Characteristics of Drug Poisonings Seen in the Emergency Department of an Urban Hospital.

Background: Drug poisoning, either intentional or non-intentional, is a frequent diagnosis in the emergency department (ED), necessitating patient management from multiple services. Objective: To describe the drug poisonings seen in the ED of a large academic urban hospital. Methods: This retrospective descriptive study used 3 years of data (2018-2020) abstracted from the hospital's electronic medical record system and linked to validated, coded extracts from the Canadian Institute for Health Information Discharge Abstract Database. Patients with a diagnosis of acute drug poisoning who presented to the ED were identified on the basis of International Statistical Classification of Diseases and Related Health Problems, 10th revision, Canada (ICD-10-CA) codes, and data were collected for demographic characteristics, the drugs involved, in-hospital management, and inpatient outcomes. Patients with diagnosis of an acute drug reaction, inebriation, or nondrug or in-hospital poisoning were excluded. Data were stratified and analyzed in relation to the intent of drug poisoning. Results: A total of 2983 visits for drug poisoning, involving 2211 unique patients (mean age 38.3 [standard deviation 16.2] years, 54.7% female), were included, yielding an overall incidence rate of 15.7 drug poisonings per 1000 ED visits (8.1 intentional, 6.4 non-intentional, and 1.3 unknown intent). Among the 1505 intentional drug poisonings, the most prevalent drug sources were antidepressants (n = 405, 26.9%), benzodiazepines (n = 375, 24.9%), and acetaminophen (n = 329, 21.9%); in contrast, opioids (n = 594, 48.1%) were most prevalent for the 1236 non-intentional poisonings. For 716 (24.0%) of the poisoning visits, the patient was admitted to acute care services, and the in-hospital mortality rate was 1.0% (n = 31). In addition, 111 patients (9.0%) with non-intentional drug poisoning left against medical advice. Finally, for 772 (25.9%) of the poisoning visits, the patient returned to the ED after discharge with a subsequent drug poisoning. Conclusions: Drug poisonings are a common cause of visits to urban EDs. They are rarely fatal but are associated with substantial utilization of hospital resources and considerable recidivism.

Contexte: L'intoxication médicamenteuse, intentionnelle ou non, est un diagnostic fréquent dans le service des urgences (SU); elle nécessite la prise en charge des patients par plusieurs services. Objectif: Décrire les intoxications médicamenteuses observées dans le SU d'un grand hôpital universitaire urbain. Méthodologie: Pour cette étude rétrospective et descriptive, des données contenues dans le système de dossiers médicaux électroniques de l'hôpital et liées à des extraits validés et codés de la base de données sur les congés des patients de l'Institut canadien d'information sur la santé pendant 3 ans (2018­2020) ont été utilisées. Les patients ayant reçu un diagnostic d'intoxication médicamenteuse aiguë qui se sont présentés à l'urgence ont été identifiés sur la base des codes de la Classification statistique internationale des maladies et des problèmes de santé connexes, 10e version, Canada (CIM-10-CA), et des données ont été recueillies pour les caractéristiques démographiques, les médicaments impliqués, la prise en charge à l'hôpital et les résultats pour les patients hospitalisés. Les patients présentant un diagnostic de réaction médicamenteuse aiguë, d'ébriété ou d'intoxication non médicamenteuse ou à l'hôpital ont été exclus. Les données ont été stratifiées et analysées en fonction de l'intention de l'empoisonnement médicamenteux. Résultats: Au total, 2983 cas mettant en cause 2211 patients (âge moyen 38,3 [écart type 16,2] ans, dont 54,7 % de femmes) ont été inclus; les résultats ont donné un taux d'incidence global de 15,7 intoxications médicamenteuses pour 1000 visites au SU (8,1 intentionnelles; 6,4 non intentionnelles; et 1,3 intention inconnue). Parmi les 1505 intoxications médicamenteuses intentionnelles, les médicaments les plus répandues étaient les antidépresseurs (n = 405, 26,9 %), les benzodiazépines (n = 375, 24,9 %) et l'acétaminophène (n = 329, 21,9 %); les opioïdes (n = 594, 48,1 %) étaient les plus répandus parmi les 1236 intoxications non intentionnelles. Dans 716 des cas (24,0 %), le patient a été admis dans les services de soins aigus. Le taux de mortalité hospitalière était de 1,0 % (n = 31). Par ailleurs, 111 patients (9,0 %) présentant une intoxication médicamenteuse non intentionnelle ont quitté l'hôpital contre avis médical. Enfin, dans 772 des cas d'intoxication (25,9 %), le patient est retourné à l'urgence après sa sortie à cause d'une intoxication médicamenteuse ultérieure. Conclusions: Les intoxications médicamenteuses sont une cause fréquente de visites dans les SU urbains. Ils sont rarement mortels, mais sont associés à une utilisation importante des ressources hospitalières et à une récidive considérable.

Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol.

INTRODUCTION: Redirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion. OBJECTIVES: Our primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians' judgement as a criterion standard. Our tertiary objective is to examine how the ED physician's perception of a virtual ED care alternative correlates with the EDAC. METHODS AND ANALYSIS: A randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC. ETHICS AND DISSEMINATION: This study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.

Video in situ simulation for medical student education during the COVID-19 pandemic.

The COVID-19 pandemic has limited in-person experiences for medical students, especially in situations involving aerosol-generating procedures. We designed a video in situ simulation to orient students to critical steps in COVID-19 intubation algorithms. Small groups of students were paired virtually with facilitators (faculty and residents) and watched a video of an in situ simulation of emergency staff performing a protected intubation, with discussion points appearing on screen at discrete times. The simple design drives engagement, discussion and allows for scheduling flexibility with no risk to the learners. It can be adapted to several different scenarios or levels of training.

La pandémie de la COVID-19 a limité les expériences en personne pour les étudiants en médecine, en particulier les interventions qui produisent des aérosols. Nous avons conçu une simulation in situ par vidéo portant sur les étapes critiques des algorithmes de l'intubation dans les cas de COVID-19. De petits groupes d'étudiants, jumelés virtuellement avec des animateurs (enseignants et résidents), ont regardé une vidéo de la simulation in situ d'une intubation sécuritaire effectuée par une équipe d'urgence. À des moments précis de la simulation, des points de discussion apparaissaient à l'écran. Cette formule simple, sans risque pour les apprenants, favorise l'engagement et la discussion et elle permet la planification en toute souplesse. Elle peut être adaptée à plusieurs scénarios et à divers niveaux de formation.

Endotracheal intubation with barrier protection.

Given the high risk of healthcare worker (HCW) infection with COVID-19 during aerosol-generating medical procedures, the use of a box barrier during intubation for protection of HCWs has been examined. Previous simulation work has demonstrated its efficacy in protecting HCWs from cough-expelled droplets. Our objective was to assess its ability to protect HCWs against aerosols generated during aerosol-generating medical procedures. We used a battery-powered vapouriser to assess movement of vapour with: (1) no barrier; (2) a box barrier; and (3) a box barrier and a plastic sheet covering the box and patient's body. We visualised the trajectory of vapour and saw that the vapour remained within the barrier space when the box barrier and plastic sheet were used. This is in contrast to the box barrier alone, where vapour diffused towards the feet of the patient and throughout the room, and to no barrier where the vapour immediately diffused to the laryngoscopist. This demonstrates that the box with the plastic sheet has the potential to limit the spread of aerosols towards the laryngoscopist, and thus may play a role in protecting HCWs during aerosol-generating medical procedures. This is of particular importance in the care of patients with suspected COVID-19.

Obstacle course runs: review of acquired injuries and illnesses at a series of Canadian events (RACE).

BACKGROUND: The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on emergency medical services (EMS) and local EDs. Literature concerning the safety of these events is minimal and mostly consists of media reports. We sought to characterise the injury and illness profile of OCRs and the level of medical care required. METHODS: This study analysed OCR events occurring in eight locations across Canada from May to August 2015 (total 45 285 participants). Data were extracted from event medical charts of patients presenting to the onsite medical team, including injury or illness type, onsite treatment and disposition. RESULTS: There were 557 race participants treated at eight OCR events (1.2% of all participants). There were 609 medical complaints in total. Three quarters of injuries were musculoskeletal in nature. Eighty-nine per cent returned to the event with no need for further medical care. The majority of treatments were completed with first aid and basic medical equipment. Eleven patients (2% of patients) required transfer to hospital by EMS for presentations including fracture, dislocation, head injury, chest pain, fall from height, and abdominal pain. CONCLUSIONS: We found that 1.2% of race participants presented to onsite medical services. The majority of complaints were minor and musculoskeletal in nature. Only 2% of those treated were transferred to hospital through EMS. This is consistent with other types of mass gathering events.

Antitumor Efficacy of Intravesical BCG, Gemcitabine, Interferon-α and Interleukin-2 as Mono- or Combination-Therapy for Bladder Cancer in an Orthotopic Tumor Model.

OBJECTIVE: To reduce adverse effects and improve efficacy of intravesical BCG for bladder cancer, alternative treatment options were investigated in an orthotopic rat tumor model. METHODS: Superficial bladder cancer was established in syngeneic female rat bladders by instillation of AY-27 cells. Animals were randomly assigned to treatment groups including dose escalation of intravesical BCG with or without interferon-α (IFN-α) or interleukin-2 (IL-2); or graded doses of gemcitabine alone; or BCG plus gemcitabine. Treatments were given twice weekly for 3 weeks. Rats in control groups received saline instillations. Treatment response was monitored by animals' well-being, survival days, tumor growth inhibition, and histological examination at necropsy. RESULTS: Rats receiving monotherapy with intravesical BCG, gemcitabine, or IFN-α, attained significantly better survival and tumor reduction compared with control (P = 0.002; 0.001; 0.002, respectively, Log-rank Test). A dose-dependent treatment response was observed in animals with established bladder tumor receiving escalated BCG instillations. Only high-dose BCG significantly improved animal survival. Although high-dose BCG plus gemcitabine or IFN-α did not increase benefit over monotherapies, low-dose BCG plus IL-2 did show improved efficacy (P = 0.01). CONCLUSION: Intravesical monotherapies with gemcitabine and IFN-α were as effective as BCG for treatment of early non-muscle-invasive urothelial bladder cancer in this immune competent rat model. Combining these agents with high-dose BCG did not further increase efficacy. However, combining low-dose BCG with IL-2 enhanced BCG effectiveness.

A novel intravesical therapy for superficial bladder cancer in an orthotopic model: oncolytic reovirus therapy.

PURPOSE: To our knowledge this is the first report of intravesical oncolytic reovirus for therapy of superficial bladder cancer in an orthotopic bladder tumor model. Superficial bladder carcinomas are often multifocal and have high recurrences after surgical resection. In 20% of cases intravesical immunotherapy fails to prevent recurrence and complications from bacillus Calmette-Guerin (BCG) are common. Human reovirus is an oncolytic virus that selectively destroys cancer cells with an activated Ras pathway. We examined the ability of this virus to kill bladder cancer cells in vitro and inhibit tumor growth in vivo. MATERIALS AND METHODS: Following cytotoxicity assays in vitro dose escalation of intravesical reovirus was tested for tumor control and toxicity in a rat model. Treatments were done twice weekly for 3 weeks. In parallel intravesical BCG was studied. Animals were monitored on a daily basis for health status and by routine urine cytology. Animals underwent necropsy at study end point and appropriate tissues were taken for histology. RESULTS: Side effects in reovirus groups were minor compared with BCG complications. Tumor response (animal survival) was 90% 100 days after tumor implantation in reovirus treated animals, whereas the highest survival in BCG treated groups was 50%. Animals treated with reovirus had significantly higher tumor-free survival than those treated with immunotherapy or normal saline (log rank test p = 0.0002 and 0.04, respectively). CONCLUSIONS: Intravesical reovirus is safe and effective in this animal model and it may have clinical applications for bladder cancer treatment.

Selective reovirus killing of bladder cancer in a co-culture spheroid model.

Up to 50% of the transitional cell carcinomas (TCC) express an activated EGF pathway involving MAP/MEK and RAF kinase thus providing a novel means to selectively eliminate transformed cells expressing such proteins. This EGF pathway expression phenotype was also confirmed in our MGH-U3 and room temperature-112 human TCC cell lines, which makes them a suitable model target for the reovirus oncolysis. We report here on an in vitro assay of co-culture spheroids using either human or rat TCC cells with their corresponding fibroblasts to examine the potential of viral selective lysis for TCC. Reovirus, a respiratory enteric orphan virus, which mammals are exposed to early in life, was used in this study. Selective killing of transformed versus normal cells was assayed by time-lapse photography, vital dye staining, immunohistochemistry, and MTT assay. In this in vitro bladder cancer model, reovirus selectively destroyed the transformed cells by lysis or induction of apoptosis. Based on these findings we have initiated an in vivo pre-clinical study on intravesical administration of reovirus in an animal model to further explore the effect of reovirus-mediated oncolysis of TCC.