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Radio Interview available for Download!
Shout it out!
Hey folks, if you missed my radio interview on "Where Monsters Dwell," check it out on the link below. We talk comics, film, Jackie Chan, Marvel, DC, Topps, upcoming books for the mainstream, the Olympics...hockey in Texas! You name it!
Episode #89 is available for download!
http://wheremonstersdwell.ca/
On a personal note, I had a blast. :-) And I even tried to enunciate... without a Texan accent.. yeah, right! LOL. Give it a listen ya'll!
--R.
Labels: 2010 Olympics, DC Comics, Hal-Con, Jackie Chan, joe jusko, Marvel, Topps, Where Monsters Dwell
Golden, Texeira and Witterstaetter at "Comic Book Marketplace," Feb. 27th!
Note: Artwork Attached
Golden and Texeira Hit the Mark at the "Comic Book Marketplace"
New Art Books Available/ Visionaries Panel Planned
New York, NY-- There is no venue quite like the Big Apple, and with the weather getting a bit chilly out there, here's the perfect chance to warm up, grab your own bite of what the city has to offer, and meet some of your favorite comic book creators in town for this unique one day event, all at the same time!
Mike Carbo's New York Comic Book Marketplace is set for Saturday, February 27th, from 11am to 7pm, at the Penn Plaza Pavilion, 401 7th Ave at 33rd St, New York City! Admission is only $10 for the day, and the show is sure to feature lots of dealers selling comics, toys, DVD's and more. We already hear that some of our favorites will be there, including Shelton Drum of Heroes Aren't Hard to Find, and our friends at Motor City Comics as well!
The guest list is something any 3-day show would be proud to boast, with the likes of Michael Golden, Mark Texeira, Ilya Salkind, Matthew Clark, Herb Trimpe, David Roya, Steve Mannion, Gene Colan, Bob Wiacek, Rodney Ramos, Rudy Nebres, Chris Claremont, Renee Witterstaetter, Bill Sienkiewicz, Khary Randolph, Danny Fingeroth, Trevor Von Eeden, Larry Hama, Cliff Chiang, Sean Chen, Jim Starlin, Dick Ayers, James H. Williams III, Irwin Hasen, Guy Dorian, Ian Dorian, Dan Slott, Billy Tucci, Jim Salicrup and Janet Jackson!
Michael Golden and Mark Texeira will also have copies of their respective art books from Vanguard Productions available, "Excess: The Art of Michael Golden" and "Tex: The Art of Mark Texeira" as well as their sketchbooks from Eva Ink Publishing, "Michael Golden's Heroes and Villains, and "Tex: Babes and Brawn." Also inquire about numerous prints, and limited sketching as the day allows--so get there EARLY!
In addition, Michael Golden, Bill Sienkiewicz and James H. Williams III will be on the "Visionaries" panel slated for 1:00-1:45, moderated by writer/publisher Renee Witterstaetter.
For more information on this and future shows, visit: http://www.nycbm.com/
For more information on Michael Golden and Mark Texeira, visit: www.evaink.com
Labels: bill sienkiewicz, Billy Tucci, Chris Claremont, Doctor Strange, Herb Trimpe, James H. Williams III, jim starlin, Larry Hama, Mark Texeira, Michael Golden, Vanguard Productions
The Case of Dr. Who's Possessed Neck Warmer
Alas, I have not been a avid watcher of Dr. Who. I know. Forgive me in advance!
But I did find this story fun, nevertheless. :-)
Having been the victim of boots that seem to shrink and grow for no accountable reason. Gloves and socks that disappear and reappear seemingly at will, and cel phones that call people I really have no interest in talking with and at the most inopportune times, I can relate.
In this case... Communication my friends. It's all about the communication. And a little about making lemonade out of lemons. Oh...And a little about possessed scarves. :-) --R.
The Mysterious Scarf of Dr. Who
When Tom Baker was introduced as Dr. Who in 1974, the costume designer contacted a knitter named Begonia Pope to provide him a scarf. He gave her an armload of different yarns and sent her on her way. Begonia returned with a twenty foot scarf.
Despite the misunderstanding, that the designer simply wanted Begonia to choose a colour and knit a scarf instead of using all the yarn, the icon scarf stayed and was first seen in episode "Robot".
Over the years, the scarf went through sizing changes as well as color changes without explanation. Costume designer James Acheson was quoted as saying, "it was so completely bizarre, for weeks the scarf would be fine, and then all of a sudden, one day we would come in to work and it would have shrunk three feet. We couldn't explain it."
Though the crew was wary of giving too much credit to the strange happenings with the scarf, Tom Baker began complaining that the scarf would become uncommonly clingy and often caught tightly around this throat. At this point both cast and crew couldn't ignore the behavior of the scarf even if they couldn't explain it and decided to retire the well known accessory.
Some of the more superstitious crew members went to question Begonia Pope, the women who knit the scarf, but neighbors had claimed she had not been seen for almost seven months and her leaving was quite abrupt as her home was intact, though covered in a thick layer of dust.
In 2005 the strange scarf was auctioned off to Richard Cohen from Long Island. He was more than happy to answer questions about the scarf and has admitted to wearing around a few times but denies having worn it after the first three months. He appeared upset when questions about the odd happenings with the scarf were brought up however. He denied noticing anything out of the ordinary and quickly changed the subject.
(The above was taken off an internet blog site. Can't find the link right now. I didn't write it or report it. But interesting nonetheless.)
Labels: doctor who, dr. who, scarf
Radio Interview Set for February 24th!
Renee Witterstaetter on "Where Monsters Dwell" Radio Broadcast
Music/Arts - Listening Party
Radio/Internet
Renee Witterstaetter will be on the radio show "Where Monsters Dwell" this Wednesday night, February 24th at 8:30 pm. EST. Join Renee as she talks publishing, writing, traveling, new book projects she is currently writing for the mainstream, the "Creator Chronicles" DVD series, as well as up coming trade shows.... and ....of course COMICS!
http://wheremonstersdwell.ca
Click 'listen to CHSR'. Click on the blue 'here'. The station streams on the internet 24/7. The show starts at 9:30 (AST)/ 8:30 (EST) on Wednesday night.
Posted by Eva Ink Artist Group / Pros and Cons Celebrity Booking / HappySpacePOPCon.com at 11:19 AM No comments:
A Heart is from the Heart. Happy Valentine's Day WEEK! Heck, why not YEAR!
Hi All--
Hoping you had a wonderful day with your loved one and friends. My nostalgia for Valentine's Day always comes from remembering the glue, glitter and paper envelopes I made in grade school--complete with our names to put on the room wall-- and the one day when everyone in our little class exchanged carefully chosen little Valentines to distribute.... oh and those little candy fortune telling hearts. :-) And I always remembered Mom's delight, too, when Dad came home with one of those gigantic heart shaped boxes of candy, usually with bows galore on top! She would always eat just one piece a day, making it last...making her feel a bit special every time she opened the big heart and picked the piece for that day, I'm sure. I admire her will power, thinking back on those times. LOL
Now, Valentine's Day for me doesn't have to happen on any given day. I try to not give into the commercialism too much-- we don't need Hallmark to tell us how to feel or when to buy a card, but it's not bad to be reminded of things, times and people we should be grateful for. So, with that in mind, I enjoy expressing the sentiment of the day. In fact, sometimes, it's nice to even save that special dinner for a few days after Feb 14th--the restaurants are less crowded, less expensive and more intimate. It's doesn't HAVE to happen on Feb. 14th! The sentiment can be the same.
A big day for me too is usually Feb. 15th when I scour the stores looking for the biggest chocolate heart I can find to send my Mom (like the one My Dad use to give her those many years ago... but since his death in 1992, I've been buying them for her). I made that trek today in fact, searching 6 different drug stores until I found the heart I was looking for! :-) It will go into the mail tomorrow. A post Valentine's Day surprise. She still eats just ONE piece a day...
I am always somewhat bemused by the holiday's origins though. It makes you wonder what current events today will be turned into a festival 1,000 years from now. LOL.
Anyway, I'm busy eating chocolate right now.. I'll get back with you later. In the meantime, have a wonderful Valentine's Day WEEK-- and for fun....some interesting facts:
Origins of Valentine's Day:
Every February, across the country, candy, flowers, and gifts are exchanged between loved ones, all in the name of St. Valentine. But who is this mysterious saint and why do we celebrate this holiday? The history of Valentine's Day — and its patron saint — is shrouded in mystery. But we do know that February has long been a month of romance. St. Valentine's Day, as we know it today, contains vestiges of both Christian and ancient Roman tradition.
So, who was Saint Valentine and how did he become associated with this ancient rite? Today, the Catholic Church recognizes at least three different saints named Valentine or Valentinus, all of whom were martyred.
One legend contends that Valentine was a priest who served during the third century in Rome. When Emperor Claudius II decided that single men made better soldiers than those with wives and families, he outlawed marriage for young men — his crop of potential soldiers. Valentine, realizing the injustice of the decree, defied Claudius and continued to perform marriages for young lovers in secret. When Valentine's actions were discovered, Claudius ordered that he be put to death.
Other stories suggest that Valentine may have been killed for attempting to help Christians escape harsh Roman prisons where they were often beaten and tortured.
According to one legend, Valentine actually sent the first 'valentine' greeting himself. While in prison, it is believed that Valentine fell in love with a young girl — who may have been his jailor's daughter — who visited him during his confinement. Before his death, it is alleged that he wrote her a letter, which he signed 'From your Valentine,' an expression that is still in use today. Although the truth behind the Valentine legends is murky, the stories certainly emphasize his appeal as a sympathetic, heroic, and, most importantly, romantic figure. It's no surprise that by the Middle Ages, Valentine was one of the most popular saints in England and France.
While some believe that Valentine's Day is celebrated in the middle of February to commemorate the anniversary of Valentine's death or burial — which probably occurred around 270 A.D — others claim that the Christian church may have decided to celebrate Valentine's feast day in the middle of February in an effort to 'christianize' celebrations of the pagan Lupercalia festival. In ancient Rome, February was the official beginning of spring and was considered a time for purification. Houses were ritually cleansed by sweeping them out and then sprinkling salt and a type of wheat called spelt throughout their interiors. Lupercalia, which began at the ides of February, February 15, was a fertility festival dedicated to Faunus, the Roman god of agriculture, as well as to the Roman founders Romulus and Remus.
To begin the festival, members of the Luperci, an order of Roman priests, would gather at the sacred cave where the infants Romulus and Remus, the founders of Rome, were believed to have been cared for by a she-wolf or lupa. The priests would then sacrifice a goat, for fertility, and a dog, for purification.
The boys then sliced the goat's hide into strips, dipped them in the sacrificial blood and took to the streets, gently slapping both women and fields of crops with the goathide strips. Far from being fearful, Roman women welcomed being touched with the hides because it was believed the strips would make them more fertile in the coming year. Later in the day, according to legend, all the young women in the city would place their names in a big urn.
The city's bachelors would then each choose a name out of the urn and become paired for the year with his chosen woman. These matches often ended in marriage. Pope Gelasius declared February 14 St. Valentine's Day around 498 A.D. The Roman 'lottery' system for romantic pairing was deemed un-Christian and outlawed. Later, during the Middle Ages, it was commonly believed in France and England that February 14 was the beginning of birds' mating season, which added to the idea that the middle of February — Valentine's Day — should be a day for romance. The oldest known valentine still in existence today was a poem written by Charles, Duke of Orleans to his wife while he was imprisoned in the Tower of London following his capture at the Battle of Agincourt. The greeting, which was written in 1415, is part of the manuscript collection of the British Library in London, England. Several years later, it is believed that King Henry V hired a writer named John Lydgate to compose a valentine note to Catherine of Valois.
In Great Britain, Valentine's Day began to be popularly celebrated around the seventeenth century. By the middle of the eighteenth century, it was common for friends and lovers in all social classes to exchange small tokens of affection or handwritten notes. By the end of the century, printed cards began to replace written letters due to improvements in printing technology. Ready-made cards were an easy way for people to express their emotions in a time when direct expression of one's feelings was discouraged. Cheaper postage rates also contributed to an increase in the popularity of sending Valentine's Day greetings. Americans probably began exchanging hand-made valentines in the early 1700s. In the 1840s, Esther A. Howland began to sell the first mass-produced valentines in America.
According to the Greeting Card Association, an estimated one billion valentine cards are sent each year, making Valentine's Day the second largest card-sending holiday of the year. (An estimated 2.6 billion cards are sent for Christmas.)
Approximately 85 percent of all valentines are purchased by women. In addition to the United States, Valentine's Day is celebrated in Canada, Mexico, the United Kingdom, France, and Australia.
Valentine greetings were popular as far back as the Middle Ages (written Valentine's didn't begin to appear until after 1400), and the oldest known Valentine card is on display at the British Museum. The first commercial Valentine's Day greeting cards produced in the U.S. were created in the 1840s by Esther A. Howland. Howland, known as the Mother of the Valentine, made elaborate creations with real lace, ribbons and colorful pictures known as "scrap".
Read more of the interesting history at: http://en.wikipedia.org/wiki/Valentine's_Day
Wishing you all happiness and wonderful Valentine's Day YEAR! :-)
--Renee
Posted by Eva Ink Artist Group / Pros and Cons Celebrity Booking / HappySpacePOPCon.com at 2:20 PM No comments:
How to be a Miserable Artist!
My facebook friend, and real-life friend, Cully Hamner posted this on his wall, and I thought it was food for thought for all my artist friends. :-) Tell what you think? --R.
(Thanks to Rafael Albuquerque)
How To Feel Miserable As An Artist
(Or What Not To Do-- Underline Any That Currently Apply)
1. Constantly compare yourself to other artists.
2. Talk to your family about what you do and expect them to cheer you on.
3. Base the success of your entire career on one project.
4. Stick with what you know.
5. Undervalue your expertise.
6. Let money dictate what you do.
7. Bow to societal pressures.
8. Only do work that your family would love.
9. Do whatever the client/gallery owner/patron/investor asks.
10. Set unachievable/overwhelming goals. To be accomplished by tomorrow.
So, I ask you, fellow artists: Any of those sound familiar?
Labels: cully hamner, how to be a miserable artist, van gogh
Review of "Tex: The Art of Mark Texeira" on Weekly Book Buzz!
Hi Everyone-- Below is a review of my just released book on Mark Texeira. :-) Give it a read. This book is available in book stores, but you can also order it from me directly, or pick it up at one of my appearances this year, while supplies last.
"Tex: The Art of Mark Texeira"
by: Renee Witterstaetter and Mark Texeira
Like a lot of comic book fans, I first took note of Mark Texeira when we worked on the revamped Ghost Rider title for Marvel Comics in the early 1990s. Texeira's bold, heavy style seemed a perfect match for this new and more terrifying version of Ghost Rider. Since then, "Tex" has cemented his place among the best artists in comics, leaving an indelible impression on every title he has worked on.
Vanguard's collection traces Texeira's roots from growing up in New York and attending the prestigious Art & Design High School in Manhattan, to his career as one of the premiere comic book artists and illustrators of the last twenty years. Throughout the book, Texeira comments on his life and career, giving readers an insight into how he has developed as an artist, and his incredible work ethic. Mark also discusses growing up in a tough Bronx neighborhood where gangs were prevalent and butting heads with his father who didn't think that an artists was a suitable profession.
While Ghost Rider may have catapulted him to stardom, fame didn't come overnight. Texeira was assisting Rich Buckler on Spider-Man Vs. Superman in the late 1970s and got his break with Marvel doing an adaptation of "Buckaroo Banzai" in the mid-1980s. But it's all about the art isn't it and Vanguard has included an incredible collection of Texeira's work. Interior pages, covers, sketches, full color oil paintings, and private commissions…many of them never published previously. In particular there are wonderful oil paintings of Thor, Vampirella, and the Black Cat; incredible watercolor illustrations of Batman and Wonder Woman; and Texeira's take on Frank Frazetta's "Death Dealer". It's simply a superb collection of one of the best, and one of my favorite artists. Grade A
http://www.mania.com/weekly-book-buzz-latest-anita-blake-novel_article_120286.html
Posted by Eva Ink Artist Group / Pros and Cons Celebrity Booking / HappySpacePOPCon.com at 9:35 AM No comments:
Labels: DC Comics, Ghost Rider, Mark Texeira, Marvel Comics, Renee Witterstaetter, Vanguard Productions
Golden, Texeira and Witterstaetter at "Comic Book ...
A Heart is from the Heart. Happy Valentine's Day W...
Review of "Tex: The Art of Mark Texeira" on Weekly...


text:
New Zealand Defence Force: Photographs (172)
Neil Macbeth's Photographs (97)
Rebekah Rogers's WEMO Photographs (16)
Sonja Farmer's WEMO Photographs (10)
Fulton Hogan BMX Pump Track (6)
500 Days: Churchill Park (6)
Foamapalooza (6)
St Luke's Labyrinth (5)
Christchurch: A Board Game (5)
Street Football (4)
Jim Baltaxe's WEMO Photographs (3)
Photographs of Gap Filler project 20 (2)
US Embassy: Photographs (2)
Jennifer Middendorf's Blog: Diary of a Kiwi Bookcrosser (2)
Fairfax Media Videos September 2010 (2)
Julia Holden's Photographs 2013 (2)
Seismics and the City 2012 (2)
Sep 2010 - Nov 2013
New Zealand Army (76)
Student Volunteer Army (75)
NZDF (73)
New Zealand Defence Force (73)
SVA (62)
liquefaction (52)
NZ Army (45)
RedZoneApp (36)
barbeque (27)
Operation Christchurch Quake (26)
University of Canterbury (20)
chemical toilets (20)
RNZAF (15)
cordon (15)
Big Top (14)
Royal New Zealand Air Force (12)
video/mp4 (4)
Army (x)
Photograph captioned by BeckerFraserPhotos, "One of the Army personnel who staff the cordon and check people and vehicles travelling in and out of the cordon standing in front of one of the cordon huts".
4:24am 23rd June 2012
army personnel, CBD, checkpoint, Colombo Street, cordon entry point, soldier
UC Civil and Natural Resources Engineering Photograph 201
A photograph of an army van outside the Christchurch Art Gallery on Montreal Street. The Art Gallery served as the headquarters for Civil Defence after the 22 February 2011 earthquake.
Christchurch Art Gallery, New Zealand Army, van, Civil Defence, Community
Elizabeth Ackermann Photograph 108
A photograph of a camouflaged army vehicle on a road near Hagley Park.
Elizabeth Ackermann
Hagley Park, NZ Army, New Zealand Army, camouflage, Community
Christchurch Press Infographic: 5 November 2012
A page banner promoting an article about The Concert.
The Concert, volunteer, Student Volunteer Army, Media, Communications and Journalism
Members of the Student Volunteer Army assembling wheelbarrows in the UCSA car park. The wheelbarrows will be used to clear liquefaction from Christchurch properties.
9:16pm 1st March 2011
University of Canterbury, SVA, Student Volunteer Army, liquefaction, Community
Labour Party leader Phil Goff speaking to members of the Student Volunteer Army as they assemble wheelbarrows in the USCA car park. The wheelbarrows will be used to clear liquefaction from Christchurch properties.
Phil Goff, SVA, Student Volunteer Army, UCSA, wheelbarrow, liquefaction, Community
Student Volunteer Army members from Riccarton High School on a break from clearing liquefaction from Christchurch properties.
12:19am 2nd March 2011
SVA, Student Volunteer Army, Riccarton High School, liquefaction, Community
Labour Party leader Phil Goff speaking to Student Volunteer Army organiser Sam Johnson in the UCSA car park at the University of Canterbury.
Former Labour Party leader, Phil Goff, talking to students assembling wheelbarrows for the Student Volunteer Army at the University of Canterbury. The wheelbarrows will be used to clear silt from Christchurch properties.
SVA, Student Volunteer Army, liquefaction, wheelbarrow, Community
Members of the Student Volunteer Army digging up liquefaction in from a resident's property. The liquefaction is being placed in wheelbarrows where it will be transported to the street and left in piles for the City Council to pick up.
Student Volunteer Army, SVA, wheelbarrows, Avonside, Community
Photograph captioned by Neil Macbeth, "Members of the Student Volunteer Army clearing liquefaction in earthquake-ravaged Avonside. The Student Volunteer Army are mostly University of Canterbury students who are helping to clean up the liquefaction from Christchurch properties.
SVA, Student Volunteer Army, liquefaction, wheelbarrow, shovel, Community
Labour Party leader Phil Goff speaking to members of the Student Volunteer Army in the UCSA car park outside the UCSA's "Big Top" tent. The tent was erected to provide support for students at the University of Canterbury in the aftermath of the 22 February 2011 earthquake. Behind them members of the Student Volunteer Army are assembling wheelbarrows which will be used to clear liquefaction from Christchurch properties.
Phil Goff, SVA, Student Volunteer Army, Big Top, UCSA, wheelbarrow, liquefaction, Community
Members of the Student Volunteer Army assembling wheelbarrows in the UCSA car park at the University of Canterbury. The wheelbarrows will be used by student volunteers to clear liquefaction from Christchurch properties. They have been spray painted with the Student Volunteer Army's so that they are not confused with those the students have brought themselves.
USCA, Student Volunteer Army, SVA, car park, wheelbarrow, liquefaction, spray-paint, Community
Wheelbarrows belonging to the Student Volunteer Army stacked up outside the UCSA's "Big Top". The tent was erected to provide support for students at the University of Canterbury in the aftermath of the 22 February 2011 earthquake.
USCA, Student Volunteer Army, SVA, car park, wheelbarrow, liquefaction, Big Top, Community
Members of the Student Volunteer Army leaving the UCSA car park on their way to clearing liquefaction from Christchurch properties.
USCA, Student Volunteer Army, SVA, car park, Community
New Zealand Defence Force photograph 622
Members of the New Zealand Army delivering chemical toilets to residents in an eastern suburb. The suburb has been without water and power for over ten days.
Judith Watts
12:05am 5th March 2011
Operation Christchurch Quake, NZDF, New Zealand Defence Force, chemical toilets, New Zealand Army, Government and Politics
Linda Cheung, a resident from one of Christchurch's eastern suburbs, collecting a chemical toilet from the Army. Linda's suburb has been without water and power for over ten days.

redpajama_set_name: RedPajamaCommonCrawl


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Board Votes to Change TAA Leadership; Promotes VP Bewley to Interim CEO
Share via Email: Board Votes to Change TAA Leadership; Promotes VP Bewley to Interim CEO Share via Twitter: Board Votes to Change TAA Leadership; Promotes VP Bewley to Interim CEO Share via Linkedin: Board Votes to Change TAA Leadership; Promotes VP Bewley to Interim CEO Share via Facebook: Board Votes to Change TAA Leadership; Promotes VP Bewley to Interim CEO
Danette Bewley
Danette Bewley was named Interim President and CEO of the Tucson Airport Authority Friday (July 19) during a special meeting of the authority's Board of Directors.
The appointment takes effect immediately. Bewley, who has been Vice President of Operations and Chief Operating Officer since May 2014, replaces Bonnie Allin who began with the Tucson Airport Authority 43 years ago in a career that took her to Texas and back to the TAA where she had been CEO the past 17 years.
"It has been my privilege to be a part of this extraordinary group of people who just this week celebrated our latest customer satisfaction survey results that showed an astonishingly high 99 percent in overall satisfaction," Allin said.
TAA Board Chair Lisa Lovallo also praised the work of the TAA team and said the board's action "is a change in leadership intended to further leverage the assets of both Tucson International and Ryan Airfield."
Bewley has 30 years of experience in all facets of commercial airport management. Before joining the TAA in 2012, Bewley held management positions with the Reno-Tahoe Airport Authority, the Jacksonville Aviation Authority and the Port of San Diego/San Diego County Regional Airport Authority.
She is an accredited airport executive (A.A.E.) through the American Association of Airport Executives and currently serves as the vice chair of association's Contract Tower Association and Commercial Space Working Group. Bewley also serves on several other committees and is a former AAAE Board member.
"The TAA has an outstanding team of aviation professionals and I am confident we will continue to maintain our airports' highest safety and operational standards and commitment to our passengers and customers," Bewley said.
The TAA will begin a national search before naming a permanent CEO.


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Canadian Journal of Emergency Medicine (20)
Canadian Association of Emergency Physicians (CAEP) (20)
LO03: Validation of The Ottawa Troponin Pathway
B. Lam, J. Li, M. Mukarram, M. Nemnom, R. Booth, V. Thiruganasambandamoorthy
Journal: Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
Published online by Cambridge University Press: 02 May 2019, p. S7
Introduction: Our team developed "The Ottawa Troponin Pathway" (OTP) for Non-ST Elevation Myocardial Infarction (NSTEMI) diagnosis using serial conventional troponin (cTnI) 3 hours apart to aid in safe and early disposition of ED patients. The primary objective of this study is to validate the diagnostic accuracy of the OTP in the cohort of patients with cTnI values above the 99th percentile ( > 45ng/L). Methods: This study is a health records review conducted at the Civic and General Campuses of The Ottawa Hospital from August 2017 to December 2017. Adults (≥18 years) who presented to the ED with symptoms of ACS, and who had serial cTnI (at least two values 3 hours ±15 minutes apart) performed for diagnosis of NSTEMI and at least one cTnI value > 45ng/L were included. Patients with cardiac arrest, STEMI, unstable angina or those with TnI values ≤45ng/L were excluded. The outcomes were death due to unknown cause or NSTEMI adjudicated by two blinded investigators within 30 days. Data collected include baseline characteristics, ED management, length of stay, cTnI values and times of measurement, disposition, and outcome. We used descriptive statistics and test diagnostic characteristics to analyze our data. Results: We screened 53,077 patients, of whom 635 patients were included in the study (mean age 71.6 years; 57.6% males; 59.7% hospitalized; median ED length of stay 4.7 hours.). 107 patients (16.9%; 95%CI 14.1%-20.0%) were diagnosed with NSTEMI within 30 days. Among patients with TNI values above the 99th percentile, the OTP did not miss any patients diagnosed with NSTEMI. The sensitivity and the specificity of the OTP were 100% (95%CI 96.6%-100%) and 32.2% (95%CI 28.2%-36.4%) respectively. Conclusion: Our results show that the OTP is diagnostically accurate in ruling out NSTEMI among patients with cTNI values above the 99th percentile with symptoms concerning for ACS. Using the OTP will allow for early referral to consulting services for management, safe and early discharge home, and improve ED crowding.
MP46: Creatine kinase in the emergency department: antiquated relic or useful adjunct in diagnosis of NSTEMI: A systematic review
D. Beamish, T. Maniuk, M. Mukarram, V. Thiruganasambandamoorthy
Published online by Cambridge University Press: 02 May 2019, p. S59
Introduction: The diagnosis of non-ST elevated myocardial infarction (NSTEMI) depends on a combination of history, ECG and cardiac biomarkers. Many hospitals continue to automatically order less sensitive and specific biomarkers such as Creatine Kinase (CK) alongside cardiac Troponin (cTn) as part of an extended panel of bloodwork for work-up of patients with suspected NSTEMI. Methods: We undertook a systematic review to assess the usefulness of CK measurements in addition to cTnI in NSTEMI diagnosis. Medline, EMBASE and Cochrane databases were searched from 1995 until May 31, 2018. We added additional articles after reviewing the reference list of pertinent articles and consulting experts. A total of 1123 papers were screened, of which 8 were included in the final analysis. These papers all compared CK and troponin (TnI) testing in the diagnosis of NSTEMI. Results: Of the 8 papers included in the analysis none showed CK having a greater sensitivity or specificity than the TnI assays. Furthermore, no paper originally published evidence of CK diagnosing NSTEMI when Troponin was negative. One author, when contacted, described 10% of patients diagnosed with NSTEMI as having discordant data (eg. +CK, -Troponin). However, the outcome data such as angiography and echocardiography were not available for these patients, making definitive diagnosis unclear. Conclusion: Troponin has consistently shown to have greater sensitivity and specificity than CK in the diagnosis of NSTEMI with CK adding no improvements in diagnosis. We believe CK should not be used in the emergency department work-up for NSTEMI diagnosis.
MP14: Use of conventional cardiac troponin assay for diagnosis of non-ST-elevation myocardial infarction: 'The Ottawa Troponin Pathway'
V. Thiruganasambandamoorthy, I. Stiell, H. Chaudry, M. Mukarram, R. Booth, C. Toarta, G. Hebert, R. Beanlands, G. Wells, M. Nemnom, M. Taljaard
Introduction: Guidelines recommend serial conventional cardiac troponin (cTn) measurements 6-9 hours apart for non-ST-elevation myocardial infarction (NSTEMI) diagnosis. We sought to develop a pathway based on absolute/relative changes between two serial conventional cardiac troponin I (cTnI) values 3-hours apart for 15-day MACE identification. Methods: This was a prospective cohort study conducted in the two large ED's at the Ottawa Hospital. Adults with NSTEMI symptoms were enrolled over 32 months. Patients with STEMI, hospitalized for unstable angina, or with only one cTnI were excluded. We collected baseline characteristics, Siemens Vista cTnI at 0 and 3-hours after ED presentation, disposition, and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (AMI, revascularization, or death due to cardiac ischemia/unknown cause). We analysed cTnI values by 99th percentile cut-off multiples (45, 100 and 250ng/L). Results: 1,683 patients (mean age 64.7 years; 55.3% female; median ED LOS 7 hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI ≤45ng/L; and 58 (3.4%) of the 213 patients with one value≥100ng/L but both <250ng/L or ≤20% change did not suffer MACE. Among 124 patients (7.4%) with one value >45ng/L but both <100ng/L based on 3 or 6-hour cTnI, one patient with Δ<10ng/L and 6 of 19 patients with Δ≥20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95%CI 96.7-100%) and 94.6% specificity (95%CI 93.4-95.7%). Conclusion: The OTP, using two conventional cTnI measurements performed 3-hours apart, should lead to better identification of NSTEMI particularly those with values >99th percentile cut-off, standardize management and reduce the ED LOS.
LO30: Prevalence of pulmonary embolism among emergency department patients with syncope: a multicenter prospective cohort study
V. Thiruganasambandamoorthy, M. L.A. Sivilotti, B. H. Rowe, A. D. McRae, M. Mukarram, A. Yagapen, M. Nemnom, B. Sun
Introduction: The prevalence of pulmonary embolism (PE) among patients with syncope is understudied. Based on a recent study with an exceptionally high PE prevalence, some advocate investigating all syncope patients for PE, including those with another clear cause for their syncope. We sought to evaluate the PE prevalence among emergency department (ED) patients with syncope. Methods: We combined data from two large prospective studies enrolling adults with syncope from 17 EDs in Canada and the United States. Each study collected the results of investigations related to PE (i.e. D-dimer or ventilation-perfusion (VQ) scan, or computed tomography pulmonary angiogram (CTPA)), and 30-day adjudicated outcomes including diagnosis of PE, arrhythmia, myocardial infarction, serious hemorrhage and/or death. Results: Of the 9,091 patients (median age 66 years, 51.9% females, 39.1% hospitalized) with 30-day follow-up, 546 (6.0%) were investigated for PE: 278 (3.1%) had D-dimer, 39 (0.4%) had VQ and 347 (3.8%) patients had CTPA performed. 30-day outcomes included: 874 (9.6%) patients with any serious outcome; 0.9% deaths; and 818 (9.0%) patients with non-PE serious outcomes. Overall, 56 patients (prevalence 0.6%; 95% CI 0.5% 0.8%) were diagnosed with PE, including 8 (0.1%) of those admitted to hospital at the index presentation. Only 11 patients (0.1%) with a non-PE serious condition had a concomitant underlying PE identified. Conclusion: The prevalence of PE is very low among ED patients with syncope, including those hospitalized following syncope. While acknowledging syncope may be caused by an underlying PE, clinicians should be cautious against indiscriminate over-investigations for PE.
LO55: Role of n-terminal pro brain natriuretic peptide (NT Pro-BNP) in emergency department syncope risk stratification: a multicenter study
V. Thiruganasambandamoorthy, M. L.A. Sivilotti, A. D. McRae, I. G. Stiell, M. Mukarram, L. Huang, K. Arcot, G. A. Wells, B. H. Rowe
Introduction: Two published studies reported natriuretic peptides can aid in risk-stratification of Emergency Department (ED) syncope. We sought to assess the role of N-Terminal pro Brain Natriuretic Peptide (NT pro-BNP) to identify syncope patients at risk for serious adverse events (SAE) within 30 days of the ED visit, and its value above that of the Canadian Syncope Risk Score (CSRS). Methods: We conducted a multicenter prospective cohort study at 6 large Canadian EDs from Nov 2011 to Feb 2015. We enrolled adults who presented within 24-hours of syncope and excluded those with persistent altered mentation, obvious seizure, and intoxication. We collected patient characteristics, nine CSRS predictors (includes troponin), ED management and NT pro-BNP levels. Adjudicated serious adverse events (SAE) included death, cardiac SAE (arrhythmias, myocardial infarction, serious structural heart disease) and non-cardiac SAE (pulmonary embolism, severe hemorrhage and procedural interventions within 30-days). We used two tailed t-test and logistic regression analysis. Results: Of the 1359 patients (mean age 57.2 years, 54.7% females, 13.3% hospitalized) enrolled, 148 patients (10.9%; 0.7% deaths, 7.9% cardiac SAE including 6.1% arrhythmia) suffered SAE within 30-days. The mean NT pro-BNP values, when compared to the patients with no SAE (499.8ng/L) was significantly higher among the 56 patients who suffered SAE after ED disposition (3147ng/L, p=0.001), and among the 35 patients with cardiac SAE after ED disposition (2016.2ng/L, p=0.02). While there was a trend to higher levels among patients who suffered arrhythmia after the ED visit, it was not statistically significant (1776.4ng/L, p=0.07). In a model with CSRS predictors, the adjusted odds ratio for NT pro-BNP was 8.0 (95%CI 1.8, 35.9) and troponin was 3.8 (95%CI 1.7, 8.8). The addition of NT pro-BNP did not significantly improve the classification performance (p=0.76) with areas under the curves for CSRS was 0.91 (95%CI 0.88, 0.95) and CSRS with NT pro-BNP was 0.92 (95%CI 0.88, 0.95). Conclusion: In this multicenter study, mean NT pro-BNP levels were significantly higher among ED syncope patients who suffered SAE including cardiac SAE after ED disposition. Though NT pro-BNP was a significant independent predictor of SAE after ED disposition, it did not improve accuracy in ED syncope risk-stratification when compared to CSRS. Hence, we do not recommend NT pro-BNP measurement for ED syncope management.
LO58: Long-term outcomes among emergency department syncope patients: a systematic review
C. Leafloor, P. Jiho Hong, L. Sikora, J. Elliot, M. Mukarram, V. Thiruganasambandamoorthy
Introduction: Approximately 50% of patients discharged from the Emergency Department (ED) after syncope have no cause found. Long-term outcomes among syncope patients are not well studied, to guide physicians regarding outpatient testing and follow-up. The objective of this study was to conduct a systematic review for long-term (one year) outcomes among ED patients with syncope. We aim to use the results of this review to guide us in prospective analysis of one year outcomes with our large database of syncope patients. Methods: We searched Cochrane Central Register of Controlled Trials, Medline and Medline in Process, PubMed, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from the inception to June, 2017. We included studies that reported long-term outcomes among adult ED patients (16 years or older) with syncope. We excluded studies on pediatric patients, and studies that included syncope mimickers: pre-syncope, seizure, intoxication, loss of consciousness after head trauma. We also excluded case reports, letters to the editor and review articles. Outcomes included death, syncope recurrence requiring hospitalization, arrhythmias and procedural interventions for arrhythmias. We selected articles based on title and abstract review during phase-1 and conducted full article review during phase-2. Meta-analysis was performed by pooling the outcomes using random effects model (RevMan v.5.3; Cochrane Collaboration). Results: Initial literature search generated 2094 articles after duplicate removal. 50 articles remained after phase-1 (=0.85) and 16 articles were included in the systematic review after phase-2 (=0.86). The 16 included studies enrolled a total of 44,755 patients. Pooled analysis at 1-year follow-up showed the following outcomes: 7% mortality; 14% recurrence of syncope requiring hospitalization; one study reported that 0.6% of patients had a pacemaker inserted; and two studies reported 0.8 11.5% of patients suffered new arrhythmias. Conclusion: An important proportion of ED patients with syncope suffer outcomes at 1-year. Appropriate follow-up is needed to prevent long-term adverse outcomes. Further prospective research to identify patients at risk for long-term important cardiac outcomes and death is needed.
LO54: Prospective mulitcenter validation of the Canadian syncope risk score
V. Thiruganasambandamoorthy, M. Mukarram, M. L.A. Sivilotti, J. Yan, N. Le Sage, P. Huang, I. G. Stiell, M. Nemnom, G. A. Wells, M. Taljaard
Introduction: The Canadian Syncope Risk Score (CSRS) was developed to identify patients at risk for serious adverse events (SAE) within 30 days of an Emergency Department (ED) visit for syncope. We sought to validate the score in a new cohort of ED patients. Methods: We conducted a multicenter prospective cohort study at 8 large academic tertiary-care EDs across Canada from March 2014 to Dec 2016. We enrolled adults (age 16 years) who presented within 24 hours of syncope, after excluding those with persistent altered mentation, witnessed seizure, intoxication, and major trauma requiring hospitalization. Treating ED physicians collected the nine CSRS predictors at the index visit. Adjudicated SAE included death, arrhythmias and non-arrhythmic SAE (myocardial infarction, serious structural heart disease, pulmonary embolism, severe hemorrhage and procedural interventions within 30-days). We assessed area under the Receiver Operating Characteristic (ROC) curve, score calibration, and the classification performance for the various risk categories. Results: Of the 2547 patients enrolled, 146 (5.7%) were lost to follow-up and 111 (4.3%) had serious condition during the index ED visit and were excluded. Among the 2290 analyzed, 79 patients (3.4%; 0.4% death, 1.4% arrhythmia) suffered 30-day serious outcomes after ED disposition. The accuracy of the CSRS remained high with area under the ROC curve at 0.87 (95%CI 0.82-0.92), similar to the derivation phase (0.87; 95%CI 0.84-0.89). The score showed excellent calibration at the prespecified risk strata. For the very-low risk category (0.3% SAE of which 0.2% were arrhythmia and no deaths) the sensitivity was 97.5% and negative predictive value was 99.7% (95%CI 98.7-99.9). For the very high-risk category (61.5% SAE of which 26.9% were arrhythmia and 11.5% death) the specificity was 99.4% and positive predictive value was 61.5% (95% CI 43.0-77.2). Conclusion: In this multicenter validation study, the CSRS accurately risk stratified ED patients with syncope for short-term serious outcomes after ED disposition. The score should aid in minimizing investigation and observation of very-low risk patients, and prioritization of inpatient vs outpatient investigations or following of the rest. The CSRS is ready for implementation studies examining ED management decisions, patient safety and health care resource utilization.
LO60: Diagnostic utility of creatine kinase in the diagnosis and management of non-ST elevation myocardial infarction
B. Lam, H. Chaudry, S. Kim, M. Nemnom, I. G. Stiell, G. Hebert, M. Taljaard, R. Beanlands, G. A. Wells, R. Booth, M. Mukarram, V. Thiruganasambandamoorthy
Introduction: Creatine kinase (CK) measurement, despite not being recommended for the diagnosis of a Non-ST Elevation Myocardial Infarction (NSTEMI) is still routinely performed in the emergency department (ED) for the workup of NSTEMI. The diagnostic utility of CK among ED patients with suspected NSTEMI is still not well understood. The objectives of this study were to assess: the additional value of CK in NSTEMI diagnosis and the correlation between the highest CK/TNI values and ejection fraction (EF) on follow-up echocardiography among patients with suspected NSTEMI. Methods: This was a prospective cohort study conducted at the Civic and General Campuses of The Ottawa Hospital from March 2014 to March 2016. We enrolled adults (18 years) for whom troponin (TNI) and CK were ordered for chest pain or non-chest pain symptoms within the past 24 hours concerning for NSTEMI and excluded those with suspected ST-Elevation Myocardial Infarction (STEMI). Primary outcome was a 30-day NSTEMI adjudicated by two blinded physicians. Demographics, medical history, and ED CK/TNI values were collected. We used descriptive statistics and report test diagnostic characteristics. Results: Of the 1,663 patients enrolled, 84 patients (5.1%) suffered NSTEMI. The sensitivity and specificity of CK was 30.9% (95%CI 21.1, 40.8) and 91.4% (95%CI 90.0, 92.8) respectively. The sensitivity and specificity of troponin was 96.4% (95%CI 92.4, 100) and 88.1% (95%CI 86.5, 89.7) respectively. Among 3 (0.2%) patients with missed NSTEMI diagnosis with TNI, CK measurements did not add value. The mean CK values were not significantly different between those with normal and abnormal EF on follow-up (132.4 U/L and 146.3 U/L respectively; p=0.44), whereas the mean TNI values were significantly different (0.5 µg/L and 1.3 µg/L respectively; p=0.046). Conclusion: CK measurements neither provide any additional value in the work-up of NSTEMI in the ED nor correlate with EF on follow-up. Discontinuing routine CK measurements would reduce overall costs and improve resource utilization in the ED, and streamline the management of patients in the ED with chest pain.
MP27: Costs of emergency syncope care in Canada
S. Kim, O. Cook, L. Yau, M.A. Mukarram, K. Arcot, A. Ishimwe, K. Thavorn, M. Taljaard, M. Sivilotti, B.H. Rowe, V. Thiruganasambandamoorthy
Introduction: Syncope is a common emergency department (ED) presentation and constitutes 1% of all ED visits, approximately 160,000 visits annually across Canada. Lack of standardized syncope care has economic and cost implications. Currently, emergency medical services (EMS) is over utilized, variations in ED management exist and a substantial proportion (46.5%) are hospitalized for cardiac monitoring. Our previous studies have proposed ways to reduce health care utilization through development of EMS clinical decision tool, ED risk scores and remote cardiac monitoring. We sought to: 1) Estimate costs associated with syncope care in the pre-hospital, ED and inpatient settings; and 2) Determine potential cost savings if the proposed alternate strategies were adopted. Methods: A prospective cohort study was conducted in five Canadian EDs from 2010-2014. We enrolled adult (≥16 years) syncope patients and excluded those with prolonged loss of consciousness, mental status changes, seizure, significant trauma, or alcohol/illicit drug abuse. Demographics, medical history, mode of arrival, EMS time points, reasons for hospitalization, ED and inpatient length of stay, final ED diagnosis and any serious adverse event within 30 days of index visit were collected. Descriptive and inferential statistics were used. Results: Out of 4,064 patients enrolled, 67.3% were transported to the ED by EMS and the average cost per event was $262.78 (range at study sites: $156.43-$553.03). The average cost per ED visit was $267.98 (range: $174.66-$374.95). 12.9% of the patients were admitted and the average of cost per admission was $9,886.15 (range: $9,715.23-$10,277.98). Syncope is associated with an estimated total annual cost of $257 million. In Canada, we estimate that diverting low-risk patients will save $5 million in the pre-hospital setting and $15 million in the ED annually, and implementing a remote cardiac monitoring strategy will save $50 million annually. Conclusion: It is estimated that the proposed strategies will save $70 million annually. This is likely an underestimation as cost savings due to reduction in investigations related to diversion of ED patients, reduction in ED length of stay and hospitalization are unaccounted. Adoption of similar strategies will likely lead to significantly higher cost savings in countries with higher resource utilization for syncope management.
LO31: Identification of high risk factors associated with 30 day serious adverse events among syncope patients transported to the emergency department by emergency medical services
L. Yau, M.A. Mukarram, S. Kim, K. Arcot, K. Thavorn, M. Taljaard, M. Sivilotti, B.H. Rowe, V. Thiruganasambandamoorthy
Introduction: The majority of syncope patients transported to the emergency department (ED) by emergency medical services (EMS) are low-risk with very few suffering serious adverse events (SAE) within 30-days and over 50% are diagnosed with vasovagal syncope. These patients can potentially be diverted by EMS to alternate pathways of care (primary care or syncope clinic) if appropriately identified. We sought to identify high-risk factors associated with SAE within 30-days of ED disposition as a step towards developing an EMS clinical decision tool. Methods: We prospectively enrolled adult syncope patients who were transported to 5 academic EDs by EMS. We collected standardized variables at EMS presentation from history, clinical examination and investigations including ECG and ED disposition. We also collected concerning symptoms identified and EMS interventions. Adjudicated SAE included death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, hemorrhage and procedural interventions. Multivariable logistic regression was used for analysis. Results: 990 adult syncope patients (mean age 58.9 years, 54.9% females and 16.8% hospitalized) were enrolled with 137 (14.6%) patients suffering SAE within 30-days of ED disposition. Of 42 candidate predictors, we identified 5 predictors that were significantly associated with SAE on multivariable analysis: ECG abnormalities [OR=1.77; 95%CI 1.36-2.48] (non-sinus rhythm, high degree atrioventricular block, left bundle branch block, ST-T wave changes or Q waves), cardiac history [OR=2.87; 95%CI 1.86-4.41] (valvular or coronary heart disease, cardiomyopathy, congestive heart failure, arrhythmias or device insertions), EMS interventions or concerning symptoms [OR=4.88; 95%CI 3.13- 7.62], age >50 years [OR=3.18; 95%CI 1.68-6.02], any abnormal vital signs [OR=1.58; 95%CI 1.03-2.42] (any EMS systolic blood pressure >180 or <100 mmHg, heart rate <50 or >100/minute, respiratory rate >25/minute, oxygen saturation <91%). [C-statistic: 0.81; Hosmer Lemeshow p=0.30]. Conclusion: We identified high-risk factors that are associated with 30-day SAE among syncope patients transported to the ED by EMS. This will aid in the development of a clinical decision tool to identify low-risk patients for diversion to alternate pathways of care.
LO98: Optimal length of observation for emergency department patients with syncope: a time to event analysis
V. Thiruganasambandamoorthy, M. Sivilotti, M.A. Mukarram, C. Leafloor, K. Arcot, G.A. Wells, B.H. Rowe, A. Krahn, L. Huang, M. Taljaard
Introduction: Concern for occult serious conditions leads to variations in ED syncope management [hospitalization, duration of ED/inpatient monitoring including Syncope Observation Units (SOU) for prolonged monitoring]. We sought to develop evidence-based recommendations for duration of ED/post-ED ECG monitoring using the Canadian Syncope Risk Score (CSRS) by assessing the time to serious adverse event (SAE) occurrence. Methods: We enrolled adults with syncope at 6 EDs and collected demographics, time of syncope and ED arrival, CSRS predictors and time of SAE. We stratified patients as per the CSRS (low, medium and high risk as ≤0, 1-3 and ≥4 respectively). 30-day adjudicated SAEs included death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism or serious hemorrhage. We categorized arrhythmias, interventions for arrhythmias and death from unknown cause as arrhythmic SAE and the rest as non-arrhythmic SAE. We performed Kaplan-Meier analysis using time of ED registration for primary and time of syncope for secondary analyses. Results: 5,372 patients (mean age 54.3 years, 54% females, and 13.7% hospitalized) were enrolled with 538 (10%) patients suffering SAE (0.3% died due to an unknown cause and 0.5% suffered ventricular arrhythmia). 64.8% of SAEs occurred within 6 hours of ED arrival. The probability for any SAE or arrhythmia was highest within 2-hours of ED arrival for low-risk patients (0.65% and 0.31%; dropped to 0.54% and 0.06% after 2-hours) and within 6-hours for the medium and high-risk patients (any SAE 6.9% and 17.4%; arrhythmia 6.5% and 18.9% respectively) which also dropped after 6-hours (any SAE 0.99% and 2.92%; arrhythmia 0.78% and 3.07% respectively). For any CSRS threshold, the risk of arrhythmia was highest within the first 15-days (for CSRS ≥2 patients 15.6% vs. 0.006%). ED monitoring for 2-hours (low-risk) and 6-hours (medium and high-risk) and using a CSRS ≥2 cut-off for outpatient 15-day ECG monitoring will lead to 52% increase in arrhythmia detection. The majority (82.2%) arrived to the ED within 2-hours (median time 1.1 hours) and secondary analysis yielded similar results. Conclusion: Our study found 2 and 6 hours of ED monitoring for low-risk and medium/high-risk CSRS patients respectively, with 15-day outpatient ECG monitoring for CSRS ≥2 patients will improve arrhythmia detection without the need for hospitalization or observation units.
LO06: Role of the age adjusted D-dimer in suspected deep venous thrombosis
P. Reardon, S. Patrick, M. Taljaard, K. Thavorn, M.A. Mukarram, S. Kim, G. Le Gal, V. Thiruganasambandamoorthy
Introduction: It is well established that a negative D-dimer will reliably rule out thromboembolism in selected low risk patients. Multiple modified D-dimer cutoffs have been suggested for older patients to improve diagnostic specificity. However, these approaches are better established for pulmonary embolism than for deep venous thrombosis (DVT). This study will evaluate the diagnostic performance of previously suggested D-dimer cutoffs for low risk DVT patients in the ED, and assess for a novel cutoff with improved performance. Methods: This health records review included patients >50 years with suspected DVT who were low-risk and had a D-dimer performed. Our analysis evaluated the diagnostic accuracy of D-dimer cutoffs of 500 and the age adjusted (age x 10) rule for patients >50 years; and 750, and 1,000 cutoffs for patients >60 years. 30-day outcome was a diagnosis of DVT. We also assessed the diagnostic accuracy for a novel cutoff (age x 12.5). Results: 1,000 patients (mean age 68 years; 59% female) were included. Of these, 110 patients (11%) were diagnosed with DVT. The conventional cutoff of <500 µg/L demonstrated a sensitivity of 99.1% (95% CI 95.0-99.9) and a specificity of 36.4% (95% CI 33.2-39.7). For patients >60 years, the absolute cutoffs of 750 and 1,000 showed sensitivity of 98.7% (95% CI, 92.9, 99.9), and the specificity increased to 48.6% (95% CI, 44.5-52.8%) and 62.1% (95% CI, 58.1-66.1%) respectively. For all study patients, age adjusted D-dimer demonstrated a sensitivity of 99.1% (95% CI 95.0-99.9) and a specificity of 51.2% (95% CI, 47.9-54.6). A novel age adjusted cutoff (age x 12.5) for patients >50, demonstrated a sensitivity of 97.3% (95% CI 92.2-99.4) and a specificity of 61.2% (95% CI 58.0-64.5). When compared to conventional cutoff, the age adjusted cutoffs (age x 10 and age x 12.5) would have resulted in an absolute decrease in further investigations of 13.1% and 22.2%, respectively, with false negative rates of 0.1% and 0.3%. Conclusion: Among older patients with suspected DVT and low clinical probability, the age adjusted D-dimer increases the proportion of patients among whom DVT can be ruled out. A novel cutoff (age x 12.5) demonstrated improved specificity. Future large scale prospective studies are needed to confirm this finding and to explore the cost savings of these approaches.
LO96: Syncope prognosis based on emergency department diagnosis: a prospective cohort study
C. Toarta, M.A. Mukarram, K. Arcot, S. Kim, S. Gaudet, M. Sivilotti, B.H. Rowe, V. Thiruganasambandamoorthy
Introduction: Relatively little is known about outcomes after disposition among syncope patients assigned various diagnostic categories during emergency department (ED) evaluation. We sought to measure the 30-day serious outcomes among 4 diagnostic groups (vasovagal, orthostatic hypotension, cardiac, other/unknown) within 30 days of the index ED visit. Methods: We prospectively enrolled adult syncope patients at six EDs and excluded patients with pre-syncope, persistent mental status changes, intoxication, seizure, and major trauma. Patient characteristics, ED management, diagnostic impression (vasovagal, orthostatic, cardiac, or other/unknown) at the end of the ED visit and physicians' confidence in assigning the etiology were collected. Serious outcomes at 30-days included: death, arrhythmia, myocardial infarction, structural heart disease, pulmonary embolism, and hemorrhage. Results: 5,010 patients (mean age 53.4 years; 54.8% females) were enrolled; 3.5% suffered serious outcomes: deaths (0.3%), arrhythmias (1.8%), non-arrhythmic cardiac (0.5%) and non-cardiac (0.9%). The cause of syncope was determined as vasovagal among 53.3% and cardiac in 5.4% of patients. The proportion of patients with ED investigations (p<0.001) and short-term serious outcomes increased (p<0.01) increased in each diagnostic category in the following order: vasovagal, orthostatic hypotension, other/unknown cause and cardiac. No deaths occurred in patients with vasovagal syncope. A higher proportion of all serious outcomes occurred among patients suspected of cardiac syncope in the ED (p<0.01). Confidence was highest among physicians for a vasovagal syncope diagnosis and lowest when the cause was other/unknown. Conclusion: Short-term serious outcomes strongly correlated with the etiology assigned in the ED visit. The physician's clinical judgment should be incorporated in risk-stratification for prognostication and safe management of ED syncope patients.
LO03: Application and usefulness of outpatient cardiac testing among emergency department patients with syncope
O. Cook, M.A. Mukarram, S. Kim, K. Arcot, M. Taljaard, M. Sivilotti, B.H. Rowe, V. Thiruganasambandamoorthy
Introduction: 2.6% of emergency department (ED) syncope patients will have underlying cardiac serious conditions (e.g. arrhythmia, serious structural heart disease) identified within 30-days of disposition. If those at risk are discharged home, outpatient cardiac testing can detect underlying arrhythmias and structural heart disease, and thereby improve patient safety. We describe the frequency of outpatient referrals for cardiac testing and the proportion of cardiac serious adverse events (SAE) among high risk and non-high (low and medium) risk ED syncope patients, as defined by the Canadian Syncope Risk Score (CSRS). Methods: We conducted a multicenter prospective cohort study to enroll adult syncope patients across five large tertiary care EDs. We collected demographics, medical history, disposition, CSRS value, outpatient referrals and testing results (holter, echocardiography), and cardiac SAE. Adjudicated 30-day SAE included death due to unknown cause, myocardial infarction, arrhythmia, and structural heart disease. We used descriptive analysis. Results: Of 4,064 enrolled patients, a total of 955 patients (23%) received an outpatient referral (mean age 57.7 years, 52.1% female). Of the 299 patients (7%) hospitalized, 154 received outpatient cardiac testing after discharge. Among the 3,765 patients discharged home from the ED, 40% of the non-high risk patients (305/756) and 56% of the high risk patients (25/45) received outpatient cardiac testing. Of all patients who received outpatient cardiac testing, 4 patients (0.8%) had serious cardiac conditions identified and all were arrhythmias. Among those with no cardiac testing, 5 patients (0.9%) suffered cardiac SAE (80% arrhythmias) outside the hospital. Of the 20 (44%) high risk patients who did not receive outpatient cardiac testing, 2 (10%) patients suffered arrhythmias outside the hospital. While among the 451 non-high risk patients, only 0.8% suffered arrhythmia outside the hospital. Conclusion: Outpatient cardiac testing among ED syncope patients is largely underutilized, especially among high risk patients. Better guidelines for outpatient cardiac testing are needed, as current practice is highly variable and mismatched with patient risk.
LO01: Prevalence of pulmonary embolism among Canadian emergency department patients with syncope: a multicenter prospective cohort study
V. Thiruganasambandamoorthy, M. Sivilotti, A. McRae, M.A. Mukarram, S. Kim, B.H. Rowe, L. Huang
Introduction: A recent cross-sectional study reported a 17.3% prevalence of pulmonary embolism (PE) among patients with syncope. However, the study had several flaws including spectrum and work-up bias with over-diagnosis due to excessive investigations. We sought to evaluate the prevalence of PE among Canadian emergency department (ED) patients presenting with syncope. Methods: We enrolled adults with syncope at 5 EDs and collected demographics, proportion of patients evaluated for suspected PE, their Wells PE score values and results of investigations [d-dimer, computed angiography (CT) of chest or ventilation-perfusion (VQ) scan]. 30-day adjudicated outcome included diagnosis of PE requiring treatment. We used descriptive statistics to report the results. Results: 4,739 patients [mean age 54.3 years, 54.4% females, and 587 (12.4%) hospitalized] were enrolled. 323 patients (6.8%) had further evaluation and investigations performed for suspected PE: 255 patients had D-dimer performed, 140 had CT chest and 17 had VQ performed. Of the 323 patients, 300 patients were low risk (Wells score ≤4) and 23 were high-risk (score >4). A total of 16 patients (0.3%) in the study cohort were diagnosed with PE: 10 patients were diagnosed in the ED, 5 patients were diagnosed while hospitalized as inpatient, and 1 patient was diagnosed on a return ED visit. Overall the prevalence of PE was 0.3% among all ED patients with syncope; and a 0.9% among those hospitalized for syncope. Conclusion: Our study shows that the prevalence of PE is very low among all patients presenting to the ED with syncope. The prevalence is also very low among those hospitalized for syncope than previously reported. While PE should be suspected and further investigations performed among syncope patients if clinically appropriate, caution should also be taken against indiscriminate over-investigations for PE.
MP23: The yield of computed tomography of the head in patients presenting with syncope: a systematic review
J.A. Viau, H. Chaudry, A. Hannigan, M. Boutet, M.A. Mukarram, V. Thiruganasambandamoorthy
Published online by Cambridge University Press: 15 May 2017, pp. S72-S73
Introduction: Syncope accounts for 1-3% of Emergency Department (ED) visits. Previous studies have reported overuse of computed tomography (CT) of the head among syncope patients. Professional organizations including Choosing Wisely have recommended against its use in the absence of high-risk features. However, a review of CT head use among syncope patients and its diagnostic yield has not been previously reported. Methods: We conducted a systematic review using EMBASE, Medline, and Cochrane databases from inception to August 2016. We included studies involving adult syncope patients that reported CT head use and its diagnostic yield during acute management by a two-step process: first title/abstract review and then full-text review of selected articles. We excluded case reports, narrative reviews and those involving children. We collected the proportion of patients who had CT head performed, and its diagnostic yield. Outcomes included identification of acute intracranial conditions (hemorrhage, mass or infarct) that require further management. Two reviewers independently abstracted the data and discrepancies were resolved by consensus. We calculated inter-observer reliability for inclusion in the systematic review using kappa values. We performed meta-analysis for diagnostic yield of the CT head. Results: Fifteen studies with 2,802 syncope patients in four sub-groups (proportion of patients among whom CT head was performed and its yield in ED and inpatient settings; studies that reported only the yield among those with CT head performed; and the use and yield among syncope patients ≥65 years old) were included. The inter-observer agreement for inclusion of final articles for meta-analysis was κ=0.925 [95% CI: 0.861-0.990]. Seven ED studies (n=1,261) reported 55.7% patients (95% CI: 32.1-78.0%) had head CT performed with a yield of 4.0% (95% CI: 2.7-5.6%); 5 studies with 1138 hospitalized patients reported that 38.6% (95% CI: 20.4-58.6%) had head CT with a yield of 1.1% (95% CI: 0.4-2.2%). The yield among studies that report only outcomes for CT head was 2.3% and the yield among patients' ≥65 years was 7.7%. Conclusion: Our review found that a very high proportion of syncope patients had CT head performed during acute management with a very low diagnostic yield. The yield is higher among patients ≥65 years old. A robust tool to identify patients who require a CT head will reduce unnecessary testing.
LO083: Outcomes and resource utilization among syncope patients transported by emergency medical services
Published online by Cambridge University Press: 02 June 2016, pp. S58-S59
Introduction: Syncope accounts for 1% of all annual emergency department (ED) visits in Canada with only 10.3% suffering serious adverse event (SAE) within 30-days. However, 66% are transported to ED by Emergency Medical Services (EMS). Our objectives were to assess 30 day SAE among syncope patients transported by Emergency medical services (EMS), assess the need to develop an EMS clinical decision aid, and estimate anticipated health care savings by diverting patients from the ED to alternative care pathways. Methods: We conducted a prospective cohort study at four tertiary care EDs from Feb 2012 to Feb 2013. We included patients ≥16 years of age with syncope and who arrived to the ED via EMS. We collected patient demographics, medical history, 30 day SAE, EMS time points (call received, EMS arrival on scene, EMS departure from scene, time of transfer of care in the ED), critical EMS interventions, and ED length of stay. We assessed for the occurrence of any SAE (death, arrhythmia, other cardiac and non-cardiac conditions) within 30 days of ED disposition. We used descriptive analysis, unpaired two-tailed t-test and chi-square test. Ethics approval was obtained at all study sites. Results: Of 1,475 ED patients with syncope during the study period, 992 (67.3%) arrived by EMS. Mean times (SD) for EMS arrival to the scene, patient assessment at the scene and transfer of patient from scene to the ED were 10.1 (6.4), 18.9 (8.3), and 14.6 (11.5) minutes respectively. Only two patients had critical interventions enroute (pacing and defibrillation). Overall 138 (13.9%) patients suffered a SAE; 32 (3.2%) detected by EMS, 58 (5.8%) detected during ED evaluation, 48 (4.8%) after ED disposition. The average ED length of stay was 5.9(4.2) hours. Based on average of cost from two sites, we estimated that total cost of transporting syncope patients from the scene to the ED to be $4 million in Canada. The total cost of ED care for syncope patients transported by EMS in Canada was calculated at $21.5 million. Conclusion: A substantial proportion of patients arriving to the ED via EMS suffer no SAE within 30 days. Correspondingly, our results suggest a need for an EMS clinical decision aid to divert low-risk syncope patients to alternative care pathways such as family physicians or rapid access clinics. If developed and implemented, this tool can potentially reduce EMS burden, ED crowding, and reduce healthcare costs.
LO101: Predicting short-term risk of arrhythmia among patients with syncope: the Canadian Syncope Arrhythmia Risk Score
V. Thiruganasambandamoorthy, M.A. Mukarram, K. Arcot, K. Kwong, M. Sivilotti, B.H. Rowe, A. McRae, I.G. Stiell, M. Taljaard, G.A. Wells
Published online by Cambridge University Press: 02 June 2016, p. S65
Introduction: Suspicion of arrhythmias among syncope patients is the leading cause of emergency department (ED) referrals and hospitalization. However, the risk factors for short-term arrhythmias are not well defined. We sought to develop a risk prediction tool to identify syncope patients at risk for 30-day arrhythmia or death after ED disposition. Methods: This prospective cohort study involved 6 academic EDs that enrolled adult syncope patients. We collected standardized variables at index presentation from history, clinical examination, investigations including ECG, and patients' disposition. Adjudicated outcomes included death (due to arrhythmia or unknown cause), arrhythmia or procedural intervention to treat arrhythmias within 30-days after ED disposition. Multivariable logistic regression was used to derive the model; bootstrap sampling for internal validation and to estimate shrinkage and optimism. Results: 5,010 adult syncope patients (mean age 53.4 years, 54.8% females, and 9.5% hospitalized) were enrolled with 106 (3.6%) patients suffering arrhythmia or death within 30-days after ED disposition. Of 39 candidate predictors examined, eight were included in the final model: vasovagal predisposition, heart disease, any ED systolic blood pressure <90 or >180 mmHg, troponin (>99%ile), QRS duration >130msec, QTc interval >480msec and ED diagnosis of cardiac, or vasovagal syncope [Optimism corrected c-statistic: 0.91 (95%CI 0.87-0.93); Hosmer-Lemeshow p=0.08]. The Canadian Syncope Arrhythmia Risk Score had a risk ranging from 0.2% for a score of -2 to 74.5% for a score of 8. Sensitivity for threshold score ≤-1 was 100% (95% CI 96.5-100) and specificity for a score of ≥4 was 97.0% (95% CI 96.5-97.5). Conclusion: The Canadian Syncope Arrhythmia Risk Score can improve acute management of ED patients with syncope by better identification of those at higher-risk for short-term arrhythmia or death. Once validated, the tool can be used to guide disposition decision and can also aid in selection of patients for out-of-hospital cardiac monitoring if discharged home.
MP023: Reasons for referral and hospitalization among emergency department patients with syncope
O. Cook, M.A. Mukarram, M. Rahman, S. Kim, K. Arcot, K. Thavorn, M. Taljaard, M. Sivilotti, B.H. Rowe, V. Thiruganasambandamoorthy
Introduction: Syncope can be caused by serious life-threatening conditions not obvious during the initial ED assessment leading to wide variations in management. We aimed to identify the reasons for consultations and hospitalizations, outcomes, and the potential cost savings if an outpatient cardiac monitoring strategy were developed. Methods: We conducted a prospective cohort study of adult syncope patients at 5 academic EDs over 41 months. We collected baseline characteristics, reasons for consultation and hospitalization, hospital length of stay and average total inpatient cost. Adjudicated 30-day serious adverse events (SAEs) included death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage and procedural intervention. We used descriptive statistics with 95% CI. Results: Of the 4,064 patients enrolled (mean age 53.1 years, 55.9% female), 3,255 (80.1%) were discharged from the ED, 209 (5.2%) had a SAE identified in the ED, 600 (14.8%) with no SAE were referred for consultation in the ED and 299 (7.4%) were hospitalized: 55.5% of referrals and 55.2% of hospitalizations were for suspected cardiac syncope (46.5% admitted for cardiac monitoring of whom 71.2% had no cause identified). SAE among groups were 9.7% in total; 2.5% discharged by ED physician; 3.4% discharged by consultant from ED; 21.7% as inpatient and 4.8% following discharge from hospital. The mean hospital length of stay for cardiac syncope was 6.7 (95%CI 5.8, 7.7) days with total estimated costs of $7,925 per patient (95% CI: 7434, 8417). Conclusion: Suspected cardiac syncope, particularly arrhythmia, was the major reason for ED referral and hospitalization. The majority of patients hospitalized for cardiac monitoring had no identified cause. An important number of patients suffered SAE, particularly arrhythmias outside the hospital. These findings highlight the need to develop a robust syncope prediction tool and a remote cardiac monitoring strategy to improve patient safety while saving substantial health care resources.
LO004: Short-term risk of arrhythmias among syncope patients presenting with atrial fibrillation/flutter to Canadian emergency departments
C. Toarta, K. Kwong, I.G. Stiell, M.A. Mukarram, M. Taljaard, R. Sheldon, G.A. Wells, V. Thiruganasambandamoorthy
Introduction: Short-term risk of arrhythmia or death among emergency department (ED) syncope patients with atrial fibrillation/flutter (AFF) has not been reported in the literature. Our objectives were to assess the incidence and the independent risk of 30-day arrhythmia or death for syncope patients with AFF after ED disposition. Methods: We conducted a prospective study at 6 Canadian academic EDs to include adults with syncope. We collected demographic, clinical and ECG characteristics while our outcome assessments were completed by medical records review and by telephone follow-up of patients after 30 days. Primary outcome was arrhythmia or death within 30-days after ED disposition and secondary outcomes included non-arrhythmic cardiac and non-cardiac outcomes. We performed descriptive and logistic regression analyses. Results: We enrolled 4,266 patients: mean age 53.4 years, 55.4% females, and 8.5% with AFF. After excluding those with outcomes in the ED, lost to follow-up and those with other non-sinus rhythms, 3,417 patients in the sinus and 280 patients in the AFF groups were analyzed. The incidence of arrhythmia or death was significantly higher in the AFF group (Relative Risk 5.1; 95% CI 3.1-8.4; p<0.0001) but there were no significant differences in secondary outcomes between the groups. The unadjusted odds ratio for 30-days arrhythmia or deaths among ED syncope patients with AFF was 5.4 (95% CI 3.2- 9.2). After adjusting for important baseline risk factors by multivariable analysis, the odds ratio for arrhythmia or death in patients with AFF was 1.5 (95% CI 0.8-2.7). Conclusion: The risk of AFF for 30-day arrhythmia or death among syncope patients after ED disposition is higher but is attenuated when adjusted for important patient characteristics. Future research should assess long-term outcomes among syncope patients with AFF to guide follow-up after ED discharge.


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About Jose Feliciano
It is synonymous with an international presence that has influenced popular music for more than two generations. It is synonymous with a presence that has bridged musical styles in a way that has never been equaled. Jose Feliciano is recognized as the first Latin Artist to cross over into the English music market, opening the doors to others who now play an important part in the American music industry.
As importantly, Feliciano has been acclaimed by critics throughout the world as "The greatest living guitarist". Referred to as "The Picasso of his Realm," Jose Feliciano's accolades are repeatedly celebrated. Guitar Player Magazine awarded him "Best Pop Guitarist," placing him in their "Gallery of the Greats," and he's been voted both Best Jazz and Best Rock Guitarist in the Playboy Magazine reader's poll, as well. He's been awarded over forty-five Gold and Platinum records; has won sixteen Grammy nominations, earning him eight Grammy Awards and is in receipt of countless prestigious awards the world over.
In 1996, Jose Feliciano was selected to receive Billboard Magazine's Lifetime Achievement Award and New York City honored him by re-naming Public School 155 in East Harlem, "The Jose Feliciano Performing Arts School." And In 2001, Jose received a Doctor of Humane Letters degree from Sacred Heart University in Fairfield, Connecticut, for his musical, as well as humanitarian, contributions to the world.
Being constantly in demand, Jose has performed for and with some of the most important people on Earth. He enjoys playing with many of the top symphonic orchestras including the London Symphony, the Los Angeles Philharmonic and the Vienna Symphony Orchestra. He's appeared on major television shows worldwide; he has done a number of his own specials and his music has been featured on television, in films and on the stage.
Jose was born blind, to humble beginnings on September 10, 1945, in Lares, Puerto Rico. One of eleven boys, his love affair with music began at the age of three when he first accompanied his uncle on a tin cracker can. When he was five, his family immigrated to New York City. Young Jose learned to play the concertina at age six, using a handful of records as his teacher. At eight, he performed for his classmates at PS 57, and at nine, performed at The Puerto Rican Theater in the Bronx. Venturing beyond the accordion, he taught himself to play the guitar with undaunted determination and again, with nothing but records as his teacher, practicing for as many as 14 hours a day. Exposed to the rock-n-roll of the 50′s, Jose was then inspired to sing.
At 17, Jose quit school. His father was not working at the time and he needed to help his family. He played in coffee houses in Greenwich Village and for his salary — as was customary during that time period in small clubs — they'd "pass the hat". He played his first professional engagement that same year in Detroit, Michigan. Shortly thereafter, a music critic writing of his performance at Gerde's Folk City, referred to him as a "10-fingered wizard who romps, runs, rolls, picks and reverberates his six strings in an incomparable fashion." And added, "If you want to witness the birth of a star, catch Mr. Feliciano before he leaves tomorrow night."
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La Sirena Y Orquestra Mar De Ashe
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Miklavec – wieś w Chorwacji, w żupanii medzimurskiej, w gminie Podturen. W 2011 roku liczyła 474 mieszkańców.

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