bluuebunny/crossref_metadata_2025_split huggingface dataset:
LO62: Cannabis-induced psychotic disorder at a Canadian tertiary care emergency department
Authors: Skoblenick K. , Rumley A. , Gauri A. , Marsh-Joyal M. 
Published: May 2020

Introduction: Acute psychosis is a disruptive change in mental state that requires the mobilization of significant resources for its immediate treatment and ongoing management in the emergency department (ED). Cannabis-induced psychotic disorder (CIP) is one potential cause; however, the diagnosis may be overlooked due to limited understanding of the etiology of CIP. Methods: This study employed a retrospective cohort analysis of all CIP cases admitted from a tertiary care ED in Edmonton, Alberta between 10/2016 and 10/2018 – the month cannabis was legalized in Canada. Charts were identified based on a most responsible diagnosis of CIP, as defined by ICD-10 code F12.5. Two reviewers abstracted data using a standardized form, which was entered into a database; 10% of charts were analyzed by both reviewers to examine inter-rater reliability. Patients were excluded if there was any documentation of methamphetamine use within the week prior to presentation. Outcomes included management, symptom profile, and length of stay. Results: In total there were 44 cases of CIP identified in 40 unique patients during the two-year period. The largest age group of patients (n = 14, 35%) were between 15-20 years old and the median length of admission was 6 days. A minority of patients (n = 13, 32.5%) had a previous psychiatric diagnosis. A distinct clinical picture evolved during the summation of patient symptoms in the ED with 65% of patients (n = 26) exhibiting persecutory delusions and 52.5% endorsing auditory hallucinations (n = 21). Only four patients were found to have visual hallucinations, three of which also had auditory hallucinations. Most patients (n = 34, 85%) were treated with an antipsychotic medication in the ED and during their time as inpatients, but only 70% of patients were prescribed an antipsychotic medication at the time of discharge (n = 28). Conclusion: This study is the first of its kind describing a cohort of patients with CIP in a Canadian ED setting. The patients presenting to the ED who would later be diagnosed CIP were more likely to be 15-20 years old, experiencing persecutory delusions, and unlikely to be experiencing isolated visual hallucinations. With the recent legalization of cannabis in Canada, further prospective research is required to determine any changes in the characteristics, incidence, and prevalence of CIP, as well as data from other centers to look for any regional differences in the presentation and management of CIP.
LO68: Kelowna emergency department buprenorphine/naloxone for opioid use disorder: a program evaluation study
Authors: Jones M. , Bailey B. , Nevers W. , Hill M. , Lappalainen L. , Williams D. 
Published: May 2020

Introduction: Emergency department (ED) buprenorphine/naloxone inductions for opioid use disorder are an effective and safe way to initiate addictions care in the ED. Kelowna General Hospital's ED buprenorphine/naloxone (KEDSS) program was implemented in September 2018 in order to respond to a community need for accessible and evidence-based addictions care. The objective of our program evaluation study was to examine the implementation of the first five months of the KEDSS program through evaluating patient characteristics and service outcomes. Methods: The KEDSS treatment pathway consists of a standardized protocol (pre-printed order set) to facilitate buprenorphine/naloxone induction and stabilization in the acute care setting (ED and inpatient wards) at Kelowna General Hospital, a community academic hospital. All patients referred to the outpatient addictions clinic via the order set during September 2018-January 2019 (the first 5 months) were included in the study population. A retrospective descriptive chart review was completed. Outcome measures included population characteristics (sociodemographic information, clinical characteristics) and service outcomes (number of patients initiated, patient follow-up). Descriptive statistics and bivariate analyses using t-tests or Pearson's χ2 statistic, as appropriate, were conducted to compare the ED-initiated group with the inpatient-initiated group. Results: During the first five months of the KEDSS program, a total of 35 patients (26% female, mean age 36.6 years, 54% homeless) were started on the treatment pathway, 16 (46%) in the ED. Compared to the inpatient-initiated group, the ED-initiated group were less likely to have psychiatric comorbidities (ED 1.0 vs. inpatient 1.5, p = 0.002), require methadone or sustained-release oral morphine (ED 13% vs. inpatient 37%, p = 0.048), and have attended follow-up (ED 56% vs. inpatient 84%, p = 0.004). Conclusion: This study provides a preliminary look at a new opioid agonist therapy (OAT) treatment pathway (KEDSS) at Kelowna General Hospital, and provides insight into the population that is accessing the program. We found that the majority of patients who are started on buprenorphine/naloxone in the ED are seen in follow-up at the addictions clinic. Future work will examine ongoing follow-up and OAT adherence rates in the study population to quantify the program's impact on improving access to addictions treatment within this community hospital setting.
LO69: Haloperidol versus ondansetron for hyperemesis due to cannabis (HaVOC): a randomized, controlled clinical trial
Authors: Ruberto A. , Sivilotti M. , Forrester S. , Hall A. , Crawford F. , Day A. 
Published: May 2020

Introduction: One of the most common adverse effects of habitual cannabis use is hyperemesis—recurrent bouts of protracted vomiting, retching and abdominal pain superimposed on a baseline of daily nausea and anorexia. Largely anecdotal evidence supports the use of haloperidol, benzodiazepines or topical capsaicin over traditional antiemetics, yet little is known about the cause or optimal treatment of this newly recognized disorder. We report the results of one of the first clinical trials on so-called cannabis hyperemesis syndrome (NCT03056482). Methods: We approached adults with a working diagnosis of hyperemesis due to cannabis, provided they had ongoing emesis for >2 hours, a cyclic pattern of 3+ episodes in the last 2 years, and near daily use of cannabis by inhalation. We excluded those who were pregnant, deemed unreliable, or using opioids. Subjects provided written consent to be randomized during the index or any subsequent visit to either haloperidol (with a nested randomization to either 0.05 mg/kg or 0.1 mg/kg) or ondansetron 8 mg intravenously in a quadruple-blind fashion, and to be followed for 7 days. The primary outcome was the average reduction from baseline in abdominal pain and nausea (each measured on a 10-cm VAS) at 2 hours. While the original trial design allowed for crossover, the primary analysis used only the first treatment period since fewer than the prespecified threshold of 20% of subjects crossed over. Results: We enrolled 33 subjects, of whom 30 (16 men, 29+/-11 years old, using 1.5+/-0.9 g/day since age 19+/-2 years) were treated at least once (haloperidol 13, ondansetron 17). Haloperidol at either dose was superior to ondansetron (difference 2.3 cm [95%CI 0.6, 4.0]; p = 0.01), with similar improvements in both pain and nausea, as well as less rescue antiemetics (27% vs 61%; p = 0.04), and shorter time to ED departure (3.1+/-1.7 vs 5.6+/-4.5 hours; p = 0.03 Wilcoxon rank sum). There were two (haloperidol) vs six (ondansetron) return visits for ongoing nausea/vomiting, as well as two return visits for acute dystonia, both in the higher dose haloperidol group. Conclusion: Haloperidol is superior to ondansetron for the acute symptomatic treatment of patients with ongoing hyperemesis attributed to habitual cannabis use. The efficacy of this agent over ondansetron provides insight into the mechanism of this new disorder, now almost a daily diagnosis in many Canadian emergency departments.
LO70: Emergency department use and migration patterns of people experiencing homelessness
Authors: Hossain R. , Burcul I. , Dai J. , Hossain R. , Strobel S. , Ma Z. , Jamani S. 
Published: May 2020

Introduction: Understanding how homeless patients interact with healthcare systems can be challenging. The nature of the population is such that identifying and following these persons can be severely limited by data. Previous studies have used survey data which relies on self-reporting and selected samples such as those persons admitted to homeless shelters (Gray et al. 2011). Other studies have been able to leverage administrative data but only for selected local geographic areas (Somers et al. 2016, Tompkins et al 2003). It is possible that the current literature has not examined a large proportion of homeless persons and their healthcare use. This is concerning because this population can have higher associated medical costs and greater medical resource utilization especially with regards to psychiatric and emergency department (ED) resources (Tulloch et al. 2012, Forchuk et al, 2015). Methods: Administrative health data (2010 to 2017) is used to analyze ambulatory care records for homeless individuals in Ontario, Canada. Uniquely, we are able to use ED contacts as a way of identifying homeless migrations from region to region within Ontario. Using a network analysis we identify high impact ED nodes and discrete hospital networks where homeless patients congregate. We are also able to more fully characterize this population's demographics, health issues, and disposition from the ED. Results: We provide a more complete understanding of migration patterns for homeless individuals, across Ontario and their concomitant ED use and hospitalizations. The three most frequented regions in Ontario (n = 640,897) were Toronto Central (35.96%), Hamilton Niagara Halimand Brant (8.9%) and Champlain (7.84%). In subsequent visits, the majority of patients presented to different EDs, however a subgroup who always presented to the same site was present. Over the 7 year period, migration between visits occurred most often between urban areas, and increased as a whole. Conclusion: The results of the study allow for the enhancement care coordination for vulnerable populations and enhance the availability and delivery of services for sub-groups of homelessness whose care needs may differ based on migration patterns. Services can be coordinated between jurisdictions for homeless individuals, and appropriate referrals can be made across the health care system. Further evidence is provided for a novel method of mapping migration among the homeless and its associations and effects on ED use.
LO72: Spotting potential opportunities for teachable moments
Authors: Alrimawi H. , BCh MB , Sample S. , Chan T. 
Published: May 2020

Introduction: With the transition of Emergency Medicine into competency based medical education (CBME), entrustable professional activities (EPAs) are used to evaluate residents on performed clinical duties. This study aimed to determine if implementing a case-based orientation, designed to increase recognition of available EPAs, into CBME orientation would help residents increase the number of EPAs completed. Methods: We designed an intervention consisting of clinical cases that were reviewed by national EPA experts who identified which EPAs could be assessed from each case. A case-based session was incorporated into the 2019 CBME orientation for The McMaster Emergency Medicine Program. Postgraduate Year (PGY)1 residents read the cases and discussed which EPAs could be obtained with PGY2/faculty facilitators. The number of EPAs completed in the first two blocks of PGY1 was determined from local program data and Student's t-test was used to compare averages between cohorts. Results: We analyzed data from 22 trainees (7 in 2017, 8 in 2018, and 7 in 2019). In the first two blocks of PGY1, the intervention cohort (2019) had a significantly higher average number of EPAs completed per trainee (47.4 [SD 11.8]) than the historical cohort (25.3 [SD 6.7]) (p < 0.001) (Cohen's d = 2.3). No significant difference existed in the number EPAs obtained between the 2017/2018 cohorts, with averages of 24.3 [SD 6.8] and 26.1 [SD 7.0] per trainee respectively (p = 0.6). Conclusion: Implementation of a case-based orientation led by CBME-experienced facilitators nearly doubled the EPA acquisition rate of our PGY1s. The consistent EPA acquisition by the 2017/2018 cohorts suggest that the post-intervention increase was not solely due to developed familiarity with the CBME curriculum.
LO77: Performance enhancing psychological skills in clinical simulation
Authors: Johannessen E. , Davies T. , Valeriano A. , Blackmore E. , Belyea A. , Gilic F. 
Published: May 2020

Introduction: Clinical simulations in are designed to evoke feelings of stress and uncertainty in order to mimic challenges that learners will face in the real world. When not managed properly, these sources of extraneous cognitive load cause a burden on working memory, leading to a hindered ability to acquire new information. The “Beat the Stress Fool” (BTSF) protocol is a performance-enhancing tool designed to reduce cognitive overload during acute care scenarios. It involves breathing exercises, positive self-talk, visualization, and deliberate articulations. This study aims to validate the BTSF protocol as a method for reducing cognitive load using both psychometric and physiologic measures. Methods: Data collection took place during the Queen's University “Nightmares-FM” course. This clinical simulation program involves team-based scenarios designed to teach the fundamentals of acute care to first-year family medicine residents. Participants were divided equally into experimental and control groups based on pre-existing cohorts. Participants completed a baseline state-trait anxiety inventory and a demographics survey. The experimental group was guided through the BTSF protocol prior to each of 16 simulations; in both groups, physiologic and psychometric cognitive load measurements were collected for the alternating team leader. Galvanic skin response (GSR) and heart rate (HR) were collected during a 15-second baseline and throughout each simulation using a Shimmer 3 GSR+ wearable sensor. Self-reported cognitive load was assessed after each scenario using the 9-point Paas scale. Results: The mean Paas scores for the BTSF group were significantly lower than the control group (6.2 vs 6.9, p < 0.05), indicating lower subjective cognitive load. GSR signal magnitude (p = 0.086), spike amplitude (p = 0.066), and spike density (p = 0.584) were also lower in the BTSF group. There was no difference in HR between groups. There was not a significant correlation between self-reported cognitive load and the normalized physiologic measures. Conclusion: The results demonstrate the effectiveness of the BTSF protocol in lowering the amount of perceived mental effort required to perform clinical simulation tasks. These findings were mirrored in the galvanic skin response signal, though our study was likely underpowered for significance. This is the first study to validate a proof-of-concept for the BTSF protocol in learners during simulated training.
LO85: Unhelmeted injured cyclists in the emergency department: demographics, cycling behaviour, and attitudes towards helmet use
Authors: Friedman S. , Porplycia D. , Varriano B. 
Published: May 2020

Introduction: We seek to characterize unhelmeted injured cyclists presenting to the emergency department (ED): demographics, cycling behaviour, and attitudes towards helmet use. Methods: This was a prospective cohort study in a downtown teaching hospital, from May 2016 - Sept 2019. Injured cyclists presenting to the ED were recruited if they were not wearing a helmet at time of injury and over age 18. Exclusion criteria included intoxication, inability to consent, or admission to hospital. A standardized survey was administered by a research coordinator. Descriptive statistics were used to summarize the data, and survey responses reported as percentages. Results: We surveyed a convenience sample of 68 unhelmeted injured cyclists (UICs) with mean age of 33.6 years (range 18 to 68, median 29.5 years). Ratio of males to females was 1:1. The majority of UICs cycled most days per week or every day in non-winter months (89.6 %, n = 60). Cycling in Toronto was perceived as somewhat dangerous (45.6%, n = 31) or very dangerous (5.9%, n = 4) by most, and very safe (2.94 %, n = 2) or somewhat safe (19.12%, n = 13) by few. Almost a third (29.4 %, n = 20) had been in a cycling accident in the prior year, some of these (15.0%, n = 3) prompting an ED visit. All cyclists were riding their personal bike (100 %, n = 68) at time of injury, and most (98.5%, n = 67) had planned to cycle when they departed home that day. Purpose of trip was primarily for commuting to work (50%, n = 34), social activities (19.1%, n = 13), school (7.4%, n = 5), and recreation (7.4%, n = 5). Bicycle helmet ownership was low (41.2 %, n = 28). UICs reported rarely (10.3%, n = 7) or never (64.7%, n = 44) wearing a helmet when cycling. Reported factors discouraging helmet use included inconvenience (33.8%, n = 23), lack of ownership (32.4%, n = 22), discomfort (29.4%, n = 20), and ‘messed hair’ (14.7%, n = 10). Few characterized helmets as unnecessary (10.3%, n = 7) or ineffective (1.5%, n = 1). The majority had a college diploma or more advanced education (77.9%, n = 53), and spoke English at home (85.3%, n = 58). Conclusion: Unhelmeted injured cyclists surveyed were frequent commuter cyclists who do not regard cycling as safe, yet choose not to wear helmets for reasons largely related to convenience rather than perceptions regarding safety or necessity. Initiatives to increase helmet use in this subgroup should address the reasons given for not wearing a helmet, potentially using principles of adult education and behavioral economics.
LO87: Influence of co-injuries on post-concussion symptoms after a mild traumatic brain injury
Authors: Ouellet V. , Boucher V. , Beauchamp F. , Neveu X. , Archambault P. , Berthelot S. , Chauny J. , de Guise E. , Émond M. , Frenette J. , Lang E. , Lee J. , Mercier É. , Moore L. , Ouellet M. , Perry J. , Le Sage N. 
Published: May 2020

Introduction: Each year, 3/1000 Canadians sustain a mild traumatic brain injury (mTBI). Many of those mTBI are accompanied by various co-injuries such as dislocations, sprains, fractures or internal injuries. A number of those patients, with or without co-injuries will suffer from persistent post-concussive symptoms (PPCS) more than 90 days post injury. However, little is known about the impact of co-injuries on mTBI outcome. This study aims to describe the impact of co-injuries on PPCS and on patient return to normal activities. Methods: This multicenter prospective cohort study took place in seven large Canadian Emergency Departments (ED). Inclusion criteria: patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Patients who were admitted following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. A research nurse then conducted three follow-up phone interviews at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to estimate the influence of co-injuries. Results: A total of 1674 patients were included, of which 1023 (61.1%) had at least one co-injury. At 90 days, patients with co-injuries seemed to be at higher risk of having 3 symptoms ≥2 points according to the RPQ (RR: 1.28 95% CI 1.02-1.61) and of experiencing the following symptoms: dizziness (RR: 1.50 95% CI 1.03-2.20), fatigue (RR: 1.35 95% CI 1.05-1.74), headaches (RR: 1.53 95% CI 1.10-2.13), taking longer to think (RR: 1.50 95% CI 1.07-2.11) and feeling frustrated (RR: 1.45 95% CI 1.01-2.07). We also observed that patients with co-injuries were at higher risk of non-return to their normal activities (RR: 2.31 95% CI 1.37-3.90). Conclusion: Patients with co-injuries could be at higher risk of suffering from specific symptoms at 90 days post-injury and to be unable to return to normal activities 90 days post-injury. A better understanding of the impact of co-injuries on mTBI could improve patient management. However, further research is needed to determine if the differences shown in this study are due to the impact of co-injuries on mTBI recovery or to the co-injuries themselves.
LO92: The effect of prehospital intravenous fluids on mortality in trauma: a systematic review and meta-analysis
Authors: Davison M. , Schenk M. , Ohle R. , Savage D. , Scully J. , Regalado S. , Affleck A. 
Published: May 2020

Introduction: Hemorrhage is the primary cause of death in 39% of trauma patients. In prehospital trauma management, there is debate over pursuing a ‘scoop-and-run’ approach versus early intravenous (IV) fluid therapy. We evaluated the literature regarding the effect of prehospital IV fluid therapy on mortality in adult trauma patients. Methods: A librarian-assisted search was conducted in PubMed, Medline and Embase. The population was adults with blunt and/or penetrating trauma. The intervention was total prehospital IV fluid volume 0-500 mL, and the control was prehospital fluid volume >500 mL. The outcome of interest was in-hospital mortality. Randomized controlled trials (RCTs), cohort and case-matched studies were included. Two reviewers used the Cochrane Risk of Bias (RoB) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools to evaluate biases, and kappa was calculated for inter-rater agreement. A summary relative risk (RR) of in-hospital mortality was calculated and heterogeneity (I2) analysis performed using RevMan 5 software. Results: Four RCT's and eleven observational studies were identified, with n = 15,448 patients. Two RCTs and four observational studies were excluded due to non-English language, and the location or volume of IV fluid administered, leaving eight studies with n = 4,568 patients. Inter-rater agreement was high with the ROBINS-I (unweighted κ=0.8841) and RoB tool (unweighted κ=0.8276). Two studies found decreased mortality, one found increased mortality, and five found no significant relationship to mortality with 0-500 mL prehospital IV fluid. The summary relative risk of mortality with 0-500 mL IV fluid compared to >500 mL IV fluid was not significant (RR = 0.98 [0.87, 1.11]). The heterogeneity for all studies was high (I2 = 84%), but was low (I2 = 0%) with removal of two studies. Conclusion: The majority of studies did not find a relationship between the volume of prehospital IV fluids and in-hospital mortality. Study heterogeneity was low except for two studies: this may be explained by mortality only being recorded at emergency department discharge in one study, and the high rate of penetrating gunshot and stabbing wounds in the other. There is a paucity of high-quality RCTs on the topic, and many studies are at significant risk of bias. Further research is needed to delineate the best approach to IV fluid therapy in adult trauma patients.