Emergency management of fever and neutropenia in children with cancer: A review.

INTRODUCTION: Care of pediatric cancer patients is increasingly being provided by physicians in community settings, including general emergency departments. Guidelines based on current evidence have standardized the care of children undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT) presenting with fever and neutropenia (FN). OBJECTIVE: This narrative review evaluates the management of pediatric patients with cancer and neutropenic fever and provides comparison with the care of the adult with neutropenic fever in the emergency department. DISCUSSION: When children with cancer and FN first present for care, stratification of risk is based on a thorough history and physical examination, baseline laboratory and radiologic studies and the clinical condition of the patient, much like that for the adult patient. Prompt evaluation and initiation of intravenous broad-spectrum antibiotics after cultures are drawn but before other studies are resulted is critically important and may represent a practice difference for some emergency physicians when compared with standardized adult care. Unlike adults, all high-risk and most low-risk children with FN undergoing chemotherapy require admission for parenteral antibiotics and monitoring. Oral antibiotic therapy with close, structured outpatient monitoring may be considered only for certain low-risk patients at pediatric centers equipped to pursue this treatment strategy. CONCLUSIONS: Although there are many similarities between the emergency approach to FN in children and adults with cancer, there are differences that every emergency physician should know. This review provides strategies to optimize the care of FN in children with cancer in all emergency practice settings.

A qualitative assessment of emergency medicine residents' receptivity to feedback.

BACKGROUND: Effective feedback is the cornerstone of competency-based education. The emergency department (ED) is a unique learning and feedback environment. Developing our understanding of emergency medicine (EM) residents' experiences around feedback will improve resident training and inform EM faculty development programs. OBJECTIVE: This qualitative study explores the feedback culture and practices in EM and resident's experiences and attitudes toward feedback in this specific training environment. METHODS: At a large categorical EM program, 15 residents voluntarily participated in semistructured interviews regarding feedback. These individual interviews were performed by a nonphysician investigator and transcripts underwent an inductive multistep coding process. Transcripts were analyzed to identify common factors influencing feedback and then comparisons were made between residents to explore the interconnectedness of identified factors and further categorize consistent themes. RESULTS: Factors inherent to the ED environment make the delivery of effective feedback challenging. Residents also revealed that feedback-seeking/-avoidant behavior and receptivity to feedback are multifactorial. Residents actively seek feedback when they feel that they performed well but tend to avoid feedback interactions when they expect constructive feedback. Finally, residents filter feedback based on attending personality and perceived practice style as well as their own desired practice style. CONCLUSIONS: It is important for program leaders to understand their residents' experiences with feedback and engage both faculty and residents in conversations around feedback delivery and receptivity. An improved understanding of these experiences might also reveal barriers to performance assessment and guide efforts to improve the accuracy and reliability of resident evaluations.

Diagnostic yield of computed tomographic pulmonary angiography for suspected pulmonary embolism varies across settings within a community-based health system.

PURPOSE: The diagnostic yield of computed tomographic pulmonary angiography (CTPA) for pulmonary embolism varies in the literature, and very little data is available regarding community-based systems. This study evaluates the yield of CTPA for pulmonary embolism across a variety of patient care settings in a community-based healthcare system, providing relevant benchmarks for potential quality improvement efforts. METHODS: This retrospective study included data collected from three sites within a single community-based healthcare system, including a tertiary care level 1 trauma center, an urban community hospital, and a suburban free-standing emergency department. CTPAs were identified by Current Procedural Terminology codes, and diagnoses of pulmonary embolism were identified via International Classification of Diseases codes. A total of 7850 CTPA studies met criteria for inclusion between January 1, 2012, and October 8, 2014. RESULTS: Pulmonary embolism was found in 884 (11.3%) of the studies performed. Outpatients had a lower yield of pulmonary embolism (3.8%, p < 0.001) compared with inpatients (14.1%) and emergency department patients (10.7%, p < 0.001). Patients with diagnoses of deep vein thrombosis or neoplasm had increased incidence of pulmonary embolism when compared with patients without these diagnoses (p < 0.001 for both). CONCLUSION: The overall yield of CTPA for pulmonary embolism in this community-based system was similar to that at academic centers. The yield was significantly lower in the outpatient setting compared with studies originating in the emergency department or inpatient setting.

Data-driven design of metal-organic frameworks for wet flue gas CO2 capture.

Limiting the increase of CO2 in the atmosphere is one of the largest challenges of our generation1. Because carbon capture and storage is one of the few viable technologies that can mitigate current CO2 emissions2, much effort is focused on developing solid adsorbents that can efficiently capture CO2 from flue gases emitted from anthropogenic sources3. One class of materials that has attracted considerable interest in this context is metal-organic frameworks (MOFs), in which the careful combination of organic ligands with metal-ion nodes can, in principle, give rise to innumerable structurally and chemically distinct nanoporous MOFs. However, many MOFs that are optimized for the separation of CO2 from nitrogen4-7 do not perform well when using realistic flue gas that contains water, because water competes with CO2 for the same adsorption sites and thereby causes the materials to lose their selectivity. Although flue gases can be dried, this renders the capture process prohibitively expensive8,9. Here we show that data mining of a computational screening library of over 300,000 MOFs can identify different classes of strong CO2-binding sites-which we term 'adsorbaphores'-that endow MOFs with CO2/N2 selectivity that persists in wet flue gases. We subsequently synthesized two water-stable MOFs containing the most hydrophobic adsorbaphore, and found that their carbon-capture performance is not affected by water and outperforms that of some commercial materials. Testing the performance of these MOFs in an industrial setting and consideration of the full capture process-including the targeted CO2 sink, such as geological storage or serving as a carbon source for the chemical industry-will be necessary to identify the optimal separation material.

Temperature-dependent interchromophoric interaction in a fluorescent pyrene-based metal-organic framework.

Compounds exhibiting tuneable fluorescence emission upon heating or cooling are considered smart materials as their optical properties can be exquisitely controlled by adjusting the external temperature. Herein, we report such a material, which is a porous pyrene-based metal-organic framework with a chemical formula of [Mg1.5(HTBAPy)(H2O)2]·3DMF (H4TBAPy = 1,3,6,8-tetrakis(p-benzoic acid)pyrene), named SION-7. The bulk solid material of SION-7 can display either monomer or excimer fluorescence emission due to the temperature-dependent extent of interchromophoric interactions between the HTBAPy3- ligands within the framework. Consequently, the fluorescence emission colours gradually change from blue at low temperature (80 K) to yellow-green at high temperature (450 K). Interestingly, while kept in a relatively wide temperature range of 80-200 K, SION-7 displays a structured monomer-like spectrum and its colour changes reversibly from deep to light blue. Ex situ variable-temperature (100-350 K) single-crystal X-ray diffractometry studies revealed the impact of solvent content on the optical properties of SION-7, and illustrated the correlation between the position of the phenylene groups of the HTBAPy3- ligands at different temperatures and the interchromophoric interaction. Our study demonstrates a step forward towards the design of tuneable thermofluorochromic materials sought by optoelectronics.

Quantitative analysis of 14N quadrupolar coupling using 1H detected 14N solid-state NMR.

Magic-angle spinning solid-state NMR is increasingly utilized to study the naturally abundant, spin-1 nucleus 14N, providing insights into the structure and dynamics of biological and organic molecules. In particular, the characterisation of 14N sites using indirect detection has proven useful for complex molecules, where the 'spy' nucleus provides enhanced sensitivity and resolution. Here we exploit the sensitivity of proton detection, to indirectly characterise 14N sites using a moderate rf field to generate coherence between the 1H and 14N at moderate and fast-magic-angle spinning frequencies. Efficient numerical simulations have been developed that have allowed us to quantitatively analyse the resulting 14N lineshapes to determine both the size and asymmetry of the quadrupolar interaction. Exploiting only naturally occurring abundant isotopes will aid the analysis of materials with the need to resort to isotope labelling, whilst providing additional insights into the structure and dynamics that the characterisation of the quadrupolar interaction affords.

Investigation of age-adjusted D-dimer using an uncommon assay.

BACKGROUND: Use of an age-adjusted D-dimer for the evaluation of acute pulmonary embolus (PE) has been prospectively validated in the literature and has become a practice recommendation from major medical societies. Most research on this subject involves the most common D-dimer assays reporting in Fibrinogen Equivalent Units (FEU) with a non-age-adjusted manufacturer-recommended cutoff of 500 ng/ml FEU. Limited research to date has evaluated age-adjustment in assays that report in D-Dimer Units (D-DU), which use a manufacturer-recommended cutoff of 230 ng/ml D-DU. Despite scant evidence, an age-adjusted formula using D-DU has been recently endorsed by the American College of Emergency Physicians (ACEP). This formula seems arbitrary in its derivation and unnecessarily deviates from existing thresholds, thus prompting the creation of our novel-age adjustment formula. The goal of this study was to retrospectively evaluate the test characteristics of our novel age-adjusted D-dimer formula using the D-DU assay in comparison to existing traditional and age-adjusted D-dimer thresholds for the evaluation of acute PE in the ED. METHODS: This was a retrospective chart review at an academic quaternary health system with three EDs and 195,000 combined annual ED visits. Only patients with D-dimer testing and CT PE protocol (CTPE) imaging were included. Admission and discharge diagnosis codes were used to identify acute PE. Outcome measures were sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an unadjusted traditional threshold (230) compared with both novel and ACEP-endorsed age adjusted thresholds, (Age × 5) - 20 and Age × 5 if >50, respectively. Estimates with their exact 95% threshold were performed. RESULTS: 4846 adult patients were evaluated from January 2012 to July 2017. Group characteristics include a mean age of 52 and a frequency of acute PE diagnosis by CTPE of 8.25%. Traditional D-dimer cutoff demonstrated a sensitivity of 99.8% (95% CI 98.6-100), specificity of 16.7% (95% CI 15.6-17.8) and NPV of 99.9% (95% CI 99.3-100). Our novel age-adjusted D-dimer thresholds had a sensitivity of 97.0% (95% CI 94.8-98.4), specificity of 27.9% (95% CI 26.6-29.2) and NPV of 99.0% (95% CI 98.3-99.5) with the ACEP-endorsed formula demonstrating similar test characteristics. CONCLUSION: Use of an age-adjusted D-dimer on appropriately selected patients being evaluated for acute PE in the ED with a D-DU assay increases specificity while maintaining a high sensitivity and NPV. Both our novel formula and the ACEP-endorsed age-adjusted formula performed well, with our novel formula showing a trend towards improved testing characteristics.

The Flipped Journal Club.

INTRODUCTION: Educators struggle to develop a journal club format that promotes active participation from all levels of trainees. The explosion of social media compels residencies to incorporate the evaluation and application of these resources into evidence-based practice. We sought to design an innovative "flipped journal club" to achieve greater effectiveness in meeting goals and objectives among residents and faculty. METHODS: Each journal club is focused on a specific clinical question based on a landmark article, a background article, and a podcast or blog post. With the "flipped" model, residents are assigned to prepare an in-depth discussion of one of these works based on their level of training. At journal club, trainees break into small groups and discuss their assigned readings with faculty facilitation. Following the small-group discussions, all participants convene to summarize key points. In redesigning our journal club, we sought to achieve specific educational outcomes, and improve participant engagement and overall impressions. RESULTS: Sixty-one residents at our emergency medicine program participated in the flipped journal club during the 2015-2016 academic year, with supervision by core faculty. Program evaluation for the flipped journal club was performed using an anonymous survey, with response rates of 70% and 56% for residents and faculty, respectively. Overall, 95% of resident respondents and 100% of faculty respondents preferred the flipped format. CONCLUSION: The "flipped journal club" hinges upon well-selected articles, incorporation of social media, and small-group discussions. This format engages all residents, holds learners accountable, and encourages greater participation among residents and faculty.

A Randomized Trial of SMART Goal Enhanced Debriefing after Simulation to Promote Educational Actions.

INTRODUCTION: Goal setting is used in education to promote learning and performance. Debriefing after clinical scenario-based simulation is a well-established practice that provides learners a defined structure to review and improve performance. Our objective was to integrate formal learning goal generation, using the SMART framework (Specific, Measurable, Attainable, Realistic, and Time-bound), into standard debriefing processes (i.e., "SMART Goal Enhanced Debriefing") and subsequently measure the impact on the development of learning goals and execution of educational actions. METHODS: This was a prospective multicenter randomized controlled study of 80 emergency medicine residents at three academic hospitals comparing the effectiveness of SMART Goal Enhanced Debriefing to a standard debriefing. Residents were block randomized on a rolling basis following a simulation case. SMART Goal Enhanced Debriefing included five minutes of formal instruction on the development of SMART learning goals during the summary/application phase of the debrief. Outcome measures included the number of recalled learning goals, self-reported executed educational actions, and quality of each learning goal and educational action after a two-week follow-up period. RESULTS: The mean number of reported learning goals was similar in the standard debriefing group (mean 2.05 goals, SD 1.13, n=37 residents), and in the SMART Goal Enhanced Debriefing group (mean 1.93, SD 0.96, n=43), with no difference in learning goal quality. Residents receiving SMART Goal Enhanced Debriefing completed more educational actions on average (Control group actions completed 0.97 (SD 0.87), SMART debrief group 1.44 (SD 1.03) p=0.03). CONCLUSION: The number and quality of learning goals reported by residents was not improved as a result of SMART Goal Enhanced Debriefing. Residents did, however, execute more educational actions, which is consistent with the overarching intent of any educational intervention.

Extreme event medicine: considerations for the organisation of out-of-hospital care during obstacle, adventure and endurance competitions.

Obstacle, adventure and endurance competitions in challenging or remote settings are increasing in popularity. A literature search indicates a dearth of evidence-based research on the organisation of medical care for wilderness competitions. The organisation of medical care for each event is best tailored to specific race components, participant characteristics, geography, risk assessments, legal requirements, and the availability of both local and outside resources. Considering the health risks and logistical complexities inherent in these events, there is a compelling need for guiding principles that bridge the fields of wilderness medicine and sports medicine in providing a framework for the organisation of medical care delivery during wilderness and remote obstacle, adventure and endurance competitions. This narrative review, authored by experts in wilderness and operational medicine, provides such a framework. The primary goal is to assist organisers and medical providers in planning for sporting events in which participants are in situations or locations that exceed the capacity of local emergency medical services resources.

The dipolar endofullerene HF@C60.

The cavity inside fullerenes provides a unique environment for the study of isolated atoms and molecules. We report the encapsulation of hydrogen fluoride inside C60 using molecular surgery to give the endohedral fullerene HF@C60. The key synthetic step is the closure of the open fullerene cage with the escape of HF minimized. The encapsulated HF molecule moves freely inside the cage and exhibits quantization of its translational and rotational degrees of freedom, as revealed by inelastic neutron scattering and infrared spectroscopy. The rotational and vibrational constants of the encapsulated HF molecules were found to be redshifted relative to free HF. The NMR spectra display a large (1)H-(19)F J coupling typical of an isolated species. The dipole moment of HF@C60 was estimated from the temperature dependence of the dielectric constant at cryogenic temperatures and showed that the cage shields around 75% of the HF dipole.

Sol-gel preparation of low oxygen content, high surface area silicon nitride and imidonitride materials.

Reactions of Si(NHMe)4 with ammonia are effectively catalysed by small ammonium triflate concentrations, and can be used to produce free-standing silicon imide gels. Firing at various temperatures produces amorphous or partially crystallised silicon imidonitride/nitride samples with high surface areas and low oxygen contents. The crystalline phase is entirely α-Si3N4 and structural similarities are observed between the amorphous and crystallised materials.

The 5Cs of Consultation: Training Medical Students to Communicate Effectively in the Emergency Department.

BACKGROUND: Effective communication is critical for health care professionals, particularly in the Emergency Department (ED). However, currently, there is no standardized consultation model that is consistently practiced by physicians or used for training medical graduates. Recently, the 5Cs of Consultation model (Contact, Communicate, Core Question, Collaborate, and Close the Loop) has been studied in Emergency Medicine residents using simulated consultation scenarios. OBJECTIVE: Using an experimental design, we aimed to evaluate the efficacy of the 5Cs consultation model in a novel learner population (medical students) and in a "real time and real world" clinical setting. METHODS: A prospective, randomized, controlled study was conducted at eight large, academic, urban, tertiary-care medical centers (U.S. and Canada). Intervention involved two experimental groups (asynchronous and live training) compared to a baseline control group. All participants placed up to four consult phone calls. A senior physician observed and assessed each call using a preapproved 5Cs checklist and a Global Rating Scale (GRS). RESULTS: Participants who received training (asynchronous or live) scored significantly higher on the 5Cs checklist total and GRS than the control group. Both training methods (asynchronous and live) were equally effective. Importantly, learning gains were sustained as students' 5Cs checklist total and GRS scores remained consistently higher at their second, third, and fourth consult (relative to their first consult). At posttest, all participants reported feeling more confident and competent in relaying patient information. CONCLUSION: Medical students can be trained to use the 5Cs model in a timely, inexpensive, and convenient manner and increase effectiveness of physician consultations originating from the ED.

Synthesis and characterisation of an open-cage fullerene encapsulating hydrogen fluoride.

The first encapsulation of hydrogen fluoride in an open-cage fullerene is reported. Solution and solid-state NMR spectra of the novel open-cage endofullerene are described.

Emergency medicine residents' self-assessments play a critical role when receiving feedback.

OBJECTIVES: Emergency medicine (EM) faculty often aim to improve resident performance by enhancing the quality and delivery of feedback. The acceptance and integration of external feedback is influenced by multiple factors. However, it is interpreted through the "lens" of the learner's own self-assessment. Ideally, following an educational activity with feedback, a learner should be able to generate and act upon specific learning goals to improve performance. Examining the source of generated learning goals, whether from one's self-assessment or from external feedback, might shed light on the factors that lead to improvement and guide educational initiatives. Using a standard oral board scenario, the objective of this study was to determine the effects that residents' self-assessment and specific feedback from faculty have on not only the generation of learning goals but also the execution of these goals for performance improvement. METHODS: In this cross-sectional educational study at four academic programs, 72 senior EM residents participated in a standardized oral board scenario. Following the scenario, residents completed a self-assessment form. Next, examiners used a standardized checklist to provide both positive and negative feedback. Subsequently, residents were asked to generate "SMART" learning goals (specific, measurable, attainable, realistic, and time-bound). The investigators categorized the learning goals as stemming from the residents' self-assessments, feedback, or both. Within 4 weeks, the residents were asked to recall their learning goals and describe any actions taken to achieve those goals. These were grouped into similar categories. Descriptive statistics were used to summarize the data. RESULTS: A total of 226 learning goals were initially generated (mean ± SD = 3.1 ± 1.3 per resident). Forty-seven percent of the learning goals were generated by the residents' self-assessments only, while 27% were generated by the feedback given alone. Residents who performed poorly on the case incorporated feedback more often than high performers when generating learning goals. Follow-up data collection showed that 62 residents recalled 89 learning goals, of which 52 were acted upon. On follow-up, the numbers of learning goals from self-assessment and feedback were equal (25% each, 13 of 52), while the greatest number of reportedly executed learning goals came from self-assessments and feedback in agreement (40%). CONCLUSIONS: Following feedback on an oral board scenario, residents generated the majority of their learning goals from their own self-assessments. Conversely, at the follow-up period, they recalled an increased number of learning goals stemming from feedback, while the largest proportion of learning goals acted upon stemmed from both feedback and self-assessments in agreement. This suggests that educators need to incorporate residents' self-assessments into any delivered feedback to have the greatest influence on future learning goals and actions taken to improve performance.