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Ambulances are where patient care is often initiated or maintained, but this setting poses safety risks for paramedics. Paramedics have found that in order to optimize patient care, they must compromise their own safety by standing unsecured in a moving ambulance.
This study sought to compare the quality of chest compressions in the two positions they can be delivered within an ambulance.
A randomized, counterbalanced study was carried out with 24 paramedic students. Simulated chest compressions were performed in a stationary ambulance on a cardiopulmonary resuscitation (CPR) manikin for two minutes from either: (A) an unsecured standing position, or (B) a seated secured position. Participants’ attitudes toward the effectiveness of the two positions were evaluated.
The mean total number of chest compressions was not significantly different standing unsecured (220; SD = 12) as compared to seated and secured (224; SD = 21). There was no significant difference in mean compression rate standing unsecured (110 compressions per minute; SD = 6) as compared to seated and secured (113 compressions per minute; SD = 10). Chest compressions performed in the unsecured standing position yielded a significantly greater mean depth (52 mm; SD = 6) than did seated secured (26 mm; SD = 7; P < .001). Additionally, the standing unsecured position produced a significantly higher percentage (83%; SD = 21) for the number of correct compressions, as compared to the seated secured position (8%; SD = 17; P < .001). Participants also believed that chest compressions delivered when standing were more effective than those delivered when seated.
The quality of chest compressions delivered from a seated and secured position is inferior to those delivered from an unsecured standing position. There is a need to consider how training, technologies, and ambulance design can impact the quality of chest compressions.
Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.
A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.
Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).
Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.
The accounts of social freedom offered by G. W. F. Hegel and Axel Honneth identify the normative demands on social institutions and explain how individual freedom is realized through rational participation in such institutions. While both offer normative reconstructions of the market economy, public sphere and family, they both derive the norms of educational institutions from education’s role in preparing people for participation in other institutions. We argue that this represents a significant defect in their accounts of social freedom because they both fail to account for the distinctive aims and norms of education. Only educational institutions bring individuals into a both shared and autonomous standpoint necessary for participation in social life. We thus argue both that Hegel’s and Honneth’s accounts are empirically inadequate and that they neglect the normative demands on schools to contribute to individual moral and intellectual development.
When it comes to social criticism of the economy, Critical Theory has thus far failed to discover specific immanent norms in that sphere of activity. In response, we propose that what is needed is to double down on the idealism of Critical Theory by taking seriously the sophisticated structure of agency developed in Hegel’s own account of freedom as self-determination. When we do so, we will see that the anti-metaphysical gestures of recent Critical Theory work in opposition to its attempts to develop immanent critique. In this paper we first briefly reconsider Axel Honneth’s project as it concerns economic institutions and then respond by returning to the problem of freedom and articulating a view according to which the problem of individual self-determination and the problem of social production are the same problem seen from different angles. Then we present briefly Hegel’s own social theory from this perspective before moving on to trace the outlines of such a critical theory of contemporary capitalism.
This article challenges the restrictive association of critical theory with the Frankfurt School by exploring the differential reception of Hegel by German critical thinkers on both sides of the Iron Curtain after 1945. In the West, Theodor Adorno held Hegelian ‘identity thinking’ partly responsible for the atrocities of National Socialism. Meanwhile in the East, Ernst Bloch turned Hegel into a weapon against the communist regime. The difference between Adorno and Bloch’s positions is shown to turn on the relationship between speculation, dialectics and critique. Whereas for Adorno Hegelian speculation was the root of dangerous identity thinking, Bloch saw the repression of speculative thought as a cornerstone of totalitarianism. However, it is argued that ultimately Bloch and Adorno were united in their reception of Hegel by a shared understanding that the goal of critical theory, namely the transformation of the social totality, could not be achieved without utopian speculation.
Contemporary philosophy of recognition represents probably the most prominent direction that presently claims to introduce an updated version of classical German idealism into ongoing debates, including the debate on the nature of sociality. In particular, studies of Axel Honneth offer triggering contributions in Frankfurt School fashion while at the same time rejuvenating Hegel’s philosophy in terms of a philosophy of recognition. According to Honneth, this attempt at a rejuvenation also involves substantial modification of Hegelian doctrines. It is shown that Honneth underestimates the implications of Hegel’s thoughts about the theme, method and systematic form of philosophy. As a consequence, Honneth’s social philosophy is, on the one hand, in need of a plausible foundation. This leads, on the other hand, to a different construction of the social within philosophy than Honneth offers.
Adorno’s Drei Studien zu Hegel (Hegel: Three Studies, 1963) offers his most focused treatment of what he took to be the core principles of Hegelian dialectic. Moreover, the book professes the central importance of Hegel for Adorno’s own development. As such, it is a pivotal document that simultaneously looks back towards Adorno’s most sustained personal work, Minima Moralia (1951), and ahead to what he took to be his most important systematic work, Negative Dialectics (1966). Adorno’s interpretation of Hegel is critical and unique in both its tone and substance. Although there are many cross-cutting lines of argumentation, the one that stands out is Adorno’s understanding of determinate negation in Hegel and his own suggestion for improving that concept. This paper reconstructs Adorno’s main arguments in this domain, assesses them as interpretations of Hegel and investigates their importance for Adorno’s emerging conception of ‘negative dialectics’.
Limited continuity of care, poor communication between healthcare providers, and ineffective self-management are barriers to recovery as seniors transition back to the community following an Emergency Department (ED) visit or hospitalization. The intensive geriatric service worker (IGSW) role is a new service developed in southern Ontario, Canada to address gaps for seniors transitioning home from acute care to prevent rehospitalization and premature institutionalization through the provision of intensive support and follow-up to ensure adherence to care plans, facilitate communication with care providers, and promote self-management. This study describes the IGSW role and provides preliminary evidence of its impact on clients, caregivers and the broader health system.
This mixed methods evaluation included a chart audit of all clients served, tracking of the achievement of goals for IGSW involvement, and interviews with clients and caregivers and other key informants.
During the study period, 632 clients were served. Rates of goal achievement ranged from 25%–87% and in cases where achieved, the extent of IGSW involvement mostly exceeded recommendations. IGSWs were credited with improving adherence with treatment recommendations, increasing awareness and use of community services, and improving self-management, which potentially reduced ED visits and hospitalizations and delayed institutionalization.
The IGSW role has the potential to improve supports for seniors and facilitate more appropriate use of health system resources, and represents a promising mechanism for improving the integration and coordination of care across health sectors.
Background: The Canadian GILENYA® Go ProgramTM provides education and support to people with relapsing-remitting multiple sclerosis during fingolimod treatment. Methods: Data were collected and analyzed from the time of the first individual enrolled in March 2011 to March 31, 2014. Individuals were excluded if they withdrew from the program prior to receiving the first dose, or had not completed the first dose observation (FDO) at the time of data cut-off. Reports of adverse effects were validated with a database of adverse events reported to Novartis Pharmaceuticals Canada Inc. Results: A total of 2,399 individuals had completed FDO at the end of the three-year observation period. Mean age was 41.2 years; 75.2% were female. The most recent prior therapies reported were interferon-β agents (50.2%), glatiramer acetate (31.1%), natalizumab (14.2%), no prior therapy (3.3%), and other agent (1.1%). Reasons for switching to fingolimod were lack of efficacy (34.9%), side effects (34.6%), and dissatisfaction with injections/infusion (30.4%). Continuation rates with fingolimod at 12, 24 and 30 months were 80.7%, 76.6% and 76.0%, respectively. The discontinuation rate due to reported lack of efficacy during the three-year period was 1.3%. There was 94.4% adherence to the scheduled ophthalmic examination. Conclusions: The GILENYA® Go ProgramTM captures data for virtually all fingolimod-treated patients in Canada, enabling the evaluation of fingolimod use in routine practice. Ongoing patient support and reminders to take the medication, in conjunction with physicians’ and/or patients’ perception of the efficacy and tolerability of fingolimod, resulted in a high rate of continuation during longer-term therapy.
Background: Pediatric onset multiple sclerosis (MS) negatively affects cognitive function, mood and health related quality of life (HRQOL). We aimed to explore the cognitive, psychological and HRQOL impacts of pediatric MS on young adults and to explore the relationships between disability, disease duration, cognition, mood and HRQOL in this hypotheses generating study. Methods: Thirty-four young adults with pediatric onset MS at St. Michael’s Hospital in Toronto were included in this cross-sectional study (mean age 21.3 years, 56% female). Participants completed assessments of physical disability (Expanded Disability Status Scale (EDSS)), cognitive function (Symbol Digit Modalities Test (SDMT)), mood (Beck Depression Inventory II (BDI-II)), and HRQOL (Short Form Health Survey (SF-36v2)). Findings were compared to age- and gender- matched normative data. Results: Individuals with pediatric MS performed worse on the SDMT compared to normative data, with 53% demonstrating cognitive impairment. There was no difference in BDI-II scores from normative data, but 21% showed at least mild depression. There was a non-significant impairment in physical HRQOL compared to normative data. Decreased physical HRQOL was related to disability (EDSS), while mental HRQOL was related to depression (BDI-II). Conclusions: Young adults with pediatric MS have reduced cognitive function. Non-significant reductions in HRQOL may be partly attributed to physical disability and depression. These factors should be addressed in the care of adults with pediatric MS. Further studies including control groups and longitudinal design are needed to confirm these findings.
Background: A definitive diagnosis of multiple sclerosis (MS), as distinct from a clinically isolated syndrome, requires one of two conditions: a second clinical attack or particular magnetic resonance imaging (MRI) findings as defined by the McDonald criteria. MRI is also important after a diagnosis is made as a means of monitoring subclinical disease activity. While a standardized protocol for diagnostic and follow-up MRI has been developed by the Consortium of Multiple Sclerosis Centres, acceptance and implementation in Canada have been suboptimal. Methods: To improve diagnosis, monitoring, and management of a clinically isolated syndrome and MS, a Canadian expert panel created consensus recommendations about the appropriate application of the 2010 McDonald criteria in routine practice, strategies to improve adherence to the standardized Consortium of Multiple Sclerosis Centres MRI protocol, and methods for ensuring effective communication among health care practitioners, in particular referring physicians, neurologists, and radiologists. Results: This article presents eight consensus statements developed by the expert panel, along with the rationale underlying the recommendations and commentaries on how to prioritize resource use within the Canadian healthcare system. Conclusions: The expert panel calls on neurologists and radiologists in Canada to incorporate the McDonald criteria, the Consortium of Multiple Sclerosis Centres MRI protocol, and other guidance given in this consensus presentation into their practices. By improving communication and general awareness of best practices for MRI use in MS diagnosis and monitoring, we can improve patient care across Canada by providing timely diagnosis, informed management decisions, and better continuity of care.
The rock art of Southeast Asia has been less thoroughly studied than that of Europe or Australia, and it has generally been considered to be more recent in origin. New dating evidence from Mainland and Island Southeast Asia, however, demonstrates that the earliest motifs (hand stencils and naturalistic animals) are of late Pleistocene age and as early as those of Europe. The similar form of the earliest painted motifs in Europe, Africa and Southeast Asia suggests that they are the product of a shared underlying behaviour, but the difference in context (rockshelters) indicates that experiences in deep caves cannot have been their inspiration.
Alterations in intestinal microbiota composition and function have been linked to conditions including functional gastrointestinal disorders, obesity and diabetes. The gut microbiome encodes metabolic capability in excess of that encoded by the human genome, and bacterially produced enzymes are important for releasing nutrients from complex dietary ingredients. Previous culture-based studies had indicated that the gut microbiota of older people was different from that of younger adults, but the detailed findings were contradictory. Small-scale studies had also shown that the microbiota composition could be altered by dietary intervention or supplementation. We showed that the core microbiota and aggregate composition in 161 seniors was distinct from that of younger persons. To further investigate the reasons for this variation, we analysed the microbiota composition of 178 elderly subjects for whom the dietary intake data were available. The data revealed distinct microbiota composition groups, which overlapped with distinct dietary patterns that were governed by where people lived: at home, in rehabilitation or in long-term residential care. These diet–microbiota separations correlated with cluster analysis of NMR-derived faecal metabolites and shotgun metagenomic data. Major separations in the microbiota correlated with selected clinical measurements. It should thus be possible to programme the microbiota to enrich bacterial species and activities that promote healthier ageing. A number of other studies have investigated the effect of certain dietary components and their ability to modulate the microbiota composition to promote health. This review will discuss dietary interventions conducted thus far, especially those in elderly populations and highlight their impact on the intestinal microbiota.
Differences in Multiple sclerosis (MS) disease-modifying therapy (DMT) prescribing patterns between different groups of neurologists have not been explored.
To examine concentrations of prescribing patterns and to assess if MS-specialists use a broader range of DMTs relative to general neurologists.
We conducted a cross-sectional study using administrative claims databases in Ontario, Canada to link neurologists to 2009 DMT prescription data. MS specialization was defined using both practice location and prescription patterns. Lorenz curves and Gini coefficients were constructed to examine prescribing patterns, separating neurologist characteristics dichotomously and separating Avonex from the other standard DMTs (Betaseron, Rebif and Copaxone). Gini coefficient 95% confidence intervals (CIs) were derived using jack-knife statistical techniques.
Prescriptions were highly concentrated with 12% of Ontario neurologists prescribing 80% of DMTs. There was a trend towards Avonex being more commonly prescribed relative to the other DMTs. When MS specialization was defined by DMT prescribing, high-volume prescribing neurologists showed a broader range of DMT prescribing (Gini 0.38-0.44) in comparison to low-volume prescribers (Gini 0.57-0.66).
The majority of DMTs are prescribed by a small subset of neurologists. High-volume prescribing MS-specialists show more variability in DMT use while low-volume prescribers tend to individually focus on a narrower range of DMTs.