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Coronavirus disease 2019 personal protective equipment has been reported to affect communication in healthcare settings. This study sought to identify those challenges experimentally.
Bamford–Kowal–Bench speech discrimination in noise performance of healthcare workers was tested under simulated background noise conditions from a variety of hospital environments. Candidates were assessed for ability to interpret speech with and without personal protective equipment, with both normal speech and raised voice.
There was a significant difference in speech discrimination scores between normal and personal protective equipment wearing subjects in operating theatre simulated background noise levels (70 dB).
Wearing personal protective equipment can impact communication in healthcare environments. Efforts should be made to remind staff about this burden and to seek alternative communication paradigms, particularly in operating theatre environments.
OBJECTIVES/GOALS: Specific Aim 1 To examine sex distribution of psoas cross sectional area (CSA) on CT imaging in a cohort of trauma patients age 55 and older. We will use three methods of assessing psoas CSA: psoas CSA averaged between left and right, average psoas CSA adjusted for height, and average psoas CSA adjusted for body surface area (psoas index). Specific Aim 2 Use multivariable logistic regression prediction modeling to compare the 3 methods of CT psoas muscle measurement widely used in the literature in their ability to predict a composite of in-hospital morbidity and mortality in trauma patients ages 55 and older. METHODS/STUDY POPULATION: The Maine Medical Center Trauma Registry is maintained by the Trauma Surgery Service at Maine Medical Center in Portland, Maine, the only Level-1 trauma center in the state. After receiving approval from the Institutional Review Board of Maine Medical Center for this retrospective cohort study, we queried the Maine Medical Center Trauma Registry for all adults 55 years and older who underwent evaluation by the Trauma Service between January 1, 2015 and January 1, 2019. In the case of multiple admissions within the study time period, only a patient’s index admission was used. MaineHealth IMPACS imaging software was used to measure bilateral psoas CSA on each patient CT. The Maine Medical Center electronic medical record was queried for additional clinical information including the ICD codes associated with each patient encounter. Data analysis was performed using R statistical software (R project, Vienna, Austria). Data is reported as median + IQR for CSA measurements. The agreement between the three methods of quantifying psoas CSA was evaluated using Pearson correlation (R package “stats”). Inter-rater reliability of psoas muscle measurements was evaluated using intra-class correlation (R package “irr”). Prediction models for the composite outcome of in-hospital morbidity and mortality were constructed using multivariable logistic regression. Bootstrapping was used for internal validation and shrinkage to avoid overfitting. Models including psoas CSA were compared to a baseline model without psoas CSA to evaluated incremental added predictive ability. RESULTS/ANTICIPATED RESULTS: This cohort provides a basis for examining the population distribution of psoas CSA in adults 55 years and older. IN addition to a high level of agreement between the three methods of measuring psoas CSA (Spearman coefficient > 0.9), there was also high level of inter rater reliability in psoas muscle assessment (intraclass correlation 0.9). We anticipate that psoas CSA adjusted for body surface area will add the most incremental predictive ability to a model predicting in-hospital morbidity and mortality. DISCUSSION/SIGNIFICANCE OF IMPACT: Given the heterogeneity of health status amongst elderly trauma patients, a major challenge lies in the rapid objective identification of those elderly trauma patients who are frail. Due to the limitations in current frailty measures, there has been a surge of interest in surrogate markers of frailty, such as muscle mass, as predictive factors of poor outcomes after trauma.Several studies have found that sarcopenia is associated with post injury morbidity and mortality. Estimates of the prevalence of sarcopenia among trauma patients vary across studies due to differences in definition and sample characteristics. In order to appropriately categorize patients as sarcopenic, the population distribution of psoas CSA on CT must be established. The psoas measurement that best correlates with outcomes has yet to be determined, and it is unclear which measurement should be implemented in usual practice. Our main objective is to improve the outcomes of sarcopenic patients hospitalized with trauma by implementing in the future patient-centered interventions which will account for sarcopenia.
Introduction: CAEP recently developed the acute atrial fibrillation (AF) and flutter (AFL) [AAFF] Best Practices Checklist to promote optimal care and guidance on cardioversion and rapid discharge of patients with AAFF. We sought to assess the impact of implementing the Checklist into large Canadian EDs. Methods: We conducted a pragmatic stepped-wedge cluster randomized trial in 11 large Canadian ED sites in five provinces, over 14 months. All hospitals started in the control period (usual care), and then crossed over to the intervention period in random sequence, one hospital per month. We enrolled consecutive, stable patients presenting with AAFF, where symptoms required ED management. Our intervention was informed by qualitative stakeholder interviews to identify perceived barriers and enablers for rapid discharge of AAFF patients. The many interventions included local champions, presentation of the Checklist to physicians in group sessions, an online training module, a smartphone app, and targeted audit and feedback. The primary outcome was length of stay in ED in minutes from time of arrival to time of disposition, and this was analyzed at the individual patient-level using linear mixed effects regression accounting for the stepped-wedge design. We estimated a sample size of 800 patients. Results: We enrolled 844 patients with none lost to follow-up. Those in the control (N = 316) and intervention periods (N = 528) were similar for all characteristics including mean age (61.2 vs 64.2 yrs), duration of AAFF (8.1 vs 7.7 hrs), AF (88.6% vs 82.9%), AFL (11.4% vs 17.1%), and mean initial heart rate (119.6 vs 119.9 bpm). Median lengths of stay for the control and intervention periods respectively were 413.0 vs. 354.0 minutes (P < 0.001). Comparing control to intervention, there was an increase in: use of antiarrhythmic drugs (37.4% vs 47.4%; P < 0.01), electrical cardioversion (45.1% vs 56.8%; P < 0.01), and discharge in sinus rhythm (75.3% vs. 86.7%; P < 0.001). There was a decrease in ED consultations to cardiology and medicine (49.7% vs 41.1%; P < 0.01), but a small but insignificant increase in anticoagulant prescriptions (39.6% vs 46.5%; P = 0.21). Conclusion: This multicenter implementation of the CAEP Best Practices Checklist led to a significant decrease in ED length of stay along with more ED cardioversions, fewer ED consultations, and more discharges in sinus rhythm. Widespread and rigorous adoption of the CAEP Checklist should lead to improved care of AAFF patients in all Canadian EDs.
Introduction: The Brain Injury Guidelines (BIG) stratifies complicated mild traumatic brain injury (mTBI) patients into 3 groups to guide hospitalization, neurosurgical consultation and repeat head-CT. BIG-1 patients could be managed safely without neurosurgical consultation or transfer. Systematic transfer to neurotrauma centers provide few benefits to this subgroup leading to overtriage. Similarly, unnecessary clinical and radiological follow-ups utilize significant health-care resources. Objective: to validate the safety and efficacy of the BIG for complicated mTBIs. Methods: We performed a multicenter historical cohort study in 3 level-1 trauma centers in Quebec. Patients ≥16 years old assessed in the Emergency Department (ED) with complicated mTBI between 2014 and 2017 were included. Patients with penetrating trauma, cerebral aneurysm or tumor were excluded. Clinical, demographic and radiological data, BIG variables, TBI-related death and neurosurgical intervention were collected using a standardized form. A second reviewer assessed all ambiguous files. Descriptive statistics, over- and under-triage were calculated. Results: A total of 342 patients’ records were assessed. Mean age was 63 ± 20,7 and 236 (69 %) were male. Thirty-five patients were classified under BIG-1 (10.2%), 110 under BIG-2 (32.2%) and 197 under BIG-3 (57.6%). Twenty-six patients (7%) required neurosurgical intervention, all were BIG-3. 90% of TBI-related deaths occurred in BIG-3 and none were classified BIG-1. Among the 192 transfers (51%), 14 were classified under BIG-1 (7.3%) and should not have been transferred according to the guidelines and 50 under BIG-2 (26%). In addition, 40% of BIG-1 received a repeat head computed tomography, although not indicated. Similarly, 7 % of all patients had a neurosurgical consult even if not required. Projected implementation of BIG would lead to 47% of overtriage and 0.3% of undertriage. Conclusion: Our results suggest that the Brain Injury Guidelines could safely identify patients with negative outcomes and could lead to a safe and effective management of complicated mTBI. Applying these guidelines to our cohort could have resulted in significantly fewer repeat head CTs, neurosurgical consults and transfers to level 1 neurotrauma centers.
Introduction: An important challenge physicians face when treating acute heart failure (AHF) patients in the emergency department (ED) is deciding whether to admit or discharge, with or without early follow-up. The overall goal of our project was to improve care for AHF patients seen in the ED while avoiding unnecessary hospital admissions. The specific goal was to introduce hospital rapid referral clinics to ensure AHF patients were seen within 7 days of ED discharge. Methods: This prospective before-after study was conducted at two campuses of a large tertiary care hospital, including the EDs and specialty outpatient clinics. We enrolled AHF patients ≥50 years who presented to the ED with shortness of breath (<7 days). The 12-month before (control) period was separated from the 12-month after (intervention) period by a 3-month implementation period. Implementation included creation of rapid access AHF clinics staffed by cardiology and internal medicine, and development of referral procedures. There was extensive in-servicing of all ED staff. The primary outcome measure was hospital admission at the index visit or within 30 days. Secondary outcomes included mortality and actual access to rapid follow-up. We used segmented autoregression analysis of the monthly proportions to determine whether there was a change in admissions coinciding with the introduction of the intervention and estimated a sample size of 700 patients. Results: The patients in the before period (N = 355) and the after period (N = 374) were similar for age (77.8 vs. 78.1 years), arrival by ambulance (48.7% vs 51.1%), comorbidities, current medications, and need for non-invasive ventilation (10.4% vs. 6.7%). Comparing the before to the after periods, we observed a decrease in hospital admissions on index visit (from 57.7% to 42.0%; P <0.01), as well as all admissions within 30 days (from 65.1% to 53.5% (P < 0.01). The autoregression analysis, however, demonstrated a pre-existing trend to fewer admissions and could not attribute this to the intervention (P = 0.91). Attendance at a specialty clinic, amongst those discharged increased from 17.8% to 42.1% (P < 0.01) and the median days to clinic decreased from 13 to 6 days (P < 0.01). 30-day mortality did not change (4.5% vs. 4.0%; P = 0.76). Conclusion: Implementation of rapid-access dedicated AHF clinics led to considerably increased access to specialist care, much reduced follow-up times, and possible reduction in hospital admissions. Widespread use of this approach can improve AHF care in Canada.
In this study evidence is brought forth from large treasuries of scholastic manuscripts at Hereford and Lincoln that challenges R. M. Thomson's assessment of the importance of those collections during the High Middle Ages. As it turns out, as early as the twelfth century those libraries contained copies of the most important works in the developing Parisian theological curriculum, and the earliest copies of those works may reside in these and other English cathedral libraries. Manuscripts preserving early versions of the Sentences are especially interesting, since they make it possible to study the evolution of Peter Lombard's thought during his lifetime.
The uncertainty surrounding high intakes of folic acid and associations with cognitive decline in older adults with low vitamin B12 status has been an obstacle to mandatory folic acid fortification for many years. We estimated the prevalence of combinations of low/normal/high vitamin B12 and folate status and compared associations with global cognitive function using two approaches, of individuals in a population-based study of those aged ≥50 years in the Republic of Ireland. Cross-sectional data from 3781 men and women from Wave 1 of The Irish Longitudinal Study on Ageing were analysed. Global cognitive function was assessed by the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). Prevalence estimates for combinations of vitamin B12 (plasma vitamin B12 < or ≥258 pmol/l) and folate (plasma folate ≤ or >45·3 nmol/l) concentrations were generated. Negative binomial regression models were used to investigate the associations of vitamin B12 and folate status with global cognitive function. Of the participants, 1·5 % (n 51) had low vitamin B12 (<258 pmol/l) and high folate (>45·3 nmol/l) status. Global cognitive performance was not significantly reduced in these individuals when compared with those with normal status for both B-vitamins (n 2433). Those with normal vitamin B12/high folate status (7·6 %) had better cognitive performance (MMSE: incidence rate ratio (IRR) 0·82, 95 % CI 0·68, 0·99; P = 0·043, MoCA: IRR 0·89, 95 % CI 0·80, 0·99; P = 0·025). We demonstrated that high folate status was not associated with lower cognitive scores in older adults with low vitamin B12 status. These findings provide important safety information that could guide fortification policy recommendations in Europe.
The endothelial glycocalyx layer (EGL) is a brush-like layer that lines the internal surfaces of blood vessels. It is thought to serve a number of physiological functions, including as a mechanotransducer of fluid loadings to the vessel wall. However, the fragility of the EGL makes it difficult to examine experimentally, and so there is much value in theoretical models that can help to explain the dynamical behaviour of the EGL. Most previous models have employed mixture theory to mechanically describe the layer, which treats the EGL as a isotropic linearly poroelastic layer. However, there is increasing experimental evidence to suggest that the EGL has a well-defined organisational structure that might not necessarily be well captured by such mixture theory descriptions. We therefore employ homogenisation theory to incorporate into the models some of the possible EGL microstructure suggested by the current biological literature. We explore how mechanotransduction varies under the different possible EGL microstructures, which potentially has important consequences to our understanding of how structural changes to the EGL might affect a vessel’s ability to respond to hemodynamical cues. We also find that, whereas mechanotransduction through the solid components of the EGL is dominated by the fluid tractions applied at the lumen–EGL interface, the component carried through its fluid phase is most sensitive to pressure gradients within the bulk EGL. This is relevant, since it is known that the underlying endothelial cells respond differently to these two different forms of mechanical loading.
Bipolar disorder (BD) is associated with impaired psychosocial behaviours. Little is known about deficits in neurocognitive functions like decision-making possibly related both to these behaviours and to the nature of the disorder.
To determine whether decision-making impairments exist in manic (M), depressed (D) and euthymic (E) bipolar patients (BP) and to determine whether illness and course-of-illness characteristics can predict participants’ performance
A power analysis was conducted. A total of 315 subjects, including 45 M and 32 D inpatients and 90 E outpatients with BD I, medicated, and 150 Healthy Controls (HC), age, IQ and gender-matched, were included. Decision-making ability and sensitivity to punishment frequency were assessed with the Iowa Gambling Task (IGT).
On the IGT, MBP (p< 0.001), DBP (p< 0.01) and EBP (p< 0.05) selected significantly more cards from the risky decks than HC with no significant differences between BP groups. Unlike HC, MBP (p< 0.001), DBP (p< 0.05) and EBP (p< 0.05) showed little capacity to learn from incurred losses with no significant differences between BP groups, but, like HC, BP preferred decks that yielded infrequent penalties over those decks that yielded frequent penalties. In a multivariate analysis, decision-making impairment in the BP was significantly (p=0.001) predicted by low level of education, high total number of admissions and family history of BD.
BP clearly show defects in decision-making predicted by course-of-illness illness characteristics. Impaired decision-making might be a trait-related neurocognitive deficit in BD and partly explain impaired psychosocial behaviours of BP.
Interest exists in identifying the factors that specifically contribute to the increased prevalence of cardiovascular disease observed in psychiatric disease. The apolipoprotein-E (APOE) gene codes for a protein that has a key role in metabolism of cholesterol and triglycerides, with increased levels of apoE found in specific areas of post-mortem schizophrenic brains. This study investigated whether apoE variants influence the prevalence of cardiovascular risk factors (obesity, diabetes and dyslipidaemia), in patients receiving antipsychotic treatment, due to extension of the risk seen in the general population, but also due to the role of the APOE gene in mediating antipsychotic-induced side effects. Seven polymorphisms (rs741780, rs483082, rs429358, rs7412, rs10119, rs439401 and rs405509) were genotyped in 427 American Caucasian patients who were either receiving, or had been prescribed risperidone. Our results support the hypothesis that APOE gene variants influence the prevalence of diabetes and possibly overweight in psychiatric patients. Unfortunately, due to the cross sectional nature of this study, the contribution of antipsychotic treatment was not determined. These associations warrant prospective study to assess interaction between APOE gene variants and the propensity of antipsychotics to induce cardiovascular risk factors.
Atomoxetine, a highly selective noradrenaline reuptake inhibitor, shows efficacy in the treatment of ADHD. Despite evidence that atomoxetine improved inhibitory control in animals and healthy volunteers, studies had yet to explore short-term cognitive effects in patients with ADHD.
The cognitive effects of a single oral dose of atomoxetine (60mg) were evaluated in n=22 adults with DSM-IV ADHD, using a within-subject placebo-controlled double-blind design. Assessment included the stop-signal test and Rapid Visual Information Processing test from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Cardiovascular responses were monitored. Normative cognitive data from 20 healthy volunteers were collected for comparison.
Atomoxetine was associated with shorter stop-signal reaction times (p<0.05) and lower numbers of commission errors (p<0.05) on the sustained attention task in the ADHD patients.
These findings suggest that atomoxetine exerts beneficial effects on aspects of inhibitory control in ADHD, which may belie the efficacy of this medication in the treatment of impulsive features of the disorder. These findings also have potential clinical implications for other impulse dysregulation disorders such as trichotillomania and Tourette's Syndrome.
Negative symptoms have been previously reported during the psychosis prodrome, however our understanding of their relationship with treatment-phase negative symptoms remains unclear.
We report the prevalence of psychosis prodrome onset negative symptoms (PONS) and ascertain whether these predict negative symptoms at first presentation for treatment.
Presence of expressivity or experiential negative symptom domains was established at first presentation for treatment using the Scale for Assessment of Negative Symptoms (SANS) in 373 individuals with a first episode psychosis. PONS were established using the Beiser Scale. The relationship between PONS and negative symptoms at first presentation was ascertained and regression analyses determined the relationship independent of confounding.
PONS prevalence was 50.3% in the schizophrenia spectrum group (n = 155) and 31.2% in the non-schizophrenia spectrum group (n = 218). In the schizophrenia spectrum group, PONS had a significant unadjusted (χ2 = 10.41, P < 0.001) and adjusted (OR = 2.40, 95% CI = 1.11–5.22, P = 0.027) association with first presentation experiential symptoms, however this relationship was not evident in the non-schizophrenia spectrum group. PONS did not predict expressivity symptoms in either diagnostic group.
PONS are common in schizophrenia spectrum diagnoses, and predict experiential symptoms at first presentation. Further prospective research is needed to examine whether negative symptoms commence during the psychosis prodrome.
The comparative effectiveness of antidepressant medication and cognitive-behaviour therapy for the acute treatment of depression is contentious.
To compare the acute outcomes of antidepressant medication, cognitive-behaviour therapy (CBT), and the combination of the two, in adult, depressed patients.
Sixteen electronic databases together with reference lists were searched for randomised and other clinical trials that compared CBT, antidepressants, or their combination.
In the comparison between CBT and antidepressants, 8 studies met inclusion criteria. Five studies met the inclusion criteria for the second comparison between single therapy and combination therapy. In the antidepressant and CBT comparison, effect sizes favoured CBT over antidepressants with a significant advantage for CBT on some outcome measures. Combined treatment appeared more effective than antidepressants. However, combined treatment did not emerge more effective than CBT.
Antidepressants may not be considered more efficacious than CBT for the acute treatment of depressed patients nor can combination therapy be regarded as more effective than CBT alone.
Worldwide, the Irish diaspora experience elevated psychiatric morbidity across generations, not accounted for through socioeconomic position. The present study assessed the contribution of intergenerational migration and settlementrelated adversity in accounting for adult mental health, in second generation Irish people.
Analysis of prospective data from a nationally representative birth cohort from Britain, comprising 17,000 babies born in a single week in 1958 and followed up to mid-life. Common mental disorders were assessed at age 44/ 45.
Relative to the rest of the cohort, second generation Irish children grew up in marked material and social disadvantage, which tracked into early adulthood. By mid-life, parity was reached between second generation Irish cohort members and the rest of the sample on most disadvantage indicators. At age 23 Irish cohort members were more likely to screen positive for common mental disorders (OR: 1.44; 95% CI: 1.06, 1.94). This had reduced slightly by mid-life (OR: 1.27; 95% CI: 0.96, 1.69). Adjustment for childhood and early adulthood adversity fully attenuated differences in adult mental health disadvantages.
Social and material disadvantage experienced in childhood continues to have long-range adverse effects on mental health at mid-life, in second generation Irish cohort members. This suggests important mechanisms over the lifecourse, which may have important policy implications in the settlement of migrant families.
The purpose of this paper was to examine national differences in the desire to participate in decision-making of people with severe mental illness in six European countries.
The data was taken from a European longitudinal observational study (CEDAR; ISRCTN75841675). A sample of 514 patients with severe mental illness from the study centers in Ulm, Germany, London, England, Naples, Italy, Debrecen, Hungary, Aalborg, Denmark and Zurich, Switzerland were assessed as to desire to participate in medical decision-making. Associations between desire for participation in decision-making and center location were analyzed with generalized estimating equations.
We found large cross-national differences in patients’ desire to participate in decision-making, with the center explaining 47.2% of total variance in the desire for participation (P < 0.001). Averaged over time and independent of patient characteristics, London (mean = 2.27), Ulm (mean = 2.13) and Zurich (mean = 2.14) showed significantly higher scores in desire for participation, followed by Aalborg (mean = 1.97), where scores were in turn significantly higher than in Debrecen (mean = 1.56). The lowest scores were reported in Naples (mean = 1.14). Over time, the desire for participation in decision-making increased significantly in Zurich (b = 0.23) and decreased in Naples (b = −0.14). In all other centers, values remained stable.
This study demonstrates that patients’ desire for participation in decision-making varies by location. We suggest that more research attention be focused on identifying specific cultural and social factors in each country to further explain observed differences across Europe.
Being able to vote empowers people with mental illness to have a political voice and promotes social inclusion. Evidence shows that patients with mental illness are less likely to vote compared to the general population.
This study explores the knowledge and uptake of the voting rights of adult patients in a psychiatric hospital in the 2015 UK general election.
To understand patients’ eligibility and intentions to vote during the 2015 UK general election. To establish what assistance patients may require in order to vote.
A staff-assisted survey was undertaken in all mental health wards in the Gordon Hospital, Westminster prior to the general election in May 2015.
A total of 51 surveys were returned. Seventy-five percent thought they were eligible to vote, and 47% had already registered. Of those that had not yet registered, 37% wanted staff support to do so. Fifty-seven percent of the respondents intended to vote and of those 9 out of 10 intended to vote in person. Twenty-six percent of those intending to vote identified needing assistance in this process.
The majority of inpatients were aware of their eligibility to vote. Over half of the respondents planned to vote, which is lower than the UK average. As 1 in 4 patients intending to vote requested support, this suggests potential barriers impacting on their ability to exercise their right.
Multidisciplinary teams can provide valuable assistance to patients in the voting process in many ways, including information provision, organisation of leave and providing staff escort.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Anorexia nervosa (AN) is the most severe in terms of morbidity psychiatric illness with the highest mortality rate increased by 23 fold. Treatments are limited effectiveness. AN has a strong genetic component with heritability at 70% but despite ∼ 200 studies no major gene was identified. Epigenetics, such as DNA methylation, is another component of heritability that could explain the high heritability. Methylation is poorly studied in AN from small samples, and is focused on few candidate genes among publications. Under publication, a first genome-wide methylation study investigated 10 restrictive type AN patients, 19 binging/purging type of AN patients and 15 normal eaters using DNAs from whole blood (Booij, 2015). Of the 480K CpG sites that can be methylated of Infinium Human Methylation450 BeadChip Kit, authors focused on 24,000 sites located close to genes and they identified candidate genes with a different profile of methylation between AN and controls.
Our work is to replicate the results of Booji and also to investigate the AN remitters.
Our goal is to identify epigenetic signatures of the AN disorder and the prognostic of remission.
Twenty-four AN patients, 24 AN remitters will be compared to 48 healthy control women for methylation using the Infinium Human Methylation450.
As Booji et al., we will compare methylation for 24,000 sites located close to genes for 24 AN, 24 remitters and 48 controls.
We expected to replicate the published results of Booji and to identify genes with a methylation signature specific of the AN remission.
Disclosure of interest
The authors have not supplied their declaration of competing interest.