Bone health in symptomatic carriers of haemophilia A: a protocol for a multicentre prospective matched-cohort study

IntroductionHaemophilia A is an X linked inherited bleeding disorder, caused by a decrease in coagulation factor VIII. Persons with haemophilia experience repeated musculoskeletal bleeding, which can lead to decreased range of motion, irreversible joint damage, low bone mineral density (BMD), and are at greater risk for osteoporosis. Women heterozygous for this mutation, also known as haemophilia A carriers, can have bleeding symptoms and even experience joint bleeding evidenced by radiological soft tissue and osteochondral changes. The prevalence of low BMD as a risk factor for osteoporosis has never been evaluated in carriers of haemophilia, and given the recent findings which suggest subclinical musculoskeletal bleeding in carrier women, we hypothesise that they too are at risk of impaired bone health.Methods and analysisThis is a national multicentre prospective matched-cohort study to compare BMD T-scores among symptomatic haemophilia A carriers, 50 years of age or older, with age-matched and body mass index-matched non-carriers (1:1). A total of 40 symptomatic carriers and 40 matched non-carriers will be recruited from St. Michael’s Hospital, Kingston General Hospital in Ontario, Canada and Foothills Medical Centre in Alberta, Canada. Multivariable linear regression models will be used to estimate the effect of haemophilia carriership on BMD T-scores, adjusting for age, body mass index and other relevant covariates.Ethics and disseminationThe protocol was designed and will be conducted in compliance with applicable laws, rules and regulations. Research ethics approval was obtained from St. Michael’s Hospital, Foothills Medical Centre, and Kingston General Hospital. Findings will be presented at international venues such as the American Society of Haematology and the World Federation of Haemophilia World Congress. The authors of this study will seek publication in journals such as Blood, Journal of Thrombosis and Haemostasis, American Journal ofHematology and British Journal ofHaematology.

P112: In situ simulation: A team sport?

Introduction: Identification of latent safety threats (LSTs) in the emergency department is an important aspect of quality improvement that can lead to improved patient care. In situ simulation (ISS) takes place in the real clinical environment and multidisciplinary teams can participate in diverse high acuity scenarios to identify LSTs. The purpose of this study is to examine the influence that the profession of the participant (i.e. physician, registered nurse, or respiratory therapist) has on the identification of LSTs during ISS. Methods: Six resuscitation- based adult and pediatric simulated scenarios were developed and delivered to multidisciplinary teams in the Kingston General Hospital ED. Each ISS session consisted of a 10- minute scenario, followed by 3-minutes of individual survey completion and a 7- minute group debrief led by ISS facilitators. An objective assessor recorded LSTs identified during each debrief. Surveys were completed prior to debrief to reduce response bias. Data was collected on participant demographics and perceived LSTs classified in the following categories: medication; equipment; resources and staffing; teamwork and communication; or other. Two reviewers evaluated survey responses and debrief notes to formulate a list of unique LSTs across scenarios and professions. The overall number and type of LSTs from surveys was identified and stratified by health care provider. Results: Thirteen ISS sessions were conducted with a total of 59 participants. Thirty- four unique LSTs (8 medication, 15 equipment, 5 resource, 4 communication, and 2 miscellaneous issues) were identified from surveys and debrief notes. Overall, MDs (n = 12) reported 19 LSTss (n = 41) reported 77 LSTs, and RTs (n = 6) reported 4 LSTs based on individual survey data. The most commonly identified category of LSTs reported by MDs (36.8%) and RTs (75%) was equipment issues while RNs most commonly identified medication issues (36.4%). Participants with □5 years of experience in their profession, on average identified more LSTs in surveys than participants with >5 years experience (1.9 LSTs vs 1.5 LSTs respectively). Conclusion: Nursing staff identified the highest number of LSTs across all categories. There was fairly unanimous identification of major LSTs across professions, however each profession did identify unique perspectives on LSTs in survey responses. ISS programs with the purpose of LST identification would benefit from multidisciplinary participation.

A Century of Snatching

This paper examines nineteenth-century body snatching in Kingston, Ontario, focusing on the roles of the medical students, the local medical profession, and community reactions. Drawing primarily on newspapers and documents from the Queen’s University Medical Faculty and the Kingston General Hospital, this chronological and thematic analysis explores the socio-medical evolution of the practice. The results invite reconsideration of earlier body snatching narratives in Canada.

The Value of Community Service‐Learning as an Alternative Learning Strategy: A Reflection on Experiential Education and Self‐Discovery in the Department of Volunteer Services at Kingston General Hospital

Community Service‐Learning (CSL) is a strategy that enables teaching and learning through valuable community service, by teaching civic responsibility and enforcing the importance of reflection. CSL allows for student participation in community service that directly relates to specific learning outcomes. This ensures a mutual benefit for both the organization receiving voluntary service and the individual participating in CSL. For the individual, benefits include developing self‐awareness, critical thinking, and a commitment to volunteerism and public service. In my current CSL placement at Kingston General Hospital (KGH), a number of institutional, community and personal benefits resulted from a full academic year placement in the Department of Volunteer Services. In thinking carefully about my experience— reflecting on what I had seen, heard and experienced—it became obvious that the issues arising from the reflection process could serve as an alternative learning experience for students. Specifically, the CSL approach to learning provides a tangible learning opportunity that enables students to develop a deeper understanding of their experiences. In this presentation, I will provide an argument as to why a hands‐on, practical form of learning is better than concentrating on academic in‐class instruction alone. Thus I will establish reasons why CSL supplements the regular learning process and results in a well‐rounded educational experience.

P087: Cellulitis and erysipelas management at an academic emergency department: current practice vs the literature

Introduction: Cellulitis and erysipelas are common presentations for the general practitioner. Antibiotic therapy targeting beta-hemolytic streptococci and Staphylococcus aureus is the mainstay of treatment for children and adults with these infections. Although evidence-based Canadian guidelines for appropriate management exist, inconsistent practices persist. Our objective was to determine the level of adherence to current evidence by emergency physicians at two academic hospitals in Kingston, Ontario. Methods: We conducted a retrospective chart review of 200 randomly selected electronic medical records. Records belonged to patients with a discharge diagnosis of cellulitis or erysipelas who were seen in the emergency departments of Kingston General Hospital or Hotel Dieu Hospital between January 1 and June 30, 2015. We manually collected data describing patient demographics, medical history, and medical management. Results: There were 707 total visits to the emergency departments in the study period for cellulitis or erysipelas. In our random sample, for those diagnosed with cellulitis, 44% received oral cephalexin alone, which was the most common form of therapy for uncomplicated infection. Of all the patients who received any antibiotics, 36% received at least one dose of parenteral antibiotics, despite only 6.7% showing systemic signs of illness. Emergency physicians chose ceftriaxone for 88% of the patients who received parenteral antibiotics. Conclusion: There was wide variation in antibiotic selection and route of administration for patients with cellulitis or erysipelas. Ceftriaxone was chosen for most patients receiving parenteral antibiotics, but it may not have been the most effective antibiotic in some cases. Overuse of antibiotics is common, and we believe medication choice should be justified based on disease severity, spectrum of activity, and regional antibiotic resistance patterns, among other factors. In conclusion, we found that emergency physicians could more closely align management plans with current guidelines to improve management of uncomplicated infection and reduce unnecessary administration of parenteral antibiotics.

Case File: Cardiac amyloidosis using on routine hand-held ultrasound

A 64 year-old man presented to the Kingston General Hospital with cardiac arrest. At the time of EMS arrival, the ECG showed ventricular tachycardia. The patient was intubated and ventilated. Multiple defibrillations were required to convert the patient back to normal sinus rhythm.

Case File: Use of POCUS for assessment of dyspnea in the Emergency Department

A 65 year-old man presented to the Emergency Department at Kingston General Hospital with progressive shortness of breath, fatigue, dull chest discomfort that worsened with deep breathing and exertion. The patient was referred to cardiology for congestive heart failure and ordered troponin, chest x-ray (CXR), and electrocardiogram (ECG).

Adherence to complementary feeding recommendations for infants and implications for public health

ObjectiveThe current study investigates (i) the extent to which breast-feeding and non-breast-feeding mothers follow the Canadian Nutrition for Healthy Term Infants (NHTI) recommendations; (ii) the first complementary foods given and the differences by breast-feeding status; (iii) whether any breast-feeding is associated with earlier introduction to complementary foods relative to non-breast-feeding, after controlling for potentially confounding factors; and (iv) the need for improvements in timing and resources of interventions by examining breast-feeding rates over time and information sources used by mothers.DesignLongitudinal data from the Kingston, Frontenac, and Lennox & Addington (KFL&A) Infant Feeding Survey were used. Mothers completed a survey at the end of their hospital stay and were interviewed by telephone at 2, 4, 6 and 12 months thereafter.SettingThe study took place in the KFL&A region of Ontario, Canada.SubjectsThe sample consisted of 325 mothers who gave birth to a live infant of at least 36 weeks’ gestation and a birth weight of at least 1500 g at Kingston General Hospital between January and July of 2008.ResultsFour in five mothers introduced complementary foods prior to 6 months. Mothers not breast-feeding at 6 months introduced water, juice, infant cereals, fruit and vegetables, and foods not recommended by Canada’s Food Guide sooner than breast-feeding mothers. Breast-feeding mothers were more likely to introduce milks appropriately, but had low adherence to giving their infants vitamin D supplements.ConclusionsTo support adherence to NHTI recommendations, interventions should be conducted during early infancy and deliver consistent, evidence-based recommendations.

Injuries in recreational curling include head injuries and may be prevented by using proper footwear

Introduction Our study examines a recreational curling population to describe patterns of injury occurrence, estimate risk of injury and to gauge attitudes towards equipmentbased prevention strategies. Methods In a retrospective case series, we queried the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), a national injury surveillance database, for curling injuries entered between 1993 and 2011. Kingston General Hospital and Hotel Dieu Hospital provide the two Kingston, Ontario, sites for emergency department (ED) care and participate in CHIRPP. Each retrieved entry underwent a chart review. A secondary survey was mailed to select individuals who had experienced curling injuries to solicit details on their injury and attitudes towards equipment to prevent injury. We used descriptive statistics for rates and proportions. Results Over 90% of acute curling injuries resulted from a fall, and 31.7% were head impacts. We found that acute injuries requiring ED presentation occur at a rate of approximately 0.17 per 1000 athlete-exposures (95% CI: 0.12–0.22). The secondary survey was completed by 54% of potential respondents. Of survey respondents, 41.3% attributed their fall to a lack of proper footwear and 73.5% of respondents agreed with mandatory sport-specific footwear as a prevention strategy, but only 8% agreed with mandatory helmet wear. Conclusion Although curling injuries requiring medical care are not common, head injuries make up a large proportion. Mandated use of appropriate footwear appears to be the most effective prevention strategy, as well as the measure deemed most acceptable by players.