Emergency Episodes Research Articles

Emergence of novel lineage of foot-and-mouth disease virus serotype Asia1 BD-18 (G-IX) in Bangladesh.

Foot-and-mouth disease virus (FMDV) is a highly evolutionary divergent pathogen causing great economic havoc in many countries. Among its seven existing serotypes, Asia1 is the least divergent with a single topotype both genetically and antigenically. It is reported sporadically in Indian subcontinent and was classified under lineage G-VIII. In 2018, serotype Asia1 re-emerged in Bangladesh after 2013, along with circulation of a novel serotype Asia1 BD-18 (G-IX) lineage. VP1 phylogeny and sequence variation clearly demonstrated the novel strains which was estimated to have at least>5% nucleotide divergence with distinct clade formation. Also, the Bayesian phylogeographic inferences traced back to the origin time of lineage G-IX in early 2017 and a possible origin in Bangladesh. Mutational analysis considering established eight lineages revealed that the virus strains belonged to lineage G-IX contained a unique mutation at 44 position in the B-C loop region of VP1. Inappropriate vaccination and inefficient outbreak surveillance possibly contributed to the current episode of emergence. Therefore, active surveillance and continued vigilance are essential to assess and timely detect the occurrence, extent and distribution of this novel Asia1 strains in Bangladesh and theneighbouring countries.

Toward Value-Based Healthcare through Interactive Process Mining in Emergency Rooms: The Stroke Case.

The application of Value-based Healthcare requires not only the identification of key processes in the clinical domain but also an adequate analysis of the value chain delivered to the patient. Data Science and Big Data approaches are technologies that enable the creation of accurate systems that model reality. However, classical Data Mining techniques are presented by professionals as black boxes. This evokes a lack of trust in those techniques in the medical domain. Process Mining technologies are human-understandable Data Science tools that can fill this gap to support the application of Value-Based Healthcare in real domains. The aim of this paper is to perform an analysis of the ways in which Process Mining techniques can support health professionals in the application of Value-Based Technologies. For this purpose, we explored these techniques by analyzing emergency processes and applying the critical timing of Stroke treatment and a Question-Driven methodology. To demonstrate the possibilities of Process Mining in the characterization of the emergency process, we used a real log with 9046 emergency episodes from 2145 stroke patients that occurred from January 2010 to June 2017. Our results demonstrate how Process Mining technology can highlight the differences between the flow of stroke patients compared with that of other patients in an emergency. Further, we show that support for health professionals can be provided by improving their understanding of these techniques and enhancing the quality of care.

PP133 Ensuring Secure Health Data Exchange Across Europe. The SHIELD Project

IntroductionData exchange protection is one of the main challenges in e-health. Nowadays, many people move from one country to another for various reasons, even though they may have chronic diseases or multiple pathologies. The main objective of the SHIELD project is to create an open and extendable security architecture, with supported privacy mechanisms that citizens can trust, to provide systematic protection for the storage and exchange of health data across European borders.MethodsepSOS is a European project that deals with the security and interoperability of e-health data, and has developed an Open National Contact Point (OpenNCP) architecture. For the initial validation of the framework, two OpenNCP virtual nodes were used to simulate the real nodes between Italy and Spain. For secure data exchange, different prototype tools were designed: end-to-end user interfaces (profiles for administrative staff, nurses, physicians, etc.); sensitivity and data hiding tools; consent management tools; report translation tools; and mobile device tampering detection tools.ResultsValidation scenarios (realistic use cases) were developed in Italy, Spain, and the United Kingdom. The first scenario was an Italian citizen traveling to Spain who has an acute emergency episode (e.g. stroke) and loses consciousness. The Spanish emergency department physician assisting the patient checks the patient's health record. The first round of SHIELD framework validations was successfully completed, and the results were presented to the European Commission.ConclusionsSecurity challenges need to be addressed when assessing e-health solutions. The challenges include issues with interoperability, confidentiality, availability, integrity, privacy, ethics, regulations, and e-health data. In addition, decisions must be made as to which data will be shared and how. The results of the initial validations provide a basis for the in-depth requirements analysis and for setting the main pillars of the SHIELD architecture design.

Psychiatric Day Hospital and Its Impact on Patients Clinical Stability: The Reality of Faro (Portugal) Unit

Psychiatric Day Hospitals are alternatives to classic hospitalization, staying in an intermediate position between full-time hospitalization and outpatient treatment. The main purpose of this work was to investigate the impact of the therapeutic program developed in a Psychiatric Day Hospital (of Faro-Portugal) on the clinical stability of the patients. It is a descriptive-correlational retrospective study, implemented through the consultation of the SCLINIC computer platform regarding the years 2015, 2016 and 2017. The records of 127 users were analysed. There was a predominance of mood disorders (n = 55; 43.3%), followed by schizophrenia, schizotypal and delusional disorders (n = 43, 33.9%). The majority of patients had a structured occupational plan after discharge (n = 106, 83.46%). In the year following the frequency of Day Hospital, compared to the year prior to admission, there was a reduction in the number of full-time hospitalizations, outpatient visitations/consultations, prescribed drugs and emergency episodes, with statistically significant differences. The positive impact of the frequency of Day Hospital had on patients’ clinical stability was the improvement in all studied variables. The Psychiatric Day Hospital of Faro-Portugal contributes to decreasing the number of full time hospitalizations, outpatient visitations/consultations and emergency episodes, maintaining patients’ clinical stability and reducing the public financial costs related to their therapeutic intervention.

Calcareous nannofossil, nummulite and ostracod assemblages from Paleocene to Miocene successions in the Bekaa Valley (Lebanon) and its paleogeographic implications

Paleogeographic interpretations have been carried out in Lebanon by means of paleontological analysis. This study is complementary to previous records which have explained the paleogeographic setting of the western side of Lebanon during the Cenozoic. Extensive fieldwork and sampling were performed in the area of Zahle (west part of the Bekaa Valley). Samples collected from this locality provided diverse microfossil assemblages. The results show that there is a major change in the paleogeographic setting during the transitional period extending from early Eocene to Miocene. These changes in paleogeographic setting resulted from repeated episodes of emergence and submergence due to oscillating tectonic movements, leading to variations in the sedimentation patterns across the Bekaa Basin. The new findings of calcareous nannofossils in the chalky facies of Zahle area frame the paleogeographic settings during the Paleocene and early Eocene. Regression was clearly recognized during the early middle Eocene, which was revealed by the change in marine setting from the deep in the early Eocene (represented by the chalky facies), to the shallow settings in the middle Eocene where the nummulite banks were formed. This sedimentation pattern appears to coincide with major break in the sea level curve already reported by many researchers. During the Oligocene, the collision between the African-Arabian and Eurasian plates started causing further uplift of the Lebanese structures and consequent partial erosion (non-sedimentation) of the above-mentioned lithologies. The sedimentation pattern during the Miocene in Lebanon reveals a major change shifting from a primarily marine regime to fully lacustrine.

Managing acutely aggressive or agitated people in a psychiatric setting: a survey in Lebanon.

Background: Violent patients constitute 10% of all psychiatric admissions. Treatment options and clinical practice interventions vary across the globe and no survey of practice in a Middle Eastern setting exists. Surveying treatments in Lebanon will show treatment interventions used in this part of the world and, most importantly, provide the treatment options that could potentially be used for clinical trials pertaining to emergency psychiatry. Methods: A survey of clinicians’ opinions and practice was conducted between July and August 2017 at the largest psychiatric hospital in Lebanon. Results: Five of seven experienced psychiatrists provided opinions when interviewed of their preferred intervention when dealing with an emergency psychiatric episode. Whilst this varied in detail, there was a consistent view that there should first be verbal control, then use of medications, and finally physical restrain of the patient. A total of 39 emergency episodes (28 people) occurred in the one month (64% men in their 30s). Bipolar disorder was the most frequent single diagnosis behind the aggression (n=16, 41%; 12 people 43%) but the combined schizophrenia-like illnesses underlay 18 of the 39 episodes (46%; 13/28 people 46%). In clinical life, we found evidence of high family involvement, but little attempts made at initial verbal control in the hospital. All 39 episodes involved administration of pharmacological interventions. Medications were used in 29 of cases (74%) and non-medication interventions used in the remaining 10/39 (26%). Conclusion: This survey provides some evidence that clinicians’ preferences may not fully reflect clinical practice but also that experienced clinicians are using several clearly effective techniques to manage these very difficult situations. However, as for other parts of the world, treatment in Lebanon has limited or no underpinning by evidence from well-designed, conducted and reported evaluative studies.

Frente a la emergencia. Una aproximación fenomenológica al territorio desde la Academia

The emergency episodes that have been generated in a cyclical and recurrent manner in the Chilean context are a consequence of the effects of climate change and deficient management at the time of planning the territory. Faced with this complex scenario, it is considered necessary to redefine the role and responsibility of academic teaching, and thus provide future professionals with the appropriate tools to efficiently address the present challenges. This implies a deep change of paradigm in the investigative scope, which will have as input to deepen in one of the dimensions less studied between those that configure the territory: the phenomenological one. The dynamic condition of its variables will mean a progress in the traditional operating methodology, generating new systems of representation and new approaches on an operative level. The character of its methodology in constant development, will change the way to approach the natural disasters: from giving a response to the extraordinary episode of the emergency, to evolve towards resilience. Phenomenology, a possible new line of academic research supported by the study of different case studies, will aim to tackle in a more efficient way the sustainable development of the territory.

Payment systems and hospital length of stay: a bunching-based evidence.

Despite the huge attention on the long average hospital length of stay (LOS) in Japan, there are limited empirical studies on the impacts of the payment systems on LOS. In order to shed new light on this issue, we focus on the fact that reimbursement for hospital care is linked to the number of patient bed-days, where a "day" is defined as the period from one midnight to the next. This "midnight-to-midnight" definition may incentivize health care providers to manipulate hospital acceptance times in emergency patients, as patients admitted before midnight would have an additional day for reimbursement when compared with those admitted after midnight. We test this hypothesis using administrative data of emergency transportations in Japan from 2008 to 2011 (N = 2,146,498). The results indicate that there is a significant bunching in the number of acceptances at the emergency hospital around midnight; the number heaps a few minutes before midnight, but suddenly drops just after midnight. Given that the occurrence of emergency episode is random and the density is smooth during nighttime, bunching in the number of hospital acceptances around midnight suggests that hospital care providers shift the hospital acceptance times forward by hurrying-up to accept the patients. This manipulation clearly leads to longer LOS by one bed-day. In addition, the manipulation is observed in the prefectures where private hospitals mainly provide emergency medical services, suggesting hospital ownership is associated with the manipulation of hospital acceptance time.

Peripheral Facial Palsy in Emergency Department.

Peripheral facial palsy (PFP) is commonly diagnosed in every emergency department. Despite being a benign condition in most cases, PFP causes loss in quality of life mostly due to facial dysmorphia. The etiology of PFP remains unknown in most cases, while medical opinion on epidemiology, risk factors and optimal treatment is not consensual. The aim of this study was to review the demographic characteristics of our patients and the medical care administered in our emergency department. Emergency episodes occurring in a 4-year period and codified as facial nerve pathology were analyzed. IBM SPSS software was used for statistical analysis. In total, 582 emergency episodes were obtained. Due to inexpressive representation of other causes of PFP in our study, we focused our analyses on the 495 patients who were considered to have idiopathic PFP. There was equal distribution among genders, and all age ranges were affected. There were no clear epidemic phenomena. Hypertension was not a statistically significant risk factor for Bell's palsy. Most patients sought medical care in the early stages of the disease and complained of isolated facial weakness. Most patients had mild-to-moderate symptoms. Previous upper way infections (PUAI) were more frequent among children. There was a statistically significant difference regarding computed tomography (CT) scan requests among specialties. Epidemiologic findings were consistent with most literature on Bell's palsy. Drug therapy is widely used and follows current guidelines. The role of PUAI in the pediatric population must be investigated. Despite evidence of good medical practice, there was an excess of CT scans requested by physicians other than otorhinolaryngologists.

Shock Connectivity and the Late Cycle 24 Solar Energetic Particle Events in July and September 2017

AbstractAs solar activity steadily declined toward the cycle 24 minimum in the early months of 2017, the expectation for major solar energetic particle (SEP) events diminished with the sunspot number. It was thus surprising (though not unprecedented) when a new, potentially significant active region rotated around the East limb in early July that by midmonth was producing a series of coronal eruptions, reaching a crescendo around 23 July. This series, apparently associated with the birth of a growing pseudostreamer, produced the largest SEP event(s) seen since the solar maximum years. Activity abated with the decay of the active region, but a second episode of magnetic flux emergence in the same area in early September initiated a new round of eruptions. The western longitude of the erupting region, together with its similar coronal setting in both cases, resulted in a set of nearly homologous multipoint SEP event periods at Earth, Solar TErrestrial RElations Observatory‐A and Mars (Mars Atmosphere and Volatile EvolutioN) for July and September 2017. We use a combination of WSA‐ENLIL‐cone heliospheric simulation results, together with SEPMOD SEP event modeling, to illustrate how the event similarities at the three observer sites can be understood from their relative positions and their connectivities to the generated interplanetary shocks.

The applicability of modern tidal analogues to pre‐vegetation paralic depositional models

AbstractIn modern siliciclastic environments terrestrial and aquatic vegetation binds substrate, controls weathering and erosion rates, influences run‐off, sediment supply and subsequent depositional architecture. This study assesses the applicability of modern depositional models that are impacted by vascular vegetation, as analogues for ancient pre‐land plant systems. A review of pre‐Devonian published literature demonstrates a paucity of described tidal successions; this is possibly due to the application of modern analogues for interpreting the record when there is a lack of tidal indicators. This paucity suggests a need for revised models of tidal deposition that consider the different environmental conditions prior to land plant evolution. This study examines the Ordovician–Silurian Tumblagooda Sandstone, which is exposed in the gorge of the Murchison River and coastal cliffs near Kalbarri, Western Australia. The Tumblagooda Sandstone comprises stacked sand‐rich facies, with well‐preserved bedforms and trace fossils. Previous interpretations of the depositional setting have proposed from a mixed sheet‐braided fluvial and intertidal flats; to a continental setting dominated by fluvial and aeolian processes. An enigmatic element is the rarity of mud‐rich facies preserved in the succession. Outcrop logging, facies and petrographic analysis record dominantly shallow water conditions with episodes of emergence. Abundant ichnotaxa indicate that marine conditions and bi‐directional flow structures are evidence for an intertidal and subtidal depositional environment. A macrotidal estuary setting is proposed, with evidence for tidal channels and repeated fluvial incursions. Physical and biogenic sedimentary structures are indicative of tidal conditions. The lack of clay and silt resulted in the absence of flaser or lenticular‐bedding. Instead cyclic deposition of thin beds and foreset bioturbation replaced mud drape deposits. Higher energy conditions prevailed in the absence of the binding activity of plants in the terrestrial and marine realm. This is suggestive of different weathering processes and a reduction in the preservation of some sedimentary features.

Routine hospital data - is it good enough for trials? An example using England's Hospital Episode Statistics in the SHIFT trial of Family Therapy vs. Treatment as Usual in adolescents following self-harm.

Background:Use of routine data sources within clinical research is increasing and is endorsed by the National Institute for Health Research to increase trial efficiencies; however there is limited evidence for its use in clinical trials, especially in relation to self-harm. One source of routine data, Hospital Episode Statistics, is collated and distributed by NHS Digital and contains details of admissions, outpatient, and Accident and Emergency attendances provided periodically by English National Health Service hospitals. We explored the reliability and accuracy of Hospital Episode Statistics, compared to data collected directly from hospital records, to assess whether it would provide complete, accurate, and reliable means of acquiring hospital attendances for self-harm – the primary outcome for the SHIFT (Self-Harm Intervention: Family Therapy) trial evaluating Family Therapy for adolescents following self-harm.Methods:Participant identifiers were linked to Hospital Episode Statistics Accident and Emergency, and Admissions data, and episodes combined to describe participants’ complete hospital attendance. Attendance data were initially compared to data previously gathered by trial researchers from pre-identified hospitals. Final comparison was conducted of subsequent attendances collected through Hospital Episode Statistics and researcher follow-up. Consideration was given to linkage rates; number and proportion of attendances retrieved; reliability of Accident and Emergency, and Admissions data; percentage of self-harm episodes recorded and coded appropriately; and percentage of required data items retrieved.Results:Participants were first linked to Hospital Episode Statistics with an acceptable match rate of 95%, identifying a total of 341 complete hospital attendances, compared to 139 reported by the researchers at the time. More than double the proportion of Hospital Episode Statistics Accident and Emergency episodes could not be classified in relation to self-harm (75%) compared to 34.9% of admitted episodes, and of overall attendances, 18% were classified as self-harm related and 20% not related, while ambiguity or insufficient information meant 62% were unclassified. Of 39 self-harm-related attendances reported by the researchers, Hospital Episode Statistics identified 24 (62%) as self-harm related while 15 (38%) were unclassified. Based on final data received, 1490 complete hospital attendances were identified and comparison to researcher follow-up found Hospital Episode Statistics underestimated the number of self-harm attendances by 37.2% (95% confidence interval 32.6%–41.9%).Conclusion:Advantages of routine data collection via NHS Digital included the acquisition of more comprehensive and timely trial outcome data, identifying more than double the number of hospital attendances than researchers. Disadvantages included ambiguity in the classification of self-harm relatedness. Our resulting primary outcome data collection strategy used routine data to identify hospital attendances supplemented by targeted researcher data collection for attendances requiring further self-harm classification.

Is small size at birth associated with early childhood morbidity in white British and Pakistani origin UK children aged 0\u20133? Findings from the born in Bradford cohort study

Low birthweight is associated with increased infant morbidity, poorer developmental outcomes and risk of adult disease and its prevention remains a public health priority. South Asian children are more likely to be born small and there is some debate around whether this is a normal phenomenon within this population or whether they have a greater risk of morbidity. We examined the association between small size at birth and morbidity in White British and Pakistani origin children aged 0–3 participating in the Born in Bradford cohort study. We included 4119 White British and 4731 Pakistani origin children and examined health service use (General Practitioner (GP) consultations, the most common prescribing categories (analgesics, antibiotics, bronchodilators), emergency and elective hospital episodes) as markers of morbidity, in children born small defined as: (i) low birthweight (< 2500 g) (ii) small for gestational age (SGA) using customised birth charts. We used negative binomial regression models to predict the adjusted incidence of morbidity markers. 8.7% of Pakistani and 5% of White British children were born with a low birthweight (< 2500 g). Using customised charts, these proportions were 15.3 and 6.2% respectively. Children born small in both groups irrespective of the criteria used, generally had a higher rate of episodes for morbidity markers compared to normal weight children. Incidence of GP consultations (IRR 1.48 (95% CI 1.27, 1.73) to 1.55 (95% CI 1.36, 1.76) depending on birthweight category), analgesic (IRR 1.76 (95% CI 1.37, 2.25) to 2.31 (95% CI 2.19, 2.45) and antibiotic prescriptions (IRR 1.13 (95% CI 0.08, 1.46) to 1.38 (95% CI 1.30, 1.48) and emergency hospital episodes (IRR 1.20 (95% CI 1.06, 1.36) to 1.46 (95% CI 0.92, 2.32), was higher in Pakistani origin children with either a low or normal birthweight. Being born small is associated with greater morbidity estimated by use of health services, in both White British and Pakistani origin children underlining the importance of public health policy to reduce low birthweight. Pakistani origin children access health services more frequently than White British children irrespective of birthweight and this has implications for health service planning in areas with South Asian populations.

Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC)

BackgroundWith a higher proportion of older people in the UK population, new approaches are needed to reduce emergency hospital admissions, thereby shifting care delivery out of hospital when possible and safe.Study aimTo evaluate the introduction of predictive risk stratification in primary care.ObjectivesTo (1) measure the effects on service usage, particularly emergency admissions to hospital; (2) assess the effects of the Predictive RIsk Stratification Model (PRISM) on quality of life and satisfaction; (3) assess the technical performance of PRISM; (4) estimate the costs of PRISM implementation and its effects; and (5) describe the processes of change associated with PRISM.DesignRandomised stepped-wedge trial with economic and qualitative components.SettingAbertawe Bro Morgannwg University Health Board, south Wales.ParticipantsPatients registered with 32 participating general practices.InterventionPRISM software, which stratifies patients into four (emergency admission) risk groups; practice-based training; and clinical support.Main outcome measuresPrimary outcome – emergency hospital admissions. Secondary outcomes – emergency department (ED) and outpatient attendances, general practitioner (GP) activity, time in hospital, quality of life, satisfaction and costs.Data sourcesRoutine anonymised linked health service use data, self-completed questionnaires and staff focus groups and interviews.ResultsAcross 230,099 participants, PRISM implementation led to increased emergency admissions to hospital [ΔL = 0.011, 95% confidence interval (CI) 0.010 to 0.013], ED attendances (ΔL = 0.030, 95% CI 0.028 to 0.032), GP event-days (ΔL = 0.011, 95% CI 0.007 to 0.014), outpatient visits (ΔL = 0.055, 95% CI 0.051 to 0.058) and time spent in hospital (ΔL = 0.029, 95% CI 0.026 to 0.031). Quality-of-life scores related to mental health were similar between phases (Δ = –0.720, 95% CI –1.469 to 0.030); physical health scores improved in the intervention phase (Δ = 1.465, 95% CI 0.774 to 2.157); and satisfaction levels were lower (Δ = –0.074, 95% CI – 0.133 to –0.015). PRISM implementation cost £0.12 per patient per year and costs of health-care use per patient were higher in the intervention phase (Δ = £76, 95% CI £46 to £106). There was no evidence of any significant difference in deaths between phases (9.58 per 1000 patients per year in the control phase and 9.25 per 1000 patients per year in the intervention phase). PRISM showed good general technical performance, comparable with existing risk prediction tools (c-statistic of 0.749). Qualitative data showed low use by GPs and practice staff, although they all reported using PRISM to generate lists of patients to target for prioritised care to meet Quality and Outcomes Framework (QOF) targets.LimitationsIn Wales during the study period, QOF targets were introduced into general practice to encourage targeting care to those at highest risk of emergency admission to hospital. Within this dynamic context, we therefore evaluated the combined effects of PRISM and this contemporaneous policy initiative.ConclusionsIntroduction of PRISM increased emergency episodes, hospitalisation and costs across, and within, risk levels without clear evidence of benefits to patients.Future research(1) Evaluation of targeting of different services to different levels of risk; (2) investigation of effects on vulnerable populations and health inequalities; (3) secondary analysis of the Predictive Risk Stratification: A Trial in Chronic Conditions Management data set by health condition type; and (4) acceptability of predictive risk stratification to patients and practitioners.Trial and study registrationCurrent Controlled Trials ISRCTN55538212 and PROSPERO CRD42015016874.FundingThe National Institute for Health Research Health Services Delivery and Research programme.

Surges and Si iv Bursts in the Solar Atmosphere: Understanding IRIS and SST Observations through RMHD Experiments

Abstract Surges often appear as a result of the emergence of magnetized plasma from the solar interior. Traditionally, they are observed in chromospheric lines such as Hα 6563 and Ca ii 8542 . However, whether there is a response to the surge appearance and evolution in the Si iv lines or, in fact, in many other transition region lines has not been studied. In this paper, we analyze a simultaneous episode of an Hα surge and a Si iv burst that occurred on 2016 September 03 in active region AR 12585. To that end, we use coordinated observations from the Interface Region Imaging Spectrograph and the Swedish 1-m Solar Telescope. For the first time, we report emission of Si iv within the surge, finding profiles that are brighter and broader than the average. Furthermore, the brightest Si iv patches within the domain of the surge are located mainly near its footpoints. To understand the relation between the surges and the emission in transition region lines like Si iv, we have carried out 2.5D radiative MHD (RMHD) experiments of magnetic flux emergence episodes using the Bifrost code and including the nonequilibrium ionization of silicon. Through spectral synthesis, we explain several features of the observations. We show that the presence of Si iv emission patches within the surge, their location near the surge footpoints and various observed spectral features are a natural consequence of the emergence of magnetized plasma from the interior to the atmosphere and the ensuing reconnection processes.

Volume or Value? The Role of the Radiologist in Managing Radiological Exams

The purpose of this study was to understand the reasons and quantify the number of ultrasounds and computed tomographies that are potentially wasted in the hospital emergency in our institution, and the importance that the radiologist can have in the management and screening of these exams. It was decided that urgent tests that were pending for more than seven days would be the object of analysis as to why they were not performed, consulting the electronic medical records. Six causes were used to cancel the requests: 'Changing the patient's status', 'Patient's withdrawal, refusal or abandonment', 'Patient's death'; 'No criteria or contraindicated', 'Lack of human resources' and 'Mistaken request'. In the year 2015 we obtained 1211 canceled exams, since they were pending more than a week ago. The first four causes totaled 602 exams (sum of 283, 94, 41 and 184). The last two, 609 (sum of 29 and 580). It was verified that the 602 exams corresponding to the sum of the first four causes reflected a potential waste in clinical tests since they were not determinant in the approach of the Emergency episode nor on the final destiny of the patient. Under the tip of the iceberg may exist further examinations and patients who have not escaped inadequate or unjustified examinations. The radiologist can better manage the required radiological examinations, effectively screening within a multidisciplinary team environment, promoting the development and supporting the respect of guidelines, and potentially reducing requests through opinions or second opinions.

A window into the Cambrian basement and early Carboniferous sedimentation of the Hathern Shelf: the British Geological Survey borehole at Ticknall, South Derbyshire, UK

The Ticknall Borehole was drilled in 1995 to a depth of 209 m in order to investigate the succession on the Hathern Shelf, a fault-bounded structural province that lies on the southern margin of the Widmerpool Half-graben, part of a major early Carboniferous rift system. The borehole demonstrated a ‘basement’ of Upper Cambrian cleaved mudrocks, correlated with the Stockingford Shale Group. Unconformably overlying this is a basal Carboniferous unit, the Calke Abbey Sandstone Formation, of probable Visean (?Holkerian) age, comprising 82.34 m of fluvial sandstones and conglomerates, with interbedded red-grey palaeosols exhibiting highly distinctive ‘pseudogley’ fabrics indicative of emergent episodes. The unit may have been deposited in a localized, possibly fault-controlled basin and was in part sourced from the Precambrian volcanic terrain of Charnwood Forest. As rifting and subsidence proceeded, the encroachment of nearshore/peritidal environments is indicated at the top of the formation by interbedded calcilutites that have yielded marine faunas. Fully marine conditions were established during deposition of the overlying Peak Limestone Group, comprising the early Asbian Cloud Hill Dolostone Formation succeeded by the Ticknall Limestone Formation, of Brigantian age. Comparisons between the Ticknall Borehole and Peak Limestone strata exposed in quarries farther east, around Breedon, show major changes in water depths over a distance of only 4.5 km. Such variations can be reconciled with seismostratigraphical studies in the adjacent Widmerpool Half-graben, which show that sedimentation on the Hathern Shelf was in part controlled by movements along nearby rift-bounding faults.

Study to evaluate the interruption of care on the Phoenix centre for rehabilitation

In the phoenix centre for rehabilitation, patients receive ongoing rehabilitation by the means of goal directed physiotherapy, occupational therapy, psychology and other members of the MDT. This ongoing care on occasions is interrupted by both planned and unplanned events. The aim of the study was to identify the number of patients that had episode(s) of interrupted care, onset of interruption, identifying the nature of interruption as well as the age groups and patient category at risk of interruptions. Also, to monitor the impact on rehabilitation by the means of FIM and FAM and RCS scores. Retrospective study that included all admissions to the Phoenix rehabilitation unit from May 2015 to June 2016. Data was collected from patients’ notes, investigations and blood results as well as from the Rehabilitation network Discharge summaries. Ten patients out of 77 (13%) admissions required interruption of their care and transferred to acute services. A total of 17 episodes occurred: 11 unplanned (emergency) episodes and 6 planned episodes. Higher age groups (> 60 years) had higher incidence of interruption of care. The 1st week of admission had the highest number of interruptions. Neurology patients had the most interruptions to their care. Sepsis was the main reason for unplanned (emergency) transfer and chemotherapy treatment was main reason for planned transfers. Successful Improvement in FIM and FAM scores as well as reduction in RCS score was noted for all patients despite interruption of care. The study showed the need for closer monitoring of higher age groups and closer monitoring in the first week of admission. More emphasis on infection control measures and means to reduce the risk of sepsis. Despite interruption of care most patients’ assessment, scores showed successful improvement in targeted function. We aim to extend the study to involve a larger cohort of patients.

Rumbles and Bangs: Innovation, Contention, and the Emergence of New Industries

While the stages of industry emergence have received much attention from researchers, emergence triggers remain an understudied topic. In this paper, I argue that understanding the triggers for industry emergence is a necessary foundation for any predictive models of emergence. I construct a typology for industry emergence triggers based on the two main dimensions that researchers have used in prior research: technological innovation and contention. The conflation of these two dimensions reveals a tendency for most of available research to focus on emergence episodes happening as a result of radical innovations or highly contentious stakeholders’ interactions. To further validate the typology, I present a case study for the emergence of the secondary phosphorus industry in the Netherlands as an example of an emergence episode in the absence of radical technological innovation and/or highly contentious relationships between stakeholders. I use a combination of in- depth interviews and trade publications an...

Effect of social deprivation on the admission rate and outcomes of adult respiratory emergency admissions

BackgroundPatients with respiratory disorders constitute a major source of activity for Acute Medicine. We have examined the impact of Socio-Economic Status (SES) and weather factors on the outcomes (30-day in-hospital mortality) of emergency hospitalisations with a respiratory presentation. MethodsAll emergency respiratory admissions to St. James Hospital, Dublin, from 2002 to 2014 were evaluated. Patients were categorized by quintile of Deprivation Index, and evaluated against hospital admission rate (/1000 population) and 30-day in-hospital mortality. Univariate and multivariable risk estimates (Odds Ratios (OR) or Incidence Rate Ratios (IRR)) were calculated, using logistic or zero truncated Poisson regression as appropriate. ResultsThere were 32,538 episodes in 14,093 patients, representing 39.5% of medical emergency episodes over the 13-yr period. Deprivation Quintile independently predicted the admission rate, with incidence rate ratios (IRR) of Q3 2.02 (95% CI: 1.27, 3.23), Q4 2.55 (95% CI: 1.35, 4.83) and Q5 5.68 (95% CI: 3.56, 9.06). The 30-day in-hospital mortality for the highest quintile was increased (p < 0.01), Q5 1.31 (95% CI: 1.07, 1.61). Particulate matter (PM10) was predictive for the top two quintiles (>17.2 and 23.8 μg/m3 respectively) with an OR for a worse outcome of Q4 1.22 (95% CI: 1.07, 1.40) and Q5 1.24 (95% CI: 1.08, 1.42). Weather (season) and the daily temperature did not affect the admission rate but were significantly associated with worse outcome. ConclusionSocio-Economic Status influences the admission rate incidence and hospital mortality of respiratory emergency admissions; local environmental conditions (air pollution and temperature) appear only relevant to the mortality outcomes.