Discharge of patients with an acute upper gastrointestinal bleed from the emergency department using an extended Glasgow Blatchford Score

Objective To use an extended Glasgow-Blatchford Score (GBS) cut-off of ≤1 to aid discharge of patients presenting with acute upper gastrointestinal bleeding (AUGIB) from emergency departments. Background The GBS accurately predicts the need for intervention and death in AUGIB, and a cut-off of 0 is recommended to identify patients for discharge without endoscopy. However, this cut-off is limited by identifying a low percentage of low-risk patients. Extension of the cut-off to ≤1 or ≤2 has been proposed to increase this proportion, but there is controversy as to the optimal cut-off and little data on performance in routine clinical practice. Methods Dual-centre study in which patients with AUGIB and GBS ≤1 were discharged from the emergency department without endoscopy unless there was another reason for admission. Retrospective analysis of associated adverse outcome defined as a 30-day combined endpoint of blood transfusion, intervention or death. Results 569 patients presented with AUGIB from 2015 to 2018. 146 (25.7%) had a GBS ≤1 (70, GBS=0; 76, GBS=1). Of these, 103 (70.5%) were managed as outpatients, and none had an adverse outcome. GBS ≤1 had a negative predictive value=100% and the GBS had an area under receiver operator characteristic​​ (AUROC)=0.89 (95% CI 0.86 to 0.91) in predicting adverse outcomes. In 2008–2009, prior to risk scoring (n=432), 6.5% of patients presenting with AUGIB were discharged safely from the emergency department in comparison with 18.1% (p<0.001) in this cohort. A GBS cut-off ≤2 was associated with an adverse outcome in 8% of cases. Conclusion GBS of ≤1 is the optimal cut-off for the discharge of patients with an AUGIB from the emergency department

‘Synthetic cannabis’: A dangerous misnomer

The term 'synthetic cannabis' has been widely used in public discourse to refer to a group of cannabinoid receptor agonists. In this paper we detail the characteristics of these drugs, and present the case that the term is a misnomer. We describe the pharmacodynamics of these drugs, their epidemiology, mechanisms of action, physiological effects and how these differ substantially from delta-9-tetrahydrocannabinol (THC). We argue that not only is the term a misnomer, but it is one with negative clinical and public health implications. Rather, the substances referred to as 'synthetic cannabis' in public discourse should instead be referred to consistently as synthetic cannabinoid receptor agonists (SCRAs), a drug class distinct from plant-derived cannabinoids. SCRAs have greater potency and efficacy, and psychostimulant-like properties. While such terminology may be used in the scientific community, it is not widely used amongst the media, general public, people who use these drugs or may potentially do so. A new terminology has the potential to reduce the confusion and harms that result from the misnomer ‘synthetic cannabis’. The constant evolution of this distinct drug class necessitates a range of distinct policy responses relating to terminology, harm reduction, epidemiology, treatment, and legal status

Design, Analysis, and Optimization of a Dual Tank Solar-Assisted Heat Pump System

This work investigates the performance of a dual tank solar-assisted heat pump (SAHP) system. These systems combine solar thermal collectors (STCs) and a heat pump (HP) into a hybrid system to meet building thermal loads. The main goals of a system of this type are to reduce energy consumption and provide a method to deliver thermal energy with sustainable sources. This research project undertook the design, testing, model creation and tuning, performance evaluation, and optimization of a dual tank SAHP system for domestic hot water (DHW). The novel SAHP configuration developed uses a second thermal storage tank to create more modes of operation with the intent of decreasing the amount of purchased energy. A key aspect of the work was a test apparatus built at the University of Waterloo (UW) to facilitate equipment testing and mapping, identify operational problems such as HP short-cycling, and tune mode components. Alternatives were modelled in TRNSYS to develop design recommendations and assess economic justification for the dual tank SAHP system. Despite noticeable electricity savings by these systems, an analysis of tolerable capital cost versus electricity cost shows that SAHP systems are not justifiable for single family dwellings at the current time. The impact of electricity time-of-use charges was investigated, which revealed that the DHW, SDHW, and single tank SAHP systems consume a similar amount of electricity during off-peak hours. The performance of the dual tank SAHP system in many global climate types was assessed to identify locations best suited for such a system. Many recommendations are provided to improve economic justification of the system. Overall, the performance benefits of a dual tank SAHP system over the alternatives was demonstrated. Due to the high capital costs of the additional equipment required, economic justification is difficult for a single-family residential application. There are promising applications and system augmentations that should be investigated which can lead to a successful demonstration project of a dual tank solar-assisted heat pump system

Cross-Modal Health State Estimation

Individuals create and consume more diverse data about themselves today than any time in history. Sources of this data include wearable devices, images, social media, geospatial information and more. A tremendous opportunity rests within cross-modal data analysis that leverages existing domain knowledge methods to understand and guide human health. Especially in chronic diseases, current medical practice uses a combination of sparse hospital based biological metrics (blood tests, expensive imaging, etc.) to understand the evolving health status of an individual. Future health systems must integrate data created at the individual level to better understand health status perpetually, especially in a cybernetic framework. In this work we fuse multiple user created and open source data streams along with established biomedical domain knowledge to give two types of quantitative state estimates of cardiovascular health. First, we use wearable devices to calculate cardiorespiratory fitness (CRF), a known quantitative leading predictor of heart disease which is not routinely collected in clinical settings. Second, we estimate inherent genetic traits, living environmental risks, circadian rhythm, and biological metrics from a diverse dataset. Our experimental results on 24 subjects demonstrate how multi-modal data can provide personalized health insight. Understanding the dynamic nature of health status will pave the way for better health based recommendation engines, better clinical decision making and positive lifestyle changes.Comment: Accepted to ACM Multimedia 2018 Conference - Brave New Ideas, Seoul, Korea, ACM ISBN 978-1-4503-5665-7/18/1

Amplified ambivalence: having a sibling with juvenile idiopathic arthritis

Despite increased awareness of family responses to chronic illness and disability, there is still a need to understand experiences of well siblings. We begin to address this by asking “What is it like to have a sibling with juvenile idiopathic arthritis?” (JIA).Eight families with an adolescent diagnosed with JIA participated. Four members of each family, including one healthy sibling, were interviewed and transcripts analyzed using grounded theory. Analysis suggests healthy siblings see their family as different to ‘normal’ families, forfeit time with peers, share vicariously adverse experiences of their ill sibling, and feel inadequately informed. Such experiences amplify the ambivalent nature of sibling relationships and are possibly felt most strongly during late childhood and early adolescence. Support from extended family can reduce these negative experiences and facilitate social and emotional adjustment which also occurs over time as the children mature. These findings have implications for healthcare professionals and voluntary organizations

Inequality, poverty and the privatization of essential services: A "systems of provision" study of water, energy and local buses in the UK

This paper is concerned with the distributional effects of the deregulation and privatization of essential services in Britain since the 1980s, based on a cross-sector study of water, energy and local bus transport. Our approach locates end users within the structures and processes, and prevailing narratives that underpin both production and consumption. This framework highlights the ways that the provisioning of these vital services is contested, contradictory and underpinned by power relations. We show that, at one end, investors in these sectors have made generous returns on their investments but their methods of profit maximization are often not in the public interest. Meanwhile these profits are financed by end users’ payments of bills and fares. Many lower-income households face challenges in terms of affording, and even accessing, these essential services. Regulation has failed to provide adequate social protection. We argue that adverse social outcomes emerge from systemic factors embedded in these modes of provision. A narrative of politically-neutral, technocratic solutions belies the underlying contested nature of privatized monopolistic shared essential services. Moreover, a policy preoccupation with markets and competition obscures the inequality embedded in the underlying structures and processes and undermines more collective and equitable forms of provisioning

Recognition without identification, erroneous familiarity, and déjà vu

Déjà vu is characterized by the recognition of a situation concurrent with the awareness that this recognition is inappropriate. Although forms of déjà vu resolve in favor of the inappropriate recognition and therefore have behavioral consequences, typical déjà vu experiences resolve in favor of the awareness that the sensation of recognition is inappropriate. The resultant lack of behavioral modification associated with typical déjà vu means that clinicians and experimenters rely heavily on self-report when observing the experience. In this review, we focus on recent déjà vu research. We consider issues facing neuropsychological, neuroscientific, and cognitive experimental frameworks attempting to explore and experimentally generate the experience. In doing this, we suggest the need for more experimentation and amore cautious interpretation of research findings, particularly as many techniques being used to explore déjà vu are in the early stages of development.PostprintPeer reviewe

Priorities, policies and (time)scales : the delivery of emissions reductions in the UK transport sector

Peer reviewedPreprin