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Introduction: In 2018, Canadian postgraduate specialist Emergency Medicine (EM) programs began implementing a competency-based medical education (CBME) assessment system. To support improvement of this assessment program, we sought to evaluate its short-term educational outcomes nationally and within individual programs. Methods: Program-level data from the 2018 resident cohort were amalgamated and analyzed. The number of Entrustable Professional Activity (EPA) assessments (overall and for each EPA) and the timing of resident promotion through program stages was compared between programs and to the guidelines provided by the national EM specialty committee. Total EPA observations from each program were correlated with the number of EM and pediatric EM rotations. Results: Data from 15 of 17 (88.2%) EM programs containing 9,842 EPA observations from 68 of the 77 (88.3%) Canadian EM specialist residents in the 2018 cohort were analyzed. The average number of EPAs observed per resident in each program varied from 92.5 to 229.6 and correlated strongly with the number of blocks spent on EM and pediatric EM (r = 0.83, p < 0.001). Relative to the guidelines outlined by the specialty committee, residents were promoted later than expected and with fewer EPA observations than suggested. Conclusion: We present a new approach to the amalgamation of national and program-level assessment data. There was demonstrable variation in both EPA-based assessment numbers and promotion timelines between programs and with national guidelines. This evaluation data will inform the revision of local programs and national guidelines and serve as a starting point for further reaching outcome evaluation. This process could be replicated by other national assessment programs.
Introduction: CAEP recently developed the acute atrial fibrillation (AF) and flutter (AFL) [AAFF] Best Practices Checklist to promote optimal care and guidance on cardioversion and rapid discharge of patients with AAFF. We sought to assess the impact of implementing the Checklist into large Canadian EDs. Methods: We conducted a pragmatic stepped-wedge cluster randomized trial in 11 large Canadian ED sites in five provinces, over 14 months. All hospitals started in the control period (usual care), and then crossed over to the intervention period in random sequence, one hospital per month. We enrolled consecutive, stable patients presenting with AAFF, where symptoms required ED management. Our intervention was informed by qualitative stakeholder interviews to identify perceived barriers and enablers for rapid discharge of AAFF patients. The many interventions included local champions, presentation of the Checklist to physicians in group sessions, an online training module, a smartphone app, and targeted audit and feedback. The primary outcome was length of stay in ED in minutes from time of arrival to time of disposition, and this was analyzed at the individual patient-level using linear mixed effects regression accounting for the stepped-wedge design. We estimated a sample size of 800 patients. Results: We enrolled 844 patients with none lost to follow-up. Those in the control (N = 316) and intervention periods (N = 528) were similar for all characteristics including mean age (61.2 vs 64.2 yrs), duration of AAFF (8.1 vs 7.7 hrs), AF (88.6% vs 82.9%), AFL (11.4% vs 17.1%), and mean initial heart rate (119.6 vs 119.9 bpm). Median lengths of stay for the control and intervention periods respectively were 413.0 vs. 354.0 minutes (P < 0.001). Comparing control to intervention, there was an increase in: use of antiarrhythmic drugs (37.4% vs 47.4%; P < 0.01), electrical cardioversion (45.1% vs 56.8%; P < 0.01), and discharge in sinus rhythm (75.3% vs. 86.7%; P < 0.001). There was a decrease in ED consultations to cardiology and medicine (49.7% vs 41.1%; P < 0.01), but a small but insignificant increase in anticoagulant prescriptions (39.6% vs 46.5%; P = 0.21). Conclusion: This multicenter implementation of the CAEP Best Practices Checklist led to a significant decrease in ED length of stay along with more ED cardioversions, fewer ED consultations, and more discharges in sinus rhythm. Widespread and rigorous adoption of the CAEP Checklist should lead to improved care of AAFF patients in all Canadian EDs.
Correlation of Rodinian and Gondwanan crustal domains relies on a thorough knowledge of those vestiges preserved today. The Bunger Hills hold a critical place in East Antarctica, recording the Mesoproterozoic assembly of Australo-Antarctica in Rodinia and the Neoproterozoic–Cambrian amalgamation of Indo- and Australo-Antarctica in Gondwana. It is situated in a region of disputed overlap between the different components of Rodinia and Gondwana, where there is little consensus on the location of sutures in this region and thus often speculative geological interpretations. The Bunger Hills therefore provide an opportunity to better understand the tectonic setting and palaeogeography during the assembly of these supercontinents. Recent work has confirmed that the Bunger Hills are one of few rare outcrops in Wilkes Land, East Antarctica that can be directly correlated with the broader Musgrave–Albany–Fraser–Wilkes Orogen (MAFWO). Whilst other constituent terranes of the MAFWO have been intensely studied, our geological knowledge of the Bunger Hills was comparatively limited until recently. In light of recent geological and geophysical developments, this contribution serves as an updated and concise standalone reference for the present state of knowledge of the Neoarchean–Cambrian evolution of the Bunger Hills region.
Studies suggest that alcohol consumption and alcohol use disorders have distinct genetic backgrounds.
We examined whether polygenic risk scores (PRS) for consumption and problem subscales of the Alcohol Use Disorders Identification Test (AUDIT-C, AUDIT-P) in the UK Biobank (UKB; N = 121 630) correlate with alcohol outcomes in four independent samples: an ascertained cohort, the Collaborative Study on the Genetics of Alcoholism (COGA; N = 6850), and population-based cohorts: Avon Longitudinal Study of Parents and Children (ALSPAC; N = 5911), Generation Scotland (GS; N = 17 461), and an independent subset of UKB (N = 245 947). Regression models and survival analyses tested whether the PRS were associated with the alcohol-related outcomes.
In COGA, AUDIT-P PRS was associated with alcohol dependence, AUD symptom count, maximum drinks (R2 = 0.47–0.68%, p = 2.0 × 10−8–1.0 × 10−10), and increased likelihood of onset of alcohol dependence (hazard ratio = 1.15, p = 4.7 × 10−8); AUDIT-C PRS was not an independent predictor of any phenotype. In ALSPAC, the AUDIT-C PRS was associated with alcohol dependence (R2 = 0.96%, p = 4.8 × 10−6). In GS, AUDIT-C PRS was a better predictor of weekly alcohol use (R2 = 0.27%, p = 5.5 × 10−11), while AUDIT-P PRS was more associated with problem drinking (R2 = 0.40%, p = 9.0 × 10−7). Lastly, AUDIT-P PRS was associated with ICD-based alcohol-related disorders in the UKB subset (R2 = 0.18%, p < 2.0 × 10−16).
AUDIT-P PRS was associated with a range of alcohol-related phenotypes across population-based and ascertained cohorts, while AUDIT-C PRS showed less utility in the ascertained cohort. We show that AUDIT-P is genetically correlated with both use and misuse and demonstrate the influence of ascertainment schemes on PRS analyses.
Emerging cybertechnologies, such as social digibots, bend epistemological conventions of life and culture already complicated by human and animal relationships. Virtually-augmented niches of machines and organic life promise new free-energy-governed selection of intelligent digital life. These provocative eco-evolutionary contexts demand a theory of (natural and artificial) minds to characterize and validate the immersive social phenomena universally-shaping cultural affordances.
A developing application of laser-driven currents is the generation of magnetic fields of picosecond–nanosecond duration with magnitudes exceeding
. Single-loop and helical coil targets can direct laser-driven discharge currents along wires to generate spatially uniform, quasi-static magnetic fields on the millimetre scale. Here, we present proton deflectometry across two axes of a single-loop coil ranging from 1 to 2 mm in diameter. Comparison with proton tracking simulations shows that measured magnetic fields are the result of kiloampere currents in the coil and electric charges distributed around the coil target. Using this dual-axis platform for proton deflectometry, robust measurements can be made of the evolution of magnetic fields in a capacitor coil target.
Subcutaneous adipose tissue (scAT) and peripheral blood mononuclear cells (PBMC) play a significant role in obesity-associated systemic low-grade inflammation. High-fat diet (HFD) is known to induce inflammatory changes in both scAT and PBMC. However, the time course of the effect of HFD on these systems is still unknown. The aim of the present study was to determine the time course of the effect of HFD on PBMC and scAT. New Zealand white rabbits were fed HFD for 5 or 10 weeks (i.e. HFD-5 and HFD-10) or regular chow (i.e. control (CNT)-5 and CNT-10). Thereafter, metabolic and inflammatory parameters of PBMC and scAT were quantified. HFD induced hyperfattyacidaemia in HFD-5 and HFD-10 groups, with the development of insulin resistance in HFD-10, while no changes were observed in scAT lipid metabolism and inflammatory status. HFD activated the inflammatory pathways in PBMC of HFD-5 group and induced modified autophagy in that of HFD-10. The rate of fat oxidation in PBMC was directly associated with the expression of inflammatory markers and tended to inversely associate with autophagosome formation markers in PBMC. HFD affected systemic substrate metabolism, and the metabolic, inflammatory and autophagy pathways in PBMC in the absence of metabolic and inflammatory changes in scAT. Dietary approaches or interventions to avert HFD-induced changes in PBMC could be essential to prevent metabolic and inflammatory complications of obesity and promote healthier living.
Additional crystallographic data are given for the recently reported mineral middlebackite, which has been described for discoveries at Iron Knob in South Australia and Passo di San Lugano near Trento, Italy. The material examined in the present study was from a third finding of the mineral, viz. from a quartz outcrop at Mooloo Downs Station in Western Australia within which it was co-located with the chemically- and structurally-related mineral moolooite, CuIIC2O4·nH2O, reported by Clarke and Williams (1986). In this study, the crystal structure was elucidated independently of the other studies using a combination of the a priori charge flipping and simulated annealing methods with synchrotron radiation diffraction (SRD) powder data. The principal crystal data for the Mooloo Downs material are: space group P21/c with lattice parameters a = 7.2659(18) Å, b = 5.7460(11) Å, c = 5.6806(11) Å, β = 104.588(3)°; Vc = 229.46(18) Å3; empirical formula CuII2C2O4(OH)2 with 2 formula units per unit cell; and calculated density = 3.605 g cm−3. The lattice parameters agree approximately with values given for the other studies, but not within the reported error estimates. The atom coordinates, interatomic distances, and angles for the Mooloo Downs material are compared with those from the other studies using single crystal data, with the values from all three studies agreeing approximately, but again not within the reported uncertainties. The crystal chemistry found for middlebackite received strong confirmation through the synthesis for the first time of di-copper oxalate di-hydroxide. Laboratory X-ray diffraction powder data for the synthetic form of the mineral from this study agree closely with the SRD data for the natural mineral.
Endoscopic ear surgery is a technique that is growing in popularity. It has potential advantages in the low-resource setting for teaching and training, for the relative ease of transporting and storing the surgical equipment and for telemedicine roles. There may also be advantages to the patient, with reduced post-operative pain, facilitating the ability to complete procedures as out-patients.
Our Ear Trainer has previously been validated for headlight and microscope otology skills, including foreign body removal and ventilation tube insertion, in both the high- and low-resource setting. This study aimed to assess the Ear Trainer for similar training and assessment of endoscopic ear surgery skills in the low-resource setting. The study was conducted in Uganda on ENT trainees.
Despite a lack of prior experience with endoscopes, with limited practice time most participants showed improvements in: efficiency of instrument movement, steadiness of the camera view obtained, overall global rating of the task and performance time (faster task performance).
These results indicate that the Ear Trainer is a useful tool in the training and assessment of endoscopic ear surgery skills.
The orthorhombic mineral moolooite, CuC2O4. nH2O, described by Clarke and Williams (1986) using Debye-Scherrer photographic data, has a fully-disordered stacking fault (FDSF) structure. Related monoclinic models have been reported for various synthesised samples based on Schmittler (1968). In the present study, synchrotron radiation diffraction data for moolooite and synthesised specimens have been examined with particular reference to crystallographic disorder. The moolooite data correspond to space group Pnnm, with a = 5.3064(2), b = 5.6804(2), c = 2.5630(1) Å; Vc = 77.26(1) Å3; and Z = 1; and the FDSF structure along the b-direction has been confirmed. The synthetic specimen data from the study indicate partial ordering, with space group P21/n; and the cell parameters for one specimen being a = 5.957(7), b = 5.611(5), c = 5.133(7) Å; β = 115.16(2)°; Vc = 155.27 Å3 and Z = 2. The level of zeolitic water in the materials has been considered using the approach of Schmittler based on thermogravimetry and pycnometry. The new data for natural topotype material correspond to CuC2O4.1.0H2O. It is postulated that the level of water for natural and synthetic specimens may be attributed to the conditions under which the material forms.
Some neurotropic enteroviruses hijack Trojan horse/raft commensal gut bacteria to render devastating biomimicking cryptic attacks on human/animal hosts. Such virus-microbe interactions manipulate hosts’ gut-brain axes with accompanying infection-cycle-optimizing central nervous system (CNS) disturbances, including severe neurodevelopmental, neuromotor, and neuropsychiatric conditions. Co-opted bacteria thus indirectly influence host health, development, behavior, and mind as possible “fair-weather-friend” symbionts, switching from commensal to context-dependent pathogen-like strategies benefiting gut-bacteria fitness.
Foraging for nutritional sustenance represents common significant learned/heritable survival strategies evolved for phylum-diverse cellular life on Earth. Unicellular aneural to multicellular neural foragers display conserved rational or irrational decision making depending on outcome predictions for noise-susceptible real/illusory homeodynamic and ambient dietary cues. Such context-dependent heuristic-guided foraging enables optimal, suboptimal, or fallacious decisions that drive organismal adaptation, health, longevity, and life history.
To examine the feasibility of using social media to assess the consumer nutrition environment by comparing sentiment expressed in Yelp reviews with information obtained from a direct observation audit instrument for grocery stores.
Trained raters used the Nutrition Environment Measures Survey in Stores (NEMS-S) in 100 grocery stores from July 2015 to March 2016. Yelp reviews were available for sixty-nine of these stores and were retrieved in February 2017 using the Yelp Application Program Interface. A sentiment analysis was conducted to quantify the perceptions of the consumer nutrition environment in the review text. Pearson correlation coefficients (ρ) were used to compare NEMS-S scores with Yelp review text on food availability, quality, price and shopping experience.
Detroit, Michigan, USA.
Yelp reviews contained more comments about food availability and the overall shopping experience than food price and food quality. Negative sentiment about food prices in Yelp review text and the number of dollar signs on Yelp were positively correlated with observed food prices in stores (ρ=0·413 and 0·462, respectively). Stores with greater food availability were rated as more expensive on Yelp. Other aspects of the food store environment (e.g. overall quality and shopping experience) were captured only in Yelp.
While Yelp cannot replace in-person audits for collecting detailed information on the availability, quality and cost of specific food items, Yelp holds promise as a cost-effective means to gather information on the overall cost, quality and experience of food stores, which may be relevant for nutrition outcomes.
Although school-based programmes for the identification of children and young people (CYP) with mental health difficulties (MHD) have the potential to improve short- and long-term outcomes across a range of mental disorders, the evidence-base on the effectiveness of these programmes is underdeveloped. In this systematic review, we sought to identify and synthesise evidence on the effectiveness and cost-effectiveness of school-based methods to identify students experiencing MHD, as measured by accurate identification, referral rates, and service uptake.
Electronic bibliographic databases: MEDLINE, Embase, PsycINFO, ERIC, British Education Index and ASSIA were searched. Comparative studies were included if they assessed the effectiveness or cost-effectiveness of strategies to identify students in formal education aged 3–18 years with MHD, presenting symptoms of mental ill health, or exposed to psychosocial risks that increase the likelihood of developing a MHD.
We identified 27 studies describing 44 unique identification programmes. Only one study was a randomised controlled trial. Most studies evaluated the utility of universal screening programmes; where comparison of identification rates was made, the comparator test varied across studies. The heterogeneity of studies, the absence of randomised studies and poor outcome reporting make for a weak evidence-base that only generate tentative conclusions about the effectiveness of school-based identification programmes.
Well-designed pragmatic trials that include the evaluation of cost-effectiveness and detailed process evaluations are necessary to establish the accuracy of different identification models, as well as their effectiveness in connecting students to appropriate support in real-world settings.
The successful provision of middle-ear surgery requires appropriate anaesthesia. This may take the form of local or general anaesthesia; both methods have their advantages and disadvantages. Local anaesthesia is simple to administer and does not require the additional personnel required for general anaesthesia. In the low-resource setting, it can provide a very safe and effective means of allowing middle-ear surgery to be successfully completed. However, some middle-ear surgery is too complex to consider performing under local anaesthesia and here general anaesthesia will be required.
This article highlights considerations for performing middle-ear surgery in a safe manner when the available resources may be more limited than those expected in high-income settings. There are situations where local anaesthesia with sedation may prove a useful compromise of the two techniques.
At the heart of surgical care needs to be the education and training of staff, particularly in the low-income and/or resource-poor setting. This is the primary means by which self-sufficiency and sustainability will ultimately be achieved. As such, training and education should be integrated into any surgical programme that is undertaken. Numerous resources are available to help provide such a goal, and an open approach to novel, inexpensive training methods is likely to be helpful in this type of setting.
The need for appropriately trained audiologists in low-income countries is well recognised and clearly goes beyond providing support for ear surgery. However, where ear surgery is being undertaken, it is vital to have audiology services established in order to correctly assess patients requiring surgery, and to be able to assess and manage outcomes of surgery. The training requirements of the two specialties are therefore intimately linked.
This article highlights various methods, resources and considerations, for both otolaryngology and audiology training, which should prove a useful resource to those undertaking and organising such education, and to those staff members receiving it.
Introduction: There have been an increasing number of studies published since 2011 investigating the benefits of in situ simulation as a quality improvement (QI) modality. We instituted an emergency department (ED) in situ simulation program at Kelowna General Hospital in 2015 with the aims of improving inter-professional collaboration, improving team communication, developing resident resuscitation leadership skills, educating ED professionals on resuscitation medical expertise, and identifying QI action items from each simulation session. Methods: We applied the SMART framework. Our specific, measureable, and attainable goal was to select two QI action items discovered from each simulation session. Realistic and timely follow-up on each action item was conducted by the nurse educator group who reported back to the local ED network, pharmacy, or manager depending on the action item. This ensured sustainability of our model. Results: A total of 65 individuals participated in 2015 at program inception. This increased to 213 individuals in 2017 with an average of 24 participants/session. Attendants included nurses (31%), ED physicians (20%), ED residents (18%), paramedics (10%), and medical students, respiratory therapists, pharmacists, and others (21%). Our QI action items were grouped as (1) team/communication, (2) equipment/resources, and (3) knowledge/tasks. Examples of each category were: (1) Inability to hear paramedic bedside reports resulting in reinforcement of one paramedic speaking while the team remains quiet, (2) Difficulty in looking up medication information in the resuscitation bay resulting in installation of an additional computer in the resuscitation bay, and (3) Uncertainty of local process for initiating extra corporeal membrane oxygenation (ECMO) in the ED resulting in review of team placement, patient transfer, and initiation of ECMO lines in the ED. Inter-professional team members have reported through electronic feedback on the value of these sessions, including improved inter agency cooperation and understanding. Conclusion: This quality improvement initiative used in situ simulation as a QI tool. We were able to identify latent safety threats, test new patient care protocols, find equipment issues, and foster teamwork in a sustainable way to improve the quality of care in our ED. We hope that this serves as encouragement to others who are initiating a similar program. Our main suggestions after reflection include: (1) Engage a multidisciplinary team in the development of an in situ simulation program, (2) Start with aims and objectives, (3) Foster attendance and buy in by making it convenient for people to attend, (4) Celebrate your successes through interdepartmental communication, and (5) Recruit individuals with expertise in simulation based education.
We present deep low radio frequency (230-470 MHz) observations from the Karl G. Jansky Very Large Array of the Perseus cluster, probing the non-thermal emission from the old particle population of the AGN outflows. Our observations of this nearby relaxed cool core cluster have revealed a multitude of new structures associated with the mini-halo, extending to hundreds of kpc in size. Its irregular morphology seems to have been influenced both by the AGN activity and by the sloshing motion of the cluster’ gas. In addition, it has a filamentary structure similar to that seen in radio relics found in merging clusters. These results illustrate the high-quality images that can be obtained with the new JVLA at low radio-frequencies.
Accurate and reproducible patient positioning is a critical step in radiotherapy for breast cancer. This has seen the use of permanent skin markings becoming standard practice in many centres. Permanent skin markings may have a negative impact on long-term cosmetic outcome, which may in turn, have psychological implications in terms of body image. The aim of this study was to investigate the feasibility of using a semi-permanent tattooing device for the administration of skin marks for breast radiotherapy set-up.
Materials and methods
This was designed as a phase II double-blinded randomised-controlled study comparing our standard permanent tattoos with the Precision Plus Micropigmentation (PPMS) device method. Patients referred for radical breast radiotherapy were eligible for the study. Each study participant had three marks applied using a randomised combination of the standard permanent and PPMS methods and was blinded to the type of each mark. Follow up was at routine appointments until 24 months post radiotherapy. Participants and a blind assessor were invited to score the visibility of each tattoo at each follow-up using a Visual Analogue Scale. Tattoo scores at each time point and change in tattoo scores at 24 months were analysed by a general linear model using the patient as a fixed effect and the type of tattoo (standard or research) as covariate. A simple questionnaire was used to assess radiographer feedback on using the PPMS.
In total, 60 patients were recruited to the study, of which 55 were available for follow-up at 24 months. Semi-permanent tattoos were more visible at 24 months than the permanent tattoos. Semi-permanent tattoos demonstrated a greater degree of fade than the permanent tattoos at 24 months (final time point) post completion of radiotherapy. This was not statistically significant, although it was more apparent for the patient scores (p=0·071) than the blind assessor scores (p=0·27). No semi-permanent tattoos required re-marking before the end of radiotherapy and no adverse skin reactions were observed.
The PPMS presents a safe and feasible alternative to our permanent tattooing method. An extended period of follow-up is required to fully assess the extent of semi-permanent tattoo fade.