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Introduction: An important challenge physicians face when treating acute heart failure (AHF) patients in the emergency department (ED) is deciding whether to admit or discharge, with or without early follow-up. The overall goal of our project was to improve care for AHF patients seen in the ED while avoiding unnecessary hospital admissions. The specific goal was to introduce hospital rapid referral clinics to ensure AHF patients were seen within 7 days of ED discharge. Methods: This prospective before-after study was conducted at two campuses of a large tertiary care hospital, including the EDs and specialty outpatient clinics. We enrolled AHF patients ≥50 years who presented to the ED with shortness of breath (<7 days). The 12-month before (control) period was separated from the 12-month after (intervention) period by a 3-month implementation period. Implementation included creation of rapid access AHF clinics staffed by cardiology and internal medicine, and development of referral procedures. There was extensive in-servicing of all ED staff. The primary outcome measure was hospital admission at the index visit or within 30 days. Secondary outcomes included mortality and actual access to rapid follow-up. We used segmented autoregression analysis of the monthly proportions to determine whether there was a change in admissions coinciding with the introduction of the intervention and estimated a sample size of 700 patients. Results: The patients in the before period (N = 355) and the after period (N = 374) were similar for age (77.8 vs. 78.1 years), arrival by ambulance (48.7% vs 51.1%), comorbidities, current medications, and need for non-invasive ventilation (10.4% vs. 6.7%). Comparing the before to the after periods, we observed a decrease in hospital admissions on index visit (from 57.7% to 42.0%; P <0.01), as well as all admissions within 30 days (from 65.1% to 53.5% (P < 0.01). The autoregression analysis, however, demonstrated a pre-existing trend to fewer admissions and could not attribute this to the intervention (P = 0.91). Attendance at a specialty clinic, amongst those discharged increased from 17.8% to 42.1% (P < 0.01) and the median days to clinic decreased from 13 to 6 days (P < 0.01). 30-day mortality did not change (4.5% vs. 4.0%; P = 0.76). Conclusion: Implementation of rapid-access dedicated AHF clinics led to considerably increased access to specialist care, much reduced follow-up times, and possible reduction in hospital admissions. Widespread use of this approach can improve AHF care in Canada.
Little is known about who would benefit from Internet-based personalised nutrition (PN) interventions. This study aimed to evaluate the characteristics of participants who achieved greatest improvements (i.e. benefit) in diet, adiposity and biomarkers following an Internet-based PN intervention. Adults (n 1607) from seven European countries were recruited into a 6-month, randomised controlled trial (Food4Me) and randomised to receive conventional dietary advice (control) or PN advice. Information on dietary intake, adiposity, physical activity (PA), blood biomarkers and participant characteristics was collected at baseline and month 6. Benefit from the intervention was defined as ≥5 % change in the primary outcome (Healthy Eating Index) and secondary outcomes (waist circumference and BMI, PA, sedentary time and plasma concentrations of cholesterol, carotenoids and omega-3 index) at month 6. For our primary outcome, benefit from the intervention was greater in older participants, women and participants with lower HEI scores at baseline. Benefit was greater for individuals reporting greater self-efficacy for ‘sticking to healthful foods’ and who ‘felt weird if [they] didn’t eat healthily’. Participants benefited more if they reported wanting to improve their health and well-being. The characteristics of individuals benefiting did not differ by other demographic, health-related, anthropometric or genotypic characteristics. Findings were similar for secondary outcomes. These findings have implications for the design of more effective future PN intervention studies and for tailored nutritional advice in public health and clinical settings.
E. M. Forster's immersion in the thriving community of european writers and artists in alexandria increased his confidence as a writer; it also mitigated the social alienation he had experienced on his arrival in Egypt in 1915 to volunteer with the Red Cross. His theatrical sketch “Pericles in Paradise” (1918), published here for the irst time, is populated by characters modeled on the Alexandrian elite that fostered his sense of belonging. In addition, it bears the mark of a privileged position Forster himself was uneasy about: that of an En glishman navigating a city under British rule and removed from the realities faced by the native Egyptian population.
Background: Painful diabetic neuropathy (PDN) is a frequent complication of diabetes mellitus. Current treatment recommendations are based on short-term trials, generally of ≤3 months’ duration. Limited data are available on the long-term outcomes of this chronic disease. The objective of this study was to determine the long-term clinical effectiveness of the management of chronic PDN at tertiary pain centres. Methods: From a prospective observational cohort study of patients with chronic neuropathic non-cancer pain recruited from seven Canadian tertiary pain centres, 60 patients diagnosed with PDN were identified for analysis. Data were collected according to Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials guidelines including the Brief Pain Inventory. Results: At 12-month follow-up, 37.2% (95% confidence interval [CI], 23.0-53.3) of 43 patients with complete data achieved pain reduction of ≥30%, 51.2% (95% CI, 35.5-66.7) achieved functional improvement with a reduction of ≥1 on the Pain Interference Scale (0-10, Brief Pain Inventory) and 30.2% (95% CI, 17.2-46.1) had achieved both these measures. Symptom management included at least two medication classes in 55.3% and three medication classes in 25.5% (opioids, antidepressants, anticonvulsants). Conclusions: Almost one-third of patients being managed for PDN in a tertiary care setting achieve meaningful improvements in pain and function in the long term. Polypharmacy including analgesic antidepressants and anticonvulsants were the mainstays of effective symptom management.
Common beans (Phaseolus vulgaris L.) are a nutrient-dense, low glycemic index food that supports healthy weight management in people and was examined for dogs. The objectives of this study were to evaluate the apparent total tract digestibility (ATTD) and nutrient utilisation of navy (NB) and black (BB) bean-based diets in overweight or obese companion dogs undergoing a weight loss intervention. A nutritionally complete, dry extruded dog food was used as the control (CON) diet and two isocaloric, nutrient matched bean diets, containing either 25% w/w cooked BB or NB powder formed the test diets. Diets were fed to adult, overweight companion dogs for either four weeks (short-term study, n = 30) or for twenty-six weeks (long-term study, n = 15) at 60% of maintenance calories for ideal weight. Apparent weight loss increased over time in both the short- and long-term studies (p < 0.001) but was not different between the three study groups: apparent weight loss was between 4.05% – 6.14% for the short-term study and 14.0% – 17.9% in the long-term study. The ATTD was within expected ranges for all groups, whereby total dry matter and crude protein ATTD was 7–8% higher in the BB diet compared to CON (P < 0.05), crude fat ATTD was similar across all diets, and nitrogen free extract ATTD was 5–6% higher in both BB and NB compared to CON (P < 0.05). Metabolisable energy was similar for all diets, and ranged from 3,434–3,632 kcal/kg. At the end of each study period, dogs had haemoglobin levels ≥12 g/dl, packed cell volume ≥36%, albumin ≥2.4 g/dl, ALP ≤ 300 IU/l and all median values for each group were within defined limits for nutritional adequacy. This investigation demonstrated that BB and NB diets were safe, digestible, and supported weight loss in calorically restricted, overweight or obese, adult companion dogs.
Dietary assessment in older adults can be challenging. The Novel Assessment of Nutrition and Ageing (NANA) method is a touch-screen computer-based food record that enables older adults to record their dietary intakes. The objective of the present study was to assess the relative validity of the NANA method for dietary assessment in older adults. For this purpose, three studies were conducted in which a total of ninety-four older adults (aged 65–89 years) used the NANA method of dietary assessment. On a separate occasion, participants completed a 4 d estimated food diary. Blood and 24 h urine samples were also collected from seventy-six of the volunteers for the analysis of biomarkers of nutrient intake. The results from all the three studies were combined, and nutrient intake data collected using the NANA method were compared against the 4 d estimated food diary and biomarkers of nutrient intake. Bland–Altman analysis showed a reasonable agreement between the dietary assessment methods for energy and macronutrient intake; however, there were small, but significant, differences for energy and protein intake, reflecting the tendency for the NANA method to record marginally lower energy intakes. Significant positive correlations were observed between urinary urea and dietary protein intake using both the NANA and the 4 d estimated food diary methods, and between plasma ascorbic acid and dietary vitamin C intake using the NANA method. The results demonstrate the feasibility of computer-based dietary assessment in older adults, and suggest that the NANA method is comparable to the 4 d estimated food diary, and could be used as an alternative to the food diary for the short-term assessment of an individual's dietary intake.
We present the KMOS (K-band Multi-Object Spectrograph) Cluster and VIRIAL (VLT IRIFU Absorption Line) Guaranteed Time Observation (GTO) programs. KMOS provides 24 arms each feeding an integral field unit (14×14 spaxels of 0.2″ pixels) for IZ, YJ, H and K band near infrared (NIR) medium resolution spectroscopy (R ∼ 3500). Targets are selected from a 7.2′ diameter patrol field. Ultra-deep spectroscopy of ∼ 80 early-type cluster galaxies (∼ 20hr on source) and ∼ 200 (∼ 10hr on source) early-type field galaxies at 1 < z < 2 will dramatically improve the situation at z > 1 for which measurements of stellar velocity dispersions and absorption indices are limited to a few, often relatively young passively evolving galaxies (e.g. Bezanson 2013). In ESO Periods P92 and P93, 15 nights worth of data has been collected for KMOS-Clusters and 6 nights for VIRIAL: this will be supplemented with more data in upcoming semesters. All galaxies have multiband HST imaging including existing or upcoming WFC3 IR imaging, providing stellar mass maps and sizes. Combined with our dispersion measurements, this will allow us to examine the fundamental plane and the dynamical mass of a large sample of z > 1 galaxies for the first time, for both cluster and field galaxies.
The development activity of a new experimental technique for the study of the fast electron transport in high density matter is reported. This new diagnostic tool enables the X-ray 2D imaging of ultrahigh intensity laser plasmas with simultaneous spectral resolution in a very large energy range to be obtained. Results from recent experiments are discussed, in which the electron propagation in multilayer targets was studied by using the Kα. In particular, results highlighting the role of anisotropic Bremsstrahlung are reported, for the sake of the explanation of the capabilities of the new diagnostics. A discussion of a test experiment conceived to extend the technique to a single-shot operation is finally given.
Six wheat/Agropyron intermedium addition lines are described on the basis of their phenotype and biochemical markers. An assessment of homoeology of each addition chromosome is made. Chromosome morphology, plant phenotype, isozyme and protein studies are compared with similar data for other wheat/alien addition lines and other members of the Triticeae. These comparisons give consistent results and it is concluded that addition lines L1, L2, L3, L4, L5 and L7 carry Agropyron chromosomes of homoeologous groups 7, 3, 1, 4, 5 and 6 respectively. This agrees with previously published work with one exception: the L5 chromosome belongs to homoeologous group 5 and not group 2 as proposed by Figueiras et al. (1986).
The aim of the reported research is to contribute to investigation of new processes and methods interlinking nuclear and laser-plasma physics. With respect to requirements of nuclear experiments at medium-size high-power lasers, the selection of proper candidates for studying the excitation and decay of low-lying nuclear states is reviewed. An experimental approach to the identification of low-energy nuclear transitions is discussed, simple estimates of the 181Ta excitation yield in the laser-generated plasma provide a theoretical basis for planning future work. First tests and results of the experiments at the laser facility PALS are presented.
Toxic anterior segment syndrome (TASS), a complication of cataract surgery, is a sterile inflammation of the anterior chamber of the eye. An outbreak of TASS was recognized at an outpatient surgical center and its affiliated hospital in December 2002.
Medical records of patients who underwent cataract surgery during the outbreak were reviewed, and surgical team members who participated in the operations were interviewed. Potential causes of TASS were identified and eliminated. Feedwater from autoclave steam generators and steam condensates were analyzed by use of spectroscopy and ion chromatography.
During the outbreak, 8 (38%) of 21 cataract operations were complicated by TASS, compared with 2 (0.07%) of 2,713 operations performed from January 1996 through November 2002. Results of an initial investigation suggested that cataract surgical equipment may have been contaminated by suboptimal equipment reprocessing or as a result of personnel changes. The frequency of TASS decreased (1 of 44 cataract operations) after reassignment of personnel and revision of equipment reprocessing procedures. Further investigation identified the presence of impurities (eg, sulfates, copper, zinc, nickel, and silica) in autoclave steam moisture, which was attributed to improper maintenance of the autoclave steam generator in the outpatient surgical center. When impurities in autoclave steam moisture were eliminated, no cases of TASS were observed after more than 1,000 cataract operations.
Suboptimal reprocessing of cataract surgical equipment may evolve over time in busy, multidisciplinary surgical centers. Clinically significant contamination of surgical equipment may result from inappropriate maintenance of steam sterilization systems. Standardization of protocols for reprocessing of cataract surgical equipment may prevent outbreaks of TASS and may be of assistance during outbreak investigations.
Based on new spectra spanning wavelengths from 0.8 to 2.4μm, we study the properties of bright near-IR clusters in M82. We focus on age and extinction, which are critical parameters when one uses dynamical masses to constrain the stellar IMF. The modelling of red supergiant evolution by various authors leads to very significant differences in synthetic cluster spectra. Near-IR fluxes alone therefore do not rule out a normal IMF for cluster F, previously found to be deficient in low mass stars. Combined optical and near-IR studies are being undertaken.
Intense continua of electromagnetic radiation of very
brief duration are formed in the interaction of focused
ultra-short terawatt laser pulses with matter. Two different
kinds of experiments, which have been performed utilizing
the Lund 10 Hz titanium-doped sapphire terawatt laser system
are being described, where visible radiation and X-rays,
respectively, have been generated. Focusing into water
leads to the generation of a light continuum through self-phase
modulation. The propagation of the light through tissue
was studied addressing questions related to optical mammography
and specific chromophore absorption. When terawatt laser
pulses are focused onto a solid target with high nuclear
charge Z, intense X-ray radiation of few ps duration
and with energies exceeding hundreds of keV is emitted.
Biomedical applications of this radiation are described,
including differential absorption and gated-viewing imaging.
We create hot (Te > 200 eV) and dense (Ne > 1023 cm−3) plasmas in the colliding zone of two thin foils accelerated by two laser beams of the LULI facilities. Three spectroscopic diagnostics (two 1D space-resolved spectrographs and a 2D monochromatic imaging) are used to drive the efficiency of the compression. We show that 2D effects are important. Realistic simulations of these experiments must be done, taking into account the inhomogeneity of the laser intensity in the focal spot, the foil distorsion, the plasma lateral expansion, and the lateral thermal conduction. Two-dimensional LASNEX code results are in good agreement with our experimental results. The optimized compressed plasmas generated are favorable for the exhibition of dense plasma effects due to molecular formations, and they reproduce in laboratory some astrophysical situations.