A calcareous nannofossil and organic geochemical study of marine palaeoenvironmental changes across the Sinemurian/Pliensbachian (early Jurassic, ~191Ma) in Portugal

The Sinemurian/Pliensbachian boundary (~ 191 Ma) is acknowledged as one of the most important steps in the radiation of planktonic organisms, especially primary producers such as dinoflagellates and coccolithophores. To date, there is no detailed study documenting changes in planktonic assemblages related to palaeoceanographic changes across this boundary. The aim of this study is to characterize the palaeoenvironmental changes occurring across the Sinemurian/Pliensbachian boundary at the São Pedro de Moel section (Lusitanian Basin, Portugal) using micropalaeontology and organic geochemistry approaches. Combined calcareous nannofossil assemblage and lipid biomarker data document for a decrease in primary productivity in relation to a major sea-level rise occurring above the boundary. The Lusitanian Basin was particularly restricted during the late Sinemurian with a relatively low sea level, a configuration that led to the recurrent development of black shales. After a sharp sea-level fall, the basin became progressively deeper and more open during the earliest Pliensbachian, subsequently to a major transgression. This sea-level increase seems to have been a global feature and could have been related to the opening of the Hispanic Corridor that connected the Tethys and palaeo-Pacific oceans. The palaeoceanographic and palaeoclimatic changes induced by this opening may have played a role in the diversification of coccolithophores with the first occurrence or colonization of Tethyan waters by placolith-type coccoliths

Trends of pre-hospital emergency medical services activity over 10 years : a population-based registry analysis

BACKGROUND: The number of requests to pre-hospital emergency medical services (PEMS) has increased in Europe over the last 20 years, but epidemiology of PEMS interventions has little be investigated. The aim of this analysis was to describe time trends of PEMS activity in a region of western Switzerland. METHODS: Use of data routinely and prospectively collected for PEMS intervention in the Canton of Vaud, Switzerland, from 2001 to 2010. This Swiss Canton comprises approximately 10% of the whole Swiss population. RESULTS: We observed a 40% increase in the number of requests to PEMS between 2001 and 2010. The overall rate of requests was 35/1000 inhabitants for ambulance services and 10/1000 for medical interventions (SMUR), with the highest rate among people aged ≥ 80. Most frequent reasons for the intervention were related to medical problems, predominantly unconsciousness, chest pain respiratory distress, or cardiac arrest, whereas severe trauma interventions decreased over time. Overall, 89% were alive after 48 h. The survival rate after 48 h increased regularly for cardiac arrest or myocardial infarction. CONCLUSION: Routine prospective data collection of prehospital emergency interventions and monitoring of activity was feasible over time. The results we found add to the understanding of determinants of PEMS use and need to be considered to plan use of emergency health services in the near future. More comprehensive analysis of the quality of services and patient safety supported by indicators are also required, which might help to develop prehospital emergency services and new processes of care

P298 Comparison between clinical and patient-reported symptoms among Crohn's disease and ulcerative colitis patients

Background: There is no symptom-based patient-reported outcomes (PRO) measurement available in IBD. Disease scores contain a mixture of PRO and physician's observations and have shown serious limitations in clinical trials. Comparison between healthcare professionals (HCP) and patient (P) reports on scores' items is a first step toward disease scores refinement. In our IBD cohort study, we were able to collect P and HCP-reported symptoms independently. We assessed the agreement between both measures, and tested the correlation between the general well-being item (GWB) and two health-related quality of life (HRQoL) measures. Methods: Between 2012 and 2015, we collected CDAI and MTWAI items 1) during follow-up medical visits, 2) through P self-reported follow-up questionnaire, except lab values. We compared items independently reported by HCP and P, stratified by diagnostic and Δt HCP-P reports. We calculated the Cohen's kappa (κ) statistic for agreement. A quadratic weight was applied for more severely serious disagreements. For EIM & complications, we computed a pooled κ based on the average between observed and expected probability of agreement over sub-items. A pooled κ was computed to summarize agreement over all examined variables. We also collected SF-36 and IBDQ scores. Pearson correlation coefficients r were calculated between both scores and GWB reports of HCP and P. Results: 2427 reports could be evaluated (Δt: 537<1 month, 390 1–2, 1500 2–6), referring to 1385 patients (52% females, 58% CD)

A systematic review of cost-effectiveness studies comparing conventional, biological and surgical interventions for inflammatory bowel disease.

Inflammatory bowel disease (IBD) is a chronic disease placing a large health and economic burden on health systems worldwide. The treatment landscape is complex with multiple strategies to induce and maintain remission while avoiding long-term complications. The extent to which rising treatment costs, due to expensive biologic agents, are offset by improved outcomes and fewer hospitalisations and surgeries needs to be evaluated. This systematic review aimed to assess the cost-effectiveness of treatment strategies for IBD. A systematic literature search was performed in March 2017 to identify economic evaluations of pharmacological and surgical interventions, for adults diagnosed with Crohn's disease (CD) or ulcerative colitis (UC). Costs and incremental cost-effectiveness ratios (ICERs) were adjusted to reflect 2015 purchasing power parity (PPP). Risk of bias assessments and a narrative synthesis of individual study findings are presented. Forty-nine articles were included; 24 on CD and 25 on UC. Infliximab and adalimumab induction and maintenance treatments were cost-effective compared to standard care in patients with moderate or severe CD; however, in patients with conventional-drug refractory CD, fistulising CD and for maintenance of surgically-induced remission ICERs were above acceptable cost-effectiveness thresholds. In mild UC, induction of remission using high dose mesalazine was dominant compared to standard dose. In UC refractory to conventional treatments, infliximab and adalimumab induction and maintenance treatment were not cost-effective compared to standard care; however, ICERs for treatment with vedolizumab and surgery were favourable. We found that, in general, while biologic agents helped improve outcomes, they incurred high costs and therefore were not cost-effective, particularly for use as maintenance therapy. The cost-effectiveness of biologic agents may improve as market prices fall and with the introduction of biosimilars. Future research should identify optimal treatment strategies reflecting routine clinical practice, incorporate indirect costs and evaluate lifetime costs and benefits

Earth current monitoring circuit for inductive loads

The search for higher magnetic fields in particle accelerators increasingly demands the use of superconducting magnets. This magnet technology has a large amount of magnetic energy storage during operation at relatively high currents. As such, many monitoring and protection systems are required to safely operate the magnet, including the monitoring of any leakage of current to earth in the superconducting magnet that indicates a failure of the insulation to earth. At low amplitude, the earth leakage current affects the magnetic field precision. At a higher level, the earth leakage current can additionally generate local losses which may definitively damage the magnet or its instrumentation. This paper presents an active earth fault current monitoring circuit, widely deployed in the converters for the CERN Large Hadron Collider (LHC) superconducting magnets. The circuit allows the detection of earth faults before energising the circuit as well as limiting any eventual earth fault current. The electrical stress on each circuit component is analyzed and advice is given for a totally safe component selection in relation to a given load

Development of a monitoring instrument to assess the performance of the Swiss primary care system.

The Swiss health system is customer-driven with fee-for-service paiement scheme and universal coverage. It is highly performing but expensive and health information systems are scarcely implemented. The Swiss Primary Care Active Monitoring (SPAM) program aims to develop an instrument able to describe the performance and effectiveness of the Swiss PC system. Based on a Literature review we developed a conceptual framework and selected indicators according to their ability to reflect the Swiss PC system. A two round modified RAND method with 24 inter-/national experts took place to select primary/secondary indicators (validity, clarity, agreement). A limited set of priority indicators was selected (importance, priority) in a third round. A conceptual framework covering three domains (structure, process, outcome) subdivided into twelve sections (funding, access, organisation/ workflow of resources, (Para-)Medical training, management of knowledge, clinical-/interpersonal care, health status, satisfaction of PC providers/ consumers, equity) was generated. 365 indicators were pre-selected and 335 were finally retained. 56 were kept as priority indicators.- Among the remaining, 199 were identified as primary and 80 as secondary indicators. All domains and sections are represented. The development of the SPAM program allowed the construction of a consensual instrument in a traditionally unregulated health system through a modified RAND method. The selected 56 priority indicators render the SPAM instrument a comprehensive tool supporting a better understanding of the Swiss PC system's performance and effectiveness as well as in identifying potential ways to improve quality of care. Further challenges will be to update indicators regularly and to assess validity and sensitivity-to-change over time

Field evaluation of the CATT/Trypanosoma brucei gambiense on blood-impregnated filter papers for diagnosis of human African trypanosomiasis in southern Sudan.

Most Human African Trypanosomiasis (HAT) control programmes in areas endemic for Trypanosoma brucei gambiense rely on a strategy of active mass screening with the Card Agglutination Test for Trypanosomiasis (CATT)/T. b. gambiense. We evaluated the performance, stability and reproducibility of the CATT/T. b. gambiense on blood-impregnated filter papers (CATT-FP) in Kajo-Keji County, South-Sudan, where some areas are inaccessible to mobile teams. The CATT-FP was performed with a group of 100 people with a positive CATT on whole blood including 17 confirmed HAT patients and the results were compared with the CATT on plasma (CATT-P). The CATT-FP was repeated on impregnated filter papers stored at ambient and refrigerated temperature for 1, 3, 7 and 14 days. Another 82 patients with HAT, including 78 with a positive parasitology, were tested with the CATT-FP and duplicate filter paper samples were sent to a reference laboratory to assess reproducibility. The CATT-FP was positive in 90 of 99 patients with HAT (sensitivity: 91%). It was less sensitive than the CATT-P (mean dilution difference: -2.5). There was no significant loss of sensitivity after storage for up to 14 days both at ambient and cool temperature. Reproducibility of the CATT-FP was found to be excellent (kappa: 0.84). The CATT-FP can therefore be recommended as a screening test for HAT in areas where the use of CATT-P is not possible. Further studies on larger population samples in different endemic foci are still needed before the CATT-FP can be recommended for universal use

Increasing prehospital emergency medical service interventions for nursing home residents.

QUESTION: In the ageing European population, the proportion of interventions by the emergency medical services (EMS) for elderly patients is increasing, but little is known about the recent trend of EMS interventions in nursing homes. The aim of this analysis was to describe the evolution of the incidence of requests for prehospital EMS interventions for nursing home residents aged 65 years and over between 2004 and 2013. METHODS: A prospective population-based register of routinely collected data for each EMS intervention in the Canton of Vaud. Linear time trends of incidence of requests to the EMS in nursing homes were calculated and stratified by age categories. RESULTS: The number of ambulance interventions in nursing homes for people aged 65 years and over (65+) increased by 68.9% (1124‒1898) between 2004 and 2013. A significant linear increase of the annual incidence of requests to EMS per 1,000 nursing home residents was found for people aged 65-79 (10.2, 95% confidence interval [CI] 6.2-14.2), 80-89 (16.5, 95% CI 14.0-19.0) and over 90 (12.1, 95% CI 5.8-18.4). EMS interventions in nursing home residents who required an emergency physician increased during the same period by 205.6% (from 106 to 324), representing an increase from 2% to 7% of all emergency physician interventions in the Canton. CONCLUSIONS: Our results confirmed an important increase in the incidence of EMS interventions in nursing homes during the last decade, far exceeding the actual increase of the nursing home population during the same period. This evolution represents an important opportunity to reconsider the EMS missions in the context of an ageing society

The probability of having advanced medical interventions is associated with age in out-of-hospital life-threatening situations.

The use of out-of-hospital emergency medical services by old and very old individuals is increasing. These patients frequently require complex evaluation and decision-making processes to determine a strategy of care, therapeutic choices or withdrawal of care in life-threatening situations. During out-of-hospital missions, thorough decision-making is difficult because of the limited amount of time and lack of direct access to medical charts or to pre-existing advance directives. In this setting, age may be used as a proxy to determine strategy of care, therapeutic choices or withdrawal of care, particularly in relation to advanced medical interventions. We aimed to determine how an emergency physician's initiation of out-of-hospital advanced medical interventions varies with the patient's age. We performed a retrospective analysis of the missions conducted by the emergency physicians-staffed emergency medical services in a Swiss region. We used logistic regression analysis to determine whether the probability of receiving an advanced medical intervention was associated with the patient's age. Among 21,922 out-of-hospital emergency adult missions requiring an emergency physician, the probability of receiving an advanced medical intervention decreased with age. It was highest among those aged 18 - 58 years and significantly lower among those aged ≥ 89 years (OR = 0.66; 95 % CI: 0.53 - 0.82). The probability of cardiopulmonary resuscitation attempts progressively decreased with age and was significantly lower for the three oldest age deciles (80 - 83, 84 - 88 and ≥ 89 years). The number of out-of-hospital advanced medical interventions significantly decreased for patients aged ≥ 89 years. It is unknown whether this lower rate of interventions was related only to age or to other medical characteristics of these patients, such as the number or severity of comorbidities. Thus, further studies are needed to confirm whether this observation corresponds to underuse of advanced medical interventions in very old patients