Risk factors associated with 1-week revisit among emergency department patients with alcohol withdrawal.

BACKGROUND: Approximately one-quarter of emergency department (ED) visits for alcohol withdrawal result in unscheduled 1-week ED return visits, but it is unclear what patient and clinical factors may impact this outcome METHODS: From January 1, 2015, to December 31, 2018, at three urban EDs in Vancouver, Canada, we studied patients who were discharged with a primary or secondary diagnosis of alcohol withdrawal. We performed a structured chart review to ascertain patient characteristics, ED treatments, and the outcome of an ED return within 1 week of discharge. We used univariable and multivariable Bayesian binomial regression to identify characteristics associated with being in the upper quartile of 1-week ED revisits. RESULTS: We collected 935 ED visits among 593 unique patients. Median age was 45 years (interquartile range 34 to 55 years) and 71% were male. The risk of a 1-week ED revisit was 15.0% (IQR 12.3; 19.5%). After adjustment, factors independently associated with a high risk for return included any prior ED visit within 30 days, no fixed address, initial blood alcohol level > 45 mmol/L, and initial Clinical Institute Withdrawal Assessment-alcohol revised score > 23. These factors explained 41% of the overall variance in revisits. CONCLUSION: Among discharged ED patients with alcohol withdrawal, we describe high-risk patient characteristics associated with 1-week ED revisits, and these findings may assist clinicians to facilitate appropriate discharge planning with access to integrated follow-up support.

RéSUMé: CONTEXTE: Environ un quart des visites aux urgences pour sevrage alcoolique se traduit par un retour non programmé aux urgences pendant une semaine, mais les facteurs cliniques et relatifs aux patients qui peuvent avoir une incidence sur ce résultat ne sont pas clairs. MéTHODES: Du 1er janvier 2015 au 31 décembre 2018, dans trois urgences urbaines de Vancouver, au Canada, nous avons étudié les patients qui sont sortis avec un diagnostic primaire ou secondaire de sevrage alcoolique. Nous avons procédé à une analyse structurée des dossiers afin de déterminer les caractéristiques des patients, les traitements aux urgences et l'issue d'un retour aux urgences dans la semaine suivant la sortie. Nous avons utilisé une régression binomiale bayésienne univariable et multivariable pour identifier les caractéristiques associées au fait d'être dans le quartile supérieur des visites aux urgences à une semaine. RéSULTATS: Nous avons recueilli 935 visites aux urgences parmi 593 patients uniques. L'âge médian était de 45 ans (intervalle interquartile de 34 à 55 ans) et 71 % étaient des hommes. Le risque d'une nouvelle visite aux urgences à une semaine était de 15,0% (IQR 12,3 ; 19,5%). Après ajustement, les facteurs indépendamment associés à un risque élevé de retour comprenaient toute visite antérieure à l'urgence dans les 30 jours, aucune adresse fixe, le taux d'alcoolémie initial > 45 mmol/L, et l'évaluation initiale du sevrage de l'Institut clinique ­ cote d'alcoolémie révisée > 23. Ces facteurs expliquaient 41 % de la variance globale des visites. CONCLUSIONS: Parmi les patients sortants des urgences en sevrage alcoolique, nous décrivons les caractéristiques des patients à haut risque associés à la réadmission aux urgences après une semaine de sevrage alcoolique. Ces résultats peuvent aider les cliniciens à planifier de manière appropriée la sortie de l'hôpital et à accéder à un suivi intégré.

Transforming Disruption Into Innovation: A Partnership Between the COVID-19 Medical Student Response Team and the University of British Columbia.

The COVID-19 pandemic caused substantial disruptions in medical education. The University of British Columbia (UBC) MD Undergraduate Program (MDUP) is the sixth-largest medical school in North America. MDUP students and faculty developed a joint response to these disruptions to address the curriculum and public health challenges that the pandemic posed. After clinical activities were suspended in March 2020, third- and fourth-year MDUP students formed a COVID-19 Medical Student Response Team (MSRT) to support frontline physicians, public health agencies, and community members affected by the pandemic. A nimble organizational structure was developed across 4 UBC campuses to ensure a rapid response to meet physician and community needs. Support from the faculty ensured the activities were safe for the public, patients, and students and facilitated the provision of curricular credit for volunteer activities meeting academic criteria. As of June 19, 2020, more than 700 medical students had signed up to participate in 68 projects. The majority of students participated in projects supporting the health care system, including performing contact tracing, staffing public COVID-19 call centers, distributing personal protective equipment, and creating educational multimedia products. Many initiatives have been integrated into the MDUP curriculum as scholarly activities or paraclinical electives for which academic credit is awarded. This was made possible by the inherent flexibility of the MDUP curriculum and a strong existing partnership between students and faculty. Through this process, medical students were able to develop fundamental leadership, advocacy, communication, and collaboration skills, essential competencies for graduating physicians. In developing a transparent, accountable, and inclusive organization, students were able to effectively meet community needs during a crisis and create a sustainable and democratic structure capable of responding to future emergencies. Open dialogue between the MSRT and the faculty allowed for collaborative problem solving and the opportunity to transform disruption into academic innovation.

Environmental Sustainability in Canadian Critical Care: A Nationwide Survey Study on Medical Waste Management.

BACKGROUND: To date, the literature surrounding healthcare sustainability has focused largely on operating rooms, energy efficiency and biohazardous waste management. Few studies have looked at the sustainability within intensive care units (ICUs). OBJECTIVE: Our study sought to capture the array of sustainability initiatives undertaken by Canadian ICUs and gain a better understanding of current practices with regard to the management of single-use equipment waste. METHODS: We conducted a nationwide e-mail survey through the Canadian Critical Care Network. RESULTS: We received responses from a total of 81 hospital sites representing all 10 Canadian provinces and approximately 28.3% of all Canadian ICUs. The vast majority of responses came from ICU managers or nursing leadership. Our study identified variable waste management practices across the country and showcased successful initiatives undertaken by Canadian ICUs toward increased environmental sustainability.

Depolarization of the conductance-voltage relationship in the NaV1.5 mutant, E1784K, is due to altered fast inactivation.

E1784K is the most common mixed long QT syndrome/Brugada syndrome mutant in the cardiac voltage-gated sodium channel NaV1.5. E1784K shifts the midpoint of the channel conductance-voltage relationship to more depolarized membrane potentials and accelerates the rate of channel fast inactivation. The depolarizing shift in the midpoint of the conductance curve in E1784K is exacerbated by low extracellular pH. We tested whether the E1784K mutant shifts the channel conductance curve to more depolarized membrane potentials by affecting the channel voltage-sensors. We measured ionic currents and gating currents at pH 7.4 and pH 6.0 in Xenopus laevis oocytes. Contrary to our expectation, the movement of gating charges is shifted to more hyperpolarized membrane potentials by E1784K. Voltage-clamp fluorimetry experiments show that this gating charge shift is due to the movement of the DIVS4 voltage-sensor being shifted to more hyperpolarized membrane potentials. Using a model and experiments on fast inactivation-deficient channels, we show that changes to the rate and voltage-dependence of fast inactivation are sufficient to shift the conductance curve in E1784K. Our results localize the effects of E1784K to DIVS4, and provide novel insight into the role of the DIV-VSD in regulating the voltage-dependencies of activation and fast inactivation.