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Alteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals.
Methods
Red Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017.
Results
A total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60–103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22–42 minutes) (p < 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period.
Conclusion
Community hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.
The canon law dictum that ‘dubius in fide infidelis est’ offers a seemingly definitive statement on the place of doubt and uncertainty in medieval Catholicism. Yet where Catholic teaching was open to question, doubt was inseparable from faith, not merely as its obverse but as part of the process of achieving faithfulness – the trajectory outlined by Abelard in the twelfth century. The challenge for the Church was not that doubters lacked faith, but that having tested their doubts they might end up with the wrong faith: doubt preceded assurance, one way or the other. That problem is addressed in this essay by a broad examination of the ties between faith and doubt across the late Middle Ages (from the twelfth to the sixteenth centuries), arguing that uncertainty and doubt were almost unavoidable in medieval Catholicism. As the starting points in a process which could lead to heresy and despair, they also had a positive role in developing and securing orthodox faith.
The WISSARD (Whillans Ice Stream Subglacial Access Research Drilling) traversable hot-water drill system was designed to create various-diameter ice boreholes to a depth of >800 m, with most major components being controllable from a single user interface. The drill control system operates four low-pressure pumps for water generation and circulation, two hot-water generation units containing a total of six diesel burner modules with integrated high-pressure pumps, three winches (one with independent level-wind motor), a four-motor linear traction drive, and a large number of analog and digital sensors to monitor system performance and cleanliness. Due to development time constraints the control system design focused on utilizing commercial off-the-shelf components, while being highly modular, easily expandable and rapidly deployable. Additional emphasis was placed on providing redundant manual operator controls and maintaining a low degree of system automation to avoid dependence on software control loops for first-season deployment. The result of this design paradigm was a control system that was taken from concept to full operation in <6 months, successfully performing in the field without insurmountable problems.
When infants are at risk of being born at a very premature gestation (22–25 weeks), parents face important life-support decisions because of the high mortality for such infants. Concurrently, providers are challenged with providing parents a supportive environment within which to make these decisions. Practice guidelines for medical care of these infants and the principles of perinatal palliative care for families can be resources for providers, but there is limited research to bridge these medical and humanistic approaches to infant and family care. The purpose of this article is to describe how parents at risk of delivering their infant prior to 26 weeks gestation interpreted the quality of their interpersonal interactions with healthcare providers.
Methods:
Directed content analysis was employed to perform secondary analysis of data from 54 parents (40 mothers and 14 fathers) from the previously coded theme “Quality of Interactions.” These categorized data described parents' encounters, expectations, and experiences of interactions that occurred prenatally with care providers. For this analysis, Swanson's theory of caring was selected to guide analysis and to delineate parents' descriptions of caring and uncaring interactions.
Results:
Parents' expectations for caring included: (a) respecting parents and believing in their capacity to make the best decisions for their family (maintaining belief); (b) understanding parents' experiences and their continued need to protect their infant (knowing); (c) physically and emotionally engaging with the parents (being with); (d) providing unbiased information describing all possibilities (enabling); and (e) helping parents navigate the system and creating a therapeutic environment for them in which to make decisions (doing for).
Significance of Results:
Understanding parents' prenatal caring expectations through Swanson's theory gives deeper insights, aligning their expectations with the palliative care movement.
Fifty-two Australian couples who had experienced the death of at least one member of a multiple birth (twin or higher order), with at least one survivor of that birth, were interviewed about their experiences at the time of the death, and since. This study compared parents' coping after the twins' deaths using the Beck Depression Inventory II, Perinatal Grief Scale, and unstructured interviews with some structured queries. Parents provided information on the influence of family, community and medical staff. According to retrospective reports, mothers experienced significantly more depression and grief than fathers at the time of loss. Both parents found the death of their twins grievous, but fathers, unlike mothers, were not encouraged to express their emotions. Although parents generally agreed about what helped them cope, fathers believed that they should be able to cope regardless of their grief. The strength of parents' spiritual beliefs had increased significantly since their loss, and there was some evidence that depressed and grieving mothers turned to spiritual support. Parents whose children died earlier reported levels of depression similar to those reported by parents whose children died later. To date, this is the largest study of grief in couples who have experienced the death of a twin and who have a surviving twin or higher order multiple.
This paper reports the identification of some fragments of an inscription now preserved in a window at All Saints, North Street, York, as the remnants of a statement of indulgences to reward prayers before a painted image in a window. As far as is known, this is the only surviving glass to demonstrate the proclamation of indulgences in medieval English church windows, although antiquarian evidence of at least one other is recorded.
from
SECTION TWO
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ANALGESIA FOR THE EMERGENCY PATIENT
By
David E. Fosnocht, Division of Emergency Medicine, University of Utah, 30 North 1900 East Rm AC218, Salt Lake City, UT 84132, Email: davefosnocht@comcast.net,
Robert L. Stephen, Division of Emergency Medicine, University of Utah, 30 North 1900 East Rm AC218, Salt Lake City, UT 84132,
Eric R. Swanson, Division of Emergency Medicine, University of Utah, 30 North 1900 East Rm AC218, Salt Lake City, UT 84132
The concepts of patient expectation and desired outcomes for patients with acute pain in the emergency department (ED) are surprisingly simple. Most patients present to the ED with pain. Patients with pain expect pain relief. The obvious desired outcome is relief of pain. Our ability to move from this simplistic ideal to scientific, evidence-based solutions that facilitate patient expectations, at the same time defining reasonable outcomes for pain relief, is much more complex. This complexity accounts for a great deal of the continued problem of inadequate pain management in the ED.
CLINICAL ASSESSMENT
The clinical assessment of pain is one of the more challenging aspects of defining patient expectations and outcomes for pain relief. Pain assessment methods have various advantages and disadvantages in ease of use, scientific validity, and practicality for use with different patient populations. Unfortunately each pain assessment process suffers from the common question of “What does a pain score of ‘X’ mean?”
The lack of clinician confidence in pain measurement translates to even more confusion in trying to use these scales to define pain relief outcomes. The task of defining and meeting individual patient expectations for pain relief is similarly complex. At the present time there is no widely accepted assessment tool available that defines patient expectations for pain relief or delineates appropriate outcomes for pain relief.
Rather than starting with traits and speculating whether selective forces drove evolution in past environments, we propose starting with a candidate gene associated with a trait and testing first for patterns of selection at the DNA level. This can provide limitations on the number of traits to be evaluated subsequently by adaptationism as described by Andrews et al.
There is growing need for accurate information regarding the bioavailability of carotenoids, both with respect to carotenoids per se and to the vitamin A value of provitamin A carotenoids in foods or supplement preparations. Little quantitative information is currently available, owing primarily to the lack of adequate methods to assess carotenoid bioavailability. Methods applied to xenobiotic drugs are in most cases not useful for carotenoids, many of which circulate in appreciable quantities in human plasma. Reported ranges of carotenoid bioavailability (% dose absorbed) range from 1–99, and variability is generally high both within and between treatments. With the current methods, relative bioavailability is more readily assessed than absolute bioavailability. The most commonly applied methods include measuring the increase in plasma carotenoid concentration following chronic intervention, and use of postprandial chylomicron (PPC) carotenoid or retinyl ester response following a single dose of carotenoid. The advantages and limitations of these approaches, together with examples of each, are discussed. A new PPC approach utilizing extrinsic-stable-isotope-labelled vitamin A (2H4-labelled retinyl acetate) is under development in our laboratory, and examples of its application are presented. The currently available data suggest that oil solutions of carotenoids are more bioavailable than those from food matrices, and heating can improve the bioavailability of carotenoids from some food products. Increased availability of labelled carotenoids and retinoids should aid the development of reliable methods of carotenoid bioavailability assessment. Such data are needed for dietary recommendations, supplement formulation, and design of intervention strategies involving carotenoids.