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To identify modifiers of emergency medical services (EMS) oversight quality, including facilitators and barriers, and inform best practices and policy related to EMS oversight and system performance.
We used a qualitative design, including 4 focus groups and 10 in-depth, 1-on-1 interviews. Primary data were collected from EMS stakeholders in Michigan from June to July 2016. Qualitative data were analyzed using the rapid assessment technique.
Emergent themes included organizational structure, oversight and stakeholder leadership, interorganizational communication and relationships, competition or collaboration among MCA stakeholders, quality improvement practices, resources, and needs specific to rural communities.
EMS is a critical component of disaster response. This study revealed salient themes and modifiers, including facilitators and barriers, of EMS oversight quality. These findings were evaluated in the context of current evidence and informed state policy to improve the quality of EMS oversight and prehospital care for both routine and disaster settings. Some were particular to geographic regions and communities, whereas others were generalizable.
The study aims to investigate the recognition of patients with Obsessive-Compulsive Disorder (OCD) in psychiatric outpatients.
Subjects and methods
A total of 2282 outpatients seen at 14 different psychiatric clinics in South Germany were asked to participate in the study. Five hundred and eighty-nine (30%) of the original 2282 patients met screening criteria for OCD, and of those, 237 (42%) participated in the final interview including DSM-IV diagnosis, and comorbidity.
Sixty-nine of 589 participating patients who screened positively for obsessive symptoms actually had an Obsessive-Compulsive Disorder. Only 19 (28%) of the outpatients diagnosed with OCD according to DSM-IV criteria were also given this diagnosis by their consultant. The psychopathology scores indicated that the OCD patients had clinically relevant OCD with a mean Yale-Brown Obsessive Compulsive Score (Y-BOCS) of 17.5 (± 5.4), and a mean Clinical Global Impression Score (CGI) of 5.2 (± 1.2).
In outpatient clinics over 70% of OCD patients remain unrecognised and thus untreated by consultants. Screening questions provide a rapid way of identifying those who may have OCD and should be incorporated into every mental state examination by consultants.
In a 2015 report, the Institute of Medicine (IOM; Washington, DC USA), now the National Academy of Medicine (NAM; Washington, DC USA), stated that the field of Emergency Medical Services (EMS) exhibits signs of fragmentation; an absence of system-wide coordination and planning; and a lack of federal, state, and local accountability. The NAM recommended clarifying what roles the federal government, state governments, and local communities play in the oversight and evaluation of EMS system performance, and how they may better work together to improve care.
This systematic literature review and environmental scan addresses NAM’s recommendations by answering two research questions: (1) what aspects of EMS systems are most measured in the peer-reviewed and grey literatures, and (2) what do these measures and studies suggest for high-quality EMS oversight?
To answer these questions, a systematic literature review was conducted in the PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Web of Science (Thomson Reuters; New York, New York USA), SCOPUS (Elsevier; Amsterdam, Netherlands), and EMBASE (Elsevier; Amsterdam, Netherlands) databases for peer-reviewed literature and for grey literature; targeted web searches of 10 EMS-related government agencies and professional organizations were performed. Inclusion criteria required peer-reviewed literature to be published between 1966-2016 and grey literature to be published between 1996-2016. A total of 1,476 peer-reviewed titles were reviewed, 76 were retrieved for full-text review, and 58 were retained and coded in the qualitative software Dedoose (Manhattan Beach, California USA) using a codebook of themes. Categorizations of measure type and level of application were assigned to the extracted data. Targeted websites were systematically reviewed and 115 relevant grey literature documents were retrieved.
A total of 58 peer-reviewed articles met inclusion criteria; 46 included process, 36 outcomes, and 18 structural measures. Most studies applied quality measures at the personnel level (40), followed by the agency (28) and system of care (28), and few at the oversight level (5). Numerous grey literature articles provided principles for high-quality EMS oversight.
Limited quality measurement at the oversight level is an important gap in the peer-reviewed literature. The grey literature is ahead in this realm and can guide the policy and research agenda for EMS oversight quality measurement.
TaymourRK, AbirM, ChamberlinM, DunneRB, LowellM, WahlK, ScottJ. Policy, Practice, and Research Agenda for Emergency Medical Services Oversight: A Systematic Review and Environmental Scan. Prehosp Disaster Med. 2018;33(1):89–97.
Depressive symptoms are highly prevalent in nursing home (NH) residents. The relationship between depressive symptoms and everyday competence in terms of basic (BaCo) and expanded everyday competence (ExCo; see Baltes et al., 2001) in the NH setting is, however, not clear. Applying Lewinsohn's depression model, we examined how residents’ BaCo and ExCo relate to their depressive symptoms. Furthermore, we investigated the mediating role of perceived control.
Cross-sectional data from 196 residents (Mage = 83.7 years, SD = 9.4 years) of two German NHs were analyzed. Study variables were assessed by the Geriatric Depression Scale-Residential (GDS-12R), maximal gait speed (BaCo), proxy ratings of residents’ in-home activity participation, and self-initiated social contact done by staff (ExCo). Structural equation modeling (SEM) was used and a simulation study was included to determine power and potential estimation bias.
At the descriptive level, one quarter of the residents showed symptoms of depression according to the GDS-12R cut-off criterion. Residents’ BaCo and ExCo were independently and equally strongly associated with their depressive symptoms in the SEM analysis. These findings were affected neither by cognitive impairment, sex, nor age. Perceived control mediated between BaCo but not ExCo and depressive symptoms.
Future research needs to follow the connection between residents’ everyday competence and their depressive symptoms longitudinally to better understand the underlying mechanisms.
Although magnetic resonance imaging is a primary modality for following patients with connective tissue diseases, only a limited amount of the image data is utilised. The purpose of this study was to show the clinical applicability of an automated four-dimensional analysis method of magnetic resonance images of the aorta and develop normative data for the cross-sectional area of the entire thoracic aorta.
Magnetic resonance imaging was obtained serially over 3 years from 32 healthy individuals and 24 patients with aortopathy and a personal or family history of connective tissue disorder. Graph theory-based segmentation was used to determine the cross-sectional area for the thoracic aorta. Healthy individual data were used to construct a nomogram representing the maximum cross-sectional area 5th–95th percentile along the entire thoracic aorta. Aortic root diameters calculated from the cross-sectional area were compared to measured diameters from echocardiographic data. The cross-sectional area of the entire thoracic aorta in patients was compared to healthy individuals.
Calculated aortic root diameters correlated with measured diameters from echo data – correlation coefficient was 0.74–0.87. The cross-sectional area in patients was significantly greater in the aortic root, ascending aorta, and descending aorta compared to healthy individuals.
The presentation of the dimensional data for the entire thoracic aorta shows an important clinical tool for following patients with connective tissue disorders and aortopathy.
Over 400 office workers from the same unit of a manufacturing company in Stockholm County, Sweden, fell ill with gastroenteritis. A retrospective cohort study of office workers in the affected unit demonstrated that canteen visitors on one day had an increased risk of illness [risk ratio (RR) 27·1, 95% confidence interval (CI) 15·7–46·8] compared to non-visitors. A second study, investigating canteen visitors' consumption of particular food items, showed that both tomatoes from the salad buffet (RR 5·6, 95% CI 3·2–9·6) and hamburgers (RR 4·9, 95% CI 2·4–9·8) were the most likely vehicles of infection. Norovirus GI.3 (Desert Shield) was identified in stool samples from three office workers and from a food handler who prepared the tomatoes for the salad buffet and hamburger ingredients before vomiting at the workplace on 12 November. The outbreak could have been prevented if the food items prepared by the food handler some hours before vomiting had not been served.
Objective: The purpose of this study was to evaluate the
psychometric properties of the Herth Hope Index (HHI) in a representative
sample of the Norwegian population.
Methods: The HHI-N was administered to 4000 people randomly
selected from the Norwegian population. 1893 questionnaires were usable,
yielding a response rate of 48.5%.
Results: The internal consistency of the HHI-N, estimated by
Cronbach's alpha, was 0.81. Factor analysis resulted in a two-factor
solution, which explained 38% of the variance. The correlation between
hope and overall quality of life was 0.48 (p < 0.001), and
between hope and fatigue severity −0.30 (p < 0.001).
Significance of results: Further testing, especially with
regard to the dimensionality of the instrument, is recommended.
Objective: The aim of the present study was to evaluate
competence development in palliative treatment, nursing and care in
students (n = 25) undergoing a two-year postgraduate education
program in palliation at a university college in Norway.
Methods: A questionnaire was handed out on five occasions
during the education period.
Results: Results showed that the students rated their
competence level as between some competence and good competence before
entering the course. However, the competence level rose throughout the
course period, and at the end of their education most of the students
perceived themselves at a very good or extremely good competence level.
Significance of results: Statistically significant
differences in all questions measuring competence in palliation were found
on all occasions. Further studies are needed to confirm the effect of
education on students' perceived competence development and whether
it has a positive impact on clinical practice.
Background and objective: Isoflurane is a chiral volatile anaesthetic, routinely administered as racemate. It has a low metabolic rate and is mostly eliminated via respiration. In blood samples, S(+) enantiomers are found in greater proportion in the days immediately after administration of isoflurane racemate whereas the ratio in breath samples is unknown.
Methods: Breath and blood samples were drawn immediately after recovery and daily up to 19 days after operation from patients undergoing anaesthesia with isoflurane racemate. The percentage of isoflurane enantiomer was determined by gas chromatography mass spectrometry in blood and thermodesorption gas chromatography mass spectrometry in breath samples.
Results: In breath samples, there were significant differences in S(+) enantiomers at all time points compared to the racemate. During the early postoperative phase, the percentage of S(+) enantiomers were significantly enhanced whereas 5 days after surgery predominantly R(−) enantiomers (50.41%) were detected in the breath samples. Also in blood samples a statistical significant accumulation of the S(+) enantiomer was noted between days 1 and 5 compared to isoflurane racemate blood control. S(+) enantiomers were significantly higher in blood compared to breath samples and was most evident on the third day after surgery (51.43%).
Conclusions: During the first days after application of isoflurane racemate, the percentage of S(+) enantiomers are higher in breath and blood samples of patients. We suggest that resorbtion and/or redistribution of enantiomers are responsible for the different kinetics of isoflurane enantiomers.
Rough surface contact plasticity at microscale and nanoscale is of crucial importance in many new applications and technologies, such as nano-imprinting and nano-welding. This paper summarizes our recent progress in understanding contact plasticity from a multiscale point of view, and also presents our perspectives. We first discuss a contact model based on fractal roughness and continuum plasticity theory. Interestingly, our simple, elastic-plastic contact model of the Weierstrass-Archard type gives rise to many practical scaling relations of contact pressure, contact compliance etc. The usefulness of those predictions is discussed for experimental measurements of the thermal/electrical contact resistance. A material length scale can be introduced by a nonlocal plasticity theory, or implicitly by dislocation mechanics modeling. The recent work on micro-plasticity of surface steps gives a variety of surface yielding and hardening behaviors, depending on interface adhesion, roughness features and slip systems. As a consequence, a rough surface contact at mesoscale can lead to the formation of a boundary layer with sub-layer dislocation structures, which cannot be predicted by existing strain gradient plasticity theories. The micromechanical analysis of surface plasticity could serve as the connection between microscale bulk dislocation plasticity and nanoscale atomistic simulations.
Our recent progress in elevated temperature nanoindentation is reviewed, with an emphasis on the study of discrete events (i.e., pop-in phenomena) observed during nanoindentation. For crystalline materials the incipient plasticity problem is associated with the nucleation of dislocations, an effect which we show to be significantly temperature dependent. For metallic glasses it is the operation of individual shear bands beneath the indenter that gives rise to pop-in events; here we also show this to be a temperature dependent phenomenon. Approaches to extract the activation volume and energy of defects involved in plastic flow beneath the indenter are also briefly described.
In this study, the microstructural change of the surface of Si single crystal (Si(100)) after the scratching tests under very small loading forces was investigated. At first, line-scratching tests and scanning-scratching tests were carried out using an atomic force/friction force microscope (AFM/FFM). Next, cross-sectional TEM observations of the wear marks which were generated by the scratching tests were carried out. As a result of the TEM observations after the line-scratching tests, it was found that dislocations were observed in the area of less than 100nm thickness from the surface of the wear marks which were formed under the loading forces of more than 5μN. In the case of the loading forces of more than 20μN, an amorphous region was also observed just under the wear marks. As a result of the TEM observations after the scanning-scratching tests, it was found that the introduction of dislocations took place and no amorphous region appeared. It was also found that the several atomic layers at the top surface of the wear marks shifted in parallel to (100).
Based on the effects of residual surface stress on the unloading curves of indentation load-depth responses, an experimental scheme for determination of the residual stress by depth-sensing indentation is proposed. From the point that the elastic unloading portion of the load-depth curves can be expected to be unaffected by the residual stresses, the formula for evaluating surface stress by indentation is derived based on energy method. The proposed formula is verified by using FEM simulated indentation load-depth responses for different surface stress levels. The levels of surface stress evaluated by the proposed formula show a good agreement with the ones used as input parameters in FEM simulation.
Cortical bone is an anisotropic material, and its mechanical properties are determined by its composition as well as its microstructure. Mechanical properties of bone are a consequence of the proportions of, and the interactions between, mineral, collagen and water. Mid-shaft palmar cortical tissue from the equine third metacarpal bone is relatively dense and uniform with low porosity. The mainly primary osteons are aligned to within a few degrees of the long axis of the bone. Beams of compact cortical bone were prepared to examine effects of dehydration and embedding and to study contribution of collagen and mineral to nano-scale material properties. Five beams were tested: untreated (hydrated); 100% ethanol (dehydrated); or embedded in poly-methylmethacrylate (PMMA) for one normal, one decalcified, and one deproteinated bone sample. Elastic modulus was obtained by nanoindentation using spherical indenters, with the loading direction transverse  and longitudinal to the bone axis. By selectively removing water, mineral and organic components from the composite, insights into the ultrastructure of the tissue can be gained from the corresponding changes in the experimentally determined elastic moduli.
Instrumented indentation and micro-Raman spectroscopy were used to investigate the mechanical and structural properties of Bombyx mori silk films. Twelve different films were prepared from B. mori silk fibroin protein using a variety of post-deposition processing treatments (e.g. soaking in methanol, soaking in water, stretching, and/or enzymatic etching). The results show that different treatments lead to changes in both the conformation of the silk fibroin protein and the mechanical properties of the films.
Nanoscratching on GaAs (001) by a pyramidal diamond tip (Berkovitch) indenter has been carried on under different loads, scratching velocities and directions. Plastic deformation and fractures induced by scratching have been investigated by atomic force microscopy (AFM), and by scanning and transmission electron microscopy (SEM and TEM, respectively). Surface images revealed radial and surface tensile cracks. Focused ion beam (FIB) milling of the contact area revealed median and shear fracture distribution in the volume. The different cracks were characterized for various scratching conditions in terms of their direction of propagation, extension and frequencies. Plastic deformations have been characterized by vertical displacement of material. No purely ductile zone was observed, GaAs deformation occurred by fractures and plastic strain. Their preponderances are discussed in terms of material properties.
A new generation of sensors based on biologically inspired whisking action will help determine the presence and location of solid objects and fluid vortices similar to mechanisms used by whisker bearing animals such as rats and seals. By using nanoindentation, we demonstrate that mechanical properties are essentially uniform by cross section, but vary longitudinally from the whisker base (a 3.9 GPa elastic modulus) to the tip (a 3.1 GPa elastic modulus). Several recent studies show propagation of high frequency information through whiskers that are tuned by their physical properties. In order to fully understand and model these properties, this study demonstrates a more complex whisker structure than previously assumed.
A technique is described to measure the rotations of the crystal lattice in the deformed region around a nanoindent from volumes smaller than 3 × 10−5 μm3. To demonstrate this method, a copper crystal has been indented on its (001) face to depths of 500 and 1300 nm. Cross-sections of nanoindents were prepared for transmission electron microscopy by focused ion beam milling, and rotations were measured about the ,  and  axes using convergent beam electron diffraction.