Spatial Disorientation Impact on the Precise Approach in Simulated Flight

BACKGROUND: The risks posed by flight illusions impacting pilot spatial orientation have been determined as a safety concern from numerous past aviation accident investigations. Early demonstration of the adverse effects of flight illusions on spatial orientation would be desirable for all pilots, especially at the early training stages to deeply embed good practices for onset detection, flight correction, and response mitigation.METHOD: Simulated flights on a disorientation demonstrator were performed by 19 pilots for 3 conditions: no illusion, somatogyral illusion, and Coriolis illusion. An objective approach for assessing pilot performance degradation due to flight illusions can be done by using a defined flight profile: instrument landing system (ILS) flight trajectory during final instrument approach. Deviations to the standard ILS profile were recorded to measure and evaluate the influence of the demonstrated flight illusion on pilot performance.RESULTS: The results show the expectation that the smallest deviations from the ideal trajectory are caused by pilot tracking error (no illusion), and the greatest deviations are caused by the Coriolis illusion. Results demonstrated a statistically significant effect of illusions on performance. According to statements from pilots, training for flight illusion response is essential to complement training in aircraft regulations and aerodynamics.DISCUSSION: Measuring the influence of vestibular illusions on flight profile with a simulator allows assessment of individual differences and improvement of pilot performance under the conditions of no illusion, the somatogyral illusion, and the Coriolis illusion.Boril J, Smrz V, Blasch E, Lone M. Spatial disorientation impact on the precise approach in simulated flight. Aerosp Med Hum Perform. 2020; 91(10):767775.

Toxic leukoencephalopathy-When a Boxer's fracture requires an MRI and LP

This case report describes a young patient presenting to the ED with altered mental status several days after being diagnosed with a Boxer's fracture and ultimately discovered to have toxic leukoencephalopathy. We review the clinical features in his presentation leading to his diagnosis, as well as MRI imaging findings frequently found in his condition.

Confusion, respiratory rate, shock index (CRSI-65) score in the emergency department triage may be a new severity scoring method for community-acquired pneumonia

Objectives:

To investigate whether confusion, respiratory rate, shock index-age ≥65 years (CRSI-65) score, consisting of basic physiological parameters, can be used for severity prediction in patients with community-acquired pneumonia.

Methods:

This is a prospective cohort and single-center study conducted in Bolu Abant Izzet Baysal University Hospital, Bolu, Turkey between January 2018 and June 2018. The study investigated CRSI-65 score in predicting 4-week mortality and the need for intensive care for patients with community-acquired pneumonia.

Results:

A total of 58 patients with community-acquired pneumonia admitted to the emergency department were included in this study. Of the patients, 62.1% were males (n=36), and the mean age of the patients was 72.87 ± 12.30 years. After 4 weeks of follow-up, CURB-65 and CRSI-65 scores showed similar results in predicting mortality with respect to specificity, sensitivity, and positive and negative predictive values. Area under the receiver operating characteristic curve was 0.926 for the CURB-65 (95% confidence interval [CI] 0.853-0.999) and 0.954 for the CRSI-65 (95% CI 0.899-0.999).

Conclusion:

Similar to the CURB-65 score, the CRSI-65 score appears to be useful in predicting 4-week mortality. The evaluation of CRSI-65 score can be used in emergency department triage, primary care, and non-hospital settings.

[Lashing out in the A&E department]

BACKGROUND

Subacute hemichorea-hemiballismus in an older patient can be induced by non-ketotic hyperglycaemia. The triad of onset of subacute hemichorea-hemiballismus, hyperglycaemia and hyperdensity in the contralateral putamen on a CT scan or hyperintensity on a T1-weighted MRI scan is pathognomic for this diagnosis. Close observation of the motor restlessness and knowledge of this triad are important for making this diagnosis.

CASE DESCRIPTION

A 92-year-old female patient was admitted to the accident and emergency department with a history of motor restlessness for the past few days, confused speech and a glucose level of 20.5 mmol/l. Delirium was initially suspected. Abnormalities on the CT scan were indicative of hemichorea-hemiballismus caused by hyperglycaemia. The patient recovered fully once euglycaemic levels were restored.

CONCLUSION

Hemichorea-hemiballismus is a rare motor disorder, often due to an infarct in the contralateral basal ganglia. It can, however, be an expression of non-ketotic hyperglycaemia. The condition is sometimes confused with the motor restlessness of delirium.

Both trusting and understanding medical advice: Assessing patient alliance and confusion after medical consultations

OBJECTIVE

The current objective is to validate the Medical Consultation Experience Questionnaire (MCEQ) and to examine distinctions between constructs of patient perceived alliance and experienced confusion in relation to key health outcomes.

METHODS

A total of 857 participants were recruited online across two samples (adults with various medical conditions and with diabetes and/or hypertension specifically).

RESULTS

A confirmatory factor analysis demonstrated good fit and high item loadings for the theoretical bifactor model. Item response theory analyses showed very high individual item discrimination and good test information across a wide range of values. Confusion was uniquely and significantly more strongly related to psychological distress than was alliance; the same was true for alliance with positive affect. Both alliance and confusion significantly contributed to treatment motivation. Only confusion explained unique variance in control of HbA1C levels and blood pressure after controlling for alliance and other variables.

CONCLUSIONS

The MCEQ is a valid instrument for assessing distinct constructs of alliance and confusion. Future research should focus on the unique role of confusion for patient outcomes.

PRACTICE IMPLICATIONS

By using the MCEQ to assess patient alliance and confusion, it may be possible to detect and prioritize individual patient needs and improve patient outcomes.

Epileptic psychoses are underrecognized by French neurologists and psychiatrists

This study evaluates the knowledge about psychotic disorders associated with epilepsy among medical practitioners in France. A self-report questionnaire was sent, and responses of 486 participants were collected. Results showed the rate of correct responses being higher among neurologists compared to psychiatrists, respectively 70.6% and 58.3% (p < 10^-11). The highest rate of correct responses was found for the participants trained in epileptology (71%), and a regression analysis confirmed that epilepsy-training was the most influential variable. However, we found that knowledge about epileptic psychosis was imprecise among all participants: current classification was not known to most participants (77%), there were false beliefs concerning postictal confusion and psychosis (41%), and both prevalence and duration of postictal psychosis were not well-known. There is the first survey to highlight such gaps of knowledge, and hopefully lead to measures to remedy this, especially specialists such as psychiatrists, neurologists, and epileptologists who may be called upon to treat such patients.

In-flight spatial disorientation induces roll reversal errors when using the attitude indicator

We hypothesized that an incorrect expectation due to spatial disorientation may induce roll reversal errors. To test this, an in-flight experiment was performed, in which forty non-pilots rolled wings level after receiving motion cues. A No-leans condition (subthreshold motion to a bank angle) was included, as well as a Leans-opposite condition (leans cues, opposite to the bank angle) and a Leans-level condition (leans cues, but level flight). The presence of leans cues led to an increase of the roll reversal error (RRE) rate by a factor of 2.6. There was no significant difference between the Leans-opposite and Leans-level condition. This suggests that the expectation strongly affects the occurrence of an RRE, and that people tend to base their responses on motion cues instead of on information on the AI. We conclude that expectation and spatial disorientation have a large effect on piloting errors and may cause hazardous aircraft upsets.

Pre-loss personal factors and prolonged grief disorder in bereaved mothers

BACKGROUND

Identifying characteristics of individuals at greatest risk for prolonged grief disorder (PGD) can improve its detection and elucidate the etiology of the disorder. The Safe Passage Study, a study of women at high risk for sudden infant death syndrome (SIDS), prospectively examined the psychosocial functioning of women while monitoring their healthy pregnancies. Mothers whose infants died of SIDS were followed in bereavement.

METHODS

Pre-loss data were collected from 12 000 pregnant mothers and analyzed for their associations with grief symptoms and PGD in 50 mothers whose infants died from SIDS, from 2 to 48 months after their infant's death, focusing on pre-loss risk factors of anxiety, depression, alcohol use, maternal age, the presence of other living children in the home, and previous child loss.

RESULTS

The presence of any four risk factors significantly predicted PGD for 24 months post-loss (p < 0.003); 2-3 risk factors predicted PGD for 12 months (p = 0.02). PGD rates increased in the second post-loss year, converging in all groups to approximately 40% by 3 years. Pre-loss depressive symptoms were significantly associated with PGD. Higher alcohol intake and older maternal age were consistently positively associated with PGD. Predicted risk scores showed good discrimination between PGD and no PGD 6-24 months after loss (C-statistic = 0.83).

CONCLUSIONS

A combination of personal risk factors predicted PGD in 2 years of bereavement. There is a convergence of risk groups to high rates at 2-3 years, marked by increased PGD rates in mothers at low risk. The risk factors showed different effects on PGD.

A meta-synthesis of how parents of children with autism describe their experience of advocating for their children during the process of diagnosis

The diagnostic process for children with autism can be complex for parents to navigate as they advocate for their child in order to obtain answers to their concerns, and receive the subsequent support they need. Gaining an understanding of parents' experiences during this process, will assist service providers in supporting families adequately. This systematic review was undertaken to consolidate in-depth qualitative data from parents of their experience of advocating for their child with autism, during the process of diagnosis. A qualitative meta-synthesis was conducted, whereby fifteen databases were systematically searched. Twenty-two studies were identified and appraised using an adapted version of the Critical Appraisal Skills Programme tool. Data were synthesised into themes through the steps of review, meta-aggregation, integration, and interpretation. The date range of the included studies spans 1999-2016. The voices of 1,178 parents are presented in this review describing their experiences in two overarching themes: "Pathway to diagnosis-Confusion and not feeling heard"; and "Pursuing diagnosis-Resilience and commitment." Each one of these main themes had sub-themes. Our findings highlight the intense emotional journey for parents during identification of their initial concerns and the formal process of diagnosis, and their perceptions of not being supported by others on this journey. This review illustrates the significant impact that positive experiences with first-line professionals have during the process of diagnosis, and how these experiences lay the foundation for all future relationships with other service providers. As a result, awareness of parents' experiences will assist service providers to reconsider their communication style, information sharing, provision of support and to incorporate parents' contributions in facilitating a more streamlined and more supportive process of diagnosis.

The experiences and perceptions of care in acute settings for patients living with dementia: A qualitative evidence synthesis

BACKGROUND

Increasing numbers of people with dementia are presenting to acute care facilities for management of medical conditions and co-morbidities. They require an individual approach to care due to the confusion and disorientation which may accompany their illness. Current evidence syntheses on this topic explore how staff, family and carers view their care. This review aims to complement previous work in the area by exploring care from the perspective of the patient living with dementia.

OBJECTIVES

The aim of this qualitative evidence synthesis was to explore the experiences and perceptions of patients living with dementia on the care they receive in acute settings.

DESIGN

Qualitative evidence synthesis systematically draws the findings from individual studies together to create valid, reliable and meaningful evidence for healthcare policy development. Framework synthesis was utilised and guided by the VIPS framework; Values, Individualised, Perspective, and Social and psychological. The VIPS framework has previously been used for exploring staffs' views of care in the acute setting and provides guidance to caring for people with dementia.

REVIEW METHODS

Following screening, data were extracted and appraised using Critical Appraisal Skills Programme. Framework synthesis, incorporating thematic synthesis, was conducted and the confidence in findings was assessed using GRADE CERQual.

DATA SOURCES

Seven qualitative studies that explored care in acute hospitals as experienced or perceived by the person living with dementia.

RESULTS

The VIPS framework helped to capture views of care. Patients often experienced rushed and task- based approaches, poor communication, and exclusion in some cases. The environments were clearly unsuitable, sometimes exacerbating behaviours of concern, thus leading to unnecessary restraint due to an inability to protect this group.

CONCLUSIONS

Further research needs to be conducted in testing existing or developing new interventions to improve the physical environment, the systems of care and to provide more person-centred approaches to care. Organisational structures must ensure patients are cared for in a dementia friendly environment by a dementia trained workforce. At local level, involving support workers, eliminating unnecessary care practices, and facilitating individual choices of patients are recommended.

Virtual patients designed for training against medical error: Exploring the impact of decision-making on learner motivation

Objectives

Medical error is a significant cause of patient harms in clinical practice, but education and training are recognised as having a key role in minimising their incidence. The use of virtual patient (VP) activities targeting training in medical error allows learners to practice patient management in a safe environment. The inclusion of branched decision-making elements in the activities has the potential to drive additional generative cognitive processing and improved learning outcomes, but the increased cognitive load on learning risks negatively affecting learner motivation. The aim of this study is to better understand the impact that the inclusion of decision-making and inducing errors within the VP activities has on learner motivation.

Methods

Using a repeated study design, over a period of six weeks we provided undergraduate medical students at six institutions in three countries with a series of six VPs written around errors in paediatric practice. Participants were divided into two groups and received either linearly structured VPs or ones that incorporated branched decision-making elements. Having completed all the VPs, each participant was asked to complete a survey designed to assess their motivation and learning strategies.

Results

Our analysis showed that in general, there was no significant difference in learner motivation between those receiving the linear VPs and those who received branched decision-making VPs. The same results were generally reflected across all six institutions.

Conclusions

The findings demonstrated that the inclusion of decision-making elements did not make a significant difference to undergraduate medical students’ motivation, perceived self-efficacy or adopted learning strategies. The length of the intervention was sufficient for learners to overcome any increased cognitive load associated with branched decision-making elements being included in VPs. Further work is required to establish any immediate impact within periods shorter than the length of our study or upon achieved learning outcomes.

Verbal probabilities: Very likely to be somewhat more confusing than numbers

People interpret verbal expressions of probabilities (e.g. 'very likely') in different ways, yet words are commonly preferred to numbers when communicating uncertainty. Simply providing numerical translations alongside reports or text containing verbal probabilities should encourage consistency, but these guidelines are often ignored. In an online experiment with 924 participants, we compared four different formats for presenting verbal probabilities with the numerical guidelines used in the US Intelligence Community Directive (ICD) 203 to see whether any could improve the correspondence between the intended meaning and participants' interpretation ('in-context'). This extends previous work in the domain of climate science. The four experimental conditions we tested were: 1. numerical guidelines bracketed in text, e.g. X is very unlikely (05-20%), 2. click to see the full guidelines table in a new window, 3. numerical guidelines appear in a mouse over tool tip, and 4. no guidelines provided (control). Results indicate that correspondence with the ICD 203 standard is substantially improved only when numerical guidelines are bracketed in text. For this condition, average correspondence was 66%, compared with 32% in the control. We also elicited 'context-free' numerical judgements from participants for each of the seven verbal probability expressions contained in ICD 203 (i.e., we asked participants what range of numbers they, personally, would assign to those expressions), and constructed 'evidence-based lexicons' based on two methods from similar research, 'membership functions' and 'peak values', that reflect our large sample's intuitive translations of the terms. Better aligning the intended and assumed meaning of fuzzy words like 'unlikely' can reduce communication problems between the reporter and receiver of probabilistic information. In turn, this can improve decision making under uncertainty.

[Susac syndrome is an important differential diagnosis in monosymptomatic encephalopathy in young adults]

This is a case report of a 29-year-old man, who presented with progressive confusion, memory problems and personality changes during 1.5 months. Later, he developed bilateral hearing impairment but had no visual symptoms. A brain MRI showed numerous small hyperintensities in both hemispheres, a retinal fluorescence angiography revealed multiple hyperfluorescent arterial occlusions, and an audiogram showed bilateral hearing impairment. The patient was treated for Susac syndrome with high-dose corticosteroids initially, followed by intravenous immunoglobulin and cyclophosphamide.

An evaluation of tactile symbols in public environment for the visually impaired

This study evaluated the identification performance of a set of tactile symbols used in public environments for the visually impaired. A questionnaire survey was carried out to investigate the public environment needs from 60 visually impaired associations. A two-stage experiment with a matching test was then conducted to explore the identification efficiency of graphic tactile public information symbols. Eighty-one students were recruited as participants from a school for the visually impaired. The survey results show that fourteen public buildings were frequently visited and ten architectural elements were mostly needed by the visually impaired. The experimental results showed the correct response of graphic symbols tested in both two-stage experiments could meet the identification criterion of 90% and even better except for the escalator/elevator with 87.0% in the second stage. Relevant confusion among the graphic symbols tested was found. Some suggestions were made in the study.

What color are emergency exit signs? Egress behavior differs from verbal report

Illuminated emergency exit signs inform building occupants about safe egress routes in emergencies. These exit signs are often found in the presence of other colored signs, which may distract occupants when searching for safe exits. Such distractions can lead to confusing and even harmful outcomes, especially if occupants misinterpret the sign colors, mistaking non-exit signs for exit signs. We studied which colored signs people were most likely to infer were exit signs in a simulated emergency evacuation using virtual reality (VR). Participants were immersed in a virtual room with two doors (left and right), and an illuminated sign with different colored vertical bars above each door. They saw all pairwise combinations of six sign colors across trials. On each trial, a fire alarm sounded, and participants walked to the door that they thought was the exit. We tested two hypotheses: a local exposure hypothesis that color inferences are determined by exit sign colors in the local environment (i.e., red) and a semantic association hypothesis that color inferences are determined by color-concept associations (i.e. green associated with "go" and "safety"). The results challenged the local exposure hypothesis and supported the semantic association hypothesis. Participants predominantly walked toward green signs, even though the exit signs in the local environment-including the building where the experiment took place-were red. However, in a post-experiment survey, most participants reported that exit signs should be red. The results demonstrated a dissociation between the way observers thought they would behave in emergency situations (red = exit) and the way they did behave in simulated emergencies (green = exit). These findings have implications for the design of evacuation systems. Observers, and perhaps designers, do not always anticipate how occupants will behave in emergency situations, which emphasizes the importance of behavioral evaluations for egress safety.