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Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF) or atrial flutter (AFL). However, OAC initiation rates in patients discharged directly from the emergency department (ED) are low. We aimed to address this care gap by implementing a quality improvement intervention.
The study was performed in four Canadian urban EDs between 2015 and 2016. Patients were included if they had an electrocardiogram (ECG) documenting AF/AFL in the ED, were directly discharged from the ED, and were alive after 90 days. Baseline rates of OAC initiation were determined prior to the intervention. Between June and December 2016, we implemented our intervention in two EDs (ED-intervention), with the remaining sites acting as controls (ED-control). The intervention included a reminder statement prompting OAC initiation according to guideline recommendations, manually added to ECGs with a preliminary interpretation of AF/AFL, along with a decision-support algorithm that included a referral sheet. The primary outcome was the rate of OAC initiation within 90 days of the ED visit.
Prior to the intervention, 37.2% OAC-naïve patients with ECG-documented AF/AFL were initiated on OAC. Following implementation of the intervention, the rate of OAC initiation increased from 38.6% to 47.5% (absolute increase of 8.5%; 95% CI, 0.3% to 16.7%, p=0.04) among the ED-intervention sites, whereas the rate remained unchanged in ED-control sites (35.3% to 35.9%, p=0.9).
Implementation of a quality improvement intervention consisting of a reminder and decision-support tool increased initiation of OAC in high-risk patients. This support package can be readily implemented in other jurisdictions to improve OAC rates for AF/AFL.
This literature review aimed to identify the range of methods used in after action reviews (AARs) of public health emergencies and to develop appraisal tools to compare methodological reporting and validity standards.
A review of biomedical and gray literature identified key approaches from AAR methodological research, real-world AARs, and AAR reporting templates. We developed a 50-item tool to systematically document AAR methodological reporting and a linked 11-item summary tool to document validity. Both tools were used sequentially to appraise the literature included in this study.
This review included 24 highly diverse papers, reflecting the lack of a standardized approach. We observed significant divergence between the standards described in AAR and qualitative research literature, and real-world AAR practice. The lack of reporting of basic methods to ensure validity increases doubt about the methodological basis of an individual AAR and the validity of its conclusions.
The main limitations in current AAR methodology and reporting standards may be addressed through our 11 validity-enhancing recommendations. A minimum reporting standard for AARs could help ensure that findings are valid and clear for others to learn from. A registry of AARs, based on a common reporting structure, may further facilitate shared learning. (Disaster Med Public Health Preparedness. 2019;13:618-625)
Around ninety per cent of all patients with mental health problems are managed solely in primary care, including thirty-fifty per cent of all those with serious mental illness. Primary care plays an increasingly essential role in developing and delivering mental health services, and in the wellbeing of communities. In this book, internationally respected authors provide both a conceptual background and practical advice for primary care clinicians and specialist mental health professionals liaising with primary care. Clinical, policy and professional issues, such as working effectively at the interface between services, are addressed, with a key focus on patient and service user experience. Following the highly successful first edition, which was awarded first prize at the BMA Medical Book Awards in the category of Primary Health Care, this fully updated volume includes new chapters on mental health and long-term physical conditions, prison populations, improving access to care and public mental health.
The Caledonides of Britain and Ireland include terranes attributed to both Laurentian and Gondwanan sources, separated along the Solway line. Gondwanan elements to the south have been variably assigned to the domains Ganderia and East Avalonia. The Midland Platform forms the core of East Avalonia but its provenance is poorly known. Laser ablation split-stream analysis yields information about detrital zircon provenance by providing simultaneous U–Pb and Lu–Hf data from the same ablated volume. A sample of Red Callavia Sandstone from uppermost Cambrian Stage 3 of the Midland Platform yields a U–Pb age spectrum dominated by Neoproterozoic and Palaeoproterozoic sources, resembling those in the Welsh Basin, the Meguma Terrane of Nova Scotia and NW Africa. Initial εHf values suggest that the Neoproterozoic zircon component was derived mainly from crustal sources < 2 Ga, and imply that the more evolved Palaeoproterozoic grains were transported into the basin from an older source terrane, probably the Eburnean Orogen of West Africa. A sample from Cambrian Stage 4 in the Bray Group of the Leinster–Lakesman Terrane shows, in contrast, a distribution of both U–Pb ages and εHf values closely similar to those of the Gander Terrane in Newfoundland and other terranes attributed to Ganderia, interpreted to be derived from the margin of Amazonia. East Avalonia is clearly distinct from Ganderia, but shows evidence for older crustal components not present in West Avalonia of Newfoundland. These three components of the Appalachian–Caledonide Orogen came from distinct sources on the margin of Cambrian Gondwana.
UK Biobank is a well-characterised cohort of over 500 000 participants that offers unique opportunities to investigate multiple diseases and risk factors.
An online mental health questionnaire completed by UK Biobank participants was expected to expand the potential for research into mental disorders.
An expert working group designed the questionnaire, using established measures where possible, and consulting with a patient group regarding acceptability. Case definitions were defined using operational criteria for lifetime depression, mania, anxiety disorder, psychotic-like experiences and self-harm, as well as current post-traumatic stress and alcohol use disorders.
157 366 completed online questionnaires were available by August 2017. Comparison of self-reported diagnosed mental disorder with a contemporary study shows a similar prevalence, despite respondents being of higher average socioeconomic status than the general population across a range of indicators. Thirty-five per cent (55 750) of participants had at least one defined syndrome, of which lifetime depression was the most common at 24% (37 434). There was extensive comorbidity among the syndromes. Mental disorders were associated with high neuroticism score, adverse life events and long-term illness; addiction and bipolar affective disorder in particular were associated with measures of deprivation.
The questionnaire represents a very large mental health survey in itself, and the results presented here show high face validity, although caution is needed owing to selection bias. Built into UK Biobank, these data intersect with other health data to offer unparalleled potential for crosscutting biomedical research involving mental health.
Declaration of interest
G.B. received grants from the National Institute for Health Research during the study; and support from Illumina Ltd. and the European Commission outside the submitted work. B.C. received grants from the Scottish Executive Chief Scientist Office and from The Dr Mortimer and Theresa Sackler Foundation during the study. C.S. received grants from the Medical Research Council and Wellcome Trust during the study, and is the Chief Scientist for UK Biobank. M.H. received grants from the Innovative Medicines Initiative via the RADAR-CNS programme and personal fees as an expert witness outside the submitted work.
The Neotoma Paleoecology Database is a community-curated data resource that supports interdisciplinary global change research by enabling broad-scale studies of taxon and community diversity, distributions, and dynamics during the large environmental changes of the past. By consolidating many kinds of data into a common repository, Neotoma lowers costs of paleodata management, makes paleoecological data openly available, and offers a high-quality, curated resource. Neotoma’s distributed scientific governance model is flexible and scalable, with many open pathways for participation by new members, data contributors, stewards, and research communities. The Neotoma data model supports, or can be extended to support, any kind of paleoecological or paleoenvironmental data from sedimentary archives. Data additions to Neotoma are growing and now include >3.8 million observations, >17,000 datasets, and >9200 sites. Dataset types currently include fossil pollen, vertebrates, diatoms, ostracodes, macroinvertebrates, plant macrofossils, insects, testate amoebae, geochronological data, and the recently added organic biomarkers, stable isotopes, and specimen-level data. Multiple avenues exist to obtain Neotoma data, including the Explorer map-based interface, an application programming interface, the neotoma R package, and digital object identifiers. As the volume and variety of scientific data grow, community-curated data resources such as Neotoma have become foundational infrastructure for big data science.