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Introduction: Opioid overdoses (OODs) have become a public health emergency, yet little is known about their long-term outcomes following an OD. We determined the one-year all-cause mortality and associated risk factors in a cohort of patients treated in an urban emergency department (ED) for an OOD. Methods: We reviewed records of all patients who visited St. Paul's Hospital ED from January 2013 to August 2017 and had a discharge diagnosis of OOD or had received naloxone in the ED as per pharmacy records. Patients with a suspected OOD were identified on structured chart review. A patient's first visit for an OOD during the study period was used as the index visit, with subsequent visits excluded. The primary outcome was mortality during the year after the index visit. Mortality was assessed by linking patient electronic medical records with Vital Statistics data. Deaths that occurred in the ED on the index visit were excluded. Patients admitted to hospital following ED treatment were included in this study. We described patient characteristics, calculated mortality rates, and used Cox regression to identify risk factors. Results: A total of 2239 patients visited the ED for an OOD during the study period, with a median patient age of 37 years (IQR 29, 49). Males comprised 73% of patients, while 28% had no fixed address, and 21% received take-home naloxone at the index visit. In total, 137 patients (6.1%) died within 1 year of the index visit. Eighty-one deaths (3.6%) occurred within 6 months, including 24 deaths (1.1%) that occurred within 1 month. The highest mortality rate occurred in 2017, with 8.0% of patients entering the cohort that year dying within 1 year. Gender did not significantly impact mortality risk. A Cox regression analysis controlled for gender, housing status, and whether take-home naloxone was provided at the index visit indicated that advancing age (adjusted hazards ratio [AHR] 1.03; 95%CI: 1.01-1.04 for each year increase in age) and the index visit calendar year (AHR 1.30; 95%CI: 1.10-1.54 for each yearly increase in the study period) were significant factors for mortality within 1 year. Conclusion: The mortality rate following an opioid OD treated in the ED is high, with over 6% of patients in our study dying within 1 year. The rising mortality risk with increasing calendar year may reflect the growing harms of fentanyl-related OODs. Patients visiting the ED for an OOD should be considered high risk and offered preventative treatment and referrals prior to discharge.
This study provides an in-depth examination of the understanding and implementation of cognitive–behavioural approaches (CBA) by Australian teachers of students with both autism spectrum disorder and intellectual disability. Semistructured interviews were completed with 13 New South Wales teachers and several themes emerged. Interviewed teachers appeared to have limited knowledge about CBA; their description of the application of CBA and their reported practices included few features specific and unique to CBA. They primarily perceived CBA as a tool for behaviour management; addressing emotion was a theme but addressing cognition was not a salient feature of their practice. Most teachers seemed unaware of the potential of CBA in fostering generalisation or maintenance, and important student characteristics appeared to be seldom considered in teacher planning of their CBA programs. Directions for enhancing teacher knowledge and supporting their practice of CBA are suggested.
This study of loneliness across adult lifespan examined its associations with sociodemographics, mental health (positive and negative psychological states and traits), subjective cognitive complaints, and physical functioning.
Analysis of cross-sectional data
340 community-dwelling adults in San Diego, California, mean age 62 (SD = 18) years, range 27–101 years, who participated in three community-based studies.
Loneliness measures included UCLA Loneliness Scale Version 3 (UCLA-3), 4-item Patient-Reported Outcomes Measurement Information System (PROMIS) Social Isolation Scale, and a single-item measure from the Center for Epidemiologic Studies Depression (CESD) scale. Other measures included the San Diego Wisdom Scale (SD-WISE) and Medical Outcomes Survey- Short form 36.
Seventy-six percent of subjects had moderate-high levels of loneliness on UCLA-3, using standardized cut-points. Loneliness was correlated with worse mental health and inversely with positive psychological states/traits. Even moderate severity of loneliness was associated with worse mental and physical functioning. Loneliness severity and age had a complex relationship, with increased loneliness in the late-20s, mid-50s, and late-80s. There were no sex differences in loneliness prevalence, severity, and age relationships. The best-fit multiple regression model accounted for 45% of the variance in UCLA-3 scores, and three factors emerged with small-medium effect sizes: wisdom, living alone and mental well-being.
The alarmingly high prevalence of loneliness and its association with worse health-related measures underscore major challenges for society. The non-linear age-loneliness severity relationship deserves further study. The strong negative association of wisdom with loneliness highlights the potentially critical role of wisdom as a target for psychosocial/behavioral interventions to reduce loneliness. Building a wiser society may help us develop a more connected, less lonely, and happier society.
Growth among infants with CHD is poor, and is multifactorial with multiple contributing factors. Unexplained hypophosphataemia has been reported among infants and children with complex medical needs consuming amino acid infant formula as the sole source of nutrition. The aim of this audit was therefore to review the incidence of hypophosphataemia among infants with CHD.
The use of an electronic patient record search for “amino acid infant formula”, “CHD”, and “cardiac” yielded 136 infants <12 months of age. Preterm infants (n=24), children with chromosomal abnormalities (n=4), those >1 year of age (n=11) and infants with a structurally normal heart (n=31) were excluded from the study. The remaining 66 infants with CHD were given amino acid infant formula.
Measurements and main results
In all, 1059 serum phosphate measures were available. After the introduction of amino acid infant formula, significantly more infants with CHD had episodes of hypophosphataemia: 15% (n=10/66) before treatment versus 29% (n=19/66) after treatment (p=0.049). Mean serum phosphate levels were significantly lower in infants with CHD following consumption of amino acid infant formula (2.0±0.5 versus 1.5±0.5 mmol/L following treatment (p<0.0001)). Infants with CHD and hypophosphataemia, associated with amino acid infant formula, use demonstrated significantly lower weight gain compared with those with normal phosphate levels (weight-for-age z scores −2.1±1.4 versus –0.9±1.5; p<0.0001).
After the introduction of an amino acid formula, weight gain was significantly lower among those infants with low phosphate levels. There was a significantly higher prevalence of hypophosphataemia among infants with CHD after the introduction of amino acid infant formula. Lower phosphate levels were associated with lower weight-for-age z scores. Infants with CHD are susceptible to poor weight gain; it is therefore, crucial the nutritional status of infants prescribed amino acid infant formula is more closely monitored to ensure adequate growth.
Konjac glucomannan (KGM) is a viscous dietary fibre that can form a solid, low-energy gel when hydrated and is commonly consumed in a noodle form (KGM-gel). Increased meal viscosity from gel-forming fibres have been associated with prolonged satiety, but no studies to date have evaluated this effect with KGM-gel. Thus, our objective was to evaluate subsequent food intake and satiety of KGM-gel noodles when replacing a high-carbohydrate preload, in a dose–response manner. Utilising a randomised, controlled, cross-over design, sixteen healthy individuals (twelve females/four males; age: 26·0 (sd 11·8) years; BMI: 23·1 (sd 3·2) kg/m2) received 325 ml volume-matched preloads of three KGM-gel noodle substitution levels: (i) all pasta with no KGM-gel (1849 kJ (442 kcal), control), half pasta and half KGM-gel (1084 kJ (259 kcal), 50-KGM) or no pasta and all KGM-gel (322 kJ (77 kcal), 100-KGM). Satiety was assessed over 90 min followed by an ad libitum dessert. Compared with control, cumulative energy intake was 47 % (−1761 kJ (−421 kcal)) and 23 % (−841 kJ (−201 kcal)) lower for 100-KGM and 50-KGM, respectively (both P<0·001), but no differences in subsequent energy intake was observed. Ratings of hunger were 31 % higher (P=0·03) for 100-KGM when compared with control, and were 19 % lower (P=0·04) for fullness and 28 % higher (P=0·04) for prospective consumption when comparing 100-KGM to 50-KGM. Palatability was similar across all treatments. Replacement of a high-carbohydrate preload with low-energy KGM-gel noodles did not promote additional food intake despite large differences in energy. The energy deficit incurred from partial KGM-gel substitution may have relevance in weight loss regimens, and should be further evaluated beyond the healthy population.
Central nervous system infections (CNSI) are a leading cause of death and long-term disability in children. Using ICD-10 data from 2005 to 2015 from three central hospitals in Ho Chi Minh City (HCMC), Vietnam, we exploited generalized additive mixed models (GAMM) to examine the spatial-temporal distribution and spatial and climatic risk factors of paediatric CNSI, excluding tuberculous meningitis, in this setting. From 2005 to 2015, there were 9469 cases of paediatric CNSI; 33% were ⩽1 year old at admission and were mainly diagnosed with presumed bacterial CNSI (BI) (79%), the remainder were >1 year old and mainly diagnosed with presumed non-bacterial CNSI (non-BI) (59%). The urban districts of HCMC in proximity to the hospitals as well as some outer districts had the highest incidences of BI and non-BI; BI incidence was higher in the dry season. Monthly BI incidence exhibited a significant decreasing trend over the study. Both BI and non-BI were significantly associated with lags in monthly average temperature, rainfall, and river water level. Our findings add new insights into this important group of infections in Vietnam, and highlight where resources for the prevention and control of paediatric CNSI should be allocated.
Depression is one of the most common mental disorders and identifying effective treatment strategies is crucial for the control of depression. Well-conducted systematic reviews (SRs) and meta-analyses can provide the best evidence for supporting treatment decision-making. Nevertheless, the trustworthiness of conclusions can be limited by lack of methodological rigour. This study aims to assess the methodological quality of a representative sample of SRs on depression treatments.
A cross-sectional study on the bibliographical and methodological characteristics of SRs published on depression treatments trials was conducted. Two electronic databases (the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects) were searched for potential SRs. SRs with at least one meta-analysis on the effects of depression treatments were considered eligible. The methodological quality of included SRs was assessed using the validated AMSTAR (Assessing the Methodological Quality of Systematic Reviews) tool. The associations between bibliographical characteristics and scoring on AMSTAR items were analysed using logistic regression analysis.
A total of 358 SRs were included and appraised. Over half of included SRs (n = 195) focused on non-pharmacological treatments and harms were reported in 45.5% (n = 163) of all studies. Studies varied in methods and reporting practices: only 112 (31.3%) took the risk of bias among primary studies into account when formulating conclusions; 245 (68.4%) did not fully declare conflict of interests; 93 (26.0%) reported an ‘a priori’ design and 104 (29.1%) provided lists of both included and excluded studies. Results from regression analyses showed: more recent publications were more likely to report ‘a priori’ designs [adjusted odds ratio (AOR) 1.31, 95% confidence interval (CI) 1.09–1.57], to describe study characteristics fully (AOR 1.16, 95% CI 1.06–1.28), and to assess presence of publication bias (AOR 1.13, 95% CI 1.06–1.19), but were less likely to list both included and excluded studies (AOR 0.86, 95% CI 0.81–0.92). SRs published in journals with higher impact factor (AOR 1.14, 95% CI 1.04–1.25), completed by more review authors (AOR 1.12, 95% CI 1.01–1.24) and SRs on non-pharmacological treatments (AOR 1.62, 95% CI 1.01–2.59) were associated with better performance in publication bias assessment.
The methodological quality of included SRs is disappointing. Future SRs should strive to improve rigour by considering of risk of bias when formulating conclusions, reporting conflict of interests and authors should explicitly describe harms. SR authors should also use appropriate methods to combine the results, prevent language and publication biases, and ensure timely updates.
Introduction: Medication discrepancies are unintended differences between a patient’s outpatient and inpatient medication regimens, and occur in up to 60% of hospital admissions. Canadian emergency departments (EDs) have implemented medication reconciliation forms that are pre-populated with outpatient medication dispensing data in order to reduce medication discrepancies and resultant adverse drug events. However, these forms may introduce errors of commission by prompting prescribers to reorder discontinued or potentially harmful medications. Our objective was to evaluate the incidence of medication discrepancies and errors of commission after the implementation of pre-populated medication reconciliation forms. Methods: This chart review included admitted patients who were enrolled in a parent study in which a research pharmacist prospectively collected best-possible medication histories (BPMHs) in the ED using all available information sources. Following discharge, research assistants uninvolved with the parent study compared medication orders documented within 48 h of admission with the BPMH to identify medication discrepancies and errors of commission. Errors of commission were defined as inappropriate continuations of medications and reordering discontinued medications. An independent panel adjudicated the clinical significance of the errors. We used regression methods to identify factors associated with errors. The sample size was limited by enrolment into the parent study. Results: Of 151 patients, 71 (47%; 95%CI 39.2-54.9) were exposed to 112 medication errors. Of these errors, 75.9% (85/112; 95%CI 67.1-82.9) were discrepancies, of which 18.8% (16/85; 95%CI 12.0-28.4) were clinically significant. Errors of commission made up 24.1% (27/112; 95%CI 17.3-32.8) of all errors, of which 37.0% (10/27; 95%CI 18.8-55.2) were clinically significant. Taking 8 or more medications was associated with a 5-fold greater odds of experiencing a medication error after controlling for confounders (OR 5.00; 95%CI 2.45-10.17; p<0.001). Conclusion: Clinically significant medication discrepancies and errors of commission remain common despite the implementation of electronically pre-populated medication reconciliation forms. Prospective studies are needed to evaluate whether using pre-populated medication reconciliation forms increases the risk of introducing errors of commission.
Introduction: The following adverse outcomes have been described in patients treated in hospital for opioid overdose: pulmonary edema, cardiac dysrhythmias, neurologic injury secondary to hypoxia, prolonged opioid toxicity, recurrent opioid toxicity. In addition, patients who take an overdose of fentanyl may develop fentanyl induced chest rigidity, a life-threatening complication that appears to be uniquely related to fentanyl. The prevalence of adverse outcomes and the clinical course of patients that develop these complications have been described in patients who have taken an overdose of heroin. However, in British Columbia there has been a dramatic increase in the number of patients who overdose on fentanyl and other ultrapotent opioids. The proportion of illicit drug overdose deaths in British Columbia for which fentanyl was detected was only 5% in 2012 but, by 2016, this proportion had increased to 62%. It is very important to know the prevalence of adverse outcomes and the clinical course of patients that develop these adverse outcomes in patients with an overdose of fentanyl or another ultrapotent opioid. Methods: We are completing a retrospective cohort study to evaluate the prevalence of the following adverse outcomes for patients treated in hospital for an opioid overdose: i) pulmonary edema, ii) cardiac dysrhythmias, iii) fentanyl induced chest rigidity, iv) neurologic injury secondary to hypoxia, v) prolonged opioid toxicity, vi) recurrent opioid toxicity. Health records of patients treated for opioid overdose in the emergency departments of six greater Vancouver hospitals from Jan 1, 2014 to Dec 31, 2016 are being reviewed. Results: All Institutional approvals have been obtained. The dataset of 3600 ED visits for opioid overdose has been obtained and 160 health records have now been reviewed as of January 8, 2017. We will describe the type and prevalence (with 95% confidence intervals) of complications sustained by these patients. Conclusion: The results of this study will guide management of opioid overdose in a setting were ultrapotent opioids are commonly ingested. All health records will have been reviewed and the data analysis completed by May 2017.
We report the temperature dependence of Er optical centers in GaN epilayers prepared by metal-organic chemical vapor deposition under the resonant excitation (4I15/2 → 4I9/2) excitation using a Ti:Sapphire laser (λexc = 809 nm). High resolution infrared spectroscopy and temperature dependence measurements of photoluminescence intensity from Er ions in GaN have been performed to identify the crystal filed splitting of the first excited state, 4I13/2. Here, we have employed a simple approach to determine activation energies which are related to the thermal population of electrons from the lowest level to the higher level of the crystal field splitting of the first excited state.
Experiments on the National Ignition Facility show that multi-dimensional effects currently dominate the implosion performance. Low mode implosion symmetry and hydrodynamic instabilities seeded by capsule mounting features appear to be two key limiting factors for implosion performance. One reason these factors have a large impact on the performance of inertial confinement fusion implosions is the high convergence required to achieve high fusion gains. To tackle these problems, a predictable implosion platform is needed meaning experiments must trade-off high gain for performance. LANL has adopted three main approaches to develop a one-dimensional (1D) implosion platform where 1D means measured yield over the 1D clean calculation. A high adiabat, low convergence platform is being developed using beryllium capsules enabling larger case-to-capsule ratios to improve symmetry. The second approach is liquid fuel layers using wetted foam targets. With liquid fuel layers, the implosion convergence can be controlled via the initial vapor pressure set by the target fielding temperature. The last method is double shell targets. For double shells, the smaller inner shell houses the DT fuel and the convergence of this cavity is relatively small compared to hot spot ignition. However, double shell targets have a different set of trade-off versus advantages. Details for each of these approaches are described.
Oats are a rich source of β-glucan, a viscous, soluble fibre recognised for its cholesterol-lowering properties, and are associated with reduced risk of CVD. Our objective was to conduct a systematic review and meta-analysis of randomised-controlled trials (RCT) investigating the cholesterol-lowering potential of oat β-glucan on LDL-cholesterol, non-HDL-cholesterol and apoB for the risk reduction of CVD. MEDLINE, Embase, CINAHL and Cochrane CENTRAL were searched. We included RCT of ≥3 weeks of follow-up, assessing the effect of diets enriched with oat β-glucan compared with controlled diets on LDL-cholesterol, non-HDL-cholesterol or apoB. Two independent reviewers extracted data and assessed study quality and risk of bias. Data were pooled using the generic inverse-variance method with random effects models and expressed as mean differences with 95 % CI. Heterogeneity was assessed by the Cochran’s Q statistic and quantified by the I2-statistic. In total, fifty-eight trials (n 3974) were included. A median dose of 3·5 g/d of oat β-glucan significantly lowered LDL-cholesterol (−0·19; 95 % CI −0·23, −0·14 mmol/l, P<0·00001), non-HDL-cholesterol (−0·20; 95 % CI −0·26, −0·15 mmol/l, P<0·00001) and apoB (−0·03; 95 % CI −0·05, −0·02 g/l, P<0·0001) compared with control interventions. There was evidence for considerable unexplained heterogeneity in the analysis of LDL-cholesterol (I2=79 %) and non-HDL-cholesterol (I2=99 %). Pooled analyses showed that oat β-glucan has a lowering effect on LDL-cholesterol, non-HDL-cholesterol and apoB. Inclusion of oat-containing foods may be a strategy for achieving targets in CVD reduction.
We describe an optical, spectroscopic survey of the nuclei of the 500 brightest galaxies in the northern sky. The primary goal is to search for low-luminosity active galactic nuclei (LLAGNs) in the centers of nearby galaxies. The results of this survey will have many astrophysical applications, including quantifying the faint end of the local AGN luminosity function and estimating the contribution of LLAGNs to the X-ray background. We summarize the statistical properties of the survey, describe our methods of analysis, and present some preliminary results based on ∼ 60% of the sample.
The inner few hundred parsecs of the Milky Way, the Central Molecular Zone (CMZ), is our closest laboratory for understanding star formation in the extreme environments (hot, dense, turbulent gas) that once dominated the universe. We present an update on the first large-area survey to expose the sites of star formation across the CMZ at high-resolution in submillimeter wavelengths: the CMZoom survey with the Submillimeter Array (SMA). We identify the locations of dense cores and search for signatures of embedded star formation. CMZoom is a three-year survey in its final year and is mapping out the highest column density regions of the CMZ in dust continuum and a variety of spectral lines around 1.3 mm. CMZoom combines SMA compact and subcompact configurations with single-dish data from BGPS and the APEX telescope, achieving an angular resolution of about 4″ (0.2 pc) and good image fidelity up to large spatial scales.
Between 1984 and 1990 we conducted a survey at Palomar Observatory (Filippenko and Sargent 1985) to quantify the luminosity function of nearby active galactic nuclei (AGNs). The Hale 5 m telescope was used to obtain high-quality, moderate-resolution optical spectra of a nearly statistically complete sample of about 500 bright (BT ≤ 12.5 mag), northern (δ > 0°) galaxies (see Ho et al. 1995 for details). The survey has now been completed, and the first scientific results are reported in a series of papers by Ho et al. (1997a, b, c).
Introduction: Compared to pseudo-pulseless electrical activity (PEA with myocardial contractions present), true PEA is hypothesized to carry a poorer prognosis and to show bradycardia and a wide QRS complex on ECG. Our objective was to study the predictive potential of ECG characteristics on survival to hospital discharge (SHD) for out-of-hospital cardiac arrest (OHCA) patients with PEA initial rhythm. Methods: We studied a cohort of OHCA patients prospectively enrolled between Sept. 2007 and Oct. 2009 at the Ottawa/OPALS site (13 cities, 7 EMS, and 6 Fire services) of the ROC PRIMED study. We included adult (≥ 18) non-traumatic OHCA with PEA initial rhythm where resuscitation was attempted, and for which ECG characteristics were available. We measured mean heart rate (HR), mean QRS interval, and presence of P waves (each with kappa agreement) using the first six QRS complex available. We report patient and system characteristics using descriptive statistics and determined the impact of ECG characteristics (HR, QRS width, P waves) on return of spontaneous circulation (ROSC) and SHD using multivariate regression analysis. Results: Demographics of 332 included cases were: mean age 71.7; male 58.4%; home residence 76.5%; bystander witnessed 56.3%; bystander CPR 28.5%; interval from dispatch to paramedic arrival 6min:24sec; ROSC at ED arrival 26.5%; SHD 5.4%. Survivors had higher mean HR (66.1 vs. 52.0 bpm, p=0.83; kappa=0.69) and shorter mean QRS intervals (108.3 vs. 129.6 ms, p=0.01; kappa=0.74) compared to non-survivors. Presence of p waves could not reliably be ascertained (kappa=0.35). Predictors of ROSC were: ALS paramedic on scene (AdjOR=8.90, 95%CI 1.11-71.41; p=0.04), successful intubation (AdjOR=3.35, 1.75-6.39; p=0.0002), and use of atropine (AdjOR=0.27, 0.14 - 0.50; p<0.0001). Predictors of survival were: location of arrest (AdjOR=1.49, 1.11 - 1.99; p=0.007), and use of atropine (AdjOR=0.06, 0.02-0.22; p<0.0001). Despite various cutoff explorations, ECG characteristics were not predictive of ROSC or survival in multivariate analyses. Survivors had HR as low as 6 bpm and QRS as wide as 357 ms. Conclusion: Early ECG characteristics could not predict ROSC or SHD in a population of OHCA PEA victims, and should not be used to terminate resuscitation efforts. Atropine administration was consistently associated with decreased likelihood of ROSC and survival.
We describe a new sample of Seyfert nuclei discovered during the course of an optical spectroscopic survey of nearby galaxies. The majority of the objects, many recognized as AGNs for the first time, have luminosities much lower than those of classical Seyferts and populate the faint end of the AGN luminosity function. A significant fraction of the nuclei emit broad Hα emission qualitatively similar to the broad lines seen in classical Seyfert 1 nuclei and QSOs.
We present new and archival Hubble Space Telescope (HST) images of circumnuclear star-forming rings in barred spiral galaxies. We find that nuclear rings in barred galaxies are composed of large numbers of super star clusters similar to those found recently in other types of starburst systems. In NGC 1097 and NGC 6951, the young clusters have absolute magnitudes of up to Mv = −14 or −15, depending on highly uncertain extinction corrections, and effective radii of 2–3 pc. The images (especially that of NGC 6951) also show intricate spiral dust lane structure interior to the rings.
Theoretical studies suggest that large-scale stellar bars can be highly effective in delivering gas to the central few hundred parsecs of a spiral galaxy, which may then initiate rapid star formation. Further instabilities may lead to additional inflow to physical scales relevant for active galactic nuclei. We test these predictions in light of recent observations. Compared to unbarred spirals, barred galaxies of type S0-Sbc have a higher probability of exhibiting nuclear star formation, as well as a higher formation rate of massive stars; neither effect is present in spirals of later morphological type. Bars, on the other hand, do not have an obvious influence on active nuclei. We discuss the implications of these findings for the fueling of central star formation and active nuclei.