bluuebunny/crossref_metadata_2025 huggingface dataset:
Coal’s Last Chance
Authors: Mintz Testa Bridget
Published: July 2018

This article presents an overview of clean coal technologies that promise to produce electricity with fewer emissions. The 600 MW John W. Turk Jr. power plant built by American Electric Power near Fulton is the first “ultra-supercritical” electric-generating clean coal unit in the U.S. Turk’s efficiency is 39 percent to 40 percent, versus about 35 percent for conventional plants. Turk burns roughly 11 percent less coal than a subcritical plant would need to produce the same amount of power. Less coal means fewer emissions, and what’s left – aside from carbon dioxide – is further reduced by the state-of-the-art emission control technologies. Another clean coal technology that has seen wider adoption is the circulating fluidized bed combustion (CFBC) technology. One of CFBS’ greatest advantages is that since the furnaces burn at low temperatures, it can use very low-quality fuel, such as waste piles left over from mining and even chicken litter.
An Industry of R&D
Authors: Hutchinson Harry
Published: July 2018

This article discusses how Singapore is amassing a brain trust to compensate for resources that nature didn’t provide to it. CREATE or “Campus for Research Excellence and Technological Enterprise” is one of the most ambitious projects of Singapore’s National Research Foundation. CREATE seeks to unite Singapore’s universities with world-class research institutions to study issues ranging from urban planning to medical treatment. The organization has partnerships with 10 foreign universities, including Massachusetts Institute of Technology, the Technical University of Munich, Cambridge University, and the Swiss Federal Institute of Technology. There are five research groups in CREATE’s partnership with Massachusetts Institute of Technology. The research areas are infectious diseases, environmental sensing and modeling, biosystems and micromechanics, urban mobility, and low-energy electronic systems. The University of California, Berkeley, has two research programs with CREATE. One aims to improve the efficiency of buildings in the tropics, and the other is working on raising the electrical output of photovoltaic devices.
Keeping Ground Robots on the Move Through Battery & Mission Management
Authors: Ersal Tulga , Kim Youngki , Broderick John , Guo Tianyou , Sadrpour Amir , Stefanopoulou Anna , Siegel Jason , Tilbury Dawn , Atkins Ella , Peng Huei , Jin Jionghua (Judy) , Galip Ulsoy A.
Published: July 2018

This article summarizes a recent collaboration at the University of Michigan's Automotive Research Center that considered best use of batteries in ground robots from several perspectives, such as planning the mission and tracking energy during its execution. The paper illustrates the four main subproblems addressed in this collaboration. Specifically, an area coverage problem is considered using a tracked robot, and the development of an energy-efficient coverage plan is first addressed. Track-terrain interaction is then modeled to better predict the power consumption due to locomotion on different types of terrains. Using a coverage problem as an example, this article shows that managing the battery and the mission properly is critical for ground robots to successfully complete given tasks and make maximum use of their capabilities. To this end, the problems of energy-efficient coverage planning, predicting the locomotion power requirements, controlling the battery power with thermal and electrical constraints, and tracking the mission energy requirements online based on a combination of prior knowledge and real-time data are all tightly connected to each other.
Upper Extremity Exoskeleton for Robot-Aided Rehabilitation
Authors: Sergi Fabrizio , Blank Amy , O’Malley Marcia
Published: July 2018

This article discusses development of upper extremity exoskeleton devices for robot-aided rehabilitation. Neurological injuries, including stroke and spinal cord injury, typically result in significant motor impairments. These impairments negatively impact an individual’s movement coordination, in turn affecting their ability to function independently. Exoskeleton type devices are now being developed to isolate the motion of individual joints. These devices tend to have higher complexity and reduced range of motion as compared to endpoint manipulators, but they target more selectively the desired joint(s), and they enable more precise data collection about the motion of the patient's limb. Recent designs have focused on systems that match the full range of motion of the targeted joints, aiming towards actuated systems that have both high torque output, to assist patients with muscle tone, and low intrinsic impedance, to minimally perturb independent arm movements. Satisfying all of these requirements while simultaneously maintaining a high priority on patient safety is still an active area of research.
Pitfalls of Conducting and Interpreting Estimates of Energy Availability in Free-Living Athletes
Authors: Burke Louise M. , Lundy Bronwen , Fahrenholtz Ida L. , Melin Anna K.
Published: July 2018

The human body requires energy for numerous functions including, growth, thermogenesis, reproduction, cellular maintenance, and movement. In sports nutrition, energy availability (EA) is defined as the energy available to support these basic physiological functions and good health once the energy cost of exercise is deducted from energy intake (EI), relative to an athlete’s fat-free mass (FFM). Low EA provides a unifying theory to link numerous disorders seen in both female and male athletes, described by the syndrome Relative Energy Deficiency in Sport, and related to restricted energy intake, excessive exercise or a combination of both. These outcomes are incurred in different dose–response patterns relative to the reduction in EA below a “healthy” level of ∼45 kcal·kg FFM−1·day−1. Although EA estimates are being used to guide and monitor athletic practices, as well as support a diagnosis of Relative Energy Deficiency in Sport, problems associated with the measurement and interpretation of EA in the field should be explored. These include the lack of a universal protocol for the calculation of EA, the resources needed to achieve estimates of each of the components of the equation, and the residual errors in these estimates. The lack of a clear definition of the value for EA that is considered “low” reflects problems around its measurement, as well as differences between individuals and individual components of “normal”/“healthy” function. Finally, further investigation of nutrition and exercise behavior including within- and between-day energy spread and dietary characteristics is warranted since it may directly contribute to low EA or its secondary problems.
Patient-ventilator asynchrony in preterm infants on nasal intermittent positive pressure ventilation
Authors: de Waal Cornelia G , van Leuteren Ruud W , de Jongh Frans H , van Kaam Anton H , Hutten Gerard J
Published: July 2018

Objective

To describe the incidence of patient-ventilator asynchrony and different types of asynchrony in preterm infants treated with non-synchronised nasal intermittent positive pressure ventilation (nIPPV).

Design

An observational study was conducted including preterm infants born with a gestational age (GA) less than 32 weeks treated with non-synchronised nIPPV. During 1 hour, spontaneous breathing was measured with transcutaneous electromyography of the diaphragm simultaneous with ventilator inflations. An asynchrony index (AI), a percentage of asynchronous breaths, was calculated and the incidence of different types of inspiratory and expiratory asynchrony were reported.

Results

Twenty-one preterm infants with a mean GA of 26.0±1.2 weeks were included in the study. The mean inspiratory AI was 68.3%±4.7% and the mean expiratory AI was 67.1%±7.3%. Out of 5044 comparisons of spontaneous inspirations and mechanical inflations, 45.3% of the mechanical inflations occurred late, 23.3% of the mechanical inflations were early and 31.4% of the mechanical inflation were synchronous. 40.3% of 5127 expiratory comparisons showed an early termination of ventilator inflations, 26.7% of the mechanical inflations terminated late and 33.0% mechanical inflations terminated in synchrony with a spontaneous expiration. In addition, 1380 spontaneous breaths were unsupported and 611 extra mechanical inflations were delivered.

Conclusion

Non-synchronised nIPPV results in high patient-ventilator asynchrony in preterm infants during both the inspiratory and expiratory phase of the breathing cycle. New synchronisation techniques are urgently needed and should address both inspiratory and expiratory asynchrony.
Does a multidisciplinary approach have a beneficial effect on the development of a structured patient handover process between acute surgical wards in one of Scotland’s largest teaching hospitals?
Authors: Ramsay Neil , Maresca Gianluca , Tully Vicki , Campbell Kevin
Published: July 2018

Background

Effective handover is key in preventing harm.1In the Acute Surgical Receiving Unit of Ninewells Hospital, Dundee, large numbers of patients are transferred daily. However, lack of medical handover during transfer means important tasks are missed. Our aim was to understand and reflect on the current system and test changes to improve medical handover.

Aim

Our aim was to ensure that 95% of patients being transferred from the Acute Surgical Receiving Unit receive a basic medical handover within 2 months.

Methods

Initially, we collated issues that were missed when patients were transferred. These data coupled with questionnaire data from members of the team fed into the creation of a handover tool. We proposed to link our tool with the nursing handover, hence creating one unified handover tool. We completed six full Plan-Do-Study-Act (PDSA) cycles (two on communication to aide handover and four on the tool itself) to assess and develop our tool.

Results

By our final PDSA cycle, 84% (33/39) of the patients had a handover, meaning no tasks were missed during transfer. After 4 months, 9 out of 10 staff felt that the introduction of the handover sheet made the handover process smoother and 8 out of 10 felt that the handover sheet improved patient safety and quality of care.

Conclusions

Improving handover can be challenging. However, we have shown that a relatively simple intervention can help promote better practice. Challenges are still present as uptake was only 84%, so work still has to be done to improve this. A wider cultural change involving communication and education would be required to implement this tool more widely.
Education and coaching to optimise blood culture volumes: continuous quality improvement in microbiology
Authors: Libertin Claudia R , Sacco Keith A , Peterson Joy H
Published: July 2018

The blood volume cultured in the detection of bacteraemia is a major variable in treating patients with systemic inflammatory response syndrome. The fact that drawing optimal volumes (8–10 mL) of blood for culture increases the sensitivity of the method is well established. This study aimed to optimise the mean blood volumes (mBVs) to that recommended level in a small rural hospital by implementing a continuous quality improvement programme in clinical microbiology. The education of phlebotomists, followed by monthly feedback and coaching sessions, can influence the blood volume drawn by phlebotomists and improve the sensitivity of blood cultures. Statistically significant increase (p<0.001) in both mBVs and median blood culture volumes occurred within 5 months compared with the baseline values obtained in the preceding 10 months. This quality improvement was sustained over 1 year. The mBVs inoculated into aerobic culture bottles met the manufacturer’s instructions of a fill volume of 8 to 10 mL of blood per bottle and optimised the yield of isolation of organisms from blood cultures.
Effectiveness of a submassive pulmonary embolism protocol to standardise patient evaluation and treatment
Authors: Galanos Kelly , Jaeger Cassie , Coakley Kevin , White Peter , Griffen David
Published: July 2018

Treatment recommendations for submassive pulmonary embolus (SMPE), defined as pulmonary embolus (PE) resulting in right ventricular dysfunction and/or myocardial necrosis, vary. The objective of this study was to develop an investigative protocol at our tertiary care hospital to standardise the approach to patients with SMPE and to evaluate the effect of the protocol on process measures including consultation with cardiology and critical care physicians and time to echocardiogram and treatment. Triggered by right ventricle/left ventricle ratios >0.9, the protocol standardised ancillary studies and immediate consultation with critical care and cardiology. Post-protocol implementation, the percent of patients with SMPE evaluated by critical care specialists increased from 26% (19/74) to 93% (41/44) (p<0.001) and cardiology consultations increased from 35% (26/74) to 89% (39/44) (p<0.001). Patient arrival to echocardiogram was reduced from 15 hours to 5 hours post-protocol implementation. In addition, average time to anticoagulation was reduced from greater than 7 hours to 3 hours 27 min post-protocol implementation. The protocol has helped to identify patients with SMPE and standardise the care they receive after diagnosis.
Implementing a non-steroidal anti-inflammatory drugs communication bundle in remote and rural pharmacies and dispensing practices
Authors: Morrison Clare , Beauchamp Tracy , MacDonald Helen , Beattie Michelle
Published: July 2018

Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with more emergency hospital admissions due to adverse drug reactions than any other class of medicine. One way to tackle this is to ensure that patients understand how to take their NSAIDs in the safest way possible. The aim of this project was to ensure that key safety information is given to every patient, every time an NSAID is sold or dispensed. The project started as part of the Scottish Patient Safety Programme’s Pharmacy in Primary Care Collaborative. An NSAIDs bundle was developed, tested and implemented using the Model for Improvement as a framework, including multiple Plan, Do, Study, Act cycles. The bundle, and associated improvement package, was developed during phase I of the project and tested by seven teams (five pharmacies and two dispensing practices). Phase II tested the spread of the defined improvement package across an additional five community pharmacies and eight dispensing general practitioner practices. The project has resulted in the development of a simple package to improve communication with patients about NSAIDs, which should enable patients to take NSAIDs safely. Three key safety messages were developed, typical for a care bundle approach, and simple tools were employed to ensure every patient received these three key messages every time. The project aim of 95% compliance with the NSAIDs bundle within the seven initial sites by December 2015 was achieved (when an exclusion was applied). The spread of the defined improvement package to a further 13 sites was achieved by December 2016. By December 2017, all 81 community pharmacies in National Health Service (NHS) Highland had agreed to implement the NSAIDs bundle. In June 2018, a national NSAIDs bundle, based on the NHS Highland work, was introduced in community pharmacies across Scotland. We also believe that the approach could be replicated for other high-risk medicines.
Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors
Authors: Singh Aminder , Adams Angela , Dudley Bethany , Davison Eliza , Jones Lauren , Wales Lucy
Published: July 2018

High-quality perioperative diabetes care is essential to improve surgical outcomes for patients with diabetes. Inadequate perioperative diabetes care is associated with increased wound complications, higher mortality rates and increased length of hospital stay. Despite national guidelines, surgical wards remain a high-risk area for poor diabetes care. An initial baseline audit in 2014 of vascular patients with diabetes undergoing major lower limb amputation identified poor glycaemic control in 90% of patients, with high rates of hypoglycaemia and insulin management errors in 75%. Less than 15% of patients received specialist diabetes input and 20% required third-party assistance for hypoglycaemia. This quality improvement project aimed to reduce hypoglycaemia, insulin management errors and patient harm events by 50% in vascular surgery patients over a 3-year period. Key interventions over three successive Plan, Do, Study, Act cycles included educational and guideline initiatives (2015), establishing a diabetes in-reach service (2016) and implementing a whiteboard sugar cube alert system for poor glycaemic control (2017). The final introduction of the whiteboard sugar cube alert system delivered the greatest impact in reducing hypoglycaemia rates by more than 50%, insulin management errors by 70% and patient harm events by 75%.
Impact of straight to test pathways on time to diagnosis in oesophageal and gastric cancer
Authors: Jones James Andrew , Catton James , Howard Glen , Leeder Paul , Brewer Lesley , Hatton James , Shaw Dominick E
Published: July 2018

Background

Cancer survival in the UK has doubled in the last 40 years; however, 1-year and 5-year survival rates are still lower than other countries. One cause may be a delay between referral into secondary care and subsequent investigation. We set out to evaluate the impact of a straight to test pathway (STTP) on time to diagnosis for upper gastrointestinal (UGI) cancer.

Methods

Six hospital Trusts across the East Midlands Clinical Network introduced a STTP enabling general practitioners to refer patients with suspected UGI cancer (oesophageal/gastric) for immediate investigation, without the need to see a hospital specialist first. Data were collected for all patients referred between 2013 and 2015 with suspected UGI cancer and stratified by STTP or traditional referral pathway. Overall time from referral to diagnosis was compared. Data from two Trusts who did not implement STTP acted as control.

Results

340 patients followed the STTP pathway and 495 followed the traditional route. STTP saved a mean of 7 days from referral to treatment (with a 95% CI of 3 to 11 days, p<0.008) and a mean of 16 days from referral to diagnosis, when compared with a traditional referral pathway. The number of diagnostic tests performed using STTP or traditional referral pathways were similar.

Conclusion

A STTP is associated with an overall reduction of 1 week from referral to treatment for UGI cancer. The approach is feasible and did not require more resource. Larger studies are required to assess whether this time saving translates into improved cancer outcomes.
Duration of corticosteroid use in chronic obstructive pulmonary disease exacerbations: improving prescribing practices on clinical teaching units with peer-to-peer teaching
Authors: Matte Catherine , Hoang Johnston , Jayaraman Dev , Green Laurence , Morin Suzanne N
Published: July 2018

Introduction

The most recent Global Initiative for Chronic Obstructive Lung Disease consensus recommends a 5-day course of corticosteroid (CS) therapy for acute chronic obstructive pulmonary disease exacerbations (ACOPDE). As inappropriate use of CS therapy is associated with adverse events, we implemented a peer-to-peer education intervention to improve adherence to guidelines for patients with ACOPDE admitted to a medical clinical teaching unit at a tertiary care university centre.

Methods

Our study was a before–after design study with a concurrent control of a 15 min peer-to-peer educational intervention targeting medical residents at the beginning of a 4-week rotation for 12 consecutive months. Another medical teaching unit within the same university network, but at a different site, served as a concurrent control. The primary outcome was the proportion of patients who received appropriate duration of CS therapy (5 days) for ACOPDE during the intervention period as compared with the 12-month preintervention period at the intervention and control hospitals.

Results

Following the intervention, there was an increase in the proportion of patients receiving appropriate duration of CS therapy (34.2% to 51.3%, p=0.02) at the intervention hospital and no significant difference at the control hospital (22.8% to 34.1%, p=0.15). This effect was maintained at the intervention hospital 3 months postintervention period.

Conclusion

A short peer-to-peer educational intervention targeting medical residents on a clinical teaching unit improved adherence to appropriate duration of CS therapy for ACOPDE.
Comparative performance reports in anaesthesia: impact on clinical outcomes and acceptability to clinicians
Authors: Collyer Thomas , Robertson Martyn , Lawton Thomas , Rothwell Alice
Published: July 2018

In anaesthesia, the use of comparative performance reports, their impact on patient care and their acceptability is yet to be fully clarified. Since April 2010, postoperative data on theatre cases in our trust have been analysed and individual comparative performance reports distributed to anaesthetists. Our primary aim was to investigate whether this process was associated with improvement in overall patient care. A short survey was used to assess our secondary aim, the usefulness and acceptability of the process. There were significant improvements in the odds of all outcomes other than vomiting: 39% improvement in hypothermia (p<0.001); 9.9% improvement in severe pain (p<0.001%); 9.6% improvement in moderate pain (p<0.001); 5.3% improvement in percentage pain free (p=0.04); 9.7% improvement in nausea (p=0.02); 30% improvement in unexpected admissions (p=0.001). 100% of consultant respondents agreed that performance reports prompted reflective practice and that this process had the potential to improve patient care. The provision of comparative performance reports was thus associated with an improvement in outcomes while remaining acceptable to the anaesthetists involved.
Do ward round stickers improve surgical ward round? A quality improvement project in a high-volume general surgery department
Authors: Ng Jimmy , Abdelhadi Ahmed , Waterland Peter , Swallow Jonathan , Nicol Deborah , Pandey Steve , Zilvetti Miguel , Karim Ahmed
Published: July 2018

Introduction

Increasing pressure and limitations on the NHS necessitate simple and effective ways for maintaining standards of patient care. This quality improvement project aims to design and implement user-friendly and clear ward round stickers as an adjunct to surgical ward rounds to evidence standardised care.

Project design and strategy

Baseline performance was measured against the recommended standards by the Royal College of Physicians, General Medical Council and a study performed at the Imperial College London. A total of 16 items were studied. All members of staff in surgery department were informed that an audit on ward round entries would be implemented but exact dates and times were not revealed. In the first cycle, ward round sticker was implemented and results collected across three random days for use and non-use of sticker. Feedback was collected through the use of questionnaires. In the second cycle, the ward round sticker was redesigned based on feedback and results collected for use and non-use of sticker.

Results

Baseline performance noted in 109 ward round entries showed that checking of drug chart, intravenous fluid chart, analgesia, antiemetic, enoxaparin, thromboembolic deterrents ranged from 0% to 6%. With the introduction of ward round stickers in both cycles, there was noticeable improvement from baseline in all items; in ward round entries where stickers were not used, performance was similar to baseline.

Conclusion

This quality improvement project showed that the use of stickers as an adjunct to surgical ward round is a simple and effective way of evidencing good practice against recommended standards. Constant efforts need to be made to promote compliance and sustainability. Commitment from all levels of staff are paramount in ensuring standardised patient care without overlooking basic aspects.
Connecting perspectives on quality and safety: patient-level linkage of incident, adverse event and complaint data
Authors: de Vos Marit S , Hamming Jaap F , Chua-Hendriks Jolanda J C , Marang-van de Mheen Perla J
Published: July 2018

Background and objective

Incident, adverse event (AE) and complaint data are typically used separately, but may be related at the patient level with one event triggering a cascade of events, ultimately resulting in a complaint. This study examined relations between incidents, AEs and complaints that co-occurred in admissions.

Methods

Independently and routinely collected incident, AE and complaint data were retrospectively linked for surgical admissions in an academic centre (2008–2014). Two investigators reviewed whether incidents/AEs in admissions were clinically related and in what sequence (incident preceding vs following AE). Likelihood of occurrence of AEs and AE cascades (ie, ≥3 AEs) was studied using logistic regression analyses.

Results

Complaints were filed for 33 (0.1%) of 26 383 admissions. Complaints filed by patients with incidents and/or AEs (n=13) mostly addressed quality/safety problems, whereas other complaints mostly addressed relationship problems. Incidents and AEs co-occurred in 730 (2.8%) admissions, which seemed clinically related in 34% of these cases. Incidents with related AEs preceded as well as followed AEs (56.6%/44.4%). Patients with incidents were at greater risk of AEs than patients without incidents, even for seemingly unrelated AEs (OR 1.4; 95% CI 1.3 to 1.6). Risk of AE cascades was greater when patients with AEs also had incidents, regardless of whether these seemed related (unrelated: OR 2.0; 95% CI 1.6 to 2.5; related: OR 5.7; 95% CI 4.3 to 7.4) or whether incidents preceded or followed AEs in these admissions (53% vs 52%, P>0.05).

Conclusions

Patient-level linkage of incident, AE and complaint data can reveal relations between events that otherwise remain obscured, such as incidents that trigger as well as follow AEs, introducing event cascades, regardless of whether clinical relations seem present.
Conflict resolution in anaesthesia: systematic review
Authors: Almghairbi Dalal Salem , Marufu Takawira C , Moppett Iain K
Published: July 2018

Background

Conflict is a significant and recurrent problem in most modern healthcare systems. Given its ubiquity, effective techniques to manage or resolve conflict safely are required.

Objective

This review focuses on conflict resolution interventions for improvement of patient safety through understanding and applying/teaching conflict resolution skills that critically depend on communication and improvement of staff members’ ability to voice their concerns.

Methods

We used the Population-Intervention-Comparator-Outcome model to outline our methodology. Relevant English language sources for both published and unpublished papers up to February 2018 were sourced across five electronic databases: the Cochrane Library, EMBASE, MEDLINE, SCOPUS and Web of Science.

Results

After removal of duplicates, 1485 studies were screened. Six articles met the inclusion criteria with a total sample size of 286 healthcare worker participants. Three training programmes were identified among the included studies: (A) crisis resource management training; (B) the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training; and (C) the two-challenge rule (a component of TeamSTEPPS), and two studies manipulating wider team behaviours. Outcomes reported included participant reaction and observer rating of conflict resolution, speaking up or advocacy-inquiry behaviours. Study results were inconsistent in showing benefits of interventions.

Conclusion

The evidence for training to improve conflict resolution in the clinical environment is sparse. Novel methods that seek to influence wider team behaviours may complement traditional interventions directed at individuals.
Infectious disease outbreaks: how online clinical decision support could help
Authors: Walsh Kieran
Published: July 2018

This paper describes an evaluation of how doctors might use an online clinical decision support tool to improve the care that they would provide to patients with infectious disease and what features they would expect in such a clinical decision support tool. Semistructured interviews were conducted by telephone with doctors to evaluate the utility of a clinical decision support tool in helping them to improve the care that they would provide to patients with infectious disease and to assess the features that they would value in such a tool. The doctors were primarily interested in how they could use the tool to improve care. They were short of time and so needed to be able to access the content that they needed really quickly. They expected content that was both evidence based and current, and they used a range of devices to access the content. They used desktops, laptops, mobiles and sometimes mobile apps. Doctors view the utility of clinical decision support in the management of rare infectious diseases from a number of perspectives. However, they primarily see utility in the tools as a result of their capacity to improve clinical practice in infectious diseases.
Development of a new clinical decision rule for cervical CT to detect cervical spine injury in patients with head or neck trauma
Authors: Inagaki Takeshi , Kimura Akio , Makishi Go , Tanaka Shigeru , Tanaka Noriko
Published: July 2018

Objective

Previous cervical spine imaging decision rules have been based on positive findings on plain X-ray and are limited by lack of specificity, age restrictions and complicated algorithms. We previously derived and validated a clinical decision rule (Rule 1) for detecting cervical spine injury (CSI) on CT in a single-centre study. This recommended CT for patients with (1) GCS score <14, (2) GCS 14–15 and posterior cervical tenderness or neurological deficit, (3) age ≥60 years and fall down stairs, or (4) age <60 and injured in a motorcycle collision or fallen from height. This study assessed the accuracy and reliability of this rule and refined the rule.

Methods

We conducted a prospective, dual-centre study at two Japanese EDs between August 2012 and March 2014. Patients with head or neck injury ≥16 years of age were included. Clinical data were collected from medical records. Imaging was at the discretion of the treating physician. CSI was diagnosed as a fracture or dislocation seen on CT; patients who were not imaged were followed for 14 days. We analysed the sensitivity and specificity of Rule 1 and refined it post hoc using recursive partitioning.

Results

1192 patients were enrolled. 927 completed follow-up. Of these, 584 (63.0%) underwent CT imaging and 38 had CSI. Sensitivity and specificity of Rule 1 were 92.1% (95% CI 79.2% to 97.3%) and 58.6% (95% CI 55.4% to 61.9%). A second rule (Rule 2) was derived recommending CT for those with any of the following: GCS <14, cervical tenderness, neurological deficit or mechanism of injury (fall down stairs, motorcycle collision or fall from height) without age limits. Sensitivity and specificity were 100% (95% CI 90.8% to 100%) and 51.9% (95% CI 48.6% to 55.2%), respectively.

Conclusions

Our initial CT decision rule had lower sensitivity than in our initial validation study. A refined decision rule based on GCS, neck tenderness, neurological deficit and mechanism of injury showed excellent sensitivity with a small loss of specificity. Rule 2 will now need validation in an independent cohort.
Transcranial magnetic stimulation predicts cognitive decline in patients with Alzheimer’s disease
Authors: Motta Caterina , Di Lorenzo Francesco , Ponzo Viviana , Pellicciari Maria Concetta , Bonnì Sonia , Picazio Silvia , Mercuri Nicola Biagio , Caltagirone Carlo , Martorana Alessandro , Koch Giacomo
Published: July 2018

Objective

To determine the ability of transcranial magnetic stimulation (TMS) in detecting synaptic impairment in patients with Alzheimer’s disease (AD) and predicting cognitive decline since the early phases of the disease.

Methods

We used TMS-based parameters to evaluate long-term potentiation (LTP)-like cortical plasticity and cholinergic activity as measured by short afferent inhibition (SAI) in 60 newly diagnosed patients with AD and 30 healthy age-matched subjects (HS). Receiver operating characteristic (ROC) curves were used to assess TMS ability in discriminating patients with AD from HS. Regression analyses examined the association between TMS-based parameters and cognitive decline. Multivariable regression model revealed the best parameters able to predict disease progression.

Results

Area under the ROC curve was 0.90 for LTP-like cortical plasticity, indicating an excellent accuracy of this parameter in detecting AD pathology. In contrast, area under the curve was only 0.64 for SAI, indicating a poor diagnostic accuracy. Notably, LTP-like cortical plasticity was a significant predictor of disease progression (p=0.02), while no other neurophysiological, neuropsychological and demographic parameters were associated with cognitive decline. Multivariable analysis then promoted LTP-like cortical plasticity as the best significant predictor of cognitive decline (p=0.01). Finally, LTP-like cortical plasticity was found to be strongly associated with the probability of rapid cognitive decline (delta Mini-Mental State Examination score ≤−4 points at 18 months) (p=0.04); patients with AD with lower LTP-like cortical plasticity values showed faster disease progression.

Conclusions

TMS-based assessment of LTP-like cortical plasticity could be a viable biomarker to assess synaptic impairment and predict subsequent cognitive decline progression in patients with ADs.
Late functional improvement after lacunar stroke: a population-based study
Authors: Ganesh Aravind , Gutnikov Sergei A , Rothwell Peter Malcolm ,   for the Oxford Vascular Study
Published: July 2018

Background

Recovery in function after stroke involves neuroplasticity and adaptation to impairments. Few studies have examined differences in late functional improvement beyond 3 months among stroke subtypes, although interventions for late restorative therapies are often studied in lacunar stroke. Therefore, we compared rates of functional improvement beyond 3 months in patients with lacunar versus non-lacunar strokes.

Methods

In a prospective, population-based cohort of 3-month ischaemic stroke survivors (Oxford Vascular Study; 2002–2014), we examined changes in functional status (modified Rankin Scale (mRS), Rivermead Mobility Index (RMI), Barthel Index (BI)) in patients with lacunar versus non-lacunar strokes from 3 to 60 months poststroke, stratifying by age. We used logistic regression adjusted for age, sex and baseline disability to compare functional improvement (≥1 mRS grades, ≥1 RMI points and/or ≥2 BI points), particularly from 3 to 12 months.

Results

Among 1425 3-month survivors, 234 patients with lacunar stroke did not differ from others in 3-month outcome (adjusted OR (aOR) for 3-month mRS >2 adjusted for age/sex/National Institutes of Health Stroke Scale score/prestroke disability: 1.14, 95% CI 0.75 to 1.74, p=0.55), but were more likely to demonstrate further improvement between 3 months and 1 year (aOR (mRS) adjusted for age/sex/3-month mRS: 1.64, 1.17 to 2.31, p=0.004). The results were similar on restricting analyses to patients with 3-month mRS 2–4 and excluding recurrent events (aOR (mRS): 2.28, 1.34 to 3.86, p=0.002), or examining BI and RMI (aOR (RMI) adjusted for age/sex/3-month RMI: 1.78, 1.20 to 2.64, p=0.004).

Conclusion

Patients with lacunar strokes have significant potential for late functional improvement from 3 to 12 months, which should motivate patients and clinicians to maximise late improvements in routine practice. However, since late recovery is common, intervention studies enrolling patients with lacunar strokes should be randomised and controlled.
Age at onset of genetic (E200K) and sporadic Creutzfeldt-Jakob diseases is modulated by the CYP4X1 gene
Authors: Poleggi Anna , van der Lee Sven , Capellari Sabina , Puopolo Maria , Ladogana Anna , De Pascali Eleonora , Lia Debora , Formato Alessia , Bartoletti-Stella Anna , Parchi Piero , van Duijn Cornelia , Pocchiari Maurizio
Published: July 2018

Objectives

The Glu to Lys change at codon 200 (E200K) of the PRNP gene is the most frequent mutation associated to genetic Creutzfeldt-Jakob disease (CJD) and the only one responsible for geographical clusters. Patients carrying this mutation develop disease at different ages and show variable clinical phenotypes that are not affected by the methione/valine polymorphism at codon 129 of the PRNP gene suggesting the influence of other factors. The objective of this study is to look for genes other than PRNP that might be responsible of this variability.

Methods

We searched for other genes by performing genome-wide analyses (GWA) on 19 patients with genetic CJD and 18 healthy subjects carrying the E200K mutation of PRNP and belonging to the Calabrian cluster in Italy. We then validate this result in 32 patients with E200K CJD from non-cluster areas and 259 patients with sporadic CJD referred to the Italian CJD national registry.

Results and conclusions

We identified two single nucleotide polymorphisms on the CYP4X1 gene locus as candidate disease modifiers in patients with E200K CJD of the cluster area and confirmed this finding in 32 patients with E200K CJD from non-cluster areas and 259 patients with sporadic CJD. Our results indicate that the CYP4X1 gene modulates the onset of disease in patients with E200K genetic and sporadic CJD. This finding improves our understanding on the pathogenesis of CJD, suggests new targets for developing novel therapeutic strategies and might be useful for the stratification of patients in future preventive treatment trials.
Recent insights into decision-making and their implications for informed consent
Authors: Vos Irene M L , Schermer Maartje H N , Bolt Ineke L L E
Published: July 2018

Research from behavioural sciences shows that people reach decisions in a much less rational and well-considered way than was often assumed. The doctrine of informed consent, which is an important ethical principle and legal requirement in medical practice, is being challenged by these insights into decision-making and real-world choice behaviour. This article discusses the implications of recent insights of research on decision-making behaviour for the informed consent doctrine. It concludes that there is a significant tension between the often non-rational choice behaviour and the traditional theory of informed consent. Responsible ways of dealing with or solving these problems are considered. To this end, patient decisions aids (PDAs) are discussed as suitable interventions to support autonomous decision-making. However, current PDAs demand certain improvements in order to protect and promote autonomous decision-making. Based on a conception of autonomy, we will argue which type of improvements are needed.
When slippery slope arguments miss the mark: a lesson from one against physician-assisted death
Authors: Blackstone Eric , Youngner Stuart J
Published: July 2018

In 1989, Susan Wolf convincingly warned of a troublesome consequence that should discourage any movement in American society towards physician-assisted death—a legal backlash against the gains made for limiting life-sustaining treatment. The authors demonstrate that this dire consequence did not come to pass. As physician-assisted suicide gains a foothold in USA and elsewhere, many other slippery slope arguments are being put forward. Although many of these speculations should be taken seriously, they do not justify halting the new practice. Instead, our courts, regulatory agencies, journalists, professional organisations and researchers should carefully monitor and study it as it unfolds, allowing continuous improvement just as our society has done in implementing the practice of limiting life-sustaining treatment.
Association between benzene and congenital anomalies in Oklahoma, 1997–2009
Authors: Janitz Amanda E , Dao Hanh Dung , Campbell Janis E , Stoner Julie A , Peck Jennifer D
Published: July 2018

Objectives

Although the most common cause of death in infants, little is known about the aetiology of congenital anomalies. Recent studies have increasingly focused on environmental exposures, including benzene. While benzene is known to affect the central nervous system, the effects on the developing fetus are unclear.

Methods

We conducted a retrospective cohort study to evaluate the association between ambient benzene exposure and the prevalence of congenital anomalies among 628 121 singleton births in Oklahoma from 1997 to 2009. We obtained benzene from the Environmental Protection Agency’s 2005 National-Scale Air Toxics Assessment for the census tract of the birth residence. We used modified Poisson regression with robust SEs to calculate prevalence proportion ratios (PPRs) and 95% CIs between quartiles of benzene exposure and critical congenital heart defects (CCHDs), neural tube defects (NTDs) and oral clefts adjusted for maternal education and tobacco use.

Results

Median benzene exposure concentration in Oklahoma was 0.57 µg/m3. We observed no association between benzene exposure and oral clefts, CCHDs or NTDs. When specific anomalies were examined, we observed an increased prevalence of cleft lip among those exposed to the second quartile of benzene compared with the first (PPR 1.50, 95% CI 1.05 to 2.13), though no association with higher levels of exposure.

Conclusions

Our findings do not provide support for an increased prevalence of anomalies in areas more highly exposed to benzene. Future studies would benefit from pooling data from multiple states to increase statistical power and precision in studies of air pollutants and specific anomalies.
Association between night-shift work, sleep quality and metabolic syndrome
Authors: Lim Yin Cheng , Hoe Victor C W , Darus Azlan , Bhoo-Pathy Nirmala
Published: July 2018

Objectives

Occupational factors, particularly night-shift work, are attracting growing interest as a possible determinant of metabolic syndrome (MetS). This study aimed to determine the association between night-shift work and MetS, and assess whether sleep quality is a mediating factor.

Methods

A cross-sectional study was conducted among Malaysian manufacturing workers, aged 40–65 years old. They completed a self-administered questionnaire on sociodemographics, lifestyle and family history, and the Pittsburgh Sleep Quality Index (PSQI) questionnaire. Waist circumference, blood pressure, fasting blood sugar, triglycerides and high-density lipoprotein levels were measured. Baron and Kenny’s method, Sobel test and multiple mediation models with bootstrapping were used to determine whether the PSQI global score or its components mediated the association between night-shift work and MetS.

Results

Of the 494 participants, 177 (36%) worked night shift and 51% were men. The prevalence of MetS was 37%. Night-shift work was independently associated with a twofold increase in the risk of MetS (adjusted OR: 1.92, 95% CI 1.24 to 2.97). However, the association between night-shift work and MetS did not appear to be modified by sex. Night-shift workers also reported significantly poorer sleep quality, longer sleep latency, shorter sleep duration, sleep disturbances and daytime dysfunction. Robust mediation analysis nonetheless showed that neither PSQI global score nor its components mediated the association between night-shift work and MetS.

Conclusion

Early screening and management of MetS and the development of programmes to improve sleep quality should be carried out among night-shift workers. Future research should investigate other modifiable mediators linking night-shift work and MetS.
Contribution of obstructive sleep apnoea to arterial stiffness: a meta-analysis using individual patient data
Authors: Joyeux-Faure Marie , Tamisier Renaud , Borel Jean-Christian , Millasseau Sandrine , Galerneau Louis-Marie , Destors Marie , Bailly Sébastien , Pepin Jean Louis
Published: July 2018

Background

Arterial stiffness, measured by pulse wave velocity (PWV), is a strong independent predictor of late cardiovascular events and mortality. It is recognised that obstructive sleep apnoea (OSA) is associated with cardiovascular comorbidities and mortality. Although previous meta-analyses concluded that PWV is elevated in OSA, we feel that an individual patient data analysis from nine relatively homogeneous studies could help answer: to what extent does OSA drive arterial stiffness?

Methods

Individual data from well-characterised patients referred for suspicion of OSA, included in nine studies in which carotid–femoral PWV was measured using a Complior device, were merged for an individual patient data meta-analysis.

Results

893 subjects were included (age: 56±11 (mean±SD), 72% men, 84% with confirmed OSA). Body Mass Index varied from 15 to 81 kg/m2 (30±7 kg/m2). PWV ranged from 5.3 to 20.5 m/s (10.4±2.3 m/s). In univariate analysis, log(PWV) was strongly related to age, gender, systolic blood pressure, presence of type 2 diabetes (all p<0.01) as well as to dyslipidaemia (p=0.03) and an Epworth Sleepiness Scale score ≥9 (p=0.04), whereas it was not related to obesity (p=0.54), a severe Apnoea–Hypopnoea Index (p=0.14), mean nocturnal saturation (p=0.33) or sleep time with oxygen saturation below 90% (p=0.47). In multivariable analysis, PWV was independently associated with age, systolic blood pressure and diabetes (all p<0.01), whereas severe OSA was not significantly associated with PWV.

Conclusion

Our individual patient meta-analysis showed that elevated arterial stiffness in patients with OSA is driven by conventional cardiovascular risk factors rather than apnoea parameters.
Exploring miRNA-mRNA regulatory network in cardiac pathology in Na+/H+exchanger isoform 1 transgenic mice
Authors: Xue Jin , Zhou Dan , Poulsen Orit , Hartley Iain , Imamura Toshihiro , Xie Edward X. , Haddad Gabriel G.
Published: July 2018

Numerous studies have demonstrated that Na+/H+exchanger isoform 1 (NHE1) is elevated in myocardial diseases and its effect is detrimental. To better understand the involvement of NHE1, we have previously studied cardiac-specific NHE1 transgenic mice and shown that these mice develop cardiac hypertrophy, interstitial fibrosis, and cardiac dysfunction. The purpose of current study was to identify microRNAs and their mRNA targets involved in NHE1-mediated cardiac injury. An unbiased high-throughput sequencing study was performed on both microRNAs and mRNAs. RNA sequencing showed that differentially expressed genes were enriched in hypertrophic cardiomyopathy pathway by Kyoto Encyclopedia of Genes and Genomes annotation in NHE1 transgenic hearts. These genes were classified as contraction defects (e.g., Myl2, Myh6, Mybpc3, and Actb), impaired intracellular Ca2+homeostasis (e.g., SERCA2a, Ryr2, Rcan1, and CaMKII delta), and signaling molecules for hypertrophic cardiomyopathy (e.g., Itga/b, IGF-1, Tgfb2/3, and Prkaa1/2). microRNA sequencing revealed that 15 microRNAs were differentially expressed (2-fold, P < 0.05). Six of them (miR-1, miR-208a-3p, miR-199a-5p, miR-21-5p, miR-146a-5p, and miR-30c-5p) were reported to be related to cardiac pathological functions. The integrative analysis of microRNA and RNA sequencing data identified several crucial microRNAs including miR-30c-5p, miR-199a-5p, miR-21-5p, and miR-34a-5p as well as 10 of their mRNA targets that may affect the heart via NFAT hypertrophy and cardiac hypertrophy signaling. Furthermore, important microRNAs and mRNA targets were validated by quantitative PCR. Our study comprehensively characterizes the expression patterns of microRNAs and mRNAs, establishes functional microRNA-mRNA pairs, elucidates the potential signaling pathways, and provides novel insights on the mechanisms underlying NHE1-medicated cardiac injury.