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Introduction: This study aims to evaluate the accuracy of the Échelle québécoise de triage préhospitalier en traumatologie (EQTPT) to identify patients who will need urgent and specialized trauma care in the La Capitale-Nationale region, province of Quebec. Methods: A detailed review of prehospital and in-hospital medical charts was conducted for a sample of patients transported following a trauma by ambulance to one of the five CHU de Quebec's emergency departments (ED) between November 2016 and March 2017. Data related to the trauma mechanism, population, injuries sustained, diagnosis, intervention and patient outcomes were extracted. The study primary outcome was the use of at least one urgent and specialized trauma care defined as: admission to the intensive care unit (ICU), urgent surgery within less than 24 hours after arrival (excluding orthopedic surgery for one limb only), intubation in ED, angioembolization within 24 hours after ED arrival, activation of a massive transfusion protocol in the ED. Also, patients who died secondary to their trauma were also considered as requiring urgent care. Results: 902 patients were included. The mean age (SD) was 59 (28.5) years old, 494 (54.8%) were female. The main trauma mechanisms were falls (592 (65.6%)) followed by motor vehicle accident (201 (22%)). 367 (40.7%) patients were transported directly to the tertiary trauma centre from the field. 231 (25.6%) patients had at least one criteria included in the steps 1, 2 or 3 of the EQTPT. Subsequently, most patients (649 (71.9%) were discharged home from the ED while 177 (19.6%) patients were admitted to the hospital. 82 (9.1%) patients required urgent and specialized trauma care. Of these 82 patients, 27 patients (32%) were identified in step 1 of the protocol, 12 patients (14.6%) in step 2, 5 patients (6.1%) in step 3, 13 patients (15.9%) in step 4 and 2 patients (2.4%) in step 5 while 23 (28.0%) patients were not identified by any steps of the EQTPT protocol. Therefore, 44 (53.6%) of the patients requiring urgent and specialized trauma care were identified by the criteria proposed in the steps 1, 2 or 3. Conclusion: In this retrospective cohort study, the EQTPT was insensitive to identify trauma patients who will need prompt and complex trauma management. Studies are required to determine the factors that could help improve its accuracy.
Introduction: Trauma care is highly complex and prone to medical errors. Accordingly, several studies have identified adverse events and conditions leading to potentially preventable or preventable deaths. Depending on the availability of specialized trauma care and the trauma system organization, between 10 and 30% of trauma-related deaths worldwide could be preventable if optimal care was promptly delivered. This narrative review aims to identify the main determinants and areas for improvements associated with potentially preventable trauma mortality. Methods: A literature review was performed using Medline, Embase and Cochrane Central Register of Controlled Trials from 1990 to a maximum of 6 months before submission for publication. Experimental or observational studies that have assessed determinants and areas for improvements that are associated with trauma death preventability were considered for inclusion. Two researchers independently selected eligible studies and extracted the relevant data. The main areas for improvements were classified using the Joint Commission on Accreditation of Healthcare Organizations patient event taxonomy. No statistical analyses were performed given the data heterogeneity. Results: From the 3647 individual titles obtained by the search strategy, a total of 37 studies were included. Each study included between 72 and 35311 trauma patients who had sustained mostly blunt trauma, frequently following a fall or a motor vehicle accident. Preventability assessment was performed for 17 to 2081 patients using either a single expert assessment (n = 2, 5,4%) or an expert panel review (n = 35, 94.6%). The definition of preventability and the taxonomy used varied greatly between the studies. The rate of potentially preventable or preventable death ranged from 2.4% to 76.5%. The most frequently reported areas for improvement were treatment delay, diagnosis accuracy to avoid missed or incorrect diagnosis and adverse events associated with the initial procedures performed. The risk of bias of the included studies was high for 32 studies because of the retrospective design and the panel review preventability assessment. Conclusion: Deaths occurring after a trauma remain often preventable. Included studies have used unstandardized definitions of a preventable death and various methodologies to perform the preventability assessment. The proportion of preventable or potentially preventable death reported in each study ranged from 2.4% to 76.5%. Delayed treatment, missed or incorrect initial diagnosis and adverse events following a procedure were commonly associated with preventable trauma deaths and could be targeted to develop quality improvement and monitoring projects.
Introduction: Each year, 3/1000 Canadians sustain a mild traumatic brain injury (mTBI). Many of those mTBI are accompanied by various co-injuries such as dislocations, sprains, fractures or internal injuries. A number of those patients, with or without co-injuries will suffer from persistent post-concussive symptoms (PPCS) more than 90 days post injury. However, little is known about the impact of co-injuries on mTBI outcome. This study aims to describe the impact of co-injuries on PPCS and on patient return to normal activities. Methods: This multicenter prospective cohort study took place in seven large Canadian Emergency Departments (ED). Inclusion criteria: patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Patients who were admitted following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. A research nurse then conducted three follow-up phone interviews at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to estimate the influence of co-injuries. Results: A total of 1674 patients were included, of which 1023 (61.1%) had at least one co-injury. At 90 days, patients with co-injuries seemed to be at higher risk of having 3 symptoms ≥2 points according to the RPQ (RR: 1.28 95% CI 1.02-1.61) and of experiencing the following symptoms: dizziness (RR: 1.50 95% CI 1.03-2.20), fatigue (RR: 1.35 95% CI 1.05-1.74), headaches (RR: 1.53 95% CI 1.10-2.13), taking longer to think (RR: 1.50 95% CI 1.07-2.11) and feeling frustrated (RR: 1.45 95% CI 1.01-2.07). We also observed that patients with co-injuries were at higher risk of non-return to their normal activities (RR: 2.31 95% CI 1.37-3.90). Conclusion: Patients with co-injuries could be at higher risk of suffering from specific symptoms at 90 days post-injury and to be unable to return to normal activities 90 days post-injury. A better understanding of the impact of co-injuries on mTBI could improve patient management. However, further research is needed to determine if the differences shown in this study are due to the impact of co-injuries on mTBI recovery or to the co-injuries themselves.
Introduction: Mild traumatic brain injury (mTBI) is a serious public health issue and as much as one third of mTBI patients could be affected by persistent post-concussion symptoms (PPCS) three months after their injury. Even though a significant proportion of all mTBIs are sports-related (SR), little is known on the recovery process of SR mTBI patients and the potential differences between SR mTBI and patients who suffered non-sports-related mTBI. The objective of this study was to describe the evolution of PPCS among patients who sustained a SR mTBI compared to those who sustained non sport-related mTBI. Methods: This Canadian multicenter prospective cohort study included patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of Emergency Department (ED) visit, with a Glasgow Coma Scale score of 13-15. Patients who were hospitalized following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. Three follow-up phone interviews were conducted by a research nurse at 7, 30 and 90 days post-injury to assess symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to demonstrate the impact of the mechanism of injury (sports vs non-sports) on the presence and severity of PPCS. Results: A total of 1676 mTBI patients were included, 358 (21.4%) of which sustained a SR mTBI. At 90 days post-injury, patients who suffered a SR mTBI seemed to be significantly less affected by fatigue (RR: 0.70 (95% CI: 0.50-0.97)) and irritability (RR: 0.60 (95% CI: 0.38-0.94)). However, no difference was observed between the two groups regarding each other symptom evaluated in the RPQ. Moreover, the proportion of patients with three symptoms or more, a score ≥21 on the RPQ and those who did return to their normal activities were also comparable. Conclusion: Although persistent post-concussion symptoms are slightly different depending on the mechanism of trauma, our results show that patients who sustained SR-mTBI could be at lower risk of experiencing some types of symptoms 90 days post-injury, in particular, fatigue and irritability.
To describe snacking characteristics and patterns in children and examine associations with diet quality and BMI.
Children’s weight and height were measured. Participants/adult proxies completed multiple 24 h dietary recalls. Snack occasions were self-identified. Snack patterns were derived for each sample using exploratory factor analysis. Associations of snacking characteristics and patterns with Healthy Eating Index-2010 (HEI-2010) score and BMI were examined using multivariable linear regression models.
Childhood Obesity Prevention and Treatment Research (COPTR) Consortium, USA: NET-Works, GROW, GOALS and IMPACT studies.
Two snack patterns were derived for three studies: a meal-like pattern and a beverage pattern. The IMPACT study had a similar meal-like pattern and a dairy/grains pattern. A positive association was observed between meal-like pattern adherence and HEI-2010 score (P for trend < 0⋅01) and snack occasion frequency and HEI-2010 score (β coefficient (95 % CI): NET-Works, 0⋅14 (0⋅04, 0⋅23); GROW, 0⋅12 (0⋅02, 0⋅21)) among younger children. A preference for snacking while using a screen was inversely associated with HEI-2010 score in all studies except IMPACT (β coefficient (95 % CI): NET-Works, −3⋅15 (−5⋅37, −0⋅92); GROW, −2⋅44 (−4⋅27, −0⋅61); GOALS, −5⋅80 (−8⋅74, −2⋅86)). Associations with BMI were almost all null.
Meal-like and beverage patterns described most children’s snack intake, although patterns for non-Hispanic Blacks or adolescents may differ. Diets of 2–5-year-olds may benefit from frequent meal-like pattern snack consumption and diets of all children may benefit from decreasing screen use during eating occasions.
Introduction: Low acuity patients have been controversially tagged as a source of emergency department (ED) misuse. Authorities for many Canadian health regions have set up policies so these patients preferably present to walk-in clinics (WIC). We compared the cost and quality of the care given to low acuity patients in an academic ED and a WIC of Québec City during fiscal year 2015-16. Methods: We conducted an ambidirectional (prospective and retrospective) cohort study using a time-driven activity-based costing method. This method uses duration of care processes (e.g., triage) to allocate to patient care all direct costs (e.g., personnel, consumables), overheads (e.g., building maintenance) and physician charges. We included consecutive adult patients, ambulatory at all time and discharged from the ED or WIC with a diagnosis of upper respiratory tract infection (URTI), urinary tract infection (UTI) or low back pain. Mean cost [95%CI] per patient per condition was compared between settings after risk-adjustment for age, sex, vital signs, number of regular medications and co-morbidities using generalized log-gamma regression models. Proportions [95%CI] of antibiotic prescription and chest X-Ray use in URTI, compliance with provincial guidelines on use of antibiotics in UTI, and column X-Ray use in low back pain were compared between settings using a Pearson Chi-Square test. Results: A total of 409 patients were included. ED and WIC groups were similar in terms of age, sex and vital signs on presentation, but ED patients had a greater burden of comorbidities. Adjusted mean cost (2016 CAN$) of care was significantly higher in the ED than in the WIC (p < 0.0001) for URTI (78.42[64.85-94.82] vs. 59.43[50.43-70.06]), UTI (78.88[69.53-89.48] vs. 53.29[43.68-65.03]), and low back pain (87.97[68.30-113.32] vs. 61.71[47.90-79.51]). For URTI, antibiotics were more frequently prescribed in the WIC (44.1%[34.3-54.3] vs. 5.8%[1.2-16.0]; p < 0.0001) and chest X-Rays, more frequently used in the ED (26.9%[15.6-41.0] vs. 13.7%[7.7-22.0]; p = 0.05). No significant differences were observed in the compliance with guidelines on use of antibiotics in UTI and in the use of column X-Ray in low back pain. Conclusion: Total cost of care for low acuity patients is lower in walk-in clinics than in EDs. However, our results suggest that quality-of-care issues should be considered in determining the best alternate setting for treating ambulatory emergency patients.
Objectives: Caregivers of youth with heavy prenatal alcohol exposure report impaired communication, which can significantly impact quality of life. Using data collected as part of the Collaborative Initiative on Fetal Alcohol Spectrum Disorders (CIFASD), we examined whether cognitive variables predict communication ability of youth with histories of heavy prenatal alcohol exposure. Methods: Subjects (ages 10–16 years) comprised two groups: adolescents with heavy prenatal alcohol exposure (AE) and non-exposed controls (CON). Selected measures of executive function (NEPSY, Delis-Kaplan Executive Function System), working memory (CANTAB), and language were tested in the child, while parents completed communication ratings (Vineland Adaptive Behavior Scales – Second Edition). Separate multiple regression analyses determined which cognitive domains predicted communication ability. A final, global model of communication comprised the three cognitive models. Results: Spatial Working Memory and Inhibition significantly contributed to communication ability across groups. Twenty Questions performance related to communication ability in the CON group only while Word Generation performance related to communication ability in the AE group only. Effects remained significant in the global model, with the exception of Spatial Working Memory. Conclusions: Both groups displayed a relation between communication and Spatial Working Memory and Inhibition. Stronger communication ability related to stronger verbal fluency in the AE group and Twenty Questions performance in the CON group. These findings suggest that alcohol-exposed adolescents may rely more heavily on learned verbal storage or fluency for daily communication while non-exposed adolescents may rely more heavily on abstract thinking and verbal efficiency. Interventions aimed at aspects of executive function may be most effective at improving communication ability of these individuals. (JINS, 2018, 24, 1026–1037)
Thanks especially to the ALMA interferometer, there are several new detections of CO gas in debris disks. Based on our own and archival ALMA observations, we found that the presence of CO gas in dust-rich debris disks around young (10–50 Myr) A-type stars is common. Interestingly, similarly dust-rich debris disks around young F-K type stars exhibit significantly lower gas incidence. The main difference between the two subsamples is related to a special population of gaseous debris disks whose total CO gas quantity is comparable to that of the less massive Herbig Ae disks. The origin of gas in these CO-rich debris systems is not fully clarified yet.
DQ Tau is a young low-mass spectroscopic binary, consisting of two almost equal-mass stars on a 15.8 day period surrounded by a circumbinary disk. We analyzed DQ Tau’s light curves obtained by Kepler K2, the Spitzer Space Telescope, and ground-based facilities. We observed variability phenomena, including rotational modulation by stellar spots, energetic stellar flares, brightening events around periastron due to increased accretion, and short dips due to temporary circumstellar obscuration. The study on DQ Tau will help in discovering and understanding the formation and evolution of other real-world examples of “Tatooine-like” systems. This is especially important because more and more evidence points to the possibility that all Sun-like stars were born in binary or multiple systems that broke up later due to dynamical interactions.
There is limited knowledge on vitamin D status of children residing in the Andes and its association with undernutrition. We evaluated the vitamin D status of children residing in a low socio-economic status (SES) setting in the Ecuadorian Andes and assessed the association between vitamin D status, stunting and underweight. We hypothesized that children who were underweight would have lower serum 25-hydroxyvitamin D (25(OH)D) levels and lower 25(OH)D levels would be associated with a higher risk of stunting.
We conducted a cross-sectional secondary analysis of a randomized controlled trial, the Vitamin A, Zinc and Pneumonia study. Children had serum 25(OH)D concentrations measured. A sensitivity analysis was undertaken to determine a vitamin D cut-off specific for our endpoints. Associations between serum 25(OH)D and underweight (defined as weight-for-age Z-score≤−1) and stunting (defined as height-for-age Z-score≤−2) were assessed using multivariate logistic regression.
Children residing in five low-SES peri-urban neighbourhoods near Quito, Ecuador.
Children (n 516) aged 6–36 months.
Mean serum 25(OH)D concentration was 58·0 (sd 17·7) nmol/l. Sensitivity analysis revealed an undernutrition-specific 25(OH)D cut-off of <42·5 nmol/l; 18·6 % of children had serum 25(OH)D<42·5 nmol/l. Children who were underweight were more likely to have serum 25(OH)D<42·5 nmol/l (adjusted OR (aOR)=2·0; 95 % CI 1·2, 3·3). Children with low serum 25(OH)D levels were more likely to be stunted (aOR=2·8; 95 % CI 1·6, 4·7).
Low serum 25(OH)D levels were more common in underweight and stunted Ecuadorian children.
We performed a spatial-temporal analysis to assess household risk factors for Ebola virus disease (Ebola) in a remote, severely-affected village. We defined a household as a family's shared living space and a case-household as a household with at least one resident who became a suspect, probable, or confirmed Ebola case from 1 August 2014 to 10 October 2014. We used Geographic Information System (GIS) software to calculate inter-household distances, performed space-time cluster analyses, and developed Generalized Estimating Equations (GEE). Village X consisted of 64 households; 42% of households became case-households over the observation period. Two significant space-time clusters occurred among households in the village; temporal effects outweighed spatial effects. GEE demonstrated that the odds of becoming a case-household increased by 4·0% for each additional person per household (P < 0·02) and 2·6% per day (P < 0·07). An increasing number of persons per household, and to a lesser extent, the passage of time after onset of the outbreak were risk factors for household Ebola acquisition, emphasizing the importance of prompt public health interventions that prioritize the most populated households. Using GIS with GEE can reveal complex spatial-temporal risk factors, which can inform prioritization of response activities in future outbreaks.
A core challenge of a multidisciplinary and multi-organizational translational research enterprise such as a Clinical and Translational Research Award (CTSA) is coordinating and integrating the work of individuals, workgroups, and organizations accustomed to working independently and autonomously. Tufts Clinical and Translational Science Institute (CTSI) undertook and studied a multifacted intervention to address this challenge and to create a culture of systems thinking, process awareness, responsive to others' needs, and shared decision-making.
The intervention, based on relational coordination, included 1) relational interventions, in three staff retreats and a diagnostic survey to provide feedback on the current quality of relational coordination, and 2) structural interventions, in the launching of five new cross-functional teams with regular meeting structures.
A mixed-methods evaluation yielded quantitative data via two types of team surveys and qualitative data via interviews and meeting observations.
The findings suggest that interventions to improve relational coordination are feasible for CTSAs, including good fidelity to the model and staff/physician engagement. Survey and interview data suggest model improvements in coordination and alignment. Further research about their optimal design is warranted.
Introduction: Mild traumatic brain injury (mTBI) is a common problem and until now, ED physicians don’t have any tool to predict when the patient will return to work. The purpose of this study is to develop and validate a clinical decision rule to identify the ED patients who are at risk of non-return to work or to school three months after a mTBI. Methods: Patients were recruiting in five Level I and II Trauma Centers ED in the province of Québec. All patients were referred for a systematic telephone follow-up after three months. Information about their return to work/school, partial or complete, was collected. Log binomial regression was used to develop a predictive model and the validation of this model was performed on a different prospective cohort. Results: 13,7% of the patients did not return to work/school at three months. The final model was derived from a prospective cohort of 398 patients and included three risk factors: motor vehicle accident (2 points), loss of consciousness (1 point) and headache during the emergency department assessment (1 point). With a one-point threshold, this model has a sensitivity of 97% and a negative predictive value (NPV) of 98%. However, the specificity is only 23% and the positive predictive value (PPV) is 17%. The area under the curve is 0.786. Validation of the model was performed with a new prospective cohort of 517 patients, and demonstrated a sensitivity of 86% and a NPV of 91%. Conclusion: Although this model is not very specific, its high sensitivity and NPV indicate to the clinician that mTBI patients who don’t have any of the three criteria are at low risk of prolonged work stoppage after their trauma.
Introduction: Mild traumatic brain injury (mTBI) is a major cause of morbidity but there are no validated tools to help clinicians predict post-concussion symptoms. This systematic review and meta-analysis aimed to determine the prognostic value of S-100B protein to predict post-concussion symptoms following a mTBI in adults. Methods: The protocol of this systematic review was registered with the PROSPERO database (CRD42016032578). A search strategy was performed on seven databases (CINAHL, Cochrane CENTRAL, EMBASE, MEDLINE, Web of Knowledge, PyscBITE, PsycINFO) from their inception to October 2016. Studies evaluating the association between S-100B protein level and post-concussion symptoms assessed at least seven days after the mTBI were eligible. Individual patient data were requested. Studies eligibility assessment, data extraction and risk of bias assessment were performed independently by two researchers. Analyses were done following the meta-analysis using individual participant data or summary aggregate data guidelines from the Cochrane Methodology Review Group. Results: Outcomes were dichotomised as persistent (≥3 months) or early (≥7 days <3 months). Our search strategy yielded 23,298 citations of which 29 studies presenting between seven and 223 patients (n=2505) were included. Post-concussion syndrome (PCS) (16 studies), neuropsychological symptoms (9 studies) and health-related quality of life (4 studies) were the most frequently presented outcomes. The S-100B protein serum level of patients with no PCS was similar to that of patients experiencing persistent PCS (mean difference 0.00 [-0.05, 0.04]) or early PCS (mean difference 0.03 [-0.02, 0.08]). The odds of having persistent PCS (OR 0.56 (95% CI: 0.29-1.10) or early PCS (OR 1.67 (95% CI: 0.98-2.85) in patients with an elevated S-100B protein serum level was not significantly different from that of patients with normal values. No meta-analysis was performed for other outcomes than PCS due to heterogeneity and small samples. Studies’ overall risk of bias was considered moderate. Conclusion: Results suggest that the prognostic value of S-100B protein serum level to predict persistent and early post-concussion symptoms is limited. Variability in injury to S-100B protein sample time and outcomes assessed could potentially explain the lack of association and needs further evaluation.
Introduction: Mild traumatic brain injury (mTBI) is an understudied worldwide health problem and a socio-economic burden that remains a major cause of morbidity. However, there is no prognostication tool to help clinicians predict the occurrence of post-concussion symptoms. This systematic review aimed to determine the prognostic value of neuron-specific enolase (NSE) to predict post-concussion symptoms following a mTBI in adults. Methods: The protocol of this systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (registration number CRD42016033683). Seven databases (CINAHL, Cochrane CENTRAL, EMBASE, MEDLINE, PsycBITE, PsycINFO, Web of Knowledge/Biosis) were searched for cohort studies evaluating the association between NSE levels and post-concussion symptoms assessed at least seven days after the mild TBI. Grey literature was also screened using databases on dissertations and theses as well as abstracts from relevant congresses. Two researchers independently screened studies for inclusion, extracted data, and appraised their quality using the Quality in Prognostic Studies (QUIPS) tool from the Cochrane Collaboration Group. Results: Our search strategy yielded a total of 23,298 citations from which eight cohorts presented in 10 studies were included. Studies included between 45 and 141 patients (total=608 patients). The most frequently assessed outcomes were post-concussion syndrome (PCS) (13 assessments), neuropsychological disorders (10 assessments), return to work or sick leave (2 assessments) and Glasgow Outcome Scale (GOS) (2 assessments). No association was found between an elevated NSE serum level and the occurrence of PCS. Of the 33 outcomes assessments performed, only three showed an association between a higher level of serum NSE and a post-concussion symptom (alteration of at least three cognitive domains at 2 weeks, standardised physician assessment at 6 weeks and headache at 6 months following a mild TBI). Included studies’ overall risk of bias was considered moderate. Conclusion: Results of this systematic review conclude that based on current levels of evidence, serum NSE levels alone do not provide prognostic information on persistent or early post-concussion symptoms after a mTBI.
Introduction: Poor physicians’ knowledge of health care costs has been identified as an important barrier to improving efficiency and reducing overuse in care delivery. Moreover, costs of tests and treatments estimated with traditional costing methods have been shown to be imprecise and unreliable. We estimated the cost of frequent care activities in the emergency department (ED) using the time-driven activity-based costing (TDABC) method. Methods: We conducted a TDABC study in the ED of the CHUL, Québec city (77000 visits/year). We estimated the cost of all potential care activities (e.g. triage) provided to adult patients with selected urgent (e.g. pulmonary sepsis) and non urgent (e.g. urinary tract infection) conditions frequently encountered in the ED. Following Lean management principles, process maps were developed by a group of ED care providers for each care activity to identify human resources, supplies and equipment involved, and to estimate the time required to complete each process. Resource unit cost (e.g. cost per minute of a nurse) and overhead rate were calculated using financial information from fiscal year 2015-16. Estimated cost of each care activity (e.g. chest X-ray) including physicians’ charges was calculated by summing overhead allocation and the cost of each process (e.g. disinfection of the X-ray machine) as obtained by multiplying the resource unit cost by the time for process completion. Results: Process maps were developed for 14 conditions and 68 ED care activities. We estimated the costs of activities (CAN$) related to nursing (e.g. urinalysis and culture triage ordering $14.70), clerk tasks (e.g. patient registration $3.40), physicians (e.g. FAST scan $20.90), laboratory testing (e.g. CBC $6.30), diagnostic imaging (e.g. abdominal CT scan $146.50), therapy (e.g. 5 mg of iv morphine $20.40), and resuscitation (rapid sequence intubation with ketamine and succinylcholine $146.40). Overall, emergency physicians’ charges, personnel salaries and overheads accounted for 38%, 22% and 16% of all ED care costs, respectively. Conclusion: Our results represent an important step toward increasing emergency physicians’ awareness on the real cost of their interventions and empowering them to adopt more cost-effective practice patterns.
Visual Image analysis (VIA) of carcass traits provides the opportunity to estimate carcass primal cut yields on large numbers of slaughter animals. This allows carcases to be better differentiated and farmers to be paid based on the primal cut yields. It also creates more accurate genetic selection due to high volumes of data which enables breeders to breed cattle that better meet the abattoir specifications and market requirements. In order to implement genetic evaluations for VIA primal cut yields, genetic parameters must first be estimated and that was the aim of this study. Slaughter records from the UK prime slaughter population for VIA carcass traits was available from two processing plants. After edits, there were 17 765 VIA carcass records for six primal cut traits, carcass weight as well as the EUROP conformation and fat class grades. Heritability estimates after traits were adjusted for age ranged from 0.32 (0.03) for EUROP fat to 0.46 (0.03) for VIA Topside primal cut yield. Adjusting the VIA primal cut yields for carcass weight reduced the heritability estimates, with estimates of primal cut yields ranging from 0.23 (0.03) for Fillet to 0.29 (0.03) for Knuckle. Genetic correlations between VIA primal cut yields adjusted for carcass weight were very strong, ranging from 0.40 (0.06) between Fillet and Striploin to 0.92 (0.02) between Topside and Silverside. EUROP conformation was also positively correlated with the VIA primal cuts with genetic correlation estimates ranging from 0.59 to 0.84, whereas EUROP fat was estimated to have moderate negative correlations with primal cut yields, estimates ranged from −0.11 to −0.46. Based on these genetic parameter estimates, genetic evaluation of VIA primal cut yields can be undertaken to allow the UK beef industry to select carcases that better meet abattoir specification and market requirements.
The Universe is permeated by hot, turbulent, magnetized plasmas. Turbulent plasma is a major constituent of active galactic nuclei, supernova remnants, the intergalactic and interstellar medium, the solar corona, the solar wind and the Earth’s magnetosphere, just to mention a few examples. Energy dissipation of turbulent fluctuations plays a key role in plasma heating and energization, yet we still do not understand the underlying physical mechanisms involved. THOR is a mission designed to answer the questions of how turbulent plasma is heated and particles accelerated, how the dissipated energy is partitioned and how dissipation operates in different regimes of turbulence. THOR is a single-spacecraft mission with an orbit tuned to maximize data return from regions in near-Earth space – magnetosheath, shock, foreshock and pristine solar wind – featuring different kinds of turbulence. Here we summarize the THOR proposal submitted on 15 January 2015 to the ‘Call for a Medium-size mission opportunity in ESAs Science Programme for a launch in 2025 (M4)’. THOR has been selected by European Space Agency (ESA) for the study phase.
Introduction: Delirium is a dreadful complication in seniors’ acute care. Many studies are available on the incidence of delirium, however ED-induced delirium is far less studied. We aim to evaluate the incidence and impact of ED-induced delirium among older non-delirious admitted ED patients who have prolonged ED stays (≥ 8 hours). Methods: This prospective INDEED study phase 1 included patients recruited from 4 Canadian EDs. Inclusion criteria: 1) Patients aged 65 and over; 2) ED stay ≥ 8 hours; 3) Patient is admitted to the hospital; 4) Patient is non-delirious upon arrival and at the end of the first 8 hours; 5) Independent or semi-independent patient. Eligible patients were assessed by a research assistant after an 8 hour exposition to the ED and evaluated twice a day up to 24h after ward admission. Patients’ functional and cognitive status were assessed using validated OARS and TICS-m tools. The Confusion Assessment Method was used to detect incident delirium. Hospital length of stays (LOS) were obtained. Univariate and multivariate analyses were conducted to evaluate outcomes. Results: Of the 380 patients prospectively followed, mean age was 76.5 (± 8.9), male represent 50% and 16.5% very old seniors (> 85 y.o.). The overall incidence of ED-induced delirium was 8.4%. Distribution by the 4 sites was: 10%, 13.8%, 5.5% & 13.4%. The mean ED LOS varied from 29 to 48 hours. The mean hospital LOS was increase by 6.1 days in the delirious patients compared to non-delirious patient (p<0.05). Increase mean hospital LOS distribution by site was by: 6.9, 8.5, 4.3 and 5.2 days for the ED-induced delirium patients. Conclusion: ED-induced delirium was recorded in nearly one senior out of ten after a minimal 8 hour exposure in the ED environment. An episode of delirium increases hospital LOS by about a week and therefore could contribute to ED overcrowding.