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Little is known about long-term employment outcomes for patients with first-episode schizophrenia-spectrum (FES) disorders who received early intervention services.
We compared the 10-year employment trajectory of patients with FES who received early intervention services with those who received standard care. Factors differentiating the employment trajectories were explored.
Patients with FES (N = 145) who received early intervention services in Hong Kong between 1 July 2001 and 30 June 2002 were matched with those who entered standard care 1 year previously. We used hierarchical clustering analysis to explore the 10-year employment clusters for both groups. We used the mixed model test to compare cluster memberships and piecewise regression analysis to compare the employment trajectories of the two groups.
There were significantly more patients who received the early intervention service in the good employment cluster (early intervention: N = 98 [67.6%]; standard care: N = 76 [52.4%]; P = 0.009). In the poor employment cluster, there was a significant difference in the longitudinal pattern between early intervention and standard care for years 1–5 (P < 0.0001). The number of relapses during the first 3 years, months of full-time employment during the first year and years of education were significant in differentiating the clusters of the early intervention group.
Results suggest there was an overall long-term benefit of early intervention services on employment. However, the benefit was not sustained for all patients. Personalisation of the duration of the early intervention service with a focus on relapse prevention and early vocational reintegration should be considered for service enhancement.
Declaration of interests
No relevant conflicts of interests reported by C.L.M.H., Y.N.S., P.S., H.H.P. and K.K.Y. S.K.W.C., W.C.C. and E.H.M.L. report that they are members of the working group of the Early Assessment Service for Young People with Psychosis (EASY) programme of the Hospital Authority in Hong Kong. E.Y.H.C. is the convener of the working group of the EASY programme of the Hospital Authority in Hong Kong.
Introduction: Many drugs, including cannabis and alcohol, cause impairment and contribute to motor vehicle collisions (MVCs). Policy makers require knowledge of the prevalence of drug use in crash-involved drivers, and types of drugs used in order to develop effective prevention programs. This issue is particularly relevant with the recent legalization of cannabis. We aim to study the prevalence of alcohol, cannabis, sedating medications, and other drugs in injured drivers from 4 Canadian Provinces. Methods: This prospective cohort study obtained excess clinical blood samples from consecutive injured drivers who attended a participating Canadian trauma centre following a MVC. Blood samples were analyzed using a broad spectrum toxicology screen capable of detecting cannabinoids, cocaine, amphetamines (including their major analogues), and opioids as well as psychotropic pharmaceuticals (including antihistamines, benzodiazepines, other hypnotics, and sedating antidepressants). Alcohol and cannabinoids were quantified. Health records were reviewed to extract demographic, medical, and MVC information using a standardized data collection tool. Results: This study has been collecting data in 4 trauma centres in British Columbia (BC) since 2011 and was launched in 2 trauma centres in Alberta (AB), 1 in Saskatchewan (SK), and 2 in Ontario (ON) in 2018. In preliminary results from BC (n = 2412), 8% of injured drivers tested positive for THC and 13% for alcohol. Preliminary results from other provinces (n = 301) suggest a regional variation in prevalence of drivers testing positive for THC (10% - 27%), alcohol (17% - 29%), and other drugs. By May 2018, an estimated 4500 cases from BC, 600 from AB, 150 from SK, and 650 from ON will have been analyzed. We will report the prevalence of positive tests for alcohol, THC, other recreational drugs, and sedating medications, pre and post cannabis legalization. The number of cases with alcohol and/or THC levels above Canadian per se limits will also be reported. Results will be reported according to province, driver sex, age, single vs. multi vehicle crashes, and requirement for hospital admission. Conclusion: This will be among the largest international datasets on drug use by injured drivers. Our findings will provide patterns of drug and alcohol impairment in 4 Canadian provinces pre and post cannabis legalization. The significance of these findings and implication for impaired driving policy and prevention programs in Canada will be discussed.
Innovation Concept: Mass Casualty Incidents (MCI) are complex events that most paramedics encounter only a few times in their careers. Triaging and managing multiple patients during an incident requires different skills than typically practiced by prehospital providers. Simulation and drills can provide an opportunity to practice those skills, but are costly and resource intensive while only allowing a few providers to be in a triage or leadership role. It is important to find engaging and less expensive methods for teaching MCI triage and initial scene management. Methods: The authors have developed and are testing a card game based on the previously published GridlockED board game. The game was developed utilizing an iterative process previously described. This game was tested with paramedics as well as other emergency medicine learners to determine usability, engagement, fidelity, as well as usefulness in teaching MCI triage and patient-flow concepts. Curriculum, Tool or Material: The card game provides a focused learning experience to allow providers to practice initial triage of multiple injured patients as well as manage patient flow from the scene to area hospitals when faced with limited prehospital resources and capabilities. Players work together in various simulated scenarios to correctly triage injured patients and send them to the correct healthcare facility. Conclusion: Serious gaming has gained momentum in medical education. Developing novel curriculae around low frequency, high stakes situations using a game like TriagED may hold the key to ensure prehospital care providers are trained for these incidents. In the future, games which integrate an element of Incident Command or receiving hosptials (e.g. full integration with GridlockED game) may help to further explore the relationship between scene management and patient flow within receiving hospitals.
Upper respiratory tract infections (URTIs) account for substantial attendances at emergency departments (EDs). There is a need to elucidate determinants of antibiotic prescribing in time-strapped EDs – popular choices for primary care despite highly accessible primary care clinics. Semi-structured in-depth interviews were conducted with purposively sampled physicians (n = 9) in an adult ED in Singapore. All interviews were analysed using thematic analysis and further interpreted using the Social Ecological Model to explain prescribing determinants. Themes included: (1) reliance on clinical knowledge and judgement, (2) patient-related factors, (3) patient–physician relationship factors, (4) perceived practice norms, (5) policies and treatment guidelines and (6) patient education and awareness. The physicians relied strongly on their clinical knowledge and judgement in managing URTI cases and seldom interfered with their peers’ clinical decisions. Despite departmental norms of not prescribing antibiotics for URTIs, physicians would prescribe antibiotics when faced with uncertainty in patients’ diagnoses, treating immunocompromised or older patients with comorbidities, and for patients demanding antibiotics, especially under time constraints. Participants had a preference for antibiotic prescribing guidelines based on local epidemiology, but viewed hospital policies on prescribing as a hindrance to clinical judgement. Participants highlighted the need for more public education and awareness on the appropriate use of antibiotics and management of URTIs. Organisational practice norms strongly influenced antibiotic prescribing decisions by physicians, who can be swayed by time pressures and patient demands. Clinical decision support tools, hospital guidelines and patient education targeting at individual, interpersonal and community levels could reduce unnecessary antibiotic use.
The humble pendulum is often invoked as the archetype of a simple, gravity driven, oscillator. Under ideal circumstances, the oscillation frequency of the pendulum is independent of its mass and swing amplitude. However, in most real-world situations, the dynamics of pendulums is not quite so simple, particularly with additional interactions between the pendulum and a surrounding fluid. Here we extend the realm of pendulum studies to include large amplitude oscillations of heavy and buoyant pendulums in a fluid. We performed experiments with massive and hollow cylindrical pendulums in water, and constructed a simple model that takes the buoyancy, added mass, fluid (nonlinear) drag and bearing friction into account. To first order, the model predicts the oscillation frequencies, peak decelerations and damping rate well. An interesting effect of the nonlinear drag captured well by the model is that, for heavy pendulums, the damping time shows a non-monotonic dependence on pendulum mass, reaching a minimum when the pendulum mass density is nearly twice that of the fluid. Small deviations from the model’s predictions are seen, particularly in the second and subsequent maxima of oscillations. Using time-resolved particle image velocimetry (TR-PIV), we reveal that these deviations likely arise due to the disturbed flow created by the pendulum at earlier times. The mean wake velocity obtained from PIV is used to model an extra drag term due to incoming wake flow. The revised model significantly improves the predictions for the second and subsequent oscillations.
There is increasing evidence of an association between depressive symptoms and mild cognitive impairment (MCI) in cross-sectional studies, but the longitudinal association between depressive symptoms and risk of MCI onset is less clear. The authors investigated whether baseline symptom severity of depression was predictive of time to onset of symptoms of MCI.
These analyses included 300 participants from the BIOCARD study, a cohort of individuals who were cognitively normal at baseline (mean age = 57.4 years) and followed for up to 20 years (mean follow-up = 2.5 years). Depression symptom severity was measured using the Hamilton Depression Scale (HAM-D). The authors assessed the association between dichotomous and continuous HAM-D and time to onset of MCI within 7 years versus after 7 years from baseline (reflecting the mean time from baseline to onset of clinical symptoms in the cohort) using Cox regression models adjusted for gender, age, and education.
At baseline, subjects had a mean HAM-D score of 2.2 (SD = 2.8). Higher baseline HAM-D scores were associated with an increased risk of progression from normal cognition to clinical symptom onset ≤ 7 years from baseline (p = 0.043), but not with progression > 7 years from baseline (p = 0.194). These findings remained significant after adjustment for baseline cognition.
These results suggest that low levels of depressive symptoms may be predictive of clinical symptom onset within approximately 7 years among cognitively normal individuals and may be useful in identifying persons at risk for MCI due to Alzheimer’s disease.
To provide an overview of the current state of research of advance care planning (ACP), highlighting most studied topics, publication time, quality of studies and reported outcomes, and to identify gaps to improve ACP receptivity, utilization, implementation, and outcomes.
Cochrane methodology for conducting overviews of systematic reviews. Study quality was assessed using a modified version of the Assessing the Methodological Quality of Systematic Reviews tool. The following databases were searched from inception to April 2017: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE. Searches were supplemented with gray literature and manual searches.
Eighty systematic reviews, covering 1,662 single articles, show that ACP-related research focuses on nine main topics: (1) ACP as part of end-of-life or palliative care interventions, (2) care decision-making; (3) communication strategies; (4) factors influencing ACP implementation; (5) ACP for specific patient groups, (6) ACP effectiveness; (7) ACP experiences; (8) ACP cost; and (9) ACP outcome measures. The majority of this research was published since 2014, its quality ranges from moderate to low, and reports on documentation, concordance, preferences, and resource utilization outcomes.
Significance of results
Despite the surge of ACP research, there are major knowledge gaps about ACP initiation, timeliness, optimal content, and impact because of the low quality and fragmentation of the available evidence. Research has mostly focused on discrete aspects within ACP instead of using a holistic evaluative approach that takes into account its intricate working mechanisms, the effects of systems and contexts, and the impacts on multilevel stakeholders. Higher quality studies and innovative interventions are needed to develop effective ACP programs and address research gaps.
TiO2 nanomaterials with platelet or nanosheet morphologies can offer improved properties for photocatalytic applications, but established methods to produce them typically require structure-directing agents since anatase-phase TiO2 does not have a layered structure. In the present work, the preparation of TiO2 nanosheets by the chemical oxidation of TiS2 nanosheets is demonstrated. Electrochemical exfoliation of bulk TiS2 into TiS2 nanosheets, followed by the hydrothermal treatment at 180 °C for 14 h is performed. The results show that polycrystalline TiO2 nanosheets with the anatase structure are formed, and that the nanosheet morphology can still be maintained after the hydrothermal treatment. The TiO2 nanosheets show good photocatalytic activity for the degradation of methylene blue, but the performance is negatively affected by the residual carbon black that was needed in the TiS2 electrode to enable electrochemical exfoliation. These results show that conversion of TiS2 nanosheets to TiO2 nanosheets is a promising synthetic strategy but highlights how the interfacial properties of the obtained materials could be affected by ancillary components in the preparation method.
Introduction: Emergency medicine clinicians (physicians, nurses, paramedics, physician assistants) utilize podcasts for learning. However, their versatility produces variability in the ways they are used (e.g. their speed can be increased or decreased, unrelated activities can be performed simultaneously, or they can be accompanied by active learning methods). This study investigated how and why podcasts are used by an international cohort of clinicians. Methods: An international sample of medical students, residents, physicians, nurses, physician assistants, and paramedics was recruited to complete a survey hosted on FluidSurveys software using social media (Twitter and Facebook), direct contact from our international authorship group, infographics, and a study website (https://METRIQstudy.org/). Participants who indicated interest in the study were sent an email containing the study survey. Reminder emails were sent every 5-10 days a maximum of three times. Results: 462 clinicians expressed interest and 397 completed the survey (86.0% completion rate). Participants hailed from 34 countries (38.8% Canada, 30% United States, 31.2% outside of North America) and a majority (61.9%) were physicians. Approximately half (45.8%) of the participants listened to podcasts weekly. Podcasts were used to learn core material (75.1%), refresh memory (72.3%), or review new literature (75.8%). Most listened on iPhones (61%) and the native Apple App (66.1%). The preferred Android apps were Pocket Casts (22.8%) and Google Play (18.5%). Many listened to podcasts while driving (72.3%). Active learning techniques such as pausing, repeating segments, taking notes, or listening to a podcast more than once were rarely used (1/4 of the time or less) by the majority of participants. Conclusion: This study describes how and why medical education podcasts are used by emergency medicine clinicians and should inform both podcast producers and future research investigating the impact of various listening habits on retention. Further analysis of the data will elucidate differences in listening habits
Introduction: Cognitive processing theories postulate that decision making depends on both fast and slow thinking. Experienced physicians (EPs) make diagnoses quickly and with less effort by using fast, intuitive thinking, whereas inexperienced medical students rely on slow, analytical thinking. This study used a cognitive task analysis to examine EPs cognitive processes and ability to provide knowledge translation to learners. Methods: A novel mind mapping approach was used to examine how EPs translate their clinical reasoning to learners, when evaluating a patient for a possible venous thromboembolism (VTE). Nine EPs were interviewed and shown two different videos of a medical student patient interview (randomized from six possible videos). Results: EPs were asked to demonstrate their clinical approach to the scenario using a mind map, assuming they were teaching a learner in the Emergency Department. EPs were later re-interviewed to examine response stability, and given the opportunity to make clarifying or substantive mind map modifications. Maps were broken into component pieces and analyzed using mixed-methods techniques. A mean of 15.7 component pieces were identified within each mind map (standard deviation (SD) 7.8). Maps were qualitatively coded, with a mean of 2.8 clarifying amendments (e.g. adding a time course caveat) (SD 1.5-5.75) and 4.4 substantive modifications (e.g. changing the flow of the map) (SD 2-5). Conclusion: Resulting mind maps displayed significant heterogeneity in teaching points and the degree to which EPs used slow thinking. EPs frequently made fast thinking jumps, although learners could prompt slow thinking by questioning unclear points. This is particularly important as learners engage in cognitive apprenticeship throughout their training. An improved understanding of EPs cognitive processes through mind mapping will allow learners to improve their own clinical reasoning (Merrit et al., 2017). Educating EPs on these processes will allow modification of their teaching styles to better suit learners.
Introduction: Medical education includes a diverse range of topics and disciplines. For junior clinician educators, it may be difficult to get a grasp of pertinent literature. Our study aims to retrospectively identify whether senior clinician educators (SCEs) and junior clinician educators (JCEs) differ in their selection of what they perceive as key medical education articles. Methods: As a part of the Academic Life in Emergency Medicine (ALiEM) Faculty Incubator program, we developed a series of primer articles for JCEs over the preceding year, designed to enhance their educational growth by identifying and discussing key articles within specific medical education arenas. Each set of articles within the primer series were selected based on data collected from JCEs and SCEs, who ranked the specific articles with respect to their perceived relevancy to the JCEs. ANOVA analysis was performed for each of the nine primer series to determine whether there was a statistically significant difference between senior and junior CEs ratings of articles. Results: 216 total articles were evaluated within the nine different primer topics. Through a multilevel regression analysis of the data, no statistically significant difference was found between the rankings of papers by SCEs and JCEs (95%CI: -0.27, 0.40). However, a subgroup analysis of the data found that 3 of the 9 primers showed statistically significant divergence based on seniority (p<0.05). Conclusion: Based on this data, involvement of JCEs in the consensus-building process was important in identifying divergence in views between JCEs and SCEs in one-third of cases. To our knowledge, no other group have compared whether junior and senior clinical educators may have divergent opinions about the relevance of medical education literature. Our findings suggest that it may be important to involve JCEs in selecting articles that are worthwhile for their learning, since SCEs may not fully understand their needs.
Introduction: The accuracy of ultrasound (US) for diagnosing lower extremity deep vein thrombosis (DVT) in non-pregnant patients has been well validated. However, in pregnant women with suspected DVT and an initial negative US (with imaging of the iliac veins), serial US is recommended. We aimed to determine the ability of single negative US to exclude DVT in symptomatic pregnant women. Methods: Two authors independently reviewed the following databases: MEDLINE, PubMed and EMBase from inception until May 2017. Three authors reviewed all full text papers and data were extracted from included studies by four authors. An overlap among study populations was identified in 4 of the manuscripts, all from one multicentre Canadian study. Two authors performed data re-extraction from the hard copy research charts from this study. We assessed the risk of bias using the CLARITY group tool for prognostic studies. Results: Of 109 potentially relevant articles, 8 studies (7 prospective studies and 1 retrospective) were included. Risk of bias was low for the included populations, and low or moderate for method of measurement and for completeness of follow up. A total of 635 pregnant patients with symptoms of DVT had an initial negative US examination. Of those, 6 had positive DVT during serial US (0.94%) and 3 developed DVT during 3-month follow-up after serial ultrasound (0.47%). Using random-effects model, the pooled false negative rate of a single ultrasound was 1.27% (95% confidence interval, 0.42 to 2.56), I2= 27%. Conclusion: The false negative rate of a single ultrasound with iliac vein imaging for DVT in pregnancy is low. Our results will help inform shared decision making around planning repeat ultrasound scans in these patients.
Introduction: Online medical education resources are widely used in emergency medicine (EM), but strategies to assess quality remain elusive. We previously derived the Medical Education Translational Resources: Impact and Quality (METRIQ) 8 instrument to evaluate quality in medical education blog posts. Methods: As part of a subsequent validation study (The METRIQ Blog Study), a mixed-methods usability analysis was performed to obtain user feedback on the quality assessment instrument in order to improve its clarity and reliability. Participants in the METRIQ Study were first asked to rate five blog posts using the METRIQ-8 Score. They then evaluated the METRIQ-8 instruments ease of use and likelihood of being recommended to others using a 7-point Likert scale and free text comments. Participants were also asked to flag and comment on items within the score that they felt were unclear. Global usability ratings were summarized using median scores or percent rated unclear. We used ANOVA to test associations between ease of use and demographic factors. A thematic analysis was performed on the comments. Results: 309 EM medical students, residents, and attendings completed the survey. Global ratings were generally very favorable (median 2 [IQR 2-3], with 7 being the lowest score) for ease of use and likelihood of recommendation, and did not vary by participants country of origin, frequency of blog use, or learner level. Participants stated that the score was structured, systematic, and straightforward. They found it useful for junior learners and for guiding blog creation. Four questions in the score (questions 2, 4, 5, and 7) were identified by 10% of subjects to be unclear. Thematic analysis of comments identified suggested four main themes for improving the score: adding clearer definitions with marking rubrics; shortening the 7-point scale; adding items evaluating blog post presentation and utility; and, rephrasing the wording of certain questions for clarity. Conclusion: A mixed methods usability analysis of the METRIQ-8 instrument for assessing blog quality was globally well received by EM medical students, residents, and attendings. Qualitative analyses revealed multiple areas to improve the instruments clarity and usability. The METRIQ score is a promising instrument for evaluating the quality of blogs; further development and testing is needed to improve its utility.