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Introduction: Transportation of patients better served at an alternative destinations (diversion) is part of a proposed solution to emergency department (ED) overcrowding. We evaluated the pilot implementation of the “Mental Health and Addiction Triage and Transport Protocol”. This is the first Canadian diversion protocol that allows paramedics to transport intoxicated or mental health patients to an alternative facility, bypassing the ED. Our aim was to implement a safe diversion protocol to allow patients to access more appropriate service without transportation to the emergency department. Methods: A retrospective analysis was conducted on patients presenting to EMS with intoxication or psychiatric issues. Study outcomes were protocol compliance, determined through missed protocol opportunities, noncompliance, and protocol failure (presentation to ED within 48 hours of appropriate diversion); and protocol safety, determined through patient morbidity (hospital admission within 48 hours of diversion) and mortality. Data was abstracted from EMS reports, hospital records, and discharge forms from alternative facilities. Data was analyzed qualitatively and quantitatively. Results: From June 1st, 2015 to May 31st, 2016 Greater Sudbury Paramedic Services responded to 1376 calls for mental health or intoxicated patients. 241 (17.5%) met diversion criteria, 158 (12.9%) patients were diverted and 83 (4.6%) met diversion criteria but were transported to the ED. Of the diverted patients 9 (5.6%) represented to the ED <48rs later and were admitted. Of the 158 diversions, 113 (72%) were transported to Withdrawal Management Services (WMS) and 45 (28%) were taken to Crisis Intervention (CI). There was protocol noncompliance in 77 cases, 69 (89.6%) were due to incomplete recording of vital signs; 6 (10.3%) were direct protocol violations of being transferred with vital sings outside the acceptable range. Conclusion: The Mental Health and Addiction Triage and Transport Protocol has the potential to safely divert 1 in 6 mental health or addiction patients to an alternative facility.
Animal studies have suggested that exposure of the middle ear to topical local anaesthesia may be ototoxic. This study aimed to report sensorineural hearing outcomes and patients’ satisfaction in those who underwent myringotomy and ventilation tube insertion using topical local anaesthesia.
Twenty-nine patients (32 ears) were operated on. Pre- and post-operative audiology findings were compared. A Likert-type questionnaire on treatment satisfaction was completed at the end of the procedure.
Median patient age was 55 years (range, 27–88 years). Pre- and post-operative bone conduction pure tone averages were 26.76 dB and 25.26 dB respectively (mean reduction of −1.22 dB, 95 per cent confidence interval of −5.91 to 8.13 dB; p = 0.7538). One ear (3 per cent) had a reduction in pure tone average of 10 dB.
The results suggest that sensorineural hearing loss is not a complication of ear exposure to topical local anaesthesia during myringotomy and ventilation tube insertion. The procedure was well perceived.
Evans Ice Stream, West Antarctica, has five tributaries and a complex grounding zone. The grounding zone of Evans Ice Stream, between the landward and seaward limits of tidal flexing, was mapped using SAR interferometry. The width of the mapped grounding zone was compared with that derived from an elastic beam model, and the tidal height changes derived from interferometry were compared with the results of a tidal model. Results show that in 1994 and 1996 the Evans grounding zone was located up to 100 km upstream of its location in the BEDMAP dataset. The grounding line of Evans Ice Stream is subjected to 5 m vertical tidal forcing, which would clearly affect ice-stream flow.
Introduction: Prehospital transport of patients to an alternative destination (diversion) has been proposed as part of a solution to overcrowding in emergency departments (ED). We evaluated compliance and safety of an EMS bypass protocol allowing paramedics to transport intoxicated patients directly to an alternate facility [Withdrawal Management Services (WMS)], bypassing the ED. Patients were eligible for diversion if they were ≥18 years old, classified as CTAS level III-IV, scored <4 on the Prehospital Early Warning (PHEW) score, and did not have any vital sign parameters in a danger zone (as per PHEW score criteria). Methods: A retrospective analysis was conducted on intoxicated patients presenting to Sudbury EMS. Data was abstracted from EMS reports, hospital medical records, and discharge forms from WMS. Protocol compliance was measured using missed protocol opportunities (patients eligible for diversion but taken directly to the ED) and protocol noncompliance rates; protocol safety was measured using protocol failure (presentation to ED within 48 hours of appropriate diversion) and patient morbidity rates (hospital admission within 48 hours of diversion). Data was analysed qualitatively and quantitatively using proportions. Results: EMS responded to 681 calls for intoxication. Of the 568 taken directly to the ED, 65 met diversion criteria; these were missed protocol opportunities (11%). 113 patients were diverted. There was protocol noncompliance in 41 cases (36%), but 35 were due to incomplete recording of vital signs. There were direct protocol violations in only 6 cases (5%). There was protocol failure in 16 cases (22%), and patient morbidity in 1 case (1%). No patients died within 48 hours of diversion. Conclusion: EMS providers were fairly compliant with the protocol when transporting patients directly to the ED. There was some protocol non-compliance with patients diverted to WMS, though this is largely attributed to incomplete recording of vital signs; direct protocol violations were low. The protocol provides high levels of safety for patients diverted to WMS. Broader implementation of the protocol could reduce the volume of intoxicated patients seen in the ED, and improve quality of care received by this population.
Introduction: Prehospital transport of patients to an alternative destination (diversion) has been proposed as part of a solution to overcrowding in emergency departments (ED). We evaluated compliance and safety of an EMS protocol allowing paramedics to transport medically stable patients with psychiatric issues directly to an alternate facility [Crisis Intervention (CI)], bypassing the ED. Patients were eligible for diversion if they were ≥18 years old, classified as CTAS III-IV, scored <4 on the Prehospital Early Warning (PHEW) score, and did not have any vital sign parameters in a danger zone (as per PHEW score criteria). Methods: A retrospective analysis was conducted on patients presenting to Sudbury EMS with behavioural or psychiatric issues. Data was abstracted from EMS reports, hospital medical records, and discharge forms from CI. Protocol compliance was measured using missed protocol opportunities (patients eligible for diversion but taken directly to the ED) and protocol noncompliance rates; protocol safety was measured using protocol failure (presentation to ED within 48 hours of appropriate diversion) and patient morbidity rates (hospital admission within 48 hours of diversion). Data was analysed qualitatively and quantitatively using proportions. Results: EMS responded to 695 calls with psychiatric complaints. Of the 650 taken directly to the ED, 18 met diversion criteria; these were missed protocol opportunities (3%). 45 patients were diverted. There was protocol noncompliance in 36 cases (80%), but 34 were due to incomplete recording of vital signs. There were direct protocol violations in only 2 cases (4%). There was protocol failure in 3 cases (33%), and patient morbidity in 8 cases (18%). No patients died within 48 hours of diversion. Conclusion: EMS providers were highly compliant with the protocol when transporting patients directly to the ED. There were high levels of protocol non-compliance in diverting patients to CI, though this is largely attributed to incomplete recording of vital signs; direct protocol violations were low. The protocol provides moderate levels of safety in diverted patients. Broader implementation of a diversion protocol could reduce the volume of mental health patients seen in the ED, and improve quality of care received by this patient population.
Fluid balance and renal function can be difficult to manage in the postoperative infant with tetralogy of Fallot. High fluid volumes are often needed to maintain cardiac output.
To stratify patients at risk for advanced renal support following tetralogy of Fallot repair.
Retrospective analysis of all consecutive tetralogy of Fallot cases operated at a single centre in a 3-year period.
A total of 41 children were identified. All cases had loop diuretics administered. Of the cases, 17% required support with a peritoneal dialysis catheter, with only one complication of peritoneal dialysis catheter blockage. The mean length of paediatric intensive care unit stay in those receiving peritoneal dialysis catheter insertion was prolonged by an additional mean of 6 days (p<0.001). No statistical significance was found between those children requiring peritoneal dialysis and those who did not when considering patient age and weight at time of repair, cardiopulmonary bypass and aortic cross clamp times, the presence of a transannular patch, or junctional ectopic tachycardia. However, volume requirement of more than 35 ml/kg in the first 12 hours following repair did increase the likelihood to need peritoneal dialysis (p<0.0001). Furthermore, the higher the peak creatinine, the longer the stay on intensive care (p<0.01).
Peritoneal dialysis is an effective method of dealing with fluid balance in children after tetralogy of Fallot repair, with minimal complications. Early consideration should be given to peritoneal dialysis when it is clear that high fluid volumes are required postoperatively.
We introduce a game theoretical model of stealing interactions. We model the situation as
an extensive form game when one individual may attempt to steal a valuable item from
another who may in turn defend it. The population is not homogeneous, but rather each
individual has a different Resource Holding Potential (RHP). We assume that RHP not only
influences the outcome of the potential aggressive contest (the individual with the larger
RHP is more likely to win), but that it also influences how an individual values a
particular resource. We investigate several valuation scenarios and study the prevalence
of aggressive behaviour. We conclude that the relationship between RHP and resource value
is crucial, where some cases lead to fights predominantly between pairs of strong
individuals, and some between pairs of weak individuals. Other cases lead to no fights
with one individual conceding, and the order of strategy selection is crucial, where the
individual which picks its strategy first often has an advantage.
The facilitation of plant coexistence via temporal variation in plant recruitment is increasingly studied (see this volume plus Pake and Venable 1996, Chesson and Huntly 1997, Kelly and Bowler 2002, Verhulst et al. 2008). For the most part however, corroborating studies have examined fluctuations in abiotic factors and the role of biotic agents has been largely overlooked. This omission is symptomatic of the plant coexistence literature in general; the role of predators, herbivores, pathogens and parasites in maintaining species coexistence is more often assumed than demonstrated (but see Kelly and Bowler 2009a). Nonetheless, while a number of agents, biotic and abiotic, result in the death of entire seedling cohorts, foremost among the factors limiting seedling recruitment is herbivory (Moles and Westoby 2004, Fenner and Thompson 2005). Herbivore attack has obvious effects on seedling demography (Lindquist and Carroll 2004, Maron and Crone 2006, Maron and Kauffman 2006), but even beyond population-level considerations, selective seedling removal also exerts long-lasting effects on plant community composition. We propose that temporal fluctuation in herbivore populations, and consequently variation in the intensity of herbivory experienced by plants during their regeneration phase, exerts a powerful influence over plant species contribution to the established community.
There are four necessary conditions of any temporal dynamic involving herbivory. First, seedling herbivores must be capable of moderating plant community composition in established vegetation. Second, herbivores should select preferred seedlings on the basis of readily apparent ecophysiological characteristics. Third, and related to the previous assumption, any variation in seedling susceptibility to herbivore attack (i.e. defensive traits) will most probably correlate with competitive ability. Finally, herbivore populations must show fluctuations in numbers and therefore variation in their influence on regenerating plants. Consequently, before it is possible to develop any conceptual framework to explain how temporal variation in seedling herbivory influences species coexistence, we must first evaluate the evidence for these conditions.
Few studies have prospectively investigated psychological morbidity in UK head and neck cancer patients. This study aimed to explore changes in psychological symptoms over time, and associations with patients' tumour and treatment characteristics, including toxicity.
Two hundred and twenty patients were recruited to complete the Hospital Anxiety and Depression Scale and the Late Effects on Normal Tissue (Subjective, Objective, Management and Analytic) (‘LENT-SOMA’) questionnaires, both pre- and post-treatment.
Anxiety was highest pre-treatment (38 per cent) and depressive symptoms peaked at the end of treatment (44 per cent). Anxiety significantly decreased and depression significantly increased, comparing pre- versus post-treatment responses (p < 0.001). Hospital Anxiety and Depression Scale scores were significantly correlated with toxicity, age and chemotherapy (p < 0.01 for all).
This is the first study to analyse the relationship between Hospital Anxiety and Depression Scale scores and toxicity scores in head and neck cancer patients. It lends support for the use of the Hospital Anxiety and Depression Scale and the Late Effects on Normal Tissue (Subjective, Objective, Management and Analytic) questionnaire in routine clinical practice; furthermore, continued surveillance is required at multiple measurement points.
The Dawn spacecraft orbited Asteroid (4) Vesta for a year, and returned disk-resolved images and spectra covering visible and near-infrared wavelengths at scales as high as 20 m/pix. The visible geometric albedo of Vesta is ~ 0.36. The disk-integrated phase function of Vesta in the visible wavelengths derived from Dawn approach data, previous ground-based observations, and Rosetta OSIRIS observations is consistent with an IAU H-G phase law with H=3.2 mag and G=0.28. Hapke's modeling yields a disk-averaged single-scattering albedo of 0.50, an asymmetry factor of -0.25, and a roughness parameter of ~20 deg at 700 nm wavelength. Vesta's surface displays the largest albedo variations observed so far on asteroids, ranging from ~0.10 to ~0.76 in geometric albedo in the visible wavelengths. The phase function of Vesta displays obvious systematic variations with respect to wavelength, with steeper slopes within the 1- and 2-micron pyroxene bands, consistent with previous ground-based observations and laboratory measurement of HED meteorites showing deeper bands at higher phase angles. The relatively high albedo of Vesta suggests significant contribution of multiple scattering. The non-linear effect of multiple scattering and the possible systematic variations of phase function with albedo across the surface of Vesta may invalidate the traditional algorithm of applying photometric correction on airless planetary surfaces.
The electroglottogram approximate entropy value is a numerical variable which gives an overall measure of voice quality. It is derived by analysing the complexity of the electroglottogram waveform using regulatory statistics.
(1) To use electroglottogram approximate entropy to measure voice quality in patients with glottic pathology and in normal subjects, to ascertain whether this parameter can distinguish between pathological and normal voices. (2) To ascertain whether electroglottogram approximate entropy can measure voice change over time within individual subjects. (3) To determine any correlation between electroglottogram approximate entropy and the grade–roughness–breathiness–asthenia–strain scale.
One hundred and forty-one normal volunteers were recruited to characterise electroglottogram approximate entropy in the normal voice. One hundred and eighty-six patients with glottic squamous cell carcinoma underwent electroglottogram approximate entropy measurement prior to radiotherapy and then three to six months and one year after treatment. Subjects’ voices were categorised by a speech therapist using the grade–roughness–breathiness–asthenia–strain scale.
The mean electroglottogram approximate entropy of the normal volunteers was 0.302 (range 0.05–0.42). The mean electroglottogram approximate entropy of the glottic squamous cell carcinoma patients was significantly lower prior to treatment, at 0.227 (range 0.001–0.397; p < 0.0005), but improved after radiotherapy to 0.277 at three to six months and 0.282 at one year. Electroglottogram approximate entropy results correlated significantly with grade–roughness–breathiness–asthenia–strain scale results.
Electroglottogram approximate entropy can be used to assess change in voice quality resulting from glottic morphological abnormality. Electroglottogram approximate entropy values improve as voice quality improves after treatment. Electroglottogram approximate entropy values correlate significantly with grade–roughness–breathiness–asthenia–strain scale results.