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IntroductionIncreased intracranial pressure (ICP) is a significant neurological issue that may lead to permanent neurological sequelae. When evaluating patients with traumatic brain injury, it is crucial to identify those with high ICP in order to expedite ICP lowering measures and maintain adequate cerebral perfusion. Several measures are used to recognise patients with increased ICP including CT scan, MRI, ICP monitor, and lumbar puncture (LP). However, these tests can be invasive, associated with radiation exposure, contraindicated, or not readily available. Ultrasonography measurement of the optic nerve sheath diameter (ONSD) is proposed as a non-invasive and quick measure to identify high ICP. The aim of this systematic review and meta-analysis will be to examine the accuracy of ONSD sonography for increased ICP diagnosis.Methods and analysesWe will include published and unpublished randomised controlled trials, observational studies, and abstracts, with no publication type or language restrictions. Search strategies will be designed to peruse the MEDLINE, Embase, Web of Science, WHO Clinical Trials, ClinicalTrials.gov, CINAHL, and the Cochrane Library databases. We will also implement strategies to search grey literature. Two reviewers will independently complete data abstraction and conduct quality assessment. Included studies will be assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We will construct the hierarchical summary receiver operating characteristic curve for included studies and pool sensitivity and specificity using the bivariate model. We also plan to conduct prespecified subgroup analyses to explore heterogeneity. The overall quality of evidence will be rated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).Ethics and disseminationResearch ethics board approval is not required for this study as it draws from published data and raises no concerns related to patient privacy. This review will provide a comprehensive assessment of the evidence on ONSD sonography diagnostic accuracy and is directed to a wide audience. Results from the review will be disseminated extensively through conferences and submitted to a peer-reviewed journal for publication.PROSPERO registration numberCRD42017055485.Clinical trial numberTrial registration number is NCT00783809.

Introduction-Mean daily temperatures in Canada rose 1.7 • C between 1948 and 2016, and the frequency, severity, and duration of extreme heat events has increased. These events can exacerbate underlying health conditions, bringing patients to emergency departments (EDs). This retrospective analysis assessed the impact of temperature and humidex on ED volume and length of stay (LOS).Methods-LOS is an indicator of ED overcrowding and system performance. Using daily maximum temperatures and humidex values, this study investigated the impact of mean 3-d temperatures and humidex preceding ED presentation on the median and maximum ED LOS and patient volume in 2 community hospitals in Montreal, Quebec, during the summer months of 2016 to 2018. Data were analyzed with 1-way analysis of variance with post hoc Fisher least significant difference tests and Spearman correlation tests.Results-The mean maximum temperature and humidex were 26.1 • C and 30.4 • C, respectively (n=276 d). Mean 3-d temperatures ≥30 • C were associated with higher daily ED volumes in both hospitals (138 vs 121, P=0.002 and 132 vs 125, P=0.03) and with increased median LOS at 1 hospital (8.9 vs 7.6 h, P=0.03). Mean 3-d humidex ≥35 was associated with higher daily ED volumes at both hospitals as well (136 vs 123, P=0.01 and 133 vs 125, P=0.009) with an increased median LOS at 1 hospital (8.6 vs 6.9 h, P=0.0001) with humidex values of 25 to 29.9 • C.Conclusions-Heat events were associated with increased ED presentations and LOS. This study suggests that a warming climate can impede emergency service provision by increasing the demand for and delaying timely care.

Purpose: To compare the impact of institutional and epidemiologic factors on differences in application trends of Canadian medical graduates (CMGs) from different medical schools to FRCPC emergency medicine (EM) residency programs. Methods: This was a retrospective cohort study. Data from 2013-2018 were obtained from the Canadian Resident Matching Service (CaRMS) database and standardized questionnaires sent to Canadian medical schools. Results: CaRMS data were available for all schools and survey data was available for 76% schools. Five schools yielded significantly higher rates of applications to FRCPC-EM programs (8.8-13.1%, p<0.05), and 5 schools had significantly lower rates compared to the national mean (2.9-5.1%, p<0.05). Increased exposure to EM (a core rotation and/or elective rotation in EM in the third year of medical school at home-school) yielded 28-55% higher application rates (p<0.001). The presence of an FRCPC-EM residency program at the applicant's home school, and a home school program with 5 or more CMG residency positions at a CMG’s increased the application rates by 39 and 17%, respectively (p<0.05). Conclusion: These data demonstrate a significant difference in application rates of CMGs graduating from Canadian medical schools and certain factors may affect application rates. This information could be used by medical schools to modify curricula, increase exposure to EM, and contribute towards addressing the forecasted national shortage of EM physicians.

Introduction: The average temperature in Canada has risen 1.7°C between 1948-2016, increasing the frequency, severity and duration of extreme heat events. These events can exacerbate underlying health conditions, bringing patients to emergency departments (EDs). There is limited data associating sustained heat events to Canadian ED volumes and performance. This retrospective analysis assessed the impact of humidex and temperature on ED volume and length of stay (LOS). Methods: LOS is an indicator of ED overcrowding and system performance. The authors compared median and maximum LOS (hours) and patient volumes in both ambulatory and stretcher ED sections of two community hospitals (NDH, VH) in Montreal, QC to humidex and temperature during the summers of 2016-2018. Data were analyzed with one-way ANOVA and post hoc means analysis with Fisher LSD tests of a priori determined thresholds of mean three-day maximum humidex and temperature preceding ED presentation. Results: The mean maximum humidex and temperature values for the 2016-2018 summers in Montreal, QC were 30.4 and 26.1°C, respectively (n = 276 days). Elevated mean three-day maximum humidex was associated with increased ED volumes (F[3,88] = 4.2,p = 0.008) and median LOS (F[3,88] = 7.7,p = 0.0001) in the NDH. Mean three-day maximum humidex was associated with ED volumes (F[3,272) = 2.9,p = 0.03) but not with median and maximum LOS (p > 0.05) in the VH. Parallel comparisons with mean three-day maximum temperature similarly showed an association with increased ED volumes (F[3,88] = 5.0,p = 0.003) and increased duration of median LOS (F[3,88] = 3.5,p = 0.02) in the NDH. Mean three-day maximum temperature was associated with increased ED volumes (F[3,272] = 3.3,p = 0.02) but not with median and maximum LOS (p > 0.05) in the VH. Conclusion: Warming climates are associated with an increased number of ED presentations and longer median ED LOS. As heat events disproportionately impacted NDH, future investigations need to determine why these two hospitals were affected differently. This study provides local evidence that climate change can disrupt emergency services by increasing the demand for and delaying timely care. This is the first study that the authors are aware of that demonstrates these findings. Hospitals need to be climate ready. Heat waves often happen during times when summer bed closures and vacations already impact system capacity. EDs should dynamically adapt to meet community needs during periods of extreme heat.