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

Derivation and validation of a novel risk score to predict need for haemostatic intervention in acute upper gastrointestinal bleeding (London Haemostat Score)

Background: Acute Upper Gastrointestinal Bleeding (AUGIB) is a common medical emergency which takes up considerable healthcare resources. However, only approximately 20-30% of bleeds require urgent haemostatic intervention. Current standard of care is for all patients admitted to hospital to undergo endoscopy within 24 hours for risk stratification, but this is difficult to achieve in practice, invasive and costly. Aim To develop a novel non-endoscopic risk stratification tool for AUGIB to predict the need for haemostatic intervention by endoscopic, radiological or surgical treatments. We compared this with the Glasgow-Blatchford Score (GBS). Design: Model development was carried out using a derivation (n=466) and prospectively collected validation cohort (n=404) of patients who were admitted with AUGIB to three large hospitals in London, UK (2015-2020). Univariable and multivariable logistic regression analysis was used to identify variables that were associated with increased or decreased chances of requiring haemostatic intervention. This model was converted into a risk scoring system, the London Haemostat Score (LHS). Results: The LHS was more accurate at predicting need for haemostatic intervention than the GBS, in the derivation cohort (Area Under the Receiver Operating Curve [AUROC] 0.82; 95% Confidence Interval (CI), 0.78-0.86 vs 0.72; 95% CI, 0.67-0.77; p<0.001) and validation cohort (AUROC 0.80; 95% CI, 0.75-0.85 vs 0.72; 95% CI, 0.67-0.78; p<0.001). At cut-off scores at which LHS and GBS identified patients who required haemostatic intervention with 98% sensitivity, the specificity of the LHS was 41% vs 18% with the GBS (p<0.001). This could translate to 32% of inpatient endoscopies for AUGIB being avoided at a cost of only a 0.5% false negative rate. Conclusions: The London Haemostat score is accurate at predicting the need for haemostatic intervention in AUGIB and could be used identify a proportion of low-risk patients who can undergo delayed or outpatient endoscopy. Validation in other geographical settings is required before routine clinical use

The role of perceived environment, neighbourhood characteristics, and attitudes in walking behaviour: evidence from a rapidly developing city in China

The associations between objective and subjective dimensions of the built environment and walking behaviour have been examined extensively in existing studies. However, the interaction effects of those dimensions of the built environment on walking behaviour are understudied and may be more complex than hitherto suggested. Apart from the subjective dimensions of the built environment, walking attitudes also play a role in moderating these relationships. This paper investigates the independent and joint effects of objective neighbourhood characteristics, people’s perceptions of the neighbourhood environment, and walking attitudes on the frequency of walking by using Shenzhen as a case study. Since those effects may vary across different kinds of walking trips, the analysis looks separately at three major types of walking at the neighbourhood level—walking for work/school, walking for leisure/recreation, and walking for household responsibilities. Logistic regression analyses confirm that the correlates of people’s walking frequency vary considerably among different types of walking. Statistically significant interaction effects of objective neighbourhood characteristics and perceived environment are found. The results suggest that positive perceptions of the environment can compensate for the effect that low objective walkability of neighbourhoods has on people’s walking frequency. When seeking to encouraging walking at the neighbourhood level, policymakers should not only concentrate on improving objective neighbourhood characteristics but also consider people’s perception of the neighbourhood environment and their attitudes towards walking

Comparative evaluation of three TSPO PET radiotracers in a LPS-induced model of mild neuroinflammation in rats.

PURPOSE: Over the past 20 years, neuroinflammation (NI) has increasingly been recognised as having an important role in  many neurodegenerative diseases, including Alzheimer's disease. As such, being able to image NI non-invasively in patients is critical to monitor pathological processes and potential therapies targeting neuroinflammation. The translocator protein (TSPO) has proven a reliable NI biomarker for positron emission tomography (PET) imaging. However, if TSPO imaging in acute conditions such as stroke provides strong and reliable signals, TSPO imaging in neurodegenerative diseases has proven more challenging. Here, we report results comparing the recently developed TSPO tracers [(18)F]GE-180 and [(18)F]DPA-714 with (R)-[(11)C]PK11195 in a rodent model of subtle focal inflammation. PROCEDURES: Adult male Wistar rats were stereotactically injected with 1 μg lipopolysaccharide in the right striatum. Three days later, animals underwent a 60-min PET scan with (R)-[(11)C]PK11195 and [(18)F]GE-180 (n = 6) or [(18)F]DPA-714 (n = 6). Ten animals were scanned with either [(18)F]GE-180 (n = 5) or [(18)F]DPA-714 (n = 5) only. Kinetic analysis of PET data was performed using the simplified reference tissue model (SRTM) with a contralateral reference region or a novel data-driven input to estimate binding potential BPND. Autoradiography and immunohistochemistry were performed to confirm in vivo results. RESULTS: At 40-60 min post-injection, [(18)F]GE-180 dual-scanned animals showed a significantly increased core/contralateral uptake ratio vs. the same animals scanned with (R)-[(11)C]PK11195 (3.41 ± 1.09 vs. 2.43 ± 0.39, p = 0.03); [(18)]DPA-714 did not (2.80 ± 0.69 vs. 2.26 ± 0.41). Kinetic modelling with a contralateral reference region identified significantly higher binding potential (BPND) in the core of the LPS injection site with [(18)F]GE-180 but not with [(18)F]DPA-714 vs. (R)-[(11)C]PK11195. A cerebellar reference region and novel data-driven input to the SRTM were unable to distinguish differences in tracer BPND. CONCLUSIONS: Second-generation TSPO-PET tracers are able to accurately detect mild-level NI. In this model, [(18)F]GE-180 shows a higher core/contralateral ratio and BPND when compared to (R)-[(11)C]PK11195, while [(18)F]DPA-714 did not

Advancing participatory backcasting for climate change adaptation planning using 10 cases from 3 continents

In the face of climate change, a major challenge is to inform and guide long-term climate change adaptation planning under deep uncertainty, while aiming at transformative change. Normative futures studies approaches, such as participatory backcasting, visioning and transition management, are increasingly applied, but their potential for climate change adaptation research and practice remains undervalued. This paper aims to advance the potential of backcasting in climate adaptation, by comparing various climate change adaptation studies that have used backcasting or visioning approaches. A framework has been further developed and applied to evaluate 10 cases in Africa, Europe and North America, using four dimensions: (i) inputs and settings; (ii) process and methods (iii) results, and (iv), impact. Our evaluation provides key insights into the use and further development of backcasting for climate adaptation. Key elements to add are advanced system modeling, robust elements, pathway switching and hybrid pathways, enhancing participation of marginal groups, and contributing to impact by facilitating the utilization of results and knowledge in practice and decision making

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

Exploring passenger rail markets using new station catchment size and shape metrics

This paper presents a novel spatial market segmentation method to determine key user groups of a train station (such as gender, age and access mode), based on the size and shape of the station catchment area of each group. Two new indices–area ratio and composite ratio–are developed to quantify the importance of user groups for a train station. This method is applied to identify key user groups at seven train stations in Perth, Western Australia. The study offers a new way to explore the travel behaviour of train users and provides insights for rail transport planning and marketing

Do institutional arrangements make a difference to transport policy and implementation? Lessons for Britain

This paper describes local government decision-making in transport in three areas of the UK, London, West Yorkshire and Edinburgh, in which major changes in local government decision-making structures have taken place over the last decade, and between which arrangements are now very different. The research discusses whether institutional change has had a beneficial or adverse effect, and whether any of the current structures provides a more effective framework for policy development and implementation. The results show that although the sites share a broadly common set of objectives there are differences in devolved responsibilities and in the extent to which various policy options are within the control of the bodies charged with transport policy delivery. The existence of several tiers of government, coupled with the many interactions required between these public sector bodies and the predominantly private sector public transport operators appears to create extra transactional barriers and impedes the implementation of the most effective measures for cutting congestion. There is, however, a compelling argument for the presence of an overarching tier of government to organise travel over a spatial scale compatible with that of major commuter patterns. The extent to which such arrangements currently appear to work is a function of the range of powers and the funding levels afforded to the co-ordinating organisation

Performativity, fabrication and trust: exploring computer-mediated moderation

Based on research conducted in an English secondary school, this paper explores computer mediated moderation as a performative tool. The Module Assessment Meeting (MAM) was the moderation approach under investigation. I mobilise ethnographic data generated by a key informant, and triangulated with that from other actors in the setting, in order to examine some of the meanings underpinning moderation within a performative environment. Drawing on the work of Ball (2003), Lyotard (1979) and Foucault (1977, 1979), I argue that in this particular case performativity has become entrenched in teachers’ day-to-day practices, and not only affects those practices but also teachers’ sense of self. I suggest that MAM represented performative and fabricated conditions and (re)defined what the key participant experienced as a vital constituent of her educational identities - trust. From examining the case in point, I hope to have illustrated for those interested in teachers’ work some of the implications of the interface between technology and performativity