We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.
To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure no-reply@cambridge.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
To measure the impact of an automated hand hygiene monitoring system (AHHMS) and an intervention program of complementary strategies on hand hygiene (HH) performance in both acute-care and long-term care (LTC) units.
Single Veterans Affairs Medical Center (VAMC), with 2 acute-care units and 6 LTC units.
Methods:
An AHHMS that provides group HH performance rates was implemented on 8 units at a VAMC from March 2021 through April 2022. After a 4-week baseline period and 2.5-week washout period, the 52-week intervention period included multiple evidence-based components designed to improve HH compliance. Unit HH performance rates were expressed as the number of dispenses (events) divided by the number of patient room entries and exits (opportunities) × 100. Statistical analysis was performed with a Poisson general additive mixed model.
Results:
During the 4-week baseline period, the median HH performance rate was 18.6 (95% CI, 16.5–21.0) for all 8 units. During the intervention period, the median HH rate increased to 21.6 (95% CI, 19.1–24.4; P < .0001), and during the last 4 weeks of the intervention period (exactly 1 year after baseline), the 8 units exhibited a median HH rate of 25.1 (95% CI, 22.2–28.4; P < .0001). The median HH rate increased from 17.5 to 20.0 (P < .0001) in LTC units and from 22.9 to 27.2 (P < .0001) in acute-care units.
Conclusions:
The intervention was associated with increased HH performance rates for all units. The performance of acute-care units was consistently higher than LTC units, which have more visitors and more mobile veterans.
Background: We aim to assess the effect of simultaneous acute code stroke activation(ACSA) in patients undergoing reperfusion therapies in the emergency department on home time at 90 days. Methods: We assessed ACSA over 20 months from the QuICR(Quality Improvement and Clinical Research Alberta Stroke Program) Registry. We defined Simultaneous reperfusion therapy as, ACSA within 60 min of the arrival of any patient receiving intravenous thrombolysis or ACSA within 150 min of the arrival of any patient receiving endovascular thrombectomy (based on the Canadian Triage and Acuity Scale, average localdoor-to-needle and door-to-puncture times)Results: A total of 2607 ACSA occurred at a mean±SD of 130.8±17.1 per month during the study period. 545 (20.9%) underwent acute reperfusion therapy with a mean age of 70.6±14.2 years, 45.9%(n=254) were female and a median (IQR) NIHSS of 13(8-18). Simultaneous reperfusion therapies occurred in 189(34.6%). There was no difference in the median door-to-CT time between the simultaneous (16, 11-23 min) and non-simultaneous (15, 11–21 min, p=0.3) activations. There was no difference in the median home time at 90 days between the two groups. Conclusions: Simultaneous ACSA occurs in one-third of patients receiving acute reperfusion therapies. An optimal workflow may help mitigate the clinical and system burden associated with simultaneity.
The impact of tight stapes crimping on hearing is a matter of debate. Several studies postulate that tight crimping is essential for lifelong success, whereas others have debated whether firm attachment leads to incus necrosis. Several types of prostheses with different coupling mechanisms have been developed, and manual crimping remains the most frequently used technique. This study investigates whether tightness really does affect hearing outcome.
Methods
The hearing results of patients who underwent primary stapedotomies using three different titanium pistons were analysed. The surgeons categorised the firmness of the piston attachment into ‘tight’ and ‘loose’ crimping groups. Hearing outcome and reasons for revision surgical procedures were investigated.
Results
The mean post-operative air–bone gap for frequencies of 0.5–4 kHz was 8.80 dB for the tight crimping group (n = 308) and 9.55 dB for the loose crimping group (n = 39). No significant difference was found (p = 0.4650). Findings at revision procedures were comparable (1.6 per cent vs 5 per cent).
Conclusion
Although firm crimping is strongly advised, a movable loop upon palpation does not lead to unsatisfactory hearing results, and does not mandate piston replacement or bone cement use.
To determine how engagement of the hospital and/or vendor with performance improvement strategies combined with an automated hand hygiene monitoring system (AHHMS) influence hand hygiene (HH) performance rates.
The study was conducted in 58 adult and pediatric inpatient units located in 10 hospitals.
Methods:
HH performance rates were estimated using an AHHMS. Rates were expressed as the number of soap and alcohol-based hand rub portions dispensed divided by the number of room entries and exits. Each hospital self-assigned to one of the following intervention groups: AHHMS alone (control group), AHHMS plus clinician-based vendor support (vendor-only group), AHHMS plus hospital-led unit-based initiatives (hospital-only group), or AHHMS plus clinician-based vendor support and hospital-led unit-based initiatives (vendor-plus-hospital group). Each hospital unit produced 1–2 months of baseline HH performance data immediately after AHHMS installation before implementing initiatives.
Results:
Hospital units in the vendor-plus-hospital group had a statistically significant increase of at least 46% in HH performance compared with units in the other 3 groups (P ≤ .006). Units in the hospital only group achieved a 1.3% increase in HH performance compared with units that had AHHMS alone (P = .950). Units with AHHMS plus other initiatives each had a larger change in HH performance rates over their baseline than those in the AHHMS-alone group (P < 0.001).
Conclusions:
AHHMS combined with clinician-based vendor support and hospital-led unit-based initiatives resulted in the greatest improvements in HH performance. These results illustrate the value of a collaborative partnership between the hospital and the AHHMS vendor.
Background: Clinical outcomes following childhood arterial ischaemic stroke (AIS) depend on age at the time of stroke, infarct size and location. However, other important variables including health inequity and stroke onset to arrival times remain inadequately addressed. This study reported trends in health inequity and stroke onset to arrival times along with proximity to a stroke centre in Canada. Methods: Childhood AIS patients (N=234) with stroke onset between 2004-2019 at a Level 2 (comprehensive) stroke centre were included. Measures of material deprivation included household income, education, single-parent families, and housing quality. Patients were stratified into 3 cohorts (by date of stroke onset) and postal codes were categorized as minimal, moderate, or most deprived neighbourhoods. Results: Over the 16-year period, an increasing number of patients arrived from the most deprived neighbourhoods. Although, there was no significant association between material deprivation and stroke onset to arrival time, an increasing number of patients presented within 6 hours of stroke onset (χ2 = 13.8, p = 0.008). Furthermore, most patients arrived from urban neighbourhoods. Conclusions: The faster stroke onset to arrival trend is encouraging, however, material deprivation trends are concerning. Thus, future studies exploring post-stroke outcomes should consider material deprivation, stroke onset to arrival times, and geographical proximity.
Engineering changes are necessary to stay competitive, unavoidable and occur more frequently with increased product complexity. Currently, scheduling of engineering changes into production and supply chain is a manual process. With new possibilities in the field of artificial intelligence, this publication presents the vision of a flexible multi-agent system with four agents and a single shared database. By autonomously scheduling changes and predicting KPI impacts of implementation dates, the agent-system provides additional capacity and decision-making support to the organisation.
We present a software package for single-dish data processing of spacecraft signals observed with VLBI-equipped radio telescopes. The Spacecraft Doppler tracking (SDtracker) software allows one to obtain topocentric frequency detections with a sub-Hz precision and reconstructed and residual phases of the carrier signal of any spacecraft or landing vehicle at any location in the Solar System. These data products are estimated using the ground-based telescope’s highly stable oscillator as a reference, without requiring an a priori model of the spacecraft dynamics nor the downlink transmission carrier frequency. The software has been extensively validated in multiple observing campaigns of various deep space missions and is compatible with the raw sample data acquired by any standard VLBI radio telescope worldwide. In this paper, we report the numerical methodology of SDtracker, the technical operations for deployment and usage, and a summary of use cases and scientific results produced since its initial release.
Living organisms have engineered remarkable protein-based materials through billions of years of evolution. These multifunctional materials have unparalleled mechanical, optical, and electronic properties and have served as inspiration for scientists to study and mimic these natural protein materials. New tools from synthetic biology are poised to revolutionize the ability to rapidly engineer and produce proteins for material applications. Specifically, advancements in new production hosts and cell-free systems are enabling researchers to overcome the significant challenges of cloning and expressing large nonnative proteins. The articles in this issue cover the mechanical and rheological properties of structural protein materials and nanocomposites; advancements in the synthesis and assembly of optical, electronic, and nanoscale protein materials; and recent development in the processing of protein materials using liquid–liquid phase separation and three-dimensional printing.
Purposeful qualitative modelling of embodiment function relations is a challenge in embodiment design. This contribution investigates the applicability and usefulness of the Contact and Channel Approach as a qualitative modelling approach in a survey study. From 23 development and research projects, advantages and challenges regarding applicability and usefulness are identified. A further result is that many different models are used additionally to the Contact and Channel Approach. Based on the findings, research potential for optimization and development of links to other models emerges.
Introduction: Competency based medical education (CBME) has triggered widespread utilization of workplace-based assessment (WBA) tools in postgraduate training programs. These WBAs predominately use rating scales with entrustment anchors, such as the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE). However, little is known about the factors that influence a supervising physician's decision to assign a particular rating on scales using entrustment anchors. This study aimed to identify the factors that influence supervisors’ ratings of trainees using WBA tools with entrustment anchors at the time of assessment and to explore the experiences with and challenges of using entrustment anchors in the emergency department (ED). Methods: A convenience sample of full-time emergency medicine (EM) faculty were recruited from two sites within a single academic Canadian EM hospital system. Fifty semi-structured interviews were conducted with EM physicians within two hours of completing a WBA for an EM trainee. Interviews were audio-recorded, transcribed verbatim, and independently analyzed by two members of the research team. Themes were stratified by trainee level, rating and task. Results: Interviews involved 73% (27/37) of all EM staff and captured assessments completed on 83% (37/50) of EM trainees. The mean WBA rating of studied samples was 4.34 ± 0.77 (2 to 5), which was similar to the mean rating of all WBAs completed during the study period. Overall, six major factors were identified that influenced staff WBA ratings: amount of guidance required, perceived competence through discussion and questioning, trainee experience, clinical context, past experience working with the trainee, and perceived confidence. The majority of staff denied struggling to assign ratings. However, when they did struggle, it involved the interpretation of WBA anchors and their application to the clinical context in the ED. Conclusion: Several factors appear to be taken into account by clinical supervisors when they make decisions regarding the particular rating that they will assign a trainee on a WBA that uses entrustment anchors. Not all of these factors are specific to that particular clinical encounter. The results from this study further our understanding on the use of entrustment anchors within the ED and may facilitate faculty development regarding WBA completion as we move forward in CBME.
Agitation is a common symptom in schizophrenia and bipolar mania, causing marked distress and posing considerable risks for patients. Intramuscular formulations of psychotropic medication can provide a fast acting treatment of severe agitation in patients with acute episodes of schizophrenia or mania. As effective as these treatments are, particular antipsychotics can be associated with a heightened risk of dystonia and related Extrapyramidal Symptoms (EPS). Patients presenting to emergency care settings are also likely to have coexisting intoxications and medical conditions that may contribute to this risk.
Methods:
The aim of this observational prospective study was to document the safety and effectiveness of all IM psychotropic drugs during the 24 hours following an initial injection in acutely agitated patients suffering from schizophrenia or bipolar disorder under naturalistic conditions.
Results:
Two-hundred-thirty-two (232) participating investigator sites (12 European countries) observed 1940 patients (mean age: 39 y, 42% female, 66% schizophrenia diagnosis). The primary endpoint was the occurrence of extrapyramidal symptoms (EPS), further endpoints were clinical severity measured by PANSS-EC and CGI-S. A total of 1311 (68%) patients received a monotherapy injection at baseline. Within 24 hours after the first injection, 190 (10%) of all 1940 patients experienced EPS. All intramuscular psychotropic drugs were shown to be effective in reducing measures of acute agitation.
Conclusion:
This study provides favourable results on EPS related adverse events and effectiveness of intramuscular psychotropic medication for the management of acute agitation in patients within a naturalistic setting during the first 24 hours of treatment.
The aim of this study was to detect longitudinal differences in white matter brain structures in adults with schizophrenia compared to healthy controls.
Methods
Twenty adult patients with multi-episode schizophrenia under stable antipsychotic medication and twenty-two age- and sex-matched healthy subjects were included in the study. Diffusion Tensor Imaging (DTI) was applied at baseline (t1), after 6weeks (t2) and after 3months (t3) and data processing was done with tract-based spatial statistics (p<0.05, corrected). Two subjects in the schizophrenic sample dropped out at t2 and one healthy subject at t3. Clinical and neuropsychological variables were measured and correlated with the most significant DTI findings.
Results
Compared with healthy age- and sex-matched controls schizophrenic patients showed widespread decreases in mean fractional anisotropy values (p<0.05, corrected). The most obvious FA decrease in the long-term was found in the anterior part of the corpus callosum (p<0.005, corrected), the left temporal lobe (p<0.004, corr.) and the mid-cingulate gyrus bilateral (p<0.004, corr.). Correlations to demographic variables, clinical rating scales (PANSS, CGI and GAF), verbal learning and memory and working memory will be presented.
Conclusion
Magnetic resonance imaging was able to detect altered structural connectivity in patients with multi-episode schizophrenia in a longitudinal design.
This naturalistic, observational pan-European study assessed the safety and early effectiveness of intramuscular (IM) psychotropic treatments in patients with acute agitation suffering from schizophrenia or bipolar mania. One thousand nine hundred and forty of 1945 patients completed the 24-hour observation period after initial IM treatment. Patients from 12 European countries were included (mean age 39 years; 58% male, 66% schizophrenia). IM treatment was at the physician's discretion. The primary objective was to describe the acute tolerability of IM psychotropic therapies in clinical practice, with particular emphasis on EPS. At baseline, 68% of the patients received IM monotherapy, with IM olanzapine most commonly prescribed (36%). During the first 24hours, 190 (9.8%) patients experienced EPS. The occurrence of EPS was statistically significantly lower in patients treated with IM olanzapine compared to those treated with other IM psychotropic medications (mainly typical antipsychotics and benzodiazepines): acute dystonia: 1.1%, 95% CI 0.5–2.3 and 2.9%, CI 2.0–4.0; akathisia: 2.3%, CI 1.3–3.7 and 5.5%, CI 4.3–6.9; Parkinsonism: 2.9%, CI 1.8–4.4 and 7.8%, CI 6.4–9.4, respectively. Anticholinergic treatment was given to 12% IM olanzapine versus 31% non-olanzapine treated patients. Acute agitation after 24hours was reduced by 1.68 (95% CI 1.46–1.91) points on the Clinical Global Impression of Severity (CGI-S) in IM olanzapine patients and 1.51 (95% CI 1.30–1.73) points in non-olanzapine patients. Additional psychotropic medication was required for 90% of the patients during the first 24hours of treatment. Results provide naturalistic evidence for low EPS rates and improvement of agitation with IM psychotropic medications during acute states of patients suffering from acute mania or schizophrenia.
Pregabalin is a novel GABA-analogue approved for the treatment of partial onset seizures, neuropathic pain, and general anxiety disorder. Pregabalin has been classified as a Schedule V drug with a low risk of inflicting abuse or addiction. However, some publications have indicated that pregabalin may have a potential for abuse among patients with past or current opiate addiction.
Aims:
We hypothesized that pregabalin might be abused my patients who were undergoing an opiate replacement therapy and never had an indication for taking pregabalin on medical grounds.
Methods:
Urine specimens from 124 patients with opiate dependency syndrome and from 111 patients with other addiction disorders (alcohol, benzodiazepines, cannabis, amphetamines) were screened for pregabalin by means of a mass spectrometer analysis.
Results:
We found 12.1% of all urine specimens from patients with opiate addiction to be positive for pregabalin. None of the patients concerned had a medical indication for using pregabalin. In the control group, 2.7% of the patients were tested positively for pregabalin, due to their taking it regularly for chronic pain or general anxiety.
Conclusions:
Our data suggest that pregabalin is liable to be abused among patients with opiate dependency syndrome. Thus, vigilance and caution are called for when patients with a past or current opiate dependency are exposed to treatment with pregabalin.
Although male and female patients with major depression (MDD) differ in psychopathology and other illness characteristics, a potentially confounding effect of gender has not been systematically controlled or investigated in most of the previous neuroimaging studies.
Objectives
We investigated activation patterns during processing of ambiguous stimuli in MDD by functional MRI.
Aims
We aimed at examining potential activation differences between male and female patients.
Methods
A matching task was employed in which two stimuli with varying degrees of perceptual uncertainty had to be compared with respect to their sameness. Eighteen patients meeting DSM-IV criteria of MDD and eighteen healthy control subjects participated in this study.
Results
Whereas on the level of behavioral performance no significant group differences could be detected we found distinct disorder- and gender-related differences in the brain activation. Patients activated significantly stronger in superior parietal, prefrontal and cingulate regions. Gender specific analyses revealed that the hyperactivity in the patient group was mainly attributable to hyperactivity in the male patients who activated significantly stronger than the female patients in an extensive fronto-temporo-limbic network, which partly overlapped with the network we found when comparing patients and healthy controls.
Discussion
Our results indicate that male patients seem to be reliant on a significantly stronger metabolism in task-relevant regions to maintain an equal level of performance.
Conclusion
The present results provide evidence for gender-related differences in the functional organization of the brain in patients with MDD. Gender differences should be taken into consideration when investigating the neural correlates of MDD.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Gene × environment (G × E) interactions in eating pathology have been increasingly investigated, however studies have been limited by sample size due to the difficulty of obtaining genetic data.
Objective
To synthesize existing G × E research in the eating disorders (ED) field and provide a clear picture of the current state of knowledge with analyses of larger samples.
Method
Complete data from seven studies investigating community (n = 1750, 64.5% female) and clinical (n = 426, 100% female) populations, identified via systematic review, were included. Data were combined to perform five analyses: 5-HTTLPR × Traumatic Life Events (0–17 events) to predict ED status (n = 909), 5-HTTLPR × Sexual and Physical Abuse (n = 1097) to predict bulimic symptoms, 5-HTLPR × Depression to predict bulimic symptoms (n = 1256), and 5-HTTLPR × Impulsivity to predict disordered eating (n = 1149).
Results
The low function (s) allele of 5-HTTLPR interacted with number of traumatic life events (P < .01) and sexual and physical abuse (P < .05) to predict increased likelihood of an ED in females but not males (Fig. 1). No other G × E interactions were significant, possibly due to the medium to low compatibility between datasets (Fig. 1).
Conclusion
Early promising results suggest that increased knowledge of G × E interactions could be achieved if studies increased uniformity of measuring ED and environmental variables, allowing for continued collaboration to overcome the restrictions of obtaining genetic samples.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
One of the biggest challenges for in situ heating transmission electron microscopy (TEM) and scanning transmission electron microscopy (STEM) is the ability to measure the local temperature of the specimen accurately. Despite technological improvements in the construction of TEM/STEM heating holders, the problem of being able to measure the real sample temperature is still the subject of considerable discussion. In this study, we review the present literature on methodologies for temperature calibration. We analyze calibration methods that require the use of a thermometric material in addition to the specimen under study, as well as methods that can be performed directly on the specimen of interest without the need for a previous calibration. Finally, an overview of the most important characteristics of all the treated techniques, including temperature ranges and uncertainties, is provided in order to provide an accessory database to consult before an in situ TEM/STEM temperature calibration experiment.
Determine the impact of an automated hand hygiene monitoring system (AHHMS) plus complementary strategies on hand hygiene performance rates and healthcare-associated infections (HAIs).
Hand hygiene compliance rates were estimated using direct observations. An AHHMS, installed on 4 nursing units in a sequential manner, determined hand hygiene performance rates, expressed as the number of hand hygiene events performed upon entering and exiting patient rooms divided by the number of room entries and exits. Additional strategies implemented to improve hand hygiene included goal setting, hospital leadership support, feeding AHHMS data back to healthcare personnel, and use of Toyota Kata performance improvement methods. HAIs were defined using National Healthcare Safety Network criteria.
Results:
Hand hygiene compliance rates generated by direct observation were substantially higher than performance rates generated by the AHHMS. Installation of the AHHMS without supplementary activities did not yield sustained improvement in hand hygiene performance rates. Implementing several supplementary strategies resulted in a statistically significant 85% increase in hand hygiene performance rates (P < .0001). The incidence density of non–Clostridioies difficile HAIs decreased by 56% (P = .0841), while C. difficile infections increased by 60% (P = .0533) driven by 2 of the 4 study units.
Conclusion:
Implementation of an AHHMS, when combined with several supplementary strategies as part of a multimodal program, resulted in significantly improved hand hygiene performance rates. Reductions in non–C. difficile HAIs occurred but were not statistically significant.