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Introduction: The Emergency Departments (ED) is a gateway to the health care system for many psychiatric patients. As a consequence of hospital administrative factors and overcrowding, admitted psychiatric patients are often boarded in the ED while waiting for an inpatient bed. There is currently a lack of evidence to quantify the effect that ED boarding has on psychiatric patients. The primary objective of this study is to determine whether a patient's length of stay is related to longer ED boarding time. Methods: This study is a retrospective cohort using data from an administrative source, which was obtained from patient records captured in the Sunrise Clinical Manager EMR used across Calgary, Alberta EDs from 2014-2018. A hierarchical Bayesian regression analysis was used to model the several patient-level and hospital-level factors. The mean and variance was defined by the exposure of interest, namely hours in the Emergency Department after admission to psychiatry unit expressed as a continuous variable. An interaction between this exposure and patient-level confounders was used to model the changing effect of a patient's severity in the ED on their boarding time. Results: The median boarding time for patients in our study was 6.6 hours (standard deviation 17.3), while the average was 13.6 hours. Patients who were boarded for greater than 6 hours more frequently required an antipsychotic (37% vs 11%; SMD 0.651), sedative (52% vs 29%; SMD 0.483) or restraints (18% vs. 14%; SMD 0.102). In crude analysis there was no difference in median length of stay for patients that were boarding more than 6 hours compared to those boarded for less than 6 hours (8 days vs 9 days; SMD 0.012).The rate ratio for length of stay is 1.05 with 95% posterior interval 1.04 - 1.06 for each 24 hour increase in boarding time. This means that for each 1 day worth of boarding time, the length of stay (in days) increases 1.05 times (or 0.05 days/day boarding time). Conclusion: Boarding time is associated with a small but absolute increase in length of stay for psychiatric patients. Decreasing boarding time could have ripple effects for ED efficiency and overall patient outcomes.
Schizophrenia is associated with altered neural development. We assessed neurological soft signs (NSS) and dermatoglyphic anomalies (total a–b ridge count (TABRC) and total finger ridge count) in 15 pairs of twins concordant and discordant for schizophrenia. Within-pair differences in both NSS and TABRC scores were significantly greater in discordant compared to concordant monozygotic pairs. There was no significant difference in NSS and TABRC scores between subjects with schizophrenia and their co-twins without the illness. However, monozygotic discordant twins with schizophrenia had higher ABRCs on their right hands compared to their co-twins without the illness. These findings suggest that an unidentified environmental event acting between weeks 6 and 15 of gestation affects the development of monozygotic twins who go on to develop schizophrenia but does not have a corresponding effect on their co-twins who do not develop the illness. The effect of such an event on dermatoglyphic profiles appears lateralised to the right hand in affected twins.
This study investigated the attitudes of medical students towards psychiatry, both as a subject on the medical curriculum and as a career choice. Three separate questionnaires previously validated on medical student populations were administered prior to and immediately following an 8-week clinical training programme. The results indicate that the perception of psychiatry was positive prior to clerkship and became even more so on completion of training. On completion of the clerkship, there was a rise in the proportion of students who indicated that they might choose a career in psychiatry. Attitudes toward psychiatry correlated positively with the psychiatry examination results. Those that intended to specialise in psychiatry achieved significantly higher examination scores in the psychiatry examination.
A number of large naturalistic trials of anti-psychotic medication have been carried out in recent years. These include SOHO, CATIE, CAFÉ, EUFEST, and CUTLASS.
These studies have attempted to demonstrate the efficacy in practice of second generation drugs as compared to first generation drugs. the results of these studies have been hotly debated and various conclusions have been drawn.
However, it is necessary to question what methodological issues have arisen in these studies, and hence how safe are the conclusions.
It is now also necessary to examine what findings appear to have been demonstrated by these trials, and whether certain findings are corroborated by several trials, while other trial results contradict each other.
In the presentation, each of the five studies will be critically appraised by a contributor who is a practicing clinician, but who has not participated as a principal investigator in the study concerned. Conclusions will be drawn as to whether the trials are useful for developing guidelines for the use of antipsychotics in the management of psychotic illness, what findings are corroborated by several trials, and indeed, whether methodological flaws might undermine some conclusions from some of the studies.
Achieving control over the morphology of conjugated polymer (CP) blends at nanoscale is crucial for enhancing their performances in diverse organic optoelectronic devices, including thin film transistors, photovoltaics, and light emitting diodes. However, the complex CP chemical structures and intramolecular interactions often make such control difficult to implement. We demonstrate here that cooperative combination of non-covalent interactions, including hydrogen bonding, coordination interactions, and π-π interactions, etc., can be used to effectively define the morphology of CP blend films, in particular being able to achieve accurate spatial arrangement of nanoparticles within CP nanostructures. Through UV-vis absorption spectroscopy and transmission electron microscopy, we show strong attachment of fullerene molecules, CdSe quantum dots, and iron oxide nanoparticles, onto well-defined CP nanofibers. The resulting core/shell hybrid nanofibers exhibit well-defined donor/acceptor interface when employed in photovoltaic devices, which also contributes to enhanced charge separation and transport. These findings provide a facile new methodology of improving CP/nanoparticle interfacial properties and controlling blend morphology. The generality of this methodology demonstrated in current studies points to a new way of designing hybrid materials based on organic polymers and inorganic nanoparticles towards applications in modern electronic devices.
The active inference framework offers an attractive starting point for understanding cultural cognition. Here, we argue that affective dynamics are essential to include when constructing this type of theory. We highlight ways in which interactions between emotional responses and the perception of those responses, both within and between individuals, can play central roles in both motivating and constraining sociocultural practices.
Middle infrared (~2000 to 200 cm–1 or 5 to 50 μm) data are extremely useful for compositional determination of geologic materials because this wavelength region hosts the fundamental (“Reststrahlen”) vibrational bands of most minerals. Analysis of remotely sensed data requires comparison to well-developed spectral libraries populated with a wide variety of mid-IR mineral spectra (and additional rock or meteorite spectra). Here we present the theory behind molecular vibrations of mineral structures and the simple harmonic oscillators that define them mathematically. We present dispersion theory that describes how energy travels through a crystal and how propagating energy is affected by the crystal lattice structure, specifically along the various crystal axes. The equipment required for these types of laboratory measurements (both emissivity and reflectivity) is presented as well as a discussion about how mid-IR data are affected by particle size and how related volume scattering affects spectral data. Finally, mid-IR emissivity spectra acquired in a dry, 1-atm environment are provided for 93 different minerals and meteorites. These spectra are available as ancillary data files.
Introduction: The quick Sepsis-related Organ Failure Assessment (qSOFA) score was developed to provide clinicians with a quick assessment for patients with latent organ failure possibly consistent with sepsis at high-risk for mortality. With the clinical heterogeneity of patients presenting with sepsis, a Bayesian validation approach may provide a better understanding of its clinical utility. This study used a Bayesian analysis to assess the prediction of hospital mortality by the qSOFA score among patients with infection transported by paramedics. Methods: A one-year cohort of adult patients transported by paramedics in a large, provincial EMS system was linked to Emergency Department (ED) and hospital administrative databases, then restricted to those patients with an ED diagnosed infection. A Bayesian binomial regression model was constructed using Hamiltonian Markov-Chain Monte-Carlo sampling, normal priors for each parameter, the calculated score, age and sex as the predictors, and hospital mortality as the outcome. Discrimination was assessed using posterior predictions to calculate a “Bayesian” C statistic, and calibration was assessed with calibration plots of the observed and predicted probability distributions. The independent predictive ability of each measure was tested by including each component measure (respiratory rate, Glasgow Coma Scale, and systolic blood pressure) as continuous predictors in a second model. Results: A total of 9,920 patients with ED diagnosed infection were included. 264 (2.7%) patients were admitted directly to the ICU, and 955 (9.6%) patients died in-hospital. As independent predictors, the probability of mortality increased as each measure became more extreme, with the Glasgow Coma Scale predicting the greatest change in mortality risk from a high to low score; however, no dramatic change in the probability supporting a single decision threshold was seen for any measure. For the calculated score, the C statistic for predicting mortality was 0.728. The calibration curve had no overlap of predictions, with a probability of 0.5 (50% credible interval 0.47-0.53) for patients with a qSOFA score of 3. Conclusion: Although no single decision threshold was identified for each component measure, a calculated qSOFA score provides good prediction of mortality for patients with ED diagnosed infection. When validating clinical prediction scores, a Bayesian approach may be used to assess probabilities of interest for clinicians to support better clinical decision making. Character count 2494
Introduction: Early and accurate diagnosis of critical conditions is essential in emergency medical services (EMS). Serum lactate testing may be used to identify patients with worse prognosis, including sepsis. Recently, the use of a point-of-care lactate (POCL) test has been evaluated in guiding treatment in patients with sepsis. Operating as part of the Prehospital Evidence Based Practice (PEP) Program, the authors sought to identify and describe the body of evidence for POCL use in EMS and the emergency department (ED) for patients with sepsis. Methods: Following PEP methodology, in May 2018, PubMed was searched in a systematic manner. Title and abstract screening were conducted by the program coordinator. These studies were collected, appraised and added to the existing body of literature contained within the PEP database. Evidence appraisal was conducted by two reviewers who assigned both a level of evidence (LOE) on a novel three tier scale and a direction of evidence (supportive, neutral or opposing; based on primary outcome). Data on setting and study design were also extracted. Results: Eight studies were included in our analysis. Three of these studies were conducted in the ED setting; each investigating the POCL test's ability to predict severe sepsis, ICU admission or death. All three studies found supportive results for POCL. A systematic review on the use of POCL in the ED determined that this test can also improve time to treatment. Five of the total 8 studies were conducted prehospitally. Two of these studies were supportive of POCL use in the prehospital setting; in terms of feasibility and the ability to predict sepsis. Both of these study sites used this early information as part of initiating a “sepsis alert” pathway. The other three prehospital studies provide neutral support for POCL. One study demonstrated moderate ability of POCL to predict severe illness. Two studies found poor agreement between prehospital POCL and serum lactate values. Conclusion: Limited low and moderate quality evidence suggest POCL may be feasible and helpful in predicting sepsis in the prehospital setting. However, there is sparse and inconsistent support for specific important outcomes, including accuracy.
Introduction: Despite their widespread use, measures of classification accuracy (i.e. sensitivity and specificity) have several limitations that conceals relevant information and may bias decision-making. Assessing the predictive ability of clinical tools instead may provide more useful prognostic information to support decision-making, particularly in an Emergency setting. We sought to contrast classification accuracy versus predictive ability of the Systemic Inflammatory Response Syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) Sepsis scores for determining mortality risk among patients with infection transported by paramedics. Methods: A one-year cohort of patients with infections transported to the Emergency Department by paramedics was linked to in-hospital administrative databases. Hospital mortality was determined for each patient at the time of discharge. We calculated sensitivity and specificity of SIRS and qSOFA for classifying hospital mortality across different score thresholds, and estimated discrimination (assessed using the C statistic) and calibration (assessed visually) of prediction. Prediction models for hospital mortality were constructed using the aggregated SIRS or qSOFA scores for each patient as a predictor, while accounting for clustering by institution and adjusting for differences in patient age and sex. Predicted and observed risk were plotted to assess calibration and change in risk across levels of each score. Results: A total of 10,409 patients with infection who were transported by paramedics were successfully linked, with an overall mortality rate of 9.2%. The median SIRS score among non-survivors was 2, while the median qSOFA score was 1. SIRS score had higher sensitivity estimates than qSOFA for classifying hospital mortality at all thresholds (0.11 – 0.83 vs. 0.08 – 0.80), but the qSOFA score had better discrimination (C statistic 0.76 vs. 0.71) and calibration. The risk of hospital mortality predicted by the SIRS score ranged from 6.6-24% across score values, whereas the risk predicted by the qSOFA score ranged from 8.6-53%. Conclusion: Assessing the SIRS and qSOFA scores predictive ability reveals that the qSOFA score provides more information to clinicians about a patient's mortality risk despite having worse sensitivity. This study highlights important limitations of classification accuracy for diagnostic test studies and supports a shift toward assessing predictive ability instead. Character count 2490
Introduction: The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated Emergency Medical Services (EMS) evidence repository. This summary describes the research evidence for the identification and management of adult patients suffering from sepsis syndrome or septic shock. Methods: PubMed was searched in a systematic manner. One author reviewed titles and abstracts for relevance and two authors appraised each study selected for inclusion. Primary outcomes were extracted. Studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and a three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings based on the studies’ primary outcome for each intervention). LOE and DOE of each intervention were plotted on an evidence matrix (DOE x LOE). Results: Eighty-eight studies were included for 15 interventions listed in PEP. The interventions with the most evidence were related to identification tools (ID) (n = 26, 30%) and early goal directed therapy (EGDT) (n = 21, 24%). ID tools included Systematic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA) and other unique measures. The most common primary outcomes were related to diagnosis (n = 30, 34%), mortality (n = 40, 45%) and treatment goals (e.g. time to antibiotic) (n = 14, 16%). The evidence rank for the supported interventions were: supportive-high quality (n = 1, 7%) for crystalloid infusion, supportive-moderate quality (n = 7, 47%) for identification tools, prenotification, point of care lactate, titrated oxygen, temperature monitoring, and supportive-low quality (n = 1, 7%) for vasopressors. The benefit of prehospital antibiotics and EGDT remain inconclusive with a neutral DOE. There is moderate level evidence opposing use of high flow oxygen. Conclusion: EMS sepsis interventions are informed primarily by moderate quality supportive evidence. Several standard treatments are well supported by moderate to high quality evidence, as are identification tools. However, some standard in-hospital therapies are not supported by evidence in the prehospital setting, such as antibiotics, and EGDT. Based on primary outcomes, no identification tool appears superior. This evidence analysis can guide selection of appropriate prehospital therapies.
Respiratory viral infections are a leading cause of disease worldwide. A variety of respiratory viruses produce infections in humans with effects ranging from asymptomatic to life-treathening. Standard surveillance systems typically only target severe infections (ED outpatients, hospitalisations, deaths) and fail to track asymptomatic or mild infections. Here we performed a large-scale community study across multiple age groups to assess the pathogenicity of 18 respiratory viruses. We enrolled 214 individuals at multiple New York City locations and tested weekly for respiratory viral pathogens, irrespective of symptom status, from fall 2016 to spring 2018. We combined these test results with participant-provided daily records of cold and flu symptoms and used this information to characterise symptom severity by virus and age category. Asymptomatic infection rates exceeded 70% for most viruses, excepting influenza and human metapneumovirus, which produced significantly more severe outcomes. Symptoms were negatively associated with infection frequency, with children displaying the lowest score among age groups. Upper respiratory manifestations were most common for all viruses, whereas systemic effects were less typical. These findings indicate a high burden of asymptomatic respiratory virus infection exists in the general population.
Particle loading affects the dynamics of buoyant plumes, since the difference between particle and fluid densities is much greater than that in the fluid alone. In stratified environments, plume rise is density limited; after initial overshoot, the plume reaches a terminal level and spreads radially. Particles dropping from this horizontal intrusion may be re-entrained. This recycling of dense matter reduces plume buoyancy and intrusion height and, for sufficient load, can lead to plume collapse. Entrainment-based formulae yield a steady-state plume rise. We identify a new conserved quantity for such plumes. Integrating paths of particles dropping from the intrusion yields the fraction re-entrained. A simple mathematical model predicts from buoyancy ratio at source (
negative particle buoyancy divided by positive fluid buoyancy) whether a particle-laden plume will collapse. Under this model, for small settling velocity, a particle-laden plume will not collapse if
. Above this, collapse depends also on the amount of particle-free ambient fluid entrained in the overshoot region. For pure plumes, experimental evidence suggests that this is small. For forced plumes, more substantial overshoot and entrainment is shown to increase the critical ratio. An extension, based on successive recycling, estimates time to collapse. To investigate further we develop a simple computational model, coupling a ‘top-hat’ plume model, an analytical formula for radially decaying concentrations in the intrusion and an axisymmetric finite-volume solution for time-dependent settling and entrainment. The model can predict the impact of particle load on final rise, as well as the occurrence and time scales of plume collapse.
We sought to define the prevalence of echocardiographic abnormalities in long-term survivors of paediatric hematopoietic stem cell transplantation and determine the utility of screening in asymptomatic patients. We analysed echocardiograms performed on survivors who underwent hematopoietic stem cell transplantation from 1982 to 2006. A total of 389 patients were alive in 2017, with 114 having an echocardiogram obtained ⩾5 years post-infusion. A total of 95 patients had echocardiogram performed for routine surveillance. The mean time post-hematopoietic stem cell transplantation was 13 years. Of 95 patients, 77 (82.1%) had ejection fraction measured, and 10/77 (13.0%) had ejection fraction z-scores ⩽−2.0, which is abnormally low. Those patients with abnormal ejection fraction were significantly more likely to have been exposed to anthracyclines or total body irradiation. Among individuals who received neither anthracyclines nor total body irradiation, only 1/31 (3.2%) was found to have an abnormal ejection fraction of 51.4%, z-score −2.73. In the cohort of 77 patients, the negative predictive value of having a normal ejection fraction given no exposure to total body irradiation or anthracyclines was 96.7% at 95% confidence interval (83.3–99.8%). Systolic dysfunction is relatively common in long-term survivors of paediatric hematopoietic stem cell transplantation who have received anthracyclines or total body irradiation. Survivors who are asymptomatic and did not receive radiation or anthracyclines likely do not require surveillance echocardiograms, unless otherwise indicated.
Detecting gastrointestinal (GI) infection transmission among men who have sex with men (MSM) in England is complicated by a lack of routine sexual behavioural data. We investigated whether gender distributions might generate signals for increased transmission of GI pathogens among MSM. We examined the percentage male of laboratory-confirmed patient-episodes for patients with no known travel history for 10 GI infections of public health interest in England between 2003 and 2013, stratified by age and region. An adult male excess was observed for Shigella spp. (annual maximum 71% male); most pronounced for those aged 25–49 years and living in London, Brighton and Manchester. An adult male excess was observed every year for Entamoeba histolytica (range 59.8–76.1% male), Giardia (53.1–57.6%) and Campylobacter (52.1–53.5%) and for a minority of years for hepatitis A (max. 69.8%) and typhoidal salmonella (max. 65.7%). This approach generated a signal for excess male episodes for six GI pathogens, including a characterised outbreak of Shigella among MSM. Stratified analyses by geography and age group were consistent with MSM transmission for Shigella. Optimisation and routine application of this technique by public health authorities elsewhere might help identify potential GI infection outbreaks due to sexual transmission among MSM, for further investigation.
Introduction: EMS time factors such as total prehospital, activation, response, scene and transport intervals have been used as a measure of EMS system quality with the assumption that shorter EMS time factors save lives. The objective was to assess in adults and children accessing ground EMS (population), whether operational time factors (intervention and control) were associated with survival at hospital discharge (outcome). Methods: Medline, EMBASE, and CINAHL were searched up to January 2015 for articles reporting original data that associated EMS operational time factors and survival. Conference abstracts and non-English language articles were excluded. Two investigators independently assessed the candidate titles, abstracts, and full text with discrepant reviews resolved by consensus. Risk of bias was assessed using GRADE. Results: A total of 10,151 abstracts were screened for potential inclusion, 199 articles were reviewed in full-text, and 73 met inclusion criteria. Amongst included studies, 49 investigated response time, while 24 investigated other time factors. All articles were observational studies. Amongst the 14 (28.6%) studies where response time was the primary analysis, statistically significant associations between shorter response time and increased survival were found in 5 of 7 cardiac arrest, 1 of 5 general EMS population, and 0 of 2 trauma studies. Other time factors were reported in the primary analysis in 10 (41.7%) studies. One study reported shorter combined scene and transport intervals associated with increased survival in acute heart failure patients. Two studies in trauma patients had somewhat conflicting results with one study reporting shorter prehospital interval associated with increased survival whereas the other reported increased survival associated with longer scene and transport intervals. Study design, analysis, and methodological quality were of considerable variability, and thus, meta-analyses were not possible. Conclusion: There is a substantial body of literature describing the association between EMS time factors and survival, but evidence informing these relationships are heterogeneous and complex. Important details such as patient population, EMS system characteristics, and analytical approach must be taken into consideration to appropriately translate these findings to practice. These results will be important for EMS leaders wishing to create evidence-based time policies.
Introduction: Outside of key conditions such as cardiac arrest and trauma, little is known about the epidemiology of mortality of all transported EMS patients. The objective of this study is to describe characteristics of EMS patients who after transport die in a health care facility. Methods: EMS transport events over one year (April, 2015-16) from a BLS/ALS system serving an urban/rural population of approximately 2 million were linked with in-hospital datasets to determine proportion of all-cause in-hospital mortality by Medical Priority Dispatch System (MPDS) determinant (911 call triage system), age in years (>=18 yrs. - adult, <=17 yrs. - pediatric), sex, day of week, season, time (in six hour periods), and emergency department Canadian Triage and Acuity Scale (CTAS). The MPDS card, patient chief complaint, and ED diagnosis category (International Classification of Disease v.10 - Canadian) with the highest proportion of mortality are also reported. Analyses included two-sided t-test or chi-square with alpha <0.05. Results: A total of 239,534 EMS events resulted in 159,507 patient transports; 141,114 were included for analysis after duplicate removal (89.1% linkage), with 127,867 reporting final healthcare system outcome. There were 4,269 who died (3.3%; 95%CI 3.2%, 3.4%). The proportion of mortality by MPDS determinant was, from most to least critical 911 call, Echo (7.3%), Delta (37.2%), Charlie (31.3%), Bravo (5.8%), Alpha (18.3%), and Omega (0.3%). For adults the mean age of survivors was less than non-survivors (57.7 vs. 75.8; p<0.001), but pediatric survivors were older than non-survivors (8.7 vs. 2.8; p<0.001). There were more males that died than females (53.0% vs. 47.0%; p<0.001). There was no statistically significant difference in the day of week (p=0.592), but there was by season with the highest mortality in winter (27.1%; p=0.045). The highest mortality occurred with patients presenting to EMS between 0600-1200 hours (34.6%), and the lowest between 0000-0600 hours (11.8%; p<0.001). Mortality by CTAS was category 1 (27.1%), 2 (36.7%), 3 (29.9%), 4 (4.3%), and 5 (0.5%). The highest mortality was seen in MPDS card 26-Sick Person (specific diagnosis) (19.1%), chief complaint shortness of breath (19.3%), and ED diagnoses pertaining to the circulatory system (31.1%). Conclusion: Significant all-cause in-hospital mortality differences were found between event, patient, and clinical characteristics. These data provide foundational and hypothesis generating knowledge regarding mortality in transported EMS patients that can be used to guide research and training. Future research should further explore the characteristics of those that access health care through the EMS system.