Hyperbaric Oxygen Post Established Stroke.

BACKGROUND AND PURPOSE: Hyperbaric oxygen therapy (HBOT) has been reported to improve neurological function in the chronic phase of stroke in a single trial having significant limitations, including a lack of a sham control. METHODS: We conducted a single-center, parallel-group, randomized trial to determine the effectiveness of HBOT compared with a sham control in adults who were 6 to 36 months post-ischemic stroke. The treatment group received 40 sessions of HBOT at the Vancouver General Hospital Hyperbaric Unit. The control group received 40 sessions of sham treatment designed to replicate an HBOT experience. Due to recruitment challenges and timeline/feasibility tracking by the research team, the control arm was altered after 20 months to a waitlist in the hope of increasing participation. In the second phase, participants were randomized to receive HBOT immediately or following an eight-week observation period. The primary outcome was the post-treatment Stroke Impact Scale-16 (SIS-16). Secondary outcomes included the National Institute of Health Stroke Scale, Berg Balance Test, Digit Symbol Substitution Test, 5-Metre Walk Test, 6-Minute Walk Test, Grip Strength, Montreal Cognitive Assessment, Box/Block Test, and Center for Epidemiological Studies - Depression and Short Form-36. Based on detecting a clinically important between-group difference of 10 on the SIS-16 score, our target sample size was 68 participants per arm.  Results: From January 5, 2016 to October 9, 2018, 34 participants were enrolled in the trial, 27 during the first phase and seven in the second phase. The study was stopped after 36 months, and prior to meeting the sample size target, due to low recruitment. At the end of treatment, the difference in the SIS-16 between groups was 5.5 (95% CI: 1.3 to 9.7, p = 0.01) in favor of the sham group. CONCLUSIONS: Our results exclude a clinically important benefit of HBOT on the primary outcome of the SIS-16. These findings do not support the use of HBOT in chronic stroke survivors.

External Validation of the Post-Concussion Symptoms Rule for Predicting Mild Traumatic Brain Injury Outcome.

Persistent symptoms are common after a mild traumatic brain injury (mTBI). The Post-Concussion Symptoms (PoCS) Rule is a newly developed clinical decision rule for the prediction of persistent post-concussion symptoms (PPCS) 3 months after an mTBI. The PoCS Rule includes assessment of demographic and clinical characteristics and headache presence in the emergency department (ED), and follow-up assessment of symptoms at 7 days post-injury using two thresholds (lower/higher) for symptom scoring. We examined the PoCS Rule in an independent sample. We analyzed a clinical trial that recruited participants with mTBI from EDs in Greater Vancouver, Canada. The primary analysis used data from 236 participants, who were randomized to a usual care control group, and completed the Rivermead Postconcussion Symptoms Questionnaire at 3 months. The primary outcome was PPCS, as defined by the PoCS authors. We assessed the overall performance of the PoCS rule (area under the receiver operating characteristic curve [AUC]), sensitivity, and specificity. More than 40% of participants (median age 38 years, 59% female) reported PPCS at 3 months. Most participants (88%) were categorized as being at medium risk based on the ED assessment, and a majority were considered as being at high risk according to the final PoCS Rule (81% using a lower threshold and 72% using a higher threshold). The PoCS Rule showed a sensitivity of 93% (95% confidence interval [CI], 88-98; lower threshold) and 85% (95% CI, 78-92; higher threshold), and a specificity of 28% (95% CI, 21-36) and 37% (95% CI, 29-46), respectively. The overall performance was modest (AUC 0.61, 95% CI 0.59, 0.65). In conclusion, the PoCS Rule was sensitive for PPCS, but had a low specificity in our sample. Follow-up assessment of symptoms can improve risk stratification after mTBI.

Evaluation of Patient Engagement in a Clinical Emergency Care Network: Findings From the BC Emergency Medicine Network.

The British Columbia Emergency Medicine Network (EM Network) has collaborated with patient partners to utilize their experiential knowledge to inform planning and implementation. Patient partners participated in several EM Network committees and initiatives. This study evaluated how patient partners and other leaders in the EM Network perceived patient engagement efforts 1 year after launch. The Public and Patient Engagement Evaluation Tool V2.0 found that there was an appropriate level of patient engagement at this early stage, an opportunity to attract more patient partners as the EM Network grows, and a need to ensure adequate resources to support more activities.

Process and findings informing the development of a provincial emergency medicine network.

We describe the process undertaken to inform the development of the recently launched British Columbia (BC) Emergency Medicine Network (EM Network). Five methods were undertaken: (1) a scoping literature review, (2) a survey of BC emergency practitioners and EM residents, (3) key informant interviews, (4) focus groups in sites across BC, and (5) establishment of a brand identity. There were 208 survey respondents: 84% reported consulting Internet resources once or more per emergency department shift; however, 26% reported feeling neutral, somewhat unsatisfied, or very unsatisfied with searching for information on the Internet to support their practice. Enthusiasm was expressed for envisioned EM Network resources, and the key informant interviews and focus group results helped identify and refine key desired components of the EM Network. In describing this, we provide guidance and lessons learned for health leaders and others who aspire to establish similar clinical networks, whether in EM or other medical disciplines.

The British Columbia Emergency Medicine Network: A Paradigm Shift in a Provincial System of Emergency Care.

As generalists, emergency practitioners face challenges in providing state-of-the-art care owing to the broad spectrum of practice and the rapid rate of new knowledge generation. Networks have become increasingly prevalent in health care, and it was in this backdrop, and the resulting opportunity to advance evidence-informed emergency care in the Canadian province of British Columbia (BC), that a new "Emergency Medicine Network" (EM Network) was launched in 2017. The EM Network consists of four programs, each led by a physician with expertise and a track record in the domain: (1) Clinical Resources; (2) Innovation; (3) Continuing Professional Development; and (4) Real-time Support. This paper provides an overview of the EM Network, including its background, purpose, programs, anticipated evolution, and impact on the BC health care system.

Realism of procedural task trainers in a pediatric emergency medicine procedures course.

BACKGROUND: Pediatric emergency medicine (PEM) physicians have minimal experience in life saving procedures and have turned to task trainers to learn these skills. Realism of these models is an important consideration that has received little study. METHOD: PEM physicians and trainees participated in a day long procedural training course that utilized commercially available and homemade task trainers to teach pericardiocentesis, chest tube insertion, cricothyroidotomy and central line insertion. Participants rated the realism of the task trainers as part of a post-course survey. RESULTS: The homemade task trainers received variable realism ratings, with 91% of participants rating the pork rib chest tube model as realistic, 82% rating the gelatin pericardiocentesis mold as realistic and 36% rating the ventilator tubing cricothyroidotomy model as realistic. Commercial trainers also received variable ratings, with 45% rating the chest drain and pericardiocentesis simulator as realistic, 74% rating the crichotracheotomy trainer as realistic and 80% rating the central line insertion trainer as realistic. CONCLUSIONS: Task training models utilized in our course received variable realism ratings. When deciding what type of task trainer to use future courses should carefully consider the desired aspect of realism, and how it aligns with the procedural skill, balanced with cost considerations.

The TACTIC: development and validation of the Tool for Assessing Chest Tube Insertion Competency.

OBJECTIVES: Pediatric emergency medicine (PEM) physicians receive little opportunity to practice and perform chest tube insertion. We sought to develop and validate a scoring tool to assess chest tube insertion competency and identify areas where training is required for PEM physicians. METHODS: We developed a 40-point, 20-item (scored 0, 1, or 2) assessment tool entitled the Tool for Assessing Chest Tube Insertion Competency (TACTIC) and studied how PEM physicians and fellows scored when inserting a chest tube into a pork rib model. Participants were scored at baseline and compared to themselves after receiving targeted training using Web-based animations and presentations followed by expert instruction and practice on chest tube insertion task trainers. All insertions were video recorded and reviewed by two blinded reviewers. Eight common videos were reviewed to assess interrater reliability. RESULTS: The TACTIC demonstrated good interrater reliability with an r 2 =0.86. Our cohort demonstrated a significant improvement in TACTIC scores by taking part in targeted training (precourse TACTIC=65%, 95% CI 54-76 v. postcourse TACTIC=84%, 95% CI 80-88), highlighting the construct validity of the TACTIC. Individual participants increased their TACTIC scores by an average of 17%. CONCLUSIONS: The TACTIC demonstrates good interrater reliability, content validity, and construct validity in assessing a PEM practitioner's skill inserting chest tubes in a simulated setting.

Controversies in the medical clearance of recreational scuba divers: updates on asthma, diabetes mellitus, coronary artery disease, and patent foramen ovale.

Primary care and sports medicine physicians are frequently consulted on medical clearance for prospective recreational divers. We discuss four common and controversial medical conditions--asthma, diabetes mellitus, coronary artery disease, and patent foramen ovale--as they relate to fitness to dive. For each condition we review the relevant anatomy and physiology, current recommendations, and the pertinent medical literature. Finally, we offer evidence-based recommendations regarding fitness to dive for potential divers with these conditions.

An assessment of the telehealth needs and health-care priorities of Tanna Island: a remote, under-served and vulnerable population.

We surveyed eight Canadian physicians who had each provided medical care for six months on the remote and under-served island of Tanna in Vanuatu. The most frequently encountered medical problems on Tanna were infectious diseases (tuberculosis, hepatitis, abscesses, malaria, pneumonia, typhoid fever, meningitis and skin infections). When physicians were asked about the top three health-care priorities, they ranked tuberculosis control, clean water and improved health-care delivery/communication between hospital and outposts as most important. The key issues were: (1) basic public health needs and infrastructure development are higher in priority than telehealth; (2) telehealth consultants must have knowledge pertinent to local conditions and resources available to the population; (3) electronic equipment suited to tropical environments is needed; (4) projects must be developed locally rather than internationally. Understanding how telehealth can provide support to health professionals under challenging conditions may assist with the health priorities in developing countries and potentially provide access to resources both locally and internationally.