Emergency Department Management of Uncomplicated Hyperglycemia in Patients without History of Diabetes.

BACKGROUND: Hyperglycemia is a common finding in patients presenting to the emergency department (ED). Recommendations addressing uncomplicated hyperglycemia in the ED are limited, and the management of those without a prior diagnosis of diabetes presents a challenge. OBJECTIVE: This narrative review will discuss the ED evaluation and management of hyperglycemic adult patients without a history of diabetes who do not have evidence of a hyperglycemic crisis, such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. DISCUSSION: Many adults who present to the ED have risk factors for diabetes and meet American Diabetes Association (ADA) criteria for diabetes screening. A new diagnosis of type 2 diabetes can be established in the ED by the ADA criteria in patients with a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L) and symptoms of hyperglycemia. The diagnosis should be considered in patients with an elevation in random blood glucose > 140 mg/dL (7.8 mmol/L). Treatment may begin in the ED and varies depending on the presenting severity of hyperglycemia. Treatment options include metformin, long-acting insulin, or deferring for close outpatient management. CONCLUSIONS: Emergency clinician knowledge of the evaluation and management of new-onset hyperglycemia and diabetes is important to prevent long-term complications.

Prevalence and consequences of chromosomal abnormalities in Canadian commercial swine herds.

BACKGROUND: Structural chromosome abnormalities are well known as factors that reduce fertility rate in domestic pigs. According to large-scale national cytogenetic screening programs that are implemented in France, it is estimated that new chromosome abnormalities occur at a rate of 0.5 % in fertility-unproven boars. RESULTS: This work aimed at estimating the prevalence and consequences of chromosome abnormalities in commercial swine operations in Canada. We found pig carriers at a frequency of 1.64 % (12 out of 732 boars). Carrier pigs consistently showed lower fertility values. The total number of piglets born for litters from carrier boars was between 4 and 46 % lower than the herd average. Similarly, carrier boars produced litters with a total number of piglets born alive that was between 6 and 28 % lower than the herd average. A total of 12 new structural chromosome abnormalities were identified. CONCLUSIONS: Reproductive performance is significantly reduced in sires with chromosome abnormalities. The incidence of such abnormal sires appears relatively high in populations without routine cytogenetic screening such as observed for Canada in this study. Systematic cytogenetic screening of potential breeding boars would minimise the risk of carriers of chromosome aberrations entering artificial insemination centres. This would avoid the large negative effects on productivity for the commercial sow herds and reduce the risk of transmitting abnormalities to future generations in nucleus farms.

Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism.

STUDY OBJECTIVE: The objective of this study was to determine the diagnostic performance of right ventricular dilatation identified by emergency physicians on bedside echocardiography in patients with a suspected or confirmed pulmonary embolism. The secondary objective included an exploratory analysis of the predictive value of a subgroup of findings associated with advanced right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, McConnell's sign). METHODS: This was a prospective observational study using a convenience sample of patients with suspected (moderate to high pretest probability) or confirmed pulmonary embolism. Participants had bedside echocardiography evaluating for right ventricular dilatation (defined as right ventricular to left ventricular ratio greater than 1:1) and right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, or McConnell's sign). The patient's medical records were reviewed for the final reading on all imaging, disposition, hospital length of stay, 30-day inhospital mortality, and discharge diagnosis. RESULTS: Thirty of 146 patients had a pulmonary embolism. Right ventricular dilatation on echocardiography had a sensitivity of 50% (95% confidence interval [CI] 32% to 68%), a specificity of 98% (95% CI 95% to 100%), a positive predictive value of 88% (95% CI 66% to 100%), and a negative predictive value of 88% (95% CI 83% to 94%). Positive and negative likelihood ratios were determined to be 29 (95% CI 6.1% to 64%) and 0.51 (95% CI 0.4% to 0.7%), respectively. Ten of 11 patients with right ventricular hypokinesis had a pulmonary embolism. All 6 patients with McConnell's sign and all 8 patients with paradoxical septal motion had a diagnosis of pulmonary embolism. There was a 96% observed agreement between coinvestigators and principal investigator interpretation of images obtained and recorded. CONCLUSION: Right ventricular dilatation and right ventricular dysfunction identified on emergency physician performed echocardiography were found to be highly specific for pulmonary embolism but had poor sensitivity. Bedside echocardiography is a useful tool that can be incorporated into the algorithm of patients with a moderate to high pretest probability of pulmonary embolism.

Sonographic confirmation of intubation: comparison of 3 methods in a pig model.

OBJECTIVES: Several recent studies have investigated methods to confirm endotracheal tube (ETT) placement with sonography, using diaphragmatic movement, lung sliding, and transtracheal visualization of the ETT. To our knowledge, no studies have directly compared these 3 methods. This study aimed to directly compare the test characteristics of these 3 methods to determine ETT placement. Additionally, we compared the time required to complete the sonographic examination and the performers' confidence in their findings. METHODS: We conducted a prospective randomized single-blinded study. Twenty-five recently euthanized pigs were intubated either in the esophagus or trachea, for a total of 50 intubations. Each of the 3 sonographic methods of intubation confirmation was performed by sonographers of different skill levels. Sonographic findings, the time to findings, and confidence in findings were recorded. RESULTS: A total of 150 sonographic examinations were performed. There were no significant differences in the sensitivity, specificity, positive predictive value, negative predictive value, or accuracy for correct ETT placement between the 3 methods of intubation confirmation. On average, the transtracheal and thoracic methods were faster (12.5 and 14.0 seconds, respectively) than the diaphragmatic method (21.0 seconds; P < .01). There were no significant differences in operator confidence between the confirmation methods. CONCLUSIONS: All 3 methods for determining ETT placement had similar test characteristics. Transtracheal and thoracic sonography were faster than diaphragmatic sonography for determining ETT placement in pigs.

Routinely used interventions to improve attachment in infants and young children: a national survey and two systematic reviews.

BACKGROUND: Attachment refers to an infant's innate tendency to seek comfort from their caregiver. Research shows that attachment is important in promoting healthy social and emotional development. Many parenting interventions have been developed to improve attachment outcomes for children. However, numerous interventions used in routine practice have a limited evidence base, meaning that we cannot be sure if they are helpful or harmful. OBJECTIVES: This research aimed to conduct a large-scale survey to identify what interventions are being used in UK services to improve child attachment; conduct a systematic review to evaluate the evidence for parenting attachment interventions; and develop recommendations for future research and practice. DESIGN AND METHODS: We worked closely with our Expert Reference Group to plan a large-scale survey focused on relevant UK services. We then conducted two systematic reviews. One searched for all randomised controlled trial evidence for any attachment parenting intervention. The second searched for all research for the top 10 routinely used interventions identified from the survey. RESULTS: The survey collected 625 responses covering 734 UK services. The results identified the 10 most commonly used interventions. The responses showed a limited use of validated measures and a wide variety of definitions of attachment. For the first review, seven studies were included from 2516 identified records. These were combined with results from previous reviews conducted by the team. Meta-analyses showed that, overall, parenting interventions are effective in reducing disorganised attachment (pooled odds ratio 0.54, 95% confidence interval 0.39 to 0.77) and increasing secure attachment (pooled odds ratio 1.85, 95% confidence interval 1.36 to 2.52). The second review searched the literature for the top 10 routinely used interventions identified by the survey; 61 studies were included from 1198 identified records. The results showed that many of the most commonly used interventions in UK services have a weak evidence base and those with the strongest evidence base are not as widely used. CONCLUSIONS: There is a need for better links between research and practice to ensure that interventions offered to families are safe and effective. Possible reasons for the disparity include the cost and accessibility of training. There is also a need for improved understanding by professionals regarding the meaning of attachment. LIMITATIONS: Although the survey had good geographical spread, most respondents were based in England. For review 2 we were unable to access a large number of papers; however, we conducted extensive reference checking to account for this. FUTURE WORK: There is a need for robust research to test the efficacy of routinely used attachment interventions. Research could also explore why routinely used interventions are not consistently subject to thorough evaluation; how to embed dissemination, cost-effectiveness, fidelity and sustainability into research; and how to keep clinical practice up to date with research developments. STUDY REGISTRATION: This study is registered as PROSPERO CRD42019137362. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 2. See the NIHR Journals Library website for further project information.

Attachment refers to an infant's natural instinct to seek comfort from their main carers. There are four ways in which infants show attachment ('attachment patterns'). These are known as secure, insecure-avoidant, insecure-resistant and disorganised. Secure attachment usually occurs with consistent and responsive parenting/caregiving and is linked with positive social and emotional child development. Inconsistent, neglectful or abusive parenting/caregiving can lead to problems with attachment, including disorganised attachment, and is linked to poorer outcomes. Parenting support, education and therapies help parents improve infant attachment and their child's outcomes. We surveyed UK services to see what they offered families with attachment problems. A total of 734 UK services responded. This identified 10 therapies or support packages most commonly offered to parents. We checked what research had been done on these. We found very little. We found 61 studies of support packages with quite good evidence, but these were generally not ones offered by UK services. We also looked in detail at research for all types of support/therapies to improve attachment. We looked for the best research (called 'randomised controlled trials'); 26 studies had tested therapies to see if they improved secure attachment and 20 had tested whether or not they improved (i.e. reduced) disorganised attachment. We found that these therapies or support packages are good at increasing secure attachment and improving disorganised attachment. Mostly they did this by helping parents/caregivers improve caregiving and particularly how sensitive and responsive they are to their child and their needs. Currently, practice is not following research, and research is not being done to properly evaluate current practice. We need to improve the evidence and the way it links to practice, including how those organising and paying for services are made aware of up-to-date research to make sure that the best treatments are available. High-quality training for staff is also important.

Children on the autism spectrum: grandmother involvement and family functioning.

BACKGROUND: This study investigated associations between the presence of a child with autism or Asperger's disorder in the family, family functioning and grandmother experiences with the goal of better understanding grandparent involvement in the lives of grandchildren on the autism spectrum and their families. METHODS: Mothers and grandmothers of children who were either typically developing or on the autism spectrum completed parallel forms of a grandparent involvement measure. Mothers reported on the functioning of the immediate family. Data were analysed via multilevel modelling with mother-grandmother dyads as the unit of observation. RESULTS: Autism spectrum disorders in children were associated with more flexible family functioning, lower levels of family satisfaction, greater grandmother difficulties and more grandmother information needs. CONCLUSIONS: Participation of grandparents in diagnostic and treatment meetings and increased communication among family members may facilitate grandparent support and involvement in families with a child on the autism spectrum.

A Safety Evaluation of Midazolam use for Nasogastric Tube Placement.

OBJECTIVE: Nasogastric tube (NGT) insertion is one of the most painful procedures in the emergency department (ED). A recent study determined that giving intravenous (IV) midazolam before NGT insertion decreased patients' pain; however, the sample size was insufficient to draw the conclusions on safety. We conducted a retrospective chart review of patients who received IV midazolam for NGT insertion to determine the frequency of adverse events. METHODS: All patients treated at a Level 1 trauma center ED from June 2016 to June 2019 who received IV midazolam for NGT insertion were included. The medical records were screened for the following serious adverse events: hypoxia, respiratory suppression, excessive somnolence/sedation, hemodynamic instability, epistaxis, vomiting, and choking. Adverse events, patient demographics, chief complaint, diagnosis, disposition, number of midazolam administrations, dose per administration, and total dose were recorded for the analysis. FINDINGS: Three out of 159 participants (2%) were identified as having an adverse event. In two cases, the adverse event was hypoxia, which was corrected with the administration of supplemental oxygen through nasal cannula. The third adverse event was somnolence noted in a patient who was also hypotensive and in atrial fibrillation around the time of midazolam administration. CONCLUSION: It is safe to premedicate patients with midazolam before NGT insertions. Patients with borderline oxygen saturation and those receiving opioid analgesics may warrant dose titration with close vital sign monitoring.

Memory for the September 11, 2001, terrorist attacks one year later in patients with Alzheimer's disease, patients with mild cognitive impairment, and healthy older adults.

Although there are many opportunities to study memory in patients with Alzheimer's disease (AD) in the laboratory, there are few opportunities to study memory for real world events in these patients. The September 11, 2001 terrorist attacks provided one such opportunity. Patients with AD, patients with mild cognitive impairment (MCI), and healthy older adults were given a telephone questionnaire in the initial weeks after the event, again three to four months later, and finally one year afterwards to evaluate their memory for the September 11, 2001 terrorist attacks. We were particularly interested in using the attacks as an opportunity to examine the decline of episodic memory in patients with AD, patients with MCI, and older adult controls over a period of months. We found that compared to healthy older adults, patients with AD and MCI showed impaired memory at the initial time point, more rapid forgetting from the initial to the three-month time point, and very similar changes in memory from the three-month to the one-year time point. We speculated that these findings were consistent with patients with AD and MCI showing initial impaired encoding and a more rapid rate of forgetting compared with healthy older adults, but that once the memories had been consolidated, their decay rate became similar to that of healthy older adults. Lastly, although memory distortions were common among all groups, they were greatest in the patients with AD.

Mis-attribution errors in Alzheimer's disease: the illusory truth effect.

Patients with mild Alzheimer's disease (AD) and age-matched controls were compared on a series of tasks designed to measure errors of mis-attribution, the act of attributing a memory or idea to an incorrect source. Mis-attribution was indexed through the illusory truth effect, the tendency for participants to judge previously encountered information to be true. Cognitive theories have suggested that the illusory truth effect reflects the mis-attribution of experimentally produced familiarity (a nonspecific sense that an item has been previously encountered) to the veracity of previously encountered information. Consistent with earlier suggestions that AD impairs both familiarity and recollection (specific memory for contextual details of the study episode), AD patients demonstrated significantly fewer mis-attribution errors under conditions in which the illusory truth effect is thought to rely on relative familiarity (uncued condition), but more mis-attribution errors under conditions thought to rely on relative amounts of contextual recollection (cued condition). These results help further specify the precise nature of memory impairments in AD.

Comparing source-based and gist-based false recognition in aging and Alzheimer's disease.

This study examined 2 factors contributing to false recognition of semantic associates: errors based on confusion of source and errors based on general similarity information or gist. The authors investigated these errors in patients with Alzheimer's disease (AD), age-matched control participants, and younger adults, focusing on each group's ability to use recollection of source information to suppress false recognition. The authors used a paradigm consisting of both deep and shallow incidental encoding tasks, followed by study of a series of categorized lists in which several typical exemplars were omitted. Results showed that healthy older adults were able to use recollection from the deep processing task to some extent but less than that used by younger adults. In contrast, false recognition in AD patients actually increased following the deep processing task, suggesting that they were unable to use recollection to oppose familiarity arising from incidental presentation.

Late frontal brain potentials distinguish true and false recognition.

Brain potentials associated with true and false recognition were recorded using a paradigm consisting of categorized color photographs. Two ERP components were identified. A parietal component was most positive for both true and false recognition, less positive for rejection of lures, and least positive for rejection of novel items. A later frontal component was more positive for false recognition, rejection of lures, and misses than for true recognition and rejection of novel items. The authors suggest that the parietal component may reflect the extent to which test items engender recollection of the gist representation of the study list, while the late frontal component may reflect the engagement of effortful post-retrieval processes.

Associative recognition in Alzheimer's disease: evidence for impaired recall-to-reject.

Patients with mild Alzheimer's disease (AD) were compared with age-matched control subjects on an associative recognition task. Subjects studied pairs of unrelated words and were later asked to distinguish between these same studied pairs (intact) and new pairs that contained either rearranged studied words (rearranged) or non-studied words (non-studied). Studied pairs were presented either once or 3 times. Repetition increased hits to intact pairs in both groups, but repetition increased false alarms to rearranged pairs only in patients. This latter pattern indicates that repetition increased familiarity of the rearranged pairs, but only the control subjects were able to counter this familiarity by recalling the originally studied pairs (a recall-to-reject process). AD impaired this recall-to-reject process, leading to more familiarity based false alarms. These data support the idea that recollection-based monitoring processes are impaired in mild AD.

Memory and emotions for the september 11, 2001, terrorist attacks in patients with Alzheimer's disease, patients with mild cognitive impairment, and healthy older adults.

National traumatic events can produce extremely vivid memories. Using a questionnaire administered during telephone interviews, the authors investigated emotional responses to, and memory for. the September 11, 2001, terrorist attacks in patients with Alzheimer's disease (AD), patients with mild cognitive impairment (MCI), and healthy older adults in the initial weeks following the event and again 3-4 months later. There were several notable findings. First, patients with AD showed less memory than patients with MCI and older adults. Second, patients with AD, but not patients with MCI or older adults, appeared to retain more memory for personal versus factual information. Third, patients with AD and older adults did not differ in the intensity of their reported emotional responses to the attacks, whereas patients with MCI reported relatively less intense emotional responses. Last, distortions of memory for personal information were frequent for all participants but were more common in patients with AD.

Factors associated with longer time to treatment for patients with suspected acute coronary syndromes: a cohort study.

BACKGROUND: Rapid treatment of acute coronary syndromes (ACS) is important; causes of delay in emergency medical services care of ACS are poorly understood. METHODS AND RESULTS: We performed an analysis of data from IMMEDIATE (Immediate Myocardial Metabolic Enhancement during Initial Assessment and Treatment in Emergency Care), a randomized controlled trial of emergency medical services treatment of people with symptoms suggesting ACS, using hierarchical multiple regression of elapsed time. Out-of-hospital ECGs were performed on 54,230 adults calling 9-1-1; 871 had presumed ACS, 303 of whom had ST-segment elevation myocardial infarction and underwent percutaneous coronary intervention. Women, participants with diabetes mellitus, and participants without previous cardiovascular disease waited longer to call 9-1-1 (by 28 minutes, P<0.01; 10 minutes, P=0.03; and 6 minutes, P=0.02, respectively), compared with their counterparts. Time from emergency medical services arrival to ECG was longer for women (1.5 minutes; P<0.01), older individuals (1.3 minutes; P<0.01), and those without a primary complaint of chest pain (3.5 minutes; P<0.01). On-scene times were longer for women (2 minutes; P<0.01) and older individuals (2 minutes; P<0.01). Older individuals and participants presenting on weekends and nights had longer door-to-balloon times (by 10, 14, and 11 minutes, respectively; P<0.01). Women and older individuals had longer total times (medical contact to balloon inflation: 16 minutes, P=0.01, and 9 minutes, P<0.01, respectively; symptom onset to balloon inflation: 31.5 minutes for women; P=0.02). CONCLUSIONS: We found delays throughout ACS care, resulting in substantial differences in total times for women and older individuals. These delays may impact outcomes; a comprehensive approach to reduce delay is needed.

Semantic versus phonological false recognition in aging and Alzheimer's disease.

Patients with Alzheimer's disease (AD) have been found to exhibit lower levels of false recognition of semantic associates compared with healthy older adults. Because these patients may show impaired performance of episodic and semantic memory tasks, this finding could be explained by deficits in episodic memory, semantic memory, or both. The authors adapted a paradigm for comparison of semantic versus phonological false recognition. They found that: (a) patients with AD exhibited lower levels of corrected false recognition of semantic, phonological, and hybrid (mixed semantic and phonological) lists than older adults, and (b) patients with AD showed very similar levels of false recognition for all list types. These results suggest that only episodic memory deficits are necessary to explain the lower level of false recognition of semantic associates observed in patients with AD when compared to older adults. Additionally, (c) older adults showed greater levels of semantic, phonological, and hybrid false recognition than younger adults, extending previous false recognition research of semantically related words and categorized colored photographs to phonologically related words.

False recognition in Alzheimer disease: evidence from categorized pictures.

OBJECTIVES: To better understand memory distortions and false recognition in patients with Alzheimer disease (AD), using a paradigm of categorized color photographs. BACKGROUND: Previous research has found that patients with AD and older adults showed similar levels of uncorrected false recognition of semantic associates and of perceptually related novel objects. In contrast to these results, using a paradigm in which semantically related words were accompanied by black and white line drawings, it was found that patients with AD showed a trend toward higher levels of uncorrected false recognition compared with older adults. METHODS: To explore this trend, 24 patients with AD and 24 older adults matched for age, education, and gender were examined using a false recognition paradigm consisting of categorized color photographs (e.g., flowers, motorcycles, cats). RESULTS: Compared with older adults, patients with AD showed higher levels of uncorrected false recognition, but lower levels of corrected false recognition and lower levels of item-specific recollection. CONCLUSIONS: The authors suggest that these results may be attributable to the poor ability of patients with AD to acquire both gist and item-specific information as well as these patients' inherent frontal lobe dysfunction leading to difficulty inhibiting responses on the basis of familiarity alone.