Introduction: CAEP recently developed the acute atrial fibrillation (AF) and flutter (AFL) [AAFF] Best Practices Checklist to promote optimal care and guidance on cardioversion and rapid discharge of patients with AAFF. We sought to assess the impact of implementing the Checklist into large Canadian EDs. Methods: We conducted a pragmatic stepped-wedge cluster randomized trial in 11 large Canadian ED sites in five provinces, over 14 months. All hospitals started in the control period (usual care), and then crossed over to the intervention period in random sequence, one hospital per month. We enrolled consecutive, stable patients presenting with AAFF, where symptoms required ED management. Our intervention was informed by qualitative stakeholder interviews to identify perceived barriers and enablers for rapid discharge of AAFF patients. The many interventions included local champions, presentation of the Checklist to physicians in group sessions, an online training module, a smartphone app, and targeted audit and feedback. The primary outcome was length of stay in ED in minutes from time of arrival to time of disposition, and this was analyzed at the individual patient-level using linear mixed effects regression accounting for the stepped-wedge design. We estimated a sample size of 800 patients. Results: We enrolled 844 patients with none lost to follow-up. Those in the control (N = 316) and intervention periods (N = 528) were similar for all characteristics including mean age (61.2 vs 64.2 yrs), duration of AAFF (8.1 vs 7.7 hrs), AF (88.6% vs 82.9%), AFL (11.4% vs 17.1%), and mean initial heart rate (119.6 vs 119.9 bpm). Median lengths of stay for the control and intervention periods respectively were 413.0 vs. 354.0 minutes (P < 0.001). Comparing control to intervention, there was an increase in: use of antiarrhythmic drugs (37.4% vs 47.4%; P < 0.01), electrical cardioversion (45.1% vs 56.8%; P < 0.01), and discharge in sinus rhythm (75.3% vs. 86.7%; P < 0.001). There was a decrease in ED consultations to cardiology and medicine (49.7% vs 41.1%; P < 0.01), but a small but insignificant increase in anticoagulant prescriptions (39.6% vs 46.5%; P = 0.21). Conclusion: This multicenter implementation of the CAEP Best Practices Checklist led to a significant decrease in ED length of stay along with more ED cardioversions, fewer ED consultations, and more discharges in sinus rhythm. Widespread and rigorous adoption of the CAEP Checklist should lead to improved care of AAFF patients in all Canadian EDs.

Background: Insertion of an external ventricular drain (EVD) is performed to treat elevated intracranial pressure. EVD catheters are associated with complications such as EVD catheter infection (ECI), intracranial hemorrhage (ICH) and suboptimal catheter placement. As part of the Canadian Neurosurgery Research Collaborative, we sought to investigate the national rate of such complications and their risk factors. Methods: Prospective study of 273 patients from eight academic Canadian neurosurgery centres Results: Infection rate was 6% and predicted by smaller incisions and not peri-procedure antibiotics, tunneling distance, type of antiseptic used or catheter flushing (p>0.05). The mean duration of EVD was 17.7±3.7 in ECI and ventriculitis group which was significantly higher than in patients without ECI (9.4±8.1) (p=0.045). Although the risk of developing ICH was 9.3%, symptomatic ICH was rare. Pre-procedure pharmacological DVT prophylaxis predicted EVD-related ICH(OR 4.73). The rate of suboptimal catheter location was 31% and predicted by the number of passes (p=0.02), but not image guidance, level of training or catheter placement in an operating room setting (p>0.05). Conclusions: This study reports EVD complication rates and their associated risk factors observed within an academic, multicentre Canadian cohort. This information will help to identify strategies to increase the safety of this common neurosurgical procedure.

Background: External ventricular drain (EVD) insertion is a common neurosurgical procedure performed in patients with life-threatening conditions, but can be associated with complications. The objectives of this study are to evaluate data on national practice patterns and complications rates in order to optimize clinical care Methods: The Canadian Neurosurgery Research Collaborative conducted a prospective multi-centre registry of patients undergoing EVD insertions at Canadian residency programs Results: In this interim analysis, 4 sites had recruited 46 patients (mean age: 53.9 years, male:female 2:1). Most EVD insertions occurred outside of the operating theatre, using free-hand technique, and performed by junior neurosurgery residents (R1-R3). The catheter tip was in the ipsilateral frontal horn or body of the lateral ventricle in 76% of cases. Suboptimally placed catheters did not have higher rates of short-term occlusion. EVD-related hemorrhage occurred in 6.5% (3/45) with only 1 symptomatic patient. EVD-related infection occurred in 13% (6/46) at a mean of 6 days and was associated with longer duration of CSF drainage (P=0.039; OR: 1.13) Conclusions: Interim results indicate rates of EVD-related complications may be higher than previously thought. This study will continue to recruit patients to confirm these findings and determine specific risk factors associated with them

Introduction: Patients with acute atrial fibrillation or flutter (AAFF) are the most common acute arrhythmia cases requiring care in the ED. Our goal was to adapt the existing Canadian Cardiovascular Society (CCS) AF Management Guidelines into an emergency physician-friendly best practices checklist. Methods: We chose to adapt, for use by emergency physicians, existing high-quality clinical practice guidelines (CPG) previously developed by the CCS using the GRADE system. We used the Canadian CAN-IMPLEMENT© process adapted from the ADAPTE Collaboration. We created an Advisory Committee consisting of 14 academic and community emergency physicians, three cardiologists, one PhD methodologist, and two patients. The Advisory Committee communicated by a two-day face-to-face meeting, teleconferences, and email. The checklist was prepared and revised through a process of feedback and discussions through ten iterations until consensus was achieved. We then circulated the draft checklist for comment to approximately 300 emergency medicine and cardiology colleagues whose written feedback was further incorporated into the final approved version. Results: The final CAEP ED AAFF Guidelines are comprised of two algorithms and four sets of checklists, organized by 1) Assessment and Risk Stratification, 2) Rhythm and Rate Control, 3) Long-term Stroke Prevention with the CHADS-65 Algorithm, and 4) Disposition and Follow-up. The guidelines have been endorsed by CAEP and accepted for publication in the Canadian Journal of Emergency Medicine. During the consensus and feedback processes, we addressed a number of issues and concerns. We highlighted the issue that many unstable patients are actually suffering from underlying medical problems rather than a primary arrhythmia. One controversial recommendation is to consider rate control or transesophageal echocardiography guided cardioversion if the duration of symptoms is 24-48 hours and the patient has two or more CHADS-65 criteria. We emphasize the importance of evaluating long-term stroke risk by use of the CHADS-65 algorithm and encourage ED physicians to prescribe anticoagulants where indicated. Conclusion: We have created the CAEP AAFF Best Practices Checklist which we hope will standardize and improve care of AAFF patients in all EDs across Canada. We believe that most of these patients can be managed rapidly and safely with ED rhythm control, early discharge, and appropriate use of anticoagulants.

To engage in the community and the workplace requires physical, mental, and social health and wellbeing. Health promotion is a crucial rehabilitation counselling function for the health and wellbeing of people living with chronic illness and disability (CID). This exploratory review seeks to examine theories and models of motivation applicable to health promotion interventions in rehabilitation counselling practice. Although no single theory can address all the potential variables affecting people with CID's health behaviours, Bandura's (1977) concept of self-efficacy and outcome expectancy appear to be the most common factors in the health promotion models we surveyed. Among theories of motivation, only self-determination theory specifically includes a motivation variable, autonomy (internal and external motivation). We developed a diagram to depict a model, including all the theories and models covered in this exploratory review and identify commonalities among their constructs. This diagram can be used by rehabilitation counsellors to apply theories and models of motivation in case conceptualisation, formulating clinical hypotheses, developing treatment plans, and selecting and implementing evidence-based health promotion interventions for their clients.

Introduction: Heart failure (HF) is a common ED presentation that is associated with significant morbidity and mortality. Despite recent evidence and recommendations for early palliative care (PC) involvement in these patients, they are still significantly under-served by PC services, often resulting in multiple ED visits. We sought to evaluate use of PC services in patients with HF presenting to the ED. Secondary objectives of the study were to investigate: 1) one year mortality, ED visits, and admissions; 2) application of a novel palliative care referral score. Methods: We conducted a health records review of 500 consecutive HF patients who presented to two academic hospital EDs. We included patients aged 65 years or older who were diagnosed as having a HF exacerbation by the emergency physician (ICD-10 code 150.-). Our primary outcome was PC involvement. Secondary outcomes included one year mortality rates, ED visits, admissions to hospital, as well as the application of a novel PC referral score developed by the institutional cardiac Palliative Care Committee. The score consisted of 6 different aspects of the patient’s illness, including laboratory tests, hospital usage, and markers of decompensation. We conducted appropriate univariate analyses. Results: Patients were mean age 80.7 years, women (53.2%), and had significant comorbidities (atrial fibrillation (51.2%), diabetes (40.4%) and COPD (20.8%)). Compared to those with no PC, the 79 (15.8%) patients with PC involvement had a higher one year mortality rate (70.9% vs. 18.8%, p<0.0001), more ED visits/year for HF (0.82 vs. 0.52, p<0.0001), and more hospital admissions/year for HF (1.4 vs. 0.85, p<0.0001). Using the heart failure palliative care score criteria, 60 patients had scores >=2. Compared to those with scores <2, these patients had a higher 1-year mortality rate (50% vs. 24%, p<0.0001) and more ED visits/year for HF (0.83 vs. 0.54, p<0.01). Only 40.0% of these high risk patients had any PC involvement. Conclusion: We found that few HF patients had PC services involved in their care. Using this novel HF palliative care referral score, we were able to identify patients with a significantly greater risk of mortality and morbidity. This study provides evidence that the ED is an appropriate setting to identify and refer high risk HF patients who would likely benefit from earlier PC involvement and may be a future avenue for PC access for these patients.

Introduction: Cognitive dysfunction is getting more common in geriatric emergency department (ED) patients, as the number of seniors visiting our EDs is increasing. ED guidelines recommend a systematic mental status screening for seniors presenting to the ED. As the existing tools are not suitable for the busy ED environment, we need quicker and easier ways to assess altered mental status, such as the O3DY. The purpose of this study is to assess the effectiveness of the French version of the O3DY to screen for cognitive dysfunction in seniors presenting to the ED. Methods: This is a planned sub-study of the INDEED project, which was conducted between February and May 2016 in 4 hospitals across the province of Québec. Inclusion criteria were: patients aged ≥65, with an 8-hour ED stay, admitted on a care unit, independent or semi-independent in their activities of daily living. Exclusion criteria were: patient living in a long-term nursing facility, with an unstable medical condition, pre-existing psychiatric condition or severe dementia, a delirium within the 8-hour exposure to the ED. A trained research assistant collected the following data upon initial interview: socio-demographic information, cognitive assessment (TICS-m), functional assessment (OARS) and delirium screening (CAM). The O3DY was also administered at initial interview and during patient follow-ups, as well as the CAM. Results: This study population was composed of 305 participants, of which 47.7% were men. Mean age was 76 years old (SD: 10.8). Nine of these participants had a previous history of dementia. 151 of these participants (47,04%) had a negative O3DY and 154 (47,98%) a positive O3DY at the initial encounter. When compared to the CAM, the O3DY presents a sensitivity of 85.0% (95% CI [62.1, 96.8]) and a specificity of 57.7% (95% CI [51.8, 63.6]) for prevalent delirium. When compared to the TICS, the O3DY presents a sensitivity of 76.7% (95% CI [66.4, 85.2]) and a specificity of 68.1% (95% CI [61.3, 74.3]) for cognitive impairment. The combined measure presents a sensitivity of 76.7% (95% CI [66.6, 84.9]) and a specificity of 68.4% (95% CI [61.7, 74.5]). Conclusion: A negative result to the O3DY indicates the absence of prevalent delirium or undetected cognitive impairment. The O3DY could be a useful tool for the triage nurses in the ED.

Background: Research has suggested that female athletes have a higher incidence of concussion compared to their male counterparts. As such, programs designed to improve knowledge and attitudes of concussion should target this high-risk population. Previous work demonstrated the effect of a novel Concussion-U educational presentation on knowledge and attitudes of concussion amongst male Bantam and Midget AAA hockey players. The objective of this study was to determine if the same presentation was effective in improving the knowledge and attitudes of concussion in a cohort of elite female hockey players. Methods: 26 elite female high-school aged (14-17) hockey players from the province of New Brunswick consented to participate in the study. Each participant completed a modified version of Rosenbaum and Arnett’s Concussion Knowledge and Attitudes Survey questionnaire immediately before and after a Concussion-U educational presentation. Results were compared across the two time-points to assess the effectiveness of the presentation. Results: Concussion knowledge and attitude scores significantly (p<.001) increased from pre-presentation to post-presentation by 12.5% and 13.4%, respectively. Conclusions: A Concussion-U educational presentation resulted in increased knowledge and improved attitudes towards concussion in elite female hockey players. Future research should examine the long-term retention of these improvements.

Background: Ataluren is the first drug to treat the underlying cause of nmDMD. Methods: Phase 2 and 3 studies of ataluren in nmDMD were reviewed, with efficacy and safety/tolerability findings summarized. Results: Ataluren nmDMD trials include: a Phase 2a proof-of-concept study (N=38); a Phase 2b randomized controlled trial (RCT) (N=174); an ongoing US-based open-label safety extension study (N=108); an ongoing non-US-based open-label safety/efficacy extension study (N=94); and a Phase 3 RCT, ACT DMD (N=228), whose primary endpoint was change in six-minute walk distance (6MWD) over 48 weeks. The proof-of-concept study demonstrated increased dystrophin production in post-treatment muscle biopsies from ataluren-treated patients with nmDMD. The Phase 2b results demonstrated an ataluren treatment effect in 6MWD, timed function tests, and other measures of physical functioning, The Phase 3 ACT DMD results demonstrated an ataluren treatment effect in patients with nmDMD in both primary and secondary endpoints, particularly in those with a baseline 6MWD of 300-400m. Ataluren was consistently well-tolerated in all three trials, as well as in the ongoing extension studies. Trial findings will be presented in detail. Conclusions: The totality of the results demonstrates that ataluren enables nonsense mutation readthrough in the dystrophin mRNA, producing functional dystrophin and slowing disease progression.

Supported by: PTC Therapeutics Inc.

Background: The diagnosis of a concussion is often dependent on the athlete self-reporting their symptoms. It has been suggested that improving athlete’s knowledge and attitudes towards concussions may increase self-reporting behavior; however, research in this area is inconclusive. The objective of this study is to determine if a Concussion-U educational presentation improves knowledge and attitudes of youth hockey players towards concussions. This is part of a larger study designed to determine the impact of an informational presentation on the knowledge and attitudes over a full hockey season. Methods: 56 elite male Bantam and Midget hockey players (mean age=14.52±1.13 years) were recruited from the local community. Each participant completed a modified version of Rosenbaum and Arnett’s Concussion Knowledge and Attitudes Survey (RoCKAS) questionnaire immediately before and after a Concussion-U educational presentation on the subject. Results: Concussion knowledge and attitude scores significantly (p<.001) increased from pre-presentation to post-presentation by 13.1% and 8.7%, respectively. Discussion: A Concussion-U educational presentation designed to improve concussion knowledge and attitudes in youth hockey players resulted in increased knowledge and improved attitudes towards concussion in elite male Bantam and Midget hockey players. Future research should examine the long-term effects of such presentations.

Obsessive-compulsive disorder (OCD) and related conditions (trichotillomania, pathological skin-picking, pathological nail-biting) are common and disabling. Current treatment approaches fail to help a significant proportion of patients. Multiple tiers of evidence link these conditions with underlying dysregulation of particular cortico-subcortical circuitry and monoamine systems, which represent targets for treatment. Animal models designed to capture aspects of these conditions are critical for several reasons. First, they help in furthering our understanding of neuroanatomical and neurochemical underpinnings of the obsessive-compulsive (OC) spectrum. Second, they help to account for the brain mechanisms by which existing treatments (pharmacotherapy, psychotherapy, deep brain stimulation) exert their beneficial effects on patients. Third, they inform the search for novel treatments. This article provides a critique of key animal models for selected OC spectrum disorders, beginning with initial work relating to anxiety, but moving on to recent developments in domains of genetic, pharmacological, cognitive, and ethological models. We find that there is a burgeoning literature in these areas with important ramifications, which are considered, along with salient future lines of research.

The very small number of known ferromagnetic superconductors places the study of such compounds at the frontier of superconductivity research. Recently, UCoGe has emerged as a new member of the class of materials exhibiting coexistence of ferromagnetism and superconductivity (Curie temperature TCurie = 3 K; superconducting critical temperature Ts = 0.8 K). This compound has generated much excitement, in part because it has been proposed that the superconductivity derives from spin triplet pairing mediated by ferromagnetic interactions. Therefore, a key question is how changes in the magnetic state of UCoGe affect the superconducting properties. We have carried out a comprehensive study of the UCo1-xFexGe and UCo1-xNixGe series of compounds across the entire range of composition 0 ≤ x ≤ 1. We report the results of x-ray diffraction, electrical resistivity, and magnetization measurements to elucidate the magnetic and superconducting phase diagram of the U[Fe, Co, Ni]Ge system. Substitution of either Ni or Fe into UCoGe initially results in an increase in the Curie temperature. At higher dopant concentrations (x), the ferromagnetic state crosses over to paramagnetism in UCo1-xFexGe and antiferromagnetism in UCo1-xNixGe.