685 research outputs found
Development and validation of a pragmatic prehospital tool to identify stroke mimic patients
Aim Stroke mimics (SM) are non-stroke conditions producing stroke-like symptoms. Prehospital stroke identification tools prioritise sensitivity over specificity.1 It is estimated that >25% of prehospital suspected stroke patients are SM.2 Failure to identify SM creates inefficient use of ambulances and specialist stroke services. We developed a pragmatic tool to identify SM amongst suspected prehospital stroke patients. Method The tool was developed using regression analysis of clinical variables documented in ambulance records of suspected stroke patients linked to primary hospital diagnoses (derivation dataset, n=1,650, 40% SM).3 It was refined using feedback from paramedics (n=3) and hospital clinicians (n=9), and analysis of an expanded prehospital derivation dataset (n=3,797, 41% SM (original 1650 patients included)). Results The STEAM tool combines six variables: 1 point for Systolic blood pressure 38.5°C with Abstracts A2 BMJ Open 2018;8(Suppl 1):A1–A34 (NHS). Protected by copyright. on 14 August 2019 at Manchester University NHS Foundation Trust http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2018-EMS.6 on 16 April 2018. Downloaded from heart rate >90 bpm; 1 point for seizures or 2 points for seizures with known diagnosis of Epilepsy; 1 point for Age <40 years or 2 points for age <30 years; 1 point for headache with known diagnosis of Migraine; 1 point for FAST-ve. A score of 2 on STEAM predicted SM diagnosis in the derivation dataset with 5.5% sensitivity, 99.6% specificity and positive predictive value (PPV) of 91.4%. External validation (n=1,848, 33% SM) showed 5.5% sensitivity, 99.4% specificity and a PPV of 82.5%. Conclusion STEAM uses common clinical characteristics to identify SM patients with high certainty. The benefits of using STEAM to reduce SM admissions to stroke services need to be weighed up against delayed admissions for stroke patients wrongly identified as SM. https://bmjopen.bmj.com/content/8/Suppl_1/A2.3 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/bmjopen-2018-EMS.
The frequency, characteristics and aetiology of stroke mimic presentations::a narrative review
A significant proportion of patients with acute stroke symptoms have an alternative ‘mimic’ diagnosis. A narrative review was carried out to explore the frequency, characteristics and aetiology of stroke mimics. Prehospital and thrombolysis-treated patients were described separately. Overall, 9972 studies were identified from the initial search and 79 studies were included with a median stroke mimic rate of 19% (range: 1–64%). The prehospital median was 27% (range: 4–43%) and the thrombolysis median 10% (range: 1–25%). Seizures, migraines and psychiatric disorders are the most frequently reported causes of stroke mimics. Several characteristics are consistently associated with stroke mimics; however, they do not fully exclude the possibility of stroke. Nineteen per cent of suspected stroke patients had a mimic condition. Stroke mimics were more common with younger age and female sex. The range of mimic diagnoses, a lack of clear differentiating characteristics and the short treatment window for ischaemic stroke create challenges for early identification
The positive predictive value of stroke identification by ambulance clinicians in North East England: a retrospective cohort study
Introduction/background Accurate prehospital identification of patients who had an acute stroke enables rapid conveyance to specialist units for time-dependent treatments such as thrombolysis and thrombectomy. Misidentification leads to patients who had a ‘stroke mimic’ (SM) being inappropriately triaged to specialist units. We evaluated the positive predictive value (PPV) of prehospital stroke identification by ambulance clinicians in the North East of England. Methods This service evaluation linked routinely collected records from a UK regional ambulance service identifying adults with any clinical impression of suspected stroke to diagnostic data from four National Health Service hospital trusts between 1 June 2013 and 31 May 2016. The reference standard for a confirmed stroke diagnosis was inclusion in Sentinel Stroke National Audit Programme data or a hospital diagnosis of stroke or transient ischaemic attack in Hospital Episode Statistics. PPV was calculated as a measure of diagnostic accuracy. Results Ambulance clinicians in North East England identified 5645 patients who had a suspected stroke (mean age 73.2 years, 48% male). At least one Face Arm Speech Test (FAST) symptom was documented for 93% of patients who had a suspected stroke but a positive FAST was only documented for 51%. Stroke, or transient ischaemic attack, was the final diagnosis for 3483 (62%) patients. SM (false positives) accounted for 38% of suspected strokes identified by ambulance clinicians and included a wide range of non-stroke diagnoses including infections, seizures and migraine. Discussion In this large multisite data set, identification of patients who had a stroke by ambulance clinicians had a PPV rate of 62% (95% CI 61 to 63). Most patients who had a suspected stroke had at least one FAST symptom, but failure to document a complete test was common. Training for stroke identification and SM rates need to be considered when planning service provision and capacity. http://dx.doi.org/10.1136/emermed-2019-208902. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0
A survey of UK paramedics’ views about their stroke training, current practice and the identification of stroke mimics
Aims ‐ Paramedics play a crucial role in identifying patients with suspected stroke and transporting them to appropriate acute care. Between 25% and 50% of suspected stroke patients are later diagnosed with a condition other than stroke known as a ‘stroke mimic’. If stroke mimics could be identified in the pre-hospital setting, unnecessary admissions to stroke units could potentially be avoided. This survey describes UK paramedics’ stroke training and practice, their knowledge about stroke mimic conditions and their thoughts about pre-hospital identification of these patients.Methods ‐ An online survey invitation was circulated to members within the UK College of Paramedics and promoted through social media (8 September 2016 and 23 October 2016). Topics included: stroke training; assessment of patients with suspected stroke; local practice; and knowledge about and identification of stroke mimics.Results ‐ There were 271 responses. Blank responses (39) and non-paramedic (1) responses were removed, leaving 231 responses from paramedics which equates to 2% of College of Paramedics membership and 1% of Health and Care Professions Council registered paramedics. The majority of respondents (78%) thought that they would benefit from more training on pre-hospital stroke care. Narrative comments focused on a desire to improve the assessment of suspected stroke patients and increase respondents’ knowledge about atypical stroke presentations and current stroke research. The Face Arm Speech Test was used by 97% of respondents to assess suspected stroke patients, although other tools such as Recognition of Stroke in the Emergency Room (17%) and Miami Emergency Neurological Deficit (11%) were also used. According to those responding, 50% of stroke patients were taken to emergency departments, 35% went straight to a stroke ward and 8% were taken directly to CT scan. Most respondents (65%) were aware of the term ‘stroke mimic’. Two-thirds of respondents (65%) thought a tool that predicted the likelihood of a suspected stroke being a stroke mimic would be useful in pre-hospital care.Conclusion ‐ This study reports a survey of UK paramedics’ views about the stroke care they provide. Conclusions are limited by the low number of responses. Assessment of suspected stroke patients was recognised as an important skill by paramedics and an area where many would like further training. Respondents’ current practice varied in terms of the stroke assessment tools used and whether suspected stroke patients were taken to the emergency department or direct to a stroke ward. A stroke mimic identification tool would be useful if it allowed stroke mimic patients to be directed to appropriate care, but it would need to have a high level of specificity and not adversely impact on time to treatment for true stroke patients
Radiative Transfer Models of a Possible Planet in the AB Aurigae Disk
Recent coronagraphic imaging of the AB Aurigae disk has revealed a region of
low polarized scattered light suggestive of perturbations from a planet at a
radius of ~100 AU. We model this darkened region using our fully
non-plane-parallel radiative-transfer code combined with a simple hydrostatic
equilibirum approximation to self-consistently solve for the structure of the
disk surface as seen in scattered light. By comparing the observations to our
models, we find that the observations are consistent with the absence of a
planet, with an upper limit of 1 Jupiter mass.Comment: Accepted to ApJ Letter
Sulfate but not thiosulfate reduces calculated and measured urinary ionized calcium and supersaturation: implications for the treatment of calcium renal stones
BACKGROUND: Urinary sulfate (SO 4 2− ) and thiosulfate (S 2 O 3 2− ) can potentially bind with calcium and decrease kidney stone risk. We modeled the effects of these species on the concentration of ionized calcium (iCa) and on supersaturation (SS) of calcium oxalate (CaOx) and calcium phosphate (CaP), and measured their in vitro effects on iCa and the upper limit of stability (ULM) of these salts. METHODS: Urine data from 4 different types of stone patients were obtained from the Mayo Nephrology Clinic (Model 1). A second data set was obtained from healthy controls and hypercalciuric stone formers in the literature who had been treated with sodium thiosulfate (STS) (Model 2). The Joint Expert Speciation System (JESS) was used to calculate iCa and SS. In Model 1, these parameters were calculated as a function of sulfate and thiosulfate concentrations. In Model 2, data from pre- and post STS urines were analyzed. ULM and iCa were determined in human urine as a function of sulfate and thiosulfate concentrations. RESULTS: Calculated iCa and SS values for all calcium salts decreased with increasing sulfate concentration. Thiosulfate had no effect on these parameters. In Model 2, calculated iCa and CaOx SS increased after STS treatment, but CaP SS decreased, perhaps due to a decrease in pH after STS treatment. In confirmatory in vitro experiments supplemental sulfate, but not thiosulfate, significantly increased the calcium needed to achieve the ULM of CaP and tended to increase the oxalate needed to reach the ULM of CaOx. Sulfate also significantly decreased iCa in human urine, while thiosulfate had no effect. CONCLUSION: Increasing urinary sulfate could theoretically reduce CaOx and CaP stone risk. Although STS may reduce CaP stone risk by decreasing urinary pH, it might also paradoxically increase iCa and CaOx SS. As such, STS may not be a viable treatment option for stone disease
Paleomagnetism of the Devonian Onondaga Limestone Revisited
Ninety-six oriented samples were collected from 13 sites in the Onondaga limestone of New York for paleomagnetic study, including rock magnetism and magnetic susceptibility anisotropy. The sites were located in a small penecontemporaneous fold and a larger fold of imprecisely known origin, as well as flatlying beds. The natural remanent magnetizations (NRM) give directions (declination 195.1°, inclination 84.4°, and α_95 = 6.9° for N = 13 sites) that are similar to those originally measured for the Onondaga limestone by Graham (1956). Alternating field and thermal demagnetization analyses show that the NRM is a composite of a large viscous component along the present geomagnetic field and a smaller, more stable component of magnetization with a shallow and southerly direction. The site mean directions after 300 Oe of magnetic cleaning, but without correction for bedding tilt, give a formation mean of declination 168.7°, inclination 13.6°, and α_95 = 8.3° for N = 9 sites (the magnetizations at four sites could not be adequately resolved and are omitted). Although the stable magnetization is shown to be of postfolding origin, essentially the same direction is obtained at sites with flat-lying bedding as at the sites with folded bedding prior to tilt correction. Rock magnetic investigations indicate that some form of magnetite is the important magnetic mineral in the limestone. The similarity in magnetic fabric between a small penecontemporaneous fold and a larger fold suggests acquisition of magnetic properties while the sediment was still unconsolidated. The postfolding origin of stable remanence is therefore interpreted as a form of postdepositional detrital remanent magnetism. The paleomagnetic pole position derived from the formation mean direction is located at latitude 39.7°N, longitude 120.7°E (dp = 4.3°, dm = 8.5°) and agrees reasonably well with other Devonian poles from cratonic North America, although a Permian age for the magnetizations of the Onondaga cannot be entirely discounted
Cost-Effectiveness of Treating Upper Limb Spasticity Due to Stroke with Botulinum Toxin Type A: Results from the Botulinum Toxin for the Upper Limb after Stroke (BoTULS) Trial
Stroke imposes significant burdens on health services and society, and as such there is a growing need to assess the cost-effectiveness of stroke treatment to ensure maximum benefit is derived from limited resources. This study compared the cost-effectiveness of treating post-stroke upper limb spasticity with botulinum toxin type A plus an upper limb therapy programme against the therapy programme alone. Data on resource use and health outcomes were prospectively collected for 333 patients with post-stroke upper limb spasticity taking part in a randomized trial and combined to estimate the incremental cost per quality adjusted life year (QALY) gained of botulinum toxin type A plus therapy relative to therapy alone. The base case incremental cost-effectiveness ratio (ICER) of botulinum toxin type A plus therapy was £93,500 per QALY gained. The probability of botulinum toxin type A plus therapy being cost-effective at the England and Wales cost-effectiveness threshold value of £20,000 per QALY was 0.36. The point estimates of the ICER remained above £20,000 per QALY for a range of sensitivity analyses, and the probability of botulinum toxin type A plus therapy being cost-effective at the threshold value did not exceed 0.39, regardless of the assumptions made
Removal of steroid estrogens in carbonaceous and nitrifying activated sludge processes
This is the post-print version of the final paper published in Chemosphere. The published article is available from the link below. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. Copyright @ 2010 Elsevier B.V.A carbonaceous (heterotrophic) activated sludge process (ASP), nitrifying ASP and a nitrifying/denitrifying ASP have been studied to examine the role of process type in steroid estrogen removal. Biodegradation efficiencies for total steroid estrogens (ΣEST) of 80 and 91% were recorded for the nitrifying/denitrifying ASP and nitrifying ASP respectively. Total estrogen biodegradation (ΣEST) was only 51% at the carbonaceous ASP, however, the extent of biodegradation in the absence of nitrification clearly indicates the important role of heterotrophs in steroid estrogen removal. The low removal efficiency did not correlate with biomass activity for which the ASPcarbonaceous recorded 80 μg kg−1 biomass d−1 compared to 61 and 15 μg kg−1 biomass d−1 at the ASPnitrifying and ASPnitrifying/denitrifying respectively. This finding was explained by a moderate correlation (r2 = 0.55) between total estrogen loading (ΣEST mg m−3 d−1) and biomass activity (μg ΣEST degraded kg−1 d−1) and has established the impact of loading on steroid estrogen removal at full-scale. At higher solids retention time (SRT), steroid estrogen biodegradation of >80% was observed, as has previously been reported. It is postulated that hydraulic retention time (HRT) is as important as SRT as this governs both reaction time and loading. This observation is based on the high specific estrogen activity determined at the ASPcarbonaceous plant, the significance of estrogen loading and the positive linear correlation between SRT and HRT.Public Utilities Board of Singapore, Anglian Water Ltd., Severn Trent Water Ltd., Thames Water Utilities Ltd., United Utilities Plc., and Yorkshire Water Services Ltd
Perspectives on “Giving Back”: A Conversation Between Researcher and Refugee
Our chapter—“Perspectives on ‘giving back’: A conversation between researcher and refugee”—offers personal reflections on the ethics of research with refugees and what it means for researchers to “give back” to refugee participants beyond “policy impact”. Written as a dialogue between an academic and a Rohingya refugee youth leader, we explore the blurry lines between academic work and advocacy when the issues of refugee protection are pressing, as well as the appropriateness of researchers giving monetary donations and volunteering for refugee causes as payback for data. In this chapter, we also examine what it means to build trust and relationships between researchers and refugees, and how too often researchers fail to develop meaningful research interactions with refugee participants who share their time, energy and personal stories of vulnerability
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