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Although testing is widely regarded as critical to fighting the COVID-19 pandemic, what measure and level of testing best reflects successful infection control remains unresolved. Our aim was to compare the sensitivity of two testing metrics – population testing number and testing coverage – to population mortality outcomes and identify a benchmark for testing adequacy. We aggregated publicly available data through 12 April on testing and outcomes related to COVID-19 across 36 OECD (Organization for Economic Development) countries and Taiwan. Spearman correlation coefficients were calculated between the aforementioned metrics and following outcome measures: deaths per 1 million people, case fatality rate and case proportion of critical illness. Fractional polynomials were used to generate scatter plots to model the relationship between the testing metrics and outcomes. We found that testing coverage, but not population testing number, was highly correlated with population mortality (rs = −0.79, P = 5.975 × 10−9vs. rs = −0.3, P = 0.05) and case fatality rate (rs = −0.67, P = 9.067 × 10−6vs. rs = −0.21, P = 0.20). A testing coverage threshold of 15–45 signified adequate testing: below 15, testing coverage was associated with exponentially increasing population mortality; above 45, increased testing did not yield significant incremental mortality benefit. Taken together, testing coverage was better than population testing number in explaining country performance and can serve as an early and sensitive indicator of testing adequacy and disease burden.
Dense, small particles suspended in turbulent smooth-wall flow are known to migrate towards the wall. It is, however, not clear if the particle migration continues in a rough-wall flow and what the responsible mechanism is, especially with changing roughness parameters. Here, we address this using direct numerical simulation of a turbulent pipe flow of a fixed friction Reynolds numbers and changing the roughness size as well as the Stokes number of the particles. The transport and deposition mechanisms of particles are segregated into three different regimes dictated by the Stokes number. Particles with small Stokes number follow the carrier fluid and are affected by the turbulent structures of the rough wall. Flow separation in the wake of the roughness and stagnant flow in the trough of the roughness causes these particles to be trapped in the roughness canopy. Particles with very large Stokes number, on the other hand, are attracted to the wall due to turbophoresis and collide with the rough wall where the frequency of wall collision increases with increasing Stokes number. These ballistic particles are unaffected by the turbulent fluctuations of the flow and their trajectory is determined by the roughness topography. At intermediate Stokes numbers, the transport of the particles is influenced by both the wall collisions and also the turbulent flow. Particles in this range of Stokes number occasionally collide with the wall and are entrained by the turbulent flow. In this regime, the particles may have a mean streamwise velocity that is larger than the bulk flow rate of the fluid. Finally, we observe that bulk particle velocity scale better with a time scale based on the roughness elements rather than the usual viscous time scale.
This chapter examines the psychology of women in entrepreneurship and reviews research from Western and non-Western perspectives. As more women are attracted to engaging in entrepreneurship worldwide, understanding this phenomenon would be of academic and practical relevance. In particular, we focus on discussing some of the stereotypes and characteristics associated with entrepreneurs, entrepreneurial intentions and motivations, and the challenges of gathering financial resources. In the final part of the chapter, we propose several future research directions. There are numerous opportunities to increase our knowledge on women’s entrepreneurship from a psychological and cross-cultural perspective.
Innovation Concept: EM Sim Cases is an innovative, open-access website that was created in 2015 to publish medical simulation resources including standardized, peer-reviewed simulation cases. Herein we describe our interim analysis. Methods: We performed a massive online needs assessment using a methodology previously described by Chan et. al. to determine how we can shape EM Sim Cases to meet the needs of learners and educators who use it. We engaged with simulation experts from the Emergency Medicine Simulation Education Research Collaborative to design a Google Forms survey using best practices in survey design. We distributed the survey to our target community of practice via Twitter, email, and a blog post published on emsimcases.com. Curriculum, Tool, or Material: We received 81 responses from simulation educators representing 8 medical specialties and 13 countries. Most survey respondents identified themselves as staff physicians (n = 44) and specialized in emergency medicine (n = 39). They had 0-21+ years of experience. 37% of respondents (n = 30) stated that material from EM Sim Cases makes up 25% or more of their simulation curriculum. Several respondents noted that using this content made them feel more confident and more current. Respondents praised EM Sim Cases for a well-organized case format, the proper level of detail, consistency between case designs, and the wide variety of cases. Suggested improvements included an opportunity to directly comment on cases and more cases in pediatric, rural, and advanced airway management situations. Suggestions were made to improve the navigability of the website. Respondents wanted to see additional blog content on debriefing strategies and self-made task/skill trainers. Conclusion: EM Sim Cases is a novel, free open-access simulation resource. Using a massive online needs assessment we were able to determine future directions including case topics, website reorganization, and educational material. We were also able to capture how impactful a resource like this can be to clinical and educational practice outside of the simulation setting.
Introduction: In 2018, Canadian postgraduate specialist Emergency Medicine (EM) programs began implementing a competency-based medical education (CBME) assessment system. To support improvement of this assessment program, we sought to evaluate its short-term educational outcomes nationally and within individual programs. Methods: Program-level data from the 2018 resident cohort were amalgamated and analyzed. The number of Entrustable Professional Activity (EPA) assessments (overall and for each EPA) and the timing of resident promotion through program stages was compared between programs and to the guidelines provided by the national EM specialty committee. Total EPA observations from each program were correlated with the number of EM and pediatric EM rotations. Results: Data from 15 of 17 (88.2%) EM programs containing 9,842 EPA observations from 68 of the 77 (88.3%) Canadian EM specialist residents in the 2018 cohort were analyzed. The average number of EPAs observed per resident in each program varied from 92.5 to 229.6 and correlated strongly with the number of blocks spent on EM and pediatric EM (r = 0.83, p < 0.001). Relative to the guidelines outlined by the specialty committee, residents were promoted later than expected and with fewer EPA observations than suggested. Conclusion: We present a new approach to the amalgamation of national and program-level assessment data. There was demonstrable variation in both EPA-based assessment numbers and promotion timelines between programs and with national guidelines. This evaluation data will inform the revision of local programs and national guidelines and serve as a starting point for further reaching outcome evaluation. This process could be replicated by other national assessment programs.
Introduction: The oral case presentation is recognized as a core educational and patient care activity but has not been well studied in the emergency setting. The objectives of this study are: 1) to develop a competency-based assessment tool to formally evaluate the emergency medicine oral case presentation (EM-OCP) competency of medical students and ‘transition to discipline’ residents, and 2) to develop, implement and evaluate a curriculum to enhance oral case presentation (OCP) communication skills in the emergency medicine (EM) setting. Methods: Using data from a literature review, a Canadian Association of Emergency Physicians national survey, and local focus groups, the authors designed an OCP framework, blended learning curriculum, and EM-OCP assessment tool. Ninety-six clerkship students were randomly assigned to receive either the control, the standard clerkship curriculum, or intervention, the blended learning curriculum. At the beginning of their emergency medicine rotation, learners completed a pre-test using a standardized patient (SP) case to assess their baseline OCP skills. The intervention group then completed the EM-OCP curriculum. All students completed post-tests with a different SP at the end of the six-week EM rotation. Audio-recordings of pre and post-tests were evaluated using the assessment tool by two blinded evaluators. Results: Using the Kruskal-Wallis test, all students demonstrated improvement in EM-OCP skills between their pre-test and post-test, however, those who received the blended learning curriculum showed significantly greater improvement in synthesis of information (p = 0.044), management (p = 0.006) and overall entrustment decision score (p = 0.000). Conclusion: Implementation of a novel EM-OCP curriculum resulted in more effective communication and higher entrustment scores. This curriculum could improve OCP performance not only in emergency medicine settings but also across specialties where medical students and residents must manage critical patients.
Introduction: With the transition of Emergency Medicine into competency based medical education (CBME), entrustable professional activities (EPAs) are used to evaluate residents on performed clinical duties. This study aimed to determine if implementing a case-based orientation, designed to increase recognition of available EPAs, into CBME orientation would help residents increase the number of EPAs completed. Methods: We designed an intervention consisting of clinical cases that were reviewed by national EPA experts who identified which EPAs could be assessed from each case. A case-based session was incorporated into the 2019 CBME orientation for The McMaster Emergency Medicine Program. Postgraduate Year (PGY)1 residents read the cases and discussed which EPAs could be obtained with PGY2/faculty facilitators. The number of EPAs completed in the first two blocks of PGY1 was determined from local program data and Student's t-test was used to compare averages between cohorts. Results: We analyzed data from 22 trainees (7 in 2017, 8 in 2018, and 7 in 2019). In the first two blocks of PGY1, the intervention cohort (2019) had a significantly higher average number of EPAs completed per trainee (47.4 [SD 11.8]) than the historical cohort (25.3 [SD 6.7]) (p < 0.001) (Cohen's d = 2.3). No significant difference existed in the number EPAs obtained between the 2017/2018 cohorts, with averages of 24.3 [SD 6.8] and 26.1 [SD 7.0] per trainee respectively (p = 0.6). Conclusion: Implementation of a case-based orientation led by CBME-experienced facilitators nearly doubled the EPA acquisition rate of our PGY1s. The consistent EPA acquisition by the 2017/2018 cohorts suggest that the post-intervention increase was not solely due to developed familiarity with the CBME curriculum.
Introduction: The ways in which Emergency Medicine (EM) physicians interact with the medical literature has been transformed with the rise of Free Open Access Medical Education (FOAM). Although nearly all residents use FOAM resources, some criticize the lack of universal quality assurance. This problem is a particular risk for trainees who have many time constraints and incompletely developed critical appraisal skills. One potential safeguard is journal club, which is used by virtually all EM residency programs in North America to review new literature. However, EM resident perspectives have not been studied. Our research objective was to describe how residents perceive journal club to influence how they translate the medical literature into their clinical practice. Our research question was whether FOAM has influenced residents’ goals and perceived value of journal club. Methods: We developed a semi-structured interview script in conjunction with a methods expert and refined it via pilot testing. Following constructivist grounded theory, and using both purposive and theoretical sampling, we conducted a focus group (n = 7) and 18 individual interviews with EM residents at the 4 training sites of the University of British Columbia. In total, we analyzed 920 minutes of recorded audio. Two authors independently coded each transcript, with discrepancies reconciled by discussion and consensus. Constant comparative analysis was performed. We conducted return of findings through public presentations. Results: We found evidence that journal club works as a community of practice with a progression of roles from junior to senior residents. Participants described journal club as a safe venue to compare practice patterns and to gain insight into the practical wisdom of their peers and mentors. The social and academic activities present at journal club interacted positively to foster this environment. In asking residents about ways that journal club accelerates knowledge translation, we actually found that residents cite journal club as a quality check to prevent premature adoption of new research findings. Residents are hesitant to adopt new literature into their practice without positive validation, which can occur during journal club. Conclusion: Journal club functions as a community of practice that is valued by residents. Journal club is a primary way that new evidence can be validated before being put into practice, and may act as quality assurance in the era of FOAM.
Innovation Concept: Canadian medical students completing their Emergency Medicine (EM) clerkship rotations must develop approaches to undifferentiated patients. Increasingly used in postgraduate EM education, Open Educational Resources (OERs) are a convenient and flexible solution to meeting medical student educational needs on their EM rotation. We hoped to supplement Canadian medical student EM education through the development of ‘ClerkCast’, a novel OER and podcast-based curriculum on CanadiEM.org. Methods: We utilized the Kern Six Step approach to curriculum development for ‘ClerkCast’. A general needs assessment involved a review of available OERs and identified a lack of effective EM OERs specific for medical students. A specific online needs assessment was used to determine which EM topics required further education for medical students. The survey was shared directly with key Canadian medical student and undergraduate medical educator stakeholder groups, and distributed globally through the CanadiEM social media networks. Results of the needs assessment highlighted shared perceptions of educational needs for medical students, with an emphasis on increased need for education on critical care and common EM presentations. We used the topics determined to be highest priority for the development of our first ten episodes of ‘ClerkCast’. Curriculum, Tool or Material: Podcast episodes are released from CanadiEM biweekly. Episodes are 30 to 45 min in length, and focus on cognitive approaches to a common EM presentation for medical students. Content is anchored on medical student interactions with a staff or resident EM co-host. Podcasts are supplemented by infographics and blog posts highlighting the key points from each episode. Learners are also encouraged to interact with the content through review quizzes on a provided question bank. Quality assurance of the content is provided by physician co-hosts who review episode scripts both prior to recording. Post-production feedback is elicited via comments on the curriculum's host website, CanadiEM.org, and through direct email correspondence to the ClerkCast address. Conclusion: With an ever increasing number of OERs in EM and critical care, the systematic development of new resources is important to avoid redundancies in content and medium while also addressing unmet learner needs. We describe the successful use of the Kern Six Steps for curriculum development for the creation of our novel EM OER for Canadian medical students, ‘ClerkCast’.
Introduction: Time-to-treatment plays a pivotal role in survival from sudden cardiac arrest (SCA). Every minute delay in defibrillation results in a 7-10% reduction in survival. This is particularly problematic in rural and remote regions, where bystander and EMS response is often prolonged and automated external defibrillators (AED) are often not available. Our objective was to examine the feasibility of a novel AED drone delivery method for rural and remote SCA. A secondary objective was to compare times between AED drone delivery and ambulance response to various mock SCA resuscitations. Methods: We conducted 6 simulations in two different rural communities in southern Ontario. During phase 1 (4 simulations) a “mock” call was placed to 911 and a single AED drone and an ambulance were simultaneously dispatched from the same location to a pre-determined destination. Once on scene, trained first responders retrieved the AED from the drone and initiated resuscitative efforts on a manikin. The second phase (2 scenarios) were done in a similar manner save for the drone being dispatched from a regionally optimized location for drone response. Results: Phase 1: The distance from dispatch location to scene varied from 6.6 km to 8.8 km. Mean (SD) response time from 911 call to scene arrival was 11.2 (+/- 1.0) minutes for EMS compared to 8.1 (+/- 0.1) for AED drone delivery. In all four simulations, the AED drone arrived before EMS, ranging from 2.1 to 4.4 minutes faster. The mean time for trained responders to retrieve the AED and apply it to the manikin was 35 (+/- 5) sec. No difficulties were encountered in drone activation by dispatch, drone lift off, landing or removal of the AED from the drone by responders. Phase 2: The ambulance response distance was 20km compared to 9km for the drone. Drones were faster to arrival at the scene by 7 minutes and 8 minutes with AED application 6 and 7 minutes prior to ambulance respectively. Conclusion: This implementation study suggests AED drone delivery is feasible with improvements in response time during a simulated SCA scenario. These results suggest the potential for AED drone delivery to decrease time to first defibrillation in rural and remote communities. Further research is required to determine the appropriate distance for drone delivery of an AED in an integrated EMS system as well as optimal strategies to simplify bystander application of a drone delivered AED.
Introduction: Despite studies highlighting the inaccuracies of self-assessment, practicing physicians continue to rely on self-perception to maintain clinical competence. Many approaches have been proposed to augment physician performance. In the realm of Quality Improvement (QI), Audit and Feedback (A&F) has a modest effect. Educators have proposed coaching interventions and academic constructs have invoked training for early-career clinicians. Very few of these are driven by the perceptions and the needs of the end-user - the physicians. We currently lack a model to understand physicians’ perceptions of their own practice data and an understanding of the factors which would enable practice change. In this study, we sought to develop a model for data feedback which may best help physicians change practice. Methods: In a previous study, we conducted a needs analysis of 105 physicians in the Hamilton-Niagara area in order to understand which data metrics were most valuable to physicians. Using the survey results, we designed an interview guide that was used as a qualitative study of physicians’ perspectives on A&F. By intentional sampling, we recruited 15 physicians amongst gender groups, types of practice (academic vs community) and durations of practice. We conducted this interview with all 15 participants which were then transcribed. We then performed thematic analysis and extraction of all interviews using a realist framework. These were then translated into broader themes and, by using a grounded theory framework, created a model to understand how physicians relate practice data to their own sense of self. Interviews were anonymized and no identifying data was shared as part of the interview. All interviewees consented to participation at the outset and could withdraw at any time. Results: Via stakeholder interviews from 15 key informants, we developed a model for the understanding of how a physician's sense of self and the nature of the data (quantity and quality) may be combined to understand the likelihood of practice change and the adoption of the change strategy. Using this model, it is possible to understand the conditions under which A&F would provide the greatest opportunity for practice change. Conclusion: Physician identity intersects with A&F data to shed insights on practice improvement. Understanding the core identity constructs of different physician groups may allow for increased uptake in A&F processes.
Background: Emergency physicians (EPs) can choose from several evidence-based pathways to diagnose pulmonary embolism (PE), however literature suggests that EPs frequently use computer tomography (CT) scanning as a stand-alone test for PE. This is a program of research to improve adherence to evidence-based PE diagnosis in the emergency department (ED). Aim Statement: To create a novel approach to PE diagnosis in the ED based on a framework explaining EP diagnostic PE behaviour and barriers to using evidence-based PE testing. Measures & Design: We conducted two types of qualitative interviews: 1). EPs in 5 Canadian cities watched videos of 2 simulated cases and then explained how they would test the patient. 2). Semi-structured EP interviews using the theoretical domains framework (TDF). The results of our analyses informed the construction of an explanatory framework for common EP diagnostic PE behaviours. Barriers to evidence-based behaviour were classified into domains. A Canadian EP expert group reviewed these results along with the existing evidence on ED PE diagnostic implementation. We developed a new approach to diagnosis of PE in the ED which addresses each of our domains. Evaluation/Results: We conducted 71 interviews. We identified 4 domains, each addressed in our pathway. ‘PE in a mythical and deadly beast’ PE kills and can masquerade so EPs look for PE in places where it does not exist and are rewarded for ‘over-testing’. Response: Creating a departmental conversation about missing PE, talking about the facts, busting the myths. EP feedback on PE testing including positive rate. ‘The end goal is CTPE’ PE creates anxiety for EPs and ordering a CTPE hands over responsibility to the radiologist. Response: A departmental protocol for PE testing which starts with D-dimer for every patient. Shifting focus to ruling out PE with D-dimer. Protocol is automated once initiated by EP. ‘PERC eases anxiety’ PERC is documented when it is negative and allows EP to stop. Response: EPs can choose to use and document PERC. ‘No-one has been fighting for the Wells score’ Poor understanding of purpose and function. Often at odds to Gestalt. Response: Protocol does not use Wells score. Discussion/Impact: We have developed a new diagnostic PE pathway which addresses current barriers to evidence-based practice which we will evaluate further.
To describe the infection control preparedness measures undertaken for coronavirus disease (COVID-19) due to SARS-CoV-2 (previously known as 2019 novel coronavirus) in the first 42 days after announcement of a cluster of pneumonia in China, on December 31, 2019 (day 1) in Hong Kong.
A bundled approach of active and enhanced laboratory surveillance, early airborne infection isolation, rapid molecular diagnostic testing, and contact tracing for healthcare workers (HCWs) with unprotected exposure in the hospitals was implemented. Epidemiological characteristics of confirmed cases, environmental samples, and air samples were collected and analyzed.
From day 1 to day 42, 42 of 1,275 patients (3.3%) fulfilling active (n = 29) and enhanced laboratory surveillance (n = 13) were confirmed to have the SARS-CoV-2 infection. The number of locally acquired case significantly increased from 1 of 13 confirmed cases (7.7%, day 22 to day 32) to 27 of 29 confirmed cases (93.1%, day 33 to day 42; P < .001). Among them, 28 patients (66.6%) came from 8 family clusters. Of 413 HCWs caring for these confirmed cases, 11 (2.7%) had unprotected exposure requiring quarantine for 14 days. None of these was infected, and nosocomial transmission of SARS-CoV-2 was not observed. Environmental surveillance was performed in the room of a patient with viral load of 3.3 × 106 copies/mL (pooled nasopharyngeal and throat swabs) and 5.9 × 106 copies/mL (saliva), respectively. SARS-CoV-2 was identified in 1 of 13 environmental samples (7.7%) but not in 8 air samples collected at a distance of 10 cm from the patient’s chin with or without wearing a surgical mask.
Appropriate hospital infection control measures was able to prevent nosocomial transmission of SARS-CoV-2.
This study aimed to highlight the key studies that have led to the current understanding and treatment of head and neck cancer.
The Thomson Reuters Web of Science database was used to identify relevant manuscripts. The results were ranked according to the number of citations. The 100 most cited papers were analysed.
A total of 63 538 eligible papers were returned. The median number of citations was 626. The most cited paper compared radiotherapy with and without cetuximab (3205 citations). The New England Journal of Medicine had the most citations (23 514), and the USA had the greatest number of publications (n = 66). The most common topics of publication were the treatment (n = 45) and basic science (n = 19) of head and neck cancer, followed by the role of human papillomavirus (n = 16).
This analysis highlighted key articles that influenced head and neck cancer research and treatment. It serves as a guide as to what makes a ‘citable’ paper in this field.
Abnormal effort-based decision-making represents a potential mechanism underlying motivational deficits (amotivation) in psychotic disorders. Previous research identified effort allocation impairment in chronic schizophrenia and focused mostly on physical effort modality. No study has investigated cognitive effort allocation in first-episode psychosis (FEP).
Cognitive effort allocation was examined in 40 FEP patients and 44 demographically-matched healthy controls, using Cognitive Effort-Discounting (COGED) paradigm which quantified participants’ willingness to expend cognitive effort in terms of explicit, continuous discounting of monetary rewards based on parametrically-varied cognitive demands (levels N of N-back task). Relationship between reward-discounting and amotivation was investigated. Group differences in reward-magnitude and effort-cost sensitivity, and differential associations of these sensitivity indices with amotivation were explored.
Patients displayed significantly greater reward-discounting than controls. In particular, such discounting was most pronounced in patients with high levels of amotivation even when N-back performance and reward base amount were taken into consideration. Moreover, patients exhibited reduced reward-benefit sensitivity and effort-cost sensitivity relative to controls, and that decreased sensitivity to reward-benefit but not effort-cost was correlated with diminished motivation. Reward-discounting and sensitivity indices were generally unrelated to other symptom dimensions, antipsychotic dose and cognitive deficits.
This study provides the first evidence of cognitive effort-based decision-making impairment in FEP, and indicates that decreased effort expenditure is associated with amotivation. Our findings further suggest that abnormal effort allocation and amotivation might primarily be related to blunted reward valuation. Prospective research is required to clarify the utility of effort-based measures in predicting amotivation and functional outcome in FEP.