Canadian emergency medicine and critical care physician perspectives on pandemic triage in COVID-19.

INTRODUCTION: Local and regional policies to guide the allocation of scarce critical care resources have been developed, but the views of prospective users are not understood. We sought to investigate the perspectives of Canadian acute care physicians toward triaging scarce critical care resources in the COVID-19 pandemic. METHODS: We rapidly deployed a brief survey to Canadian emergency and critical care physicians in April 2020 to investigate current attitudes toward triaging scarce critical care resources and identify subsequent areas for improvement. Descriptive and between-group analyses along with thematic coding were used. RESULTS: The survey was completed by 261 acute care physicians. Feelings of anxiety related to the pandemic were common (65 percent), as well as fears of psychological distress if required to triage scarce resources (77 percent). Only 49 percent of respondents felt confident in making resource allocation decisions. Both critical care and emergency physicians favored multidisciplinary teams over single physicians to allocate scarce critical care resources. Critical care physicians were supportive of decision making by teams not involved in patient care (3.4/5 versus 2.9/5 p = 0.04), whereas emergency physicians preferred to maintain their involvement in such decisions (3.4/5 versus 4.0/5 p = 0.007). Free text responses identified five themes for subsequent action including the need for further guidance on existing triage policies, ethical support in decision making, medicolegal protection, additional tools for therapeutic communications, and healthcare provider psychological support. CONCLUSION: There is an urgent need for collaboration between policymakers and frontline physicians to develop critical care resource triage policies that wholly consider the diversity of provider perspectives across practice environments.

Creation of a national emergency medicine enhanced competency directory for residency training.

Canadian emergency medicine Royal College residency training allows for pursuing extra training in enhanced competency areas. A wealth of enhanced competency training opportunities exist nationally. However, the search for the right fit is a challenging one because there is no centralized resource that catalogues all of these opportunities. A working group of the Canadian Association of Emergency Physicians (CAEP) Resident Section was assembled in 2016 to create a freely accessible and comprehensive directory of Canadian enhanced competency areas. The working group used stakeholder surveys (of residents, recent graduates, and faculty members), social media engagement, and program website searches. Information was collated into the first edition of a national enhanced competency directory, which is available at no cost at http://caep.ca/sites/caep.ca/files/enhancedcompdoc.pdf. Limitations include the scope defined by the working group and survey responses. A biannual update is also incorporated into the CAEP Resident Section portfolio to ensure it remains up-to-date.

Successful nilotinib treatment in a child with chronic myeloid leukemia.

A 16-year-old female was diagnosed incedentally with chronic myeloid leukemia (CML) in the chronic phase. She showed complete remission after 3 months of nilotinib treatment. CML is a rare malignant neoplasm in pediatric age. It is characterized by a Philadelphia chromosome, which comes from a genetic translocation between chromosomes 9 and 22. This translocation results in an abnormal fusion called BCR-ABL oncogene which encodes a chimeric BCR-ABL protein. This protein is the underlying cause of CML. Nilotinib is a newly licensed drug for CML in adults. Structurally, it is similar to imatinib (the older tyrosine kinase inhibitor), but it is much more potent in inhibiting BCR-ABL due to its much increased affinity for its binding site. Specific guidelines for CML treatment in children have yet to be determined. In our patient, nilotinib was used as an off-label drug because it is not licensed for children. According to the pharmacokinetic response to drugs, children cannot be considered small adults irrespective of their weight. Off-label drug use based on evidence that it is the best treatment available is an important tool in the hands of expert treating physicians.

Visuospatial anatomy comprehension: the role of spatial visualization ability and problem-solving strategies.

The present study explored the problem-solving strategies of high- and low-spatial visualization ability learners on a novel spatial anatomy task to determine whether differences in strategies contribute to differences in task performance. The results of this study provide further insights into the processing commonalities and differences among learners beyond the classification of spatial visualization ability alone, and help elucidate what, if anything, high- and low-spatial visualization ability learners do differently while solving spatial anatomy task problems. Forty-two students completed a standardized measure of spatial visualization ability, a novel spatial anatomy task, and a questionnaire involving personal self-analysis of the processes and strategies used while performing the spatial anatomy task. Strategy reports revealed that there were different ways students approached answering the spatial anatomy task problems. However, chi-square test analyses established that differences in problem-solving strategies did not contribute to differences in task performance. Therefore, underlying spatial visualization ability is the main source of variation in spatial anatomy task performance, irrespective of strategy. In addition to scoring higher and spending less time on the anatomy task, participants with high spatial visualization ability were also more accurate when solving the task problems.

Distinct visual cues mediate aperture shaping for grasping and pantomime-grasping tasks.

The authors examined whether the top-down requirements of dissociating the spatial relations between stimulus and response in a goal-directed grasping task renders the mediation of aperture trajectories via relative visual information. To address that issue, participants grasped differently sized target objects (i.e., grasping condition) and also grasped to a location that was dissociated from the target object (i.e., pantomime-grasping condition). Just noticeable difference (JND) values associated with the early through late stages of aperture shaping were computed to examine the extent to which motor output adhered to, or violated, the psychophysical principles of Weber's law. As expected, JNDs during the late stages of the grasping condition violated Weber's law: a result evincing the use of absolute visual information. In contrast, JNDs for the pantomime-grasping condition produced a continuous adherence to Weber's law. Such a result indicates that dissociating a stimulus from a response is a perception-based task and results in aperture shaping via relative visual information.

Grasping time does not influence the early adherence of aperture shaping to Weber's law.

The "just noticeable difference" (JND) represents the minimum amount by which a stimulus must change to produce a noticeable variation in one's perceptual experience (i.e., Weber's law). Recent work has shown that within-participant standard deviations of grip aperture (i.e., JNDs) increase linearly with increasing object size during the early, but not the late, stages of goal-directed grasping. A visually based explanation for this finding is that the early and late stages of grasping are respectively mediated by relative and absolute visual information and therefore render a time-dependent adherence to Weber's law. Alternatively, a motor-based explanation contends that the larger aperture shaping impulses required for larger objects gives rise to a stochastic increase in the variability of motor output (i.e., impulse-variability hypothesis). To test the second explanation, we had participants grasp differently sized objects in grasping time criteria of 400 and 800 ms. Thus, the 400 ms condition required larger aperture shaping impulses than the 800 ms condition. In line with previous work, JNDs during early aperture shaping (i.e., at the time of peak aperture acceleration and peak aperture velocity) for both the 400 and 800 ms conditions scaled linearly with object size, whereas JNDs later in the response (i.e., at the time of peak grip aperture) did not. Moreover, the 400 and 800 ms conditions produced comparable slopes relating JNDs to object size. In other words, larger aperture shaping impulses did not give rise to a stochastic increase in aperture variability at each object size. As such, the theoretical tenets of the impulse-variability hypothesis do not provide a viable framework for the time-dependent scaling of JNDs to object size. Instead, we propose that a dynamic interplay between relative and absolute visual information gives rise to grasp trajectories that exhibit an early adherence and late violation to Weber's law.

Pro- and antisaccades: dissociating stimulus and response influences the online control of saccade trajectories.

The authors examined whether the diminished online control of antisaccades is related to a trade-off between movement planning and control or the remapping of target properties to a mirror-symmetrical location (i.e., vector inversion). Pro- and antisaccades were examined in a standard no-delay schedule wherein target onset served as the movement imperative and a delay cuing schedule wherein responses were initiated 2,000 ms following target onset. Importantly, the delay cuing schedule was employed to equate pro- and antisaccade reaction times. Online control was evaluated by indexing the strength of trajectory amendments at normalized increments of movement time. Antisaccades exhibited fewer online corrections than prosaccades, and this result was consistent across cuing schedules. Thus, the diminished online control of antisaccades cannot be tied to a trade-off between movement planning and control. Rather, the authors propose that the intentional nature of dissociating stimulus and response (i.e., vector inversion) engenders a slow mode of cognitive control that is not optimized for fast oculomotor corrections.

Visually and memory-guided grasping: aperture shaping exhibits a time-dependent scaling to Weber's law.

The 'just noticeable difference' (JND) represents the minimum amount by which a stimulus must change to produce a noticeable variation in one's perceptual experience and is related to initial stimulus magnitude (i.e., Weber's law). The goal of the present study was to determine whether aperture shaping for visually derived and memory-guided grasping elicit a temporally dependent or temporally independent adherence to Weber's law. Participants were instructed to grasp differently sized objects (20, 30, 40, 50 and 60mm) in conditions wherein vision of the grasping environment was available throughout the response (i.e., closed-loop), when occluded at movement onset (i.e., open-loop), and when occluded for a brief (i.e., 0ms) or longer (i.e., 2000ms) delay in advance of movement onset. Within-participant standard deviations of grip aperture (i.e., the JNDs) computed at decile increments of normalized grasping time were used to determine participant's sensitivity to detecting changes in object size. Results showed that JNDs increased linearly with increasing object size from 10% to 40% of grasping time; that is, the trial-to-trial stability (i.e., visuomotor certainty) of grip aperture (i.e., the comparator) decreased with increasing object size (i.e., the initial stimulus). However, a null JND/object size scaling was observed during the middle and late stages of the response (i.e., >50% of grasping time). Most notably, the temporal relationship between JNDs and object size scaling was similar across the different visual conditions used here. Thus, our results provide evidence that aperture shaping elicits a time-dependent early, but not late, adherence to the psychophysical principles of Weber's law.

The visual coding of grip aperture shows an early but not late adherence to Weber's law.

An exemplar metric of goal-directed grasping (i.e., peak grip aperture) has been shown to be refractory to a psychophysical principle governing visuoperceptual estimations of object size (i.e., Weber's law). This dissociation suggests that vision for action and vision for perception are mediated by absolute and relative visual information, respectively. The present investigation examined whether aperture shaping elicits a unitary or process-dependent violation of Weber's law. Participants grasped differently sized objects (20, 30, 40, 50 and 60 mm of width) and just noticeable difference (JND) scores related to grip aperture were computed at the time of peak grip aperture as well as at normalized deciles of the response (i.e., 10-90% of grasping time). JNDs during the early and middle stages of the trajectory scaled to object size whereas values late in the trajectory (>50% of grasping time and including the time of peak grip aperture) did not. Thus, results show an early, but not late, adherence to Weber's law and indicate that movement planning and movement control are supported via relative and absolute visual information, respectively.