This is an epidemiological study of carbapenem-resistant Enterobacteriaceae (CRE) in Veterans’ Affairs medical centers (VAMCs). In 2017, almost 75% of VAMCs had at least 1 CRE case. We observed substantial geographic variability, with more cases in urban, complex facilities. This supports the benefit of tailoring infection control strategies to facility characteristics.

A survey of Veterans’ Affairs Medical Centers on control of carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-producing CRE (CP-CRE) demonstrated that most facilities use VA guidelines but few screen for CRE/CP-CRE colonization regularly or regularly communicate CRE/CP-CRE status at patient transfer. Most respondents were knowledgeable about CRE guidelines but cited lack of adequate resources.

This article provides an overview of selected ongoing international efforts that have been inspired by Edward Zigler's vision to improve programs and policies for young children and families in the United States. The efforts presented are in close alignment with three strategies articulated by Edward Zigler: (a) conduct research that will inform policy advocacy; (b) design, implement, and revise quality early childhood development (ECD) programs; and (c) invest in building the next generation of scholars and advocates in child development. The intergenerational legacy left by Edward Zigler has had an impact on young children not only in the United States, but also across the globe. More needs to be done. We need to work together with a full commitment to ensure the optimal development of each child.

Introduction: Acute bloody diarrhea obligates rapid and accurate diagnostic evaluation; few studies have described such cohorts of children. Methods: We conducted a planned secondary analysis employing the Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE) acute gastroenteritis study cohort to describe the characteristics of children with acute bloody diarrhea, compared to a cohort of children without hematochezia. Children <18 years of age presenting to 2 pediatric tertiary care emergency departments (EDs) in Alberta, with ≥3 episodes of diarrhea and/or vomiting in the preceding 24 hours and <7 days of symptoms were consecutively recruited. Stools were tested for 17 viruses, bacteria and parasites. Primary outcomes were clinical characteristics and pathogens identified. Secondary outcomes included interventions and resource utilization. Results: Of 2257 children enrolled between October 2015 and August 2018, hematochezia before or at the index ED visit was reported in 122 (5.4%). Compared to children with nonbloody diarrhea, children with hematochezia had longer illness duration [59.5 vs. 41.5 hrs, difference 10.6, 95% CI 3.5, 19.9], more diarrheal episodes in a 24-hour period [8 vs. 5, difference 3, 95% CI 2, 4], and less vomiting [55.7% vs. 91.1%; difference -35.3%; 95% CI -44.7, -26.3]. They received more intravenous fluids [32.0% vs. 18.3%; difference 13.7%, 95% CI 5.5, 23.0], underwent non-study stool testing [53.7% vs. 4.8%; difference 49.0%, 95% CI 39.6, 58.0], experienced longer ED visits [4.1 vs. 3.3 hours, difference 0.9, 95% CI 0.3, 1.0] and were more likely to have repeat healthcare visits within 14 days [54.8% vs. 34.2%; difference 20.6%, 95% CI 10.8, 30.1]. A bacterial enteric pathogen was found in 31.9% of children with hematochezia versus 6.6% without bloody diarrhea (difference 25.4%, 95% CI 17.2, 34.7). In children with hematochezia, the most commonly detected bacteria were Salmonella spp. (N = 15), Shiga toxin-producing E. coli (N = 9), Campylobacter spp. (N = 7), and Shigella spp. (N = 5). Viruses were detected in 32.8% of children with bloody diarrhea, most commonly adenovirus (N = 15), norovirus (N = 14), sapovirus (N = 8) and rotavirus (N = 7). Conclusion: Children with hematochezia differed clinically from those without hematochezia and required more healthcare resources. While bacterial etiologies are common, several viruses were also detected.

Introduction: The Cunningham reduction method for anterior shoulder dislocation offers an atraumatic alternative to traditional reduction techniques without the inconvenience and risk of procedural sedation and analgesia (PSA). Unfortunately, success rates as low as 27% have limited widespread use of this method. Inhaled methoxyflurane (I-MEOF) offers a rapidly administered, minimally invasive option for short-term analgesia. We conducted a pilot study to evaluate the feasibility of studying whether I-MEOF increased success rates for atraumatic reduction of anterior shoulder dislocation. Methods: A convenience sample of 20 patients with uncomplicated anterior shoulder dislocations were offered the Cunningham reduction method supported by methoxyflurane analgesia under the guidance of an advanced care paramedic. Operators were instructed to limit their attempt to the Cunningham method. Outcomes included success rate without the requirement for PSA, time to discharge, and operator and patient satisfaction with the procedure. Results: 20 patients received I-MEOF and an attempt at Cunningham reduction. 80% of patients were male, median age was 38.6 (range 18-71), and 55% were first dislocations of that joint. 35% (8/20 patients) had reduction successfully achieved by the Cunningham method under I-MEOF analgesia. The remainder proceeded to closed reduction under PSA. All patients had eventual successful reduction in the ED. 60% of operators reported good to excellent satisfaction with the process, with inadequate muscle relaxation being identified as the primary cause of failed initial attempts. 80% of patients reported good to excellent satisfaction. Conclusion: Success with the Cunningham technique was marginally increased with the use of I-MEOF, although 65% of patients still required PSA to facilitate reduction. The process was generally met with satisfaction by both providers and patients, suggesting that early administration of analgesia is appreciated. Moreover, one-third of patients had reduction achieved atraumatically without need for further intervention. A larger, randomized study may identify patient characteristics which make this reduction method more likely to be successful.

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.