To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
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.
Children with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals (TOF/MAPCAs) are at risk for post-operative respiratory complications after undergoing unifocalisation surgery. Thus, we assessed and further defined the incidence of airway abnormalities in our series of over 500 children with TOF/MAPCAs as determined by direct laryngoscopy, chest computed tomography (CT), and/or bronchoscopy.
The medical records of all patients with TOF/MAPCAs who underwent unifocalisation or pulmonary artery reconstruction surgery from March, 2002 to June, 2018 were reviewed. Anaesthesia records, peri-operative bronchoscopy, and/or chest CT reports were reviewed to assess for diagnoses of abnormal or difficult airway. Associations between chromosomal anomalies and airway abnormalities – difficult anaesthetic airway, bronchoscopy, and/or CT findings – were defined.
Of the 564 patients with TOF/MAPCAs who underwent unifocalisation or pulmonary artery reconstruction surgery at our institution, 211 (37%) had a documented chromosome 22q11 microdeletion and 28 (5%) had a difficult airway/intubation reported at the time of surgery. Chest CT and/or peri-operative bronchoscopy were performed in 234 (41%) of these patients. Abnormalities related to malacia or compression were common. In total 35 patients had both CT and bronchoscopy within 3 months of each other, with concordant findings in 32 (91%) and partially concordant findings in the other 3.
This is the largest series of detailed airway findings (direct laryngoscopy, CT, and bronchoscopy) in TOF/MAPCAS patients. Although these findings are specific to an at-risk population for airway abnormalities, they support the utility of CT and /or bronchoscopy in detecting airway abnormalities in patients with TOF/MAPCAs.
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.
The aim of this study is to identify the types of community paramedicine programs and the training for each.
A systematic review of MEDLINE, Embase, grey literature, and bibliographies followed a search strategy using common community paramedicine terms. All studies published in English up to January 22, 2018, were captured. Screening and extraction were completed in duplicate by two independent reviewers. The Mixed Methods Appraisal Tool (MMAT) was used to assess studies’ methodological quality (full methodology on PROSPERO: CRD42017051774).
From 3,004 papers, there were 64 papers identified (58 unique community paramedicine programs). Of the papers with an appraisable study design (40.6%), the median MMAT score was 3 of 4 criteria met, suggesting moderate quality. Programs most often served frequent 911 callers (48.3%) and individuals at risk for emergency department admission, readmission, or hospitalization (41.4%); and 70.7% of programs were preventive home visits. Common services provided were home assessment (29.5%), medication management (39.7%), and referral and/or transport to community services (37.9%); and 77.6% of programs involved interprofessional collaboration. Community paramedicine training was described by 57% of programs and expanded upon traditional paramedicine training and emphasized technical skills. Study heterogeneity prevented meta-analysis.
Community paramedicine programs and training were diverse and allowed community paramedics to address a spectrum of population health and social needs. Training was poorly described. Enabling more programs to assess and report on program and training outcomes would support community paramedicine growth and the development of formalized training or education frameworks.
Background: Human induced pluripotent stem cell-derived neural stem cells (hiPS-NSCs) represent an exciting therapeutic approach for traumatically spinal cord injury (SCI). Unfortunately, most patients are the in chronic injury phase where a dense perilesional chondroitin sulfate proteoglycan (CSPG) scar significantly hinders regeneration. CSPG-degrading enzymes can enhance NSC-mediated recovery, however, nonspecific intrathecal administration causes off-target effects. We aimed to genetically engineer hiPS-NSCs to express a scar-degrading ENZYME into their local environment to enhance functional recovery. Methods: A bicistronic scar-degrading ENZYME and RFP reporter vector was non-virally integrated into hiPS-NSCs and monoclonalized. ENZYME activity was assessed by WST-1 and DMMB biochemical assays and an in vitro CSPG spot assay with hiPS-NSC-derived neurons. To assess in vivo efficacy, T-cell deficient rats (N=60) with chronic (8wk) C6-7 SCIs were randomized to receive (1)SMaRT cells, (2)hiPS-NSCs, (3)vehicle, or (4)sham surgery. Results: SMaRT cells retained key hiPS-NSC characteristics while stably expressing ENZYME. The expressed ENZYME could appropriately degrade in vitro and ex vivo CSPGs. While blinded neurobehavioural and immunohistochemical assessments are ongoing at 40wks post-injury, an interim analysis demonstrated human cells extending remarkably long (≥20,000µm) axons along host white matter tracts. Conclusions: This work provides exciting proof-of-concept data that genetically-engineered SMaRT cells can degrade CSPGs and human NSCs can extend long-distance processes in chronic SCI.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Introduction: The management of patient flow in the emergency department (ED) is crucial for the practice of emergency medicine (EM). However, this skill is difficult to teach didactically and is learned implicitly in the latter half of residency training. To help expedite the learning process, we developed the GridlockED board game as an educational tool to simulate ED patient flow. By having junior medical trainees play this game, we believe that they will develop a greater understanding of patient flow and resource management in the ED. Additionally, since GridlockED is a cooperative game, players may also benefit by improving their communication and teamwork skills. Methods: GridlockED was developed over twenty months of iterative gameplay and review. Feedback from attending emergency physicians, residents, and medical students was integrated into the game through a Plan-Do-Study-Act (PDSA) model. Emergency medicine nurses, physicians and residents at McMaster University were recruited to play GridlockED. Each player completed a pre-survey to collect demographic data and to assess their prior experience with playing board games. All play sessions were recorded for data collection purposes. Following each game session, a member of the research team conducted an exit interview with the players to gather information about their play experience and the educational value of the game. A post-survey was also sent to each participant for further feedback. Results: Eighteen gameplay sessions were conducted from June to August 2017. A total of thirty-two participants played the game (13 emergency physicians, 15 residents, and four nurses). Overall responses to the post-gameplay survey showed that players endorsed GridlockED as a useful potential teaching tool (75%, n=24/32) and the majority felt that it had the potential to improve patient flow in the ED (56%, n=18/32). Most participants found that the game was easy to play (91%, n=27/29), and that the instructions were clear (87.5%, n=28/32). Respondents also felt that the game reflected real life scenarios (56%, n=18) and that cases reflected the types of patients that they saw in the ED (78%, n=25). Conclusion: Our results have shown an overall positive response to GridlockED, with most participants supporting it as both an engaging board game and potential teaching tool. We believe that future studies with larger sample sizes and medical students will further validate the use of serious games in medical education.
The purpose of this study was to investigate whether significant difference exists on radiation dose delivered to organs at risks in megavoltage computed tomography (MVCT) verification using three predefined scanning modes, namely fine (2 mm), normal (4 mm) and coarse (6 mm). This will provide information for the imaging protocol of tomotherapy for the left breast.
Materials and methods
Organ doses were measured using thermoluminescent dosimeters (TLD-100) placed within a female Rando phantom for MVCT imaging. Kruskal–Wallis test was conducted with p<0·05 to evaluate the significant difference between the three MVCT scanning modes.
Statistically significant difference existed in organ absorbed dose between different scan mode selections (p<0·001). Relative to the normal scan selection (4 mm), the absorbed dose to the organs of interests can be scaled down by 0·7 and scaled up by 2·1 for coarse (6 mm) and fine scans (2 mm) respectively.
Optimisation of imaging protocols is of paramount importance to keep the radiation exposure ‘as low as reasonably achievable’. The recommendation of undergoing daily coarse mode for MVCT verification in breast tomotherapy not only mitigates the radiation exposure to normal tissues, but also trims the scan-acquisition time.
Mycobacterial diseases are prevalent in cancer and rheumatoid arthritis (RA) patients, especially those receiving tumor necrosis factor-α inhibitor (TNFi). However, the impact of cancer development on the risk of mycobacterial diseases among RA patients is unknown. Data from the Taiwan National Health Insurance Research Database were used to conduct a retrospective study to assess the occurrence of mycobacterial diseases in RA patients developing cancer (cancer-positive), those using TNFi (TNFi-exposure), those with cancer and using TNFi (cancer-TNFi-comb), and those without cancer and not using TNFi (cancer-TNFi-free). Cancer and TNFi exposure were time-dependent, and independent risk factors of mycobacterial diseases were assessed by Cox regression. Among 1344 RA patients diagnosed during 2000–2013, 68 (5·1%) developed cancer before their end points. The incidence rates of mycobacterial diseases in the cancer-positive (n = 56), TNFi-exposure (n = 290), cancer-TNFi-comb (n = 12), and cancer-TNFi-free (n = 986) subgroups were 6·7, 2·0, 7·6, and 1·3 per 1000 person-years, respectively. As compared with the cancer-TNFi-free group, the risk for mycobacterial diseases increased for the TNFi-exposure group (adjusted HR = 3·6, 95% confidence interval (95% CI) 1·1–11·5, P = 0·032) and remained high for cancer-positive (adjusted HR = 14·6, 95% CI 3·3–63·7, P < 0·001) after adjustment. This study suggested that cancer development increased the risk of mycobacterial diseases in RA patients, and risk assessment for this subgroup should be considered.
Faster eating rates are associated with increased energy intake, but little is known about the relationship between children’s eating rate, food intake and adiposity. We examined whether children who eat faster consume more energy and whether this is associated with higher weight status and adiposity. We hypothesised that eating rate mediates the relationship between child weight and ad libitum energy intake. Children (n 386) from the Growing Up in Singapore Towards Healthy Outcomes cohort participated in a video-recorded ad libitum lunch at 4·5 years to measure acute energy intake. Videos were coded for three eating-behaviours (bites, chews and swallows) to derive a measure of eating rate (g/min). BMI and anthropometric indices of adiposity were measured. A subset of children underwent MRI scanning (n 153) to measure abdominal subcutaneous and visceral adiposity. Children above/below the median eating rate were categorised as slower and faster eaters, and compared across body composition measures. There was a strong positive relationship between eating rate and energy intake (r 0·61, P<0·001) and a positive linear relationship between eating rate and children’s BMI status. Faster eaters consumed 75 % more energy content than slower eating children (Δ548 kJ (Δ131 kcal); 95 % CI 107·6, 154·4, P<0·001), and had higher whole-body (P<0·05) and subcutaneous abdominal adiposity (Δ118·3 cc; 95 % CI 24·0, 212·7, P=0·014). Mediation analysis showed that eating rate mediates the link between child weight and energy intake during a meal (b 13·59; 95 % CI 7·48, 21·83). Children who ate faster had higher energy intake, and this was associated with increased BMI z-score and adiposity.
In continuation of our earlier studies (Singh, Roxburgh & Chan 1997a,b; hereafter SRC97a,b) we perform some further tests to study the general behaviour of penetrative convection and its scaling with rms vertical velocity by varying a number of input parameters like the aspect ratio and the positioning of the interface between the unstable-lower stable layer.
In this study, attention is focused on the numerical simulations of laminar fluid flow and heat transfer in straight smooth-walled parallelogram channels with various aspect ratios (α) and inclined angles (θ). The Reynolds number (Re), characterized by the channel hydraulic diameter and the working fluid of water, is fixed at 100. The examined α and θ range from 1 to 10 and 45° to 90°, respectively. Their effects on the thermal fluid features are explored under three thermal boundary conditions: constant wall temperature (TBC), constant axial heat transfer rate with constant peripheral temperature (H1BC), and constant wall heat flux (H2BC). The SIMPLE algorithm is employed for velocity–pressure coupling with the algebraic multigrid method, while the second-order upwind scheme is utilized for spatial discretization in pressure term; the momentum and energy equations are solved with a QUICK scheme; Least Squares Cell-Based Gradient Evaluation is applied for predicting scalar values at the cell faces and for computing secondary diffusion terms and velocity derivatives. One of the new findings is that there exists a critical value of θ = 70° below which the Nusselt number under H2BC increases with increasing α whereas beyond which the trend reverses, a result distinct from those computed with TBC and H1BC. Moreover, TBC is found to be a time-saving alternative to H1BC. Furthermore, both Nusselt numbers under the three thermal boundary conditions and friction factor times Re are successfully and compactly correlated with α and θ to offer useful reference for designing micro-cooling channels.
Relapse is distressingly common after the first episode of psychosis, yet it is poorly understood and difficult to predict. Investigating changes in cognitive function preceding relapse may provide new insights into the underlying mechanism of relapse in psychosis. We hypothesized that relapse in fully remitted first-episode psychosis patients was preceded by working memory deterioration.
Visual memory and verbal working memory were monitored prospectively in a 1-year randomized controlled trial of remitted first-episode psychosis patients assigned to medication continuation (quetiapine 400 mg/day) or discontinuation (placebo). Relapse (recurrence of positive symptoms of psychosis), visual (Visual Patterns Test) and verbal (Letter–Number span test) working memory and stressful life events were assessed monthly.
Remitted first-episode patients (n = 102) participated in the study. Relapsers (n = 53) and non-relapsers (n = 49) had similar baseline demographic and clinical profiles. Logistic regression analyses indicated relapse was associated with visual working memory deterioration 2 months before relapse [odds ratio (OR) 3.07, 95% confidence interval (CI) 1.19–7.92, P = 0.02], more stressful life events 1 month before relapse (OR 2.11, 95% CI 1.20–3.72, P = 0.01) and medication discontinuation (OR 5.52, 95% CI 2.08–14.62, P = 0.001).
Visual working memory deterioration beginning 2 months before relapse in remitted first-episode psychosis patients (not baseline predictor) may reflect early brain dysfunction that heralds a psychotic relapse. The deterioration was found to be unrelated to a worsening of psychotic symptoms preceding relapse. Testable predictors offer insight into the brain processes underlying relapse in psychosis.
Spectra at 16 - 45 μm of several regions within the central 80″ of the Galaxy have been obtained at 20″ resolution using the Goddard Cryogenic Grating Spectrometer No. 2 on the Kuiper Airborne Observatory. A broad band of excess emission extending from 24 to 45 μm is present in the spectra at positions covering the “tongue” and the inner edge of the circumnuclear disk. A similar dust emission feature has been observed in some carbon-rich evolved stars and in a nitrogen-rich evolved massive star. The observations reported here are the first detection of this dust emission feature in the interstellar medium. After considering several possible candidates of the carrier for this 30 μm dust feature, we find that MgS is the best owing to its good fit to the observed spectra. The origin of this ~ 30 μm feature in the Galactic center is unknown. Based on the theoretical results of dust condensation and elemental abundances in a supernova, we find that the supernovae in the central 500 pc could provide the amount of MgS dust, which we proposed as the carrier of the 30 μm dust feature, observed in the central 3 pc.
Carbapenem-resistant Acinetobacter baumannii (CRAB) with diverse multilocus sequence typing emerged among our nursing home residents (6.5%) with a high background rate of MRSA (32.2%). Rectal swabs yielded a higher rate of CRAB detection than axillary or nasal swabs. Bed-bound status, use of adult diapers, and nasogastric tube were risk factors for CRAB colonization.
During 1990 we surveyed the southern sky using a multi-beam receiver at frequencies of 4850 and 843 MHz. The half-power beamwidths were 4 and 25 arcmin respectively. The finished surveys cover the declination range between +10 and −90 degrees declination, essentially complete in right ascension, an area of 7.30 steradians. Preliminary analysis of the 4850 MHz data indicates that we will achieve a five sigma flux density limit of about 30 mJy. We estimate that we will find between 80 000 and 90 000 new sources above this limit. This is a revised version of the paper presented at the Regional Meeting by the first four authors; the surveys now have been completed.
Neurological soft signs (NSS) have long been considered potential endophenotypes for schizophrenia. However, few studies have investigated the heritability and familiality of NSS. The present study examined the heritability and familiality of NSS in healthy twins and patient–relative pairs.
The abridged version of the Cambridge Neurological Inventory was administered to 267 pairs of monozygotic twins, 124 pairs of dizygotic twins, and 75 pairs of patients with schizophrenia and their non-psychotic first-degree relatives.
NSS were found to have moderate but significant heritability in the healthy twin sample. Moreover, patients with schizophrenia correlated closely with their first-degree relatives on NSS.
Taken together, the findings provide evidence on the heritability and familiality of NSS in the Han Chinese population.