Publications by authors named "Judy Morris"

56 Publications

Comparing the Visual Perception According to the Performance Using the Eye-Tracking Technology in High-Fidelity Simulation Settings.

Behav Sci (Basel) 2021 Mar 5;11(3). Epub 2021 Mar 5.

Department of Anesthesiology, Faculty of Medicine, Montreal, Centre d'Apprentissage des Attitudes et Habiletés Cliniques (CAAHC), Université de Montréal, Montréal, QC H1T 2M4, Canada.

Introduction: We used eye-tracking technology to explore the visual perception of clinicians during a high-fidelity simulation scenario. We hypothesized that physicians who were able to successfully manage a critical situation would have a different visual focus compared to those who failed.

Methods: A convenience sample of 18 first-year emergency medicine residents were enrolled voluntarily to participate in a high-fidelity scenario involving a patient in shock with a 3rd degree atrioventricular block. Their performance was rated as pass or fail and depended on the proper use of the pacing unit. Participants were wearing pre-calibrated eye-tracking glasses throughout the 9-min scenario and infrared (IR) markers installed in the simulator were used to define various Areas of Interest (AOI). Total View Duration (TVD) and Time to First Fixation (TFF) by the participants were recorded for each AOI and the results were used to produce heat maps.

Results: Twelve residents succeeded while six failed the scenario. The TVD for the AOI containing the pacing unit was significantly shorter (median [quartile]) for those who succeeded compared to the ones who failed (42 [31-52] sec vs. 70 [61-90] sec, = 0.0097). The TFF for the AOI containing the ECG and vital signs monitor was also shorter for the participants who succeeded than for those who failed (22 [6-28] sec vs. 30 [27-77] sec, = 0.0182).

Discussion: There seemed to be a connection between the gaze pattern of residents in a high-fidelity bradycardia simulation and their performance. The participants who succeeded looked at the monitor earlier (diagnosis). They also spent less time fixating the pacing unit, using it promptly to address the bradycardia. This study suggests that eye-tracking technology could be used to explore how visual perception, a key information-gathering element, is tied to decision-making and clinical performance.
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http://dx.doi.org/10.3390/bs11030031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7998119PMC
March 2021

Fruit-Induced Anaphylaxis: Clinical Presentation and Management.

J Allergy Clin Immunol Pract 2021 Mar 13. Epub 2021 Mar 13.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

Background: Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis.

Objective: To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use.

Methods: Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting.

Results: We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting.

Conclusions: Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further.
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http://dx.doi.org/10.1016/j.jaip.2021.02.055DOI Listing
March 2021

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study.

JMIR Res Protoc 2021 Feb 22;10(2):e25619. Epub 2021 Feb 22.

Department of Medicine, University of Toronto, Toronto, ON, Canada.

Background: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal.

Objective: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease.

Methods: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness.

Results: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025.

Conclusions: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative.

International Registered Report Identifier (irrid): PRR1-10.2196/25619.
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http://dx.doi.org/10.2196/25619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7939947PMC
February 2021

Optimizing collaborative relationships in emergency medicine research.

CJEM 2021 Feb 18. Epub 2021 Feb 18.

Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.

Objective: The objective of the Canadian Association of Emergency Physicians (CAEP) 2020 Academic Symposium Panel was to present recommendations for collaboration on (1) writing a grant application; (2) conducting a study; (3) writing an abstract; and (4) writing a manuscript.

Methods: We assembled an expert panel of eight experienced emergency medicine clinician scientists from across Canada. Panel members performed literature searches for each of the four topics. Draft recommendations were developed and refined in an iterative fashion by panel members. We solicited external feedback on the draft recommendations online from identified researchers known to CAEP and in person at the Network of Canadian Emergency Researchers meeting in February 2020. We obtained additional feedback during an online symposium presentation on October 15th, 2020, open to all members of the Canadian Association of Emergency Physicians.

Results: Four sets of recommendations were established for each component including: 14 for writing a grant application including relevant timelines; 23 for conducting a study; 13 for writing an abstract; and 18 for writing a manuscript. Forming a strong team, including patients, appropriate methodologists, content experts and a mix of senior and junior investigators, establishing and following clear timelines, and proactive communications were common themes.

Conclusions: We offer recommendations for research collaboration for (1) writing a grant, (2) conducting a study, (3) writing an abstract, and (4) writing a manuscript. We believe these recommendations will help to improve the science, improve grant success, and improve the impact of the abstracts and manuscripts.
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http://dx.doi.org/10.1007/s43678-020-00080-wDOI Listing
February 2021

Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study.

BMJ 2021 02 4;372:n49. Epub 2021 Feb 4.

Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.

Objective: To validate the previously derived Canadian TIA Score to stratify subsequent stroke risk in a new cohort of emergency department patients with transient ischaemic attack.

Design: Prospective cohort study.

Setting: 13 Canadian emergency departments over five years.

Participants: 7607 consecutively enrolled adult patients attending the emergency department with transient ischaemic attack or minor stroke.

Main Outcome Measures: The primary outcome was subsequent stroke or carotid endarterectomy/carotid artery stenting within seven days. The secondary outcome was subsequent stroke within seven days (with or without carotid endarterectomy/carotid artery stenting). Telephone follow-up used the validated Questionnaire for Verifying Stroke Free Status at seven and 90 days. All outcomes were adjudicated by panels of three stroke experts, blinded to the index emergency department visit.

Results: Of the 7607 patients, 108 (1.4%) had a subsequent stroke within seven days, 83 (1.1%) had carotid endarterectomy/carotid artery stenting within seven days, and nine had both. The Canadian TIA Score stratified the risk of stroke, carotid endarterectomy/carotid artery stenting, or both within seven days as low (risk ≤0.5%; interval likelihood ratio 0.20, 95% confidence interval 0.09 to 0.44), medium (risk 2.3%; interval likelihood ratio 0.94, 0.85 to 1.04), and high (risk 5.9% interval likelihood ratio 2.56, 2.02 to 3.25) more accurately (area under the curve 0.70, 95% confidence interval 0.66 to 0.73) than did the ABCD2 (0.60, 0.55 to 0.64) or ABCD2i (0.64, 0.59 to 0.68). Results were similar for subsequent stroke regardless of carotid endarterectomy/carotid artery stenting within seven days.

Conclusion: The Canadian TIA Score stratifies patients' seven day risk for stroke, with or without carotid endarterectomy/carotid artery stenting, and is now ready for clinical use. Incorporating this validated risk estimate into management plans should improve early decision making at the index emergency visit regarding benefits of hospital admission, timing of investigations, and prioritisation of specialist referral.
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http://dx.doi.org/10.1136/bmj.n49DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859838PMC
February 2021

Relationship between acute pain trajectories after an emergency department visit and chronic pain: a Canadian prospective cohort study.

BMJ Open 2020 12 7;10(12):e040390. Epub 2020 Dec 7.

Department of Emergency Medicine, Hopital du Sacre-Coeur de Montreal, Montréal, Quebec, Canada.

Objectives: Inadequate acute pain management can reduce the quality of life, cause unnecessary suffering and can often lead to the development of chronic pain. Using group-based trajectory modelling, we previously identified six distinct pain intensity trajectories for the first 14-day postemergency department (ED) discharge; two linear ones with moderate or severe pain during follow-up (~40% of the patients) and four cubic polynomial order trajectories with mild or no pain at the end of the 14 days (low final pain trajectories). We assessed if previously described acute pain intensity trajectories over 14 days after ED discharge are predictive of chronic pain 3 months later.

Design: Prospective cohort study.

Setting: Tertiary care trauma centre academic hospital.

Participants: This study included 18 years and older ED patients who consulted for acute (≤2 weeks) pain conditions that were discharged with an opioid prescription. Patients completed a 14-day diary in which they listed their daily pain intensity (0-10 numeric rating scale).

Outcomes: Three months after ED visit, participants were questioned by phone about their current pain intensity (0-10 numeric rating scale). Chronic pain was defined as patients with current pain intensity ≥4 at 3 months.

Results: A total of 305 participants remained in the study at 3 months, 49% were women and a mean age of 55±15 years. Twelve per cent (11.9; 95% CI 8.2 to 15.4) of patients had chronic pain at the 3-month follow-up. Controlling for age, sex and pain condition, patients with moderate or severe pain trajectories and those with only a severe pain trajectory were respectively 5.1 (95% CI 2.2 to 11.8) and 8.2 (95% CI 3.4 to 20.0) times more likely to develop chronic pain 3 months later compared with patients in the low final pain trajectories.

Conclusion: Specific acute pain trajectories following an ED visit are closely related to the development of chronic pain 3 months later.

Trial Registration Number: NCT02799004; Results.
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http://dx.doi.org/10.1136/bmjopen-2020-040390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722811PMC
December 2020

Can a Shockable Initial Rhythm Identify Out-of-Hospital Cardiac Arrest Patients with a Short No-flow Time?

Resuscitation 2021 Jan 19;158:57-63. Epub 2020 Nov 19.

Université de Montréal, Montréal, Québec, Canada; Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, Montréal, Québec, Canada.

Aims: Initial shockable rhythms may be a marker of shorter duration between collapse and initiation of cardiopulmonary resuscitation, known as no-flow time (NFT), for patients suffering an out-of-hospital cardiac arrest (OHCA). Eligibility for extracorporeal resuscitation is conditional on a short NFT. Patients with an unwitnessed OHCA could be candidate for extracorporeal resuscitation despite uncertain NFT if an initial shockable rhythm is a reliable stand-in. Herein, we sought to describe the sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minutes or less.

Methods: Using a registry of OHCA in Montreal, Canada, adult patients who experienced a witnessed non-traumatic OHCA, but who did not receive bystander cardiopulmonary resuscitation, were included. The sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minute or less were calculated. The association between the NFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression.

Results: A total of 2450 patients were included, of whom 863 (35%) had an initial shockable rhythm and 1085 (44%) a NFT of five minutes or less. The sensitivity of an initial shockable rhythm to predict a NFT of five minutes or less was 36% (95% confidence interval [95%CI] 33-39), specificity was 66% (95%CI 63-68), the positive likelihood ratio was 1.05 (95%CI 0.94-1.17) and the negative likelihood ratio of 0.97 (95%CI 0.92-1.03). The probabilities of observing a shockable rhythm stayed stable up to 15 minutes, while the probabilities of observing a PEA lowered rapidly initially. Longer NFT were associated with lower odds of observing an initial shockable rhythm (adjusted odds ratio = 0.97 [95%CI 0.94-0.99], p = 0.012).

Conclusions: An initial shockable rhythm is a poor predictor of a short NFT, despite there being an association between the NFT and the presence of a shockable rhythm.
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http://dx.doi.org/10.1016/j.resuscitation.2020.11.012DOI Listing
January 2021

Risk of peanut- and tree-nut-induced anaphylaxis during Halloween, Easter and other cultural holidays in Canadian children.

CMAJ 2020 Sep;192(38):E1084-E1092

Division of Allergy and Clinical Immunology (Leung, Gabrielli, Ben-Shoshan), Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montréal, Que.; Division of Rheumatology (Clarke, Shand), Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Morris), Hôpital Sacré-Coeur; Division of Pediatric Emergency Medicine (Gravel), Department of Pediatrics, Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Division of Pediatric Emergency Medicine (Lim), Department of Pediatrics, Children's Hospital at London Health Sciences Centre, London, Ont.; Divisions of Allergy and Immunology (Chan) and Emergency Medicine (Goldman, Enarson), Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC; Department of Pediatrics (O'Keefe), Faculty of Medicine, Memorial University, St. John's, NL; Food Allergy Canada (Gerdts), Toronto, Ont.; Division of Clinical Immunology & Allergy (Chu), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Chu), McMaster University, Hamilton, Ont.; Division of Immunology and Allergy (Upton), Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Centre for Outcomes Research and Evaluation (Zhang), Research Institute of McGill University Health Centre, Montréal, Que.

Background: It is not established whether the risk of anaphylaxis induced by peanuts or tree nuts in children increases at specific times of the year. We aimed to evaluate the risk of peanut-and tree-nut-induced anaphylaxis during certain cultural holidays in Canadian children.

Methods: We collected data on confirmed pediatric cases of anaphylaxis presenting to emergency departments in 4 Canadian provinces as part of the Cross-Canada Anaphylaxis Registry. We assessed the mean number of cases per day and incidence rate ratio (IRR) of anaphylaxis induced by unknown nuts, peanuts and tree nuts presenting during each of 6 holidays (Halloween, Christmas, Easter, Diwali, Chinese New Year and Eid al-Adha) versus the rest of the year. We estimated IRRs and 95% confidence intervals (CIs) using Poisson regression.

Results: Data were collected for 1390 pediatric cases of anaphylaxis between 2011 and 2020. Their median age was 5.4 years, and 864 (62.2%) of the children were boys. During Halloween and Easter, there were higher rates of anaphylaxis to unknown nuts (IRR 1.66, 95% CI 1.13-2.43 and IRR 1.71, 95% CI 1.21-2.42, respectively) and peanuts (IRR 1.86, 95% CI 1.12-3.11 and IRR 1.57, 95% CI 0.94-2.63, respectively) compared to the rest of the year. No increased risk of peanut- or tree-nut-induced anaphylaxis was observed during Christmas, Diwali, Chinese New Year or Eid al-Adha. Anaphylaxis induced by unknown nuts, peanuts and tree nuts was more likely in children aged 6 years or older than in younger children.

Interpretation: We found an increased risk of anaphylaxis induced by unknown nuts and peanuts during Halloween and Easter among Canadian children. Educational tools are needed to increase awareness and vigilance in order to decrease the risk of anaphylaxis induced by peanuts and tree nuts in children during these holidays.
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http://dx.doi.org/10.1503/cmaj.200034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532006PMC
September 2020

Anaphylaxis as a presenting symptom of food allergy in children with no known food allergy.

J Allergy Clin Immunol Pract 2020 09 26;8(8):2811-2813.e2. Epub 2020 Apr 26.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2020.04.033DOI Listing
September 2020

Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial.

Lancet 2020 02;395(10221):339-349

Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.

Background: Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion.

Methods: We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058.

Findings: Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68).

Interpretation: Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes.

Funding: Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.
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http://dx.doi.org/10.1016/S0140-6736(19)32994-0DOI Listing
February 2020

Health human resources for emergency medicine: a framework for the future.

CJEM 2020 01;22(1):40-44

St. Michael's Hospital, Toronto, ON, Canada.

In June of 2016, the Collaborative Working Group (CWG) on the Future of Emergency Medicine presented its final report at the Canadian Association of Emergency Physicians (CAEP) annual meeting in Quebec City. The CWG report made a number of recommendations concerning physician Human Health Resource (HHR) shortfalls in emergency medicine, specific changes for both the Royal College of Physicians and Surgeons of Canada (FRCPC) and the College of Family Physicians of Canada (CCFP-EM) training programs, HHR needs in rural and remote hospitals, future collaboration of the CCFP-EM and FRCPC programs, and directions for future research. All recommendations were endorsed by CAEP, the Royal College of Physicians and Surgeons of Canada (RCPSC), and the College of Family Physicians of Canada (CFPC). The CWG report was published in CJEM and has served as a basis for ongoing discussion in the emergency medicine community in Canada. The CWG identified an estimated shortfall of 478 emergency physicians in Canada in 2016, rising to 1071 by 2020 and 1518 by 2025 assuming no expansion of EM residency training capacity. In 2017, the CAEP board struck a new committee, The Future of Emergency Medicine in Canada (FEMC), to advocate with appropriate stakeholders to implement the CWG recommendations and to continue with this important work. FEMC led a workshop at CAEP 2018 in Calgary to develop a regional approach to HHR advocacy, recognizing different realities in each province and region. There was wide representation at this workshop and a rich and passionate discussion among those present. This paper represents the output of the workshop and will guide subsequent deliberations by FEMC. FEMC has set the following three goals as we work toward the overarching purpose to improve timely access to high quality emergency care: (1) to define and describe categories of emergency departments (EDs) in Canada, (2) define the full time equivalents required by category of ED in Canada, and (3) recommend the ideal combination of training and certification for emergency physicians in Canada. A fourth goal supports the other three goals: (4) urge further consideration and implementation of the CWG-EM recommendations related to coordination and optimization of the current two training programs. We believe that goals 1 and 2 can largely be accomplished by the CAEP annual meeting in 2020, and goal 3 by the CAEP annual meeting in 2021. Goal 4 is ongoing with both the RCPSC and the CFPC. We urge the EM community across Canada to engage with our committee to support improved access and EM care for all Canadians.
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http://dx.doi.org/10.1017/cem.2019.446DOI Listing
January 2020

When and how pediatric anaphylaxis cases reach the emergency department: Findings from the Cross-Canada Anaphylaxis Registry.

J Allergy Clin Immunol Pract 2020 04 31;8(4):1406-1409.e2. Epub 2019 Oct 31.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, QC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2019.10.009DOI Listing
April 2020

Point-of Care Ultrasonographically Guided Proximal External Aortic Compression in the Emergency Department.

Ann Emerg Med 2019 11;74(5):706-710

Department of Family Medicine and Emergency Medicine, Montreal, Quebec, Canada; Department of Emergency Medicine, Centre intégré universitaire de santé et de services sociaux Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada. Electronic address:

In cases of severe subdiaphragmatic vascular trauma, only in extremis interventions such as emergency thoracotomy with aortic cross clamping or resuscitative endovascular balloon occlusion of the aorta are available for temporization until definitive care. This case report proposes a noninvasive approach consisting of localizing the proximal aorta with ultrasonographic guidance and applying a compressive force to occlude the aorta and limit distal flow. Using point-of-care ultrasonography allows precise compression, continuous monitoring of its efficacy, and early detection of return of spontaneous circulation in arrest patients. We present the case of a patient who sustained a gunshot wound causing a left iliac artery injury and subsequent cardiac arrest while he was on route to the hospital. Point-of-care ultrasonographically guided proximal external aortic compression was attempted and return of spontaneous circulation was achieved and maintained, allowing transfer of the patient to the operating room. This single-case report suggests that point-of-care ultrasonographically guided proximal external aortic compression could be used as a bridge to definitive care or to more advanced techniques such as resuscitative endovascular balloon occlusion of the aorta and emergency department thoracotomy with aortic cross clamping.
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http://dx.doi.org/10.1016/j.annemergmed.2019.06.007DOI Listing
November 2019

Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain.

Acad Emerg Med 2019 08 18;26(8):847-855. Epub 2019 Jul 18.

Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada.

Background: Studies evaluating long-term prescription opioid use are retrospective and based on filled opioid prescriptions from governmental databases. These studies cannot evaluate if opioids were really consumed and are unable to differentiate if they were used for a new pain or chronic pain or were misused. The aim of this study was to assess opioid use rate and reasons for consuming 3 months after being discharged from the emergency department (ED) with an opioid prescription.

Methods: This is a prospective cohort study conducted in the ED of a tertiary care urban center with a convenience sample of discharged patients ≥ 18 years who consulted for an acute pain condition (≤2 weeks). Three months post-ED visit, participants were interviewed by phone on their past 2-week opioid consumption and their reasons for consuming: a) for pain related to the initial ED visit, b) for a new unrelated pain, or c) for another reason.

Results: Of the 524 participants questioned at 3 months (mean ± SD age = 51 ± 16 years, 47% women), 47 patients (9%, 95% confidence interval [CI] = 7%-12%) reported consuming opioids in the previous 2 weeks. Among those, 34 (72%) reported using opioids for their initial pain, nine (19%) for a new unrelated pain and four (9%) for another reason (0.8%, 95% CI = 0.3%-2.0%, of the whole cohort). Patients who used opioids during the 2 weeks after the ED visit were 3.8 (95% CI = 1.2-12.7) times more likely to consume opioids at 3 months.

Conclusion: Opioid use at the 3-month follow-up in ED patients discharged with an opioid prescription for an acute pain condition is not necessarily associated with opioid misuse; 91% of those patients consumed opioids to treat pain. Of the whole cohort, less than 1% reported using opioids for reasons other than pain. The rate of long-term opioid use reported by prescription-filling database studies should not be viewed as a proxy for incidence of opioid misuse.
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http://dx.doi.org/10.1111/acem.13628DOI Listing
August 2019

Perceptions of Emergency Medicine Residents of Multisource Feedback: Different, Relevant, and Useful Information.

Ann Emerg Med 2019 11 4;74(5):660-669. Epub 2019 Jul 4.

Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.

Study Objective: Multisource feedback is a process through which different members of the care team assess and provide feedback on residents' competencies, usually those that are less often addressed by traditional assessment methods (ie, communication, collaboration, and professionalism). Feasibility and reliability of multisource feedback have been addressed in previous research. The present study explores emergency residents' perceptions of multisource feedback provided by teaching physicians, nurses, and patients they have worked with during a rotation in an emergency department (ED).

Methods: A multisource feedback intervention was proposed to residents during 9 months in the ED of a tertiary care university hospital. Residents distributed feedback questionnaires to physicians, nurses, and patients that focused on competencies (collaboration, communication, and professionalism) from the CanMEDS framework. Responses were compiled and reported to participating residents. To assess residents' perceptions of multisource feedback, semistructured group and individual interviews were held 3 months after the intervention. Transcripts were analyzed qualitatively, following Miles and Huberman's method for intrasite case analysis.

Results: According to residents (n=10), each source (physicians, nurses, and patients) provided relevant comments that differed significantly in their content. Physicians focused primarily on medical expertise; nurses addressed competencies related to leadership, collaboration, and communication; and patients commented on the competencies of professionalism and communication. Residents concluded that obtaining feedback from nurses and patients was acceptable and useful. They reported modifying certain behaviors after receiving the multisource feedback.

Conclusion: Residents perceived the multisource feedback to be acceptable and useful for the assessment of medical competencies such as communication, collaboration, professionalism, and leadership.
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http://dx.doi.org/10.1016/j.annemergmed.2019.05.019DOI Listing
November 2019

Side effects from opioids used for acute pain after emergency department discharge.

Am J Emerg Med 2020 04 3;38(4):695-701. Epub 2019 Jun 3.

Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada.

Objective: Opioid side effects are common when treating chronic pain. However, the frequency of opioid side effects has rarely been examined in acute pain conditions, particularly in a post emergency department (ED) setting. The objective of this study was to evaluate the short-term incidence of opioid-induced side effects (constipation, nausea/vomiting, dizziness, drowsiness, sweating, and weakness) in patients discharged from the ED with an opioid prescription.

Methods: This is a prospective cohort study of patients aged ≥18 years who visited the ED for an acute pain condition (≤2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain medication use and side effects.

Results: We recruited 386 patients with a median age of 54 years (IQR:43-66); 50% were women. During the 2-week follow-up, 80% of patients consumed opioids. Among the patients who used opioids, 79% (95%CI:75-83) reported side effects compared to 38% (95%CI:27-49) for non-users. Adjusting for age, sex, and pain condition, patients who used opioids were more likely to report constipation (OR:7.5; 95%CI:3.1-17.9), nausea/vomiting (OR:4.1; 95%CI:1.8-9.5), dizziness (OR:5.4; 95%CI: 2.2-13.2), drowsiness (OR:4.6; 95%CI:2.5-8.7), and weakness (OR:4.2; 95%CI:1.6-11.0) compared to non-users. A dose-response trend was observed for constipation but not for the other side effects. Nausea/vomiting (OR:2.0; 95%CI:1.1-3.6) and dizziness (OR:1.9; 95%CI:1.1-3.4) were more often associated with oxycodone than with morphine.

Conclusion: As observed for chronic pain treatment, side effects are highly prevalent during short-term opioid treatment for acute pain. Physicians should inform patients about those side effects and should consider prescribing laxatives.
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http://dx.doi.org/10.1016/j.ajem.2019.06.001DOI Listing
April 2020

Profile of trauma mortality and trauma care resources at rural emergency departments and urban trauma centres in Quebec: a population-based, retrospective cohort study.

BMJ Open 2019 06 2;9(6):e028512. Epub 2019 Jun 2.

Centre de recherche du CISSS Chaudière-Appalaches, Chaire de recherche en médecine d'urgence ULaval - CISSS Chaudière-Appalaches, Lévis, Canada.

Objectives: As Canada's second largest province, the geography of Quebec poses unique challenges for trauma management. Our primary objective was to compare mortality rates between trauma patients treated at rural emergency departments (EDs) and urban trauma centres in Quebec. As a secondary objective, we compared the availability of trauma care resources and services between these two settings.

Design: Retrospective cohort study.

Setting: 26 rural EDs and 33 level 1 and 2 urban trauma centres in Quebec, Canada.

Participants: 79 957 trauma cases collected from Quebec's trauma registry.

Primary And Secondary Outcome Measures: Our primary outcome measure was mortality (prehospital, ED, in-hospital). Secondary outcome measures were the availability of trauma-related services and staff specialties at rural and urban facilities. Multivariable generalised linear mixed models were used to determine the relationship between the primary facility and mortality.

Results: Overall, 7215 (9.0%) trauma patients were treated in a rural ED and 72 742 (91.0%) received treatment at an urban centre. Mortality rates were higher in rural EDs compared with urban trauma centres (13.3% vs 7.9%, p<0.001). After controlling for available potential confounders, the odds of prehospital or ED mortality were over three times greater for patients treated in a rural ED (OR 3.44, 95% CI 1.88 to 6.28). Trauma care setting (rural vs urban) was not associated with in-hospital mortality. Nearly all of the specialised services evaluated were more present at urban trauma centres.

Conclusions: Trauma patients treated in rural EDs had a higher mortality rate and were more likely to die prehospital or in the ED compared with patients treated at an urban trauma centre. Our results were limited by a lack of accurate prehospital times in the trauma registry.
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http://dx.doi.org/10.1136/bmjopen-2018-028512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549736PMC
June 2019

Prognostic impact of the conversion to a shockable rhythm from a non-shockable rhythm for patients suffering from out-of-hospital cardiac arrest.

Resuscitation 2019 07 4;140:43-49. Epub 2019 May 4.

Université de Montréal, Montréal, Québec, Canada; Institut de Cardiologie de Montréal, Montréal, Québec, Canada; Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.

Objective: For patients suffering from an out-of-hospital cardiac arrest (OHCA), having an initial shockable rhythm is a marker of good prognosis. It has been suggested as one of the main prognosticating factors for the selection of patients for extracorporeal resuscitation (E-CPR). However, the prognostic implication of converting from a non-shockable to a shockable rhythm, as compared to having an initial shockable rhythm, remains uncertain, especially among patients that can otherwise be considered eligible for E-CPR. The objective of this study was to evaluate the association between the initial rhythm and its subsequent conversion and survival following an OHCA, for the general population and for E-CPR candidates.

Methods: This study used a registry of OHCA in Montreal, Canada. Adult patients suffering from a non-traumatic OHCA for whom the initial rhythm was known were included. The association between the initial rhythm and its subsequent conversion or not and survival to discharge was assessed using a multivariable logistic regression.

Results: Of 6681 included patients, 1788 (27%) had an initial shockable rhythm, 1749 (26%) had pulseless electrical activity (PEA) and no subsequent shockable rhythm, 295 (4%) had PEA and a subsequent shockable rhythm, 2694 (40%) had asystole and no subsequent shockable rhythm, and 155 (2%) asystole and a subsequent shockable rhythm. As compared to patients having an initial shockable rhythm, patients in all other groups had significantly lower odds of survival to hospital discharge (p < 0.001 for all comparisons). Univariate analyses were performed for E-CPR candidates. Among these 556 (8%) patients, more patients with an initial shockable rhythm survived than patients in all other groups (p < 0.001 for all comparisons).

Conclusions: The initial rhythm remains a much better prognostic marker than subsequent rhythms for all patients suffering from an OHCA, including in the subset of potential E-CPR candidates.
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http://dx.doi.org/10.1016/j.resuscitation.2019.04.044DOI Listing
July 2019

Evaluation of Prehospital Management in a Canadian Emergency Department Anaphylaxis Cohort.

J Allergy Clin Immunol Pract 2019 Sep - Oct;7(7):2232-2238.e3. Epub 2019 Apr 26.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

Background: Studies assessing the use of antihistamines and corticosteroids for the treatment of anaphylaxis have not supported a conclusive effect.

Objective: To assess prehospital management of anaphylaxis by measuring the effect of epinephrine use compared with antihistamines and corticosteroids on negative outcomes of anaphylaxis (intensive care unit/hospital ward admission, multiple doses of epinephrine in the emergency department [ED], and intravenous fluids given in the ED).

Methods: The Cross-Canada Anaphylaxis Registry is a cohort study that enrolls anaphylaxis cases presenting to EDs in 5 Canadian provinces over a 6-year period. Participants were recruited prospectively and retrospectively and were excluded if the case did not meet the definition of anaphylaxis.

Results: A total of 3498 cases of anaphylaxis, of which 80.3% were children, presented to 9 EDs across Canada. Prehospital treatment with epinephrine was administered in 31% of cases, whereas antihistamines and corticosteroids were used in 46% and 2% of cases, respectively. Admission to the intensive care unit/hospital ward was associated with prehospital treatment with corticosteroids (adjusted odds ratio, 2.84; 95% confidence interval [CI], 1.55, 6.97) while adjusting for severity, treatment with epinephrine and antihistamines, asthma, sex, and age. Prehospital treatment with epinephrine (adjusted odds ratio, 0.23; 95% CI, 0.14, 0.38) and antihistamines (adjusted odds ratio, 0.61; 95% CI, 0.44, 0.85) decreased the likelihood of receiving multiple doses of epinephrine in the ED, while adjusting for severity, treatment with corticosteroids, asthma, sex, and age.

Conclusions: Prompt epinephrine treatment is crucial. Use of antihistamines in conjunction with epinephrine may reduce the risk of uncontrolled reactions (administration of 2 or more doses of epinephrine in the ED), although our findings do not support the use of corticosteroids.
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http://dx.doi.org/10.1016/j.jaip.2019.04.018DOI Listing
September 2020

Acute Pain Resolution After an Emergency Department Visit: A 14-Day Trajectory Analysis.

Ann Emerg Med 2019 08 21;74(2):224-232. Epub 2019 Feb 21.

Department of Emergency Medicine, Research Centre, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montreal, Quebec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montreal, Quebec, Canada.

Study Objective: The objective of the study is to evaluate the acute pain intensity evolution in emergency department (ED) discharged patients, using group-based trajectory modeling. This method identifies patient groups with similar profiles of change over time without assuming the existence of a particular pattern or number of groups.

Methods: This was a prospective cohort study of ED patients aged 18 years or older, with an acute pain condition (≤2 weeks), and discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level (numeric rating scale of 0 to 10) and pain medication use.

Results: Among the 372 included patients, 6 distinct post-ED pain intensity trajectories were identified. Two started with severe levels of pain; one remained with severe pain intensity (12.6% of the sample) and the other ended with a moderate pain intensity level (26.3%). Two other trajectories had severe initial pain; one decreased to mild pain (21.7%) and the other to no pain (13.8%). Another trajectory had moderate initial pain that decreased to a mild level (15.9%) and the last one started with mild pain intensity and had no pain at the end of the 14-day period (9.7%). The pain trajectory patterns were significantly associated with age, type of painful conditions, pain intensity at ED discharge, and opioid consumption.

Conclusion: Acute pain resolution after an ED visit seems to progress through 6 different trajectory patterns that are more informative than simple linear models and could be useful to adapt acute pain management in future research.
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http://dx.doi.org/10.1016/j.annemergmed.2019.01.019DOI Listing
August 2019

Transcutaneous cardiac pacing competency among junior residents undergoing an ACLS course: impact of a modified high fidelity manikin.

Adv Simul (Lond) 2018 7;3:24. Epub 2018 Dec 7.

3Department of Anesthesiology and Centre d'apprentissage des attitudes et habiletés cliniques de l'Université de Montreal (CAAHC), Pavillon Roger-Gaudry, Université de Montréal, 2900, boul. Édouard-Montpetit, 8e étage, local N-805, Montréal, Québec H3T 1J4 Canada.

Background: Transcutaneous cardiac pacing (TCP) is recommended to treat unstable bradycardia. Simulation might improve familiarity with this low-frequency procedure. Current mannequins fail to reproduce key features of TCP, limiting their usefulness. The objective of this study was to measure the impact of a modified high-fidelity mannequin on the ability of junior residents to achieve six critical tasks for successful TCP.

Methods: First-year residents from various postgraduate programs taking an advanced cardiovascular life support (ACLS) course were enrolled two consecutive years (2015 and 2016). Both cohorts received the same standardized course content. An ALS simulator® mannequin was used to demonstrate and practice TCP during the bradycardia workshop of the first cohort (control cohort, 2015) and a modified high-fidelity mannequin that reproduces key features of TCP was used for the second cohort (intervention cohort, 2016). Participants were tested after training with a simulation scenario requiring TCP. Performances were graded based on six critical tasks. The primary outcome was the successful use of TCP, defined as having completed all tasks.

Results: Eighteen participants in the intervention cohort completed all tasks during the simulation scenario compared to none in the control cohort (36 vs 0%,  < 0.001). Participants in the intervention cohort were more likely to recognize when pacing was inefficient (86 vs 12%), obtain ventricular capture (48 vs 2%), and check for a pulse rate to confirm capture (48 vs 0%).

Conclusions: TCP is a difficult skill to master for junior residents. Training using a modified high-fidelity mannequin significantly improved their ability to establish TCP during a simulation scenario.
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http://dx.doi.org/10.1186/s41077-018-0082-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286521PMC
December 2018

Emergency Management of Anaphylaxis Due to an Unknown Trigger: An 8-Year Follow-Up Study in Canada.

J Allergy Clin Immunol Pract 2019 04 23;7(4):1166-1173.e1. Epub 2018 Nov 23.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada.

Background: Anaphylaxis due to unknown trigger (AUT) is anaphylaxis not explained by a proved or presumptive cause or stimulus at the time of the reaction. Research describing the management and follow-up of AUT is limited.

Objective: To assess and compare the demographic and clinical characteristics and the management of adult and pediatric AUT cases across Canada.

Methods: Participants were identified between 2011 and 2018 in emergency departments at 8 centers across Canada as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting the reaction and management in children and adults was completed. Patients were contacted for follow-up to determine assessment by an allergist.

Results: A total of 295 AUT cases (7.5%) were recruited among 3,922 cases of anaphylaxis. In the prehospital setting, children (adjusted odds ratio [aOR], 1.20; 95% CI, 1.05-1.37) and those with a known food allergy (aOR, 1.14; 95% CI, 1.02-1.28) were more likely to receive treatment with epinephrine. Children were also more likely to be assessed by an allergist after their reaction (aOR, 1.43; 95% CI, 1.13-1.81) and were more likely to have an identified trigger for their reaction (aOR, 1.35; 95% CI, 1.07-1.70). Among patients contacted for follow-up, food was identified as the cause of reaction in 11 of 76 patients. A new food allergy was diagnosed in 4 patients (2 children and 2 adults).

Conclusions: Our findings highlight important differences between management and follow-up of adult and pediatric AUT cases. It is crucial to follow up all cases of AUT and establish appropriate treatment and management guidelines.
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http://dx.doi.org/10.1016/j.jaip.2018.11.015DOI Listing
April 2019

The prognostic significance of repeated prehospital shocks for out-of-hospital cardiac arrest survival.

CJEM 2019 05 8;21(3):330-338. Epub 2018 Nov 8.

*Faculty of Medicine, Université de Montréal,Montréal,QC.

Objectives: Patients suffering from an out-of-hospital cardiac arrest (OHCA) associated with an initial shockable rhythm have a better prognosis than their counterparts. The implications of recurrent or refractory malignant arrhythmia in such context remain unclear. The objective of this study is to evaluate the association between the number of prehospital shocks delivered and survival to hospital discharge among patients in OHCA.

Methods: This cohort study included adult patients with an initial shockable rhythm over a 5-year period from a registry of OHCA in Montreal, Canada. The relationship between the number of prehospital shocks delivered and survival to discharge was described using dynamic probabilities. The association between the number of prehospital shocks delivered and survival to discharge was assessed using multivariable logistic regression.

Results: A total of 1,788 patients (78% male with a mean age of 64 years) were included in this analysis, of whom 536 (30%) received treatments from an advanced care paramedic. A third of the cohort (583 patients, 33%) survived to hospital discharge. The probability of survival was highest with the first shock (33% [95% confidence interval 30%-35%]), but decreased to 8% (95% confidence interval 4%-13%) following nine shocks. A higher number of prehospital shocks was independently associated with lower odds of survival (adjusted odds ratio=0.88 [95% confidence interval 0.85-0.92], p < 0.001).

Conclusion: Survival remains possible even after a high number of shocks for patients suffering from an OHCA with an initial shockable rhythm. However, requiring more shocks is independently associated with worse survival.
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http://dx.doi.org/10.1017/cem.2018.437DOI Listing
May 2019

Quantity of opioids consumed following an emergency department visit for acute pain: a Canadian prospective cohort study.

BMJ Open 2018 09 17;8(9):e022649. Epub 2018 Sep 17.

Department of Emergency Medicine, Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Sacré-Coeur Hospital, Québec, Canada.

Objectives: Prescription opioid diversion is a significant contributor to the opioid misuse epidemic. We examined the quantity of opioids consumed by emergency department (ED) discharged patients after treatment for an acute pain condition (musculoskeletal, fracture, renal colic, abdominal pain and other), and the percentage of unused opioids available for potential misuse.

Design: Prospective cohort study.

Setting: Tertiary care trauma centre academic hospital.

Participants: A convenience sample of patients ≥18 years who visited the ED for an acute pain condition (≤2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day paper diary of daily pain medication use. To reduce lost to follow-up, participants also responded to standardised phone interview questions about their previous 14-day pain medication use.

Outcomes: Quantity of morphine 5 mg tablets (or equivalent) prescribed, consumed and unused during a 14-day follow-up. Quantity of opioids to adequately supply 80% of patients for 2 weeks and 95% of patients for the first 3 days was also calculated.

Results: Results for 627 patients were analysed (mean age ±SD: 51±16 years, 48% women). Patients consumed a median of seven tablets of morphine 5 mg (32% of the total prescribed opioids). The quantity of opioids to adequately supply 80% of patients for 2 weeks was 20 tablets of morphine 5 mg for musculoskeletal pain, 30 for fracture, 15 for renal colic or abdominal pain and 20 for other pain conditions. The quantity to adequately supply 95% of patients for the first 3 days was 15 tablets of morphine 5 mg.

Conclusions: Patients discharged from the ED with an acute pain condition consumed a median of fewer than 10 tablets of morphine 5 mg (or equivalent). ED physicians should consider prescribing a smaller quantity of opioids and asking the pharmacist to dispense them in portions to minimise unused opioids.

Trial Registration Number: NCT02799004; Results.
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http://dx.doi.org/10.1136/bmjopen-2018-022649DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6144484PMC
September 2018

Teenagers and those with severe reactions are more likely to use their epinephrine autoinjector in cases of anaphylaxis in Canada.

J Allergy Clin Immunol Pract 2019 03 28;7(3):1073-1075.e3. Epub 2018 Aug 28.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.jaip.2018.07.044DOI Listing
March 2019

Short- and long-term management of cases of venom-induced anaphylaxis is suboptimal.

Ann Allergy Asthma Immunol 2018 08 12;121(2):229-234.e1. Epub 2018 Apr 12.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

Background: Venom-induced anaphylaxis (VIA) accounts for severe reactions. However, little is known about the short- and long-term management of VIA patients.

Objective: To assess the short- and long-term management of VIA.

Methods: Using a national anaphylaxis registry (C-CARE), we identified VIA cases presenting to emergency departments in Montreal and to emergency medical services (EMSs) in western Quebec over a 4-year period. Data were collected on clinical characteristics, triggers, and management. Consenting patients were contacted annually regarding long-term management. Univariate and multivariate logistic regressions were used to identify factors associated with epinephrine use, allergist assessment, and administration of immunotherapy.

Results: Between June 2013 and May 2017, 115 VIA cases were identified. Epinephrine was administered to 63.5% (95% confidence interval [CI], 53.9%-72.1%) of all VIA cases by a health care professional. Treatment of reactions without epinephrine was more likely in reactions occurring at home and in nonsevere cases (no hypotension, hypoxia, or loss of consciousness). Among 48 patients who responded to a follow-up questionnaire, 95.8% (95% CI, 84.6%-99.3%) were prescribed epinephrine auto-injector, 68.8% (95% CI, 53.6%-80.9%) saw an allergist who confirmed the allergy in 63.6% of cases, and 81.0% of those with positive testing were administered immunotherapy. Among cases with follow-up, seeing an allergist was less likely in patients with known ischemic heart disease.

Conclusion: Almost 30% of patients with suspected VIA did not see an allergist, only two thirds of those seeing an allergist had allergy confirmation, and almost one fifth of those with confirmed allergy did not receive immunotherapy. Educational programs are needed to bridge this knowledge-to-action gap.
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http://dx.doi.org/10.1016/j.anai.2018.04.006DOI Listing
August 2018

Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest.

Resuscitation 2018 04 2;125:28-33. Epub 2018 Feb 2.

Université de Montréal, Montréal, Québec, Canada; Institut de Cardiologie de Montréal, Montréal, Québec, Canada; Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.

Aims: Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital. Percutaneous coronary intervention (PCI) is often indicated following OHCA. This study's primary objective was to determine the association between being transported to a PCI-capable hospital and survival to discharge for patients with OHCA. The additional delay to hospital arrival which could offset a potential increase in survival associated with being transported to a PCI-capable center was also evaluated.

Methods: This study used a registry of OHCA in Montreal, Canada. Adult patients transported to a hospital following a non-traumatic OHCA were included. Hospitals were dichotomized based on whether PCI was available on-site or not. The effect of hospital type on survival to discharge was assessed using a multivariable logistic regression. The added prehospital delay which could offset the increase in survival associated with being transported to a PCI-capable center was calculated using that regression.

Results: A total of 4922 patients were included, of whom 2389 (48%) were transported to a PCI-capable hospital and 2533 (52%) to a non-PCI-capable hospital. There was an association between being transported to a PCI-capable center and survival to discharge (adjusted odds ratio = 1.60 [95% confidence interval 1.25-2.05], p < .001). Increasing the delay from call to hospital arrival by 14.0 min would offset the potential benefit of being transported to a PCI-capable center.

Conclusions: It could be advantageous to redirect patients suffering from OHCA patients to PCI-capable centers if the resulting expected delay is of less than 14 min.
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http://dx.doi.org/10.1016/j.resuscitation.2018.01.048DOI Listing
April 2018

Disparities in rate, triggers, and management in pediatric and adult cases of suspected drug-induced anaphylaxis in Canada.

Immun Inflamm Dis 2018 03 1;6(1):3-12. Epub 2017 Nov 1.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

Introduction: Data is sparse on drug-induced anaphylaxis (DIA) and there have not been studies assessing the differences in clinical characteristics and management of DIA between adults and children.

Objective: We assessed the percentage, diagnosis, and management of DIA among all anaphylaxis visits in three pediatric and one adult emergency departments (ED) across Canada.

Methods: Children presenting to the Montreal Children's Hospital (MCH), British Columbia Children's Hospital (BCCH), and Children's Hospital at London Health Sciences Center and adults presenting to Hôpital du Sacré-Coeur with anaphylaxis were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized data form documenting the reaction and management was completed and patients were followed annually to determine assessment by allergist and use of confirmatory tests.

Results: From June 2012 to May 2016, 51 children were recruited from the pediatric centers and 64 adults from the adult center with drug-induced anaphyalxis. More than half the cases were prospectively recruited. The percentage of DIA among all cases of anaphylaxis was similar in all three pediatric centers but higher in the adult center in Montreal. Most reactions in children were triggered by non-antibiotic drugs, and in adults, by antibiotics. The majority of adults and a third of children did not see an allergist after the initial reaction. In those that did see an allergist, diagnosis was established by either a skin test or an oral challenge in less than 20% of cases.

Conclusions: Our results reveal disparities in rate, culprit, and management of DIA in children versus adults. Further, most cases of suspected drug allergy are not appropriately diagnosed. Guidelines to improve assessment and diagnosis of DIA are required.
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http://dx.doi.org/10.1002/iid3.201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818453PMC
March 2018

Potential impact of a prehospital redirection system for refractory cardiac arrest.

Resuscitation 2017 10 5;119:37-42. Epub 2017 Aug 5.

Université de Montréal, Montréal, Québec, Canada; Institut de Cardiologie de Montréal, Montréal, Québec, Canada; Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.

Aim: A change in prehospital redirection practice could potentially increase the proportion of E-CPR eligible patients with out-of-hospital cardiac arrest (OHCA) transported to extracorporeal cardiopulmonary resuscitation (E-CPR) capable centers. The objective of this study was to quantify this potential increase of E-CPR candidates transported to E-CPR capable centers.

Methods: Adults with non-traumatic OHCA refractory to 15min of resuscitation were selected from a registry of adult OHCA collected between 2010 and 2015 in Montreal, Canada. Using this cohort, three simulation scenarios allowing prehospital redirection to E-CPR centers were created. Stringent eligibility criteria for E-CPR and redirection for E-CPR (e.g. age <60years old, initial shockable rhythm) were used in the first scenario, intermediate eligibility criteria (e.g. age <65years old, at least one shock given) in the second scenario and inclusive eligibility criteria (e.g. age <70years old, initial rhythm ≠ asystole) in the third scenario. All three scenarios were contrasted with equivalent scenarios in which patients were transported to the closest hospital. Proportions were compared using McNemar's test.

Results: The proportion of E-CPR eligible patients transported to E-CPR capable centers increased in each scenario (stringent criteria: 48 [24.5%] vs 155 patients [79.1%], p<0.001; intermediate criteria: 81 [29.6%] vs 262 patients [95.6%], p<0.001; inclusive criteria: 238 [23.9%] vs 981 patients [98.5%], p<0.001).

Conclusions: A prehospital redirection system could significantly increase the number of patients with refractory OHCA transported to E-CPR capable centers, thus increasing their access to this potentially life-saving procedure, provided allocated resources are planned accordingly.
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http://dx.doi.org/10.1016/j.resuscitation.2017.08.001DOI Listing
October 2017

Food-induced anaphylaxis to a known food allergen in children often occurs despite adult supervision.

Pediatr Allergy Immunol 2017 11 30;28(7):715-717. Epub 2017 Aug 30.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Center, Montreal, QC, Canada.

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http://dx.doi.org/10.1111/pai.12770DOI Listing
November 2017