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Background: The emergency department (ED) is an at-risk area for medical error. We measured the frequency and characteristics of patients with unanticipated death within 7 days of ED discharge and whether medical error contributed. Aim Statement: This study aimed to calculate the frequency of patients experiencing death within 7 days after ED discharge and determine whether these deaths were related to their index ED visit, were unanticipated, and whether possible medical error occurred. Measures & Design: We performed a single-centre health records review of 200 consecutive cases from an eligible 458,634 ED visits from 2014-2017 in two urban, academic, tertiary care EDs. We included patients evaluated by an emergency physician who were discharged and died within 7 days. Three trained and blinded reviewers determined if deaths were related to the index visit, anticipated or unanticipated, or due to potential medical error. Reviewers performed content analysis to identify themes. Evaluation/Results: Of the 200 cases, 129 had sufficient information for analysis, translating to 44 deaths per 100,000 ED discharges. We found 13 cases per 100,000 ED discharges were related and unanticipated deaths and 18 of these were due to potential medical errors. Over half (52.7%) of 129 patients displayed abnormal vital signs at discharge. Patients experienced pneumonia (27.1%) as their most common cause of death. Patient characteristic themes were: difficult historian, multiple complaints, multiple comorbidities, acute progression of chronic disease, recurrent falls. Provider themes were: failure to consider infectious etiology, failure to admit high-risk elderly patient, missed diagnosis. System themes included multiple ED visits or recent admission, no repeat vital signs recorded. Discussion/Impact: Though the frequency of related and unanticipated deaths and those due to medical error was low, these results highlight opportunities to potentially enhance ED discharge decisions. These data add to the growing body of ED diagnostic error literature and emphasize the importance of identifying potentially high risk patients as well as being cognizant of the common medical errors leading to patient harm.
Introduction: Early recognition of sepsis can improve patient outcomes yet recognition by paramedics is poor and research evaluating the use of prehospital screening tools is limited. Our objective was to evaluate the predictive validity of the Regional Paramedic Program for Eastern Ontario (RPPEO) prehospital sepsis notification tool to identify patients with sepsis and to describe and compare the characteristics of patients with an emergency department (ED) diagnosis of sepsis that are transported by paramedics. The RPPEO prehospital sepsis notification tool is comprised of 3 criteria: current infection, fever &/or history of fever and 2 or more signs of hypoperfusion (eg. SBP<90, HR 100, RR24, altered LOA). Methods: We performed a review of ambulance call records and in-hospital records over two 5-month periods between November 2014 February 2016. We enrolled a convenience sample of patients, assessed by primary and advanced care paramedics (ACPs), with a documented history of fever &/or documented fever of 38.3°C (101°F) that were transported to hospital. In-hospital management and outcomes were obtained and descriptive, t-tests, and chi-square analyses performed where appropriate. The RPPEO prehospital sepsis notification tool was compared to an ED diagnosis of sepsis. The predictive validity of the RPPEO tool was calculated (sensitivity, specificity, NPV, PPV). Results: 236 adult patients met the inclusion criteria with the following characteristics: mean age 65.2 yrs [range 18-101], male 48.7%, history of sepsis 2.1%, on antibiotics 23.3%, lowest mean systolic BP 125.9, treated by ACP 58.9%, prehospital temperature documented 32.6%. 34 (14.4%) had an ED diagnosis of sepsis. Patients with an ED diagnosis of sepsis, compared to those that did not, had a lower prehospital systolic BP (114.9 vs 127.8, p=0.003) and were more likely to have a prehospital shock index >1 (50.0% vs 21.4%, p=0.001). 44 (18.6%) patients met the RPPEO sepsis notification tool and of these, 27.3% (12/44) had an ED diagnosis of sepsis. We calculated the following predictive values of the RPPEO tool: sensitivity 35.3%, specificity 84.2%, NPV 88.5%, PPV 27.3%. Conclusion: The RPPEO prehospital sepsis notification tool demonstrated modest diagnostic accuracy. Further research is needed to improve accuracy and evaluate the impact on patient outcomes.
Introduction/Innovation Concept: In 2014, Eastern Ontario paramedic services, their medical director staff and area community colleges developed an EMS Boot Camp experience to orient Queen’s University and the University of Ottawa emergency medicine residents to the role of paramedics and the challenges they face in the field. Current EMS ride-alongs and didactic classroom sessions were deemed ineffective at adequately preparing residents to provide online medical control. From those early discussions came the creation of a real-world, real-time (RWRT) educational experience. Methods: Specific challenges unique to paramedicine are difficult to communicate to a medical control physician at the other end of a telephone. The goal of this one-day educational experience is for residents to gain insight into the complexity and time sensitive nature of delivering medical care in the field. Residents are immersed as responding paramedics in a day of intense RWRT simulation exercises reflecting the common paramedic logistical challenges to delivering patient care in an uncontrolled and dynamic environment. Curriculum, Tool, or Material: Scenarios, run by paramedic students, are overseen by working paramedics from participating paramedic services. Residents learn proper use of key equipment found on an Ontario ambulance while familiarize themselves with patient care standards and medical directives. Scenarios focus on prehospital-specific clinical care issues; performing dynamic CPR in a moving vehicle, extricating a bariatric patient with limited personnel, large scale multi-casualty triage as well as other time sensitive, high risk procedures requiring online medical control approval (i.e. chest needle thoracostomy). Conclusion: EMS Boot Camp dispels preconceived biases regarding “what it’s really like” to deliver high quality prehospital clinical care. When providing online medical control in the future, the residents will be primed to understand and expect certain challenges that may arise. The educational experience fosters collaboration between prehospital and hospital-based providers. The sessions provide a reproducible, standardized experience for all participants; something that cannot be guaranteed with traditional EMS ride-alongs. Future sessions will evaluate participant satisfaction and self-efficacy with the use of a standard evaluation form including pre/post self-evaluations.
Introduction: Recent years have brought an epidemic of opioid abuse to Canada. At present, in Ontario, Naloxone may not be administered by any paramedic without the direct online medical approval of a Base Hospital Physician (BHP). The objective of this study was to review the use of Naloxone by Emergency Medical Service (EMS) personnel, under the existing Advanced Life Support Patient Care Standards (ALS-PCS) medical directive for opioid toxicity, for safety and potential complications that may occur with removal of the mandatory patch point. Methods: This study was a retrospective ambulance call report review of consecutive Naloxone requests placed to a BHP of the Regional Paramedic Program of Eastern Ontario (RPPEO) between Oct 1st, 2013 and Oct 31st, 2015. The RPPEO consists of 10 prehospital services, both urban and rural jurisdictions, and has a mix of advance care and primary care paramedics. All ambulance call reports are electronically stored at the secured RPPEO data warehouse. Data was extracted using a standardized data collection tool. All ambulance call reports were reviewed by 2 independent authors (VC, NC). Compliance with the existing medical directive for opioid toxicity was determined. We calculated the frequency of denied Naloxone requests and the rationale for each patch refusal was recorded. We also categorized all adverse events associated with Naloxone administration. Results: From 244 patches, 215 patients were administered Naloxone. Only 7.8% (19/215) of requests for Naloxone were refused; 78.9% (15/19) did not meet existing inclusion criteria for Naloxone administration in the ALS-PCS medical directive for opioid toxicity because the patient’s respiration rate was above 12/min. Of the 215 patients who were administered Naloxone, adverse events were extremely uncommon: 5 (2.3%) became violent or verbally abusive, 1 (0.5%) was transiently hypertensive and 4 (1.9%) vomited. Conclusion: Requests for Naloxone to a BHP are common and yet are seldom declined. The use of prehospital Naloxone is associated with few adverse events. These results demonstrate that it would be safe to remove online medical direction for Naloxone from the ALS-PCS medical directive for opioid toxicity if combined with updated paramedic education.
Continuous positive airway pressure (CPAP) is commonly used in the treatment of acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In-hospital evidence is robust: CPAP has been shown to improve respiratory status and to reduce intubation rates. There is less evidence on prehospital CPAP, although the emergency medical services (EMS) adoption of this modality is increasing. The objectives of this study were to 1) measure the effectiveness of prehospital CPAP on morbidity, mortality, and transport times; and 2) audit the selection of patients by medics for appropriateness and safety.
We conducted a before-and-after study from August 1 to October 31 in 2010 and 2011, before and after the implementation of prehospital CPAP in a city of one million people with large rural areas. Medics were trained to apply CPAP to patients with respiratory distress and a presumed diagnosis of ACPE or AECOPD. Charts were selected using the search criteria of the chief complaint of shortness of breath, emergent transport to hospital, and any patients receiving CPAP in the field. Data extracted from ambulance call reports and hospital records were analysed with appropriate univariate statistics.
A total of 373 patients enrolled (186 pre-non-invasive ventilation [NIV] and 187 post-NIV), mean age 71.5 years, female 51.4%, and final diagnoses of ACPE 18.9%, AECOPD 21.9%. In the post group of 84 patients meeting NIV criteria, 41.6% received NIV; and of 102 patients not meeting the criteria, 5.2% received NIV. There were 12 minor adverse events in 36 applications (33.3%) as per protocol. Comparing post versus pre, there were higher rates of emergency department (ED) NIV (20.0% v. 13.4%, p<0.0001) and higher overall mortality (18.8% v. 14.9%, p<0.0001). There were no differences in ED intubation (2.1% v. 2.3%, p<0.001) and length of stay (6.8 v. 8.7 days, p=0.24).
Despite the robust in-hospital data supporting its use, we could not find benefit from CPAP in our prehospital setting with respect to morbidity, mortality, and length of stay. EMS must exercise caution in making the decision to invest in the equipment and training required to implement prehospital CPAP.
We intend to give in this paper a short account of (1) the laws concerning the supply of drinking water to ships in some of the chief civilised countries of the world; (2) the results of bacteriological examination of the water on steamships; (3) the chief deficiencies in supply and storage which have come under our notice, and (4) the reforms which we consider urgently necessary.
The Committee on Space Research (COSPAR) Capacity-Building Programme introduces astronomers in the developing world to the rich resource of space research online archives. The programme consists of a series of regional workshops which each bring together about 30 developing world astronomers with around 8 teaching faculty for lectures and hands-on projects. Five workshops have been held so far with another two planned for next year and a budget which enables on average one workshop each year. Proposals for future workshops are encouraged.
The preoperative delayed memory performance on the Rey-Osterrieth Complex Figure (Lezak, 1983) of 54 patients with complex partial seizures of temporal lobe origin was analyzed using 3 different indices. One index (composite) was derived using a common scoring method that included both spatial and figural aspects of memory in its score. The other two indices were derived emphasizing either spatial or figural aspects of memory for the elements of the figure separately. All 3 indices distinguished between individuals with right-sided (RTLE) and left-sided (LTLE) seizure onset. However, spatial memory was significantly lower than figural memory in individuals with RTLE as compared to those with LTLE. Both the spatial and figural memory indices were significantly lower in the presence of magnetic resonance imaging (MRI) evidence for hippocampal selerosis in individuals with RTLE. Results suggest that while both the spatial and figural aspects of nonverbal memory are sensitive to right hippocampal dysfunction, figural memory may be less vulnerable to the effects of RTLE. (JINS, 1996, 2, 535–540.)
We present early results from the UK ROSAT Deep and Extended Deep Surveys. A total of 240 faint X-ray sources have been detected, most of which are expected to be QSOs and Seyfert galaxies at redshifts z < 3, although normal galaxies and starburst galaxies are also present. We will use these surveys, together with our parallel VLA 20cm & 6cm radio surveys and multicolour optical CCD surveys, to determine the evolution of the faint end of the X-ray and optical luminosity functions (LF) of QSOs, study the multiwaveband emission mechanisms of QSOs, map their distribution over a ‘wedge’ of high redshift sky, and investigate the X-ray evolution of distant clusters of galaxies.
The Multiwaveband Surveys.
The ROSAT survey was performed in a region of high-latitude sky of very low, and uniform, Galactic column density (71019 cm−2), as determined by our 21cm and IRAS 100µm measurements. The deep survey reaches a limiting X-ray flux of 410−15 erg cm−2s−1 (0.5–2keV) over a 40 arcmin diameter region of sky and contains 96 faint X-ray sources. The extended survey stretches over a 4° × 40 arcmin strip starting from the position of the deep survey, with a limiting flux of 10−14 erg cm−2s−1 (0.5–2 keV).
Deep VLA radio maps at 20cm (and at 6cm in the deep survey area only) have been constructed to flux limits of 0.5 mJy on the deep survey field and 2mJy on the extended survey.
Let Mm (r, f) denote the mean-value of a real-valued integrable function f over a geodesic sphere with centre m and radius r in an n-dimensional Riemannian manifold M. We obtain an expansion of Mm (r, f) in powers of r, thereby generalizing Pizzetti's formula valid in euclidean space. From this expansion we prove that the property
for every harmonic function near m, characterizes Einstein spaces. We define super-Einstein spaces and prove that they are characterized by the property
The management of the pregnant epileptic requires close cooperation between the neurologist and obstetrician.
To prevent complications, knowledge is required about the natural history of epilepsy during pregnancy, the possible teratogenic effects of antiepileptic drugs, and changes in their absorption, biotransformation, and excretion. Close plasma antiepileptic drug monitoring is required because of the change in the handling of antiepileptic drugs during pregnancy. The treatment of status epilepticus with intravenous phenytoin is effective. Drug interactions which may lead to toxic plasma levels of some drugs and subtherapeutic plasma levels of others should be anticipated. The risk of problems resulting from antiepileptic drug therapy during pregnancy appears to be minor, provided that proper medical supervision is available. Newer antiepileptic drugs should not be administered to the pregnant epileptic until their safety in pregnancy is fully established.
Valproic acid in therapeutic doses was used in the treatment of postanoxic intention myoclonus. Disappearance of the myoclonus occurred with marked improvement in the electroencephalogram. No significant side effects were noted. Hepatic function tests were monitored. Determination of valproic acid plasma levels was used to guide therapy. Levels above 55 ßg were generally required. The patient remains free of myoclonus after four and one half months.
This is a contribution to the general problem of determining the extent to which the geometry of a riemannian manifold is determined by properties of its geodesic spheres. In particular we show that total umbilicity of geodesic spheres determines riemannian manifolds of constant sectional curvature; quasi-umbilicity of geodesic spheres determines Kähler and nearly-Kähler manifolds of constant holomorphic sectional curvature; and the condition that geodesic spheres have only two different principal curvatures, one having multiplicity 3, determines manifolds locally isometric to the quaternionic projective spaces. The use of Jacobi vector fields leads to a unified treatment of these different cases.
Valproic acid is a new antiepileptic drug recently introduced in the United States for the treatment of absence seizures. In this study on patients with absence and other seizure types, the majority of patients achieved optimal control within four weeks of therapy. No patient responded to valproic acid who did not show an initial clinical response by four weeks of active therapy. Optimal response was generally achieved when plasma levels were greater than 55 μg/ml. Excellent clinical response was observed in the treatment of absence and myoclonic seizures. Twenty-two patients continued in a long term study have maintained the same degree of seizure control as observed at the time of optimal control.
Prior to the launch of the Ariel V satellite in 1974, four transient X-ray sources had been observed. We placed the study of sources of this type amongst the major objectives of the satellite, and so ensured that the spacecraft ground centre was capable of quick reaction, and that experimenters had rapid access to their data, so that new transients could be rapidly recognised, and an observing programme for them produced and carried out. This has been very successful - in its first 18 months of operation the satellite made observations of at least 14 transients.
Of these transients, five form a rather well defined class whose properties are rapidly becoming clearer. This class I shall call the “classical” transient. The remainder form a much more miscellaneous collection which cannot be clearly distinguished from the normal X-ray sources. There is some indication that the classical transients include two species, so to start with I shall describe one of each which has been particularly well-observed by Ariel V and SAS-3.
This Association came into existence nearly one hundred years ago with the prime object of improving the teaching of geometry and although its field of interest has widened considerably the teaching of geometry remains a very important issue. Of course, the question “Whither Geometry?” is rather meaningless unless one specifies whether one is talking about geometry as taught to primary, junior or secondary school levels, to Colleges of Education and the Polytechnics, to undergraduates and postgraduates at University, or geometry as understood by professional research mathematicians. Moreover the motivation for studying geometry may well be quite different at these different levels. I shall try to deal with the question as it affects all these various levels of mathematics.