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Quality improvement and patient safety (QIPS) competencies are increasingly important in emergency medicine (EM) and are now included in the CanMEDS framework. We conducted a survey aimed at determining the Canadian EM residents’ perspectives on the level of QIPS education and support available to them.
An electronic survey was distributed to all Canadian EM residents from the Royal College and Family Medicine training streams. The survey consisted of multiple-choice, Likert, and free-text entry questions aimed at understanding familiarity with QIPS, local opportunities for QIPS projects and mentorship, and the desire for further QIPS education and involvement.
Of 535 EM residents, 189 (35.3%) completed the survey, representing all 17 medical schools; 77.2% of respondents were from the Royal College stream; 17.5% of respondents reported that QIPS methodologies were formally taught in their residency program; 54.7% of respondents reported being “somewhat” or “very” familiar with QIPS; 47.2% and 51.5% of respondents reported either “not knowing” or “not having readily available” opportunities for QIPS projects and QIPS mentorship, respectively; 66.9% of respondents indicated a desire for increased QIPS teaching; and 70.4% were interested in becoming involved with QIPS training and initiatives.
Many Canadian EM residents perceive a lack of QIPS educational opportunities and support in their local setting. They are interested in receiving more QIPS education, as well as project and mentorship opportunities. Supporting residents with a robust QIPS educational and mentorship framework may build a cohort of providers who can enhance the local delivery of care.
The role of silicon (Si) in alleviating the effects of biotic and abiotic stresses, including defence against insect herbivores, in plants is widely reported. Si defence against insect herbivores is overwhelmingly studied in grasses (especially the cereals), many of which are hyper-accumulators of Si. Despite being neglected, legumes such as soybean (Glycine max) have the capacity to control Si accumulation and benefit from increased Si supply. We tested how Si supplementation via potassium, sodium or calcium silicate affected a soybean pest, the native budworm Helicoverpa punctigera Wallengren (Lepidoptera: Noctuidae). Herbivory reduced leaf biomass similarly in Si-supplemented (+Si) and non-supplemented (–Si) plants (c. 29 and 23%, respectively) relative to herbivore-free plants. Both Si supplementation and herbivory increased leaf Si concentrations. In relative terms, herbivores induced Si uptake by c. 19% in both +Si and –Si plants. All Si treatments reduced H. punctigera relative growth rates (RGR) to a similar extent for potassium (−41%), sodium (−49%) and calcium (−48%) silicate. Moreover, there was a strong negative correlation between Si accumulation in leaves and herbivore RGR. To our knowledge, this is only the second report of Si-based herbivore defence in soybean; the rapid increase in leaf Si following herbivory being indicative of an induced defence. Taken together with the other benefits of Si supplementation of legumes, Si could prove an effective herbivore defence in legumes as well as grasses.
The RemoveDEBRIS mission has been the first mission to successfully demonstrate, in-orbit, a series of technologies that can be used for the active removal of space debris. The mission started late in 2014 and was sponsored by a grant from the EC that saw a consortium led by the Surrey Space Centre to develop the mission, from concept to in-orbit demonstrations, that terminated in March 2019. Technologies for the capture of large space debris, like a net and a harpoon, have been successfully tested together with hardware and software to retrieve data on non-cooperative target debris kinematics from observations carried out with on board cameras. The final demonstration consisted of the deployment of a drag-sail to increase the drag of the satellite to accelerate its demise.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
Background: Focal cortical dysplasias (FCDs) are congenital structural abnormalities of the brain, and represent the most common cause of medication-resistant focal epilepsy in children and adults. Recent studies have shown that somatic mutations (i.e. mutations arising in the embryo) in mTOR pathway genes underlie some FCD cases. Specific therapies targeting the mTOR pathway are available. However, testing for somatic mTOR pathway mutations in FCD tissue is not performed on a clinical basis, and the contribution of such mutations to the pathogenesis of FCD remains unknown. Aim: To investigate the feasibility of screening for somatic mutations in resected FCD tissue and determine the proportion and spatial distribution of FCDs which are due to low-level somatic mTOR pathway mutations. Methods: We performed ultra-deep sequencing of 13 mTOR pathway genes using a custom HaloPlexHS target enrichment kit (Agilent Technologies) in 16 resected histologically-confirmed FCD specimens. Results: We identified causal variants in 62.5% (10/16) of patients at an alternate allele frequency of 0.75–33.7%. The spatial mutation frequency correlated with the FCD lesion’s size and severity. Conclusions: Screening FCD tissue using a custom panel results in a high yield, and should be considered clinically given the important potential implications regarding surgical resection, medical management and genetic counselling.
Background: Cervical sponylotic myelopathy (CSM) may present with neck and arm pain. This study investiagtes the change in neck/arm pain post-operatively in CSM. Methods: This ambispective study llocated 402 patients through the Canadian Spine Outcomes and Research Network. Outcome measures were the visual analogue scales for neck and arm pain (VAS-NP and VAS-AP) and the neck disability index (NDI). The thresholds for minimum clinically important differences (MCIDs) for VAS-NP and VAS-AP were determined to be 2.6 and 4.1. Results: VAS-NP improved from mean of 5.6±2.9 to 3.8±2.7 at 12 months (P<0.001). VAS-AP improved from 5.8±2.9 to 3.5±3.0 at 12 months (P<0.001). The MCIDs for VAS-NP and VAS-AP were also reached at 12 months. Based on the NDI, patients were grouped into those with mild pain/no pain (33%) versus moderate/severe pain (67%). At 3 months, a significantly high proportion of patients with moderate/severe pain (45.8%) demonstrated an improvement into mild/no pain, whereas 27.2% with mild/no pain demonstrated worsening into moderate/severe pain (P <0.001). At 12 months, 17.4% with mild/no pain experienced worsening of their NDI (P<0.001). Conclusions: This study suggests that neck and arm pain responds to surgical decompression in patients with CSM and reaches the MCIDs for VAS-AP and VAS-NP at 12 months.
The Royal College of Physicians and Surgeons of Canada (RCPSC) emergency medicine (EM) programs transitioned to the Competence by Design training framework in July 2018. Prior to this transition, a nation-wide survey was conducted to gain a better understanding of EM faculty and senior resident attitudes towards the implementation of this new program of assessment.
A multi-site, cross-sectional needs assessment survey was conducted. We aimed to document perceptions about competency-based medical education, attitudes towards implementation, perceived/prompted/unperceived faculty development needs. EM faculty and senior residents were nominated by program directors across RCPSC EM programs. Simple descriptive statistics were used to analyse the data.
Between February and April 2018, 47 participants completed the survey (58.8% response rate). Most respondents (89.4%) thought learners should receive feedback during every shift; 55.3% felt that they provided adequate feedback. Many respondents (78.7%) felt that the ED would allow for direct observation, and most (91.5%) participants were confident that they could incorporate workplace-based assessments (WBAs). Although a fair number of respondents (44.7%) felt that Competence by Design would not impact patient care, some (17.0%) were worried that it may negatively impact it. Perceived faculty development priorities included feedback delivery, completing WBAs, and resident promotion decisions.
RCPSC EM faculty have positive attitudes towards competency-based medical education-relevant concepts such as feedback and opportunities for direct observation via WBAs. Perceived threats to Competence by Design implementation included concerns that patient care and trainee education might be negatively impacted. Faculty development should concentrate on further developing supervisors’ teaching skills, focusing on feedback using WBAs.
Introduction: There is increasing evidence to support the integration of simulation into medical training; however, no national emergency medicine (EM) simulation curriculum currently exists. Using Delphi methodology, we aimed to identify and establish content validity evidence for EM curricular content best suited for simulation-based training to inform national postgraduate EM training. Methods: A national panel of experts in EM simulation-related education iteratively rated potential curricular topics, on a 4-point scale, to determine those best suited for simulation-based training. After each round, responses were analyzed and topics scoring <2/4 were removed. Remaining topics were resent to the panel for further ratings until consensus was achieved, defined as Cronbach α ≥ 0.95. At conclusion of the Delphi process, topics that were rated ≥3.5/4 were considered core curricular topics, while those rated 3.0-3.5 were considered extended curricular topics. Results: Forty-four experts from 13 Canadian centres participated. Two hundred and eighty potential curricular topics, in 29 domains, were generated from a systematic review of the literature, analysis of relevant educational documents and a survey of Delphi panelists. Three rounds of Delphi surveys were completed before consensus was achieved, with response rates ranging from 93-100%. Twenty-eight topics, in 8 domains, reached consensus as core curricular topics. An additional 35 topics, in 14 domains, reached consensus as extended curricular topics. Conclusion: Delphi methodology allowed for achievement of expert consensus and content validation of EM curricular content best suited for simulation-based training. These results provide a foundation for improved integration of simulation into postgraduate EM training and can be used to inform a national simulation curriculum to supplement clinical training and optimize learning.
Introduction: Simulation has assumed an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High quality simulation-based research (SBR) is required to ensure the effective and efficient use of this tool. This study sought to establish national SBR priorities and describe the barriers and facilitators of SBR in Emergency Medicine (EM) in Canada. Methods: Simulation leads (SLs) from all fourteen Canadian Departments or Divisions of EM associated with an adult FRCP-EM training program were invited to participate in three surveys and a final consensus meeting. The first survey documented active EM SBR projects. Rounds two and three established and ranked priorities for SBR and identified the perceived barriers and facilitators to SBR at each site. Surveys were completed by SLs at each participating institution, and priority research themes were reviewed by senior faculty for broad input and review. Results: Twenty SLs representing all 14 invited institutions participated in all three rounds of the study. 60 active SBR projects were identified, an average of 4.3 per institution (range 0-17). 49 priorities for SBR in Canada were defined and summarized into seven priority research themes. An additional theme was identified by the senior reviewing faculty. 41 barriers and 34 facilitators of SBR were identified and grouped by theme. Fourteen SLs representing 12 institutions attended the consensus meeting and vetted the final list of eight priority research themes for SBR in Canada: simulation in CBME, simulation for interdisciplinary and inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology. Conclusion: Conclusion: This study has summarized the current SBR activity in EM in Canada, as well as its perceived barriers and facilitators. We also provide a consensus on priority research themes in SBR in EM from the perspective of Canadian simulation leaders. This group of SLs has formed a national simulation-based research group which aims to address these identified priorities with multicenter collaborative studies.
Shiga-toxin producing Escherichia coli (STEC) is a pathogen that can cause bloody diarrhoea and severe complications. Cases occur sporadically but outbreaks are also common. Understanding the incubation period distribution and factors influencing it will help in the investigation of exposures and consequent disease control. We extracted individual patient data for STEC cases associated with outbreaks with a known source of exposure in England and Wales. The incubation period was derived and cases were described according to patient and outbreak characteristics. We tested for heterogeneity in reported incubation period between outbreaks and described the pattern of heterogeneity. We employed a multi-level regression model to examine the relationship between patient characteristics such as age, gender and reported symptoms; and outbreak characteristics such as mode of transmission with the incubation period. A total of 205 cases from 41 outbreaks were included in the study, of which 64 cases (31%) were from a single outbreak. The median incubation period was 4 days. Cases reporting bloody diarrhoea reported shorter incubation periods compared with cases without bloody diarrhoea, and likewise, cases aged between 40 and 59 years reported shorter incubation period compared with other age groups. It is recommended that public health officials consider the characteristics of cases involved in an outbreak in order to inform the outbreak investigation and the period of exposure to be investigated.
The leaf-eating caterpillar, Opisina arenosella Walker, is the most destructive pest of coconut palm in India and Southeast Asia. The management practices employed against O. arenosella so far have been unsuccessful in many instances in India, due to the pest behaviour and coconut palm phenology. The life cycle, incidence and behaviour of O. arenosella are rather interesting and useful for the intervention of pheromone trapping technique for its management. We conducted the present study with the intention of identifying the female sex pheromone of O. arenosella and testing its efficacy under field conditions. Gas chromatography coupled electroantennographic detection (GC–EAD) and gas chromatography–mass spectrometry (GC–MS) analysis of female pheromone glands extract of one-day-old O. arenosella females confirmed the presence of (Z,Z,Z)-3,6,9-tricosatriene (Z3Z6Z9-23Hy) as the dominant sex pheromone component. The male antennal response to female pheromone gland extract and synthetic Z3Z6Z9-23Hy was recorded using GC–EAD, and the results revealed that antennal response was positive to both the treatments at 0.13 mV and 0.14 mV respectively, compared to control (air), which was 0.016 mV. It was also evident from wind-tunnel experiments that the male moth response was high (80%) with the female gland extract, compared to 60% with synthetic pheromone and 0% for control (air). Male moths caught in the traps with and without lure were assessed in two field sites and recorded 69.26% and 54.25% more moth catches in the traps with the lure. We also observed a similar result in the cage experiment in which male moths caught in the traps with and without lure were 64.50% and 12.40%, respectively. The study also confirmed that 93.20% moths caught in the pheromone-baited traps were male. From the study, it is evident that the presence of (Z,Z,Z)-3,6,9-tricosatriene, which is the sex pheromone compound from the female gland extract of O. arenosella, is an effective attractant in pheromone traps for the male moth under field conditions.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.
The flora of Laos remains one of the least known within the Indo-Burma biodiversity hotspot. A floristic inventory was carried out in Phou Hin Poun National Biodiversity Conservation Area, an under-explored area of the Khammouane Limestone. This study provides a list of 27 taxa that are additions to the most recent country checklists. The Ebenaceae, Euphorbiaceae and Myrtaceae are the families with the highest species number. In this list, four species are endemic to Indochina (Cambodia, Laos and Vietnam): Cynometra dongnaiensis Pierre, Jasminum vidalii P.S.Green, Memecylon chevalieri Guillaumin and Pothos gigantipes Buchet ex P.C.Boyce. These results illustrate the paucity of our knowledge of the region surveyed and of the flora of Laos in general.
A range of endophenotypes characterise psychosis, however there has been limited work understanding if and how they are inter-related.
This multi-centre study includes 8754 participants: 2212 people with a psychotic disorder, 1487 unaffected relatives of probands, and 5055 healthy controls. We investigated cognition [digit span (N = 3127), block design (N = 5491), and the Rey Auditory Verbal Learning Test (N = 3543)], electrophysiology [P300 amplitude and latency (N = 1102)], and neuroanatomy [lateral ventricular volume (N = 1721)]. We used linear regression to assess the interrelationships between endophenotypes.
The P300 amplitude and latency were not associated (regression coef. −0.06, 95% CI −0.12 to 0.01, p = 0.060), and P300 amplitude was positively associated with block design (coef. 0.19, 95% CI 0.10–0.28, p < 0.001). There was no evidence of associations between lateral ventricular volume and the other measures (all p > 0.38). All the cognitive endophenotypes were associated with each other in the expected directions (all p < 0.001). Lastly, the relationships between pairs of endophenotypes were consistent in all three participant groups, differing for some of the cognitive pairings only in the strengths of the relationships.
The P300 amplitude and latency are independent endophenotypes; the former indexing spatial visualisation and working memory, and the latter is hypothesised to index basic processing speed. Individuals with psychotic illnesses, their unaffected relatives, and healthy controls all show similar patterns of associations between endophenotypes, endorsing the theory of a continuum of psychosis liability across the population.
As chemical management options for weeds become increasingly limited due to selection for herbicide resistance, investigation of additional nonchemical tools becomes necessary. Harvest weed seed control (HWSC) is a methodology of weed management that targets and destroys weed seeds that are otherwise dispersed by harvesters following threshing. It is not known whether problem weeds in western Canada retain their seeds in sufficient quantities until harvest at a height suitable for collection. A study was conducted at three sites over 2 yr to determine whether retention and height criteria were met by wild oat, false cleavers, and volunteer canola. Wild oat consistently shed seeds early, but seed retention was variable, averaging 56% at the time of wheat swathing, with continued losses until direct harvest of wheat and fababean. The majority of retained seeds were >45 cm above ground level, suitable for collection. Cleavers seed retention was highly variable by site-year, but generally greater than wild oat. The majority of seed was retained >15 cm above ground level and would be considered collectable. Canola seed typically had >95% retention, with the majority of seed retained >15 cm above ground level. The suitability ranking of the species for management with HWSC was canola>cleavers>wild oat. Efficacy of HWSC systems in western Canada will depend on the target species and site- and year-specific environmental conditions.
Accurate knowledge of pathogen incubation period is essential to inform public health policies and implement interventions that contribute to the reduction of burden of disease. The incubation period distribution of campylobacteriosis is currently unknown with several sources reporting different times. Variation in the distribution could be expected due to host, transmission vehicle, and organism characteristics, however, the extent of this variation and influencing factors are unclear. The authors have undertaken a systematic review of published literature of outbreak studies with well-defined point source exposures and human experimental studies to estimate the distribution of incubation period and also identify and explain the variation in the distribution between studies. We tested for heterogeneity using I2 and Kolmogorov–Smirnov tests, regressed incubation period against possible explanatory factors, and used hierarchical clustering analysis to define subgroups of studies without evidence of heterogeneity. The mean incubation period of subgroups ranged from 2·5 to 4·3 days. We observed variation in the distribution of incubation period between studies that was not due to chance. A significant association between the mean incubation period and age distribution was observed with outbreaks involving only children reporting an incubation of 1·29 days longer when compared with outbreaks involving other age groups.