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Capillary collimators have found a number of uses in fluorescence, diffraction and other x-ray fields. Most of these applications are realized with single, straight glass capillaries. Focussing of synchrotron x-radiation beams has been shown with tapered capillaries. In addition, numerous straight and bent capillaries, bundled into lens-like optics, offer experimenters many other possibilities for better use of the x-radiation from tubes, synchrotron radiation, and plasma sources or the x-ray intensity collected from samples.
Introduction: Introduction: Transitions in care (TiC) interventions have been proposed to improve the management and outcomes of patients in emergency departments (ED). The objective of this review was to examine the effectiveness of ED-based TiC interventions to improve outcomes for adult patients presenting to an ED with acute atrial fibrillation or flutter (AFF). Methods: Methods: A comprehensive search of eight electronic databases and various grey literature sources was conducted. Comparative studies assessing the effectiveness of interventions to improve TiC for patients presenting to the ED with acute AFF were eligible. Two independent reviewers completed study selection, quality assessment, and data extraction. When applicable, relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity was reported among studies using I-square (I2) statistics. Results: Results: From 744 citations, seven studies were included, consisting of three randomized controlled trials (RCT), three before-after (B/A) studies, and one cohort study. Study quality ranged from unclear to low for the RCTs according to the risk of bias tool, moderate in the BA trials according to the BA quality assessment tool, and high quality of the cohort study according to the Newcastle Ottawa scale. The majority of interventions were set within-ED (n=5), including three clinical pathways/management guidelines and two within-ED observation units. Post-ED interventions (n=2) included patient education and general practitioner referral. Four studies reported a decreased overall hospital length of stay (LoS) for AFF patients undergoing TiC interventions compared to control, ranging from 26.4 to 53 hours; however, incomplete and non-standardized outcome reporting precluded meta-analysis. An increase in conversion to normal sinus rhythm among TiC intervention patients was noted, which may be related to increased utilization of electrical cardioversion among the RCTs (RR=2.16; 95% CI: 1.42, 3.30; I2=%), B/A studies (RR=2.69, 95% CI: 2.17, 3.33), and cohort study (RR=1.39; 95% CI: 1.24, 1.56). Conclusion: Conclusions: Within-ED TiC interventions may reduce hospital LoS and increase use of electrical cardioversion. However, no clear recommendations to implement such interventions in EDs can be generated from this systematic review and more efforts are required to improve TiC for patients with AFF.
Rumen protected fats are often included in dairy cow rations in order to increase the energy density of the ration without compromising rumen function. Various studies have examined the effects of protected fats, with some studies reporting an improvement in various fertility parameters (McNamara et al., 2003). This study examined the effect of feeding protected fat (Megalac™) on production parameters, and on the reproductive performance of high-yielding Holstein-Friesian dairy cattle.
Supplemental fat is often used to increase the energy density of diets for dairy cows, with the aim of improving tissue energy balance (TEB), milk production and herd fertility. In this study, the effects of supplemental calcium salts of palm fatty acids (CSFA) on production parameters, dry matter intake (DMI) and TEB were assessed in highly productive, early-lactation cows offered typical UK diets.
In contrast to the Holstein-Friesian (HF) breed, Norwegian dairy cattle (NC) have been selected with emphasis on disease resistance and beef characteristics as well as milk production, and hence may be more suited to beef production than high genetic merit Holstein animals. The objective of this study was to evaluate the beef production potential of NC bulls, and to compare their performance with that of HF bulls.
In ruminant diets, whole oilseeds are potential sources of polyunsaturated fatty acids (PUFA), which, because they are protected by the intact seed pericarp, may escape rumen biohydrogenation (Murphy et. al., 1990). Some seed coats are highly resistant to microbial and enzymic digestion and seed lipids may therefore be poorly degraded. Mild chemical treatment of oilseeds with sodium hydroxide has been suggested as a way to allow only limited ruminal lipid digestion but more extensive intestinal digestion of seed lipids (Aldrich et. al., 1997). Such treatments may allow the manipulation of milk composition by strategic use of selected oilseeds. Linseed is rich in C18:3n-3, an essential component of a healthy human diet which is normally only present at low levels in cows milk. This study evaluated the effect of inclusion of caustic-treated linseed in dairy cow rations on the protein, fat and fatty acid composition of milk
The Northern Ireland beef herd currently incorporates a very diverse range of genotypes which produces a very varied product in terms of carcass weight, fatness and conformation (Kirkland et al., 2004). However, factors other than genotype may also influence the expression of maternal traits and progeny carcass characteristics. The objective of the present study was to evaluate the influence of dam conformation, irrespective of genotype, on dystocia and progeny carcass traits.
Meat from Holstein-Friesian bulls, which are bred for dairy traits, is generally regarded as low quality and is usually destined for the commodity (mince) market. However, given their ready availability as a by-product from the dairy herd, it is important to determine if meat from these animals would be suited to higher-priced markets. Furthermore, meat from bulls is generally considered to be lower quality than that from steers, though there is a paucity of data comparing meat from both sources. Hence, the objective of this study was to evaluate the effect of slaughter weight on meat quality characteristics of Holstein-Friesian bulls and steers offered a cereal-based ration.
The suckler beef industry in Northern Ireland comprises many differing dam breeds and breed crosses. However, there is a paucity of data on the influence of dam breed on parameters such as carcass weight, fatness and conformation, and on factors affecting management of the herd (e.g. dystocia and fertility). The latter are particularly important in view of the increasing number of part time beef farmers in Northern Ireland. The objective of the present study was to evaluate the influence of dam breed on production characteristics of the suckler herd in Northern Ireland.
A considerable proportion of beef produced in the UK is a byproduct of the dairy industry. Young animals from this source are generally regarded as low in quality and meat from animals of this type is usually destined for the commodity minced beef market. The objective of the present study was to evaluate the effect of slaughter weight on sensory characteristics of meat from Holstein-Friesian bulls and steers offered a cereal-based ration.
The commercial value of beef carcasses can be assessed by several methods including the yield of primal joints and meat quality characteristics. However, it is also important to determine the composition of the carcass in terms of lean, fat and bone concentrations, and to evaluate individual fat components of the carcass, to provide an overall assessment of the commercial value of the carcass. The objective of the present study was to evaluate the effect of slaughter weight on carcass composition of Holstein-Friesian bulls and steers offered cereal-based rations.
Introduction: Headache is a common emergency department (ED) presentation. Benign (i.e., non-pathological) headaches are particularly common, including exacerbations of chronic migraine, tension, and cluster headache. Several studies have reported concerns over the frequent use of advanced imaging, specifically computed tomography (CT), in the ED management of benign or primary headache presentations. This systematic review examined the proportion of adult ED benign headache presentations who receive a CT(head). Methods: Eight bibliographic databases and the grey literature were searched. All studies reporting the proportion of benign headache patients receiving a CT(head) in the ED were eligible for inclusion. Studies which included a secondary headache population of 15% of their total study population or less where eligible for inclusion. Two reviewers independently assessed study inclusion and completed quality assessment and data extraction. Weighted medians were calculated for the primary and secondary outcomes, as appropriate. Results: The search returned 2,444 unique citations, of which 20 met the inclusion criteria (21 patient groups were analyzed). The majority of the studies were descriptive in nature and conducted in North America. The reported proportion of benign headache patients receiving a CT(head) varied considerably (range: 2.06-67.21%); with a weighted median of 30.0% (interquartile range: 30.0, 30.0). Studies published in 2000 or later (18/21 groups) were found to have a higher weighted median percentage compared to those published pre-2000 (p=0.016). Neither the country of origin nor the proportion of patients with secondary headache included within the study population had a significant effect on CT utilization. Of the three studies which reported the discharge diagnosis of all patients, sub-arachnoid hemorrhage was discovered in 2/241 (0.83%) of CT scans. Conclusion: Considerable variation in CT utilization for benign headache ED presentations exists and estimates indicate that more than a quarter of patients receive a CT(head). Overall, these CT scans rarely identify significant pathology, suggesting imaging may be safely reduced. Further research is required to identify interventions which can safely and effectively reduce unnecessary imaging among headache presentations.
Introduction: The objective of this systematic review was to investigate the psychometric properties and diagnostic performance of instruments used in the emergency department to identify pediatric mental health and substance use problems. Methods: A search of seven electronic databases and the grey literature was conducted. Studies assessing any instrument to identify and or diagnose mental illness, emotional or behavioural problems, or substance use disorders in pediatric patients with presentations for mental health or substance use issues were considered eligible for inclusion. Two independent reviewers judged the relevance and study quality of the studies. A descriptive analysis of the outcomes was reported. Results: From 4832 references, 14 studies were included. Eighteen instruments were evaluated for identifying suicide risk, alcohol use disorders, mood disorders, and ED decision-making. The HEADS-ED has good inter-rater reliability (r=0.785) for identifying general mental health problems and modest evidence for ruling out patients requiring hospital admission (positive likelihood ratio, LR+=6.30). The internal consistency varied for tools to screen for suicide risk (α=0.46-0.97); no tools have both high sensitivity and high specificity. The Ask Suicide-Screening Questionnaire (ASQ) is highly sensitive (98%) and provides strong evidence to rule out risk (negative likelihood ratio, LR−=0.04). Among tools to screen for alcohol use disorders, a two-item tool based on DSM-IV criteria was found to be the most accurate in identifying patients with a disorder (area under the curve: 0.89), and has modest evidence to rule in and rule out risk (LR+=8.80, LR−=0.13). Conclusion: Reliable, valid, and accurate instruments are available for use with pediatric mental health ED visits. Based on available evidence, emergency care clinicians are recommended to use the HEADS-ED to rule in ED admission, ASQ to rule out suicide risk, and DSM-IV two-item tool to rule in/rule out alcohol use disorders.
Introduction: Active substance use and unstable housing are both associated with increased emergency department (ED) utilization. This study examined ED health care costs among a cohort of substance using and/or homeless adults following an index ED visit, relative to a control ED population. Methods: Consecutive patients presenting to an inner-city ED between August 2010 and November 2011 who reported unstable housing and/or who had a chief presenting complaint related to acute or chronic substance use were evaluated. Controls were enrolled in a 1:4 ratio. Participants’ health care utilization was tracked via electronic medical record for six months after the index ED visit. Costing data across all EDs in the region was obtained from Alberta Health Services and calculated to include physician billing and the cost of an ED visit excluding investigations. The cost impact of ED utilization was estimated by multiplying the derived ED cost per visit by the median number of visits with interquartile ranges (IQR) for each group during follow up. Proportions were compared using non-parametric tests. Results: From 4679 patients screened, 209 patients were enrolled (41 controls, 46 substance using, 91 unstably housed, 31 both unstably housed and substance using (UHS)). Median costs (IQR) per group over the six-month period were $0 ($0-$345.42) for control, $345.42 ($0-$1139.89) for substance using, $345.42 ($0-$1381.68) for unstably housed and $1381.68 ($690.84-$4248.67) for unstably housed and substance using patients (p<0.05). Conclusion: The intensity of excess ED costs was greatest in patients who were both unstably housed and presenting with a chief complaint related to substance use. This group had a significantly larger impact on health care expenditure relative to ED users who were not unstably housed or who presented with a substance use related complaint. Further research into how care or connection to community resources in the ED can reduce these costs is warranted.
Introduction: Some low acuity Emergency Department (ED) presentations are considered non-urgent or convenience visits and potentially avoidable with improved access to primary care. This study explored self-reported reasons why non-urgent patients presented to the ED. Methods: Patients, 17 years and older, were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada during weekdays (0700 to 1900). A 47-item questionnaire was completed by each consenting patient, which included items on whether the patient believed the ED was their best care option and the rationale supporting their response. A thematic content analysis was performed on the responses, using previous experience and review of the literature to identify themes. Results: Of the 2144 eligible patients, 1408 (65.7%) questionnaires were returned, and 1402 (65.4%) were analyzed. For patients who felt the ED was their best option (n = 1234, 89.3%), rationales included: safety concerns (n = 309), effectiveness of ED care (n = 284), patient-centeredness of ED (n = 277), and access to health care professionals in the ED (n = 204). For patients who felt the ED was not their best care option (n = 148, 10.7%), rationales included a perception that: access to health professionals outside the ED was preferable (n = 39), patient-centeredness (particularly timeliness) was lacking in the ED (n = 26), and their health concern was not important enough to require ED care (n = 18). Conclusion: Even during times when alternative care options are available, the majority of non-urgent patients perceived the ED to be the most appropriate location for care. These results highlight that simple triage scores do not accurately reflect the appropriateness of care and that understanding the diverse and multi-faceted reasons for ED presentation are necessary to implement strategies to support non-urgent, low acuity care needs.
Introduction: Some non-urgent/low-acuity Emergency Department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study surveyed patients who presented to the ED and explored their self-reported reasons and barriers for not being connected to a primary care provider (PCP). Methods: Patients aged 17 years and older were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada. Following initial triage, stabilization, and verbal informed consent, patients completed a 47-item questionnaire. Data from the survey were cross-referenced to a minimal patient dataset consisting of ED and demographic information. The questionnaire collected information on patient characteristics, their connection to a PCP, and patients' reasons for not having a PCP. Results: Of the 2144 eligible patients, 1408 (65.7%) surveys were returned and 1402 (65.4%) were completed. The majority of patients (74.4%) presenting to the ED reported having a family physician; however, the ‘closeness’ of the connection to their family physician varied greatly among ED patients with the most recent family physician visit ranging from 1 hour before ED presentation to 45 years prior. Approximately 25% of low acuity ED patients reported no connection with a family physician. Reasons for a lack of PCP connection included: prior physician retired, left, or died (19.8%), they had never tried to find one (19.2%), they had recently moved to Alberta (18.0%), and they were unable to find one (16.5%). Conclusion: A surprisingly high proportion of ED patients (25.6%) have no identified PCP. Patients had a variety of reasons for not having a family physician. These need to be understood and addressed in order for primary care access to successfully contribute to diverting non-urgent, low acuity presentations from the ED.
Introduction: Substance use and unstable housing are associated with heavy use of the Emergency Department (ED). This study examined the impact of substance use and unstable housing on the probability of future ED use. Methods: Case-control study of patients presenting to an urban ED. Patients were eligible if they were unstably housed for the past 30 days, and/or if their chief complaint was related to substance use. Following written informed consent, patients completed a baseline survey and health care use was tracked via electronic medical records for the next six months. Controls were enrolled in a 1:4 ratio. More than 2 ED visits during the follow-up was pre-specified as a measure of excess ED use. Descriptive analyses included proportions and medians with interquartile ranges (IQR). Binomial logistic regression models were used to estimate the impact of housing status, high-risk alcohol use (AUDIT) and drug use (DUDIT), and combinations of these factors on subsequent acute care system contacts (ED visits + admissions). We controlled for age, gender, comorbidities at baseline, and baseline presenting acuity. Results: 41 controls, 46 substance using, 91 unstably housed, and 31 both unstably housed and substance using patients were enrolled (n = 209). Median ED visits during follow up were 0 (IQR: 0-1.0) for controls, 1.0 (IQR: 0-3.3) for substance using, 1.0 (IQR: 0-4.0) for unstably housed and 4 (IQR: 2-12.3) for unstably housed and substance using patients. The median acute care system contacts over the same period was 1.0 (IQR 0-2.0) for controls, 1.0 (IQR: 0-4.0) for substance using, 1.0 (IQR: 0-5.0) for unstably housed and 4.5 (IQR: 2.8-14.3) for unstably housed and substance using patients. Being unstably housed was the factor most strongly associated with having > 2 ED visits (b=3.288, p<0.005) followed by high-risk alcohol and drug use (b=2.149, p<0.08); high risk alcohol use alone was not significantly associated with ED visits (b=1.939, p<0.1). The number of comorbidities present at baseline was a small but statistically significant additional risk factor (b=0.478, p<0.05). The model correctly predicted 70.1% of patients’ ED utilization status. Conclusion: Unstable housing is a substantial risk factor for ED use; high-risk alcohol and drug use, and comorbidities at baseline increased this risk. The intensity of excess ED use was greatest in patients who were unstably housed and substance using.
To perform a cost-effectiveness analysis to evaluate preoperative use of mupirocin in patients with total joint arthroplasty (TJA).
Simple decision tree model.
Outpatient TJA clinical setting.
Hypothetical cohort of patients with TJA.
A simple decision tree model compared 3 strategies in a hypothetical cohort of patients with TJA: (1) obtaining preoperative screening cultures for all patients, followed by administration of mupirocin to patients with cultures positive for Staphylococcus aureus; (2) providing empirical preoperative treatment with mupirocin for all patients without screening; and (3) providing no preoperative treatment or screening. We assessed the costs and benefits over a 1-year period. Data inputs were obtained from a literature review and from our institution's internal data. Utilities were measured in quality-adjusted life-years, and costs were measured in 2005 US dollars.
Main Outcome Measure.
Incremental cost-effectiveness ratio.
The treat-all and screen-and-treat strategies both had lower costs and greater benefits, compared with the no-treatment strategy. Sensitivity analysis revealed that this result is stable even if the cost of mupirocin was over $100 and the cost of SSI ranged between $26,000 and $250,000. Treating all patients remains the best strategy when the prevalence of S. aureus carriers and surgical site infection is varied across plausible values as well as when the prevalence of mupirocin-resistant strains is high.
Empirical treatment with mupirocin ointment or use of a screen-and-treat strategy before TJA is performed is a simple, safe, and cost-effective intervention that can reduce the risk of SSI. S. aureus decolonization with nasal mupirocin for patients undergoing TJA should be considered.