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Following release by emergency department (ED) for acute heart failure (AHF), returns to ED represent important adverse health outcomes. The objective of this study was to document relapse events and factors associated with return to ED in the 14-day period following release by ED for patients with AHF.
The primary outcome was the number of return to ED for patients who were release by ED after the initial visit, for any related medical problem within 14 days of this initial ED visit.
Return visits to the EDs occurred in 166 (20%) patients. Of all patients who returned to ED within the 14-day period, 77 (47%) were secondarily admitted to the hospital. The following factors were associated with return visits to ED: past medical history of percutaneous coronary intervention or coronary artery bypass graft (aOR=1.51; 95% CIs [1.01-2.24]), current use of antiarrhythmics medications (1.96 [1.05-3.55]), heart rate above 80 /min (1.89 [1.28-2.80]), systolic blood pressure below 140 mm Hg (1.67[1.14-2.47]), oxygen saturation (SaO2) above 96% (1.58 [1.08-2.31]), troponin above the upper reference limit of normal (1.68 [1.15-2.45]), and chest X-ray with pleural effusion (1.52 [1.04-2.23]).
Many heart failure patients (i.e. 1 in 5 patients) are released from the ED and then suffer return to ED. Patients with multiple medical comorbidities, and those with abnormal initial vital signs are at increased risk for return to ED and should be identified.
Two major processes underlie human decision-making: experiential (intuitive) and rational (conscious) thinking. The predominant thinking process used by working paramedics and student paramedics to make clinical decisions is unknown.
A survey was administered to ground ambulance paramedics and to primary care paramedic students. The survey included demographic questions and the Rational Experiential Inventory-40, a validated psychometric tool involving 40 questions. Twenty questions evaluated each thinking style: 10 assessed preference and 10 assessed ability to use that style. Responses were provided on a five-point Likert scale, with higher scores indicating higher affinity for the style in question. Analysis included both descriptive statistics and t tests to evaluate differences in thinking style.
The response rate was 88.4% (1172/1326). Paramedics (n=904) had a median age of 36 years (IQR 29–42) and most were male (69.5%) and primary or advanced care paramedics (PCP=55.5%; ACP=32.5%). Paramedic students (n=268) had a median age of 23 years (IQR 21–26), most were male (63.1%) and had completed high school (31.7%) or an undergraduate degree (25.4%) prior to paramedic training. Both groups scored their ability to use and favourability toward rational thinking significantly higher than experiential thinking. The mean score for rational thinking was 3.86/5 among paramedics and 3.97/5 among paramedic students (p<0.001). The mean score for experiential thinking was 3.41/5 among paramedics and 3.35/5 among paramedic students (p=0.06).
Working paramedics and student paramedics prefer and perceive that they have the ability to use rational over experiential thinking. This information adds to our current knowledge on paramedic decision-making and is potentially important for developing continuing education and clinical support tools.
Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.
Previous behavioural and neuroimaging studies of emotion processing in autistic spectrum disorder (ASD) have focused on the use of facial stimuli. To date, however, no studies have examined emotion processing in autism across a broad range of social signals.
This study addressed this issue by investigating emotion processing in a group of 23 adults with ASD and 23 age- and gender-matched controls. Recognition of basic emotions (‘happiness’, ‘sadness’, ‘anger’, disgust' and ‘fear’) was assessed from facial, body movement and vocal stimuli. The ability to make social judgements (such as approachability) from facial stimuli was also investigated.
Significant deficits in emotion recognition were found in the ASD group relative to the control group across all stimulus domains (faces, body movements and voices). These deficits were seen across a range of emotions. The ASD group were also impaired in making social judgements compared to the control group and this correlated with impairments in basic emotion recognition.
This study demonstrates that there are significant and broad-ranging deficits in emotion processing in ASD present across a range of stimulus domains and in the auditory and visual modality; they cannot therefore be accounted for simply in terms of impairments in face processing or in the visual modality alone. These results identify a core deficit affecting the processing of a wide range of emotional information in ASD, which contributes to the impairments in social function seen in people with this condition.
Inflammation is a stereotypical physiological response to infections and tissue injury; it initiates pathogen killing as well as tissue repair processes and helps to restore homeostasis at infected or damaged sites. Acute inflammatory reactions are usually self-limiting and resolve rapidly, due to the involvement of negative feedback mechanisms. Thus, regulated inflammatory responses are essential to remain healthy and maintain homeostasis. However, inflammatory responses that fail to regulate themselves can become chronic and contribute to the perpetuation and progression of disease. Characteristics typical of chronic inflammatory responses underlying the pathophysiology of several disorders include loss of barrier function, responsiveness to a normally benign stimulus, infiltration of inflammatory cells into compartments where they are not normally found in such high numbers, and overproduction of oxidants, cytokines, chemokines, eicosanoids and matrix metalloproteinases. The levels of these mediators amplify the inflammatory response, are destructive and contribute to the clinical symptoms. Various dietary components including long chain ω-3 fatty acids, antioxidant vitamins, plant flavonoids, prebiotics and probiotics have the potential to modulate predisposition to chronic inflammatory conditions and may have a role in their therapy. These components act through a variety of mechanisms including decreasing inflammatory mediator production through effects on cell signaling and gene expression (ω-3 fatty acids, vitamin E, plant flavonoids), reducing the production of damaging oxidants (vitamin E and other antioxidants), and promoting gut barrier function and anti-inflammatory responses (prebiotics and probiotics). However, in general really strong evidence of benefit to human health through anti-inflammatory actions is lacking for most of these dietary components. Thus, further studies addressing efficacy in humans linked to studies providing greater understanding of the mechanisms of action involved are required.
To determine the effects of EPA, stearidonic acid (STA) or γ-linolenic acid (GLA) on immune outcomes, healthy male subjects consumed one of seven oil blends for 12 weeks. EPA consumption increased the EPA content of peripheral blood mononuclear cells (PBMC). Consumption of GLA (2·0 g/d) in the absence of STA or EPA increased di-homo-GLA content in PBMC. Neither STA nor its derivative 20:4n-3 appeared in PBMC when STA (<1·0 g/d) was consumed. However, STA (1·0 g/d), in combination with GLA (0·9 g/d), increased the proportion of EPA in PBMC. None of the treatments altered neutrophil or monocyte phagocytosis or respiratory burst, production of inflammatory cytokines by monocytes, T lymphocyte proliferation or the delayed-type hypersensitivity response. Production of cytokines by T lymphocytes increased in all groups, with no differences among them. The proportion of lymphocytes that were natural killer cells decreased significantly in subjects receiving 2·0 g EPA or GLA/d. There were no other effects on lymphocyte sub-populations. Plasma IgE concentration decreased in most groups, but not in the control group. Plasma IgG2 concentration increased in the EPA group. Thus, EPA or GLA at a dose of 2·0 g/d have little effect on key functions of neutrophils, monocytes and T lymphocytes, although at this dose these fatty acids decrease the number of natural killer cells. At this dose EPA increases IgG2 concentrations. STA can increase immune cell EPA status, but at 1·0 g/d does not affect human immune function.
The growth of ewe lambs of the Shropshire breed declined and in some cases ceased at the end of July, when they grazed permanent pastures at the Experimental Farm, Nappan, Nova Scotia. This decline in growth coincided with a decrease of about three orders of magnitude in the numbers of viable rumen bacteria. At the end of July an increase of one to two orders of magnitude was observed in the numbers of viable fungi collected from the pastures. Lambs grazing pastures developed from tidal marsh of the Bay of Fundy had a better growth performance than lambs grazing adjacent pastures developed from mixed conifer-deciduous forest. The forest soils supported a greater fungal population than the marshland soil, and several species were found predominantly on the forest soil.
Land development through pasture improvement has made great strides in recent years in many parts of the world. This has been made possible by a better understanding of the principles of pasture production following the pioneering work of the late Sir George Stapledon and his school of grassland enthusiasts. Improved strains of pasture plants, the use of lime and fertilisers, the development of mechanical aids and a better understanding of the animal in grazing management have all been involved in the development.
Two good friends have supplied me with the material for a note which I dedicate, with kind wishes, to a third.
Michael Ballance inaugurated the epigraphical harvest of our journey in 1954 with the discovery of two remarkable inscriptions at Emircik near Beyce Sultan (territory of Eumeneia). One of these served to clinch an argument in Anatolian Studies, V, 1955, p. 38. The second is no. 1 below.
A few days later Habip Zebir Ağa, itinerant tinker of Sandıklı, called at the excavation headquarters to remind me of an earlier encounter which I had forgotten. He had visited Synnada in the exercise of his craft in 1930 while the American Society's expedition was working there, and I had taught him how to copy Greek inscriptions and urged him to make copies of any monuments he might find in the course of his work in central Phrygia. He brought with him a bundle of copies he had made during the intervening years, mainly from Synnada, the Pentapolis and the Eumeneticus Campus. A number of these copies are of known monuments and show that, for one ignorant of Latin and Greek, he is a careful and reliable copyist. One of his copies is no. 2 below.
The earliest Christians of Phrygia were the nameless converts made by Paul the Apostle when he preached to a congregation of Jews and “Godfearing” gentiles (the latter being Greek or Greco-Phrygian incolae or cives of the colonia and Greek-speaking members of Roman colonial families in the synagogue at Colonia Caesareia Antiocheia in A.D. 49; and before Paul's death the Christian mission to Phrygia had been launched from bases both in the east (Iconium and Antioch) and in the west (Laodicea, Hierapolis and Colossae). Between the middle of the first and the end of the second century, five generations of Phrygian Christians (as Paul expressed it on the same occasion) “fell on sleep and were laid unto their fathers”—in surface family sepulchres along the roads outside the cities and in country graveyards throughout all the hellenised districts of Phrygia. During this period the strong conservatism of Phrygian sepulchral custom, reinforced by the prudence in the face of persecution or proscription held to be enjoined by Scripture (had not Jesus himself withdrawn into Gethsemane?), precluded the open display on tombstones—in all ages the consecrated tokens of sorrow and of hope—of any trace of the Christian profession.