence information—national security interests—disclosure to defendants—fair trails
Authors: Bodansky Daniel , Cogan Jacob Katz
Published: May 2019

Prosecutor v. Milutinović et al., Case No. IT-05-87-AR108bis.2, Decision on Request of the United States of America for Review.

Prosecutor v. Milutinović et al., Case No. IT-05-87-AR108bis.l, Decision on Request of the North Atlantic Treaty Organisation for Review.

International Criminal Tribunal for the Former Yugoslavia, Appeals Chamber, May 12 and May 15, 2006, respectively.

In May 2006, the appeals chamber of the International Criminal Tribunal for the Former Yugoslavia (ICTY) granted the requests of the United States (U.S. Review Decision) and the North Atlantic Treaty Organization (NATO) (NATO Review Decision) and set aside the trial chamber's decision ordering the production of intercepted communications sought by defendant Dragolj ub Ojdanić. The appeals chamber held that Rule 54bis of the ICTY Rules of Procedure and Evidence does not require the possessor of intelligence information to produce that information when that state or international organization is not its owner or originator and that an order under Rule 54bis (“Orders Directed to States for the Production of Documents”) will not issue when a party refuses a state's cooperative efforts to provide information pursuant to Rule 70 (“Matters Not Subject to Disclosure”).
JSJ DECOMPOSITIONS OF DOUBLES OF FREE GROUPS
Authors: HEIL SIMON
Published: May 2019

We classify all possible JSJ decompositions of doubles of free groups of rank two, and we also compute the Makanin–Razborov diagram of a particular double of a free group and deduce that in general limit groups are not freely subgroup separable.
Design for Control: Surgery, Science, and Space at the Royal Victoria Hospital, Montreal, 1893–1956
Authors: Adams Annmarie , Schlich Thomas
Published: May 2019

In this paper we explore the relationship of modern architecture and modern surgery in the twentieth century. Our central argument is that environments designed for surgery in the modern hospital became more like laboratories at the end of a remarkable metamorphosis, which we explain through three distinct types of spaces in a particularly significant case study, the Royal Victoria Hospital (RVH) in Montreal, Quebec. As the changing design of surgical spaces constitutes our primary evidence, our approach engages the methods of material culture and material history, a methodology infrequently used in the history of science and medicine. In turn, in order to interpret the changes in operating room design, we situate them in the context of the history of surgery. The architecture of health care both illustrates and shapes the identity of patients and doctors, as well as their inter-relationship. It structures surgeons' activities and expresses their status as actors, as well as reinforcing specific scientific theories. Thus, spatial structures like operating rooms can be understood as material evidence of ongoing changes in the status and self-image of surgeons.
Health, Sickness and Medical Services in Spain's Armed Forces c.1665–1700
Authors: Storrs Christopher
Published: May 2019

The early modern era saw important changes in the character of warfare in Europe, including the development of larger, permanent armies and navies. Historians have studied many key aspects of what some call the “military revolution”, whose character and timing have become a matter of debate; but some important features of these emerging military communities remain largely unexplored. One subject which has not attracted the attention it merits is that of the health of soldiers and sailors and of medical provision in the new armies and navies. The issue has not been entirely neglected, either generally, or as it relates to specific states, but focused studies are rare. This is unfortunate, not least because of the importance attached to the issue of sickness and medical provision by contemporaries, and the value of medical provision as a sort of test case by which to measure the effectiveness of medical services and hence to contribute to the “military revolution” debate. For some historians the later seventeenth and eighteenth centuries saw the first significant efforts to develop a structure of military and naval hospitals; for others, however, the extent of illness and the inadequacy of medical support services before the French Revolutionary and Napoleonic era suggests that many states failed to meet the organizational challenge posed by the growth of standing armed forces in the sixteenth, seventeenth and eighteenth centuries. What follows is an investigation of the extent and nature of illness, and the effectiveness of medical provision in the armies and navies of one major player of the period, Spain in the reign of the last Habsburg, Charles II (1665–1700).