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The aim of this study was to use longitudinal population-based data to examine the associations between childhood sexual abuse (CSA) and risk for adverse outcomes in multiple life domains across adulthood. In 937 individuals followed from birth to age 45y, we assessed associations between CSA (retrospectively reported at age 26y) and the experience of 22 adverse outcomes in seven domains (physical, mental, sexual, interpersonal, economic, antisocial, multi-domain) from young adulthood to midlife (26 to 45y). Analyses controlled for sex, socioeconomic status, prospectively reported child harm and household dysfunction adverse childhood experiences, and adult sexual assault, and considered different definitions of CSA. After adjusting for confounders, CSA survivors were more likely than their peers to experience internalizing, externalizing, and thought disorders, suicide attempts, health risk behaviors, systemic inflammation, poor oral health, sexually transmitted diseases, high-conflict relationships, benefit use, financial difficulties, antisocial behavior, and cumulative problems across multiple domains in adulthood. In sum, CSA was associated with multiple persistent problems across adulthood, even after adjusting for confounding life stressors, and the risk for particular problems incremented with CSA severity. The higher risk for most specific problems was small to moderate, but the cumulative long-term effects across multiple domains reflect considerable individual and societal burden.
Hyperkalemia (HK) is common and potentially a life-threatening condition. If untreated, HK can progress to ventricular arrhythmia and cardiac arrest. Early treatment reduces mortality in HK. This study evaluates a novel protocol for identification and empiric management of presumed HK in the prehospital setting.
This was a retrospective, observational chart review of a single, large, suburban Emergency Medical Services (EMS) system. Patients treated for presumed HK, with both a clinical concern for HK and electrocardiogram (ECG) changes consistent with HK, from February 2018 through February 2021 were eligible for inclusion. Patients were excluded if found to be in cardiac arrest on EMS arrival. Empiric treatment of HK included administration of calcium, sodium bicarbonate, and albuterol. Post-treatment, patients were placed on cardiac monitoring and adverse events recorded enroute to receiving hospital. Protocol compliance was assessed by two independent reviewers. Serum potassium (K) level was obtained from hospital medical records.
A total of 582 patients were treated for HK, of which 533 patients were excluded due to cardiac arrest prior to EMS arrival. The remaining 48 patients included in the analysis had a mean age of 56 (SD = 20) years and were 60.4% (n = 29) male with 77.1% (n = 37) Caucasian, 10.4% (n = 5) African American, and 12.5% (n = 6) Hispanic. Initial blood draw at the receiving facilities showed K >5.0mEq/L in 22 (45.8%), K of 3.5-5.0mEq/L in 23 (47.9%), and K <3.5mEq/L in three patients (6.3%). Independent review of the EMS ECG found the presence of hyperkalemic-related change in 43 (89.6%) cases, and five (10.4%) patients did not meet criteria for treatment due to lack of either appropriate ECG findings or clinical suspicion. No episodes of unstable tachyarrhythmia or cardiac arrest occurred during EMS treatment or transport.
The study evaluated a novel protocol for detecting and managing HK in the prehospital setting. It is feasible for EMS crews to administer this protocol, although a larger study is needed to make the results generalizable.
Depression is associated with lower educational attainment, but there has been little investigation of long-term educational trajectories in large cohorts with diagnosed depression.
To describe the educational attainment trajectories of children with a depression diagnosis in secondary care, and to investigate whether these trajectories vary by sociodemographic characteristics.
We identified new referrals to South London and Maudsley's NHS Foundation Trust between 2007 and 2013 who received a depression diagnosis at under 18 years old. Linking their health records to the National Pupil Database, we standardised their performance on three assessments (typically undertaken at ages 6–7 years (school Year 2), 10–11 (Year 6) and 15–16 (Year 11)) relative to the local reference population in each academic year. We used mixed models for repeated measures to estimate attainment trajectories.
In our sample of 1492 children, the median age at depression diagnosis was 15 years (interquartile range = 14–16). Their attainment showed a decline between school Years 6 and 11. Attainment was consistently lower among males and those eligible for free school meals. Black ethnic groups also showed lower attainment than White ethnic groups between Years 2 and 6, but showed a less pronounced drop in attainment at Year 11.
Those who receive a depression diagnosis during their school career show a drop in attainment in Year 11. Although this pattern was seen among multiple sociodemographic groups, gender, ethnicity and socioeconomic status predict more vulnerable subgroups within this clinical population who might benefit from additional educational support or more intensive treatment.
The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency.
This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record.
Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals.
These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.
Three herbaceous regimes were established, using herbicides, to examine the effects of interference on growth and biomass partitioning in loblolly pine (Pinus taeda L.). Trees were sampled near Auburn and Tallassee, AL. Trees at the Auburn site grown with low weed interference (LWI) had 4, 10, 10, 8, and 4 times greater total aboveground biomass than did trees with high weed interference (HWI) for ages one through five, respectively. Medium weed interference (MWI, Auburn site only) resulted in three times greater biomass the first 4 yr and two times greater total biomass by the fifth year compared to trees grown with HWI. Trees growing with LWI were 5, 8, 10, and 6 times larger than those with HWI for ages one through four, respectively, at the Tallassee site. At all levels of interference, the percentage of total biomass in foliage decreased, and stem and branch components increased, with increasing tree size at both sites. Trees growing with HWI had a lower percentage of total biomass in foliage and a greater percentage of total biomass in stem than those growing with LWI when compared over a common size. Growth efficiency per tree, expressed as annual increase in stem biomass per unit leaf area (g m−2), was slightly greater for trees growing with LWI compared to HWI when leaf area index (LAI3, total surface) was less than 0.2. For LAI values greater than 0.2 the relationship was reversed. The latter contradicts the idea that growth efficiency can be used as a measure of vigor for young loblolly pine. Changes in carbon partitioning to the development of leaf area are suggested to be driving the accelerated growth responses associated with a reduction of weed interference.
The objective of this study was to evaluate the effect of the Stop Stroke (Pulsara; Bozeman, Montana USA) medical application on door-to-needle (DTN) time in patients presenting to the emergency department (ED) with an acute ischemic stroke (AIS).
This was a retrospective cohort study of the Good Shepherd Health System (Longview, Texas USA) stroke quality improvement dashboard for a 25-month period from February 2012 through February 2014. Data analysis includes all data from Center for Medicare and Medicaid Services (CMS; Baltimore, Maryland USA) reportable cases receiving Tissue Plasminogen Activator (TPA) for AIS during the study period. The primary outcome was mean DTN times before and after initiating Stop Stroke. Secondary outcome was the effect on the DTN≤60-minute benchmark.
During the study period, there were 533 stroke activations (200 before Stop Stroke implementation and 333 after). A total of 68 patients meeting inclusion criteria were analyzed (34 pre-app and 34 post- app). The observed mean DTN times post-app decreased 21 minutes (77 to 56 minutes), a 28% improvement (P=.001). Further, the patients meeting DTN≤60 minutes improved from 32% (11 of 34) to 82% (28 of 34) after the app’s implementation.
In this cohort of patients with AIS, Stop Stroke improved mean DTN times and number of patients treated within 60 minutes of arrival. These results demonstrate the app’s effect of increasing awareness of suspected AIS and improving coordination of care, evidenced by the magnitude of its effect on treatment times.
DicksonR, NedelcutA, McPeek NedelcutM. Stop Stroke: A Brief Report on Door-to-Needle Times and Performance After Implementing an Acute Care Coordination Medical Application and Implications to Emergency Medical Services. Prehosp Disaster Med. 2017;32(3):343–347.
In 2007, populations of Italian ryegrass were observed surviving applications of glyphosate under field conditions in southeast Arkansas. At least 10 reports of Italian ryegrass escaping glyphosate applications followed in subsequent years in Arkansas. These were unconfirmed reports of resistance from county agents, consultants, and farmers. The objectives of this research were to confirm resistance to glyphosate in a suspected resistant population collected in 2007 (Desha 2007) and to determine the level of resistance of a putative glyphosate-resistant population collected in 2009, both from Desha County, AR. Other objectives were to determine the resistance frequency in these populations, to determine whether the 2009 population was also acetolactate synthase (ALS) or acetyl-CoA carboxylase (ACCase-resistant), and to determine the effect on plant size as it relates to dose–response to glyphosate. The Desha, AR, 2007 population exhibited a low level of resistance to glyphosate. The estimated glyphosate dose that would control this population 50% was 1,260 g ae ha−1, compared with 190 g ae ha−1 for the susceptible check. In 2009, a population of Italian ryegrass (Des03) was identified that survived a glyphosate application of 1,740 g ae ha−1 made in the field, which is twice the commercial use rate for glyphosate. Dose–response experiments determined that an estimated 3,890 g ae ha−1 glyphosate was required to obtain 50% biomass reduction of Des03; this was 23 times that of the susceptible standard. Neither growth stage nor glyphosate rate evaluated affected the level of resistance observed in the Des03 population. This population was determined to be more than 70% resistant at the levels reported. In addition to glyphosate, Des03 was also resistant to diclofop, a commonly used herbicide in wheat in Arkansas and other areas. As a result, alternative management strategies for Italian ryegrass are currently being explored.
Materiality and the material are important in medieval romance. The essays here focus both on the physical forms of romance texts (manuscripts, verse form, illustrations and visual portryals), and on how romances themselves inhabit and reflect on the material culture of the Middle Ages. Specific themes discussed include social, historical, and physical space; bodies and gender politics; and romance illustrations in manuscripts, and in other media. Nicholas Perkins is University Lecturer and Tutor in medieval English, University of Oxford. Contributors: Siobhain Bly Calkin, Nancy Mason Bradbury, Aisling Byrne, Anna Caughey, Neil Cartlidge, Mark Cruse, Morgan Dickson, Rosalind Field, Elliott Kendall, Megan Leitch, Henrike Manuwald, Ad Putter, Raluca Radulescu, Robert Rouse,
This article reports on the childhood origins and adult outcomes of female versus male antisocial behavior trajectories in the Dunedin longitudinal study. Four antisocial behavior trajectory groups were identified among females and males using general growth mixture modeling and included life-course persistent (LCP), adolescent-onset, childhood-limited, and low trajectory groups. During childhood, both LCP females and males were characterized by social, familial and neurodevelopmental risk factors, whereas those on the adolescent-onset pathway were not. At age 32, women and men on the LCP pathway were engaging in serious violence and experiencing significant mental health, physical health, and economic problems. Females and males on the adolescent-onset pathway were also experiencing difficulties at age 32, although to a lesser extent. Although more males than females followed the LCP trajectory, findings support similarities across gender with respect to developmental trajectories of antisocial behavior and their associated childhood origins and adult consequences. Implications for theory, research, and practice are discussed.
Back pain and back injury is an extremely common problem, producing chronic, debilitating symptoms for sufferers, and resulting in millions of pounds of lost revenue in absence from work and paid in compensation for spinal injuries. Originally published in 2004, The Medico-Legal Back addresses the problem for a legal readership, in a clear, concise and reader-friendly style. It does away with the need to search for and then extract complex information from many different sources, and as such will be an indispensable guide to the problem for all lawyers, judges and medico-legal experts, as well as being of value to the orthopaedic surgeon with an interest in the spine. Of particular value is the use throughout the book of analogies drawn on anatomical technicalities and common movements, situations and incidents of everyday life.
Those of us in reasonable health and full-time well-paid employment in the medical and legal professions do not, perhaps, realise how fortunate we are. By contrast, to a young bread winner with a family to support and a mortgage and other financial responsibilities and looking forward to enhanced security in the future, a severe injury resulting in significant symptoms as well as an inability to continue working is a catastrophic event. What would we do if it happened to us and how would we cope physically, emotionally and financially? Clearly, financial compensation from a genuine accident-related disability is entirely appropriate and well deserved, but it is no substitute for normality.
We have always been, and will remain, staunch supporters of the concept that an individual who is damaged deserves compensation. That is why compensation for damages is entirely valid, but such damages do seem to be often unfairly distributed.
THE EXPERT WITNESS
Experts involved in trying to help the medico-legal process should, we think, know something about the matter in hand and demonstrate reasonable clinical experience. Orthopaedic surgeons deal with the surgical aspects of all hard parts of the body, the bones and joints, and the muscles, tendons, ligaments and nerves that work them; that is, all bar the contained soft organs.