Applying molecular genetic data at different scales to support conservation assessment of European Habitats Directive listed species: A case study of Eurasian otter in Austria.

Evaluating intraspecific genetic structure and diversity is fundamental to assessing a species' conservation status, but direct incorporation of such information into legal frameworks such as the EU's Habitats Directive is surprisingly rare. How genetic structure aligns with EU member state boundaries or biogeographic regions may be very important in designing management plans or achieving legislative goals. The Eurasian fish otter experienced a sharp population decline during the 20th century but is currently re-expanding in several countries. The species is listed under Annex II and IV of the European Habitats Directive, and member states are obliged to assess the species separately across different biogeographic regions. We genotyped 2492 otter spraints across four provinces in Austria, collected between 2017 and 2021. A total of 384 different genotypes were identified, supporting densities along river habitats from 0.1 to 0.47 otters per river km (mean: 0.306), with a resampling-based simulation supporting limited density overestimation at survey lengths of 20 km or more. Three distinct genetic clusters were revealed, two of them presumably reflecting two relict populations whereas the source of the third cluster is unknown. The geographic extent of the three clusters does not coincide with provincial or biogeographic boundaries, both relevant for assessment and management within existing national or European legislative frameworks. We advocate more consideration of genetic structure in the assessment and conservation management planning of species listed in the European Habitats Directive.

Evaluating a species phylogeny using ddRAD SNPs: Cyto-nuclear discordance and introgression in the salmonid genus Thymallus (Salmonidae).

Hybridization and introgression are very common among freshwater fishes due to the dynamic nature of hydrological landscapes. Cyclic patterns of allopatry and secondary contact provide numerous opportunities for interspecific gene flow, which can lead to discordant paths of evolution for mitochondrial and nuclear genomes. Here, we used double digest restriction-site associated DNA sequencing (ddRADseq) to obtain a genome-wide single nucleotide polymorphism (SNP) dataset comprehensive for allThymallus (Salmonidae)species to infer phylogenetic relationships and evaluate potential recent and historical gene flow among species. The newly obtained nuclear phylogeny was largely concordant with a previously published mitogenome-based topology but revealed a few cyto-nuclear discordances. These incongruencies primarily involved the placement of internal nodes rather than the resolution of species, except for one European species where anthropogenic stock transfers are thought to be responsible for the observed pattern. The analysis of four contact zones where multiple species are found revealed a few cases of mitochondrial capture and limited signals of nuclear introgression. Interestingly, the mechanisms restricting interspecific gene flow might be distinct; while in zones of secondary contact, small-scale physical habitat separation appeared as a limiting factor, biologically based reinforcement mechanisms are presumed to be operative in areas where species presumably evolved in sympatry. Signals of historical introgression were largely congruent with the routes of species dispersal previously inferred from mitogenome data. Overall, the ddRADseq dataset provided a robust phylogenetic reconstruction of the genus Thymallus including new insights into historical hybridization and introgression, opening up new questions concerning their evolutionary history.

A comprehensive DNA barcode inventory of Austria's fish species.

Austria is inhabited by more than 80 species of native and non-native freshwater fishes. Despite considerable knowledge about Austrian fish species, the latest Red List of threatened species dates back 15 years and a systematic genetic inventory of Austria's fish species does not exist. To fulfill this deficit, we employed DNA barcoding to generate an up-to-date and comprehensive genetic reference database for Austrian fish species. In total, 639 newly generated cytochrome c oxidase subunit 1 (COI) sequences were added to the 377 existing records from the BOLD data base, to compile a near complete reference dataset. Standard sequence similarity analyses resulted in 83 distinct clusters almost perfectly reflecting the expected number of species in Austria. Mean intraspecific distances of 0.22% were significantly lower than distances to closest relatives, resulting in a pronounced barcoding gap and unique Barcode Index Numbers (BINs) for most of the species. Four cases of BIN sharing were detected, pointing to hybridization and/or recent divergence, whereas in Phoxinus spp., Gobio spp. and Barbatula barbatula intraspecific splits, multiple BINs and consequently cryptic diversity were observed. The overall high identification success and clear genetic separation of most of the species confirms the applicability and accuracy of genetic methods for bio-surveillance. Furthermore, the new DNA barcoding data pinpoints cases of taxonomic uncertainty, which need to be addressed in further detail, to more precisely assort genetic lineages and their local distribution ranges in a new National Red-List.

The rare and enigmatic mayfly Prosopistoma pennigerum (Müller, 1785): Habitat characteristics, recent records from the Volga (Russia) and Vjosa (Albania) rivers, and a proposal for flagship species status.

Nymphs of all 29 described Prosopistoma species share a conspicuous synapomorphy: a round mesonotal shield, the carapace. They occur in the Palaearctic (nine species), the Oriental (12 species) and the Afrotropic as well as Australian regions (six and two species, respectively). Relatively little is known about their ecology, but past and extant distribution patterns indicate an association with undisturbed conditions. Prosopistoma pennigerum is a rare European mayfly with conspicuous nymphs. Formerly common in large rivers, it has been extirpated from central Europe over the last century.This study evaluated general habitat characteristics and human pressures for historical and current records of this rare species. Prosopistoma pennigerum is currently known from only three European rivers, all with gravel substrates, naturally dynamic discharge regimes, summer-warm water temperatures, and little human pressure.This study showed that nymphs from the Vjosa and upper Volga rivers, two relatively natural watercourses 2,000 km apart, are morphologically indistinguishable, and show no variation across a ca. 600-bp fragment of the mitochondrial cytochrome c oxidase I gene.Flagship species were first designated in the 1980s, when charismatic species with high habitat requirements such as the Bengal tiger or the giant panda, but also invertebrates are used to communicate conservation and protection needs. We propose that Europe's rarest mayfly P. pennigerum, with its unusual nymphs and remaining populations in naturally dynamic river courses, can serve as a flagship species promoting the preservation of ecological integrity in European rivers.

Sepsis alerts in EMS and the results of pre-hospital ETCO2.

BACKGROUND: Field sepsis alerts have the ability to expedite initial ED sepsis treatment. Our hypothesis is that in patients that meet EMS sepsis alert criteria there is a strong relationship between prehospital end-tidal carbon dioxide (ETCO2) readings and the outcome of diagnosed infection. METHODS: In 2014, our EMS service initiated a protocol requiring hospitals to receive notification of a "sepsis alert" on all suspected sepsis patients. The EMS service transports 70,000 patients/year to a number of urban centers. All patients transported to our major urban teaching hospital by our EMS service in one year in which a sepsis alert was announced were included in this study. The primary outcome variable was diagnosed infection and secondary outcomes were hospital admission, ICU admission and mortality. Positive lactate was defined as >4.0 mmol/L. ROC curve analysis was used to define the best cutoff for ETCO2. RESULTS: 351 patients were announced as EMS sepsis alert patients and transported to our center over a one year period. Positive outcomes were as follows: diagnosed infection in 28% of patients, hospital admission in 63% and ICU admission in 11%. The correlation between lactate and ETCO2 was -0.45. A ROC curve analysis of ETCO2 vs. lactate >4 found that the best cutoff to predict a high lactate was an ETCO2 of 25 or less, which was considered a positive ETCO2 (AUC = 0.73). 27% of patients had a positive ETCO2 and 24% had a positive lactate. A positive ETCO2 predicted a positive lactate with 76% accuracy, 63% sensitivity and 80% specificity. 27% of those with a positive ETCO2 and 44% of those with a positive lactate had a diagnosed infection. 59% of those with a positive ETCO2 and 89% of those with a positive lactate had admission to the hospital. 15% of those with a positive ETCO2 and 18% of those with a positive lactate had admission to the ICU. Neither lactate nor ETCO2 were predictive of an increased risk for diagnosed infection, hospital admission or ICU admission in this patient population. CONCLUSION: While ETCO2 predicted the initial ED lactate levels it did not predict diagnosed infection, admission to the hospital or ICU admission in our patient population but did predict mortality.

Assessing the Prevalence and Predictors of Bullying Among Emergency Medical Service Providers.

Background: Bullying as a stressor in the workplace has been evaluated in numerous settings. It has never been evaluated in the emergency medical service (EMS) environment where bullying can occur from many different sources. The Negative Acts Questionnaire-Revised (NAQ-R) is a 22-question validated tool for evaluating bullying. Our hypothesis was that we could identify a shortened version of the NAQ-R that identifies bullying as accurately as the full screening tool. Methods: This was a cross sectional study of EMS providers in our local EMS transport agency. The local EMS agency transports approximately 50,000 patients per year and is a paramedic level response system. Results on the NAQ-R were on a 5-point Likert scale for each of 22 different categories of bullying that were summed by adding each questions 1-5 response for the 22 questions. Respondents were also categorized as victims or non-victims of bullying based on being positive for any of the 22 types of bullying at least once a week. We performed a binomial decision tree analysis and a cross-validation. Results: Data were collected from 153 providers. Mean age was 33 ± 10 years and 50% were male. Total years in EMS were 8 ± 8 years. NAQ-R summed results in our group ranged between 22 and 88, with an average of 40 ± 15. A NAQ-R score of 33 or less was 91% accurate in identifying non-victims and a score of 45 or more was 94% accurate in identifying victims. The majority at 51% (77/152) of respondents were victims of one or more types of bullying. A combination of five questions was 94% accurate in identifying a victim of bullying among EMS providers. Cross validation resulted in a misclassification risk estimate of 0.12 ± .03. Conclusion: NAQ-R bullying scores in EMS are similar or higher than numbers in other fields. Five questions on the NAQ-R were 94% accurate in identifying victims of bullying in EMS providers.

Thyroid stimulating hormone testing in ED evaluation of patients with atrial fibrillation and various psychiatric diagnoses.

BACKGROUND: Previous studies of thyroid stimulating hormone (TSH) levels in Emergency Department (ED) patients largely have centered on patients with atrial fibrillation (AF). In our ED patients with AF as well as patients with Psychiatric diagnoses (psych) are screened. The purpose of the present study was to compare TSH levels in the 2 groups. Our hypotheses were that an abnormal TSH and/or AF predicted the need for hospital admission and that TSH is more likely decreased in AF and increased in psych patients. METHODS: Our goal in the study was to compare the use of TSH testing in two ED populations, AF vs. psych patients. The study was a cross sectional cohort of AF vs. psych patients who had TSH levels drawn in the ED over a two year period. Our laboratory ranges were used to determine high vs. low TSH. Two chart examiners collected data after a training process. Charts were reviewed extracting demographic data, TSH levels, outcome (admit vs. discharge), history of AF, thyroid disease, psych diagnoses, presence of CHF, diabetes, hypertension. We compared AF vs. Psych groups using chi square and t-tests for parametric data. Odds ratios were calculated for comparisons between the 2 groups. For non-parametric data Mann Whitney U was used. A logistic regression was performed with the outcome of admission vs. discharge to find predictors of hospital admission. Kappa was calculated for inter-rater agreement. An a priori power analysis showed 80% power with 2 groups of 100 with an absolute difference of 20% between the 2 groups. RESULTS: 252 patients were included, 101 with AF and 152 Psych. Demographics differed in age only with AF patients being older. Mean TSH for AF vs. 2.4 for AF, 2.9 for psych (NS) with no differences in percentages with high or low TSH in the 2 groups. Fifty-three patients had abnormal TSH levels (21%), 27% of AF and 17% of Psych patients (NS). There were significant differences in incidence of CHF, DM, HTN, and tachycardia with more in the AF group (P < 0.001). Significantly more of the psych patients had a history of hypothyroidism (OR 2.28). Our logistic regression showed that taking into account demographics including age, the only predictors of admission were the presence of CHF (aOR 18.6) and having a diagnosis of AF (aOR 4.0). CONCLUSION: There were no differences in TSH levels between the 2 groups. Twenty-one percent had an abnormal level. CHF and AF predicted hospital admission on regression analysis. Many with these AF or Psych diagnoses had abnormal ED TSH levels that could be useful in diagnosis, maintenance, or continuous treatment for their conditions diagnoses.

Bathing Habits in Emergency Department Patients with Cellulitis or Abscess Versus Controls.

OBJECTIVE: Cellulitis is a leading cause of emergency department (ED) visits, with more than 200 cases per 100,000 people per year. Although many risk factors have been identified, including edema, skin breakdown, and penetrance of the skin, there are few data available on whether personal hygiene habits (bathing and clean clothes) are associated with increased risk for soft tissue infection. Studies looking at chlorhexidine baths in the intensive care unit to prevent soft tissue infections have shown conflicting and limited efficacy. Our objective was to determine whether poor personal hygiene, as manifested in poor bathing habits, a lack of access to clean clothes, or frequent needle self-injections, are associated with cellulitis or abscesses. METHODS: The research is a cross-sectional cohort study of patients with either cellulitis, soft tissue abscess, or both (cases) versus a control group of patients with abdominal pain without prior surgeries in a large, urban ED in a convenience sampling. We asked about bathing habits, access to clean clothing, and skin breaks from intravenous (IV) drug use as risk factors. The two groups were compared using descriptive statistics, and a regression analysis was performed to determine the characteristics that are predictive of soft tissue infections. The study was powered at 0.8 to detect a 20% difference in adequate bathing habits with 100 per group. RESULTS: In an approximate 1-year study period, 108 cases were identified and compared with 104 abdominal pain controls selected at random from patients presenting to the same ED. In the cellulitis/abscess group the mean age was 47 and 81% were men, and in the control group the mean age was 45 and 39% were men. There were significantly more men in the cellulitis/abscess group (Diff 22%, 95% confidence interval [CI] 8-34, P < 0.01). Seventy percent (76 of 108) of cases versus 58% (80 of 104) of controls bathed daily (odds ratio [OR] 1.7, 95% CI 0.98-3.1, not significant). There was a significant difference between the two groups in laundry habits: 66% (71 of 108) of cases versus 42% (44 of 104) of controls did not have access to clean laundry daily (adjusted OR [AOR] 2.5, 95% CI 1.4-5.0, P < 0.01). The most profound and significant difference was noted between cases and controls regarding the use of IV drugs, in which 20 of 108 cases (19%) used IV drugs versus 3 of 104 controls (3%, P < 0.01). Finally, 35 of 108 (32%) of our cases had a history of infections, whereas only 5 of 104 (5%) of the controls had cellulitis or an abscess previously (P < 0.01). On regression analysis significant predictors of soft tissue infection were history of skin infection (AOR 7.0) and not cleaning clothes daily (AOR 2.5). CONCLUSIONS: There was no significant difference in bathing habits, but there was a significant difference in laundry habits between the case and control groups. Our study further confirms that IV drug use is a risk factor for cellulitis and no access to clean clothes daily was significantly related to the development of cellulitis. Failing to obtain daily showers was not associated with an increase in infection.

Explaining negative refraction without negative refractive indices.

Negative refraction through a triangular prism may be explained without assigning a negative refractive index to the prism by using array theory. For the case of a beam incident upon the wedge, the array theory accurately predicts the beam transmission angle through the prism and provides an estimate of the frequency interval at which negative refraction occurs. The hypotenuse of the prism has a staircase shape because it is built of cubic unit cells. The large phase delay imparted by each unit cell, combined with the staircase shape of the hypotenuse, creates the necessary conditions for negative refraction. Full-wave simulations using the finite-difference time-domain method show that array theory accurately predicts the beam transmission angle.

Inferring phylogenetic structure, hybridization and divergence times within Salmoninae (Teleostei: Salmonidae) using RAD-sequencing.

Phylogenetic studies focusing on Salmonidae have revealed significant obstacles in trying to clarify some interspecific relationships within the Salmoninae subfamily, due to a limited number of markers typed, conflicting phylogenetic signals and ancient hybridization events. To infer reliable phylogenetic relationships, evaluate several putative scenarios of ancient hybridization, and estimate divergence times within Salmoninae, we applied restriction-site associated DNA sequencing (RAD-seq) to 43 samples, including 26 genetic lineages across 21 species, largely representing the subfamily, with an emphasis on the genus Salvelinus. We identified 28,402 loci and 28,363 putatively unlinked SNPs, which were used in downstream analyses. Using an iterative k-means partitioned dataset and a Maximum Likelihood approach; we generated a well-supported phylogeny, providing clear answers to several previous phylogenetic uncertainties. We detected several significant introgression signals, presumably ancient, in the genus Salvelinus. The most recent common ancestor of Salmonidae dates back to approximately 58.9MY ago (50.8-64 MY) and the crown age of Salmoninae was estimated to be 37.7 MY (35.2-40.8 MY) using a Bayesian molecular dating analysis with a relaxed molecular clock. The divergence among genera of the subfamily occurred between the late Eocene and middle of the Miocene (≈38-11 MY) such as the divergence between the genus Oncorhynchus and Salvelinus, which we estimated to 21.2 MY ago (95% HPD: 19.8-23.0 MY), while species diversification took place mainly during the Neogene (≈22-1.5 MY), with more than half of these events occurring in the last 10 MY.

Cross-Sectional Study of the Relation of Health Literacy to Primary Language and Emergency Department Length of Stay.

OBJECTIVES: The primary aim of this study was to determine whether emergency department (ED) length of stay (LOS) or primary language was related to the degree of health literacy of patients. METHODS: Adult English-speaking and Spanish-speaking patients were recruited for the study. Participants completed the Newest Vital Sign (NVS) tool (English and Spanish versions), a 6-question validated scale. Patients with NVS scores of 0 to 3 were considered to be at risk for limited health literacy, whereas those with adequate health literacy were defined as scoring a 4 to 6. After completion of their ED visit, a retrospective chart review was performed to identify the patient's ED LOS (time from registration to time of disposition) and ED disposition. In addition, 2 single-item questions were compared with the NVS for validity. RESULTS: Participants included 250 English-speaking and 257 Spanish-speaking subjects. Per the NVS, 71% (359 of 507) of all patients had limited health literacy. By language group, significantly more Spanish-speaking than English-speaking patients had limited health literacy (93% vs 48%, diff 45%, 95% confidence interval 37-51). There was no significant difference in LOS between the limited health literacy group and adequate health literacy group (medians 440 vs 461 min). The 2 single-item questions had fair validity in comparison to the NVS scale (κ 0.2-0.3). CONCLUSIONS: There was a significant difference in health literacy based on language, with 93% of all Spanish-speaking patients in our sample having limited health literacy. We found no significant difference in ED LOS between patients with limited health and adequate health literacy in an academic urban ED setting.

A Comparison of QTc Intervals in Alcohol Withdrawal Patients Versus Acute Coronary Syndrome Patients.

OBJECTIVES: Patients with an alcohol use disorder experiencing acute intoxication or withdrawal may be at risk for electrocardiograph (ECG) abnormalities, including prolongation of repolarization (long QTc [corrected QT]) that may contribute to arrhythmias and may be associated with a threefold increase in the likelihood of sudden cardiac events. Patients with acute coronary syndrome may have prolonged QTc as well. To our knowledge, no previous studies have compared the QTc of ACS with acute ethanol (EtOH) withdrawal syndromes in the emergency department (ED). The purpose of our study was to compare the QTc of those with EtOH withdrawal emergencies with patients with ACS in our ED. Our hypothesis was that the QTc would be similarly prolonged in the two cohorts. METHODS: The study compared two cohort groups, those with ACS and those with EtOH withdrawal-related ED visits over a 1-year period. We compared ECG QTc, cardiac medication use, and electrolyte differences. We considered a QTc of >450 ms elevated for men and >470 ms elevated for women based on the literature. Fifty subjects in whom an ECG, serum osmolality, and EtOH level were recorded within 2 hours of one another and who were administered a Clinical Institute Withdrawal Assessment protocol were compared with 203 patients with ACS during the same period. We excluded patients with incomplete data. Medications compared included clopidogrel, acetylsalicylic acid, ß-blockers, angiotensin-converting enzyme inhibitors, and statins. ECG QT and QTc, as well as electrolytes, were recorded and compared. Data were extracted by two investigators with a 20% sample re-evaluated by the other extractor as a reliability measure. Descriptive statistics including medians and interquartile ranges were measured for continuous variables. Comparisons were made using two-tailed t tests for parametric data and the Mann-Whitney U test for nonparametric data. RESULTS: Agreement in the 20% sampling between investigators was high (96%). The mean QTc in the ACS group was 457 ms and the mean QTc in the EtOH withdrawal-related group was 468 ms (diff 11, not significant). Significantly more patients had a prolonged QTc in the EtOH withdrawal group than in the ACS group 62% vs 46%; diff 16; 95% CI (0.1, 30). There was significantly more use of clopidogrel, acetylsalicylic acid, angiotensin-converting enzyme inhibitors, and statins (P < 0.05 for all) in the ACS group compared with the EtOH withdrawal group; however, there was no difference in ß-blocker usage. There was a significantly higher admission rate: 100% of ACS compared with 76% of the EtOH withdrawal group (P < 0.01, diff 24, 95% confidence interval 18-29). Electrolytes were not significantly different in the two groups. CONCLUSIONS: More patients with EtOH withdrawal-related ED visits had a long QTc than patients presenting with ACS. ED physicians should carefully monitor patients experiencing EtOH withdrawal for cardiac arrhythmias and obtain an ECG. If any medications that prolong the QTc are considered, then an ECG should be obtained before administering medications that may affect the myocardium to make medication safer for the patient.

Comparison of QTc and Troponin Levels in ST Elevation MIs Compared with Non-ST Elevation MIs.

OBJECTIVES: ST elevation myocardial infarctions (STEMIs) and non-ST elevation myocardial infarctions (NSTEMIs) have differences that can be important to differentiate. Our primary hypothesis was that corrected QT (QTc) duration and troponin I levels were higher in STEMIs compared with NSTEMIs. The objective of our study was to compare STEMIs with NSTEMIs for QTc duration and troponin levels. METHODS: This was a retrospective case-control study of all STEMIs and a random sample of NSTEMIs during a 1-year period. STEMIs were retrieved by searching our electrocardiogram database for all of the cardiology-diagnosed STEMIs. NSTEMIs were found by selecting a randomized sample of all of the patients with a final discharge diagnosis of NSTEMI. Records and electrocardiograms were reviewed for initial troponin I levels and QTc duration. Data extractors were educated formally and a 5% sample was reevaluated by the other extractor as a reliability measure. Data analysis included χ2 tests and parametric or nonparametric analysis, where appropriate. A logistic regression model was created with variables selected a priori for predictors of STEMIs compared with NSTEMIs. RESULTS: A total of 92 STEMIs and 111 NSTEMIs were evaluated, and interrater reliability showed 90% agreement. Patients with NSTEMIs had significantly longer QTc. Troponin I did not differ on univariate analysis. In a logistic model, Hispanics were more likely than whites to have a STEMI (adjusted odds ratio [AOR] 2.2, 95% confidence interval [CI] 1.09-4.5). An increase in troponin I of 1 was associated with a 7% increase in the AOR of a STEMI (AOR 1.7, 95% CI 1.03-1.12) and an increase in QTc by 10 was associated with a 13% decrease in the AOR of a STEMI (AOR 0.87, 95% CI 0.78-0.93). CONCLUSIONS: Patients with NSTEMIs had longer QTc intervals and lower troponin I levels than those with STEMIs.

Impact of an emergency medicine pharmacist on antibiotic dosing adjustment.

OBJECTIVE: Overall medication-related errors in the emergency department (ED) are 13.5 times more likely to occur in the absence of an emergency medicine pharmacist (EMP). Although the effectiveness of pharmacist-driven renal dosing adjustment has been studied in the intensive care unit, data are lacking in the ED setting. The aim of our study was to evaluate the appropriateness of antibiotic dosing when an EMP is physically present in the ED compared to when absent. METHODS: This was a retrospective cohort study of patients treated in a level I trauma center with 75 adult and 12 pediatric beds and an annual census of 90000 patients. The study period was from March 1 to September 30, 2014. An EMP was physically present in the ED from 11:00 to 01:30 and absent from 01:31 to 10:59. Male and female patients 18years and older were considered for inclusion if cefazolin, cefepime, ciprofloxacin, piperacillin-tazobactam, or vancomycin was ordered. The primary outcome was the composite rate of correct antibiotic dose and frequency. Statistics included a multivariable logistic regression using age, sex, presence of EMP, and creatinine clearance as independent predictors of correct antibiotic use. RESULTS: A total 210 cases were randomly chosen for evaluation, half during times when EMPs were present and half when they were absent. There were 130 males (62%) with an overall mean age of 54±18years. Overall, 178 (85%) of 210 of the antibiotic orders were appropriate, with 95% appropriate when an EMP was present compared to 74% when an EMP was absent (odds ratio, 6.9; 95% confidence interval, 2.5-18.8). In a logistic regression model, antibiotic appropriateness was independently associated with the presence of the EMP and creatinine clearance. CONCLUSION: Antibiotics that require renal and/or weight dosing adjustment are 6.5 times more likely to be appropriate in the ED when an EMP is present. Prevalence of antibiotic dosing error is related to both the presence of EMPs and the degree of renal impairment.

The meaning of elevated troponin I levels: not always acute coronary syndromes.

BACKGROUND: Troponin elevation can be caused by etiologies other than acute coronary syndromes (ACS). Our hypothesis was that elevated troponins occur more frequently in non-ACS cases but that ACS cases (type 1 ST-elevation myocardial infarction [STEMI] and type 1 non-STEMI [NSTEMI]) have significantly higher troponin elevations. METHODS: This was a cross-sectional cohort analysis of a random subset of all patients with elevated troponins (defined as ≥0.06 ng/mL) over a 1-year period from July 2013 to June 2014. The first positive troponin I and the peak were used in this study. All included patients had medical record reviews looking for whether our cardiologists or hospitalists attributed the elevated troponin to an ACS (NSTEMI or STEMI) or non-ACS cause. Non-ACS causes were categorized as infection, cancer, renal diseases, cardiovascular disease, pulmonary disease, trauma, cardiac arrest, neurologic disease, hypertension, or other. Data were extracted by 2 investigators on the cause of the elevated troponin. Three sessions to educate data extractors were arranged and methods of data extraction discussed, then a 5% sample was reevaluated by the other extractor to determine interrater agreement measures. Parametric data were evaluated with t test and analysis of variance. Dichotomous variables were compared using χ(2) test. Troponin data were evaluated using nonparametric Kruskal-Wallis or Mann-Whitney U. A logistic regression model was created with variables selected a priori to evaluate the predictive ability of these variables in differentiating ACS vs non-ACS causes of elevated troponin. RESULTS: We evaluated 458 randomly selected patients from 1317 unique cases of all patients with initial elevated troponins at least 0.06 mg/mL during the study period. There was 84% interrater agreement in the 5% sampling. Seventy-nine percent had a non-ACS cause of elevated troponin, and the average initial positive troponin I level was significantly lower in the non-ACS cases (0.14; 95% confidence interval [CI], 0.08-0.37) than those with documented STEMI (10.2; 95% CI, 0.75-20.1) or NSTEMIs (0.4; 95% CI, 0.13-1.7). In the non-ACS group, the median initial troponin was 0.14 ng/mL (0.08-0.37 ng/mL). Peak troponin levels were highest in STEMI, next NSTEMI, and lowest in non ACS causes. The most frequent subgroups in the non-ACS group were non-ACS cardiovascular, infectious, renal, or hypertensive causes. In a linear regression model adjusting for age and sex, higher troponin levels had higher odds of being related to ACS causes (adjusted odds ratio, 1.4; 95% CI, 1.2-1.6) than non-ACS causes. CONCLUSION: The etiology for most initial elevated troponin I levels in a randomly selected population is the result of non-ACS causes. As initial + troponin levels increased, they were more likely associated with ACS causes than with non-ACS causes. Average initial + and peak troponin values were highest in STEMIs, next highest in NSTEMIs, and lowest overall in non-ACS causes.

Randomized single-blinded clinical trial on effects of nursery songs for infants and young children's anxiety before and during head computed tomography.

OBJECTIVE: The objective of this clinical trial was to determine if an intervention of listening to nursery songs with integrated heartbeat sounds resulted in changes in anxiety levels in infants and children younger than 4 years in an emergent setting. METHODS: This is a randomized single-blinded controlled trial. The study included 62 children younger than 4 years who were deemed by the emergency physician to need a computed tomographic (CT) scan. The experimental group (Exp) (n=30) listened to recorded children's songs with integrated heartbeat sounds (Baby Go To Sleep compact disc) before and during the head CT. The controls (Con) (n=32) had no music. Two scales to measure agitation were completed by a trained research associate: (1) a 10-cm visual analog scale (VAS) and (2) the Modified Ramsay Sedation Scale (MRSS). The research associate wore headphones blocking out all music. The research associate recorded agitation levels preintervention and postintervention on the 2 scales, whether there was successful completion of the head CT without pharmacologic intervention, and the frequency of medication use. Mann-Whitney U, t test, and logistic regression were used for analysis, and P<.05 was considered significant. RESULTS: There were no differences between groups in the age, sex, initial vital signs, diagnostic category, ethnicity, insurance status, rate of completion of head CT, rate of medication use, hospital admissions, or initial VAS or MRSS score. There was improvement on the VAS score in 53% of the Exp group subjects and 25% of the Con group subjects. The VAS score in the Exp group improved by 1.6 cm, whereas the Con group worsened by 0.8 cm after the intervention (difference=2.4 cm, P=.03). There were no significant changes in MRSS scores. Accounting for age, sex, and admission status, the adjusted odds of having an improved sedation score were 3.2 (1.0-9.7) in the Exp group. CONCLUSION: Measured on a VAS, there was a significant decrease in agitation in children undergoing a head CT when children's songs with integrated heartbeat sounds were played before and during the procedure.

Disparity in Patients' Self-Reported and Charted Medication Allergy Information.

OBJECTIVES: The objective of this study was to compare current adverse drug/allergy reaction reporting in patient electronic medical records/charts against information gathered during patient interviews in the emergency department. Our hypothesis was that current methods for allergy reporting results in significant discrepancy between what is documented and the actual allergy history upon interviewing the patient. METHODS: The study was conducted between December 2011 and April 2012 in an academic emergency department. This was a convenience sample study comparing a prospective patient interview with previously documented allergy histories. Demographics for sex, age, and race were recorded. Patients to be interviewed were adults with at least one documented allergy in their chart. Descriptive statistics and percentages were used for demographic and prevalence data. Agreement between interviews and charts was assessed for both the reaction type and the reaction descriptor. RESULTS: There were 101 patients interviewed during this 4-month period, and a total of 235 adverse drug reactions were recorded. There were 66 women and 35 men included in this study. The mean age was 51 ± 17 years. The median number of allergy instances for women was 2 (interquartile range 1-3) and for men the median number of allergy instances was 1 (interquartile range 1-2). The percentage of agreements for overall allergies was 85% and 50% for the type of reaction. Total profile agreement occurred in nine patients. CONCLUSIONS: The percentage of agreement between interviews and charting for reaction type was 50%. Even with the use of electronic medical records, better methods are needed to properly record allergies to ensure patient safety and care.

Co-Speciation of the Ectoparasite Gyrodactylus teuchis (Monogenea, Platyhelminthes) and Its Salmonid Hosts.

Co-speciation is a fundamental concept of evolutionary biology and intuitively appealing, yet in practice hard to demonstrate as it is often blurred by other evolutionary processes. We investigate the phylogeographic history of the monogenean ectoparasites Gyrodactylus teuchis and G. truttae on European salmonids of the genus Salmo. Mitochondrial cytochrome oxidase subunit 1 and the nuclear ribosomal internal transcribed spacer 2 were sequenced for 189 Gyrodactylus individuals collected from 50 localities, distributed across most major European river systems, from the Iberian- to the Balkan Peninsula. Despite both anthropogenic and naturally caused admixture of the principal host lineages among major river basins, co-phylogenetic analyses revealed significant global congruence for host and parasite phylogenies, providing firm support for co-speciation of G. teuchis and its salmonid hosts brown trout (S. trutta) and Atlantic salmon (S. salar). The major split within G. teuchis, coinciding with the initial divergence of the hosts was dated to ~1.5 My BP, using a Bayesian framework based on an indirect calibration point obtained from the host phylogeny. The presence of G. teuchis in Europe thus predates some of the major Pleistocene glaciations. In contrast, G. truttae exhibited remarkably low intraspecific genetic diversity. Given the direct life cycle and potentially high transmission potential of gyrodactylids, this finding is interpreted as indication for a recent emergence (<60 ky BP) of G. truttae via a host-switch. Our study thus suggests that instances of two fundamentally different mechanisms of speciation (co-speciation vs. host-switching) may have occurred on the same hosts in Europe within a time span of less than 1.5 My in two gyrodactylid ectoparasite species.