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Introduction: Adolescents who present to emergency departments (ED) following intentional injuries present a challenge in terms of ascertaining their intent and risk for future self-injurious or suicidal behaviour. Our ED has seen an 80% increase in visits for mental health issues over the past ten years. As usage of our Emergency Mental Health and Addictions Services (EMHAS) team continues to rise, it is increasingly important to understand the incidence of NSSI among our youth, explore if NSSI is reported at triage and identify characteristics that may distinguish these adolescents from others presenting for mental health assessment. Methods: This is an exploratory research study using retrospective data. Patients who had an Emergency Mental Health Triage (EMHT) form on their health record from an ED visit between June 1, 2017 and May 31, 2018 were eligible. Trained research assistants, using a structured data collection form in REDCap. abstracted data from the EMHT form, the EMHAS Assessment form, the Assessment of Suicide Risk Inventory and our CHIRPP (Canadian Hospitals Injury Reporting and Prevention Program) database. We calculated kappa values and 95% confidence intervals to describe the extent to which the forms agree with respect to identifying NSSI. We will compare the cohort who reports NSSI with the cohort who does not report NSSI using chi-square statistics depending. We will use descriptive statistics to characterize the NSSI patients. Results: During the one-year study period 955 patients had an EMHT form completed. In preliminary analysis 558 (58.4%) reported a history of NSSI. Patients reported NSSI on both the EMHT form and the EMHAS assessment form 64.7% of the time (kappa 0.56) indicating moderate agreement. In patients with NSSI, 9.5% of patients reported it only at triage and 25.8% of patients reported it only during their EMHAS assessment. Between group comparisons and descriptive analysis is underway. Conclusion: More than half of youth triaged with an emergency mental health complaint in our ED reported a history of NSSI. Screening at triage was moderately effective in identifying adolescents with NSSI compared to an in-depth assessment by the mental health team. Further research is needed to clarify how NSSI relates to risk for suicide.
Introduction: Croup is a common viral upper airway infection in children aged 6 months to 6 years. Although a single dose of dexamethasone decreases return visits, the prescribed dose varies from 0.15mg/kg to 0.6mg/kg. Our objective was to examine the effect of varied dexamethasone dosing on unplanned return ED visits for croup. Methods: This was a retrospective chart review of IWK ED patient treatment records from September 1, 2014 – August 31, 2016 of children aged 6 months to 6 years with an ICD-10 discharge diagnosis code of croup. Data were abstracted by trained research assistants using a structured data collection form in REDCap. A sample of 5% of charts had double data abstraction to test for agreement. Our primary outcome was return visits to the ED within 7 days. Secondary outcomes were ED length of stay (LOS), admission to hospital and admission to the pediatric intensive care unit (PICU). Data were analyzed using descriptive statistics and chi-square for between group comparisons. Results: The dataset included 1595 patient visits for croup. Data analysis is in progress. Triage acuity as per CTAS included: resuscitation n = 5; emergent n = 351; urgent n = 558; less urgent n = 605; and, non-urgent n = 2. Most patients had no co-morbid conditions (n = 1548). Dexamethasone dosing varied: 0.15 mg/kg n = 64; 0.3 mg/kg n = 838; and, 0.6 mg/kg n = 493. ED LOS was under 1 hour in 483 patients, 1-3 hours in 805, 3-6 hours in 225 and 6-12 hours in 9 patients. Few patients were admitted to hospital (n = 22) and no patients were admitted to PICU. Within 7 days of the index visit, 78 patients had an unplanned return visit to the ED for croup. Conclusion: The data analysis is in progress. This study will inform our future research on a practice change in our ED to comply with the dose of dexamethasone recommended by the Canadian Pediatric Society for the treatment of croup in 2017.
Introduction: Emergency departments (ED) play a vital role in asthma care for patients of all ages. Our objective was to review and synthesize all practice change interventions in ED settings that focused on improving the health outcomes of adults and children with asthma. Methods: This study was a systematic review adhering to the methods outlined by the Effective Practice and Organization of Care (EPOC) Cochrane Review Group. We developed a search strategy with a library scientist for the following databases: AMED, CINAHL, Embase, ERIC, MEDLINE, HealthStar, CENTRAL, DARE and Cochrane's EPOC and Airways registers. We also hand searched the Journal of Asthma, Pediatrics and Chest. Two reviewers independently reviewed titles, abstracts and full text using predetermined criteria. Data were extracted by two independent reviewers who used a structured abstraction form and assessed risk of bias. All discrepancies were resolved by consensus. Results: Our search strategy yielded 8,878 titles and abstracts for review. A total of 214 studies underwent full text screening and we extracted data from 27 studies. Risk of bias was judged as low in 10 studies, moderate in 8 studies and high in 9 studies. A range of interventions were employed, with education (n = 14) and reminders (n = 8) being the most prevalent. In pediatric settings, most studies targeted changing the behaviour of parents (n = 11). Four studies targeted health care providers and four studies targeted both providers and parents. We identified a major deficit in the use of behaviour change theory to guide intervention design. The most common primary outcomes of interest were unscheduled return visits (n = 14), primary care follow-up (n = 9), quality of life (n = 5) and ED length of stay (n = 4). We were not able to perform a meta-analysis due to heterogeneity in interventions and outcomes. Conclusion: Although we found a range of interventions used to improve asthma care in EDs, there was significant variation in reported primary outcomes. Both unscheduled return visits and primary care follow-ups, the most common primary outcomes, varied in the timeframe and manner in which they were collected. Most interventions were educational and based on an assumption that education would change behaviour. Future research in this ares would benefit from standardized outcome measures and intervention designs based upon models of behaviour change model.
Introduction: Cardioactive steroid poisoning occurs worldwide with the use of pharmaceutical digoxin and botanical cardiac glycosides. The wholesale price of the antidote, digoxin immune fab, has increased over 300% from 2010 to 2015. Our objective was to identify gaps in the existing literature with respect to the use of digoxin immune fab in cardioactive steroid toxicity in acute care settings. Methods: We used scoping study methodology, as described by Arksey and O'Malley, to assess the range and scope of empiric research and will report: 1) sources of cardioactive steroid toxicity in acute settings; 2) doses of digoxin immune fab used in treatment; and, 3) intervention outcomes of acute cardioactive steroid toxicity following the administration of digoxin immune fab as first or second-line therapy. We collaborated with a library scientist to devise search strategies for PubMed, CINAHL, EMBASE, CENTRAL and Toxnet. We sought unpublished literature through the Canadian Electronic Library, Proquest, and Scopus and searched reference lists of included studies. We hand searched relevant conference proceedings and applicable guidelines. Two reviewers independently reviewed titles and abstracts using predetermined criteria. Using a structured data abstraction form, two reviewers independently extracted data. All discrepancies were resolved through consensus. Results: Our search strategy yielded 3458 results. After screening titles and abstracts 384 underwent full text screening. We included 147 studies and are currently extracting data from 12 French studies and 135 English studies. To date we have extracted data from 90 case reports and case series. Conclusion: Given concerns over rising costs, our findings will shed light on the extent of the evidence for use of digoxin immune fab in acute care settings.
Laboratory identification of carbapenem-resistant Enterobacteriaceae (CRE) is a key step in controlling its spread. Our survey showed that most Veterans Affairs laboratories follow VA guidelines for initial CRE identification, whereas 55.0% use PCR to confirm carbapenemase production. Most respondents were knowledgeable about CRE guidelines. Barriers included staffing, training, and financial resources.
Rare copy number variants (CNVs) are associated with risk of neurodevelopmental disorders characterised by varying degrees of cognitive impairment, including schizophrenia, autism spectrum disorder and intellectual disability. However, the effects of many individual CNVs in carriers without neurodevelopmental disorders are not yet fully understood, and little is known about the effects of reciprocal copy number changes of known pathogenic loci.
We aimed to analyse the effect of CNV carrier status on cognitive performance and measures of occupational and social outcomes in unaffected individuals from the UK Biobank.
We called CNVs in the full UK Biobank sample and analysed data from 420 247 individuals who passed CNV quality control, reported White British or Irish ancestry and were not diagnosed with neurodevelopmental disorders. We analysed 33 pathogenic CNVs, including their reciprocal deletions/duplications, for association with seven cognitive tests and four general measures of functioning: academic qualifications, occupation, household income and Townsend Deprivation Index.
Most CNVs (24 out of 33) were associated with reduced performance on at least one cognitive test or measure of functioning. The changes on the cognitive tests were modest (average reduction of 0.13 s.d.) but varied markedly between CNVs. All 12 schizophrenia-associated CNVs were associated with significant impairments on measures of functioning.
CNVs implicated in neurodevelopmental disorders, including schizophrenia, are associated with cognitive deficits, even among unaffected individuals. These deficits may be subtle but CNV carriers have significant disadvantages in educational attainment and ability to earn income in adult life.
Measurements of a sample from ~580 m depth in the WAIS Divide (WDC06A) ice core reveal that bubbles are preferentially elongated in the basal plane of their parent grain, as expected if bubble shape preserves the record of dominant basal glide. This suggests that a method using bubbles as strain gauges could provide insights to grain-scale ice deformation. We introduce a technique using fabric and image analyses of paired thin and thick sections. Comparison of the crystallographic orientations of 148 grains and the shape orientations of 2377 intragrain bubbles reveals a strongly preferred elongation of bubbles in the grain basal planes (R2 = 0.96). Elongation magnitudes are consistent with a balance between ice flow deformation and diffusive restoration, with larger bubbles more elongated. Assuming bubbles record ice strain, grains with greater resolved stress on their basal planes from the far-field ice flow stresses show greater deformation, but with large variability suggesting that heterogeneity of the local stress field causes deformation even in unfavorably oriented grains. A correlation is also observed among bubble elongation, grain size, and bubble size, explaining a small but significant fraction of the variance ( P< 0.05), with implications for controls on ice deformation, as discussed here.
Ethical realists hold (i) that our ethical concepts, thoughts, and claims are in the business of representing ethical reality, by representing evaluative or normative properties and facts as aspects of reality, and (ii) that such representations are at least sometimes accurate. Non-naturalist realists add the further claim that ethical properties and facts are ultimately non-natural, though they are nonetheless worldly. My aim is threefold: to elucidate the sort of representation involved in ethical evaluation on realist views; to clarify what exactly is represented and how non-naturalism comes into the picture for non-naturalists; and to defend worldly non-naturalism against some objections. The first question addressed is how we should model evaluation on any realist view, which should in turn guide the identification of which properties and facts are credibly regarded as ‘evaluative’ ones. Then the question is: what role might non-natural properties and facts play, and how are they related to what is represented in ethical evaluation? Once that is clear, we will be in a position to answer certain objections to non-naturalist realism from Jackson, Gibbard, Bedke, and Dreier. I argue that the objections all mischaracterize the role played by non-natural properties and facts on plausible versions of non-naturalist realism.
The goal of this study was to examine the mental health needs of children and youth who present to the emergency department (ED) for mental health care and to describe the type of, and satisfaction with, follow-up mental health services accessed.
A 6-month to 1.5-year prospective cohort study was conducted in three Canadian pediatric EDs and one general ED, with a 1-month follow-up post-ED discharge. Measures included 1) clinician rating of mental health needs, 2) patient and caregiver self-reports of follow-up services, and 3) interviews regarding follow-up satisfaction. Data analysis included descriptive statistics and the Fisher’s exact test to compare sites.
The cohort consisted of 373 children and youth (61.1% female; mean age 15.1 years, 1.5 standard deviation). The main reason for ED presentations was a mental health crisis. The three most frequent areas of need requiring action were mood (43.8%), suicide risk (37.4%), and parent-child relational problems (34.6%). During the ED visit, 21.6% of patients received medical clearance, 40.9% received a psychiatric consult, and 19.4% were admitted to inpatient psychiatric care. At the 1-month post-ED visit, 84.3% of patients/caregivers received mental health follow-up. Ratings of service recommendations were generally positive, as 60.9% of patients obtained the recommended follow-up care and 13.9% were wait-listed.
Children and youth and their families presenting to the ED with mental health needs had substantial clinical morbidity, were connected with services, were satisfied with their ED visit, and accessed follow-up care within 1-month with some variability.
Infections caused by multidrug-resistant gram-negative organisms (MDRGNOs) have been increasing every year. The objective of this study was to describe the prevalence of MDRGNOs and factors associated with MDRGNOs in patients with spinal cord injury or disorder (SCI/D).
Retrospective cohort study.
Department of Veterans Affairs (VA) electronic health record data from 142 VA facilities were evaluated for 19,642 patients with SCI/D. Multivariable cluster-adjusted models were fit to identify factors associated with MDRGNO.
Gram-negative (GN) cultures occurred in 44% of patients with SCI/D receiving care at VA facilities, and 11,527 (41.3%) GN cultures had an MDRGNO. The most frequent GN organisms (GNOs) were Escherichia coli (28.5%), Klebsiella pneumoniae (17.0%), and Pseudomonas aeruginosa (16.0%). Two-thirds of GN cultures were from the outpatient setting, where MDRGNO prevalence was 37.6%. Significant geographic variation in the prevalence of MDRGNOs was identified (South, 44.7%; Northeast, 44.3%; West, 36.8%; Midwest, 34.4%). Other factors associated with an MDRGNO were older age, injury characteristics, comorbidities, specimen type, healthcare setting, and healthcare exposure. Black (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.39–1.78) and Hispanic race (OR, 1.58; 95% CI, 1.28–1.95), polymicrobial culture (OR, 2.67; 95% CI, 2.46–2.90), and antibiotic use in the previous 90 days (OR, 1.62; 95% CI, 1.50–1.76) were also associated with having an MDRGNO.
MDRGNOs were common in community and healthcare settings among veterans with SCI/D, with significant geographic variation. Health care and antibiotic exposures were significant factors associated with MDRGNOs. Priority should be given to controlling the spread of MDRGNOs in this special population, including a focus on judicious use of antibiotics.
Introduction/Innovation Concept: University Departments of Emergency Medicine are responsible for the supervision of research and other scholarly projects for fellows, residents and students, though often lack resources to provide adequate input and oversight. Many departments cover large geographical areas and several programs. We piloted new research committee structures and processes to improve oversight and output of research projects. Methods: We created an interactive group supervision tool based around formation of a collaborative research committee, with rotating chairs from each program, to provide supervision and face to face interaction, and direction for research learners. Included were all Dalhousie University adult and pediatric emergency medicine residency and fellowship programs, as well as trauma and EMS programs across Nova Scotia, New Brunswick, and Prince Edward Island. In addition to providing expertise in clinical trial coordination, database management, research administration, grant applications and Research Ethics Board submissions, we have completed a 2-year pilot of our interactive group supervision tool for research projects. Curriculum, Tool, or Material: The interactive tool consists of a structured PICOD form; allocation of topic and research mentors; standardized yearly milestones from project development through presentation and publication; and regular video-conferenced and in-person interactive group sessions involving several project leads, as well as program research directors, researchers, and co-ordinators. To date, all participating program learners have engaged with the tool, with positive feedback from learners, supervisors and program directors. Conclusion: We report our development of a regional collaborative interactive group supervision tool, that maximizes expert resources in the provision of research and scholarly project supervision.
In the face of environmental uncertainty due to anthropogenic climate change, islands are at the front lines of global change, threatened by sea level rise, habitat alteration, extinctions and declining biodiversity. Islands also stand at the forefront of scientific study for understanding the deep history of human ecodynamics and to build sustainable future systems. We summarize the long history of human interactions with Polynesian, Mediterranean, Californian and Caribbean island ecosystems, documenting the effects of various waves of human settlement and socioeconomic systems, from hunter–gatherer–fishers, to agriculturalists, to globalized colonial interests. We identify degradation of island environments resulting from human activities, as well as cases of human management of resources to enhance productivity and create more sustainable systems. These case studies suggest that within a general global pattern of progressive island degradation, there was no single trajectory of human impact, but rather complex effects based on variable island physiographies, human subsistence strategies, population densities, technologies, sociopolitical organization and decision-making.
Research shows that cognitive stimulation therapy (CST) improves cognitive function, quality of life, and well-being of people with mild–moderate dementia. Despite consistent evidence and recommendations, CST is not routinely available in Ireland post-diagnosis. The aim of the current research was to develop and evaluate community-based CST for people with mild–moderate dementia, run by the Alzheimer Society of Ireland across four pilot sites in Ireland.
Participants with mild–moderate dementia attended once weekly CST sessions for 14 weeks. Baseline and post-intervention assessments were completed by CST participants, carers, and CST facilitators. Primary outcomes of interest for CST participants included quality of life (Quality of Life in Alzheimer Disease Scale), cognitive function (Montreal Cognitive Assessment), and subjective cognitive function (Memory Awareness Rating Scale-Functioning Subscale). Secondary outcomes included well-being, cognitive ability, satisfaction with cognitive performance, and engagement and confidence of CST participants; well-being of carers; and job satisfaction of facilitators. Post-intervention interviews supplemented quantitative analyses.
In total, 20 CST participants, 17 carers, and six CST facilitators completed evaluation assessments. Results showed that CST improved participants’ satisfaction with cognitive performance (p=0.002), level of engagement (p=0.046), level of confidence (p=0.026). Improvements on subjective cognitive function just fell short of significance (p=0.055). Qualitative analysis of interview data identified consistent themes of cognitive and overall benefits of CST; and provided support for quantitative data.
Community-based CST positively impacted the lives of people with dementia and their families. This study supports prior recommendations that CST should be made routinely available to people with mild–moderate dementia, particularly in light of the lack of post-diagnostic interventions currently offered in Ireland.
To describe the burden of extended-spectrum β-lactamase (ESBL) Enterobacteriaceae in veterans with spinal cord injury or disorder (SCI/D), to identify risk factors for ESBL acquisition, and to assess impact on clinical outcomes
Retrospective case-case-control study
PATIENTS AND SETTING
Veterans with SCI/D and utilization at a Veterans’ Affairs medical center from January 1, 2012, to December 31, 2013.
Patients with a positive culture for ESBL Klebsiella pneumoniae, Escherichia coli, or Proteus mirabilis were matched with patients with non-ESBL organisms by organism, facility, and level of care and to uninfected controls by facility and level of care. Inpatients were also matched by time at risk. Univariate and multivariate matched models were assessed for differences in risk factors and outcomes.
A total of 492 cases (62.6% outpatients) were matched 1:1 with each comparison group. Recent prior use of fluoroquinolones and prior use of third- and fourth-generation cephalosporins were independently associated with ESBL compared to the non-ESBL group (adjusted odds ratio [aOR], 2.61; 95% confidence interval [CI], 1.77–3.84; P<.001 for fluoroquinolones and aOR, 3.86; 95% CI, 2.06–7.25; P<.001 for third- and fourth-generation cephalosporins) and the control group (aOR, 2.10; 95% CI, 1.29–3.43; P = .003 for fluoroquinolones; and aOR, 3.31; 95% CI, 1.56–7.06; P=.002 for third- and fourth-generation cephalosporins). Although there were no differences in mortality rate, the ESBL group had a longer post-culture length of stay (LOS) than the non-ESBL group (incidence rate ratio, 1.36; 95% CI, 1.13–1.63; P=.001).
All SCI/D patients with ESBL were more likely to have had recent exposure to fluoroquinolones or third- and fourth-generation cephalosporins, and hospitalized patients were more likely to have increased post-culture LOS. Programs targeted toward reduced antibiotic use in SCI/D patients may prevent subsequent ESBL acquisition.
Epidemiological data are often fragmented, partial, and/or ambiguous and unable to yield the desired level of understanding of infectious disease dynamics to adequately inform control measures. Here, we show how the information contained in widely available serology data can be enhanced by integration with less common type-specific data, to improve the understanding of the transmission dynamics of complex multi-species pathogens and host communities. Using brucellosis in northern Tanzania as a case study, we developed a latent process model based on serology data obtained from the field, to reconstruct Brucella transmission dynamics. We were able to identify sheep and goats as a more likely source of human and animal infection than cattle; however, the highly cross-reactive nature of Brucella spp. meant that it was not possible to determine which Brucella species (B. abortus or B. melitensis) is responsible for human infection. We extended our model to integrate simulated serology and typing data, and show that although serology alone can identify the host source of human infection under certain restrictive conditions, the integration of even small amounts (5%) of typing data can improve understanding of complex epidemiological dynamics. We show that data integration will often be essential when more than one pathogen is present and when the distinction between exposed and infectious individuals is not clear from serology data. With increasing epidemiological complexity, serology data become less informative. However, we show how this weakness can be mitigated by integrating such data with typing data, thereby enhancing the inference from these data and improving understanding of the underlying dynamics.
Genetic testing in psychiatry promises to improve patient care through
advances in personalised medicine. However, there are few clinically
To determine whether patients with a well-established genetic subtype of
schizophrenia show a different response profile to the antipsychotic
clozapine than those with idiopathic schizophrenia.
We retrospectively studied the long-term safety and efficacy of clozapine
in 40 adults with schizophrenia, half with a 22q11.2 deletion (22q11.2DS
group) and half matched for age and clinical severity but molecularly
confirmed to have no pathogenic copy number variant (idiopathic
Both groups showed similar clinical improvement and significant
reductions in hospitalisations, achieved at a lower median dose for those
in the 22q11.2DS group. Most common side-effects were similarly prevalent
between the two groups, however, half of the 22q11.2DS group experienced
at least one rare serious adverse event compared with none of the
idiopathic group. Many were successfully retried on clozapine.
Individuals with 22q11.2DS-schizophrenia respond as well to clozapine
treatment as those with other forms of schizophrenia, but may represent a
disproportionate number of those with serious adverse events, primarily
seizures. Lower doses and prophylactic (for example anticonvulsant)
management strategies can help ameliorate side-effect risks. This first
systematic evaluation of antipsychotic response in a genetic subtype of
schizophrenia provides a proof-of-principle for personalised medicine and
supports the utility of clinical genetic testing in schizophrenia.