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Recent work has demonstrated that Goshen points overlap in time with another group of unfluted lanceolate points from the Plains, Plainview points. This has raised the question of whether the two types should be kept separate or consolidated into a single type. We sought to resolve this issue by applying geometric morphometric methods to a sample of points from well-documented Goshen and Plainview assemblages. We found that their shapes were statistically indistinguishable, which indicates that Goshen and Plainview points should be assigned to the same type. Because Plainview points were recognized before Goshen points, it is the latter type name that should be dropped. Sinking Goshen into Plainview allows us to move beyond taxonomic issues and toward understanding both the spatiotemporal variation that exists among Plainview assemblages and what it can tell us about the adaptations and social dynamics of Plainview groups.
Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM).
Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators.
Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology.
This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.
Important Bird and Biodiversity Areas (IBAs) are sites identified as being globally important for the conservation of bird populations on the basis of an internationally agreed set of criteria. We present the first review of the development and spread of the IBA concept since it was launched by BirdLife International (then ICBP) in 1979 and examine some of the characteristics of the resulting inventory. Over 13,000 global and regional IBAs have so far been identified and documented in terrestrial, freshwater and marine ecosystems in almost all of the world’s countries and territories, making this the largest global network of sites of significance for biodiversity. IBAs have been identified using standardised, data-driven criteria that have been developed and applied at global and regional levels. These criteria capture multiple dimensions of a site’s significance for avian biodiversity and relate to populations of globally threatened species (68.6% of the 10,746 IBAs that meet global criteria), restricted-range species (25.4%), biome-restricted species (27.5%) and congregatory species (50.3%); many global IBAs (52.7%) trigger two or more of these criteria. IBAs range in size from < 1 km2 to over 300,000 km2 and have an approximately log-normal size distribution (median = 125.0 km2, mean = 1,202.6 km2). They cover approximately 6.7% of the terrestrial, 1.6% of the marine and 3.1% of the total surface area of the Earth. The launch in 2016 of the KBA Global Standard, which aims to identify, document and conserve sites that contribute to the global persistence of wider biodiversity, and whose criteria for site identification build on those developed for IBAs, is a logical evolution of the IBA concept. The role of IBAs in conservation planning, policy and practice is reviewed elsewhere. Future technical priorities for the IBA initiative include completion of the global inventory, particularly in the marine environment, keeping the dataset up to date, and improving the systematic monitoring of these sites.
It has long been assumed that Folsom points are more standardized than Clovis points, although an adequate test of this proposition has yet to be undertaken. Here, we address that deficiency by using data from a sample of Folsom and Clovis points recovered from sites across the western United States. We used geometric morphometric techniques to capture point shape and then conducted statistical analyses of variability associated with Clovis and Folsom point bases and blades. Our results demonstrate that Folsom bases and blades are less variable than those on earlier Clovis points, indicating an increase in point standardization during the Early Paleoindian period. In addition, despite published claims to the contrary, Clovis and Folsom point bases are no more variable than blades. Based on these results, we conducted additional analyses to examine the modularity and size of Clovis and Folsom points. The results suggest Clovis points have more integrated base and blade segments than Folsom points. We suggest that several classes of Clovis points—intended for different functions—might have been in use during the Clovis period and that the later Folsom points might have served only as weapon tips, the shape of which were constrained by the fluting process.
Rapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation.
A prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience.
During 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location.
Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed.
LemaPC, O’BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB.Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound. Prehosp Disaster Med.2018;33(4):406–410
We compared sepsis “time zero” and Centers for Medicare and Medicaid Services (CMS) SEP-1 pass rates among 3 abstractors in 3 hospitals. Abstractors agreed on time zero in 29 of 80 (36%) cases. Perceived pass rates ranged from 9 of 80 cases (11%) to 19 of 80 cases (23%). Variability in time zero and perceived pass rates limits the utility of SEP-1 for measuring quality.
Lewy body dementia (consisting of dementia with Lewy bodies and Parkinson's disease dementia) is a common neurodegenerative disease characterised by visual hallucinations, fluctuating attention, motor disturbances, falls, and sensitivity to antipsychotics. This combination of features presents challenges for pharmacological management. Given this, we sought to review evidence for non-pharmacological interventions with patients with Lewy body dementia and their carers. Bibliographic databases were searched using a wide range of search terms and no restrictions were placed on study design, language, or clinical setting. Two reviewers independently assessed papers for inclusion, rated study quality, and extracted data. The search identified 21 studies including two randomised controlled trials with available subgroup data, seven case series, and 12 case studies. Most studies reported beneficial effects of the interventions used, though the only sizeable study was on dysphagia, showing a benefit of honey-thickened liquids. Given the heterogeneity of interventions and poor quality of the studies overall, no quantitative synthesis was possible. Overall, identified studies suggested possible benefits of non-pharmacological interventions in Lewy body dementia, but the small sample sizes and low quality of studies mean no definite recommendations can be offered. Our findings underscore the clear and urgent need for future research on this topic.
The insurance hypothesis is a reasonable explanation for the current obesity epidemic. One alternative explanation is that the marketing of high-sugar foods, especially sugar-sweetened beverages, drives the rise in obesity. Another prominent hypothesis is that obesity spreads through social influence. We offer a framework for estimating the extent to which these different models explain the rise in obesity.
Alterations in the visual system may underlie visual hallucinations in
dementia with Lewy bodies (DLB). However, cortical excitability as measured
by transcranial magnetic stimulation (TMS) and functional magnetic resonance
imaging (fMRI) activation of lower visual areas (V1–3) to visual stimuli
appear normal in DLB. We explored the relationship between TMS-determined
phosphene threshold and fMRI-related visual activation and found a positive
relationship between the two in controls but a negative one in DLB. This
double dissociation suggests a loss of inhibition in the visual system in
DLB, which may predispose individuals to visual dysfunction and visual
Imaging biomarkers for Alzheimer's disease include medial temporal lobe
atrophy (MTLA) depicted on computed tomography (CT) or magnetic resonance
imaging (MRI) and patterns of reduced metabolism on fluorodeoxyglucose
positron emission tomography (FDG-PET).
To investigate whether MTLA on head CT predicts the diagnostic usefulness
of an additional FDG-PET scan.
Participants had a clinical diagnosis of Alzheimer's disease
(n = 37) or dementia with Lewy bodies (DLB;
n = 30) or were similarly aged controls
(n = 30). We visually rated MTLA on coronally
reconstructed CT scans and, separately and blind to CT ratings, abnormal
appearances on FDG-PET scans.
Using a pre-defined cut-off of MTLA ⩾5 on the Scheltens (0–8) scale, 0/30
controls, 6/30 DLB and 23/30 Alzheimer's disease had marked MTLA. FDG-PET
performed well for diagnosing Alzheimer's disease v. DLB
in the low-MTLA group (sensitivity/specificity of 71%/79%), but in the
high-MTLA group diagnostic performance of FDG-PET was not better than
In the presence of a high degree of MTLA, the most likely diagnosis is
Alzheimer's disease, and an FDG-PET scan will probably not provide
significant diagnostic information. However, in cases without MTLA, if
the diagnosis is unclear, an FDG-PET scan may provide additional
clinically useful diagnostic information.
Ronald Mason’s hypothesis from the 1960s that the southeastern United States possesses greater Paleoindian projectile-point diversity than other regions is regularly cited, and often assumed to be true, but in fact has never been quantitatively tested. Even if valid, however, the evolutionary meaning of this diversity is contested. Point diversity is often linked to Clovis “origins,” but point diversity could also arise from group fissioning and drift, admixture, adaptation, or multiple founding events, among other possibilities. Before archaeologists can even begin to discuss these scenarios, it is paramount to ensure that what we think we know is representative of reality. To this end, we tested Mason’s hypothesis for the first time, using a sample of 1,056 Paleoindian points from eastern North America arui employing paradigmatic classification and rigorous statistical tools used in the quantification of ecological biodiversity. Our first set of analyses, which compared the Southeast to the Northeast, showed that the Southeast did indeed possess significantly greater point-class richness. Although this result was consistent with Mason’s hypothesis, our second set of analyses, which compared the Upper Southeast to the Lower Southeast and the Northeast showed that in terms of point-class richness the Upper Southeast > Lower Southeast > Northeast. Given current chronometrie evidence, we suggest that this latter result is consistent with the suggestion that the area of the Ohio, Cumberland, and Tennessee River valleys, as well as the mid-Atlantic coastal plain, were possible initial and secondary “staging areas” for colonizing Paleoindian foragers moving from western to eastern North America.
It is said we are in trouble, we humanists. “The humanities are under pressure all over the world, Rens Bod begins (xii). James Turner ends, “Without question, the humanities now face greater flux than they have routinely endured in the past century” (385). The trouble and the flux seem to take two forms. There is the usual business of intellectual disciplines forming and re-forming, of new paradigms restructuring institutions, a process that one might regard as discomforting but sometimes healthy. But there is the other business of universities being governed by anti-intellectuals, aficionados of the spreadsheet, counted beans, and the alumni dinner. These predators roam campuses, sneer at libraries, abolish departments, and plan the day when, the cost-effective triumphant, scholarship will be little more than a digital ghost. At the University of Essex, lately Marina Warner was coldly informed of this new order, defined by a “Tariff of Expectations” (seventeen targets to be met) and a “workload allocation” handed down from on high. There was an indifference to what had gone before, what creative people had once hoped for for Colchester. “That is all changing now,” the executive dean for humanities briskly explained. “That is over.” The past, that is. Fed up, Warner resigned, hearing too loudly “the tick of the deathwatch beetle” in the fabric of the house she wished to inhabit, a university that valued scholarship and the life of the mind, as it once had.
Sustainability, culture change, inequality and global health are among the much-discussed challenges of our time, and rightly so, given the drastic effects such variables can have on modern populations. Yet with many populations today living in tightly connected geographic communities—cities, for example—or in highly networked electronic communities, can we still learn anything about societal challenges by studying simple farming communities from many thousands of years ago? We think there is much to learn, be it Malthusian pressures and ancient societal collapse, the devastating effects of European diseases on indigenous New World populations or endemic violence in pre-state societies (e.g. Pinker 2012). By affording a simpler, ‘slow motion’ view of processes that are greatly accelerated in this century, the detailed, long-term record of the European Neolithic can offer insight into many of these fundamental issues. These include: human adaptations to environmental change (Palmer & Smith 2014), agro-pastoral innovation, human population dynamics, biological and cultural development, hereditary inequality, specialised occupations and private ownership.
Positron emission tomography (PET) and single photon emission computed tomography (SPECT) brain imaging are widely used as diagnostic tools for suspected dementia but no studies have directly compared participant views of the two procedures. We used a range of methods to explore preferences for PET and SPECT.
Patients and controls (and accompanying carers) completed questionnaires immediately after undergoing PET and SPECT brain scans. Pulse rate data were collected during each scan. Scan attributes were prioritized using a card sorting exercise; carers and controls additionally answered willingness to pay (WTP) questions.
Few differences were found either between the scans or groups of participants, although carers marginally preferred SPECT. Diagnostic accuracy was prioritized over other scan characteristics. Mean heart rate during both scans was lower than baseline heart rate measured at home (p < 0.001).
Most participants viewed PET and SPECT scans as roughly equivalent and did not have a preference for either scan. Carer preference for SPECT is likely to reflect their desire to be with the patient (routine practice for SPECT but not for PET), suggesting that they should be able to accompany vulnerable patients throughout imaging procedures wherever possible. Pulse rate data indicated that brain imaging was no more stressful than a home visit (HV) from a researcher. The data do not support the anecdotal view that PET is a more burdensome procedure and the use of PET or SPECT scans in dementia should be based on diagnostic accuracy of the technique.
The primary aim of this study was to determine the characteristics and develop a predictive model describing low acuity users of the emergency department (ED) by patients followed by a family health team (FHT). The secondary aim was to contrast this information with characteristics of high acuity users. We also sought to determine what factors were predictive of leaving without being seen (LWBS).
This retrospective descriptive correlational study explored characteristics and factors predictive of low acuity ED utilization. The sample included all FHT patients with ED visits in 2011. The last ED record was chosen for review. Sex, age, Canadian Triage and Acuity Scale (CTAS), presenting complaint(s), time of day, day of week, number of visits, and diagnosis were recorded.
Of 1580 patients who visited the ED in 2011, 56% were CTAS 1–3 visits, 24% CTAS 4–5 and 20% had no CTAS recorded. Patients who were older than age 65 were approximately half as likely to have a CTAS level of 4–5 compared to younger patients (OR=0.605, CI=0.441,0.829). Patients older than age 65 were 1.75 times more likely to be CTAS level 1–2 (OR=1.745, CI=1.277, 2.383). Patients who went to the ED during the day were less likely to LWBS compared to night visits (OR=0.697, CI=0.532, 0.912).
Most low acuity ED utilization is by patients under the age of 65, while high acuity ED utilization is more common among patients older than age 65. Patients are more likely to LWBS during late evening and overnight periods (9 pm–7 am).