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Innovation Concept: Emergency physicians (EP) rarely receive timely, iterative feedback on clinical performance that aids their reflective practice. The Calgary zone ED recently implemented a novel email-based alert system wherein an EP is notified when a patient whose ED care they were involved in is admitted to hospital within 72-hours of discharge from an index ED visit. Our study sought to evaluate the general acceptability of this form of audit and feedback and determine whether it encourages practice reflection. Methods: This mixed methods realist evaluation consisted of two sequential phases. An initial quantitative phase used data from our electronic health record and a survey to examine the general features and acceptability of 72-hour readmission alerts sent from May 2017-2018. A subsequent qualitative phase involved semi-structured interviews exploring the alert's role in greater depth. Quantitative data were summarized using descriptive statistics and qualitative data were analyzed using thematic and template analysis techniques. Results of both phases were used to guide construction of context-mechanism-outcome statements to refine our program theory. Curriculum, Tool, or Material: 4024 alerts were sent over a 1-year period, with each physician receiving approximately 17 alerts per year (Q1: 7, Q3: 25, IQR: 18). The top five CEDIS complaints on index presentations were abdominal pain, flank pain, shortness of breath, vomiting and/or nausea, and chest pain (cardiac features). The majority of re-admissions (78.6%) occurred within 48 hours after discharge. Immediate alert survey feedback provided by EP's noted that 52.65% (N = 471) of alerts were helpful. Thematic analysis of 17 semi-structured interviews suggests that the alert was generally acceptable to physicians, However, certain EPs were concerned that the alert impacted hire/fire decisions even when leadership didn't endorse this sentiment. Physicians who didn't believe alerts were involved in hire/fire decisions, described greater engagement in the reflective process. Conversely, physicians, who believed alerts were involved in hire/fire decisions, were more likely to defensively change their practice. Conclusion: Most EPs noted that timely notification of 72-hour readmissions made them more mindful of documenting discharge instructions. Our implementation of a 72- hour readmission alert was an acceptable format for audit and feedback and appeared to facilitate physician reflection under certain conditions.
Amazon's Mechanical Turk is widely used for data collection; however, data quality may be declining due to the use of virtual private servers to fraudulently gain access to studies. Unfortunately, we know little about the scale and consequence of this fraud, and tools for social scientists to detect and prevent this fraud are underdeveloped. We first analyze 38 studies and show that this fraud is not new, but has increased recently. We then show that these fraudulent respondents provide particularly low-quality data and can weaken treatment effects. Finally, we provide two solutions: an easy-to-use application for identifying fraud in the existing datasets and a method for blocking fraudulent respondents in Qualtrics surveys.
Increasing evidence suggests that symptoms of Attention Deficit Hyperactivity disorder (ADHD) could persist into adult life in a substantial proportion of cases. The aim of the present study is to investigate the impact of 1) adverse events, 2) personality traits and 3) genetic variants chosen on the basis of previous findings and 4) their possible interactions on adult ADHD severity in a sample of 110 Caucasian patients.
One hundred and ten individuals diagnosed with adult ADHD were evaluated for occurrence of adverse events in childhood and adulthood, and personality traits by the Temperament and Character Inventory (TCI). Common polymorphisms within a set of nine important candidate genes (SLC6A3, DBH, DRD4, DRD5, HTR2A, CHRNA7, BDNF, PRKG1 and TAAR9) were genotyped for each subject. Life events, personality traits and genetic variations were analyzed in relationship to severity of current symptoms, evaluated by the Brown Attention Deficit Disorder Scale (BADDS).
Genetic variations were not significantly associated with severity of ADHD symptoms and life stressors displayed only a minor effect as compared to personality traits. Indeed, symptoms’ severity was significantly correlated with the temperamental trait of Harm avoidance and the character trait of Self directedness.
The results of the present work are in line with previous evidence of a significant correlation between some personality traits and adult ADHD. However, several limitations such as the small sample size and the exclusion of patients with other severe comorbid psychiatric disorders could have influenced the significance of present findings.
Childhood Attention deficit hyperactivity disorder (ADHD) symptomatology persists in a substantial proportion of cases into adult life. ADHD is highly heritable but the etiology of ADHD is complex and heterogeneous, involving both genetic and non-genetic factors. In the present paper we analyzed the influence of both genetics and adverse life events on severity of ADHD symptoms in 110 adult ADHD patients. Subjects were genotyped for the norepinephrine transporter (NET), the Catechol-O-methyltransferase (COMT), the serotonin transporter promoter polymorphism (SERTPR) and the more rare A/G variant within SERTPR. Three main outcomes were obtained: (1) adverse events showed a small but positive correlation with current ADHD severity; (2) NET, COMT and the A/G variant within SERTPR were not associated with ADHD severity; (3) taking into account stressors, the long (L) SERTPR variant showed a mild effect on ADHD, being associated with an increased severity, particularly as regard affective dysregulations; on the other hand, in subjects exposed to early stressors, it showed a protective effect, as compared to the S variant (see table). In conclusion, our data support the role of environmental factors in adult ADHD symptomatology. SERTPR may be involved in some features of the illness and act as a moderator of environmental influences in ADHD.
rTMS is an emerging treatment for major depressive disorder (MDD) refractory to medications and psychotherapy. The conventional target for rTMS in MDD is the dorsolateral prefrontal cortex (DLPFC). However, convergent evidence from lesion, stimulation, and neuroimaging studies suggests that the dorsomedial prefrontal cortex (DMPFC) may play a more central role in emotion regulation. We have recently demonstrated robust and potentially superior antidepressant properties for excitatory rTMS of the DMPFC. However, one of the enduring limitations of rTMS is the long duration of each treatment session under conventional protocols, which require ~40 minutes per day over 20-30 sessions for maximum efficacy using conventional 10 Hz stimulation. More recent studies have suggested that theta-burst stimulation (TBS) protocols can achieve stronger and more durable effects in markedly less time. Intermittent theta-burst stimulation (iTBS) generates robust and long-lasting excitatory effects with 600 pulses over ~3 min. Pilot studies have previously reported antidepressant effects with TBS over the DLPFC. However, TBS over the DMPFC has not previously been studied. Here we report robust antidepressant effects for a 7 min course of iTBS, administered bilaterally over the DMPFC with MRI-guidance at 120% resting motor threshold, over 20-30 sessions, in an open-label series of 40 patients with refractory MDD. Safety, efficacy, and tolerability are comparable to a 10 Hz rTMS protocol requiring 30-40 min of treatment. iTBS of the DMPFC may effectively reduce the duration (and cost) of rTMS >4-fold, thus increasing patient capacity per clinic and improving the overall accessibility of rTMS in refractory MDD.
Linear gyrokinetic simulations of magnetically confined electron–positron plasmas are performed for the first time in the geometry and parameter regimes likely to be relevant for upcoming laboratory experiments. In such plasmas, the density will be sufficiently small as to render the plasma effectively collisionless. The magnetic field will be very large, meaning that the Debye length will exceed the gyroradius by a few orders of magnitude. We show the results of linear simulations in flux tubes close to the current carrying ring and also in the bulk of the plasma, demonstrating the existence of entropy modes and interchange modes in pair plasmas. We study linear stability and show that in the relevant configurations, almost complete linear stability is attainable in large swathes of parameter space.
Dipole and stellarator geometries are capable of confining plasmas of arbitrary neutrality, ranging from pure electron plasmas through to quasineutral. The diocotron mode is known to be important in non-neutral plasmas and has been widely studied. However, drift mode dynamics, dominating quasineutral plasmas, has received very little by way of attention in the non-neutral context. Here, we show that non-neutral plasmas can be unstable respect to both density-gradient- and temperature-gradient-driven instabilities. A local shearless slab limit is considered for simplicity. A key feature of non-neutral plasmas is the development of strong electric fields, in this local limit of straight field line geometry, the effect of the corresponding
drift is limited to the Doppler shift of the complex frequency
. However, the breaking of the quasineutrality condition still leads to interesting dynamics in non-neutral plasmas. In this paper we address the behaviour of a number of gyrokinetic modes in electron–ion and electron–positron plasmas with arbitrary degree of neutrality.
A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.
We present the case of a 17-year-old boy with a cardiac venous malformation. This case highlights the diagnostic challenges of such tumours and demonstrates the potential efficacy of a watch-and-wait management approach.
Introduction: Adolescents who present to emergency departments (ED) following intentional injuries present a challenge in terms of ascertaining their intent and risk for future self-injurious or suicidal behaviour. Our ED has seen an 80% increase in visits for mental health issues over the past ten years. As usage of our Emergency Mental Health and Addictions Services (EMHAS) team continues to rise, it is increasingly important to understand the incidence of NSSI among our youth, explore if NSSI is reported at triage and identify characteristics that may distinguish these adolescents from others presenting for mental health assessment. Methods: This is an exploratory research study using retrospective data. Patients who had an Emergency Mental Health Triage (EMHT) form on their health record from an ED visit between June 1, 2017 and May 31, 2018 were eligible. Trained research assistants, using a structured data collection form in REDCap. abstracted data from the EMHT form, the EMHAS Assessment form, the Assessment of Suicide Risk Inventory and our CHIRPP (Canadian Hospitals Injury Reporting and Prevention Program) database. We calculated kappa values and 95% confidence intervals to describe the extent to which the forms agree with respect to identifying NSSI. We will compare the cohort who reports NSSI with the cohort who does not report NSSI using chi-square statistics depending. We will use descriptive statistics to characterize the NSSI patients. Results: During the one-year study period 955 patients had an EMHT form completed. In preliminary analysis 558 (58.4%) reported a history of NSSI. Patients reported NSSI on both the EMHT form and the EMHAS assessment form 64.7% of the time (kappa 0.56) indicating moderate agreement. In patients with NSSI, 9.5% of patients reported it only at triage and 25.8% of patients reported it only during their EMHAS assessment. Between group comparisons and descriptive analysis is underway. Conclusion: More than half of youth triaged with an emergency mental health complaint in our ED reported a history of NSSI. Screening at triage was moderately effective in identifying adolescents with NSSI compared to an in-depth assessment by the mental health team. Further research is needed to clarify how NSSI relates to risk for suicide.
Stiffened wing and fuselage panels often have a postbuckling reserve of strength, enabling them to carry loads far in excess of their critical buckling loads. Therefore allowing for postbuckling in design can reduce their weight, hence reducing fuel consumption and environmental impact. The present paper extends the postbuckling analysis in the exact strip software VICONOPT to more accurately reflect the skewed mode shapes arising from shear load and anisotropy. Such mode shapes are represented by a series of sinusoidal responses with different half-wavelengths which are coupled together using Lagrangian multipliers to enforce the boundary conditions. In postbuckling analysis the in-plane deflections involve responses with additional half-wavelengths which are absent from the out-of-plane deflection series. Numerical results are presented and compared with finite element analysis for validation. The present analysis gives close results compared to the finite element and finite strip methods and saves computational time significantly.
Gyrokinetic stability of plasmas in different magnetic geometries is studied numerically using the GENE code. We examine the stability of plasmas, varying the mass ratio between the positive and negative charge carriers, from conventional hydrogen plasmas through to electron–positron plasmas. Stability is studied for prescribed temperature and density gradients in different magnetic geometries: (i) An axisymmetric, circular flux surface, low
(tokamak) configuration. (ii) A non-axisymmetric quasi-isodynamic (optimised stellarator) configuration using the geometry of the stellarator Wendelstein 7-X. We also present the analytic theory of trapped particle modes in electron–positron plasmas. We found similar behaviour of the growth rate and real frequency compared to previous studies on the tokamak case. We are able to identify two distinct regimes dominated by modes propagating in the electron diamagnetic direction and modes propagating in the ion/positron diamagnetic direction, depending on the mass ratio. In both the tokamak and the stellarator case we observe that the real frequency tends to zero as the mass ratio approaches unity and are able to explain this using gyrokinetic theory.
There is renewed interest in the inverse association between psychiatric hospital and prison places, with reciprocal time trends shown in more than one country. We hypothesised that the numbers of admissions to psychiatric hospitals and committals to prisons in Ireland would also correlate inversely over time (i.e. dynamic measures of admission and committal rather than static, cross-sectional numbers of places).
Publicly available activity statistics for psychiatric hospitals and prisons in Ireland were collated from 1986 to 2010.
There was a reciprocal association between psychiatric admissions and prison committals (Pearson r=−0.788, p<0.001), an increase of 91 prison committals for every 100 psychiatric hospital admissions foregone.
Penrose’s hypothesis applies to admissions to psychiatric hospitals and prisons in Ireland over time (dynamic measures), just as it does to the numbers of places in psychiatric hospitals and prisons in Ireland and elsewhere (static, cross-sectional measures). Although no causal connection can be definitively established yet, mentally disordered prisoners are usually known to community mental health services. Psychiatric services for prisons and the community should be linked to ensure that the needs of those currently accessing care through prisons can also be met in the community.
An experiment was carried out to examine the effects of offering beef cattle five silage diets. These were perennial ryegrass silage (PRGS) as the sole forage, tall fescue/perennial ryegrass silage (FGS) as the sole forage, PRGS in a 50:50 ratio on a dry matter (DM) basis with lupin/triticale silage (LTS), lupin/wheat silage (LWS) and pea/oat silage (POS). Each of the five silage diets was supplemented with 4 and 7 kg of concentrates/head/day in a five silages × two concentrate intakes factorial design. A total of 90 cattle were used in the 121-day experiment. The grass silages were of medium digestibility and were well preserved. The legume/cereal silages had high ammonia N, high acetic acid, low lactic acid, low butyric acid and low digestible organic matter concentrations (542, 562 and 502 g/kg DM for LTS, LWS and POS, respectively). Silage treatment did not significantly affect liveweight gain, carcass gain, carcass characteristics, the instrumental assessment of meat quality or fatty acid composition of the M. longissimus dorsi muscle. In view of the low yields of the legume/cereal crops, it is concluded that the inclusion of spring-sown legume/cereal silages in the diets of beef cattle is unlikely to be advantageous.
An experiment was carried out to examine the effects of offering beef steers grass silage (GS) as the sole forage, lupins/triticale silage (LTS) as the sole forage, a mixture of LTS and GS at a ratio of 70:30 on a dry matter (DM) basis, vetch/barley silage (VBS) as the sole forage, a mixture of VBS and GS at a ratio of 70:30 on a DM basis, giving a total of five silage diets. Each of the five silage diets was supplemented with 2 and 5 kg of concentrates/head/day in a 5 × 2 factorial design to evaluate the five silages at two levels of concentrate intake and to examine possible interactions between silage type and concentrate intake. A total of 80 beef steers were used in the 122-day experiment. The GS was well preserved while the whole crop cereal/legume silages had high ammonia-nitrogen (N) concentrations, low lactic acid concentrations and low butyric acid concentrations For GS, LTS, LTS/GS, VBS and VBS/GS, respectively, silage DM intakes were 6.5, 7.0, 7.2, 6.1 and 6.6 (s.e.d. 0.55) kg/day and live weight gains were 0.94, 0.72, 0.63, 0.65 and 0.73 (s.e.d. 0.076) kg/day. Silage type did not affect carcass fatness, the colour or tenderness of meat or the fatty acid composition of the intramuscular fat in the longissimus dorsi muscle.
Culturally linked family influences during adolescence are important predictors of health and well-being for Latino youth, yet few studies have examined whether these familial influences are associated with indicators of typical physiological stress processes. Following a cultural neurobiology framework, we examined the role of family in the everyday lives of Latino adolescents (N = 209; Mage = 18.10; 85.1% Mexican descent; 64.4% female) by investigating familism values and perceptions of parent support as well as daily family assistance behaviors in relation to hypothalamic–pituitary–adrenal axis diurnal patterns, indexed by salivary cortisol five times a day for 3 weekdays. Three-level growth curve analyses revealed that perceptions of parental support were associated with greater cortisol awakening responses, whereas familism values were not associated with diurnal cortisol patterns. In day-to-day analyses, assisting family during the day (compared to not assisting family) was associated with lower waking cortisol levels and flatter diurnal slopes the next day. Our findings highlight the dynamic associations and multiple time courses between cultural values and behaviors, daily experiences, and physiological stress processes for Latino adolescents. Further, we identified important cultural risk and promotive factors associated with physiological regulation in daily life and potential pathways toward health outcomes in adulthood.
Prenatal adversity shapes child neurodevelopment and risk for later mental health problems. The quality of the early care environment can buffer some of the negative effects of prenatal adversity on child development. Retrospective studies, in adult samples, highlight epigenetic modifications as sentinel markers of the quality of the early care environment; however, comparable data from pediatric cohorts are lacking. Participants were drawn from the Maternal Adversity Vulnerability and Neurodevelopment (MAVAN) study, a longitudinal cohort with measures of infant attachment, infant development, and child mental health. Children provided buccal epithelial samples (mean age = 6.99, SD = 1.33 years, n = 226), which were used for analyses of genome-wide DNA methylation and genetic variation. We used a series of linear models to describe the association between infant attachment and (a) measures of child outcome and (b) DNA methylation across the genome. Paired genetic data was used to determine the genetic contribution to DNA methylation at attachment-associated sites. Infant attachment style was associated with infant cognitive development (Mental Development Index) and behavior (Behavior Rating Scale) assessed with the Bayley Scales of Infant Development at 36 months. Infant attachment style moderated the effects of prenatal adversity on Behavior Rating Scale scores at 36 months. Infant attachment was also significantly associated with a principal component that accounted for 11.9% of the variation in genome-wide DNA methylation. These effects were most apparent when comparing children with a secure versus a disorganized attachment style and most pronounced in females. The availability of paired genetic data revealed that DNA methylation at approximately half of all infant attachment-associated sites was best explained by considering both infant attachment and child genetic variation. This study provides further evidence that infant attachment can buffer some of the negative effects of early adversity on measures of infant behavior. We also highlight the interplay between infant attachment and child genotype in shaping variation in DNA methylation. Such findings provide preliminary evidence for a molecular signature of infant attachment and may help inform attachment-focused early intervention programs.