Proportion Of Calls Research Articles

A single-sample gene-expression classifier for the intrinsic consensus molecular subtypes in colorectal cancer.

e15587 Background: An analysis of colorectal cancer epithelial cells showed two intrinsic subtypes called iCMS2 and iCMS3, in addition to the bulk consensus subtypes (CMS1-4). The intrinsic subtypes are prognostically important. We present a robust method for calculating the iCMS subtypes in individual samples, as opposed to batches, applicable in a clinical setting. Methods: We selected the subset of iCMS genes (N = 201) with the strongest epithelial expression in colorectal cancer, aiming to reduce the signal from other cell types. We then calculated gene expression centroids by taking the per-gene mean expression of 8 random samples from three non-batch corrected datasets (1779 samples total) that were previously used to derive the iCMS subtypes. Thirty-two centroids were calculated per dataset and per iCMS, for a total of 192 centroids. The single sample classifier (SSC) calculates the most likely iCMS class based on the class of the nearest centroid by non-parametric correlation distance. A confident call is made when the correlation is at least 0.1 and distance from the nearest centroid of the opposite iCMS class is greater than 0.05. Results: The SSC achieved 98.3% agreement with the reference calls in training data. The SSC was applied to unseen data for validation, by classifying non-batch corrected samples one at a time. The same data were clustered with the reference published iCMS public dataset and the reference iCMS was estimated at the batch level by proximity to reference samples in the hierarchical tree structure. Concordance between reference and SSC calls was 91.4% in non-batch corrected data and only modestly improved to 93.9% when batch correction was applied, showing the robustness of this approach. Concordance remained acceptable even when non-confident SSC calls were included (86.9%). The proportion of calls that were judged confident with the SSC was 77.9%, slightly lower than the proportion of confident reference calls (87.6%). In addition, the SSC was applied to data from the VELOUR trial, for which reference iCMS calls were also available. The SSC iCMS was prognostic (HR 0.601 for OS in iCMS2 vs iCMS3, P < 0.00001) and performed at least as well as the reference iCMS (HR 0.669, P = 0.0004). Conclusions: The SSC reproduces the iCMS classification and appears robust to batch effect. The SSC calls are prognostic in clinical trial data. The SSC R package is available for download (https://github.com/CRCrepository/iCMS.SSC). [Table: see text]

Refining ambulance clinical response models: The impact on ambulance response and emergency department presentations.

The ambulance service in Victoria, Australia implemented a revised clinical response model (CRM) in 2016 which was designed to increase the diversion of low-acuity Triple Zero (000) calls to secondary telephone triage and reduce emergency ambulance dispatches. The present study evaluates the influence of the revised CRM on emergency ambulance response times and ED presentations. A retrospective study of emergency calls for ambulance between 1 January 2015 and 31 December 2018. Ambulance data were linked with ED presentations occurring up to 48 h after contact. Interrupted time series analyses were used to evaluate the impact of the revised CRM. A total of 2 365 529 calls were included. The proportion allocated a Code 1 (time-critical, lights/sirens) dispatch decreased from 56.6 to 41.0% after implementation of the revised CRM. The proportion of calls not receiving an emergency ambulance increased from 10.4 to 19.6%. Interrupted time series analyses demonstrated an improvement in Code 1 cases attended within 15 min (Key Performance Indicator). However, for patients with out-of-hospital cardiac arrest or requiring lights and sirens transport to hospital, there was no improvement in response time performance. By the end of the study period, there was also no difference in the proportion of callers presenting to ED when compared with the estimated proportion assuming the revised CRM had not been implemented. The revised CRM was associated with improved Code 1 response time performance. However, there was no improvement in response times for high acuity patients, and no change in the proportion of callers presenting to ED.

Advantages of using a portable cardiac monitor in outpatients with paroxysmal atrial fibrillation

Aim. To study the advantages of using a portable electrocardiographic (ECG) monitor in outpatients with paroxysmal atrial fibrillation (AF).Material and methods. We examined 88 patients (26 men, 62 women, mean age, 63 [57;68] years) with paroxysmal AF with an average frequency of arrhythmia episodes of 1,0 [0.3;3.75] per month. Forty three (49%) patients were included in the remote monitoring (RM) group using the ECG Dongle monitor, and 45 (51%) patients were included in the conventional monitoring (CM) group. Patients underwent scheduled examinations 2, 6 and 12 months after the start of therapy. Unscheduled consultations were carried out in case of AF recurrence. Patients from the RM group, using portable cardiac monitor, additionally self-registered ECG 1 time per week and in case of symptoms suggestive of AF. ECG strips were sent to the clinical investigator for analysis.Results. With the help of portable cardiac monitor, 2477 ECG strips were collected and analyzed: 2159 (87,2%) — sinus rhythm, 318 (12,8%) — AF and atypical atrial flutter. Forty four episodes of AF in 3 patients were asymptomatic. In addition, 211 (8,5%) sinus rhythm ECG strips were recorded by 13 patients with symptoms suggestive of AF. In the RM group, 7 (16%) patients were hospitalized due to recurrent AF, while in the CM group, 20 (44%) patients (p=0,004). The total number of emergency hospitalizations was 8 and 29 in the RM and CM groups, respectively. The number of patients who called an ambulance was significantly lower in the RM group: in the CM group, 37 calls for an ambulance were made by 22 patients, while in the RM group — 12 patients made 15 calls (p=0,044). The proportion of calls followed by hospitalization (40 vs 70%, p=0,043) was significantly lower in the RM group.Conclusion. Remote ECG monitoring using the ECG Dongle system is a useful way to monitor patients with paroxysmal AF, which make it possible to register asymptomatic AF episodes, differentiate the causes of palpitations, and significantly reduce the frequency of emergency calls and hospitalizations.

Level of Suicidal Ideation Among Callers to the Danish Suicide Prevention Helpline

Objective The aim of this study was to: (1) determine the proportion of callers to a national helpline for suicide prevention who were evaluated to be at risk of suicide; (2) identify characteristics associated with being at risk; (3) determine the level of suicidal ideation among callers, as measured by a clinical scale, and compared to the general population. Method Data on all calls answered at the Danish helpline for suicide prevention during 2018–2019 were analyzed. These consisted of socio-demographic covariates and items related to suicidality, including the Suicidal Ideation Attribute Scale (SIDAS). Data on SIDAS for the general population derived from a survey. Being at risk of suicide, as evaluated by the counselors, was examined as outcome in adjusted logistic regressions. Results Among 42,393 answered calls, 24,933 (59%) related to personal concerns. Of these, 47% and 14% of callers, respectively, had suicidal thoughts and concrete suicidal plans, while 53% were evaluated to be at risk. Higher risks were found when issues related to self-harm, mental health problems, eating disorders, incest, physical health problems, substance abuse, or sexual assault were mentioned. In all 37% of callers who were administered the SIDAS scale were evaluated to be at high risk of suicide compared to 1.5% in the general population. Conclusions A substantial share of callers to a national helpline for suicide prevention were evaluated to be at risk of suicide, also when using a clinical scale. This emphasizes the potential for counselors to prevent suicidal behavior. Highlights More than half of callers reaching out to the helpline were evaluated to be at risk of suicide, and 37% were identified as being at high risk using SIDAS, a clinical scale. Being woman, of younger age, having a history of previous suicide attempt as well as experiencing problems related to self-harm, mental disorders, sexual assault, substance abuse, and physical health problems was associated with risk of suicide, as evaluated by counselors. This seemingly is the first study to compare clinical scores of helpline callers to those of the general population and significantly higher levels of suicidal ideation were found among helpline callers.

Call volume, triage outcomes, and protocols during the first wave of the COVID-19 pandemic in the United Kingdom: Results of a national survey.

ObjectivesDuring the first wave of the COVID‐19 pandemic in the United Kingdom (UK), to describe volume and pattern of calls to emergency ambulance services, proportion of calls where an ambulance was dispatched, proportion conveyed to hospital, and features of triage used.MethodsSemistructured electronic survey of all UK ambulance services (n = 13) and a request for routine service data on weekly call volumes for 22 weeks (February 1–July 3, 2020). Questionnaires and data request were emailed to chief executives and research leads followed by email and telephone reminders. The routine data were analyzed using descriptive statistics, and questionnaire data using thematic analysis.ResultsCompleted questionnaires were received from 12 services. Call volume varied widely between services, with a UK peak at week 7 at 13.1% above baseline (service range ‐0.5% to +31.4%). All services ended the study period with a lower call volume than at baseline (service range ‐3.7% to ‐25.5%). Suspected COVID‐19 calls across the UK totaled 604,146 (13.5% of all calls), with wide variation between services (service range 3.7% to 25.7%), and in service peaks of 11.4% to 44.5%. Ambulances were dispatched to 478,638 (79.2%) of these calls (service range 59.0% to 100.0%), with 262,547 (43.5%) resulting in conveyance to hospital (service range 32.0% to 53.9%). Triage models varied between services and over time. Two primary call triage systems were in use across the UK. There were a large number of products and arrangements used for secondary triage, with services using paramedics, nurses, and doctors to support decision making in the call center and on scene. Frequent changes to triage processes took place.ConclusionsCall volumes were highly variable. Case mix and workload changed significantly as COVID‐19 calls displaced other calls. Triage models and prehospital outcomes varied between services. We urgently need to understand safety and effectiveness of triage models to inform care during further waves and pandemics.

Telemedicine in Oculoplastics: The Real-Life Application of Video Consultation Clinics.

Our oculoplastic service piloted a new video consultation (VC) clinic in response to the COVID-19 pandemic. Data were collected to determine whether specific patients are better suited to VC, and to quantify the true benefit of VC in patients that successfully attended. Data were collected prospectively on predetermined data collection forms, including consultation duration, diagnosis, management plan, and issues that arose. 37.8% of new referrals and 60.9% of return patients were vetted as suitable for VC. Of those invited to attend, 83.4% agreed to a VC appointment. Of the patients appointed to a VC clinic, 71.7% (new)/75% (return) successfully completed VC, 14.9%/15.8% attempted a VC which ultimately failed, and 13.4%/9.2% did not attend. VC successfully prevented face-to-face consultation in 81.3% of new cases and 91.1% of returns. Ectropion, entropion and dermatochalasis (new referrals), and postoperative follow-up (return patients) were well suited to VC, while patients with "watery eye" (new), and lid or conjunctival lesions (return), often required face-to-face consultation. Problems (most common issues with patients connecting to the consultation, video quality, and audio quality) were encountered during 50.3% of calls, although 82.6% of attempted calls were ultimately successful. Age was not associated with the proportion of calls that were successful. VC is a useful tool for oculoplastic patients, irrespective of age, as long as the patient's notes/referrals are carefully vetted to determine suitability. Patients with ectropion, entropion and dermatochalasis, and postoperative reviews are better suited to VC than those with "watery eye," lid lesions, and conjunctival lesions.

Predictors of recognition of out of hospital cardiac arrest by emergency medical services call handlers in England: a mixed methods diagnostic accuracy study

BackgroundThe aim of this study was to identify key indicator symptoms and patient factors associated with correct out of hospital cardiac arrest (OHCA) dispatch allocation. In previous studies, from 3% to 62% of OHCAs are not recognised by Emergency Medical Service call handlers, resulting in delayed arrival at scene.MethodsRetrospective, mixed methods study including all suspected or confirmed OHCA patients transferred to one acute hospital from its associated regional Emergency Medical Service in England from 1/7/2013 to 30/6/2014. Emergency Medical Service and hospital data, including voice recordings of EMS calls, were analysed to identify predictors of recognition of OHCA by call handlers. Logistic regression was used to explore the role of the most frequently occurring (key) indicator symptoms and characteristics in predicting a correct dispatch for patients with OHCA.ResultsA total of 39,136 dispatches were made which resulted in transfer to the hospital within the study period, including 184 patients with OHCA. The use of the term ‘Unconscious’ plus one or more of symptoms ‘Not breathing/Ineffective breathing/Noisy breathing’ occurred in 79.8% of all OHCAs, but only 72.8% of OHCAs were correctly dispatched as such. ‘Not breathing’ was associated with recognition of OHCA by call handlers (Odds Ratio (OR) 3.76). The presence of key indicator symptoms ‘Breathing’ (OR 0.29), ‘Reduced or fluctuating level of consciousness’ (OR 0.24), abnormal pulse/heart rate (OR 0.26) and the characteristic ‘Female patient’ (OR 0.40) were associated with lack of recognition of OHCA by call handlers (p-values < 0.05).ConclusionsThere is a small proportion of calls in which cardiac arrest indicators are described but the call is not dispatched as such. Stricter adherence to dispatch protocols may improve call handlers’ OHCA recognition. The existing dispatch protocol would not be improved by the addition of further terms as this would be at the expense of dispatch specificity.

Calls to a State Poison Center Concerning Cleaners and Disinfectants From the Onset of the COVID-19 Pandemic Through April 2020.

An increased use of disinfectants during the coronavirus disease 2019 (COVID-19) pandemic may increase the number of adverse health effects among people who apply them or among those who are in the area being disinfected. For the 3-month period from January 1 to March 30, 2020, the number of calls about exposure to cleaners and disinfectants made to US poison centers in all states increased 20.4%, and the number of calls about exposure to disinfectants increased 16.4%. We examined calls about cleaners and disinfectants to the Michigan Poison Center (MiPC) since the onset of the COVID-19 pandemic. We compared all calls related to exposure to cleaners or disinfectants, calls with symptoms, and calls in which a health care provider was seen during the first quarters of 2019 and 2020 and in relationship to key COVID-19 dates. From 2019 to 2020, the number of all disinfectant calls increased by 42.8%, the number of calls with symptoms increased by 57.3%, the average number of calls per day doubled after the first Michigan COVID-19 case, from 4.8 to 9.0, and the proportion of calls about disinfectants among all exposure calls to the MiPC increased from 3.5% to 5.0% (P < .001). Calls for exposure to cleaners did not increase significantly. Exposure occurred at home for 94.8%97.1% of calls, and ingestion was the exposure route for 59.7% of calls. Information about the adverse health effects of disinfectants and ways to minimize exposure should be included in COVID-19 pandemic educational materials.

264 Trends and Characteristics of Fentanyl Exposures Reported to the US Poison Centers

Overdoses due to synthetic opioids increased by 45% between 2016 and 2017, primarily driven by fentanyl and analogs. Although between 2016 and 2017, more than 5 million prescriptions were dispensed, there is a paucity of nationally representative U.S. fentanyl overdose data. This study aims to examine the national trends in tramadol exposures reported to U.S. poison centers (PCs). The National Poison Data System (NPDS) was queried for all fentanyl exposures from 2013 to 2019. We identified and descriptively assessed the relevant demographic and clinical characteristics. Fentanyl reports from acute care hospitals and Emergency Departments (ACHs) were analyzed as a sub-group. Trends in frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2013) were reported with the corresponding 95% confidence intervals (95% CI). There were 12,843 fentanyl exposures reported to the PCs from 2013 to 2019, with the calls increasing from 1,544 to 2,761 during the study period. Confirmed reports of illicit fentanyl overdoses grew from 3 reports in 2013 to 141 in 2019. The proportion of calls from ACH increased from 64% to 67.4% during the study. Multiple substance exposures accounted for 69.9% of the overall fentanyl calls and 53.4% of the calls from ACH. The most frequent co-occurring substances reported were benzodiazepines (15.5%) and heroin (7.2%). Residence was the most common site of exposure (80.1%) and 73.1% cases were enroute to the hospital when the PC was notified. Tachycardia and respiratory depression were the most frequently demonstrated clinical effects. Naloxone was a reported therapy for 44.1% cases, with this therapy being performed prior to PC contact in most cases. Demographically, 55.5% of cases were males, and the most frequent age groups were 20-29 years (22.5%) and 30-39 years (21.3%). Intentional misuse (41.4%) and suspected suicides (16.8%) were commonly observed reasons for exposure, with the proportion of suicides being higher in cases reported by ACH (22.8%). Approximately 22% of the patients reporting fentanyl exposures were admitted to the critical care unit (CCU). Major effects were seen in 18.2% cases and the case fatality rate was 9.2%, with deaths increasing significantly during the study period (62 deaths in 2013 to 1,184 deaths in 2019). The frequency of exposures increased by 78.8% (95% CI: 68%, 90.3%; p<0.001), and the rate of exposures increased by 82.3% (95% CI: 36.3%, 143.9%; p<0.001). PC data demonstrated an increasing trend of fentanyl exposures, which may in part be attributed to the due to increased use of illegally or illicitly made fentanyl. A significant proportion of fentanyl exposures were associated with intentional abuse, suicide and increasing mortality. Fentanyl exposure reports from acute care hospitals and EDs during the study increased.

Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed?

Background Emergency Medical Services (EMS) often respond to 911 calls using red lights and sirens (RLS). RLS is associated with increased collisions and increased injuries to EMS personnel. While some patients might benefit from time savings, there is little evidence to guide targeted RLS response strategies. Objective To describe the frequency and nature of 911 calls that result in potentially life-saving interventions (PLSI) during the call. Methods Using data from ESO (Austin, Texas, USA), a national provider of EMS electronic health records, we analyzed all 911 calls in 2018. We abstracted the use of RLS, call nature, and interventions performed. A liberal definition of PLSI was developed a priori through a consensus process and included both interventions, medications, and critical hospital notifications. We calculated the proportion of calls with RLS response and with PLSI performed, both overall and stratified by call nature. Results There were 5,977,612 calls from 1,187 agencies included in the analysis. The majority (85.8%) of calls utilized RLS, yet few (6.9%) resulted in PLSI. When stratified by call nature, cardiac arrest calls had the highest frequency PLSI (45.0%); followed by diabetic problems (37.0%). Glucose was the most frequently given PLSI, n = 69,036. When including multiple administrations to the same patient, epinephrine was given most commonly PLSI, n = 157,282 administrations). Conclusion In this large national dataset, RLS responses were very common (86%) yet potentially life-saving interventions were infrequent (6.9%). These data suggest a methodology to help EMS leaders craft targeted RLS response strategies.

Dissemination Strategies and Usage of Psychological Assistance Hotlines During the COVID-19 Outbreak in China

When the 2019 novel coronavirus disease (COVID-19) was rapidly spreading in China in early 2020, China’s National Health Commission quickly responded to the psychological crisis by issuing guidelines for establishing mental health intervention systems, including providing psychological assistance hotlines. However, recent critiques have emphasized China’s lack of pre-established mental health interventions which resulted in an inefficient response. This is the first empirical study to systematically examine mental health service use in China during the COVID-19 outbreak. The current study focused on the use of mental health hotlines in a Northern Chinese region. This region originally had a regional level hotline. During the outbreak, 12 out of its 16 sub-regional juridical areas started providing their own hotlines. Data regarding the regional level hotline and the 12 sub-regional level hotlines were obtained, including daily number of calls received, strategies for disseminating hotline services, and callers’ expressed concerns. Confirmed COVID-19 cases in China, in the region, and in each of the sub-regional juridical area were also recorded daily during China’s peak period of COVID-19. Analyses of these data revealed that the mental health hotlines tended to have low usage overall. Hotlines that merely provided their numbers to community centers and quarantine centers tended to receive few calls. Hotlines that encouraged individuals to advertise the service on personal social media accounts tended to receive more calls. The daily number of confirmed COVID-19 cases in the country was closely related the number of phone calls received at the regional hotline. Sub-regional hotline operators reported that a significant proportion of callers had concerns about contracting COVID-19, negative emotions from prolonged social isolation, and family conflicts while stay-at-home policies were implemented. It was also observed that the sub-regional level hotlines did not start until COVID-19 cases in the country started to decline. Overall, the psychological assistance hotlines provided during COVID-19 satisfied some mental health needs. However, consistent with recent commentaries, the hotline services were not established during the time that demand likely peaked. Future studies are warranted to determine the best strategies to improve the accessibility of mental health hotline services.

Automated identification of avian vocalizations with deep convolutional neural networks

AbstractPassive acoustic monitoring is an emerging approach to wildlife monitoring that leverages recent improvements in automated recording units and other technologies. A central challenge of this approach is the task of locating and identifying target species vocalizations in large volumes of audio data. To address this issue, we developed an efficient data processing pipeline using a deep convolutional neural network (CNN) to automate the detection of owl vocalizations in spectrograms generated from unprocessed field recordings. While the project was initially focused on spotted and barred owls, we also trained the network to recognize northern saw‐whet owl, great horned owl, northern pygmy‐owl, and western screech‐owl. Although classification performance varies across species, initial results are promising. Recall, or the proportion of calls in the dataset that are detected and correctly identified, ranged from 63.1% for barred owl to 91.5% for spotted owl based on raw network output. Precision, the rate of true positives among apparent detections, ranged from 0.4% for spotted owl to 77.1% for northern saw‐whet owl based on raw output. In limited tests, the CNN performed as well as or better than human technicians at detecting owl calls. Our model output is suitable for developing species encounter histories for occupancy models and other analyses. We believe our approach is sufficiently general to support long‐term, large‐scale monitoring of a broad range of species beyond our target species list, including birds, mammals, and others.

Distribution of a photographic atlas did not reduce postoperative care utilization after pediatric circumcision or the indispensability of the pediatric urology clinic nurse

Surgery in children is increasingly ambulatory, and caregiver responsibilities for postoperative care can produce anxiety. Prior studies have suggested the distribution of a photographic atlas can mitigate caregiver anxiety and reduce clinic phone calls and in-person presentations after pediatric penile surgery. A pilot study of the ability of a photographic atlas, distributed to caregivers, was aimed to be conducted to reduce postoperative resource utilization. Patients undergoing circumcision or revision circumcision were randomized to standard postoperative instructions vs. standard instructions with a photographic atlas representing appropriate penile appearance at successive time points. Electronic records were reviewed for phone calls or in-person presentations to the clinic or emergency department (ED) within 1 month of surgery. Fourteen patients (44%) received the atlas, and 18 (56%) did not. Patients who received the atlas did not differ significantly from patients who did not receive it in their rate of clinic phone calls (36% vs 39%, p=0.85), calls per patient (0.5 vs. 0.7, p=0.78), ED visits (7% vs. 11%, p=0.70), calls and visits combined (44% vs. 43%, p=0.93), or the proportion of calls and emergency room presentations related to concerns about the penile appearance (22% vs. 36%, p=0.66). Overall, 19 postoperative phone calls were received from 12 patients, and 4 visits to the ED were made by 3 patients. Reasons for calls to the clinic were diverse, and 9 distinct categories of concern were identified apart from wound appearance. The impressive diversity of caregiver concerns prompting postoperative communication may partly underlie the failure of the atlas to reduce resource utilization in this study. Most postoperative calls or visits were unrelated to concern about the penile appearance, which limits the degree to which this or any visual guide to wound healing can reduce the need for postoperative attention. Receipt of the atlas did not significantly reduce postoperative contacts or affect the proportion of contacts represented by concerns about penile appearance. Resources must remain directed toward individualized attention to caregiver concerns, delivered by experienced urologic support staffs, who remain the mainstay of postoperative support.

Social isolation produces no effect on ultrasonic vocalization production in adult female CBA/CaJ mice.

Mice produce ultrasonic vocalizations (USVs) in a wide variety of social contexts, including courtship, investigation, and territorial defense. Despite the belief that mouse USVs are innate, social experience may be necessary for mice to learn the appropriate situation to emit USVs. Mouse USVs have been divided into categories based on their spectrotemporal parameters, but it is currently unclear if social experience changes these parameters (e.g., frequency and duration) or the proportion of calls from each category produced. Social isolation has been found to influence USV production in male mice. To investigate the influence of social isolation on vocal behavior in female mice, recordings were made of USVs emitted to unfamiliar male and female mice by subjects with one of three types of social experience. Twenty-four adult female CBA/CaJ mice either lived alone, lived with other females only, or lived with other females and had limited access to a male. Mice were recorded while in isolation, ensuring all recorded USVs were from the female of interest. Vocalizations were separated into nine categories and peak frequency, duration, and bandwidth were measured for every call. Socially isolated mice did not produce significantly more USVs or USV types than socially experienced mice. Social isolation did not have a significant effect on the features of USVs, suggesting production of USVs may not be learned in female mice.

Epidemiology of Suspected Pesticide Poisoning in Livestock

ObjectiveThis study characterizes the epidemiology of suspected pesticide poisoning in livestock in the United States (U.S.) and Canada using data from calls to the American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Poison Control Center (APCC).IntroductionPesticides are used in agriculture and in the home to control pests such as insects, weeds, fungi and rodents. Pesticide poisoning in animals is usually due to misuse or accidental exposure1. Information on poisonings in livestock in North America is largely lacking2. Examples of hotlines in the U.S. for animal poisoning consultations include the APCC ($65.00 fee) and the Pet Poison Helpline (PPH) ($59.00 fee). The APCC fields calls 24 hours/day, 7 days/week about animal poisonings from the U.S., its territories and Canada. Using data from almost 4 years of APCC calls we describe the occurrence, category and class of pesticides involved, and outcomes of suspected pesticide exposures in livestock. This information is useful to raise awareness, encourage the proper use of pesticides and identify specific pesticides with negative impact on livestock health.MethodsAPHIS contracts with the APCC to receive de-identified data weekly on livestock calls for the purpose of conducting surveillance. This retrospective study used data from all calls concerning bovine, camelid, caprine, equine, ovine, porcine and poultry species from 10/1/2013 to 9/2/2017, where the caller reported suspected pesticide exposure. There were 1,025 calls regarding 3,028 animals meeting this criteria, representing 52% of all livestock calls with any type of toxic exposure. Caller type was 80% animal owners, 10% veterinarian or veterinary staff, and 10% other types. Most callers (92%) provided their zip code, with 96% of calls from the U.S. and 4% from Canada. Variables used for descriptive analysis were: species; APCC staff assessment that illness was due to pesticide exposure; severity of illness; clinical signs; first, second and third ingredients of the pesticide, and pesticide ingredient class (e.g. pyrethrin). Pesticides were grouped based on the first active ingredient into fungicide, herbicide, insecticide, and rodenticide categories.ResultsThe proportion of calls by species was equine (33%), poultry (26%), bovine (25%), caprine (8%), porcine (6%), ovine (2%), and camelid (0.5%). Some animals were exposed to &gt;1 pesticide product and some pesticide products had &gt;1 ingredient class. The pesticide category with the highest number of exposed animals was insecticides (2,151), followed by herbicides (839), rodenticides (765) and fungicides (286). The treemap below illustrates the number and proportions of animals exposed to the 4 pesticide categories and the top 3 pesticide classes within each category based on the first active ingredient. For all pesticide exposures in all species, no illness was reported in 68% of animals. According to assessment by APCC staff, only 35% (333) of animals showing clinical signs were considered with confidence (medium or high likelihood) to be due to pesticide exposure. For these 333 animals, severity of illness was mild for 80% (266 animals), moderate for 18% (61 animals), major for 1% (3 animals) and caused death in 1% (3 animals). Among animals with confidence that clinical signs were due to pesticide exposure the most frequent syndrome was dermatologic.ConclusionsSuspected pesticide exposure was the most frequent reason a call concerning livestock was made to the APCC. Callers reported that most animals showed no illness, and major illness or death was rare. Livestock were most frequently exposed to the insecticide category, and 46% of the animals with exposure to insecticides were exposed to the pyrethrin class. This is consistent with the phasing out of organophosphate insecticides for residential use since 2000 and the increasing use of pyrethrin insecticides3, which are considered less toxic. Limitations of this study include: 1) data from only one major animal poison control hotline was available for analysis and people may call their veterinarian directly or use the internet 2) calls regarding specific ingredients may be over represented due to corporate client relationships with the APCC 3) illness may have occurred after the call was made, therefore the proportion of animals with illness following suspected exposure may be an underestimate.

Insurance Status and Access to Urgent Primary Care Follow-up After an Emergency Department Visit in 2016

We examine the availability of follow-up appointments for emergency department (ED) patients without established primary care by insurance and clinical condition. We used "secret shopper" methodology, employing 2 black men to telephone all 53 primary care practices in greater New Haven, posing as new patients discharged from the ED and requesting follow-up appointments. Each practice received 6 scripted calls from each caller during an 8-month period, reflecting all possible scenarios based on 3insurance types (Medicaid, state exchange, and commercial) and 2 conditions (hypertension and back pain). Primary outcome was the proportion of calls that obtained an appointment in 7 calendar days (7-day appointment rate). Secondary outcomes included overall appointment rate and appointment wait time. Among the total of 604 calls completed, the 7-day appointment rate was 30.7% (95% confidence interval [CI] 22.6% to 38.8%). Compared with commercial insurance, Medicaid calls had lower 7-day rate (25.5% versus 35.7%; difference 10.2%; 95% CI 2.2% to 18.1%) and overall appointment rate (53.5% versus 77.8%; difference 24.4%; 95% CI 13.4% to 35.4%). There was no significant difference between state exchange and commercial insurance calls in 7-day rate (30.9% versus 35.7%; difference 4.8%; 95% CI -3.1% to 12.6%) or overall appointment rate (73.4% versus 77.8%; difference 4.4%; 95% CI -2.7% to 11.6%). Back pain, compared with hypertension, had lower 7-day appointment rate (27.6% versus 33.7%; difference 6.1%; 95% CI 1.0% to 11.2%), but no significant difference in overall appointment rates (67.0% versus 69.4%; difference 2.4%; 95% CI -2.7% to 7.5%). For patients without established primary care, obtaining timely follow-up after acute care in the ED is difficult, particularly for Medicaid beneficiaries.

Simulation-based decision support framework for dynamic ambulance redeployment in Singapore

ObjectiveDynamic ambulance redeployment policies tend to introduce much more flexibilities in improving ambulance resource allocation by capitalizing on the definite geospatial-temporal variations in ambulance demand patterns over the time-of-the-day and day-of-the-week effects. A novel modelling framework based on the Approximate Dynamic Programming (ADP) approach leveraging on a Discrete Events Simulation (DES) model for dynamic ambulance redeployment in Singapore is proposed in this paper. MethodsThe study was based on the Singapore’s national Emergency Medical Services (EMS) system. Based on a dataset comprising 216,973 valid incidents over a continuous two-years study period from 1 January 2011–31 December 2012, a DES model for the EMS system was developed. An ADP model based on linear value function approximations was then evaluated using the DES model via the temporal difference (TD) learning family of algorithms. The objective of the ADP model is to derive approximate optimal dynamic redeployment policies based on the primary outcome of ambulance coverage. ResultsConsidering an 8min response time threshold, an estimated 5% reduction in the proportion of calls that cannot be reached within the threshold (equivalent to approximately 8000 dispatches) was observed from the computational experiments. The study also revealed that the redeployment policies which are restricted within the same operational division could potentially result in a more promising response time performance. Furthermore, the best policy involved the combination of redeploying ambulances whenever they are released from service and that of relocating ambulances that are idle in bases. ConclusionThis study demonstrated the successful application of an approximate modelling framework based on ADP that leverages upon a detailed DES model of the Singapore’s EMS system to generate approximate optimal dynamic redeployment plans. Various policies and scenarios relevant to the Singapore EMS system were evaluated.

The value of a poison control center in preventing unnecessary ED visits and hospital charges: A multi-year analysis

ObjectiveThe purpose of this study is to determine the economic value of the Utah Poison Control Center (UPCC) by examining its contribution to the reduction of unnecessary emergency department (ED) visits and associated charges across multiple years. MethodsA multi-year (2009–2014) analysis of cross-sectional data was performed. Callers were asked what they would do for a poison emergency if the UPCC was not available. Healthcare charges for ED visits averted were calculated according to insurance status using charges obtained from a statewide database. ResultsOf the 10,656 survey attempts, 5018 were completed. Over 30,000 cases were managed on-site each year. Using the proportion of callers who noted they would call 911, visit an ED, or call a physician's office, between 20.0 and 24.2 thousand ED visits were potentially prevented each year of the survey. Between $16.6 and $24.4 million dollars in unnecessary healthcare charges were potentially averted annually. ConclusionsCompared to the cost of operation, the service UPCC provides demonstrates economic value by reducing ED visits and associated charges. As the majority of patients have private insurance, the largest benefit falls to private payers.

Characteristics and Proximal Outcomes of Calls Made to Suicide Crisis Hotlines in California.

Suicide hotlines are commonly used to prevent suicides, although centers vary with respect to their management and operations. To describe variability across suicide prevention hotlines. Live monitoring of 241 calls was conducted at 10 suicide prevention hotlines in California. Call centers are similar with respect to caller characteristics and the concerns callers raise during their calls. The proportion of callers at risk for suicide varied from 3 to 57%. Compliance with asking about current suicide risk, past ideation, and past attempts also ranged considerably. Callers to centers that were part of the National Suicide Prevention Lifeline (NSPL) were more likely to experience reduced distress than callers to centers that were not part of the NSPL. Because callers do not generally choose the center or responder that will take their call, it is critical to promote quality across call centers and minimize the variability that currently exists. Accrediting bodies, funders, and crisis centers should require that centers continuously monitor calls to ensure and improve call quality.

Protocol: simulation training to improve 9-1-1 dispatcher identification of cardiac arrest.

Background9-1-1 dispatchers are often the first contact for bystanders witnessing an out-of-hospital cardiac arrest. In the time before Emergency Medical Services arrives, dispatcher identification of the need for, and provision of Telephone-CPR (T-CPR) can improve survival. Our study aims to evaluate the use of phone-based standardized patient simulation training to improve identification of the need for T-CPR and shorten time to start of T-CPR instructions.Methods/DesignThe STAT-911 study is a randomized controlled trial. We will recruit 160 dispatchers from 9-1-1 call-centers in the Pacific Northwest; they are randomized to an intervention or control group. Intervention participants complete four telephone simulation training sessions over 6–8 months. Training sessions consist of three mock 9-1-1 calls, with a standardized patient playing a caller witnessing a medical emergency. After the mock calls, an instructor who has been listening in and scoring the dispatcher’s call management, connects to the dispatcher and provides feedback on select call processing skills. After the last training session, all participants complete the simulation test: a call session that includes two mock 9-1-1 calls of medium complexity. During the study, audio from all actual cardiac arrest calls handled by the dispatchers will be collected. All dispatchers complete a baseline survey, and after the intervention, a follow-up survey to measure confidence. Primary outcomes are proportion of calls where dispatchers identify the need for T-CPR, and time to start of T-CPR, assessed by comparing performance on two calls in the simulation test. Secondary outcomes are proportion of actual cardiac arrest calls in which dispatchers identify the need for T-CPR and time to start of T-CPR; performance on call-taking skills during the simulation test; self-reported confidence in the baseline and follow-up surveys; and calculated costs of the intervention training sessions and projected costs for field implementation of training sessions.DiscussionThe STAT-911 study will evaluate if over-the-phone simulation training with standardized patients can improve 9-1-1 dispatchers’ ability identify the need for, and promptly begin T-CPR. Furthermore, it will advance knowledge on the effectiveness of simulation training for health services phone-operators interacting with clients, patients, or bystanders in diagnosis, triage, and treatment decisions.Trial registrationClinicalTrials.gov Registration Number: NCT01972087. Registered 23 October 2013.