Clinical Suspicion and Language Translation in the Pediatric Emergency Department.

ABSTRACT: Elucidating a medical history and gaining patient consent and buy-in are difficult in any teenager presenting to a North American pediatric emergency department, but especially so when they present with limited English fluency. Translators can make this process easier, but both limited availability and impreciseness in translation can reduce their utility. We describe 2 teenage females who presented to our pediatric emergency department within 48 hours with similar presentations but no obvious organic cause or examination findings to suggest a specific diagnosis. We demonstrate how complex language translation issues in these adolescents contributed to prolonged diagnoses and advocate for independent interpreters to be available on first presentation to hospital.

CanadiEM: Accessing a Virtual Community of Practice to Create a Canadian National Medical Education Institution.

BACKGROUND: The rise of free open-access medical education (FOAM) has led to a wide range of online resources in emergency medicine. Canadian physicians have been active contributors to FOAM. OBJECTIVES: We aimed to create a virtual community of practice that would serve as a national platform for collaboration, learning, and knowledge dissemination. METHODS: CanadiEM was formed in 2016 from the merger of two Canadian websites and a podcast. Using a community-of-practice model, we introduced two training programs to support junior community members in becoming core editorial team members and employed asynchronous Web technologies to facilitate collaboration. We also introduced a coached peer review process and formed strategic alliances that aim to ensure a high quality of publication. RESULTS: CanadiEM has become a portal for readers to access a broad range of FOAM content. The website has published 782 articles. Of these, 71 have undergone a coached peer review process. The website has received over 2.5 million page views from 217 countries, and the associated CRACKCast podcast has been downloaded over 750,000 times. CONCLUSIONS: CanadiEM has succeeded in building a national multi-interface dissemination network that fosters collaboration and knowledge sharing in emergency medicine while fostering junior digital scholars. The construction of a community of practice has been facilitated by quality assurance, training programs, and the use of asynchronous Web technologies. Ongoing challenges in sustainability include a volunteer workforce with high turnover.

[Microsurgical approach to the ambient cistern]. / Abordaje a la Cisterna Ambiens.

OBJECTIVE: To describe a step-by-step approach to the ambient cistern by the suboccipital retrosigmoid supracerebellar infratentorial (RSI) approach. DESCRIPTION: The RSI approach is performed in the same manner as the suboccipital retrosigmoid approach, usually used to access the pathology of the cerebellopontine angle, with the following modifications: (1) we always use the semi-sitting position, (2) the craniotomy-craniectomy must expose the transverse sinus and extend 5 cm medially to the inion, (3) when performing the dural opening it is necessary to mobilize the dura with the transverse sinus upwards, (4) under magnification with surgical microscope the cerebellomedullary cistern should be opened in order to drain cerebrospinal fluid for relaxing the cerebellum, and (5) arachnoidal adherences and bridging veins must be coagulated and cut if necessary. These maneuvers create a wide corridor to the ambient cistern. CONCLUSION: This approach allows a safe access to the ambient cistern, especially to the infratentorial portion.

Does oxygen delivery explain interindividual variation in forearm critical impulse?

Within individuals, critical power appears sensitive to manipulations in O2 delivery. We asked whether interindividual differences in forearm O2 delivery might account for a majority of the interindividual differences in forearm critical force impulse (critical impulse), the force analog of critical power. Ten healthy men (24.6 ± 7.10 years) completed a maximal effort rhythmic handgrip exercise test (1 sec contraction-2 sec relaxation) for 10 min. The average of contraction impulses over the last 30 sec quantified critical impulse. Forearm brachial artery blood flow (FBF; echo and Doppler ultrasound) and mean arterial pressure (MAP; finger photoplethysmography) were measured continuously. O2 delivery (FBF arterial oxygen content (venous blood [hemoglobin] and oxygen saturation from pulse oximetry)) and forearm vascular conductance (FVC; FBF·MAP(-1)) were calculated. There was a wide range in O2 delivery (59.98-121.15 O2 mL·min(-1)) and critical impulse (381.5-584.8 N) across subjects. During maximal effort exercise, O2 delivery increased rapidly, plateauing well before the declining forearm impulse and explained most of the interindividual differences in critical impulse (r(2) = 0.85, P < 0.01). Both vasodilation (r(2) = 0.64, P < 0.001) and the exercise pressor response (r(2) = 0.33, P < 0.001) independently contributed to interindividual differences in FBF. In conclusion, interindividual differences in forearm O2 delivery account for most of the interindividual variation in critical impulse. Furthermore, individual differences in pressor response play an important role in determining differences in O2 delivery in addition to vasodilation. The mechanistic origins of this vasodilatory and pressor response heterogeneity across individuals remain to be determined.

Persistence of functional sympatholysis post-exercise in human skeletal muscle.

Blunting of sympathetic vasoconstriction in exercising muscle is well-established. Whether it persists during the early post-exercise period is unknown. This study tested the hypothesis that it persists in human skeletal muscle during the first 10 min of recovery from exercise. Eight healthy young males (21.4 ± 0.8 yrs, SE) performed 7 min of forearm rhythmic isometric handgrip exercise at 15% below forearm critical force (fCF). In separate trials, a cold pressor test (CPT) of 2 min duration was used to evoke forearm sympathetic vasoconstriction in each of Rest (R), Steady State Exercise (Ex), 2-4 min Post-Exercise (PEearly), and 8-10 min Post-Exercise (PElate). A 7 min control exercise trial with no CPT was also performed. Exercising forearm brachial artery blood flow, arterial blood pressure, cardiac output (CO), heart rate (HR), forearm deep venous catecholamine concentration, and arterialized venous catecholamine concentration were obtained immediately prior to and following the CPT in each trial. CPT resulted in a significant increase in forearm venous plasma norepinephrine concentration in all trials (P = 0.007), but no change in arterialized plasma norepinephrine (P = 0.32). CPT did not change forearm venous plasma epinephrine (P = 0.596) or arterialized plasma epinephrine concentration (P = 0.15). As assessed by the %reduction in forearm vascular conductance (FVC) the CPT evoked a robust vasoconstriction at rest that was severely blunted in exercise (R = -39.9 ± 4.6% vs. Ex = 5.5 ± 7.4%, P < 0.001). This blunting of vasoconstriction persisted at PEearly (-12.3 ± 10.1%, P = 0.02) and PElate (-18.1 ± 8.2%, P = 0.03) post-exercise. In conclusion, functional sympatholysis remains evident in human skeletal muscle as much as 10 min after the end of a bout of forearm exercise. Persistence of functional sympatholysis may have important implications for blood pressure regulation in the face of a challenge to blood pressure following exercise.

A collaboratively-derived science-policy research agenda.

The need for policy makers to understand science and for scientists to understand policy processes is widely recognised. However, the science-policy relationship is sometimes difficult and occasionally dysfunctional; it is also increasingly visible, because it must deal with contentious issues, or itself becomes a matter of public controversy, or both. We suggest that identifying key unanswered questions on the relationship between science and policy will catalyse and focus research in this field. To identify these questions, a collaborative procedure was employed with 52 participants selected to cover a wide range of experience in both science and policy, including people from government, non-governmental organisations, academia and industry. These participants consulted with colleagues and submitted 239 questions. An initial round of voting was followed by a workshop in which 40 of the most important questions were identified by further discussion and voting. The resulting list includes questions about the effectiveness of science-based decision-making structures; the nature and legitimacy of expertise; the consequences of changes such as increasing transparency; choices among different sources of evidence; the implications of new means of characterising and representing uncertainties; and ways in which policy and political processes affect what counts as authoritative evidence. We expect this exercise to identify important theoretical questions and to help improve the mutual understanding and effectiveness of those working at the interface of science and policy.