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For centuries, paleontologists have sought functional explanations for the uniquely complex internal walls (septa) of ammonoids, extinct shelled cephalopods. Ammonoid septa developed increasingly complex fractal margins, unlike any modern shell morphologies, throughout more than 300 million years of evolution. Some have suggested these morphologies provided increased resistance to shell-crushing predators. We perform the first physical compression experiments on model ammonoid septa using controlled, theoretical morphologies generated by computer-aided design and 3D printing. These biomechanical experiments reveal that increasing complexity of septal margins does not increase compression resistance. Our results raise the question of whether the evolution of septal shape may be tied closely to the placement of the siphuncle foramen (anatomic septal hole). Our tests demonstrate weakness in the centers of uniformly thick septa, supporting work suggesting reinforcement by shell thickening at the center of septa. These experiments highlight the importance of 3D reconstruction using idealized theoretical morphologies that permit the testing of long-held hypotheses of functional evolutionary drivers by recreating extinct morphologies once rendered physically untestable by the fossil record.
This research communication reports the results from questionnaires used to identify the impact of recent research into the disinfection of cattle foot-trimming equipment to prevent bovine digital dermatitis (BDD) transmission on (a) biosecurity knowledge and (b) hygiene practice of foot health professionals. An initial questionnaire found that more than half of participating farmers, veterinary surgeons and commercial foot-trimmers were not considering hand or hoof-knife hygiene in their working practices. The following year, after the release of a foot-trimming hygiene protocol and a comprehensive knowledge exchange programme by the University of Liverpool, a second survey showed 35/80 (43.8%) farmers, veterinary surgeons and commercial foot-trimmers sampled considered they were now more aware of the risk of spreading BDD during foot- trimming. Furthermore, 36/80 (45.0%) had enhanced their hygiene practice in the last year, impacting an estimated 1383 farms and 5130 cows trimmed each week. Participants who reported having seen both the foot-trimming hygiene protocol we developed with AHDB Dairy and other articles about foot-trimming hygiene in the farming and veterinary press, were significantly more likely to have changed their working practices. Difficulties accessing water and cleaning facilities on farms were identified as the greatest barrier to improving biosecurity practices. Participants' preferred priority for future research was continued collection of evidence for the importance and efficacy of good foot-trimming hygiene practices.
The extent to which Clinical and Translational Science Award (CTSA) programs offer publicly accessible online resources for training in community-engaged research (CEnR) core competencies is unknown. This study cataloged publicly accessible online CEnR resources from CTSAs and mapped resources to CEnR core competency domains.
Following a search and review of the current literature regarding CEnR competencies, CEnR core competency domains were identified and defined. A systematic review of publicly accessible online CEnR resources from all 64 current CTSAs was conducted between July 2018 and May 2019. Resource content was independently reviewed by two reviewers and scored for the inclusion of each CEnR core competency domain. Domain scores across all resources were assessed using descriptive statistics.
Eight CEnR core competency domains were identified. Overall, 214 CEnR resources publicly accessible online from 35 CTSAs were eligible for review. Scoring discrepancies for at least one domain within a resource initially occurred in 51% of resources. “CEnR methods” (50.5%) and “Knowledge and relationships with communities” (40.2%) were the most frequently addressed domains, while “CEnR program evaluation” (12.1%) and “Dissemination and advocacy” (11.2%) were the least frequently addressed domains. Additionally, challenges were noted in navigating CTSA websites to access CEnR resources, and CEnR competency nomenclature was not standardized.
Our findings guide CEnR stakeholders to identify publicly accessible online resources and gaps to address in CEnR resource development. Standardized nomenclature for CEnR competency is needed for effective CEnR resource classification. Uniform organization of CTSA websites may maximize navigability.
OBJECTIVES/GOALS: The extent that Clinical and Translational Science Award (CTSA) programs offer resources accessible online for training in community-engaged research (CEnR) core competencies is unknown. This study cataloged CEnR resources accessible online from CTSAs and mapped resources to CEnR core competencies. METHODS/STUDY POPULATION: Eight domains of CEnR core competencies were identified: knowledge/perceptions of CEnR; personal traits necessary for CEnR; knowledge of/relationships with communities; training for performing CEnR; CEnR methods; program evaluation; resource sharing and communication; and dissemination and advocacy. A systematic review of CEnR resources accessible online from CTSAs was conducted between July 2018 and May 2019. Resource content was independently reviewed by two reviewers and scored for inclusion of each domain of CEnR core competencies. Domain scores across all resources and inter-rater reliability in scoring domains were assessed using descriptive statistics and Cohen’s kappa coefficients. RESULTS/ANTICIPATED RESULTS: Overall, 214 resources available from 24 CTSAs were eligible for full review. Scoring discrepancies for at least one domain within a resource initially occurred in 51% of resources. “CEnR methods” (50.5%; 108 of 214) and “Knowledge of/relationships with the community” (40.2%; 86 of 214) were most frequently addressed and “Program evaluation” (12.1%; 26 of 214) and “Dissemination and advocacy” (11.2%; 24 of 214) were least frequently addressed domains. Additionally, challenges were noted in navigating CTSA websites to access CEnR resources, and CEnR competency nomenclature was not standardized. DISCUSSION/SIGNIFICANCE OF IMPACT: Our findings guide CEnR stakeholders to identify CEnR resources accessible online and gaps to address in CEnR resource development. Standardized nomenclature for CEnR competencies is needed for effective CEnR resource classification. Uniform organization of CTSA websites may maximize navigability. CONFLICT OF INTEREST DESCRIPTION: In addition to the funding information listed previously (see above), within the last three years, R.J. Piasecki has been employed as: Project Coordinator, CEnR Online Learning Project, Johns Hopkins University School of Nursing (Current) Temporary Employee (Doctoral Student Intern), Michigan State University Institute for Health Policy (Current) Clinical RN, Intrastaff at the Johns Hopkins Health System (Past) Research Data Analysis Assistant, Maryland Institute for Emergency Medical Services (Past - contracted)
Introduction: Paramedics commonly administer intravenous dextrose to severely hypoglycemic patients. Typically, the treatment provided is a 25g ampule of 50% dextrose (D50). This dose of D50 is meant to ensure a return to consciousness. However, this dose may be unnecessary and lead to harm or difficulties regulating blood glucose post treatment. We hypothesize that a lower dose such as dextrose 10% (D10) or titrating the D50 to desired level of consciousness may be optimal and avoid adverse events. Methods: We systematically searched Medline, Embase, CINAHL and Cochrane Central on June 5th 2019. PRISMA guidelines were followed. The GRADE methods and risk of bias assessments were applied to determine the certainty of the evidence. We included primary literature investigating the use of intravenous dextrose in hypoglycemic diabetic patients presenting to paramedics or the emergency department. Outcomes of interest were related to the safe and effective reversal of symptoms and blood glucose levels (BGL). Results: 660 abstracts were screened, 40 full text articles, with eight studies included. Data from three randomized controlled trials and five observational studies were analyzed. A single RCT comparing D10 to D50 was identified. The primary significant finding of the study was an increased post-treatment glycemic profile by 3.2 mmol/L in the D50 group; no other outcomes had significant differences between groups. When comparing pooled data from all the included studies we find higher symptom resolution in the D10 group compared to the D50 group; at 99.8% and 94.9% respectively. However, the mean time to resolution was approximately 4 minutes longer in the D10 group (4.1 minutes (D50) and 8 minutes (D10)). There was more need for subsequent doses in the D10 group at 23.0% versus 16.5% in the D50 group. The post treatment glycemic profile was lower in the D10 group at 5.9 mmol/L versus 8.5 mmol/L in the D50 group. Both treatments had nearly complete resolution of hypoglycemia; 98.7% (D50) and 99.2% (D10). No adverse events were observed in the D10 group (0/871) compared to 12/133 adverse events in the D50 group. Conclusion: D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia. Although the desired effect can take several minutes longer there appear to be fewer adverse events. The post treatment glycemic profile may facilitate less challenging ongoing glucose management by the patients.
Introduction: The Prehospital Evidence-based Practice (PEP) program is an online, freely accessible, continuously updated repository of appraised EMS research evidence. This report is an analysis of published evidence for EMS interventions used to assess and treat patients suffering from hypoglycemia. Methods: PubMed was systematically searched in June 2019. One author screened titles, abstracts and full-texts for relevance. Trained appraisers reviewed full text articles, scored each on a three-point Level of Evidence (LOE) scale (based on study design and quality) and three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings for each intervention's primary outcome), abstracted the primary outcome, setting and assigned an outcome category (patient or process). Second party appraisal was conducted for all included studies. The level and direction of each intervention was plotted in an evidence matrix, based on appraisals. Results: Twenty-nine studies were included and appraised for seven interventions: 5 drugs (Dextrose 50% (D50), Dextrose 10% (D10), glucagon, oral glucose and thiamine), one assessment tool (point-of-care (POC) glucose testing) and one call disposition (treat-and-release). The most frequently reported study primary outcomes were related to: clinical improvement (n = 15, 51.7%), feasibility/safety (n = 8, 27.6%), and diagnostics (n = 6, 20.7%). The majority of outcomes were patient focused (n = 18, 62.0%). Conclusion: EMS interventions for treating hypoglycemia are informed by high-quality supportive evidence. Both D50 and D10 are supported by high-quality evidence; suggesting D10 may be an effective alternative to the standard D50. “Treat-and-release” practices for hypoglycemia are supported by moderate-quality evidence for the patient related outcomes of relapse, patient preference and complications. This body of evidence is high-quality, patient-focused and conducted in the prehospital setting thus generalizable paramedic practice.
We describe an ultra-wide-bandwidth, low-frequency receiver recently installed on the Parkes radio telescope. The receiver system provides continuous frequency coverage from 704 to 4032 MHz. For much of the band (
), the system temperature is approximately 22 K and the receiver system remains in a linear regime even in the presence of strong mobile phone transmissions. We discuss the scientific and technical aspects of the new receiver, including its astronomical objectives, as well as the feed, receiver, digitiser, and signal processor design. We describe the pipeline routines that form the archive-ready data products and how those data files can be accessed from the archives. The system performance is quantified, including the system noise and linearity, beam shape, antenna efficiency, polarisation calibration, and timing stability.
Multiple lines of evidence suggest the presence of altered neuroimmune processes in patients with schizophrenia (Sz) and severe mood disorders. Recent studies using a novel free water diffusion tensor imaging (FW DTI) approach, proposed as a putative biomarker of neuroinflammation, atrophy, or edema, have shown significantly increased FW in patients with Sz. However no studies to date have investigated the longitudinal stability of FW alterations during the early course of psychosis, nor have studies focused separately on FE psychosis patients with Sz or bipolar disorder (BD) with psychotic features.
The current study included 188 participants who underwent diffusion magnetic resonance imaging scanning at baseline. Sixty-four participants underwent follow-up rescanning after 12 months. DTI-based alterations in patients were calculated using voxelwise tract-based spatial statistics and region of interest analyses.
Patients with FE psychosis, both Sz and BD, exhibited increased FW at illness onset which remained unchanged over the 12-month follow-up period. Preliminary analyses suggested that antipsychotic medication exposure was associated with higher FW in gray matter that reached significance in the BD group. Higher FW in white matter correlated with negative symptom severity.
Our results support the presence of elevated FW at the onset of psychosis in both Sz and BD, which remains stable during the early course of the illness, with no evidence of either progression or remission.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
Introduction: Early and accurate diagnosis of critical conditions is essential in emergency medical services (EMS). Serum lactate testing may be used to identify patients with worse prognosis, including sepsis. Recently, the use of a point-of-care lactate (POCL) test has been evaluated in guiding treatment in patients with sepsis. Operating as part of the Prehospital Evidence Based Practice (PEP) Program, the authors sought to identify and describe the body of evidence for POCL use in EMS and the emergency department (ED) for patients with sepsis. Methods: Following PEP methodology, in May 2018, PubMed was searched in a systematic manner. Title and abstract screening were conducted by the program coordinator. These studies were collected, appraised and added to the existing body of literature contained within the PEP database. Evidence appraisal was conducted by two reviewers who assigned both a level of evidence (LOE) on a novel three tier scale and a direction of evidence (supportive, neutral or opposing; based on primary outcome). Data on setting and study design were also extracted. Results: Eight studies were included in our analysis. Three of these studies were conducted in the ED setting; each investigating the POCL test's ability to predict severe sepsis, ICU admission or death. All three studies found supportive results for POCL. A systematic review on the use of POCL in the ED determined that this test can also improve time to treatment. Five of the total 8 studies were conducted prehospitally. Two of these studies were supportive of POCL use in the prehospital setting; in terms of feasibility and the ability to predict sepsis. Both of these study sites used this early information as part of initiating a “sepsis alert” pathway. The other three prehospital studies provide neutral support for POCL. One study demonstrated moderate ability of POCL to predict severe illness. Two studies found poor agreement between prehospital POCL and serum lactate values. Conclusion: Limited low and moderate quality evidence suggest POCL may be feasible and helpful in predicting sepsis in the prehospital setting. However, there is sparse and inconsistent support for specific important outcomes, including accuracy.
Introduction: The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated Emergency Medical Services (EMS) evidence repository. This summary describes the research evidence for the identification and management of adult patients suffering from sepsis syndrome or septic shock. Methods: PubMed was searched in a systematic manner. One author reviewed titles and abstracts for relevance and two authors appraised each study selected for inclusion. Primary outcomes were extracted. Studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and a three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings based on the studies’ primary outcome for each intervention). LOE and DOE of each intervention were plotted on an evidence matrix (DOE x LOE). Results: Eighty-eight studies were included for 15 interventions listed in PEP. The interventions with the most evidence were related to identification tools (ID) (n = 26, 30%) and early goal directed therapy (EGDT) (n = 21, 24%). ID tools included Systematic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA) and other unique measures. The most common primary outcomes were related to diagnosis (n = 30, 34%), mortality (n = 40, 45%) and treatment goals (e.g. time to antibiotic) (n = 14, 16%). The evidence rank for the supported interventions were: supportive-high quality (n = 1, 7%) for crystalloid infusion, supportive-moderate quality (n = 7, 47%) for identification tools, prenotification, point of care lactate, titrated oxygen, temperature monitoring, and supportive-low quality (n = 1, 7%) for vasopressors. The benefit of prehospital antibiotics and EGDT remain inconclusive with a neutral DOE. There is moderate level evidence opposing use of high flow oxygen. Conclusion: EMS sepsis interventions are informed primarily by moderate quality supportive evidence. Several standard treatments are well supported by moderate to high quality evidence, as are identification tools. However, some standard in-hospital therapies are not supported by evidence in the prehospital setting, such as antibiotics, and EGDT. Based on primary outcomes, no identification tool appears superior. This evidence analysis can guide selection of appropriate prehospital therapies.
We investigate the effect of constant-vorticity background shear on the properties of wavetrains in deep water. Using the methodology of Fokas (A Unified Approach to Boundary Value Problems, 2008, SIAM), we derive a higher-order nonlinear Schrödinger equation in the presence of shear and surface tension. We show that the presence of shear induces a strong coupling between the carrier wave and the mean-surface displacement. The effects of the background shear on the modulational instability of plane waves is also studied, where it is shown that shear can suppress instability, although not for all carrier wavelengths in the presence of surface tension. These results expand upon the findings of Thomas et al. (Phys. Fluids, vol. 24 (12), 2012, 127102). Using a modification of the generalized Lagrangian mean theory in Andrews & McIntyre (J. Fluid Mech., vol. 89, 1978, pp. 609–646) and approximate formulas for the velocity field in the fluid column, explicit, asymptotic approximations for the Lagrangian and Stokes drift velocities are obtained for plane-wave and Jacobi elliptic function solutions of the nonlinear Schrödinger equation. Numerical approximations to particle trajectories for these solutions are found and the Lagrangian and Stokes drift velocities corresponding to these numerical solutions corroborate the theoretical results. We show that background currents have significant effects on the mean transport properties of waves. In particular, certain combinations of background shear and carrier wave frequency lead to the disappearance of mean-surface mass transport. These results provide a possible explanation for the measurements reported in Smith (J. Phys. Oceanogr., vol. 36, 2006, pp. 1381–1402). Our results also provide further evidence of the viability of the modification of the Stokes drift velocity beyond the standard monochromatic approximation, such as recently proposed in Breivik et al. (J. Phys. Oceanogr., vol. 44, 2014, pp. 2433–2445) in order to obtain a closer match to a range of complex ocean wave spectra.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.
During the recent Ebola crisis in West Africa, individual person-level details of disease onset, transmissions, and outcomes such as survival or death were reported in online news media. We set out to document disease transmission chains for Ebola, with the goal of generating a timely account that could be used for surveillance, mathematical modeling, and public health decision-making. By accessing public web pages only, such as locally produced newspapers and blogs, we created a transmission chain involving two Ebola clusters in West Africa that compared favorably with other published transmission chains, and derived parameters for a mathematical model of Ebola disease transmission that were not statistically different from those derived from published sources. We present a protocol for responsibly gleaning epidemiological facts, transmission model parameters, and useful details from affected communities using mostly indigenously produced sources. After comparing our transmission parameters to published parameters, we discuss additional benefits of our method, such as gaining practical information about the affected community, its infrastructure, politics, and culture. We also briefly compare our method to similar efforts that used mostly non-indigenous online sources to generate epidemiological information.
Introduction/Innovation Concept: University Departments of Emergency Medicine are responsible for the supervision of research and other scholarly projects for fellows, residents and students, though often lack resources to provide adequate input and oversight. Many departments cover large geographical areas and several programs. We piloted new research committee structures and processes to improve oversight and output of research projects. Methods: We created an interactive group supervision tool based around formation of a collaborative research committee, with rotating chairs from each program, to provide supervision and face to face interaction, and direction for research learners. Included were all Dalhousie University adult and pediatric emergency medicine residency and fellowship programs, as well as trauma and EMS programs across Nova Scotia, New Brunswick, and Prince Edward Island. In addition to providing expertise in clinical trial coordination, database management, research administration, grant applications and Research Ethics Board submissions, we have completed a 2-year pilot of our interactive group supervision tool for research projects. Curriculum, Tool, or Material: The interactive tool consists of a structured PICOD form; allocation of topic and research mentors; standardized yearly milestones from project development through presentation and publication; and regular video-conferenced and in-person interactive group sessions involving several project leads, as well as program research directors, researchers, and co-ordinators. To date, all participating program learners have engaged with the tool, with positive feedback from learners, supervisors and program directors. Conclusion: We report our development of a regional collaborative interactive group supervision tool, that maximizes expert resources in the provision of research and scholarly project supervision.
Introduction: Patients who require end of life (EoL)/palliative care occasionally need assistance from paramedics. This review evaluated the evidence for paramedic-delivered EoL/palliative care interventions. Methods: The Canadian Prehospital Evidence-based Practice (PEP) Project methodology was used. A PubMed search was conducted, using Medical Subject headings and title/abstract key words. Titles and abstracts were reviewed for relevance. Studies were not required to be EMS based but must have focused on interventions available to EMS personnel. Included full text studies were scored by trained primary appraisers on a three-point Level of Evidence (LOE) scale (high = 1, moderate = 2 and low = 3) and three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing). Studies were categorized by clinical condition (n=5) and by intervention (n=25), and plotted on 3×3 (DOE × LOE) tables. The study primary outcome and setting were determined. Results: The search returned 3255 articles; 86 were selected for abstract review; with 30 full text articles ultimately included. Intervention recommendations were: LOE 1-supportive (n=3, 12%), 2-supportive (n=2, 8%), 3-supportive (n=2, 8%), 1-neutral (n=2, 8%), 2-neutral (n=2, 8%), 3-neutral (n=4, 16%). No primary studies were identified for 10 (40%) interventions. Conditions with 1-supportive studies were: ‘breathlessness’ and ‘analgesia’. ‘Secretions’ condition had no relevant evidence. Interventions with 1-supportive evidence were: Haldol for agitation (n=1), fentanyl and morphine for analgesia (n=3 and n=1), narcotics for breathlessness (n=1). No intervention had opposing evidence. Primary outcomes were more commonly related to symptom relief (n=26, 87%), safety (n=3, 10%), or tolerability (n=1, 3%). Only one included study was conducted in the EMS setting. Conclusion: Evidence for interventions used by paramedics in the treatment of patients requiring EoL/palliative care was identified, as were evidence gaps. Little research was conducted in the EMS setting, and most interventions had few studies. These PEP findings highlight topics requiring high quality EMS research specific to EoL/palliative care to inform this growing aspect of paramedic practice.
The Parkes 64 m telescope has been used to survey a complete sample of nearby red giants (i.e. not members of close binaries or showing strong emission lines of CaII). The sample consisted of all 82 stars in the Bright Star Catalogue within 30 pc having spectral types G, K, M and luminosity classes I, II, III south of the celestial equator.