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The suboptimal provision of analgesia to children in the emergency department (ED) is well-described. A yet unexplored barrier is caregiver or child refusal of analgesia. We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED.
We conducted a two-centre cross-sectional study of 743 caregivers of children 4–17 years presenting to the pediatric ED with an acutely painful condition using a survey and medical record review. The primary outcome was the proportion of children/caregiver pairs who accepted analgesia in the ED.
The median (IQR) age of children was 11 (7) years, and 339/743 (45.6%) were female. The overall survey response rate was 73% (743/1018). In the 24 hours preceding ED arrival, the median (IQR) maximal pain score rated by children and caregivers was 8/10 (4) and 5/10 (2), respectively, and 30.4% (226/743) of caregivers offered analgesia. In the ED, children reported a median (IQR) pain score of 8/10 (2) and 54.9% (408/743) were offered analgesia. When offered in the ED, analgesia was accepted by 91% (373/408). Overall, 55.7% (414/743) of children received some form of analgesia.
Most caregivers/children accept analgesia when offered by ED personnel, suggesting refusal is not a major barrier to optimal management of children’s pain and highlighting the importance of ED personnel in encouraging adequate analgesia. A large proportion of children in pain are not offered analgesia by caregivers or ED personnel. Educational strategies for recognizing and treating pain should be directed at children, caregivers, and ED personnel.
To determine parental experiences and preferences regarding the conduct of pediatric research in an emergency department (ED) setting.
We conducted a cross-sectional study of parents of children ages 0 – 14 years who visited the ED of a tertiary care children’s hospital. Parents completed a Web-based survey designed to assess perceptions regarding: 1) background/training of research personnel, 2) location and timing of research discussions, and 3) factors influencing their consent/refusal decision.
Parents totalling 339 were approached, and 227 (67%) surveys were completed. Overall, 87% (197/227; 95% confidence interval [CI] 83, 92) reported they would be comfortable being approached by a university student to discuss research. This proportion did not change when stratified by the child’s gender, illness severity, or season of visit. Whereas only 37% (84/227; 95% CI 31, 43) of respondents would be comfortable being approached in the waiting room, 68% (154/227; 95% CI 62, 75) would be comfortable if approached in a separate area of the main waiting room. The majority reported comfort with follow-up via email (83%; 188/227; 95% CI 78, 88) or telephone (80%; 182/227; 95% CI 75, 85); only 51% (116/227; 95% CI 44, 57) would be comfortable with a scheduled follow-up visit in the hospital. Participants identified potential complications or side effects as the most common reason for declining consent (69%; 157/227; 95% CI 63, 75).
The majority of parents are comfortable being approached by trained university students, preferably in a separate area of an ED waiting room, and email and telephone follow-ups are preferred over a scheduled re-visit.
Populations of grey petrels have declined globally due to both incidental capture in commercial fisheries and predation by introduced mammals at breeding sites. In the New Zealand region, grey petrels only breed on Campbell and Antipodes islands. Rats were successfully eradicated from Campbell Island in 2001. We assessed the spatial extent and conducted the first quantitative population estimate of the grey petrel population on Campbell Island and surrounding islets. There was an estimated c. 96 pairs (95% CI: 83, 109) of breeding grey petrels from the four colonies. Since work was conducted during the middle of the chick-rearing stage, this is an underestimate of the breeding population. The Campbell Island grey petrel breeding population remains small. Our study provides a baseline for future population estimates of grey petrels on Campbell Island.
Children with suspected appendicitis are at risk for suboptimal pain management. We sought to describe pain management patterns for suspected appendicitis across Canadian pediatric emergency departments (PEDs).
A retrospective medical record review was undertaken at 12 Canadian PEDs. Children ages 3 to 17 years who were admitted to the hospital in February or October 2010 with suspected appendicitis were included. Patients were excluded if partially assessed or treated at another hospital. Data were abstracted using a study-specific, standardized electronic data extraction tool. The primary outcome was the proportion of children who received analgesia while in the emergency department (ED). Secondary outcomes included the proportion of children receiving intravenous (IV) morphine and the timing of analgesic provision.
A total of 619 health records were abstracted; mean (SD) patient age was 11.4 (3.5) years. Sixty-one percent (381/616) of patients received analgesia in the ED; 42.8% (264/616) received IV morphine. Other analgesic agents provided included oral acetaminophen (23.5% [145/616]) and oral ibuprofen (5.8% [36/616]). The median (IQR) initial dose of IV morphine was 0.06 (0.04, 0.09) mg/kg. The median (IQR) time from triage to the initial dose of analgesia was 196 (101, 309.5) minutes. Forty-three percent (117/269) of children receiving analgesia received the initial dose following surgical consultation; 43.7% (121/277) received their first analgesic after abdominal ultrasound was performed.
Suboptimal and delayed analgesia remains a significant issue for children with suspected appendicitis in Canadian PEDs. This suggests a role for multidimensional knowledge translation interventions and care protocols to improve timely access to analgesia.
The present study investigated whether parent/child pairs would select more healthful foods when: (i) products were labelled with front-of-package (FOP) nutrition labels relative to packages without labels; (ii) products were labelled with colour-coded Multiple Traffic Light (MTL) FOP labels relative to monochromatic Facts up Front (FuF) FOP labels; and (iii) FOP labels were explained via in-aisle signage v. unexplained.
Participants were randomly assigned to one of five conditions: (i) FuF labels with in-aisle signs explaining the labels; (ii) FuF labels, no signage; (iii) MTL labels with in-aisle signage; (iv) MTL labels, no signage; (v) control group, no labels/signage. Saturated fat, sodium, sugar and energy (calorie) content were compared across conditions.
The study took place in a laboratory grocery aisle.
Parent/child pairs (n 153) completed the study.
Results did not support the hypothesis that MTL labels would lead to more healthful choices than FuF labels. The presence of FOP labels did little to improve the healthfulness of selected foods, with few exceptions (participants with v. without access to FOP labels selected lower-calorie cereals, participants with access to both FOP labels and in-aisle explanatory signage selected products with less saturated fat v. participants without explanatory signage).
Neither MTL nor FuF FOP labels led to food choices with significantly lower saturated fat, sodium or sugar. In-aisle signs explaining the FOP labels were somewhat helpful to consumers in making more healthful dietary decisions. New FOP labelling programmes could benefit from campaigns to increase consumer awareness and understanding of the labels.
We examined the effect of a full bladder on proportions of diagnostic ultrasound (US) studies in children with suspected appendicitis. We also examined the effect of a full bladder on proportions of fully visualized ovaries on US in children with suspected appendicitis.
We conducted a retrospective health record review of children aged 2-17 years presenting to a tertiary pediatric emergency department (ED) with suspected appendicitis who had an ultrasound performed. We compared proportions of diagnostic US studies in children with full and sub-optimally filled bladders. We also compared proportions of ovarian visualization in females with full and sub-optimally filled bladders.
678 children were included in our final analysis. The proportion of diagnostic US studies did not vary significantly between groups with a full (132/283, 47%, 95% confidence interval [CI] 38%-56%) or sub-optimally filled bladder (205/395, 52%, 95% CI 47%-57%)(p=0.17). Rates of ovarian visualization were higher in females with a full bladder (196/205, 96%, 95% CI 93%-99%) compared to those with a sub-optimally filled bladder (180/223, 81%, 95% CI 76%-86%) (p<0.01).
Administrators and clinical decision makers should consider removing routine bladder filling practice from current pediatric appendicitis protocols in males and in pre-pubertal females where ovarian pathology is not suspected. Selective bladder filling prior to US should be performed in females when ovarian pathology is suspected.
Evidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation.
Physician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillman’s Tailored Design method was used to distribute the survey from June to July 2014.
Overall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition.
Pediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts.
Financing for climate adaptation is governed by an unusual arrangement whereby the GEF channels funds through other IGOs – including the World Bank, UNEP and UNDP – which in turn develop and implement projects on the ground. The concept and techniques of orchestration outlined by the framework authors help us understand this complicated governance arrangement. The GEF, as orchestrator, supports and steers various intermediaries (the “implementing agencies”) to effect change in target states (developing-country recipients). In our explanation of this outcome, we find support for four of the volume’s hypotheses: intermediary availability, orchestrator focality, goal divergence and state oversight. We also explore whether the relationship between the GEF and its implementing agencies is efficient and complementary. We find that this is generally the case and that the orchestrator capabilities and intermediary availability hypotheses capture this arrangement quite well. While the climate adaptation case offers considerable support for the theoretical framework, recent developments raise concerns about the robustness of orchestration as a governance equilibrium, which may evolve over time toward harder and direct modes of governance.
International relations (IR) scholars have devoted considerable attention to explaining the design and functions of IGOs. Most existing work, theoretical and empirical, has focused on individual institutions as the unit of analysis (Hawkins et al. 2006; Koremenos, Lipson and Snidal 2004), yet many issue areas are governed by multiple IGOs with overlapping mandates and complicated relationships (Alter and Meunier 2009; Biermann et al. 2009; Gehring and Oberthür 2008).
The bizarre morphology of living Pycnogonida, known colloquially as sea spiders, has long fueled dissent over their status within the arthropods. Pycnogonids figure prominently in recent analyses of anterior limb homologies and ancestral crown-group euarthropod relationships, with support for the concept of Pycnogonida as sister taxon to Euchelicerata now contested by proponents of a more basal position between Radiodonta and all other arthropods. A challenge to further elucidation of their phylogenetic position is the exceptional rarity and disjunct distribution of pycnogonids in the fossil record, due largely to their fragile unmineralized exoskeletons. New fossil discoveries therefore have the potential to add significantly to knowledge of their evolution, paleoecology, and paleobiogeography. Here we report the first known occurrence of fossil pycnogonids from rocks of Ordovician age, bridging a 65 Myr gap between controversial late Cambrian larval forms and a single documented Silurian specimen. The new taxon, Palaeomarachne granulata n. gen. n. sp., from the Upper Ordovician (ca. 450 Ma) William Lake Konservat-Lagerstätte deposit in Manitoba, Canada, is also the first reported from Laurentia. It is the only record thus far of a fossil sea spider in rocks of demonstrably shallow marine origin. Four incomplete, partially disarticulated molts represent a relatively large, robust animal with a series of five segment-like elements in a ‘head’ region that does not incorporate the first of four preserved limb-bearing trunk segments. This unique pattern may reflect the plesiomorphic condition prior to complete fusion of anterior ‘head’ elements and first trunk segment to form a cephalosoma, as seen in all eupycnogonids. Palaeomarachne granulata is interpreted as occupying a basal stem-group position in the Pycnogonida.
The formal commissioning of the IRWG occurred at the 1991 Buenos Aires General Assembly, following a Joint Commission meeting at the IAU GA in Baltimore in 1988 that identified the problems with ground-based infrared photometry. The meeting justification, papers, and conclusions, can be found in Milone (1989). In summary, the challenges involved how to explain the failure to achieve the milli-magnitude precision expected of infrared photometry and an apparent 3% limit on system transformability. The proposed solution was to redefine the broadband Johnson system, the passbands of which had proven so unsatisfactory that over time effectively different systems proliferated, although bearing the same “JHKLMNQ” designations; the new system needed to be better positioned and centered in the spectral windows of the Earth's atmosphere, and the variable water vapour content of the atmosphere needed to be measured in real time to better correct for atmospheric extinction.
Reticulitermes flavipes (Kollar) is best known throughout southwestern counties of Ontario, Canada, as an urban pest. Little is known, however, of the presence of this termite in nonurban settings in Ontario. In this study, we confirmed the existence of a population of R. flavipes on the shores of Lake Erie within Point Pelee National Park. A systematic trap survey conducted along the park's semi-vegetated west beach revealed several zones of termite activity. An analysis of trap response at one location indicated an association between termite activity and smaller sized, moderately decayed woody debris. Further, microsatellite DNA analysis suggested the presence of at least three genetically distinct colonies, each likely headed by multiple inbred reproductives. Together these data suggest that termite activity is linked to food quality, and that single colonies are potentially long-lived through multiple generations of inbreeding. Assuming it is derived from a population reported from Point Pelee in 1929, the study population is the oldest known eastern subterranean termite population in Ontario.
Thin films of tungsten silicide with resistivities of 30 – 35 μΩ-cm have been formed by sputter depositing 71 nm of W metal onto (100) oriented, 5 Ω-cm, p-type silicon wafers that were etched in BOE 500 solution. The samples were fast radiatively processed in an RTA system under high vacuum for time anneals ranging from 15 – 50 seconds at a temperature of ∼ 1100°C. The inevitable oxide barrier at the interface is shown to decrease with increasing RTA time.
Superconducting transition temperatures (Tc'S) in the Tl-Ba-Ca-Cu-O system are shown to be a function of processing for both single crystals and bulk ceramics. Crystals with the identical structural phase and nominal composition but slightly different lattice constants can have significant differences in Tc. We report the effects of high temperature annealing in vacuum or flowing oxygen on Tc for single crystal plates of two common phases with nominal stochiometries Tl2Ba2Ca1Cu2O8 and Tl2Ba2Ca2Cu3O10. Contradictory results on nominally similar crystals suggest that strain, Tl content and TI/Ca site disorder are as important as the oxygen stoichiometry in determining Tc This interpretation is supported by complementary annealing studies in bulk ceramic, including a powder where Tc increased by 5 K following high-pressure shock loading which introduced substantial residual strain.
The formal origin of the IRWG occured at the Buenos Aires General Assembly, following a Joint Commission meeting at the IAU GA in Baltimore in 1988 that identified the problems with ground-based infrared photometry. The situation is summarized in Milone (1989). In short, the challenges involved how to explain the failure to achieve the milli-magnitude precision expected of infrared photometry and an apparent 3% limit on system transformability. The proposed solution was to redefine the broadband Johnson system, the passbands of which had proven so unsatisfactory that over time effectively different systems proliferated, although bearing the same JHKLMNQ designations; the new system needed to be better positioned and centered in the atmospheric windows of the Earth's atmosphere, and the variable water vapour content of the atmosphere needed to be measured in real time to better correct for atmospheric extinction.