Introduction: Quality improvement and patient safety (QIPS) are increasingly recognized as integral to the provision and advancement of emergency medicine (EM) care. In 2015, QIPS were added to the Canadian Medical Education Directives for Specialists (CanMEDS) framework. However, the level of QIPS education and support that Canadian EM residents receive is unknown. In order to better plan national QIPS efforts aimed at enabling EM residents to improve their local care settings, we sought to assess the current state of QIPS education and support in Canadian EM residency programs. Methods: This was a descriptive, cross-sectional electronic survey that was disseminated to all current Canadian EM residents from both Royal College (RC) and Family Medicine - EM training streams. Residents were recruited either directly or through their program's administrative assistant. The survey consisted of multiple-choice, Likert and free-text entry questions. Themes included a) familiarity with QIPS; b) local opportunities for QIPS projects and mentorship; and c) desire for further QIPS education and involvement. The survey was open for a five-week period, with formal reminders after the first and third weeks. Descriptive statistics are reported. Results: 189 (35%) of 535 current EM residents completed the survey, representing all 17 medical schools. 77% of respondents were from the RC stream. 54.7% of respondents reported being “somewhat” or “very” familiar with QIPS. 47.2% of respondents reported “not knowing” or “not having readily available” QIPS projects to participate in their local environment, and 51.5% had equivalent responses with respect to QIPS mentorship opportunities. Only 17.5% of respondents reported that QIPS methodologies were already formally taught in their residency program, and 66.9% indicated a desire for increased QIPS teaching. The majority of respondents were “slightly” (35.9%), “moderately” (23.2%) or “very” (11.3%) interested in becoming involved with QIPS training and initiatives. Conclusion: Responding Canadian EM residents are interested in obtaining greater QIPS education as well as project and mentorship opportunities, but many perceive that they do not have adequate access to these at the current time. As the importance of QIPS increases in the EM community, supporting residents with more robust educational infrastructures may be necessary. Future efforts may include the standardizing of QIPS postgraduate curricula and improving access to QIPS opportunities across the country.

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.

This paper summarises developments in understanding sea level change during the Quaternary in Scotland since the publication of the Quaternary of Scotland Geological Conservation Review volume in 1993. We present a review of progress in methodology, particularly in the study of sediments in isolation basins and estuaries as well as in techniques in the field and laboratory, which have together disclosed greater detail in the record of relative sea level (RSL) change than was available in 1993. However, progress in determining the record of RSL change varies in different areas. Studies of sediments and stratigraphy offshore on the continental shelf have increased greatly, but the record of RSL change there remains patchy. Studies onshore have resulted in improvements in the knowledge of rock shorelines, including the processes by which they are formed, but much remains to be understood. Studies of Late Devensian and Holocene RSLs around present coasts have improved knowledge of both the extent and age range of the evidence. The record of RSL change on the W and NW coasts has disclosed a much longer dated RSL record than was available before 1993, possibly with evidence of Meltwater Pulse 1A, while studies in estuaries on the E and SW coasts have disclosed widespread and consistent fluctuations in Holocene RSLs. Evidence for the meltwater pulse associated with the Early Holocene discharge of Lakes Agassiz–Ojibway in N America has been found on both E and W coasts. The effects of the impact of storminess, in particular in cliff-top storm deposits, have been widely identified. Further information on the Holocene Storegga Slide tsunami has enabled a better understanding of the event, but evidence for other tsunami events on Scottish coasts remains uncertain. Methodological developments have led to new reconstructions of RSL change for the last 2000 years, utilising state-of-the-art GIA models and alongside coastal biostratigraphy to determine trends to compare with modern tide gauge and documentary evidence. Developments in GIA modelling have provided valuable information on patterns of land uplift during and following deglaciation. The studies undertaken raise a number of research questions which will require addressing in future work.

Dynamic surficial changes and changes in the position of the firn line and the areal extent of Hofsjökull ice cap, Iceland, were studied through analysis of a time series (1973–98) of synthetic-aperture radar (SAR) and Landsat data. A digital elevation model of Hofsjökull, which was constructed using SAR interferometry, was used to plot the SAR backscatter coefficient (σ°) vs elevation and air temperature along transects across the ice cap. Seasonal and daily σ° patterns are caused by freezing or thawing of the ice-cap surface, and abrupt changes in σ° are noted when the air temperature ranges from ∼−5° to 0°C. Late-summer 1997 σ° (SAR) and reflectance (Landsat) boundaries agree and appear to be coincident with the firn line and a SAR σ° boundary that can be seen in the January 1998 SAR image. In January 1994 through 1998, the elevation of this σ° boundary on the ice cap was quite stable, ranging from 1000 to 1300 m, while the equilibrium-line altitude, as measured on the ground, varied considerably. Thus the equilibrium line may be obscured by firn from previous years. Techniques are established to measure long-term changes in the elevation of the firn line and changes in the position of the ice margin.

A pulse is a type of unstable glacier flow intermediate between normal flow and surging. Using Landsat MSS, TM and ETM+ imagery and feature-tracking software, a time series of mostly annual velocity maps from 1973 to 2012 was produced that reveals five pulses of Ruth Glacier, Alaska. Peaks in ice velocity were found in 1981, 1989, 1997, 2003 and 2010, approximately every 7 years. During these peak years the ice velocity increased 300%, from approximately 40 m a–1 to 160 m a–1. Based on the spatio-temporal behavior of Ruth Glacier during the pulse cycles, we suggest the pulses are due to enhanced basal motion via deformation of a subglacial till. The cyclical nature of the pulses is interpreted to be due to a thin till, with low permeability, that causes incomplete drainage of the till between the pulses, followed by eventual recharge and dilation of the till. These findings suggest care is needed when attempting to correlate changes in regional climate with decadal-scale changes in velocity, because in some instances basal conditions may have a greater influence on ice dynamics than climate.

Unusual speleothems, associated with hyperalkaline (pH > 12) groundwaters have formed within a shallow, abandoned railway tunnel at Peak Dale, Derbyshire, UK. The hyperalkaline groundwaters are produced by the leaching of a thin layer (<2 m) of old lime-kiln waste on the soil-bedrock surface above the tunnel by rainwater. This results in a different reaction and chemical process to that more commonly associated with the formation of calcium carbonate speleothems from Ca-HCO3-type groundwaters and degassing of CO2. Stalagmites within the Peak Daletunnel have grown rapidly (averaging 33 mm y–1), following the closure of the tunnel 70 years ago. They have an unusual morphology comprising a central sub-horizontally-laminated column of micro- to nano-crystalline calcium carbonate encompassed by an outer sub-vertical assymetricripple-laminated layer. The stalagmites are composed largely of secondary calcite forming pseudomorphs (<1 mm) that we believe to be predominantly after the 'cold climate' calcium carbonate polymorph, ikaite (calcium carbonate hexahydrate: CaCO3·6H2O), withminor volumes of small (<5 μm) pseudomorphs after vaterite. The tunnel has a near constant temperature of 8–9°C, which is slightly above the previously published crystallization temperatures for ikaite (<6°C). Analysis of a stalagmite actively growing at the time ofsampling, and preserved immediately within a dry nitrogen cryogenic vessel, indicates that following crystallization of ikaite, decomposition to calcite occurs rapidly, if not instantaneously. We believe this is the first occurrence of this calcium carbonate polymorph observed within speleothems.

The evolution of four dynamic radar glacier zones at the surface of an alpine icefield in British Columbia is monitored using a time series of 35 First European Remote Sensing Satellite (ERS-1) synthetic aperture radar (SAR) images acquired from 1992 to 1994. These zones result from changing wetness and textural properties, and appear to represent: (1) cold snow with no liquid water present; (2) an initial melt front with an upper boundary near the elevation of the 0° isotherm; (3) metamorphosed, rapidly melting first-year snow with a rough or pitted surface; and (4) bare ice. This interpretation is aided by temperature and runoff data, air photographs and field measurements of snowpack properties acquired with two ERS-1 SAR scenes, ice-surface elevations derived from 1:50 000 topographic maps and simulations of radar backscatter from a geometric optics model of surface scattering. Meltwater production is affected by the development of zones (2), (3) and (4), which form, migrate up-elevation and disappear each year between April and September.

The Antarctic Roadmap Challenges (ARC) project identified critical requirements to deliver high priority Antarctic research in the 21st century. The ARC project addressed the challenges of enabling technologies, facilitating access, providing logistics and infrastructure, and capitalizing on international co-operation. Technological requirements include: i) innovative automated in situ observing systems, sensors and interoperable platforms (including power demands), ii) realistic and holistic numerical models, iii) enhanced remote sensing and sensors, iv) expanded sample collection and retrieval technologies, and v) greater cyber-infrastructure to process ‘big data’ collection, transmission and analyses while promoting data accessibility. These technologies must be widely available, performance and reliability must be improved and technologies used elsewhere must be applied to the Antarctic. Considerable Antarctic research is field-based, making access to vital geographical targets essential. Future research will require continent- and ocean-wide environmentally responsible access to coastal and interior Antarctica and the Southern Ocean. Year-round access is indispensable. The cost of future Antarctic science is great but there are opportunities for all to participate commensurate with national resources, expertise and interests. The scope of future Antarctic research will necessitate enhanced and inventive interdisciplinary and international collaborations. The full promise of Antarctic science will only be realized if nations act together.

Skin and soft tissue infections (SSTIs) due to Staphylococcus aureus have become increasingly common in the outpatient setting; however, risk factors for differentiating methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) SSTIs are needed to better inform antibiotic treatment decisions. We performed a case-case-control study within 14 primary-care clinics in South Texas from 2007 to 2015. Overall, 325 patients [S. aureus SSTI cases (case group 1, n = 175); MRSA SSTI cases (case group 2, n = 115); MSSA SSTI cases (case group 3, n = 60); uninfected control group (control, n = 150)] were evaluated. Each case group was compared to the control group, and then qualitatively contrasted to identify unique risk factors associated with S. aureus, MRSA, and MSSA SSTIs. Overall, prior SSTIs [adjusted odds ratio (aOR) 7·60, 95% confidence interval (CI) 3·31–17·45], male gender (aOR 1·74, 95% CI 1·06–2·85), and absence of healthcare occupation status (aOR 0·14, 95% CI 0·03–0·68) were independently associated with S. aureus SSTIs. The only unique risk factor for community-associated (CA)-MRSA SSTIs was a high body weight (⩾110 kg) (aOR 2·03, 95% CI 1·01–4·09).

Introduction: Point of care ultrasound has become an established tool in the initial management of patients with undifferentiated hypotension. Current established protocols (RUSH, ACES, etc) were developed by expert user opinion, rather than objective, prospective data. We wished to use reported disease incidence to develop an informed approach to PoCUS in hypotension using a “4 F’s” approach: Fluid; Form; Function; Filling. Methods: We summarized the incidence of PoCUS findings from an international multicentre RCT, and using a modified Delphi approach incorporating this data we obtained the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. The modified Delphi tool was developed to reach an international consensus on how to integrate PoCUS for hypotensive emergency department patients. Results: Rates of abnormal PoCUS findings from 151 patients with undifferentiated hypotension included left ventricular dynamic changes (43%), IVC abnormalities (27%), pericardial effusion (16%), and pleural fluid (8%). Abdominal pathology was rare (fluid 5%, AAA 2%). After two rounds of the survey, using majority consensus, agreement was reached on a SHoC-hypotension protocol comprising: A. Core: 1. Cardiac views (Sub-xiphoid and parasternal windows for pericardial fluid, cardiac form and ventricular function); 2. Lung views for pleural fluid and B-lines for filling status; and 3. IVC views for filling status; B. Supplementary: Additional cardiac views; and C. Additional views (when indicated) including peritoneal fluid, aorta, pelvic for IUP, and proximal leg veins for DVT. Conclusion: An international consensus process based on prospectively collected disease incidence has led to a proposed SHoC-hypotension PoCUS protocol comprising a stepwise clinical-indication based approach of Core, Supplementary and Additional PoCUS views.

Introduction: Point of care ultrasound (PoCUS) provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We consider that a consensus-based priority checklist using a “4 F’s” approach (Fluid; Form; Function; Filling), would provide a better algorithm during ACLS. Methods: The ultrasound subcommittee of the Australasian College for Emergency Medicine (ACEM) drafted a checklist incorporating PoCUS into the ACLS algorithm. This was further developed using the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. A modified Delphi tool was developed to reach an international consensus on how to integrate ultrasound into cardiac arrest algorithms for emergency department patients. Results: Consensus was reached following 3 rounds. The agreed protocol focuses on the timing of PoCUS as well as the specific clinical questions. Core cardiac windows performed during the rhythm check pause in chest compressions are the sub-xiphoid and parasternal cardiac views. Either view should be used to detect pericardial fluid, as well as examining ventricular form (e.g. right heart strain) and function, (e.g. asystole versus organized cardiac activity). Supplementary views include lung views (for absent lung sliding in pneumothorax and for pleural fluid), and IVC views for filling. Additional ultrasound applications are for endotracheal tube confirmation, proximal leg veins for DVT, or for sources of blood loss (AAA, peritoneal/pelvic fluid). Conclusion: The authors hope that this process will lead to a consensus-based SHoC-cardiac arrest guideline on incorporating PoCUS into the ACLS algorithm.

Our knowledge of the universe comes from recording the photon and particle fluxes incident on the Earth from space. We thus require sensitive measurement across the entire energy spectrum, using large telescopes with efficient instrumentation located on superb sites. Technological advances and engineering constraints are nearing the point where we are recording as many photons arriving at a site as is possible. Major advances in the future will come from improving the quality of the site. The ultimate site is, of course, beyond the Earth’s atmosphere, such as on the Moon, but economic limitations prevent our exploiting this avenue to the degree that the scientific community desires. Here we describe an alternative, which offers many of the advantages of space for a fraction of the cost: the Antarctic Plateau.