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The dispatch of Advanced Life Support (ALS) teams in Emergency Medical Services (EMS) is still a hardly studied aspect of prehospital emergency logistics. In 2015, the dispatch algorithm of Emilia Est Emergency Operation Centre (EE-EOC) was implemented and the dispatch of ALS teams was changed from primary to secondary based on triage of dispatched vehicles for high-priority interventions when teams with Immediate Life Support (ILS) skills were dispatched.
This study aimed to evaluate the effects on the appropriateness of ALS teams’ intervention and their employment time, and to compare sensitivity and specificity of the algorithm implementation.
This was a retrospective before-after observational study.
Settings and Participants:
Primary dispatches managed by EE-EOC involving ambulances and/or ALS teams were included. Two groups were created on the basis of the years of intervention (2013-2014 versus 2017-2018).
A switch from primary to secondary dispatch of ALS teams in case of high-priority dispatches managed by ILS teams was implemented.
Appropriateness of ALS team intervention, total task time of ALS vehicles, and sensitivity and specificity of the algorithm were reviewed.
The study included 242,501 emergency calls that generated 56,567 red code dispatches. The new algorithm significantly increased global sensitivity and specificity of the system in terms of recognition of potential need of ALS intervention and the specificity of primary ALS dispatch. The appropriateness of ALS intervention was significantly increased; total tasking time per day for ALS and the number of critical dispatches without ALS available were reduced.
The revision of the dispatch criteria and the extension of the two-tiered dispatch for ALS teams significantly increased the appropriateness of ALS intervention and reduced both the global tasking time and the number of high-priority dispatches without ALS teams available.
This paper examines price convergence and changes in the efficiency of wheat markets, covering the period from the mid-fourteenth to the early twentieth century and most of Europe. The analysis is based on a new data set of prices from almost 600 markets. Unlike previous research, we find that convergence was a predominantly pre-modern phenomenon. It started in the late fifteenth century, advanced rapidly until the beginning of the seventeenth century when it temporarily stalled, resumed after the Thirty Years’ War, and accelerated after the Napoleonic Wars in response to trade liberalization. From the late 1840s, convergence petered out and turned into divergence after 1875 as policy decisions dominated technological change. Our results point to the ‘Little Divergence’ between North-Western Europe and the rest of the continent as starting about 1600. Long-term improvements in market efficiency began in the early sixteenth century, with advances over time being as uneven as in price convergence. We trace this to differential institutional change and the non-synchronous spread of modern media and systems of information transmission that affected the ability of merchants to react to news.
Sierra Leone is one of the least developed low-income countries (LICs), slowly recovering from the effects of a devastating civil war and an Ebola outbreak. The health care system is characterized by chronic shortage of skilled human resources, equipment, and essential medicines. The referral system is weak and vulnerable, with 75% of the country having insufficient access to essential health care. Consequently, Sierra Leone has the highest maternal and child mortality rates in the world. This manuscript describes the implementation of a National Emergency Medical Service (NEMS), a project aiming to create the first prehospital emergency medical system in the country. In 2017, a joint venture of Doctors with Africa (CUAMM), Veneto Region, and Research Center in Emergency and Disaster Medicine (CRIMEDIM) was developed to support the Ministry of Health and Sanitation (MOHS) in designing and managing the NEMS system, one of the very few structured, fully equipped, and free-of-charge prehospital service in the African continent. The NEMS design was the result of an in-depth research phase that included a preliminary assessment, literature review, and consultations with key stakeholders and managers of similar systems in other African countries. From May 27, 2019, after a timeframe of six months in which all the districts have been progressively trained and made operational, the NEMS became operative at national level. By the end of March 2020, the NEMS operation center (OC) and the 81 ambulances dispatched on the ground handled a total number of 36,814 emergency calls, 35,493 missions, and 31,036 referrals.
Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services.
To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3.
Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach.
A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62–0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60–0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46–0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates.
Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.
An unprecedented wave of patients with acute respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) hit emergency departments (EDs) in Lombardy, starting in the second half of February 2020. This study describes the direct and indirect impacts of the SARS-CoV-2 outbreak on an urban major-hospital ED.
Data regarding all patients diagnosed with COVID-19 presenting from February 1 to March 31, 2020, were prospectively collected, while data regarding non-COVID patients presenting within the same period in 2019 were retrospectively retrieved.
ED attendance dropped by 37% in 2020. Two-thirds of this reduction occurred early after the identification of the first autochthonous COVID-19 case in Lombardy, before lockdown measures were enforced. Hospital admissions of non-COVID patients fell by 26%. During the peak of COVID-19 attendance, the ED faced an extraordinary increase in: patients needing oxygen (+239%) or noninvasive ventilation (+725%), transfers to the intensive care unit (+57%), and in-hospital mortality (+309%), compared with the same period in 2019.
The COVID-19 outbreak determined an unprecedented upsurge in respiratory failure cases and mortality. Fear of contagion triggered a spontaneous, marked reduction of ED attendance, and, presumably, some as yet unknown quantity of missed or delayed diagnoses for conditions other than COVID-19.
For many years, dementia care has been dominated by the standard medical approach, in which dementia is treated mainly with drugs, such as anti-anxiety, antidepressant and anti-psychotic medications. With the aim of seeking effective treatments for patients with dementia, over the last years, several contributions have criticised the pervasive use of drugs for the management of behavioural and physiological symptoms related to dementia, proposing personalised interventions aimed at supporting patients and their relatives from diagnosis until death. With particular reference to long-term settings, in this work, we aim at understanding the organisational implications of three types of interventions (labelled supportive care interventions – SCIs) that have characterised this shift in dementia care: person-centred, palliative and multi-disciplinary care. Conducted by following the integrative review method, our review underlines how SCIs have controversial consequences on the quality of care, the care-givers’ quality of life and cultural backgrounds. After an in-depth analysis of selected papers, we offer some considerations about the implications of SCIs for long-term care organisations and future research directions.
This paper proposes novel inference procedures for instrumental variable models in the presence of many, potentially weak instruments that are robust to the presence of heteroskedasticity. First, we provide an Anderson–Rubin-type test for the entire parameter vector that is valid under assumptions weaker than previously proposed Anderson–Rubin-type tests. Second, we consider the case of testing a subset of parameters under the assumption that a consistent estimator for the parameters not under test exists. We show that under the null, the proposed statistics have Gaussian limiting distributions and derive alternative chi-square approximations. An extensive simulation study shows the competitive finite sample properties in terms of size and power of our procedures. Finally, we provide an empirical application using college proximity instruments to estimate the returns to education.
Despite the great number of resting state functional connectivity studies on Eating Disorders (ED), no biomarkers could be detected yet. Therefore, we here focus on a different measure of resting state activity that is neuronal variability. The objective of this study was to investigate neuronal variability in the resting state of women with ED and to correlate possible differences with clinical and psychopathological indices.
58 women respectively 25 with Anorexia Nervosa (AN), 16 with Bulimia Nervosa (BN) and 17 matched healthy controls (CN) were enrolled for the study. All participants were tested with a battery of psychometric tests and underwent a functional Magnetic Resonance Imaging (fMRI) resting state scanning. We investigated topographical patterns of variability measured by the Standard Deviation (SD) of the Blood-Oxygen-Level-Dependent (BOLD) signal (as a measure of neuronal variability) in the resting-state and their relationship to clinical and psychopathological indices.
Neuronal variability was increased in both anorectic and bulimic subjects specifically in the Ventral Attention Network (VAN) compared to healthy controls. No significant differences were found in the other networks. Significant correlations were found between neuronal variability of VAN and various clinical and psychopathological indices.
We here show increased neuronal variability of VAN in ED patients. As the VAN is relevant for switching between endogenous and exogenous stimuli, our results showing increased neuronal variability suggest unstable balance between body attention and attention to external world. These results offer new perspective on the neurobiological basis of ED. Clinical and therapeutic implication will be discussed.
The origins of the Italian North-South divide have always been controversial. We fill this gap by estimating a new dataset of real wages (Allen 2001; Allen et al. 2011) from Unification (1861) to WWI. Italy was very poor throughout the period, with a modest improvement since the late nineteenth century. This improvement started in the Northwest industrializing regions, while real wages in other macro-areas remained stagnant. The gap Northwest/South widened until the end of the period. Focusing on the drivers of regional trends, we find that human capital formation exerted strong positive effect on the growth of real wages.
This paper outlines the development of world trade from 1800 to 1938. It relies on a newly compiled database, which, unlike previous works (e.g. Lewis 1981), reports series of imports and exports at current and constant prices and at current and constant (1913) borders for almost all existing polities. In the first sections, we outline the estimation methodology and assess the reliability of the series (now available at http://www.uc3m.es/tradehist_db). World trade grew very fast throughout the «long» 19th century, but growth rates were higher before 1870. We measure the effects of war and the Great Depression on total trade and trade by continent and polity. Within this general upward trend, the performance of polities differed by geographical location, level of development, political status and factor endowment. Finally, we estimate trends in the share of primary products, which declined until World War One, with an acceleration in the second half of the 19th century.
Late-life depression is often associated with cognitive impairments and disability, which may persist even after adequate antidepressant drug treatment. Physical exercise is increasingly recognized as an effective antidepressant agent, and may exert positive effects on these features too. However, few studies examined this issue, especially by comparing different types of exercises.
We performed secondary analyses on data from the Safety and Efficacy of Exercise for Depression in Seniors study, a trial comparing the antidepressant effectiveness of sertraline (S), sertraline plus thrice-weekly non-progressive exercise (S+NPE), and sertraline plus thrice-weekly progressive aerobic exercise (S+PAE). Exercise was conducted in small groups and monitored by heart rate meters. Patients with late-life depression without severe cognitive impairment were recruited from primary care and assessed at baseline and 24 weeks, using the Montreal Cognitive Assessment (MOCA, total and subdomain scores) and Brief Disability Questionnaire. Analyses were based on Generalized Linear Models.
In total, 121 patients (mean age 75, 71% females) were randomized to the study interventions. Compared with the S group, patients in the S+PAE group displayed greater improvements of MOCA total scores (p=0.006, effect size=0.37), visuospatial/executive functions (p=0.001, effect size=0.13), and disability (p=0.02, effect size=−0.31). Participants in the S+NPE group did not display significant differences with the control group.
Adding aerobic, progressive exercise to antidepressant drug treatment may offer significant advantages over standard treatment for cognitive abilities and disability. These findings suggest that even among older patients exercise may constitute a valid therapeutic measure to improve patients’ outcomes.
The impact of protection on economic growth has enjoyed a revival in recent times, with the publication of a number of comparative quantitative papers. They all share a common weakness: they measure protection as the ratio of custom revenues to import value, which biases results if demand for imports is not perfectly inelastic. In this article, we show that the measure of protection matters. We estimate the James Anderson and Peter Neary (2005) Trade Restrictiveness Index for Italy from unification to the Great Depression. We suggest a different interpretation of some key moments of Italian trade policy and we show that the aggregate welfare losses were small in the long run and mostly related to protection on sugar in the 1880s and 1890s. We document that using different measures of protection affects results of the causal relation between trade policy on economic growth in Italy and in the United States. Accordingly, we argue that a systematic re-estimating of protection in the economic history of trade policy is needed.
In the last two centuries, world agriculture succeeded in producing enough to provide more food per capita than ever before, in spite of an almost seven-fold increase in population, and to supply industries with raw materials, all using less land, capital, and labor per unit of output. Production can be augmented by using more inputs such as capital, labor, and land, and/or by using them more efficiently. This chapter highlights a key distinction between the number of agricultural workers and their share of the total workforce. The farmers have introduced thousands of innovations, which for the purpose of illustration can be grouped into four categories. They are new practices of cultivation, new plants and animals, chemical products, and machinery. In the economists' jargon, institutions can be defined as the set of formal or informal rules that determine the ownership of the goods and factors and regulate the interactions among individual agents or households.
Agriculture has been the main source of livelihood for the overwhelming majority of the world's population for thousands of years, from the first production of crops some 8,000 years ago to the start of world wide industrialization in the nineteenth century. The acceleration in the rate of growth of the world population after World War ii was matched by an even sharper acceleration in the rate of growth of agricultural production, from about 1 percent per annum to over 2 percent. The increase of trade relative to output is strong evidence of a growing specialization of agricultural production. Since the beginning of the movement, credit cooperatives have established regional and national organizations for mutual support. In more recent times, these private organizations have been given formal guarantees by governments. Finally, the chapter focuses on extensive growth, modern property rights, intensive growth, consumer protection, competition policy, and the support given to scientific research.
Giant, deep-seated gravitational slope deformations (DSGSDs) affecting entire high-relief valley walls are common in alpine areas, and influence the evolution of mountain landscapes and the related hazards. In the last few years, new characterization approaches and emerging technology shed new light on the occurrence, distribution, activity, and mechanisms of these spectacular slope failures. This chapter aims to provide an overview of alpine DSGSD, as well as a discussion of outstanding issues and future research needs.
We review the definition of DSGSD and its typical features, field evidence, settings, and mechanisms. We discuss the distribution and controls on DSGSD occurrence based on the analysis of the first-ever orogen-scale inventory of these phenomena, including over 900 occurrences in the European Alps. We demonstrate that DSGSDs are widespread in active orogenic settings and chiefly occur in formerly glaciated areas under significant structural controls, and show that alpine DSGSDs are often active phenomena with engineering significance. We use the classic case study of the Cima di Mandriole sackung to illustrate the complex relations between rock structure, the morphoclimatic evolution of alpine valleys, and man-made structures, and suggest future research needs.
Rockfalls pose a significant threat to life and property, although significant advances in rockfall protection have been made in the past decade. Determining rockfall processes and related hazard, however, remains a difficult task because of the complexity and intrinsic stochastic nature of the physics involved. The appropriate application of rockfall modeling tools requires a thorough understanding of their logic, assumptions, advantages, and limitations, as well as careful assessment of rockfall sources, block and slope characteristics, and model calibration data. This chapter provides a discussion of major issues in rockfall definition, characterization, and modeling, with special emphasis on rockfall runout. Our discussion is supported by modeling examples carried out using the 3D simulator Hy-STONE. Different modeling approaches are critically evaluated, including the empirical shadow angle method, and 2D and 3D mathematical models. Application of the shadow angle concept requires the user to be aware of several issues related to definition of the shadow angle and the effects of morphological constraints. Most limitations of empirical approaches can be overcome with mathematical models that account for slope morphology and roughness, energy dissipation at impact or by rolling, and the effects of vegetation, block fragmentation, and block–structure interaction. We discuss different modeling approaches and calibration problems and the important dependency of model parameters and results on correct characterization of the topography.