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Growth in emergency department (ED) attendance and acute medical admissions has been managed to very low rates for 18 years in Canterbury, New Zealand, using a combination of community and hospital avoidance strategies. This paper describes the specific strategies that supported management of acutely unwell patients in the community as part of a programme to integrate health services.
Community-based acute care was established by a culture of close collaboration and trust between all sectors of the health system, with general practice closely involved in the design and management of the services, and support provided by hospital specialists, coordination and diagnostic units, and competent informatics. Introduction of the community-based services was aided by a clinical guidance website and an education programme for general practice teams and allied health professionals.
Attendance at EDs and acute medical admission rates have been held at low growth and, in some cases, shorter lengths of hospital stay. This trend was especially evident in elderly patients and those with ambulatory care sensitive or chronic disorders.
A system of community-based care and education has resulted in sustained gains for the Canterbury health system and freed-up hospital resources. This outcome has engendered a sense of empowerment for general practice teams and their patients.
Introduction: Biphasic anaphylactic reactions are a concern in emergency medicine. Risk factors associated with this type of reaction remain ill-defined. The aim of this study was to investigate elements associated with biphasic anaphylactic reactions and to determine the impact of anaphylaxis treatments on biphasic reactions. Methods: From the multicenter Cross-Canada Anaphylaxis Registry prospective cohort, we selected adults (≥18 years) with a visit to the emergency department (ED) of Sacré-Cœur Hospital, an urban tertiary-care hospital. Then, a structured chart review was done to collect additional information on types and timing of treatments for the initial anaphylactic reaction, presence and treatment of biphasic reactions during the initial ED visit or upon patients’ return. Biphasic reactions were defined by the recurrence of any anaphylaxis symptoms within 72 hours of a resolved anaphylaxis episode. Potential factors associated with biphasic reactions were studied using Chi-Square and Mann-Whitney tests. Results: Patients with anaphylaxis were enrolled between April 2014 and February 2018. From the cohort, 401 adult patients were identified. We found 37 patients who developed a biphasic reaction. Amongst them, 33 received treatments and 9 required more than one dose of intramuscular epinephrine. None of the biphasic reaction patients required intravenous epinephrine, other vasopressors, ICU admission, or endotracheal intubation. Biphasic reactions appeared in a median time of 13.3h after the initial reaction ranging from 1.1h to 69.6h (IQR 30.2). There was no difference in age or gender of patients who developed a biphasic reaction compared those who did not. Pertinent past medical history, daily medications, mean of arrival to the ED, allergen type, ingestion route, or initial symptoms during the anaphylaxis episode were not significantly different in the two groups. Treatment with corticosteroids was similar in the two groups (9.0% vs. 8.1% p = 0.82). Treatment, dose and route of administration of epinephrine was not different in the two groups but longer delays before treatment with the first dose of epinephrine was more frequent in biphasic reaction patients (median delay of 64 minutes, p = 0.015). Conclusion: No patient characteristic, allergen, route of ingestion, symptom, nor treatment with corticosteroids has shown to be significantly different in patients with and without biphasic reactions. Delayed treatment with epinephrine is significantly associated with biphasic reactions.
While life has been increasing in length an increasing proportion of that life is in a state of poor health and decrepitude. Indeed, an increasing proportion of life is in that poor state because of its increased length. Medicine always fails to catch up, and increasingly so in providing a life of good health overall set by the end point of inevitable death. This requires a change in attitude from the zealous concentration on medical interventions whose chief aim is to increase the length of life, and a move to being able to consider more readily refusing some medical treatments, along with a more resigned attitude to our death, which must come anyway.
Alteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals.
Red Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017.
A total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60–103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22–42 minutes) (p < 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period.
Community hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.
In precision agriculture, the selection and use of appropriate sensors determine the type and quality of information that will feed decision-support models. A wide variety of sensors, spectral ranges, data collection and processing approaches are used, sometimes leading to confusion. Whether in transmission or reflectance mode, multispectral or hyperspectral, laboratory or field-based or even satellite-borne, in order to achieve meaningful and accurate measurements it is essential to have a clear understanding of which part of the electromagnetic spectrum the sensors relate to and how the corresponding radiation interacts with the substrate (e.g. soils, crops, livestock products). Sensors in the visible range (390-700 nm) use colour to identify certain properties of the substrate (e.g. chlorophyll and pigments in crops, organic matter contents in soil) and can be used to detect and quantify colour changes that could, in turn, be correlated with changes in those properties. Alternatively, radiation in the near (NIR, 750-2500 nm) and mid infrared (MIR, 2500-25 000 nm) interacts with the molecular bonds that constitute organic and inorganic matter and, therefore, sensors with detectors in these ranges provide different but interrelated information on the chemical composition of the substrate. Shorter wavelength radiation in the form of X-Rays (0.1-10 nm) induces fluorescence in the substrate and XRF sensors provide elemental atomic information that is highly applicable to the study of soils, sediments and fluids. At the James Hutton Institute, we have expertise in the use of all these types of sensors and are developing practical applications based on a thorough understanding of the processes involved. In this paper we provide an overview of the capabilities and applications of the different sensors used in precision agriculture, not only with a theoretical understanding, but also with an awareness of the practicalities involved.
While children both understand the concept of, and have died by, suicide, little research has been conducted on children's experiences of healthcare systems during and after a suicidal crisis. This article focuses on three case studies of mothers with suicidal daughters and aims to describe the health service experiences of parents whose children have attempted suicide. The case studies were selected as exemplars of three different healthcare experiences of mothers with suicidal daughters younger than 16 years of age. Interviews were conducted with the mothers, focusing on their experiences when trying to find care for their daughters after a suicide attempt. A ‘dirty text’ analysis was undertaken on the transcripts, which aimed to find potential redemption within stories of trauma. Narratives were analysed to see how their stories were told, but also how experiences could be shared or be dissimilar. Significant gaps currently exist in the care and support provided to suicidal children, particularly in the critical post-discharge phase. Adults were not always able to recognise when a child was suicidal, or sometimes take that suicidality seriously. Support must often be proactively sought, and even organisations that are meant to target children and adolescents may not always provide appropriate care.
The answer to the question of why there is Something rather than Nothing is that there has to be Something and that Nothing is impossible. There cannot not be Something so there cannot be Nothing. The paper justifies this conclusion, while also explaining why we might believe there may be Nothing. In the course of this, the so-called subtraction-argument is shown to be inadequate and question-begging.
There is a growing body of research emphasizing the advantages of teaching students social and emotional (SE) skills in school. Here we examine the economic value of these skills within a benefit-cost analysis (BCA) framework. Our examination has three parts. First, we describe how the current method of BCA must be expanded to adequately evaluate SE skills, and we identify important decisions analysts must make. Second, we review the evidence on the benefits of SE skills, again noting key methodological issues with respect to shadow pricing. Finally, we perform BCA of four selected social and emotional learning (SEL) interventions: 4Rs; Second Step, Life Skills Training; and Responsive Classroom. These analyses illustrate both methodological and empirical challenges in estimating net present values for these interventions. Even with these challenges, we find that the benefits of these interventions substantially outweigh the costs. We highlight promising areas of research for improving the application of BCA to SEL.
The role of hypothetical acts, as opposed to actual acts, has been neglected in understanding the nature of what is required by the Respect for Persons formulation of the Categorical Imperative in concrete moral relations between persons. This had led to a failure to understand fully the way and the extent to which the Categorical Imperative may be present in all such relations with others as encapsulated in an appropriate attitude towards others that may refer to hypothetical acts, as well as actual acts. The result is an underestimation of the direct relevance and moral efficacy of the Categorical Imperative.
Objectives: We present our experience of an annual research symposium for psychiatric trainees in Scotland. This paper aimed to consider trainees' involvement in research by examining firstly rates of publication and secondly the views of trainees.
Methods: A list of all presentations to the Senior Trainees' Annual Research Symposium (STARS) meetings 2007-2009 was compiled and a detailed search made of major research databases. A questionnaire survey examined the views of attendees at the 2009 meeting.
Results: Fifty percent of presented work achieved publication. Feedback from symposia attendees was almost universally positive.
Conclusions: At a time of debate on the value of research sessions as part of higher training and a recent reduction in time allocated to research in the UK, we report on a thriving annual meeting. Research symposia for higher trainees were valued by participants and may be one useful means of encouraging trainee research.
The following argument presents a refutation of the existence of God under a certain description, which, it will be maintained, is the only description that most traditional monotheists could accept. Therefore, either God, as defined by traditional monotheism, does not exist or something that might be called ‘God’ exists, but would not be acceptable to monotheism as truly being God. Either way, God does not exist.1
Allen Shand works as a general adult psychiatrist at Royal Cornhill Hospital, Aberdeen. He has always been an enthusiastic artist but only took up photography in 2004 while living in Melbourne, Australia where he worked as a registrar in psychiatry. He describes Recovery as follows:
Imagine a universe without human beings. Now imagine a universe devoid of any creatures like human beings, beings who could think about the universe and in so doing consider it as divided up into different kinds of things that could be objects of understanding. Now imagine – this is harder – your not being there, or anyone else, to imagine such a universe. Next think about setting about describing in physical laws such a universe in line with a completist physicalist program: that all the facts about the world are physical facts. But where would one begin? Why would one begin? Remember there is no-one around to take more interest in any part of the universe than any other. This contrasts with what we do now. What we do now is take chunks of the universe – stars, planets, water, trees, air, particles – and demarcate the physical laws in such a way as to explain how these objects behave against a background of other objects and ultimately the universe as a whole. But what if we were not around? Why would we there be any reason to demarcate groups of physical laws in this or any other way? My suggestion is that there would be none. The grouping of the physical laws to form complex classes and layers of explanations (how trees and water are related; how planets move as part of a solar system) is parasitic upon creatures having particular interests giving them a perspective (‘perspective’ is being used here in a somewhat technical sense) upon the universe or world, which in turn derives from the kind of limited creatures they happen to be. But the perspective itself is not a physical fact about the universe. Rather it is a way of coming to form a system of facts about the universe. Further, not only might the perspective have been otherwise, there might be none at all. In which case the demarcation of physical laws, given meaning by their application to entities picked out as having a certain significance to us, would not get off the ground. At best there might be a random bunching of laws covering regions of the universe. But such random bunchings would have no meaning; they would be unintelligible; they wouldn't really be about anything. For laws to be about things you have to have limited creatures who differentiate between parts of the universe, and for whom different parts have a variable significance and value. Things stand out for them; they literally exist. Without such creatures, things we take for granted would, in the literal sense, not exist. It is the very limitedness of our perspective and capabilities, such that things are problems for us, and wherefore we literally or metaphorically bump into things, that brings objects into existence for us. Otherwise the universe would be utterly ‘flat’ and undifferentiated. A limitation of perspective is required for there to be objects of thought, and thus for thought itself. Thus, the intelligibility of the laws of physics is logically parasitic upon our having varying interests in different segments of the universe.
Settling definitions is often seen as a central tool for clarifying concepts, and answering ‘What is X?’ questions. Examples might be ‘What is knowledge?’, ‘What is a work of art?’ or ‘What is a dog?’. A common way of answering such questions is by formulating necessary and sufficient conditions for a thing to be of a certain sort. It is this form of real definition that is of concern here.