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Older patients with complex care needs and limited personal and social resources are heavy users of emergency department (ED) services and are often admitted when they present to the ED. Updated information is needed regarding the most effective strategies to appropriately avoid ED presentation and hospital admission among older patients.
This systematic review aimed to identify interventions that have demonstrated effectiveness in decreasing ED use and hospital admissions in older patients. We conducted a comprehensive literature search within Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials from database inception to July 2019 with no language restrictions. Interventional study designs conducted in populations of 65 years and older were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included hospital readmission, mortality, cost, and patient-reported outcomes.
Of 7,943 citations reviewed for eligibility, 53 studies were included in our qualitative synthesis, including 26 randomized controlled trials (RCT), 8 cluster-RCTs, and 19 controlled before-after studies. Data characterization revealed that community-based strategies reduced ED visits, particularly those that included comprehensive geriatric assessments and home visits. These strategies reported decreases in mean ED use (for interventions versus controls) ranging from -0.12 to -1.32 visits/patient. Interventions that included home visits also showed reductions in hospital admissions ranging from -6% to -14%. There was, however, considerable variability across individual studies with respect to outcome reporting, statistical analyses, and risk of bias, which limited our ability to further quantify the effect of these interventions.
Various interventional strategies to avoid ED presentations and hospital admissions for older patients have been studied. While models of care that include comprehensive geriatric assessments and home visits may reduce acute care utilization, the standardization of outcome measures is needed to further delineate which parts of these complex interventions are contributing to efficacy. The potential effects of multidisciplinary team composition on patient outcomes also warrant further investigation.
The objective of the CAEP Global Emergency Medicine (EM) panel was to identify successes, challenges, and barriers to engaging in global health in Canadian academic emergency departments, formulate recommendations for increasing engagement of faculty, and guide departments in developing a Global EM program.
A panel of academic Global EM practitioners and residents met regularly via teleconference in the year leading up to the CAEP 2018 Academic Symposium. Recommendations were drafted based on a literature review, three mixed methods surveys (CAEP general members, Canadian Global EM practitioners, and Canadian academic emergency department leaders), and panel members’ experience. Recommendations were presented at the CAEP 2018 Academic Symposium in Calgary and further refined based on feedback from the Academic Section.
A total of nine recommendations are presented here. Seven of these are directed towards Canadian academic departments and divisions and intend to increase their engagement in Global EM by recognizing it as an integral part of the practice of emergency medicine, deliberately incorporating it into strategic plans, identifying local leaders, providing tangible supports (i.e., research, administration or financial support, shift flexibility), mitigating barriers, encouraging collaboration, and promoting academic deliverables. The final two recommendations pertain to CAEP increasing its own engagement and support of Global EM.
These recommendations serve as guidance for Canadian academic emergency departments and divisions to increase their engagement in Global EM.
Apolipoprotein E (APOE) E4 is the main genetic risk factor for Alzheimer’s disease (AD). Due to the consistent association, there is interest as to whether E4 influences the risk of other neurodegenerative diseases. Further, there is a constant search for other genetic biomarkers contributing to these phenotypes, such as microtubule-associated protein tau (MAPT) haplotypes. Here, participants from the Ontario Neurodegenerative Disease Research Initiative were genotyped to investigate whether the APOE E4 allele or MAPT H1 haplotype are associated with five neurodegenerative diseases: (1) AD and mild cognitive impairment (MCI), (2) amyotrophic lateral sclerosis, (3) frontotemporal dementia (FTD), (4) Parkinson’s disease, and (5) vascular cognitive impairment.
Genotypes were defined for their respective APOE allele and MAPT haplotype calls for each participant, and logistic regression analyses were performed to identify the associations with the presentations of neurodegenerative diseases.
Our work confirmed the association of the E4 allele with a dose-dependent increased presentation of AD, and an association between the E4 allele alone and MCI; however, the other four diseases were not associated with E4. Further, the APOE E2 allele was associated with decreased presentation of both AD and MCI. No associations were identified between MAPT haplotype and the neurodegenerative disease cohorts; but following subtyping of the FTD cohort, the H1 haplotype was significantly associated with progressive supranuclear palsy.
This is the first study to concurrently analyze the association of APOE isoforms and MAPT haplotypes with five neurodegenerative diseases using consistent enrollment criteria and broad phenotypic analysis.
OBJECTIVES/SPECIFIC AIMS: The purpose of this study is to use the baboon as a novel animal model for breath research and to identify and characterize baboon breath metabolites that reflect cardiometabolic function to inform us in the development of a noninvasive, cost-effective, and repeatable point-of-care diagnostic breath test. METHODS/STUDY POPULATION: Blood and urine was collected from control and IUGR at the approximate age of 3.5 years. Both groups were then placed on a high fat, high sugar, high salt diet for 7 weeks, after which blood, urine, and breath were collected. The breath samples were then subjected to comprehensive, 2-dimensional gas chromatography coupled with time-of-flight mass spectrometry. Using ChromaTOF software, breath VOCs were identified with at least an 80% spectral match against the National Institute of Standards and Technology (NIST) chemical reference library. The raw data were then statistically analyzed using MetaboAnalyst. We then interrogated multiple online databases to characterize and identify the role of VOCs that were present in both control and IUGR groups. RESULTS/ANTICIPATED RESULTS: Preliminary analyses of the breath VOCs indicate differences in expression between sexes and in control Versus IUGR groups. These results indicate unique “breath signatures.” Further analysis of the breath VOCs reveals the presence of metabolites that are involved in β-oxidation and oxidative stress pathways. DISCUSSION/SIGNIFICANCE OF IMPACT: This breath study, a first of its kind, will develop the baboon as a superior animal model for breath biomarker research. Our observed unique “breath signatures” indicate changes in lipid metabolism and oxidative stress pathways, which we hypothesize are the early metabolic changes at the cellular level that are not yet reflected in clinical lab measures. Future directions include analyzing breath VOCs that did not meet 80% spectral match, validation using SPME technology and commercial standards, and initiating a human pilot study in clinically obese, at-risk children in collaboration with physicians at the Children’s Hospital of San Antonio to develop a noninvasive, cost-effective, rapid, and repeatable point-of-care diagnostic breath test.
Because individuals develop dementia as a manifestation of neurodegenerative or neurovascular disorder, there is a need to develop reliable approaches to their identification. We are undertaking an observational study (Ontario Neurodegenerative Disease Research Initiative [ONDRI]) that includes genomics, neuroimaging, and assessments of cognition as well as language, speech, gait, retinal imaging, and eye tracking. Disorders studied include Alzheimer’s disease, amyotrophic lateral sclerosis, frontotemporal dementia, Parkinson’s disease, and vascular cognitive impairment. Data from ONDRI will be collected into the Brain-CODE database to facilitate correlative analysis. ONDRI will provide a repertoire of endophenotyped individuals that will be a unique, publicly available resource.
We report on the analysis of virtual powder-diffraction patterns from serial femtosecond crystallography (SFX) data collected at an X-ray free-electron laser. Different approaches to binning and normalizing these patterns are discussed with respect to the microstructural characteristics which each highlights. Analysis of SFX data from a powder of Pr0.5Ca0.5MnO3 in this way finds evidence of other trace phases in its microstructure which was not detectable in a standard powder-diffraction measurement. Furthermore, a comparison between two virtual powder pattern integration strategies is shown to yield different diffraction peak broadening, indicating sensitivity to different types of microstrain. This paper is a first step in developing new data analysis methods for microstructure characterization from serial crystallography data.