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Yoo N, Song YB, Dubinsky I, Altshuler J. Single Dose of Sodium Zirconium Cyclosilicate Versus Sodium Polystyrene Sulfonate in Hospitalized Patients With Hyperkalemia. Ann Pharmacother 2023; 57:1044-1052. [PMID: 36637028 DOI: 10.1177/10600280221141918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Sodium zirconium cyclosilicate (SZC) is an inorganic zirconium silicate compound that selectively exchanges potassium for hydrogen and sodium. "Once" doses of SZC (with option to redose) in patients with hyperkalemia in hospitalized settings have not been evaluated. We hypothesized that a once dose of SZC would be non-inferior to sodium polystyrene sulfonate (SPS) in reducing serum potassium. OBJECTIVE The objective of our study is to evaluate the effect of a "once" dose of SZC when compared with SPS in reducing serum potassium levels. METHODS This was a retrospective analysis of patients who received either a "once" dose of SZC or single or repeated doses of SPS for hyperkalemia. The primary endpoint was mean absolute reduction in the first serum potassium value at least 4 hours after administration. The secondary efficacy endpoints were the rate of additional potassium-lowering therapies and the rate of normokalemia within 48 hours. Safety endpoints were the incidence of electrolyte abnormalities, hypoglycemia, hypertension, hypotension, and colonic necrosis. RESULTS A total of 260 patients were included in the analysis. The mean initial serum potassium was similar between groups (5.6 ± 0.4). The absolute serum potassium reduction was -0.88 ± 0.64 mEq/L and -0.75 ± 0.65 mEq/L with SZC and SPS, respectively. The "once" regimen of SZC demonstrated non-inferiority compared with SPS (P < 0.0001). The proportion of patients achieving normokalemia within 48 hours and the proportion of patients receiving additional potassium-lowering therapies did not differ between groups. CONCLUSION AND RELEVANCE The "once" dose regimen (with redose option) of SZC was non-inferior to the "once" or repeated dosing regimen of SPS with regard to absolute potassium reduction. There were no significant differences in the rate of additional potassium-lowering therapies and the rate of normokalemia at 48 hours. The incidence of hypertension was less common among patients who received SZC.
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Affiliation(s)
- Noah Yoo
- JFK University Medical Center, Hackensack Meridian Health, Edison, NJ, USA
| | - Yong-Bum Song
- JFK University Medical Center, Hackensack Meridian Health, Edison, NJ, USA
| | - Ilya Dubinsky
- JFK University Medical Center, Hackensack Meridian Health, Edison, NJ, USA
| | - Jerry Altshuler
- JFK University Medical Center, Hackensack Meridian Health, Edison, NJ, USA
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Fourcand F, Sahito S, Ali C, Marandi E, Haimi J, Dubinsky I, Song YB, Mehta S, Tabibzadeh N, Gadallah NE, Panezai S, Kirmani JF. Abstract TP3: Network-wide Incidence Of Intracranial Hemorrhage In Patients With Acute Ischemic Stroke Receiving Tenecteplase. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Intravenous tenecteplase (TNK) is currently being used as a thrombolytic agent in acute ischemic stroke (AIS) and has has been shown to be non-inferior to intravenous alteplase according to recent studies. Intracranial hemorrhage (ICH) as a complication of alteplase is approximately at 6%. The aim of our study was to determine the rate of significant ICH in patients receiving TNK indicated for AIS in a real world setting.
Methods:
A network-wide (3 CSCs, 6 PSCs), multicenter retrospective chart review of patients receiving TNK from February 2020 to January 2022 was performed using the Get With The Guidelines database. TNK bolus dose of 0.25mg/kg was used according to a network-wide policy. ICH was categorized using ECASS-3 criteria. Fisher exact test statistic was used to determine if a significant association existed between the presence of ICH and baseline ASPECTS score, endovascular treatment (EVT), and IV eptifibatide use. A benchmark less than 2% PH-2 incidence was set based on historical alteplase related PH-2 rates within our network. Social science statistics software was used for data analysis.
Results:
Out of 180 patients who received TNK, 25 subjects (13.89%) developed hemorrhagic transformation. Mean age was 71.88 (95% CI 65.54, 78.22). Forty-eight percent of subjects were female. Median ASPECTS score was 8 (95% CI 7.54, 8.78). Median 90 day mRS was 3 (95% CI 2.1, 3.9). Hemorrhagic transformation was classified as HI-1 in 5% (n=9), HI-2 in 1.7% (n=3), PH-1 in 3.8% (n=7), and PH-2 in 3.3% (n=6) subjects. No significant difference between subjects with other subtypes versus PH-2 was identified when adjusting for ASPECTS score >=7 versus <7 (Fisher value=1), EVT versus no EVT (Fisher value=0.65), or use of IV eptifibatide (Fisher value=0.06).
Conclusion:
Tenecteplase is associated with higher rates of PH-2 intracranial hemorrhage when compared with our benchmark rates of alteplase-related PH-2. This study is significantly limited by small sample size, retrospective nature, and uncontrolled variables. Larger, prospective studies are needed to validate our results.
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Panezai S, Dubinsky I, Sahito S, Gadallah N, Suhan L, Mehta S, Kirmani J. Early Experience With Tenecteplase at a Comprehensive Stroke Center. Neurol Clin Pract 2021; 11:e885-e889. [PMID: 34987884 PMCID: PMC8723952 DOI: 10.1212/cpj.0000000000001096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/28/2021] [Indexed: 11/20/2022]
Abstract
Purpose of Review Tenecteplase has been studied and recommended as an alternative thrombolytic agent in patients with acute stroke. A brief review of clinical trials and guidelines pertinent to our clinical decision algorithm is described. This is followed by operational steps that were made to create and implement a clinical pathway based on available evidence in which tenecteplase is used in select patients with stroke at our comprehensive stroke center. Recent Findings A number of patients have been treated at our center with IV tenecteplase. A case is presented to illustrate the successful implementation of this new process. Summary Development of our protocol is discussed in detail to enable other centers to create their own clinical pathways for thrombolytic treatment of acute ischemic stroke using tenecteplase.
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Affiliation(s)
- Spozhmy Panezai
- HMH JFK University Medical Center (SP, SS, NG, LS, SM, JK), Neuroscience Institute, Edison, NJ; and Emergency Department (ID), HMH JFKUMC, Edison, NJ
| | - Ilya Dubinsky
- HMH JFK University Medical Center (SP, SS, NG, LS, SM, JK), Neuroscience Institute, Edison, NJ; and Emergency Department (ID), HMH JFKUMC, Edison, NJ
| | - Sindhu Sahito
- HMH JFK University Medical Center (SP, SS, NG, LS, SM, JK), Neuroscience Institute, Edison, NJ; and Emergency Department (ID), HMH JFKUMC, Edison, NJ
| | - Nancy Gadallah
- HMH JFK University Medical Center (SP, SS, NG, LS, SM, JK), Neuroscience Institute, Edison, NJ; and Emergency Department (ID), HMH JFKUMC, Edison, NJ
| | - Laura Suhan
- HMH JFK University Medical Center (SP, SS, NG, LS, SM, JK), Neuroscience Institute, Edison, NJ; and Emergency Department (ID), HMH JFKUMC, Edison, NJ
| | - Siddhart Mehta
- HMH JFK University Medical Center (SP, SS, NG, LS, SM, JK), Neuroscience Institute, Edison, NJ; and Emergency Department (ID), HMH JFKUMC, Edison, NJ
| | - Jawad Kirmani
- HMH JFK University Medical Center (SP, SS, NG, LS, SM, JK), Neuroscience Institute, Edison, NJ; and Emergency Department (ID), HMH JFKUMC, Edison, NJ
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Abstract
On June 10 to 11 this year, the Residents’ Section of the Canadian Association of Emergency Physicians (CAEP-RS) held its first official national forum for future emergency physicians — the First Canadian EM Residents Workshop, in conjunction with CAEP 2000. To celebrate the event, the RS decided to invite a nationally recognized emergency medicine leader, advocate, and teacher to be the first to address the Annual Residents’ Dinner. We were grateful for the privilege of having Dr. Isser Dubinsky be that person. Dr. Dubinsky, currently Chief of Emergency Services at the University Health Network in Toronto, was asked to speak about “The Future of Emergency Medicine.” Dr. Dubinsky's speech, filled with warmth, wisdom, and humanity, is transcribed below. — Jason Frank, MD, Chair CAEP-RS
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Affiliation(s)
- I Dubinsky
- Department of Emergency Services, University Health Network, Toronto, Ontario, Canada
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Abstract
Many residents of long-term care (LTC) facilities are transferred to Emergency Departments without advance directives (AD). The goal of this study was to describe an ideal model for the transfer of AD from LTC facilities to Emergency Departments. Health care providers were asked to describe their ideal model for the completion and transfer of the ADs of LTC residents. A grounded theory methodology was used to identify significant themes. The model we present as a result of this analysis acknowledges the importance of simplifying and standardizing ADs, but focuses more attention on the process of completing and transferring the AD. A key feature of this model is an emphasis on the education of LTC residents and their relatives about ADs and advance-care planning. This education should involve a variety of resources used in creative ways; it should begin as soon as LTC placement is being considered, and the emphasis should be on providing information and discussing options rather than pressuring residents to make a decision.
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Affiliation(s)
- M A Pauls
- Department of Emergency Medicine, Queen Elizabeth II Health Science Centre and Department of Emergency Medicine, Dalhousie University, 1796 Summer Street, Halifax, Nova Scotia, Canada B3H 3A7
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Abstract
The assessment and management of acute pain is an essential part of care received in the emergency department (ED). This study was undertaken to measure how ED caregivers interpret and treat acute pain. A convenience cohort of 71 patients in a tertiary care teaching hospital were asked to rate their pain on arrival to the ED using a visual analog scale (VAS) and numerical rating scale (NRS). These ratings were compared with those given by their nurse and physician. Both physicians and nurses gave statistically significantly lower NRS and VAS pain ratings than those reported by the patients. Nurses' NRS pain ratings were found to be lower than physicians' ratings of the same patients. On chart review, no pain scale assessments were employed, and only one chart noted that a patient's pain had been relieved after treatment. Approximately half the patients (49%, n = 35) felt on discharge from the ED that their pain had not been relieved. Pain assessment and treatment in the ED appears to be inadequate. The integration of pain assessment before and after treatment is essential in monitoring the effectiveness of pain management in the ED.
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Affiliation(s)
- V Guru
- Department of Emergency Medicine, The Toronto Hospital, Faculty of Medicine, University of Toronto, Ontario, Canada
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Mah G, Wong K, Dubinsky I. Is a rapid bedside troponin T assay predictive of outcomes in unstable angina? Am J Emerg Med 1999; 17:740-1. [PMID: 10597107 DOI: 10.1016/s0735-6757(99)90177-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Pauls MA, Singer PA, Dubinsky I. Developing a new model for transmitting advance directives from long-term care facilities to emergency departments. Ann Emerg Med 1999. [DOI: 10.1016/s0196-0644(99)80503-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Shirley L, Dubinsky I. Is spiral computed tomography the diagnostic imaging of choice for patients with renal colic? Ann Emerg Med 1999. [DOI: 10.1016/s0196-0644(99)80375-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lee S, Dubinsky I. Can patients with renal colic be safely discharged from the emergency department without an imaging procedure? Ann Emerg Med 1999. [DOI: 10.1016/s0196-0644(99)80352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Ovarian Hyperstimulation Syndrome (OHSS) is a serious disorder complicating the use of ovary-stimulating drugs in assisted reproduction programs. While its pathogenesis is not fully understood, it is believed that human chorionic gonadotropin (hCG) stimulation is vital to the development of OHSS. Further evidence suggests that the renin-angiotensin pathway, vascular endothelial growth factor, endothelin-1, and cytokines all play a role in altering ovarian capillary permeability, leading to increased interstitial fluid. OHSS can produce a myriad of symptoms and signs involving numerous body systems, up to and including hypovolemic shock and acute renal failure. As growing numbers of women opt for assisted reproduction, it becomes increasingly important for emergency physicians to be able to recognize this condition. Clinical classification into mild, moderate, severe, and critical forms of OHSS can help the physician plan appropriate investigations, admission requirements, and acute management. Two cases of OHSS, representing the spectrum of this problem, are presented along with a review of the literature.
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Affiliation(s)
- A Rutkowski
- University of Sydney Medical School, Australia
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Boushy D, Dubinsky I. Primary care physician and patient factors that result in patients seeking emergency care in a hospital setting: the patient's perspective. J Emerg Med 1999; 17:405-12. [PMID: 10338229 DOI: 10.1016/s0736-4679(99)00015-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Much has been written about "abuse" and "overutilization" of Emergency Departments (EDs). We undertook to study, from the patient's perspective, physician and patient factors that influence the patient's decision to seek ED care. The study was designed as a convenience cohort, multi-centre survey, conducted in 13 hospitals in the Greater Toronto Area. In our study group of 948, most ambulatory patients (93%) seeking care in an ED have a primary care physician. From the patient's perspective, most (76%) primary care physicians are not educating their patients about which situations warrant ED care and up to 54% are not informing their patients about which services are offered in the office. As many as 55% of patients presented to the ED because it was more convenient. Only a minority (23%) of patients felt their acuity of illness warranted an ED visit. Primary care physicians need to play a stronger role in educating their patients about the utilization of emergency care and the services offered in the office setting.
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Affiliation(s)
- D Boushy
- Department of Emergency Medicine, Toronto Hospital, University of Toronto, Ontario, Canada
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Abstract
OBJECTIVE To determine whether the provision of advanced life support (ALS) field care has any impact on patient outcome in the urban Canadian environment. METHODS A convenience cohort study was conducted of all emergent ambulance transfers of adults to an urban Canadian hospital from May 22 to July 31, 1996. Data were collected from ambulance call reports regarding presenting complaint and field interventions applied, and from hospital records regarding time in the ED, hospital length of stay (LOS), and discharge disposition. Patient outcomes were compared within 7 presenting complaint groups (chest pain, altered level of consciousness, shortness of breath, abdominal pain, motor vehicle crash, falls, and other) by field care level: level 1--BLS (basic life support) vs levels 2 and 3--ALS. RESULTS The study population consisted of 1,397 patients. No significant differences were seen between BLS and ALS patients on baseline demographics. ED triage score did not depend on field care level for any group, implying that those in the ALS group were not inherently sicker. Outcome measures (ED LOS, admission rates, and hospital LOS) showed no significant differences between BLS and ALS for each presenting complaint group. Discharge dispositions were analyzed by chi2 but were not varied enough to allow reliable analysis. Observation of trends suggested no difference between BLS and ALS. CONCLUSIONS There was no beneficial impact on the measured patient outcomes found in association with the provision of ALS vs BLS field care in Metropolitan Toronto for patients who were brought to a nontrauma center.
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Affiliation(s)
- J S Eisen
- Queen's University Faculty of Medicine, Kingston, Ontario, Canada
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Dubinsky I, McGowan H. Case report: retinal tear as a consequence of air bag inflation. Can Fam Physician 1997; 43:1576-7. [PMID: 9303236 PMCID: PMC2255344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- I Dubinsky
- Department of Emergency Medicine, Toronto Hospital
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Abstract
Non-life-threatening blunt chest trauma is a commonly occurring phenomenon. No clear guidelines exist in the literature regarding the appropriate investigation and treatment, and most clinicians' practice patterns are based on anecdote, individual experience, and the theoretical risk of complications. A prospective study was undertaken of all patients with non-life-threatening blunt chest trauma presenting to a high-volume, community-based teaching hospital emergency department. No clinical features were found to have a high enough positive predictive value for rib fracture or any other injury to warrant their use as a screening tool for further investigations. No significant lung injury was detected in the study cohort of patients, on either an immediate or delayed basis. In the absence of compelling evidence of an underlying lung injury, the performance of chest or rib radiography is of no benefit, and considerable cost savings can potentially be realized.
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Affiliation(s)
- I Dubinsky
- Department of Emergency Medicine, North York General Hospital, Willowdale, Ontario, Canada
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Dubinsky I, Chang D. Acute myocardial infarction management flowsheet and performance. Acad Emerg Med 1996; 3:1073-5. [PMID: 8922021 DOI: 10.1111/j.1553-2712.1996.tb03359.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Dubinsky I. Rattlesnake bite in a patient with horse allergy and von Willebrand's disease: case report. Can Fam Physician 1996; 42:2207-11. [PMID: 8939322 PMCID: PMC2146932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Massasauga rattlesnakes are the only poisonous snakes in Ontario. While death from bites of this species is rare, the bite could cause a coagulopathy. I report a case of rattlesnake bite in a patient with asthma, horse allergy, and a documented congenital clotting abnormality.
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Affiliation(s)
- I Dubinsky
- Department of Emergency Medicine, North York General Hospital
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Dubinsky I. Time is muscle. Can Fam Physician 1996; 42:1269-70, 1278-9. [PMID: 8754689 PMCID: PMC2146787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Abstract
Stercoral perforation of the colon is a rarely reported illness, with 67 cases reported in the literature (1). A literature review revealed no case reports in the Emergency Medicine literature. A case report of a 47-year-old female with a history of chronic constipation and sudden onset of severe abdominal pain with physical signs of peritonitis is presented. Initial hematologic and radiologic investigations were normal. After 12 h of hospitalization, a fever developed, and the signs of peritonitis continued, but her abdominal X-ray studies and white blood count remained normal. Because of her persistent abdominal findings, laparotomy was carried out, at which time a stercoral perforation of the rectum was found. A colostomy was performed. This condition is notoriously covert, but if undetected may be life-threatening. A review of the literature will highlight suspected etiologies, diagnostic tests of choice, and a preferred treatment plan.
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Affiliation(s)
- I Dubinsky
- Department of Emergency Medicine, North York General Hospital, Ontario, Canada
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Dubinsky I. Ingestions and overdoses: Changing trends and current controversies. Can Fam Physician 1992; 38:1883-1888. [PMID: 21221321 PMCID: PMC2145755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Dubinsky I. Emergency medicine training. Can Fam Physician 1989; 35:999-1000. [PMID: 21248932 PMCID: PMC2280343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Dubinsky I. Co-operation in Emergency Care. Can Fam Physician 1988; 34:1660-1662. [PMID: 21253066 PMCID: PMC2218940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Dubinsky I. Emergency care: the debate continues. Can Fam Physician 1988; 34:527-528. [PMID: 21253141 PMCID: PMC2219050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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