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The Fontan Outcomes Network was created to improve outcomes for children and adults with single ventricle CHD living with Fontan circulation. The network mission is to optimise longevity and quality of life by improving physical health, neurodevelopmental outcomes, resilience, and emotional health for these individuals and their families. This manuscript describes the systematic design of this new learning health network, including the initial steps in development of a national, lifespan registry, and pilot testing of data collection forms at 10 congenital heart centres.
Introduction: CTAS is a validated five-level triage score utilized in EDs across Canada and internationally. Moderate interrater reliability between prehospital paramedic and triage nurse application of CTAS during clinical practice has been found. This study is the first assessment of the variation in distribution of CTAS scores with increasing departmental pressure as measured by the NEDOCs scale comparing triage allocations made by triage nurses with those made by triage paramedics. Methods: We conducted a retrospective, observational cohort study of EDIS data of all patients triaged in the Halifax Infirmary Emergency Department from January 1, 2017-May 30, 2017 and January 1, 2018 - May 30, 2018. CTAS score assignment by nursing and paramedic triage staff were compared with increasing levels of ED overcrowding, as determined by the department NEDOCS score. Results: Nurses were more likely to assign higher acuity scores in all situations of department crowding; there was a 3% increased probability that a nurse, as compared to a paramedic, would triage as emergent when the ED was not overcrowded (Pearson chi-square(1) = 4.21, p < 0.05, Cramer's v = 0.028, n = 5314), and a 10% increased probability that a nurse, as compared to a paramedic, would triage a patient as emergent when EDs were overcrowded (Pearson chi-square(1) = 623.83, p < 0.001, Cramer's v = 0.11, n = 56 018). Conclusion: Increasing levels of ED overcrowding influence triage nurse CTAS score assignment towards higher acuity to a greater degree than scores assigned by triage paramedics.
Studies have revealed that areas associated with violent behaviour are located in the prefrontal cortex, medial temporal regions and limbic regions. Key regions commonly found to be impaired in population of violent homicide offenders include prefrontal cortex, temporal gyrus, amygdala-hippocampal complex, and anterior cingulate cortex. Recent findings have confirmed link between large arachnoid cysts and psychotic symptoms. There is no scientific data in literature on the case of homicidal forensic patient with large arachnoidal cyst and lesion of frontal and temporal brain regions.
We present the first forensic clinical case of male homicidal patient, age 29, with arachnoidal cyst (Galassi III) occupying large portion of the right brain hemisphere. The patient is presented with acute psychotic behavior after he killed his father and was escorted to our department for psychiatric evaluation. The patient was catatonic upon admission to the hospital and completely non-cooperative (mute). After interviewing patient's family members we have collected data regarding visible changes in his behaviour in the last two years accompanied with frequent attacks of headache. MRI study revealed large arachnoid cyst in the right brain hemisphere compressing right frontal and temporal cortex with lesions in frontal and temporal cortex and lesion of the white brain matter in insular region of both hemispheres. The patient was ordered antipsychotic therapy (clozapin) and schedulled for further psychiatric observation.
This clinical case represents highly probable link between structural brain changes and homicidal forensic patient. We have shown multiple structural brain abnormalities supporting neuroscientific hypothesis that impulsive homicide offenders lack the prefrontal “inhibitory” machinery.
In several countries including Hungary no emergency care guidelines are available, and studies regarding everyday clinical emergency practice are also lacking.
The aims of the present study was to assess practice related to emergency care of agitated-psychotic patients in emergency settings in Hungary as well as to compare it with internationals trends.
Anonymous survey questionnaires were dispatched to 210 institutions providing psychiatric care in Hungary in 2013 consisting of questions related to care of an agitated patient showing psychotic symptoms. The results were compared with data from the latest international studies carried out in this field.
155 completed questionnaires were returned. Of the participating clinicians 18.7% would apply monotherapy, 76.1% dual combination, 5.2% a triple combination of medications. 92.9% of participants indicated haloperidol among first-line medications. 80.6% of participants would take a combination with benzodiazepines. 59.4% would use IV and 23.9% IM therapy, and 9% would apply the combination of these two. 7.7% of participants did not answer this question.
Our results indicate that administration of haloperidol and benzodiazepines is a widespread practice in the emergency care of agitated psychotic patients in Hungary which corresponds to dominant trends in international practice as reflected by the latest international survey. The international survey including 21 countries indicate that three countries (India, Romania, Slovenia) regularly use IV medications, whereas others do not do this at all, and only use IM medication. Hungarian clinicians disagree on mode of administration, but the majority would prefer IV therapy.
Number of patients who are again unexpectedly admitted to hospital after a previous hospitalization are used to evaluating the quality of hospital care. Readmission can be represented by the total number and by readmission rate.
Understanding the risk factors that can lead to readmission is a factor for the development of interventions that can improve the quality of care.
The purpose of this study was to examine number and predictors of psychiatric readmission within 14 days, 30 days and, 3 and 6 months.
In this retrospective study, analyses were conducted in a sample of 566 discharge adult patients who were admitted to a Psychiatric Hospital of Sarajevo Canton from 1st January to 31st December 2013.
Total number of readmission was 14%. The readmission rate within 30 days was 2.8%, number of readmission quarterly was 9.1%, number of readmission within 6 months after discharge was 13%.
In the study, several factors were significantly associated with increased risk of readmission including non-compliance with drug treatment, social problems, aggressiveness, suicidality.
Our study suggesting that the prevention of psychiatric readmission requires continuous multidisciplinary work with patients and family members.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The paper discusses the problem of psychiatric treatment of rare diseases and “diagnostic screening” of certain psychic symptoms that affect people with intellectual disabilities. Prader–Willi (PWS) is a genetic syndrome that belongs to a group of rare diseases and is caused by deficiency or loss of function of genes on chromosome 15 inherited from the father. This disease affects both sexes and its main characteristics are: obesity, hyperphagia, mental retardation and hypogonadism. Chronical feeling of insatiable hunger and slow metabolism leads to excessive body weight which is, according to existing date sources and monitoring studies, the primary cause of premature death of patients with PWS. Anxiety, psychomotor agitation, behavioral problems, difficulties with short-term memory, frequent skin injury in the form of wounds and bruises are the symptoms of this disease that hinder diagnosis and treatment. Research suggests that patients with PWS have unusual reactions to the standard drug dosages, specifically anxiolytics.
We shall present a multidisciplinary approach of pharmacological and psychotherapeutic treatment of a 16-year-old female patient with PWS.
This patient responded well to a small dosage of quetiapine, at the same time monitoring other physical parametres. Pharmacotherapy, combined with psychotherapy, along with providing counseling and support for parents resulted in decreased psychomotor restlessness and, subsequently, better control of food intake and prevention of weight gain.
This paper has emphasis on the importance of a multidisciplinary approach, as well as experience from clinical practice in the treatment of complex and rare syndrome diseases.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Advance care planning and palliative care are gaining recognition as critical care components for adults with CHD, yet these often do not occur. Study objectives were to evaluate ACHD providers’ 1) comfort managing patients’ physical symptoms and psychosocial needs and 2) perspectives on the decision/timing of advance care planning initiation and palliative care referral.
Cross-sectional study of ACHD providers. Six hypothetical patients were described in case format, followed by questions regarding provider comfort managing symptoms, initiating advance care planning, and palliative care referral.
Fifty providers (72% physicians) completed surveys. Participants reported low levels of personal palliative care knowledge, without variation by gender, years in practice, or prior palliative care training. Providers appeared more comfortable managing physical symptoms and discussing prognosis than addressing psychosocial needs. Providers recognised advance directives as important, although the percentage who would initiate advance care planning ranged from 18 to 67% and referral to palliative care from 14 to 32%. Barriers and facilitators to discussing advance care planning with patients were identified. Over 20% indicated that advance care planning and end-of-life discussions are best initiated with the development of at least one life-threatening complication/hospitalisation.
Providers noted high value in advance directives yet were themselves less likely to initiate advance care planning or refer to palliative care. This raises the critical questions of when, how, and by whom discussion of these important matters should be initiated and how best to support ACHD providers in these endeavours.
To provide an overview on the magnitude of the impact of schizophrenia on the healthcare system in Europe and to gain a better understanding on the most important factors influencing the variation of costs.
Studies reporting costs and healthcare utilization among patients with schizophrenia were searched in MEDLINE (via Scopus), EMBASE (via Scopus) and Cochrane Database of Systematic Reviews on 19th January 2017.
Twenty-three studies, from the 1075 references initially identified, were included in this review. The annual cost per patient ranged from €533 in Ukraine to €13,704 in the Netherlands. Notably drug costs contributed to less than 25% of the direct healthcare cost per patient in every country, which might be explained by similar pharmaceutical prices among countries due to the reference pricing system applied in Europe. Inpatient costs were the largest component of health service costs in the majority of the countries. Despite methodological heterogeneity across studies, four major themes could be identified (age, severity of symptoms, continuation of treatment/persistence, hospitalization) that have substantial impact on the costs of schizophrenia.
Schizophrenia represents a substantial cost for the healthcare system in Europe driven by the high cost per patient. Substantial savings could potentially be achieved by increasing investment in the following areas: (1) reducing the number of hospitalizations e.g. by increasing the efficiency of outpatient care; (2) working out interventions targeted at specific symptoms; (3) improving patient persistence and adherence in antipsychotic therapy.
Phosphate belongs to the major mineral nutrient category in plants and is a non-renewable resource. Many natural soils are phosphate deficient, and phosphate fixation into insoluble mineral complexes limits plant growth by decreasing root uptake. Different strategies have appeared during the evolution of land plants to cope with this situation, one of which is to interact with various microbes (bacteria and fungi) located in the plant rhizosphere. This chapter will focus on three major groups of fungi that colonise the roots of most land plants: arbuscular mycorrhizal fungi (Glomeromycotina), fungi from the order Sebacinales (Basidiomycota) and the diverse form-group of dark septate endophytes (Ascomycota). Three major mechanisms of fungal contribution to plant nutrition will be discussed. First, fungi are able to solubilise phosphate from inorganic sources that are not available to plants. Second, fungi can set free mineral nutrients from organic compounds/sources. Third, fungi are able to transport phosphate along their hyphae towards the plant, thereby bridging phosphate depletion zones around the roots. In this chapter, we summarise published knowledge on this topic and present some new non-published data to complete our current model.
Adults with congenital heart disease face psychological challenges although an understanding of depression vs. anxiety symptoms is unclear. We analyzed the prevalence of elevated symptoms of anxiety and depression and explored associations with demographic and medical factors as well as quality of life.
Adults with congenital heart disease enrolled from an outpatient clinic completed the Hospital Anxiety and Depression Scale and two measures of quality of life: the Linear Analogue Scale and the Satisfaction with Life Scale. Medical data were obtained by chart review.
Of 130 patients (median age = 32 years; 55% female), 55 (42%) had elevated anxiety symptoms and 16 (12%) had elevated depression symptoms on subscales of the Hospital Anxiety and Depression Scale. Most patients with elevated depression symptoms also had elevated anxiety symptoms (15/16; 94%). Of 56 patients with at least one elevated subscale, 37 (66%) were not receiving mental health treatment. Compared to patients with 0 or 1 elevated subscales, patients with elevations in both (n=15) were less likely to be studying or working (47% vs. 81%; p=0.016) and reported lower scores on the Linear Analogue Scale (60 vs. 81, p<0.001) and the Satisfaction with Life Scale (14 vs. 28, p<0.001).
Among adults with congenital heart disease, elevated anxiety symptoms are common and typically accompany elevated depressive symptoms. The combination is associated with unemployment and lower quality of life. Improved strategies to provide psychosocial care and support appropriate engagement in employment are required.
This paper investigates how we infer the status of others from their social relationships. In a series of experimental studies, we test the effects of a social relationship's type and direction on the status judgments of others. We demonstrate empirically, possibly for the first time, a widely-assumed connection between network structure and perceptions of status; that is, that observers do infer the status positions of group members from their relationships. Moreover, we find that observers' status judgments vary with the direction and type of social relationship. We theorize that underlying this variance in status judgments are two relational schemas which differentially influence the processing of the observed social ties. Our finding that only the linear-ordering schema leads to status inferences provides an important scope condition to prior research on network cognition, and specifically on the perceptions of social status.
The adult CHD population is increasing and ageing and remains at high risk for morbidity and mortality. In a retrospective single-centre study, we conducted a comprehensive review of non-elective hospitalisations of adults with CHD and explored factors associated with length of stay.
We identified adults (⩾18 years) with CHD admitted during a 12-month period and managed by the adult CHD service. Data regarding demographics, cardiac history, hospital admission, resource utilisation, and length of stay were extracted.
There were 103 admissions of 91 patients (age 37±10 years; 52% female). Of 91 patients, 96% had moderate or complex defects. Of 103 admissions, 45% were through the emergency department. The most common reasons for admission were arrhythmia (37%) and heart failure (28%); 29% of admissions included a stay in the ICU. The mean number of consultations by other services was 2.0. Electrophysiology and anaesthesiology departments were most frequently consulted. After removing outliers, the mean length of stay was 7.9±7.4 days (median=5 days). The length of stay was longer for patients admitted for heart failure (12.2±10.3 days; p=0.001) and admitted directly to the ward (9.6±8.9 days; p=0.009).
Among non-electively hospitalised adults with CHD in a tertiary-care centre, management often entails an interdisciplinary approach, and the length of stay is longest for patients admitted with heart failure. The healthcare system must ensure optimal resources to maintain high-quality care for this expanding patient population.
Studies have shown that nutrient requirement of suckling kits is not satisfied, but they can be fed a double quantity of milk (double nursing) resulting in improved BW and weight gain. The aim of our trials was to give additional solid feed during the early suckling period (3 to 15 days of age) when rabbit kits drink exclusively milk. Two experiments were conducted with animals from Pannon Rabbit Breeding Program. In experiment 1 (n=77 does, 734 kits) the does received commercial feed (C) or C pellet supplemented with 0.2 g powdered thyme/kg (CT). Within both dietary groups of the does three groups of litters were formed: no additional solid creep feeding (N); soya bean-based pellet (S); S pellet with 1% added powdered thyme (ST). In group S and ST, cylinder-shaped solid pellets were made. At the beginning (3 days of age) two pieces of pellets were placed daily into the nestbox after nursing. Later on it was increased to six pellets till 15 days of age. The kits consumed the additional solid feed (S and ST), however, it did not affect the BW, weight gain or survival. In experiment 2 (n=30 does, 240 kits) all does consumed commercial feed. The additional feed for kits was based on commercial piglet feed. Three groups were formed: the litters in control group were fed no additional solid feed (K), kits were fed additionally with pellets (8 mm of diameter) based on piglet feed powder, pellet adhesive and water (PI), and extra glycerin powder was added to the mixture of piglet feed powder and water (PG). The experiment lasted from the age of 3 days till 21 days. At the beginning six pellets were placed on the nest material. Later on the amount was gradually increased to 24 pellets till age of 15 days. The kits consumed the pellets. The BW of PI group differed from group PG at age of 5, 9, 12 and 21 days by +7.3%, +6.5%, +5.9%, +4.8%, respectively (P<0.05) and from group K at age of 12 days by +5.9% (P< 0.05). The differences were more expressed at age of 16 and 19 days in favour of group PI (from K by +7.1%, +6.9% and from PG by +5.9%, +5 8%, respectively, P<0.01) and at 21 days of age (from K by +6.2%, P<0.01). To find appropriate composition of creep feed for kits further studies are needed.
Catheter-associated urinary tract infections (CAUTIs) are among the most common hospital-acquired infections (HAIs). Reducing CAUTI rates has become a major focus of attention due to increasing public health concerns and reimbursement implications.
To implement and describe a multifaceted intervention to decrease CAUTIs in our ICUs with an emphasis on indications for obtaining a urine culture.
A project team composed of all critical care disciplines was assembled to address an institutional goal of decreasing CAUTIs. Interventions implemented between year 1 and year 2 included protocols recommended by the Centers for Disease Control and Prevention for placement, maintenance, and removal of catheters. Leaders from all critical care disciplines agreed to align routine culturing practice with American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines for evaluating a fever in a critically ill patient. Surveillance data for CAUTI and hospital-acquired bloodstream infection (HABSI) were recorded prospectively according to National Healthcare Safety Network (NHSN) protocols. Device utilization ratios (DURs), rates of CAUTI, HABSI, and urine cultures were calculated and compared.
The CAUTI rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. The DUR was 0.7 in 2013 and 0.68 in 2014. The HABSI rates per 1,000 patient days decreased from 2.8 in 2013 to 2.4 in 2014.
Effectively reducing ICU CAUTI rates requires a multifaceted and collaborative approach; stewardship of culturing was a key and safe component of our successful reduction efforts.
Shifting prey distributions due to global warming are expected to generate dramatic ecosystem-wide changes in trophic structure within Arctic marine ecosystems. Yet a relatively poor understanding of contemporary Arctic food webs makes it difficult to predict the consequences of such changes for Arctic predators. Doing so requires quantitative approaches that can track contemporary changes in predator diets through time, using accurate, well-defined methods. Here we use fatty acids (FA) to quantify differences in consumer diet using permutational multivariate analysis of variance tests that characterize spatial and temporal changes in consumer FA signatures. Specifically we explore differences in Greenland shark (Somniosus microcephalus) FA to differentiate their potential trophic role between Svalbard, Norway and Cumberland Sound, Canada. Greenland shark FA signatures revealed significant inter-annual differences, probably driven by varying seal and Greenland halibut responses to environmental conditions such as the NAO, bottom temperature, and annual sea-ice extent. Uncommon FA were also found to play an important role in driving spatial and temporal differences in Greenland shark FA profiles. Our statistical approach should facilitate quantification of changing consumer diets across a range of marine ecosystems.
Because depressive illness is recurrent, recurrence prevention should be a mainstay for reducing its burden on society. One way to reach this goal is to identify malleable risk factors. The ability to attenuate sadness/dysphoria (mood repair) and parasympathetic nervous system functioning, indexed as respiratory sinus arrhythmia (RSA), are impaired during depression and after it has remitted. The present study therefore tested the hypothesis that these two constructs also may mirror risk factors for a recurrent major depressive episode (MDE).
At time 1 (T1), 178 adolescents, whose last MDE had remitted, and their parents, reported on depression and mood repair; youths’ RSA at rest and in response to sad mood induction also were assessed. MDE recurrence was monitored until time 2 (T2) up to 2 years later. Mood repair at T1 (modeled as a latent construct), and resting RSA and RSA response to sadness induction (RSA profile), served to predict onset of first recurrent MDE by T2.
Consistent with expectations, maladaptive mood repair predicted recurrent MDE, above and beyond T1 depression symptoms. Further, atypical RSA profiles at T1 were associated with high levels of maladaptive mood repair, which, in turn, predicted increased risk of recurrent MDE. Thus, maladaptive mood repair mediated the effects of atypical RSA on risk of MDE recurrence.
This study documented that a combination of behavioral and physiological risk factors predicted MDE recurrence in a previously clinically referred sample of adolescents with depression histories. Because mood repair and RSA are malleable, both could be targeted for modification to reduce the risk of recurrent depression in youths.
Knowledge regarding interactions between predators and their prey is fundamental for understanding underlying links between climate change and ecosystem responses, including predator demographics, in the Southern Ocean. This study reports data on reproductive performance, total population size and diet composition for macaroni and chinstrap penguins breeding at Nyrøysa on Bouvetøya during the summers of 1996–97, 1998–99, 2000–01 and 2007–08. The breeding populations of these two species at Nyrøysa decreased significantly over the study period, with an 80% decline for chinstraps and a 50% decline for macaroni penguins, despite relatively high levels of chick production. During this period macaroni penguins at this site ate a diverse diet, dominated by myctophid fish and two krill species, whereas chinstrap penguins were Antarctic krill specialists. The population changes are probably primarily due to the expanding Antarctic fur seal population, and also to landslides that are the result of increased melting on the island which have destroyed penguin breeding sites. Additional impacts from global warming of the ocean might also be playing a role and could exacerbate the decline in these penguin populations if krill and other prey are negatively impacted in the future in this region. The local chinstrap penguin population would probably be most heavily affected given its narrow feeding niche and small current population size.