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Introduction: For rhythm control of acute atrial flutter (AAFL) in the emergency department (ED), choices include initial drug therapy or initial electrical cardioversion (ECV). We compared the strategies of pharmacological cardioversion followed by ECV if necessary (Drug-Shock), and ECV alone (Shock Only). Methods: We conducted a randomized, blinded, placebo-controlled trial (1:1 allocation) comparing two rhythm control strategies at 11 academic EDs. We included stable adult patients with AAFL, where onset of symptoms was <48 hours. Patients underwent central web-based randomization stratified by site. The Drug-Shock group received an infusion of procainamide (15mg/kg over 30 minutes) followed 30 minutes later, if necessary, by ECV at 200 joules x 3 shocks. The Shock Only group received an infusion of saline followed, if necessary, by ECV x 3 shocks. The primary outcome was conversion to sinus rhythm for ≥30 minutes at any time following onset of infusion. Patients were followed for 14 days. The primary outcome was evaluated on an intention-to-treat basis. Statistical significance was assessed using chi-squared tests and multivariable logistic regression. Results: We randomized 76 patients, and none was lost to follow-up. The Drug-Shock (N = 33) and Shock Only (N = 43) groups were similar for all characteristics including mean age (66.3 vs 63.4 yrs), duration of AAFL (30.1 vs 24.5 hrs), previous AAFL (72.7% vs 69.8%), median CHADS2 score (1 vs 1), and mean initial heart rate (128.9 vs 126.0 bpm). The Drug-Shock and Shock only groups were similar for the primary outcome of conversion (100% vs 93%; absolute difference 7.0%, 95% CI -0.6;14.6; P = 0.25). The multivariable analyses confirmed the similarity of the two strategies (P = 0.19). In the Drug-Shock group 21.2% of patients converted with the infusion. There were no statistically significant differences for time to conversion (84.2 vs 97.6 minutes), total ED length of stay (9.4 vs 7.5 hours), disposition home (100% vs 95.3%), and stroke within 14 days (0 vs 0). Premature discontinuation of infusion (usually for transient hypotension) was more common in the Drug-Shock group (9.1% vs 0.0%) but there were no serious adverse events. Conclusion: Both the Drug-Shock and Shock Only strategies were highly effective and safe in allowing AAFL patients to go home in sinus rhythm. IV procainamide alone was effective in only one fifth of patients, much less than for acute AF.
Psychoanalytic psychotherapy was found superior to usual treatment among borderline patients and should be further investigated in subject samples with adequate adherence to effective treatment and careful evaluation of psychotherapy process and its relationship to outcome. According to this rationale we tested the comparative cost-effectiveness of an innovative model of time limited psychoanalytic psychotherapy aimed at working-out conflicting mourning process associated with traumatic abandonment from a romantic partner.
Eighty patients aged 18-60, who had been referred to medical emergency room with self-intoxication, DSMIV-R major depression and DSMIV-R borderline personality disorder were investigated in a 3-month randomized clinical trial. At general hospital discharge consecutive subjects were allocated to time-limited mourning focused psychoanalytic psychotherapy and venlafaxine and psychodynamic crisis intervention and venlafaxine. Reliable evaluations were conducted at intake, treatment discharge and 6-month follow-up on a battery of standardized instruments. Service consume was assessed via the computerized case register of the Geneva state health services system.
Intensive psychoanalytic psychotherapy was found a cost-effective treatment choice among borderline patients in a suicidal crisis.
A combination of ambulatory psychoanalytic psychotherapy and venlafaxine protocol is a feasible, safe and cost-effective treatment for acutely suicidal borderline patients.
Over the last few years, a new comprehensive program for acutely suicidal borderline patients has been developed in the Geneva area (careful description is provided in a distinct section of this workshop). The present work will report the results of a service research oriented study aimed at evaluating the impact of the implementation of such multidimensional intervention on a system of psychiatric services in a 500.000 inhabitant catchment area. Specifically, a pre-post design has been utilized to compare two distinct patient cohorts meeting criteria for borderline personality disorder who had bee referred to medical emergency room with suicidal attempt. Both cohorts had follow-up at 3-month and 1 year to assess treatment failure, repetition, hospitalization and direct costs. The results indicate that the program is feasible and may be associated with improved outcome and substantial costs savings among acutely suicidal borderline patients.
There is wide acknowledgement that apathy is an important behavioural syndrome in Alzheimer’s disease and in various neuropsychiatric disorders. In light of recent research and the renewed interest in the correlates and impacts of apathy, and in its treatments, it is important to develop criteria for apathy that will be widely accepted, have clear operational steps, and that will be easily applied in practice and research settings. Meeting these needs is the focus of the task force work reported here.
The task force includes members of the Association Française de Psychiatrie Biologique, the European Psychiatric Association, the European Alzheimer’s Disease Consortium and experts from Europe, Australia and North America. An advanced draft was discussed at the consensus meeting (during the EPA conference in April 7th 2008) and a final agreement reached concerning operational definitions and hierarchy of the criteria.
Apathy is defined as a disorder of motivation that persists over time and should meet the following requirements. Firstly, the core feature of apathy, diminished motivation, must be present for at least four weeks; secondly two of the three dimensions of apathy (reduced goal-directed behaviour, goal-directed cognitive activity, and emotions) must also be present; thirdly there should be identifiable functional impairments attributable to the apathy. Finally, exclusion criteria are specified to exclude symptoms and states that mimic apathy.
Consideration of ethical, legal, and social issues plus patient values (ELSI+) in health technology assessment (HTA) is challenging because of a lack of conceptual clarity and the multi-disciplinary nature of ELSI+. We used concept mapping to identify key concepts and inter-relationships in the ELSI+ domain and provide a conceptual framework for consideration of ELSI+ in HTA.
We conducted a scoping review (Medline and EMBASE, 2000–2016) to identify ELSI+ issues in the HTA literature. Items from the scoping review and an expert brainstorming session were consolidated into eighty ELSI+-related statements, which were entered into Concept Systems® Global MAX™ software. Participants (N = 38; 36 percent worked as researchers, 21 percent as academics; 42 percent self-identified as HTA experts) sorted the statements into thematic groups, and rated them on importance in making decisions about adopting technologies in Canada, from 1 (not at all important) to 5 (extremely important). We used Concept Systems® Global MAX™ software to create and analyze concept maps with four to sixteen clusters.
Our final ELSI+ map consisted of five clusters, with each cluster representing a different concept and the statements within each cluster representing the same concept. Based on the concepts, we named these clusters: patient preferences/experiences, patient quality of life/function, patient burden/harm, fairness, and organizational. The highest mean importance ratings were for the statements in the patient burden/harm (3.82) and organizational (3.92) clusters.
This study suggests an alternative approach to ELSI+, based on conceptual coherence rather than academic disciplines. This will provide a foundation for incorporating ELSI+ into HTA.
The completion of a laser safety course remains a core surgical curriculum requirement for otolaryngologists training in the UK. This project aimed to develop a comprehensive laser safety course utilising both technical and non-technical skills simulation.
Otolaryngology trainees and consultants from the West of Scotland Deanery attended a 1-day course comprising lectures, two high-fidelity simulation scenarios and a technical simulation of safe laser use in practice.
The course, and in particular the use of simulation training, received excellent feedback from otolaryngology trainees and consultants who participated. Both simulation scenarios were validated for future use in laser simulation.
The course has been recognised as a laser safety course sufficient for the otolaryngology Certificate of Completion of Training. To the authors’ knowledge, this article represents the first description of using in situ non-technical skills simulation training for teaching laser use in otolaryngology.
Introduction: For rhythm control of acute atrial fibrillation (AAF) in the emergency department (ED), choices include initial drug therapy or initial electrical cardioversion (ECV). We compared the strategies of pharmacological cardioversion followed by ECV if necessary (Drug-Shock), and ECV alone (Shock Only). Methods: We conducted a randomized, blinded, placebo-controlled trial (1:1 allocation) comparing two rhythm control strategies at 11 academic EDs. We included stable adult patients with AAF, where onset of symptoms was <48 hours. Patients underwent central web-based randomization stratified by site. The Drug-Shock group received an infusion of procainamide (15mg/kg over 30 minutes) followed 30 minutes later, if necessary, by ECV at 200 joules x 3 shocks. The Shock Only group received an infusion of saline followed, if necessary, by ECV x 3 shocks. The primary outcome was conversion to sinus rhythm for ≥30 minutes at any time following onset of infusion. Patients were followed for 14 days. The primary outcome was evaluated on an apriori-specified modified intention-to-treat (MITT) basis excluding patients who never received the study infusion (e.g. spontaneous conversion). Data were analyzed using chi-squared tests and logistic regression. Our target sample size was 374 evaluable patients. Results: Of 395 randomized patients, 18 were excluded from the MITT analysis; none were lost to follow-up. The Drug-Shock (N = 198) and Shock Only (N = 180) groups (total = 378) were similar for all characteristics including mean age (60.0 vs 59.5 yrs), duration of AAF (10.1 vs 10.8 hrs), previous AF (67.2% vs 68.3%), median CHADS2 score (0 vs 0), and mean initial heart rate (119.9 vs 118.0 bpm). More patients converted to normal sinus rhythm in the Drug-Shock group (97.0% vs 92.2%; absolute difference 4.8%, 95% CI 0.2-9.9; P = 0.04). The multivariable analyses confirmed the Drug-Shock strategy superiority (P = 0.04). There were no statistically significant differences for time to conversion (91.4 vs 85.4 minutes), total ED length of stay (7.1 vs 7.7 hours), disposition home (97.0% vs 96.1%), and stroke within 14 days (0 vs 0). Premature discontinuation of infusion was more common in the Drug-Shock group (8.1% vs 0.6%) but there were no serious adverse events. Conclusion: Both the Drug-Shock and Shock Only strategies were highly effective and safe in allowing AAF patients to go home in sinus rhythm. A strategy of initial cardioversion with procainamide was superior to a strategy of immediate ECV.
The self-report of some autistic individuals that they experience social motivation should not be interpreted as a refutation of neuroimaging evidence supporting the social motivation hypothesis of autism. Neuroimaging evidence supports subtle differences in unconscious reward processing, which emerge at the group level and which may not be perceptible to individuals, but which may nonetheless impact an individual's behavior.
With the recent discovery of a dozen dusty star-forming galaxies and around 30 quasars at z > 5 that are hyper-luminous in the infrared (μ LIR > 1013 L⊙, where μ is a lensing magnification factor), the possibility has opened up for SPICA, the proposed ESA M5 mid-/far-infrared mission, to extend its spectroscopic studies toward the epoch of reionisation and beyond. In this paper, we examine the feasibility and scientific potential of such observations with SPICA’s far-infrared spectrometer SAFARI, which will probe a spectral range (35–230 μm) that will be unexplored by ALMA and JWST. Our simulations show that SAFARI is capable of delivering good-quality spectra for hyper-luminous infrared galaxies at z = 5 − 10, allowing us to sample spectral features in the rest-frame mid-infrared and to investigate a host of key scientific issues, such as the relative importance of star formation versus AGN, the hardness of the radiation field, the level of chemical enrichment, and the properties of the molecular gas. From a broader perspective, SAFARI offers the potential to open up a new frontier in the study of the early Universe, providing access to uniquely powerful spectral features for probing first-generation objects, such as the key cooling lines of low-metallicity or metal-free forming galaxies (fine-structure and H2 lines) and emission features of solid compounds freshly synthesised by Population III supernovae. Ultimately, SAFARI’s ability to explore the high-redshift Universe will be determined by the availability of sufficiently bright targets (whether intrinsically luminous or gravitationally lensed). With its launch expected around 2030, SPICA is ideally positioned to take full advantage of upcoming wide-field surveys such as LSST, SKA, Euclid, and WFIRST, which are likely to provide extraordinary targets for SAFARI.
Forage maize (Zea mays L.) is often grown year after year on the same land on many intensive dairy farms in north-west Europe. This results in agronomical problems such as weed resistance and decline of soil quality, which may be solved by ley-arable farming. In the current study, forage maize was grown at different nitrogen (N) fertilization levels for 3 years on permanent arable land and on temporary arable land after ploughing out different types of grass–clover swards. Swards differed in management (grazing or cutting) and age (temporary or permanent). Maize yield and soil residual mineral N content were measured after the maize harvest. There was no effect on maize yield of the management of ploughed-out grass–clover swards but a clear effect of the age of grass–clover swards. The N fertilizer replacement value (NFRV) of all ploughed grass–clover swards was >170 kg N/ha in the first year after ploughing. In the third year after ploughing, NFRV of the permanent sward still exceeded 200 kg N/ha, whereas that of the temporary swards decreased to 30 kg N/ha on average. Soil residual nitrate (NO3−) remained below the local, legal threshold of 90 kg NO3− N/ha except for the ploughed-out permanent sward in the third year after ploughing (166 kg NO3− N/ha). The current study highlights the potential of forage maize – ley rotations in saving fertilizer N. This is beneficial both for the environment and for the profitability of dairy production in north-western Europe.
Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. In 2015, the American Heart Association release updated guidelines dictating best practices in post-return of spontaneous circulation (ROSC) care, advocating for more liberal utilization of emergent coronary angiography. We sought to determine if the post-ROSC care at our centre during our study period adhered to the previously published (2010) guidelines. Methods: We performed a retrospective analysis (Sept. 2011 - June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Key variables included rates of post-ROSC emergent angiography, survival to hospital discharge and survival to hospital discharge with favourable neurologic outcome (modified Rankin score 2). Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. Of those who achieved sustained ROSC, median age was 65 years (IQR=21.75), 66.8% were male. ECG interpretation data was available on 214 patients, of whom 56 had definite STEMI, and 135 had definite absence of STEMI. 37/56 (66.1%) definite STEMI patients received coronary angiography within 24 hours of presentation, as per AHA guidelines. 58/262 (22.1%) post-ROSC patients overall received coronary angiography within 24 hours of presentation to the ED. Of those 58 patients who received emergent angiography, 38 (65.5%) underwent percutaneous coronary intervention (PCI). No patients received fibrinolysis. Of post-ROSC patients who received emergent coronary angiography, 40/58 (69.0%) survived to hospital discharge and 37/58 (63.8%) survived with good neurologic outcome. In comparison, 55/204 (27.0%) who did not receive emergent angiography survived to hospital discharge and 18.8% survived with good neurologic outcome. Conclusion: Only 22.1% of patients with OHCA, and only 66.1% with ECG-proven STEMI underwent emergent coronary angiography post-ROSC. Further investigation into causes for delay or the withholding of emergent angiography is necessary.
Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. We sought to determine if outcomes from out of hospital cardiac arrest (OHCA) at our centre were consistent with recently published North American outcomes data from the Resuscitation Outcomes Consortium (ROC). Methods: We performed a retrospective analysis (Sept 2011 June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, in-hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. 92 (35.1%) were receiving ongoing CPR at the time of their presentation to the ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. A total of 95 patients survived to hospital discharge (36.3% of patients who achieved sustained ROSC, 17.1% of those who were transported to the ED, and 10.4% of the all OHCA). Of those who survived to hospital discharge who had neurologic outcome data, 90.5% had a modified Rankin score of 2. Initial presenting rhythm with EMS was ventricular fibrillation or pulseless ventricular tachycardia in 233 patients. Of these, 212 (91.0%) were transported to the ED, 134 (57.5%) achieved sustained ROSC, and 71 (30.5%) survived to hospital discharge. 54/60 (90.0%) of those with a documented neurologic exam had a favourable neurologic outcome. Initial presenting rhythm with EMS was PEA or asystole in 636 patients. Of these, 320 (50.3%) were transported to the ED, 115 (18.1%) achieved sustained ROSC, and 17 (2.7%) survived to hospital discharge. 9/10 (90%) of those with a documented neurologic exam had a favourable neurologic outcome. 358 of the arrests were witnessed. Of these, 274 (76.5%) were transported to the ED, 150 (41.9%) achieved sustained ROSC, and 51 (15.9%) survived to hospital discharge. 47/53 (88.7%) of those with a documented neurologic exam had a favourable neurologic outcome. Conclusion: Outcomes from out of hospital cardiac arrest in London, Ontario are comparable to other sites across North America.
Clinical decision support (CDS) has been implemented in many clinical settings in order to improve decision-making. Their potential to improve diagnostic accuracy and reduce unnecessary testing is well documented; however, their effectiveness in impacting physician practice in real world implementations has been limited by poor physician adherence. The objective of this systematic review and meta-regression was to establish the effectiveness of CDS tools on adherence and identify which characteristics of CDS tools increase physician use of and adherence. Methods: A systematic review and meta-analysis was conducted. MEDLINE, EMBASE, PsychINFO, the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched from inception to June 2017. Included studies examined CDS in a hospital setting, reported on physician adherence to or use of CDS, utilized a comparative study design, and reported primary data. All tool type was classified based on the Cochrane Effective Practice and Organization of Care (EPOC) classifications. Studies were stratified based on study design (RCT vs. observational). Meta-regression was completed to assess the different effect of characteristics of the tool (e.g. whether the tool was mandatory or voluntary, EPOC classifications). Results: A total of 3,359 candidate articles were identified. Seventy-two met inclusion criteria, of which 46 reported outcomes appropriate for meta-regression (5 RCTs and 41 observational studies). Overall, a trend of increased CDS use was found (pooled RCT OR: 1.36 [95% CI: 0.97-1.89]; pooled observational OR: 2.12 [95% CI: 1.75-2.56]).When type of tool is considered, clinical practice guidelines were superior compared to other interventions (p=.150). Reminders (p=.473) and educational interventions (p=.489) were less successful than other interventions. Multi-modal tools were not more successful that single interventions (p=.810). Lastly, voluntary tools may be supperior to than mandatory tools (p=.148). None of these results are statistically significant. Conclusion: CDS tools accompanied by a planned intervention increases physician utilization and adherence to the tool. Meta-regression found that clinical practice guidelines had the biggest impact on physician adherence although not statistically significant. Further research is required to understand the most effective intervention to maximize physician utilization of CDS tools.
To identify predominant dietary patterns in four African populations and examine their association with obesity.
We used data from the Africa/Harvard School of Public Health Partnership for Cohort Research and Training (PaCT) pilot study established to investigate the feasibility of a multi-country longitudinal study of non-communicable chronic disease in sub-Saharan Africa. We applied principal component analysis to dietary intake data collected from an FFQ developed for PaCT to ascertain dietary patterns in Tanzania, South Africa, and peri-urban and rural Uganda. The sample consisted of 444 women and 294 men.
We identified two dietary patterns: the Mixed Diet pattern characterized by high intakes of unprocessed foods such as vegetables and fresh fish, but also cold cuts and refined grains; and the Processed Diet pattern characterized by high intakes of salad dressing, cold cuts and sweets. Women in the highest tertile of the Processed Diet pattern score were 3·00 times more likely to be overweight (95 % CI 1·66, 5·45; prevalence=74 %) and 4·24 times more likely to be obese (95 % CI 2·23, 8·05; prevalence=44 %) than women in this pattern’s lowest tertile (both P<0·0001; prevalence=47 and 14 %, respectively). We found similarly strong associations in men. There was no association between the Mixed Diet pattern and overweight or obesity.
We identified two major dietary patterns in several African populations, a Mixed Diet pattern and a Processed Diet pattern. The Processed Diet pattern was associated with obesity.
The SPICA mid- and far-infrared telescope will address fundamental issues in our understanding of star formation and ISM physics in galaxies. A particular hallmark of SPICA is the outstanding sensitivity enabled by the cold telescope, optimised detectors, and wide instantaneous bandwidth throughout the mid- and far-infrared. The spectroscopic, imaging, and polarimetric observations that SPICA will be able to collect will help in clarifying the complex physical mechanisms which underlie the baryon cycle of galaxies. In particular, (i) the access to a large suite of atomic and ionic fine-structure lines for large samples of galaxies will shed light on the origin of the observed spread in star-formation rates within and between galaxies, (ii) observations of HD rotational lines (out to ~10 Mpc) and fine structure lines such as [C ii] 158 μm (out to ~100 Mpc) will clarify the main reservoirs of interstellar matter in galaxies, including phases where CO does not emit, (iii) far-infrared spectroscopy of dust and ice features will address uncertainties in the mass and composition of dust in galaxies, and the contributions of supernovae to the interstellar dust budget will be quantified by photometry and monitoring of supernova remnants in nearby galaxies, (iv) observations of far-infrared cooling lines such as [O i] 63 μm from star-forming molecular clouds in our Galaxy will evaluate the importance of shocks to dissipate turbulent energy. The paper concludes with requirements for the telescope and instruments, and recommendations for the observing strategy.
Saturn's moon Enceladus has vents emerging from a sub-surface ocean, offering unique probes into the liquid environment. These vents drain into the larger neutral torus in orbit around Saturn. We present a methanol (CH3OH) detection observed with IRAM 30-m from 2008 along the line-of-sight through Saturn's E-ring. Additionally, we also present supporting observations from the Herschel public archive of water (ortho-H2O; 1669.9 GHz) from 2012 at a similar elongation and line-of-sight. The CH3OH 5(1,1)-4(1,1) transition was detected at 5.9σ confidence. The line has 0.43 km s−1 width and is offset by +8.1 km s−1 in the moon's reference frame. Radiative transfer models allow for gas cloud dimensions from 1750 km up to the telescope beam diameter ~73 000 km. Taking into account the CH3OH lifetime against solar photodissociation and the redshifted line velocity, there are two possible explanations for the CH3OH emission: methanol is primarily a secondary product of chemical interactions within the neutral torus that: (1) spreads outward throughout the E-ring or (2) originates from a compact, confined gas cloud lagging Enceladus by several km s−1. We find either scenario to be consistent with significant redshifted H2O emission (4σ) measured from the Herschel public archive. The measured CH3OH:H2O abundance (>0.5%) significantly exceeds the observed abundance in the direct vicinity of the vents (~0.01%), suggesting CH3OH is likely chemically processed within the gas cloud with methane (CH4) as its parent species.
IR spectroscopy in the range 12–230 μm with the SPace IR telescope for Cosmology and Astrophysics (SPICA) will reveal the physical processes governing the formation and evolution of galaxies and black holes through cosmic time, bridging the gap between the James Webb Space Telescope and the upcoming Extremely Large Telescopes at shorter wavelengths and the Atacama Large Millimeter Array at longer wavelengths. The SPICA, with its 2.5-m telescope actively cooled to below 8 K, will obtain the first spectroscopic determination, in the mid-IR rest-frame, of both the star-formation rate and black hole accretion rate histories of galaxies, reaching lookback times of 12 Gyr, for large statistically significant samples. Densities, temperatures, radiation fields, and gas-phase metallicities will be measured in dust-obscured galaxies and active galactic nuclei, sampling a large range in mass and luminosity, from faint local dwarf galaxies to luminous quasars in the distant Universe. Active galactic nuclei and starburst feedback and feeding mechanisms in distant galaxies will be uncovered through detailed measurements of molecular and atomic line profiles. The SPICA’s large-area deep spectrophotometric surveys will provide mid-IR spectra and continuum fluxes for unbiased samples of tens of thousands of galaxies, out to redshifts of z ~ 6.