bluuebunny/crossref_metadata_2025 huggingface dataset:
P093: Quality assurance programs for tests pending at discharge from emergency departments: a systematic review
Authors: Mikhaeil J. , Jalali H. , Orchanian-Cheff A. , Chartier L.
Published: May 2019

Introduction: Emergency department (ED) care allows for the rapid assessment of patient concerns, but often leads to tests being performed that are not finalized or reviewed prior to patients leaving the ED. The follow-up for these tests pending at discharge (TPADs), most commonly final diagnostic imaging (DI) reports and microbiology cultures, is a major medico-legal concern for ED providers and significant safety concern for patients. We therefore performed a systematic review of the literature to identify existing ED quality assurance (QA) processes to address TPADs relating to final DI reports and microbiology cultures. Methods: Comprehensive literature searches were developed with a medical librarian and conducted in Ovid Medline, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and CINAHL from inception through May 8, 2018. Studies were included if they described an intervention or program designed to follow-up relevant ED TPADs, and excluded if they pertained to communication between departments or clinicians only rather than with patients. Study selection was performed independently by two reviewers in two steps (title and abstract review, then full-text review), with all discrepancies resolved by consensus with a senior reviewer. The primary outcome was the description of any QA process to follow-up on TPADs and secondary outcomes included quantifiable results of successful interventions or programs. Results: From the 11,685 articles identified, 58 were selected for full-text review, and 12 met eligibility criteria. In the included studies, the responsibility for following up on TPADs was owned by different members of the care team (e.g., ED physicians, nurses or radiologists) and recorded in a variety of ways (e.g., electronic medical record, paper chart, system designed for TPADs). Follow-up pathways with variable standardization were described, ranging from dedicated assignment for TPAD duties with protected/remunerated time to do so, to follow-up completion done by the first clinician to receive the TPAD result. Studies that evaluated their QA process implementation found that more patients were notified of abnormal test results, follow-up times decreased, and fewer unnecessary antibiotics were used. Conclusion: A variety of QA processes have been implemented to follow up on ED TPADs in terms of personnel involved, charting and logistics, and when evaluated, they have improved patient care.
P102: Perspectives surrounding paediatric procedural sedation using intranasal ketamine administration: a qualitative study of emergency nurses
Authors: Wonnacott D. , Scott S. , Flynn R. , Ali S. , Poonai N.
Published: May 2019

Introduction: Intranasal ketamine (INK) has an emerging role for procedural sedation (PSA) in children in the emergency department (ED). While INK is less invasive and requires fewer personnel than IV ketamine, widespread adoption in the paediatric ED would require strong nursing acceptance. To inform INK implementation strategies, we explored nursing perspectives surrounding INK, including perceived barriers to its adoption. Methods: Nurses in the paediatric ED of London Health Sciences Centre, London, Ontario were recruited by email. Two, one-hour, in-person focus groups were conducted on January 26 and February 2, 2018 using a semi-structured interview format. Transcription was performed by a professional medical transcription service and analyzed using an inductive qualitative approach involving code words corresponding to recurring topics. Thematic analysis was used to group similar codes into themes. The analytic process was managed using the NVivo 11 software package. Results: Results: Eight nurses participated. All nurses were female and had a mean of 8.9 (range: 2.5 - 26) years of pediatric emergency nursing experience. Seven nurses had experience monitoring and administering INK to children for PSA. Five themes emerged: 1) attributes of INK, 2) INK effects on patients and families, 3) INK effects on health care providers, 4) INK effects on the ED environment, and 5) uncertainty regarding INK's effectiveness, predictability, and fit into institutional sedation protocols. Subthemes included 1) perceptions that INK produced a relatively shallower, slower-onset, and/or less titratable sedation, 2) the importance of patient cooperation (i.e. INK may be preferred by providers for older patients undergoing relatively painful or long procedures), 3) belief that INK was an effective anxiolytic and sedative with the potential to improve nursing resource utilization, and 4) belief that physician resistance to change and lack of personal familiarity were barriers to adoption. Conclusion: Conclusions: We identified clinical advantages to using INK in children, the importance of selecting appropriate patients, and barriers to widespread INK adoption. Importantly, our findings highlighted uncertainty about INK's effectiveness and incorporation into sedation protocols. Our findings will inform future knowledge translation strategies when implementing INK in the clinical setting.
P105: Charting in the electronic medical record: Perspectives of Emergency Medicine residents
Authors: Rajaram A. , Patel N. , Hickey Z. , Newbigging J. , Wolfrom B.
Published: May 2019

Introduction: The literature reveals that residents spend significant amounts of time working with and charting in electronic medical records (EMR). As adoption of EMRs accelerates among emergency medicine (EM) departments, postgraduate programs will need to adapt curricula related to communication in the patient record. In order to make targeted changes, clinician-educators need a better understanding of how the documentation practices of trainees develop and change over residency, as well as the challenges they face in effectively charting. We gathered the perspectives of EM residents on data entry in the EMR to identify opportunities for such change. Methods: We recruited residents from all five years of the Royal College EM residency program at Queen's University and conducted focus groups from August to October 2018. Data collection was audio recorded and later transcribed. Line-by-line coding was performed independently by both AR and NP. A final codebook was validated by ZH. The codebook was then thematically analyzed to identify and characterize themes from the data. The study was approved by the Queen's University Health Sciences Research Ethics Board. Results: 15 EM residents participated. Groups discussed similar challenges with charting, including time constraints, ensuring sufficient, but appropriate detail, variable preceptor expectations, and an inability to draw diagrams. All residents noted formal teaching of the SOAP note framework during medical school and reported receiving an introductory EMR session. Groups highlighted the importance of feedback, especially from physicians with medicolegal experience. They also described more informal learning strategies, including receiving tips from preceptors during shifts and reading the notes of others. They also reported that changes in their documentation practices as junior and senior residents were largely due to a graduation of responsibility and medicolegal considerations. Conclusion: Our results suggest there is a lack of formal postgraduate training for EM residents with respect to documentation in the EMR with reliance on informal teaching and feedback. Future work should explore opportunities to address this gap with various educational strategies, including the development of specific objectives, application of consistent expectations, modelling of excellent chart notes in teaching, and instruction by preceptors with medicolegal experience.
P117: Procedural skills training in emergency medicine physicians within the Edmonton zone: a needs assessment
Authors: Schonnop R. , Stauffer B. , Gauri A. , Ha D.
Published: May 2019

Introduction: Procedural skills are a key component of an emergency physician's practice. The Edmonton Zone is a health region that comprises eleven tertiary, urban community and rural community emergency departments (EDs) that represents over three hundred emergency physicians. We report the initial stakeholder and site leadership needs assessment used to inform the development of a comprehensive continuing professional development (CPD) procedural skills curriculum for the Edmonton Zone. Methods: A list of procedural skills was distributed to the two Edmonton Zone Clinical Department Heads of Emergency Medicine (EM). This list was based on a previous Canadian study that utilized procedures from the Objectives of Training in EM. Based on perceived needs, twenty-five procedures were chosen by consensus from zone leadership and study authors as the initial focus for a skills curriculum. This list was sent via survey to the physician site leads of all EDs in the zone. Each site lead was asked to indicate the fifteen procedure curriculum they felt would most benefit their respective physician groups. Responses were collated to look at all departments as a group and stratified by the type of ED (tertiary, urban and rural community). Results: Every site chief of Edmonton Zone EDs completed the survey (100% response rate). Cricothyrotomy and pediatric intubation were the two procedures prioritized by every site. One procedure (ultrasound guided central lines) was prioritized by 10/11 sites while three procedures (ultrasound guided central lines, adult intubation and chest tube insertion) were specified by 9/11 sites as needs. Two procedures (pericardiocentesis and thoracotomy) were named as priorities only by tertiary centers. Conversely, three procedures (extensor tendon repair, anterior and posterior nasal packing) were highlighted by all rural sites, but not consistently by any urban sites. Conclusion: Over the next few years, competency-based CPD will emerge for physicians in practice. Our preliminary needs assessment showed that while a common zone-wide curriculum will be possible, targeted curricula tailored to the unique needs of the various types of EDs will also be necessary. This has implications for the resources and teaching requirements needed to deliver effective and recurring CPD courses to an entire health region. A targeted needs assessment to all Edmonton Zone physicians will be the next step to verify and further elaborate on these preliminary results.
P147: Your emergency department journey: piloting a patient poster explaining the emergency department care process
Authors: Krebs L. , Villa-Roel C. , Ushko D. , Sandhar G. , Ruske H. , Couperthwaite S. , Holroyd B. , Ospina M. , Rowe B.
Published: May 2019

Introduction: Qualitative research with emergency department (ED) patients in Alberta has revealed that some patients have limited understanding of the ED care process and that this increases the anxiety, frustration and confusion experienced throughout their visit. The objective of this study was to design, implement, and test the usefulness of a poster explaining the ED care process. Methods: As part of a stepped-wedge ED intervention trial in Alberta, a 4′ x 3′ poster portraying the patient ED care process was developed and posted in 15 study site waiting rooms. Trained research assistants approached patients in 3 urban ED waiting areas and invited them to complete a short paper-based survey on the acceptability and usefulness of the poster. Results are reported as proportions. Results: A total of 316 patients agreed to participate in this study. Approximately half of the participants were male and 60% were between the ages of 17 and 49. The majority of participants identified themselves as white (72%) and nearly half (49%) were accompanied by someone. A third (37%) of patients had read the wall poster prior to being approached to complete the survey. Most patients (62%) who had not read it prior to being approached hadn't noticed the poster or couldn't see it because of its location. Once patients reviewed the poster, the vast majority (92%) reported completely or largely understanding the information and most (84%) found it at least moderately helpful in preparing them for their ED journey. Approximately 45% of respondents agreed that they learned something new about the ED care process by reading the poster and 20% wanted additional information added to the poster; largely, wait time estimates (53% of responses). Conclusion: Placing posters in the ED is one method for equipping patients for their ED care process; however, this study revealed the potential limited utility of this engagement method by the small number of patients who noticed the poster and read the information. Location and content (e.g., time estimates) were identified as key factors for implementation. Condition-specific guides may need to supplement general ED process guides to better prepare patients for their individual ED journey and to actively engage them in their ED care.
LO13: Characteristics of emergency department visits by community-dwelling older adults who screened positive for elder abuse during home care assessments
Authors: Mercier E. , Jones A. , Brousseau A. , Hirdes J. , Mowbray F. , Emond M. , Melady D. , Costa A.
Published: May 2019

Introduction: Elder abuse is infrequently detected in the emergency department (ED) and less than 2% are reported to proper law authorities by ED physicians. This study aims to examine the characteristics of community-dwelling older adults who screened positive for elder abuse during home care assessments and the epidemiology of ED visits by these patients relative to other home care patients. Methods: This study utilized a population-based retrospective cohort study of home care patients in Canada between April 1, 2007 and March 31, 2015. Standardized, comprehensive home care assessments were extracted from the Home Care Reporting System. A positive screen for elder abuse was defined as at least one these criteria: fearful of a caregiver; unusually poor hygiene; unexplained injuries; or neglected, abused, or mistreated. Home care assessments were linked to the National Ambulatory Care Reporting System in the regions and time periods in which population-based estimates could be obtained to identify all ED visits within 6 months of the home care assessment. Results: A total of 30,413 from the 2,401,492 patients (1.3%) screened positive for elder abuse during a home care assessment. They were more likely to be male (40.5% versus 35.3%, p < 0.001), to have a cognitive impairment (82.9% versus 65.3%, p < 0.001), a higher frailty index (0.27 versus 0.22, p < 0.001) and to exhibit more depressive symptoms (depression rating scale 1 or more: 68.7% versus 42.7%, p < 0.001). Patient who screened positive for elder abuse were less likely to be independent in activities of daily living (41.9% versus 52.7%, p < 0.001) and reported having fallen more frequently (44.2% versus 35.5%, p < 0.001). Caregiver expressing distress was associated with elder abuse (35.3% versus 18.3%, p < 0.001) but not a higher number of hours caring for the patient. Victims of elder abuse were more likely to attend the ED for low acuity conditions (Canadian triage and acuity scale (CTAS) 4 or 5). Diagnosis at discharge from ED were similar with the exception of acute intoxication that was more frequent in patients who are victims of abuse. Conclusion: Elder abuse is infrequently detected during home care assessments in community-dwelling older adults. Higher frailty index, cognitive impairment, depressive symptoms were associated with elder abuse during homecare assessments. Patients who are victims of elder abuse are attending EDs more frequently for low acuity conditions but ED diagnosis at discharge, except for acute intoxication, are similar.
LO17: Barriers and enablers that influence guideline-based care of geriatric falls patients presenting to the emergency department
Authors: Parks A. , Eagles D. , Cheung W. , Ge Y. , Stiell I.
Published: May 2019

Introduction: Geriatric patients commonly present to the emergency department (ED) after a fall. Unfortunately, recent evidence suggests that ED physicians are poorly adherent to published ED-specific geriatric falls guidelines. This study applied a theoretical domains framework (TDF)-driven approach to systematically investigate barriers and enablers in the provision of guideline-based care to older patients presenting to the ED with a fall. Methods: From June to September 2017, semi-structured interviews of staff ED physicians practicing in Ontario, Canada were conducted and analyzed. An interview guide based on the TDF was used to capture 14 domains that may influence provision of guideline-based care. Interview transcripts were analyzed, and specific beliefs were generated by grouping similar responses. Relevant domains were identified based on frequencies of beliefs, existence of conflicting beliefs, and evidence of strong beliefs that would influence provision of guideline-based care. Results: Eleven interviews were conducted with practicing ED physicians. Thirty specific belief statements across 13 different TDF domains (all except Optimism) were identified as relevant. Overall, Ontario ED physicians are supportive of providing guideline-based care and believe it would lead to better outcomes for geriatric falls patients. Important barriers include knowledge, skills, time and workload constraints, and inconsistent allied health support. Conclusion: This study identified important barriers and enablers to provision of guideline-based care in geriatric ED falls patients. These results will help guide implementation of guidelines nationally and internationally, with a focus on improved knowledge dissemination, implementation of training interventions, and improvements in allied health coverage and supports.
LO24: What patients need early surgical intervention for acute ureteric colic?
Authors: Innes G. , Grafstein E. , Law M. , McRae A. , Scheuermeyer F. , Andruchow J.
Published: May 2019

Introduction: Ureteral colic is a common painful disorder. Early surgical intervention is an attractive management option but existing evidence does not clarify which patients benefit. Based on lack of evidence, current national specialty guidelines provide conflicting recommendations regarding who is a candidate for early intervention. We compared treatment failure rates in patients receiving early intervention to those in patients offered spontaneous passage to identify subgroups that benefit from early intervention. Methods: We used administrative data and structured chart review to study consecutive patients attending one of nine hospitals in two provinces with an index emergency department (ED) visit and a confirmed 2.0-9.9 mm ureteral stone. We described patient, stone and treatment variables, and used multivariable regression to identify factors associated with treatment failure, defined as the need for rescue intervention or hospitalization within 60 days. Our secondary outcome was ED revisit rate. Results: Overall, 1168 (37.9%) of 3081 eligible patients underwent early intervention. Patients with small stones <5mm experienced more treatment failures (31.5% v. 9.9%) and more ED revisits (38.5% v. 19.7%) with early intervention than with spontaneous passage. Patients with large stones ≥7.0mm experienced fewer treatment failures (34.7% v. 58.6%) and similar ED revisit rates with early intervention. Patients with intermediate-sized 5.0-6.9mm stones had fewer treatment failures with intervention (37.4% v. 55.5%), but only if stones were in the proximal or middle ureter. Conclusion: This study clarifies stone characteristics that identify patients likely to benefit from early intervention. We recommend low-risk patients with uncomplicated stones <5mm generally undergo initial trial of spontaneous passage, while high-risk patients with proximal or middle stones >5mm, or any stone >7mm, be offered early intervention.
LO35: Characterizing pain in children with acute gastroenteritis presenting to the emergency department
Authors: Ali S. , Maki C. , Xie J. , Lee B. , Graham T. , Vanderkooi O. , MacDonald S. , Poonai N. , Thull-Freedman J. , Rajagopal M. , Dow N. , Sivakumar M. , Freedman S. ,   Alberta Provincial Pediatric EnTeric Infection TEam (APPETITE), Pediatric Emergency Research Canada (PERC)
Published: May 2019

Introduction: Although acute gastroenteritis is an extremely common childhood illness, there is a paucity of literature characterizing the associated pain and its management. Our primary objective was to quantify the pain experienced by children with acute gastroenteritis in the 24-hours prior to emergency department (ED) presentation. Secondary objectives included describing maximum pain, analgesic use, discharge recommendations, and factors that influenced analgesic use in the ED. Methods: Study participants were recruited into this prospective cohort study by the Alberta Provincial Pediatric EnTeric Infection TEam between January 2014 and September 2017. This study was conducted at two Canadian pediatric EDs; the Alberta Children's Hospital (Calgary) and the Stollery Children's Hospital (Edmonton). Eligibility criteria included < 18 years of age, acute gastroenteritis (□ 3 episodes of diarrhea or vomiting in the previous 24 hours), and symptom duration □ 7 days. The primary study outcome, caregiver-reported maximum pain in the 24-hours prior to presentation, was assessed using the 11-point Verbal Numerical Rating Scale. Results: We recruited 2136 patients, median age 20.8 months (IQR 10.4, 47.4); 45.8% (979/2136) female. In the 24-hours prior to enrolment, 28.6% (610/2136) of caregivers reported that their child experienced moderate (4-6) and 46.2% (986/2136) severe (7-10) pain in the preceding 24-hours. During the emergency visit, 31.1% (664/2136) described pain as moderate and 26.7% (571/2136) as severe. In the ED, analgesia was provided to 21.2% (452/2131) of children. The most commonly administered analgesics in the ED were ibuprofen (68.1%, 308/452) and acetaminophen (43.4%, 196/452); at home, acetaminophen was most commonly administered (77.7%, 700/901), followed by ibuprofen (37.5%, 338/901). Factors associated with analgesia use in the ED were greater pain scores during the visit, having a primary-care physician, shorter illness duration, fewer diarrheal episodes, presence of fever and hospitalization. Conclusion: Although children presenting to the ED with acute gastroenteritis experience moderate to severe pain, both prior to and during their emergency visit, analgesic use is limited. Future research should focus on appropriate pain management through the development of effective and safe pain treatment plans.
LO52: Classification versus prediction of mortality using the Systemic Inflammatory Response score and quick Sepsis-related Organ Failure Assessment scores in patients with infection
Authors: Lane D. , Lin S. , Scales D.
Published: May 2019

Introduction: Despite their widespread use, measures of classification accuracy (i.e. sensitivity and specificity) have several limitations that conceals relevant information and may bias decision-making. Assessing the predictive ability of clinical tools instead may provide more useful prognostic information to support decision-making, particularly in an Emergency setting. We sought to contrast classification accuracy versus predictive ability of the Systemic Inflammatory Response Syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) Sepsis scores for determining mortality risk among patients with infection transported by paramedics. Methods: A one-year cohort of patients with infections transported to the Emergency Department by paramedics was linked to in-hospital administrative databases. Hospital mortality was determined for each patient at the time of discharge. We calculated sensitivity and specificity of SIRS and qSOFA for classifying hospital mortality across different score thresholds, and estimated discrimination (assessed using the C statistic) and calibration (assessed visually) of prediction. Prediction models for hospital mortality were constructed using the aggregated SIRS or qSOFA scores for each patient as a predictor, while accounting for clustering by institution and adjusting for differences in patient age and sex. Predicted and observed risk were plotted to assess calibration and change in risk across levels of each score. Results: A total of 10,409 patients with infection who were transported by paramedics were successfully linked, with an overall mortality rate of 9.2%. The median SIRS score among non-survivors was 2, while the median qSOFA score was 1. SIRS score had higher sensitivity estimates than qSOFA for classifying hospital mortality at all thresholds (0.11 – 0.83 vs. 0.08 – 0.80), but the qSOFA score had better discrimination (C statistic 0.76 vs. 0.71) and calibration. The risk of hospital mortality predicted by the SIRS score ranged from 6.6-24% across score values, whereas the risk predicted by the qSOFA score ranged from 8.6-53%. Conclusion: Assessing the SIRS and qSOFA scores predictive ability reveals that the qSOFA score provides more information to clinicians about a patient's mortality risk despite having worse sensitivity. This study highlights important limitations of classification accuracy for diagnostic test studies and supports a shift toward assessing predictive ability instead. Character count 2490
Decrease in vancomycin-resistantEnterococcuscolonization associated with a reduction in carbapenem use as empiric therapy for febrile neutropenia in patients with acute leukemia
Authors: Ford Clyde D. , Coombs Jana , Stofer Michaela Gazdik , Lopansri Bert K. , Webb Brandon J. , Ostronoff Fabiana , Asch Julie , Hoda Daanish
Published: May 2019

Objective:

To compare the effects of empiric carbapenems versus cycling cefepime and piperacillin/tazobactam on the rates of vancomycin-resistantEnterococcus(VRE) colonization, bloodstream infections, and outcomes of patients admitted with acute leukemia.

Design:

Retrospective clinical study with VRE molecular strain typing and gastrointestinal microbiome comparison.

Setting:

A regional referral center for acute leukemia.

Patients:

342 consecutive patients admitted with newly diagnosed acute leukemia.

Methods:

In September 2015, we changed our empiric antibiotic of choice for neutropenic fever from a carbapenem to the cycling regimen. We studied 214 consecutive patients during the carbapenem period and 128 during the cycling period. Surveillance for VRE stool colonization was conducted weekly. Representative stool samples were analyzed for VRE MLST types and changes in the composition and diversity of the fecal microbiota.

Results:

The change in empiric antibiotics was associated with a significant decrease in VRE colonization (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.27–0.66), a switch in the dominant VRE MLST types on the unit, and some modifications in the gastrointestinal microbiome. There were no differences in total gram-positive or gram-negative BSIs. During the carbapenem period, we observed higher absolute numbers ofCandidaspp and fewer ESBL BSIs, but these did not reach statistical significance. Patients during the carbapenem period had longer lengths of stay and durations of severe neutropenia and 10% higher hospital cost.

Conclusions:

Carbapenem-sparing empiric antibiotic regimens may have advantages related to VRE ecology, gastrointestinal dysbiosis, duration of neutropenia, cost and length of stay.
Syn-kinematic palaeogeographic evolution of the West European Platform: correlation with Alpine plate collision and foreland deformation
Authors: Sissingh W.
Published: May 2019

Sequence stratigraphic correlations indicate that intermittent changes of the kinematic far-field stress-field regimes, and the associated geodynamic re-organisations at the plate-tectonic contacts of the African, Apulian, Iberian and European plates, affected the Tertiary palaeogeographic evolution of the West European Platform through a combination of intra-plate tectonics and fluctuations of relative sea level. A temporal sequence of first-order stages in structural, palaeotopographic and palaeohydrographic development of the platform can be distinguished from the Paleocene onwards. These formative stages are closely linked to major plate-boundary events involving the development of the Pyrenean and Alpine orogens, and can be traced throughout the West European Platform.
Fifty Years
Authors:   The Editorial committee
Published: May 2019

This issue, and the supplement published simultaneously, conclude the fiftieth volume of the International Review of Social History. In 1956 when the first issue appeared, A.J.C. Rüter, director of the International Institute of Social History (IISH) at the time, provided three reasons for launching the journal. He observed that the “rather meagre” interest in social history in the current journals (including the French Annales) was “a fact readily explained by the space available on the one hand and the supply of manuscripts on the other”. He believed, moreover, that there was a demand for an international medium, where social historians from different countries and continents could exchange views on mutual similarities and differences. Finally, Rüter noted that social historiography, which had slowly come to fruition under the protective aegis of economic historiography, had become emancipated and had acquired its own dynamics.
The Frustrations of Families: Henry Lynch, Heredity, and Cancer Control, 1962–1975
Authors: Cantor David
Published: May 2019

When Henry T Lynch thought that he had discovered the existence of hereditary cancers among Nebraskan families in the 1960s, his hope was that it would lead to more effective means of cancer control. Lynch argued that the identification of such cancers offered tremendous opportunities for improving detection and treatment. If cancer ran in families, he claimed, the discovery of a hereditary cancer in one family member should be an alert to the possibility of cancer in others, and so prompt careful scrutiny for any signs that might indicate the presence of the disease in “healthy” individuals. Lynch hoped that by targeting cancer families it would be possible to catch more cancers at an earlier stage than was hitherto possible. Cancers caught early were often curable, the American Cancer Society (ACS) claimed.
The Scurvy Scandal at Millbank Penitentiary: A Reassessment
Authors: Higgins Peter McRorie
Published: May 2019

Historical myths die hard: one such is of a supposed outbreak of scurvy—said by some to be the result of medical insouciance—at Millbank penitentiary in 1823. Thus, Sean McConville in his masterly account of prisons in the reform period writes: “The decision [to reduce the diet] was a major factor in the scurvy epidemic which followed shortly afterwards, causing at least thirty deaths”. Other authors take a similar line: “Fifteen months later, after 30 had died, and after the whole convict population had been evacuated from the prison, Holford was convinced that the disease had been sea-scurvy”; “there was a serious outbreak of scurvy not long after the new diet was adopted”; “In the winter of 1823, the inmates began to succumb to typhus, dysentery, and scurvy. Thirty-one died and four hundred others were incapacitated”; “The scurvy was the prevailing disease, and was seen in over half of the 860 inmates”. Joe Sim in his generally condemnatory evaluation of medical staff working in prisons states: “Millbank was at the centre of a major controversy when an outbreak of scurvy occurred and thirty-one prisoners died. The [Prison Medical Service] was deeply implicated”, and he goes on to associate the physician in charge with “experiments” on the bodies and minds of the confined.
Impact of levamisole in co-administration with benznidazole on experimental Chagas disease
Authors: Rocha Simões-Silva Marianne , Brandão Peres Raiza , Britto Constança , Machado Cascabulho Cynthia , de Melo Oliveira Gabriel , Nefertiti da Gama Aline , França da Silva Cristiane , Lima da Costa Karine , Finamore Araújo Paula , Diego de Souza Campos Jerônimo , Meuser Batista Marcos , Cristina Demarque Kelly , da Cruz Moreira Otacílio , de Nazaré Correia Soeiro Maria
Published: May 2019

Levamisole (Lms) is an anthelminthic drug with immunomodulatory activity. Chagas disease (CD) is caused byTrypanosoma cruziand there is very low access to the drugs available, benznidazole (Bz) and nifurtimox, both far from ideal. In a drug-repurposing strategy to test potential activity as antiparasitic and immunomodulatory agent for CD, Lms was assayed on acuteT. cruzimurine infection, alone and in co-administration with Bz. During protocol standardization, 100 and 10 mpk of Bz given for five consecutive days resulted in parasitaemia suppression and 100% animal survival only with the highest dose. Flow cytometry showed that both optimal (100 mpk) and suboptimal (10 mpk) doses of Bz equally decreased the plasma levels of cytokines commonly elevated in this acute infection model. Lms alone (10–0.5 mpk) did not decrease parasitaemia nor mortality rates. Co-administration was investigated using the suboptimal dose of Bz and different doses of Lms. While Bz 10 mpk did not alter parasitaemia, the combo partially reduced it but only slightly promoted animal survival. This effect could be related to Th1-response modulation since interleukin-6 and interferon-γwere higher after treatment with the combo.
Cognitive effects of brief and ultrabrief pulse bitemporal electroconvulsive therapy: a randomised controlled proof-of-concept trial
Authors: Martin Donel , Katalinic Natalie , Hadzi-Pavlovic Dusan , Ingram Anna , Ingram Nicholas , Simpson Brett , McGoldrick Jenny , Dowling Nathan , Loo Colleen
Published: May 2019

Background

Reduction of the pulse width has been reported to improve ECT outcomes with unilateral ECT (similar efficacy, fewer cognitive side effects), but has been minimally studied for bitemporal ECT. The only study comparing brief and ultrabrief pulse bitemporal ECT found reduced efficacy for bitemporal ultrabrief compared to bitemporal brief pulse stimulation. This randomised controlled trial (RCT) aimed to test if ultrabrief pulse bitemporal ECT results in fewer cognitive side effects than brief pulse bitemporal ECT, when given at doses adjusted with the aim of achieving comparable efficacy.

Methods

Thirty-six participants were randomly assigned to receive ultrabrief (at 3 times seizure threshold) or brief (at 1.5 times seizure threshold) pulse bitemporal ECT given 3 times a week in a double-blind, controlled proof-of-concept trial. Blinded raters assessed mood and cognitive functioning over the ECT course.

Results

Efficacy and cognitive outcomes did not differ significantly between the two treatment groups over the ECT course. The ultrabrief pulse group performed better on a test of visual memory assessed acutely after an ECT treatment.

Conclusions

This study suggests there may be a small cognitive advantage in giving bitemporal ECT with an ultrabrief pulse when dosage is increased to match the efficacy of brief pulse bitemporal ECT, but the study was underpowered to fully examine this issue.

Clinical Trials Registration: www.clinicaltrials.gov, NCT00870805.
Patient Preferences Concerning Alternative Treatments for Neuroendocrine Tumors: Results of the “PIANO-Study”
Authors: Mühlbacher Axel C. , Juhnke Christin
Published: May 2019

Objectives

Neuroendocrine tumors (NETs) are rare, slow-growing malignant tumors. So far, there are no data on patient preferences regarding its therapy. This empirical study aimed to elicit patient preferences in the drug treatment of NET.

Methods

Based on qualitative patient interviews and an analytic hierarchy process, six patient-relevant attributes were analyzed and weighted using a discrete-choice experiment. Patients were recruited with the help of a NET support group. An experimental 3*3 + 6*3 –MNL design was created using NGene. The design consisted of eighty-four choices, divided into seven blocks. Participants were randomly assigned to these blocks. The analysis included random parameter logit and latent class models.

Results

A total of 275 participants (51.6 percent female; mean age, 58.4 years) were included. The preference analysis within the random parameter logit model, taking into account the 95 percent confidence interval, showed predominance for the attribute “overall survival.” The attributes “response to treatment” and “stabilization of tumor growth” followed. The side effects “nausea/vomiting” and “diarrhea” were considered of relatively equal importance. Latent class analysis of possible subgroup differences revealed three preference patterns.

Conclusions

Preferences can influence therapeutic decisions. Preference analyses indicated that “overall survival” had the strongest influence, with participants clearly weighing outcome attributes higher than side effect attributes. In conclusion, mono-criterial decisions would not fully reflect patient perspectives.
Clobazam as Add-on Therapy in Children with Epileptic Encephalopathy
Authors: Silva Rosana Carvalho , Montenegro Maria Augusta , Guerreiro Carlos A.M. , Guerreiro Marilisa M.
Published: May 2019

Rationale:

Clobazam has been used successfully in adults and children with partial epilepsy. The purpose of this study was to evaluate the safety and efficacy of clobazam as add-on therapy in children with epileptic encephalopathy.

Methods:

This was a retrospective study conducted at the pediatric epilepsy clinic of our university hospital. Children less than 18-years of age with epileptic encephalopathy were included in the study. Clobazam was introduced as add-on therapy, starting with 5 mg/Kg/day and increased in minimally effective doses, up to the maximum tolerated dose. Data were obtained from clinical files and follow-up visits.

Results:

Ninety-seven patients were included in the study (39 girls), aged between 1 and 17-years-old (mean = 9.9). Twenty-six patients had Lennox-Gastaut syndrome, seven had myoclonic astatic epilepsy, nine had West syndrome and, in 57 patients, the type of epileptic encephalopathy could not be determined. Clobazam dosage ranged from 5 to 60 mg/day (mean = 37.5 mg/day). Forty (41%) patients presented with adverse events, most of which were mild and transitory, and clobazam needed to be withdrawn in only 11 patients. Nine (9.2%) patients were seizure-free after clobazam adjunctive therapy. In 11 (11.3%) patients seizure improvement was >75%, in 16 (16.5%) it was >50%, in 17 (17.5%) improvement was <50% and in 44 (45.5%) there was no change in seizure frequency. Three patients were lost to follow-up. In 85% of the patients with seizure improvement, the results lasted for more than one year.

Conclusion:

Clobazam is safe and effective in the treatment of epileptic encephalopathies of childhood.
Monitoring of FES2 reactions using high-temperature XRD coupled with gas chromatography
Authors: Stirrup K.-A. M. , Rodriguez M. A. , Coker E. N. , Griego J. J. M. , Anderson T. M.
Published: May 2019

High-temperature X-ray diffraction with concurrent gas chromatography (GC) was employed in the study of iron disulfide (FeS2) cathode pellets disassembled from thermal batteries. When FeS2 cathode materials were analyzed in an air environment, reaction of the KCl and LiCl salt phases led to the formation of Li2(SO4) and KFe2S3 phases beginning at ~230 °C. These phases subsequently reacted to generate various forms of potassium iron sulfates in the 280–500 °C range, with the final products resulting in a β-Fe2O3 phase and K2(SO4). Independent simultaneous thermal analysis coupled with mass spectroscopy (MS) augmented the diffraction results and supported the overall picture of FeS2 decomposition. Both gas analysis measurements (i.e. GC and MS) from the independent experiments confirmed the formation of SO2 off-gas species during the breakdown of the FeS2. In contrast, characterization of the same cathode material under inert conditions showed the persistence of the initial FeS2 phase throughout the entire temperature range of analysis.
Variable past participles in Portuguese perfect constructions
Authors: Schwenter Scott A. , Hoff Mark , Christodulelis Eleni , Pflum Chelsea , Dauphinais Ashlee
Published: May 2019

Some Portuguese verbs have two past participle forms: one regular (stem +-do), and the other irregular (often identical to the first person singular present indicative). Per grammars, the perfect auxiliariester/havertake regulars, while irregulars appear with passive/adjectivalser/estar. To test these claims, we analyzed naturally-occurring data from Brazil (twentieth century) and Portugal (nineteenth and twentieth). We coded 1077 tokens from 21 verbs for ten predictors and performed mixed-effects logistic regressions in R. Irregulars appear withter/haver54% overall and in 68% of cases from Portugal. Our results demonstrate that past participle choice is determined by the interaction of several linguistic factors. While lexical verb is the most significant predictor of participle selection, verbs with irregular participles identical to the first person singular present indicative occur in the irregular significantly more than other verbs. We conclude that analogical processes underpin the variation. This conclusion allows us to adjudicate between competing accounts of past participle choice in Portuguese.
Medical Control Decisions: When Does a Neonate Become a Separate Patient?
Authors: Venegas Ashley , Ann Maggiore W. , Wells Radosveta , Baker Russell , Watts Susan
Published: May 2019

Patient refusal for care or transport is a common request to medical control physicians, and it is an especially challenging decision in the case of minors. Parents or guardians are able to refuse medical care for a minor if there is not an imminent threat of harm to the minor. However, if a minor patient is presumed to be in need of emergent medical care to prevent harm, medical personnel have the right to treat the minor, even if the parent or guardian objects. If the minor patient is a fetus or a neonate, it is not always clear when they are considered to be a separate patient. Apparently, there is no over-riding general rule or law and, consequently, Emergency Medical Services (EMS) protocols vary greatly from state to state. This case report describes one patient case that involved some of these unclear legal areas and how it fit with local EMS protocols. The legal question arose when a pregnant patient delivered her baby, but the umbilical cord was not cut. Are the mother’s rights violated by cutting the umbilical cord if she objects to the procedure? How is the medical control physician to decide when to go beyond established EMS protocols to ensure that the safest and most ethical care is provided to a patient in the field? Does the care of the infant or the mother take precedence? Continued analyses of cases are required to ensure that protocols and guidelines are protecting both patients and providers.

Venegas A, Ann Maggiore W, Wells R, Baker R, Watts S. Medical control decisions: when does a neonate become a separate patient? Prehosp Disaster Med. 2019;34(2):224–225
The psychosis proneness: psychosis persistence model as an explanation for the association between urbanicity and psychosis
Authors: Spauwen Janneke , Van Os Jim
Published: May 2019

Given the relatively high attributable risks associated with urbanicity it is crucially important to learn more on how this exposure impacts on population risk for schizophrenia. Further elucidation of the environmental influences that currently go under the name of “urbanicity” therefore is a crucial step in unravelling the etiology of schizophrenia. In order to make the step from association to cause, a plausible mechanism detailing the pathway from impact of exposure to onset of psychotic symptoms is needed. This paper outlines possible avenues and clues to the identification of possible mechanisms and pathways. The focus is on mechanisms of gene-environment interaction in the context of both functional genetic polymorphisms and epigenetic variation.
Disentangling associations between poverty at various levels of aggregation and mental health
Authors: Drukker Marjan , Gunther Nicole , van Os Jim
Published: May 2019

The present editorial discusses whether socioeconomic status of the individual and of the neighbourhood could be important in prevalence, treatment and prevention of psychiatric morbidity. Previous research showed that patients diagnosed with mental disorders are concentrated in socioeconomically disadvantaged areas. This could be the result of (1) an association between individual socioeconomic status and mental health, (2) an association between neighbourhood socioeconomic status and mental health, or (3) social selection. Research disentangling associations between individual and neighbourhood socioeconomic status on the one hand and mental health outcomes on the other, reported that neighbourhood socioeconomic disadvantage was associated with individual mental health over and above individual-level socioeconomic status, indicating deleterious effects for all inhabitants both poor and affluent. In conclusion, subjective mental health outcomes showed stronger evidence for an effect of neighbourhood socioeconomic status than research focussing on treated incidence. Within the group of patients, however, service use was higher in patients living in disadvantaged neighbourhoods. Social capital was identified as one of the mechanisms whereby neighbourhood socioeconomic disadvantage may become associated with observed reductions in mental health. After controlling for individual socioeconomic status, there is evidence for an association between neighbourhood socioeconomic status and objective as well as subjective mental health in adults. Evidence for such an association in young children is even stronger.
The diffusion and the reason for the use of complementary and alternative medicine among users of mental health services: a systematic review of literature
Authors: Pellegrini Nadia , Ruggeri Mirella
Published: May 2019

Aims- A systematic review of the studies on use of alternative and complementary medicine by mental health services' users to investigate the prevalence and motivations of CAM used to treat mental disorders.Methods- This paper shows a part of the results of a literature review, limited to studies between 1966 and 2005, was carried out using Ovid Medline, PsycINFO and EBM Reviews databases. This was supplemented by hand searching of reference lists.Results- Ninety-one studies on CAM's use by psychiatric patients were analyzed. In this paper the twenty-five articles about the CAM's prevalence and use's motivations are described. The use of complementary and alternative medicine (CAM) varies across countries: data suggest that from 50% to 80% of people suffering of mental disorders use CAM. Heterogeneous methods, samples and results characterizing the studies make generalizations results difficult. Patients motivations of CAM's use were poorly investigated by research, however it seems that persons affected by mental disorders use MAC prevalently because they are dissatisfied with conventional medicine and/or because these alternatives approaches are congruent with their own values, beliefs and philosophical orientation toward health care.Conclusions- The review emphasize the importance of a best physicians' education and information about CAM to improve the management of non-conventional and orthodox medicine relationship. The motivations of CAM's use underline the relevance of patient's holistic conception and the therapeutic role of a patient-physician relationship based on emphaty. Besides it seems important to investigate furtherly patients' psychological and social aspects that influence their choise to use CAM.