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Previous studies focusing on the age disparity in COVID-19 severity have suggested that younger individuals mount a more robust innate immune response in the nasal mucosa after infection with SARS-CoV-2. However, it is unclear if this reflects increased immune activation or increased immune residence in the nasal mucosa. We hypothesized that immune residency in the nasal mucosa of healthy individuals may differ across the age range. We applied single-cell RNA-sequencing and measured the cellular composition and transcriptional profile of the nasal mucosa in 35 SARS-CoV-2 negative children and adults, ranging in age from 4 months to 65 years. We analyzed in total of ~ 30,000 immune and epithelial cells and found that age and immune cell proportion in the nasal mucosa are inversely correlated, with little evidence for structural changes in the transcriptional state of a given cell type across the age range. Orthogonal validation by epigenome sequencing indicate that it is especially cells of the innate immune system that underlie the age-association. Additionally, we characterize the predominate immune cell type in the nasal mucosa: a resident T cell like population with potent antiviral properties. These results demonstrate fundamental changes in the immune cell makeup of the uninfected nasal mucosa over the lifespan. The resource we generate here is an asset for future studies focusing on respiratory infection and immunization strategies.

We implemented a novel transition-to-practice curriculum incorporating four new processes to prepare CCFP(EM) residents for independent practice. These elements were: 1) explicit sequencing of competency progression; 2) establishment of coaching teams; 3) establishment of independent shifts; and 4) implementation of a transition-to-practice seminar series. Exit surveys of residents rated the new curriculum highly with 15/17 (88.2%) residents reporting they felt prepared for independent practice. All residents rated competency progression, coaching teams, independent shifts and transition-to-practice series favourably. This framework can be used by other 1-year enhanced skills or other fellowship programs to prepare their residents for independent practice.

Background In 2018, Canadian postgraduate emergency medicine (EM) programs began implementing a competency-based medical education (CBME) assessment program. Studies evaluating these programs have focused on broad outcomes using data from national bodies and lack data to support program-specific improvement. Objective We evaluated the implementation of a CBME assessment program within and across programs to identify successes and opportunities for improvement at the local and national levels. 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 were 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%) programs containing 9842 EPA observations from 68 of 77 (88%) EM residents in the 2018 cohort were analyzed. Average numbers of EPAs observed per resident in each program varied from 92.5 to 229.6, correlating with the number of blocks spent on EM and pediatric EM (r = 0.83, P < .001). Relative to the specialty committee's guidelines, residents were promoted later than expected (eg, one-third of residents had a 2-month delay to promotion from the first to second stage) and with fewer EPA observations than suggested. Conclusions There was demonstrable variation in EPA-based assessment numbers and promotion timelines between programs and with national guidelines.

ObjectivesThe Emergency Medicine (EM) Specialty Committee of the Royal College of Physicians and Surgeons of Canada (RCPSC) specifies that resuscitation entrustable professional activities (EPAs) can be assessed in the workplace and simulated environments. However, limited validity evidence for these assessments in either setting exists. We sought to determine if EPA ratings improve over time and whether an association exists between ratings in the workplace v. simulation environment.MethodsAll Foundations EPA1 (F1) assessments were collected for first-year residents (n = 9) in our program during the 2018–2019 academic year. This EPA focuses on initiating and assisting in the resuscitation of critically ill patients. EPA ratings obtained in the workplace and simulation environments were compared using Lin's concordance correlation coefficient (CCC). To determine whether ratings in the two environments differed as residents progressed through training, a within-subjects analysis of variance was conducted with training environment and month as independent variables.ResultsWe collected 104 workplace and 36 simulation assessments. No correlation was observed between mean EPA ratings in the two environments (CCC(8) = -0.01; p = 0.93). Ratings in both settings improved significantly over time (F(2,16) = 18.8; p < 0.001; η2= 0.70), from 2.9 ± 1.2 in months 1–4 to 3.5 ± 0.2 in months 9–12. Workplace ratings (3.4 ± 0.1) were consistently higher than simulation ratings (2.9 ± 0.2) (F(2,16) = 7.2; p = 0.028; η2= 0.47).ConclusionsNo correlation was observed between EPA F1 ratings in the workplace v. simulation environments. Further studies are needed to clarify the conflicting results of our study with others and build an evidence base for the validity of EPA assessments in simulated and workplace environments.

This interactive session was held at the 51st Annual Meeting of the Canadian Association of Pediatric Surgeons (CAPS) in preparation for the transition of Pediatric Surgery training in Canada to Competency by Design (a CBME-based model of residency training developed by the Royal College of Physicians and Surgeons of Canada).

BackgroundCompetence committees play a key role in a competency-based system of assessment. These committees are tasked with reviewing and synthesizing clinical performance data to make judgments regarding residents’ competence. Canadian emergency medicine (EM) postgraduate training programs recently implemented competence committees; however, a paucity of literature guides their work.ObjectiveThe objective of this study was to develop consensus-based recommendations to optimize the function and decisions of competence committees in Canadian EM training programs.MethodsSemi-structured interviews of EM competence committee chairs were conducted and analyzed. The interview guide was informed by a literature review of competence committee structure, processes, and best practices. Inductive thematic analysis of interview transcripts was conducted to identify emerging themes. Preliminary recommendations, based on themes, were drafted and presented at the 2019 CAEP Academic Symposium on Education. Through a live presentation and survey poll, symposium attendees representing the national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback and identified consensus among symposium attendees on a final set of nine high-yield recommendations.ConclusionThe Canadian EM community used a structured process to develop nine best practice recommendations for competence committees addressing: committee membership, meeting processes, decision outcomes, use of high-quality performance data, and ongoing quality improvement. These recommendations can inform the structure and processes of competence committees in Canadian EM training programs.

ObjectivesCricothyrotomy is an intervention performed to salvage “can't intubate, can't ventilate” situations. Studies have shown poor accuracy with landmarking the cricothyroid membrane, particularly in female patients by surgeons and anesthesiologists. This study examines the perceived versus actual success rate of landmarking the cricothyroid membrane by resident and staff emergency physicians using obese and non-obese models.MethodsFive male and female volunteers were models. Each model was placed supine, and a point-of-care ultrasound expert landmarked the borders of each cricothyroid membrane; 20 residents and 15 staff emergency physicians were given one attempt to landmark five models. Overall accuracy and accuracy stratified by sex and obesity status were calculated.ResultsOverall landmarking accuracy amongst all participants was 58% (SD 18%). A difference in accuracy was found for obese males (88%) versus obese females (40%) (difference = 48%, 95% CI = 30–65%, p < 0.0001), and non-obese males (77%) versus non-obese females (46%) (difference = 31%, 95% CI = 12–51%, p = 0.004). There was no association between perceived difficulty and success (correlation = 0.07, 95% CI = −0.081–0.214, p = 0.37). Confidence levels overall were higher amongst staff physicians (3.0) than residents (2.7) (difference = 0.3, 95% CI = 0.1–0.6, p = 0.02), but there was no correlation between confidence in an attempt and its success (p = 0.33).ConclusionWe found that physicians demonstrate significantly lower accuracy when landmarking cricothyroid membranes of females. Emergency physicians were unable to predict their own accuracy while landmarking, which can potentially lead to increased failed attempts and a longer time to secure the airway. Improved training techniques may reduce failed attempts and improve the time to secure the airway.

OBJECTIVES: The outcome of emergency medicine (EM) training is to produce physicians who can competently run an emergency department (ED) shift. However, there are few tools with supporting validity evidence specifically designed to assess multiple key competencies across an entire shift. The investigators developed and gathered validity evidence for a novel entrustment‐based tool to assess a resident’s ability to safely run an ED shift. METHODS: Through a nominal group technique, local and national stakeholders identified dimensions of performance that are reflective of a competent ED physician and are required to safely manage an ED shift. These were included as items in the Ottawa Emergency Department Shift Observation Tool (O‐EDShOT), and each item was scored using an entrustment‐based rating scale. The tool was implemented in 2018 at the University of Ottawa Department of Emergency Medicine, and quantitative data and qualitative feedback were collected over 6 months. RESULTS: A total of 1,141 forms were completed by 78 physicians for 45 residents. An analysis of variance demonstrated an effect of training level with statistically significant increases in mean O‐EDShOT scores with each subsequent postgraduate year (p

The COVID-19 pandemic has created numerous unique challenges for the recruitment of prospective trainees. Cancellation of visiting electives and in-person interviews created challenges for programs to showcase elements that have been shown to influence applicants' program selection, including geographical considerations and program collegiality. Novel strategies have been recommended and employed to facilitate candidate recruitment, but it is unclear how influential such strategies are on candidates' program ranking. It is also unclear what factors influence program selection among CCFP(EM) candidates. We sought to evaluate the impact of novel recruitment strategies on applicants' ranking of the University of Ottawa CCFP(EM) program and determine factors which were most influential in applicants' first-choice program selection.An online survey was distributed to all candidates (n = 127) who applied to the University of Ottawa CCFP(EM) program. The survey instrument included 33 items. Respondents were asked to rate on a 3-point scale how influential specific recruitment strategies were on their ranking of our program and the influence of different training factors on their selection of first-choice program.The survey response rate was 27% (34/127). Recruitment strategies rated as most positively influential included virtual one-on-one meetings with program directors (100%), virtual QA sessions (77.8%), virtual communication with chief residents (73.3%), and a mailed personalized recruitment package (72.2%). The top factors influencing applicants' first-choice program selection included: collegiality between faculty and residents (96.4%); level of responsibility given to residents (96.4%); support within the program (96.4%); and procedural opportunities within the program (96.3%).Facilitating virtual personal interaction with program leadership is highly influential in how CCFP(EM) candidates rank programs. CCFP(EM) candidates value characteristics of a training program over the geographical location and available amenities. Program leaders should consider these findings when recruiting prospective candidates.RéSUMé: OBJECTIF: La pandémie de COVID-19 a créé de nombreux défis uniques pour le recrutement de stagiaires potentiels. L'annulation des stages optionnels et des entrevues en personne a créé des difficultés pour les programmes de présenter des éléments qui se sont avérés influer sur la sélection des programmes des candidats, y compris les considérations géographiques et la collégialité du programme. De nouvelles stratégies ont été recommandées et utilisées pour faciliter le recrutement des candidats, mais on ne sait pas dans quelle mesure ces stratégies influent sur le classement des programmes des candidats. On ne sait pas non plus quels facteurs influencent la sélection des programmes parmi les candidats au CCFP(EM). Nous avons cherché à évaluer l'impact de nouvelles stratégies de recrutement sur le classement des candidats du programme CCFP(EM) de l'Université d'Ottawa et à déterminer les facteurs qui ont eu le plus d'influence sur la sélection du programme de premier choix des candidats. MéTHODES: Un sondage en ligne a été distribué à tous les candidats (n = 127) qui ont postulé au programme CCFP(EM) de l'Université d'Ottawa. L'instrument d'enquête comprenait 43 points. Les répondants devaient évaluer sur une échelle de 3 points l'influence de stratégies de recrutement spécifiques sur leur classement de notre programme et l'influence de différents facteurs de formation sur leur choix du programme de premier choix. RéSULTATS: Le taux de réponse au sondage était de 27% (34/127). Les stratégies de recrutement jugées les plus influentes sont les réunions virtuelles en tête-à-tête avec les directeurs de programme (100%), les séances virtuelles de questions-réponses (77,8%), la communication virtuelle avec les chefs résidents (73,3%) et l'envoi par courrier d'un dossier de recrutement personnalisé (72,2%). Les principaux facteurs influençant le choix du programme de premier choix des candidats comprenaient: la collégialité entre le corps professoral et les résidents (96,4%); le niveau de responsabilité donné aux résidents (96,4%); le soutien au sein du programme (96,4%); et les possibilités de procédures au sein du programme (96,3%). CONCLUSION: Faciliter l’interaction virtuelle personnelle avec le leadership du programme a une grande influence sur la façon dont les candidats du CCFP(EM) classent les programmes. Les candidats CCFP(EM) valorisent les caractéristiques d'un programme de formation plutôt que à l'emplacement géographique et les commodités disponibles. Les chefs de programme devraient tenir compte de ces constatations lorsqu’ils recrutent des candidats éventuels.

SummarySevere coronavirus disease of 2019 (COVID-19) positively correlates with age (Centers for Disease Control), develops after progression of infection from the upper airway to the lower respiratory tract (LRT), and can worsen into acute respiratory distress syndrome (ARDS) (Shi et al., 2020). Why children seem to be less likely to develop severe disease remains unclear. As the nasal mucosa (NM) is the first site of contact and defense for respiratory pathogens such as SARS-CoV-2 before dissemination to the LRT (Casadei and Salinas, 2019), we hypothesized that differences in this tissue across the age range may help explain the disparity in COVID-19 severity. To this end, we profiled NM samples across the lifespan in health and disease. We find that global transcriptomic changes including the expression of SARS-CoV-2 and coronavirus-associated receptors and factors are not correlated with age or the novel virus type, since pediatric NM cells mount similar antiviral response to both SARS-CoV-2 or Influenza B. Rather, we find immune cell residency in NM decreases dramatically with age especially cells of the innate immune system. This includes a resident-memory-like T cell subset with antiviral properties. These observations give plausible biological explanation to the observed clinical differences in disease spectrum and provide a foundation for future experimental studies.

Clinical competency committees (CCCs) are increasingly used within health professions education as their decisions are thought to be more defensible and fairer than those generated by previous training promotion processes. However, as with most group-based processes, it is inevitable that conflict will arise. In this paper the authors explore three ways conflict may arise within a CCC: (1) conflicting data submissions that are presented to the committee, (2) conflicts between members of the committee, and (3) conflicts of interest between a specific committee member and a trainee. The authors describe each of these conflict situations, dissect out the underlying problems, and explore possible solutions based on the current literature.

ObjectiveLittle is known about how the Royal College of Emergency Medicine (RCEM) residency programs are selecting their residents. This creates uncertainty regarding alignment between current selection processes and known best practices. We seek to describe the current selection processes of Canadian RCEM programs.MethodsAn online survey was distributed to all RCEM program directors and assistant directors. The survey instrument included 22 questions and sought both qualitative and quantitative data from the following six domains: application file, letters of reference, elective selection, interview, rank order, and selection process evaluation.ResultsWe received responses from 13 of 14 programs for an aggregate response rate of 92.9%. A candidate's letters of reference were identified as the most important criterion from the paper application (38.5%). Having a high level of familiarity with the applicant was the most important characteristic of a reference letter author (46.2%). In determining rank order, 53.8% of programs weighed the interview more heavily than the paper application. Once final candidate scores are established following the interview stage, all program respondents indicated that further adjustment is made to the final rank order list. Only 1 of 13 program respondents reported ever having completed a formal evaluation of their selection process.ConclusionWe have identified elements of the selection process that will inform recommendations for programs, students, and referees. We encourage programs to conduct regular reviews of their selection process going forward to be in alignment with best practices.

Background In a time of major medical education transformation, emergency medicine (EM) needs to nurture education scholars who will influence EM education practice. However, the essential ingredients to ensure a career with impact in EM education are not clear. Objective To describe how to prepare EM educators for a high-impact career. Methods The Canadian Association of Emergency Physicians (CAEP) Academic Section commissioned an “Education Impact” working group (IWG) to guide the creation of consensus recommendations from the EM community. EM educators from across Canada were initially recruited from the networks of the IWG members, and additional educators were recruited via snowball sampling. “High impact educators” were nominated by this network. The high impact educators were then interviewed using a structured question guide. These interviews were transcribed and coded for themes using qualitative methods. The process continued until no new themes were identified. Proposed themes and recommendations were presented to the EM community at the CAEP 2016 Academic Symposium. Feedback was then incorporated into a final set of recommendations. Results Fifty-five (71%) of 77 of identified Canadian EM educators participated, and 170 names of high impact educators were submitted and ranked by frequency. The IWG achieved sufficiency of themes after nine interviews. Five recommendations were made: 1) EM educators can pursue a high impact career by leveraging either traditional or innovative career pathways; 2) EM educators starting their education careers should have multiple senior mentors; 3) Early-career EM educators should immerse themselves in their area of interest and cultivate a community of practice, not limited to EM; 4) Every academic EM department and EM teaching site should have access to an EM educator with protected time and recognition for their EM education scholarship; and 5) Educators at all stages should continuously compile an impact portfolio. Conclusions We describe a unique set of recommendations to develop educators who will influence EM, derived from a consensus from the EM community. EM leaders, educators, and aspiring educational scholars should consider how to implement this guide towards enhancing our specialty’s educational mission.

Introduction: Workplace based assessments (WBAs) are integral to emergency medicine residency training. However many biases undermine their validity, such as an assessor's personal inclination to rate learners leniently or stringently. Outlier assessors produce assessment data that may not reflect the learner's performance. Our emergency department introduced a new Daily Encounter Card (DEC) using entrustability scales in June 2018. Entrustability scales reflect the degree of supervision required for a given task, and are shown to improve assessment reliability and discrimination. It is unclear what effect they will have on assessor stringency/leniency – we hypothesize that they will reduce the number of outlier assessors. We propose a novel, simple method to identify outlying assessors in the setting of WBAs. We also examine the effect of transitioning from a norm-based assessment to an entrustability scale on the population of outlier assessors. Methods: This was a prospective pre-/post-implementation study, including all DECs completed between July 2017 and June 2019 at The Ottawa Hospital Emergency Department. For each phase, we identified outlier assessors as follows: 1. An assessor is a potential outlier if the mean of the scores they awarded was more than two standard deviations away from the mean score of all completed assessments. 2. For each assessor identified in step 1, their learners’ assessment scores were compared to the overall mean of all learners. This ensures that the assessor was not simply awarding outlying scores due to working with outlier learners. Results: 3927 and 3860 assessments were completed by 99 and 116 assessors in the pre- and post-implementation phases respectively. We identified 9 vs 5 outlier assessors (p = 0.16) in the pre- and post-implementation phases. Of these, 6 vs 0 (p = 0.01) were stringent, while 3 vs 5 (p = 0.67) were lenient. One assessor was identified as an outlier (lenient) in both phases. Conclusion: Our proposed method successfully identified outlier assessors, and could be used to identify assessors who might benefit from targeted coaching and feedback on their assessments. The transition to an entrustability scale resulted in a non-significant trend towards fewer outlier assessors. Further work is needed to identify ways to mitigate the effects of rater cognitive biases.

Introduction: Point-of-care ultrasound (POCUS) has become standard practice in emergency departments ranging from remote rural hospitals to well-resourced academic centres. To facilitate quality assurance, the Canadian Association of Emergency Physicians (CAEP) recommends image archiving. Due in part to poor infrastructure and lack of a national standard, however, archiving remains uncommon. Our objective was to establish a minimum standard archiving protocol for the core emergency department POCUS indications. Methods: Itemization of potential archiving standards was created through an extensive literature review. An online, three-round, modified Delphi survey was conducted with the thirteen POCUS experts on the national CAEP Emergency Ultrasound Committee tasked with representing diverse practice locations and experiences. Participants were surveyed to determine the images or clips, measurements, mode, and number of views that should comprise the minimum standard for archiving. Consensus was pre-defined as 80%. Results: All thirteen experts participated fully in the three rounds. In establishing minimum image archiving standards for emergency department POCUS, complete consensus was achieved for first trimester pregnancy, hydronephrosis, cardiac activity versus standstill, lower extremity deep venous thrombosis, and ultrasound-guided central line placement. Consensus was achieved for the majority of statements regarding abdominal aortic aneurysm, extended focused assessment with sonography in trauma, pericardial effusion, left and right ventricular function, thoracic B-line assessment, cholelithiasis and cholecystitis scans. In total, consensus was reached for 58 of 69 statements (84.1%). This included agreement on 41 of 43 statements (95.3%) describing mandatory images for archiving in the above indications. Conclusion: Our modified Delphi-derived consensus represents the first national standard archiving requirements for emergency department POCUS. Depending on the clinical context, additional images may be required beyond this minimum standard to support a diagnosis.

Introduction: Little is known about how Royal College emergency medicine (RCEM) residency programs are selecting their residents. This creates uncertainty regarding alignment between our current selection processes and known best practices and results in a process that is difficult to navigate for prospective candidates. We seek to describe the current selection processes of Canadian RCEM programs. Methods: An online survey was distributed to all RCEM program directors and assistant directors. The survey instrument included 22 questions consisting of both open-ended (free text) and closed-ended (Likert scale) elements. Questions sought qualitative and quantitative data from the following 6 domains; paper application, letters of reference, elective selection, interview, rank order, and selection process evaluation. Descriptive statistics were used. Results: We received responses from 13/14 programs for an aggregate response rate of 92.9%. A candidate's letter of reference was identified as the single most important item from the paper application (38.5%). Having a high level of familiarity with the applicant was considered to be the most important characteristic of a reference letter author (46.2%). Respondents found that providing a percentile rank of the applicant was useful when reviewing candidate reference letters. Once the interview stage is reached, 76.9% of programs stated that the interview was weighted at least as heavily as the paper application; 53.8% weighted the interview more heavily. Once final candidate scores are established for both the paper application and the interview, 100% of programs indicated that further adjustment is made to the rank order list. Only 1/13 programs reported ever having completed a formal evaluation of their selection process. Conclusion: The information gained from this study helps to characterize the landscape of the RCEM residency selection process. We identified significant heterogeneity between programs with respect to which application elements were most valued. Canadian emergency medicine residency programs should re-evaluate their selection processes to achieve improved consistency and better alignment with selection best practices.

BackgroundGeriatric patients commonly present to the ED after a fall. Recent evidence suggests that ED physicians are poorly adherent to published ED-specific geriatric fall guidelines. This study applied a theoretical domains framework (TDF) approach to systematically investigate barriers and enablers in the provision of guideline-based care to ED geriatric fall patients.MethodsFrom June to September 2017, semistructured interviews of staff ED physicians practising in Ontario, Canada, were conducted and analysed. An interview guide based on the TDF was used to capture 14 domains influencing provision of guideline-based care. Relevant domains were identified based on frequencies of beliefs, existence of conflicting beliefs and evidence of strong beliefs that would influence provision of guideline-based care.ResultsEleven interviews were conducted with practising ED physicians. Thirty belief statements were identified across 13 relevant TDF domains (all except Optimism). Prominent themes included lack of knowledge, paucity of evidence, heterogeneous self-perceived skills, perceived increased time and workload, importance of allied health support, inconsistently available allied health workers, lack of positive reinforcement, emotions negatively impacting these clinical encounters and support for memory aids. Overall, ED physicians were supportive of guideline implementation, and believe it will lead to better outcomes for geriatric fall patients.ConclusionThis study identified important barriers and enablers to provision of guideline-based care in geriatric ED fall patients. Based on these findings, future implementation of guidelines nationally and internationally should focus on improving knowledge and training on guidelines, improving positive reinforcement for guideline-appropriate management, greater allied health support and further research to support guidelines.

OBJECTIVE Mentorship is perceived to be an important component of residency education. However, evidence of the impact of mentorship on professional development in Emergency Medicine (EM) is lacking. METHODS Online survey distributed to attending physician members of the Canadian Association of Emergency Physicians (CAEP), using a modified Dillman method. Survey contained questions about mentorship during residency training, and perceptions of the impact of mentorship on career development. RESULTS The response rate was 23.5% (309/1314). 63.6% reported having at least one mentor during residency. The proportion of participants with a formal mentorship component during residency was higher among those with mentors (44.5%) compared to those without any formal mentorship component during residency (8.0%, p

Introduction: When a patient is incapable of making medical decisions for themselves, choices are made according to the patient's previously expressed, wishes, values, and beliefs by a substitute decision maker (SDM). While interventions to engage patients in their own advance care planning exist, little is known about public readiness to act as a SDM on behalf of a loved one. This mixed-methods survey aimed to describe attitudes, enablers and barriers to preparedness to act as a SDM, and support for a population-level curriculum on the role of an SDM in end-of-life and resuscitative care. Methods: From November 2017 to June 2018, a mixed-methods street intercept survey was conducted in Ottawa, Canada. Descriptive statistics and logistic regression analysis were used to assess predictors of preparedness to be a SDM and understand support for a high school curriculum. Responses to open-ended questions were analyzed using inductive thematic analysis. Results: The 430 respondents were mostly female (56.5%) with an average age of 33.9. Although 73.0% of respondents felt prepared to be a SDM, 41.0% of those who reported preparedness never had a meaningful conversation with loved ones about their wishes in critical illness. The only predictors of SDM preparedness were the belief that one would be a future SDM (OR 2.36 95% CI 1.34-4.17), and age 50-64 compared to age 16-17 (OR 7.46 95% CI 1.25-44.51). Thematic enablers of preparedness included an understanding of a patient's wishes, the role of the SDM and strong familial relationships. Barriers included cultural norms, family conflict, and a need for time for high stakes decisions. Most respondents (71.9%) believed that 16 year olds should learn about SDMs. They noted age appropriateness, potential developmental and societal benefit, and improved decision making, while cautioning the need for a nuanced approach respectful of different maturity levels, cultures and individual experiences. Conclusion: This study reveals a concerning gap between perceived preparedness and actions taken in preparation to be an SDM for loved ones suffering critical illness. The results also highlight the potential role for high school education to address this gap. Future studies should further explore the themes identified to inform development of resources and curricula for improved health literacy in resuscitation and end-of-life care.

Introduction: Competence committees (CCs) struggle with incorporating professionalism issues into resident progression decisions. This study examined how professionalism concerns influence individual faculty decisions about resident progression using simulated CC reviews. Methods: In 2017, the investigators conducted a survey of 25 program directors of Royal College emergency medicine residency training programs in Canada and those faculty members who are members of the CCs (or equivalent) at their home institution. The survey contained twelve resident portfolios, each containing formative and summative information available to a CC for making progression decisions. Six portfolios outlined residents progressing as expected and six were not progressing as expected. Further, a professionalism variable (PV) was added to six portfolios, evenly split between those residents progressing as expected and not. Participants were asked to make progression decisions based on each portfolio. Results: Raters were able to consistently identify a resident needing an educational intervention versus those who did not. When a PV was added, the consistency among raters decreased by 34.2% in those residents progressing as expected, versus increasing by 3.8% in those not progressing as expected (p = 0.01). Conclusion: When using an unstructured review of a simulated resident portfolio, individual reviewers can better discriminate between trainees progressing as expected when professionalism concerns are added. Considering this, educators using a competence committee in a CBME program must have a system to acquire and document professionalism issues to make appropriate progress decisions.

Innovation Concept: The outcome of emergency medicine training is to produce physicians who can competently run an emergency department (ED) shift. While many workplace-based ED assessments focus on discrete tasks of the discipline, others emphasize assessment of performance across the entire shift. However, the quality of assessments is generally poor and these tools often lack validity evidence. The use of entrustment scale anchors may help to address these psychometric issues. The aim of this study was to develop and gather validity evidence for a novel tool to assess a resident's ability to independently run an ED shift. Methods: Through a nominal group technique, local and national stakeholders identified dimensions of performance reflective of a competent ED physician. These dimensions were included in a new tool that was piloted in the Department of Emergency Medicine at the University of Ottawa during a 4-month period. Psychometric characteristics of the items were calculated, and a generalizability analysis used to determine the reliability of scores. An ANOVA was conducted to determine whether scores increased as a function of training level (junior = PGY1-2, intermediate = PGY3, senior = PGY4-5), and varied by ED treatment area. Safety for independent practice was analyzed with a dichotomous score. Curriculum, Tool or Material: The developed Ottawa Emergency Department Shift Observation Tool (O-EDShOT) includes 12-items rated on a 5-point entrustment scale with a global assessment item and 2 short-answer questions. Eight hundred and thirty-three assessment were completed by 78 physicians for 45 residents. Mean scores differed significantly by training level (p < .001) with junior residents receiving lower ratings (3.48 ± 0.69) than intermediate residents who received lower ratings (3.98 ± 0.48) than senior residents (4.54 ± 0.42). Scores did not vary by ED treatment area (p > .05). Residents judged to be safe to independently run the shift had significantly higher mean scores than those judged not to be safe (4.74 ± 0.31 vs 3.75 ± 0.66; p < .001). Fourteen observations per resident, the typical number recorded during a 1-month rotation, were required to achieve a reliability of 0.80. Conclusion: The O-EDShOT successfully discriminated between junior, intermediate and senior-level residents regardless of ED treatment area. Multiple sources of evidence support the O-EDShOT producing valid scores for assessing a resident's ability to independently run an ED shift.

Introduction: Acute atrial fibrillation (AAF) is the most common arrhythmia managed in the Emergency Department (ED). Direct costs of AAF are primarily attributed to ED visits and subsequent admission to hospital. A better understanding of patients attitudes regarding ED attendance is necessary to develop strategies to improve the patient care experience while simultaneously reducing ED presentation and inappropriate hospital admissions. This study aims to describe patient perspectives on ED use for AAF using in-depth qualitative interviews. Methods: An interview template designed to explore why patients attend the ED for AAF was constructed based on the Theoretical Domains Framework, a theory-informed approach that utilizes 14 domains to describe influencers of behavior. We conducted audio-recorded, semi-structured interviews of patients following their presentation to the ED for management of AAF. Interviews were anonymized, transcribed and imported into NVivo for coding and analysis. Two independent reviewers used a direct approach to code participant statements. Discrepancies were resolved by a third party. Belief statements were generated and relevant domains identified based on high frequency scores, conflicting belief statements or evidence of strong influencing beliefs. Results: 12 patient interviews, mean age 63.1 years, 91.7% male, 75.0% recurrent AAF, were completed. Patients stated that they attended the ED because: 1) symptom severity; 2) they were instructed by physicians to attend the ED should their AAF recur; and 3) they were encouraged by family members to attend. Their primary goal was to have relief of their symptoms. There was no expectation of specialist consultation or admission to hospital. Even though most patients stated they were open to managing these episodes independently, they reported that they did not have the knowledge or tools to do so. Conclusion: Patients with AAF present to the ED because of their symptom burden, social influences (physician and family) and lack of other management options. This study demonstrates the need for development of patient self-management strategies which will empower patients in their disease management and may decrease future ED visits.

We propose the n -dimensional scale invariant feature transform ( n-SIFT) method for extracting and matching salient features from scalar images of arbitrary dimensionality, and compare this method's performance to other related features. The proposed features extend the concepts used for 2-D scalar images in the computer vision SIFT technique for extracting and matching distinctive scale invariant features. We apply the features to images of arbitrary dimensionality through the use of hyperspherical coordinates for gradients and multidimensional histograms to create the feature vectors. We analyze the performance of a fully automated multimodal medical image matching technique based on these features, and successfully apply the technique to determine accurate feature point correspondence between pairs of 3-D MRI images and dynamic 3D + time CT data.

The rise of antibiotic resistant pathogens is one of the most pressing global health issues. Discovery of new classes of antibiotics has not kept pace; new agents often suffer from cross-resistance to existing agents of similar structure. Short, cationic peptides with antimicrobial activity are essential to the host defenses of many organisms and represent a promising new class of antimicrobials. This paper reports the successful in silico screening for potent antibiotic peptides using a combination of QSAR and machine learning techniques. On the basis of initial high-throughput measurements of activity of over 1400 random peptides, artificial neural network models were built using QSAR descriptors and subsequently used to screen an in silico library of approximately 100,000 peptides. In vitro validation of the modeling showed 94% accuracy in identifying highly active peptides. The best peptides identified through screening were found to have activities comparable or superior to those of four conventional antibiotics and superior to the peptide most advanced in clinical development against a broad array of multiresistant human pathogens.

Chronic subcutaneous infusion of ouabain causes hypertension via central pathways involving angiotensin type 1 (AT1) receptor stimulation. The present study assessed plasma and tissue ANG I and II levels as well as AT1 receptor and angiotensin-converting enzyme (ACE) mRNA levels and binding densities by real-time PCR and in vitro autoradiography in relevant brain nuclei and peripheral tissues (heart and kidney) in rats at 1 and/or 2 wk after start of ouabain infusion at 50 μg/day. After 2 wk (but not after 1 wk), blood pressures significantly increased (+15 mmHg). At 2 wk, plasma ANG I and II levels were markedly suppressed by ouabain. In contrast, in the heart and kidneys, ANG I levels were not affected, and ANG II levels tended to decrease, whereas in the hypothalamus ANG II content clearly increased. At 1 wk, no changes in ACE and AT1 receptor densities were seen. After 2 wk, there were significant decreases in AT1 receptor mRNA and densities in the organum vasculosum of the lamina terminalis (OVLT), subfornical organ (SFO), and paraventricular nucleus (PVN). ACE densities decreased only in the OVLT and SFO, but ACE mRNA showed more variable responses (decrease in OVLT vs. increase in PVN). In the kidneys, at 2 wk both AT1 receptor and ACE densities were decreased, but mRNA abundance did not change. The heart showed no significant changes. The increase in hypothalamic ANG II content and associated decreases in central AT1 receptor and ACE densities support the involvement of the brain renin-angiotensin system in the central hypertensive mechanism of action of ouabain.

Introduction: Much of the literature investigating the challenges associated with completing high quality work-based assessments (WBAs) have raised specific concerns over the appropriate documentation of assessments of underperforming trainees or trainees in difficulty. The purpose of this study was to examine the relationship between resident performance and the quality of assessments documented by supervisors on Daily Encounter Cards (DECs). The effect of trainee proximity (i.e. on-service versus off-service status) on this relationship was also examined. Methods: A series of DECs from the Department of Emergency Medicine at the University of Ottawa was scored by two raters using the Completed Clinical Evaluation Report Rating (CCERR). The CCERR is a 9-item instrument that has previously demonstrated reliable ratings and the ability to discriminate the quality of completed DECs. A proxy measure of resident performance was calculated by averaging the scores across performance items on the DEC to produce a “mean DEC rating”. Linear regression analysis was conducted with “mean DEC rating” as the independent measure and CCERR score as the dependent measure. Separate linear regression analyses were repeated for DECs completed for on-service versus off-service residents. Results: Linear regression analysis demonstrated a small but significant inverse relationship between mean DEC rating and CCERR score (pConclusion: Resident performance and trainee proximity are important factors impacting the quality of documented clinical performance assessments. Greater attention needs to be given to determining ways of improving the quality of assessments reported for residents who are appropriately progressing in their clinical competence as well as for off-service trainees.

Objectives Studies suggest that intraosseous (IO) access is underutilized in adult resuscitations, despite recommendations from advanced trauma and cardiac life support guidelines. The objective was to determine factors associated with IO access use by physicians during adult resuscitations when intravenous (IV) access is not immediately achievable. Methods This study was an online survey among physicians purposefully recruited from various clinical care areas at three teaching hospitals. Questions were generated from the qualitative results of 20 iterative interviews, verified for internal validity, and piloted. The interview guide was based on the constructs of the Theory of Planned Behavior (TPB), which elicits salient attitudes, social influences, and control beliefs that potentially influence intention to use IO access. Recruitment took place in September 2012 until reaching more than 100% of the required sample size (n = 200). Internal consistency was measured using Cronbach's alpha, and the effect of TPB constructs and specific beliefs were assessed with regression analyses. Results For the 205 respondents, the mean age was 35 years (range = 20 to 66 years), and 53.3% were male. Participants’ departmental affiliations were 50.3% emergency medicine (EM), 16.9% internal medicine, 14.9% anesthesia, 10.8% general surgery, and 7.2% critical care. Residents comprised 60.7% of the sample, and 39.3% were attending physicians. Median intention to use IO access when IV is not immediately achievable was 4.67 (interquartile range [IQR] = 4 to 5) out of 5 (5 highest) and predicted by the following TPB constructs: attitudes (AdjCoefficients = 0.504; 95% confidence interval [CI] = 0.334 to 0.673), social influences (AdjCoefficients = 0.285; 95% CI = 0.172 to 0.398), and control beliefs (AdjCoefficients 0.217; 95% CI = 0.113 to 0.320). Physicians were more likely to use IO access if they believed that it provided rapid vascular access for delivering large volumes of fluids, could prevent delays in care, and was associated with a low complication rate. Conversely, the perception that nurses are not familiar or supportive of IO access and a lack of physician confidence regarding the appropriate indications for IO access were barriers to use. Conclusions These data are an important step in the knowledge-to-action process, as they identify specific factors associated with physician use of IO access. Interventions addressing these actionable facilitators and barriers are likely to have a positive effect on increasing the appropriate physician use of this potentially life-saving technique in adult patients requiring emergent vascular access. Resumen Objetivos Los estudios indican que la via intraosea (IO) esta infrautilizada en la reanimacion de adultos, a pesar de las recomendaciones de las guias clinicas de soporte vital cardiaco y traumatologico avanzado. El objetivo fue determinar los factores asociados con el uso de la via IO por los medicos durante las reanimaciones de los adultos cuando la via intravenosa (IV) no esta accesible de forma inmediata. Metodologia Este estudio fue una encuesta electronica entre los medicos reclutados para este fin de varias areas de atencion clinica de tres hospitales universitarios. Las preguntas se generaron de los resultados cualitativos de 20 entrevistas iterativas, verificadas para validez interna, y testadas. La entrevista guia se baso en constructos de la Teoria del Comportamiento Planificado (TCP), que obtiene actitudes, influencias sociales y creencias controladas que potencialmente influyen en la intencion de usar una via IO. El reclutamiento tuvo lugar en septiembre de 2012 hasta alcanzar mas del 100% del tamano muestral requerido (n = 200). La consistencia interna se midio usando el estadistico alfa de Cronbach, y el efecto de los constructos TCP y las creencias especificas se evaluaron con un analisis de regresion. Resultados Para los 205 encuestados, la edad media fue de 35 anos (rango 20 a 66 anos) y el 53,3% fueron hombres. Las filiaciones a los servicios de los participantes fueron 50,3% medicina de urgencias y emergencias, 16,9% medicina interna, 14,9% anestesia, 10,8% cirugia general y 7,2% medicina intensiva. Los residentes constituyeron un 60,7% de la muestra y el 39,3% fueron medicos adjuntos. La mediana de intencion para usar una via IO cuando la IV no esta inmediatamente accesible fue de un 4,67 (RIC 4 a 5) de 5 (5 lo mas alto), y se predijo para los siguientes constructos del TCP: actitudes (coeficiente ajustado 0,504; IC 95% = 0,334 a 0,673), influencias sociales (coeficiente ajustado 0,285; IC 95%= 0,172 a 0,398) y creencias controladas (coeficiente ajustado 0,217; IC 95% = 0,113 a 0,320). Los medicos tenian mayor probabilidad para usar la via IO si creian que proporcionaria un acceso vascular rapido para administrar gran volumen de fluidos, que podria prevenir los retrasos en la atencion y que se asociaba con un bajo porcentaje de complicacion. Contrariamente, fueron barreras para su utilizacion la percepcion de que las enfermeras no estan familiarizadas con la via IO y la falta de confianza del medico en relacion con las indicaciones apropiadas para la via IO. Conclusiones Estos datos son un paso importante en el proceso de conocimiento y accion, ya que identifican los factores especificos asociados con el uso medico de la via IO. Las intervenciones que valoran estos elementos facilitadores y estas barreras es probable que tengan un impacto positivo en incrementar el uso medico apropiado de esta tecnica que salva vidas en los pacientes adultos que requieren un acceso vascular urgente.

Introduction: In response to concerns in the literature over the quality of completed work-based assessments (WBAs), faculty development and rater training initiatives have been developed. The Completed Clinical Evaluation Report Rating (CCERR) was designed to evaluate these interventions by providing a measure of the quality of documented assessments on In-Training Evaluation Reports (ITERs). Daily Encounter Cards (DECs) are a common form of WBA used in the Emergency Department setting. A tool to evaluate initiatives aimed at improving the quality of completion of this widely used WBA is also needed. The purpose of this study was to provide validity evidence to support using the CCERR to assess the quality of DEC completion. Methods: This study was conducted in the Department of Emergency Medicine at the University of Ottawa. Six experts in resident assessment grouped 60 DECs into three quality categories (high, average, poor) based on their perception of how informative each DEC was for reporting judgments of the resident’s performance. Eight clinical supervisors (blinded to the expert groupings) scored the 10 most representative DECs in each group using the CCERR. Mean scores were compared using a univariate ANOVA to determine if the CCERR was able to discriminate DEC quality. Reliability for the CCERR scores was determined using a generalizability analysis. Results: Mean CCERR scores for the high (37.3, SD=1.2), average (24.2, SD=3.3), and poor (14.4, SD=1.4) quality groups differed (pConclusion: There is strong validity evidence to support the use of the CCERR to evaluate DEC quality. It can be used to provide feedback to supervisors for improving assessment reporting, and offers a quantitative measure of change in assessor behavior when utilized as a program evaluation instrument for determining the quality of completed DECs.

We present a fully automated multimodal medical image matching technique. Our method extends the concepts used in the computer vision SIFT technique for extracting and matching distinctive scale invariant features in 2D scalar images to scalar images of arbitrary dimensionality. This extension involves using hyperspherical coordinates for gradients and multidimensional histograms to create the feature vectors. These features were successfully applied to determine accurate feature point correspondence between pairs of medical images (3D) and dynamic volumetric data (3D+time).

Background: MEDLINE®/PubMed® currently indexes over 18 million biomedical articles, providing unprecedented opportunities and challenges for text analysis. Using Medical Subject Heading Over-representation Profiles (MeSHOPs), an entity of interest can be robustly summarized, quantitatively identifying associated biomedical terms and predicting novel indirect associations. Methods: A procedure is introduced for quantitative comparison of MeSHOPs derived from a group of MEDLINE® articles for a biomedical topic (for example, articles for a specific gene or disease). Similarity scores are computed to compare MeSHOPs of genes and diseases. Results: Similarity scores successfully infer novel associations between diseases and genes. The number of papers addressing a gene or disease has a strong influence on predicted associations, revealing an important bias for gene-disease relationship prediction. Predictions derived from comparisons of MeSHOPs achieves a mean 8% AUC improvement in the identification of gene-disease relationships compared to gene-independent baseline properties. Conclusions: MeSHOP comparisons are demonstrated to provide predictive capacity for novel relationships between genes and human diseases. We demonstrate the impact of literature bias on the performance of gene-disease prediction methods. MeSHOPs provide a rich source of annotation to facilitate relationship discovery in biomedical informatics.