To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
The aim of this study was to assess change in temperature, audiometric outcomes and post-operative complications following exposure to different light sources during endoscopic ear surgery.
A total of 64 patients diagnosed with chronic otitis media with central perforation and pure conductive hearing loss underwent endoscopic type 1 tympanoplasty. The patients were randomised into two groups based on the light source used: xenon or light-emitting diode. Temperature was measured using a K type thermocouple at the promontory and round window niche. Mean temperature change with respect to operating time, mean audiometric change, incidence of vomiting in the first 24 hours, vertigo and tinnitus at the end of the first week were observed.
Mean temperature change showed a statistically significant difference with increasing length of operating time with the xenon light source and when the two light sources were compared for a particular time interval. Mean audiometric change showed statistically significant deterioration at higher frequencies (4, 6 and 8 kHz) with the xenon light source but only at 8 kHz for the light emitting diode source. When the mean audiometric change was compared between light sources for a particular frequency, statistical significance was found at 4, 6 and 8 kHz. Post-operative complications were vomiting, vertigo and tinnitus (p-values of 0.042, 0.099 and 0.147, respectively, between two groups).
Light emitting diodes are associated with less significant middle-ear temperature rises and audiometric changes at higher frequencies when compared to xenon light sources. Hence, xenon should be replaced with cooler light sources.
Case fatality rate (CFR) and doubling time are important characteristics of any epidemic. For coronavirus disease 2019 (COVID-19), wide variations in the CFR and doubling time have been noted among various countries. Early in the epidemic, CFR calculations involving all patients as denominator do not account for the hospitalised patients who are ill and will die in the future. Hence, we calculated cumulative CFR (cCFR) using only patients whose final clinical outcomes were known at a certain time point. We also estimated the daily average doubling time. Calculating CFR using this method leads to temporal stability in the fatality rates, the cCFR stabilises at different values for different countries. The possible reasons for this are an improved outcome rate by the end of the epidemic and a wider testing strategy. The United States, France, Turkey and China had high cCFR at the start due to low outcome rate. By 22 April, Germany, China and South Korea had a low cCFR. China and South Korea controlled the epidemic and achieved high doubling times. The doubling time in Russia did not cross 10 days during the study period.
Two paediatric congenital heart disease patients presented with a brief history of low-grade fever without any focal symptoms. Their clinical features and laboratory tests were unremarkable; however, their blood cultures were positive that prompted further work-up. Infective endocarditis should be considered in any paediatric congenital heart disease patient who presents with fever without any other associated clinical features.
Non-invasive diagnostic tests (Table 3.1) are undertaken to support the clinical impression of and to quantify the extent of cardiac disease. Repeating the investigations over time allows for monitoring of management protocols and follow-up on disease progression. Information may be supplemented with advanced and invasive investigations (e.g. angiography in suspected coronary artery disease (CAD)).
Schizophrenic patients may be more susceptible to bone fractures because of the mental illness and/or the effects of psychotropic drugs. However, these patients also suffer from other medical conditions which may further increase their risk. The objective of this study was to make a general assessment of previous bone fractures in schizophrenics seen in an Internist's office.
We questioned 115 consecutive patients with the primary diagnosis of schizophrenia, seen in an Internist's office, for a wide variety of medical problems. Of these seventy nine (68.7%) were males and thirty six (31.3%) were females. Their ages ranged from 19 to 81. They were all on psychotropic drugs and under the care of a psychiatrist.
Of the total number of 115 patients, fifty one (44%) gave a history of previous bone fractures. Thirty eight (33%) gave a history of single fractures and thirteen (11.3%) gave a history of multiple fractures. Twenty six (22.6%) involved fractures of the upper limbs and twenty three (20%) involved fractures of the lower limbs and eight (6.9%) involved fractures of both the upper and lower limbs. Thirteen (11.3%) had non-extremity fractures. Of these eight (61.5%) had only non-extremity fractures and five (38.5%) had non-extremity fractures in addition to extremity fractures.
We found a significantly high prevalence of previous bone fractures in this schizophrenic population. Further study is necessary to elucidate whether this elevated risk is due to the mental illness, the use of psychotropic drugs, both, or some other associated etiology.
Hypothyroidism is common in the general population. Since symptoms and signs of hypothyroidism often mimic or overlap those of schizophrenia, they might be an under diagnosis of hypothyroidism in this population. Further, these patients may not be regularly seen by an Internist and may not be subject to routine thyroid profile testing. Treating occult thyroid abnormality is critical in these patients.
We studied the thyroid panel in 64 consecutive patients with schizophrenia seen in an Internist's office. Of these forty six (71.9%) were males and eighteen (28.1%) were females. The age ranged from 19 to 82. They were all on psychotropic medications. None were on lithium or thyroid supplementation. None of the patients exhibited clinical signs or symptoms of hypothyroidism. All of these patients underwent a routine thyroid profile testing.
Of these 64 patients, two (3.1%) patients were found to have elevated TSH. One had normal T3 and normal free T4, indicating subclinical hypothyroidism. The second patient had low T3 and low free T4 indicating overt hypothyroidism. Sixty two (96.9%) patients had an euthyroid profile.
In our study of 64 consecutive schizophrenic patients seen in an Internist's office, two were found to suffer from undiagnosed and untreated hypothyroidism. This limited study suggests that although not as common as suggested by the literature, undiagnosed and untreated hypothyroidism does exist in this population. All patients with schizophrenia should undergo a routine thyroid profile testing as part of a regular medical physical exam.
India, with its rich and distinct socio-cultural heritage, bestow diverse impact over individual symptom complexes, coloring the picture and causing wide variation in presentation and prognosis of psychiatric illnesses. With the widespread use of atheoretical categorical diagnostic systems such as DSM-IV, ICD-10, etc. and success of psychopharmacological treatment approach, psychiatrists in developing and underdeveloped countries have tended to overlook the role of psycho-social and cultural factors and their interplay with neurobiological factors in governing illness patterns, and are reluctant initiators of non-pharmacological treatment measures.
The study aims to descriptively analyze and compare the use of pharmacological to non-pharmacological intervention initiation in outpatients in a general hospital setting.
The study sample will comprise of consecutive patients referred to psychiatry outpatient department from February to July 2009. The socio-demographic and clinical profile will be analyzed using a semi-structured proforma and diagnosis will be made as per ICD-10-DCR. An analysis of pharmacological and non-pharmacological intervention initiation will be made and compared. Descriptive statistical analysis for continuous and categorical variables will be done as needed.
The study is currently been undertaken and the results and conclusion will be presented at the conference.
Symptoms have a major influence on expectations to the degree to which they affect patients’ perceptions of what might be wrong (cognitive states) and reactions to illness (emotional states).
This study investigated the relationship of patient and caregiver's expectations of illness to the diagnosis.
Two hundred new cases with their caregivers were consecutively included from the Out-Patient Department of psychiatry and assessed through a semi-structured proforma and Clinical Global Impression scale.
Somatic symptoms were the predominant complaints compared to psychic complaints. Patients presenting with more psychological symptoms had more uncommon and unmet expectations compared to those with biological symptoms. Most considered their illness to be of medical nature (71% in patients; 83% in caregivers). Patients gave social causes a higher priority (23.5% in patients and 6.5% in caregivers) while caregivers give higher priority to supernatural cause (5.5% in patients and 13% in caregivers). 54.5% patients and 63.5% caregivers considered the illness to be severe which on objective assessment was for only 38%. 54% patient had co morbid psychiatric illness and 46% had only psychiatric illness and 9% had only medical illness. More was the severity of illness; more the treatment in form of medication prescription was expected.
Objective severity of patients' disease condition, and their awareness of illness, can predict their adherence and can contribute to better targeting of health messages and treatment advice by providers.
Polypharmacy, involving anti-psychotic drugs as well as drugs for co-morbid conditions is common. We report a patient on 31 different medications involving taking at least 40 pills a day.
To highlight the problem with excessive polypharmacy.
To report a case of extreme polypharmacy.
The medical and medication chart of one patient was reviewed due to extreme polypharmacy.
The female patient aged 67 was on the following 32 medications: Fexofenadine 180 mg, Amlodipine 5 mg, Asprin 81 mg, Bupropion-XL 150 mg, Citalopram 10 mg, Citalopram 20 mg, Clobetasol 0.05% cream, Clonazepam 1 mg, Rosuvastatin 10 mg, Divalproex-ER 500 mg, Ferrous Sulphate 325 mg, Furosemide 20 mg, HC Valerate 0.2% cream, Ibandronate Sod 150 mg, Lamotrigine 100 mg, Levothyroxine 50 mcg, Losartan Pot 100 mg, Meloxicam 7.5 mg, Metoclopram 10 mg, Oxycod/Apap 5-325, Plavix 75 mg, Polyeth Glyc 3350 NF Powder, Pot. Cl Micro 20 Meq, Promethazine DM, Omeprazole 20 mg, Os Cal 500 plus D, Quetiapine Fum 200 mg, Quetiapine 300 mg, Multivitamin Stovite One,Trazodone 100 mg, and Vitamin D 400 units. Overall, the patient was taking 38 - 41 pills per day, oral liquid medication 2-5 per day and applying two lotions for a total of 4 times per day.
This case illustrates extreme polypharmacy. Although all medications may be clinically warranted, co-morbid conditions and seeing different specialists can result in runaway polypharmacy. Non-compliance, drug-drug interactions and serious side effects can result from extreme polypharmacy. The cure can potentially become a disease.
In healthy volunteers, light acting through serotonin pathways, decreases the threshold for sweet, but not salt taste; similar to SSRI paroxetine. In depressive disorders, there is deficiency of serotonin throughput, which is remedied by SSRI medications, and results in improvement in symptoms of depression. Thus, we report on taste thresholds before and after SSRI treatment.
To study the variation in thresholds for sweet with SSRI treatment in depressed patients in short- and long-term.
To compare the threshold for sweet (test) and salt (control) after 1 and 4 weeks of SSRI escitalopram therapy in depressed patients.
The project was approved by the institutional ethics committee. Following informed consent, depressed patients were initiated on escitalopram 10 mg/d (increased to 15 or 20 mg, if required after 1 week,). Taste recognition threshold, intensity and pleasantness were measured for sweet and salt. Each tastant was made −1 to −3 (100 mM–1 mM). Regional recognition thresholds were determined at the tip of the tongue using a cotton bud well soaked in the tastant.
Three males and 4 females of mean ages 39.1 years completed the study. There was significant shift to the left for sweet thresholds between days 0 and 7, and 7 and 28 [F(Dfn, Dfd) = 9.242 (4.162) P < 0.0001]. A similar shift to the left was seen for salt but day 7 only [F(Dfn, Dfd) = 6.213 (4.162)].
The increase in serotonin throughput as envisaged through SSRI treatment was paralleled by decrease in sweet thresholds.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
We describe the design and deployment of GREENBURST, a commensal Fast Radio Burst (FRB) search system at the Green Bank Telescope. GREENBURST uses the dedicated L-band receiver tap to search over the 960–1 920 MHz frequency range for pulses with dispersion measures out to
. Due to its unique design, GREENBURST is capable of conducting searches for FRBs when the L-band receiver is not being used for scheduled observing. This makes it a sensitive single pixel detector capable of reaching deeper in the radio sky. While single pulses from Galactic pulsars and rotating radio transients will be detectable in our observations, and will form part of the database we archive, the primary goal is to detect and study FRBs. Based on recent determinations of the all-sky rate, we predict that the system will detect approximately one FRB for every 2–3 months of continuous operation. The high sensitivity of GREENBURST means that it will also be able to probe the slope of the FRB fluence distribution, which is currently uncertain in this observing band.
In recent years, the discovery of massive quasars at
has provided a striking challenge to our understanding of the origin and growth of supermassive black holes in the early Universe. Mounting observational and theoretical evidence indicates the viability of massive seeds, formed by the collapse of supermassive stars, as a progenitor model for such early, massive accreting black holes. Although considerable progress has been made in our theoretical understanding, many questions remain regarding how (and how often) such objects may form, how they live and die, and how next generation observatories may yield new insight into the origin of these primordial titans. This review focusses on our present understanding of this remarkable formation scenario, based on the discussions held at the Monash Prato Centre from November 20 to 24, 2017, during the workshop ‘Titans of the Early Universe: The Origin of the First Supermassive Black Holes’.
Patient assessment is a fundamental feature of community paramedicine, but the absence of a recognized standard for assessment practices contributes to uncertainty about what drives care planning and treatment decisions. Our objective was to summarize the content of assessment instruments and describe the state of current practice in community paramedicine home visit programs.
We performed an environmental scan of all community paramedicine programs in Ontario, Canada, and used content analysis to describe current assessment practices in home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy.
A total of 43 of 52 paramedic services in Ontario, Canada, participated in the environmental scan with 24 being eligible for further investigation through content analysis of intake assessment forms. Among the 24 services, 16 met inclusion criteria for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Most assessments included some content from each of the domains outlined in the ICF. At the subdomain level, only assessment of impairments of the functions of the cardiovascular, hematological, immunological, and respiratory systems appeared in all assessments.
Although community paramedicine home visit programs may differ in design and aim, all complete multi-domain assessments as part of patient intake. If community paramedicine home visit programs share similar characteristics but assess patients differently, it is difficult to expect that the resulting referrals, care planning, treatments, or interventions will be similar.
Innovation Concept: Competence in procedural skills is vital within the emergency department. Challenging procedures such as cricothyroidotomy are difficult to master as they are rare and hard to train for. Additionally, common procedures such as chest tube insertions require practice to become sufficiently competent. Opportunities to hone these skills are essential in residency training. This project aimed to create instructional video modules for specific emergency medicine (EM) procedures and to gauge its utility as an adjunctive resource for procedural learning in the EM residency curriculum. Methods: Tutorial videos for clamshell thoracotomy, cricothyroidotomy, and chest tube insertion were filmed within a cadaver lab with step-by-step instructions. The footage was edited and overlaid with a prepared audio narration using Camtasia®/Apple® Video Editing software. These videos were embedded within modules that included foundational knowledge relevant to the procedures including anatomy, physiology and pathophysiology. The modules were peer-edited by licensed EM staff physicians and distributed to EM residents and staff physicians for analysis. Qualitative and quantitative analysis relied upon participants’ answers to questions and a Modified Task Value Scale (measures the value of a module for overall learning), respectively. Curriculum, Tool or Material: Ten participants were included in the analysis, including EM residents (n = 6) and staff emergency physicians (n = 4). Qualitative feedback suggested that positive aspects of the modules included visuals, content, narration, and review of anatomy. Negative aspects included the lack of indications for procedures, technical details, real patient examples, and a speed up function. Quantitative feedback resulted in scores of 4 and above out of 5 (1 = lowest value, 5 = highest value) on the Motivated Task Value Scale across all aspects for all the modules. Furthermore, analysis revealed an average score of 3.9/5 for inclination to access more modules such as these, and a score of 4.4/5 for overall perception of the modules. Conclusion: Participants found the video modules valuable to their learning, both qualitatively and quantitatively. This study was limited by a small sample size of modules and a low number of participants. Furthermore, a more detailed analysis with further measures, including self-efficacy and self-confidence, would yield more comprehensive conclusions. However, video modules provide an effective and easily accessible adjunctive tool to acquire skill and confidence with EM procedures, for medical learners and staff physicians.
To propose a new classification of inner-ear anomalies that is more clinically oriented and surgically relevant: the SMS (Sawai Man Singh) classification of cochleovestibular malformations.
A retrospective multicentric study was conducted of 436 cochlear implantations carried out in 3 Indian tertiary care institutes. Patients with anomalous anatomy were included and classified, as per the new SMS classification, into cochleovestibular malformation types I, II, III and IV, based on cochlear morphology, modiolus and lamina cribrosa.
There were 19, 23, 8 and 4 patients with cochleovestibular malformation types I, II, III and IV, respectively. Two-year post-operative Meaningful Auditory Integration Scale scores were statistically analysed.
This new classification for inner-ear anomalies is a simpler, more practical, outcome-oriented classification that can be used to better plan the surgery. These merits make it a more uniform classification for recording results.
Introduction: Patient assessment is a fundamental feature of non-emergency community paramedicine (CP) home visit programs. In the absence of a recognized standard for CP assessment, current assessment practices in CP programs are unknown. Without knowing what community paramedics are assessing, it is difficult to ascertain what should be included in patient care plans, whether interventions are beneficial, or whether paramedics are meeting program objectives. Our objective was to summarize the content of assessment instruments used in CP programs in order to describe the state of current practice. Methods: We performed an environmental scan of all CP programs in Ontario, Canada, and employed content analysis to describe current assessment practices in CP home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy. Findings were compared at the domain and sub-domain of the ICF. Results: Of 54 paramedic services in Ontario, 43 responded to our request for information. Of 24 services with CP home visit programs, 18 provided their intake assessment forms for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Overall, most assessments included some content from each of the domains outlined in the ICF, including: Impairments of Body Functions, Impairments of Body Structures, Activity Limitation and Participation, and Environmental Factors. At the sub-domain level, only assessment of Impairments of the Functions of the Cardiovascular, Haematological, Immunological and Respiratory systems appeared in all assessments. Few CP home visit program assessments covered most ICF sub-domain categories and many items classified to specific categories were included in only a few assessments. Conclusion: CP home visit programs complete multi-domain assessments as part of patient intake. The content of CP assessments varied across Ontario, which suggests that care planning and resources may not be consistent. Current work on practice guidelines and paramedic training can build from descriptions of assessment practices to improve quality of care and patient safety. By identifying what community paramedics assess, evaluation of the quality of CP home visit programs and their ability to meet program objectives can be improved and benchmarks in patient care can be established.
Introduction: Competence in procedural skills is vital within the emergency department. Challenging procedures such as cricothyroidotomy are difficult to master as they are rare and hard to train for. Additionally, common procedures such as chest tube insertions require practice to become sufficiently competent. Opportunities to hone these skills are essential in residency training. This project aimed to create instructional video modules for specific emergency medicine (EM) procedures and gauge their utility as adjunctive resources for procedural learning in the EM residency curriculum. Methods: Tutorial videos for clamshell thoracotomy, cricothyroidotomy, and chest tube insertion were filmed within a cadaver lab with step-by-step instructions. The footage was edited and overlaid with a pre-prepared audio narration using Camtasia®/Apple® Video Editing software. These videos were embedded within modules that included foundational knowledge relevant to the procedures, including anatomy, physiology and pathophysiology. The modules were peer-edited by licensed EM staff physicians and distributed to EM residents and staff physicians for analysis. Qualitative and quantitative analysis relied upon participants’ answers to questions and a Modified Task Value Scale, respectively. Results: Ten participants were included in the analysis, including EM residents (n = 6) and staff emergency physicians (n = 4). Qualitative feedback suggested that positive aspects of the modules included visuals, content, narration, and review of anatomy. Negative aspects included the lack of indications for procedures, technical details, real patient examples, and a speed up function. Quantitative feedback resulted in scores of 4 and above out of 5 on the Motivated Task Value Scale across all aspects for all the modules. Furthermore, analysis revealed an average score of 3.9 for inclination to access more modules such as these, and a score of 4.4 for overall perception of the modules. Conclusion: Participants found the video modules valuable to their learning, both qualitatively and quantitatively. This study was limited by a small sample size of modules and a low number of participants. Furthermore, a more detailed analysis with further measures, including self-efficacy and self-confidence, would yield more comprehensive conclusions. However, video-based modules provide an effective and easily accessible adjunctive tool to acquire skill and confidence with EM procedures, for medical learners and staff physicians.
Recent work has implicated one type of horizontal strabismus (exotropia) as a risk factor for schizophrenia. This new insight raises questions about a potential common developmental origin of the two diseases. Seasonality of births is well established for schizophrenia. Seasonal factors such as light exposure affect eye growth and can cause vision abnormalities, but little is known about seasonality of births in strabismus. We examined birth seasonality in people with horizontal strabismus in a retrospective study in Washoe County, Nevada, and re-examined similar previously obtained data from Osaka, Japan. We then compared seasonal patterns of births between strabismus, refractive error, schizophrenia and congenital toxoplasmosis. Patients with esotropia had a significant seasonality of births, with a deficit in March, then increasing to an excess in September, while patients with exotropia had a distinctly different pattern, with an excess of births in July, gradually decreasing to a deficit in November. These seasonalities were statistically significant with either χ2 or Kolmogorov–Smirnov-type statistics. The birth seasonality of esotropia resembled that for hyperopia, with an increase in amplitude, while the seasonality for myopia involved a phase-shift. There was no correlation between seasonality of births between strabismus and congenital toxoplasmosis. The pattern of an excess of summer births for people with exotropia was remarkably similar to the well-established birth seasonality of one schizophrenia subtype, the deficit syndrome, but not schizophrenia as a whole. This suggests a testable hypothesis: that exotropia may be a risk factor primarily for the deficit type of schizophrenia.
The aim of this study is to identify the types of community paramedicine programs and the training for each.
A systematic review of MEDLINE, Embase, grey literature, and bibliographies followed a search strategy using common community paramedicine terms. All studies published in English up to January 22, 2018, were captured. Screening and extraction were completed in duplicate by two independent reviewers. The Mixed Methods Appraisal Tool (MMAT) was used to assess studies’ methodological quality (full methodology on PROSPERO: CRD42017051774).
From 3,004 papers, there were 64 papers identified (58 unique community paramedicine programs). Of the papers with an appraisable study design (40.6%), the median MMAT score was 3 of 4 criteria met, suggesting moderate quality. Programs most often served frequent 911 callers (48.3%) and individuals at risk for emergency department admission, readmission, or hospitalization (41.4%); and 70.7% of programs were preventive home visits. Common services provided were home assessment (29.5%), medication management (39.7%), and referral and/or transport to community services (37.9%); and 77.6% of programs involved interprofessional collaboration. Community paramedicine training was described by 57% of programs and expanded upon traditional paramedicine training and emphasized technical skills. Study heterogeneity prevented meta-analysis.
Community paramedicine programs and training were diverse and allowed community paramedics to address a spectrum of population health and social needs. Training was poorly described. Enabling more programs to assess and report on program and training outcomes would support community paramedicine growth and the development of formalized training or education frameworks.