bluuebunny/crossref_metadata_2025 huggingface dataset:
Restoration of the external Scandinavian Caledonides
Authors: RICE A. HUGH N. , ANDERSON MARK W.
Published: July 2016

Three models are evaluated for restoring basement rocks coring tectonic windows (Window-Basement) in the Scandinavian Caledonides; parautochthonous (Model I) and allochthonous (models II/III), with initial imbrication of the Window-Basement post-dating or pre-dating, respectively, that in the external imbricate zone (Lower Allochthon). In Model I, the Window-Basement comes from the eastern margin of the basin now imbricated into the Lower Allochthon, while in models II/III it comes from the western margin. In Model II, the Window-Basement formed a basement-high between Tonian and Cryogenian sediments imbricated into the Middle and Lower allochthons; in Model III deposition of the Lower Allochthon sediments commenced in Ediacaran times. Balanced cross-sections and branch-line restorations of four transects (Finnmark–Troms, Västerbotten–Nordland, Jämtland–Trøndelag, Telemark–Møre og Romsdal) show similar restored lengths for the models in two transects and longer restorations for models II/III in the other transects. Model I can result inc.280 km wide gaps in the restored Lower Allochthon, evidence for which is not seen in the sedimentology. The presence of <3 km thick alluvial-fan deposits at the base of the Middle Allochthon indicates proximal, rapidly uplifting basement during Tonian–Cryogenian periods, taken as the origin of the Window-Basement during thrusting in models II/III. Model I requires multiple changes in thrusting-direction and predicts major thrusts or back-thrusts, currently unrecognized, separating parts of the Lower Allochthon; neither are required in models II/III. Metamorphic data are consistent with models II/III. Despite considerable along-strike structural variability in the external Scandinavian Caledonides, models II/III are preferred for the restoration of the Window-Basement.
Hierarchies in World Politics
Authors: Mattern Janice Bially , Zarakol Ayşe
Published: July 2016

Hierarchy-centered approaches to IR promise to deliver what anarchy-centered approaches have not: a framework for theorizing and empirically analyzing world politics as a global system rather than just an international one. At the core of this proposition are three features of hierarchical systems as they are represented across the growing IR literature on the topic. First, the structures of differentiation at the core of hierarchical systems are deeply implicated with power. Hierarchical systems are thus intrinsically political. Second, in world politics, hierarchies stratify, rank, and organize the relations not only among states but also other kinds of actors as well, and often even a mix of different actors within a single structure of differentiation. Third, there are many different kinds of hierarchical relations in world politics, each of which generate different “logics” influencing social, moral, and behavioral outcomes. Hierarchy has been understood in the IR literature in two ways: narrowly, as a relationship of legitimate authority; and broadly, as intersubjective manifestations of organized inequality. Hierarchy operates in a variety of different ways that range from ordering solutions to deep structures. We identify three such “logics” that have been fruitfully explored in IR scholarship and that can form the basis of a future research agenda: hierarchy as an institutionalized functional bargain between actors (a logic of trade-offs); hierarchy as differentiated social and political roles shaping behavior (a logic of positionality); and hierarchy as a productive political space or structure (a logic of productivity).
Inequalities for the perimeter of an ellipse
Authors: Jameson G. J. O.
Published: July 2016

The perimeter of the ellipse x2/a2 + y2/b2 = 1 is 4J (a, b), where J (a, b) is the ‘elliptic integral’

This integral is interesting in its own right, quite apart from its application to the ellipse. It is often considered together with the companion integral

Of course, we may as well assume that a and b are non-negative.
Dodecahedral slices and polyhedral pieces
Authors: French Doug , Jordan David
Published: July 2016

Figure 1 shows how a regular dodecahedron can be dissected into three slices by two planes through the two sets of vertices, each set defining a regular pentagon parallel to the top and bottom faces. A surprising result emerges if we calculate the ratio of the volumes of the three slices. We first prove this result directly and then show it by a dissection argument using simple polyhedral pieces of five types. These pieces can be used to build many polyhedra, including the regular dodecahedron, the regular icosahedron, the great dodecahedron, the small and great stellated dodecahedra and all the Archimedean polyhedra which have icosahedral symmetry.
Molecular prevalence and genetic characterization of piroplasms in dogs from Tunisia
Authors: RJEIBI MOHAMED R. , AMAIRIA SAFA , ROUATBI MARIEM , BEN SALEM FATMA , MABROUK MOEZ , GHARBI MOHAMED
Published: July 2016

In this study, the prevalence of piroplasms in dogs was assessed using polymerase chain reaction (PCR) to identifyBabesiaandTheileriaspecies in 200 dogs from Northern and Central Tunisia between spring and autumn 2014. The overall molecular prevalence for piroplasms was 14·5% ± 0·05 (29/200); PCR detected 2 species, namelyBabesia vogeliandTheileria annulatawith an overall prevalence of 12·5 ± 0·04 and 2% ± 0·02, respectively. No differences in the molecular prevalences ofB. vogeliwere revealed for age and sex (P> 0·05). The molecular prevalence ofB. vogeliwas significantly higher in central Tunisia (26·5% ± 0·01) compared with the North (9·6% ± 0·04) (P< 0·05). More working and companion dogs were infected byB. vogeli(25·8 ± 0·15 and 21·1% ± 0·13, respectively) in comparison with guarding dogs (1·8% ± 0·03) (P< 0·05). ConcerningT. annulata,no significant variation was observed for all studied risk factors (P> 0·05). Comparison of the partial sequences of18S rRNAandTams 1genes confirmed the presence of 2 novelB. vogeliandT. annulatagenotypes. This is the first molecular detection ofT. annulataand genetic characterization of dogs’ piroplasms in Tunisia. Further studies are needed to better assess the epidemiological feature of piroplasms infection in North Africa.
Students' experiences of collaborative creation through songcrafting in primary school: Supporting creative agency in ‘school music’ programmes
Authors: Muhonen Sari
Published: July 2016

The study reported in this article investigates students’ experiences (n=41) of their primary school songcrafting, examining the potential to support creative agency within school music education programmes. Songcrafting refers to a collaborative composing practice in which everyone is considered to be a capable creator of melodies and lyrics, and where negotiation, collaboration, and openness to the situation are essential. Through semi-structured individual interviews with students who had experienced songcrafting in the past, analysed with qualitative methods, it was found that the students' narration of songcrafting included meanings related to general agency, creative agency, musical participation within the classroom community, and documented and shared collaborative musical products, or ‘oeuvres’.

The results of this study illustrate the various often unforeseeable meanings produced through participation in collaborative musical activities. Furthermore, they highlight the potential to enrich meaningful teaching practices and pedagogy through the examination of students' experiences, and exploring the potentials in narrating one's musical stories. These findings suggest that music education practices could benefit from the inclusion of a broader range of opportunities for the students to create their own music, and the sensitive facilitation of collaborative music creation processes.
The functional roles of epiphytes and arboreal soils in tropical montane cloud forests
Authors: Gotsch Sybil G. , Nadkarni Nalini , Amici Autumn
Published: July 2016

Epiphytes and their associated decomposing litter and arboreal soils (herein, epiphytic material, EM) are ubiquitous features of tropical montane cloud forests (TMCF) and play important roles in ecosystem function. EM intercepts water and nutrients from the atmosphere and from intercepted host tree sources, and may contribute significant inputs of these resources to the forest floor. Despite the importance of EM in the TMCF, a systematic review of the ecosystem roles of EM has not been compiled before. We have synthesized the literature that documents functions of EM in undisturbed TMCFs and discuss how these roles may be affected by disturbances, including changes in climate and land use. The range of EM biomass and water storage in the TMCF varies greatly across sites, with different amounts associated with stand age and microclimate. EM is important as habitat and food for birds and mammals, with over 200 species of birds documented as using EM in the Neotropics. Given its sensitivity to moisture, projected shifts in cloud base heights or precipitation due to changes in climate will likely have a large impact on this community and changes in EM diversity or abundance may have cascading impacts on the ecosystem function of the TMCF.
Parsing apart the persisters: Etiological mechanisms and criminal offense patterns of moderate- and high-level persistent offenders
Authors: Amemiya Jamie , Vanderhei Susan , Monahan Kathryn C.
Published: July 2016

Longitudinal investigations that have applied Moffitt's dual taxonomic framework to criminal offending have provided support for the existence of adolescent-limited and life-course persistent antisocial individuals, but have also identified additional trajectories. For instance, rather than a single persistent trajectory, studies have found both high-levelandmoderate-level persistent offenders. To inform theory and progress our understanding of chronic antisocial behavior, the present study used a sample of serious adolescent offenders (N=1,088) followed from middle adolescence to early adulthood (14–25 years), and examined how moderate-level persistent offenders differed from low-rate, desisting, and high-level persistent offenders. Results indicated that moderate-level persisters' etiology and criminal offense patterns were most similar to high-level persisters, but there were notable differences. Specifically, increasing levels of contextual adversity characterized both moderate-level and high-level persisting trajectories, but moderate-level persisters reported consistently lower levels of environmental risk. While both high- and moderate-level persisters committed more drug-related offenses in early adulthood compared to adolescence, moderate-level persisters engaged in lower levels of antisocial behavior across all types of criminal offenses. Taken cumulatively, the findings of this study suggest that sociocontextual interventions may be powerful in reducing both moderate- and high-level persistence in crime.
How does restricted and repetitive behavior relate to language and cognition in typical development?
Authors: Larkin Fionnuala , Meins Elizabeth , Centifanti Luna C. M. , Fernyhough Charles , Leekam Susan R.
Published: July 2016

Relations between restricted and repetitive behavior at age 26 months and children's concurrent (N = 203) and later (n = 161) social cognition and language development were investigated. Restricted and repetitive behavior was assessed using two scales: sensory and motor repetitive behaviors and rigidity/routines/restricted interests. Language was assessed at ages 26 and 51 months; social cognition was assessed at ages 26 (symbolic play) and 51 and 61 months (theory of mind). Sensory and motor repetitive behavior was negatively related to children's (a) language performance at 26 and 51 months, (b) instructed symbolic play at 26 months, and (c) theory of mind performance at 51 and 61 months. Path analyses showed that children's sensory and motor repetitive behavior at age 26 months was related to lower receptive verbal ability and theory of mind at 51 months, which led to lower theory of mind at 61 months. Rigidity/routines/restricted interests at 26 months were unrelated to concurrent and later social cognition and language. These results are discussed in terms of the pathways via which sensory and motor repetitive behavior might impact negatively on development.
A cascade from disregard for rules of conduct at preschool age to parental power assertion at early school age to antisocial behavior in early preadolescence: Interplay with the child's skin conductance level
Authors: Kochanska Grazyna , Brock Rebecca L. , Boldt Lea J.
Published: July 2016

Young children's disregard for conduct rules (failing to experience discomfort following transgressions and violating adults' prohibitions) often foreshadows future antisocial trajectories, perhaps in part because it elicits more power-assertive parental discipline, which in turn promotes children's antisocial behavior. This process may be particularly likely for children with low skin conductance level (SCL). In 102 two-parent community families, we tested a model in which children's SCL, assessed at 8 years, was posed as a moderator of the cascade from children's disregard for conduct rules at 4.5 years to parents' power assertion at 5.5 and 6.5 years to antisocial behavior at 10 and 12 years. Children's disregard for conduct rules was observed in scripted laboratory paradigms, parents' power assertion was observed in discipline contexts, and children's antisocial behavior was rated by parents. Conditional process analyses revealed that the developmental cascade from early disregard for rules to future parental power assertion to antisocial outcomes occurred only for the children with low SCL (below median), but not their high-SCL (above median) peers. By elucidating the specific interplay among children's disregard for rules, the parenting they receive, and their psychophysiology, this study represents a developmentally informed, multilevel approach to early etiology of antisocial behavior.
Time-varying effects of families and peers on adolescent marijuana use: Person–environment interactions across development
Authors: Epstein Marina , Hill Karl G. , Roe Stephanie S. , Bailey Jennifer A. , Iacono William G. , McGue Matt , Kristman-Valente Allison , Catalano Richard F. , Haggerty Kevin P.
Published: July 2016

Studies have demonstrated that the effects of two well-known predictors of adolescent substance use, family monitoring and antisocial peers, are not static but change over the course of adolescence. Moreover, these effects may differ for different groups of youth. The current study uses time-varying effect modeling to examine the changes in the association between family monitoring and antisocial peers and marijuana use from ages 11 to 19, and to compare these associations by gender and levels of behavioral disinhibition. Data are drawn from the Raising Healthy Children study, a longitudinal panel of 1,040 youth. The strength of association between family monitoring and antisocial peers and marijuana use was mostly steady over adolescence, and was greater for girls than for boys. Differences in the strength of the association were also evident by levels of behavioral disinhibition: youth with lower levels of disinhibition were more susceptible to the influence of parents and peers. Stronger influence of family monitoring on girls and less disinhibited youth was most evident in middle adolescence, whereas the stronger effect of antisocial peers was significant during middle and late adolescence. Implications for the timing and targeting of marijuana preventive interventions are discussed.
Skeleton composition versus stable process systems in Eden
Authors: DIETERLE M. , HORSTMEYER T. , LOOGEN R. , BERTHOLD J.
Published: July 2016

We compare two inherently different approaches to implement complex process systems in Eden:stable process systemsand acompositionalapproach. Astable process systemis characterised by handling several computation stages in each of the participating processes. Often, processes communicate using streams of data, change behaviour with the different computation phases, and more often than not, exactly one process is allocated to each processor element. In contrast, a complex process system can also be achieved byskeleton compositionof a number of elementary skeletons, such as parallel transformation, reduction, or special communication patterns. In a compositional implementation, each computation phase leads to a new set of interacting processes. When implementing complex parallel algorithms, skeleton composition is usually easier and more flexible, but has a larger overhead from additional process creation and communication. We present case studies of different parallel application kernels implemented as stable systems and using composition in Eden, including a comprehensive description of Eden's features. Our results show that the compositional performance loss can be alleviated by co-locating processes which directly communicate, and by using Eden's remote data concept to enable such direct communication. Moreover, Eden's parallel runtime system handles communication between co-located processes in an optimised way. EdenTV visualisations of execution traces are invaluable to analyse program characteristics and for targeted optimisations towards better process placement and communication avoidance.
The universality of polynomial time Turing equivalence
Authors: MARKS ANDREW
Published: July 2016

We show that polynomial time Turing equivalence and a large class of other equivalence relations from computational complexity theory are universal countable Borel equivalence relations. We then discuss ultrafilters on the invariant Borel sets of these equivalence relations which are related to Martin's ultrafilter on the Turing degrees.
An Accidental Special Issue
Authors: LUDLOW PIERS
Published: July 2016

This was not intended to be a special issue. Instead, my task as editor was simply meant to be that of selecting an interesting selection of pieces from those articles available, or nearly ready, for publication. But upon looking at the list of possible candidates it quickly became clear that a large number dealt squarely with the history of European integration and that two others concentrated on other aspects of Europe's post-war institutional landscape. It therefore seemed to make sense to group them together.
The Tie That Binds: Exploring Community College Curriculum Design
Authors: Gentry Bobbi , Lawrence Christopher , Richards Erin
Published: July 2016

More students are beginning their college careers at community colleges before completing degrees at four-year institutions. As enrollments swell at these two-year institutions, issues surrounding transfer and articulation agreements are increasingly important, and two- and four-year institutions must work together on the recruitment, retention, and transition of political science majors. Central to this collaboration is the curriculum. Building on conclusions from the 2011 Leadership Collaborative Core Curriculum and General Education track regarding a common curriculum in the discipline, this article examines the political science curriculum using data from 47 two-year colleges with separate political science departments. We examined similarities and differences among these programs and found sufficient commonality in curriculum to allow students to transfer credits to four-year institutions. The article also offers community colleges an indication of common curricular features and informs the wider profession about community college curriculum design.
Psychotic disorders in DSM-5 and ICD-11
Authors: Biedermann Falko , Fleischhacker W. Wolfgang
Published: July 2016

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was published by the American Psychiatric Association (APA) in 2013, and the Work Group on the Classification of Psychotic disorders (WGPD), installed by the World Health Organization (WHO), is expected to publish the new chapter about schizophrenia and other primary psychotic disorders in 2017. We reviewed the available literature to summarize the major changes, innovations, and developments of both manuals. If available and possible, we outline the theoretical background behind these changes. Due to the fact that the development of ICD-11 has not yet been completed, the details about ICD-11 are still proposals under ongoing revision. In this ongoing process, they may be revised and therefore have to be seen as proposals. DSM-5 has eliminated schizophrenia subtypes and replaced them with a dimensional approach based on symptom assessments. ICD-11 will most likely go in a similar direction, as both manuals are planned to be more harmonized, although some differences will remain in details and the conceptual orientation. Next to these modifications, ICD-11 will provide a transsectional diagnostic criterion for schizoaffective disorders and a reorganization of acute and transient psychotic and delusional disorders. In this manuscript, we will compare the 2 classification systems.
Are the ICD-10 or DSM-5 diagnostic systems able to define those who will benefit from treatment for depression?
Authors: Montgomery Stuart
Published: July 2016

Two widely used diagnostic systems, theInternational Statistical Classification of Diseases and Related Health Problems(ICD-10) and theDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), are reviewed for their ability to define those who will benefit from active treatment rather than placebo. Both systems suffer from a weakness in defining symptoms sufficiently clearly to separate depression from normal mood variations in the general population. Consequently, normal individuals may be medicalized and defined as suffering from and treated for depression. Also, in mild depression, unlike moderate depression, a lack of significant separation of active treatment from placebo has been shown in individual double-blind, placebo-controlled studies and in meta-analyses of these treatment studies. Both systems would be more useful for treatment purposes if they provided a clearer symptomatic definition of moderate depression, as is widely used in pivotal regulatory standard efficacy studies.
Characteristics associated with the application of an ecological approach to preventing childhood obesity
Authors: Stark Christina M , Devine Carol M , Dollahite Jamie S
Published: July 2016

Objective

Applying an ecological approach to childhood obesity prevention requires a new way of thinking and working for many community-based practitioners who are used to focusing on individual behaviour change. The present study investigated individual and organizational characteristics associated with the application of an ecological approach by practitioners 6 months post-training.

Design

Individual and organizational characteristics and outcomes of a 6-week online training course were assessed at pre-course, post-course and 6-month follow-up. The application of an ecological approach was measured by three outcomes (application of course content, implementation of an action plan and trying a different approach) and analysed using a generalized estimating equation model with a binomial distribution and logit link and linear mixed models.

Setting

An online course for participants in the USA and abroad.

Subjects

Public health nutrition and youth development educators and their community partners, and other community practitioners, who completed the course and all three surveys (n 240).

Results

One individual characteristic (networking utility) and three organizational characteristics (ecological approach within job scope, funding, course content applied to work) were positively and significantly associated with the application of an ecological approach (P<0·05). Individual characteristics that were negatively and significantly associated with the application of an ecological approach were being a registered dietitian and having ≥16 years of work experience (P<0·05).

Conclusions

Training of community practitioners and the scope and funding of their positions should explicitly emphasize the usefulness or utility of networking and the use of an ecological approach for preventing childhood obesity.
Education scholarship in emergency medicine part 1: innovating and improving teaching and learning
Authors: Sherbino Jonathan , van Melle Elaine , Bandiera Glen , McEwen Jill , LeBlanc Constance , Bhanji Farhan , Frank Jason R. , Regehr Glenn , Snell Linda
Published: July 2016

As emergency medicine (EM) education evolves, a more advanced understanding of education scholarship is required. This article is the first in a series of three articles that reports the recommendations of the 2013 education scholarship consensus conference of the Academic Section of the Canadian Association of Emergency Physicians. Adopting the Canadian Association for Medical Education's definition, education scholarship (including both research and innovation) is defined. A rationale for why education scholarship should be a priority for EM is discussed.
Education scholarship in emergency medicine part 2: supporting and developing scholars
Authors: Bandiera Glen , LeBlanc Constance , Regehr Glenn , Snell Linda , Frank Jason R. , Sherbino Jonathan
Published: July 2016

Emergency medicine (EM) is defined, in part, by clinical excellence across an immense breadth of content and the provision of exemplary bedside teaching to a wide variety of learners. The specialty is also well-suited to a number of emerging areas of education scholarship, particularly in relation to team-based learning, clinical reasoning, acute care response, and simulation-based teaching. The success of EM education scholarship will be predicated on systematic, collective attention to providing the infrastructure for this to occur. Specifically, as a new generation of emergency physicians prepares for education careers, academic organizations need to develop means not only to identify potential scholars but also to mentor, support, and encourage theircareers. This paper summarizes the supporting literature and presents related recommendations from a 2013 consensus conference on EM education scholarship led by the Academic Section of the Canadian Association of Emergency Physicians.
Pris au dépourvu par l’arrivée de maladies tropicales
Authors: Kissoon Niranjan , Uyeki Tim
Published: July 2016

La déréglementation du transport aérien, entrée en vigueur en 1978, et l’optimisation des voies aériennes ont eu un effet des plus avantageux sur les voyages à l’étranger, y compris sur ceux en provenance ou à destination du Canada, pays du G8 qui connaît l’une des plus fortes croissances de la population. Des millions de touristes provenant de pays outre-mer visitent le Canada chaque année. Par ailleurs, plus de 20% de la population canadienne (presque 7 millions de personnes) est néeàl’étranger, et au moins 50% des nouveaux immigrants arrivent de régions tropicales. De plus, les immigrants récents peuvent retourner dans leur pays d’origine et en revenir.
Medical role of first responders in an urban prehospital setting
Authors: Berringer Ross , Christenson Jim , Blitz Maurice , Spinelli John , Freeman Jeff , Maddess Glenn , Rae Sandra
Published: July 2016

Background:

Almost all North American cities have first responder programs. To date there is no published documentation of the roles first responders play, nor of the frequency and type of interventions they perform. Many urban stakeholders question the utility and safety of routinely dispatching large vehicles emergently to calls that may not require their services. Real world data on first responder interventions will help emergency medical services (EMS) directors and planners determine manpower requirements, assess training needs, and optimize dispatch protocols to reduce the rate of inappropriate “code 3” (lights and siren) responses.

Objective:

Our objectives were to determine how often first responders arrive first on scene, to estimate the time interval between first response and EMS response, and to examine the frequency and type of interventions performed by first responders.

Methods:

In a prospective observational study, trained observers were assigned to fire department first responder (FDFR) units. These observers recorded on-scene times for FDFR and EMS units, and documented the performance of first responder interventions.

Results:

FDFRs arrived first on scene in 49% of code 3 calls. They performed critical interventions in 18% of calls attended and 36% of calls where they arrived first. Oxygen administration was the most frequent critical intervention, yet occult hypoxemia was common and compliance with oxygen administration protocols was poor.

Conclusions:

First responders perform critical interventions during a minority of code 3 calls, even when “critical” is defined generously. Many “lights and siren” dispatches are unnecessary. Future research should attempt to identify dispatch criteria that more accurately predict the need for first responder intervention. First responder training and continuous quality improvement (CQI) should focus on interventions that are performed with some regularity, particularly oxygen administration.
Ultrasound in the ED: a different point of view
Authors: Filiatrault Lyne
Published: July 2016

Many published papers report excellent sensitivity, specificity and accuracy when non-radiologists employ ultrasound (U/S) to detect free intraperitoneal fluid in cases of blunt abdominal trauma (BAT). In this setting, it is best to view the FAST (focused abdominal sonogram in trauma) as a noninvasive diagnostic peritoneal lavage (DPL): It tells us whether there is free intraperitoneal fluid but does not determine the specific parenchymal injury. In other words it is a screening tool.
The Royal Flying Doctor Service
Authors: Renouf Tia
Published: July 2016

The Royal Flying Doctor Service, or RFDS, is close to every rural Australian’s heart. Five aircraft in Alice Springs cover central Australia, an area of desert the size of Spain. People in need call the flying doctor, hundreds of miles away, by telephone or radio. These aircraft, really airborne ICUs, can be wherever help is needed in 45 minutes.
Manpower crisis in emergency medicine: Can residency programs make an impact?
Authors: Steiner Ivan P. , Yoon Philip W. , Holroyd Brian R.
Published: July 2016

Une étude sur la main-d’œuvre canadienne menée en 1994 avait prédit une pénurie à l’échelle nationale de 562 médecins d’urgence qualifiés avant 2001. Plusieurs facteurs ont changé depuis la publication de ces données; cependant, aucun n’a changé l’ordre de grandeur de cette pénurie. À la lumière de ces renseignements, on a étudié la situation de la Edmonton Capital Health Region (CHR) et évalué l’impact des programmes de résidence en MU de l’Université de l’Alberta (CRMC [Collège Royal des médecins et chirurgiens du Canada] et CMFC [Collège des médecins de famille du Canada], créés en 1992) sur les besoins locaux en main-d’œuvre.

Le nombre de médecins d’urgence certifiés dans la CHR est passé de 9 du CRMC-MU et 2 du CMFC-MU en 1990 à 14 du CRMC-MU et 16 du CMFC-MU en 1999, soit une augmentation de 27 %. Le gain le plus important provenait du recrutement de 14 diplômés en médecine d’urgence de la région; cependant, malgré ce succès, et même avec un recrutement de 100 % des diplômés de l’Université de l’Alberta, on constate encore une pénurie importante de médecins d’urgence dans la CHR.

Cette situation n’est pas unique. Elle est le résultat d’un nombre insuffisant de postes de formations en médecine d’urgence au Canada. La seule solution possible à long terme serait d’augmenter considérablement le nombre de postes de résidence du CRMC tout en maintenant, et dans certaines juridictions en augmentant, le nombre de diplômés du CMFC.
Is early discharge safe after naloxone reversal of presumed opioid overdose?
Authors: Etherington Jeremy , Christenson James , Innes Grant , Grafstein Eric , Pennington Sarah , Spinelli John J. , Gao Min , Lahiffe Brian , Wanger Karen , Fernandes Christopher
Published: July 2016

Introduction:

Patients with suspected opioid overdose frequently require naloxone treatment. Despite recommendations to observe such patients for 4 to 24 hours after naloxone, earlier discharge is becoming more common. This prospective, observational study of patients with presumed opioid overdose examines the safety of early disposition decisions and the accuracy of outcome prediction by physicians 1 hour after the administration of naloxone.

Methods:

The study was carried out at St. Paul’s Hospital, an inner city teaching centre that cares for most of the injection drug users in Vancouver, BC. Patients were formally assessed 1 hour after receiving naloxone for presumed opioid overdose. Demographics, medical history and physical examination were documented on specific data forms, and physicians recorded their comfort with early discharge. Patients were followed up, and those who required a critical intervention or suffered a pre-defined adverse event (AE) within 24 hours of their 1-hour assessment were identified.

Results:

Of 573 patients, 48% were discharged in less than 2 hours, 23% in 2–4 hours and 29% in >4 hours. 94 patients who were held in the emergency department (ED) or admitted required a critical intervention, including supplemental oxygen for hypoxia (74), repeat naloxone (52), antibiotics administered intravenously (IV) (14), assisted ventilations (13), fluid bolus for hypotension (12), charcoal for associated life-threatening overdose (6), IV inotropic agents (2), antiarrhythmics for sustained tachycardia >130 beats/min (1), and administration of bicarbonate for arterial [HCO3] <5 or venous CO2 <5 (1). Physicians predicted adverse events with 94% sensitivity and 59% specificity. No discharged patients suffered a serious AE within 24 hours of ED discharge.

Conclusions:

Emergency physicians can clinically identify patients at risk of deterioration after naloxone reversal of suspected opioid overdose. Prolonged observation or hospital admission is not usually required. Selective early discharge of patients with presumed opioid overdose is feasible and appears safe. A clinical prediction rule may be useful in identifying patients eligible for early discharge.
Resource contribution by Canadian faculties of medicine to the discipline of emergency medicine
Authors: Steiner Ivan P. , Yoon Philip W. , Goldsand George , Rowe Brian H.
Published: July 2016

Objective:

Undergraduate and postgraduate emergency medicine (EM) education has developed rapidly over the last 20 years. Our objective was to establish a national educational inventory, cataloguing the human and financial resources provided to EM programs by Canadian faculties of medicine.

Methods:

A 17-question survey was distributed to all 27 Canadian EM program directors, representing 11 Royal College of Physicians and Surgeons of Canada (RCPSC) programs and 16 College of Family Physicians of Canada (CFPC-EM) programs. The questionnaire addressed teaching responsibilities, teaching support and academic support in each program.

Results:

All 27 program directors returned valid questionnaires. Annually, an estimated 3,049 students and residents participate in EM learning. This includes 1,369 undergraduates (45%), 1,621 postgraduates (53%) and 59 others (2%). Of the postgraduates, 173 are EM residents — 92 (53%) in RCPSC programs and 81 (47%) in CFPC-EM programs. Overall, 587 EM faculty teach residents and students, but only 36 (6%) of these hold academic geographical full time positions. At the university level, all 16 CFPC-EM programs are administered by departments of family medicine. Of 11 RCPSC programs, 1 has full departmental status, 2 are free-standing divisions, 3 are administered through family medicine, 3 through medicine, 1 through surgery and 1 by other arrangements. Currently 8 programs (30%) have associate faculty, 14 (52%) have designated research directors and 10 (37%) describe other human resources. Sixteen (59%) programs receive direct financial and administrative support and 17 (63%) receive financial support for resident initiatives. Only 8 program directors (30%) perceive that they are receiving adequate support.

Conclusions:

Despite major teaching and clinical responsibilities within the faculties of medicine, Canadian EM programs are poorly supported. Further investment of human and financial and human resources is required.
Prehospital vs. emergency department pronouncement of death: a cost analysis
Authors: Cheung Mathew , Morrison Laurie , Richard Verbeek P.
Published: July 2016

Objective:

National survival rates for out-of-hospital cardiac arrests are less than 5%, and substantial resources are associated with transporting cardiac arrest victims to hospital for emergency department (ED) resuscitation. The low overall survival rate and the identification of predictors of unsuccessful resuscitation have opened debate on the “futility” of transporting such patients to the ED. This study compares the costs of prehospital pronouncement of death to the costs of transporting patients to a hospital ED for physician pronouncement.

Methods:

The study was a retrospective chart review on a matched cohort of out-of-hospital cardiac arrest patients. Patients were included if documentation was adequate and ambulance response time was less than 8 minutes. A cohort of 20 patients pronounced dead in the field were matched to 20 patients pronounced dead in an ED. Cases were matched on 6 evidence-based predictors of unsuccessful resuscitation. Direct medical costs and mean physician and prehospital provider times were compared.

Results:

The total cost of pronouncement of death in the ED was $45.35 higher than the cost of field pronouncement (p < 0.001). Paramedics spent more time delivering care when death was pronounced in the field (83.3 vs. 55.9 min; p < 0.001). Base hospital physicians spent more time when patients were transported to hospital for ED pronouncement (16.3 vs. 4.3 min; p < 0.001). Total provider time for field pronouncement was 15.5 min longer (p = 0.004), but field pronouncement consumed 12.0 min less physician time.

Conclusions:

Paramedic pronouncement of death in the field is less costly than transporting patients to hospital for physician pronouncement. Pronouncement in the field requires more paramedic time but less physician time.
Quantifying delays in the recognition and management of acute compartment syndrome
Authors: Vaillancourt Christian , Shrier Ian , Falk Markus , Rossignol Michel , Vernec Alan , Somogyi Dan
Published: July 2016

Objective:

To identify where most efforts should be made to decrease ischemia time and necrosis in acute compartment syndrome (ACS) and to determine the causes for late interventions.

Methods:

This was a multicentre, historical cohort study of patients who underwent fasciotomy for ACS within the McGill Teaching Hospitals between 1989 and 1997. Patients studied had a clinical diagnosis of ACS or compartment pressures greater than 30 mm Hg. In all cases, ACS was confirmed at the time of fasciotomy. Patients were stratified into traumatic and non-traumatic groups, and a step-by-step analysis was performed for each part of the process between injury and operation.

Results:

Among the 62 traumatic ACS cases, the longest delays occurred between initial assessment and diagnosis (median time 2h56, range from 0 to 99h20) and between diagnosis and operation (median 2h13, range 0h15–29h45). Among the 14 non-traumatic ACS cases, delays primarily occurred between inciting event and hospital presentation (median 9h19, range 0h04–289h29) and between initial assessment and diagnosis (median 8h18, range 0–104h15).

Conclusions:

ACS is a limb-threatening condition for which early intervention is critical. Substantial delays occur after the time of patient presentation. For traumatic and non-traumatic ACS, increased physician awareness and faster operating room access may reduce treatment delays and prevent disability.
Delayed salicylate toxicity following enteric-coated acetylsalicylic acid overdose: a case report and review of the literature
Authors: Drummond Robert , Kadri Nadine , St-Cyr Julie
Published: July 2016

Salicylates are widely available and potentially lethal. Clinical and laboratory findings associated with enteric-coated acetylsalicylic acid (ECASA) ingestion may be delayed more than 24 hours. When dealing with patients who have a history of significant ingestion, emergency physicians should consider initiating therapy regardless of initial salicylate levels. Prolonged observation may be necessary in cases of suspected ECASA overdose.
Severe methemoglobinemia from topical anesthetic spray: case report, discussion and qualitative systematic review
Authors: Abu-Laban Riyad B. , Zed Peter J. , Purssell Roy A. , Evans Kenneth G.
Published: July 2016

Few health care professionals realize that topical anesthetic spray can cause methemoglobinemia. We describe a 56-year-old woman who was transferred to our emergency department when severe cyanosis and chest pain developed after administration of topical oropharyngeal benzocaine and lidocaine during outpatient endoscopy. Investigations revealed a methemoglobin level of 51%. Despite rapid diagnosis and treatment with methylene blue, pulmonary edema consistent with adult respiratory distress syndrome developed, endotracheal intubation was required, and the patient suffered a lengthy course in the intensive care unit. This article presents a detailed discussion of the pathophysiology, diagnosis and treatment of methemoglobinemia, as well as a qualitative systematic review of the English literature on methemoglobinemia induced by topical anesthetic. The implications of this condition for emergency physicians are also outlined.
Emergency physicians’ attitudes toward a clinical prediction rule for the identification and early discharge of low risk patients with chest discomfort
Authors: MacGougan Cameron K. , Christenson James M. , Innes Grant D. , Raboud Janet
Published: July 2016

Objectives:

To determine Canadian emergency physicians’ estimates regarding the safety and efficiency of chest discomfort management in their emergency department (ED), and their attitudes toward and perception of the need for a chest discomfort clinical prediction rule that identifies very low risk patients who are safe to discharge after a brief ED assessment.

Methods:

300 members of the Canadian Association of Emergency Physicians (CAEP) were randomly selected to receive a confidential mail survey, which invited them to provide information on current disposition of patients with chest discomfort and their opinions regarding the value of a clinical prediction rule to identify patients with chest discomfort who are safe to discharge after a brief (~2 hour) assessment.

Results:

Of the 300 physicians selected, 288 were eligible for the survey and 235 (82%) responded. Only 5% follow discharged patients to measure safe practice. Overall, 165 (70%) felt the proposed prediction rule would be very useful and 43 (18%) felt it would be useful. Almost all (94%) believed a prediction rule would be useful if it identified patients safe for discharge without increasing the current rate of missed acute myocardial infarction (estimated at 2%). Most respondents (59%) believed that a clinical prediction rule should suggest a course of action, while 30% felt it should convey a probability of disease.

Conclusions:

Canadian emergency physicians support the concept of a clinical prediction rule for the early discharge of patients with chest discomfort. Most believe that such a rule would be useful if it identified patients who are safe for discharge after a brief assessment, while maintaining current levels of safety. Future research should be aimed at deriving a clinical prediction rule to identify low risk patients who can be safely discharged after a limited emergency department evaluation.
Incidental findings during emergency sonographic examinations: a case series
Authors: Kendal John L. , Mandavia Diku
Published: July 2016

The teaching of ultrasonography is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. Most literature focuses on appropriate indications for the performance of emergency ultrasonography, and most EM-related courses and programs limit their teaching to standard focused indications. Generally this will suffice; however, occasionally, incidental findings, which are beyond the realm of what is taught in these programs, have influenced patient care. In this paper we discuss 7 cases in which incidental findings were discovered during an emergency sonographic examination. In each case the findings changed the patient’s disposition, diagnosis and, potentially, outcome.
Recurrent bleeding in acute upper gastrointestinal hemorrhage: transfusion confusion
Authors: Ginn Jeffery L. , Ducharme James
Published: July 2016

Objective:

Acute upper gastrointestinal (UGI) hemorrhage is a common, often serious condition encountered in the emergency department (ED). Previous research has suggested that transfusion of blood products may interfere with the hypercoagulable state induced by significant blood loss. Our objective was to determine whether the frequency of rebleeding is higher in patients with UGI bleeding who have received early blood transfusion.

Methods:

The study was a retrospective chart review of patients admitted to hospital through the ED with a diagnosis of UGI hemorrhage. Inclusion criteria limited analysis to patients presenting with hematemesis, melena, or bloody nasogastric aspirate, in whom a UGI lesion was confirmed endoscopically during admission.

Results:

A total of 214 charts were analyzed. Baseline demographic characteristics were similar in transfused and non-transfused patients. Presenting hemoglobin level was lower in the transfused group (86.5 v. 119.2 g/L, p < 0.001). Recurrent bleeding occurred in 99 (46%) patients and was more common in transfused patients (67 [66%] v. 33 [29%], p < 0.001). Logistic regression analysis revealed that transfusion and presenting hemoglobin level were the only variables with a statistically significant independent association with bleeding recurrence (p < 0.001 and p < 0.05 respectively).

Conclusions:

Our results support previous research suggesting that transfused UGI bleed patients have a higher rate of rebleeding. However, because of the retrospective design, causality cannot be inferred.