Ian G Stiell

Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

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Publications (326)2367.69 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The effect of sex on survival in out-of-hospital cardiac arrest (OHCA) is controversial. Some studies report more favorable outcomes in women, while others suggest the opposite, citing disparities in care. Whether sex predicts differential age-specific survival is still uncertain. The objective was to study the sex-associated variation in survival to hospital discharge in OHCA patients as well as the relationship between age and sex for predicting survival. The Ontario Prehospital Advanced Life Support (OPALS) registry, collected in a large study of rapid defibrillation and advanced life support programs, is Utstein-compliant and has data on OHCA patients (1994 to 2002) from 20 communities in Ontario, Canada. All adult OHCAs not witnessed by emergency medical services (EMS) and treated during one of the three main OPALS phases were included. Clinically significant variables were chosen a priori (age, sex, witnessed arrest, initial cardiopulmonary resuscitation [CPR], shockable rhythm, EMS response interval, and OPALS study phase) and entered into a multivariable logistic regression model with survival to hospital discharge as the outcome, with sex and age as the primary risk factors. Fractional polynomials were used to explore the relationship between age and survival by sex. A total of 11,479 (out of 20,695) OPALS cases met inclusion criteria and 10,862 (94.6%) had complete data for regression analysis. As a group, women were older than men (median age = 74 years vs. 69 years, p < 0.01), had fewer witnessed arrests (43% vs. 49%; p < 0.01), had fewer initial ventricular fibrillation/ventricular tachycardia rhythms (24% vs. 42%; p < 0.01), had a lower rate of bystander CPR (12% vs. 17%; p < 0.01), and had lower survival (1.7% vs. 3.2%; p < 0.01). Survival to hospital admission and return of spontaneous circulation did not differ between women and men (p > 0.05). The relationship between age, sex, and survival to hospital discharge could not be analyzed in a single regression model, as age did not have a linear relationship with survival for men, but did for women. Thus, age was kept as a continuous variable for women but was transformed for men using fractional polynomials [ln(age) + age(3) ]. In sex-stratified regression models, the adjusted probability of survival for women decreased as age increased (adjusted odds ratio = 0.88, 95% confidence interval = 0.81 to 0.96, per 5-year increase in age) while for men, the probability of survival initially increased with age until age 65 years and then decreased with increasing age. Women had a higher probability of survival until age 47 years, after which men maintained a higher probability of survival. Overall OHCA survival for women was lower than for men in the OPALS study. Factors related to the sex differences in survival (rates of bystander CPR and shockable rhythms) may be modifiable. The probability of survival differed across age for men and women in a nonlinear fashion. This differential influence of age on survival for men and women should be considered in future studies evaluating survival by sex in OHCA population. © 2014 by the Society for Academic Emergency Medicine.
    Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 12/2014; 21(12):1503-1511.
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    ABSTRACT: Background:Acute asthma is a common emergency department (ED) presentation. In a prospective multicenter cohort study we determined the frequency and factors associated with asthma relapse following discharge from the ED. Methods:Adults aged 18-55 years who were treated for acute asthma and discharged from 20 Canadian EDs underwent a structured ED interview and follow-up telephone interview four weeks later. Standardized anti-inflammatory treatment was offered at discharge. Multivariable analyses were performed. Results:Of 807 enrolled patients, 58% were female and the median age was 30 years. Relapse occurred in 144 patients (18%) within four weeks of ED discharge. Factors independently associated with relapse occurrence were: female sex (22% vs 12% males, adjusted odds ratio [aOR] = 1.9, 95% confidence interval [CI]: 1.2, 3.0), symptom duration of > 24 hours prior to ED visit (19% vs 13% short duration, aOR = 1.7, 95% CI: 1.3, 2.3), ever using oral corticosteroids (21% vs 12% for never use, aOR = 1.5, 95% CI: 1.1, 2.0), current use of an inhaled corticosteroids[ICS]/long-acting β-agonist combination product (25% vs 15% for ICS monotherapy, aOR = 1.9, 95% CI: 1.1, 3.2), and owning a spacer device (24% vs 15% not owning one aOR = 1.6, 95% CI: 1.3, 1.9). Conclusions:Despite receiving guideline-concordant anti-inflammatory treatments at ED discharge, almost one-in-five patients relapsed within four weeks. Female sex, prolonged symptoms, treatment-related factors and markers of prior asthma severity were significantly associated with relapse. These results may help clinicians target more aggressive interventions for patients at high risk of relapse.
    Chest 10/2014; · 7.13 Impact Factor
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    ABSTRACT: Atrial fibrillation (AF) is an extremely common clinical problem with an important population morbidity and mortality burden. The management of AF is complex and fraught with many uncertain and contentious issues, which are being addressed by extensive ongoing basic and clinical research. The Canadian Cardiovascular Society AF Guidelines Committee produced an extensive set of evidence-based AF management guidelines in 2010 and updated them in the areas of anticoagulation and rate/rhythm control in 2012. In late 2013, the committee judged that sufficient new information regarding AF management had become available since 2012 to warrant an update to the Canadian Cardiovascular Society AF Guidelines. After extensive evaluation of the new evidence, the committee has updated the guidelines for: (1) stroke prevention principles; (2) anticoagulation of AF patients with chronic kidney disease; (3) detection of AF in patients with stroke; (4) investigation and management of subclinical AF; (5) left atrial appendage closure in stroke prevention; (6) emergency department management of AF; (7) periprocedural anticoagulation management; and (8) rate and rhythm control including catheter ablation. This report presents the details of the updated recommendations, along with their background and rationale. In addition, a complete set of presently applicable recommendations, those that have been updated and those that remain in force from previous guideline versions, is provided in the Supplementary Material.
    The Canadian journal of cardiology 10/2014; 30(10):1114-30. · 3.12 Impact Factor
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    ABSTRACT: -The 2010 AHA guidelines suggested an increase in CPR compression depth with a target greater than 50 mm and no upper limit. This target is based upon limited evidence and we sought to determine the optimal compression depth range.
    Circulation 09/2014; · 15.20 Impact Factor
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    ABSTRACT: This retrospective chart audit examined the demographics, investigations, management and outcomes of adult patients with diabetes mellitus presenting to Canadian emergency departments (EDs).
    Canadian Journal of Diabetes 08/2014; · 0.46 Impact Factor
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    ABSTRACT: Electrical cardioversion is commonly used to treat patients with atrial fibrillation and atrial flutter to restore normal sinus rhythm. There has been considerable debate as to whether the electrode placement affects the efficacy of electrical cardioversion. The objective of this study was to examine the effectiveness of anteroposterior (A-P) versus anterolateral (A-L) electrode placement to restore normal sinus rhythm.
    Academic Emergency Medicine 08/2014; · 2.20 Impact Factor
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    ABSTRACT: Background Clinical decision rules (CDRs) can be an effective tool for knowledge translation in emergency medicine, but their implementation is often a challenge. This study examined whether the Theory of Planned Behaviour (TPB) could help explain the inconsistent results between the successful Canadian C-Spine Rule (CCR) implementation study and unsuccessful Canadian CT Head Rule (CCHR) implementation study. Both rules are aimed at improving the accuracy and efficiency of emergency department radiography use in clinical contexts that exhibit enormous inefficiency at the present time. The rules were prospectively derived and validated using the same methodology demonstrating high sensitivity and reliability. The rules subsequently underwent parallel implementations at 12 Canadian hospitals, yet only the CCR was observed to significantly reduce radiography ordering rates, while the CCHR failed to have any significant impact at all. The drastically different results are unlikely to be the result of differences in implementation strategies or the decision rules.Methods Physicians at the 12 participating Canadian hospitals were randomized to CCR or CCHR TPB surveys that were administered during the baseline phases of the implementation studies, before any intervention had taken place. The collected baseline survey data were linked to concurrent baseline physician and patient-specific imaging data, and subsequently analyzed using mixed effects linear and logistic models.ResultsA total of 223 of the 378 eligible physicians randomized to a TPB survey completed their assigned baseline survey (CCR: 122 of 181; CCHR: 101 of 197). Attitudes were significantly associated with intention in both settings (CCR: ß¿=¿0.40; CCHR: ß¿=¿0.30), as were subjective norms (CCR: ß¿=¿0.26; CCHR: ß¿=¿0.73). Intention was significantly associated with actual image ordering for CCR (OR¿=¿1.79), but not CCHR.Conclusions The TPB can be used to better understand processes underlying use of CDRs. TPB constructs were significantly associated with intention to perform both imaging behaviours, but intention was only associated with actual behaviour for CCR, suggesting that constructs outside of the TPB framework may need to be considered when seeking to understand use of CDRs.
    Implementation Science 08/2014; 9(1):88. · 2.37 Impact Factor
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    ABSTRACT: Survival after out-of-hospital cardiac arrest (OHCA) varies between communities, due in part to variation in the methods of measurement. The Utstein template was disseminated to standardize comparisons of risk factors, quality of care and outcomes in patients with OHCA. We sought to assess whether OHCA registries are able to collate common data using the Utstein template. A subsequent study will assess whether the Utstein factors explain differences in survival between emergency medical services (EMS) systems.
    Resuscitation 07/2014; · 4.10 Impact Factor
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    ABSTRACT: There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research.
    Annals of emergency medicine. 05/2014;
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    ABSTRACT: Isolated dysarthria is an uncommon presentation of transient ischemic attack (TIA)/minor stroke and has a broad differential diagnosis. There is little information in the literature about how often this presentation is confirmed to be a TIA/stroke, and therefore there is debate about the risk of subsequent vascular events. Given the uncertain prognosis, it is unclear how to best manage patients presenting to the emergency department (ED) with isolated dysarthria. The objective of this study was to prospectively identify and follow a cohort of patients presenting to EDs with isolated dysarthria in order to explore their natural history and risk of recurrent cerebrovascular events. Specifically, we sought to determine early outcomes of individuals with this nonspecific and atypical presentation in order to appropriately expedite their management.
    Cerebrovascular diseases extra. 05/2014; 4(2):182-5.
  • Stroke 04/2014; · 6.16 Impact Factor
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    ABSTRACT: Nontraumatic low back pain (LBP) is a common emergency department (ED) complaint and can be caused by serious pathologies that require immediate intervention or that lead to death. The primary goal of this study is to identify risk factors associated with serious pathology in adult nontraumatic ED LBP patients. We conducted a health records review and included patients aged ≥ 16 years with nontraumatic LBP presenting to an academic ED from November 2009 to January 2010. We excluded those with previously confirmed nephrolithiasis and typical renal colic presentation. We collected 56 predictor variables and outcomes within 30 days. Outcomes were determined by tracking computerized patient records and performance of univariate analysis and recursive partitioning. There were 329 patients included, with a mean age of 49.3 years; 50.8% were women. A total of 22 (6.7%) patients suffered outcomes, including one death, five compression fractures, four malignancies, four disc prolapses requiring surgery, two retroperitoneal bleeds, two osteomyelitis, and one each of epidural abscess, cauda equina, and leaking abdominal aortic aneurysm graft. Risk factors identified for outcomes were: anticoagulant use (odds ratio [OR] 15.6; 95% confidence interval [CI] 4.2-58.5), decreased sensation on physical examination (OR 6.9; CI 2.2-21.2), pain that is worse at night (OR 4.3; CI 0.9-20.1), and pain that persists despite appropriate treatment (OR 2.2; CI 0.8-5.6). These four predictors identified serious pathology with 91% sensitivity (95% CI 70-98%) and 55% specificity (95% CI 54-56%). We successfully identified risk factors associated with serious pathology among ED LBP patients. Future prospective studies are required to derive a robust clinical decision rule.
    Journal of Emergency Medicine 04/2014; · 1.33 Impact Factor
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    ABSTRACT: The diagnosis and management of acute decompensated heart failure (HF) in the prehospital setting can be challenging. The objectives of this study are to evaluate the appropriateness of furosemide use by Emergency Medical Services (EMS) and its association with adverse outcomes. This study was a multi-centre health records review of EMS patients who received prehospital furosemide or had an emergency department (ED) diagnosis of HF. We included acutely ill patients ≥50 years of age with shortness of breath transported by land EMS. Univariate and logistic regression analyses were performed to determine associations between furosemide use and serious adverse outcomes (acute renal failure, intubation, vasopressors or death). The study population consisted of 330 patients (N=58, furosemide given by EMS but no HF diagnosed in ED; N=110, furosemide given, HF diagnosed; N=162, no furosemide given, HF diagnosed). The median dose of intravenous furosemide was 80 mg (range 20-80 mg). Serious adverse outcomes occurred in 61 patients (19.0%, 23.6% and 14.8% of the three groups, respectively; p=0.18). The adjusted ORs for adverse events with furosemide use was 0.62 (95% CI 0.33 to 1.43) in patients with a diagnosis of HF and 1.14 (95% CI 0.58 to 2.23) in those without. More than a third of patients who received prehospital furosemide did not have an HF diagnosis, suggesting that the prehospital diagnosis of HF can be challenging. Serious adverse outcomes were identified in all patient groups and we found no statistically significant associations between furosemide use and adverse events.
    Emergency Medicine Journal 04/2014; · 1.65 Impact Factor
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    ABSTRACT: While Canadian ED physicians discharge most syncope patients with no specific further follow-up, approximately 5% will suffer serious outcomes after ED discharge. The goal of this study is to prospectively identify risk factors and to derive a clinical decision tool to accurately predict those at risk for serious outcomes after ED discharge within 30 days. We will conduct a prospective cohort study at 6 Canadian EDs to include adults with syncope and exclude patients with loss of consciousness > 5 minutes, mental status changes from baseline, obvious witnessed seizure, or head trauma prior to syncope. Emergency physicians will collect standardized clinical variables including historical features, physical findings, and results of immediately available tests (blood, ECG, and ED cardiac monitoring) prior to ED discharge/hospital admission. A second emergency physician will evaluate approximately 10% of study patients for interobserver agreement calculation of predictor variables. The primary outcome will be a composite serious outcome occurring within 30 days of ED discharge and includes three distinct categories: serious adverse events (death, arrhythmia); identification of serious underlying disease (structural heart disease, aortic dissection, pulmonary embolism, severe pulmonary hypertension, subarachnoid hemorrhage, significant hemorrhage, myocardial infarction); or procedures to treat the cause of syncope. The secondary outcome will be any of the above serious outcomes either suspected or those occurring in the ED. A blinded Adjudication Committee will confirm all serious outcomes. Univariate analysis will be performed to compare the predictor variables in patients with and without primary outcome. Variables with p-values <0.2 and kappa values >=0.60 will be selected for stepwise logistic regression to identify the risk factors and to develop the clinical decision tool. We will enroll 5,000 patients (with 125 positive for primary outcome) for robust identification of risk factors and clinical decision tool development. Once successfully developed, this tool will accurately risk-stratify adult syncope patients; however, validation and implementation will still be required. This program of research should lead to standardized care of syncope patients, and improve patient safety.
    BMC Emergency Medicine 03/2014; 14(1):8.
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    ABSTRACT: BACKGROUND:To assist physicians with difficult decisions about hospital admission for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) presenting in the emergency department, we sought to identify clinical characteristics associated with serious adverse events. METHODS:We conducted this prospective cohort study in 6 large Canadian academic emergency departments. Patients were assessed for standardized clinical variables and then followed for serious adverse events, defined as death, intubation, admission to a monitored unit or new visit to the emergency department requiring admission. RESULTS:We enrolled 945 patients, of whom 354 (37.5%) were admitted to hospital. Of 74 (7.8%) patients with a subsequent serious adverse event, 36 (49%) had not been admitted after the initial emergency visit. Multivariable modelling identified 5 variables that were independently associated with adverse events: prior intubation, initial heart rate ≥ 110/ minute, being too ill to do a walk test, hemoglobin < 100 g/L and urea ≥ 12 mmol/L. A preliminary risk scale incorporating these and 5 other clinical variables produced risk categories ranging from 2.2% for a score of 0 to 91.4% for a score of 10. Using a risk score of 2 or higher as a threshold for admission would capture all patients with a predicted risk of adverse events of 7.2% or higher, while only slightly increasing admission rates, from 37.5% to 43.2%. INTERPRETATION:In Canada, many patients with COPD suffer a serious adverse event or death after being discharged home from the emergency department. We identified high-risk characteristics and developed a preliminary risk scale that, once validated, could be used to stratify the likelihood of poor outcomes and to enable rational and safe admission decisions.
    Canadian Medical Association Journal 02/2014; · 6.47 Impact Factor
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    ABSTRACT: Effectiveness of a resuscitation strategy may vary across communities. We hypothesize that a strategy that prioritizes initial emergency medical services (EMS) rhythm analysis (analyze early) will be associated with survival advantage among EMS systems with lower baseline (pretrial) ventricular fibrillation survival, whereas a strategy that prioritizes initial EMS cardiopulmonary resuscitation (analyze late) will be associated with survival advantage among systems with higher ventricular fibrillation baseline survival. We conducted a secondary, post hoc study of a randomized trial of out-of-hospital cardiac arrest. Subjects were stratified according to randomization status (analyze early versus analyze late) and EMS agency baseline ventricular fibrillation survival. We used a mixed-effects model to determine whether the association between favorable functional survival to hospital discharge and trial intervention (analyze late versus analyze early) differed according to EMS agency baseline ventricular fibrillation survival (<20% or >20%). Characteristics were similar among patients randomized to analyze early (n=4,964) versus analyze late (n=4,426). For EMS agencies with baseline ventricular fibrillation survival less than 20%, analyze late compared with analyze early was associated with a lower likelihood of favorable functional survival (3.8% versus 5.5%; odds ratio [OR]=0.67 [95% CI 0.50, 0.90]). Conversely, among agencies with a ventricular fibrillation survival greater than 20%, analyze late compared with analyze early was associated with higher likelihood of favorable functional survival (7.5% versus 6.1%; OR=1.22 [95% CI 0.98, 1.52]). In the multivariable-adjusted model, for every 10% increase in baseline ventricular fibrillation survival, analyze late versus analyze early was associated with a 34% increase in odds of favorable functional survival (OR=1.34 [95% CI 1.07 to 1.66]). The findings suggest that system-level characteristics may influence resuscitation outcomes.
    Annals of emergency medicine 02/2014; · 4.33 Impact Factor
  • Ian G Stiell, Jeffrey J Perry
    Academic Emergency Medicine 01/2014; · 2.20 Impact Factor
  • JAMA The Journal of the American Medical Association 01/2014; 311(2):201-2. · 29.98 Impact Factor
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    ABSTRACT: Objectives For emergency department (ED) patients with acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), we aimed to assess the adherence to evidence-based care and determine the proportion that experienced adverse events. Methods An expert panel identified critical actions for ED care of heart failure and COPD patients based on clinical practice guidelines. We collected outcome data for discharged ED patients > age 50 with acute heart failure or COPD in a multicenter prospective cohort study at five academic EDs. We measured 3 flagged outcomes: return ED visit, admission, or death within 14 days. Three trained physician reviewers reviewed case summaries for adverse event determination (flagged outcomes related to healthcare received). We evaluated health records for adherence to the critical actions for each condition. Results We identified 122 (7.0%) flagged outcomes among 1,718 enrolled patients (61 heart failure, 59 COPD and 2 dual diagnoses). The mean age was 74.2 (SD 10.4) and 44.3% were female. Among 10 critical actions for heart failure and 13 for COPD, a mean proportion of 9.4/10 and 11.0/13 were adhered to respectively. We identified 12 adverse events (9.8%, 95%CI: 5.6-16.5%), all of which were deemed preventable, including 1 death. The most common contributors were unsafe disposition decisions (10/12, 83.3%) and diagnostic issues (5/12, 41.7%). Patients who died with heart failure were statistically significantly less likely to have guideline adherent care (P = .02). Conclusions A small proportion of return ED visits were related to index care. We believe there is need for improvement around disposition decision making for both conditions to reduce the highly preventable and clinically significant adverse events we found.
    The American Journal of Emergency Medicine. 01/2014; 32(1):29–35.
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    ABSTRACT: Background The rate and effect of coronary interventions and induced hypothermia after out-of-hospital cardiac arrest (OHCA) are unknown. We measured the association of early (≤24 hours after arrival) coronary angiography, reperfusion, and induced hypothermia with favorable outcome after OHCA. Methods We performed a secondary analysis of a multicenter clinical trial (NCT00394706) conducted between 2007 and 2009 in 10 North American regions. Subjects were adults (≥ 18 years) hospitalized after OHCA with pulses sustained ≥ 60 minutes. We measured the association of early coronary catheterization, percutaneous coronary intervention, fibrinolysis, and induced hypothermia with survival to hospital discharge with favorable functional status (modified Rankin Score ≤ 3). Results From 16,875 OHCA subjects, 3,981 (23.6%) arrived at 151 hospitals with sustained pulses. 1,317 (33.1%) survived to hospital discharge, with 1,006 (25.3%) favorable outcomes. Rates of early coronary catheterization (19.2%), coronary reperfusion (17.7%) or induced hypothermia (39.3%) varied between hospitals, and were higher in hospitals treating more subjects per year. Odds of survival and favorable outcome increased with hospital volume (per 5 subjects/year OR 1.06; 95%CI: 1.04-1.08 and OR 1.06; 95%CI: 1.04, 1.08, respectively). Survival and favorable outcome were independently associated with early coronary angiography (OR 1.69; 95%CI 1.06-2.70 and OR 1.87; 95%CI 1.15-3.04), coronary reperfusion (OR 1.94; 95%CI 1.34-2.82 and OR 2.14; 95%CI 1.46-3.14), and induced hypothermia (OR 1.36; 95%CI 1.01-1.83 and OR 1.42; 95%CI 1.04-1.94). Interpretation : Early coronary intervention and induced hypothermia are associated with favorable outcome and are more frequent in hospitals that treat higher numbers of OHCA subjects per year.
    Resuscitation 01/2014; · 4.10 Impact Factor

Publication Stats

12k Citations
2,367.69 Total Impact Points

Institutions

  • 1995–2014
    • Ottawa Hospital Research Institute
      • Clinical Epidemiology Program
      Ottawa, Ontario, Canada
  • 1991–2014
    • University of Ottawa
      • • Department of Emergency Medicine
      • • Department of Epidemiology and Community Medicine
      • • Faculty of Medicine
      Ottawa, Ontario, Canada
  • 2012
    • Orlando VA Medical Center
      Orlando, Florida, United States
  • 2010–2012
    • University of Texas Southwestern Medical Center
      • • Division of Emergency Medicine
      • • Department of Surgery
      Dallas, TX, United States
  • 2010–2011
    • University of Pittsburgh
      • Department of Emergency Medicine
      Pittsburgh, PA, United States
    • Mayo Foundation for Medical Education and Research
      • Department of Emergency Medicine
      Scottsdale, AZ, United States
  • 1991–2011
    • The Ottawa Hospital
      • • Clinical Epidemiology and Research Program
      • • Department of Medicine
      • • Department of Emergency Medicine
      Ottawa, Ontario, Canada
  • 2003–2010
    • University of Toronto
      • • Institute of Health Policy, Management and Evaluation
      • • Faculty of Medicine
      Toronto, Ontario, Canada
  • 2009
    • The University of Arizona
      • Department of Emergency Medicine
      Tucson, AZ, United States
  • 2008–2009
    • University of Washington Seattle
      • • Department of Medicine
      • • Department of Biostatistics
      Seattle, WA, United States
  • 2005–2008
    • Stanford University
      • Division of Emergency Medicine
      Stanford, CA, United States
    • Dalhousie University
      Halifax, Nova Scotia, Canada
    • McMaster University
      Hamilton, Ontario, Canada
    • Singapore General Hospital
      • Department of Emergency Medicine
      Singapore, Singapore
    • Queen's University
      • Department of Emergency Medicine
      Kingston, Ontario, Canada
  • 2007
    • Bruyère Research Institute
      Ottawa, Ontario, Canada
    • Sunnybrook Health Sciences Centre
      Toronto, Ontario, Canada
  • 2006
    • The Children's Hospital of Philadelphia
      Philadelphia, Pennsylvania, United States
  • 2004
    • University of North Carolina at Charlotte
      Charlotte, North Carolina, United States
    • University of California, San Francisco
      • Department of Emergency Medicine
      San Francisco, CA, United States
  • 1995–2001
    • University of British Columbia - Vancouver
      • Department of Emergency Medicine
      Vancouver, British Columbia, Canada
  • 1999
    • University of Michigan
      • Department of Surgery
      Ann Arbor, MI, United States