Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department-Convenience or necessity?

BACKGROUND: Peripheral Intravenous Cannulas (PIVCs) are frequently utilised in the Emergency Department (ED) for delivery of medication and phlebotomy. They are associated with complications and have an associated cost to departmental resources. A growing body of international research suggests many of the PIVCs inserted in the ED are unnecessary. METHODS: The objective of this study was to determine the rates of PIVC insertion and use. This was a prospective observational study conducted in one UK ED and one Italian ED. Adult ED patients with non-immediate triage categories were included over a period of three weeks in the UK ED in August 2016 and two weeks in the Italian ED in March and August 2017. Episodes of PIVC insertion and data on PIVC utilisation in adults were recorded. PIVC use was classified as necessary, unnecessary or unused. The proportion of unnecessary and unused PIVCs was calculated. PIVCs were defined as unnecessary if they were either used for phlebotomy only, or solely for IV fluids in patients that could have potentially been hydrated orally (determined against a priori defined criteria). PIVC classified as unused were not used for any purpose. RESULTS: A total of 1,618 patients were included amongst which 977 PIVCs were inserted. Of the 977 PIVCs, 413 (42%) were necessary, 536 (55%) were unnecessary, and 28 (3%) were unused. Of the unnecessary PIVCs, 473 (48%) were used solely for phlebotomy and 63 (6%) were used for IV fluids in patients that could drink. CONCLUSIONS: More than half of PIVCs placed in the ED were unnecessary in this study. This suggests that clinical decision making about the benefits and risks of PIVC insertion is not being performed on an individual basis.

A multilevel investigation of leader-member exchange differentiation's consequences: A moral disengagement perspective.

We examine the effects of leader-member exchange (LMX) differentiation on team members' outcomes (customer-oriented constructive and destructive deviant behaviors) by using team moral disengagement as a psychological mechanism mediating this relationship and LMX differentiation bases (i.e., performance and personal liking) moderating the relationship. Analysis of multilevel data collected from 289 frontline employees organized into 76 finance-related customer service teams shows that LMX differentiation significantly reduced team moral disengagement only when the performance basis was high, and that the negative relationship between LMX differentiation and team moral disengagement was significant only when the personal liking basis was low. Furthermore, we found that the LMX bases moderated the indirect effect of LMX differentiation on team members' outcomes through team moral disengagement. The findings advance team moral disengagement as a novel mechanism for cross-level relationship between LMX differentiation and team members' outcomes at the individual level, and project differentiation bases as a condition under which LMX differentiation unpacks the reasons for team members' favorable or unfavorable responses. They reveal LMX differentiation as a complex and multifaceted phenomenon, whose essence can only be understood if examined from multiple levels. We also contribute to the literature by revealing the cognitive pathway through which LMX differentiation may be associated with team members outcomes.

Ramadan Fasting and Changes in Thyroid Function in Hypothyroidism: Identifying Patients at Risk.

Background: Ramadan fasting (RF) is associated with major changes in meal times. This can affect thyroxine absorption and thyroid function (TF) in patients with hypothyroidism. We aimed to examine the short- and long-term impact of RF on TF in patients with primary hypothyroidism on levothyroxine. Methods: TF tests in patients with primary hypothyroidism attending an endocrine center in the United Arab Emirates were retrospectively analyzed. The impact of RF on TF, namely serum thyrotropin (TSH) TSH, free thyroxine (fT4) and free triiodothyronine (fT3), was investigated in 481 patients within 3 months before Ramadan (BR), 1-2 weeks (PR1), and 3-6 months (PR2) post-Ramadan. Controlled TF was defined as TSH between 0.45 and 4.5 µIU/mL. Inadequate control was defined as TSH >4.5 µIU/mL. Loss of control was defined as having controlled TF at BR and inadequate control at PR1. Multivariable regression analyses were used to assess the association of baseline TSH, baseline levothyroxine dose, and medication use with loss of thyroid control in Ramadan. Results: TSH increased significantly from a median of 2.0 (0.8-3.7) µIU/mL at BR to 2.9 (1.4-5.6) µIU/mL at PR1 (p < 0.001). This was accompanied by a fall in fT4 and fT3 at PR1 (p < 0.001). 25.5% of patients with previously controlled TF at BR had deterioration in TF at PR1. Sixty-one percent of patients with previously uncontrolled TF at BR remained uncontrolled at PR1. Baseline TSH was significantly associated with loss of thyroid control in Ramadan with an odds ratio (95% confidence interval) of 1.5 (1.17-1.92) (p < 0.001), whereas other variables, including medications known to affect levothyroxine absorption were not associated with loss of control. TSH, fT4, and fT3 levels returned to normal at PR2. Conclusions: RF can negatively affect TF of patients on levothyroxine replacement. Although this effect is modest and transitory in most patients, a significant minority exhibit more pronounced, and clinically relevant changes. The latter includes those with higher TSH BR, and a smaller group whose thyroid disease appears to be particularly affected by the mealtime and lifestyle changes of Ramadan.

Machine Learning of Medical Applications Involving Complicated Proteins and Genetic Measurements.

Motivations. Breast cancer is the second greatest cause of cancer mortality among women, according to the World Health Organization (WHO), and one of the most frequent illnesses among all women today. The influence is not confined to industrialized nations but also includes emerging countries since the authors believe that increased urbanization and adoption of Western lifestyles will lead to a rise in illness prevalence. Problem Statement. The breast cancer has become one of the deadliest diseases that women are presently facing. However, the causes of this disease are numerous and cannot be properly established. However, there is a huge difficulty in not accurately recognizing breast cancer in its early stages or prolonging the detection process. Methodology. In this research, machine learning is a field of artificial intelligence that employs a variety of probabilistic, optimization, and statistical approaches to enable computers to learn from past data and find and recognize patterns from large or complicated groups. The advantage is particularly well suited to medical applications, particularly those involving complicated proteins and genetic measurements. Result and Implications. However, when using the PCA method to reduce the features, the detection accuracy dropped to 89.9%. IG-ANFIS gave us detection accuracy (98.24%) by reducing the number of variables using the "information gain" method. While the ANFIS algorithm had a detection accuracy of 59.9% without utilizing features, J48, which is one of the decision tree approaches, had a detection accuracy of 92.86% without using features extraction methods. When applying PCA techniques to minimize features, the detection accuracy was lowered to the same way (91.1%) as the Naive Bayes detection algorithm (96.4%).

A Scoring System for Assessing Learning Progression of Dental Students' Clinical Skills Using Haptic Virtual Workstations.

The aim of this study was to develop and test a scoring system to assess the learning progression of novice dental students using haptic virtual workstations. For the study, 101 first-year dental students at a UK dental school conducted one practice task (task 1) and four simulated cavity removal tasks (tasks 2-5) of increasing difficulty over two laboratory sessions in 2015. Performance data on the students' attempts were recorded as haptic technology-enhanced learning (hapTEL) log-files showing the percentage of caries, healthy tissue, and pulp removed. On-screen results were photographed and submitted by the students to the tutors. A scoring system named the Accuracy of Caries Excavation (ACE) score was devised to score these results and achieve an even distribution of scores and a calculated combined score. A total of 127 individual logged attempts by 80% of the students over sessions 1 and 2 were recorded and submitted to the tutors. The mean ACE scores for both sessions for tasks 2 through 5 were 9.2, 11.6, 6.4, and 4.9, respectively; for Session 2 (tasks 3-5), scores were 12.4, 6.7, and 5.0, respectively (p<0.001). The average performance on task 3, which was attempted in similar numbers during both sessions, improved from the first to the second session (8.14 vs. 12.38; p=0.009). Using the HapTEL system in a first-year BDS curriculum improved the students' performance of simulated cavity preparation after practicing over two sessions. Use of the ACE scoring system enabled tutors to make consistent assessments across a large student cohort and provided an objective method of formative assessment.

Indeterminate Thyroid Nodules: A Pragmatic Approach.

BACKGROUND: Fine needle aspiration (FNA) cytology fails to provide a conclusive diagnosis in a subset of thyroid lesions labeled as "indeterminate" (Thy3). In this study, we aimed at ascertaining the prevalence of Thy3 thyroid nodules in a hitherto unreported ethnic group (residents of the United Arab Emirates). METHODS: We retrospectively examined 688 FNA of the thyroid performed on 584 patients. Samples were reported using the Royal College of Physicians' (RCP) Thy classification. The results of the FNA were correlated with the final surgical specimens. Ultrasonography (US) risk stratification was calculated using a web-based US risk of malignancy calculator. RESULTS: Overall sample adequacy was 97%. The indeterminate group Thy3 was found in 7% of the samples. The overall risk of malignancy in the Thy3 category was 20%. This risk was very similar in the 2 subgroups of Thy3 (17% in Thy 3a and 22% in Thy3f). Subdividing the Thy3 group into subgroups becomes less necessary if the US scoring is <24.5% since the negative predictive value, in this case, is 100%. Applying this criterion to our population would have had the potential of reducing the percentage of patients referred to surgery from 61 to 43%. CONCLUSIONS: Proper risk stratification of Thy3 lesions should be based on the combined risk assessment of clinical, cytological, radiological, and molecular data. Such a pragmatic approach is expected to reduce the percentage of inappropriate referrals to surgery.

Impact of Waterpipe Tobacco Pack Health Warnings on Waterpipe Smoking Attitudes: A Qualitative Analysis among Regular Users in London.

BACKGROUND: Despite the rise in prevalence of waterpipe tobacco smoking, it has received little legislative enforcement from governing bodies, especially in the area of health warning labels. METHODS: Twenty regular waterpipe tobacco smokers from London took part in five focus groups discussing the impact of waterpipe tobacco pack health warnings on their attitudes towards waterpipe smoking. We presented them with existing and mock waterpipe tobacco products, designed to be compliant with current and future UK/EU legislation. Data were analysed using thematic analysis. RESULTS: Participants felt packs were less attractive and health warnings were more impactful as health warnings increased in size and packaging became less branded. However, participants highlighted their lack of exposure to waterpipe tobacco pack health warnings due to the inherent nature of waterpipe smoking, that is, smoking in a café with the apparatus already prepacked by staff. Health warnings at the point of consumption had more reported impact than health warnings at the point of sale. CONCLUSIONS: Waterpipe tobacco pack health warnings are likely to be effective if compliant with existing laws and exposed to end-users. Legislations should be reviewed to extend health warning labels to waterpipe accessories, particularly the apparatus, and to waterpipe-serving premises.

Key health themes and reporting of numerical cigarette-waterpipe equivalence in online news articles reporting on waterpipe tobacco smoking: a content analysis.

INTRODUCTION: There is anecdotal evidence that health messages interpreted from waterpipe tobacco smoking (WTS) research are inconsistent, such as comparing the health effects of one WTS session with that of 100 cigarettes. This study aimed to identify key health themes about WTS discussed by online news media, and how numerical cigarette-waterpipe equivalence (CWE) was being interpreted. METHODS: We identified 1065 online news articles published between March 2011 and September 2012 using the 'Google Alerts' service. We screened for health themes, assessed statements mentioning CWE and reported differences between countries. We used logistic regression to identify factors associated with articles incorrectly reporting a CWE equal to or greater than 100 cigarettes, in the absence of any comparative parameter ('CWE ≥100 cigarettes'). RESULTS: Commonly mentioned health themes were the presence of tobacco (67%) and being as bad as cigarettes (49%), and we report on differences between countries. While 10.8% of all news articles contained at least one positive health theme, 22.9% contained a statement about a CWE. Most of these (18.6% total) were incorrectly a CWE ≥100 cigarettes, a quarter of which were made by healthcare professionals/organisations. Compared with the Middle East, articles from the USA and the UK were the most significant predictors to contain a CWE ≥100 cigarettes statement. CONCLUSIONS: Those wishing to write or publish information related to WTS may wish to avoid comparing WTS to cigarettes using numerical values as this is a major source of confusion. Future research is needed to address the impact of the media on the attitudes, initiation and cessation rates of waterpipe smokers.

Preoperative scintigraphic visualization of an orbital metastasis before identification of carcinoma in a nonfunctioning thyroid nodule.

Preoperative accumulation of Tc-99m pertechnetate and radioiodine in metastases of well-differentiated thyroid carcinoma is uncommon. The authors report the case of a 51-year-old woman with follicular thyroid carcinoma revealed by a right orbital metastasis. I-131 scintigraphy performed before thyroidectomy showed intense uptake in an orbital metastasis despite the presence of an intact thyroid gland.