Ceilings of treatment: a qualitative study in the emergency department

Background: Decision-making concerning the limitation of potentially life-prolonging treatments is often challenging, particularly in the Emergency Department (ED). Current literature in this area of Emergency Medicine is limited and heterogeneous. We seek to determine the factors that influence ceiling of treatment institution in the ED. Methods: We conducted a phenomenological qualitative study employing semi-structured interviews. Emergency Medicine Consultants were recruited via a sample of convenience from 5 hospitals in the West of Scotland. Data saturation was achieved after 15 interviews. Interviews were recorded, anonymised, transcribed, coded, and an iterative thematic analysis was carried out. Results: A model was created to illustrate the identified themes. Patient wishes are central to decision-making. Acute clinical factors and patient-specific factors lay the foundations of ceiling of treatment decisions. This is heavily contextualised by family input, collateral information, anticipated outcome, and whether the patient is accepted for higher care. This decision-making process flows through a ‘filter’ of cultural and environmental factors. The overarching nature of patient benefit was found to be of key importance, framing all aspects of ceiling of treatment institution. Ultimately, all ceiling of treatment decisions result in one of three common patient pathways: full escalation, limited escalation, and maintenance of current care with the option of palliative care initiation. Conclusions: We present a conceptual model composed of 10 major thematic factors that influence Consultant ceiling of treatment decision-making in the ED. Clinicians should be cognizant of influential factors and associated biases when making these important and challenging decisions

ACES RED Experiment #1 Environmental Test Results for Industrial Grade, Non-traditional, and Other Components Lacking Flight Heritage

Results of the thermal vacuum chamber (TVAC) testing and vibrational testing of the ACES RED Experiment #1 are presented. Performance of commercial-off-the-shelf components such as the Avnet PicoZed, the Xiphos Q7, the MAI-400, and a NovaTel GNSS during TVAC testing are provided and analyzed. To our knowledge, this is the first orbital flight of this version of the GNSS, this version of the MAI-400, and the PicoZed. The experiment utilizes a novel structural concept for ease of electronics assembly and disassembly. The health monitoring system measures temperatures, vibration, voltages, and currents for situational awareness of each of these component\u27s relative performance. An assessment and progression of the technology readiness level of the hardware is also presented

Rumen Virus Populations: Technological Advances Enhancing Current Understanding

The rumen contains a multi-kingdom, commensal microbiome, including protozoa, bacteria, archaea, fungi and viruses, which enables ruminant herbivores to ferment and utilize plant feedstuffs that would be otherwise indigestible. Within the rumen, virus populations are diverse and highly abundant, often out-numbering the microbial populations that they both predate on and co-exist with. To date the research effort devoted to understanding rumen-associated viral populations has been considerably less than that given to the other microbial populations, yet their contribution to maintaining microbial population balance, intra-ruminal microbial lysis, fiber breakdown, nutrient cycling and genetic transfer may be highly significant. This review follows the technological advances which have contributed to our current understanding of rumen viruses and drawing on knowledge from other environmental and animal-associated microbiomes, describes the known and potential roles and impacts viruses have on rumen function and speculates on the future directions of rumen viral research

Cost-effectiveness of 10-kHz Spinal Cord Stimulation Therapy Compared With Conventional Medical Management Over the First 12 Months of Therapy for Patients With Nonsurgical Back Pain: Randomized Controlled Trial

Objective: This analysis evaluated if spinal cord stimulation (SCS) at 10 kHz plus conventional medical management (CMM) is cost-effective compared with CMM alone for the treatment of nonsurgical refractory back pain (NSRBP). Methods: NSRBP subjects were randomized 1:1 into the 10-kHz SCS (n = 83) or CMM (n = 76) group. Outcomes assessed at 6 months included EQ-5D 5-level (EQ-5D-5L), medication usage, and healthcare utilization (HCU). There was an optional crossover at 6 months and follow-up to 12 months. The incremental cost-effectiveness ratio (ICER) was calculated with cost including all HCU and medications except for the initial device and implant procedure, and cost-effectiveness was analyzed based on a willingness-to-pay threshold of \u3c $50,000 per quality-adjusted life-year. Results: Treatment with 10-kHz SCS resulted in a significant improvement in quality of life (QOL) over CMM (EQ-5D-5L index score change of 0.201 vs -0.042, p \u3c 0.001) at a lower cost, based on reduced frequency of HCU resulting in an ICER of -$4964 at 12 months. The ICER was -$8620 comparing the 6 months on CMM with postcrossover on 10-kHz SCS. Conclusions: Treatment with 10-kHz SCS provides higher QOL at a lower average cost per patient compared with CMM. Assuming an average reimbursement for device and procedure, 10-kHz SCS therapy is predicted to be cost-effective for the treatment of NSRBP compared with CMM within 2.1 years

Salve Regina University Act on Climate: Strategic Plan for the University to Reach State Carbon Neutrality Goals

In order to become more sustainable and meet the mandate set by the 2021 Rhode Island Act on Climate law (RI General Law §42-6.2), Salve Regina University must work to reach net-zero greenhouse gas emissions by the year 2050. Action to meet these standards begins now and must be continually built upon to ensure that Salve Regina University, as leader in Rhode Island, is always working for a more sustainable future. Throughout the Spring 2022 semester, students of the BIO-140: Humans and Their Environment course instructed by Dr. Jameson Chace have researched ways in which Salve Regina can begin on the path to zero greenhouse gas emissions today. By focusing on change in the areas of energy, transportation, food, financial investments, and sequestration, Salve Regina can reduce the greenhouse gas emissions of today for a more sustainable tomorrow. Recommendations are broken into three time periods. Action for today to achieve by 2030 include improving energy efficiency, installing the first electric vehicle (EV) parking/charging stations, increasing carbon sequestration, reducing beef in the campus diet, and assessing the carbon impact of university financial holdings. Actions to be initiated soon and to be achieved by 2040 include shifting away from natural gas heating when system renewals take place, increasing EV parking to meet rising demand, during turnover replace current university vehicles with electric or hybrid, continuing with sequestration efforts on campus, begin phasing out high carbon diet items, and by 2040 the university investment portfolio should be carbon neutral. If carbon neutrality can be reached by 2050 the most challenging aspects of campus life that need to change will require planning now and thoughtful implementation. The class in 2022 envisions a campus in 2050 where solar lights illuminate campus and buildings through the night, all university vehicles and most faculty and staff vehicles are electric and are found charging during the day at solar powered charging stations, dining services in Miley supports community agriculture and includes incentives for meatless and low carbon meal plans, the university has become a leader in low carbon/green market investing demonstrating how careful planning can reap high returns, and carbon sequestration on campus grounds has maximized such that off campus carbon offsets are established with local land trusts to complete the carbon neutrality goals. In doing so no only will the university be recognized as a state-wide leader in climate action, but will also be a global leader in working towards a world that is more harmonious, just, and merciful.https://digitalcommons.salve.edu/bio140_arboretum/1033/thumbnail.jp

Functional deficits in carpal tunnel syndrome reflect reorganization of primary somatosensory cortex

Carpal tunnel syndrome, a median nerve entrapment neuropathy, is characterized by sensorimotor deficits. Recent reports have shown that this syndrome is also characterized by functional and structural neuroplasticity in the primary somatosensory cortex of the brain. However, the linkage between this neuroplasticity and the functional deficits in carpal tunnel syndrome is unknown. Sixty-three subjects with carpal tunnel syndrome aged 20–60 years and 28 age- and sex-matched healthy control subjects were evaluated with event-related functional magnetic resonance imaging at 3 T while vibrotactile stimulation was delivered to median nerve innervated (second and third) and ulnar nerve innervated (fifth) digits. For each subject, the interdigit cortical separation distance for each digit’s contralateral primary somatosensory cortex representation was assessed. We also evaluated fine motor skill performance using a previously validated psychomotor performance test (maximum voluntary contraction and visuomotor pinch/release testing) and tactile discrimination capacity using a four-finger forced choice response test. These biobehavioural and clinical metrics were evaluated and correlated with the second/third interdigit cortical separation distance. Compared with healthy control subjects, subjects with carpal tunnel syndrome demonstrated reduced second/third interdigit cortical separation distance (P < 0.05) in contralateral primary somatosensory cortex, corroborating our previous preliminary multi-modal neuroimaging findings. For psychomotor performance testing, subjects with carpal tunnel syndrome demonstrated reduced maximum voluntary contraction pinch strength (P < 0.01) and a reduced number of pinch/release cycles per second (P < 0.05). Additionally, for four-finger forced-choice testing, subjects with carpal tunnel syndrome demonstrated greater response time (P < 0.05), and reduced sensory discrimination accuracy (P < 0.001) for median nerve, but not ulnar nerve, innervated digits. Moreover, the second/third interdigit cortical separation distance was negatively correlated with paraesthesia severity (r = −0.31, P < 0.05), and number of pinch/release cycles (r = −0.31, P < 0.05), and positively correlated with the second and third digit sensory discrimination accuracy (r = 0.50, P < 0.05). Therefore, reduced second/third interdigit cortical separation distance in contralateral primary somatosensory cortex was associated with worse symptomatology (particularly paraesthesia), reduced fine motor skill performance, and worse sensory discrimination accuracy for median nerve innervated digits. In conclusion, primary somatosensory cortex neuroplasticity for median nerve innervated digits in carpal tunnel syndrome is indeed maladaptive and underlies the functional deficits seen in these patients

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines.

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations

Modernism, class and colonialism in Robert Noonan’s The Ragged Trousered Philanthropists

This essay explores Robert Noonan’s 1914 novel, The Ragged Trousered Philanthropists, as a work of Irish modernist fiction. Reading its fragmented narrative as a reflection of the author’s subaltern position as an Irish republican and socialist, it interprets Noonan’s work as the product of the anticolonial and class struggles in which he was involved. Its critique of capitalist and imperial hegemony and the assertions that suffering, injustice and violence are normal, natural or inevitable phenomena reflects the author’s frustration, anger and desperation. In this way the novel counters and decentres the bourgeois-imperial dynamic that was reflected in the textual stability of Victorian realism. The Ragged Trousered Philanthropists is an uneasy text that is at once ruptured and uncertain of its own aesthetic status and conveys, through its shifting, episodic plot, the precariousness of a working-class existence permanently poised “on the brink of destitution.” © 2018 Informa UK Limited, trading as Taylor & Francis Grou