Can emergency medicine practitioners predict disposition of psychiatric patients based on a brief medical evaluation?

OBJECTIVE: Emergency medicine practitioners (EMPs) often provide 'medical clearance' before evaluation by a psychiatry practitioner (PP). We set out to determine the level of agreement between EMP impression and disposition as determined by PPs. PATIENTS AND METHODS: This was a prospective observational study in an urban tertiary teaching hospital emergency department. We collected data from February to April 2011. We used a convenience sample of patient encounters evaluated by EMPs and subsequent referral for psychiatric evaluation. We asked EMPs whether they thought the patients would be admitted or discharged following psychiatric evaluation, and if discharged, whether to outpatient psychiatric follow-up or to no follow-up. EMPs were asked to base their opinion upon their general impression following their brief medical evaluation. They were not given guidelines on which to base their decision. The EMPs were blind to PP decisions. The κ-statistic was used to calculate agreement between the EMP's impression and disposition decision by the PP. We excluded patients who were acutely intoxicated, in police custody, or lived in an extended care facility. RESULTS: We included 156 patient encounters over the study period and had complete data for 152 encounters. Of these, 86 (55%) were admitted, 46 (30%) were discharged with no specific psychiatric follow-up, and 20 (13%) were discharged with a follow-up plan. EMPs predicted the exact disposition in 77/152 (51%) cases (κ=0.264, 95% confidence interval 0.77-0.333). Agreement was higher for admitted patients, with EMPs predicting inpatient admission for 57/86 (66%) of these patients. Other factors associated with higher agreement scores were years in emergency medicine practice by the EMP and suicidal ideation by the patient. CONCLUSION: EMPs did not reliably predict psychiatric disposition decisions based on clinical 'gestalt'. Future research will focus on clinical guidelines to help EMPs better independently assess need for emergency psychiatric services.

Plant root distributions and nitrogen uptake predicted by a hypothesis of optimal root foraging.

CO(2)-enrichment experiments consistently show that rooting depth increases when trees are grown at elevated CO(2) (eCO(2)), leading in some experiments to increased capture of available soil nitrogen (N) from deeper soil. However, the link between N uptake and root distributions remains poorly represented in forest ecosystem and global land-surface models. Here, this link is modeled and analyzed using a new optimization hypothesis (MaxNup) for root foraging in relation to the spatial variability of soil N, according to which a given total root mass is distributed vertically in order to maximize annual N uptake. MaxNup leads to analytical predictions for the optimal vertical profile of root biomass, maximum rooting depth, and N-uptake fraction (i.e., the proportion of plant-available soil N taken up annually by roots). We use these predictions to gain new insight into the behavior of the N-uptake fraction in trees growing at the Oak Ridge National Laboratory free-air CO(2)-enrichment experiment. We also compare MaxNup with empirical equations previously fitted to root-distribution data from all the world's plant biomes, and find that the empirical equations underestimate the capacity of root systems to take up N.

Mechanisms linking plant productivity and water status for a temperate Eucalyptus forest flux site: analysis over wet and dry years with a simple model.

A simple process-based model was applied to a tall Eucalyptus forest site over consecutive wet and dry years to examine the importance of different mechanisms linking productivity and water availability. Measured soil moisture, gas flux (CO2, H2O) and meteorological records for the site were used. Similar levels of simulated H2O flux in 'wet' and 'dry' years were achieved when water availability was not confined to the first 1.20 m of the soil profile, but was allowed to exceed it. Although the simulated effects of low soil and atmospheric water content on CO2 flux, presumably via reduction in stomatal aperture, also acted on transpiration, they were offset in the dry year by a higher vapour-pressure deficit. A sensitivity analysis identified the processes that were important in wet versus dry years, and on an intra-annual timeframe. Light-limited productivity dominated in both years, except for the driest period in the dry year. Vapour-pressure deficit affected productivity across more of each year than soil moisture, but both effects were larger in the dry year. The introduction of a reduced leaf area tended to decrease sensitivity in the dry year. Plant hydraulic architecture that increases plant available water, maximises productivity per unit water use and achieves lower sensitivity to low soil moisture levels should minimise production losses during dry conditions.

Why is plant-growth response to elevated CO2 amplified when water is limiting, but reduced when nitrogen is limiting? A growth-optimisation hypothesis.

Experimental evidence indicates that the stomatal conductance and nitrogen concentration ([N]) of foliage decline under CO2 enrichment, and that the percentage growth response to elevated CO2 is amplified under water limitation, but reduced under nitrogen limitation. We advance simple explanations for these responses based on an optimisation hypothesis applied to a simple model of the annual carbon-nitrogen-water economy of trees growing at a CO2-enrichment experiment at Oak Ridge, Tennessee, USA. The model is shown to have an optimum for leaf [N], stomatal conductance and leaf area index (LAI), where annual plant productivity is maximised. The optimisation is represented in terms of a trade-off between LAI and stomatal conductance, constrained by water supply, and between LAI and leaf [N], constrained by N supply. At elevated CO2 the optimum shifts to reduced stomatal conductance and leaf [N] and enhanced LAI. The model is applied to years with contrasting rainfall and N uptake. The predicted growth response to elevated CO2 is greatest in a dry, high-N year and is reduced in a wet, low-N year. The underlying physiological explanation for this contrast in the effects of water versus nitrogen limitation is that leaf photosynthesis is more sensitive to CO2 concentration ([CO2]) at lower stomatal conductance and is less sensitive to [CO2] at lower leaf [N].

Linking leaf and tree water use with an individual-tree model.

We tested the ability of a model to scale gas exchange from leaf level to whole-tree level by: (1) measuring leaf gas exchange in the canopy of 10 trees in a tall Eucalyptus delegatensis RT Baker forest in NSW, Australia; (2) monitoring sap flow of the same 10 trees during the measurement week; and (3) using an individual-tree-based model (MAESTRA) to link the two sets of measurements. Photosynthesis and stomatal conductance components of the model were parameterized with the leaf gas exchange data, and canopy structure was parameterized with crown heights, dimensions and leaf areas of each of the measurement trees and up to 45 neighboring trees. Transpiration of the measurement trees was predicted by the model and compared with sap flow data. Leaf gas exchange parameters were similar for all 10 trees, with the exception of two smaller trees that had relatively low stomatal conductances. We hypothesize that these trees may have experienced water stress as a result of competition from large neighboring trees. The model performed well, and in most cases, was able to replicate the time course of tree transpiration. Maximum rates of transpiration were higher than measured rates for some trees and lower than measured rates for others, which may have been a result of inaccuracy in estimating tree leaf area. There was a small lag (about 15-30 minutes) between sap flow and modeled transpiration for some trees in the morning, likely associated with use of water stored in stems. The model also captured patterns of variation in sap flow among trees. Overall, the study confirms the ability of models to estimate forest canopy transpiration from leaf-level measurements.

Pro-active management of beet armyworm (Lepidoptera: Noctuidae) resistance to tebufenozide and methoxyfenozide: baseline monitoring, risk assessment, and isolation of resistance.

Susceptibility to tebufenozide and methoxyfenozide of beet armyworm [Spodoptera exigua (Hübner)] from the southern United States and Thailand was determined through exposure of first and third instars to dipped cotton leaves. Among the field populations evaluated, tebufenozide LC50 values for first and third instars, respectively, ranged from 0.377 to 4.41 and 4.37-46.6 microg (AI) /ml of solution. Methoxyfenozide LC50 values for first and third instars of field populations ranged from 0.058 to 0.487 and 0.601-3.83 microg (AI)/ml of solution. A Thailand field strain exhibiting reduced susceptibility to both compounds was subjected to intense laboratory selection for three nonconsecutive generations. At the LC50 and LC90, selected Thailand strains were 45-68 times and 150-1,500 times less susceptible to tebufenozide and 340-320 times and 120-67 times less susceptible to methoxyfenozide as first and third instars, respectively, when compared with the laboratory reference strain. Among the U.S. field populations evaluated, ones from Belle Glade, FL, and Florence, SC, were generally the most susceptible and ones from Maricopa and Parker, AZ, were the least susceptible. Selection of the Thailand field strain with tebufenozide reduced susceptibility to both compounds, and selection of Thailand strains previously pressured with either compound further reduced susceptibility to both, suggesting at least some commonality of resistance mechanism. Characterization of this resistance will provide information that will be helpful for pro-active management of resistance for this valuable group of insecticides.