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Background: Buprenorphine/naloxone (bup/nal) is a partial opioid agonist/antagonist and recommended first line treatment for opioid use disorder (OUD). Emergency departments (EDs) are a key point of contact with the healthcare system for patients living with OUD. Aim Statement: We implemented a multi-disciplinary quality improvement project to screen patients for OUD, initiate bup/nal for eligible individuals, and provide rapid next business day walk-in referrals to addiction clinics in the community. Measures & Design: From May to September 2018, our team worked with three ED sites and three addiction clinics to pilot the program. Implementation involved alignment with regulatory requirements, physician education, coordination with pharmacy to ensure in-ED medication access, and nurse education. The project is supported by a full-time project manager, data analyst, operations leaders, physician champions, provincial pharmacy, and the Emergency Strategic Clinical Network leadership team. For our pilot, our evaluation objective was to determine the degree to which our initiation and referral pathway was being utilized. We used administrative data to track the number of patients given bup/nal in ED, their demographics and whether they continued to fill bup/nal prescriptions 30 days after their ED visit. Addiction clinics reported both the number of patients referred to them and the number of patients attending their referral. Evaluation/Results: Administrative data shows 568 opioid-related visits to ED pilot sites during the pilot phase. Bup/nal was given to 60 unique patients in the ED during 66 unique visits. There were 32 (53%) male patients and 28 (47%) female patients. Median patient age was 34 (range: 21 to 79). ED visits where bup/nal was given had a median length of stay of 6 hours 57 minutes (IQR: 6 hours 20 minutes) and Canadian Triage Acuity Scores as follows: Level 1 – 1 (2%), Level 2 – 21 (32%), Level 3 – 32 (48%), Level 4 – 11 (17%), Level 5 – 1 (2%). 51 (77%) of these visits led to discharge. 24 (47%) discharged patients given bup/nal in ED continued to fill bup/nal prescriptions 30 days after their index ED visit. EDs also referred 37 patients with OUD to the 3 community clinics, and 16 of those individuals (43%) attended their first follow-up appointment. Discussion/Impact: Our pilot project demonstrates that with dedicated resources and broad institutional support, ED patients with OUD can be appropriately initiated on bup/nal and referred to community care.
Measurements in the infrared wavelength domain allow direct assessment of the physical state and energy balance of cool matter in space, enabling the detailed study of the processes that govern the formation and evolution of stars and planetary systems in galaxies over cosmic time. Previous infrared missions revealed a great deal about the obscured Universe, but were hampered by limited sensitivity.
SPICA takes the next step in infrared observational capability by combining a large 2.5-meter diameter telescope, cooled to below 8 K, with instruments employing ultra-sensitive detectors. A combination of passive cooling and mechanical coolers will be used to cool both the telescope and the instruments. With mechanical coolers the mission lifetime is not limited by the supply of cryogen. With the combination of low telescope background and instruments with state-of-the-art detectors SPICA provides a huge advance on the capabilities of previous missions.
SPICA instruments offer spectral resolving power ranging from R ~50 through 11 000 in the 17–230 μm domain and R ~28.000 spectroscopy between 12 and 18 μm. SPICA will provide efficient 30–37 μm broad band mapping, and small field spectroscopic and polarimetric imaging at 100, 200 and 350 μm. SPICA will provide infrared spectroscopy with an unprecedented sensitivity of ~5 × 10−20 W m−2 (5σ/1 h)—over two orders of magnitude improvement over what earlier missions. This exceptional performance leap, will open entirely new domains in infrared astronomy; galaxy evolution and metal production over cosmic time, dust formation and evolution from very early epochs onwards, the formation history of planetary systems.
Effective integrated weed management in agricultural landscapes depends on the ability to identify and manage processes that drive weed dynamics. The current study reports the effects of grazing management and crop rotation strategies on the seedbank and emerged weed flora in an integrated crop-livestock system (ICLS) experiment during a 12-year period under no-tillage in sub-tropical southern Brazil. During winter, Italian ryegrass cover crops were grazed by sheep: grazing management treatments included two stocking methods (continuous and rotational) and two forage allowances (10 and 20 kg of herbage dry matter available per 100 kg animal live weight). During summer, the crop rotation treatments involved either soybean-maize or soybean-soybean in succession with winter-grazed cover crops. The treatments were part of a factorial randomized complete block design. Treatment effects were evaluated on the weed seedbank and emerged weed flora populations during winter-grazed cover crop and summer crop growth as well as during the harvest phase. The current results demonstrate that crop rotation and grazing management exhibited interactive effects on the determination of weed outcomes in an ICLS. However, overall, compared with moderate forage allowance, high forage allowance during the winter-grazed cover crop caused lower emerged weed flora in subsequent crops (20% reduction during crop growth and 90% reduction at crop harvest) and 48% reduction in seedbank size. High forage allowance promoted more residue from winter-grazed cover crop biomass, which remained during the summer crop phases and probably resulted in a physical barrier to weed emergence.
Introduction: Community Paramedics (CPs) require access to timely blood analysis in the field to guide treatment and transport decisions. Point of care testing (POCT), as opposed to traditional laboratory analysis, may offer a solution, but limited research exists on CP POCT. The objective of this study is to compare the validity of two POCT devices (Abbott i-STAT® and Alere epoc®) and their use by CPs in the community. Methods: In a CP programme responding to 6,000 annual patient care events, a split sample validation of POCT against traditional laboratory analysis for seven analytes (sodium, potassium, chloride, creatinine, hemoglobin, hematocrit, and glucose) was conducted on a consecutive sample of patients. The difference of proportion of discrepant results between POCT and laboratory was compared using a two sample proportion test. Usability was analysed by survey of CP experience, an expert heuristic evaluation of devices, a review of device-logged errors, coded observations of POCT use during quality control testing, and a linear mixed effects model of Systems Usability Scale (SUS) adjusted for CP clinical and POCT experience. Results: Of 1,649 CP calls for service screened for enrollment, 174 had a blood draw, with 108 patient care encounters (62.1%) enrolled from 73 participants. Participants had a mean age of 58.7 years (SD16.3); 49% were female. In 4 of 646 (0.6%) individual comparisons, POCT reported a critical value that the laboratory did not; with no statistically significant difference in the number of discrepant critical values reported with epoc® compared to i-STAT®. There were no instances of the laboratory reporting a critical value when POCT did not. In 88 of 1,046 (8.4%) individual comparisons, the a priori defined acceptable difference between POCT and the laboratory was exceeded; occurring more often in epoc® (10.7%;95%CI:8.1%,13.3%) compared to i-STAT® (6.1%;95%CI:4.1%,8.2%)(p=0.007). Eighteen of 19 CP surveys were returned, with 11/18 (61.1%) preferring i-STAT® over epoc®. The i-STAT® had a higher mean SUS score (higher usability) compared to the epoc® (84.0/100 vs. 59.6/100; p=0.011). Fewer field blood analysis device-logged errors occurred in i-STAT® (7.8%;95%CI:2.9%,12.7%) compared to epoc® (15.5%;95%CI:9.3%,21.7%) although not statistically significant (p=0.063). Conclusion: CP programs can expect valid results from POCT. Usability assessment suggests a preference for i-STAT.
We performed a new series of measurements on samples that were part of early measurements on radiocarbon (14C) dating made in 1948–1949. Our results show generally good agreement to the data published in 1949–1951, despite vast changes in technology, with only two exceptions where there was a discrepancy in the original studies. Our new measurements give calibrated ages that overlap with the known ages. We dated several samples at four different laboratories, and so we were also able to make a small intercomparison at the same time. In addition, new measurements on samples from other Egyptian materials used by Libby and co-workers were made at UC Irvine. Samples of tree rings used in the original studies (from Broken Flute Cave and Centennial Stump) were obtained from the University of Arizona Laboratory of Tree-Ring Research archive and remeasured. New data were compared to the original studies and other records.
Introduction: Redirecting low acuity patients from emergency departments to primary care walk-in clinics has been identified as a priority by many health authorities. Promoting family physicians for the management of ambulatory patients with urgent health concerns reflects the assumption that primary care facilities can offer high-quality and more affordable ambulatory emergency care. However, no performance assessment framework has been developed for ambulatory emergency care and consequently, quality of care provided in these alternate settings has never been formally compared. Primary objective: To identify structure, process and outcome indicators for ambulatory emergency care. Methods: We will identify and develop quality indicators (QIs) for ambulatory emergency care using a RAND/UCLA Appropriateness Method (RAM) composed of three different steps. First, we will perform a scoping literature review to inventory 1) all previously recommended QIs assessing care provided to ambulatory emergency patients in the ED or the primary care settings; 2) all conditions evaluated with the retrieved QIs; and 3) all outcomes measured by the same QIs. Second, a steering committee composed of the research team and of international experts in performance assessment in emergency and primary care will be presented with the lists of QI-related conditions and outcomes. They will be asked to identify potential outcome indicators for ambulatory emergency care by generating any relevant combinations of one condition and one outcome (e.g. acute asthma exacerbation/re-consultation). Committee members will be given the latitude to use and pair any conditions or outcomes not included in the lists as long as they think the resulting indicators are compatible with the study objectives. Using a structured nominal group approach, they will combine their suggestions and refine the list of potential QIs. This list of potential outcome indicators composed of pairs “condition/outcome” will be merged with the list of already published QIs identified during the literature review. Third, as per the RAM standards, we will assemble an international multidisciplinary panel (n=20) of patients, emergency and primary care providers, researchers and decision makers, after recommendations from international emergency and primary care associations, and from the Canadian Strategy for Patient-Oriented Research (SPOR) Support Units. Through iterative rounds of ratings using both web-based survey tools and videoconferencing, panelists will independently assess all candidate QIs. They will be asked to rate on a nine-level scale to what extent each QI is a relevant and useful measure of ambulatory emergency care quality. From one round to the next, QIs with a median panelist rating score of one to three will be excluded. Those with a median score of seven or more will be automatically included in the final list. QIs with median score of four to six will be retained for future deliberations among the panelists. Rounds of ratings will be conducted until all QIs are classified. Impact: The QIs identified will be used to develop a performance assessment framework for ambulatory emergency care. This will represent an essential step toward testing the assumption that EDs and primary care walk-in clinics provide equivalent care quality to low acuity patients.
Introduction: Social desirability bias is a systematic error in self-report measures resulting from the desire of respondents to avoid embarrassment and project a favourable image of themselves to others. This bias may decrease the accuracy of self-reported health outcomes collected in health research compromise the validity of research findings. This study compared outcomes obtained by patient self-report vs. the same outcomes after undergoing verification and external adjudication, in trial involving patients with acute asthma. Methods: Cross-sectional analysis of outcome data obtained in a randomized controlled trial conducted in 6 Canadian emergency departments (ED). Adult patients were allocated to receive usual care (UC), opinion leader [OL] guidance to their primary care provider (PCP), or OL guidance+nurse case-management [OL+CM] for patients (NCT01079000). Asthma relapses and PCP follow-up visits were blindly assessed through patient self-report 30 and 90 days after their ED presentation for acute asthma. Each reported event was verified through the provincial electronic medical record, the ED Information Systems, and by calling the PCPs’ offices. Two study investigators, blinded to the study interventions, independently reviewed and adjudicated the verified outcomes. Disagreements were resolved by consensus prior to un-blinding. Results: Overall, 367 patients were enrolled; more were female (64%) and the median age was 28 years. Overall, patient follow-up was obtained in 85% of cases. The proportion of asthma relapses occurring within the first 90 days were lower when considering patient self-report than when considering the adjudicated outcomes (17%[39/227] vs. 19%[70/367]). The proportion of PCP follow-up visits occurring within the first 30 days were higher when considering patient self-report than when considering the adjudicated outcomes (47%[139/290] vs. 40%[146/367]). The pattern was similar, regardless of the arm of the study (UC vs. OL vs. OL+CM arms); outcome disagreement did not influence the direction of magnitude of the treatment effect. Conclusion: Social desirability bias could have influenced the outcomes obtained by patient self-report in this ED-based study. The direction of the bias was the same for both outcomes; however, the variation did not change the study results. This bias may play a role in studies with smaller sample sizes.
Introduction: Many patients presenting to Emergency Departments (EDs) with acute asthma have limited or no access to health care providers, medications and preventive resources. This study explored outpatient care gaps among subjects presenting to the ED for acute asthma, before being discharged. Methods: Cross-sectional analysis of data obtained in a comparative effectiveness trial conducted in six EDs in Alberta (NCT01079000). Data were collected through patient interviews and chart reviews at ED presentation. Two clinician-investigators independently reviewed and adjudicated the following preventive actions: use of spacer devices, written asthma action plans (AAPs) and asthma medication; influenza immunization, cigarette smoking, and referral to asthma education. Agreement between adjudicators was calculated based on kappa (k) statistics. Results: The median age of the study population (n=367) was 28 years and 64% were women. Overall, 26% of patients reported not having a regular family physician. Agreement between reviewers was excellent (k=0.96). More than half (59%) reported not using spacer devices despite being indicated and 3% reported having a written AAP. Following the recommendations of the current asthma guidelines, 38% of the patients required the initiation of inhaled corticosteroids (ICS), 11% required the addition of ICS/long-acting β-agonists combination agents and 39% required reinforcement of adherence with preventer medications. Finally, 37% reported receiving influenza vaccination in the past year, 7% had been referred to asthma education in the last 10 years, and 31% were still smoking, suggesting that cessation counselling was indicated. Conclusion: The ED encounter for patients with acute asthma represents a unique opportunity to establish important partnerships across the continuum of asthma care (e.g., link them with a family doctor). This study provided a robust assessment of the outpatient care gaps in this patient population, which identified many areas for targeted interventions. The method of delivery and type of messaging needs further study.
Introduction: Approximately 20% of Canadians who present to emergency departments (EDs) with acute asthma relapse within 4 weeks of discharge. The reasons are likely multi-factorial; however, the lack of timely primary care provider (PCP) follow-up and inadequate patient self-management are thought to be important variables. Therefore, we tested the effectiveness of ED-directed multifaceted interventions that targeted PCPs and enhanced patient self-management to reduce asthma relapse following ED discharge. Methods: Adults with acute asthma discharged from 6 Alberta EDs were randomly allocated, in a centralized and concealed manner, to receive usual care (UC), opinion leader [OL] guidance to their PCPs, or OL guidance + nurse case-management [OL+CM] for patients (NCT01079000). The main outcome was asthma relapse within 90-days of ED discharge. Secondary outcomes included PCP visits, time to relapse, hospitalizations and asthma-related quality of life (QoL). Outcomes were collected independently and assessors were masked to intervention assignment. Results: From 943 screened patients, 367 patients were allocated to the study arms (UC=146; OL=110; OL+CM=111). Median age was 28 years, 64% were women, median peak flow at discharge was 350 L/min; 77% were discharged home on prednisone and 85% on either inhaled corticosteroids (ICS) or ICS/long-acting β2-agonists. Compared with UC, both interventions significantly increased rates of relapse at 90-days: UC=12%, OL=28%, OL+CM=19%; p=0.006. Based on an absolute increased risk of 0.16 (95% CI: 0.05, 0.25), the number needed to treat for harm was 6 (95% CI: 3.9, 19.0) for the OL arm. Across study differences in PCP follow-up visits, time to relapse, hospitalizations or asthma-related QoL were not identified. Conclusion: Two different theory-informed and evidenced-based interventions intended to decrease asthma relapse robustly and significantly increased rates of relapse compared with UC. While the reasons for these unintended consequences require further study, we caution against the adoption of similar interventions by other EDs.
Excessive alcohol use is associated with brain damage but less is known about brain effects from moderate alcohol use. Previous findings indicate that patients with severe mental illness, particularly schizophrenia, are vulnerable to alcohol-related brain damage. We investigated the association between levels of alcohol consumption and cortical and subcortical brain structures in schizophrenia and bipolar disorder patients and healthy controls, and investigated for group differences for this association.
1.5 T structural magnetic resonance images were acquired of 609 alcohol-using participants (165 schizophrenia patients, 172 bipolar disorder patients, 272 healthy controls), mean (s.d.) age 34.2 (9.9) years, 52% men. Past year alcohol use was assessed with the Alcohol Use Disorder Identification Test – Consumption part (AUDIT-C). General linear models were used to investigate associations between AUDIT-C score and cortical thickness, surface area, and total brain and subcortical volumes.
Increasing AUDIT-C score was linearly associated with thinner cortex in medial and dorsolateral frontal and parieto-occipital regions, and with larger left lateral ventricle volume. There was no significant interaction between AUDIT-C score and diagnostic group. The findings remained significant after controlling for substance use disorders, antipsychotic medication and illness severity.
The results show a dose-dependent relationship between alcohol use and thinner cortex and ventricular expansion. The findings are present also at lower levels of alcohol consumption and do not differ between schizophrenia or bipolar disorder patients compared to healthy controls. Our results do not support previous findings of increased vulnerability for alcohol-related brain damage in severe mental illness.
In the 1998-99 flight, BOOMERanG has produced maps of ∼4% of the sky at high Galactic latitudes, at frequencies of 90, 150, 240 and 410 GHz, with resolution ≳ 10'. The faint structure of the Cosmic Microwave Background at horizon and sub-horizon scales is evident in these maps. These maps compare well to the maps recently obtained at lower frequencies by the WMAP experiment. Here we compare the amplitude and morphology of the structures observed in the two sets of maps. We also outline the polarization sensitive version of BOOMERanG, which was flown early this year to measure the linear polarization of the microwave sky at 150, 240 and 350 GHz.
The Arcminute Cosmology Bolometer Array Receiver (Acbar) is a multifrequency millimeter-wave receiver optimized for observations of the Cosmic Microwave Background (CMB) and the Sunyaev-Zel'dovich (SZ) effect in clusters of galaxies. Acbar was installed on the 2.1 m Viper telescope at the South Pole in January 2001 and the results presented here incorporate data through July 2002. The power spectrum of the CMB at 150 GHz over the range ℓ = 150 — 3000 measured by Acbar is presented along with estimates for the values of the cosmological parameters within the context of ΛCDM models. The inclusion of ΩΛ greatly improves the fit to the power spectrum. Three-frequency images of the SZ decrement/increment are also presented for the galaxy cluster 1E0657–67.
Almost nothing is known about the potential negative effects of Internet-based psychological treatments for depression. This study aims at investigating deterioration and its moderators within randomized trials on Internet-based guided self-help for adult depression, using an individual patient data meta-analyses (IPDMA) approach.
Studies were identified through systematic searches (PubMed, PsycINFO, EMBASE, Cochrane Library). Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e. 7.68 points in the CES-D; 7.63 points in the BDI). Two-step IPDMA procedures, with a random-effects model were used to pool data.
A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention v. control conditions (3.36 v. 7.60; relative risk 0.47, 95% confidence interval 0.29–0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education. Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit–risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration.
Internet-based guided self-help is associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education.
We present NH3 and H64α+H63α VLA observations of the Radio Arc region, including the M0.20 – 0.033 and G0.10 – 0.08 molecular clouds. These observations suggest the two velocity components of M0.20 – 0.033 are physically connected in the south. Additional ATCA observations suggest this connection is due to an expanding shell in the molecular gas, with the centroid located near the Quintuplet cluster. The G0.10 – 0.08 molecular cloud has little radio continuum, strong molecular emission, and abundant CH3OH masers, similar to a nearby molecular cloud with no star formation: M0.25+0.01. These features detected in G0.10 – 0.08 suggest dense molecular gas with no signs of current star formation.
We show how estimates of parameters characterizing inflation-based theories of structure formation localized over the past year when large scale structure (LSS) information from galaxy and cluster surveys was combined with the rapidly developing cosmic microwave background (CMB) data, especially from the recent Boomerang and Maxima balloon experiments. All current CMB data plus a relatively weak prior probability on the Hubble constant, age and LSS points to little mean curvature (Ωtot = 1.08±0.06) and nearly scale invariant initial fluctuations (ns = 1.03±0.08), both predictions of (non-baroque) inflation theory. We emphasize the role that degeneracy among parameters in the Lpk = 212 ± 7 position of the (first acoustic) peak plays in defining the Ωtot range upon marginalization over other variables. Though the CDM density is in the expected range (Ωcdmh2 = 0.17 ± 0.02), the baryon density Ωbh2 = 0.030 ± 0.005 is somewhat above the independent 0.019 ± 0.002 nucleosynthesis estimates. CMB+LSS gives independent evidence for dark energy (ΩΛ = 0.66 ± 0.06) at the same level as from supernova (SN1) observations, with a phenomenological quintessence equation of state limited by SN1+CMB+LSS to wQ < −0.7 cf. the wQ=−1 cosmological constant case.
BOOMERanG has recently resolved structures on the last scattering surface at redshift ˜ 1100 with high signal to noise ratio. We review the technical advances which made this possible, and we focus on the current results for maps and power spectra, with special attention to the determination of the total mass-energy density in the Universe and of other cosmological parameters.
First-episode psychosis (FEP) patients show structural brain abnormalities. Whether the changes are progressive or not remain under debate, and the results from longitudinal magnetic resonance imaging (MRI) studies are mixed. We investigated if FEP patients showed a different pattern of regional brain structural change over a 1-year period compared with healthy controls, and if putative changes correlated with clinical characteristics and outcome.
MRIs of 79 FEP patients [SCID-I-verified diagnoses: schizophrenia, psychotic bipolar disorder, or other psychoses, mean age 27.6 (s.d. = 7.7) years, 66% male] and 82 healthy controls [age 29.3 (s.d. = 7.2) years, 66% male] were acquired from the same 1.5 T scanner at baseline and 1-year follow-up as part of the Thematically Organized Psychosis (TOP) study, Oslo, Norway. Scans were automatically processed with the longitudinal stream in FreeSurfer that creates an unbiased within-subject template image. General linear models were used to analyse longitudinal change in a wide range of subcortical volumes and detailed thickness and surface area estimates across the entire cortex, and associations with clinical characteristics.
FEP patients and controls did not differ significantly in annual percentage change in cortical thickness or area in any cortical region, or in any of the subcortical structures after adjustment for multiple comparisons. Within the FEP group, duration of untreated psychosis, age at illness onset, antipsychotic medication use and remission at follow-up were not related to longitudinal brain change.
We found no significant longitudinal brain changes over a 1-year period in FEP patients. Our results do not support early progressive brain changes in psychotic disorders.
We report on the analysis of virtual powder-diffraction patterns from serial femtosecond crystallography (SFX) data collected at an X-ray free-electron laser. Different approaches to binning and normalizing these patterns are discussed with respect to the microstructural characteristics which each highlights. Analysis of SFX data from a powder of Pr0.5Ca0.5MnO3 in this way finds evidence of other trace phases in its microstructure which was not detectable in a standard powder-diffraction measurement. Furthermore, a comparison between two virtual powder pattern integration strategies is shown to yield different diffraction peak broadening, indicating sensitivity to different types of microstrain. This paper is a first step in developing new data analysis methods for microstructure characterization from serial crystallography data.