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Background: Intoxicated patients injured in off road vehicle (ORV) crashes have higher rates of traumatic brain injury (TBI) and intensive care unit (ICU) admission, as well as prolonged ICU length of stay. This study evaluated the impact of alcohol intoxication on mortality among major TBI patients injured in off-road vehicle crashes. Methods: A retrospective analysis (2002-2014) of off-road vehicle injuries in Nova Scotia resulting in major TBI was performed. ORVs included ATVs, snowmobiles, and dirt bikes. A logistic regression model was constructed to test for in-hospital mortality and adjusted for age, Abbreviated Injury Scale (AIS) Head, Injury Severity Score, and blood alcohol concentration (BAC). Results: There were 176 drivers and passengers of off-road vehicles. Overall mortality was 28%. BAC testing was performed in 61% patients; 85% of pre-hospital deaths were BAC positive (mean BAC=31 ± 17.39 mmol/L) and 70% in-hospital deaths were BAC positive (mean BAC=26 ± 23.12 mmol/L). After adjusting for confounders, high injury severity and intoxication increased the likelihood of in-hospital mortality. Conclusions: These findings demonstrate that alcohol intoxication is a significant risk factor for mortality among off-road vehicle collisions; for every mmol/L change in BAC, there was a 10% increase in the chance of in-hospital mortality.
Online grocery shopping could improve access to healthy food, but it may not be equally accessible to all populations – especially those at higher risk for food insecurity. The current study aimed to compare the socio-demographic characteristics of families who ordered groceries online v. those who only shopped in-store.
We analysed enrollment survey and 44 weeks of individually linked grocery transaction data. We used univariate χ2 and t-tests and logistic regression to assess differences in socio-demographic characteristics between households that only shopped in-store and those that shopped online with curbside pickup (online only or online and in-store).
Two Maine supermarkets.
863 parents or caregivers of children under 18 years old enrolled in two fruit and vegetable incentive trials.
Participants had a total of 32 757 transactions. In univariate assessments, online shoppers had higher incomes (P < 0 0001), were less likely to participate in Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program (SNAP; P < 0 0001) and were more likely to be female (P = 0·04). Most online shoppers were 30–39 years old, and few were 50 years or older (P = 0·003). After controlling for age, gender, race/ethnicity, number of children, number of adults, income and SNAP participation, female primary shoppers (OR = 2·75, P = 0·003), number of children (OR = 1·27, P = 0·04) and income (OR = 3·91 for 186–300 % federal poverty line (FPL) and OR = 6·92 for >300 % FPL, P < 0·0001) were significantly associated with likelihood of shopping online.
In the current study of Maine families, low-income shoppers were significantly less likely to utilise online grocery ordering with curbside pickup. Future studies could focus on elucidating barriers and developing strategies to improve access.
This review assesses regenerative medicine of the upper aerodigestive tract during the first two decades of the twenty-first century, focusing on end-stage fibrosis and tissue loss in the upper airways, salivary system, oropharynx and tongue.
PubMed, Embase, Google Scholar, Cochrane Library, Medline and clinicaltrials.org were searched from 2000 to 2019. The keywords used were: bioengineering, regenerative medicine, tissue engineering, cell therapy, regenerative surgery, upper aerodigestive tract, pharynx, oropharynx, larynx, trachea, vocal cord, tongue and salivary glands. Original studies were subcategorised by anatomical region. Original human reports were further analysed. Articles on periodontology, ear, nose and maxillofacial disorders, and cancer immunotherapy were excluded.
Of 716 relevant publications, 471 were original studies. There were 18 human studies included, within which 8 reported airway replacements, 5 concerned vocal fold regeneration and 3 concerned salivary gland regeneration. Techniques included cell transplantation, injection of biofactors, bioscaffolding and bioengineered laryngeal structures.
Moderate experimental success was identified in the restoration of upper airway, vocal fold and salivary gland function. This review suggests that a shift in regenerative medicine research focus is required toward pathology with a higher disease burden.
The dendrite morphologies of the cast nickel-based superalloy CMSX-4® (CMSX-4® is registered trademarks of the Cannon-Muskegon Corporation) and the austenitic stainless steel HP microalloy have been obtained via an automated serial-sectioning process which allows three-dimensional (3D) microstructural characterization. The dendrite arm spacing, volume fraction of segregation, and fraction of porosity have been determined. This technique not only increases the depth, scope, and level of detailed microstructural characterization but also delivers microstructural data for modeling and simulation.
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.
Older adults with dementia are particularly vulnerable to adverse outcomes resulting from anticholinergic use. We aimed to: (i) Examine the anticholinergic burden of patients with dementia attending a Psychiatry of Later Life (PLL) service (ii) Examine concomitant prescription of acetylcholinesterase inhibitors (AChEIs) and anticholinergics and (iii) Compare the Anticholinergic Cognitive Burden (ACB) scale with a recently published composite list of anticholinergics.
Retrospective chart review of new referrals with a diagnosis of dementia (n = 66) seen by the PLL service, Tallaght University Hospital, Dublin, Ireland, over a consecutive period of 4 months.
The mean ACB score was 2.2 (range = 0–9, SD = 2.1). 37.9% (n = 25) had a clinically significant ACB score (>3) and 42.1% (n = 8) of those taking AChEIs had a clinically significant ACB score. A significantly greater number of medications with anticholinergic activity were identified using the composite list versus the traditional ACB scale (2.3 v.1.5, p = 0.001).
We demonstrated a significant anticholinergic burden amongst patients with dementia attending a specialist PLL service. There was no difference in anticholinergic burden between groups prescribed and not prescribed AChEIs, indicating that these medications are being prescribed without discontinuation of potentially inappropriate medications with anticholinergic activity. The true anticholinergic burden experienced by patients may be underestimated by the use of the ACB score alone, although the clinical significance of this finding is unclear. Calculation of true clinical anticholinergic burden load and its translation to a specific rating scale remains a challenge.
Introduction: Hypotension is known to be associated with increased mortality in severe traumatic brain injury (TBI) patients. Systolic blood pressure (SBP) of <90 mmHg is the threshold for hypotension in consensus TBI treatment guidelines; however, evidence suggests hypotension should be defined at higher levels for these patients. Our objective was to determine the influence of hypotension on mortality in TBI patients requiring ICU admission using different thresholds of SBP on arrival at the emergency department (ED). Methods: Retrospective cohort study of patients with severe TBI (Abbreviated Injury Scale Head score ≥3) admitted to ICU at the QEII Health Sciences Centre (Halifax, Canada) between 2002 and 2013. Patients were grouped by SBP on ED arrival ( <90 mmHg, <100 mmHg, <110 mmHg). We performed multiple logistic regression analysis with mortality as the dependent variable. Models were adjusted for confounders including age, gender, Injury Severity Score (ISS), injury mechanism, and trauma team activation (TTA). Results: A total of 1233 patients sustained a severe TBI and were admitted to the ICU during the study period. The mean age was 43.4 ± 23.9 years and most patients were male (919/1233; 74.5%). The most common mechanism of injury was motor vehicle collision (491/1233; 41.2%) followed by falls (427/1233; 35.8%). Mean length of stay in the ICU was 6.1 ± 6.4 days, and the overall mortality rate was 22.7%. SBP on arrival was available for 1182 patients. The <90 mmHg group had 4.6% (54/1182) of these patients; mean ISS was 20.6 ± 7.8 and mortality was 40.7% (22/54). The <100 mmHg had 9.3% (110/1182) of patients; mean ISS was 19.3 ± 7.9 and mortality was 34.5% (38/110). The <110 mmHg group had 16.8% (198/1182) of patients; mean ISS was 17.9 ± 8.0 and mortality was 28.8% (57/198). After adjusting for confounders, the association between hypotension and mortality was 2.22 (95% CI 1.19-4.16) using a <90 mmHg cutoff, 1.79 (95% CI 1.12-2.86) using a <100 mmHg cutoff, and 1.50 (95% CI 1.02-2.21) using a <110 mmHg cutoff. Conclusion: While we found that TBI patients with a SBP <90 mmHg were over 2 times more likely to die, patients with an SBP <110 mmHg on ED arrival were still 1.5 times more likely to die from their injuries compared to patients without hypotension. These results suggest that establishing a higher threshold for clinically meaningful hypotension in TBI patients is warranted.
During the 2009 influenza pandemic, a rapid assessment of disease severity was a challenge as a significant proportion of cases did not seek medical care; care-seeking behaviour changed and the proportion asymptomatic was unknown. A random-digit-dialling telephone survey was undertaken during the 2011/12 winter season in England and Wales to address the feasibility of answering these questions. A proportional quota sampling strategy was employed based on gender, age group, geographical location, employment status and level of education. Households were recruited pre-season and re-contacted immediately following peak seasonal influenza activity. The pre-peak survey was undertaken in October 2011 with 1061 individuals recruited and the post-peak telephone survey in March 2012. Eight hundred and thirty-four of the 1061 (78.6%) participants were successfully re-contacted. Their demographic characteristics compared well to national census data. In total, 8.4% of participants self-reported an influenza-like illness (ILI) in the previous 2 weeks, with 3.2% conforming to the World Health Organization (WHO) ILI case definition. In total, 29.6% of the cases reported consulting their general practitioner. 54.1% of the 1061 participants agreed to be re-contacted about providing biological samples. A population-based cohort was successfully recruited and followed up. Longitudinal survey methodology provides a practical tool to assess disease severity during future pandemics.
Significant increases in excess all-cause mortality, particularly in the elderly, were observed during the winter of 2014/15 in England. With influenza A(H3N2) the dominant circulating influenza A subtype, this paper determines the contribution of influenza to this excess controlling for weather. A standardised multivariable Poisson regression model was employed with weekly all-cause deaths the dependent variable for the period 2008–2015. Adjusting for extreme temperature, a total of 26 542 (95% CI 25 301–27 804) deaths in 65+ and 1942 (95% CI 1834–2052) in 15–64-year-olds were associated with influenza from week 40, 2014 to week 20, 2015. This is compatible with the circulation of influenza A(H3N2). It is the largest estimated number of influenza-related deaths in England since prior to 2008/09. The findings highlight the potential health impact of influenza and the important role of the annual influenza vaccination programme that is required to protect the population including the elderly, who are vulnerable to a severe outcome.
Introduction: Our emergency department (ED) sees a low volume of high acuity pediatric cases. A needs assessment revealed that 68% of our Emergency Physicians (EP) manage pediatric patients in less than 25% of their shifts. The same percentage of EPs as well as ED nurses indicated they were uncomfortable managing a critically unwell neonate. Thus, an interprofessional curriculum focused on pediatric emergencies for ED staff was developed. In-situ simulation education was chosen as the most appropriate method to consolidate each didactic block of curriculum, and uncover important system gaps. Methods: Needs assessment conducted, and emerging themes informed IPE curriculum objectives. A committee of experts in simulation, pediatric emergencies and nursing education designed a full-day, RCPSC accredited, interprofessional in-situ simulation program. Results: Progressive segmental strategy maximized learning outcomes. The initial phase (2 hrs) comprised an” early recognition of sepsis” seminar and 4 rotating skills stations (equipment familiarity, sedating the child, IV starts, and mixing IV medication). This deliberate, adaptive, customized practice was enhanced by expert facilitation at each station, directly engaging participants and providing real-time feedback. The second phase allowed interprofessional teams of MDs, RNs and Physician Assistants to apply knowledge gained from the didactic and skills stations to in-situ simulated emergencies. Each group participated in two pediatric emergency scenarios. Scenarios ran 20 minutes, followed by a 40 minute debrief. Each scenario had a trained debriefer and content expert. The day concluded with a final debrief, attended by all participants. Formalized checklists assessed participants knowledge translation during simulation exercises. Participants assessed facilitators and evaluated the simulation day and curriculum via anonymous feedback forms. Debriefing sessions were scribed and knowledge gaps and system errors were recorded. Results were distributed to ED leaders and responsibilities assigned to key stakeholders to ensure accountability and improvement in system errors. Results All participants reported the experience to be relevant and helpful in their learning. All participants requested more frequent simulation days. System gaps identified included: use of metric vs imperial measurements, non-compatible laryngoscope equipment, inadequate identification of team personnel. As a result, the above-mentioned equipment has been replaced, and we are developing resuscitation room ID stickers for all team roles. Conclusion: Simulation as a culmination to a didactic curriculum provides a safe environment to translate acquired knowledge, increasing ED staff comfort and familiarity with rare pediatric cases. Additionally, is an excellent tool to reveal system gaps and allow us to fill these gaps to improve departmental functioning and safety.
Introduction: BACKGOUND In the modern era of terrorism and senseless violence, it is essential that hospital staff have expertise in implementation of a mass casualty incident (MCI) plan. OBJECTIVES 1. To assess current gaps in implementation of an academic urban hospital code orange plan using live simulation and tabletop exercise. 2. To identify and educate front-line staff to champion a hospital-wide MCI plan. INNOVATION Historically, in order to limit resource utilization and impact on patient care, disaster response training of front-line staff involved tabletop exercises only. The tenets of experiential learning suggest that learner engagement through realistic active practice of skills achieves deeper uptake of new knowledge. We enhanced the traditional tabletop approach through novel use of live actor patients presenting to an academic, urban emergency department (ED) during a hospital-wide MCI simulation. Methods: To assess the current code orange plan, an interprofessional, committee comprising expert leaders in trauma, emergency preparedness, emergency medicine and simulation integrated tabletop and live simulation to stage a MCI based on a mock incident at a new subway station. ED staff, the trauma team and champions from medicine, surgery and critical care participated along with support departments such as Patient Flow, Patient Transport, Environmental Services and the Hospital Emergency Operations Centre. Ten live actor patients and eight virtual patients presented to the ED. The exercise occurred in situ in the ED. Other participating departments conducted tabletop exercises and received live actor patients. Results: CURRICULUM Staff decanted the ED and other participating units using their current knowledge of hospital code orange policy. Live and virtual patients were triaged and managed according to severity of injuries. Live actor patients were assessed, intervened and transported to their designated unit. Virtual patients were managed through verbal discussion with the simulation controllers. An ED debrief took place using a plus/delta approach followed by a hospital-wide debrief. Conclusion: CONCLUSION An interprofessional hospital-wide MCI simulation revealed important challenges such as communication, command and control and patient-tracking . The exercise ignited enthusiasm and commitment to longitudinal practice and improvement for identified gaps.
The discovery of the first electromagnetic counterpart to a gravitational wave signal has generated follow-up observations by over 50 facilities world-wide, ushering in the new era of multi-messenger astronomy. In this paper, we present follow-up observations of the gravitational wave event GW170817 and its electromagnetic counterpart SSS17a/DLT17ck (IAU label AT2017gfo) by 14 Australian telescopes and partner observatories as part of Australian-based and Australian-led research programs. We report early- to late-time multi-wavelength observations, including optical imaging and spectroscopy, mid-infrared imaging, radio imaging, and searches for fast radio bursts. Our optical spectra reveal that the transient source emission cooled from approximately 6 400 K to 2 100 K over a 7-d period and produced no significant optical emission lines. The spectral profiles, cooling rate, and photometric light curves are consistent with the expected outburst and subsequent processes of a binary neutron star merger. Star formation in the host galaxy probably ceased at least a Gyr ago, although there is evidence for a galaxy merger. Binary pulsars with short (100 Myr) decay times are therefore unlikely progenitors, but pulsars like PSR B1534+12 with its 2.7 Gyr coalescence time could produce such a merger. The displacement (~2.2 kpc) of the binary star system from the centre of the main galaxy is not unusual for stars in the host galaxy or stars originating in the merging galaxy, and therefore any constraints on the kick velocity imparted to the progenitor are poor.
This paper presents latest thinking from the Institute and Faculty of Actuaries’ Model Risk Working Party and follows on from their Phase I work, Model Risk: Daring to Open the Black Box. This is a more practical paper and presents the contributors’ experiences of model risk gained from a wide range of financial and non-financial organisations with suggestions for good practice and proven methods to reduce model risk. After a recap of the Phase I work, examples of model risk communication are given covering communication: to the Board; to the regulator; and to external stakeholders. We present a practical framework for model risk management and quantification with examples of the key actors, processes and cultural challenge. Lessons learned are then presented from other industries that make extensive use of models and include the weather forecasting, software and aerospace industries. Finally, a series of case studies in practical model risk management and mitigation are presented from the contributors’ own experiences covering primarily financial services.
This study aimed to determine prevalence of Ralstonia spp. in cystic fibrosis patients, look for any evidence of cross infection and to describe clinical outcomes for patients infected by Ralstonia spp. Prevalence of Ralstonia spp. was calculated annually from 2008 to 2016. Pulsed-field gel electrophoresis was performed on ⩾1 sample from patients with an isolation of Ralstonia spp. between 2008 and 2016. A prospective, longitudinal observational study of adult patients was performed with 12 months follow-up from recruitment. Prevalence of Ralstonia spp. rose from 0·6% in 2008 to 2·4% in 2016. In total 12 out of 14 (86%) patients with ⩾1 isolation of Ralstonia spp. developed chronic infection. A pair and a group of three unrelated patients with epidemiological connections shared strains of Ralstonia mannitolilytica. Lung function of Ralstonia spp. infected patients was moderately to severely impaired. Prevalence of Ralstonia spp. is low but increasing. The risk of a patient developing chronic Ralstonia spp. infection following first acquisition is high and cross-infection may be possible. Whether Ralstonia spp. infection causes increased pulmonary exacerbation frequency and lung function decline needs to be evaluated in larger prospective studies.
A phased introduction of routine influenza vaccination of healthy children was recommended in the UK in 2012, with the aim of protecting both vaccinated children and the wider population through reducing transmission. In the first year of the programme in 2013–2014, 4- to 11-year-olds were targeted in pilot areas across England. This study assesses if this was associated with school absenteeism, an important societal burden of influenza. During the spring 2014 term when influenza predominantly circulated, the proportion of absence sessions due to illness was compared between vaccination pilot and non-pilot areas for primary schools (to measure overall impact) and secondary schools (to measure indirect impact). A linear multilevel regression model was applied, adjusting for clustering within schools and potential school-level confounders, including deprivation, past absenteeism, and ethnicity. Low levels of influenza activity were reported in the community in 2013–2014. Primary schools in pilot areas had a significantly adjusted decrease in illness absenteeism of 0·05% relative to non-pilot schools; equivalent to an average of 4 days per school. In secondary schools, there was no significant indirect impact of being located in a pilot area on illness absenteeism. These insights can be used in conjunction with routine healthcare surveillance data to evaluate the full benefits of such a programme.
Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years.
The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1572) and non-students in the same age range (18–22 years; n = 4178), including non-students who recently left college without graduating (n = 702) based on surveys in 21 countries (four low/lower-middle income, five upper-middle-income, one lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioral and substance disorders were assessed with the Composite International Diagnostic Interview (CIDI).
One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders; 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders.
Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.
Background: Post concussion syndrome (PCS) can affect up to 30% of patients with concussion. Biomarkers of this condition would be beneficial for diagnosis and management. We hypothesized that eye tracking parameters would correlate with microstructural changes of white matter integrity, as measured by diffusion tensor imaging (DTI), in patients with PCS. Methods: Sixty patients with PCS and at least 2 concussions participated in our prospective study. Attention and executive function were tested using Visual Attention Scanning Technology (VAST). In a matching task, the normalized number of visits to master image before making the first selection is used as a surrogate of working memory. We related performance on VAST to white matter integrity using Tract-Based Spatial Statistics of diffusion tensor imaging data. Results: 60 participants (mean age 34.3 years, SD 13.8) had a mean of 4 concussions. There were negative correlations between fractional anisotropy (FA) of the genu, body, and splenium of the corpus callosum and normalized number of visits to master image before first selection (r=-0.432, p=0.001; r=-0.504, p<0.001; and r=-0.388, p=0.002; respectively). A negative correlation was also seen between right cingulum FA and the global processing index (r=-0.349, p=0.006). Conclusions: Impaired performance on eye tracking measures of attention and executive function may reflect alterations in white matter tracts.
Introduction: Traumatic brain injury (TBI) is a leading cause of death and disability in Nova Scotia. TBI occurs in approximately 50% of major trauma seen annually in the province. The purpose of this study was to describe the characteristics and patterns of major TBI seen in Nova Scotia over a 12-year period. Methods: This was a retrospective case series. Data were obtained from the Nova Scotia Trauma Registry for all patients presenting with major TBI (abbreviated injury score [AIS] head ≥3) between 2002 and 2013. Injury rates were calculated on the basis of 100,000 population (all ages) using population estimates from Statistics Canada. Results: Overall, 4152 major TBI patients were seen in Nova Scotia hospitals during the study period. Mean age of TBI patients was 51±25 years; 73% were male. The majority of injuries were the result of blunt trauma (93%), with relatively few major TBIs resulting from penetrating trauma (7%). The most common mechanisms of injury were falls (44%) and motor vehicle crashes (27%). Analysis of census-based subpopulations of the province showed that injury rates varied significantly among counties (from 25 to 63 per 100,000 population). We observed an increase in the number of major TBI patients over twelve years. Conclusion: Our findings suggest significant regional variation in major TBI rates in Nova Scotia. There are ongoing needs for prevention and intervention efforts that focus on unintentional falls and motor vehicle crashes, especially in older adults. These results also suggest that geographically targeted efforts may be warranted.
Introduction: Although alcohol use increases the risk of experiencing a traumatic brain injury (TBI), it remains unclear whether outcomes in alcohol-impaired patients are different from those of unimpaired patients. The objective of this study was to evaluate the effect of alcohol on length of stay (LOS) and mortality in patients with major TBI. Methods: Using data collected from the Nova Scotia Trauma Registry, we performed a retrospective analysis of all patients with major TBI (defined as having an abbreviated injury score (AIS) head ≥3) seen in Nova Scotia hospitals between 2002 and 2013. Patients were compared by blood alcohol concentration (BAC) at time of injury: negative (0-1.9 mmol/L), low (2-21 mmol/L), and moderate/high (≥22 mmol/L). A logistic regression model was constructed to test for outcomes and adjusted for the effects of age, gender, location, injury severity score (ISS), and BAC level. Results: In a twelve-year period, there were 4152 major TBI patients in Nova Scotia. Alcohol testing was performed in 43% of cases (80% male, mean age 44±20 years), with 48% having a positive BAC. Mean acute LOS was similar for all three BAC groups. Increasing age (odds ratio [OR]=1.01; p<0.001), high ISS (OR=4.92; p<0.001), injuries occurring outside of Halifax Regional Municipality (OR=1.72; p<0.001), and having a lower BAC level (OR = 0.99; p<0.001) independently predicted mortality. Conclusion: Our findings suggest that low BAC levels are associated with increased mortality in major TBI patients. Further study is warranted to elucidate alcohol’s mechanism in TBI outcomes.