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Background: Every 30-minute delay to ST-Elevation Myocardial Infarction (STEMI) reperfusion increases one-year mortality by 7.5%. A local audit found that the third of patient electrocardiograms (ECGs) not initially meeting classic STEMI criteria had an ECG-to-Activation (ETA) time of over 90 minutes, more than five times that of classic STEMIs. However, three quarters of “STEMI negative” ECGs met STEMI-equivalent patterns or rules for subtle occlusion, uncovering an opportunity for improvement. Aim Statement: We aimed to reduce ETA time, from initial emergency department (ED) ECG to activation of the cath lab, for patients whose ECGs did not meet classic STEMI criteria, by 30 minutes within one year (i.e. by Dec 2019). Measures & Design: We reviewed all ED Code STEMIs over a 35-month pre-intervention period. Root Cause analyses, including Ishikawa diagram and Pareto chart, led to our Plan-Do-Study-Act cycles: 1) a survey to engage our team; 2) a Grand Rounds presentation as an educational strategy; and 3) weekly web-based feedback to all ED physicians on STEMI-equivalents and subtle occlusions, using recent local cases. Our outcome measures were ETA times, stratified by ECGs not initially meeting STEMI criteria (primary) and those that did (secondary). Our process measures were the number of website visits and page views. Our balancing measure was the proportion of Code STEMIs without culprit lesion. We used Statistical Process Control (SPC) charts with usual special cause variation rules. Evaluation/Results: ETA time for the 37.5% of 56 ECGs that did not meet classic STEMI criteria decreased from 97.5 to 53.7 minutes (min), a 43.8-min absolute decrease (p = 0.037), while those meeting STEMI criteria remained the same (16.5 to 18.2min, p = 0.75). SPC charts did not show special cause variation. There were 2,634 page views (65.9/week) and 1,092 visits (27.3/week), in a group of 80 physicians—i.e. a third of the group each week. There was no change in Code STEMIs without culprit lesions (28.0 % to 23.3%, p = 0.41). Discussion/Impact: We reduced ETA time by 43.8min for the one third of patients with culprit lesions not initially meeting classic STEMI criteria, a magnitude associated with mortality impact. To do so, we used a multi-modal educational strategy including a novel web-based feedback approach to all ED physicians. Local feedback and education on this challenging-to-diagnose subgroup, guided by ETA time as a quality metric, could be replicated in other centres.
Introduction: Electrocardiogram (ECG) diagnosis of acute coronary occlusion has been broadening in recent years, from classic ST-Elevation Myocardial Infarction (STEMI) criteria to STEMI-equivalents and rules for subtle occlusions. However, there is no quality metric focused on emergency physicians’ decision-making. We hypothesized that the time from initial emergency department (ED) ECG to activation of Code STEMI could quantify diagnostic delay associated with automated interpretation, classic STEMI criteria, and other signs of occlusion. Methods: This multi-centre retrospective study reviewed all ED Code STEMI patients with confirmed culprit lesions from two urban academic EDs over a three-year period (Jan 2016 to Dec 2018). We reviewed charts to calculate ECG-to-Activation (ETA) time, measured from the time stamp on the initial ED ECG to the time a Code STEMI was activated (based on the hospital call centre log). We examined ECGs to determine: 1) if automated computer interpretation labelled “STEMI” or not; and 2) whether they met classic STEMI criteria, STEMI-equivalent patterns, or rules for subtle occlusion, based on a priori criteria from published guidelines or studies. All ECGs were reviewed by the lead author (JTTM) and those not obviously meeting classic STEMI criteria were independently reviewed by the other author. Results: There were 180 Code STEMIs from the ED with culprit lesions, including 177 with complete information. Average ETA time was 46.5 minutes (95% Confidence Interval [CI] 36.3-56.7min). Automated interpretation labelled 55.4% of initial ECGs as “STEMI” (ETA 13.9 min, 95%CI 9.8-18.0min), and 44.6% not as “STEMI” (ETA 86.9min, 95%CI 67.9-105.9min). Initial ECGs included 62.1% with classic STEMI criteria (ETA 17.3min, 95%CI 12.8-21.8min), 11.3% with STEMI-equivalents (ETA 49.5min, 95%CI 29.5-69.5min), 18.1% with subtle occlusions (ETA 118.3min, 95%CI 81.5-155.1min) and 8.5% with no initial sign of occlusion (ETA 102.9min, 95%CI 53.9-151.9min). Inter-rater reliability was very good (Cohen's kappa 0.84). Conclusion: Over 90% of Code STEMI patients with culprit lesions had initial ECGs diagnostic of acute coronary occlusion, but automated interpretation and classic STEMI criteria only identified 55.4% and 62.1%, respectively. STEMI-equivalents and subtle occlusions were associated with significant diagnostic delays. ETA time can serve as a quality metric for emergency physicians and may help guide ED quality improvement initiatives.
Forty years ago, Knut Fladmark (1979) argued that the Pacific Coast offered a viable alternative to the ice-free corridor model for the initial peopling of the Americas—one of the first to support a “coastal migration theory” that remained marginal for decades. Today, the pre-Clovis occupation at the Monte Verde site is widely accepted, several other pre-Clovis sites are well documented, investigations of terminal Pleistocene subaerial and submerged Pacific Coast landscapes have increased, and multiple lines of evidence are helping decode the nature of early human dispersals into the Americas. Misconceptions remain, however, about the state of knowledge, productivity, and deglaciation chronology of Pleistocene coastlines and possible technological connections around the Pacific Rim. We review current evidence for several significant clusters of early Pacific Coast archaeological sites in North and South America that include sites as old or older than Clovis. We argue that stemmed points, foliate points, and crescents (lunates) found around the Pacific Rim may corroborate genomic studies that support an early Pacific Coast dispersal route into the Americas. Still, much remains to be learned about the Pleistocene colonization of the Americas, and multiple working hypotheses are warranted.
Background: In Alberta in 2016 more people died from an opioid overdose than from motor vehicle crashes. Naloxone is an opioid antagonist - it can reverse an opioid overdose for a period of 30 to 60 minutes. Naloxone kits are available free at emergency departments and community organizations around the province with training provided at the point of pickup. It is possible that training may be refused or may be forgotten and people are often left to rely solely on the instructions included in the kit. Human centred design can improve the way people interact with overdose instructions. Aim Statement: This study will measure the effectiveness and usefulness of prototype community naloxone kit instructions over a six month period of time (2018) in Calgary and Edmonton with the aim to use human centred design principles to improve the way people interpret emergency overdose response directions. Measures & Design: Information design experts engaged people with lived experience to provide a process map outlining the current role that educational materials and instructions for community naloxone kits play in responding to an opioid overdose. Alberta Health Services (AHS) Human Factors, in collaboration with AHS harm reduction developed the protocol and administered pre- and post-questionnaire and specific ‘performance checkpoints’ intended to measure effectiveness and usefulness. A simulated overdose including a mannequin, injection trainer and anatomical paper diagram was designed and a community naloxone kit with instructions setting was provided. Participants were recruited through harm reduction nurses with pre-existing clinical relationships (experienced group), family and friends of people who use opioids and general public (non-experienced) through the University of Alberta Faculty of Art and Design. Evaluation/Results: A total of 30 voluntary participants provided their informed consent and engaged in a simulated overdose scenario using a set of prototype instructions developed by a professional information designer. Through repeated data sampling, the following points were observed and will be integrated in the next iteration of design: It isn't clear to people what opioids are. It isn't clear to people that giving a dose of naloxone will not harm a person, especially if they have not overdosed. Almost none of the participants called 911. People seem to read pictures and text equally in the non-experienced group, but in the experienced group, typically read the pictures. Many participants stated that they knew how to do rescue breaths, but did not perform them correctly. Performing the procedure is a not the same as being asked about how to perform the procedure. Discussion/Impact: Even with new instructional prototypes, many participants identified components that were unclear or confusing. The experienced group made less mistakes than the non-experienced group. They seemed to be more invested or interested in saving a friend's life. These instructions will go through another round of design to incorporate feedback from end users. The final product will be part of a larger provincial emergency medicine initiative that includes participant led design and education around emergency response in opioid overdose settings.
Acute tonsillitis represents a significant proportion of admissions to ENT departments nationally. Given current hospital pressures, it is vital to look for safe alternatives to admission. This study explores the safe management of patients in an ambulatory medical unit, without the need for admission.
A retrospective review of 48 patients’ notes was carried out. Following the development and implementation of a guideline for acute tonsillitis, a prospective re-audit of 41 patients was carried out, measuring length of stay, overnight admissions and re-admissions.
The rate of overnight admission following implementation of the guideline fell from 0.75 to 0.29, and average length of stay dropped from 19.2 to 9.5 hours. There were two re-admissions in each cycle of the audit, which represents a non-significant increase.
The tonsillitis guideline has significantly reduced admissions and length of stay. Re-admissions remain low, demonstrating that this is a safe and cost-effective intervention.
Children with intellectual and developmental disabilities (IDD) are likely to receive high-risk prescribing practices, such as polypharmacy, long-term use of psychotropic medications, and overuse of antipsychotics. Behavioural interventions, such as applied behavioural analysis, are evidence-based practices for children with IDD and should be the first-line treatment. Short-term use of psychotropic medications may be helpful in reducing the severity and frequency of challenging behaviours while evidence-based behavioural interventions are pursued. In this essay, we offer practical guidelines for better care.
Grommet insertion is a common surgical procedure in children. Long waiting times for grommet insertion are not unusual. This project aimed to streamline the process by introducing a pathway for audiologists to directly schedule children meeting National Institute for Health and Care Excellence Clinical Guideline 60 (‘CG60’) for grommet insertion.
Method and results
A period from June to November 2014 was retrospectively audited. Mean duration between the first audiology appointment and grommet insertion was 294.5 days (median = 310 days). Implementing the direct-listing pathway reduced the duration between first audiology appointment and grommet insertion (mean = 232 days; median = 231 days). There has been a reduction in the time between the first audiology appointment and surgery (mean difference of 62.5 days; p = 0.024), and a reduction in the time between second audiology appointment and surgery (28 days; p = 0.009).
Direct-listing pathways for grommet insertion can reduce waiting times and expedite surgery. Implementation involves a simple alteration of current practice, adhering to National Institute for Health and Care Excellence Clinical Guideline 60. The ultimate decision regarding surgery still rests with ENT specialists.
Mastitis can prove expensive in sheep reared for meat production due to costs associated with treatment methods, poor lamb growth and premature culling of ewes. The most commonly used method to detect mastitis, in dairy systems, is somatic cell counts. However, in many meat-producing sheep flocks ewes are not routinely handled, thus regular milk sampling is not always possible. It is, therefore, worthwhile to investigate alternative phenotypes, such as those associated with udder conformation and methods of evaluating somatic cell counts in the milk, such as the California Mastitis Test. The main objectives of this study were therefore: (a) to estimate genetic parameters of traits relating to mastitis and udder conformation in a meat sheep breed; (b) estimate the level of association between somatic cell counts and the California Mastitis Test and (c) assess the relationships between mastitis and both udder conformation and lamb live weights. Data were collected from Texel ewes based on 29 flocks, throughout the UK, during 2015 and 2016. The ewes were scored twice each year, at mid- and late-lactation. Eight different conformation traits, relating to udder and teat characteristics, and milk samples were recorded. The data set comprised of data available for 2957 ewes. The pedigree file used contained sire and dam information for 31 775 individuals. The animal models used fitted relevant fixed and random effects. Heritability estimates for traits relating to mastitis (somatic cell score and the California Mastitis Test), ranged from 0.08 to 0.11 and 0.07 to 0.11, respectively. High genetic correlations were observed between somatic cell score and the California Mastitis Test (0.76 to 0.98), indicating the California Mastitis Test to be worthwhile for assessing infection levels, particularly at mid-lactation. The strongest correlations observed between the mastitis traits and the udder conformation traits were associated with udder depth (0.61 to 0.75) also at mid-lactation. Negative phenotypic correlations were estimated between mastitis and the weight of lamb reared by the ewe (−0.15 to −0.23), suggesting that lamb weights fell as infection levels rose. Genetic correlations were not significantly different from zero. Reducing mastitis will lead to improvements in flock productivity and the health and welfare of the animals. It will also improve the efficiency of production and the resilience to disease challenge. The economic benefits, therefore, of these results combined could be substantial not only in this breed but also in the overall meat sheep industry.
The primary goal for all involved in the care of women in labor is a healthy mother and baby after delivery. For most pregnancies, which are low risk, delivery by cesarean section appears to pose greater risk of maternal morbidity and mortality than vaginal delivery and can have significant implications for future pregnancies.
To investigate the feasibility of a national audit of epistaxis management led and delivered by a multi-region trainee collaborative using a web-based interface to capture patient data.
Six trainee collaboratives across England nominated one site each and worked together to carry out this pilot. An encrypted data capture tool was adapted and installed within the infrastructure of a university secure server. Site-lead feedback was assessed through questionnaires.
Sixty-three patients with epistaxis were admitted over a two-week period. Site leads reported an average of 5 minutes to complete questionnaires and described the tool as easy to use. Data quality was high, with little missing data. Site-lead feedback showed high satisfaction ratings for the project (mean, 4.83 out of 5).
This pilot showed that trainee collaboratives can work together to deliver an audit using an encrypted data capture tool cost-effectively, whilst maintaining the highest levels of data quality.
In order to assess the extent of genotype by environment interactions (G×E) and environmental sensitivity in sheep farm systems, environmental factors must be identified and quantified, after which the relationship with the traits(s) of interest can be investigated. The objectives of this study were to develop a farm environment (FE) scale, using a canonical correlation analysis, which could then be used in linear reaction norm models. Fine-scale farm survey data, collected from a sample of 39 Texel flocks across the United Kingdom, was combined with information available at the national level. The farm survey data included information on flock size and concentrate feed use. National data included flock performance averages for 21-week-old weight (21WT), ultrasound back-fat (UFD) and muscle (UMD) depths, as well as regional climatic data. The FE scale developed was then combined with 181 555 (21WT), 175 399 (UMD) and 175 279 (UFD) records from lambs born between 1990 and 2011, on 494 different Texel flocks, to predict reaction norms for sires used within the population. A range of sire sensitivities estimated across the FE scale confirmed the presence of genetic variability as both ‘plastic’ and ‘robust’ genotypes were observed. Variations in heritability estimates were also observed indicating that the rate genetic progress was dependent on the environment. Overall, the techniques and approaches used in this study have proven to be useful in defining sheep FEs. The results observed for 21WT, UMD and UFD, using the reaction norm models, indicate that in order to improve genetic gain and flock efficiency, future genetic evaluations would benefit by accounting for the G×E observed.
The objective of this study was to define different terminal sire flock environments, based on a range of environmental factors, and then investigate the presence of genotype by environment interactions (G×E) between the environments identified. Data from 79 different terminal sire flocks (40 Texel, 21 Charollais and 18 Suffolk), were analysed using principal coordinate and non-hierarchical cluster analyses, the results of which identified three distinct environmental cluster groups. The type of grazing, climatic conditions and the use of vitamins and mineral supplements were found to be the most important factors in the clustering of flocks. The presence of G×E was then investigated using data from the Charollais flocks only. Performance data were collected for 12 181 lambs, between 1990 and 2010, sired by 515 different sires. Fifty six of the sires had offspring in at least two of the three different cluster groups and pedigree information was available for a total of 161 431 animals. Traits studied were the 21-week old weight (21WT), ultrasound muscle depth (UMD) and log transformed backfat depth (LogUFD). Heritabilities estimated for each cluster, for each trait, ranged from 0.32 to 0.45. Genetic correlations estimated between Cluster 1 and Cluster 2 were all found to be significantly lower than unity, indicating the presence of G×E. They were 0.31 (±0.17), 0.68 (±0.14) and 0.18 (±0.21) for 21WT, UMD and LogUFD, respectively. Evidence of sires re-ranking across clusters was also observed. Providing a suitable strategy can be identified, there is potential for the optimisation of future breeding programmes, by taking into account the G×E observed. This would enable farmers to identify and select animals with an increased knowledge as to how they will perform in their specific farm environment thus reducing any unexpected differences in performance.
The Australian continent is large and therefore exhibits a range of very different climatic zones. Broadly, the continent is characterised by arid climatic regimes: four-fifths of the landmass receiving an annual rainfall of less than 600 mm (Figure 12.1) and one-half of the continent receiving less than 300 mm. These arid and semi-arid regions form the greatest proportion of inland Australia, and are fringed by narrow, wet and temperate climatic zones along the southwestern, southern and eastern coastal zones (Figure 12.1). Tropical monsoonal rainfall characterises the northern coastal zones. Compared to other continents on Earth, Australia has by far the lowest average rainfall. This low precipitation rate is coupled with a high evaporation rate meaning that surface water availability is also anomalously low compared to global averages. Average annual temperature also shows significant variation (Figure 12.1) and in most areas there is also a high diurnal variation in temperature.
It is well known, however, that the currently arid areas of inland Australia were significantly wetter in the geological past, from the early Cenozoic (a period of geological time from c. 65 Ma until the present day; Gradstein et al. 2004) until at least the early Miocene (c. 23 Ma) (e.g. Kershaw et al. 1994; Martin 2006). Much of our current knowledge of climate change from the early Cenozoic to the present is deduced from observed variations in the isotopic signature of marine sediments (e.g. deMenocal 1995; Lisiecki and Raymo 2005; Raymo et al. 2006) as well as the distribution, chemistry and palynological assemblages of terrestrial and marine sediments and sedimentary rocks.
While the summit of the Antarctic Plateau has long been expected to harbor the best ground-based sites for terahertz (THz) frequency astronomical investigations, it is only recently that direct observations of exceptional THz atmospheric transmission and stability have been obtained. These observations, in combination with recent technological advancements in astronomical instrumentation and autonomous field platforms, make the recognition and realization of terahertz observatories on the high plateau feasible and timely. Here, we will explore the context of terahertz astronomy in the era of Herschel, and the crucial role that observatories on the Antarctic Plateau can play. We explore the important scientific questions to which observations from this unique environment may be most productively applied. We examine the importance and complementarity of Antarctic THz astronomy in the light of contemporary facilities such as ALMA, CCAT, SOFIA and (U)LDB ballooning. Finally, building from the roots of THz facilities in Antarctica to present efforts, we broadly highlight future facilities that will exploit the unique advantages of the Polar Plateau and provide a meaningful, lasting astrophysical legacy.
We argue for an example of “core cognition” based on Diamond and Carey's (1986) work on expertise and recognition, which is not made use of in The Origin of Concepts. This mechanism for perceptual learning seems to have all the necessary characteristics in that it is innate, domain-specific (requires stimulus sets possessing a certain structure), and demonstrably affects categorisation in a way that strongly suggests it will influence concept formation as well.
The Sxr (sex-reversed) region that carries a copy of the mouse Y chromosomal testis-determining gene can be attached to the distal end of either the Y or the X chromosome. During male meiosis, Sxr recombined freely between the X and Y chromosomes, with an estimated recombination frequency not significantly different from 50% in either direction. During female meiosis, Sxr recombined freely between the X chromosome to which it was attached and an X-autosome translocation. A male mouse carrying the original Sxra region on its Y chromosome, and the shorter Sxrb variant on the X, also showed 50% recombination between the sex chromosomes. Evidence of unequal crossing-over between the two Sxr regions was obtained: using five markers deleted from Sxrb, 3 variant Sxr regions were detected in 159 progeny (1·9%). Four other variants (one from the original cross and three from later generations) were presumed to have been derived from illegitimate pairing and crossing-over between Sxrb and the homologous region on the short arm of the Y chromosome. The generation of new variants throws light on the arrangement of gene loci and other markers within the short arm of the mouse Y chromosome.
Texel muscling quantitative trait locus (TM-QTL) is a QTL on chromosome 18, originally identified in purebred UK Texel sheep, which was reported to increase ultrasonically measured muscle depth at the third lumbar vertebra by around 4% to 7%. The objective of the present study was to comprehensively evaluate the TM-QTL and to determine whether it could provide benefits to the UK sheep industry through increased carcass meat yield in crossbred slaughter lambs. Effects of this QTL on a range of carcass traits, including those measured in vivo and by dissection, were evaluated in heterozygous carrier and non-carrier lambs produced by crossing heterozygous carrier Texel rams with non-carrier Mule (Bluefaced Leicester × Scottish Blackface) ewes from a lowland flock. The TM-QTL was found to increase loin muscling in crossbred lambs at a given live weight or carcass weight, as measured by ultrasound, X-ray computed tomography (CT) and carcass dissection. Depth of M. longissimus lumborum (MLL) was greater in TM-QTL carrier lambs compared to non-carriers as measured by both ultrasound at the third lumbar vertebra (+4.5%; P = 0.033) and CT scanning at the fifth lumbar vertebra (+6.7%; P = 0.004). Width and area of MLL measured using CT were also greater in TM-QTL carrier lambs compared to non-carriers (+3.0%; P = 0.013 and +5.1%; P = 0.047, respectively). Loin muscle volume measured using CT was greater in TM-QTL carriers than in non-carriers (+5.9%; P = 0.005) and the dissected weight of the MLL was +7.1% greater in TM-QTL carriers compared to non-carriers (P < 0.001). The proportion of the total carcass lean meat yield (LMY) that was contained within the loin region was slightly higher in TM-QTL carriers than in non-carriers (0.154 v. 0.145; P = 0.006). However, TM-QTL was found to have no significant effect on the total weight or proportion of LMY or of saleable meat yield in the carcass measured by dissection, or on muscling in the hind leg measured by CT or dissection. This work has verified that the inheritance of TM-QTL is associated with increased loin muscling in crossbred lambs, as has previously been reported for purebred Texel lambs.