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Introduction: It is recommended that seniors consulting to the Emergency Department (ED) undergo a comprehensive geriatric screening, which is difficult for most EDs. Patient self-assessment using electronic tablet could be an interesting solution to this issue. However, the acceptability of self-assessment by older ED patients remains unknown. Assessing acceptability is a fundamental step in evaluating new interventions. The main objective of this project is to compare the acceptability of older patient self-assessment in the ED to that of a standard assessment made by a professional, according to seniors and their caregivers. Methods: Design: This randomized crossover design cohort study took place between May and July 2018. Participants: 1) Patients aged ≥65 years consulting to the ED, 2) their caregiver, when present. Measurements: Patients performed self-assessment of their frailty, cognitive and functional status using an electronic tablet. Acceptability was measured using the Treatment Acceptability and Preferences (TAP) questionnaires. Analyses: Descriptive analyses were performed for sociodemographic variables. Scores were adjusted for confounding variables using multivariate linear regression. Thematic content analysis was performed by two independent analysts for qualitative data collected in the TAP's open-ended question. Results: A total of 67 patients were included in this study. Mean age was 75.5 ± 8.0 and 55.2% of participants were women. Adjusted mean TAP scores for RA evaluation and patient self-assessment were 2.36 and 2.20, respectively. We found no difference between the two types of evaluations (p = 0.0831). When patients are stratified by age groups, patients aged 85 and over (n = 11) showed a difference between the TAPs scores, 2.27 for RA evaluation and 1.72 for patient self-assessment (p = 0.0053). Our qualitative data shows that this might be attributed to the use of technology, rather than to the self-assessment itself. Data from 9 caregivers showed a 2.42 mean TAP score for RA evaluation and 2.44 for self-assessment. However, this relatively small sample size prevented us to perform statistical tests. Conclusion: Our results show that older patients find self-assessment in the ED using an electronic tablet just as acceptable as a standard evaluation by a professional.
Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.
Introduction: Delirium is a frequent pathology in the elderly presenting to the emergency department (ED) and is seldom recognised. This condition is associated with many medical complications and has been shown to increase the hospital length-of-stay. The objective of this study was to identify the predictor factors of developing delirium in this high-risk population. Methods: Design: This study was part of the multicenter prospective cohort INDEED study. Participants: Patients aged 65 and older, initially free of delirium and with an ED stay of 8h or longer, were followed up to 24h after ward admission. Measures: Clinical and demographic variables were collected by interview and chart review. A research professional assessed their delirium status twice daily using the Confusion Assessment Method (CAM). Analyses: A classification tree was used to select predictors and cut-points that minimized classification error of patients with incident delirium. After literature review, nineteen predictors were considered for inclusion in the model (eight non-modifiable and eleven modifiable factors). Results: Among the 605 patients included in this study, incident delirium was detected by the CAM in 69 patients (11.4%). In total, fourteen variables were included in a preliminary model, of which six were intrinsic to the patient and eight were modifiable in the ED. Variables with the greatest impact in the prediction of delirium includes age, cognitive status, ED length of stay, autonomy in daily activities, fragility and mobility during their hospital stay. The diagnostic performance of the model applied to the study sample gave a sensitivity of 78.3% (95% CI: 66.7 to 87.3), a specificity of 100.0% (95% CI: 99.3 to 100.0), a PPV of 100.0% (95% CI: 93.4 to 100.0) and a NPV of 97.3% (95% CI: 95.6 to 98.5). Conclusion: The delirium risk model developed in this study shows promising results with elevated sensitivity and specificity values. Considering the limited ability to predict and detect delirium among physicians, the potential increase in sensitivity provided by this tool could be beneficial to patients. This model will ultimately serve to identify high-risk patients with the goal of developing strategies to alter modifiable risk factors and subsequently decrease the incidence of delirium in this population.
La doctrine Gérin-Lajoie, qui fonde l'action internationale du Québec depuis les années 1960, s'exprime conventionnellement comme le prolongement externe des compétences internes du Québec. Comment alors expliquer que les élus québécois prennent régulièrement position sur certains conflits internationaux, qui relèvent pourtant clairement de la compétence du gouvernement fédéral ? Cet article offre un premier éclairage sur les motivations des élus québécois à se positionner sur des enjeux militaires ainsi qu'aux dynamiques qui les entourent. Trois hypothèses sont avancées et confrontées tour à tour à l'ensemble des prises de position des élus québécois depuis le 11 septembre 2001 en matière d'intervention militaire. Premièrement, la paradiplomatie québécoise pourrait être marquée par un nationalisme identitaire, agissant comme outil d'affirmation et de différenciation nationales par-delà les compétences provinciales. Deuxièmement, plutôt que de représenter une tendance à connotation identitaire, l'affirmation québécoise sur des enjeux de compétence fédérale pourrait être la manifestation d'une protodiplomatie. Troisièmement, les élus québécois pourraient s'aventurer sur le terrain de la sécurité internationale en raison de calculs électoraux. En somme, l'article cherche à évaluer si l'affirmation québécoise en matière de sécurité internationale est le fruit de motivations identitaires, souverainistes ou électorales.
Introduction: Prevalence and incidence of delirium in older patients admitted to acute and long-term care facilities ranges between 9.6% and 89% but little is known in the context of emergency department (ED) incident delirium. Literature regarding the incidence of delirium in the ED and its potential impacts on hospital length of stay (LOS), functional status and unplanned ED readmissions is scant, its consequences have yet to be clearly identified in order to orient modern acute medical care. Methods: This study is part of the multicenter prospective cohort INDEED study. Three Canadian EDs completed the two years prospective study (March-July 2015 and Feb-May 2016). Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Patients were assessed 2x/day during their entire ED stay and up to 24 hours on hospital ward by research assistants (RA). The primary outcome of this study was incident delirium in the ED or within 24 h of ward admission. Functional and cognitive status were assessed using validated Older Americans’ Resources and Services and the Telephone Interview for Cognitive Status- modified tools. The Confusion Assessment Method (CAM) was used to detect incident delirium. ED and hospital administrative data were collected. Inter-observer agreement was realized among RA. Results: Incident delirium was not different between sites, nor between phases, nor between times from one site to another. All phases confounded, there is between 7 to 11% of ED related incident delirious episodes. Differences were seen in ED LOS between sites in non-delirious patients, but also between some sites for delirious participants (p<0.05). Only one site had a difference in ED LOS between their delirious and non-delirious patients, respectively of 52.1 and 40.1 hours (p<0.05). There is also a difference between sites in the time between arrival to the ED and the incidence of delirium (p=0.003). Kappa statistics were computed to measure inter-rater reliability of the CAM. Based on an alpha of 5%, 138 patients would allow 80% power for an estimated overall incidence proportion of 15 % with 5% precision.. Other predictive delirium variables, such as cognitive status, environmental factors, functional status, comorbidities, physiological status, and ED and hospital length of stay were similar between sites and phases. Conclusion: The fact that incidence of delirium was the same for all sites, despite the differences of ED LOS and different time periods suggest that many other modifiable and non-modifiable factors along LOS influenced the incidence of ED induced delirium. Emergency physician should concentrate on improving senior-friendly environment for the ED.
Introduction: It is documented that physicians and nurses fail to detect delirium in more than half of cases from various clinical settings, which could have serious consequences for seniors and for our health care system. The present study aimed to describe the rate of documented incident delirium in 5 Canadian Emergency departments (ED) by health professionals (HP). Methods: This study is part of the multicenter prospective cohort INDEED study. Patients aged 65 years old, initially free of delirium with an ED stay 8hours were followed up to 24h after ward admission. Delirium status was assessed twice daily using the Confusion Assessment Method (CAM) by trained research assistants (RA). HP reviewed patient charts to assess detection of delirium. HP had no specific routine detection of delirious ED patients. Inter-observer agreement was realized among RA. Comparison of detection between RA and HP was realized with univariate analyses. Results: Among the 652 included patients, 66 developed a delirium as evaluated with the CAM by the RA. Among those 66 patients, only 10 deliriums (15.2%) were documented in the patients medical file by the HP. 54 (81.8%) patients with a CAM positive for delirium by the RA were not recorded by the HP, 2 had incomplete charts. The delirium index was significantly higher in the HP reported group compared to the HP not reported, respectively 7.1 and 4.5 (p<0.05). Other predictive delirium variables, such as cognitive status, functional status, comorbidities, physiological status, and ED and hospital length of stay were similar between groups. Conclusion: It seems that health professionals missed 81.8% of the potential delirious ED patients in comparison to routine structured screening of delirium. HP could identify patients with a greater severity of symptoms. Our study points out the need to better identify elders at risk to develop delirium and the need for fast and reliable tools to improve the screening of this disorder.
Snowpack base temperatures vary during accumulation and diurnally. Their measurement provides insight into physical, biological and chemical processes occurring at the snow/soil interface. Recent advances in Raman-spectra instruments, which use the scattered light in a standard telecommunications fiber-optic cable to infer absolute temperature along the entire length of the fiber, offer a unique opportunity to obtain basal snow temperatures at resolutions of 1 m, 10 s and 0.1°C. Measurements along a 330 m fiber over 24 hours during late-spring snowmelt at Mammoth Mountain, California, USA, showed basal snow temperatures of 0 ± 0.2°C using 10 s averages. Where the fiber-optic cable traversed bare ground, surface temperatures approached 40°C during midday. The durability of the fiber optic was excellent; no major damage or breaks occurred through the winter of burial. Data from the Dry Creek experimental watershed in Idaho across a small stream valley showed little variability of temperature on the northeast-facing, snow-covered slope, but clearly showed melting patterns and the effects of solar heating on southwest-facing slopes. These proof-of-concept experiments show that the technology enables more detailed spatial and temporal coverage than traditional point measurements of temperature.
Several suggestion have been put forward to explain the 3.d766 periodicity of EZ CMa (WR6): (i) WR+c system; (ii) rotating single WR star; (iii) pulsations (non—radial (NRP) or radial) with frequency reduced by some kind of filtering in the wind. In this paper, we report on a photometric investigation based on a long continuous observing run, in an attempt to verify whether EZ CMa does in fact show a unique periodicity. In particular, this work was motivated by the claim by Gosset & Vreux (1987), based on the data from Lamontagne et al. (1986, hereafter LML), that EZ CMa may have a shorter period besides the one at 3.d766, a frequency close to but not equal to the third harmonic of the 3.d766 period.
We report a first result from an extensive observing campaign for the WN8 star WR66 (HD 134877). We obtained 219 photometric observations of WR66 in a standard broadband V-filter during 61 nights, distributed in a T = 83d interval. Details of observations and data reduction can be found in Antokhin et al. (1994). The power spectra of WR66-C1, WR66-C2 and C2-C1 are shown in Fig.1. Both the WR66-C1 and WR66-C2 spectra clearly show high frequency components. The overall structure of the peaks is evidently determined by 1-day aliasing. The highest peak in both spectra has frequency v1 = 6.828 d−1 (period P = 3h.51). Inspection of the power spectra shows that C1 is a low-amplitude variable, but luckily at low frequencies only. We conclude that WR66 is significantly variable with a period of 3h.5. A phase plot of the data (WR-C2 and C2-C1) with this frequency is shown in Fig.2. Plausible scenarios which could potentially account for the observed variability are: (i) non-radial pulsations (NRP); (ii) rotational light-modulation by spots or (magnetic) loops at the stellar surface; (iii) spiral-in system (WR+c), like the massive X-ray binary Cyg X-3 (van Kerkwijk 1993).
During the 1992–1993 observing season, WR3, 6, 16, 40, 66, 82 and 134 were monitored in fast photometry mode with time-resolution 0.005—0.01 s. Only WR6 reveals a possible period of P = 0.11 s (semi-amplitude A = 0.025 mag), which is close to the derived equilibrium period of a new-born pulsar in a binary system after the rapid phase of Roche Lobe Over-Flow from the original secondary component.
EZ CMa (HD 50896, WN5) is an enigmatic object. New photometry and polarimetry of EZ CMa are presented in the figure. Again the 3.77 day period is found but, as observed at previous epochs (e.g. Drissen et ai. 1989, Ap. J., 343, 426), the shapes of the curves change. The new photometry can also be interpreted in terms of a shorter period, of 1.254 days. A period of about one day is also claimed in other sets of photometric data (e.g. van der Hucht et ai., 1990, A. A., 228, 108) and in the IUE spectra of St.-Louis et ai. (1990, this symposium). However, despite the complex nature of the light curve, the 3.77 day period is strongly supported by the polarimetry, which shows no evidence for the shorter period.
Most Wolf-Rayet binaries show phase-dependent light variations with a broad dip occurring at phase zero, when the WR star passes closest to the observer. When the orbital period is long, or the inclination is low, this dip is buried in the noise. When eclipses of the stars occur, another dip is seen when the companion passes closest to the observer; in this case, both dips are relatively deep and sharp (e.g. V444 Cygni, HD5980).
In the cases when only one dip at phase zero is seen, a simple model is derived. This involves electron scattering of companion starlight as the orbit makes it systematically traverse different amounts of the WR wind, assumed to be spherically symmetric and to follow a monotonic velocity-radius law. The shape and amplitude of the dip yield estimates of M and i (hence M when combined with M sin3i from spectroscopic orbits).
We have completed a direct narrow-band/broad-band Schmidt-plate survey of large areas of the southern Milky Way for new Wolf-Rayet stars as faint as 19th b magnitude. The 31 newly detected stars in the completed survey are amongst the reddest and/or most distant known in the Galaxy. We have obtained spectra of all candidate WR stars in the 22 fields stretching from l = 282° to l = 341° in longitude, and Δb = 3.5° in latitude, covering about 180 square degrees. We also observed two isolated Milky Way fields centered at l = 0° and l = 8°. Eighteen new WR stars are reported here for the first time. Combined with the 13 new WR stars we have already reported in Carina, our list of 31 new Galactic WR stars reaches 3–4 magnitudes fainter than previous surveys. Thirteen of the 18 new WR stars reported here are of subtype WN, while five are of subtype WC. Our new WR stars clearly demonstrate an increasing WN/WC number ratio with increasing Galactocentric distance.
Introduction: Delirium is a frequent complication among seniors in the emergency department (ED). This condition is often underdiagnosed by ED professionals even though it is associated with functional & cognitive decline, longer hospital length of stay, institutionalization and death. Frailty is increasingly recognized as an independent predictor of adverse events in seniors and screening for frailty in EDs has recently been recommended. The aim of this study was to assess if screening seniors for frailty in EDs could help identify those at risk of ED-induced delirium. Methods: This study is part of the Incidence and Impact measurement of Delirium Induced by ED-Stay study, an ongoing multicenter prospective cohort study in 5 Quebec EDs. Patients were recruited after 8 hours in the ED exposure & followed up to 24h after ward admission. Frailty was assessed at ED admission using the Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) which classified seniors from robust (1/7) to severely frail (7/7). Seniors with CSHA-CFS ≥ 5/7 were considered frail. Delirium was assessed using the Confusion assessment method and Delirium Index. Results: Of the 380 patients recruited, mean age was 76.5 (±8.9). Male were 50%. Mean stay in the ED was 1.4 day (±0.82). Preliminary data show an incidence of ED-induced delirium of 8.4%. Average frailty score at baseline was 3.5/7. 72 patients were considered frail, while 289 were considered robust. Among the frail seniors, there were 48.4% (30-66%) patients with ED-induced delirium vs 17.9% (13.7-22.0] in the non-frail ones (p<0.0001). Conclusion: Increased frailty appears to be associated with increased ED-induced delirium. Screening for frailty at emergency triage could help ED professionals identify seniors at higher risk of ED-induced delirium. Further studies are required to confirm the importance of the association between frailty and ED-induced delirium
Introduction: Delirium is a common medical complication among seniors in hospital setting. In the emergency department (ED), its prevalence varies between 7 & 14%. Delirium is associated with increased mortality & longer hospital stay. This condition is also associated with functional & cognitive decline in hospitalized seniors and higher risk of institutionalization up to 2 years after their discharge. However, no data is currently available for ED patients. The aim of this study was to evaluate the association between ED-induced delirium and functional & cognitive decline in seniors at 60 days. Methods: This study is part of the Incidence and Impact measurement of Delirium Induced by ED-Stay (INDEED) study, an ongoing multicenter prospective cohort study in 5 Quebec EDs. Patients were recruited after 8 hours in the ED and followed up to 24h after admission. A 60-day follow-up phone assessment was also conducted. Delirium was measured by the validated Confusion Assessment Method & the Delirium Index. Functional status was measured by the validated OARS. Cognitive status was measured using the validated TICS-M. Functional and cognitive decline were obtained by comparing the baseline and 60-days follow-up scores. Results: 380 seniors were recruited and 280 had 60-day follow-up data available. ED-induced delirium was 8.4% of seniors. There was a difference in mean functional decline among seniors with and without ED-induced delirium 2.95(1.23-4.67) vs 1.55(1.20-1.91, pwlicoxon= 0.05] Proportion of seniors showing a decline ≥2 points on the OARS was significantly higher In those with ED-induced delirium (65,0 % vs 40.18 %, p=0.03). Seniors with ED-induced delirium also showed a significant decline in mean TICS scores [3.31 (0,82-5.84) vs -0.01((-.071-0.75)), pwlicoxon =0.009]. There was no significant difference in the proportions of seniors showing a decline ≥ 3 OARS points between those with or without delirium (p=0.06). Conclusion: ED-induced delirium seems to be associated with poor functional and cognitive outcomes in older patients 60 days after discharge from the hospital. Further studies are required to confirm clinical importance ED-induced delirium delayed complication.
Introduction: Delirium is a dreadful complication in seniors’ acute care. Many studies are available on the incidence of delirium, however ED-induced delirium is far less studied. We aim to evaluate the incidence and impact of ED-induced delirium among older non-delirious admitted ED patients who have prolonged ED stays (≥ 8 hours). Methods: This prospective INDEED study phase 1 included patients recruited from 4 Canadian EDs. Inclusion criteria: 1) Patients aged 65 and over; 2) ED stay ≥ 8 hours; 3) Patient is admitted to the hospital; 4) Patient is non-delirious upon arrival and at the end of the first 8 hours; 5) Independent or semi-independent patient. Eligible patients were assessed by a research assistant after an 8 hour exposition to the ED and evaluated twice a day up to 24h after ward admission. Patients’ functional and cognitive status were assessed using validated OARS and TICS-m tools. The Confusion Assessment Method was used to detect incident delirium. Hospital length of stays (LOS) were obtained. Univariate and multivariate analyses were conducted to evaluate outcomes. Results: Of the 380 patients prospectively followed, mean age was 76.5 (± 8.9), male represent 50% and 16.5% very old seniors (> 85 y.o.). The overall incidence of ED-induced delirium was 8.4%. Distribution by the 4 sites was: 10%, 13.8%, 5.5% & 13.4%. The mean ED LOS varied from 29 to 48 hours. The mean hospital LOS was increase by 6.1 days in the delirious patients compared to non-delirious patient (p<0.05). Increase mean hospital LOS distribution by site was by: 6.9, 8.5, 4.3 and 5.2 days for the ED-induced delirium patients. Conclusion: ED-induced delirium was recorded in nearly one senior out of ten after a minimal 8 hour exposure in the ED environment. An episode of delirium increases hospital LOS by about a week and therefore could contribute to ED overcrowding.
It has already been shown that most, and probably all, of the DA white dwarfs become variable in a narrow temperature range as they cool down (Fontaine et al. 1982). Optical photometry and spectrophotometry has led to several determinations of the boundaries of this instability strip. The strip has been found to cover the range 10300 - 13600 K (McGraw 1979), 10400 - 12100 K (Greenstein 1982), 10000 - 13000 K (Weidemann and Koester 1984) and 11000 - 13000 K (Fontaine et al. 1985). Theoretical calculations show that the location of the blue edge is very sensitive to the efficiency of convection used in the unpertubed models (Winget et al. 1982; Winget and Fontaine 1982; Fontaine, Tassoul, and Wesemael 1984). Also, the sharpness of this boundary depends on the range of stellar mass and thickness of the hydrogen envelope found in ZZ Ceti stars. Recently, Wesemael, Lamontagne, and Fontaine (1986) and Lamontagne, Wesemael, and Fontaine (1987) have obtained and compared ultraviolet observations of several DA white dwarfs, in or near the instability strip, with published model calculations from Nelan and Wegner (1985), hereafter NW, and Koester et al. (1985), hereafter KWZV. They determined the boundaries of the variability region at 11400 - 12500 K or 11700 - 13000 K depending on which grid was used. We present here a reanalysis of these IUE observations with an improved grid of model atmospheres in order to define more precisely the location of the blue edge.
We have analysed new spectroscopic observations of 22 population I WR stars in a sample defined by b<12.5 mag, 18h<α<6h, δ > −30°. This completes the search for orbital duplicity among all of the 30 pop I WR stars contained within these limits. We thus have an unbiased data base in a volume segment bounded by a distance of 3–4 kpc for WNE and WC stars , and 4–5 kpc for WNL stars Although more observations are still needed in some cases, we have found several new binary systems. Some of these are low-amplitude, single-line binaries, often with runaway velocities and/or large separations from the galactic plane. We consider them to be candidates for a WR + collapsar stage, as originally predicted by Tutukov and Yungelson (1973) and de Loore and De Grève (1975).
Amyotrophic lateral sclerosis (ALS) is an adult-onset disease characterized by the selective degeneration of motor neurons in the brain and spinal cord resulting in progressive paralysis and death. Current diagnosis of ALS is based on clinical assessment of related symptoms, which appear only late in the disease course after degeneration of a significant number of motor neurons. As a result, the identification and development of disease-modifying therapies is difficult, making ALS an incurable disease. Novel strategies for early diagnosis of ALS, to monitor disease progression and to assess response to existing and future treatments are urgently needed.
Many neurological disorders, including ALS, are accompanied by skin changes that often precede the onset of neurological symptoms. We have developed a unique ALS tissue-engineered skin model (ALS-TES), derived from the cells of ALS patients, in order to study the earliest stages of ALS-related skin pathology. For each participant, two skin biopsies were collected using a 6-mm diameter punch biopsy. Tissue-engineered skin was then generated from isolated keratinocytes and fibroblasts, and examined by routine histochemistry and immunohistochemistry, as well as by confocal microscopy. The ALS-TES model presents a number of striking features including altered epidermal differentiation, abnormal dermo-epidermal junction, delamination, keratinocyte infiltration, collagen disorganization and cytoplasmic TDP-43 inclusions, which are not seen in skin models derived from healthy subjects. The same abnormal skin model changes were detected skin models derived from the cells of pre- symptomatic C9orf72-linked ALS patients carrying the GGGGCC DNA repeat expansion. Consequently, our ALS-TES skin model could represent a renewable source of human tissue to better understand the physiopathological mechanisms underlying this disease, including cytoplasmic TDP43 accumulation, and lead to better tools for early diagnosis and disease monitoring.