We report a case of two-month old with a functionally univentricular heart and parallel circulation who presented to the emergency department with Covid-19 and subsequently developed acute respiratory distress syndrome. The course of illness, clinical values, and laboratory markers are characterized in this report.

The Adult Attachment Interview (AAI) is a widely used measure in developmental science that assesses adults’ current states of mind regarding early attachment-related experiences with their primary caregivers. The standard system for coding the AAI recommends classifying individuals categorically as having an autonomous, dismissing, preoccupied, or unresolved attachment state of mind. However, previous factor and taxometric analyses suggest that: (a) adults’ attachment states of mind are captured by two weakly correlated factors reflecting adults’ dismissing and preoccupied states of mind and (b) individual differences on these factors are continuously rather than categorically distributed. The current study revisited these suggestions about the latent structure of AAI scales by leveraging individual participant data from 40 studies (N = 3,218), with a particular focus on the controversial observation from prior factor analytic work that indicators of preoccupied states of mind and indicators of unresolved states of mind about loss and trauma loaded on a common factor. Confirmatory factor analyses indicated that: (a) a 2-factor model with weakly correlated dismissing and preoccupied factors and (b) a 3-factor model that further distinguished unresolved from preoccupied states of mind were both compatible with the data. The preoccupied and unresolved factors in the 3-factor model were highly correlated. Taxometric analyses suggested that individual differences in dismissing, preoccupied, and unresolved states of mind were more consistent with a continuous than a categorical model. The importance of additional tests of predictive validity of the various models is emphasized.

Self-assembly, a process in which molecules, polymers, and particles are driven by local interactions to organize into patterns and functional structures, is being exploited in advancing silicon electronics and in emerging, unconventional electronics. Silicon electronics has relied on lithographic patterning of polymer resists at progressively smaller lengths to scale down device dimensions. Yet, this has become increasingly difficult and costly. Assembly of block copolymers and colloidal nanoparticles allows resolution enhancement and the definition of essential shapes to pattern circuits and memory devices. As we look to a future in which electronics are integrated at large numbers and in new forms for the Internet of Things and wearable and implantable technologies, we also explore a broader material set. Semiconductor nanoparticles and biomolecules are prized for their size-, shape-, and composition-dependent properties and for their solution-based assembly and integration into devices that are enabling unconventional manufacturing and new device functions.

Background: Healthcare services are increasingly shifting from inpatient to outpatient settings. Outpatient settings such as emergency departments (EDs), oncology clinics, dialysis clinics, and day surgery often involve invasive procedures with the risk of acquiring healthcare-associated infections (HAIs). As a leading cause of HAI, Clostridioides difficile infection (CDI) in outpatient settings has not been sufficiently described in Canada. The Canadian Nosocomial Infection Surveillance Program (CNISP) aims to describe the epidemiology, molecular characterization, and antimicrobial susceptibility of outpatient CDI across Canada. Methods: Epidemiologic data were collected from patients diagnosed with CDI from a network of 47 adult and pediatric CNISP hospitals. Patients presenting to an outpatient setting such as the ED or outpatient clinics were considered as outpatient CDI. Cases were considered HAIs if the patient had had a healthcare intervention within the previous 4 weeks, and they were considered community-associated if there was no history of hospitalization within the previous 12 weeks. Clostridioides difficile isolates were submitted to the National Microbiology Laboratory for testing during an annual 2-month targeted surveillance period. National and regional rates of CDI were stratified by outpatient location. Results: Between January 1, 2015, and June 30, 2019, 2,691 cases of outpatient-CDI were reported, and 348 isolates were available for testing. Most cases (1,475 of 2,691, 54.8%) were identified in outpatient clinics, and 72.8% (1,960 of 2,691) were classified as community associated. CDI cases per 100,000 ED visits were highest in 2015, at 10.3, and decreased to 8.1 in 2018. Rates from outpatient clinics decreased from 3.5 in 2016 to 2.7 in 2018 (Fig. 1). Regionally, CDI rates in the ED declined in Central Canada and increased in the West after 2016. Rates in outpatient clinics were >2 times higher in the West compared to other regions. RT027 associated with NAP1 was most common among ED patients (26 of 195, 13.3%), whereas RT106 associated with NAP11 was predominant in outpatient clinics (22 of 189, 11.6%). Overall, 10.4% of isolates were resistant to moxifloxacin, 0.5% were resistant to rifampin, and 24.2% were resistant to clindamycin. No resistance was observed for metronidazole, vancomycin, or tigecycline. Compared to CNISP inpatient CDI data, outpatients with CDI were younger (51.8 ± 23.3 vs 64.2 ± 21.6; P < .001), included more females (56.4% vs 50.9%; P < .001), and were more often treated with metronidazole (63.0% vs 56.1%; P < .001). Conclusions: For the first time, CDI cases identified in outpatient settings were characterized in a Canadian context. Outpatient CDI rates are decreasing overall, but they vary by region. Predominant ribotypes vary based on outpatient location. Outpatients with CDI are younger and are more likely female than inpatients with CDI.

Funding: None

Disclosures: Susy Hota reports contract research for Finch Therapeutics.

This study estimates the incubation period of COVID-19 among locally transmitted cases, and its association with age to better inform public health measures in containing COVID-19. Epidemiological data of all PCR-confirmed COVID-19 cases from all restructured hospitals in Singapore were collected between 23 January 2020 and 2 April 2020. Activity mapping and detailed epidemiological investigation were conducted by trained personnel. Positive cases without clear exposure to another positive case were excluded from the analysis. One hundred and sixty-four cases (15.6% of patients) met the inclusion criteria during the defined period. The crude median incubation period was 5 days (range 1–12 days) and median age was 42 years (range 5–79 years). The median incubation period among those 70 years and older was significantly longer than those younger than 70 years (8 vis-à-vis 5 days, P = 0.040). Incubation period was negatively correlated with day of illness in both groups. These findings support current policies of 14-day quarantine periods for close contacts of confirmed cases and 28 days for monitoring infections in known clusters. An elderly person who may have a longer incubation period than a younger counterpart may benefit from earlier and proactive testing, especially after exposure to a positive case.

When leaders meet in person, they perform a wide range of interaction rituals. They dress for the occasion, greet each other and shake hands, exchange pleasantries and gifts, arrive at the meeting venue and have themselves seated according to protocol, and so on. What do they make of the performance of such rituals? In this paper, I argue that leaders often take advantage of or outright flout what the sociologist Erving Goffman calls the prevailing ‘ceremonial idiom’ of an interaction – that is the intersubjective understanding they share on what rituals to perform and how to perform them – to realize a number of political and personal objectives, with larger international consequences. The ‘ceremonial idiom’ is deliberately transgressed and a counterpart's ‘face’ threatened – overtly but more often subtly – to achieve what are commonly known as ‘one-upmanship’ and ‘putdowns’ in interpersonal contact. Empirically, I demonstrate my argument with over two dozen episodes of face-to-face diplomacy across six categories of interaction rituals: the identity of leaders, gestural, spatial–physical, task-embedded, linguistic, and communication rules. I also outline several directions for future research.

Background: In patients with acute hip fracture, a fascia iliaca compartment block (FICB) has been shown to provide effective non-opioid analgesia, reduce the incidence of pneumonia, and potentially decrease the rate of delirium [1]. However, this procedure was infrequently used in the St. Michael's Hospital (SMH) emergency department (ED). Aim Statement: Our aim was to increase the proportion of patients with hip fracture receiving FICB in the ED to 50% in six months. Measures & Design: We completed two Plan-Do-Study-Act (PDSA) cycles, measuring rates of FICB before and after each cycle. The first was a departmental rounds presentation with information about the process and benefits of FICB, addressing barriers identified by surveying the group. The second cycle included a bundle of interventions comprising of an “instruction card” with the steps required to do the procedure, access to a video tutorial, and a list of experienced physicians willing to help less experienced providers perform FICB. Evaluation/Results: In the three months prior to the project, the rate of FICB in the ED was 12.5% (3/24). For the three months after the first PDSA cycle, the rate increased to 22.2% (8/36). Then, the second cycle was performed. In the following two months the rate further increased to 36.8% (7/19). Discussion/Impact: Despite the clear increase in FICB rate, these changes were not statistically significant (p = 0.063). Our methodology was shown to be safe and effective, and our model can be applied to other ED groups looking to increase their rates of FICB.

Innovation Concept: The Calgary Audit and Feedback Framework (CAFF) is an innovative tool developed by the Physician Learning Program (PLP). By addressing four key factors –relationships, question choice, data visualization, and facilitation – CAFF addresses common barriers to physicians receiving their practice data. The goal of this study is to assess whether CAFF-facilitated physician performance improvement (PPI) sessions: 1) improve physicians’ receptiveness to their practice data, and 2) encourage physicians to both identify opportunities for practice change and create action plans. Methods: Peer facilitators were trained to facilitate PPI sessions using the CAFF model. In Calgary, 51/180 emergency physicians have attended at least one of the six PPI sessions. The sessions were evaluated using surveys, commitment to change forms, and the Feedback Orientation Scale (FOS). The FOS is a scale developed to measure a participant's orientation to performance feedback across the four domains of utility, accountability, social awareness, and feedback self-efficacy. Curriculum, Tool, or Material: The PLP has developed and implemented CAFF as a framework to help foster socially constructed learning in audit and group feedback sessions. The CAFF model ensures that the aforementioned four key factors are considered for design and implementation of audit and group feedback. The PLP found that establishing the meaning and credibility of the data is a necessary precursor to reflection and action planning. Conclusion: The FOS was completed for 25/32 physicians. The mean FOS score improved by 0.339 (p < 0.001; z=−3.863). While the mean scores all four domains increased, ‘Feedback Self-Efficacy’ increased the most by .0620 (p < 0.001; z=−3.999). Participants reported that examples of changes made by the peer facilitators were particularly helpful. Evaluations from the sessions suggested physicians overwhelmingly agreed or strongly agreed that the peer comparison was valuable, that the reports helped them reflect on their practice, and that the session helped them identify learning opportunities and strategies to change their practice.

Introduction: Providing comfort care support at home without transport to hospital has not traditionally been part of paramedic practice. The innovative Paramedics Providing Palliative Care at Home Program includes a new clinical practice guideline, medications, a database to share goals of care, and palliative care training. This study aimed to determine essential elements for scale and spread of this model of care through the application of an implementation science model, the Consolidated Framework for Implementation Research (CFIR). Methods: Deliberative dialogue sessions were held with paramedic, palliative care, primary care, and administrative experts in a province that had the Program (Nova Scotia, March 2018) and one that had not (British Columbia, July 2018). Sessions were audio recorded and transcribed. The CFIR was used as the foundation for a framework analysis, which was conducted by four team members independently. Themes were derived by consensus with the broader research team. Results: Inter-sectoral communication between paramedics and other health care providers was key, and challenging due to privacy concerns. Relationships with health care providers are critical to promoting the new model of care to patients, managing expectations, and providing follow up/ongoing care. Training was an essential characteristic of the intervention that can be adapted to suit local needs, although cost is a factor. There were challenges due to the culture and implementation climate as a shift in the mindset of paramedics away from traditional roles is required to implement the model. Paramedic champions can play an important role in shifting the mindset of paramedics towards a new way of practice Conclusion: The CFIR construct of cosmopolitanism, emphasizing the importance of breaking down silos and engaging diverse stakeholders, emerged as one of the most important. This will be helpful for successful scale and spread of the program.

Introduction: Physician metrics extracted from an electronic medical records (EMR) system can be utilized for practice improvement. One key metric analyzed at many emergency departments (EDs) is ‘patients per hour’ (pts/hr), a proxy for physician productivity. It is often believed that early-career physicians experience rapid growth in efficiency as they acclimatize to a hospital system and develop clinical confidence. This is the first study to evaluate the following question: Do early-career ED physicians increase their productivity when beginning practice? Methods: We performed a retrospective review of EMR data of early-career ED physicians working at one or more urban, academic centers. Early-career physicians must have started practice within three months of residency completion, and were identified by privileging records and provincial medical college registration. Physicians were excluded if they did not have at least 36 months of continuous data. Monthly productivity data (pts/hr) was extracted for each physician for their first 36-months of practice. A ‘performance curve’ or graph with a trendline of productivity as a moving average was created for each physician. Each performance curve was visually evaluated by two independent reviewers to qualitatively identify the general trend as upward, downward, or stable, with disagreements resolved by conference. Each physician's first and third year average productivity was compared quantitatively as well, with a significant upward or downward trend defined as a difference of at least 0.2 pts/hr. Results: A total of 41 physicians met the inclusion and exclusion criteria. Overall monthly pts/hr averages ranged from 1.08 to 7.65. Upon visual inspection, six (14.6%) physicians had upward trends, five (12.2%) had downward trends, and 30 (73.2%) had no discernable pattern. The quantitative analysis comparing first year to third year productivity matched the qualitative inspection exactly, with the same six physicians showing increased productivity, five with decreased, and 30 without significant change. Notably, the majority (30/41) of physicians demonstrated radical productivity variations over short periods with no discernable long-term trends. Conclusion: The majority of early career physicians do not demonstrate sustained early-career productivity changes. Of those that do, an approximately equal number will become faster and slower.