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The radiocarbon (14C) calibration curve so far contains annually resolved data only for a short period of time. With accelerator mass spectrometry (AMS) matching the precision of decay counting, it is now possible to efficiently produce large datasets of annual resolution for calibration purposes using small amounts of wood. The radiocarbon intercomparison on single-year tree-ring samples presented here is the first to investigate specifically possible offsets between AMS laboratories at high precision. The results show that AMS laboratories are capable of measuring samples of Holocene age with an accuracy and precision that is comparable or even goes beyond what is possible with decay counting, even though they require a thousand times less wood. It also shows that not all AMS laboratories always produce results that are consistent with their stated uncertainties. The long-term benefits of studies of this kind are more accurate radiocarbon measurements with, in the future, better quantified uncertainties.
Introduction: Mild Traumatic Brain Injury (mTBI) is a common problem: each year in Canada, its incidence is estimated at 500-600 cases per 100 000. Between 10 and 56% of mTBI patients develop persistent post-concussion symptoms (PPCS) that can last for more than 90 days. It is therefore important for clinicians to identify patients who are at risk of developing PPCS. We hypothesized that blood biomarkers drawn upon patient arrival to the Emergency Department (ED) could help predict PPCS. The main objective of this project was to measure the association between four biomarkers and the incidence of PPCS 90 days post mTBI. Methods: Patients were recruited in seven Canadian ED. Non-hospitalized patients, aged ≥14 years old with a documented mTBI that occurred ≤24 hrs of ED consultation, with a GCS ≥13 at arrival were included. Sociodemographic and clinical data as well as blood samples were collected in the ED. A standardized telephone questionnaire was administered at 90 days post ED visit. The following biomarkers were analyzed using enzyme-linked immunosorbent assay (ELISA): S100B protein, Neuron Specific Enolase (NSE), cleaved-Tau (c-Tau) and Glial fibrillary acidic protein (GFAP). The primary outcome measure was the presence of persistent symptoms at 90 days after mTBI, as assessed using the Rivermead Post-Concussion symptoms Questionnaire (RPQ). A ROC curve was constructed for each biomarker. Results: 1276 patients were included in the study. The median age for this cohort was 39 (IQR 23-57) years old, 61% were male and 15% suffered PPCS. The median values (IQR) for patients with PPCS compared to those without were: 43 pg/mL (26-67) versus 42 pg/mL (24-70) for S100B protein, 50 pg/mL (50-223) versus 50 pg/mL (50-199) for NSE, 2929 pg/mL (1733-4744) versus 3180 pg/mL (1835-4761) for c-Tau and 1644 pg/mL (650-3215) versus 1894 pg/mL (700-3498) for GFAP. For each of these biomarkers, Areas Under the Curve (AUC) were 0.495, 0.495, 0.51 and 0.54, respectively. Conclusion: Among mTBI patients, S100B protein, NSE, c-Tau or GFAP during the first 24 hours after trauma do not seem to be able to predict PPCS. Future research testing of other biomarkers is needed in order to determine their usefulness in predicting PPCS when combined with relevant clinical data.
Introduction: Compared to other areas in Alberta Health Services (AHS), internal data show that emergency departments (EDs) and urgent care centres (UCCs) experience a high rate of workforce violence. As such, reducing violence in AHS EDs and UCCs is a key priority. This project explored staff's lived experience with patient violence with the goal of better understanding its impact, and what strategies and resources could be put in place. Methods: To obtain a representative sample, we recruited staff from EDs and a UCC (n = 6) situated in urban and rural settings across Alberta. As the interviews had the potential to be upsetting, we conducted in-person interviews in a private space. Interviews were conducted with over 60 staff members including RNs, LPNs, unit clerks, physicians, and protective services. Data collection and analysis occurred simultaneously and iteratively until saturation was reached. The analysis involved data reduction, category development, and synthesis. Key phrases and statements were first highlighted. Preliminary labels were then assigned to the data and data was then organized into meaningful clusters. Finally, we identified common themes of participants’ lived experience. Triangulation of sources, independent and team analysis, and frequent debriefing sessions were used to enhance the trustworthiness of the data. Results: Participants frequently noted the worry they carry with them when coming into work, but also said there was a high threshold of acceptance dominating ED culture. A recurring feature of this experience was the limited resources (e.g., no peace officers, scope of security staff) available to staff to respond when patients behave violently or are threatening. Education like non-violent crisis intervention training, although helpful, was insufficient to make staff feel safe. Participants voiced the need for more protective services, the addition of physical barriers like locking doors and glass partitions, more investment in addictions and mental health services (e.g., increased access to psychiatrists or addictions counsellors), and a greater shared understanding of AHS’ zero tolerance policy. Conclusion: ED and UCC staff describe being regularly exposed to violence from patients and visitors. Many of these incidents go unreported and unresolved, leaving the workforce feeling worried and unsupported. Beyond education, the ED and UCC workforce need additional resources to support them in feeling safe coming to work.
Introduction: Emergency Departments (EDs) are at high risk of workforce-directed violence (WDV). To address ED violence in Alberta Health Services (AHS), we conducted key informant interviews to identify successful strategies that could be adopted in AHS EDs. Methods: The project team identified potential participants through their ED network; additional contacts were identified through snowball sampling. We emailed 197 individuals from Alberta (123), Canada (46), and abroad (28). The interview guide was developed and reviewed in partnership with ED managers and Workplace Health and Safety. We conducted semi-structured phone interviews with 26 representatives from urban and rural EDs or similar settings from Canada, the United States, and Australia. This interview process received an ARECCI score of 2. Two researchers conducted a content analysis of the interview notes; rural and urban sites were analyzed separately. We extracted strategies, their impact, and implementation barriers and facilitators. Strategies identified were categorized into emergent themes. We aggregated similar strategies and highlighted key or unique findings. Results: Interview results showed that there is no single solution to address ED violence. Sites with effective violence prevention strategies used a comprehensive approach where multiple strategies were used to address the issue. For example, through a violence prevention working group, one site implemented weekly violence simulations, a peer mentorship support team, security rounding, and more. This multifaceted approach had positive results: a decrease in code whites, staff feeling more supported, and the site no longer being on union “concerned” lists. Another promising strategy included addressing the culture of violence by increasing reporting, clarifying policies (i.e., zero tolerance), and establishing flagging or alert systems for visitors with violent histories. Physician involvement and support was highly valued in responding to violence (e.g., support when refusing care, on the code white response team, flagging). Conclusion: Overall, one strategy is not enough to successfully address WDV in EDs. Strategies need to be comprehensive and context specific, especially when considering urban and rural sites with different resources available. We note that few strategies were formally evaluated, and recommend that future work focus on developing comprehensive metrics to evaluate the strategies and define success.
Introduction: Physician metrics extracted from an electronic medical records (EMR) system can be utilized for practice improvement. One key metric analyzed at many emergency departments (EDs) is ‘patients per hour’ (pts/hr), a proxy for physician productivity. It is often believed that early-career physicians experience rapid growth in efficiency as they acclimatize to a hospital system and develop clinical confidence. This is the first study to evaluate the following question: Do early-career ED physicians increase their productivity when beginning practice? Methods: We performed a retrospective review of EMR data of early-career ED physicians working at one or more urban, academic centers. Early-career physicians must have started practice within three months of residency completion, and were identified by privileging records and provincial medical college registration. Physicians were excluded if they did not have at least 36 months of continuous data. Monthly productivity data (pts/hr) was extracted for each physician for their first 36-months of practice. A ‘performance curve’ or graph with a trendline of productivity as a moving average was created for each physician. Each performance curve was visually evaluated by two independent reviewers to qualitatively identify the general trend as upward, downward, or stable, with disagreements resolved by conference. Each physician's first and third year average productivity was compared quantitatively as well, with a significant upward or downward trend defined as a difference of at least 0.2 pts/hr. Results: A total of 41 physicians met the inclusion and exclusion criteria. Overall monthly pts/hr averages ranged from 1.08 to 7.65. Upon visual inspection, six (14.6%) physicians had upward trends, five (12.2%) had downward trends, and 30 (73.2%) had no discernable pattern. The quantitative analysis comparing first year to third year productivity matched the qualitative inspection exactly, with the same six physicians showing increased productivity, five with decreased, and 30 without significant change. Notably, the majority (30/41) of physicians demonstrated radical productivity variations over short periods with no discernable long-term trends. Conclusion: The majority of early career physicians do not demonstrate sustained early-career productivity changes. Of those that do, an approximately equal number will become faster and slower.
Introduction: Emergency department (ED) flow is a strong predictor of patient safety, quality of care and provider satisfaction. Throughput interventions have been shown to improve flow metrics, yet few studies have considered MD leadership roles and evaluated provider experience. Our objective was to evaluate the emergency physician lead (EPL) role, a novel MD staffing initiative. Methods: This mixed-method observational time series analysis evaluated ED metrics at two tertiary EDs including ED length of stay (LOS), EMS Park LOS and physician initial assessment (PIA) time as well as 72-hour readmit and left without being seen (LWBS) rates. Data was collected from the ED information system database for control (Dec 6, 2017-Feb 28, 2018 SITE1 and Mar 1–May 31, 2018 SITE2), pre (Sept 3-Nov 30, 2018 SITE 1 and Dec 3, 2018-Feb 28, 2019 SITE2) and post (Dec 3, 2018 –Feb 28, 2019 SITE1, Mar 1- May 31, 2019 SITE2) periods for adult patients presenting to each site. Site data was analyzed independently using descriptive and inferential statistics to calculate differences in means, and means were compared using t-tests. A survey elicited provider feedback from ED physicians, nurses, and EMS professionals on the effect of the EPL on throughput, timeliness of admissions and discharges, provider workload, and the EPL as a resource to other professionals. Results: The number of ED visits at SITE1 were 13136 (Ctrl), 13236 (Pre) and 13137 (Post), and at SITE2 were 14371(Ctrl), 13866 (Pre) and 14962 (Post). Mean ED LOS was decreased by 17 min in post vs control and 20 min vs pre at SITE1 (p < 0.01). SITE2 saw an increase in ED LOS by 7 min vs control and 8 min vs pre (p < 0.01). EMS LOS at SITE1 was decreased by 21 min vs control and 22 min vs pre (p < 0.01), but was increased at SITE2 by 2 min vs control (p = 0.09) and 14 min vs pre (p < 0.01). PIA time at SITE1 was decreased by 15 min vs control (p < 0.01) and 13 min vs pre and increased by 5 min vs control and 12 min vs pre at SITE2 (p < 0.01). 72 hour readmit and LWBS rates were unchanged at both sites. Qualitative feedback from ED providers highlighted the early provision of treatments and investigations by the EPL, and many felt the EPL was an important resource. Conclusion: The inclusion of both quantitative and qualitative data in this study provided a robust analysis of the impact of the EPL role and demonstrated modest but important improvements. A site-dependent, carefully considered implementation of the EPL role may improve ED metrics and provider experiences.
Introduction: Clinical assessment of patients with mTBI is challenging and overuse of head CT in the emergency department (ED) is a major problem. During the last decades, studies have attempted to reduce unnecessary head CTs following a mTBI by identifying new tools aiming to predict intracranial bleeding. S100B serum protein level might be helpful reducing those imaging since a higher level of S-100B protein has been associated with intracranial hemorrhage following a mTBI in previous literature. The main objective of this study was to assess whether the S100B serum protein level is associated with clinically important brain injury and could be used to reduce the number of head CT following a mTBI. Methods: This prospective multicenter cohort study was conducted in five Canadian ED. MTBI patients with a Glasgow Coma Scale (GCS) score of 13-15 in the ED and a blood sample drawn within 24-hours after the injury were included. S-100B protein was analyzed using enzyme-linked immunosorbent assay (ELISA). All types of intracranial bleedings were reviewed by a radiologist who was blinded to the biomarker results. The main outcome was the presence of clinically important brain injury. Results: A total of 476 patients were included. Mean age was 41 ± 18 years old and 150 (31.5%) were female. Twenty-four (5.0%) patients had a clinically significant intracranial hemorrhage while 37 (7.8%) had any type of intracranial bleeding. S100B median value (Q1-Q3) of was: 0.043 ug/L (0.008-0.080) for patients with clinically important brain injury versus 0.039 μg/L (0.023-0.059) for patients without clinically important brain injury. Sensitivity and specificity of the S100B protein level, if used alone to detect clinically important brain injury, were 16.7% (95% CI 4.7-37.4) and 88.5% (95% CI 85.2-91.3), respectively. Conclusion: S100B serum protein level was not associated with clinically significant intracranial hemorrhage in mTBI patients. This protein did not appear to be useful to reduce the number of CT prescribed in the ED and would have missed many clinically important brain injuries. Future research should focus on different ways to assess mTBI patient and ultimately reduce unnecessary head CT.
Background: Since January 1, 2016 2358 people have died from opioid poisoning in Alberta. Buprenorphine/naloxone (bup/nal) is the recommended first line treatment for opioid use disorder (OUD) and this treatment can be initiated in emergency departments and urgent care centres (EDs). Aim Statement: This project aims to spread a quality improvement intervention to all 107 adult EDs in Alberta by March 31, 2020. The intervention supports clinicians to initiate bup/nal for eligible individuals and provide rapid referrals to OUD treatment clinics. Measures & Design: Local ED teams were identified (administrators, clinical nurse educators, physicians and, where available, pharmacists and social workers). Local teams were supported by a provincial project team (project manager, consultant, and five physician leads) through a multi-faceted implementation process using provincial order sets, clinician education products, and patient-facing information. We used administrative ED and pharmacy data to track the number of visits where bup/nal was given in ED, and whether discharged patients continued to fill any opioid agonist treatment (OAT) prescription 30 days after their index ED visit. OUD clinics reported the number of referrals received from EDs and the number attending their first appointment. Patient safety event reports were tracked to identify any unintended negative impacts. Evaluation/Results: We report data from May 15, 2018 (program start) to September 31, 2019. Forty-nine EDs (46% of 107) implemented the program and 22 (45% of 49) reported evaluation data. There were 5385 opioid-related visits to reporting ED sites after program adoption. Bup/nal was given during 832 ED visits (663 unique patients): 7 visits in the 1st quarter the program operated, 55 in the 2nd, 74 in the 3rd, 143 in the 4th, 294 in the 5th, and 255 in the 6th. Among 505 unique discharged patients with 30 day follow up data available 319 (63%) continued to fill any OAT prescription after receiving bup/nal in ED. 16 (70%) of 23 community clinics provided data. EDs referred patients to these clinics 440 times, and 236 referrals (54%) attended their first follow-up appointment. Available data may under-report program impact. 5 patient safety events have been reported, with no harm or minimal harm to the patient. Discussion/Impact: Results demonstrate effective spread and uptake of a standardized provincial ED based early medical intervention program for patients who live with OUD.
Introduction: Each year, 3/1000 Canadians sustain a mild traumatic brain injury (mTBI). Many of those mTBI are accompanied by various co-injuries such as dislocations, sprains, fractures or internal injuries. A number of those patients, with or without co-injuries will suffer from persistent post-concussive symptoms (PPCS) more than 90 days post injury. However, little is known about the impact of co-injuries on mTBI outcome. This study aims to describe the impact of co-injuries on PPCS and on patient return to normal activities. Methods: This multicenter prospective cohort study took place in seven large Canadian Emergency Departments (ED). Inclusion criteria: patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Patients who were admitted following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. A research nurse then conducted three follow-up phone interviews at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to estimate the influence of co-injuries. Results: A total of 1674 patients were included, of which 1023 (61.1%) had at least one co-injury. At 90 days, patients with co-injuries seemed to be at higher risk of having 3 symptoms ≥2 points according to the RPQ (RR: 1.28 95% CI 1.02-1.61) and of experiencing the following symptoms: dizziness (RR: 1.50 95% CI 1.03-2.20), fatigue (RR: 1.35 95% CI 1.05-1.74), headaches (RR: 1.53 95% CI 1.10-2.13), taking longer to think (RR: 1.50 95% CI 1.07-2.11) and feeling frustrated (RR: 1.45 95% CI 1.01-2.07). We also observed that patients with co-injuries were at higher risk of non-return to their normal activities (RR: 2.31 95% CI 1.37-3.90). Conclusion: Patients with co-injuries could be at higher risk of suffering from specific symptoms at 90 days post-injury and to be unable to return to normal activities 90 days post-injury. A better understanding of the impact of co-injuries on mTBI could improve patient management. However, further research is needed to determine if the differences shown in this study are due to the impact of co-injuries on mTBI recovery or to the co-injuries themselves.
Introduction: Mild traumatic brain injury (mTBI) is a serious public health issue and as much as one third of mTBI patients could be affected by persistent post-concussion symptoms (PPCS) three months after their injury. Even though a significant proportion of all mTBIs are sports-related (SR), little is known on the recovery process of SR mTBI patients and the potential differences between SR mTBI and patients who suffered non-sports-related mTBI. The objective of this study was to describe the evolution of PPCS among patients who sustained a SR mTBI compared to those who sustained non sport-related mTBI. Methods: This Canadian multicenter prospective cohort study included patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of Emergency Department (ED) visit, with a Glasgow Coma Scale score of 13-15. Patients who were hospitalized following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. Three follow-up phone interviews were conducted by a research nurse at 7, 30 and 90 days post-injury to assess symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to demonstrate the impact of the mechanism of injury (sports vs non-sports) on the presence and severity of PPCS. Results: A total of 1676 mTBI patients were included, 358 (21.4%) of which sustained a SR mTBI. At 90 days post-injury, patients who suffered a SR mTBI seemed to be significantly less affected by fatigue (RR: 0.70 (95% CI: 0.50-0.97)) and irritability (RR: 0.60 (95% CI: 0.38-0.94)). However, no difference was observed between the two groups regarding each other symptom evaluated in the RPQ. Moreover, the proportion of patients with three symptoms or more, a score ≥21 on the RPQ and those who did return to their normal activities were also comparable. Conclusion: Although persistent post-concussion symptoms are slightly different depending on the mechanism of trauma, our results show that patients who sustained SR-mTBI could be at lower risk of experiencing some types of symptoms 90 days post-injury, in particular, fatigue and irritability.
Introduction: Calgary's introduction of rentable electronic scooters (e-scooters) in July of 2019 was met with wild popularity, representing the third most popular launch after Tel-Aviv and Paris. The present study aims to characterize the injury burden seen in all Calgary Emergency Departments (EDs) and Urgent Care Centres (UCCs) attributable to e-scooters since their 2019 introduction. Methods: We retrospectively reviewed all electronic medical records of patients presenting to Calgary EDs or UCCs with the term “scooter” in the triage note, where exclusion criteria are considered for non e-scooter injuries (e.g: non-motorized scooters). Trends in scooter injuries will be compared between April - October 2018 (control arm preceding e-scooter introduction) and April - October 2019. Injury incidence, types, patient demographics, and relative risk compared to bicycle-related injuries will be determined. Descriptive statistics will be calculated. Moreover, 33 ED visits were brought in by EMS and provide information about injury types and locations of injuries involving EMS transport. Results: Preliminary data reveals 540 scooter-related visits (3.10% admitted/transferred) between July 8th and September 30th 2019 (mean age of 28, 56.30% male). Conversely, the number of bicycle-related visits and motor vehicle related injuries were 1482 and 586 (9.90% and 9.70% admitted/transferred) respectively over the same time period suggesting a greater burden but likely a lower per-ride incidence of injury requiring ED or UCC care. Moreover, between July 8th to October 1st 2019, 33 e-scooter presentations involved EMS (21.21% admitted to hospital), where 12.12% involved upper extremity injury, 21.21% were lower extremity injuries, and 6.06% were head injuries (mean age of 34, 48.48% male). Conversely, estimated EMS transfers to EDs or UCCs for bicycle injuries and motor vehicle injuries were 197 and 463 respectively over the same time period. ICU admissions or fatality were not recorded. Conclusion: Representing the most comprehensive study of e-scooter injury patterns in Canada to date, we here demonstrate a significant injury burden attributable to e-scooters following their introduction in Calgary in 2019. Bicycle-related and motor vehicle injuries were both more prevalent in this time period, and required more EMS visits. Further characterization of injury types, injuries and comparison with injury patterns prior to e-scooter introduction is yet to be determined.
Background: Traditionally, radiologists have routinely recommended oral contrast agents (such as Telebrix®) for patients undergoing a computed tomography of the abdomen/pelvis (CTAP), but recent evidence has shown limited diagnostic benefits for most emergency department (ED) patients. Additionally, the use of oral contrast has numerous drawbacks, including patient nausea/vomiting, risk of aspiration and delays to CTAP completion and increased ED length of stay (LOS). Aim Statement: The aim was to safely reduce the number of ED patients receiving oral contrast prior to undergoing CTAP and thereby reduce ED length of stay. Measures & Design: An evidence-based ED protocol was developed in collaboration with radiology. PDSA cycle #1 was implementation at a pilot site to identify potential barriers. Challenges identified included the need to change the electronic order sets to reflect the new protocol, improved communication with frontline providers and addition of an online BMI calculator. PDSA cycle #2 was widespread implementation across all 4 ED's in the Calgary zone. The protocol was incorporated into all relevant electronic ED order sets to act as a physician prompt. Using administrative data, we extracted and analyzed data using descriptive and inferential statistics for the outcomes and balancing measures from a period of 12 months pre- and 12 months post-intervention. Evaluation/Results: A total of 14,868 and 17,995 CTAP exams were included in the pre and post periods, respectively. There was a reduction in usage of oral contrast from 71% to 30% (P < 0.0001) in the pre- and post-study period, respectively. This corresponded to a reduction in average time of CT requisition to CT report completed from 3.30 hours to 2.31 hours (-0.99 hrs, P = 0.001) and a reduction in average ED LOS from 11.01 hours to 9.92 hours (-1.08 hrs, P < 0.0001). The protocol resulted in a reduction of 19,434.6 patient hrs in the ED. Run charts demonstrate change was sustained over time. Our protocol did not demonstrate an increase in rates of repeat CTAP (P = 0.563) at 30 days, nor an increase in patient re-admission within 7 days (P = 0.295). Discussion/Impact: Successful implementation of an ED and radiology developed protocol significantly reduced the use of oral contrast in patients requiring enhanced CTAP as part of their diagnostic work up and, thereby, reduced overall ED LOS without increasing the need for repeat examinations within 30 days or re-admission within 7 days.
Introduction: The elderly (65 yo and more) increase in Canada is well documented along with a disproportionate use of Emergency Departments after a minor injury. These patients requires specific care given a 16% risk of functional decline following a visit to ED. To prevent functional decline, a multidimensional assessment of the elderly is recommended in the emergency department. Objective: To determine if ED grip strength can predict functional decline at 3 or 6 months post-injury. Methods: A multicentre prospective study in 5 ED across Canada was realized between 2013 and 16. Patients 65 years old and over, autonomous in daily living activities and consulting the emergency department for minor trauma were recruited 7 days a week. Clinical-demographic data, functional status, fear of falling, number of falls in the last month, grip strength measurement were collected in the ED. Functional decline (loss of at least points to functional status) was calculated at 3 and 6 months. Descriptive statistics and linear regression model with repeated measurements were used to determine if the grip strength was predictive of functional decline at 3 or 6 months. Results: 387 patient were recruited. Mean age was 74 ± 7 years old, 52% were male. XXX experienced a fall in the last month. The initial maximum grip strength was (24 ± 10 intervention vs. 28 ± 13 control; p ≤ 0.05). grip strength is associated with pre-injury functional status (p < 0.0001) and fear of falling (p = 0.0001) but does not predict 3 or 6 month functional decline. Conclusion: Given the strong association with fear of falling and functional status at initial ED evaluation, we recommend that grip strength measurement could be included in a multidisciplinary geriatric emergency department assessment as needed.
Introduction: Very low high-sensitivity troponin-T (hs-cTnT) concentrations on presentation can rule out acute myocardial infarction (AMI), but the ability to identify patients at low risk of 30-day major adverse cardiac events (MACE) is less clear. This study examines the sensitivity of low concentrations of hs-cTnT on presentation to rule out 30-day MACE. Methods: This prospective cohort study enrolled emergency department chest pain patients with non-ischemic ECGs who underwent AMI rule-out with an hs-cTnT assay. The primary outcome was 30-day MACE; secondary outcomes were individual MACE components. Because guidelines recommend using a single hs-cTnT strategy only for patients with more than 3-hours since symptom onset, a subgroup analysis was performed for this population. Outcomes were adjudicated based on review of medical records and telephone follow-up. Results: Of 1,167 patients enrolled, 125 (10.7%) experienced 30-day MACE and 97 (8.3%) suffered AMI on the index visit. More than one-third (35.6%) had presenting hs-cTnT concentrations below the limit of detection (5ng/L), which was 94.4% (95%CI 88.8-97.7%) sensitive for 30-day MACE and 99.0% (95%CI 94.5-100%) sensitive for index AMI. Of 292 (25.0%) patients with hs-cTnT < 5ng/L and at least 3-hours since symptom onset, only 3 experienced 30-day MACE (sensitivity 97.6%, 95%CI 93.2-100%) and none suffered AMI within 30-days (sensitivity 100%, 95%CI 96.3-100%). Conclusion: Among patients with non-ischemic ECGs and >3-hours since symptom onset, low hs-cTnT concentrations on presentation confer a very low risk of 30-day MACE. In the absence of a high risk clinical presentation, further risk stratification is likely to be low yield.
To study the reliability of two depression assessment scales, the Montgomery-Asberg Depression Rating Scale and the Psychomotor Retardation Scale, 30 patients with depression according to Feighner's criteria were evaluated, by two groups of raters: 5 were trained psychiatrists or psychologists, and 6 were untrained raters. The experiment lasted three months. The patients were recorded on video-tape by two psychiatrists who did not take part in the experiment, during pre-designed interviews. Each scoring was discussed by the trained group but not by the untrained group. The Kappa test and the sign-test were used for the statistical analysis of global and itemized results, respectively. Intraclass coefficient Q3 was applied to global scores. With regard to global scores, there was no significant difference among the members of the trained group, who scored higher than those of the untrained group; a significant difference between some of the untrained raters, induced a significant difference with the trained group. With regard to each item of both scales, reliability appeared to be slight to moderate, and there was no significant difference between trained and inexpert raters. These results are discussed and modifications are proposed to improve the consistency of the two scales. The authors emphasize the necessity for therapeutic trials to be conducted with permanent groups of assessors who continue training even outside of trial procedures.
The transplant representations of patients waiting for a kidney transplantation have been studied recently. Our hypotheses is that these representations can be measured with a questionnaire and differ between recipients from living or cadaveric donor. As result of lack of clinical standardized instrument,we developed the Transplant Representation Questionnaire(TRQ) of 19 items in 4 degrees.
Compare results on the TRQ in patients waiting for a kidney transplantation from cadaveric or living donor.
390 patients included in waiting list for kidney transplantation with cadaveric or living donor were assessed with the TRQ. Since the beginning of the study, 170 patients were transplanted, 148 (87%) with cadaveric donor (CD group), and 22 (13%) with living donor (LD group). The principal component analysis has been performed on 390 patients.
The Principal component analysis of the TRQ has shown 2 factors.The factor “Donor” refers to the recipient concerns about the donor (11 items).The factor “Transplant” refers to the negative attitude of the recipient about the transplanted organ (8 items). The LD group was younger and had more social support than the CD group. It had also higher scores on the “donor” factor and similar scores on the “transplant” factor.
As compared to patients waiting for transplantation with cadaveric donor, patients waiting for transplantation with living donor have more concerns about the donor, and similar representations of their future transplant. Our preliminary results should be confirmed in more powerful studies. Further studies will assess prospectively the transplant representations after transplantation.
Psychological stress is associated with accelerated cellular aging and increased risk for aging-related diseases, but the underlying molecular mechanisms are unclear.
We examined the effect of stress on a DNA methylation age predictor that was shown to correlate strongly with chronological age across human tissues (Horvath 2013). Genome-wide DNA methylation was measured in peripheral blood using the 450K Illumina array in three independent cohorts: the Grady Trauma Project/GTP (N=366); a panic disorder case/control sample recruited at the Max Planck Institute of Psychiatry/MPI-P (N=318); and the Conte Center for the Psychobiology of Early-Life Trauma/Conte (N=42). Age acceleration was calculated by subtracting chronological age from age predicted by DNA methylation. Psychiatric symptomatology and stressors were assessed using standard questionnaires.
DNA methylation age strongly correlated with chronological age in all samples (r=0.9, p=2.5x10<sup>-133</sup>). Cumulative lifetime stress but not childhood or current stress predicted age acceleration in GTP (p=0.012) and MPI-P (p=0.021). Moreover, epigenetic age acceleration predicted depression (GTP: p=0.002; Conte: p=0.014) and panic disorder (p=0.007). In secondary analyses, we examined the effect of lifetime stress on individual CpGs of the DNA methylation age predictor. After correcting for multiple comparisons, we identified in both GTP and MPI-P a stress-regulated CpG near MCAM, a gene implicated in aging-related diseases, including cardiovascular disease and cancers.
Cumulative lifetime stress, but not childhood or current stress, and psychiatric phenotypes are associated with accelerated epigenetic aging. Our findings may explain the accelerated cellular aging and increased disease risk associated with chronic stress and psychiatric disorders.
Suicide remains the leading cause of premature death in patients with psychotic disorders. The lifetime suicide risk for schizophrenia is approximately 10%.
This study aims to compare the suicide risk over the past decade following recent onset psychosis to findings from the eighties and nineties in the same catchment area and to identify predictors of suicide in the context of the Psychosis Recent Onset Groningen – Survey (PROGR-S).
A medical file search was carried out to determine the current status of all patients admitted between 2000 and 2009. The suicide rate was compared with a study executed in 1973-1988 in the same catchment area. Predictors of suicide were investigated using Cox regression.
The status of 424 of the 614 patients was known in July 2014. Suicide occurred in 2.4% of the patients with psychotic disorders (n=10; mean follow-up 5.6 years); 6 out of 10 suicides took place within two years. Within two decades, the suicide rate dropped from 11% (follow-up 15 years, 8.5% after 5 years) to 2.4%. The Standardized Mortality Rate (SMR) of suicides compared with the general population was 41.6. A higher age was the only significant predictor for suicide. Neuroticism, living situation, disorganized and negative symptoms, and passive coping style showed a trend for significance. A significant reduction in the suicide rate was found for people with psychosis over the past decades.
A considerable drop in suicide rate was found. Given the high SMR, suicide research should have the highest priority.
First-episode psychosis (FEP) patients show structural brain abnormalities. Whether the changes are progressive or not remain under debate, and the results from longitudinal magnetic resonance imaging (MRI) studies are mixed. We investigated if FEP patients showed a different pattern of regional brain structural change over a one-year period compared to healthy controls, and if putative changes correlated with clinical characteristics and outcome.
MRIs of 79 FEP (SCID-I verified diagnoses: schizophrenia, psychotic bipolar disorder, or other psychoses, mean age 27.6 (SD 7.7), 66% male) and 82 healthy controls (age 29.3 (SD 7.2) 66% male) were acquired from the same 1.5T scanner at baseline and one-year follow up as part of the TOP study, Oslo, Norway. Scans were automatically processed with the longitudinal stream in FreeSurfer. General linear models were used to analyze longitudinal change in a wide range of subcortical volumes and detailed thickness and surface area estimates across the entire cortex, and associations to clinical characteristics.
FEP and controls did not differ significantly in annual percentage change in cortical thickness or area in any cortical region, or in any of the subcortical structures after adjustment for multiple comparisons. Within the FEP group, duration of untreated psychosis, age at illness onset, antipsychotic medication use, and remission at follow-up were not related to longitudinal brain change.
We found no longitudinal brain changes over a one-year period in FEP compared to controls. Our results do not support early progressive brain changes in psychotic disorders.
There is a growing interest in low-grade inflammatory and metabolic alterations in patients with chronic schizophrenia (SCH).
Inflammatory (tumor-necrosis factor-α [TNF-α], interferon-γ [IFN-γ], interleukins [IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10], monocyte chemo-attractant protein-1 [MCP-1]) and growth factors (vascular endothelial growth factor [VEGF], epidermal growth factor [EGF]) were measured in blood serum samples of 105 SCH patients and 148 control subjects (CS). Simultaneously the clinical biomarkers (C-reactive protein [CRP], triglycerides [TG], low-density lipoprotein [LDL-c] and high-density lipoprotein [HDL-c] cholesterol, glycated hemoglobin [HbA1c]) were measured, and body mass index (BMI) was calculated for patients.
Several cyto-/chemokines (IFN-γ, MCP-1, IL-2, IL-6, IL-8 and IL-10) were significantly (P < 0.0000001) elevated in SCH patients compared to CS. Odds ratios, obtained from logistic regression analyses, were significantly elevated for IL-2, IL-6, IL-10, INF-γ, and decreased for TNF-α in SCH group. Among the patients, higher IL-2, IL-6, INF-γ and lower MCP-1 levels as well as male gender were together significant (P < 0.000001) predictors of higher HbA1c levels, and TG/HDL-c parameter was associated with ratios of INF-γ/IL-10 (P = 0.004), and INF-γ/IL-4 (P = 0.049), HbA1c (P = 0.005), INF-γ (P = 0.009), as well as LDL-c (P = 0.02) levels.
IL-2, IL-6, IL-10 and IFN-γ were the most significant SCH-related markers among the measured cytokines in our patient group. Furthermore, significant associations between pro-/anti-inflammatory imbalance and HbA1c as well as cardio-metabolic risk marker (TG/HDL-c) were observed, indicating higher risks of diabetes and cardiovascular diseases among SCH patients.