The Code White protocol: a mixed somatic-psychiatric protocol for managing psychomotor agitation in the ED

Objectives: Clinical management of patients presenting with acute psycho­motor agitation is difficult, often because there is no predefined protocol for dealing with it. The main objective of this article is to describe our ­institution’s Code White mixed somatic-psychiatric protocol for managing acute agitation in an emergency department. Its second objective is to ­present data on how long it took to initiate and complete treatment. Methods: We retrospectively analysed 250 clinical situations over 3 years (2014–2016) from the hospital emergency department in the canton of Neuchâtel, Switzerland. Results: The median time from emergency department arrival to treatment initiation was 7 minutes; the median duration of treatment was 119 minutes. The rate of hospitalisation after emergency department treatment was 49.2%. Conclusion: This mixed somatic-psychiatric protocol seemed to reduce both the time before treatment initiation and treatment duration for ­patients presenting with acute psychomotor agitation in an emergency ­department. Implications for practice: The Code White protocol improved the emergency department’s ability to keep acutely agitated patients flowing smoothly and efficiently through it to other units or to discharge. On the qualitative level, it also improved staff safety and peace of mind, allowing them to carry out their many tasks more calmly

Patients' Needs for Care in Public Mental Health: Unity and Diversity of Self-Assessed Needs for Care.

PURPOSE: Needs assessment is recognized to be a key element of mental health care. Patients tend to present heterogeneous profiles of needs. However, there is no consensus in previous research about how patients' needs are organized. This study investigates both general and specific dimensions of patients' needs for care. METHODS: Patients' needs were assessed with ELADEB, an 18-domain self-report scale. The use of a self-assessment scale represents a unique way of obtaining patients' perceptions. A patient-centered psychiatric practice facilitates empowerment as it is based on the patients' personal motivations, needs, and wants. Four seventy-one patients' profiles were analyzed through exploratory factor analysis. RESULTS: A four-factor bifactor model, including one general factor and three specific factors of needs, was most adequate. Specific factors were (a) "finances" and "administrative tasks"; (b) "transports," "public places," "self-care," "housework," and "food"; and (c) "family," "children," "intimate relationships," and "friendship." CONCLUSION: As revealed by the general factor, patients expressing urgent needs in some domains are also more susceptible to report urgent needs in several other domains. This general factor relates to high versus low utilizers of public mental healthcare. Patients also present specific needs in life domains, which are organized in three dimensions: management, functional disabilities, and familial and interpersonal relationships. These dimensions relate to the different types of existing social support described in the literature

Hydrogen analysis in reactor containments.

The LIMIT code is a new containment analysis code capable of simulating hydrogen transport events. The BEACON [1] code served as the foundation upon which LIMIT is built. The analytical aspects of LIMIT's features are documented in the work of Manno and Golay [2]. This document is the code users manual. It is assumed that the user also possesses the original BEACON code manual since both documents are required for code utilization

Post-accident containment atmospheric stratification

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Prehospital triage accuracy in a criteria based dispatch centre.

BACKGROUND: Priority dispatch accuracy is a key issue in optimizing the match between patients' medical needs and pre-hospital resources. This study measures the accuracy of a Criteria Based Dispatch (CBD) system, by evaluating discrepancies between dispatch priorities and ambulance crews' severity evaluations. METHODS: This is a retrospective study conducted from January 2011 to December 2011. We ruled that a National Advisory Committee for Aeronautics (NACA) score > 3 (injuries/diseases which can possibly lead to deterioration of vital signs) to 7 (lethal injuries/ diseases) should require a priority dispatch with lights and siren (L&S), while NACA scores < 4 should require a priority dispatch without L&S. Over triage was defined as the proportion of L&S dispatches with a NACA score < 4, and under triage as the proportion of dispatches without L&S with a NACA score > 3. RESULTS: There were 29,008 primary missions in 2011, 1122 were excluded. Of the 15,749 L&S missions, 12,333 patients had a NACA score < 4, leading to an over triage rate of 78 %; 561 missions out of 12,137 missions without L&S had a NACA score > 3, leading to an under triage rate of 4.6 %. Sensitivity was 86 % (95 % confidence interval: 85.6-86.4 %), specificity 48 % (47.4-48.6 %), positive predictive value 21.7 % (21.2-22.2 %), and negative predictive value 95.4 % (95.2-95.6 %). CONCLUSION: The rates of over triage and under triage in our CBD are 78 and 4.6 % respectively. The lack of consistent or universal metrics is perhaps the most important limitation in dispatch accuracy research. This is mainly due to the large heterogeneity of dispatch systems and prehospital emergency system

Effects of a Weight Loss Program on Metabolic Syndrome, Eating Disorders and Psychological Outcomes: Mediation by Endocannabinoids?

To evaluate the effects of weight loss on endocannabinoids, cardiometabolic and psychological parameters, eating disorders (ED) as well as quality of life (QoL) and to elucidate the role of endocannabinoids in metabolic syndrome (MS). In total, 114 patients with obesity were prospectively included in a 12-month weight loss program. Plasma endocannabinoids were measured by mass spectrometry; ED, psychological and QoL-related parameters were evaluated by self-reported questionnaires; physical activity was measured by accelerometer. Nutritional assessment was done by a 3-day food diary. Among completers (n = 87), body weight decreased in 35 patients (-9.1 ± 8.6 kg), remained stable in 39 patients, and increased in 13 patients (+5.8 ± 3.4 kg). 75% of patients with MS at baseline were free of MS at follow-up, and their baseline plasma N-palmitoylethanolamide (PEA) values were significantly lower when compared to patients with persisting MS. At baseline, there was a positive relationship between PEA and waist circumference (p = 0.005, R2 = 0.08), fasting glucose (p < 0.0001, R2 = 0.12), total cholesterol (p = 0.001, R2 = 0.11), triglycerides (p = 0.001, R2 = 0.11), LDL-cholesterol (p = 0.03, R2 = 0.05) as well as depression score (p = 0.002, R2 = 0.29). Plasma PEA might play a role in metabolic improvement after weight loss. Even in subjects without weight loss, a multidisciplinary intervention improves psychological outcomes, ED, and QoL

Replica Field Theory for Deterministic Models (II): A Non-Random Spin Glass with Glassy Behavior

We introduce and study a model which admits a complex landscape without containing quenched disorder. Continuing our previous investigation we introduce a disordered model which allows us to reconstruct all the main features of the original phase diagram, including a low $T$ spin glass phase and a complex dynamical behavior.Comment: 35 pages with uu figures, Roma 102

Influence of the disorder on tracer dispersion in a flow channel

Tracer dispersion is studied experimentally in periodic or disordered arrays of beads in a capillary tube. Dispersion is measured from light absorption variations near the outlet following a steplike injection of dye at the inlet. Visualizations using dye and pure glycerol are also performed in similar geometries. Taylor dispersion is dominant both in an empty tube and for a periodic array of beads: the dispersivity $l\_d$ increases with the P\'eclet number $Pe$ respectively as $Pe$ and $Pe^{0.82}$ and is larger by a factor of 8 in the second case. In a disordered packing of smaller beads (1/3 of the tube diameter) geometrical dispersion associated to the disorder of the flow field is dominant with a constant value of $l\_d$ reached at high P\'eclet numbers. The minimum dispersivity is slightly higher than in homogeneous nonconsolidated packings of small grains, likely due heterogeneities resulting from wall effects. In a disordered packing with the same beads as in the periodic configuration, $l\_d$ is up to 20 times lower than in the latter and varies as $Pe^\alpha$ with $\alpha = 0.5$ or $= 0.69$ (depending on the fluid viscosity). A simple model accounting for this latter result is suggested.Comment: available online at http://www.edpsciences.org/journal/index.cfm?edpsname=epjap&niv1=contents&niv2=archive

Upregulation of peroxisome proliferator-activated receptor gamma coactivator gene ( PGC1A ) during weight loss is related to insulin sensitivity but not to energy expenditure

Aims/hypothesis: We investigated whether skeletal muscle peroxisome proliferator-activated receptor gamma coactivator-1 (PGC1A; also known as PPARGC1A) and its target mitofusin-2 (MFN2), as well as carnitine palmitoyltransferase-1 (CPT1; also known as carnitine palmitoyltransferase 1A [liver] [CPT1A]) and uncoupling protein (UCP)3, are involved in the improvement of insulin resistance and/or in the modification of energy expenditure during surgically induced massive weight loss. Materials and methods: Seventeen morbidly obese women (mean BMI: 45.9 ± 4kg/m2) were investigated before, and 3 and 12months after, Roux-en-Y gastric bypass (RYGB). We evaluated insulin sensitivity by the euglycaemic-hyperinsulinaemic clamp, energy expenditure and substrate oxidation by indirect calorimetry, and muscle mRNA expression by PCR. Results: Post-operatively, PGC1A was enhanced at 3 (p = 0.02) and 12months (p = 0.03) as was MFN2 (p = 0.008 and p = 0.03 at 3 and 12months respectively), whereas UCP3 was reduced (p = 0.03) at 12months. CPT1 did not change. The expression of PGC1A and MFN2 were strongly (p < 0.0001) related. Insulin sensitivity, which increased after surgery (p = 0.002 at 3, p = 0.003 at 12months), was significantly related to PGC1A and MFN2, but only MFN2 showed an independent influence in a multiple regression analysis. Energy expenditure was reduced at 3months post-operatively (p = 0.001 vs before RYGB), remaining unchanged thereafter until 12months. CPT1 and UCP3 were not significantly related to the modifications of energy expenditure or of lipid oxidation rate. Conclusions/interpretation: Weight loss upregulates PGC1A, which in turn stimulates MFN2 expression. MFN2 expression significantly and independently contributes to the improvement of insulin sensitivity. UCP3 and CPT1 do not seem to influence energy expenditure after RYG

Complement Activation Determines the Therapeutic Activity of Rituximab In Vivo

Rituximab is an anti-CD20 chimeric mAb effective for the treatment of B-NHL. It can lyse lymphoma cells in vitro through both C- and Ab-dependent cellular cytotoxicity. The mechanism of action of rituximab in vivo is however still unclear. We have set up a new in vivo model in nonimmunodeficient mice by stable transduction of the human CD20 cDNA in the murine lymphoma line EL4. Animals injected i.v. with the EL4-CD20+ lymphoma cells died within 30 days with evident liver, spleen, and bone marrow involvement, confirmed by immunohistochemistry and PCR analysis. A single injection of rituximab or the murine anti-CD20 Ab 1F5, given i.p. 1 day after the tumor, cured 100% of the animals. Indeed, at week 4 after tumor cell inoculation, CD20+ cells were undetectable in all organs analyzed in rituximab-treated animals, as determined by immunohistochemistry and PCR. Rituximab had no direct effect on tumor growth in vitro. Depletion of either NK cells or neutrophils or both in tumor-injected animals did not affect the therapeutic activity of the drug. Similarly, rituximab was able to eradicate tumor cells in athymic nude mice, suggesting that its activity is T cell independent. In contrast, the protective activity of rituximab or the 1F5 Ab was completely abolished in syngeneic knockout animals lacking C1q, the first component of the classical pathway of C (C1qa−/−). These data demonstrate that C activation is fundamental for rituximab therapeutic activity in vivo