bluuebunny/crossref_metadata_2025 huggingface dataset:
Concise Review: Stem Cells and Epithelial-Mesenchymal Transition in Cancer: Biological Implications and Therapeutic Targets
Authors: Sato Ryo , Semba Takashi , Saya Hideyuki , Arima Yoshimi
Published: June 2016

Cancer stem cells (CSCs) constitute a small subpopulation of cancer cells with stem-like properties that are able to self-renew, generate differentiated daughter cells, and give rise to heterogeneous tumor tissue. Tumor heterogeneity is a hallmark of cancer and underlies resistance to anticancer therapies and disease progression. The epithelial-mesenchymal transition (EMT) is a reversible phenomenon that is mediated by EMT-inducing transcription factors (EMT-TFs) and plays an important role in normal organ development, wound healing, and the invasiveness of cancer cells. Recent evidence showing that overexpression of several EMT-TFs is associated with stemness in cancer cells has suggested the existence of a link between EMT and CSCs. In this review, we focus on the roles of CSCs and EMT signaling in driving tumor heterogeneity. A better understanding of the dynamics of both CSCs and EMT-TFs in the generation of tumor heterogeneity may provide a basis for the development of new treatment options for cancer patients.
A day at the museum: The impact of field trips on middle school science achievement
Authors: Whitesell Emilyn Ruble
Published: June 2016

Field trips are an important feature of the United States’ education system, although in the current context of high‐stakes tests and school accountability, many schools are shifting resources away from enrichment. It is critical to understand how field trips and other informal learning experiences contribute to student test scores, but little research has explored the impact of field trips on standard measures of academic learning. In this study, I used 6 years of student‐level data to estimate the impact of field trips to informal science education institutions on New York City students’ performance on the state's standardized eighth‐grade science exam. Using a rigorous identification strategy with school fixed effects to capitalize on variation in field trip participation within schools over time, I found small positive effects of exposure to field trips on students’ science test scores and proficiency. Effects were largest for Hispanic students and those who qualified for free or reduced‐price lunch. This evidence that field trips can contribute positively to student achievement is meaningful for policymakers and administrators, as it suggests schools can provide enrichment experiences that families desire without sacrificing student test scores. The study suggests that field trips might be an effective tool for reducing achievement gaps. © 2016 Wiley Periodicals, Inc. J Res Sci Teach 53:1036–1054, 2016
A 0.5‐V 5.9‐fJ/conversion‐step SAR ADC in 0.18‐μm CMOS
Authors: Ren Xiaojiao , Zhuang Yiqi , Li Xiaoming , Qi Zengwei , Wang Bo
Published: June 2016

In this paper, we present a 434‐nW 8‐bit successive approximation register analog‐to‐digital converter (SAR ADC). We mainly consider the optimization of power consumption. A modified split‐capacitor array involving a novel switching scheme is proposed, which reduces the switching power consumption to just 13.8 for the single‐ended scheme without any losses in performance. Based on the SMIC CMOS 0.1 μm EEPROM 2P4M process, the simulation results show that at 0.5 V supply voltage, 300 kS/s sample frequency, and 4.98 kHz input frequency, the ADC achieves an signal‐to‐noise‐plus‐distortion ratio (SNDR) of 49.58 dB and effective number of bits (ENOB) of 7.94, and consumes 434 nW, resulting in a figure of merit of 5.9 fJ/conversion step. © 2016 Institute of Electrical Engineers of Japan. Published by John Wiley & Sons, Inc.
Analysis on burst packet buffering of communication gateway between fast IP network and slow facility fieldbus
Authors: Yamada Tomohisa , Ninagawa Chuzo
Published: June 2016

In the Internet of Things (IoT) age, fieldbuses for distributed embedded systems are often integrated with IP networks with gateways. Because of the vast difference in bit rates between both networks, buffering characteristics of these gateways are becoming important. In this paper, we modeled a fieldbus gateway using an M/M/1 queuing system for the transient packet buffering. Assuming burst packet arrivals at the gateway, time trends of the expected value and the standard deviation of the number of buffered packets were calculated analytically. Validity of our analysis was confirmed using computer simulation for CSMA/CD communications. Time trend curves for the expected value and the standard deviation matched within 5% and 20 %, respectively. Our transient analysis method provides a practical estimation method for the transient performance of the fieldbus gateways. © 2016 Institute of Electrical Engineers of Japan. Published by John Wiley & Sons, Inc.
Rotational invariance of quaternionic hopfield neural networks
Authors: Kobayashi Masaki
Published: June 2016

High‐dimensional neural networks have been studied by many researchers for their flexible representation. Quaternionic Hopfield neural networks (QHNNs) are one of them. Quaternions have the inherent property of non‐commutative multiplication. Connection weights act differently from left and right in QHNNs, and we can have left QHNNs (LQHNNs) and right QHNNs (RQHNNs). Hybrid QHNNs (HQHNNs), which are the compound models of LQHNNs and RQHNNs, have been proposed, and their excellent noise tolerance has been shown through computer simulations. It has been pointed out that the improvement in their noise tolerance is related to the avoidance of rotational invariance. Thus, it is very important to study rotational invariance. In this paper, we investigate the rotational invariance of QHNNs. Rotational invariance in LQHNNs and RQHNNs is different. We define the left and right‐rotated vectors, which are fixed in RQHNNs and LQHNNs, respectively. From the standpoint of HQHNNs, the common rotated vectors are important. We also study the common rotated vectors and provide a couple of exceptional examples. © 2016 Institute of Electrical Engineers of Japan. Published by John Wiley & Sons, Inc.
Always take the weather with you
Authors: Roy Anita
Published: June 2016

Weather trees are a little‐known way of recording the daily and seasonal changes in the weather for people around the world. Anita Roy talks to Simon Leach about his love of weather trees, why he has coloured in a leaf a day for the past twenty years and what the British love of the weather tells us about our national character.
Can reducing precision improve accuracy in weather and climate models?
Authors: Thornes Tobias
Published: June 2016

Better weather and climate forecasts are needed to maximise the ability of societies worldwide to prepare for climate change. This paper summarises work regarding the hypothesis that increasing the resolution of global models to achieve this aim could be done with existing computer technology by reducing the precision of the model variables to increase efficiency. A method of testing this idea carried out using computer simulations of the idealised Lorenz '96 atmosphere is explained. Preliminary results suggest that high‐resolution, reduced precision forecasts outperform low‐resolution ones. If these results also apply to real‐world models, the technique could yield substantial benefits.
Sir Francis Ronalds and the early years of the Kew Observatory
Authors: Ronalds Beverley F.
Published: June 2016

Sir Francis Ronalds (1788–1873) played a vital early role in the establishment of the Kew Observatory's stellar reputation in meteorology and geomagnetism. Serving as the Honorary Superintendent for its first decade, his areas of focus became longstanding features of the institution. He invented numerous instruments to institute comprehensive and long‐term measurement of meteorological parameters, atmospheric electricity and geomagnetism. He also supplied equipment around the world, trained operators in its use and compared new instruments with existing standards. Ronalds' sustained efforts and belief in Kew additionally helped to ensure its early survival.
Prognostic Analysis of Surgical Resection for Pulmonary Metastasis from Hepatocellular Carcinoma
Authors: Takahashi Yusuke , Ikeda Norihiko , Nakajima Jun , Sawabata Noriyoshi , Chida Masayuki , Horio Hirotoshi , Okumura Sakae , Kawamura Masafunmi ,   The Metastatic Lung Tumor Study Group of Japan
Published: June 2016

Introduction

Pulmonary metastases are the most common among extrahepatic recurrences from hepatocellular carcinoma (HCC). It causes high risk of HCC‐related death, despite recent progress in therapeutic options. However, a role of pulmonary metastasectomy as well as prognostic factors after metastasectomy has not been well established. We aimed to investigate survival outcomes and prognostic factors after pulmonary resection for metastases from HCC.

Methods

A series of 93 patients who underwent pulmonary resections for metastases from HCC between June 1990 and July 2013 from multi‐institutional database were retrospectively evaluated. Perioperative clinicopathological data and their association with prognosis were investigated.

Results

Of 93 patients, 77 had one pulmonary metastasis, and 16 had two or more. Recurrence after pulmonary resection was noted in 60 patients (64.5 %). The estimated 5‐year overall survival rate was 41.4 % with median survival time after pulmonary metastatectomy of 39.0 months. Univariate prognostic analysis showed that disease‐free interval of ≥12 months was significantly associated with favorable outcomes in both overall survival (5‐year rate, 59.3 vs. 28.7 %, p = 0.026) and disease‐specific survival (5‐year rate, 62.5 vs. 36.2 %; p = 0.038) after pulmonary metastatectomy. A multivariate analysis revealed that disease‐free interval was an independent prognostic factor (HR = 2.020, 95 % CI, 1.069–3.816, p = 0.030).

Conclusion

We have shown that a disease‐free interval was an independent prognostic factor in patients who underwent pulmonary resection for metastasis from HCC. Also, pulmonary metastasectomy can be one of the therapeutic choices for select patients.
Attitudes Toward Autism Spectrum Disorders Among Students of Allied Health Professions
Authors: Simonstein Frida , Mashiach‐Eizenberg Michal
Published: June 2016

The prevalence of autism has increased dramatically. The objectives of this study were to explore attitudes toward prenatal diagnosis to detect autism prenatally and avoid having an affected child and to understand social acceptability of these disorders among students of allied health professions. In this study, college students of nursing and health systems management answered a structured self‐report questionnaire (n = 305). The first part addressed the respondent's personal data. The second part targeted the respondent's attitudes toward prenatal diagnosis of non‐life‐threatening disorders, including autism spectrum disorders. We found that almost two thirds of the students responded that they would not proceed with a pregnancy if the child were diagnosed with autism, and more than half thought that they would not continue with a pregnancy if the fetus were diagnosed with Asperger's. Age, level of religiosity, and years of education were influential. This study is limited in scope; however, the positive attitude of the students toward prenatal diagnosis to avoid having an affected child might also reflect a negative view of autism spectrum disorders in future health care professionals. Further research of attitudes and the social acceptability of autism spectrum disorders, particularly among health care professionals, is required.
Characteristics of Mango Kernel Fats Extracted from 11 China‐Specific Varieties and Their Typically Fractionated Fractions
Authors: Jin Jun , Warda Pembe , Mu Hongyan , Zhang Youfeng , Jie Liang , Mao Jiahui , Xie Dan , Huang Jianhua , Jin Qingzhe , Wang Xingguo
Published: June 2016

11 China‐specific mango varieties, i.e., Tainong, Xiangya, Okrong, Keitt, Chiin Hwang, Guifei, Yuexi, Biantao, Guixiang, Zihua and Guire, were selected from South China, and the kernels were separated from pulps and then dried to extract mango kernel fats (MKF). 5.65–11.14 % of the fats could be obtained from dried kernels using hexane extraction, and their iodine values, slip melting points, triacylglycerols, sn‐2 fatty acids and micronutrients were analyzed. MKF were comprised predominantly of triacylglycerols reaching 85.09–92.72, and 78.28–84.37 % of oleic at the sn‐2 position. 29.99–55.44 % of SOS, 11.17–23.34 % of SOO and 13.10–19.79 % of POS occupied the main percentages of triacylglycerols, indicating MKF have diversified application after fractionation. Certain variety characterized as moderate values mentioned above, therefore, was selected and then fractionated by two‐stage processes to produce typical MKF fractions. The stearin (Fraction‐II) fractionated from the first solid fraction (Fraction‐I) with 68.09 % of SOS and 15.43 % of POS was more suitable as cocoa butter improver, while the olein (Fraction‐III) produced from the first liquid fraction was rich in SOO (45.59 %), POO (11.37 %) and OOO (11.14 %), which are considered as ideal cooking oil or frying fat ingredients. In addition, high amounts of micronutrients, including sterol, tocopherol and squalene, were also found in MKF ranged from 3837 to 7085, 81 to 916, and 164 to 941 mg/kg among different varieties, respectively. In particular, squalene levels were higher compared with most of other vegetable oils.
Impaired olfactory function in patients with polycystic ovary syndrome
Authors: Koseoglu Sezen Bozkurt , Koseoglu Sabri , Deveer Ruya , Derin Serhan , Kececioglu Mehmet , Sahan Murat
Published: June 2016

Polycystic ovary syndrome (PCOS) is an endocrine disorder which affects 6.6% of women of child‐bearing age. Although olfactory dysfunction is frequent in the population and it negatively affects quality of life, neither physicians or patients consider this important. This case‐control study included 30 patients diagnosed with PCOS, and 25 healthy age‐matched controls. Sniffin' sticks tests (BurghartGmbH, Wedel, Germany) were used to analyze olfactory functions, and the Beck Depression Inventory was used to evaluate depressive symptoms. The total odor score was significantly lower in the PCOS group compared to the control group (p < 0.005). The Beck depression score was higher in the PCOS group (p < 0.005). There was a negative correlation between the total odor score and the Beck Depression Score. Patients with PCOS have impaired olfactory function. This might be related to depressive disorders that are also observed in those patients.
Current status and future perspective of laparoscopic surgery in hepatobiliary disease
Authors: Choi Sae Byeol , Choi Sang Yong
Published: June 2016

Recent advances in minimally invasive surgery include laparoscopic and robotic surgery. These surgical techniques have changed the paradigm of surgical treatment for hepatobiliary diseases. Minimally invasive surgery has the advantages of minimal wound extension for cosmetic effect, early postoperative recovery, and few postoperative complications in patients. For laparoscopic liver resection, the indications have been expanded and oncological outcome was proven to be similar with open surgery in the malignant disease. Laparoscopic cholecystectomy is a classical operation for benign gallbladder diseases and the effort to decrease the surgical wound resulted to perform single incision laparoscopic cholecystectomy. For choledochal cyst, laparoscopic surgery is applied gradually despite of the difficulties associated with anastomosis, and robotic surgery for hepatobiliary disease is also performed for more minimally invasive surgery; however, while admitting the advantage of robotic surgery, robotic technology should be improved for development of more convenient and cheaper instrument and continuous efforts to enhance surgical technique to overcome long operation is necessary. In this review, the status and future perspectives of minimally invasive surgery for hepatobiliary diseases are summarized and discussed.
LO065: Reduced length of stay and adverse events using Bier block for forearm fracture reduction in the pediatric emergency department
Authors: Fauteux-Lamarre E. , Burstein B. , Cheng A. , Bretholz A.
Published: June 2016

Introduction: Distal forearm fractures are one of the most common injuries presenting to the pediatric emergency department. Procedural sedation (PS) is commonly used to provide analgesia during fracture reduction, but requires a prolonged recovery period and can be associated with adverse respiratory events. Bier block (BB) regional anesthesia is a safe alternative to PS for fracture reduction analgesia. We sought to assess the impact of BB on length of stay (LOS) and adverse events following forearm fracture reduction compared to PS. Methods: We performed a retrospective study of patients aged 6 to 18 years, presenting with forearm fractures requiring closed reduction from June 2012 to March 2014. The primary outcome measure was emergency department LOS; secondary outcomes included reduction success rates, adverse events and unscheduled return visits. Results: Two-hundred and seventy-four patients were included for analysis; 109 treated with BB, 165 underwent PS. Overall, mean LOS was 82 min shorter for patients treated in the BB group (279 min vs. 361 min, p<0.05). Sub-analysis revealed a reduced LOS among patients treated with BB for fractures involving a single bone (286 min vs. 388 min, p<0.001) and both-bones of the forearm (259 min vs. 321 min, p<0.05). Both BB and PS resulted in comparable rates of successful reduction (98.2% vs. 97.6%, p=0.74). There were no major adverse events in either group. Patients who received BB experienced significantly fewer minor adverse events (2.7% vs. 14.5%, p<0.05). Return visit rates were similar in the BB and PS groups (17.6% vs. 17.1%, p<0.05). Conclusion: Compared to PS, forearm fracture reduction performed with BB was associated with a reduced emergency department LOS and fewer adverse events, with no difference in reduction success or return visits.
LO067: Emergency department management of diabetic ketoacidosis and hyperosmolar hyperglycemic state: national survey of attitudes and practice
Authors: Hamelin A. , Yan J. , Stiell I.G.
Published: June 2016

Introduction: The 2011 Canadian Diabetes Association (CDA) Clinical Practice Guidelines were developed in order to help physicians manage hyperglycemic emergencies in the emergency department (ED), including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The goal of this study was to determine physician attitudes towards these guidelines and to identify potential barriers to their implementation in the ED. Methods: We distributed an online, cross sectional survey to 500 randomly selected members of the Canadian Association of Emergency Physicians (CAEP) who were currently practicing physicians. A total of 3 email notifications were distributed on days 1, 7 and 14. The survey consisted of 23 questions relating to physician management of DKA and HHS in the ED. The primary outcome was overall physician familiarity and usage of the guidelines using a 7-point Likert scale. Secondary outcomes included physician attitudes towards the guidelines as well as any perceived barriers to their implementation in the ED. Simple descriptive statistics were used to illustrate the survey results. Results: The survey response rate was 62.2% (311/500) with the following participant characteristics: male (62.6%), CCFP(EM) training (46.1%) and working in major academic centers (50.5%). The overall awareness rate of the CDA guidelines was 22.9% (95% CI = 18.3%, 27.5%). 58.9% (95% CI = 53.3%, 64.3%) reported the CDA guidelines being useful. The most frequently reported barriers to CDA guideline implementation were concerns about education issues (56.0%), lack of time and disruption of flow (23.9%), staffing and human resource issues (26.7%) and poor policy adherence (25.5%). Physician’s ideal changes to optimize the management of these patients included improved coordination for follow-up with family physicians (79.9%), increased diabetes education for patients (73.9%) and increased availability to diabetes specialists (47.5%). Conclusion: In this study, although Canadian ED physicians were generally supportive of the CDA guidelines, many were unaware that these guidelines existed and barriers to their implementation were reported. Future research should focus on strategies to standardize DKA and HHS management by ensuring physician awareness and education to ensure the highest quality of patient care.
LO075: Clinical exam for acute aortic dissection: a systematic review and meta-analysis
Authors: Ohle R. , Kareemi H. , Perry J.J.
Published: June 2016

Introduction: Acute aortic dissection (AAD) is difficult to diagnose and if missed carries a significant mortality rate. Our aim was to assess the accuracy of history, physical exam and plain radiographs compared to advanced imaging in the diagnosis of AAD in adults presenting to the ED with a clinical suspicion of AAD. Methods: We conducted a librarian assisted systematic review. Databases searched: Pubmed, Medline, Embase and the Cochrane database from 1968 to January 2016. No restrictions for language were imposed. Studies were reviewed and data extracted by two independent reviewers. AAD was defined by CTA, MRI or TEE Prospective and retrospective studies of patients presenting with a clinical suspicion of AAD were included. Case series were excluded. Studies were combined if low clinical and statistical heterogeonity (I2<30%). Study quality was assessed using the QUADAS tool. Bivariate random effects meta analyses using Revman 5 and SAS 9.3 was performed. Results: We identified 792 records: 61 selected for full text review, 13 included and a further 7 from reference searches. 20 studies with 4721 participants were included (mean QUADAS score 12/14 SD 1.2, Kappa 0.8). Prevalence of AAD ranged from 9.6-76.1% (mean 39.1% SD 17.1%). Mean diagnosis in those without AAD varied between studies with ACS (30.3% SD 30.1%), Anuerysm(12.4% SD 9.8%), Chest wall pain(18.1% SD 13.3%) and PE(7.9% SD 7.85%) being the most common. The clinical findings most suggestive of AAD were, neurological deficit (specificity 94% LR 4.1 [95% CI, 3.1-5.2], I2 0%, n=9), hypotension(specificity 94% LR 2.6 [95% CI 1.6-4.2], I2 0%, n=8), pulse deficit (specificity 92% LR 3.4 [95% CI 1.8-6.4], I2 0%, n=9) and syncope (specificity 92% LR 1.4 [95% CI 1.1-1.8], I2 10%, n=6). The most useful for identifying patients less likely to have AAD were an absence of a widened mediastinum (sensitivity 80% LR 0.3 [95% CI 0.2-0.5], I2 20%, n=13) and an AHA Aortic dissection risk score <1 (n=2 sensitivity 91%,99% LR 0.02,0.22, [95% CI 0.003-0.128, 95%CI 0.2-0.3]). Conclusion: Suspicion for AAD should be raised with syncope, hypotension and pulse or neurological deficit in the appropriate clinical setting. Conversely the absence of a widened mediastinum and a low ADD score decreases likelihood. Clinical exam alone cannot rule out acute aortic dissection but it can help risk stratify for further testing.
LO079: Prevalence and geographic variability of ectopic pregnancy in Ontario using inpatient and outpatient data: a 12-year surveillance study
Authors: Varner C. , Kwong J. , Campitelli M. , McLeod S.L. , Borgundvaag B.
Published: June 2016

Introduction: It is estimated that 6% to 13% of patients presenting to the emergency department (ED) with vaginal bleeding or abdominal pain will have ectopic pregnancy. Risk factors such as previous pelvic infections, assisted reproductive technologies and previous tubal surgery as well as prevalence of ectopic pregnancy vary geographically. To date, the surveillance of ectopic pregnancy in Canada has been limited to hospitalized patient data, excluding patients receiving methotrexate therapy, day surgery or expectant management, possibly underestimating the true prevalence. The objective of this study was to determine Ontario’s ectopic pregnancy rate and geographic variability using both inpatient and outpatient data sources. Methods: Data from the Canadian Institute for Health Information Discharge Abstract Database, Same Day Surgery Database, National Ambulatory Care Reporting System, and Ontario Health Insurance Plan (OHIP) Claims Database was retrieved for all females with valid OHIP coverage aged 15 to 45 years from July 2002 to August 2014. Using ICD-10 and OHIP codes for ectopic pregnancy, abortions and deliveries, the rates and distribution of ectopic pregnancy (per 1000 reported pregnancies) by age group and public health unit (PHU) were documented. These data were also compared to the rate of ectopic pregnancy documented using only hospitalized patient data. Results: Using inpatient and outpatient data sources, the rate of ectopic pregnancy in Ontario increased from 20.5 to 27.5 per 1000 reported pregnancies from 2002 to 2014, respectively. The rate of ectopic pregnancy using only hospitalized patient data decreased from 12.6 to 9.5 per 1000 reported pregnancies from 2002 to 2014, respectively. The median (IQR) rate of ectopic pregnancy over the 12-year study period varied across public health units in Ontario, ranging from 14.9 (12.5, 17.5) to 37.7 (29.1, 55.8) per 1000 reported pregnancies. Conclusion: The rate of ectopic pregnancy is increasing in Ontario and has been previously underreported using only hospitalized patient data. Further research is needed to identify the factors resulting in this increase as well as the outcomes of ectopic pregnancies in Ontario.
LO081: Novel EMS spine board to accurately weigh critically ill or injured children
Authors: Milne S.E. , Crocco A.G. , Carpenter C.R. , Milne K.
Published: June 2016

Introduction: A rapid and accurate weight of a child can be of critical importance during pediatric emergencies. The Broselow Tape (BT) is the gold standard for estimating a child’s weight based on their length. It separates children into incremental weight categories. Studies have shown that the BT is not accurate. We created a new pediatric spine board (PedEBoard) that weighs the child. The objective of this study was to compare the agreement between the actual weight vs. the PedEBoard weight and BT estimated weight of children presenting to a pediatric emergency department (ED). Methods: Ethics approval was obtained from McMaster University. A power calculation was done for sample size to detect 10% error. Consecutive children were recruited who presented to McMaster University’s Children’s ED on two days in March 2015. Children were excluded if their length was outside the BT range, non-English speaking or critically ill. Children had their weight taken by the triage nurse either on an infant scale or on a traditional standing scale. The nurse also took the child’s length using a standard measuring tape or height on the standing medical scale. Infants were placed on the PedEBoard by investigators while older children were asked to lie down on the board. Investigators were blinded to the actual weight. BT weight was determined by the palmPEDi Lite app. Bland-Altman analysis was performed, comparing the percent difference between the actual weight vs. PedEBoard weight and actual weight vs. BT weight. The correlation between the PedEBoard and BT was assessed using the Spearman coefficient of rank. Data was entered into MedCalc for Windows 98, Version 15.2.2 Results: A total of 157 children were included in the study. The mean actual weight was 19.4kg (95% CI 17.4 to 21.3) vs. the PedEBoard weight 19.4kg (95% CI 17.4 to 21.3) vs. the BT weight 16.9kg (95% CI 15.6 to 18.2). Bland-Altman percent difference was 0.1% (95% CI -2.0 to 1.8%) between the actual weight and the PedEBoard weight and 9.6% (95% CI -22.0% to 41.2%) between the actual weight and the BT weight. The Spearman coefficient of rank correlation was 1.000 p<0.0001 (95% CI 0.999 to 1.000) for the PedEBoard and 0.969 p<0.001 (95% CI 0.957 to 0.977) for the BT. The BT provided the wrong weight category 80% of the time vs. 8% for the PedEBoard. Conclusion: The PedEBoard closely agreed with the actual weight of the child while the Broselow Tape estimate often did not.
LO089: Out of province elective restrictions: implications for Royal College Emergency Medicine training
Authors: Khangura J.K. , Gupta S. , Pardhan K.
Published: June 2016

Introduction / Innovation Concept: Several provinces (AB, SK and QC) have recently introduced restrictions to out of province (OOP) electives. Concurrently, enhanced competency training is a prominent part of RCPSC Emergency Medicine (EM) programs (Thoma et al., 2015). We present the implications of OOP elective restrictions on RCPSC-EM training and education. The revised 2008 RCPSC-EM requirements specify a minimum of 6 months devoted to achieving a particular expertise pertinent to the practice of EM. The most restrictive policies permit up to 3 months OOP during the 5-year residency. This limits residents’ ability to pursue enhanced competency training opportunities outside their training site. Enhanced training might be a graduate degree, fellowship or clinical year designed by the resident and program director. Enhanced training can help achieve specific career goals, meet the needs of the institution where the resident will practice, and contribute to the growth and development of EM in Canada. Methods: New OOP policies are evaluated using the Health Reform Analysis (HRA) and SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis methodologies. Stated and implied reasons for reform are evaluated and stakeholder perspectives (health system authorities, partner universities, resident physicians and the general public) provided. Curriculum, Tool, or Material: The material includes previous out of province elective policies and recent reforms. Conclusion: Policies for the 4th year EM elective time are variable across universities. This has resulted in inconsistent approval of residents’ requests for OOP enhanced training. Thus, enhanced training that might be approved at one site, may not be at another. Several test cases already exist and will be presented. This data has not been previously collated or reported to our knowledge. Varied interpretation of newly emerging policies has implications for the consistency, equity, and future of EM residency training in Canada.
LO090: Introduction of a formalized RUSH (Rapid Ultrasound in Shock) protocol in emergency medicine residency ultrasound training
Authors: Hrymak C. , Pham C.
Published: June 2016

Introduction / Innovation Concept: Expanding point of care ultrasound education in emergency medicine (EM) programs is a necessary part of curriculum development. Our objective was to integrate core and advanced applications for point of care ultrasound in caring for critically ill patients with undifferentiated shock. We chose to develop and implement an educational module using the systematic approach of the RUSH Exam for EM residents in our institution. Methods: After review of the literature in point-of-care ultrasound, a module was designed. An educational proposal outlining the RUSH Exam training within the -EM and CCFP-EM curricula was submitted to and accepted by the residency training committee. The objectives and goals were outlined in accordance with CanMEDS roles, and the ultrasound director provided supervision for the project. Curriculum, Tool, or Material: An 8-hour educational module was implemented between October 7 and November 18, 2014. All residents received formal training on the core applications in FAST and aortic scans prior to implementation. The following components of the RUSH Exam were included: two hours of didactic teaching with video clips on advanced cardiac, IVC, DVT, and pulmonary assessment; three hours of hands-on practice on standardized patients performed in the simulation lab to practice image acquisition and interpretation; one hour of didactic teaching on the overall approach to a patient with undifferentiated shock using the RUSH Exam; and two hours of hands-on RUSH Exam practice. A corresponding research project integrating a SonoSim Livescan training platform, a simulation-based testing device, demonstrated improvement in resident performance, subjective comfort with imaging patients in shock and making clinical decisions based on the findings. Conclusion: This 8-hour RUSH Exam educational module combined theoretical learning and hands-on practice for trainees. This module significantly broadened the scope of ultrasound training in our curriculum by providing the necessary skills in approaching patients in shock in a systematic fashion. Future direction will include ongoing education in this area and expansion as appropriate.
LO093: A national needs assessment survey for the development of a quality improvement and patient safety curriculum for Canadian emergency medicine residents
Authors: Chartier L.B. , Vaillancourt S. , McGowan M. , Dainty K. , Cheng A.H.
Published: June 2016

Introduction: The Canadian Medical Education Directives for Specialists (CanMEDS) framework defines the competencies that postgraduate medical education programs must cover for resident physicians. The 2015 iteration of the CanMEDS framework emphasizes Quality Improvement and Patient Safety (QIPS), given their role in the provision of high value and cost-effective care. However, the opinion of Emergency Medicine (EM) program directors (PDs) regarding the need for QIPS curricula is unknown, as is the current level of knowledge of EM residents in QIPS principles. We therefore sought to determine the need for a QIPS curriculum for EM residents in a Canadian Royal College EM program. Methods: We developed a national multi-modal needs assessment. This included a survey of all Royal College EM residency PDs across Canada, as well as an evaluative assessment of baseline QIPS knowledge of 30 EM residents at the University of Toronto (UT). The resident evaluation was done using the validated Revised QI Knowledge Application Tool (QIKAT-R), which evaluates an individual’s ability to decipher a systematic quality problem from short clinical scenarios and to propose change initiatives for improvement. Results: Eight of the 13 (62%) PDs responded to the survey, unanimously agreeing that QIPS should be a formal part of residency training. However, challenges identified included the lack of qualified and available faculty to develop and teach QIPS material. 30 of 30 (100%) residents spanning three cohorts completed the QIKAT-R. Median overall score was 11 out of 27 points (IQR 9-14), demonstrating the lack of poor baseline QIPS knowledge amongst residents. Conclusion: QIPS is felt to be a necessary part of residency training, but the lack of available and qualified faculty makes developing and implementing such curriculum challenging. Residents at UT consistently performed poorly on a validated QIPS assessment tool, confirming the need for a formal QIPS curriculum. We are now developing a longitudinal, evidence-based QIPS curriculum that trains both residents and faculty to contribute to QI projects at the institution level.
LO097: A novel curriculum for assessing competency in resuscitation at the foundations of discipline level of training
Authors: Chaplin T. , McMurray L. , Hall A.K.
Published: June 2016

Introduction / Innovation Concept: Junior residents are often the first physicians who attend to the acutely unwell floor patient, especially at night and on weekends. The ‘Nightmares Course’ at Queen’s University was designed to address an Entrustable Professional Activity (EPA) relevant to several residency programs at the ‘Foundations of Discipline’ level of training: “to manage the acutely unwell floor patient for the first 5-10 minutes until help arrives”. In keeping with competency based medical education principles, this course offers longitudinal and repetitive practice and assessment. We have also designed a summative objective structured clinical exam (OSCE) in order to identify trainees who require additional remedial practice of this EPA. Methods: We developed simulated cases that reflect common but “scary” calls to the floor. We then, using a modified Delphi process with experts in resuscitation, defined relevant milestones applicable to the Foundations of Discipline level of training in order to inform our formative assessment. We also modified the Queen’s Simulated Assessment Tool (QSAT) to adopt CBME terminology and this will be used to provide a summative assessment during a four-scenario OSCE in the spring. Residents with QSAT scores below the competency threshold will be enrolled in a remediation course. Curriculum, Tool, or Material: Weekly sessions were led by staff physicians and were offered to first-year residents from internal medicine, core surgery, obstetrics and gynecology, and anesthesiology over the academic year. Each resident participated in one session every 4-week block. Sessions were organized into themes such as “shortness of breath” or “decreased level of consciousness” and involved three high-fidelity simulated cases with a structured debrief following each case. Formative feedback was given following each case. Conclusion: The Nightmares Course is a novel simulation-based, multidisciplinary curriculum in resuscitation medicine. It includes longitudinal practice and repetitive assessment, as well as summative testing and remediation of an EPA common to several residency programs.
MP005: Treating and Reducing Anxiety and Pain PEDs (TRAPPED 2): time for action - a PERC project
Authors: Trottier E. D. , Ali S. , Meckler G. , Blachet M. , Stang A.S. , Porter R. , Le May S. , Dubrovsky A. , Chan M. , Jain R. , Principi T. , Joubert G. , Kam A.J. , Thull-Freedman J. , Neto G. , Lagacé M. , Gravel J.
Published: June 2016

Introduction: Multiples barriers to appropriate analgesia are reported in the paediatric emergency department (PED), including limited accessibility to effective strategies. Our objective: was to evaluate the improvement in the accessibility of pain and anxiety management strategies in Canadian PEDs, after the creation of a national pediatric pain Quality Improvement Collaborative (QIC), through Pediatric Emergency Research Canada (PERC). Methods: In 2013, the TRAPPED 1 survey was administered to Canadian PEDs, in order to evaluate what resources were in place for pain and anxiety management. A pain QIC was then created to stimulate the implementation of new strategies, through information sharing between PEDs. In 2015, the TRAPPED 2 cross sectional survey was administered. Its focus was to evaluate the improvement in the accessibility of specific strategies reported by each centre, after participating in this QIC, and working to implement change within their own PEDs. Results: All 15/15 Canadian PEDs responded to the TRAPPED 1 survey in 2013 and 11 agreed to participate in the national pain QIC. In-person, phone meetings, follow up surveys and email communications were employed for information sharing. Strategies identified by the QIC to be newly introduced in individual centres were educational initiatives, distraction options, nurse-initiated protocols and intranasal (IN) medications. All 15 PEDs completed the TRAPPED 2 survey. Compared to 2013, an increased number of PEDs used face-based pain scales (14/15 vs 6/15) and behavioural scales (5/15 vs 1/15) for pain assessment in 2015. Use of reminder posters on pain management at triage increased from 4/15 to 6/15 PEDs. Availability of tablets for distraction increased from 4/15 to 10/15 PEDs. Nurse-initiated protocols for topical anesthetic and oral sucrose (for needle procedures) increased from 10/15 to 12/15 sites and from 12/15 to 14/15 sites respectively. Availability of IN medications increased; fentanyl from 9/15 to 14/15 sites and midazolam from 8/15 to 10/15 sites. Ten of the 11 PEDs involved in the QIC strategy reported the implementation of at least one of their own identified strategies. Conclusion: This study suggests that the use of a QIC may improve the introduction of new strategies to reduce pain and anxiety in EDs. QICs may also be helpful to other centres when introducing new strategies.
MP027: Automated cardiopulmonary resuscitation quality data abstraction for complete episodes of out-of-hospital cardiac arrest resuscitation
Authors: Taher A.K. , Lin S. , Turgulov A. , Buick J.E. , Byers A. , Drennan I. , Hu S. , Morrison L.J.
Published: June 2016

Introduction: Cardiopulmonary resuscitation (CPR) quality assurance and research has traditionally been limited to the first five minutes of resuscitation due to significant costs in time, resources and personnel from manual data abstraction. Moreover, CPR quality can be affected during prolonged resuscitations, which represents significant knowledge gaps. The objective of this study was to develop a software program to help automate the abstraction of CPR quality data from electronic defibrillators. Methods: We developed a software program to facilitate and help automate data abstraction from electronic defibrillator files for entire resuscitation episodes. Internal validation of the software program was performed on 50 randomly selected cardiac arrest cases with resuscitation durations of up to 60 minutes. CPR quality data variables such as number of ventilations, number of compressions, minute compression rate, minute compression depth, minute compression fraction, minute end-tidal CO2, were manually abstracted independently by two trained data abstractors and by the automated software program. Error rates and the time needed for data abstraction were measured. Results: A total of 9826 data points were abstracted. Manual data abstraction resulted in a total of six errors (0.06%) compared to zero errors by the software program. The mean time ± SD needed for manual data abstraction was 20.3 ± 2.7 minutes compared to 5.3 ± 1.4 minutes using the software program (p=0.003). Conclusion: Our CPR quality data abstraction software was 100% accurate in abstracting CPR quality data for complete resuscitation episodes and showed a significant reduction in data abstraction duration. This software will enable quality assurance programs and future cardiac arrest studies to evaluate the impact of CPR quality during prolonged resuscitations.
MP030: Problems in paramedic-physician telecommunication
Authors: Eby D. , Robson J. , Columbus M.
Published: June 2016

Introduction: Clear paramedic-physician telecommunications (patches) are critical in systems utilizing on-line medical control. In systems using extensive medical directives individual paramedics patch infrequently. Investigations of specific problem calls indicated that communication problems were more common than believed. Existing literature on this topic is sparse. This project is a quality assurance exercise undertaken to understand the extent and nature of problems in paramedic-physician telecommunications Methods: Retrospective analysis of anonymized transcriptions made from MP3 audio files recorded as part of normal operating procedures by the Central Ambulance Communication Centre during January-March 2014. All calls where telecommunication occurred between paramedics from 4 ambulance services and base hospital physicians providing on-line medical oversight during ambulance calls were included. Transcripts were read multiple times and data extracted onto spreadsheets for frequency analysis. Further thematic framework analysis of emergent themes was done. Results: All 42 patches were transcribed and used for analysis. 36 (85.7%) were for termination of resuscitation orders, 4 (9.5%) were for advice, and 2 (4.8%) were for orders not covered by medical directives. Communication problems were identified in 40 (95.2%) patches. Most had multiple problems. These included disconnections (23.8%), difficulty hearing one another (40.5%) - indicated by phrases such as “sorry?” “what?”, “I can’t hear you” - or caused by individuals interrupting each other (83.3%), and talking simultaneously (47.6%). Signaling the end of “talk turns” - such as “10-4” or “over” - was never used. Instead, terms like “yah” and “OK” were used. When communication went awry, time was spent trying to repair the mis/poor communication. This led to repeating information or attempting to ‘sell’ the case by providing information unnecessary for decision making - such as during a request for termination of resuscitation, “there is vomit on the floor”. Conclusion: Paramedic-physician telecommunication problems were extremely common. They involved technical (mechanical problems) and human factors (disorganized radio ‘technique’). The high incidence of telecommunication problems identified is concerning. Critical clinical decisions (e.g. ceasing resuscitation) depend on clear communication. Further study of these issues is warranted.
MP032: Do urine cultures in the emergency department change management of young women with symptoms of uncomplicated urinary tract infection?
Authors: Poon E. , Self L. , McLeod S.L. , Caine S. , Borgundvaag B.
Published: June 2016

Introduction: Current guidelines do not recommend the routine use of urinary cultures in the management of uncomplicated urinary tract infection (UTI) in premenopausal, non-pregnant women. Complicating factors include atypical presentation, structural abnormalities or recent recurrent infection/antibiotic use. The objective of this study was to determine the number of urine cultures ordered for women who presented to the emergency department (ED) with symptoms of uncomplicated UTI, and whether a culture result impacted subsequent management. Methods: This was a retrospective chart review of women aged 18-39 presenting to one of two academic EDs with a discharge diagnosis of uncomplicated UTI from Jan-Dec 2014. Patients were excluded if any of the following were documented: pregnancy, fever, immunocompromised state, diabetes mellitus, absence of lower urinary tract symptoms, ED administration of intravenous antibiotics, a previous UTI treated with antibiotics in the last 90 days, two weeks post-partum or post-instrumentation. Results: Of the 512 charts included in the analysis, 494 (96.5%) patients had a urinalysis, of which 463 (93.7%) had positive leukocyte esterase and 90 (18.2%) had positive nitrites. 370 patients (72.3%) had urine cultures performed, of which 236 (63.8%) were positive. 505 (98.6%) patients received antibiotics (53.9% Macrobid; 22.6% Ciprofloxacin; 15.0% Septra; 6.7% other; 1.8% not documented). 7 (1.9%) cultures grew organisms resistant to the prescribed antibiotic; 2 (0.5%) patients received new prescriptions. Conclusion: For the majority of young female patients with uncomplicated UTI, urine cultures did not change management. Almost all of these patients had a positive leukocyte esterase and were treated with antibiotics, yet approximately 40% of the patients tested did not return positive urine cultures, suggesting that better algorithms for the diagnosis of UTI in the ED are required. Unnecessary treatment with antibiotics is expensive, contributes to the development of multidrug resistant organisms, and exposes the patient to the unnecessary risks of possible allergic reactions, drug interactions and side effects.