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Epistaxis is the most common ENT emergency. This study aimed to assess one-year mortality rates in patients admitted to a large teaching hospital.
This study was a retrospective case note analysis of all patients admitted to the Queen Elizabeth University Hospital in Glasgow with epistaxis over a 12-month period.
The one-year overall mortality for a patient admitted with epistaxis was 9.8 per cent. The patients who died were older (mean age 77.2 vs 68.8 years; p = 0.002), had a higher Cumulative Illness Rating Scale-Geriatric score (9.9 vs 6.7; p < 0.001) and had a higher performance status score (2 or higher vs less than 2; p < 0.001). Other risk factors were a low admission haemoglobin level (less than 128 g/dl vs 128 g/dl or higher; p = 0.025), abnormal coagulation (p = 0.004), low albumin (less than 36 g/l vs more than 36 g/l; p < 0.001) and longer length of stay (p = 0.046).
There are a number of risk factors associated with increased mortality after admission with epistaxis. This information could help with risk stratification of patients at admission and enable the appropriate patient support to be arranged.
Chronic spontaneous urticaria (CSU) has been associated with depression and can have an impact on quality of life. Therefore, researchers have suggested the potential utility of psychological interventions for targeting depression among CSU patients. Psychological interventions that may hold the most promise are those that are brief and easily transportable, such as brief behavioural activation treatment for depression. We report results of a preliminary investigation of an uncontrolled open trial of a one-session behavioural activation treatment for depression designed for patients with CSU (BATD-CSU) at a university-based allergy and immunology clinic. Participants were 11 females with chronic, poorly controlled urticaria and symptoms of depression. Following the completion of pretreatment questionnaires, participants were administered BATD-CSU primarily by non-mental health professionals trained and supervised in its delivery. One month post-BATD-CSU, participants completed follow-up questionnaires. Participants exhibited significant reductions in depression severity, avoidance/rumination, and work/school impairment. BATD-CSU was also associated with improvements in urticaria control one month post-treatment. Moreover, five of nine patients reported reliable and clinically significant improvement on at least one outcome. Results demonstrate that BATD-CSU may have benefits for CSU patients even when consisting of one session and delivered by professionals with limited background in psychological interventions, thus speaking to its feasibility and transportability.
The South Caucasus occupies the divide between ancient Mesopotamia and prehistoric Europe, and was thus crucial in the development of Old World societies. Chronologies for the region, however, have lacked the definition achieved in surrounding areas. Concentrating on the Tsaghkahovit Plain of north-western Armenia, Project ArAGATS's multi-site radiocarbon dataset has now produced Bayesian modelling, which provides tight chronometric support for tracing the transmission of technology, population movement and social developments that shaped the Eurasian Bronze and Iron Ages.
To describe the process by which the 12 community-based primary health care (CBPHC) research teams worked together and fostered cross-jurisdictional collaboration, including collection of common indicators with the goal of using the same measures and data sources.
A pan-Canadian mechanism for common measurement of the impact of primary care innovations across Canada is lacking. The Canadian Institutes for Health Research and its partners funded 12 teams to conduct research and collaborate on development of a set of commonly collected indicators.
A working group representing the 12 teams was established. They undertook an iterative process to consider existing primary care indicators identified from the literature and by stakeholders. Indicators were agreed upon with the intention of addressing three objectives across the 12 teams: (1) describing the impact of improving access to CBPHC; (2) examining the impact of alternative models of chronic disease prevention and management in CBPHC; and (3) describing the structures and context that influence the implementation, delivery, cost, and potential for scale-up of CBPHC innovations.
Nineteen common indicators within the core dimensions of primary care were identified: access, comprehensiveness, coordination, effectiveness, and equity. We also agreed to collect data on health care costs and utilization within each team. Data sources include surveys, health administrative data, interviews, focus groups, and case studies. Collaboration across these teams sets the foundation for a unique opportunity for new knowledge generation, over and above any knowledge developed by any one team. Keys to success are each team’s willingness to engage and commitment to working across teams, funding to support this collaboration, and distributed leadership across the working group. Reaching consensus on collection of common indicators is challenging but achievable.
A cluster of Salmonella Paratyphi B variant L(+) tartrate(+) infections with indistinguishable pulsed-field gel electrophoresis patterns was detected in October 2015. Interviews initially identified nut butters, kale, kombucha, chia seeds and nutrition bars as common exposures. Epidemiologic, environmental and traceback investigations were conducted. Thirteen ill people infected with the outbreak strain were identified in 10 states with illness onset during 18 July–22 November 2015. Eight of 10 (80%) ill people reported eating Brand A raw sprouted nut butters. Brand A conducted a voluntary recall. Raw sprouted nut butters are a novel outbreak vehicle, though contaminated raw nuts, nut butters and sprouted seeds have all caused outbreaks previously. Firms producing raw sprouted products, including nut butters, should consider a kill step to reduce the risk of contamination. People at greater risk for foodborne illness may wish to consider avoiding raw products containing raw sprouted ingredients.
Studies of physical remains in aboriginal Peru have lagged behind those concerned with archaeology, and barely enough is known of Peruvian racial history to permit a synthesis at this time. Difficulties are three-fold: first, few physical anthropologists with a proper sense of problem have worked there; second, archaeologically documented skeletal series from Peru are not plentiful; and third, cranial deformation, while culturally of vital interest, tends to mask racial characters. Furthermore, sweeping generalizations from meager evidence by Imbelloni and others have persuaded the uncritical that the racial problems of the aboriginal Peru-Bolivian area have been largely solved. Actually, physical anthropology in Peru as compared to the archaeology is just entering the Uhle stage of rigorous scientific method. Now is the time, therefore, to reappraise our knowledge and to outline future research.
Introduction: To describe dosing, duration, and pre- and post-infusion analgesic administration of continuous intravenous sub-dissociative dose ketamine (SDK) infusion for managing a variety of painful conditions in the emergency department (ED). Methods: Retrospective chart review of patients aged 18 and older presenting to the ED with acute and chronic painful conditions who received continuous SDK infusion in the ED for a period over 6 years (2010-2016). Primary data analyses included dosing and duration of infusion, rates of pre- and post-infusion analgesic administration, and final diagnoses. Secondary data included pre- and post-infusion pain scores and rates of side effects. Results: 104 patients were enrolled in the study. Average dosing of ketamine infusion was 11.26 mg/hr, the mean duration of infusion was 135.87 minutes with 38% increase in patients not requiring post-infusion analgesia. The average decrease in pain score was 5.04. There were 12 reported adverse effects with nausea being the most prevalent. Conclusion: Continuous intravenous SDK infusion has a role in controlling pain of various etiologies in the ED with a potential to reduce need for co-analgesics or rescue analgesic administration. There is a need for more robust, prospective, randomized trials that will further evaluate the analgesic efficacy and safety of this modality across wide range of pain syndromes and different age groups in the ED.
On 27 April 2015, Washington health authorities identified Escherichia coli O157:H7 infections associated with dairy education school field trips held in a barn 20–24 April. Investigation objectives were to determine the magnitude of the outbreak, identify the source of infection, prevent secondary illness transmission and develop recommendations to prevent future outbreaks. Case-finding, hypothesis generating interviews, environmental site visits and a case–control study were conducted. Parents and children were interviewed regarding event activities. Odds ratios (OR) and 95% confidence intervals (CI) were computed. Environmental testing was conducted in the barn; isolates were compared to patient isolates using pulsed-field gel electrophoresis (PFGE). Sixty people were ill, 11 (18%) were hospitalised and six (10%) developed haemolytic uremic syndrome. Ill people ranged in age from <1 year to 47 years (median: 7), and 20 (33%) were female. Twenty-seven case-patients and 88 controls were enrolled in the case–control study. Among first-grade students, handwashing (i.e. soap and water, or hand sanitiser) before lunch was protective (adjusted OR 0.13; 95% CI 0.02–0.88, P = 0.04). Barn samples yielded E. coli O157:H7 with PFGE patterns indistinguishable from patient isolates. This investigation provided epidemiological, laboratory and environmental evidence for a large outbreak of E. coli O157:H7 infections from exposure to a contaminated barn. The investigation highlights the often overlooked risk of infection through exposure to animal environments as well as the importance of handwashing for disease prevention. Increased education and encouragement of infection prevention measures, such as handwashing, can prevent illness.
Developing countries are experiencing an increase in total demand for livestock commodities, as populations and per capita demands increase. Increased production is therefore required to meet this demand and maintain food security. Production increases will lead to proportionate increases in greenhouse gas (GHG) emissions unless offset by reductions in the emissions intensity (Ei) (i.e. the amount of GHG emitted per kg of commodity produced) of livestock production. It is therefore important to identify measures that can increase production whilst reducing Ei cost-effectively. This paper seeks to do this for smallholder agro-pastoral cattle systems in Senegal; ranging from low input to semi-intensified, they are representative of a large proportion of the national cattle production. Specifically, it identifies a shortlist of mitigation measures with potential for application to the various herd systems and estimates their GHG emissions abatement potential (using the Global Livestock Environmental Assessment Model) and cost-effectiveness. Limitations and future requirements are identified and discussed. This paper demonstrates that the Ei of meat and milk from livestock systems in a developing region can be reduced through measures that would also benefit food security, many of which are likely to be cost-beneficial. The ability to make such quantification can assist future sustainable development efforts.
The orientation of the earth in space changes unpredictably in a rapid and irregular manner, in addition to the uniform rotation of the earth. Observations of extra-terrestrial objects from the surface of the earth are affected by these variations, and knowledge of these changes is required for a variety of geodetic and astrometric purposes as well as being of interest in its own right. The orientation of the earth (specified by a three dimensional rotation vector) is measured by a variety of techniques; combination of these data sets is complicated by irregular changes in the spacing and accuracy of the various time series, and also by the existence of lower dimensional measurements of different linear combinations of the rotation vector components. A Kalman filter has been developed at JPL to smooth and predict earth orientation changes for application to spacecraft navigation by the NASA Deep Space Network. The filter, which provides estimates of the earth orientation changes (and of the excitation of these changes) based on whatever measurements are available, has been used for a number of research applications, both in the reduction of geodetic and astrometric data, and in research into the geophysical causes of earth orientation changes. The JPL Kalman filter uses stochastic models to account statistically for otherwise unpredictable changes in earth orientation; these models make it possible to provide reasonable estimates of the error in the smoothed time series, and to automatically vary the amount of smoothing according to the accuracy and density of the data. The derivation of the stochastic models used by the filter, the implementation of the models into the filter, a statistical description of what the filter does, and the results of filtering specific data sets will be discussed.
We use numerical simulations from the Community Coordinated Modeling Center to provide, for the first time, a coherent temporal description of the magnetic reconnection process of two dayside Electron Diffusion Regions (EDRs) identified in Magnetospheric Multiscale Mission data. The model places the MMS spacecraft near the separator line in these most intense and long-lived events. A listing of 31 dayside EDRs identified by the authors is provided to encourage collaboration in analysis of these unique encounters.
As endemic measles is eliminated through immunization, countries must determine the risk factors for the importation of measles into highly immunized populations to target control measures. Despite eliminating endemic measles, New Zealand suffers from outbreaks after introductions from abroad, enabling us to use it as a model for measles introduction risk. We used a generalized linear model to analyze risk factors for 1137 measles cases from 2007 to June 2014, provide estimates of national immunity levels, and model measles importation risk. People of European ethnicity made up the majority of measles cases. Age is a positive risk factor, particularly 0–2-year-olds and 5–17-year-old Europeans, along with increased wealth. Pacific islanders were also at greater risk, but due to 0–2-year-old cases. Despite recent high measles, mumps, and rubella vaccine immunization coverage, overall population immunity against measles remains ~90% and is lower in people born between 1982 and 2005. Greatest measles importation risk is during December, and countries predicted to be sources have historical connections and highest travel rates (Australia and UK), followed by Asian countries with high travel rates and higher measles incidences. Our results suggest measles importation due to travel is seeding measles outbreaks, and immunization levels are insufficient to continue to prevent outbreaks because of heterogeneous immunity in the population, leaving particular age groups at risk.
Capacity development is a critical component of water diplomacy, navigating the complexities of transboundary water conflicts. Performed at the institutional and personal levels, capacity development can include initiatives to improve the practitioner's technical capabilities in water resources management, understanding of international water law, interpersonal communications and dispute resolution. One example of capacity development that interweaves society, institutional and individual capacities is the effective use of methods of public participation, by which communities that are impacted by transboundary water policy become critical voices in the decision- making processes. In this chapter we discuss the individual, institutional and societal levels of capacity development and their basin- wide implications for improved outcomes in water diplomacy.
Anything else you're interested in is not going to happen if you can't breathe the air and drink the water. Don't sit this one out. Do something.
Water management is conflict management. There is no such thing as managing water for a single purpose because all water management is multi- objective and based on navigating competing interests. These interests include domestic users, agriculturists and environmentalists— any two of which are regularly at odds— and the chances of finding mutually acceptable solutions drop exponentially as more stakeholders are involved. Add international boundaries and the chances decrease exponentially yet again. (MacQuarrie et al. 2008, 176) Within each international basin, demands from environmental, domestic and economic users increases annually, while the amount of freshwater in the world remains roughly the same, as it has been throughout history. Given the scope of the problems and the resources available to address them, avoiding water conflict is vital. In international waters, the promising trend reveals a record of acute conflict over international water resources overwhelmed by a record of cooperation. Despite the tensions inherent in the international setting, riparians have shown tremendous creativity in approaching regional development, often through preventive diplomacy, and the creation of “baskets of benefits,” which allow for positive- sum, integrative allocations of joint gains (MacQuarrie et al. 2008, 177). It is in preventive diplomacy and cultivating the creativity to develop baskets of benefits where capacity building becomes an invaluable tool for improved water diplomacy.
The Dark Energy Survey is undertaking an observational programme imaging 1/4 of the southern hemisphere sky with unprecedented photometric accuracy. In the process of observing millions of faint stars and galaxies to constrain the parameters of the dark energy equation of state, the Dark Energy Survey will obtain pre-discovery images of the regions surrounding an estimated 100 gamma-ray bursts over 5 yr. Once gamma-ray bursts are detected by, e.g., the Swift satellite, the DES data will be extremely useful for follow-up observations by the transient astronomy community. We describe a recently-commissioned suite of software that listens continuously for automated notices of gamma-ray burst activity, collates information from archival DES data, and disseminates relevant data products back to the community in near-real-time. Of particular importance are the opportunities that non-public DES data provide for relative photometry of the optical counterparts of gamma-ray bursts, as well as for identifying key characteristics (e.g., photometric redshifts) of potential gamma-ray burst host galaxies. We provide the functional details of the DESAlert software, and its data products, and we show sample results from the application of DESAlert to numerous previously detected gamma-ray bursts, including the possible identification of several heretofore unknown gamma-ray burst hosts.
This study tested whether accurate dating by accelerator mass spectrometry (AMS) radiocarbon wiggle-matching of short tree-ring series (~30 annual rings) in the Medieval period could be achieved. Scientific dating plays a central role in the conservation of historic buildings in England. Precise dating helps assess the significance of particular buildings or elements of their fabric, thus allowing us to make informed decisions about their repair and protection. Consequently, considerable weight, both financial and legal, can be attached to the precision and accuracy of this dating. Dendrochronology is the method of choice, but in a proportion of cases this is unable to provide calendar dates. Hence, we would like to be able to use 14C wiggle-matching to provide a comparable level of precision and reliability, particularly on shorter tree-ring sequences (~30 annual growth rings) that up until now would not routinely be sampled. We present the results of AMS wiggle-matching five oak tree-ring sequences, spanning the period covered by the vast majority of surviving Medieval buildings in England (about AD 1180–1540) when currently we have only decadal and bidecadal calibration data.
Radiocarbon dating of marine samples requires a local marine reservoir correction, or ΔR value, for accurate age calibrations. For the Samoan Archipelago in the central Pacific, ΔR values have been proposed previously, but, unlike some Polynesian archipelagoes, ΔR values seem not to vary spatially and temporally. Here, we demonstrate such variability by reporting a ΔR of –101±72 ΔR for the Manu‘a Group—the eastern-most islands in the archipelago—for the colonization period. This value is based on accelerator mass spectrometry (AMS) 14C and uranium-thorium (U-Th) series dating of individual coral branches from pre-2300 cal BP archaeological contexts. This figure differs from the previously proposed modern ΔR of 28±26 yr derived from dated historic, pre-1950, shell samples from the western islands of Samoa. Consequently, we recommend using the ΔR of –101±72 yr for the 1st millennium BC in Manu‘a, and 28±26 yr for calibrating dates within the 2nd millennium AD in the western islands (Savai‘i to Tutuila). Until more data from across the archipelago and from throughout the entire culture-historical sequence document ΔR variability, we recommend that researchers use both of these ΔR values to evaluate how the dates of marine-derived samples compare with AMS dates on identified, short-lived wood charcoal.
Healthcare provider hands are an important source of intraoperative bacterial transmission events associated with postoperative infection development.
To explore the efficacy of a novel hand hygiene improvement system leveraging provider proximity and individual and group performance feedback in reducing 30-day postoperative healthcare-associated infections via increased provider hourly hand decontamination events.
Randomized, prospective study.
Dartmouth-Hitchcock Medical Center in New Hampshire and UMass Memorial Medical Center in Massachusetts.
Patients undergoing surgery.
Operating room environments were randomly assigned to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. Anesthesia and circulating nurse provider hourly hand decontamination events were continuously monitored and reported. All patients were followed prospectively for the development of 30-day postoperative healthcare-associated infections.
A total of 3,256 operating room environments and patients (1,620 control and 1,636 treatment) were enrolled. The mean (SD) provider hand decontamination event rate achieved was 4.3 (2.9) events per hour, an approximate 8-fold increase in hand decontamination events above that of conventional wall-mounted devices (0.57 events/hour); P<.001. Use of the hand hygiene system was not associated with a reduction in healthcare-associated infections (odds ratio, 1.07 [95% CI, 0.82–1.40], P=.626).
The hand hygiene system evaluated in this study increased the frequency of hand decontamination events without reducing 30-day postoperative healthcare-associated infections. Future work is indicated to optimize the efficacy of this hand hygiene improvement strategy.
We describe the search for δ Scuti stars in the MACHO database of bulge fields. Concentrating on a sample of high amplitude δ Scutis, we examine the light curves and pulsation modes. We also discuss their spatial distribution and evolutionary status using mean colors and absolute magnitudes.
Since the discovery of fading X-rays from Gamma-Ray Bursts (GRBs) with BeppoSAX (Piro et al. 1997, Costa et al. 1997), world-wide follow-up observations in optical band have achieved the fruitful results. The case of GRB 970228, there was an optical transient, coincides with the BeppoSAX position and faded (Paradijs et al. 1997, Sahu et al. 1997). These optical observations also confirmed the extended component, which was associated with the optical transient. The new transient are fading with a power-law function in time and the later observation of HST confirmed the extended emission is stable (Fruchter et al. 1997). This extended object seems to be a distant galaxy and strongly suggests to be the host.