Introduction: Adolescents who present to emergency departments (ED) following intentional injuries present a challenge in terms of ascertaining their intent and risk for future self-injurious or suicidal behaviour. Our ED has seen an 80% increase in visits for mental health issues over the past ten years. As usage of our Emergency Mental Health and Addictions Services (EMHAS) team continues to rise, it is increasingly important to understand the incidence of NSSI among our youth, explore if NSSI is reported at triage and identify characteristics that may distinguish these adolescents from others presenting for mental health assessment. Methods: This is an exploratory research study using retrospective data. Patients who had an Emergency Mental Health Triage (EMHT) form on their health record from an ED visit between June 1, 2017 and May 31, 2018 were eligible. Trained research assistants, using a structured data collection form in REDCap. abstracted data from the EMHT form, the EMHAS Assessment form, the Assessment of Suicide Risk Inventory and our CHIRPP (Canadian Hospitals Injury Reporting and Prevention Program) database. We calculated kappa values and 95% confidence intervals to describe the extent to which the forms agree with respect to identifying NSSI. We will compare the cohort who reports NSSI with the cohort who does not report NSSI using chi-square statistics depending. We will use descriptive statistics to characterize the NSSI patients. Results: During the one-year study period 955 patients had an EMHT form completed. In preliminary analysis 558 (58.4%) reported a history of NSSI. Patients reported NSSI on both the EMHT form and the EMHAS assessment form 64.7% of the time (kappa 0.56) indicating moderate agreement. In patients with NSSI, 9.5% of patients reported it only at triage and 25.8% of patients reported it only during their EMHAS assessment. Between group comparisons and descriptive analysis is underway. Conclusion: More than half of youth triaged with an emergency mental health complaint in our ED reported a history of NSSI. Screening at triage was moderately effective in identifying adolescents with NSSI compared to an in-depth assessment by the mental health team. Further research is needed to clarify how NSSI relates to risk for suicide.

Introduction: Croup is a common viral upper airway infection in children aged 6 months to 6 years. Although a single dose of dexamethasone decreases return visits, the prescribed dose varies from 0.15mg/kg to 0.6mg/kg. Our objective was to examine the effect of varied dexamethasone dosing on unplanned return ED visits for croup. Methods: This was a retrospective chart review of IWK ED patient treatment records from September 1, 2014 – August 31, 2016 of children aged 6 months to 6 years with an ICD-10 discharge diagnosis code of croup. Data were abstracted by trained research assistants using a structured data collection form in REDCap. A sample of 5% of charts had double data abstraction to test for agreement. Our primary outcome was return visits to the ED within 7 days. Secondary outcomes were ED length of stay (LOS), admission to hospital and admission to the pediatric intensive care unit (PICU). Data were analyzed using descriptive statistics and chi-square for between group comparisons. Results: The dataset included 1595 patient visits for croup. Data analysis is in progress. Triage acuity as per CTAS included: resuscitation n = 5; emergent n = 351; urgent n = 558; less urgent n = 605; and, non-urgent n = 2. Most patients had no co-morbid conditions (n = 1548). Dexamethasone dosing varied: 0.15 mg/kg n = 64; 0.3 mg/kg n = 838; and, 0.6 mg/kg n = 493. ED LOS was under 1 hour in 483 patients, 1-3 hours in 805, 3-6 hours in 225 and 6-12 hours in 9 patients. Few patients were admitted to hospital (n = 22) and no patients were admitted to PICU. Within 7 days of the index visit, 78 patients had an unplanned return visit to the ED for croup. Conclusion: The data analysis is in progress. This study will inform our future research on a practice change in our ED to comply with the dose of dexamethasone recommended by the Canadian Pediatric Society for the treatment of croup in 2017.

Introduction: Emergency departments (ED) play a vital role in asthma care for patients of all ages. Our objective was to review and synthesize all practice change interventions in ED settings that focused on improving the health outcomes of adults and children with asthma. Methods: This study was a systematic review adhering to the methods outlined by the Effective Practice and Organization of Care (EPOC) Cochrane Review Group. We developed a search strategy with a library scientist for the following databases: AMED, CINAHL, Embase, ERIC, MEDLINE, HealthStar, CENTRAL, DARE and Cochrane's EPOC and Airways registers. We also hand searched the Journal of Asthma, Pediatrics and Chest. Two reviewers independently reviewed titles, abstracts and full text using predetermined criteria. Data were extracted by two independent reviewers who used a structured abstraction form and assessed risk of bias. All discrepancies were resolved by consensus. Results: Our search strategy yielded 8,878 titles and abstracts for review. A total of 214 studies underwent full text screening and we extracted data from 27 studies. Risk of bias was judged as low in 10 studies, moderate in 8 studies and high in 9 studies. A range of interventions were employed, with education (n = 14) and reminders (n = 8) being the most prevalent. In pediatric settings, most studies targeted changing the behaviour of parents (n = 11). Four studies targeted health care providers and four studies targeted both providers and parents. We identified a major deficit in the use of behaviour change theory to guide intervention design. The most common primary outcomes of interest were unscheduled return visits (n = 14), primary care follow-up (n = 9), quality of life (n = 5) and ED length of stay (n = 4). We were not able to perform a meta-analysis due to heterogeneity in interventions and outcomes. Conclusion: Although we found a range of interventions used to improve asthma care in EDs, there was significant variation in reported primary outcomes. Both unscheduled return visits and primary care follow-ups, the most common primary outcomes, varied in the timeframe and manner in which they were collected. Most interventions were educational and based on an assumption that education would change behaviour. Future research in this ares would benefit from standardized outcome measures and intervention designs based upon models of behaviour change model.

Introduction: Cardioactive steroid poisoning occurs worldwide with the use of pharmaceutical digoxin and botanical cardiac glycosides. The wholesale price of the antidote, digoxin immune fab, has increased over 300% from 2010 to 2015. Our objective was to identify gaps in the existing literature with respect to the use of digoxin immune fab in cardioactive steroid toxicity in acute care settings. Methods: We used scoping study methodology, as described by Arksey and O'Malley, to assess the range and scope of empiric research and will report: 1) sources of cardioactive steroid toxicity in acute settings; 2) doses of digoxin immune fab used in treatment; and, 3) intervention outcomes of acute cardioactive steroid toxicity following the administration of digoxin immune fab as first or second-line therapy. We collaborated with a library scientist to devise search strategies for PubMed, CINAHL, EMBASE, CENTRAL and Toxnet. We sought unpublished literature through the Canadian Electronic Library, Proquest, and Scopus and searched reference lists of included studies. We hand searched relevant conference proceedings and applicable guidelines. Two reviewers independently reviewed titles and abstracts using predetermined criteria. Using a structured data abstraction form, two reviewers independently extracted data. All discrepancies were resolved through consensus. Results: Our search strategy yielded 3458 results. After screening titles and abstracts 384 underwent full text screening. We included 147 studies and are currently extracting data from 12 French studies and 135 English studies. To date we have extracted data from 90 case reports and case series. Conclusion: Given concerns over rising costs, our findings will shed light on the extent of the evidence for use of digoxin immune fab in acute care settings.

Laboratory identification of carbapenem-resistant Enterobacteriaceae (CRE) is a key step in controlling its spread. Our survey showed that most Veterans Affairs laboratories follow VA guidelines for initial CRE identification, whereas 55.0% use PCR to confirm carbapenemase production. Most respondents were knowledgeable about CRE guidelines. Barriers included staffing, training, and financial resources.

Measurements of a sample from ~580 m depth in the WAIS Divide (WDC06A) ice core reveal that bubbles are preferentially elongated in the basal plane of their parent grain, as expected if bubble shape preserves the record of dominant basal glide. This suggests that a method using bubbles as strain gauges could provide insights to grain-scale ice deformation. We introduce a technique using fabric and image analyses of paired thin and thick sections. Comparison of the crystallographic orientations of 148 grains and the shape orientations of 2377 intragrain bubbles reveals a strongly preferred elongation of bubbles in the grain basal planes (R2 = 0.96). Elongation magnitudes are consistent with a balance between ice flow deformation and diffusive restoration, with larger bubbles more elongated. Assuming bubbles record ice strain, grains with greater resolved stress on their basal planes from the far-field ice flow stresses show greater deformation, but with large variability suggesting that heterogeneity of the local stress field causes deformation even in unfavorably oriented grains. A correlation is also observed among bubble elongation, grain size, and bubble size, explaining a small but significant fraction of the variance ( P< 0.05), with implications for controls on ice deformation, as discussed here.

Ethical realists hold (i) that our ethical concepts, thoughts, and claims are in the business of representing ethical reality, by representing evaluative or normative properties and facts as aspects of reality, and (ii) that such representations are at least sometimes accurate. Non-naturalist realists add the further claim that ethical properties and facts are ultimately non-natural, though they are nonetheless worldly. My aim is threefold: to elucidate the sort of representation involved in ethical evaluation on realist views; to clarify what exactly is represented and how non-naturalism comes into the picture for non-naturalists; and to defend worldly non-naturalism against some objections. The first question addressed is how we should model evaluation on any realist view, which should in turn guide the identification of which properties and facts are credibly regarded as ‘evaluative’ ones. Then the question is: what role might non-natural properties and facts play, and how are they related to what is represented in ethical evaluation? Once that is clear, we will be in a position to answer certain objections to non-naturalist realism from Jackson, Gibbard, Bedke, and Dreier. I argue that the objections all mischaracterize the role played by non-natural properties and facts on plausible versions of non-naturalist realism.

Introduction/Innovation Concept: University Departments of Emergency Medicine are responsible for the supervision of research and other scholarly projects for fellows, residents and students, though often lack resources to provide adequate input and oversight. Many departments cover large geographical areas and several programs. We piloted new research committee structures and processes to improve oversight and output of research projects. Methods: We created an interactive group supervision tool based around formation of a collaborative research committee, with rotating chairs from each program, to provide supervision and face to face interaction, and direction for research learners. Included were all Dalhousie University adult and pediatric emergency medicine residency and fellowship programs, as well as trauma and EMS programs across Nova Scotia, New Brunswick, and Prince Edward Island. In addition to providing expertise in clinical trial coordination, database management, research administration, grant applications and Research Ethics Board submissions, we have completed a 2-year pilot of our interactive group supervision tool for research projects. Curriculum, Tool, or Material: The interactive tool consists of a structured PICOD form; allocation of topic and research mentors; standardized yearly milestones from project development through presentation and publication; and regular video-conferenced and in-person interactive group sessions involving several project leads, as well as program research directors, researchers, and co-ordinators. To date, all participating program learners have engaged with the tool, with positive feedback from learners, supervisors and program directors. Conclusion: We report our development of a regional collaborative interactive group supervision tool, that maximizes expert resources in the provision of research and scholarly project supervision.

In the face of environmental uncertainty due to anthropogenic climate change, islands are at the front lines of global change, threatened by sea level rise, habitat alteration, extinctions and declining biodiversity. Islands also stand at the forefront of scientific study for understanding the deep history of human ecodynamics and to build sustainable future systems. We summarize the long history of human interactions with Polynesian, Mediterranean, Californian and Caribbean island ecosystems, documenting the effects of various waves of human settlement and socioeconomic systems, from hunter–gatherer–fishers, to agriculturalists, to globalized colonial interests. We identify degradation of island environments resulting from human activities, as well as cases of human management of resources to enhance productivity and create more sustainable systems. These case studies suggest that within a general global pattern of progressive island degradation, there was no single trajectory of human impact, but rather complex effects based on variable island physiographies, human subsistence strategies, population densities, technologies, sociopolitical organization and decision-making.

Epidemiological data are often fragmented, partial, and/or ambiguous and unable to yield the desired level of understanding of infectious disease dynamics to adequately inform control measures. Here, we show how the information contained in widely available serology data can be enhanced by integration with less common type-specific data, to improve the understanding of the transmission dynamics of complex multi-species pathogens and host communities. Using brucellosis in northern Tanzania as a case study, we developed a latent process model based on serology data obtained from the field, to reconstruct Brucella transmission dynamics. We were able to identify sheep and goats as a more likely source of human and animal infection than cattle; however, the highly cross-reactive nature of Brucella spp. meant that it was not possible to determine which Brucella species (B. abortus or B. melitensis) is responsible for human infection. We extended our model to integrate simulated serology and typing data, and show that although serology alone can identify the host source of human infection under certain restrictive conditions, the integration of even small amounts (5%) of typing data can improve understanding of complex epidemiological dynamics. We show that data integration will often be essential when more than one pathogen is present and when the distinction between exposed and infectious individuals is not clear from serology data. With increasing epidemiological complexity, serology data become less informative. However, we show how this weakness can be mitigated by integrating such data with typing data, thereby enhancing the inference from these data and improving understanding of the underlying dynamics.