Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), often recur in patients who have poorly controlled diabetes. Identification of those at risk for recurrent hyperglycemia visits may improve health care delivery and reduce ED utilization for these patients. The objective of this study was to prospectively characterize patients re-presenting to the emergency department (ED) for hyperglycemia within 30 days of an initial ED visit. Methods: This is a prospective cohort study of patients ≥18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS from Jul 2016-Nov 2018. Trained research personnel collected data from medical records, telephoned patients at 10-14 days after the ED visit for follow-up, and completed an electronic review to determine if patients had a recurrent hyperglycemia visit to any of 11 EDs within our local health integration network within 30 days of the initial visit. Descriptive statistics were used where appropriate to summarize the data. Results: 240 patients were enrolled with a mean (SD) age of 53.9 (18.6) years and 126 (52.5%) were male. 77 (32.1%) patients were admitted from their initial ED visit. Of the 237 patients (98.8%) with 30-day data available, 55 (23.2%) had a recurrent ED visit for hyperglycemia within this time period. 21 (8.9%) were admitted on this subsequent visit, with one admission to intensive care and one death within 30 days. For all patients who had a recurrent 30-day hyperglycemia visit, 22/55 (40.0%) reported having outpatient follow-up with a physician for diabetes management within 10-14 days of their index ED visit. 7/21 (33.3%) patients who were admitted on the subsequent visit had received follow-up within the same 10-14 day period. Conclusion: This prospective study builds on our previous retrospective work and describes patients who present recurrently for hyperglycemia within 30 days of an index ED visit. Further research will attempt to determine if access to prompt follow-up after discharge can reduce recurrent hyperglycemia visits in patients presenting to the ED.

Introduction: Cannabis Hyperemesis Syndrome (CHS) is a new and poorly understood phenomenon with a subset of patients presenting to emergency departments (ED) for symptomatic control of their refractory nausea and vomiting. Curently, there is a lack of agreement and considerable practice variability on initial treatment modalities for CHS. The objective of this study was to describe the treatment modalities for patients presenting to ED with cannabis-related sequelae. Methods: This was a health records review of patients ≥18 years presenting to one of two tertiary care EDs (annual census: 150,000) with a discharge diagnosis including cannabis use with one of abdominal pain or nausea/vomiting using ICD-10 codes. Trained research personnel collected data from medical records including demographics, clinical history, results of investigations, and utilization of treatment options within the ED. Descriptive statistics are presented where appropriate. Results: From April 2014 to June 2016, 203 unique ED patients had a discharge diagnosis including cannabis use with abdominal pain or nausea/vomiting. Sixty-nine (33.4%) received any treatment during their visit with 28 (40.6%) receiving IV fluids, of which 24 (85.7%) received normal saline. Anti-emetics were used in 21 (30.4%) patients with ondansetron being the first-line agent in 11 (52.4%) patients followed by dimenhydrinate in 6 (28.6%) and haloperidol in 2 (9.5%) cases. Six patients required two doses of anti-emetics, favouring ondansetron in 3 cases followed by haloperidol, dimenhydrinate, and metoclopramide each used once. Thirteen (19%) patients required analgesia, with the first-line preference being non-opioid medications in 11 versus opioids in 2 cases. Seven patients required multiple modes of analgesia, favouring opioid medications in 4 patients. Twenty-eight (40.6%) patients required anxiolytics with lorazepam being used primarily in 16 (57.1%) patients followed by lorazepam/haloperidol in 5 (17.9%) cases. Conclusion: This ED-based study demonstrates variability of practice patterns for symptomatic treatment of cannabis related ED presentations. Despite knowledge of haloperidol being useful in patients with suspected CHS, physicians opted for ondansetron as first line anti-emetics. Future research should focus on studying various treatment modalities of patients with suspected CHS in the ED to optimize symptomatic treatment.

Introduction: Cannabis Hyperemesis Syndrome (CHS) is a poorly understood phenomenon with a subset of patients presenting to the emergency department (ED) for symptomatic control of refractory nausea and vomiting. As legalization of marijuana commenced on October 2018, it is important to recognize the presentation of patients related to marijuana consumption. The objective of this study was to describe demographic and ED visit data of patients presenting to the ED with cannabis-related sequelae. Methods: This was a health records review of patients ≥18 years presenting to one of two tertiary care EDs (annual census 150,000 visits) with a discharge diagnosis including cannabis use with one of abdominal pain or nausea/vomiting using ICD-10 codes. Trained research personnel collected data from medical records including demographics, clinical history, results of investigations within the ED. Descriptive statistics including means and standard deviations are presented where appropriate. Results: From April 2014 to June 2016, 203 unique ED patients had a discharge diagnosis including cannabis use with abdominal pain or nausea/vomiting. Mean (SD) age was 30 (13.04) years and 120 (59.1%) were male. Patients presented to the ED independently 84 (41.4%), via EMS with 104 (51.23%) and 15 (7.39%) by police. The majority of patients were triaged as CTAS-2 in 27 (33%) and CTAS-3 in 106 (52.2%) of all cases. Of patients disclosing their method of consumption, 31 (15.3%) had used combustion methods and 30 (14.8%) had edible marijuana. Mean (SD) serum potassium was 3.71 (0.48) mmol/l. 162 (79.8%) were discharged home and 9 (4.4%) were given follow up (all psychiatric). Twenty-nine (14.3%) were admitted to hospital with 28 (13.8%) admitted to psychiatry and 1 (0.5%) admitted to medicine. Conclusion: This ED-based retrospective chart review reports a description of cannabis-related presentations to the ED. Clinicians should be aware of CHS in patients presenting to the ED, especially as Canada enters the era of legalization. Future research should focus on the impact of federal legalization of marijuana on ED utilization for CHS-related presentations.

Introduction: With a shift towards competency-based medical education, it is crucial to not only emphasize learner abilities such as clinical skills but also leadership in the conduct of research. Though the Royal College of Physicians and Surgeons of Canada's (RCPSC) training objectives for Emergency Medicine (EM) residents state that the specialist physician be able to describe the principles of research, the research methodology curriculum across EM training programs in Canada is likely variable. The primary goal of this study was to describe the variability of research methodology teaching among RCPSC-EM residency programs. Methods: An electronic survey was distributed to English-speaking RCPSC-EM program directors (PDs) and EM residents. The survey investigated residents' and PDs’ thoughts on the adequacy of their local curriculum and asked them to quantify their research methodology teaching. The primary outcome was the frequency and content of current research methodology and research ethics teaching as well as a description of scholarly project requirements of EM residency programs across Canada. The data was presented with simple descriptive statistics. Results: 79 EM residents and 7 PDs responded (response rate 22.3% and 58.3%, respectively). All 7 PDs indicate having a research methodology curriculum while 71.6% of residents are aware of this curriculum. Only 57.1% of PDs report having formal assessments. Most programs (71.4%) teach via small groups while 28.6% of programs use large group sessions. Residents identify teaching as led by research staff (68.9%), staff physicians (60%), and EM researchers (57.8%), while only 17.8% use outside educators. Students noted various modalities of curriculum feedback such as online surveys, weekly forms, and verbal feedback. Regarding the strength of the curricula, 85.7% of PDs believed their curriculum prepares residents for board exams, while only 62.2% of residents felt similarly. When asked about using a standard web-based curriculum module if available, 60.5% of residents responded in favour. Conclusion: This study demonstrates that EM residency programs across Canada vary with respect to research methodology curriculum and discrepancies exist between residents’ and program directors’ perceptions of the curriculum. Given the lack of a standardized research methodology curriculum for these residency programs, there is an opportunity for curriculum development to improve training in research methodology.

Introduction: Acute aortic syndrome (AAS) is a time sensitive aortic catastrophe that is often misdiagnosed. There are currently no Canadian guidelines to aid in diagnosis. Our goal was to adapt the existing American Heart Association (AHA) and European Society of Cardiology (ESC) diagnostic algorithms for AAS into a Canadian evidence based best practices algorithm targeted for emergency medicine physicians. Methods: We chose to adapt existing high-quality clinical practice guidelines (CPG) previously developed by the AHA/ESC using the GRADE ADOLOPMENT approach. We created a National Advisory Committee consisting of 21 members from across Canada including academic, community and remote/rural emergency physicians/nurses, cardiothoracic and cardiovascular surgeons, cardiac anesthesiologists, critical care physicians, cardiologist, radiologists and patient representatives. The Advisory Committee communicated through multiple teleconference meetings, emails and a one-day in person meeting. The panel prioritized questions and outcomes, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. The algorithm was prepared and revised through feedback and discussions and through an iterative process until consensus was achieved. Results: The diagnostic algorithm is comprised of an updated pre test probability assessment tool with further testing recommendations based on risk level. The updated tool incorporates likelihood of an alternative diagnosis and point of care ultrasound. The final best practice diagnostic algorithm defined risk levels as Low (0.5% no further testing), Moderate (0.6-5% further testing required) and High ( >5% computed tomography, magnetic resonance imaging, trans esophageal echocardiography). During the consensus and feedback processes, we addressed a number of issues and concerns. D-dimer can be used to reduce probability of AAS in an intermediate risk group, but should not be used in a low or high-risk group. Ultrasound was incorporated as a bedside clinical examination option in pre test probability assessment for aortic insufficiency, abdominal/thoracic aortic aneurysms. Conclusion: We have created the first Canadian best practice diagnostic algorithm for AAS. We hope this diagnostic algorithm will standardize and improve diagnosis of AAS in all emergency departments across Canada.

We summarize the findings from an interlaboratory study conducted between ten international research groups and investigate the use of the commonly used maximum separation distance and local concentration thresholding methods for solute clustering quantification. The study objectives are: to bring clarity to the range of applicability of the methods; identify existing and/or needed modifications; and interpretation of past published data. Participants collected experimental data from a proton-irradiated 304 stainless steel and analyzed Cu-rich and Ni–Si rich clusters. The datasets were also analyzed by one researcher to clarify variability originating from different operators. The Cu distribution fulfills the ideal requirements of the maximum separation method (MSM), namely a dilute matrix Cu concentration and concentrated Cu clusters. This enabled a relatively tight distribution of the cluster number density among the participants. By contrast, the group analysis of the Ni–Si rich clusters by the MSM was complicated by a high Ni matrix concentration and by the presence of Si-decorated dislocations, leading to larger variability among researchers. While local concentration filtering could, in principle, tighten the results, the cluster identification step inevitably maintained a high scatter. Recommendations regarding reporting, selection of analysis method, and expected variability when interpreting published data are discussed.

We present the defect analysis by photoluminescence (PL) spectroscopy of CdSexTe1-x thin films, grown with varying Se content by a co-sputtered deposition method. We observe a peak at 1.203 eV in the CdSexTe1-x film for x = 0.21, which shifts towards higher energies with increase in laser power. This peak was assigned to a donor-to-acceptor (DAP) transition, with a measured j-shift of ∼4.7 meV/decade. Temperature dependent PL intensity measurements confirm that the observed DAP peak involves a shallow defect state of binding energy ∼34.7 meV. In contrast, a free-to-bound (FB) peak at 1.294 eV involving a shallow defect of binding energy ∼18.3 meV was observed in the CdSexTe1-x film for x = 0.14. Additionally, we observe band edge emission at 1.452 eV and 1.448 eV in CdSexTe1-x films for x = 0.14 and x = 0.21 respectively. Our analysis shows that the Se concentration not only changes the band gap energy of the resulting CdSexTe1-x alloy thin film, but also modifies the nature of the dominant observed defect emission.

Introduction: Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes such as recurrent ED visits, hospitalization or death. The objective of this study was to perform a systematic review to identify predictors of these adverse outcomes among patients who present to the ED with hyperglycemia. Methods: Electronic searches of Medline and EMBASE were conducted for studies published in English between the years 1946 and June 2017. Studies with patients presenting to the ED with hyperglycemia were eligible for inclusion. Both adult and pediatric populations were included, as were diabetic and non-diabetic patients. Two reviewers independently screened all titles and abstracts for relevance to the research question. If consensus could not be reached, full-length manuscripts were reviewed. For any discrepancy, a third reviewer was consulted, and disagreement was resolved through discussion. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were then extracted and presented descriptively in the systematic review. Results: Thirteen observational studies were included, with a combined total of 664,829 patients. The studies scored between 5 to 8 on the Quality Assessment Scale out of a possible total of 8. Predictors of adverse outcomes included patients in both older and younger (< 25) age groups, history of diabetes, multiple comorbidities, patients requiring insulin, sepsis and hyperlactatemia, access to a family physician, a sentinel hyperglycemia visit in the past month, and triage glucose level > 20 mmol/L. Protective factors included no admissions in the past year, care from a diabetes team while in hospital, systolic blood pressure between 90-150 mmHg and heart rate > 110 bpm. Conclusion: This systematic review found eight predictors and four protective factors for adverse outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of higher-risk patients for adverse outcomes in order to guide management and follow-up.

Introduction: Patients with diabetes who are in emerging adulthood, defined as the life stage between 18-29 years, have unique challenges in managing their illness and are at risk of acute complications and loss to follow-up. The studys objective was to describe emergency department (ED) utilization for hyperglycemia in emerging adults with diabetes and to characterize 30-day outcomes including return visits and admission for hyperglycemia. Methods: This was a health records review of emerging adults presenting over a one-year period to four tertiary care EDs with a diagnosis of hyperglycemia, diabetic ketoacidosis or hyperosmolar hyperglycemic state. Research personnel collected data on patient characteristics, treatment, disposition, and determined if patients returned to the ED for hyperglycemia within 30 days. Descriptive statistics were used to summarize the data where appropriate. Results: There were 185 ED encounters for hyperglycemia, representing 116 unique emerging adult patients. Mean (SD) age was 23 (3.5) years and 50.9% were female. 80 (69.0%) had known type 1 diabetes, 11 (9.5%) had type 2, and 25 (21.5%) were newly diagnosed in the ED. Of 185 visits, 98 (53.0%) resulted in hospital admission. 56 (30.3%) returned to the ED for hyperglycemia within 30 days of their initial encounter, and 21 (11.4%) resulted in admission on this subsequent visit. Conclusion: We characterized ED utilization and 30-day outcomes of emerging adults with diabetes for hyperglycemia. Future research should focus on earlier identification of those at higher risk for recurrent ED visits or admission and the efficacy of interventions to prevent these adverse outcomes.

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients when performing painful procedures through the use of procedural sedation (PS). Examination of the literature suggests that the application of PS appears to be variable with institutional influences and clinician disagreement on pharmacology, airway management, and monitoring. The primary goal of this research project was to describe the variability of practice with respect to pharmacologic choices and clinical applications of PS among Canadian ED physicians. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding PS indications and pharmacology. The primary outcome was the quantification of practice variability among ED physicians with respect to the above listed aspects of PS. The data was presented with simple descriptive statistics. Results: To date, 278 ED physicians responded to our survey (response rate 20.3%). Respondents were primarily academic hospital (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). There was relative agreement on the following interventions requiring PS: 98.4% applied PS for electrical cardioversion and 98.1% for brief (<10 mins) orthopedic manipulations. However, only 36.3% utilized PS for burn debridement in the ED. PS was utilized less frequently (78.1%) for prolonged (>10mins) orthopedic manipulations than brief manipulations. For all procedures aggregated, in hemodynamically stable patients with an American Society of Anesthesiology (ASA) score of 1, ED physicians utilized propofol 76.3% of the time. Additional agents were utilized at the following rates: fentanyl-propofol (7.6%), ketamine (7.6%), and fentanyl (4%). This inclination towards propofol alone appears to be consistent across modality of ER training, type of ER setting (rural vs academic), and volume of PS performed. Conclusion: This study demonstrates that Canadian ED physicians have a clear preference for propofol as a first line pharmacologic agent when administering PS in hemodynamically stable, ASA1 patients. Conversely, there appears to be more variation amongst ED physicians with respect to second line pharmaceutical choices for PS.

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients undergoing painful procedures through the use of procedural sedation (PS). While, PS is generally safe and effective in the ED, there is institutional variability and clinician disagreement with respect to the bedside equipment required for airway management and the monitoring of adverse events. The primary goal of this research project was to describe the variability of the bedside setup utilized by Canadian ED physicians preforming PS in conjunction with self-reported adverse events. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding bedside setup of airway equipment, and prevalence of self-reported adverse events. The primary outcome was the quantification of variability among ED physicians with respect to the above listed aspects of PS. Data was presented with simple descriptive statistics. Results: 278 ED physicians responded to our survey (response rate 20.9%). Respondents were primarily academic (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). The ED area in which PS was carried out varied; bedside (30.5%), procedure room (37.1%), resuscitation area (31.2%). The basic equipment set utilized appears to be a bag valve mask, suction, and an oral airway. These 3 items were present 95.4%, 95.9%, and 86.3% of the time respectively. The preparation of other items such as capnography and difficult airway equipment is highly variable and appears to be physician specific rather than clinical situation specific. The most common physician self-reported adverse events associated with PS appear to be hypoxia (Spo2<90%), hypotension (sBP<90), and prolonged sedation which occurred in 10.7%, 8.3%, and 8.1% of PS performed. Conclusion: There appears to be significant practice variability with respect to the clinical setting as well as the equipment ED physicians prefer when administering PS. Given that causal relationships cannot be inferred between airway/monitoring equipment preferences and adverse events, future studies should be targeted at identifying optimal bedside set ups which minimize adverse events.

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), carry significant morbidity for individuals even after discharge. The objective of this study was to describe the patient-important outcomes and burden of disease for emergency department (ED) patients with hyperglycemia after discharge from hospital. Methods: This was a prospective cohort study of patients 18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS over a 15-month period (Jul 2016-Oct 2017). During the ED visit, consent was obtained for a telephone follow-up call to determine patient-important outcomes. Trained research personnel collected data from medical records and completed a 14 day telephone follow-up using a standardized questionnaire to determine medication changes, missed days of school or work, and repeat admissions or visits to a healthcare provider. Descriptive statistics were used where appropriate to summarize the data. Results: Thus far, 172 patients have been enrolled in our study. Mean (SD) age is 53.9 (19.3) years and 97 (56.4%) are male. 65 (37.8%) patients were admitted from their initial ED visit. Of the 125 patients (72.7%) providing post-discharge outcomes, 75 (60.0%) required an adjustment to their diabetes medications or insulin. 21 (16.8%) patients missed days of school or work for a median (IQR) duration of 3.5 (1.3, 7.0) days. 85 (68.0%) saw another healthcare provider within a 14 day period, 45 (36.0%) saw their family physician, and 34 (27.2%) saw an internist or endocrinologist. 9 (7.2%) were seen again in the ED, 5 of these patients required admission to hospital. There was one death that occurred within the follow-up period. Conclusion: This prospective study builds on our previous retrospective work and demonstrates that visits for hyperglycemia carry a significant burden of disease beyond what may be seen in a single ED encounter. Further research will attempt to identify the factors that may be predictive of adverse outcomes in hyperglycemic patients presenting to the ED.

Methods of obtaining large grain size and high crystallinity in absorber materials play an important role in fabrication of high-performance methylammonium lead iodide (MAPbI3) perovskite solar cells. Here we study the effect of adding small concentrations of Cd2+, Zn2+, and Fe2+salts to the perovskite precursor solution used in the single-step solution fabrication process. Enhanced grain size and crystallinity in MAPbI3 films were obtained by using 0.1% of Cd2+ or Zn2+in the precursor solution. Consequently, solar cells constructed with Cd- and Zn-doped perovskite films show a significant improvement in device performance. These results suggest that the process may be an effective and facile method to fabricate high-efficiency perovskite photovoltaic devices.

The Chinese Solar and Geophysical Data (CSGD) was first issued at the Beijing Astronomical Observatory, Chinese Academy of Sciences (now the headquarter of the National Astronomical Observatories, Chinese Academy of Sciences) in 1971, when China’s satellite-industry was booming. CSGD covers the observational data (observations of the sunspots, solar flares, solar radio bursts, ionospheric storm and geomagnetic storm) from a couple of domestic observatories and the forecast data. The compiler of CSGD still keeps the data exchange with other institutes worldwide. The type of the dataset includes texts, tables, figures and so on. Up to now, we have electronized all the historic archives, making them easily accessible to people who are interested in them.

In the light curves of some solar-type stars, both rotational modulation (caused by corotating bright or dark magnetic features) and flare phenomena can be seen simultaneously. Based on these light curve observations, the relation between stellar magnetic feature activity (reflected by the rotational modulation component of the light curves) and flare activity can be investigated. Here, we analyze the light curve data of a flare-abundant solar-type star, KIC 6034120, observed with Kepler space telescope, and describe magnetic feature activity property by fluctuation range of light curves and flare activity property by time occupation ratio of flares. Distinct phase difference between long-term magnetic feature activity and flare activity is found for this star, which indicates that the source regions of stellar flares (e.g., starspots) on this star do not dominate the rotational modulation of light curves, yet they might be related to a same stellar dynamo process.