Heatstroke presentations to urban hospitals during BC's extreme heat event: lessons for the future.

BACKGROUND: Climate change is leading to more extreme heat events in temperate climates that typically have low levels of preparedness. Our objective was to describe the characteristics, treatments, and outcomes of adults presenting to hospitals with heatstroke during BC's 2021 heat dome. METHODS: We conducted a review of consecutive adults presenting to 7 hospitals in BC's Lower Mainland. We screened the triage records of all patients presenting between June 25th and 30th, 2021 for complaints related to heat, and reviewed the full records of those who met heatstroke criteria. Our primary outcome was in-hospital mortality. We used Mann-Whitney U tests and logistic regression to investigate associations between patient and treatment factors and mortality. RESULTS: Among 10,247 consecutive presentations to urban hospitals during the extreme heat event, 1.3% (139; 95% confidence intervals [CI] 1.1-1.6%) met criteria for heatstroke. Of heatstroke patients, 129 (90.6%) were triaged into the two highest acuity levels. Patients with heatstroke had a median age of 84.4 years, with 122 (87.8%) living alone, and 101 (84.2%) unable to activate 911 themselves. A minority (< 5, < 3.6%) of patients presented within 48 h of the onset of extreme heat. Most patients (107, 77.0%) required admission, and 11.5% (16) died in hospital. Hypotension on presentation was associated with mortality (odds ratio [OR] 5.3). INTERPRETATION: Heatstroke patients were unable to activate 911 themselves, and most presented with a 48-h delay. This delay may represent a critical window of opportunity for pre-hospital and hospital systems to prepare for the influx of high-acuity resource-intensive patients.

RéSUMé: CONTEXTE: Les changements climatiques entraînent une augmentation des épisodes de chaleur extrême dans les climats tempérés qui ont généralement de faibles niveaux de préparation. Notre objectif était de décrire les caractéristiques, les traitements et les résultats des adultes présentant un coup de chaleur à l'hôpital pendant le dôme de chaleur de 2021 en Colombie-Britannique. MéTHODES: Nous avons effectué un examen des adultes consécutifs qui se sont présentés dans sept hôpitaux du Lower Mainland de la Colombie-Britannique. Nous avons examiné les dossiers de triage de tous les patients qui se sont présentés entre le 25 et le 30 juin 2021 pour les plaintes liées à la chaleur et examiné les dossiers complets de ceux qui répondaient aux critères de coup de chaleur. Notre principal résultat était la mortalité à l'hôpital. Nous avons utilisé les tests de Mann-Whitney U et la régression logistique pour étudier les associations entre le patient et les facteurs de traitement et la mortalité. RéSULTATS: Parmi les 10247 présentations consécutives aux hôpitaux urbains pendant l'événement de chaleur extrême, 1,3 % (139; intervalles de confiance [IC] à 95 %) répondaient aux critères de coup de chaleur. Parmi les patients ayant subi un coup de chaleur, 129 (90,6 %) ont été classés dans les deux niveaux d'acuité les plus élevés. Les patients atteints d'un coup de chaleur avaient un âge médian de 84,4 ans, 122 (87,8 %) vivant seuls et 101 (84,2 %) incapables d'activer le 911 eux-mêmes. Une minorité (< 5, < 3,6 %) de patients se sont présentés dans les 48 heures suivant l'apparition de la chaleur extrême. La plupart des patients (107, 77,0 %) ont dû être admis et 11,5 % (16) sont décédés à l'hôpital. L'hypotension au moment de la présentation était associée à la mortalité (rapport de cotes [RC] 5.3). INTERPRéTATION: Les patients atteints d'un coup de chaleur n'ont pas pu activer le 911 eux-mêmes, et la plupart se sont présentés avec un délai de 48 heures. Ce délai peut représenter une fenêtre critique d'opportunité pour les systèmes préhospitaliers et hospitaliers de se préparer à l'afflux de patients à forte intensité de ressources.

Showing Your Thinking: Using Mind Maps to Understand the Gaps Between Experienced Emergency Physicians and Their Students.

BACKGROUND: Clinical teaching faculty rely on schemas for diagnosis. When they attempt to teach medical students, there may be a gap in the interpretation because the students do not have the same schemas. The aim of this analysis was to explore expert thinking processes through mind maps, to help determine the gaps between an expert's mind map of their diagnostic thinking and how students interpret this teaching artifact. METHODS: A novel mind-mapping approach was used to examine how emergency physicians (EPs) explain their clinical reasoning schemas. Nine EPs were shown two different videos of a student interviewing a patient with possible venous thromboembolism. EPs were then asked to explain their diagnostic approach using a mind map, as if they were thinking to a student. Later, another medical student interviewed the EPs to clarify the mind map and revise as needed. A coding framework was generated to determine the discrepancy between the EP-generated mind map and the novice's interpretation. RESULTS: Every mind map (18 mind maps from nine individuals) contained some discrepancy between the expert's mind and novice's interpretation. From the qualitative analysis of the changes between the originally created mind map and the later revision, the authors developed a conceptual framework describing types of amendments that students might expect teachers to make in their mind maps: 1) substantive amendments, such as incomplete mapping; and 2) clarifications, such as the need to explain background for a mind map element. CONCLUSION: Emergency physician teachers tend to make jumps in reasoning, most commonly including incomplete mapping and maps requiring clarifications. Educating EPs on these processes will allow modification of their teaching modalities to better suit learners.

To believe or not to believe? How voice and accent information in speech alter listener impressions of trust.

Our decision to believe what another person says can be influenced by vocally expressed confidence in speech and by whether the speaker-listener are members of the same social group. The dynamic effects of these two information sources on neurocognitive processes that promote believability impressions from vocal cues are unclear. Here, English Canadian listeners were presented personal statements (She has access to the building) produced in a confident or doubtful voice by speakers of their own dialect (in-group) or speakers from two different "out-groups" (regional or foreign-accented English). Participants rated how believable the speaker is for each statement and event-related potentials (ERPs) were analysed from utterance onset. Believability decisions were modulated by both the speaker's vocal confidence level and their perceived in-group status. For in-group speakers, ERP effects revealed an early differentiation of vocally expressed confidence (i.e., N100, P200), highlighting the motivational significance of doubtful voices for drawing believability inferences. These early effects on vocal confidence perception were qualitatively different or absent when speakers had an accent; evaluating out-group voices was associated with increased demands on contextual integration and re-analysis of a non-native representation of believability (i.e., increased N400, late negativity response). Accent intelligibility and experience with particular out-group accents each influenced how vocal confidence was processed for out-group speakers. The N100 amplitude was sensitive to out-group attitudes and predicted actual believability decisions for certain out-group speakers. We propose a neurocognitive model in which vocal identity information (social categorization) dynamically influences how vocal expressions are decoded and used to derive social inferences during person perception.

Toxic Shock Syndrome: Still a Timely Diagnosis.

BACKGROUND: Toxic shock syndrome (TSS) is an acute, severe, toxin-mediated disease, characterized by fever, hypotension, and multiorgan system involvement. Toxic shock syndrome has made headlines because of its high associated morbidity and mortality rate in previously healthy young females. Incidence peaked in the early 1980s owing to increased usage of ultra-absorbent tampons. After improved patient education and tampon labeling, the incidence of menstrual TSS has declined. CASE: A previously healthy 14-year-old girl presented to an urgent care center with a 2-day history of fever, erythematous maculopapular rash, vomiting, diarrhea, and malaise. She was found to be tachycardic and hypotensive. Investigations revealed thrombocytopenia, an elevated white count and lactate, and acute kidney injury, consistent with septic shock. Recent tampon usage with menstruation was reported, and a pelvic examination revealed purulent vaginal discharge. The patient was transferred to a pediatric intensive care unit for antibiotic and vasopressor therapy. Vaginal swabs later tested positive for Staphylococcus aureus and TSS toxin-1. CONCLUSIONS: Although the incidence of TSS has decreased in recent years, it is crucial that clinicians rapidly recognize and treat this life-threatening condition. Emergency physicians should always have a high index of suspicion for TSS in young females presenting without another obvious cause of shock. A pelvic examination should always be completed in these cases.

Outcomes of hematopoietic cell transplant recipients requiring invasive mechanical ventilation: a two-centre retrospective cohort study.

PURPOSE: Outcomes of critically ill, hematopoietic cell transplant patients who require prolonged mechanical ventilation are not well studied. We describe the baseline characteristics, critical care management, and outcomes of this population and explore potential predictors of mortality. METHODS: We performed a retrospective cohort study in two critical care units in Ontario. We included adult intensive care unit patients who required invasive mechanical ventilation within 90 days of receiving a hematopoietic cell transplant. The primary outcome was mortality at 90 days. Using logistic regression, we explored predictors of mortality including type of transplant (allogeneic vs autologous), severity of illness (assessed using the Sequential Organ Failure Assessment [SOFA] score), and baseline characteristics (such as age and sex). RESULTS: We included 70 patients from two study sites. Ninety-day mortality was 73% (n = 51) in the entire cohort, 58% (15/26) in patients post-autologous transplant, and 82% (36/44) in those post-allogeneic transplant. Ninety-one percent (10/11) of patients who required invasive mechanical ventilation for more than 21 days died. Independent predictors of all-cause mortality included allogeneic transplant, higher SOFA score, the presence of acute hypoxemic respiratory failure, and a longer interval between receiving the transplant and initiation of mechanical ventilation. CONCLUSIONS: Our study shows high rates of mortality among hematopoietic cell transplant recipients that require invasive mechanical ventilation, particularly in those post-allogeneic transplant and in those who require prolonged ventilation for more than 21 days.

Corticosteroids in Sepsis: An Updated Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis addresses the efficacy and safety of corticosteroids in critically ill patients with sepsis. DATA SOURCES: We updated a comprehensive search of MEDLINE, EMBASE, CENTRAL, and LILACS, and unpublished sources for randomized controlled trials that compared any corticosteroid to placebo or no corticosteroid in critically ill children and adults with sepsis. STUDY SELECTION: Reviewers conducted duplicate screening of citations, data abstraction, and, using a modified Cochrane risk of bias tool, individual study risk of bias assessment. DATA EXTRACTION: A parallel guideline committee provided input on the design and interpretation of the systematic review, including the selection of outcomes important to patients. We assessed overall certainty in evidence using Grading of Recommendations Assessment, Development and Evaluation methodology and performed all analyses using random-effect models. For subgroup analyses, we performed metaregression and considered p value less than 0.05 as significant. DATA SYNTHESIS: Forty-two randomized controlled trials including 10,194 patients proved eligible. Based on low certainty, corticosteroids may achieve a small reduction or no reduction in the relative risk of dying in the short-term (28-31 d) (relative risk, 0.93; 95% CI, 0.84-1.03; 1.8% absolute risk reduction; 95% CI, 4.1% reduction to 0.8% increase), and possibly achieve a small effect on long-term mortality (60 d to 1 yr) based on moderate certainty (relative risk, 0.94; 95% CI, 0.89-1.00; 2.2% absolute risk reduction; 95% CI, 4.1% reduction to no effect). Corticosteroids probably result in small reductions in length of stay in ICU (mean difference, -0.73 d; 95% CI, -1.78 to 0.31) and hospital (mean difference, -0.73 d; 95% CI, -2.06 to 0.60) (moderate certainty). Corticosteroids result in higher rates of shock reversal at day 7 (relative risk, 1.26; 95% CI, 1.12-1.42) and lower Sequential Organ Failure Assessment scores at day 7 (mean difference, -1.39; 95% CI, -1.88 to -0.89) (high certainty). Corticosteroids likely increase the risk of hypernatremia (relative risk, 1.64; 95% CI, 1.32-2.03) and hyperglycemia (relative risk, 1.16; 95% CI, 1.08-1.24) (moderate certainty), may increase the risk of neuromuscular weakness (relative risk, 1.21; 95% CI, 1.01-1.52) (low certainty), and appear to have no other adverse effects (low or very low certainty). Subgroup analysis did not demonstrate a credible subgroup effect on any of the outcomes of interest (p > 0.05 for all). CONCLUSIONS: In critically ill patients with sepsis, corticosteroids possibly result in a small reduction in mortality while also possibly increasing the risk of neuromuscular weakness.

Perceptions of the effectiveness of Advanced Practice Nurses on a neurosurgery unit in a Canadian Tertiary Care Centre: A pre-and-post implementation design.

OBJECTIVES: A framework for the advanced practice nurse (APN) role was developed in our Canadian Tertiary Care Centre, delineating five domains of advanced nursing practice: clinical practice, consultation, research, education and leadership. The goal of this study was to evaluate perceptions of the effectiveness of the implementation of an innovative APN role on an in-patient Neurosurgery unit. METHODS: A pre-and-post implementation design, incorporating both qualitative and quantitative data, was utilized. An innovative APN role was implemented within the Neurosurgery program focusing on the clinical domain and required the successful candidates to be NP prepared. This APN role was designed to improve patient flow, documentation, communication and patient and staff satisfaction. Three primary outcomes were measured: pre-implementation questionnaire (nurses), post-implementation questionnaire (nurses and residents) and number of pages to the on-call resident. RESULTS: Survey scores by nurses and residents indicated improvement across all aspects studied. Average scores increased from 1.1 to 2.6, reflecting an overall statistically significant increase. The number of pages to the on-call resident also showed a decrease. CONCLUSION: Perceptions of patient care delivery and professional collaboration improved following implementation of the APN role. Responses indicated that APNs significantly impacted patient care and improved nurses and residents' job satisfaction.

Corticosteroids in sepsis: an updated systematic review and meta-analysis (protocol).

INTRODUCTION: Sepsis is associated with a dysregulated host response to infection and impaired endogenous corticosteroid metabolism. As such, therapeutic use of exogenous corticosteroids is a promising adjunctive intervention. Despite a large number of trials examining this research question, uncertainty persists regarding the effect of corticosteroids on survival in sepsis. Several large randomised controlled trials have been published recently prompting a re-evaluation of the available literature. METHODS AND ANALYSIS: A rigorous and reproducible search and screening process from a Cochrane review on the same topic was comprehensive to October 2014. We will search MEDLINE, EMBASE, LILACS, the Cochrane trial registry and clinicaltrials.gov for eligible randomised controlled trials investigating the use of corticosteroids in patients with sepsis from September 2014. Outcomes have been chosen by a semi-independent guideline panel, created in the context of a parallel BMJ Rapid Recommendation on the topic. This panel includes clinicians, content experts, methodologists and patient representatives, who will help identify patient-important outcomes that are critical for deciding whether to use or not use corticosteroids in sepsis. Two reviewers will independently screen and identify eligible studies; a third reviewer will resolve any disagreements. We will use RevMan to pool effect estimates from included studies for each outcome using a random-effect model. We will present the results as relative risk with 95% CI for dichotomous outcomes and as mean difference or standardised mean difference for continuous outcomes with 95% CI. We will assess the certainty of evidence at the outcome level using the Grading of Recommendations, Assessment, Development and Evaluation approach. We will conduct a priori subgroup analyses, which have been chosen by the parallel BMJ Rapid Recommendation panel. ETHICS AND DISSEMINATION: The aim of this systematic review is to summarise the updated evidence on the efficacy and safety of corticosteroids in patients with sepsis. TRIAL REGISTRATION NUMBER: CRD42017058537.