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Whole grain wheat, in particular colored varieties, may have health benefits in adults with chronic metabolic disease risk factors. 29 overweight and obese adults with chronic inflammation (high sensitivity C-Reactive Protein (hs-CRP) > 1.0 mg/L) replaced four daily servings of refined grain food products with bran-enriched purple or regular whole wheat convenience bars (~ 41-45 g fiber, daily) for 8 weeks in a randomized, single-blind parallel arm study where body weight was maintained. Anthropometrics, blood markers of inflammation, oxidative stress, and lipemia and metabolites of anthocyanins and phenolic acids were compared at Days 1, 29 and 57 using repeated measures analysis of variance within groups and analysis of covariance between groups at Day 57, with Day 1 as a covariate. A significant reduction in interleukin-6 and increase in adiponectin were observed within the purple wheat (PW) group. Tumor necrosis factor (TNF)-α was lowered in both groups and ferulic acid concentration increased in the regular wheat (RW) group. Comparing between wheats, only plasma TNF-α and glucose differed significantly (P<0.05), i.e. TNF-α and glucose decreased with RW and PW, respectively. Consumption of PW or RW products showed potential to improve plasma markers of inflammation and oxidative stress in participants with evidence of chronic inflammation, with modest differences observed based on type of wheat.
Emergency medicine (EM) training programs incorporate simulation for teaching as well as formative and summative assessment. The development of a simulation curriculum for Canadian postgraduate EM programs is underway and would be facilitated by a standardized, user-friendly, nationally endorsed simulation template. We convened a nationally representative group of simulation educators to participate in a three-phase process to develop and refine a simulation case template for Canadian EM educators. Participants provided feedback by means of free text comments and focus groups which were analyzed to inform modification of the template. We anticipate that this template will facilitate the sharing of cases across sites and the development of standardized cases for simulation-based assessment.
Conquest and law are necessarily intertwined subjects. Conquerors seize not only a territory, but also sovereignty over a people. Usually the most visible display of this sovereignty is a conqueror's issuance of laws to better control or reshape what they have conquered. The Roman empire, the model state for many early medieval kingdoms, expanded its sovereignty over many independent peoples through military conquest, and followed up these conquests by imposing its law. The most famous of early medieval conquerors, Charlemagne, with his eyes on Rome, amended and fixed in form the laws of the peoples he had conquered or subordinated. In the most extreme case, he reinforced his brutal military conquest of the Saxons by issuing harsh laws to suppress their pagan religion and eliminate their political independence. Conquest was one of the preferred times for a new sovereign to impose new laws or to authorize old or existing ones. Both imposition of the new and authorization of the old were options and were often done at the same time, in the same piece of legislation.
We often treat the laws issued after a conquest as a litmus test for the level of change or continuity experienced by the conquered people, which is not unwarranted, given that laws are reflections of the policies arising out of political agendas. This, of course, is a very top down view of what a text purporting to describe the law actually represents. It also presumes the authenticity of records of the law. For the most part, texts of law codes are treated by historians as if authored by the kings whose names appear in their prologues. That the laws were the historical law-giver's is no doubt often the case. Not many historians would doubt that Roman imperial rescripts reflect the decisions of the imperial court of this or that emperor. In the same way, the laws aimed at the Saxons are considered by historians to be genuine reflections of the attitude and strategies of the Frankish conquerors who issued them.
Of course, things are not always as simple as they first appear. Early medieval law has a more complicated relationship to conquerors and to the conquered than can be explained by claiming that law reflects a winner's decision to change or maintain the existing laws of a conquered state.
In psychiatric and emergency healthcare settings, episodes of agitation and violence are relatively common. One meta-analysis reported that 32.4% of patients behaved violently during admission to a psychiatric ward; this was the mean rate of violence based on 122 studies from 11 countries (Bowers et al., 2011). The comparable rate in the UK studies was 41.7%. A study of general adult wards of a UK inner-city mental health trust found violence rates for 49% of men and 39% of women in the 6-month period studied (Hodgins et al., 2007).
Lewy body dementia, consisting of both dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD), is considerably under-recognised clinically compared with its frequency in autopsy series.
This study investigated the clinical diagnostic pathways of patients with Lewy body dementia to assess if difficulties in diagnosis may be contributing to these differences.
We reviewed the medical notes of 74 people with DLB and 72 with non-DLB dementia matched for age, gender and cognitive performance, together with 38 people with PDD and 35 with Parkinson's disease, matched for age and gender, from two geographically distinct UK regions.
The cases of individuals with DLB took longer to reach a final diagnosis (1.2 v. 0.6 years, P = 0.017), underwent more scans (1.7 v. 1.2, P = 0.002) and had more alternative prior diagnoses (0.8 v. 0.4, P = 0.002), than the cases of those with non-DLB dementia. Individuals diagnosed in one region of the UK had significantly more core features (2.1 v. 1.5, P = 0.007) than those in the other region, and were less likely to have dopamine transporter imaging (P < 0.001). For patients with PDD, more than 1.4 years prior to receiving a dementia diagnosis: 46% (12 of 26) had documented impaired activities of daily living because of cognitive impairment, 57% (16 of 28) had cognitive impairment in multiple domains, with 38% (6 of 16) having both, and 39% (9 of 23) already receiving anti-dementia drugs.
Our results show the pathway to diagnosis of DLB is longer and more complex than for non-DLB dementia. There were also marked differences between regions in the thresholds clinicians adopt for diagnosing DLB and also in the use of dopamine transporter imaging. For PDD, a diagnosis of dementia was delayed well beyond symptom onset and even treatment.
The Emergency Medicine (EM) Specialty Committee of the Royal College of Physicians and Surgeons of Canada (RCPSC) specifies that resuscitation entrustable professional activities (EPAs) can be assessed in the workplace and simulated environments. However, limited validity evidence for these assessments in either setting exists. We sought to determine if EPA ratings improve over time and whether an association exists between ratings in the workplace v. simulation environment.
All Foundations EPA1 (F1) assessments were collected for first-year residents (n = 9) in our program during the 2018–2019 academic year. This EPA focuses on initiating and assisting in the resuscitation of critically ill patients. EPA ratings obtained in the workplace and simulation environments were compared using Lin's concordance correlation coefficient (CCC). To determine whether ratings in the two environments differed as residents progressed through training, a within-subjects analysis of variance was conducted with training environment and month as independent variables.
We collected 104 workplace and 36 simulation assessments. No correlation was observed between mean EPA ratings in the two environments (CCC(8) = -0.01; p = 0.93). Ratings in both settings improved significantly over time (F(2,16) = 18.8; p < 0.001; η2 = 0.70), from 2.9 ± 1.2 in months 1–4 to 3.5 ± 0.2 in months 9–12. Workplace ratings (3.4 ± 0.1) were consistently higher than simulation ratings (2.9 ± 0.2) (F(2,16) = 7.2; p = 0.028; η2 = 0.47).
No correlation was observed between EPA F1 ratings in the workplace v. simulation environments. Further studies are needed to clarify the conflicting results of our study with others and build an evidence base for the validity of EPA assessments in simulated and workplace environments.
To assess the utility of an automated, statistically-based outbreak detection system to identify clusters of hospital-acquired microorganisms.
Multicenter retrospective cohort study.
The study included 43 hospitals using a common infection prevention surveillance system.
A space–time permutation scan statistic was applied to hospital microbiology, admission, discharge, and transfer data to identify clustering of microorganisms within hospital locations and services. Infection preventionists were asked to rate the importance of each cluster. A convenience sample of 10 hospitals also provided information about clusters previously identified through their usual surveillance methods.
We identified 230 clusters in 43 hospitals involving Gram-positive and -negative bacteria and fungi. Half of the clusters progressed after initial detection, suggesting that early detection could trigger interventions to curtail further spread. Infection preventionists reported that they would have wanted to be alerted about 81% of these clusters. Factors associated with clusters judged to be moderately or highly concerning included high statistical significance, large size, and clusters involving Clostridioides difficile or multidrug-resistant organisms. Based on comparison data provided by the convenience sample of hospitals, only 9 (18%) of 51 clusters detected by usual surveillance met statistical significance, and of the 70 clusters not previously detected, 58 (83%) involved organisms not routinely targeted by the hospitals’ surveillance programs. All infection prevention programs felt that an automated outbreak detection tool would improve their ability to detect outbreaks and streamline their work.
Automated, statistically-based outbreak detection can increase the consistency, scope, and comprehensiveness of detecting hospital-associated transmission.
The default mode network (DMN) dysfunction has emerged as a consistent biological correlate of multiple psychiatric disorders. Specifically, there is evidence of alterations in DMN cohesiveness in schizophrenia, mood and anxiety disorders. The aim of this study was to synthesize at a fine spatial resolution the intra-network functional connectivity of the DMN in adults diagnosed with schizophrenia, mood and anxiety disorders, capitalizing on powerful meta-analytic tools provided by activation likelihood estimation.
Results from 70 whole-brain resting-state functional magnetic resonance imaging articles published during the last 15 years were included comprising observations from 2,789 patients and 3,002 healthy controls.
Specific regional changes in DMN cohesiveness located in the anteromedial and posteromedial cortex emerged as shared and trans-diagnostic brain phenotypes. Disease-specific dysconnectivity was also identified. Unmedicated patients showed more DMN functional alterations, highlighting the importance of interventions targeting the functional integration of the DMN.
This study highlights functional alteration in the major hubs of the DMN, suggesting common abnormalities in self-referential mental activity across psychiatric disorders.
To make a tentative assessment of the consumption of cassava in three countries in South-east Asia and the cyanogenic potential (CNp) of the crop as a possible food safety issue.
We used data from the Ministry of Health in Vietnam and Statistics Authorities in Indonesia and Philippines (mean household consumption per province) to assess cassava consumption. Conversions of units were needed to facilitate the comparison of cassava consumption between countries. The most up-to-date data available regarding both cassava consumption and the CNp of cassava grown in the respective countries were assessed.
Vietnam, Indonesia and Philippines.
Respondents from provinces in Vietnam (nineteen), Indonesia (thirty-three) and Philippines (eighty-one) were asked to complete a recall questionnaire detailing either the previous 24-h’ or the 7-d’ cassava consumption.
Among the three countries, available data indicated that the highest median cassava-consumption figures percapita were from Indonesia and the Philippines (9·01 and 7·28 g/capita per d, respectively), with Vietnam having the least (1·14 g/capita per d). Published information regarding the CNp of cassava in the three countries was limited.
While the findings of the present study are somewhat limited by a lack of available information regarding both the extent of cassava consumption and the CNp of cassava consumed in the three countries, it appears likely that cyanogen intake arising from cassava consumption among the three countries exceeds the FAO/WHO Provisional Maximum Tolerable Daily Intake, although any risk to public health appears limited to a minority of provinces in each country.
The COVID-19 pandemic has disrupted the traditional practice of psychiatric assessment and treatment via face to face interaction. Telepsychiatry, the delivery of psychiatric care remotely through telecommunications technology, is an existing and under-utilised tool that may help to minimise disruption to patient care. Technological advancement is at a stage where it can facilitate widespread use of this practice; however concerns that limited its expansion previously were not unfounded. This article discusses the use of telepsychiatry in the context of the COVID-19 pandemic.
Individuals with tardive dyskinesia (TD) who completed a long-term study (KINECT 3 or KINECT 4) of valbenazine (40 or 80 mg/day, once-daily for up to 48 weeks followed by 4-week washout) were enrolled in a subsequent study (NCT02736955) that was primarily designed to further evaluate the long-term safety of valbenazine.
Participants were initiated at 40 mg/day (following prior valbenazine washout). At week 4, dosing was escalated to 80 mg/day based on tolerability and clinical assessment of TD; reduction to 40 mg/day was allowed for tolerability. The study was planned for 72 weeks or until termination due to commercial availability of valbenazine. Assessments included the Clinical Global Impression of Severity-TD (CGIS-TD), Patient Satisfaction Questionnaire (PSQ), and treatment-emergent adverse events (TEAEs).
At study termination, 85.7% (138/161) of participants were still active. Four participants had reached week 60, and none reached week 72. The percentage of participants with a CGIS-TD score ≤2 (normal/not ill or borderline ill) increased from study baseline (14.5% [23/159]) to week 48 (64.3% [36/56]). At baseline, 98.8% (158/160) of participants rated their prior valbenazine experience with a PSQ score ≤2 (very satisfied or somewhat satisfied). At week 48, 98.2% (55/56) remained satisfied. Before week 4 (dose escalation), 9.4% of participants had ≥1 TEAE. After week 4, the TEAE incidence was 49.0%. No TEAE occurred in ≥5% of participants during treatment (before or after week 4).
Valbenazine was well-tolerated and persistent improvements in TD were found in adults who received once-daily treatment for >1 year.
The proximity required of a thorough biomicroscopic slit-lamp examination may put ophthalmologists at increased risk for respiratory-borne infection with SARS-CoV-2. Conjunctivitis has been described in a few patients with COVID-19 and other coronavirus syndromes. Although SARS-CoV-2 has been detected in the conjunctival secretions or tears of patients with COVID-19 and conjunctivitis, transmission of infection through respiratory droplets to ophthalmologists without eye protection or masks may be the bigger concern.
Stratified medicine has been successfully used in many areas of medicine, perhaps most notably oncology. There is now both a growing evidence base and mounting enthusiasm, supported at a governmental level and across industry, academia and clinical medicine, to apply this approach to neurodegenerative illnesses, including dementia, as these provide the greatest clinical and social challenge of our times. In this article we consider definitions of stratified medicine, look at its application in other medical specialties, review the national context in the UK and consider the current state, future potential and specific considerations of applying stratified medicine to dementia.
Mild cognitive impairment (MCI) may gradually worsen to dementia, but often remains stable for extended periods of time. Little is known about the predictors of decline to help explain this variation. We aimed to explore whether this heterogeneous course of MCI may be predicted by the presence of Lewy body (LB) symptoms in a prospectively-recruited longitudinal cohort of MCI with Lewy bodies (MCI-LB) and Alzheimer's disease (MCI-AD).
A prospective cohort (n = 76) aged ⩾60 years underwent detailed assessment after recent MCI diagnosis, and were followed up annually with repeated neuropsychological testing and clinical review of cognitive status and LB symptoms. Latent class mixture modelling identified data-driven sub-groups with distinct trajectories of global cognitive function.
Three distinct trajectories were identified in the full cohort: slow/stable progression (46%), intermediate progressive decline (41%) and a small group with a much faster decline (13%). The presence of LB symptomology, and visual hallucinations in particular, predicted decline v. a stable cognitive trajectory. With time zeroed on study end (death, dementia or withdrawal) where available (n = 39), the same subgroups were identified. Adjustment for baseline functioning obscured the presence of any latent classes, suggesting that baseline function is an important parameter in prospective decline.
These results highlight some potential signals for impending decline in MCI; poorer baseline function and the presence of probable LB symptoms – particularly visual hallucinations. Identifying people with a rapid decline is important but our findings are preliminary given the modest cohort size.
Archaeologists have long subjected Clovis megafauna kill/scavenge sites to the highest level of scrutiny. In 1987, a Columbian mammoth (Mammuthus columbi) was found in spatial association with a small artifact assemblage in Converse County, Wyoming. However, due to the small tool assemblage, limited nature of the excavations, and questions about the security of the association between the artifacts and mammoth remains, the site was never included in summaries of human-killed/scavenged megafauna in North America. Here we present the results of four field seasons of new excavations at the La Prele Mammoth site that confirm the presence of an associated cultural occupation based on geologic context, artifact attributes, spatial distributions, protein residue analysis, and lithic microwear analysis. This new work identified a more extensive cultural occupation including the presence of multiple discrete artifact clusters in close proximity to the mammoth bone bed. This study confirms the presence of a second Clovis mammoth kill/scavenge site in Wyoming and shows the value in revisiting proposed terminal Pleistocene kill/scavenge sites.
Introduction: The legalization of cannabis for recreational use in 2018 remains a controversial topic. There are multiple perceived benefits of cannabis including pain relief, treatment of epilepsy syndromes, and improving body weight of cancer patients. However, there are also many potential risks. The short-term health consequences include cannabinoid hyperemesis syndrome and cannabis induced psychosis. These conditions directly impact the influx of patients presenting to Emergency Departments (ED). There is currently limited research in the area of cannabis legalization burden. However, the studies performed have shown a significant impact in those states which cannabis is legal. A study completed in Colorado found that hospitalization rates with marijuana related billing codes increased from 274 to 593 per 100 000 hospitalizations after the state legalization of recreational cannabis. This study aims to examine if Canada's hospitals are experiencing the same burden as other jurisdictions. Methods: A descriptive study was preformed via a retrospective chart review of cannabis related visits in tertiary EDs in St. John's, NL, from six months prior to the date of legalization of cannabis for recreational use, to six months after. Hospital ED visit records from both the Health Science Centre and St. Clare's Mercy Hospital were searched using keywords to identify patients who presented with symptoms related to cannabis use. We manually reviewed all visit records that included one or more of these terms to distinguish true positives from false positive cases, unrelated to cannabis use. Results: A total of 287 charts were included in the study; 123 visits were related to cannabis use six months prior to legalization, and 164 six months after legalization. A significant increase in ED visits following the legalization of recreational cannabis was seen (p < .001). There was no significant difference in the age of users between the two groups. Additionally, the number one presenting complaint due to cannabis use was vomiting (47.7%), followed by anxiety (12.2%). Conclusion: Following the implementation of the Cannabis Act in Canada, EDs in St. John's, NL had a statistically significant increase in the number of visits related to cannabis use. It is important to determine such consequences to ensure hospitals and public health agencies are prepared to treat the influx of visits and are better equipped to manage the associated symptoms.
Introduction: The primary objective of this study was to determine the incidence of clinically significant traumatic intracranial haemorrhage (T-ICH) following minor head trauma in older adults. Secondary objective was to investigate the impact of anticoagulant and antiplatelet therapies on T-ICH incidence. Methods: This retrospective cohort study extracted data from electronic patient records. The cohort consisted of patients presenting after a fall and/or head injury and presented to one of five ED between 1st March 2010 and 31st July 2017. Inclusion criteria were age ≥ 65 years old and a minor head trauma defined as an impact to the head without fulfilling criteria for traumatic brain injury. Results: From the 1,000 electronic medical records evaluated, 311 cases were included. The mean age was 80.1 (SD 7.9) years. One hundred and eighty-nine (189) patients (60.8%) were on an anticoagulant (n = 69), antiplatelet (n = 130) or both (n = 16). Twenty patients (6.4%) developed a clinically significant T-ICH. Anticoagulation and/or antiplatelets therapies were not associated with an increased risk of clinically significant T-ICH in this cohort (Odds ratio (OR) 2.7, 95% CI 0.9-8.3). Conclusion: In this cohort of older adults presenting to the ED following minor head trauma, the incidence of clinically significant T-ICH was 6.4%.
Introduction: Distributing take-home naloxone (THN) kits from Emergency Departments (EDs) is an important strategy for preventing opioid overdose deaths. However, there is a lack of clear operational guidance for implementing ED-based THN programs. This scoping review had two objectives: 1) identify key strategies for THN distribution in EDs, and 2) develop a theory-informed implementation model that can be used to optimize the effectiveness of ED-based THN programs. Methods: We systematically searched health science databases through April 18, 2019. The search strategy combined terms representing the ED, naloxone, and take-home kits/bystander administration. Two reviewers independently screened the search results. We included all peer-reviewed articles that described THN distribution within EDs. A standardized form was used for data extraction. Included studies were coded by two reviewers and mapped to domains of the Consolidated Framework for Implementation Research (CFIR). A third reviewer with content expertise adjudicated disagreements in record screening and data coding. Results: Database searching retrieved 717 records after duplicates were removed. 87 full-text studies were assessed for eligibility. Two studies were added through other sources, resulting in a total of 21 studies included in the final review. Of note, 14 studies evaluated existing ED-based THN programs. We synthesized themes that emerged within each CFIR domain and identified four key implementation strategies: 1) develop ED policies on opioid harm reduction; 2) collaborate with community and government partners to ensure programs meet patient needs; 3) address provider attitudes and knowledge gaps through dedicated training; and 4) establish guidelines to identify patients who are at risk of opioid overdose, and engage at-risk patients to maximize THN acceptance. Conclusion: ED-based THN programs must be tailored to local community needs and available hospital resources. Innovative implementation strategies are needed to promote ED provider engagement, and reduce barriers to patient acceptance of THN in the ED. This scoping review highlights key considerations for ED-THN implementation that can guide EDs to establish new programs, or refine existing programs to maximize their effectiveness.
Innovation Concept: A major barrier to the development of a national simulation case repository and multi-site simulation research is the lack of a standardized national case template. This issue was recently identified as a priority research topic for Canadian simulation based education (SBE) research in emergency medicine (EM). We partnered with the EM Simulation Education Researchers Collaborative (EM-SERC) to develop a national simulation template. Methods: The EM Sim Cases template was chosen as a starting point for the consensus process. We generated feedback on the template using a three-phase modified nominal group technique. Members of the EM-SERC mailing list were consulted, which included 20 EM simulation educators from every Canadian medical school except Northern Ontario School of Medicine and Memorial University. When comments conflicted, the sentiment with more comments in favour was incorporated. Curriculum, Tool or Material: In phase one we sought free-text feedback on the EM Sim Cases template via email. We received 65 comments from 11 respondents. An inductive thematic analysis identified four major themes (formatting, objectives, debriefing, and assessment tools). In phase two we sought free-text feedback on the revised template via email. A second thematic analysis on 40 comments from 12 respondents identified three broad themes (formatting, objectives, and debriefing). In phase three we sought feedback on the penultimate template via focus groups with simulation educators and technologists at multiple Canadian universities. This phase generated 98 specific comments which were grouped according to the section of the template being discussed and used to develop the final template (posted on emsimcases.com). Conclusion: We describe a national consensus-building process which resulted in a simulation case template endorsed by simulation educators from across Canada. This template has the potential to: 1. Reduce the replication of effort across sites by facilitating the sharing of simulation cases. 2. Enable national collaboration on the development of both simulation cases and curricula. 3. Facilitate multi centre simulation-based research by removing confounders related to the local adoption of an unfamiliar case template. This could improve the rigour and validity of these studies by reducing inter-site variability. 4. Increase the validity of any simulation scenarios developed for use in national high-stakes assessment.