Nurse-Initiated Fall and Osteoporosis Screening for Older Adults in the Emergency Department.

Background Many older adults presenting to the emergency department (ED) after a fall are discharged without adequate assessment of their fall risk. A nurse-initiated protocol was introduced for the early screening of older adults with injurious falls. We aimed to promote osteoporosis education and right-site them to appropriate outpatient resources in the community. Methodology In this study, we included ≥65-year-old adults who attended the ED with injurious falls or near falls between December 2019 and December 2020. An ED nurse trained in basic geriatric care performed the cognitive assessment and provided advice on diet, footwear, fall safety, calcium/vitamin D supplementation, and osteoporosis screening. Results A total of 70 (75.7% female) patients aged 65-93 years were included. In total, 34 (48.6%) were started on calcium/vitamin D supplements and 22 (31.4%) went on to receive outpatient bone mineral density scans. Only three patients reattended the ED for recurrent falls/fractures in the six-month follow-up period. Conclusions A nurse-initiated fall and osteoporosis screening protocol is a feasible model of care for targeted screening and education of older adults who present to the ED with injurious falls.

Lower Motor Neuron Facial Palsy Due to Facial Colliculus Syndrome.

In patients presenting to the Emergency Department (ED) with acute onset facial asymmetry, decision for disposition is usually based on whether it is an upper (UMN) or lower motor neuron (LMN) cranial nerve 7th (CN7) palsy. In my institution, patients with UMN CN7 palsy would require admission for further investigations to look for central causes. Those who have an isolated LMN facial nerve palsy can be managed as outpatients. A 36-year-old gentleman presented to the ED with acute vertigo and right facial weakness. He had no known cardiac risk factors. His vital signs on presentation were: Temperature 36.6℃, blood pressure 142/68mmHg, pulse rate 92/min, and oxygen saturation level (SpO2) 100% on room air. Initial neurological examination revealed a right LMN CN7 palsy without any other cranial nerve, cerebellar, or pyramidal deficits. He was given symptomatic treatment for vertigo without relief. Repeat examination subsequently showed a right conjugate gaze palsy with gaze-evoked nystagmus. There was no limb weakness or numbness. Gait was noted to be unsteady with a broad-based stance and truncal ataxia. Magnetic resonance imaging (MRI) of his brain subsequently showed an infarct affecting the right facial colliculus in the dorsal pons. In my department, this was the first case of a young patient with a stroke presenting with LMN CN7 palsy. He was initially treated for a possible peripheral cause of his vertigo as he had a history of vestibular neuronitis, but without symptomatic improvement. Patients with neurological symptoms (e.g. vertigo) not resolving with initial treatment should prompt consideration for repeat neurological examination because the patient may have evolving neurological signs, as well as consider the potential for initial anchoring/cognitive bias. In this case, the gaze palsy and cerebellar signs were only noted on subsequent examination. Presence of LMN CN7 palsy with other associated neurological signs (including other cranial nerve palsies) would warrant further imaging to look for more sinister intracranial causes, including cerebral infarcts or space-occupying lesions.  This case serves to remind medical practitioners to strongly consider a central cause (e.g. stroke) for patients presenting with an LMN facial palsy, even in young patients in the absence of other vascular risk factors, especially when other neurological symptoms and signs are present.

Artificial neural network model with different backpropagation algorithms and meteorological data for solar radiation prediction.

Solar energy serves as a great alternative to fossil fuels as they are clean and renewable energy. Accurate solar radiation (SR) prediction can substantially lower down the impact cost pertaining to the development of solar energy. Lately, many SR forecasting system has been developed such as support vector machine, autoregressive moving average and artificial neural network (ANN). This paper presents a comprehensive study on the meteorological data and types of backpropagation (BP) algorithms used to train and develop the best SR predicting ANN model. The meteorological data, which includes temperature, relative humidity and wind speed are collected from a meteorological station from Kuala Terrenganu, Malaysia. Three different BP algorithms are employed into training the model i.e., Levenberg-Marquardt, Scaled Conjugate Gradient and Bayesian Regularization (BR). This paper presents a comparison study to select the best combination of meteorological data and BP algorithm which can develop the ANN model with the best predictive ability. The findings from this study shows that temperature and relative humidity both have high correlation with SR whereas wind temperature has little influence over SR. The results also showed that BR algorithm trained ANN models with maximum R of 0.8113 and minimum RMSE of 0.2581, outperform other algorithm trained models, as indicated by the performance score of the respective models.

Checking for model failure and for prior-data conflict with the constrained multinomial model.

Multinomial models can be difficult to use when constraints are placed on the probabilities. An exact model checking procedure for such models is developed based on a uniform prior on the full multinomial model. For inference, a nonuniform prior can be used and a consistency theorem is proved concerning a check for prior-data conflict with the chosen prior. Applications are presented and a new elicitation methodology is developed for multinomial models with ordered probabilities.

Randomised Controlled Trial Assessing Head Down Deep Breathing Method Versus Modified Valsalva Manoeuvre for Treatment of Supraventricular Tachycardia in the Emergency Department.

INTRODUCTION: Supraventricular tachycardia (SVT) is commonly encountered in the emergency department (ED). Vagal manoeuvres are internationally recommended therapy in stable patients. The head down deep breathing (HDDB) technique was previously described as an acceptable vagal manoeuvre, but there are no studies comparing its efficacy to other vagal manoeuvres. Our objective in this study was to compare the rates of successful cardioversion with HDDB and the commonly practiced, modified Valsalva manoeuvre (VM). METHODS: We conducted a randomised controlled trial at an acute hospital ED. Patients presenting with SVT were randomly assigned to HDDB or modified VM in a 1:1 ratio. A block randomisation sequence was prepared by an independent biostatistician, and then serially numbered, opaque, sealed envelopes were opened just before the intervention. Patients and caregivers were not blinded. Primary outcome was cardioversion to sinus rhythm. Secondary outcome(s) included adverse effects/complications of each technique. RESULTS: A total of 41 patients were randomised between 1 August, 2018-1 February, 2020 (20 HDDB and 21 modified VM). Amongst the 41 patients, three spontaneously cardioverted to sinus rhythm before receiving the allocated treatment and were excluded. Cardioversion was achieved in six patients (31.6%) and seven patients (36.8%) with HDDB and modified VM, respectively (odds ratio 1.26, 95% confidence interval, 0.33, 4.84, P = 0.733). Seventeen (89.5%) patients in the HDDB group and 14 (73.7%) from the modified VM group did not encounter any adverse effects. No major adverse cardiovascular events were recorded. CONCLUSION: Both the head down deep breathing technique and the modified Valsalva manoeuvre appear safe and effective in cardioverting patients with SVT in the ED.

Australian contribution to global otolaryngology research: 2008-2018.

BACKGROUND: Obtaining research funding in Otolaryngology - Head and Neck Surgery (ORL-HNS) can be challenging. In this paper, an analysis of research output in ORL-HNS in Australia and worldwide between 2008 and 2018 was conducted and then adjusted for the number of specialist surgeons in each country. METHODS: Scopus by Elsevier was used to measure research output of Ear, Nose and Throat (ENT) surgeons in Australia between 2008 and 2018. Each individual's career and 10-year h-index was identified and then repeated with self-citations excluded. Total and 10-year citations were also recorded. The top 15 countries in terms of research output in ORL-HNS were also ranked based on the number of ENT articles published in the 10-year period, and then adjusted by the number of actively practicing ENT surgeons per country. RESULTS: Between 2008 and 2018, Australia published 1510 articles out of a total global output of 48 613 papers in ORL-HNS with the top 10 authors having an h-index placing them within the world's top 100. Whilst the USA made the greatest total contribution with 12 912 publications, when adjusted for the number of specialist ORL-HNS clinicians in each country, Australia, Canada and India in order topped the rankings. CONCLUSION: Australia has established itself as a research leader in the global field of ORL-HNS, publishing more articles per surgeon than any other country between 2008 and 2018. The Australian ORL-HNS Academic Surgeons also rank highly on an individual basis when compared to global peers.

Membrane phospholipid alteration causes chronic ER stress through early degradation of homeostatic ER-resident proteins.

Phospholipid homeostasis in biological membranes is essential to maintain functions of organelles such as the endoplasmic reticulum. Phospholipid perturbation has been associated to cellular stress responses. However, in most cases, the implication of membrane lipid changes to homeostatic cellular response has not been clearly defined. Previously, we reported that Saccharomyces cerevisiae adapts to lipid bilayer stress by upregulating several protein quality control pathways such as the endoplasmic reticulum-associated degradation (ERAD) pathway and the unfolded protein response (UPR). Surprisingly, we observed certain ER-resident transmembrane proteins, which form part of the UPR programme, to be destabilised under lipid bilayer stress. Among these, the protein translocon subunit Sbh1 was prematurely degraded by membrane stiffening at the ER. Moreover, our findings suggest that the Doa10 complex recognises free Sbh1 that becomes increasingly accessible during lipid bilayer stress, perhaps due to the change in ER membrane properties. Premature removal of key ER-resident transmembrane proteins might be an underlying cause of chronic ER stress as a result of lipid bilayer stress.

Patient preferences for types of community-based cardiac rehabilitation programme.

INTRODUCTION: Cardiac rehabilitation (CR) improves mortality, morbidity and quality of life of cardiovascular patients. However, its uptake is poor especially in the hospitals due to long travel distances and office hours constraints. Community-based CR is a possible solution. OBJECTIVES: To understand the type of community-based CR preferred and identify patient characteristics associated with certain programme combinations. METHODS: A cross-sectional survey was administered to a randomised list of patients at risk for or with cardiovascular diseases at two community-based CR centres. Participants were presented with nine hypothetical choice sets and asked to choose only one of the two alternative programme combinations in each choice set. Attributes include support group presence, cash incentives, upfront deposit and out-of-pocket cost. The counts for each combination were tallied and corrected for repeats. Chi-square test and logistic regression were performed to understand the characteristics associated with the preferred CR combination. RESULTS: After correcting for repeats, patients most (85.2%) prefer CR programmes with new group activities, support group, cash rewards, deposit and out-of-pocket cost, and few exercise equipment with physiotherapist presence without the need for monitoring equipment. Patients with more than three bedrooms in their house are less likely (OR 0.367; CI 0.17 to 0.80; P=0.011) to choose the choice with no physiotherapist and few equipment available. CONCLUSION: This is the first study to explore patients' preferences for different types of community CR. Higher income patients prefer physiotherapist presence and are willing to settle for less equipment. Our study serves as a guide for designing future community-based CR programmes.

A Systematic Review of the Quality and Utility of Observer-Based Instruments for Assessing Medical Professionalism.

BACKGROUND: Professionalism, which encompasses behavioral, ethical, and related domains, is a core competency of medical practice. While observer-based instruments to assess medical professionalism are available, information on their psychometric properties and utility is limited. OBJECTIVE: We systematically reviewed the psychometric properties and utility of existing observer-based instruments for assessing professionalism in medical trainees. METHODS: After selecting eligible studies, we employed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria to score study methodological quality. We identified eligible instruments and performed quality assessment of psychometric properties for each selected instrument. We scored the utility of each instrument based on the ability to distinguish performance levels over time, availability of objective scoring criteria, validity evidence in medical students and residents, and instrument length. RESULTS: Ten instruments from 16 studies met criteria for consideration, with studies having acceptable methodological quality. Psychometric properties were variably assessed. Among 10 instruments, the Education Outcomes Service (EOS) group questionnaire and Professionalism Mini-Evaluation Exercise (P-MEX) possessed the best psychometric properties, with the P-MEX scoring higher on utility than the EOS group questionnaire. CONCLUSIONS: We identified 2 instruments with best psychometric properties, with 1 also showing acceptable utility for assessing professionalism in trainees. The P-MEX may be an option for program directors to adopt as an observer-based instrument for formative assessment of medical professionalism. Further studies of the 2 instruments to aggregate additional validity evidence is recommended, particularly in the domain of content validity before they are used in specific cultural settings and in summative assessments.

A systematic review of the barriers affecting medication adherence in patients with rheumatic diseases.

Medication adherence is a crucial part in the management of rheumatic diseases, especially with many such patients requiring long-term medications. In this paper, we aim to systematically review the literature for the factors associated with medication adherence in the rheumatic patient population. We carried out a systematic literature search using PubMed®, PsychInfo® and Embase ® with relevant keywords and employed the PRISMA® criteria. We included English peer-reviewed articles that studied the factors affecting medication adherence in patients with rheumatic diseases, which were assessed by two independent reviewers. Hand searches were conducted and relevant factors were extracted and classified using the World Health Organization (WHO)'s five dimensions of medication adherence. A simple diagram was drawn to summarise the factors extracted. 1977 articles were identified and reviewed and 90 articles were found to be relevant. A total of 17 factors and 38 sub-factors were identified and categorized based on the WHO's five dimensions of medication adherence. A hand model for medication adherence was developed to succinctly summarise these dimension to remind clinicians the importance of medication adherence in daily practice. We conducted a systematic review on the various factors including patient, therapy, condition, health system and socioeconomic-related factors that affected medication adherence in rheumatic patients. We found 17 factors and 38 sub-factors that affected medication adherence in this population. This systematic review can facilitate future focused research in unexplored dimensions.