Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department.

BACKGROUND: Overcrowding in emergency departments (ED) is a major concern worldwide. To answer increasing health care demands, new models of care including advanced practice physiotherapists (APP) have been implemented in EDs. The purpose of this study was to assess diagnostic, treatment and discharge plan concordance between APPs and ED physicians for patients consulting to the ED for minor musculoskeletal disorders (MSKD). METHODS: Patients presenting to two EDs in Montréal (Canada) with a minor MSKD were recruited and independently assessed by an APP and ED physician. Both providers had to formulate diagnosis, treatment and discharge plans. Cohen's kappa (κ) and Prevalence and Bias Adjusted Kappas (PABAK) with associated 95%CI were calculated. Chi Square and t-tests were used to compare treatment, discharge plan modalities and patient satisfaction between providers. RESULTS: One hundred and thirteen participants were recruited, mean age was 50.3 ± 17.4 years old and 51.3% had an atraumatic MSKD. Diagnostic inter-rater agreement between providers was very good (κ = 0.81; 95% CI: 0.72-0.90). In terms of treatment plan, APPs referred significantly more participants to physiotherapy care than ED physicians (κ = 0.27; PABAK = 0.27; 95% CI: 0.07-0.45; p = 0.003). There was a moderate inter-rater agreement (κ = 0.46; PABAK = 0.64; 95% CI: 0.46-0.77) for discharge plans. High patient satisfaction was reported with no significant differences between providers (p = 0.57). CONCLUSION: There was significant agreement between APPs and ED physicians in terms of diagnosis and discharge plans, but more discrepancies regarding treatment plans. These results tend to support the integration of APPs in ED settings, but further prospective evaluation of the efficiency of these types of models is warranted.

Corrigendum: Sub-ice-shelf sediments record history of twentieth-century retreat of Pine Island Glacier.

This corrects the article DOI: 10.1038/nature20136.

Sub-ice-shelf sediments record history of twentieth-century retreat of Pine Island Glacier.

The West Antarctic Ice Sheet is one of the largest potential sources of rising sea levels. Over the past 40 years, glaciers flowing into the Amundsen Sea sector of the ice sheet have thinned at an accelerating rate, and several numerical models suggest that unstable and irreversible retreat of the grounding line-which marks the boundary between grounded ice and floating ice shelf-is underway. Understanding this recent retreat requires a detailed knowledge of grounding-line history, but the locations of the grounding line before the advent of satellite monitoring in the 1990s are poorly dated. In particular, a history of grounding-line retreat is required to understand the relative roles of contemporaneous ocean-forced change and of ongoing glacier response to an earlier perturbation in driving ice-sheet loss. Here we show that the present thinning and retreat of Pine Island Glacier in West Antarctica is part of a climatically forced trend that was triggered in the 1940s. Our conclusions arise from analysis of sediment cores recovered beneath the floating Pine Island Glacier ice shelf, and constrain the date at which the grounding line retreated from a prominent seafloor ridge. We find that incursion of marine water beyond the crest of this ridge, forming an ocean cavity beneath the ice shelf, occurred in 1945 (±12 years); final ungrounding of the ice shelf from the ridge occurred in 1970 (±4 years). The initial opening of this ocean cavity followed a period of strong warming of West Antarctica, associated with El Niño activity. Thus our results suggest that, even when climate forcing weakened, ice-sheet retreat continued.

Magnetic linear dichroism in the angular dependence of core-level photoemission from (Ga,Mn)As using hard x rays.

We report a study of the electronic properties of the ferromagnetic semiconductor (Ga,Mn)As using magnetic linear dichroism in the angular dependence of Mn 2p photoemission under hard x-ray excitation. Bulk plasmon loss satellites demonstrate that the probed Mn ions are incorporated deep within the GaAs lattice, while the observed large dichroism indicates that the spectra originate from ferromagnetic substitutional Mn. Simulations of the spectra using an Anderson impurity model show that the ferromagnetic Mn 3d electrons of substitutional Mn in (Ga,Mn)As are intermediate between localized and delocalized.

Angle-dependent x-ray magnetic circular dichroism from (Ga,Mn)As: anisotropy and identification of hybridized states.

Remarkably anisotropic Mn L2,3 x-ray magnetic circular dichroism spectra from the ferromagnetic semiconductor (Ga,Mn)As are reported. States with cubic and uniaxial symmetry are distinguished by careful analysis of the angle dependence of the spectra. The multiplet structures with cubic symmetry are qualitatively reproduced by calculations for an atomiclike d5 configuration in tetrahedral environment, and show zero anisotropy in the orbital and spin moments within the experimental uncertainty. However, hybridization with the host valence bands is reflected by the presence of a preedge feature with a uniaxial anisotropy and a marked dependence on the hole density.

Mn interstitial diffusion in (ga,mn)as.

We present a combined theoretical and experimental study of the ferromagnetic semiconductor (Ga,Mn)As which explains the remarkably large changes observed on low-temperature annealing. Careful control of the annealing conditions allows us to obtain samples with ferromagnetic transition temperatures up to 159 K. Ab initio calculations, in situ Auger spectroscopy, and resistivity measurements during annealing show that the observed changes are due to out diffusion of Mn interstitials towards the surface, governed by an energy barrier of 0.7-0.8 eV. Electric fields induced by Mn acceptors have a significant effect on the diffusion.

A mixed-drug intoxication involving venlafaxine and verapamil.

This case report describes the suicide of a 52-year-old woman whose cause of death was attributed to a mixed-drug intoxication involving venlafaxine and verapamil. Venlafaxine is prescribed for the treatment of depression and should be used with caution in patients with cardiovascular disease. Verapamil is a calcium channel blocker primarily used for treatment of cardiovascular disorders. The following drug concentrations were determined in postmortem fluids: verapamil--3.5 mg/L (femoral blood), 9.4 mg/L (subclavian blood), and 1.0 mg/L (vitreous fluid); norverapamil--1.0 mg/L (femoral blood), 2.1 mg/L (subclavian blood), and 0.20 mg/L (vitreous fluid); verapamil and norverapamil could not be detected in bile or urine due to the high levels of erythromycin present; venlafaxine--6.2 mg/L (femoral blood), 8.6 mg/L (subclavian blood), 5.3 mg/L (vitreous fluid), 54.0 mg/L (bile), and 72.3 mg/L (urine); and O-desmethylvenlafaxine--5.4 mg/L (femoral blood), 8.3 mg/L (subclavian blood), positive (vitreous fluid), 29.2 mg/L (bile), and 9.5 mg/L (urine). The cause of death was determined to be a mixed-drug intoxication resulting from an overdose of verapamil and venlafaxine. The manner of death was determined to be suicide.

High physiological levels of melatonin in the bile of mammals.

Bile is an important physiological bodily fluid which functions in the regulation of cholesterol metabolism, promotes the absorption of lipid and fat-soluble vitamins by the gut and serves in the excretion of toxic substances from the liver. Conversely, due to autooxidative processes bile is highly toxic to the hepatocyte and gastrointestinal epithelium. In this investigation, extremely high day time physiological levels of the endogenous antioxidant, melatonin, were measured in the bile of several mammals including rat, guinea pig, rabbit, pig, monkey and humans. Melatonin concentrations in the bile samples ranged from 2,000 to 11,000 pg/ml when measured by radioimmunoassay (RIA). These melatonin levels in bile are 2 to 3 orders of magnitude higher than those in day time serum. The presence of melatonin in bile was confirmed by HPLC with an electrochemical detector. This method, like the RIA, also documented very high levels of melatonin in bile. The presence of high levels of melatonin in bile may be essential to prevent oxidative damage to biliary and small intestinal epithelium induced by bile acids and oxidized cholesterol derivatives.

Evaluation of the cardiac STATus CK-MB/myoglobin card test to diagnose acute myocardial infarctions in the ED.

A study was undertaken to evaluate a Card Test called "Spectral Diagnostics Inc Cardiac STATus CK-MB/Myoglobin" (Toronto, Canada), which is distributed by Dade International Inc, Miami, FL, for the simultaneous qualitative determination of CK-MB and myoglobin levels in human serum. The Card Test is advertised by the manufacturer as an aid in diagnosing acute myocardial infarction (AMI) in the emergency department (ED). Fifty-eight consecutive serum samples were obtained from 25 patients being evaluated for AMI in an ED. Qualitative CK-MB and myoglobin results from the Card Test were compared with quantitative CK-MB and myoglobin results using the ACS-180 instrument (Ciba Corning Diagnostics, Medfield, MA) and Stratus IIntellect T (Dade International Inc, Miami, FL), respectively. Qualitative results from the STATus CK-MB/Myoglobin Card Test were similar, diagnostically, to quantified results using these automated instruments.

Mucinous adenocarcinoma arising from a suprapubic cystostomy site without bladder involvement.

Carcinoma arising from a suprapubic cystostomy site in patients with spinal cord injury has been infrequently described. In all previously reported cases, they have been squamous cell carcinomas. Our patient is a 68 year old male with T10 complete thoracic paraplegia who presented with an exophytic mass extending from his suprapubic cystostomy tract. Biopsy revealed mucinous adenocarcinoma. Carcinoma of the suprapubic cystostomy tract should be considered in those patients who present with bloody drainage and/or masses arising from the suprapubic cystostomy site.

Uterine growth responses of the mature castrate rat to estradiol-17B.

To examine estrogen-stimulated uterine growth we have monitored changes in uterine DNA synthesis, ornithine decarboxylase (ODC) activity and protein content as well as luminal epithelial (LE) cell mitotic index and ultrastructural changes. We have utilized this model to examine castrate mature rat uterine growth as a function of time between 18 and 40 hours following a single injection of 25.0 ug of estradiol-17B. LE cell mitotic index and protein content increases were maximally elevated as early as 18 hours postinjection while uterine ODC activity was maximal at 28 hours; uterine DNA synthesis increases continued throughout the experiment. In addition, the infusion of either 1 or 2 ug E2 plus progesterone over a 24 hour period, stimulated elevated ODC activity under both treatment regimens and LE cell mitotic index which was inversely related to E2 dose.