'Chugging along, plugging in and out of it': Understanding a place-based approach for community-based support of mental health recovery

Community-based Mental Health (MH) organisations in the United Kingdom (UK) are facing challenges for sustaining in-person service delivery. Without empirical evidence that demonstrates the value of a place-based approach for MH recovery, and the types of resources needed to build nurturing spaces for peer support, community-based MH organisations will struggle to maintain their physical spaces. We present empirical insights from a case study involving interviews with 20 students accessing peer support services at the Recovery College Collective, a community-based MH organisation located in the North East of England. The interview study aims to evidence how a place-based approach can afford MH recovery. We draw from discourses on place-making and interpret our interview findings through an established framework that highlights four mechanisms through which place impacts recovery: place for doing, being, becoming and belonging. We use this framework to structure our findings and highlight key qualities of place for establishing and maintaining MH recovery. Our contribution is two-fold: we address a gap in the literature by providing empirical understandings of how place influences MH recovery, whilst extending previous research by considering the role that place plays in community-based organisations. This is timely because of the challenges faced in securing in-person service delivery post-pandemic, and a shift towards remote service provision models. We highlight key implications: (i) Accessing a physical place dedicated to MH support is vital for people who do not have anywhere else to go and are socially isolated due to their health conditions; (ii) Connecting through peer-to-peer interaction is an integral part of the recovery process, and learning from people with lived experience can inform a place-based approach that best suit their needs; and (iii) Recognising the value of place for MH support, and the resources needed for peer support delivery in the community, will help secure places that our research participants described as lifesaving.

Oral mucosal melanoma in situ: a case report and review of the literature

Oral mucosal melanoma is a rare presentation of malignant melanoma with a 5-year survival rate of only 15%. Oral mucosal melanoma in situ (OMMIS) is its assumed precursor. This report describes one of only 20 documented cases of OMMIS and outlines how early clinical recognition resulted in prompt histopathological diagnosis and subsequent complete surgical excision. A literature review of existing reported cases, their management, and latest outcomes was also performed, highlighting this rare condition for consideration in the differential diagnosis of pigmented oral pathologies.

A qualitative analysis of health information-sharing networks in the Indonesian poultry sector

Animal production systems are developing into increasingly complex value chains involving a large diversity of actors with multiple and dynamic linkages, concurrently creating many opportunities for disease spread. Access to timely and good-quality animal health information is vital for designing effective disease management strategies. However, several factors may hamper information flows along those chains. Understanding the structure and dynamics of information networks is essential to develop effective and acceptable health information systems. We applied a qualitative network approach to understand how information about poultry health is generated, disseminated and used for decision-making along the poultry value chain in Indonesia. Maps of the value chain and information networks were generated based on data from key informant interviews to illustrate the linkages and information-sharing patterns between stakeholders. Four types of farm business models were identified: company-owned, contract, partnership and independent. Although companies and most independent farmers collected health and production data routinely, their systems were strongly siloed and still relied on a mix of digital and paper-based methods, which impaired their analytical capacity. Technical service providers from the upstream sector and industry associations were identified as key intermediaries in the information-sharing network with the ability to create informal bridges between separate business networks and public actors. These actors can play a strategic role in the development of integrated information systems to improve stakeholders' capacity to monitor, anticipate and manage disease threats at all levels of the value chain. This study contributes to fill an important knowledge gap regarding the layer sector and may help decision-makers to design effective policies and interventions tailored to the type of business model.

Extracranial dose and the risk of radiation-induced malignancy after intracranial stereotactic radiosurgery: is it time to establish a therapeutic reference level?

BACKGROUND

To measure extracranial doses from Gamma Knife Perfexion (GKP) intracranial stereotactic radiosurgery (SRS) and model the risk of malignancy after SRS for different treatment platforms.

METHODS

Doses were measured for 20 patients undergoing SRS on a GKP at distances of 18, 43 and 75 cm from the target, corresponding to the approximate positions of the thyroid, breast and gonads respectively. A literature review was conducted to collect comparative data from other radiosurgery platforms. All data was used to calculate the dose to body organs. The National Cancer Institute (NCI) RadRAT calculator was used to estimate excess lifetime cancer risk from this exposure. Five different age groups covering childhood and younger adults were modelled for both sexes.

RESULTS

Extracranial doses delivered during SRS with the GKP were a median 0.04%, 0.008% and 0.002% of prescription dose at 18 cm, 43 cm and 70 cm from the isocentre respectively. Comparison with the literature revealed that the extracranial dose was lowest from GKP, then linacs equipped with micro-multileaf collimators (mMLC), then linacs equipped with circular collimators (cones), and highest from Cyberknife (CK). Estimated lifetime risks of radiation-induced malignancy in the body for patients treated with SRS aged 5-45 years were 0.03-0.88%, 0.36-11%, 0.61-18% and 2.2-39% for GKP, mMLC, cones and CK respectively.

CONCLUSIONS

We have compared typical extracranial doses from different platforms and quantified the lifetime risk of radiation-induced malignancy. The risk varies with platform. This should be taken into account when treating children and young adults with SRS. The concept of a therapeutic reference level (TRL), similar to the diagnostic reference level (DRL) established in radiology, is proposed.

Determining the association between the type of intervention for ischaemic heart disease and mortality and morbidity in patients with chronic kidney disease

INTRODUCTION

Association between chronic kidney disease (CKD) and ischaemic heart disease (IHD) is well known. Clinically, because of the use of intra-arterial contrast, coronary angiograms are sometimes not performed to avoid further deterioration in kidney function amongst CKD patients. Therefore, our aim is to identify whether intervention for non-ST elevation myocardial infarction (NStemi) is associated with increased mortality or further renal deterioration.

METHOD

A retrospective observational cohort study was undertaken involving 144 patients with diagnosis of IHD in the CKD.QLD registry from May 2011 to August 2017, with minimum of 2 years follow-up. Patients were divided into two groups based on whether they obtained an interventional or medical management for NStemi.

RESULTS

59 patients had medical management and 85 patients had intervention for IHD. Patients in the medical management group were observed to be significantly older (median:78vs69years,p<0.05) with worse baseline renal function (median:31vs36ml/min/1.73m³ ,<0.05) and higher serum urate level (median:0.5vs0.4mmol/L,p=0.2). The interventional group had lower prevalence of diabetes, dyslipidaemia, cerebrovascular disease and peripheral vascular disease, , although this was not significant Kaplan-Meier analysis revealed a significant decrease in mean survival of medically managed group compared to interventional group. Furthermore, post adjustment for age and above comorbidities, medically managed group and higher age were associated with significantly higher mortality. However, the patients in the medically managed and interventional groups had no significant difference in delta eGFR.

CONCLUSION

In this observational study, intervention for IHD was associated with increased survival with no change in renal disease progression in comparison to medically managed patients. This article is protected by copyright. All rights reserved.

Hyperuricaemia, gout and allopurinol in the CKD Queensland registry

Introduction

There is scant data on the role of hyperuricaemia, gout and allopurinol treatment in chronic kidney disease (CKD). Therefore, our aim is to investigate the possible associations between hyperuricaemia, gout, prescription of allopurinol and renal outcomes in patients with CKD.

Methods

The retrospective cohort study involved 1123 Royal Brisbane and Women’s Hospital (RBWH) patients, enrolled in the CKD.QLD registry from May 2011 to August 2017. Patients were divided into two uric acid categories, with uric acid ≤ 0.36 mmol/L and > 0.36 mmol/L. Association of delta estimated glomerular filtration rate (eGFR) with gout, allopurinol treatment and hyperuricaemia were analysed.

Results

Patients with an entry urate > 0.36 mmol/L were older, had higher body mass index (BMI) and worse baseline kidney function. Proportion of patients with gout, hyperuricaemia and allopurinol treatment increased with advanced CKD stages. Age-adjusted analysis revealed a significant association between serum urate level and delta eGFR, with no significant association between gout, treatment with allopurinol and delta eGFR. Furthermore, neither gout nor the prescription of allopurinol had a significant effect on the time to renal death (composite end point of kidney replacement therapy or death).

Conclusion

Hyperuricaemia seemed to be independently associated with faster CKD progression or renal death. This was not observed with gout or prescription of allopurinol. Furthermore, allopurinol was not associated with decreased incidence of cardiovascular events. These data suggest that hyperuricaemia is likely the effect and not the cause of CKD or CKD progression.

Graphic abstract

Open inguinal hernia repair outcomes in liver transplant recipients versus patients with cirrhosis

PURPOSE

Patients with liver cirrhosis (LC) are at an increased risk for postoperative complications after open inguinal hernia repair (OIHR). It is possible that orthotopic liver transplant (OLT) recipients may have better outcomes, given reversal of liver failure pathophysiology. Therefore, we sought to compare mortality risk, complications, length of stay (LOS), and cost associated with OIHR in OLT recipients versus LC.

METHODS

From the National Inpatient Sample (NIS), using ICD-9 codes, we found 83 OLT recipients and 764 patients with LC who underwent OIHR between 2002 and 2014. We used logistic, negative binomial, and multiple linear regression models to compare peri-operative mortality risk, postoperative complications, and LOS, and cost associated with OIHR in OLT recipients versus LC patients. Models were adjusted for patient demographic and clinical characteristics, and hospital factors.

RESULTS

OLT recipients were younger (58 vs 61, p = 0.02), more likely to be privately insured (42.0% vs 24.6%, p = 0.006), less likely to have ascites at time of surgery (5.1% vs 18.9%, p = 0.003), and have surgery at large (84.3% vs 65.2%, p = 0.01) and teaching hospitals (84.2% vs 47.9%, p < 0.001). There were no mortalities among OLT recipients, but 19 (2.5%) deaths among LC patients. OLT recipients had a similar risk of overall complications (adjusted odds ratio aOR = 0.71 1.30 2.41) and hospital-associated costs (adjusted cost ratio = 0.71 0.88 1.09). However, LOS was significantly different with OLT recipients having shorter LOS (adjusted LOS ratio = 0.56 0.70 0.89).

CONCLUSION

Delaying OIHR in patients with LC until after OLT decreases LOS and may carry decreased mortality.

The profile of patients with venous leg ulcers: A systematic review and global perspective

BACKGROUND

A holistic profile that includes demographic, medical history and wound characteristics of individuals with venous leg ulceration is lacking. Lack of such a profile negatively impacts the ability to develop interventions to improve patient outcomes.

OBJECTIVES

To describe the profile of the patient population with venous leg ulceration from published observational (non-interventional) studies and to identify gaps in the knowledge base for future research in this area.

METHODS

A systematic review of observational studies that included more than 50 patients, from any world region, of any age and in any care setting.

RESULTS

twenty studies, involving 3395 patients, from all world regions met our criteria. Demographic characteristics were well reported and showed a female to male ratio of 1.2:1, average age of 47-65 years, high levels of co-morbidities including hypertension (53-71%) and diabetes (16-20%), and only one study reporting ethnicity. When reported, approximately 4-30% had high levels of depression. The average wound size was 18.6-43.39 cm²; mean wound duration was 13.8-65.5 months, mean number of recurrences was four. No study reported on demographic factors plus medical history plus wound characteristics together.

CONCLUSION

a comprehensive, holistic profile of the population with VLU is lacking. There is a critical need for more comprehensive profiling to enable the development of targeted interventions to improve outcomes.

PL3.2 Trabectedin for recurrent WHO grade II or III meningioma: a randomized phase II study of the EORTC Brain Tumor Group (EORTC-1320-BTG)

BACKGROUND

EORTC-1320-BTG investigated the activity, safety and quality of life of therapy with the tetrahydroisoquinoline alkaloid trabectedin (Yondelis®) in patients with recurrent higher-grade meningiomas. Trabectedin was originally derived from the Caribbean sea squirt, Ecteinascidia turbinata, and currently is manufactured by total synthesis.

METHODS

Adult patients with histological diagnosis of WHO grade II or III meningioma and radiologically documented progression after maximal feasible surgery and radiotherapy were randomly assigned in a 2:1 ratio to receive intravenous trabectedin (1.5 mg/m2every three weeks) or local standard of care (LOC). The primary endpoint was progression-free survival (PFS).

RESULTS

Within 22.1 months, we randomized a total of 90 patients (n=29 in LOC arm, n=61 in trabectedin arm) in 35 institutions and nine countries. In the LOC arm, the following treatments were administered: hydroxyurea (n=11), bevacizumab (n=9), none (n=4), chemotherapy (n=3), somatostatin analogue (n=1), combined chemotherapy and somatostatin analogue (n=1). With 71 PFS events, median PFS was 4.17 months in the LOC and 2.43 months in the trabectedin arm (hazard ratio [HR] for progression, 1.42; 80% CI, 1.00–2.03; p=0.204) with a PFS-6 rate of 29.1% (95% CI, 11.9%-48.8%) in the LOC and 21.1% (95% CI, 11.3%-32.9%) in the trabectedin arm. Median OS was 10.61 months in the LOC and 11.37 months in the trabectedin arm (HR for death, 0.98; 95% CI, 0.54–1.76; p=0.94).Grade 3 to 5 adverse events occurred in 44.4% (18.5% related, 4 serious adverse events, 0 lethal events) of the patients in the LOC and 59% (32.8% related, 57 serious adverse events and 2 toxic deaths) of patient in the trabectedin arm.

CONCLUSIONS

In this first prospective randomized trial performed in recurrent grade II or III meningioma, trabectedin did not improve PFS and OS and was associated with significantly higher toxicity as compared to LOC treatment. The data collected in this study may serve as benchmark for future clinical trials in this setting.

Could probiotics be the panacea alternative to the use of antimicrobials in livestock diets?

Probiotics are most frequently derived from the natural microbiota of healthy animals. These bacteria and their metabolic products are viewed as nutritional tools for promoting animal health and productivity, disease prevention and therapy, and food safety in an era defined by increasingly widespread antimicrobial resistance in bacterial pathogens. In contemporary livestock production, antimicrobial usage is indispensable for animal welfare, and employed to enhance growth and feed efficiency. Given the importance of antimicrobials in both human and veterinary medicine, their effective replacement with direct-fed microbials or probiotics could help reduce antimicrobial use, perhaps restoring or extending the usefulness of these precious drugs against serious infections. Thus, probiotic research in livestock is rapidly evolving, aspiring to produce local and systemic health benefits on par with antimicrobials. Although many studies have clearly demonstrated the potential of probiotics to positively affect animal health and inhibit pathogens, experimental evidence suggests that probiotics' successes are modest, conditional, strain-dependent, and transient. Here, we explore current understanding, trends, and emerging applications of probiotic research and usage in major livestock species, and highlight successes in animal health and performance.

The Prevalence of Alcohol Misuse Among Acute Admissions: Current Experience and Historical Comparisons

Background

Over the last 25 years there has been a large increase in alcohol related deaths in Scotland. Medical patients who misuse alcohol may have overt alcohol related disease, but may also present with other unrelated illness.

Aim

We examined alcohol misuse amongst acute medical admissions to compare this with other similar studies at the same hospital since 1974.

Patients and Methods

850 consecutive admissions to the medical receiving unit of Victoria Infirmary were assessed. They were assessed using the modified Michigan Alcohol Screening Test (MAST) and also by a medical consultant. 414 patients also had their blood ethanol levels measured on admission.

Results

18.6% admissions had a MAST greater than 5 and were considered to misuse alcohol (24.8% male and 12.2% female; p<0.0001). Patients from socio-economic group V and patients presenting with gastro-intestinal haemorrhage or self-poisoning were more likely to misuse alcohol. The sensitivity and specificity of consultant opinion regarding alcohol misuse were 0.55 and 0.97 compared with the MAST. There was an increase in the alcohol misuse amongst women admitted (12.2%) compared to 1977 (5.5%; p=0.0026) and 1981/2 (6.3%; p=0.004).

Conclusion

Alcohol misuse is common amongst acute medical admissions. Since 1979, there has been a particular increase in female medical admissions who misuse alcohol. Medical opinion regarding alcohol misuse lacks sensitivity in identifying at risk individuals compared with a validated questionnaire.

Fluorescence microscopy image noise reduction using a stochastically-connected random field model

Fluorescence microscopy is an essential part of a biologist’s toolkit, allowing assaying of many parameters like subcellular localization of proteins, changes in cytoskeletal dynamics, protein-protein interactions, and the concentration of specific cellular ions. A fundamental challenge with using fluorescence microscopy is the presence of noise. This study introduces a novel approach to reducing noise in fluorescence microscopy images. The noise reduction problem is posed as a Maximum A Posteriori estimation problem, and solved using a novel random field model called stochastically-connected random field (SRF), which combines random graph and field theory. Experimental results using synthetic and real fluorescence microscopy data show the proposed approach achieving strong noise reduction performance when compared to several other noise reduction algorithms, using quantitative metrics. The proposed SRF approach was able to achieve strong performance in terms of signal-to-noise ratio in the synthetic results, high signal to noise ratio and contrast to noise ratio in the real fluorescence microscopy data results, and was able to maintain cell structure and subtle details while reducing background and intra-cellular noise.

Modelling the expected rate of laboratory biosafety breakdowns involving rinderpest virus in the post-eradication era

Now that we are in the rinderpest post-eradication era, attention is focused on the risk of re-introduction. A semi-quantitative risk assessment identified accidental use of rinderpest virus in laboratories as the most likely cause of re-introduction. However there is little data available on the rates of laboratory biosafety breakdowns in general. In addition, any predictions based on past events are subject to various uncertainties. The aims of this study were therefore to investigate the potential usefulness of historical data for predicting the future risk of rinderpest release via laboratory biosafety breakdowns, and to investigate the impacts of the various uncertainties on these predictions. Data were collected using a worldwide online survey of laboratories, a structured search of ProMED reports and discussion with experts. A stochastic model was constructed to predict the number of laboratory biosafety breakdowns involving rinderpest that will occur over the next 10 years, based on: (1) the historical rate of biosafety breakdowns; and (2) the change in the number of laboratories that will have rinderpest virus in the next 10 years compared to historically. The search identified five breakdowns, all of which occurred during 1970-2000 and all of which were identified via discussions with experts. Assuming that our search for historical events had a sensitivity of over 60% and there has been at least a 40% reduction in the underlying risk (attributable to decreased laboratory activity post eradication) the most likely number of biosafety events worldwide was estimated to be zero over a 10 year period. However, the risk of at least one biosafety breakdown remains greater than 1 in 10,000 unless the sensitivity was at least 99% or the number of laboratories has decreased by at least 99% (based on 2000-2010 during which there were no biosafety breakdowns).

Dipyridamole and paracetamol overdose resulting in multi-organ failure

Dipyridamole intoxication is rare and few reports exist amongst the current literature. A case of dipyridamole and paracetamol overdose is described in a previously healthy 58-year-old woman, which resulted in multi-organ failure requiring dialysis, inotropic support, ventilation and extensive surgical intervention for small bowel ischaemia. This case highlights the dangers of an unusually large overdose of a commonly prescribed drug, and reviews current knowledge of dipyridamole intoxication.

Aspergillosis after liver transplantation in the context of common variable immunodeficiency: case report

Common variable immunodeficiency (CVID) is the most common primary immune defect, resulting in hypogammaglobulinemia as well as deficits in cell-mediated immunity. Although it mainly manifests in immunodeficiency and related infection, CVID can also be associated with autoimmune phenomena such as immune thrombocytopenic purpura, hemolytic anemia, rheumatoid arthritis, lupus, primary biliary cirrhosis, and autoimmune hepatitis (AIH). AIH is a less common but serious complication of CVID, which can result in early cirrhosis, ascites, and even hepatocellular carcinoma. Here, we discuss a recent case of transplantation for cirrhosis secondary to AIH in the context of CVID. Although the patient's surgery occurred without complication, he rapidly developed fulminant alveolar hemorrhage and seizures, and died secondary to disseminated neuroaspergillosis.

Impact of a single-day multidisciplinary clinic on the management of patients with liver tumours

PURPOSE

Multidisciplinary cancer clinics may improve patient care. We examined how a single-day multidisciplinary liver clinic (mdlc) affected care recommendations for patients compared with the recommendations provided before presentation to the mdlc.

METHODS

We analyzed the demographic and clinicopathologic data of 343 patients assessed in the Johns Hopkins Liver Tumor Center from 2009 to 2012, comparing imaging and pathology interpretation, diagnosis, and management plan between the outside provider (osp) and the mdlc.

RESULTS

Most patients were white (n = 259, 76%); median age was 60 years; and 146 were women (43%). Outside providers referred 182 patients (53%); the rest were self-referred. Patients travelled median of 83.4 miles (interquartile range: 42.7-247 miles). Most had already undergone imaging (n = 338, 99%) and biopsy (n = 194, 57%) at the osp, and a formal management plan had been formulated for about half (n = 168, 49%). Alterations in the interpretation of imaging occurred for 49 patients (18%) and of biopsy for 14 patients (10%). Referral to the mdlc resulted in a change of diagnosis in 26 patients (8%), of management plan in 70 patients (42%), and of tumour resectability in 7 patients (5%). Roughly half the patients (n = 174, 51%) returned for a follow-up, and 154 of the returnees (89%) received treatment, primarily intraarterial therapy (n = 88, 57%), systemic chemotherapy (n = 60, 39%), or liver resection (n = 32, 21%). Enrollment in a clinical trial was proposed to 34 patients (10%), and 21 of the 34 (62%) were accrued.

CONCLUSIONS

Patient assessment by our multidisciplinary liver clinic had a significant impact on management, resulting in alterations to imaging and pathology interpretation, diagnosis, and management plan. The mdlc is an effective and convenient means of delivering expert opinion about the diagnosis and management of liver tumours.

Blue-black rule: a simple dermoscopic clue to recognize pigmented nodular melanoma

BACKGROUND

Dermoscopy improves melanoma recognition, but most criteria were described in the context of superficial spreading melanoma.

OBJECTIVES

To test whether pigmented nodular melanoma could be recognized dermoscopically by the presence of a combination of blue and black colour within the lesion.

METHODS

Dermoscopic images of histopathologically diagnosed pigmented nodular tumours with no (or only minimal) flat component were evaluated for the presence of standard melanoma criteria and for the presence of a new feature named blue-black (BB) colour. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for standard criteria and BB feature in relation to the diagnosis of melanoma and to diagnosis of malignancy.

RESULTS

Of 283 lesions, 160 were malignant, including 78 (27·6%) melanomas, and 123 were benign. The BB feature and the standard criteria had 78·2% and 43·6% sensitivity for melanoma, respectively, whereas a combined method based on the presence of either the BB feature or one (or more) of the standard criteria reached 84·6% sensitivity, with 80·5% specificity and 93·2% negative predictive value. Sensitivity values for malignant lesions were only 24·4%, 56·9% and 60% for standard criteria, BB feature and the combined method, respectively. However, the combined method gave 91·9% specificity and 90·6% positive predictive value for malignancy.

CONCLUSIONS

Using a method based on the BB feature or one of the standard melanoma criteria, only 9·4% of positive pigmented nodular lesions were found to be benign and only 6·8% of negative lesions were found to be melanoma histopathologically.

Practical measurement of affordability: an application to medicines

OBJECTIVE

To develop two practical methods for measuring the affordability of medicines in developing countries.

METHODS

The proposed methods--catastrophic and impoverishment methods--rely on easily accessible aggregated expenditure data and take into account a country's income distribution and absolute level of income. The catastrophic method quantifies the proportion of the population whose resources would be catastrophically reduced by spending on a given medicine; the impoverishment method estimates the proportion of the population that would be pushed below the poverty line by procuring a given medicine. These methods are illustrated by calculating the affordability of glibenclamide, an antidiabetic drug, in India and Indonesia. The results were validated by comparing them with the results obtained by using household micro data for India and Indonesia.

FINDINGS

When accurate aggregate data are available, the proposed methods offer a practical way to obtain informative and accurate estimates of affordability. Their results are very similar to those obtained with household micro data analysis and are easily compared across countries.

CONCLUSION

The catastrophic and impoverishment methods, based on macro data, can provide a suitable estimate of medicine affordability when the household level micro data needed to carry out more sophisticated studies are not available. Their usefulness depends on the availability of accurate aggregated data.

Outpatient imaging for pulmonary embolism may only be suitable for a minority

In this study we model the impact of introducing outpatient investigation of pulmonary thrombo-embolism (PTE) to the acute medical unit (AMU) using the Pulmonary Embolism Severity Index (PESI) decision rule. Specifically, we ask what proportion of patients requiring imaging could be investigated without admission, and how many bed-days this would save.  We obtained records for all medical patients who had imaging for PTE in a six-month period at a large teaching hospital with a 40-bedded AMU. The patients were categorized into suitability for outpatient investigation using a combination of the PESI rule and practical considerations. Three hundred and fifty-nine separate presentations were identified. From available records, 31 patients (9.2%, 95% confidence interval [CI] 6.6-12.8%) had no contraindications to outpatient management. These patients used a total of 79 bed-days in the six-month period, or 1.1% (95% CI 0.8-1.5%) of the maximum AMU bed occupancy. Around 10% of patients who require imaging for suspected PTE could be triaged to outpatient investigation using the PESI tool. Adopting this method to triage patients of ambulatory care, would have only a modest effect on acute medical bed occupancy, but remains a valid option for motivated patients in the low-risk category.

Effects of natal male alliances on aggression and power dynamics in rhesus macaques

In the wild, male rhesus macaques disperse at sexual maturity. In captivity, however, males cannot disperse from their natal groups. Thus, the presence of natal males in captive rhesus social groups is unnatural and has the potential to negatively influence group dynamics and stability. A primary difference between natal males and non-natal (immigrant) males is that natal males have the opportunity to form long-term alliances with their maternal kin as well as nonkin. We investigated the factors associated with natal males' kin alliances and the impact of these alliances on measures of natal male behavior, group dynamics, and group stability. We found that natal males more frequently formed alliances with maternal kin when they were from high-ranking matrilines, had more siblings, and were younger. More frequent kin alliances were associated with more frequent use of intense aggression, higher individual rank, and higher degree of integration within the male displacement network. Thus, it seems that natal males use their alliances to be more active and influential in the social group, which may affect group stability. It appears that juvenile natal males from high-ranking matrilines, in particular, have the largest impact on group stability. Younger natal males from high-ranking matrilines formed alliances with kin more frequently and used intense aggression more frequently than older or lower ranking males. Furthermore, groups with a higher proportion of juvenile males from high-ranking matrilines also had higher rates of wounding. We suggest that the presence of natal males in rhesus groups may act in opposition to group stability.

Weak superconducting pairing and a single isotropic energy gap in stoichiometric LiFeAs

We report superconducting (SC) properties of stoichiometric LiFeAs (T(c)=17 K) studied by small-angle neutron scattering (SANS) and angle-resolved photoemission (ARPES). Although the vortex lattice exhibits no long-range order, well-defined SANS rocking curves indicate better ordering than in chemically doped 122 compounds. The London penetration depth lambda(ab)(0)=210+/-20 nm, determined from the magnetic field dependence of the form factor, is compared to that calculated from the ARPES band structure with no adjustable parameters. The temperature dependence of lambda(ab) is best described by a single isotropic SC gap Delta(0)=3.0+/-0.2 meV, which agrees with the ARPES value of Delta(0)(ARPES)=3.1+/-0.3 meV and corresponds to the ratio 2Delta/k(B)T(c)=4.1+/-0.3, approaching the weak-coupling limit predicted by the BCS theory. This classifies LiFeAs as a weakly coupled single-gap superconductor.

Brugada Syndrome and Brugada ECG Pattern: Unusual Causes of ST Elevation

Brugada Syndrome is a channelopathy that leads to ST elevation or right bundle branch block pattern in the right ventricular leads on ECG analysis and predisposes to ventricular tachyarrhythmias and sudden death. The ECG pattern can also be drug induced with several agents. This case describes a patient who presented after a mixed overdose of amitriptyline, olanzapine and alimemazine with ST elevation and T wave inversion on his ECG that were initially thought to be due to an Acute Coronary Syndrome.