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Background: Obesity has a major impact on health and health care, particularly in those with chronic kidney disease (CKD). Objective: The objective was to describe the prevalence, characteristics, and outcomes of people living with CKD and obesity (defined by a body mass index [BMI] ≥30 kg/m 2 ) in Canada. Design: Population-based cohort study using linked administrative health data (ICES). Patients: Adults aged 18 year and older with CKD G1-5D who had a height and weight recorded during a visit to an academic hospital in London Ontario Canada, between January 2010 and December 2019. Measures: CKD as defined by CKD 3A or higher. BMI as defined by weight kg/m 2 . Methods: As a primary interest, we described the percentage of patients with CKD across different BMI categories (

The prevalence of obesity is growing globally and has major health implications, particularly for those with chronic kidney disease (CKD). People with obesity have a higher risk of CKD progression and face barriers to transplantation. Studies on the epidemiology and outcomes of obesity in the Canadian CKD population are lacking. This population-based cohort study included adults aged 18 and over with a hospital encounter in London, Ontario, Canada from 2010 to 2019 where height and weight were recorded. They were stratified into CKD stages 1-5 (by estimated glomerular filtration rate (eGFR)), dialysis or renal transplant status and by body mass index (BMI) using Canada Obesity Guidelines. Outcomes included prevalence of BMIs by CKD stage, and CKD progression and transplant outcomes across BMI classes. Our cohort included 198,151 patients. The prevalence of BMI ≥30 kg/m2 grew as eGFR declined (i.e., 37% in stage 1, 41.5% in stage 3b, 40.9% in stage 4) but fell in end-stages (i.e., 37.4% in Stage 5, 38.8% in dialysis, 38.5% in transplant recipients). CKD progression and kidney failure appeared more frequent in those with a BMI ≥30 kg/m2. In a smaller sample, we noted that end-stage patients with a BMI ≥30 kg/m2 were less frequently transplanted, but experienced post-transplant complications less often. This study revealed that high BMI is a prevalent issue in the Canadian CKD population and may influence kidney outcomes and transplant candidacy. This data will help inform clinical trials to create and study weight loss interventions for those with CKD and obesity.

Abstract Healthcare organizations strive to deliver safe, high-quality, efficient care. These complex systems frequently harbor gaps, which if unmitigated, could result in harm. Systems-focused simulation (SFS) projects, which include systems-focused debriefing (SFD), if well designed and executed, can proactively and comprehensively identify gaps and test and improve systems, enabling institutions to improve safety and quality before patients and staff are placed at risk. The previously published systems-focused debriefing framework, Promoting Excellence and Reflective Learning in Simulation (PEARLS) for Systems Integration (PSI), describes a systematic approach to SFD. It includes an essential “pre-work” phase, encompassing evidence-informed steps that lead up to a SFD. Despite inclusion in the PSI framework, a detailed description of the pre-work phase, and how each component facilitates change management, was limited. The goal of this paper is to elucidate the PSI “Pre-work” phase, everything leading up to the systems-focused simulation and debriefing. It describes how the integration of project and change management principles ensures that a comprehensive collection of safety and quality issues are reliably identified and captured.

Integrating electronic health records (EHR) with health administrative data offer opportunities for enhanced decision support, health systems evaluations and research for improved patient care. We describe the process of integrating EHR data from 12 hospitals in Southwestern Ontario, Canada and present a health systems evaluation enabled by this linkage. With support and buy-in from the hospital Chief Executive Officers, a data sharing agreement (DSA) with ICES was executed, outlining the process to approve data transfer requests. Due to the complexity and volume of the EHR, complete data were not immediately transferred to ICES; instead, a project subcommittee comprising of physician leadership, local and regional privacy and risk officers, and ICES staff was assembled to review and approve project-specific data integration requests. An evaluation of the adoption of an electronic medication reconciliation system within the EHR on potentially inappropriate prescribing after hospital discharge was conducted using interrupted time-series analyses. The data integration request process begins with confirmation of data availability and accuracy within the EHR, enabled by a dedicated health information analyst and institutional decision support teams. Once data feasibility is confirmed, project rationale is submitted to the project subcommittee approval. Following approval, the request undergoes privacy and legal assessment as per the DSA and a project-ready dataset is submitted for linkage. An evaluation of the adoption of an electronic medication reconciliation system demonstrated an immediate and dramatic reduction in inappropriate medication prescribing and associated adverse events such as a fall or fracture among elderly patients discharged following acute inpatient stays. Administrative data are valuable at assessing population-based health, but often lack key clinical information present in EHRs. Integrating both data sources offers a more comprehensive picture of patient care and allows for robust analyses. Rigorous investigations generate trusted evidence for decision makers to inform policy and quality improvements within the healthcare system.

Abstract Healthcare systems are urged to build facilities that support safe and efficient delivery of care. Literature demonstrates that the built environment impacts patient safety. Design decisions made early in the planning process may introduce flaws into the system, known as latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) has successfully been incorporated in the post-construction evaluation process in order to identify LSTs prior to patient exposure and promote preparedness, easing the transition into newly built facilities. As the application of simulation in healthcare extends into the realm of process and systems testing, there is a need for a standardized approach by which to conduct SbCST in order to effectively evaluate newly built healthcare facilities. This paper describes a systemic approach by which to conduct SbCST and provides documentation and evaluation tools in order to develop, implement, and evaluate a newly built environment to identify LSTs and system inefficiencies prior to patient exposure.

Introduction The American Academy of Pediatrics recommends vitamin K prophylaxis at birth for all newborns to prevent vitamin K deficiency bleeding (VKDB). Despite a lack of evidence for serious harms, barriers to prophylaxis, including parental refusal, are rising, as are cases of VKDB. Methods This simulation involved an infant presenting to the emergency department who decompensated due to a cerebral hemorrhage caused by VKDB and was treated by pediatric and emergency providers. The case was incorporated into the fellow and division monthly curricula, and participants completed postsimulation surveys. The patient required a secure airway, seizure management, vitamin K, and a fresh frozen plasma infusion upon suspicion of the diagnosis, plus a coordinated transfer to definitive care. The case included a description of the simulated case, learning objectives, instructor notes, an example of the ideal flow of the scenario, anticipated management mistakes, and educational materials. Results The simulations were carried out with 48 total participants, including 40 fellows and eight attendings, from five different training institutions over 1 year. In surveys, respondents gave overall positive feedback. Ninety-four percent of participants gave the highest score on a Likert scale indicating that the simulation was relevant, and over 80% gave the highest score indicating that the experience helped them with medical management. Discussion This simulation trained physicians how to recognize and treat a distressed infant with VKDB. The case was perceived to be an effective learning tool for both fellow and attending physicians.

Abstract Background Although early detection and management of excess rates of gestational diabetes mellitus (GDM) among Indigenous women can substantially reduce maternal and offspring complications, current interventions seem ineffective for Indigenous women. While undertaking a qualitative study in a rural community in Northland, New Zealand about the complexities of living with diabetes, we observed a common emotional discourse about the burden of diabetic pregnancies. Given the significance of GDM and our commitment to give voice to Indigenous Māori women in ways that could potentially inform solutions, we aimed to explore the phenomenon of GDM among Māori women in a rural context marked by high area-deprivation. Method A qualitative and Kaupapa Māori methodology was utilised. A sub-sample of women (n = 10) from a broader study designed to improve type 2 diabetes mellitus (T2DM) who had experienced GDM or pre-existing diabetes during pregnancy and/or had been exposed to diabetes in utero were interviewed. Participants in the broader study were recruited via the local primary care clinic. Experiences of GDM, in relation to their current T2DM, was sought. Narrative data was analysed for themes. Results Intergenerational experiences informed perceptions that GDM was an inevitable heritable illness that “just runs in the family.” The cumulative effects of deprivation and living with GDM compounded the complexities of participant’ lives including perceptions of powerlessness and mental health deterioration. Missed opportunities for health services to detect and manage diabetes had ongoing health consequences for the women and their offspring. Positive relationships with healthcare providers facilitated management of GDM and helped women engage with self-management. Conclusion Māori women living with T2DM were clear that health providers had failed to intervene in ways that would have potentially slowed or prevented progression of GDM to T2DM. Participants revealed missed opportunities for appropriate diagnostic testing, treatment and health promotion programmes for GDM. Poor collaboration between health services and social services meant psychosocial issues were rarely addressed and the cycle of intergenerational poverty and disadvantage prevailed. These data highlight opportunities for extended case management to include whānau (family) engagement, input from social services, and evidence-based medicine and/or long-term management and prevention of T2DM.

Introduction Bupropion is a commonly used antidepressant, and overdose can lead to both neurologic and cardiovascular toxicity, including agitation, seizure, tachycardia, QT and QRS prolongation, and rhythm disturbances. Methods We developed this simulation case for attendings, fellows, nurse practitioners, and nurses in the pediatric emergency department (ED). The scenario involved a 13-year-old male presenting to the ED with altered mental status and a generalized tonic-clonic seizure shortly after arrival. The team needed to quickly perform primary and secondary surveys, manage his airway and breathing, and initiate treatment for seizure. The team had to obtain an abbreviated history and include ingestion in the differential. The patient then developed pulseless ventricular tachycardia, and the team needed to respond with high-quality CPR, defibrillation, and advanced airway management. Preparatory materials, a debriefing guide, and scenario evaluation forms assisted with facilitation. Results Twenty-eight physicians, 56 nurses, 10 nurse practitioners, four pharmacists, two students, and one respiratory therapist completed this simulation in 13 sessions. On a 5-point Likert scale, participants agreed with the stated objective of ability to manage a patient with a bupropion overdose (M = 4.09; range, 2-5). The scenario was rated as highly relevant (M = 4.93) and the debriefing as very effective (M = 4.85). Discussion This scenario is a complete educational resource for setting up, implementing, and debriefing in an interprofessional setting. It was well received by learners from diverse professional backgrounds working together in actual care teams in the pediatric ED.

Abstract Objective: This qualitative study explored self‐reported experiences of primary healthcare among a sample of urban Māori adults. This paper specifically focuses on the theme of relational continuity of care identified in participant discussions of access and engagement with their predominantly non‐Māori general practitioners (GPs). Methods: The study involved a purposively selected subsample (n=42) of the Christchurch Māori cohort of the Hauora Manawa Community Heart Study (n=244). Participants took part in in‐depth interviews, which were transcribed and analysed thematically. Results: Analysis identified compromised access to a preferred GP as a principal barrier to receiving quality and non‐discriminatory care from predominantly non‐Māori clinicians. In contrast to discussions of healthcare provided by usual GPs, episodic encounters with non‐regular clinicians were commonly framed as experiences discouraging utilisation and the perceived value of primary healthcare. Conclusions: Facilitating relational continuity of care for Māori patients and their clinicians may contribute towards mediating determinants of inequality at the clinical interface. Implications: Reducing significant health disparities between Māori and non‐Māori was a key goal of the reconfiguration of primary healthcare in the early 2000s. The role of relational continuity of care in achieving equitable inter‐ethnic health outcomes in primary healthcare settings is an important consideration.

Introduction Altered mental status can be a challenging presenting symptom in children due to the wide differential diagnosis, which ranges from the relatively benign to the life threatening. Marijuana ingestion and unintentional intoxication are becoming an increasingly common cause of altered mental status in children as marijuana use and availability of enticing marijuana edibles increase in the United States. Because children present with altered mental status rather than the typical marijuana toxidrome, appropriately managing these patients in emergency settings can be particularly challenging. Methods This simulation-based curriculum involved the evaluation and management of a 6-year-old boy who presented with altered mental status from acute marijuana intoxication unbeknownst to his parents. Participants systematically evaluated a pediatric patient with a broad differential diagnosis of altered mental status and managed the patient with acute marijuana intoxication. This scenario may be modified based on trainee level (medical student vs. resident vs. fellow). Results A total of 20 trainees comprising six emergency medicine fellows and 14 pediatric residents and medical students participated in this simulation curriculum over three iterations. Trainees consistently rated it as an overall positive learning experience for pediatric altered mental status and toxidrome education. Discussion Low-frequency, high-risk illnesses such as altered mental status due to marijuana intoxication require providers to be familiar with their evaluation and management. This curriculum provides instructors with the materials to successfully implement and improve the simulation over time.

Introduction Although pediatric emergencies commonly occur in the outpatient setting, studies show that primary care providers often rely on hospitals or the emergency medical system to evaluate the distressed patient. This simulation-based curriculum addresses pediatric emergencies encountered by primary care providers. The cases were facilitated by faculty at an annual conference on urgent pediatric problems. Methods Three cases are included in this curriculum: asthma, anaphylaxis, and seizure. Each features a brief narrative description of the case, learning objectives, instructor notes, an example of the ideal flow of the scenario, and anticipated management mistakes. Also provided are tools on optimizing the simulation environment, teamwork and communication, and the debrief. Educational materials are included in the respective medical pathologies. The simulations can be run using a high- or low-fidelity mannequin. Results The simulations were carried out annually for 4 years with over 100 providers. Participants overall felt the curriculum was relevant to their practice in the realms of medical management and patient-provider communication. Discussion These simulation cases train primary care providers to recognize a decompensating patient, activate the emergency response system, and initiate appropriate treatment for acutely ill pediatric patients with asthma, anaphylaxis, or seizure. The cases also reinforce teamwork and communication skills with the intention of improving overall readiness in the office. The simulations have been found to be effective learning tools at the University of Washington, which continues to train outpatient providers in emergency response annually using this curriculum.

Introduction Cardiac tamponade is an uncommon presentation to the pediatric emergency department and requires early recognition and emergent intervention. Methods We developed this patient simulation case to simulate a low-frequency, high-acuity scenario for pediatric emergency medicine fellows and resident physicians in emergency medicine, pediatrics, and family medicine. We ran the case in a pediatric emergency department using a high-fidelity pediatric mannequin and equipment found in the clinical environment, including a bedside ultrasound machine. The case involved a 10-year-old patient with Hodgkin lymphoma who presented with fever, neutropenia, and shock and was found to have a pericardial effusion with tamponade after evaluation. The providers were expected to identify signs and symptoms of shock, as well as cardiac tamponade, and demonstrate appropriate emergent evaluation and management. Required personnel included a simulation technician, instructors, and a nurse. Debriefing tools tailored specifically for this scenario were created to facilitate a formal debriefing and formative learner assessment at the end of the simulation. Results This case has been implemented with 10 pediatric emergency medicine fellows during two 3-year cycles of fellow education. Session feedback reflected a high level of satisfaction with the case and an increased awareness of bedside ultrasound in the identification of cardiac tamponade. Discussion This resource for teaching the critical components for diagnosing and managing unstable cardiac tamponade in the pediatric patient, including use of bedside ultrasound, was well received by pediatric emergency medicine fellows.

Introduction Liquid nicotine exposure is becoming more common in the pediatric population. Toxicity may occur with exposure to small quantities given the high concentrations in solutions available commercially. Effects can include altered mental status, seizure, and death. Methods This simulation-based case involves the identification and management of a toddler presenting with acute liquid nicotine exposure, with emphasis on the general approach to the acutely ill pediatric patient, consideration in toxic exposures, and the presentation of nicotine exposure. Providers should assess airway, breathing, and circulation while concurrently providing supportive care for an actively seizing simulated patient, necessitating appropriate selection of medications and acute airway management. Additionally, providers must maintain a broad differential diagnosis and obtain a focused history to narrow that differential and identify toxic exposure as a cause of the patient's presentation. Preparatory and didactic material is provided to help the instructor prepare the simulation environment, guide learners through the case, and debrief with learners afterward. Results We implemented this curriculum with four pediatric emergency medicine fellows and 15 pediatric residents during two sessions. Feedback was overwhelmingly positive; participants who completed evaluations reported high levels of confidence with knowledge and skills directly related to the educational objectives after participation (mean Likert scores of 4.9 out of 5 in response to effectiveness of the case in teaching evaluation and management of nicotine toxicity). Discussion This comprehensive resource will aid in offering continuing education for providers and specifically in educating learners with regard to acute liquid nicotine exposure in a child.

Introduction Electrical injuries are rare but potentially life-threatening medical emergencies that require providers to manage a critically ill patient while recognizing and treating the unique sequelae associated with the diagnosis. This simulation case is designed to give pediatric and emergency medicine residents, fellows, attendings, and nurses the opportunity to practice these skills in a realistic setting. Methods This simulation-based curriculum was designed for a high-fidelity mannequin in an emergency department resuscitation room but can be adapted to fit a variety of learning environments. The case featured a 16-year-old boy presenting to the emergency department after arresting in the field after sustaining an electrical injury. He developed ventricular tachycardia during the simulation and had significant hyperkalemia, requiring emergent management. The included debriefing tools assisted instructors in providing formative feedback to learners. Results A total of 40 residents, medical students, and fellows participated in this scenario and provided overwhelmingly positive feedback about the learning experience. Mean Likert scores for participant confidence related to learning objectives after the simulation were 4 or greater on a 5-point scale. Discussion This case was developed to help learners at various levels of training recognize and manage a low-frequency, high-acuity scenario in a standardized environment. Participants specifically had the opportunity to perform airway management, cardiopulmonary resuscitation, defibrillation, and management of hyperkalemia, which may present in real life from a multitude of etiologies. The included materials helped prepare and assist facilitators with debriefing, supplemental education, and bidirectional feedback.

Introduction Submersion injury or drowning is a leading preventable cause of pediatric mortality and morbidity. Submersion injuries are often accompanied by hypothermia and asphyxia that can lead to inadequate oxygen delivery to tissues and subsequent cardiac arrhythmias. Methods This simulation-based curriculum involves the identification and management of a submersion injury in a 4-year-old boy who was rescued from a cold-water submersion. The simulated patient is apneic, pulseless, bradycardic, and hypothermic; he is being bag-mask ventilated on arrival without intravenous access. He ultimately develops ventricular fibrillation. Providers must recognize the degree of submersion injury, initiate early airway protection, adequately address circulation, and be alert to developing hypothermia and cardiac arrhythmias to prevent further decompensation. This scenario can be modified based on trainee level (pediatric residents vs. pediatric emergency medicine fellows). Results A total of 22 trainees (PGY 1-PGY 6 pediatric residents and pediatric emergency medicine fellows) participated in this simulation curriculum on separate occasions and rated it as an overall positive learning experience. The curriculum's goal is to provide learners with an opportunity to manage life-threatening pediatric submersion injuries, where the correct steps need to be taken in a limited period of time. Discussion We have provided preparatory materials to help instructors set up, run, and debrief the scenario in a standardized fashion. The debriefing tools allow for adaptation depending on learners' needs and individual experiences during the simulated scenario. Also included are supporting educational materials and a learner feedback form that can be used to evaluate the session.

Introduction Child abuse, also known as nonaccidental trauma (NAT), is an important cause of pediatric morbidity and mortality. The presentation of NAT is often confounded by unclear histories and victims who are unable to provide information. Medical students and trainees may fail to consider NAT as a diagnosis or be unfamiliar with the evaluation process. Methods This curriculum uses simulation, small-group discussion, and didactics to help medical students gain an understanding of presentation of NAT. Using the case of a 2-month-old boy presenting with altered mental status and seizure, participants practice the assessment and management of an acutely ill patient. Small-group discussions facilitate schema building to enhance each participant's ability to recognize and diagnose different diseases that may present as infant seizure and to identify the signs of NAT. Didactics solidify concepts addressed during the simulation and small-group discussions. Results Medical students participating in this course reported that they felt better prepared for their internships and that working through a case with a large differential diagnosis was helpful for their understanding of causes of infant seizures, including abusive head trauma. Discussion This curriculum is unique in that it uses one unifying case to allow participants to demonstrate an understanding of the evaluation and stabilization of a critically ill pediatric patient, develop a broad differential diagnosis for a nonspecific symptom, and prioritize and evaluate possible etiologies through the gathering and interpretation of data. This curriculum may be used independently or in conjunction with other learning activities as part of a pediatric boot camp.

This essay takes as its focus the everyday writing that people compose: the self-sponsored, nonobligatory texts that people write mainly outside of work and school. Through analysis of 713 survey responses and 27 interviews with accompanying writing samples, this study provides a panoramic view of the functions of self-sponsored writing and rhetorical activity for U.S. adults, ages 18 to 65+ years, from a range of geographic, cultural, and professional backgrounds. The Taxonomy of Life Writing presented in this essay demonstrates the range of ways that writing functions in people's daily lives. It includes 19 key functions of life writing, organized into six metafunctions: Creativity and Expression, Identity and Relationships, Organization and Coordination, Preservation and Memory, Reflection and Emotion, and Teaching and Learning. Based on our findings, we affirm the important and diverse functions that life writing serves and propose expanding the threshold concepts of writing to include greater focus on nonobligatory, self-sponsored writing activity.