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Point-of-Care Ultrasound (POCUS) has become an important diagnostic tool for hospital-based clinicians. This study assesses the role of POCUS at Pemberton Music Festival 2016 (Pemberton, British Columbia [BC], Canada), a remote mass gathering where physicians face limited resources, complex disposition decisions, and a dynamic clinical environment.
This study prospectively evaluated the impact of POCUS on patient diagnosis, management, and disposition based on the self-report of the study physicians. The authors hypothesized that having ultrasound available for use would aid in diagnostic and management decisions and would reduce the need to transfer patients off-site to other health care facilities, reducing impact on the acute health services in the host community.
A handheld ultrasound was available for use by physicians in the main medical tent. All participating physicians self-reported their training and comfort using POCUS. After each POCUS scan, physicians completed a survey and recorded the indication for use, scans performed, and impact on patient diagnosis, management, and disposition.
In total, POCUS was used on 28 of the 686 patients treated in the main medical tent; POCUS was reported to narrow the differential diagnosis in 64% of cases and altered the working diagnosis in 21% of cases. Its use changed the management plan in 39% of patients. Its use was reported to reduce the burden on broader health care resource utilization in 46% of cases and prevented ambulance transport off-site in 32% of cases (nine cases in total). This corresponded to an absolute risk reduction of 1.3% for the percentage of patients transferred to hospital (PPTH; relative risk reduction of 53%).
Physicians reported that POCUS improved the diagnosis, management, and disposition of select patients at a remote, multi-day music festival. Also, POCUS reduced ambulance transfers off-site and reduced the perceived burden on broader health care utilization.
PragerR, SedgwickC, LundA, KimD, HoB, StachuraM, GutmanS. Prospective Evaluation of Point-of-Care Ultrasound at a Remote, Multi-Day Music Festival. Prehosp Disaster Med. 2018;33(5):484–489.
MOST OF THE CONTRIBUTIONS to this special forum section on the documentary A German Life (2016) begin with an observation about the filmmakers’ techniques. In particular, the film's interpreters tend to take notice of the extraordinary impact of its black and white cinematography, considering whether the black and white are meant to serve as index of good and evil, or as an allegory of dark personal depths in contrast with more visible physiological surfaces. Speculations along these lines tend to be furthered by the film's consistent employment of closeups, most of which highlight Brunhilde Pomsel's advanced age, and which prompt some to draw parallels with Leni Riefenstahl and to the interviews in which she participated when she was over ninety years old. The cinematographic choices displayed in A German Life have provided ample food for thought, but so have some of the film's revelations, including Pomsel's surprising anecdote about her access to the Scholl files, and the pride she shows when discussing her restraint in choosing not to browse them. The fleeting reference to Hans and Sophie Scholl is one route by which some of this forum's contributors were led to consider similarities and contrasts with an earlier interview film, Blind Spot: Hitler's Secretary (2002), in which Sophie Scholl is also mentioned, and Pomsel's account invites the fundamental question as to whether the film, on the one hand, makes a moral judgment against its chief interviewee or whether it, on the other hand, is more concerned with implicating its viewers in her all-tooevident moral failings.
Not all of the forum's contributors are in agreement with one another. Tobias Boes offers a critical assessment of the film, asserting that it takes too few strides in advancing our understanding of why people harm one another. Boes is not the only one to propose that different, more incisive lines of questioning might have been pursued. William Collins Donahue begins his observations with a plea for more information, indicating that it would have been instructive to know specifically what words prompted Pomsel's varied responses.
Objectives: Economic decision-support tools can provide valuable information for tobacco control stakeholders, but their usability may impact the adoption of such tools. This study aims to illustrate a mixed-method usability evaluation of an economic decision-support tool for tobacco control, using the EQUIPT ROI tool prototype as a case study.
Methods: A cross-sectional mixed methods design was used, including a heuristic evaluation, a thinking aloud approach, and a questionnaire testing and exploring the usability of the Return of Investment tool.
Results: A total of sixty-six users evaluated the tool (thinking aloud) and completed the questionnaire. For the heuristic evaluation, four experts evaluated the interface. In total twenty-one percent of the respondents perceived good usability. A total of 118 usability problems were identified, from which twenty-six problems were categorized as most severe, indicating high priority to fix them before implementation.
Conclusions: Combining user-based and expert-based evaluation methods is recommended as these were shown to identify unique usability problems. The evaluation provides input to optimize usability of a decision-support tool, and may serve as a vantage point for other developers to conduct usability evaluations to refine similar tools before wide-scale implementation. Such studies could reduce implementation gaps by optimizing usability, enhancing in turn the research impact of such interventions.
Up to the 1960s, geology was the only source of information about the times when common ancestors lived. Since then, molecular genetics has become a major contributor to knowledge of these times. By comparing genetic macromolecules from any two living cells or species, one can now tell roughly when they had a common ancestor. Our contribution aims to trace this development and assess its implications. It is a suitable occasion to offer this perspective because 1987 was the 25th anniversary of the first inkling that genes and their protein products behave as evolutionary clocks (Zuckerkandl and Pauling, 1962). It should be noted that the term “molecular clock” was intended to imply that base substitutions accumulate on surviving molecular lineages at a fairly steady rate, not as steady as the ticking of a metronome but nearly as steady as the process of radioactive decay.
Introduction: The acute onset of flashes and floaters is a common presentation to the emergency department (ED). The most emergent etiology is retinal detachment (RD), which requires prompt ophthalmologic assessment. Previous studies of point of care ultrasound (POCUS) have reported high sensitivity and specificity for RD, but are limited by small sample size, use of highly trained and experienced sonographers, and referral bias. Our primary objective was to assess the test characteristics of POCUS performed by a large heterogeneous group of emergency physicians (EPs) for the diagnosis of RD. Methods: This was a prospective diagnostic test assessment of POCUS performed by EPs with varying ultrasound experience on a convenience sample of ED patients presenting with the complaint of flashes or floaters in one or both eyes. Participating EPs completed a one hour didactic lecture and were expected to demonstrate appropriate performance of one practice scan before enrolling patients. After standard ED assessment, patients underwent an ocular POCUS scan targeted to detect RD. EPs recorded the presence or absence of RD on the data collection instrument based on their POCUS scan. After completing their ED visit, all patients were assessed by a retina specialist who was blinded to the results of the POCUS scan. We calculated sensitivity and specificity with associated exact binomial confidence intervals (CI) using the retina specialist’s determination of the final diagnosis as the criterion standard. Results: A total of 30 EPs, consisting of 21 staff physicians and 9 residents, participated in this study. These EPs performed a total of 128 POCUS scans. Of these scans, 13 were excluded. Of the remaining 115 enrolled patients, median age was 60 years, and 64% were female. The retina specialist diagnosed RD in 16 (14%) cases. The sensitivity and specificity of POCUS for detecting RD was 75% (95% CI 48% to 93%) and 94% (95% CI 87% to 98%), respectively. The positive likelihood ratio was 12.4 (95% CI 5.4 to 28.3), and negative likelihood ratio was 0.27 (95% CI 0.11 to 0.62). Conclusion: In a heterogeneous group of EPs with varying ultrasound experience, POCUS demonstrates high specificity but only intermediate sensitivity for the detection of RD. A negative POCUS scan is not sufficiently sensitive to rule out RD in a patient with new onset flashes or floaters.
Mass gatherings attract large crowds and can strain the planning and health resources of the community, city, or nation hosting an event. Mass-Gatherings Health (MGH) is an evolving niche of prehospital care rooted in emergency medicine, emergency management, public health, and disaster medicine. To explore front-line issues related to data quality in the context of mass gatherings, the authors draw on five years of management experience with an online, mass-gathering event and patient registry, as well as clinical and operational experience amassed over several decades.
Here the authors propose underlying human, environmental, and logistical factors that may contribute to poor data quality at mass gatherings, and make specific recommendations for improvement through pre-event planning, on-site actions, and post-event follow-up. The advancement of MGH research will rely on addressing factors that influence data quality and developing strategies to mitigate or enhance those factors. This is an exciting time for MGH research as higher order questions are beginning to be addressed; however, quality research must start from the ground up to ensure optimal primary data capture and quality.
GuyA, PragerR, TurrisS, LundA. Improving Data Quality in Mass-Gatherings Health Research. Prehosp Disaster Med. 2017;32(3):329–332.
We describe a remarkable artifact discovered during our 2015 excavations at the Maya site of Nim li Punit, Belize. It is a T-shaped jade pectoral worn on the chest by ancient Maya kings during rites in which they scattered copal incense (Figure 1). These rituals are described or depicted on six carved stone monuments (stelae) at the site. What is more, two stelae at the site depict rulers wearing the pectoral. The reverse side of the jade contains a long historical hieroglyphic text. Had the piece been recovered by illegal means and ended up in a private collection, much of the text would make little sense and it could not possibly be ascribed to Nim li Punit. The priceless worth of the Nim li Punit pectoral, therefore, lies not only in its hieroglyphic inscription but also in its known archaeological context and contemporary images of its use. We briefly describe that context and present a translation of the important text on the jade pectoral, which we interpret as a “wind jewel.”
Malnutrition is a frequent feature in Crohn’s disease (CD), affects patient outcome and must be recognised. For chronic inflammatory diseases, recent guidelines recommend the development of combined malnutrition and inflammation risk scores. We aimed to design and evaluate a new screening tool that combines both malnutrition and inflammation parameters that might help predict clinical outcome. In a prospective cohort study, we examined fifty-five patients with CD in remission (Crohn’s disease activity index (CDAI) <200) at 0 and 6 months. We assessed disease activity (CDAI, Harvey–Bradshaw index), inflammation (C-reactive protein (CRP), faecal calprotectin (FC)), malnutrition (BMI, subjective global assessment (SGA), serum albumin, handgrip strength), body composition (bioelectrical impedance analysis) and administered the newly developed ‘Malnutrition Inflammation Risk Tool’ (MIRT; containing BMI, unintentional weight loss over 3 months and CRP). All parameters were evaluated regarding their ability to predict disease outcome prospectively at 6 months. At baseline, more than one-third of patients showed elevated inflammatory markers despite clinical remission (36·4 % CRP ≥5 mg/l, 41·5 % FC ≥100 µg/g). Prevalence of malnutrition at baseline according to BMI, SGA and serum albumin was 2–16 %. At 6 months, MIRT significantly predicted outcome in numerous nutritional and clinical parameters (SGA, CD-related flares, hospitalisations and surgeries). In contrast, SGA, handgrip strength, BMI, albumin and body composition had no influence on the clinical course. The newly developed MIRT was found to reliably predict clinical outcome in CD patients. This screening tool might be used to facilitate clinical decision making, including treatment of both inflammation and malnutrition in order to prevent complications.
It is well-nigh impossible to give, in a short report, an adequate idea of the enormous activity in Variable-Star Astronomy during the past three years. Without attempting to be complete I shall give a summary of the most important recent occurrences in this field of research.
Statistical data for eclipsing binaries were given by Gaposchkin (Veröff. Berlin-Bab. 9, Heft 5), for long-period variable stars by Ludendorff (Sitz.-ber. Ak. d. Wiss. Berlin, 1932), Thomas (Veröff. Berlin-Bab. 9, Heft 4) and Sterne and L. Campbell (Harvard Annals).
Some valuable catalogues have been issued: a Finding List for Observers of Eclipsing Variables by Dugan (Princeton Contr. No. 15), a Catalogue of Eclipsing Variables, together with a Program of Investigations, by Martinoff (Engelhardt Obs. Bull. No. 2), a Catalogue and Ephemeris of Short-period Cepheids by Zessewitsch (Len. Un. A. 0. Bull. No. 3).
Fourteen members of the committee have failed to respond to correspondence; nearly all of the others have expressed the definite opinion that non-responsive members should be dropped from committee membership when a new list is prepared a few correspondents indicating however, that the policy should be adopted for Commission 27 only if generally adopted for all commissions of the Union.
The Commission again subscribes to a number of the good resolutions it has made in the past, for example, to follow the almost universal practice of counting the observed times, either in decimals of a day or in hours and minutes, from Greenwich mean noon, even though one is convinced that the rest of the world should adopt U.T.; and to prepare a chart, identifying the variable and the comparison stars, to form a part of the discovery announcement of a variable which cannot be easily identified through a Durchmusterung number and which is bright enough to invite further observation.
In September 2011, a patient cluster with a rare Salmonella serotype – Strathcona – was identified in Denmark. An outbreak investigation was initiated to reveal the source in order to stop the outbreak. In addition to hypothesis-generating interviews, comparable analyses of patients’ household shopping receipts were conducted. A matched case-control study with 25 cases and 56 population register controls was conducted to test the findings of the hypothesis-generating investigation. In total, 43 cases of Salmonella Strathcona were reported in Denmark. Additionally, 28 cases were reported from Germany, Italy, Austria and Belgium. The results of the investigation in Denmark showed that 8/10 cases had bought datterino tomatoes prior to disease onset. Illness was associated with a specific supermarket chain [matched odds ratio (mOR) 16·9, 95% confidence interval (CI) 2·2–130], and having consumed elongated small tomatoes (OR 28·1, 95% CI 2·6–302). Traceback investigation showed that the tomatoes came from an Italian producer. This outbreak, linked to tomatoes, underpins the growing recognition of the broad source range of Salmonella and the ability of fresh produce to cause multi-country outbreaks. It is important to strengthen the international cooperation between public-health and food-safety authorities in the European Union to investigate future multi-country outbreaks in order to prevent illness from ready-to-eat produce.
We aimed to determine the frequency of qacA/B chlorhexidine tolerance genes and high-level mupirocin resistance among MRSA isolates before and after the introduction of a chlorhexidine (CHG) daily bathing intervention in a surgical intensive care unit (SICU).
Retrospective cohort study (2005–2012)
A large tertiary-care center
Patients admitted to SICU who had MRSA surveillance cultures of the anterior nares
A random sample of banked MRSA anterior nares isolates recovered during (2005) and after (2006–2012) implementation of a daily CHG bathing protocol was examined for qacA/B genes and high-level mupirocin resistance. Staphylococcal cassette chromosome mec (SCCmec) typing was also performed.
Of the 504 randomly selected isolates (63 per year), 36 (7.1%) were qacA/B positive (+) and 35 (6.9%) were mupirocin resistant. Of these, 184 (36.5%) isolates were SCCmec type IV. There was a significant trend for increasing qacA/B (P=.02; highest prevalence, 16.9% in 2009 and 2010) and SCCmec type IV (P<.001; highest prevalence, 52.4% in 2012) during the study period. qacA/B(+) MRSA isolates were more likely to be mupirocin resistant (9 of 36 [25%] qacA/B(+) vs 26 of 468 [5.6%] qacA/B(−); P=.003).
A long-term, daily CHG bathing protocol was associated with a change in the frequency of qacA/B genes in MRSA isolates recovered from the anterior nares over an 8-year period. This change in the frequency of qacA/B genes is most likely due to patients in those years being exposed in prior admissions. Future studies need to further evaluate the implications of universal CHG daily bathing on MRSA qacA/B genes among hospitalized patients.
We assessed evidence of exposure to viruses and bacteria in an unmanaged and long-isolated population of Soay sheep (Ovis aries) inhabiting Hirta, in the St Kilda archipelago, 65 km west of Benbecula in the Outer Hebrides of Scotland. The sheep harbour many metazoan and protozoan parasites but their exposure to viral and bacterial pathogens is unknown. We tested for herpes viral DNA in leucocytes and found that 21 of 42 tested sheep were infected with ovine herpesvirus 2 (OHV-2). We also tested 750 plasma samples collected between 1997 and 2010 for evidence of exposure to seven other viral and bacterial agents common in domestic Scottish sheep. We found evidence of exposure to Leptospira spp., with overall seroprevalence of 6·5%. However, serological evidence indicated that the population had not been exposed to border disease, parainfluenza, maedi-visna, or orf viruses, nor to Chlamydia abortus. Some sheep tested positive for antibodies against Mycobacterium avium subsp. paratuberculosis (MAP) but, in the absence of retrospective faecal samples, the presence of this infection could not be confirmed. The roles of importation, the pathogen–host interaction, nematode co-infection and local transmission warrant future investigation, to elucidate the transmission ecology and fitness effects of the few viral and bacterial pathogens on Hirta.
One of the largest and longest Salmonella outbreaks in Germany within the last 10 years occurred in central Germany in 2013. To identify vehicles of infection, we analysed surveillance data, conducted a case-control study and food traceback. We identified 267 cases infected with Salmonella Infantis with symptom onset between 16 April and 26 October 2013 in four neighbouring federal states. Results of our study indicated that cases were more likely to have eaten raw minced pork from local butcher's shops [odds ratio (OR) 2·5, 95% confidence interval (CI) 1·1–5·8] and have taken gastric acid-reducing or -neutralizing medication (OR 3·8, 95% CI 1·3–13) than controls. The outbreak was traced back to contaminated raw pork products found in different butcher's shops supplied by one slaughterhouse, to pigs at one farm and to an animal feed producer. Characterization of isolates of human, food, animal, feed, and environmental origin by phage-typing and pulsed-field gel electrophoresis confirmed the chain of infection. Insufficient hygiene standards in the slaughterhouse were the most probable cause of the ongoing transmission. We recommend that persons taking gastric acid suppressants should refrain from consuming raw pork products. Improving and maintaining adequate hygiene standards and process controls during slaughter is important to prevent future outbreaks.