To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
What do states gain by sending citizens into the streets? Ruling by Other Means investigates this question through the lens of State-Mobilized Movements (SMMs), an umbrella concept that includes a range of (often covertly organized) collective actions intended to advance state interests. The SMMs research agenda departs significantly from that of classic social movement and contentious politics theory, focused on threats to the state from seemingly autonomous societal actors. Existing theories assume that the goal of popular protest is to voice societal grievances, represent oppressed groups, and challenge state authorities and other powerholders. The chapters in this volume show, however, that states themselves organize citizens (sometimes surreptitiously and even transnationally) to act collectively to advance state goals. Drawn from different historical periods and diverse geographical regions, these case studies expand and improve our understanding of social movements, civil society and state-society relations under authoritarian regimes.
Phytase has long been used to decrease the inorganic phosphorus (Pi) input in poultry diet. The current study was conducted to investigate the effects of Pi supplementation on laying performance, egg quality and phosphate–calcium metabolism in Hy-Line Brown laying hens fed phytase. Layers (n = 504, 29 weeks old) were randomly assigned to seven treatments with six replicates of 12 birds. The corn–soybean meal-based diet contained 0.12% non-phytate phosphorus (nPP), 3.8% calcium, 2415 IU/kg vitamin D3 and 2000 FTU/kg phytase. Inorganic phosphorus (in the form of mono-dicalcium phosphate) was added into the basal diet to construct seven experimental diets; the final dietary nPP levels were 0.12%, 0.17%, 0.22%, 0.27%, 0.32%, 0.37% and 0.42%. The feeding trial lasted 12 weeks (hens from 29 to 40 weeks of age). Laying performance (housed laying rate, egg weight, egg mass, daily feed intake and feed conversion ratio) was weekly calculated. Egg quality (egg shape index, shell strength, shell thickness, albumen height, yolk colour and Haugh units), serum parameters (calcium, phosphorus, parathyroid hormone, calcitonin and 1,25-dihydroxyvitamin D), tibia quality (breaking strength, and calcium, phosphorus and ash contents), intestinal gene expression (type IIb sodium-dependent phosphate cotransporter, NaPi-IIb) and phosphorus excretion were determined at the end of the trial. No differences were observed on laying performance, egg quality, serum parameters and tibia quality. Hens fed 0.17% nPP had increased (P < 0.01) duodenum NaPi-IIb expression compared to all other treatments. Phosphorus excretion linearly increased with an increase in dietary nPP (phosphorus excretion = 1.7916 × nPP + 0.2157; R2 = 0.9609, P = 0.001). In conclusion, corn–soybean meal-based diets containing 0.12% nPP, 3.8% calcium, 2415 IU/kg vitamin D3 and 2000 FTU/kg phytase would meet the requirements for egg production in Hy-Line Brown laying hens (29 to 40 weeks of age).
Recently, Echinacea purpurea and its extracts have gained much interest due to their improvement on meat quality, but little information is available on the application of the purified Echinacea purpurea polysaccharide (4-O-methyl-glucuronoarabinoxylan, 4OMG). Thus, this trial aimed at assessing the effects of dietary supplementation of 4OMG on growth performance, thigh meat quality and small intestine development of broilers. A total of 240 1-day-old female broiler chicks were randomly distributed to four groups with three replicates of 20 within each group. Each group received either 0, 15, 20 or 25 g 4OMG/kg DM of diet. During the entire experiment, broilers had ad libitum access to water and feed, and the feed intake was recorded daily. All broilers were weighed before and end of the experiment. For each group, three pens with a total of 20 broilers were randomly selected to slaughter after 30 days. Increasing dietary supplementation of 4OMG linearly increased final live weight and daily body weight gain (P = 0.013) of broilers, Gain-to-Feed ratio (P < 0.001), muscle pH (P = 0.024) and redness (P = 0.001), but decreased drip loss (P = 0.033), shear force value (P = 0.004) and hardness (P = 0.022) of the thigh meat. Broilers fed diet with higher 4OMG had greater weight index, villus height and ratio of villus height to crypt depth in both duodenum and jejunum. These results indicated that increasing dietary supplementation of 4OMG was beneficial for growth performance, meat quality and development of the small intestine of broilers.
Introduction: Selecting appropriate patients for hospitalization following emergency department (ED) evaluation of syncope is critical for serious adverse event (SAE) identification. The primary objective of this study is to determine the association of hospitalization and SAE detection using propensity score (PS) matching. The secondary objective was to determine if SAE identification with hospitalization varied by the Canadian Syncope Risk Score (CSRS) risk-category. Methods: This was a secondary analysis of two large prospective cohort studies that enrolled adults (age ≥ 16 years) with syncope at 11 Canadian EDs. Patients with a serious condition identified during index ED evaluation were excluded. Outcome was a 30-day SAE identified either in-hospital for hospitalized patients or after ED disposition for discharged patients and included death, ventricular arrhythmia, non-lethal arrhythmia and non-arrhythmic SAE (myocardial infarction, structural heart disease, pulmonary embolism, hemorrhage). Patients were propensity matched using age, sex, blood pressure, prodrome, presumed ED diagnosis, ECG abnormalities, troponin, heart disease, hypertension, diabetes, arrival by ambulance and hospital site. Multivariable logistic regression assessed the interaction between CSRS and SAE detection and we report odds ratios (OR). Results: Of the 8183 patients enrolled, 743 (9.0%) patients were hospitalized and 658 (88.6%) were PS matched. The OR for SAE detection for hospitalized patients in comparison to those discharged from the ED was 5.0 (95%CI 3.3, 7.4), non-lethal arrhythmia 5.4 (95%CI 3.1, 9.6) and non-arrhythmic SAE 6.3 (95%CI 2.9, 13.5). Overall, the odds of any SAE identification, and specifically non-lethal arrhythmia and non-arrhythmia was significantly higher in-hospital among hospitalized patients than those discharged from the ED (p < 0.001). There were no significant differences in 30-day mortality (p = 1.00) or ventricular arrhythmia detection (p = 0.21). The interaction between ED disposition and CSRS was significant (p = 0.04) and the probability of 30-day SAEs while in-hospital was greater for medium and high risk CSRS patients. Conclusion: In this multicenter prospective cohort, 30-day SAE detection was greater for hospitalized compared with discharged patients. CSRS low-risk patients are least likely to have SAEs identified in-hospital; out-patient monitoring for moderate risk patients requires further study.
Introduction: Patients with poorly-controlled diabetes often visit the emergency department (ED) for treatment of hyperglycemia. While previous qualitative studies have examined the patient experience of diabetes as a chronic illness, there are no studies describing patients’ perceptions of ED care for hyperglycemia. The objective of this study was to explore the patient experience regarding ED hyperglycemia visits, and to characterize perceived barriers to adequate glycemic control post-discharge. Methods: This study was conducted at a tertiary care academic centre in London, Ontario. A qualitative constructivist grounded theory methodology was used to understand the experience of adult patient partners who have had an ED hyperglycemia visit. Patient partners, purposively sampled to capture a breadth of age, sex, disease and presentation frequency were invited to participate in a semi-structured individual interview to probe their experiences. Sampling continued until a theoretical framework representing key experiences and expectations reached sufficiency. Data were collected and analyzed iteratively using a constant comparative approach. Results: 22 patients with type 1 or 2 diabetes were interviewed. Participants sought care in the ED over other options because of their concern of having a potentially life-threatening condition, advice from a healthcare provider or family member, or a perceived lack of convenient alternatives to the ED based on time and location. Participants’ care expectations centred around symptom relief, glycemic control, reassurance and education, and seeking referral to specialist diabetes care post-discharge. Finally, perceived system barriers that challenged participants’ glycemic control included affordability of medical supplies and medications, access to follow-up and, in some cases, the transition from pediatric to adult diabetes care. Conclusion: Patients with diabetes utilize the ED for a variety of urgent and emergent hyperglycemic concerns. In addition to providing excellent medical treatment, ED healthcare providers should consider patients’ expectations when caring for those presenting with hyperglycemia. Future studies will focus on developing strategies to help patients navigate some of the barriers that exist within our current limited healthcare system, enhance follow-up care, and improve short- and long-term health outcomes.
Introduction: Naloxone is recommended for reversing opioid-associated respiratory depression. There is wide variability in emergency department (ED) practice patterns regarding naloxone use, dosing, and observation time post-administration. This study describes the naloxone practice patterns of ED physicians managing suspected opioid overdose patients. Methods: A retrospective chart review was conducted of adult patients (≥ 18 years) presenting to an academic tertiary care centre (consisting of two EDs with an annual census 150,000 visits) in 2017 with suspected opioid overdose who were administered naloxone in the ED. Patients were identified electronically and the following information was abstracted from patient charts: demographics, naloxone dosage and infusion initiation, disposition data, indications for naloxone administration, response to therapy, and adverse effects. Variability in initial and total dose was examined. Initial dose was also compared in those with cardiorespiratory compromise (CPR given, respiratory rate < 8, or desaturation below 89%) using independent samples median tests. Data was analyzed using standard descriptive statistics. Results: 113 patients met inclusion criteria. Indications for naloxone administration were: level of consciousness (50.5%), respiratory depression (4.0%), miosis (1.0%), a combination of factors (19.8%), or undocumented (24.8%). Median initial dose was 0.40 mg (IQR: 0.20-0.40 mg). Median total naloxone administered in the ED was 0.48 mg (IQR: 0.35-1.2 mg). The initial dose resulted in a response in 43.1% of patients, with 36.0% of responding patients later experiencing subsequent respiratory depression. 31% of patients received a naloxone infusion. Initial dose in patients with cardiopulmonary compromise was significantly different only comparing patients who received CPR versus those who did not (median 0.40 mg; IQR: 0.20-0.80 mg; P = 0.019). Four patients experienced emesis following naloxone. Median length of ED stay was 7.0 hours (IQR: 4.0-9.5 hours), and median hospital length of stay was 3.0 days (IQR: 1.0-5.0 days). Median ED observation time prior to discharge was 4.0 hours (IQR: 2.0-8.0 hours). Ultimate disposition home, to the ward, or to the intensive care unit was 47.1%, 42.2%, and 9.8% respectively (1.0% deceased). Conclusion: The dose and usage of naloxone by ED physicians in this study is variable. Further prospective studies are needed to determine the effective naloxone dosing strategy.
Introduction: Extreme heat events due to climate change are becoming increasingly frequent and severe, and may have an impact on human health. Administrative database studies using International Classification of Diseases 10th revision codes (ICD-10) are powerful tools to measure the burden of acute heat illness (AHI) in Canada. We aimed to assess the validity of the coding algorithm for emergency department (ED) encounters for AHI in our region. Methods: Two independent reviewers retrospectively abstracted data from 507 medical records of patients presenting at two EDs in Ontario between May-September 2015-2018. The Gold Standard definition of an AHI is chart-documented heat exposure with a heat related complaint, such as syncope while working outdoors on a hot day. To determine ICD coding algorithm positive predictive value (PPV), records that were previously coded as ICD-10 heat illnesses were compared to the Gold Standard for AHI. To determine sensitivity (Sn), specificity (Sp) and negative predictive values (NPV), the Gold Standard was compared to randomly selected records. A total of 326,702 ED visits were included in study period with 208 having an ICD-10 code related to heat illness. Sample size calculation demonstrated a need to manually review 62 previously coded heat illnesses and 931 random cases, of which 50 and 474 have been reviewed, respectively. In both abstractions, 20% of cases underwent a blinded duplicate review. Results: In our review of 474 random records, 2 cases were identified as AHI but without an appropriate ICD-10 code, 445 were not AHIs, and no cases had been identified as having an AHI ICD-10 inappropriately applied. In our review of 50 previously coded heat illnesses, 34 were found to be appropriately coded and 16 inappropriately coded, as AHI ICD-10. Average patient age and gender of heat illness vs non-heat illness ED presentations were 32 and 48 years of age and 49% and 64% male, respectively. The leading complaint in AHI was heat stroke/exhaustion (39%), followed by headaches (15%), dizziness (9%), shortness of breath (9%) and syncope/presyncope (6%). 76% of all heat illness presentations presented following a period of physical exertion. Conclusion: Final calculation of Sn, Sp, PPV, NPV for the algorithm will occur upon completion of the review. Preliminary results suggest that ICD-10 coding for AHI may be applied correctly in the ED. This study will help to determine if administrative data can accurately be used to measure the burden of heat illness in Canada.
Introduction: Cannabinoid Hyperemesis Syndrome (CHS) in pediatric patients is poorly characterized. Literature is scarce, making identification and treatment challenging. This study's objective was to describe demographics and visit data of pediatric patients presenting to the emergency department (ED) with suspected CHS, in order to improve understanding of the disorder. Methods: A retrospective chart review was conducted of pediatric patients (12-17 years) with suspected CHS presenting to one of two tertiary-care EDs; one pediatric and one pediatric/adult (combined annual pediatric census 40,550) between April 2014-March 2019. Charts were selected based on discharge diagnosis of abdominal pain or nausea/vomiting with positive cannabis urine screen, or discharge diagnosis of cannabis use, using ICD-10 codes. Patients with confirmed or likely diagnosis of CHS were identified and data including demographics, clinical history, and ED investigations/treatments were recorded by a trained research assistant. Results: 242 patients met criteria for review. 39 were identified as having a confirmed or likely diagnosis of CHS (mean age 16.2, SD 0.85 years with 64% female). 87% were triaged as either CTAS-2 or CTAS-3. 80% of patients had cannabis use frequency/duration documented. Of these, 89% reported at least daily use, the mean consumption was 1.30g/day (SD 1.13g/day), and all reported ≥6 months of heavy use. 69% of patients had at least one psychiatric comorbidity. When presenting to the ED, all had vomiting, 81% had nausea, 81% had abdominal pain, and 30% reported weight loss. Investigations done included venous blood gas (30%), pregnancy test in females (84%), liver enzymes (57%), pelvic or abdominal ultrasound (19%), abdominal X-ray (19%), and CT head (5%). 89% of patients received treatment in the ED with 81% receiving anti-emetics, 68% receiving intravenous (IV) fluids, and 22% receiving analgesics. Normal saline was the most used IV fluid (80%) and ondansetron was the most used anti-emetic (90%). Cannabis was suspected to account for symptoms in 74%, with 31% of these given the formal diagnosis of CHS. 62% of patients had another visit to the ED within 30 days (prior to or post sentinel visit), 59% of these for similar symptoms. Conclusion: This study of pediatric CHS reveals unique findings including a preponderance of female patients, a majority that consume cannabis daily, and weight loss reported in nearly one third. Many received extensive workups and most had multiple clustered visits to the ED.
Introduction: Acute heart failure (AHF) is a common emergency department (ED) presentation and may be associated with poor outcomes. Conversely, many patients rapidly improve with ED treatment and may not need hospital admission. Because there is little evidence to guide disposition decisions by ED and admitting physicians, we sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. Methods: We conducted prospective cohort studies at 9 tertiary care hospital EDs from 2007 to 2019, and enrolled adult patients who required treatment for AHF. Each patient was assessed for standardized real-time clinical and laboratory variables, as well as for SSO (defined as death within 30 days or intubation, non-invasive ventilation (NIV), myocardial infarction, coronary bypass surgery, or new hemodialysis after admission). The fully pre-specified, logistic regression model with 13 predictors (age, pCO2, and SaO2 were modeled using spline functions with 3 knots and heart rate and creatinine with 5 knots) was fitted to the 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions and estimated a sample size of 170 SSOs. Results: The 2,246 patients had mean age 77.4 years, male sex 54.5%, EMS arrival 41.1%, IV NTG 3.1%, ED NIV 5.2%, admission on initial visit 48.6%. Overall there were 174 (7.8%) SSOs including 70 deaths (3.1%). The final risk scale is comprised of five variables (points) and had c-statistic of 0.76 (95% CI: 0.73-0.80): 1.Valvular heart disease (1) 2.ED non-invasive ventilation (2) 3.Creatinine 150-300 (1) ≥300 (2) 4.Troponin 2x-4x URL (1) ≥5x URL (2) 5.Walk test failed (2) The probability of SSO ranged from 2.0% for a total score of 0 to 90.2% for a score of 10, showing good calibration. The model was stable over 1,000 bootstrap samples. Choosing a risk model total point admission threshold of >2 would yield a sensitivity of 80.5% (95% CI 73.9-86.1) for SSO with no change in admissions from current practice (48.6% vs 48.7%). Conclusion: Using a large prospectively collected dataset, we created a concise and sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of this risk scoring scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.
Introduction: Wide variability exists in emergency department (ED) syncope management. The Canadian Syncope Risk Score (CSRS) was derived and validated to predict the probability of 30-day serious outcomes after ED disposition. The objective was to identify barriers and facilitators among physicians for CSRS use to stratify risk and guide disposition decisions Methods: We conducted semi-structured interviews with physicians involved in ED syncope care at 8 Canadian sites. We used purposive sampling, contacting ED physicians, cardiologists, internists, and hospitalists until theme saturation was reached. Interview questions were designed to understand whether the CSRS recommendations are consistent with current practice, barriers and facilitators for application into practice, and intention for future CSRS use. Interviews were conducted via telephone or videoconference. Two independent raters coded interviews using an inductive approach to identify themes, with discrepancies resolved through consensus. Our methods were consistent with the Knowledge to Action Framework, which highlights the need to assess barriers and facilitators for knowledge use and for adapting new interventions into local contexts. Results: We interviewed 14 ED physicians, 7 cardiologists, and 10 hospitalists/internists across 8 sites. All physicians reported the use of electrocardiograms for patients with syncope, a key component in the CSRS criteria. Almost all physicians reported that the low risk recommendation (discharge without specific follow-up) was consistent with current practice, while less consistency was seen for moderate (15 days outpatient monitoring) and high risk recommendations (outpatient monitoring and/or admission). Key barriers to following the CSRS included a lack of access to outpatient monitoring and uncertainty over timely follow-up care. Other barriers included patient/family concerns, social factors, and necessary bloodwork. Facilitators included assisting with patient education, reassurance of their clinical gestalt, and optimal patient factors (e.g. reliability to return, support at home, few comorbidities). Conclusion: Physicians are receptive to using the CSRS tool for risk stratification and decision support. Implementation should address identified barriers, and adaptation to local settings may involve modifying the recommended clinical actions based on local resources and feasibility.
Introduction: Emergency department (ED) syncope management is extremely variable. We developed practice recommendations based on the validated Canadian Syncope Risk Score (CSRS) and outpatient cardiac monitoring strategy with physician input. Methods: We used a 2-step approach. Step-1: We pooled data from the derivation and validation prospective cohort studies (with adequate sample size) conducted at 11 Canadian sites (Sep 2010 to Apr 2018). Adults with syncope were enrolled excluding those with serious outcome identified during index ED evaluation. 30-day adjudicated serious outcomes were arrhythmic (arrhythmias, unknown cause of death) and non-arrhythmic (MI, structural heart disease, pulmonary embolism, hemorrhage)]. We compared the serious outcome proportion among risk categories using Cochran-Armitage test. Step-2: We conducted semi-structured interviews using observed risk to develop and refine the recommendations. We used purposive sampling of physicians involved in syncope care at 8 sites from Jun-Dec 2019 until theme saturation was reached. Two independent raters coded interviews using an inductive approach to identify themes; discrepancies were resolved by consensus. Results: Of the 8176 patients (mean age 54, 55% female), 293 (3.6%; 95%CI 3.2-4.0%) experienced 30-day serious outcomes; 0.4% deaths, 2.5% arrhythmic, 1.1% non-arrhythmic outcomes. The serious outcome proportion significantly increased from low to high-risk categories (p < 0.001; overall 0.6% to 27.7%; arrhythmic 0.2% to 17.3%; non-arrhythmic 0.4% to 5.9% respectively). C-statistic was 0.88 (95%CI0.86–0.90). Non-arrhythmia risk per day for the first 2 days was 0.5% for medium-risk, 2% for high-risk and very low thereafter. We recruited 31 physicians (14 ED, 7 cardiologists, 10 hospitalists/internists). 80% of physicians agreed that low risk patients can be discharged without specific follow-up with inconsistencies around length of ED observation. For cardiac monitoring of medium and high-risk, 64% indicated that they don't have access; 56% currently admit high-risk patients and an additional 20% agreed to this recommendation. A deeper exploration led to following refinement: discharge without specific follow-up for low-risk, a shared decision approach for medium-risk and short course of hospitalization for high-risk patients. Conclusion: The recommendations were developed (with online calculator) based on in-depth feedback from key stakeholders to improve uptake during implementation.
We report the results from the first 12 months of a 2-year maintenance phase of a study evaluating long-term efficacy and safety of venlafaxine extended-release (XR) in preventing recurrence of depression.
Patients with recurrent unipolar depression (N=1096) were randomly assigned in a 3:1 ratio to 10-week treatment with venlafaxine XR (75 mg/d to 300 mg/d) or fluoxetine (20 mg/d to 60 mg/d). Responders (HAM-D17 total score ≤12 and ≥50% decrease from baseline) entered a 6-month, double-blind, continuation phase on the same medication. Continuation phase responders enrolled into the maintenance treatment period consisting of 2 consecutive 12-month phases. At the start of each maintenance phase, venlafaxine XR responders were randomly assigned to double-blind treatment with venlafaxine XR or placebo; fluoxetine responders continued for each period. Time to recurrence (HAM-D17 total score >12 and <50% reduction from acute phase baseline at 2 consecutive visits or the last visit prior to discontinuation) was evaluated using Kaplan-Meier methods and compared between groups using log-rank tests.
At the end of the continuation phase, venlafaxine XR responders were randomly assigned to venlafaxine XR (n=164) or placebo (n=172); 129 patients in each group were evaluated for efficacy. The cumulative probability of recurrence through 12 months was 23.1% (95% CI: 15.3, 30.9) for venlafaxine XR and 42.0% (95% CI: 31.8, 52.2) for placebo (P=0.005).
Twelve months of venlafaxine XR maintenance treatment was effective in preventing recurrence in depressed patients who had been successfully treated with venlafaxine XR during acute and continuation therapy.
This study evaluated the efficacy and safety of venlafaxine extended-release (XR) in preventing recurrence of depression.
Outpatients with recurrent unipolar depression (N=1096) were randomly assigned in a 3:1 ratio to 10-week treatment with venlafaxine XR (75 mg/d to 300 mg/d) or fluoxetine (20 mg/d to 60 mg/d). Responders (HAM-D17 ≤12 and ≥50% decrease from baseline) entered a 6-month, double-blind, continuation phase on the same medication. Continuation phase responders enrolled into maintenance treatment consisting of 2 consecutive 12-month phases. At the start of each maintenance phase, venlafaxine XR responders were randomized to double-blind treatment with venlafaxine XR or placebo; fluoxetine responders continued on fluoxetine. Time to recurrence (HAM-D17 >12 and <50% reduction from acute phase baseline at 2 consecutive visits or the last valid visit prior to discontinuation) was evaluated using Kaplan-Meier methods and compared between groups using log-rank tests.
In the second maintenance phase, the cumulative probabilities of recurrence through 12 months in the venlafaxine XR (n=43) and placebo (n=40) groups were 8.0% (95% CI: 0.0, 16.8) and 44.8% (95% CI: 27.6, 62.0), respectively (P<0.001). The probabilities of recurrence over 24 months for patients assigned to venlafaxine XR (n=129) or placebo (n=129) for the first maintenance phase were 28.5% (95% CI 18.3, 37.8) and 47.3% (95% CI 36.4, 58.2), respectively (P=0.005).
An additional 12 months of venlafaxine XR maintenance therapy was effective in preventing recurrence in depressed patients who had responded to venlafaxine XR after acute, continuation, and 12 months' initial maintenance therapy.
The efficacy of venlafaxine extended-release (XR) at doses between 75 mg/d and 300 mg/d has been demonstrated in patients with recurrent major depressive disorder (MDD) over 2.5 years. This analysis evaluated the long-term efficacy of venlafaxine XR ≤225 mg/d, the approved dosage in many countries.
In the primary multicenter, double-blind trial, outpatients with recurrent MDD (N=1096) were randomized to receive 10-week acute-phase treatment with venlafaxine XR (75 mg/d to 300 mg/d) or fluoxetine (20 mg/d to 60 mg/d), followed by a 6-month continuation phase. Subsequently, at the start of 2 consecutive, double-blind, 12-month maintenance phases, venlafaxine XR responders were randomized to receive venlafaxine XR or placebo. Data from the 24 months of maintenance treatment were analyzed for the combined end point of maintenance of response (ie, no recurrence of depression and no dose increase above 225 mg/d), and each component individually. Time to each outcome was evaluated with Kaplan-Meier methods using log-rank tests for venlafaxine XR-placebo comparisons.
The analysis population included 114 patients who had received venlafaxine XR doses less than or equal to 225 mg/d prior to maintenance phase baseline (venlafaxine XR: n=55; placebo: n=59). Probability estimates for maintaining response were 70% for venlafaxine XR and 38% for placebo (P=0.007), for no dose increase were 76% and 58%, respectively (P=0.019), and for no recurrence were 87% vs 65%, respectively (P=.099).
These data confirm venlafaxine XR is effective maintaining response at doses ≤225 mg/d for up to 2.5 years in patients with MDD.
One in four cases of acute aortic syndrome are missed. This national survey examined Canadian Emergency physicians’ opinion on risk stratification, the need for a clinical decision aid to risk stratify patients, and the required sensitivity of such a tool.
We surveyed 1,556 members of the Canadian Association of Emergency Physicians. We used a modified Dillman technique with a prenotification email and up to three survey attempts using electronic mail. Physicians were asked 21 questions about demographics, importance of certain high-risk features, investigation options, threshold for investigation, and if a clinical decision tool is required
We had a response rate of 32%. Respondents were 66% male, and 49% practicing >10 years, with 59% in an academic teaching hospital. A total of 93% reported a need for a clinical decision aid to risk stratify for acute aortic syndrome. A total of 99.6% of physicians were pragmatic accepting a non-zero miss-rate, two-thirds accepting <1%, and the remaining accepting a higher miss-rate.
Our national survey determined that emergency physicians would use a highly sensitive clinical decision aid to determine which patients are at low, medium, or high-risk for acute aortic syndrome. The majority of clinicians have a low threshold (<1%) for investigating for acute aortic syndrome, but accept that a zero miss-rate is not feasible.
Recently, a triple-network model suggested the abnormal interactions between the executive-control network (ECN), default-mode network (DMN) and salience network (SN) are important characteristics of addiction, in which the SN plays a critical role in allocating attentional resources toward the ECN and DMN. Although increasing studies have reported dysfunctions in these brain networks in Internet gaming disorder (IGD), interactions between these networks, particularly in the context of the triple-network model, have not been investigated in IGD. Thus, we aimed to assess alterations in the inter-network interactions of these large-scale networks in IGD, and to associate the alterations with IGD-related behaviors.
DMN, ECN and SN were identified using group-level independent component analysis (gICA) in 39 individuals with IGD and 34 age and gender matched healthy controls (HCs). Then alterations in the SN-ECN and SN-DMN connectivity, as well as in the modulation of ECN versus DMN by SN, using a resource allocation index (RAI) developed and validated previously in nicotine addiction, were assessed. Further, associations between these altered network coupling and clinical assessments were also examined.
Compared with HCs, IGD had significantly increased SN-DMN connectivity and decreased RAI in right hemisphere (rRAI), and the rRAI in IGD was negatively associated with their scores of craving.
These findings suggest that the deficient modulation of ECN versus DMN by SN might provide a mechanistic framework to better understand the neural basis of IGD and might provide novel evidence for the triple-network model in IGD.
Childhoods in urban or rural environments may differentially affect risk for neuropsychiatric disorders. Here, we leveraged on dramatic urbanization and rural-urban migration since the 1980s in China to explore the hypothesis that rural or urban childhoods may differentially influence memory processing and neural responses to neutral and aversive stimuli.
Explore the underlying mechanisms of childhood environment effect on brain function and neuropsychiatric risk.
We examined 420 adult subjects with similar current socioeconomic status and living in Beijing, China, but with differing rural (n = 227) or urban (n = 193) childhoods. In an episodic memory paradigm scanned in a 3 T GE MRI, subjects viewed blocks of neutral or aversive pictures in the encoding and retrieval sessions.
Episodic memory accuracy for neutral stimuli was less than for aversive stimuli (P < 0.001). However, subjects with rural childhoods apparently performed less accurately for memory of aversive but not neutral stimuli (P < 0.01). In subjects with rural childhoods, there was relatively increased engagement of bilateral striatum at encoding, increased engagement of bilateral hippocampus at retrieval of neutral and aversive stimuli, and increased engagement of amygdala at aversive retrieval (P < 0.05 FDR corrected, cluster size > 50).
Rural or urban childhoods appear associated with physiological and behavioural differences, particularly in the neural processing of aversive episodic memory at medial temporal and striatal brain regions. It remains to be explored the extent to which these effects relate to individual risk for neuropsychiatric or stress-related disorders.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The development of digestive organs and the establishment of gut microbiota in pullets play an important role throughout life. This study was conducted to investigate the effects of Bacillus subtilis (BS) on growth performance, intestinal function and gut microbiota in pullets from 0 to 6 weeks of age. Hy-line Brown laying hens (1-day-old, n = 504) were randomly allotted into four diets with a 2 × 2 factorial design: (1) basal diet group (control); (2) antibiotics group (AGP), the basal diet supplemented with 20 mg/kg Bacitracin Zinc and 4 mg/kg Colistin Sulphate; (3) BS group, the basal diet supplemented with 500 mg/kg BS and (4) mixed group, the basal diet supplemented with both AGP and BS. As a result, when BS was considered the main effect, BS addition (1) reduced the feed conversion ratio at 4 to 6 weeks (P < 0.05); (2) decreased duodenal and jejunal crypt depth at 3 weeks; (3) increased the villus height : crypt depth (V : C) ratio in the duodenum at 3 weeks and jejunal villus height at 6 weeks and (4) increased sucrase mRNA expression in the duodenum at 3 weeks as well as the jejunum at 6 weeks, and jejunal maltase and aminopeptidase expression at 3 weeks. When AGP was considered the main effect, AGP supplementation (1) increased the V : C ratio in the ileum at 3 weeks of age; (2) increased sucrase mRNA expression in the duodenum at 3 weeks as well as the ileum at 6 weeks, and increased maltase expression in the ileum. The BS × AGP interaction was observed to affect average daily feed intake at 4 to 6 weeks, and duodenal sucrase and jejunal maltase expression at 3 weeks. Furthermore, dietary BS or AGP addition improved caecal microbial diversity at 3 weeks, and a BS × AGP interaction was observed (P < 0.05) for the Shannon and Simpson indexes. At the genus level, the relative abundance of Lactobacillus was found to be higher in the mixed group at 3 weeks and in the BS group at 6 weeks. Moreover, Anaerostipes, Dehalobacterium and Oscillospira were also found to be dominant genera in pullets with dietary BS addition. In conclusion, BS could improve intestinal morphology and change digestive enzyme relative expression and caecum microbiota, thereby increasing the efficiency of nutrient utilization. Our findings suggested that BS might have more beneficial effects than AGP in the study, which would provide theoretical evidence and new insight into BS application in layer pullets.