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Introduction: eCTAS is a real time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The tool dynamically calculates a recommended CTAS score based on the presenting complaint, vital signs and selected clinical modifiers. The primary objective was to assess consistency of CTAS score distributions across 35 emergency departments (EDs) by 16 presenting complaints pre and post eCTAS implementation. Methods: This retrospective cohort study used population-based administrative data from January 2016 to December 2018 from all hospital EDs in Ontario that had implemented eCTAS with at least 9 months of data. Following a 3-month stabilization period, we compared data for 6 months post-eCTAS implementation to the same 6-month period the previous year (pre-implementation) to account for potential seasonal variation, patient volume and case-mix. We included triage encounters of adult (≥18 years) patients if they had one of 16 pre-specified high-volume, presenting complaints. A paired-samples t-test was used to determine consistency by estimating the absolute difference in CTAS distribution for each presenting complaint, by each hospital, pre and post eCTAS implementation, compared to the overall average of the 35 EDs. Results: There were 183,231 triage encounters in the pre-eCTAS cohort and 179,983 in the post-eCTAS cohort from 35 EDs across the province. Triage scores were more consistent with the overall average after eCTAS implementation in 6 (37.5%) presenting complaints: chest pain (cardiac features) (p < 0.001), extremity weakness/symptoms of cerebrovascular accident (p < 0.001), fever (p < 0.001), shortness of breath (p < 0.001), syncope (p = 0.02), and hyperglycemia (p = 0.03). Triage consistency was similar pre and post eCTAS implementation for the presenting complaints of altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication or vertigo. Conclusion: A standardized, electronic approach to performing triage assessments increased consistency in CTAS scores across many, but not all, high-volume CEDIS complaints. This does not reflect triage accuracy, as there are no known benchmarks for triage accuracy. Improvements in consistency were greatest for sentinel presenting complaints with a minimum allowable CTAS score.
The efficacy of venlafaxine extended-release (XR) at doses between 75 mg/d and 300 mg/d has been demonstrated in patients with recurrent major depressive disorder (MDD) over 2.5 years. This analysis evaluated the long-term efficacy of venlafaxine XR ≤225 mg/d, the approved dosage in many countries.
In the primary multicenter, double-blind trial, outpatients with recurrent MDD (N=1096) were randomized to receive 10-week acute-phase treatment with venlafaxine XR (75 mg/d to 300 mg/d) or fluoxetine (20 mg/d to 60 mg/d), followed by a 6-month continuation phase. Subsequently, at the start of 2 consecutive, double-blind, 12-month maintenance phases, venlafaxine XR responders were randomized to receive venlafaxine XR or placebo. Data from the 24 months of maintenance treatment were analyzed for the combined end point of maintenance of response (ie, no recurrence of depression and no dose increase above 225 mg/d), and each component individually. Time to each outcome was evaluated with Kaplan-Meier methods using log-rank tests for venlafaxine XR-placebo comparisons.
The analysis population included 114 patients who had received venlafaxine XR doses less than or equal to 225 mg/d prior to maintenance phase baseline (venlafaxine XR: n=55; placebo: n=59). Probability estimates for maintaining response were 70% for venlafaxine XR and 38% for placebo (P=0.007), for no dose increase were 76% and 58%, respectively (P=0.019), and for no recurrence were 87% vs 65%, respectively (P=.099).
These data confirm venlafaxine XR is effective maintaining response at doses ≤225 mg/d for up to 2.5 years in patients with MDD.
Child psychiatric service is a novel approach in Bangladesh but has proved its efficacy within a short time.
To describe how a developing country has established sustainable child psychiatric services by using limited resources effectively.
Discuss the service delivery model and recent achievements in child psychiatry in Bangladesh as well as the limitations and strengths.
Effective policy making, capacity building and community based survey are the turning point of the development of child psychiatry in Bangladesh. The prevalence of child mental disorders found 18.4% in a community based survey. By the efforts of few visionary psychiatrists the wing of child psychiatry has established in Bangabandhu Sheikh Mujib Medical University (BSMMU) and separate department named ‘Child Adolescent and Family Psychiatry’ has formed in National Institute of Mental Health (NIMH), Dhaka. Center for Neurodevelopment and Autism in Children (CNAC) also established in BSMMU with the mission to serve the children with neurodevelopmental disabilities, to increase awareness and to train the professionals. From 2008 the Child Guidance Clinic of national Institute of Mental Health Dhaka served more than three thousand children with any mental disorders.
According to the current scenario we can comment that the future prospect of child psychiatry in Bangladesh is promising. In spite of very limited resources the child psychiatry is going ahead to set an example for other developing countries in the context of sustainable service delivery model.
Bangladesh is a disaster prone country. According to one record during last 100 years, there had been 75 severe cyclones and floods in Bangladesh. On the other hand as many as 1200 kilometer of river banks are under active erosion in every year. The government of Bangladesh, nongovernmental organizations, members of the civil society, the health professionals – all of them have chalked out their programme embedded with economic relief and assistance. At best, some sort of medical aid in the form of medicine and physical treatment and recovery are extended to the affected people. The severity of mental and psychological trauma and casualties had always remained beyond their imagination. For the first time in the history of Bangladesh, multiple teams consisted of psychiatrists, psychologists, social workers and other support service staffs rushed to the Cyclone affected area to estimate the need for psychosocial care and for providing management on 2007. In 2013 a multistoried has collapsed in Bangladesh and died more than thousand peoples. Currently, the National Plan for Disaster Management 2010-2015 keeps no space for the people who ardently need post disaster psychosocial care. Consequently, the mental health care professionals are strongly lobbying for inclusion of post-disaster psychosocial rehabilitation service within the National Plan for Disaster Management. Mainstream health professionals specially the primary health care providers should be brought under coverage of a full-fledged training course on disaster psychiatry. In addition, infrastructure development and administrative reform is urgently required in this arena.
The Psychiatry Clinic Affektiva has developed a care pathway for patients with bipolar disorder (BD). It consists of one outpatient clinic and two inpatient wards. Clinical observations suggest that patients with BD benefit from treatment in a dedicated unit with tailored care programs and that better outcomes are achieved in terms of reduced average length of stay and safer transitions to outpatient care for this group.
The aim is to improve the care of bipolar patients by increasing bed-availability and overall continuity in the care pathway and monitoring core aspects in the management of outpatients in order to reduce admissions and to facilitate standardized treatment and collaboration between in- and outpatients unit.
We developed a structure to monitor and measure specific outcomes such as readmission within 28 days, relapse within 12 months and the use of lithium in this group. We also developed a standardized care protocol in order to improve the safety and the equality.
At this stage our preliminary results from our efforts are promising but further monitoring is needed to confirm our hypothesis. More data will be collected during 2017.
Affektiva Psychiatry Clinic has developed a model for continuously monitoring several essential aspects in the care of patients with BD and providing a specific care program.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Chikungunya virus (CHIKV) is a re-emerging pathogen of global importance. We attempted to gain an insight into the organisation, distribution and mutational load of the virus strains reported from different parts of the world. We describe transmission dynamics and genetic characterisation of CHIKV across the globe during the last 65 years from 1952 to 2017. The evolutionary pattern of CHIKV was analysed using the E1 protein gene through phylogenetic, Bayesian and Network methods with a dataset of 265 sequences from various countries. The time to most recent common ancestor of the virus was estimated to be 491 years ago with an evolutionary rate of 2.78 × 10−4 substitutions/site/year. Genetic characterisation of CHIKV strains was carried out in terms of variable sites, selection pressure and epitope mapping. The neutral selection pressure on the E1 gene of the virus suggested a stochastic process of evolution. We identified six potential epitope peptides in the E1 protein showing substantial interaction with human MHC-I and MHC-II alleles. The present study augments global epidemiological and population dynamics of CHIKV warranting undertaking of appropriate control measures. The identification of epitopic peptides can be useful in the development of epitope-based vaccine strategies against this re-emerging viral pathogen.
The idea that rulers must seek consent before making policy is key to democracy. We suggest that this practice evolved independently in a large fraction of human societies where executives ruled jointly with councils. We argue that council governance was more likely to emerge when information asymmetries made it harder for rulers to extract revenue, and we illustrate this with a theoretical model. Giving the population a role in governance became one means of overcoming the information problem. We test this hypothesis by examining the correlation between localized variation in agricultural suitability and the presence of council governance in the Standard Cross Cultural Sample. As a further step, we suggest that executives facing substantial information asymmetries could also have an alternative route for resource extraction—develop a bureaucracy to measure variation in productivity. Further empirical results suggest that rule by bureaucracy could substitute for shared rule with a council.
To examine the factors that are associated with changes in depression in people with type 2 diabetes living in 12 different countries.
People with type 2 diabetes treated in out-patient settings aged 18–65 years underwent a psychiatric assessment to diagnose major depressive disorder (MDD) at baseline and follow-up. At both time points, participants completed the Patient Health Questionnaire (PHQ-9), the WHO five-item Well-being scale (WHO-5) and the Problem Areas in Diabetes (PAID) scale which measures diabetes-related distress. A composite stress score (CSS) (the occurrence of stressful life events and their reported degree of ‘upset’) between baseline and follow-up was calculated. Demographic data and medical record information were collected. Separate regression analyses were conducted with MDD and PHQ-9 scores as the dependent variables.
In total, there were 7.4% (120) incident cases of MDD with 81.5% (1317) continuing to remain free of a diagnosis of MDD. Univariate analyses demonstrated that those with MDD were more likely to be female, less likely to be physically active, more likely to have diabetes complications at baseline and have higher CSS. Mean scores for the WHO-5, PAID and PHQ-9 were poorer in those with incident MDD compared with those who had never had a diagnosis of MDD. Regression analyses demonstrated that higher PHQ-9, lower WHO-5 scores and greater CSS were significant predictors of incident MDD. Significant predictors of PHQ-9 were baseline PHQ-9 score, WHO-5, PAID and CSS.
This study demonstrates the importance of psychosocial factors in addition to physiological variables in the development of depressive symptoms and incident MDD in people with type 2 diabetes. Stressful life events, depressive symptoms and diabetes-related distress all play a significant role which has implications for practice. A more holistic approach to care, which recognises the interplay of these psychosocial factors, may help to mitigate their impact on diabetes self-management as well as MDD, thus early screening and treatment for symptoms is recommended.
Background: Cerebellar atrophy is characterized by loss of cerebellar tissue, with evidence on brain imaging of enlarged interfolial spaces compared to the foliae. Genetic ataxias associated with cerebellar atrophy are a heterogeneous group of disorders. We investigated the prevalence in Canada and the diagnostic yield of whole exome sequencing (WES) for this group of conditions. Methods: Between 2011 and 2017, WES was performed in 91 participants with cerebellar atrophy as part of one of two national research programs, Finding of Rare Genetic Disease Genes (FORGE) or Enhanced Care for Rare Genetic Diseases in Canada (Care4Rare). Results: A genetic diagnosis was established in 58% of cases (53/91). Pathogenic variants were found in 24 known genes, providing a diagnosis for 46/53 participants (87%), and in four novel genes, accounting for 7/53 cases (13%). 38/91 cases (42%) remained unsolved. The most common diagnoses were channelopathies in 12/53 patients (23%) and mitochondrial disorders in 9/53 (17%). Inheritance was autosomal recessive in the majority of cases. Additional clinical findings provided useful clues to some of the diagnoses. Conclusions: This is the first report on the prevalence of genetic ataxias associated with cerebellar atrophy in Canada, and the utility of WES for this group of conditions.
The aim of this study was to examine the gender differential effects of eating habits and physical activity on overweight and obesity among school-aged adolescents in Bangladesh. Nationally representative data extracted from the 2014 Global School-based Student Health Survey (GSHS) were utilized. The survey collected information related to physical and mental health from 2989 school-aged adolescents in Bangladesh. An exploratory data analysis and multivariate logistic regression model were employed in this study. Female adolescents were at a lower risk of being overweight or obese (AOR=0.573) than males, with a prevalence of 7.4% (males: 9.9%). The results showed that high consumption of vegetables (both: AOR=0.454; males: AOR=0.504; females: AOR=0.432), high soft drink consumption (both: AOR=2.357; males: AOR=2.929; females: AOR=1.677), high fast food consumption (both: AOR=2.777; males: AOR=6.064; females: AOR=1.695), sleep disturbance (both: AOR=0.675; males: AOR=0.590; females: AOR=0.555) and regular walking or cycling to school (both: AOR=0.472; males: AOR=0.430; females: AOR=0.557) were vital influencing factors for being overweight or obese among adolescents for both sexes. Sedentary activities during leisure time were also identified as significant predictors of being overweight or obese for males. Regular fruit and vegetable consumption, the avoidance of soft drinks and fast food, an increase in vigorous physical activity, regular attendance at physical education classes and fewer sedentary leisure time activities could all help reduce the risk of being overweight or obese for both sexes.
Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, emergency department (ED) funding and workload models. The electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes that application of national triage guidelines across Ontario. The objective of this study was to evaluate triage times and score agreement in ED settings where eCTAS has been implemented. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1491 (752 pre-eCTAS, 739 post-implementation) individual patient CTAS assessments were audited over 42 (21 pre-eCTAS, 21 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 567 (75.4%) patients pre-eCTAS, compared to 685 (92.7%) patients triaged with eCTAS. Using the auditor's CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.0% vs. 5.1%; Δ 6.9, 95% CI: 4.0, 9.7) and under-triaged (12.6% vs. 2.2%; Δ 10.4, 95% CI: 7.9, 13.2). Interrater agreement was higher with eCTAS (unweighted kappa 0.89 vs 0.63; quadratic-weighted kappa 0.91 vs. 0.71). Research assistants captured triage time for 3808 patients pre-eCTAS and 3489 post implementation of eCTAS. Median triage time was 312 seconds pre-eCTAS and 347 seconds with eCTAS (Δ 35 seconds, 95% CI: 29, 40 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.
To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications.
Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit.
Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases.
In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to ≥5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive.
We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.
Background: External ventricular drain (EVD) insertion is a common neurosurgical procedure performed in patients with life-threatening conditions, but can be associated with complications. The objectives of this study are to evaluate data on national practice patterns and complications rates in order to optimize clinical care Methods: The Canadian Neurosurgery Research Collaborative conducted a prospective multi-centre registry of patients undergoing EVD insertions at Canadian residency programs Results: In this interim analysis, 4 sites had recruited 46 patients (mean age: 53.9 years, male:female 2:1). Most EVD insertions occurred outside of the operating theatre, using free-hand technique, and performed by junior neurosurgery residents (R1-R3). The catheter tip was in the ipsilateral frontal horn or body of the lateral ventricle in 76% of cases. Suboptimally placed catheters did not have higher rates of short-term occlusion. EVD-related hemorrhage occurred in 6.5% (3/45) with only 1 symptomatic patient. EVD-related infection occurred in 13% (6/46) at a mean of 6 days and was associated with longer duration of CSF drainage (P=0.039; OR: 1.13) Conclusions: Interim results indicate rates of EVD-related complications may be higher than previously thought. This study will continue to recruit patients to confirm these findings and determine specific risk factors associated with them
Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, ED funding and workload models. The Electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes the application of national triage guidelines (CTAS) across Ontario. The objective of this study was to evaluate the implementation of eCTAS in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1200 (738 pre-eCTAS, 462 post-implementation) individual patient CTAS assessments were audited over 33 (21 pre-eCTAS, 11 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients pre-eCTAS, compared to 429 (93.0%) patients triaged with eCTAS. Using the auditors CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.1% vs. 3.2%; 8.9, 95% CI: 5.7, 11.7) and under-triaged (12.9% vs. 3.9%; 9.0, 95% CI: 5.9, 12.0). Interrater agreement was higher with eCTAS (unweighted kappa 0.90 vs 0.63; quadratic-weighted kappa 0.79 vs. 0.94). Research assistants captured triage time for 4403 patients pre-eCTAS and 1849 post implementation of eCTAS. Median triage time was 304 seconds pre-eCTAS and 329 seconds with eCTAS ( 25 seconds, 95% CI: 18, 32 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.
The pathogenesis of complex visual hallucination in patients without visual lesions, appearing with eyes open and resolving with eyes closed, has been described to be associated with increased excitation at the lateral geniculate nucleus (LGN) and pulvinar of the thalamus (Winton-Brown, 2016). This reduces thefidelity of retinogeniculate transmissions and enhances aberrant projections to the visual cortex. Loss of the central sensory filtering function of the pulvinar increases “signal to noise ratio” in visual transmission. While visual hallucinations have been reported to disappear on eye closure (Manford, 1998), visual aberration with correction with refractionfollowed by focusing on actual visual images and visual hallucinations has not heretofore been reported. Such a case is presented.
Case study: This 28-year-old, myopic, right-handed man, at 5 years of age began hallucinating vivid images of people. The visual hallucinations were triggered only with his eye open. He was myopic and without visual correction, his visual sphere would be blurred. The visual hallucinations were also blurred without visual correction. With refraction, the hallucinations became clearly in focus. He would close his eyes and the visual hallucinations disappeared but would reappear in the same position upon opening his eyes. For over 20 years, he experienced about 100 hallucinations a day. Electroencephalography (EEG) revealed continuous spikes and slow waves in bilateral temporal lobes, consistent with temporal lobe status epilepticus. After treatment with diphenylhydantoin the frequency and duration of the hallucinations markedly decreased to a second epoch every other day. However, the characteristic of the hallucinations remained the same (people).
This phenomenon may involve epilepsy induced excitation of the thalamus. This then acts to reduce the fidelity of retinogeniculate transmission and increase “signal to noise ratio” in visual transmission. This may contribute to complex visual hallucinations with eyes open. The hallucinated figures becoming clearer with eyeglasses provides support that this complex hallucination arises in the pathway from retina-LGN-cortex, not from stored visual associated cortex of top-down cortical release.
Given the above, those with visual hallucinations should be queried as to the influence of refraction on the clarity of hallucination.
Endogenous melatonin is a hormone secreted by pineal gland; it has several roles in metabolism, reproduction, and remarkable antioxidant properties. Studies on the melatonin effect on the adrenal glands which are important endocrine organs, controlling essential physiological functions, are still deficient. In this study, we attempted to investigate the effect of exogenous melatonin treatment on the adrenal cortex and medulla using several approaches. Adrenal glands of 15 Soay ram were examined to detect the effect of melatonin treatment. Our results revealed that the cells of adrenal cortex of the treated animals were separated by wide and numerous blood sinusoids and showed signs of increase steroidogenic activity, which are evidenced by functional hypertrophy with increase profiles of mitochondria, smooth endoplasmic reticulum, and lipid droplets. The most striking ultrastructural features in the medulla of the treated group were the engorgement of chromaffin cells with enlarged secretory granules enclosed within a significantly increased diameter of these cells. The cytoplasm of these cells showed numerous mitochondria, rough endoplasmic reticulum (rER), Golgi apparatus, lysosomes, and glycogen granules. Exocytosis of secretory granules to the lumen of blood vessels was evident in the treated group. Piecemeal degranulation mode of secretion was recorded after melatonin treatment. Chromaffin cells in the control group expressed moderate immunoreactivity to Synaptophysin and tyrosine hydroxylase, compared with intensified expression after melatonin treatment. The ganglion cells of the melatonin-treated group showed a significant increase in diameter with numerous rER. The most interesting feature in this study is the presence of small granule chromaffin cells (SGC) and telocytes (TCs) for the first time in the adrenal glands of sheep. Moreover, these SGC cells, Schwann cells, fibroblasts, and progenitor stem cells showed a stimulatory response. The TCs were small branched cells scattered in the adrenal glands around cortical cells, chromaffin cells, nerve fibers, and blood vessels. These cells increased significantly in number, length of their telopodes, and secretory activity after melatonin treatment. In addition, multiple profiles of unmyelinated nerve fibers were demonstrated in all treated specimens. These results indicated that melatonin treatment caused a stimulatory action on all cellular and neuronal elements of the adrenal gland. This study may act as a new direction for treatment of adrenal insufficiency.