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One in four cases of acute aortic syndrome are missed. This national survey examined Canadian Emergency physicians’ opinion on risk stratification, the need for a clinical decision aid to risk stratify patients, and the required sensitivity of such a tool.
We surveyed 1,556 members of the Canadian Association of Emergency Physicians. We used a modified Dillman technique with a prenotification email and up to three survey attempts using electronic mail. Physicians were asked 21 questions about demographics, importance of certain high-risk features, investigation options, threshold for investigation, and if a clinical decision tool is required
We had a response rate of 32%. Respondents were 66% male, and 49% practicing >10 years, with 59% in an academic teaching hospital. A total of 93% reported a need for a clinical decision aid to risk stratify for acute aortic syndrome. A total of 99.6% of physicians were pragmatic accepting a non-zero miss-rate, two-thirds accepting <1%, and the remaining accepting a higher miss-rate.
Our national survey determined that emergency physicians would use a highly sensitive clinical decision aid to determine which patients are at low, medium, or high-risk for acute aortic syndrome. The majority of clinicians have a low threshold (<1%) for investigating for acute aortic syndrome, but accept that a zero miss-rate is not feasible.
Acute aortic dissection (AAD) is a time sensitive, difficult to diagnose, aortic emergency. We sought to explore the quality of history taking in AAD and assess its impact on misdiagnosis.
We studied a retrospective cohort of patients >18 years old who presented to two tertiary care emergency departments from January 1st 2004 – December 31st 2012 and were diagnosed with an acute aortic dissection (AAD) on CT, MRI or TEE. Trained reviewers’ extracted data using a standardized data collection form. The definitions of 5 pain characteristics – character, onset, duration, quality, and radiation were defined a priori.
Data were collected for 194 cases of acute aortic dissection with a mean age of 65(SD 14.1) and 66.7% male, 34(17.6%) missed on initial presentation. Only 20(14.8%) patients were asked all 5 questions. The most common initial incorrect diagnosis were acute coronary syndrome (16, 47%), pulmonary embolism (5, 14.7%) and stroke (4, 11.7%). If <2 questions were asked 1 in 5 cases were missed, 4 times greater than if >2 were asked (P < 0.01).
Clinicians should ask and document the character, onset, duration, radiation and severity of pain in any patient presenting with chest, abdominal or flank pain. A focused history still remains the keystone to reducing misdiagnosis.
To investigate the uptake of and attitudes towards a voluntary government-led energy (calorie) menu labelling initiative in Ireland among a representative sample of food-service businesses and to inform further actions that may need to be undertaken to facilitate successful implementation.
A mixed-methods approach, incorporating a national telephone survey, structured observation visits and semi-structured interviews.
Twenty-six counties in the Republic of Ireland.
A random selection of food-service businesses (n 604) participated in the telephone survey. Businesses which indicated that they did display calories were selected to participate in structured observation visits (n 42), along with a random sample (n 38) of businesses that did not display calories. A purposive sample of thirteen food-service business owners who participated in the telephone survey participated in semi-structured interviews.
In the telephone survey, 7 % (n 42) of food businesses reported displaying calories and the observation visits revealed that of these businesses, 10 % (n 4) were not displaying calorie information. Three major themes emerged from the semi-structured interviews: uncertainty, impact on business and consumer nutrition knowledge. Participants expressed concerns regarding inaccuracies in the calorie information, cost and time implications, mistrust in the food-service industry and poor nutritional knowledge among consumers. These concerns impeded the implementing of calorie menu labelling.
A multifactorial approach that incorporates guidance and support (training/tax incentives), practical assistance (user-friendly calorie calculation software), a reasonable legislative structure and a standardised monitoring system is needed to facilitate the successful implementation of calorie menu labelling.
Coercion remains a central aspect of many people's mental healthcare. It can include the use of legislation to restrict freedoms, the use of physical restraint, the restriction of freedom of movement and/or association, and the forced or covert administration of medication. There is good evidence that the use of such measures can traumatise service users. This article reports the findings of a survey of service users regarding their experiences of coercion and restraint and embeds this in the wider international and institutional environment.
Archaeological tunneling is a standard excavation strategy in Mesoamerica. The ancient Maya built new structures atop older ones that were no longer deemed usable, whether for logistical or ideological reasons. This means that as archaeologists excavate horizontal tunnels into ancient Maya structures, they are essentially moving back in time. As earlier constructions are encountered, these tunnels may deviate in many directions in order to document architectural remains. The resultant excavations often become intricate labyrinths, extending dozens of meters. Traditional forms of archaeological documentation, such as photographs, plan views, and profile drawings, are limited in their ability to convey the complexity of tunnel excavations. Terrestrial Lidar (light detection and ranging) instruments are able to generate precise 3D models of tunnel excavations. This article presents the results of a model created with a Faro™ Focus 3D 120 Scanner of tunneling excavations at the site of El Zotz, Guatemala. The lidar data document the excavations inside a large mortuary pyramid, including intricately decorated architecture from an Early Classic (A.D. 300–600) platform buried within the present form of the structure. Increased collaboration between archaeologists and scholars with technical expertise maximizes the effectiveness of 3D models, as does presenting digital results in tandem with traditional forms of documentation.
This study aimed to assess the psychological well-being and quality of life in children with hypertrophic cardiomyopathy and the potential psychosocial impact of screening.
A total of 152 children (aged 3–18 years) attending a specialist paediatric hypertrophic cardiomyopathy clinic, and their parents completed the Generic Core Scales and Cardiac Module of the Paediatric Quality of Life Inventory (PedsQL) questionnaire as well as the Strengths and Difficulties Questionnaire; 21 patients (14%) had hypertrophic cardiomyopathy (group A); 23 children (15%) harboured hypertrophic cardiomyopathy-causing sarcomeric mutations with normal echocardiograms (group G); and 108 children (71%) had a family history of hypertrophic cardiomyopathy with normal investigations and attended for clinical cardiological screening (group S).
In group A, mean PedsQLTM total scores reported by children and parents were lower than those reported by unaffected children (p<0.001). There was no significant difference between unaffected and gene-positive patients. Mean Cardiac module PedsQLTM total scores by children and parents were lower in children with hypertrophic cardiomyopathy compared with unaffected patients [mean child-reported total score 86.4 in group S versus 72.3 in group A (p<0.001) and 80.2 in group G (p=0.25); mean parent-reported total score 91.6 in group S versus 71.4 in group A (p<0.001) and 87 in group G (p=0.4)]. There was no significant difference between group S and group G on any of the scales, or between the three groups of patients in the mean Strengths and Difficulties Questionnaire scores.
Children with hypertrophic cardiomyopathy have a significantly reduced quality of life. Importantly, Quality-of-Life scores among unaffected children attending for screening were not different compared with scores from a normative UK population.
To investigate GPs’ beliefs about complementary and alternative medicine (CAM) and its role in clinical practice.
Despite the prevalence of CAM in the United Kingdom, little is known about GPs beliefs regarding these alternative approaches to patient management and how they view it in relation to their clinical conduct and practice.
A qualitative study conducted on 19 GPs recruited from the North West of England. Semi-structured telephone interviews were analysed using an inductive thematic analysis.
Three themes emerged from the data: limited evidence base, patient demand and concerns over regulation.
Despite recognising the limited evidence base of CAM, GPs continue to see a role for it within clinical practice. This is not necessarily led by patient demand that is highly related to affluence. However, GPs raised concerns over the regulation of CAM practitioners and CAM therapies.
From 1994–2007 Ceredigion County Council and a network of shore-based, volunteer observers monitored levels of boat traffic and the occurrence of bottlenose dolphins Tursiops truncatus at seven sites on the coast of Cardigan Bay, Wales. We report high rates of site use and site occupancy by this species during the summer: at Mwnt for example, dolphins were recorded in >80% of 2 hours' observation periods; and at New Quay Harbour dolphins were present in >30% of all 15-minute intervals. At Mwnt and Aberporth there was a significant annual trend for increasing sighting rates; at Ynys Lochtyn a positive trend was only marginally non-significant; at New Quay Bird's Rock the trend was ambiguous but appeared stable over the seven most recent years. Although trends in site use may not reflect population trends in the wider region, these data were consistent with recent abundance estimates that indicate that the number of bottlenose dolphins using Cardigan Bay is stable or slightly increasing. Average group size at our study sites was small (<3 animals), which contrasts with observations of larger schools of the same population elsewhere in their range. The predominant behaviour in coastal Cardigan Bay is demersal foraging, often by solitary animals in shallow near-shore habitats. There was evidence that boat traffic suppressed site use by dolphins at New Quay Harbour, the busiest monitoring site: sighting rates fell when high numbers of boats were present and sighting rates were higher in 2007 than in previous years, when boat use was reduced due to poor weather during the main tourist season. This study demonstrates that networks of volunteer observers can provide a cost-effective, non-invasive means of gathering data on marine mammals for the purposes of coastal zone management.
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