Introduction: Non-publication of trial findings results in research waste and compromises medical evidence and the safety of interventions in child health. The objectives of this study were to replicate, compare and contrast findings of a previous study (Klassen et al., 2002) to determine the impact of ethical and editorial mandates to register and publish findings. Methods: Abstracts accepted to the Pediatric Academic Societies meetings (2008-2011) were screened in duplicate to identify Phase-III RCTs enrolling pediatric populations. Subsequent publication was ascertained through a search of electronic databases. Study internal validity was measured using Cochrane Risk of Bias and Jadad Scale, and key variables (e.g., trial design, study stage) were extracted. Pearson X2, t-tests and Wilcoxon rank sum tests were used to examine association between variables and publication status. Logistic regression, log-rank tests, rank correlation and Egger regression were used to assess predictors of publication, time to publication and publication bias, respectively. Results: Compared to our previous study, fewer studies remained unpublished (27.9% vs 40.9%, p=.007). Abstracts with higher sample sizes (p=0.01) and those registered in ClinicalTrials.gov were more likely to be published (p<.0001). There were no differences in quality measures/risk of bias or in preference for positive results (p=0.36) between published and unpublished studies. Mean time to publication was 26.5 months and published manuscripts appeared most frequently in Pediatrics, the Journal of Pediatrics, and Pediatric Emergency Care. The funnel plot (p=0.04) suggests a reduced but ongoing existence of publication bias among published studies. Overall, we observed a reduction in publication bias and in preference for positive findings, and an increase in study size and publication rates over time. Conclusion: Despite heightened safeguards and editorial policy changes in recent decades, publication bias remains commonplace and presents a threat to assessing the efficacy and effectiveness of interventions in child health. Our results suggest a promising trend towards a reduction in publication bias over time and positive impacts of trial registration. Further efforts are needed to ensure the entirety of evidence can be accessed when assessing treatment effectiveness.

This paper describes the development and implementation of the INFO (immediate, not for personal assessment, fast facilitated feedback, and opportunity to ask questions) clinical debriefing process. INFO enabled charge nurses to facilitate a group debriefing after critical events across three adult emergency departments (EDs) in Calgary, Alberta. Prior to implementation at our institutions, ED critical event debriefing was a highly variable event. Post-implementation, INFO critical event debriefings have become part of our ED culture, take place regularly in our EDs (254 documented debriefings between March 2016 and September 2017), with recommendations arising from these debriefings being introduced into clinical practice. The INFO clinical debriefing process addresses two significant barriers to regular ED clinical debriefing: a lack of trained facilitators and the focus on physician-led debriefings. Our experience shows that a nurse-facilitated debriefing is feasible, can be successfully implemented in diverse EDs, and can be performed by relatively inexperienced debriefers. A structured approach means that debriefings are more likely to take place and become a routine part of improving team management of high stakes or unexpected clinical events.

Introduction: Take Home Naloxone (THN) programs prevent death from opioid poisoning by training laypersons to recognize an overdose and administer naloxone. Dispensing THN through the emergency department (ED) is particularly critical because an ED visit for opioid poisoning strongly predicts future mortality. Many EDs have implemented THN programs, yet almost no literature examines the reach of such initiatives. To address this gap, we conducted a chart review of all patients presenting for opioid poisoning to an urban tertiary hospital, with a large ED-based THN program. This exploratory study hypothesized that more than 50% of ED patients presenting for opioid poisoning would be offered a THN kit. Methods: Data on demographics, clinical characteristics, and THN kit dispensing were extracted and analyzed from the charts of all ED patients presenting with a primary diagnosis of opioid poisoning between April 1 2016 and April 30 2017. Logistic regression analyzed predictors of being offered a THN kit. Results: A total of 347 ED visits for 301 unique patients occurred during the study period. The mean age ± SD of patients was 38 ± 14 years, and 69% were male. In 49% of ED visits, a THN kit was offered; 73% of these episodes had a THN kit dispensation. Patients who were male (AOR=1.94; 95% CI 1.11 - 3.40), and reported that their overdose was unintentional (AOR=2.95; 95% CI 1.04 8.35) and caused by illegal opioids (AOR=4.73; 95% CI 2.63 8.52) were significantly more likely to be offered a THN kit. Conclusion: ED-based THN programs have the potential to reach significant proportions of patients at high risk of mortality. However, these programs may have differential reach within the target population. Further research is needed to examine barriers and facilitators to offering all eligible ED patients a THN kit.

Back pain is one of the most common presentations to the emergency department. Though case reports of patients presenting with increased back pain following chiropractic spinal manipulations are rare, we have identified a case rarely reported in the literature where a potential injury from chiropractic manipulation resulted in a diagnosis of multiple myeloma. We have reported a previously healthy 66-year-old male who presented with persistent lower back pain over 4 weeks. An initial evaluation with thoracolumbar radiographs revealed no significant findings. Following initial presentation to the family physician, the patient underwent three treatments of spinal manipulation from his local chiropractor, which resulted in worsening lower back pain. A re-examination and new radiographs in the hospital revealed multiple compression fractures and an underlying diagnosis of multiple myeloma. We have explored current literature examining the prevalence of lower back pain, as well as the incidence of spinal fracture following chiropractic manipulation, and have highlighted a potential complication from chiropractic manipulation in a patient with an undiagnosed underlying neoplastic disorder.

Hayward GN, Hay AD, Moore MV, et al. Effect of oral dexamethasone without immediate antibiotics vs. placebo on acute sore throats in adults: a randomized clinical trial. JAMA 2017;317(15):1535-43.

Acute flank pain from suspected urolithiasis is a common presenting complaint in the Emergency Department. Multiple computed tomography (CT) has traditionally been the standard imaging modality used to diagnose obstructive kidney stones, however point of care ultrasound (PoCUS) can play an important role in the diagnostic algorithm and risk stratification of acute flank pain. Here, we present the case of a 29-year-old female with suspected urolithiasis, who underwent PoCUS that revealed right-sided hydronephrosis and normal left kidney, bladder, and aorta. A subsequent KUB was negative. As the clinical course failed to improve with therapy, an abdominal and pelvic CT was ordered revealing a 5 mm distal obstructing ureteric calculus at the right vesico-ureteric junction and another 5 mm left mid ureteric calculus. To the best of our knowledge, this is the first case in which a patient presenting with acute right-sided flank pain demonstrated unilateral hydronephrosis on PoCUS, but had clinically significant bilateral ureteric stones on CT. Emergency physicians who employ PoCUS for evaluation of flank pain must be aware of its benefits and drawbacks and how they apply to each patient. As such, we have developed a script emergency physicians can use for shared decision-making with renal colic patients when deciding on the appropriate imaging modality.

Introduction: Optimal discharge communication between healthcare providers and parents who present to the emergency department (ED) with their children is not well understood. Current research regarding discharge communication is equivocal and predominantly focused on evaluating different delivery formats or strategies with little attention given to communication behaviours or the context in which the communication occurs. The objective of this study was to characterize the process and structure of discharge communication in a pediatric ED context. Methods: Real-time video observation and follow-up surveys were used in two academic pediatric EDs in Canada. Parents who presented with their child to the ED with one of six illness presentations, a Canadian Triage Acuity Score of 3-5 were eligible to participate. All ED physicians, learners, and staff members were also eligible. Provider-parent communication was analyzed using the Roter Interaction Analysis System (RIAS) to code each utterance. Parent health literacy and anxiety were measured upon admission to the ED. Parent recall of important discharge information and satisfaction with communication was assessed within 72 hours of discharge. Results: A total of 107 ED patient visits were video recorded and a total of 70,000 utterances were coded across six illness presentations: abdominal pain (n=23), asthma (n=7), bronchiolitis (n=4), diarrhea/vomiting (n=20), fever (n=27), and minor head injury (n=26). The average length of stay for participants was 3 hours, with an average of three provider interactions per visit. Interactions ranged in time from less than one minute up to 29 minutes, with an average of six minutes per interaction. The majority of visits were first episodes for the presenting illness (63.2%). Physician utterances coded most commonly involved giving medical information (22.9%), whereas nurses most commonly gave orientation instructions (20.9%). Learners were most likely to employ active listening techniques (14.2%). Communication that provided post-discharge instructions for parents comprised 8.5% of all utterances. Overall, providers infrequently assessed parental understanding of information (2.0%). Only 26% of parents recalled receiving important discharge information deemed relevant to their childs disposition. Yet, parent satisfaction with the amount of information communicated during the ED visit was generally high (89.6% agreed or strongly agreed). Conclusion: This is the first study of ED discharge communication to be conducted in a pediatric setting using video observation methods. Provider-parent communication was predominantly characterized by giving medical information, with little time devoted to preparing families to care for their child at home. Greater assessment of parent comprehension of discharge communication is needed to ensure that parents understand important instructions and know when to seek further care.