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IntroductionRedirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion.ObjectivesOur primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians’ judgement as a criterion standard. Our tertiary objective is to examine how the ED physician’s perception of a virtual ED care alternative correlates with the EDAC.Methods and analysisA randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC.Ethics and disseminationThis study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.

The coronavirus disease 2019 (COVID-19) pandemic introduced challenges to the use of simulation, including limited personal protective equipment and restricted time and personnel. Our use of video for in situ simulation aimed to circumvent these challenges and assist in the development of a protocol for protected intubation and simultaneously educate emergency department (ED) staff. We video-recorded a COVID-19 respiratory failure in situ simulation event, which was shared by a facilitator both virtually and in the ED. The facilitator led discussions and debriefs. We followed this with in situ run-throughs in which staff walked through the steps of the simulation in the ED, handling medications and equipment and becoming comfortable with use of isolation rooms. This application of in situ simulation allowed one simulation event to reach a wide audience, while allowing participants to respect social distancing, and resulted in the education of this audience and successful crowdsourcing for a protocol amidst a pandemic.

Implication statement: The COVID-19 pandemic has limited in-person experiences for medical students, especially in situations involving aerosol-generating procedures. We designed a video in situ simulation to orient students to critical steps in COVID-19 intubation algorithms. Small groups of students were paired virtually with facilitators (faculty and residents) and watched a video of an in situ simulation of emergency staff performing a protected intubation, with discussion points appearing on screen at discrete times. The simple design drives engagement, discussion and allows for scheduling flexibility with no risk to the learners. It can be adapted to several different scenarios or levels of training., Énoncé des implications de la recherche : La pandémie de la COVID-19 a limité les expériences en personne pour les étudiants en médecine, en particulier les interventions qui produisent des aérosols. Nous avons conçu une simulation in situ par vidéo portant sur les étapes critiques des algorithmes de l’intubation dans les cas de COVID-19. De petits groupes d’étudiants, jumelés virtuellement avec des animateurs (enseignants et résidents), ont regardé une vidéo de la simulation in situ d’une intubation sécuritaire effectuée par une équipe d’urgence. À des moments précis de la simulation, des points de discussion apparaissaient à l’écran. Cette formule simple, sans risque pour les apprenants, favorise l’engagement et la discussion et elle permet la planification en toute souplesse. Elle peut être adaptée à plusieurs scénarios et à divers niveaux de formation.

Given the high risk of healthcare worker (HCW) infection with COVID-19 during aerosol-generating medical procedures, the use of a box barrier during intubation for protection of HCWs has been examined. Previous simulation work has demonstrated its efficacy in protecting HCWs from cough-expelled droplets. Our objective was to assess its ability to protect HCWs against aerosols generated during aerosol-generating medical procedures. We used a battery-powered vapouriser to assess movement of vapour with: (1) no barrier; (2) a box barrier; and (3) a box barrier and a plastic sheet covering the box and patient’s body. We visualised the trajectory of vapour and saw that the vapour remained within the barrier space when the box barrier and plastic sheet were used. This is in contrast to the box barrier alone, where vapour diffused towards the feet of the patient and throughout the room, and to no barrier where the vapour immediately diffused to the laryngoscopist. This demonstrates that the box with the plastic sheet has the potential to limit the spread of aerosols towards the laryngoscopist, and thus may play a role in protecting HCWs during aerosol-generating medical procedures. This is of particular importance in the care of patients with suspected COVID-19.

Introduction: In the emergency department (ED), high-acuity presentations encountered at low frequencies are associated with reduced staff comfort. Previous studies have shown that simulation can improve provider confidence with practical skills and management of presentations in various fields of medicine. The present study examined the effect of in situ simulation on interprofessional provider comfort with the identification and management of high-acuity low-frequency events in the ED. It further assessed the feasibility of implementing weekly simulation as an interprofessional education initiative in a high-volume ED. Methods: This was a retrospective pre-test post-test quasi-experimental design. Weekly in situ simulation events were facilitated by an interdisciplinary team in a high-volume ED in Hamilton, Ontario that sees an average of 185 patients per day. To date, 34 simulation events were held between January 18, 2019 and November 22, 2019, and included neonatal, paediatric and obstetric emergencies, and adult codes. There was an average of 20 patients presenting to the ED during these events. Events included a debrief, and typically lasted 60 minutes in total. Participants included individuals from various disciplines working on shift at the time of the event. Questionnaires were administered via email following the event, in which participants were asked to rank their comfort with emergency codes before and after the simulation using two 5-point Likert scales. The data from 39 questionnaires was analyzed. T-tests were used to analyze differences in self-reported comfort scores. Results: Questionnaire responders included nurses (41%), respiratory therapists (26%), resident physicians (10%), paramedics (3%), attending physicians (3%), students of various disciplines (10%) and other (7%). 38% of participants reported increases in comfort following simulation when compared to prior. Using the 5-point scale, the average reported score for comfort pre-simulation was 3.59 (95% CI 3.30–3.88), and the average post-simulation score was 3.97 (95% CI 3.76–4.19, p = 0.03). Conclusion: Our results demonstrate that weekly interprofessional in situ simulation is feasible in a high-volume ED, and significantly improves self-reported provider comfort with the identification and management of high-acuity, low-frequency events. This warrants the implementation of this simulation design to improve staff confidence and has implications for its potential role in improving team dynamics and patient safety.

Background The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on emergency medical services (EMS) and local EDs. Literature concerning the safety of these events is minimal and mostly consists of media reports. We sought to characterise the injury and illness profile of OCRs and the level of medical care required. Methods This study analysed OCR events occurring in eight locations across Canada from May to August 2015 (total 45 285 participants). Data were extracted from event medical charts of patients presenting to the onsite medical team, including injury or illness type, onsite treatment and disposition. Results There were 557 race participants treated at eight OCR events (1.2% of all participants). There were 609 medical complaints in total. Three quarters of injuries were musculoskeletal in nature. Eighty-nine per cent returned to the event with no need for further medical care. The majority of treatments were completed with first aid and basic medical equipment. Eleven patients (2% of patients) required transfer to hospital by EMS for presentations including fracture, dislocation, head injury, chest pain, fall from height, and abdominal pain. Conclusions We found that 1.2% of race participants presented to onsite medical services. The majority of complaints were minor and musculoskeletal in nature. Only 2% of those treated were transferred to hospital through EMS. This is consistent with other types of mass gathering events.

We have examined the cytotoxic effect of gemcitabine in intravesical therapy using an in vitro co-cultured spheroid model composed of transitional cell carcinoma (TCC) and fibroblasts from both human and rat species. Immunohistochemistry analysis of the co-cultured spheroids, using cytokeratin-13 and vimentin antibodies against TCC and fibroblasts, respectively, showed the central location of fibroblasts within the spheroid, whereas TCC formed the peripheral layers. Spheroids composed of human TCC and fibroblasts (MGH-U3/CRL-1120 or RT-112/CRL-1120) as well as rat TCC and their corresponding fibroblasts (AY-27/RF-Ed1) displayed the same drug tolerance profile after an exposure of 0, 1, 3, 5, 7 and 14 days. As confirmed by time-lapse photography, MTT essay and vital dye staining, gemcitabine selectively killed the human and rat bladder cancer cell lines, but did not affect un-transformed human and rat fibroblast lines.

Introduction: The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on first responders, Emergency Medical Services (EMS) and local Emergency Departments. Literature concerning these events is minimal and mostly consists of media reports. Recognizing the lack of epidemiologic data, we sought to accurately determine the patterns and frequency of injuries and illnesses that occur at OCRs, the treatments required, and what proportion require further medical care or transfer to hospital. Methods: Data were extracted from medical charts completed for all patients presenting to the on-site medical team at OCR events across Canada from May to August, 2015. Frequency and patterns of injuries and illnesses were determined as well as treatments and disposition. There were 45 285 OCR participants in 8 events. There were 572 total patient contacts and 557 patients were included in the study. 15 patients were excluded because they were not race participants. Results: Less than 2% of participants at any event required on-site medical care. 11 patients (1.97%) required transfer to hospital by EMS. The majority of injuries were musculoskeletal in nature (74.71%). 495 patients (88.87%) returned to the event with no need for further medical care. The majority of treatments could be provided with first aid training and basic medical equipment. Conclusion: Injury and illness rates at this series of OCRs was similar to other mass gathering events. Injuries were mostly musculoskeletal in nature and required minor treatment. Having a medical team on site likely reduced local hospital and EMS volume from these events. This study raises the question of whether having a physician on site at OCRs could significantly reduce the number of patients advised to seek further medical care or the number of ambulance transfers. Prospective research is needed in order to develop plans for more appropriate resources, safety protocols, and medical staffing, thereby improving patient care and reducing the burden on local EMS and rural hospitals.

ObjectiveTo reduce adverse effects and improve efficacy of intravesical BCG for bladder cancer, alternative treatment options were investigated in an orthotopic rat tumor model.MethodsSuperficial bladder cancer was established in syngeneic female rat bladders by instillation of AY-27 cells. Animals were randomly assigned to treatment groups including dose escalation of intravesical BCG with or without interferon-α (IFN-α) or interleukin-2 (IL-2); or graded doses of gemcitabine alone; or BCG plus gemcitabine. Treatments were given twice weekly for 3 weeks. Rats in control groups received saline instillations. Treatment response was monitored by animals’ well-being, survival days, tumor growth inhibition, and histological examination at necropsy.ResultsRats receiving monotherapy with intravesical BCG, gemcitabine, or IFN-α, attained significantly better survival and tumor reduction compared with control ( P = 0.002; 0.001; 0.002, respectively, Log-rank Test). A dose-dependent treatment response was observed in animals with established bladder tumor receiving escalated BCG instillations. Only high-dose BCG significantly improved animal survival. Although high-dose BCG plus gemcitabine or IFN-α did not increase benefit over monotherapies, low-dose BCG plus IL-2 did show improved efficacy ( P = 0.01).ConclusionIntravesical monotherapies with gemcitabine and IFN-α were as effective as BCG for treatment of early non-muscle-invasive urothelial bladder cancer in this immune competent rat model. Combining these agents with high-dose BCG did not further increase efficacy. However, combining low-dose BCG with IL-2 enhanced BCG effectiveness.

Purpose: To our knowledge this is the first report of intravesical oncolytic reovirus for therapy of superficial bladder cancer in an orthotopic bladder tumor model. Superficial bladder carcinomas are often multifocal and have high recurrences after surgical resection. In 20% of cases intravesical immunotherapy fails to prevent recurrence and complications from bacillus Calmette-Guerin (BCG) are common. Human reovirus is an oncolytic virus that selectively destroys cancer cells with an activated Ras pathway. We examined the ability of this virus to kill bladder cancer cells in vitro and inhibit tumor growth in vivo. Materials and Methods: Following cytotoxicity assays in vitro dose escalation of intravesical reovirus was tested for tumor control and toxicity in a rat model. Treatments were done twice weekly for 3 weeks. In parallel intravesical BCG was studied. Animals were monitored on a daily basis for health status and by routine urine cytology. Animals underwent necropsy at study end point and appropriate tissues were taken for histology. Results: Side effects in reovirus groups were minor compared with BCG complications. Tumor response (animal survival) was 90% 100 days after tumor implantation in reovirus treated animals, whereas the highest survival in BCG treated groups was 50%. Animals treated with reovirus had significantly higher tumor-free survival than those treated with immunotherapy or normal saline (log rank test p 0.0002 and 0.04, respectively). Conclusions: Intravesical reovirus is safe and effective in this animal model and it may have clinical applications for bladder cancer treatment.

Up to 50% of the transitional cell carcinomas (TCC) express an activated EGF pathway involving MAP/MEK and RAF kinase thus providing a novel means to selectively eliminate transformed cells expressing such proteins. This EGF pathway expression phenotype was also confirmed in our MGH-U3 and room temperature-112 human TCC cell lines, which makes them a suitable model target for the reovirus oncolysis. We report here on an in vitro assay of co-culture spheroids using either human or rat TCC cells with their corresponding fibroblasts to examine the potential of viral selective lysis for TCC. Reovirus, a respiratory enteric orphan virus, which mammals are exposed to early in life, was used in this study. Selective killing of transformed versus normal cells was assayed by time-lapse photography, vital dye staining, immunohistochemistry, and MTT assay. In this in vitro bladder cancer model, reovirus selectively destroyed the transformed cells by lysis or induction of apoptosis. Based on these findings we have initiated an in vivo pre-clinical study on intravesical administration of reovirus in an animal model to further explore the effect of reovirus-mediated oncolysis of TCC.