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Operators are mindful of the balloon-to-aortic annulus ratio when performing balloon aortic valvuloplasty. The method of measurement of the aortic valve annulus has not been standardised.
Methods and results:
Patients who underwent aortic valvuloplasty at two paediatric centres between 2007 and 2014 were included. The valve annulus measured by echocardiography and angiography was used to calculate the balloon-to-aortic annulus ratio and measurements were compared. The primary endpoint was an increase in aortic insufficiency by ≥2 degrees. Ninety-eight patients with a median age at valvuloplasty of 2.1 months (Interquartile range (IQR): 0.2–105.5) were included. The angiographic-based annulus was 8.2 mm (IQR: 6.8–16.0), which was greater than echocardiogram-based annulus of 7.5 mm (IQR: 6.1–14.8) (p < 0.001). This corresponded to a significantly lower angiographic balloon-to-aortic annulus ratio of 0.9 (IQR: 0.9–1.0), compared to an echocardiographic ratio of 1.1 (IQR: 1.0–1.1) (p < 0.001). The degree of discrepancy in measured diameter increased with smaller valve diameters (p = 0.041) and in neonates (p = 0.044). There was significant disagreement between angiographic and echocardiographic balloon-to-aortic annulus ratio measures regarding “High” ratio of >1.2, with angiographic ratio flagging only 2/12 (16.7%) of patients flagged by echocardiographic ratio as “High” (p = 0.012). Patients who had an increase in the degree of aortic insufficiency post valvuloplasty, only 3 (5.5%) had angiographic ratio > 1.1, while 21 (38%) had echocardiographic ratio >1.1 (p < 0.001). Patients with resultant ≥ moderate insufficiency more often had an echocardiographic ratio of >1.1 than angiographic ratio of >1.1 There was no association between increase in balloon-to-aortic annulus ratio and gradient reduction.
Angiographic measurement is associated with a greater measured aortic valve annulus and the development of aortic insufficiency. Operators should use caution when relying solely on angiographic measurement when performing balloon aortic valvuloplasty.
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.
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.
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.
Cannabis has been reported to produce acute psychiatric reactions, among these panic anxiety and derealization, which are self-limited. We report on three patients who experienced an initial panic attack during cannabis intake. Anxiety attacks reoccurred after the cessation of intake. Two of these patients had a current depressive disorder, one of them had a single Grand Mal seizure before the onset. We suggest that cannabis may trigger the emergence of recurrent panic attacks and uncover latent panic disorders in vulnerable persons.
Studies examining OC phenomena in schizophrenic and schizoaffective disorders have shown a prevalence of such phenomena in 1 to 60% of schizophrenic or schizoaffective patients. In this prospective study, about 10% of 150 male patients suffering from acute psychotic disorders (fulfilling DSM-IV criteria for Schizophrenia or Schizoaffective Disorder) were found to have OC symptoms. These symptoms showed no correlation to the type and severity of psychosis. As only 19% of the patients with obsessions and compulsions during acute psychosis showed an obsessive-compulsive personality disorder prior to their psychotic episodes, it may be concluded that there is no clear linkage between intrapsychotic OC phenomena and premorbid anancastic personality traits.
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.
Repetitive Transcranial Magnetic Stimulation (rTMS) of the frontal cortex has been shown to improve negative symptoms in schizophrenia in a number of small studies, although inconsistent results have also been reported. Neuroimaging has shown bilateral hypofrontality in schizophrenia, and rTMS may improve brain activation. We therefore aimed to investigate whether 10 Hz stimulation of the bilateral dorsolateral prefrontal cortex during 3 weeks would yield substantial treatment effects and would improvement of frontal activation.
This study concerned a multicenter double-blind randomized controlled trial in 32 patients with schizophrenia or schizoaffective disorder. All had moderate to severe negative symptoms (Positive and Negative Syndrome Scale (PANSS) negative subscale ≥ 15). Patients were randomized to a 3-week course of active or sham rTMS. Primary outcome was severity of negative symptoms as measured with the Scale for the Assessment of Negative Symptoms (SANS) and the PANSS negative symptom score. Twenty-four patients participated in the pre- and posttreatment fMRI measurement. Analyses concerned changes in brain activation as measured with functional magnetic resonance imaging (fMRI) during the Tower of London (ToL) task from pre-treatment to post-treatment.
Brain activation increased more in the active group in the right DLPFC and the right medial frontal gyrus as compared to the sham group. Different activation change was also found in the left posterior cingulate, with decreased activation in the active and increased activation in the sham group. The changes in brain activation were accompanied by a significant improvement of negative symptoms in the treatment group (p=0.04).
Our findings suggest that treatment with rTMS over the DLPFC may potentially increase task-related activation in frontal areas and improve negative symptoms in patients with schizophrenia.
In this paper, we outline the policy implications of mobile health research conducted at the international level. We describe the manner in which such research may have an international dimension and argue that it is not likely to be excluded from conventionally applicable international regulatory tools. We suggest that closer policy attention is needed for this rapidly proliferating approach to health research.
Pathological gambling is a behavioural addiction with negative economic, social, and psychological consequences. Identification of contributing genes and pathways may improve understanding of aetiology and facilitate therapy and prevention. Here, we report the first genome-wide association study of pathological gambling. Our aims were to identify pathways involved in pathological gambling, and examine whether there is a genetic overlap between pathological gambling and alcohol dependence.
Four hundred and forty-five individuals with a diagnosis of pathological gambling according to the Diagnostic and Statistical Manual of Mental Disorders were recruited in Germany, and 986 controls were drawn from a German general population sample. A genome-wide association study of pathological gambling comprising single marker, gene-based, and pathway analyses, was performed. Polygenic risk scores were generated using data from a German genome-wide association study of alcohol dependence.
No genome-wide significant association with pathological gambling was found for single markers or genes. Pathways for Huntington's disease (P-value = 6.63 × 10−3); 5′-adenosine monophosphate-activated protein kinase signalling (P-value = 9.57 × 10−3); and apoptosis (P-value = 1.75 × 10−2) were significant. Polygenic risk score analysis of the alcohol dependence dataset yielded a one-sided nominal significant P-value in subjects with pathological gambling, irrespective of comorbid alcohol dependence status.
The present results accord with previous quantitative formal genetic studies which showed genetic overlap between non-substance- and substance-related addictions. Furthermore, pathway analysis suggests shared pathology between Huntington's disease and pathological gambling. This finding is consistent with previous imaging studies.
We explore the intrinsic jet opening angle (IJOA) of blazars, from the literature, we found that the blazar number density peaks around 0.5° of IJOA and declines quickly with increasing IJOA for flat spectrum radio quasars (FSRQs), while the number density has double peaks around 0.3° and 2.0° of IJOA for BL Lacs. We assume that the black hole accretion-produced jet may have the smaller IJOA (for its larger linear scale of launch region), and the BH spin-produced jet may have the larger IJOA (for its smaller launch region), such that the FSRQs are accretion dominated for their single peaked small IJOA, while the BL Lacs are either accretion or BH spin dominated for their double peaked IJOA.
The German Twin Family Panel (TwinLife) is a German longitudinal study of monozygotic and dizygotic same-sex twin pairs and their families that was designed to investigate the development of social inequalities over the life course. The study covers an observation period from approximately 2014 to 2023. The target population of the sample are reared-together twins of four different age cohorts that were born in 2009/2010 (cohort 1), in 2003/2004 (cohort 2), in 1997/1998 (cohort 3) and between 1990 and 1993 (cohort 4). In the first wave, the study included data on 4097 twin families. Families were recruited in all parts of Germany so that the sample comprises the whole range of the educational, occupational and income structure. As of 2019, two face-to-face, at-home interviews and two telephone interviews have been conducted. Data from the first home and telephone interviews are already available free of charge as a scientific use-file from the GESIS data archive. This report aims to provide an overview of the study sample and design as well as constructs that are unique in TwinLife in comparison with previous twin studies — such as an assessment of cognitive abilities or information based on the children’s medical records and report cards. In addition, major findings based on the data already released are displayed, and future directions of the study are presented and discussed.
In 2016, we reviewed preventive control measures for secondary transmission of Shiga-toxin producing Escherichia coli (STEC) in humans in European Union (EU)/European Free Trade Association (EEA) countries to inform the revision of the respective Norwegian guidelines which at that time did not accommodate for the varying pathogenic potential of STEC. We interviewed public health experts from EU/EEA institutes, using a semi-structured questionnaire. We revised the Norwegian guidelines using a risk-based approach informed by the new scientific evidence on risk factors for HUS and the survey results. All 13 (42%) participating countries tested STEC for Shiga toxin (stx) 1, stx2 and eae (encoding intimin). Five countries differentiated their control measures based on clinical and/or microbiological case characteristics, but only Denmark based their measures on routinely conducted stx subtyping. In all countries, but Norway, clearance was obtained with ⩽3 negative STEC specimens. After this review, Norway revised the STEC guidelines and recommended only follow-up of cases infected with high-virulent STEC (determined by microbiological and clinical information); clearance is obtained with three negative specimens. Implementation of the revised Norwegian guidelines will lead to a decrease of STEC cases needing follow-up and clearance, and will reduce the burden of unnecessary public health measures and the socioeconomic impact on cases. This review of guidelines could assist other countries in adapting their STEC control measures.
Apolipoprotein E (APOE) E4 is the main genetic risk factor for Alzheimer’s disease (AD). Due to the consistent association, there is interest as to whether E4 influences the risk of other neurodegenerative diseases. Further, there is a constant search for other genetic biomarkers contributing to these phenotypes, such as microtubule-associated protein tau (MAPT) haplotypes. Here, participants from the Ontario Neurodegenerative Disease Research Initiative were genotyped to investigate whether the APOE E4 allele or MAPT H1 haplotype are associated with five neurodegenerative diseases: (1) AD and mild cognitive impairment (MCI), (2) amyotrophic lateral sclerosis, (3) frontotemporal dementia (FTD), (4) Parkinson’s disease, and (5) vascular cognitive impairment.
Genotypes were defined for their respective APOE allele and MAPT haplotype calls for each participant, and logistic regression analyses were performed to identify the associations with the presentations of neurodegenerative diseases.
Our work confirmed the association of the E4 allele with a dose-dependent increased presentation of AD, and an association between the E4 allele alone and MCI; however, the other four diseases were not associated with E4. Further, the APOE E2 allele was associated with decreased presentation of both AD and MCI. No associations were identified between MAPT haplotype and the neurodegenerative disease cohorts; but following subtyping of the FTD cohort, the H1 haplotype was significantly associated with progressive supranuclear palsy.
This is the first study to concurrently analyze the association of APOE isoforms and MAPT haplotypes with five neurodegenerative diseases using consistent enrollment criteria and broad phenotypic analysis.
Angiostrongylus cantonensis is a pathogenic nematode and the cause of neuroangiostrongyliasis, an eosinophilic meningitis more commonly known as rat lungworm disease. Transmission is thought to be primarily due to ingestion of infective third stage larvae (L3) in gastropods, on produce, or in contaminated water. The gold standard to determine the effects of physical and chemical treatments on the infectivity of A. cantonensis L3 larvae is to infect rodents with treated L3 larvae and monitor for infection, but animal studies are laborious and expensive and also raise ethical concerns. This study demonstrates propidium iodide (PI) to be a reliable marker of parasite death and loss of infective potential without adversely affecting the development and future reproduction of live A. cantonensis larvae. PI staining allows evaluation of the efficacy of test substances in vitro, an improvement upon the use of lack of motility as an indicator of death. Some potential applications of this assay include determining the effectiveness of various anthelmintics, vegetable washes, electromagnetic radiation and other treatments intended to kill larvae in the prevention and treatment of neuroangiostrongyliasis.
The introduction of agriculture is known to have profoundly affected the ecological complexion of landscapes. In this study, a rapid transition from C3 to C4 vegetation is inferred from a shift to higher stable carbon (13C/12C) isotope ratios of soils and sediments in the Benoué River Valley and upland Fali Mountains in northern Cameroon. Landscape change is viewed from the perspective of two settlement mounds and adjacent floodplains, as well as a rock terrace agricultural field dating from 1100 cal yr BP to the recent past (<400 cal yr BP). Nitrogen (15N/14N) isotope ratios and soil micromorphology demonstrate variable uses of land adjacent to the mound sites. These results indicate that Early Iron Age settlement practices involved exploitation of C3 plants on soils with low δ15N values, indicating wetter soils. Conversely, from the Late Iron Age (>700 cal yr BP) until recent times, high soil and sediment δ13C and δ15N values reflect more C4 biomass and anthropogenic organic matter in open, dry environments. The results suggest that Iron Age settlement practices profoundly changed landscapes in this part of West Africa through land clearance and/or utilization of C4 plants.
Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration.
An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback.
Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program.
A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.