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Although the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke caused by intracranial anterior circulation large vessel occlusion (LVO) is proven, demonstration of local effectiveness is critical for health system planning and resource allocation because of the complexity and cost of this treatment.
Using our prospective registry, we identified all patients who underwent EVT for out-of-hospital LVO stroke from February 1, 2013 through January 31, 2017 (n = 44), and matched them 1:1 in a hierarchical fashion with control patients not treated with EVT based on age (±5 years), prehospital functional status, stroke syndrome, severity, and thrombolysis administration. Demographics, in-hospital mortality, discharge disposition from acute care, length of hospitalization, and functional status at discharge from acute care and at follow-up were compared between cases and controls.
For EVT-treated patients (median age 66, 50% women), the median onset-to-recanalization interval was 247 min, and successful recanalization was achieved in 30/44 (91%). Alteplase was administered in 75% of cases and 57% of controls (p = 0.07). In-hospital mortality was 11% among the cases and 36% in the control group (p = 0.006); this survival benefit persisted during follow-up (p = 0.014). More EVT patients were discharged home from acute care (50% vs. 18%, p = 0.002). Among survivors, there were nonsignificant trends in favor of EVT for median length of hospitalization (14 vs. 41 days, p = 0.11) and functional independence at follow-up (51% vs. 32%, p = 0.079).
EVT improved survival and decreased disability. This demonstration of single-center effectiveness may help facilitate expansion of EVT services in similar health-care jurisdictions.
Introduction: Telephone Triage Services (TTS) manage phone calls from the public regarding general medical problems and provide telephone advice. This telephone based care can overlap with care provided by Poison Centres. Our objective was to examine the impact of a provincial 811 TTS on the IWK Regional Poison Centre (RPC). Methods: This is a retrospective descriptive study using interrupted time series methodology. We compared monthly IWK RPC call volume in the pre-811 era (January 2007-July 2009) and the post-811 era (September 2009-December 2017). We summarized the characteristics of callers who accessed the IWK RPC in terms of client age, sex, intentionality, time of day, call disposition and outcome. Caller characteristics were compared between the pre- and post-811 eras using chi-square test for categorical variables. We used segmented regression analysis to evaluate changes in slope of call volume in the pre- and post 811 eras. The Durbin-Watson statistic was performed to test for serial correlation and the Dickey-Fuller test to investigate seasonality. Results: The dataset included 82683 calls to the IWK RPC – 27028 pre-811 and 55655 post-811. Overall, 55% of calls were for female clients and the largest age group was children aged 0-5 years (37%). Most calls originated from home (47%), followed by a health care facility (23%). Most calls were managed at home (65%). Less than 3% of calls resulted in major effect or death. The Durbin Watson statistic was not statistically significant (p = 0.94). The Dickey-Fuller test indicated series stationarity (p = 0.001). There was no statistically significant change in call volume to the IWK RPC due to the introduction of 811 (p = 0.39). There was no significant variation by time of day, day of week or month, with most calls occurring in the evening. There were significantly more calls regarding intentional ingestions in the post-811 era (23% vs. 19% pre-811, p < .001). Outcomes in the pre and post 811 eras were as follows: minor/no effect/non-toxic/minimal 80% vs. 78%; moderate 7% vs. 10%; and, major/death 1.7% vs. 2.0%. Conclusion: The introduction of a TTS did not change call volumes at our RPC. The increase in the percentage of calls about intentional ingestions may reflect an increase in call acuity as the 811-TTS likely manages calls about minor/non-toxic ingestions without consulting with the RPC. Our future research will examine the nature of poison related calls to the 811-TTS.
Introduction: We implemented a pharmacist-led antimicrobial stewardship (AMS) service for patients discharged from the pediatric emergency department (PED). This service, supported by a collaborative practice agreement, allows pharmacists to follow up with patients and independently stop, start, or adjust antimicrobial agents based on culture results. The primary objective of our study was to evaluate the impact of this service on the rate of return visits to the PED within 96 hours. The secondary objective was to evaluate the appropriateness of the prescribed antimicrobial agent at follow up. Methods: This study was completed as a retrospective chart review 6 months pre-implementation (January 1st, 2016 to June 31st, 2016) and 6 months post-implementation (February 1st, 2017 to July 31st, 2017) of a pharmacist-led AMS service. A research assistant extracted data from electronic medical records using a standardized data collection form. All patients discharged from the PED with a suspected infection whose cultures fell within the parameters of the collaborative practice agreement were included in this study. Data were reported descriptively and compared using a two-sided chi-square test. Results: This study included 1070 patient encounters pre-implementation and 1040 patient encounters post-implementation of the AMS service. The most commonly reviewed culture was urine (38% pre-implementation and 41% post-implementation). The rate of return visits to the PED within 96 hours was 12.0% (129/1070) pre-implementation vs 10.0% (100/1049) post-implementation phase (p = 0.07). A significantly higher percentage of inappropriate antimicrobial therapy was identified at the time of follow up in the pre-implementation phase (7.0%, 68/975) compared to the post-implementation phase (5.0%, 46/952), p = 0.047. Conclusion: Although this pharmacist-led AMS service did not affect the rate of return visits within 96 hours, it may have led to more judicious use of antimicrobial agents.
Producers are interested in utilising farrowing systems with reduced confinement to improve sow welfare. However, concerns of increased mortality may limit commercial uptake. Temporary confinement systems utilise a standard crate which is opened 3 to 7 days postpartum, providing protection for neonatal piglets at their most vulnerable age and later increased freedom of movement for sows. However, there is anecdotal evidence that piglet mortality increases immediately after the temporary crate is opened. The current study aims were to determine if piglet mortality increases post-opening, to trial different opening techniques to reduce post-opening piglet mortality and to identify how the different opening techniques influence sow behaviour. Three opening treatments were implemented across 416 sows: two involved opening crates individually within each farrowing house when each litter reached 7 days of age, in either the morning or afternoon (AM or PM), with a control of the standard method used on the farm to open all crates in each farrowing house simultaneously once the average litter age reached 7 days (ALL). Behavioural observations were performed on five sows from each treatment during the 6 h after crate opening, and during the same 6 h period on the previous and subsequent days. Across all treatments, piglet mortality was significantly higher in the post-opening than pre-opening period (P<0.0005). Between opening treatments, there were significant differences in piglet mortality during the 2 days after crate opening (P<0.05), whilst piglet mortality also tended to differ from crate opening until weaning (P=0.052), being highest in ALL and lowest in PM. Only sows in the PM treatment showed no increase in standing behaviour but did show an increased number of potentially dangerous posture changes after crate opening (P=0.01), which may be partly attributed to the temporal difference in observation periods. Sow behaviour only differed between AM and ALL on the day before crate opening, suggesting the AM treatment disrupted behaviour pre-opening. Sows in AM and PM treatments showed more sitting behaviour than ALL, and therefore may have been more alert. In conclusion, increases in piglet mortality after crate opening can be reduced by opening crates individually, more so in the afternoon. Sow habituation to disturbance before crate opening may have reduced post-opening piglet mortality, perhaps by reducing the difference in pre- and post-opening sow behaviour patterns.
Global interest in alternative indoor farrowing systems is increasing, leading to a growing number of farms utilising such systems alongside standard crates. There is evidence that interchanging sows between different farrowing systems affects maternal behaviour, whilst the subsequent effect of this on piglet mortality is unknown. The current study hypothesised that second parity piglet mortality would be higher if a sow farrowed in a different farrowing system to that of her first parity. Retrospective farm performance records were used from 753 sows during their first and second parities. Sows farrowed in either standard crates (crates), temporary crates (360s) or straw-bedded pens (pens), with mortality recorded as occurring either pre- or post-processing. Inter- and intra-parity sow consistency in performance were also investigated. Overall, total piglet mortality reduced from the first to the second parity, being significantly higher in the crates and higher in the 360s during the first or second parity, respectively. In the second parity, an interaction of the current and previous farrowing systems resulted in the lowest incidence of crushing for sows housed in the same system as their first parity for the crates and pens, but not the 360s. Post-processing mortality was significantly higher in the crates if a sow previously farrowed in the 360s and vice versa. Sows which previously farrowed in a pen had a significantly larger litter size and lower pre-processing mortality from crushing in their second parity than sows previously housed in the crates or the 360s. No inter-parity consistency of sow performance was found, whilst intra-parity consistency was found in the first but not second parity. In conclusion, returning sows to the same farrowing system appears to reduce piglet mortality, whilst farrowing in a pen during the first parity significantly increased second parity litter size without increasing piglet mortality.
Childhood maltreatment and a family history of a schizophrenia spectrum disorder (SSD) are each associated with social-emotional dysfunction in childhood. Both are also strong risk factors for adult SSDs, and social-emotional dysfunction in childhood may be an antecedent of these disorders. We used data from a large Australian population cohort to determine the independent and moderating effects of maltreatment and parental SSDs on early childhood social-emotional functioning.
The New South Wales Child Development Study combines intergenerational multi-agency data using record linkage methods. Multiple measures of social-emotional functioning (social competency, prosocial/helping behaviour, anxious/fearful behaviour; aggressive behaviour, and hyperactivity/inattention) on 69 116 kindergarten children (age ~5 years) were linked with government records of child maltreatment and parental presentations to health services for SSD. Multivariable analyses investigated the association between maltreatment and social-emotional functioning, adjusting for demographic variables and parental SSD history, in the population sample and in sub-cohorts exposed and not exposed to parental SSD history. We also examined the association of parental SSD history and social-emotional functioning, adjusting for demographic variables and maltreatment.
Medium-sized associations were identified between maltreatment and poor social competency, aggressive behaviour and hyperactivity/inattention; small associations were revealed between maltreatment and poor prosocial/helping and anxious/fearful behaviours. These associations did not differ greatly when adjusted for parental SSD, and were greater in magnitude among children with no history of parental SSD. Small associations between parental SSD and poor social-emotional functioning remained after adjusting for demographic variables and maltreatment.
Childhood maltreatment and history of parental SSD are associated independently with poor early childhood social-emotional functioning, with the impact of exposure to maltreatment on social-emotional functioning in early childhood of greater magnitude than that observed for parental SSDs. The impact of maltreatment was reduced in the context of parental SSDs. The influence of parental SSDs on later outcomes of maltreated children may become more apparent during adolescence and young adulthood when overt symptoms of SSD are likely to emerge. Early intervention to strengthen childhood social-emotional functioning might mitigate the impact of maltreatment, and potentially also avert future psychopathology.
Primate tourism is a recent and growing trend in primate-habitat countries. Many primate tourism operations are outgrowths of community-based conservation initiatives (Hill, 2002) and have been promoted for their potential to achieve conservation goals as well as financial and educational benefits for local communities. One of the earliest and most successful initiatives is the Mountain Gorilla Project in the Virunga Mountains (Harcourt & Stewart, 2007). Gorilla tourism has been credited with bringing an important source of foreign currency to impoverished nations, educational opportunities for local inhabitants, and even increased reproduction in gorilla groups used for tourism (Harcourt & Stewart, 2007; and see Goldsmith, this volume). However, the extent to which many primate tourist operations are meeting these goals is not clear. As a result, conservationists, who were generally enthusiastic and encouraging about establishing primate tourism operations, are sounding more cautious, noting specific examples in which tourism has harmed wild primates, and pointing out that we know little about the impact of tourism on most of the populations it targets (Butynski, 2001). Most agree that we need to do much more research to better understand the ways in which primate tourism affects primate health, behavior, and reproduction. Only then will we be able to make sound recommendations that maximize conservation goals and minimize harm. This chapter reviews some approaches to assessing the effects of tourism on primate populations, presents findings on some of the negative impacts of tourism on a population of Tibetan macaques, and offers several recommendations to reduce these negative impacts both in China and elsewhere.
True findings about schizophrenia remain elusive; many findings are not replicated and conflicting results are common. Well-conducted systematic reviews have the ability to make robust, generalizable conclusions, with good meta-analyses potentially providing the closest estimate of the true effect size. In this paper, we undertake a systematic approach to synthesising the available evidence from well-conducted systematic reviews on schizophrenia.
Reviews were identified by searching Medline, EMBASE, CINAHL, Current Contents and PsycINFO. The decision to include or exclude reviews, data extraction and quality assessments were conducted in duplicate. Evidence was graded as high quality if reviews contained large samples and robust results; and as moderate quality if reviews contained imprecision, inconsistency, smaller samples or study designs that may be prone to bias.
High- and moderate-quality evidence shows that numerous psychosocial and biomedical treatments are effective. Patients have relatively poor cognitive functioning, and subtle, but diverse, structural brain alterations, altered electrophysiological functioning and sleep patterns, minor physical anomalies, neurological soft signs, and sensory alterations. There are markers of infection, inflammation or altered immunological parameters; and there is increased mortality from a range of causes. Risk for schizophrenia is increased with cannabis use, pregnancy and birth complications, prenatal exposure to Toxoplasma gondii, childhood central nervous system viral infections, childhood adversities, urbanicity and immigration (first and second generation), particularly in certain ethnic groups. Developmental motor delays and lower intelligence quotient in childhood and adolescence are apparent.
We conclude that while our knowledge of schizophrenia is very substantial, our understanding of it remains limited.
To determine the proportion of methicillin-resistant Staphylococcus aureus (MRSA) detections identified by nasal swabbing using agar culture in comparison with multiple body site testing using agar and nutrient broth culture.
Adult patients admitted to 36 general specialty wards of 2 large hospitals in Scotland.
Patients were screened for MRSA via multiple body site swabs (nasal, throat, axillary, perineal, and wound/invasive device sites) cultured individually on chromogenic agar and pooled in nutrient broth. Combined results from all sites and cultures provided a gold-standard estimate of true MRSA prevalence.
This study found that nasal screening performed better than throat, axillary, or perineal screening but at best identified only 66% of true MRSA carriers against the gold standard at an overall prevalence of 2.9%. Axillary screening performed least well. Combining nasal and perineal swabs gave the best 2-site combination (82%). When combined with realistic screening compliance rates of 80%–90%, nasal swabbing alone probably detects just over half of true colonization in practice. Swabbing of clinically relevant sites (wounds, indwelling devices, etc) is important for a small but high-prevalence group.
Nasal swabbing is the standard method in many locations for MRSA screening. Its diagnostic efficiency in practice appears to be limited, however, and the resource implications of multiple body site screening have to be balanced against a potential clinical benefit whose magnitude and nature remains unclear.
Childhood adversity is a putative risk factor for schizophrenia, although evidence supporting this suggestion is inconsistent and controversial. The aim of this review was to pool and quality assess the current evidence pertaining to childhood adversity in people with schizophrenia compared to other psychiatric disorders and to non-psychiatric controls.
Included were case-control, cohort and cross-sectional studies. Medline, EMBASE and PsycINFO databases were searched. Study reporting was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist and pooled evidence quality was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Twenty-five studies met inclusion criteria. Moderate to high quality evidence suggests increased rates of childhood adversity in schizophrenia compared to controls [odds ratio (OR) 3.60, p < 0.00001]. Increased childhood adversity was also reported in schizophrenia compared to anxiety disorders (OR 2.54, p = 0.007), although the effect was not significant in the subgroup analysis of five studies assessing only sexual abuse. No differences in rates of childhood adversity were found between schizophrenia and affective psychosis, depression and personality disorders whereas decreased rates of childhood adversity were found in schizophrenia relative to dissociative disorders and post-traumatic stress disorder (OR 0.03, p < 0.0001).
This is the first meta-analysis to report a medium to large effect of childhood adversity in people with schizophrenia and to assess specificity for schizophrenia. Further research is required that incorporates longitudinal design and other potentially causal variables to assess additive and/or interactive effects.
Modern time-domain surveys have demonstrated that finding variable objects is relatively straightforward. The problem now is one of selecting and following up discoveries. With even larger-scale surveys on the horizon, the magnitude of the problem will inevitably increase. One way to prepare for the coming deluge is to have realistic estimates of the numbers of potential detections so that resources can be developed to meet that need. To that end, astronomers at the National Optical Astronomy Observatory (NOAO) have begun a project to characterize the variable sky in terms of type of objects, distribution on the sky and range of variation.
Lamb mortality remains a significant welfare and economic issue for sheep production. Lamb survival is to a degree dependent upon an easy delivery and the expression of appropriate behaviours from both mother and offspring, such as rapid standing, udder seeking and sucking by the lamb. Genetic solutions have the potential to improve birth assistance and lamb behaviour but large amounts of data are needed. Therefore, to achieve this objective, simple, proxy methods (scoring systems) were developed to quantify the level of birth difficulties and lamb vigour on farm. In the first study, detailed historical behavioural data from 1156 lambs (Scottish Blackface and Suffolk (S)) were analysed to develop criteria for 3 scores: birth assistance, lamb vigour and sucking assistance. The birth assistance score was developed by analysing the relationships between birth presentation and intervention levels, and intervention level and labour length. Lambs with abnormal birth positions required more assistance than normally presented lambs and lambs with long labours required more and greater assistance than those with short labours. Lamb vigour score was developed by analysing the latencies for the lamb to first perform specific behaviours; more vigorous lambs reach landmark behaviours faster than low vigour lambs. The sucking assistance score was developed from the relationship between the latency to suck successfully and assistance level, where lambs that were slow to suck required more assistance than lambs that were quick to suck. In the second study, the behaviour scoring systems (5-point categorical scales) were validated using a commercial flock of 80 twin-bearing crossbred ewes mated with either Texel (T) or S sires by simultaneously recording scores and the latency to perform specific landmark behaviours (i.e. to stand, seek the udder and suck). The vigour scores (recorded at 5 min of age) were compared with the latency from birth to standing and showed that lambs with lower (better) vigour scores were faster to stand after birth than those with higher scores. The sucking assistance scores were compared with the latency from birth to sucking, and showed that lambs with lower sucking assistance scores are quicker to suck than those with high scores. These results showed that the scoring systems could provide a practical and reliable assessment of birth assistance and lamb behaviour on farm and were sufficiently sensitive to discriminate vigour levels between lambs sired by either S or T rams.
The experiment measured lamb responses to supplementation of the pregnant ewe diet with vitamin E above requirement. Crossbred ewes were mated with either Suffolk or Texel rams. Twin-bearing ewes were randomly allocated (approximately 21 months of age at allocation) to one of four treatment groups (20 ewes per group, 10 mated with Suffolk and 10 with Texel rams). Treatments imposed were 50, 100, 150 or 250 IU supplementary vitamin E per ewe per day to give a four treatment by two sire-type factorial experimental design. Ewes were fed concentrates to meet energy requirements for stage of pregnancy and hay ad libitum. Diets were introduced approximately 6 weeks before lambing. Blood samples were obtained prior to introduction of diets, 17 days after introduction of diets and within 24 h of lambing from a subset of eight ewes per treatment (32 total). Colostrum samples were obtained from 10 ewes per treatment, 12 h after birth of the first lamb. All births were observed and a lamb vigour score was assigned to each lamb 5 min after birth. At 1 and 12 h after birth, rectal temperature, and at 12 h after birth, sex, crown-rump length and BW of each lamb were recorded. Mean ewe plasma α-tocopherol concentration prior to introduction of the diets was 1.5 μg/ml (s.e.m. 0.09) and did not differ between groups. There were positive linear (P < 0.001) effects of dietary vitamin E on plasma (17 days after introduction of diets) and colostrum (12 h after birth) α-tocopherol concentrations. Lamb vigour scores were superior (P < 0.001) for lambs sired by Texel rather than Suffolk rams but there were no differences as a result of vitamin E supplementation. Lamb mortality was low and unrelated to either sire or supplementary vitamin E. Lamb birth and weaning weights were also unaffected by vitamin E supplementation. Supplementing the ewe with vitamin E therefore had no effect on any lamb measurements.
Traditionally UK lamb finishers have used forage brassicas to extend the season of supply of lamb beyond the grazing season. Retailers however can now import low-cost chilled lamb from New Zealand from December to June so financially U.K. supply extension is now more risky. Here, two trials are described to i) evaluate the ability of currently used forage brassicas to finish lambs in Nov/Dec, and to ii) compare the most promising ones with mixtures containing chicory, plantain and clover for finishing lambs in August /Sept. The latter having shown to be bio-active with anthelmintic effects.
Neonatal lamb mortality represents both a welfare issue and an important production inefficiency. Approximately 80% of lamb mortality can be attributed to the starvation-mismothering-exposure complex and occurs in the first 3 days after birth. Sub-optimal supply of trace elements and vitamins to the ewe is a potential risk factor in lamb mortality with Se, vitamin E and fatty acids the most likely candidates (Rooke et al. 2008). Responses to vitamin E supplementation above requirement in the last third of gestation are variable probably because of differences between studies in route of administration, dose administered and pre-experiment vitamin E status of the ewe population. The object of the experiment was to characterise responses in lamb viability to supplementation of the maternal diet with vitamin E above the stated requirement.
Trials at Tulloch, Aberdeen (sandy loam soil, 820 mm rainfall) and Woodside, Elgin (light sandy loam, 730 mm) compared organically managed crop rotations containing different proportions of spring oats, swedes, potatoes and grass/clover leys (0·50 and 0·67 of the rotation at Tulloch; 0·38 and 0·50 at Woodside). The trials simulated farm conditions through the use of grazing animals and the recycling of farmyard manure. The rotations at each site gave similar financial outputs. Yields of oats were higher where these were grown after the main ley phase of the rotation than where they were grown later in the rotation (more ears/m2 and grains/ear), but were not significantly higher after a 4-year ley than after a 3-year ley at Tulloch. It was concluded that all of the rotations were agronomically and financially sustainable. Cereal yields showed large year-to-year variations but little indication of a progressive decline. There were only small changes in soil organic matter, soil P and soil K. Increased early summer weed cover in the arable crops was not matched by increases in weed invasion in the grass/clover leys and did not appear to be affecting yields.