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Opioid related mortality rate has increased 200% over the past decade. Studies show variable emergency department (ED) opioid prescription practices and a correlation with increased long-term use. ED physicians may be contributing to this problem. Our objective was to analyze ED opioid prescription practices for patients with acute fractures.
We conducted a review of ED patients seen at two campuses of a tertiary care hospital. We evaluated a consecutive sample of patients with acute fractures (January 2016–April 2016) seen by ED physicians. Patients admitted or discharged by consultant services were excluded. The primary outcome was the proportion of patients discharged with an opioid prescription. Data were collected using screening lists, electronic records, and interobserver agreement. We calculated simple descriptive statistics and a multivariable analysis.
We enrolled 816 patients, including 441 females (54.0%). Most common fracture was wrist/hand (35.2%). 260 patients (31.8%) were discharged with an opioid; hydromorphone (N = 115, range 1–120 mg) was most common. 35 patients (4.3%) had pain related ED visits <1 month after discharge. Fractures of the lumbar spine (OR 10.78 [95% CI: 3.15–36.90]) and rib(s)/sternum/thoracic spine (OR 5.46 [95% CI: 2.88–10.35)] had a significantly higher likelihood of opioid prescriptions.
The majority of patients presenting to the ED with acute fractures were not discharged with an opioid. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Overall, there were few return to ED visits. We recommend standardization of ED opioid prescribing, with attention to limiting total dosage.
Little data exists about the methodology of contextualizing version two of the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) in resource-poor settings. This paper describes the contextualisation and pilot testing of the guide in Kilifi, Kenya.
Contextualisation was conducted as a collaboration between the KEMRI-Wellcome Trust Research Programme (KWTRP) and Kilifi County Government's Department of Health (KCGH) between 2016 and 2018. It adapted a mixed-method design and involved a situational analysis, stakeholder engagement, local adaptation and pilot testing of the adapted guide. Qualitative data were analysed using content analysis to identify key facilitators and barriers to the implementation process. Pre- and post-training scores of the adapted guide were compared using the Wilcoxon signed-rank test.
Human resource for mental health in Kilifi is strained with limited infrastructure and outdated legislation. Barriers to implementation included few specialists for referral, unreliable drug supply, difficulty in translating the guide to Kiswahili language, lack of clarity of the roles of KWTRP and KCGH in the implementation process and the unwillingness of the biomedical practitioners to collaborate with traditional health practitioners to enhance referrals to hospital. In the adaptation process, stakeholders recommended the exclusion of child and adolescent mental and behavioural problems, as well as dementia modules from the final version of the guide. Pilot testing of the adapted guide showed a significant improvement in the post-training scores: 66.3% (95% CI 62.4–70.8) v. 76.6% (95% CI 71.6–79.2) (p < 0.001).
The adapted mhGAP-IG version two can be used across coastal Kenya to train primary healthcare providers. However, successful implementation in Kilifi will require a review of new evidence on the burden of disease, improvements in the mental health system and sustained dialogue among stakeholders.
Radiocarbon (14C) analysis of carbon dioxide (CO2) provides unique information on the age, turnover and source of this important greenhouse gas, raising the prospect of novel scientific investigations into a range of natural and anthropogenic processes. To achieve these measurements, cartridges containing zeolite molecular sieves are a reliable and convenient method for collecting CO2 samples. At the NERC Radiocarbon Facility (East Kilbride) we have been refining our molecular sieve methods for over twenty years to achieve high-quality, reproducible and precise measurements. At the same time, we have been developing novel field sampling methods to expand the possibilities in collecting gas from the atmosphere, soil respiration and aquatic environments. Here, we present our latest improvements to cartridge design and procedures. We provide the results of tests used to verify the methods using known 14C content standards, demonstrating reliability for sample volumes of 3 mL CO2 (STP; 1.6 mg C) collected in cartridges that had been prepared at least three months earlier. We also report the results of quality assurance standards processed over the last two years, with results for 22 out of 23 international 14C standards being within measurement uncertainty of consensus values. We describe our latest automated procedures for the preparation of cartridges prior to use.
Background: Paediatric specialist dental practitioners are often faced with the challenge of disruptive behaviour or refusal to comply with treatment. Behaviour management skills are an essential component of their role. However, little is known of the confidence or competence of practitioners in these approaches. Aim: To identify paediatric dentists’ knowledge of behavioural management principles as applied to paediatric dentistry. Method: Postal questionnaire survey of all specialists in Paediatric Dentistry on the General Dental Council UK register (n = 234), using the Knowledge of Behavioural Principles as Applied to Children Questionnaire (KBPACQ; O'Dell, 1979) adapted for the dental setting. Information was also gathered on experience in using behavioural management techniques and demographics. Results: Responses were received from 105 practitioners (45%). Participants gave the correct answer, on average, to 38% of the items (range 0 to 75%). Conclusion: Knowledge of behavioural principles amongst paediatric dentists in the United Kingdom is poor, despite their widespread reported use of such techniques.
Graphics Processing Units (GPUs) offer potential for very high performance; they are also rapidly evolving. Obsidian is an embedded language (in Haskell) for implementing high performance kernels to be run on GPUs. We would like to have our cake and eat it too; we want to raise the level of abstraction beyond CUDA code and still give the programmer control over the details relevant to kernel performance. To that end, Obsidian provides array representations that guarantee elimination of intermediate arrays while also using the type system to model the hierarchy of the GPU. Operations are compiled very differently depending on what level of the GPU they target, and as a result, the user is gently constrained to write code that matches the capabilities of the GPU. Thus, we implement not Nested Data Parallelism, but a more limited form that we call Hierarchical Data Parallelism. We walk through case-studies that demonstrate how to use Obsidian for rapid design exploration or auto-tuning, resulting in performance that compares well to the hand-tuned kernels used in Accelerate and NVIDIA Thrust.
We have mapped cold atomic gas in 21cm line H i self-absorption (HISA) at arcminute resolution over more than 90% of the Milky Way's disk. To probe the formation of H2 clouds, we have compared our HISA distribution with CO J = 1-0 line emission. Few HISA features in the outer Galaxy have CO at the same position and velocity, while most inner-Galaxy HISA has overlapping CO. But many apparent inner-Galaxy HISA-CO associations can be explained as chance superpositions, so most inner-Galaxy HISA may also be CO-free. Since standard equilibrium cloud models cannot explain the very cold H i in many HISA features without molecules being present, these clouds may instead have significant CO-dark H2.
To determine relative rates of blood culture contamination for 3 skin antisepsis interventions—10% povidone iodine aqueous solution (PI), 2% iodine tincture (IT), and 2% chlorhexidine gluconate in 70% isopropyl alcohol (CHG)—when used by dedicated phlebotomy teams to obtain peripheral blood cultures.
Randomized crossover trial with hospital floor as the unit of randomization.
Teaching hospital with 885 beds.
All adult patients undergoing peripheral blood culture collection on 3 medical-surgical floors from May 2009 through September 2009.
Each antisepsis intervention was used for 5 months on each study floor, with random crossover after a 1-month washout period. Phlebotomy teams collected all peripheral blood cultures. Each positive blood culture was adjudicated by physicians blinded to the intervention and scored as a true positive or contaminated blood culture. The primary outcome was the rate of blood culture contamination for each antisepsis agent.
In total, 12,904 peripheral blood culture sets were evaluated, of which 735 (5.7%) were positive. There were 98 contaminated cultures, representing 13.3% of all positive cultures. The overall blood culture contamination rate for the study population was 0.76%. Intent-to-treat rates of contaminated blood cultures were not significantly different among the 3 antiseptics (P = .18), yielding 0.58% with PI (95% confidence interval [CI], 0.38%-0.86%), 0.76% with IT (95% CI, 0.52%-1.07%), and 0.93% with CHG (95% CI, 0.67%-1.27%).
Choice of antiseptic agent does not impact contamination rates when blood cultures are obtained by a phlebotomy team and should, therefore, be based on costs or preference.
Population subdivision among mouflon sheep Ovis gmelini ewes and ranging behaviour of rams were investigated in the Caroux-Espinouse massif (southern France). Radio-tracking data from 32 ewes and 41 rams monitored in the course of a 10-year study were used to identify female units and to document the movement patterns of males during the rutting period. Cluster analyses, based on the distance between arithmetic centres and on the degree of overlap of locations, were computed. Ewes were found to be partitioned in three or four main units to which they were faithful. Movement patterns of rams were much more variable: half were faithful to a rutting range, overlapping one or more unit(s), and the others were not. We suggest that a combination of social and spatial attachment could explain this ranging behaviour. Females build up their spatial habits following their mothers and, when adults, they occupy the area where they have been reared. Their spatial attachment is consistent with their social preferences for other females. Males balance between antagonistic spatial attachment and social preferences for other males, and differ in terms of spatial behaviour. The genetic implications are discussed.
The Times Literary Supplement on March 21st 1975 printed an article by you entitled ‘Fashions in fashion history’. Subsequently you have said that your aim in publishing that piece was ‘to try to persuade publishers to put out some useful material’, such as annotated transcriptions of important inventories listing items of dress, and a series of books dealing with changes in fashion in particular places at particular times. What do you see as the major gaps in the literature of fashion at the present time?
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