Evaluation and treatment of altered mental status patients in the emergency department:Life in the fast lane

BACKGROUND:Altered mental status(AMS) is a very common emergency case,but the exact etiology of many AMS patients is unknown.Patients often manifest vague symptoms,thus,AMS diagnosis and treatment are highly challenging for emergency physicians.The aim of this study is to provide a framework for the assessment of AMS patients.This assessment should allow providers to better understand the etiology of mental status changes and therefore improve diagnostic skills and management.METHODS:This is a prospective cohort observational study.We recruited all adult patients with undifferentiated AMS at a single center tertiary care academic emergency department over 24months(June 2009 to June 2011).Demographic characteristics,clinical manifestations,assessment approaches,causative factors,emergency treatments and outcomes were collected prospectively.RESULTS:In 1934 patients with AMS recruited,accounting for 0.93%of all emergency department(ED) patients,1 026(53.1%) were male,and 908(46.9%) female.Their average age was 51.95±15.71 years.Etiologic factors were neurological(n=641;35.0%),pharmacological and toxicological(n=421;23.0%),systemic and organic(n=266;14.5%),infectious(n=167;9.1%),endocrine/metabolic(n=145;7.9%),psychiatric(n=71;3.9%),traumatic(n=38;2.1%),and gynecologic and obstetric(n=35;1.9%).Total mortality rate was 8.1%(n=156).The death rate was higher in elderly patients(≥60) than in younger patients(10.8%vs.6.9%,P=0.003).CONCLUSIONS:Patients with AMS pose a challenge for ED physicians.The most frequently encountered diagnostic categories causing AMS were primary CNS disorders,intoxication,organ system dysfunction,and endocrine/metabolic diseases.AMS has a high fatality rate in the ED.AMS is an important warning signal for ED patients because of its potentially fatal and reversible effects.Prompt evaluation and treatment are essential to decreasing morbidity and mortality associated with AMS.

The moderating effect of physical activity on the relationship between bullying and mental health among sexual and gender minority youth

Background:Sexual and gender minority youth frequently experience bullying,which often contributes to higher depressive symptoms and lower self-esteem.Given that physical activity(PA)can mitigate depressive symptoms and improve self-esteem,we examined the moderating effect of PA on the relationship between bullying and mental health among sexual and gender minority youth.Methods:Data from the Lesbian,Gay,Bisexual,Transgender,and Queer National Teen Survey(n=9890)were analyzed.Hierarchical regression analyses examined the influence of history and frequency of being bullied,PA,and the interaction of these variables on depressive symptoms and self-esteem.Simple slopes analyses were used to probe significant interactions.Results:Results indicated the importance of accounting for bullying history when examining effects of PA on mental health.PA was negatively related to depression(t=-4.18,p<0.001)and positively related to self-esteem(t=12.11,p<0.001).Bullying frequency was positively related to depression(t=19.35,p<0.001)and negatively related to self-esteem(t=-12.46,p<0.001).There was a significant interaction between bullying frequency and PA for depression(t=4.45,p<0.001)and self-esteem(t=-4.69,p<0.001).Post hoc analyses suggested that the positive effects of PA on mental health may be limited to those not bullied because it had a negligible effect on those who were bullied.Conclusion:Results suggest that sexual and gender minority youth exercise interventions aiming to improve mental health should first address bullying history;otherwise,their effectiveness may be limited to those who have been bullied.

Cronkhite-Canada syndrome:Report of six cases and review of literature

Cronkhite-Canada syndrome(CCS)is a rare nonfamilial polyposis syndrome characterized by epithelial disturbances in the gastrointestinal tract and skin.The aim of this study was to investigate the clinical features and potential therapies for CCS.Six patients with CCS admitted from December 1992 to July 2008 to Peking Union Medical College Hospital were evaluated.All patients had clinical manifestation of nonhereditary gastrointestinal polyposis with diarrhea,skin hyperpigmentation,alopecia,and nail dystrophy.Fecal occult blood was positive in all six cases.Serum hemoglobin,potassium,calcium and protein were below the normal range in two cases.Anti-Saccharomyces cerevisiae and antinuclear antibodies were present in three cases.Multiple polyps were found in all patients by gastroscopy and colonoscopy,with only one in the esophagus.Histologically,there were hyperplastic polyps in five cases,tubular adenoma in three,and juvenile polyp in one with chronic inflammation and mucosal edema.Comprehensive treatment led by corticosteroids can result in partial remission of clinical symptoms,and longterm follow-up is necessary.

On the role of impulsivity and decision-making in suicidal behavior

Suicide risk constitutes a complex set of interacting demographic, clinical, psychobiological and environmental variables. Impulsivity is a long-known risk factor for suicide attempts. However, research based on clearer conceptual refinement in this area is imperative. One emerging field of study is that of decision-making. Impulsivity involves a failure of higher-order control, including decision-making. Using standardized operational definitions that take into consideration relevant aspects of impulsivity, including state- and trait-components and a deeper understanding of the process of decision-making in the suicidal mind, we may come a step closer to understanding suicidality and winning the fight in this scourge of human suffering.

Attitudes toward E-Cigarettes, Reasons for Initiating E-Cigarette Use, and Changes in Smoking Behavior after Initiation: A Pilot Longitudinal Study of Regular Cigarette Smokers

Objectives: We examined 1) changes in smoking and vaping behavior and associated cotinine levels and health status among regular smokers who were first-time e-cigarette purchasers and 2) attitudes, intentions, and restrictions regarding e-cigarettes. Methods: We conducted a pilot longitudinal study with assessments of the aforementioned factors and salivary cotinine at weeks 0, 4, and 8. Eligibility criteria included being ≥18 years old, smoking ≥25 of the last 30 days, smoking ≥5 cigarettes per day (cpd), smoking regularly ≥1 year, and not having started using e-cigarettes. Of 72 individuals screened, 40 consented, 36 completed the baseline survey, and 83.3% and 72.2% were retained at weeks 4 and 8, respectively. Results: Participants reduced cigarette consumption from baseline to week 4 and 8 (p’s < 0.001);23.1% reported no cigarette use in the past month at week 8. There was no significant decrease in cotinine from baseline to week 4 or 8 (p’s = ns). At week 8, the majority reported improved health (65.4%), reduced smoker’s cough (57.7%), and improved sense of smell (53.8%) and taste (50.0%). The majority believed that e-cigarettes versus regular cigarettes have fewer health risks (97.2%) and that e-cigarettes have been shown to help smokers quit (80.6%) and reduce cigarette consumption (97.2%). In addition, the majority intended to use e-cigarettes as a complete replacement for regular cigarettes (69.4%) and reported no restriction on e-cigarette use in the home (63.9%) or car (80.6%). Conclusions: Future research is needed to document the long-term impact on smoking behavior and health among cigarette smokers who initiate use of e-cigarettes.

The <i>q</i>-Exponential Probability Discounting of Gain and Loss

Probability discounting is defined as the devaluation of outcomes as the probability of receiving or paying those decreases. A q-exponential probability discounting model based on Tsallis’ statistics has been proposed in econophysics (Takahashi, 2007, Physica A). We examined (a) fitness of the models to behavioral data of probability discounting of both gain and loss;and (b) relationships between parameters in the q-exponential probability discounting model across gain and loss. Our results demonstrated that, for both gain and loss, the q-exponential model better fits the behavioral data than exponential and hyperbolic functions, and there is the sign effect in q-exponential probability discounting. Relationships between Kahneman-Tversky’s prospect theory in behavioral economics and the q-exponential probability discounting are high-lightened.

The Power of Partners: A Qualitative Study of the Dissonance between African-American Females’ Interest in Practicing Secondary Abstinence and Continued Sexual Activity

Reducing disparities in STI/HIV rates for young heterosexual African-American women in the US is a public health priority. Although several strategies can reduce risk, some sexually experienced young women are choosing to abstain from sex for various reasons and periods of time following sexual debut, a practice known as secondary abstinence. However, others who desire to practice secondary abstinence find it difficult to do so. This qualitative study explored barriers that explained the dissonance between interest in secondary abstinence and continued sexual activity. In-depth interviews were conducted with 20 sexually-experienced African-American adolescent females, ages 18 - 23, who expressed interest in secondary abstinence. Partner-related barriers that created power imbalances presented the greatest challenges to becoming or remaining abstinent. Findings suggest that teaching young women how to recognize characteristics of healthy and unhealthy relationships, identify power imbalances, communicate assertively and develop positive coping skills can empower young women to build healthier relationships with their partners.

Lay perceptions of breast cancer in Western Kenya

AIM: To explore lay perceptions of causes, severity, presenting symptoms and treatment of breast cancer. METHODS: In October-November 2012, we recruited men and women(18 years and older) from households and health facilities in three different parts of Western Kenya, chosen for variations in their documented burdens of breast cancer. A standardized and validated tool,the breast cancer awareness measure(BCAM), was administered in face-to-face interviews. Survey domains covered included socio-demographics, opinions about causes, symptoms, severity, and treatment of breast cancer. Descriptive analyses were done on quantitative data while open-ended answers were coded, and emerging themes were integrated into larger categories in a qualitative analysis. The open-ended questions had been added to the standard BCAM for the purposes of learning as much as the investigators could about underlying lay beliefs and perceptions. RESULTS: Most respondents were female, middle-aged(mean age 36.9 years), married, and poorly educated. Misconceptions and lack of knowledge about causes of breast cancer were reported. The following(in order of higher to lower prevalence) were cited as potential causes of the condition: Genetic factors or heredity(n = 193, 12.3%); types of food consumed(n = 187, 11.9%); witchcraft and curses(n = 108, 6.9%); some family planning methods(n = 56, 3.6%); and use of alcohol and tobacco(n = 46, 2.9%). When asked what they thought of breast cancer's severity, the most popular response was "it is a killer disease"(n = 266, 19.7%) a lethal condition about which little or nothing can be done. While opinions about presenting symptoms and signs of breast cancer were able to be elicited, such as an increase in breast size and painful breasts, earlystage symptoms and signs were not widely recognized. Some respondents(14%) were ignorant of available treatment altogether while others felt breast cancer treatment is both dangerous and expensive. A minority reported alternative medicine as providing relief to patients. CONCLUSION: The impoverished knowledge in these surveys suggests that lay education as well as better screening and treatment should be part of breast cancer control in Kenya.

Problem Drinking Behaviors: Differential Effects of Stress and School Type on College Students

Given that alcohol use is highly prevalent at US colleges, we explored factors related to problem drinking behaviors (PDB;binge drinking, driving after drinking, sexual intercourse after drinking) among 4098 Black and White students from two- and four-year colleges who completed an online survey. We found an interaction between race and sex such that, among Whites, females had less PDB than males (B = 0.09, CI: 0.05;0.40, p = 0.01). An interaction between race and school type also existed, such that White students from four-year schools had greater PDB (B = 0.11, CI: 0.20;0.54, p < 0.001). An interaction between race and stress suggested that Black students were more negatively affected by stress in terms of PBD (B = 0.12, CI: 0.01;0.07, p = 0.01).

Mathematical Neurolaw of Crime and Punishment: The <i>q</i>-Exponential Punishment Function

Whether people tend to punish criminals in a socially-optimal manner (i.e., hyperbolic punishment) or not is unknown. By adopting mathematical models of probabilistic punishment behavior (i.e., exponential, hyperbolic, and q-exponential probability discounting model based on Tsallis thermodynamics and neuroeconomics, Takahashi, 2007, Physica A;Takahashi et al., 2012, Applied Mathematics), we examined 1) fitness of the models to behavioral data of uncertain punishment, and 2) deviation from the socially optimal hyperbolic punishment function. Our results demonstrated that, the q-exponential punishment function best fits the behavioral data, and people overweigh the severity of punishment at small punishing probabilities and underweigh the severity of punishment at large punishing probabilities. In other words, people tend to punish crimes too severely and mildly with high and low arrest rate (e.g., homicide vs. excess of speed limit), respectively. Implications for neuroeconomics and neurolaw of crime and punishment (Takahashi, 2012, NeuroEndocrinology Letters) are discussed.

Psychophysical Neuroeconomics of Decision Making: Nonlinear Time Perception Commonly Explains Anomalies in Temporal and Probability Discounting

Anomalies in decision over time (e.g., “hyperbolic time discounting”) and under risk (e.g., Allais paradox and hyperbolic probability discounting) have been attracting attention in behavioral and neuroeconomics. We have proposed that psychophysical time commonly explains anomalies in both decisions (Takahashi, 2011, Physica A;Takahashi et al., 2012, J Behav Econ & Finance). By adopting the q-exponential time and probability discounting models, our psychophysical and behavioral economic experiment confirmed that nonlinear distortion of psychophysical time is a common cause of the anomalies in decision both over time and under risk (i.e., intertemporal choice and decision under risk). Implications for psychophysical neuroeconomics and econophysics are discussed.

Female Genital Cut in Relation to Its Value and Health Risks among the Kisii of Western Kenya

Background: The practice of female genital cutting as a cultural obligation is widespread in Kenya but there is little consensus about its effects on health. Some of the health risks associated with female genital cut range from minor and short-term to major and long-term effects including pain, bleeding, infections, and, in the extreme, death. Female genital cut is widespread among the Kisii but there is no adequate information about how it is currently practised and the value people attach to it. Objective: The objective was to establish the value of female genital cut as well as the health risks associated with the practice among the Kisii community of western Kenya. Methods: This was a cross-sectional study, which employed a mixed method approach to generate both quantitative and qualitative data. The quantitative data were obtained from a randomly selected sample of 373 respondents while quantitative data were generated from focus group discussions as well as key informants interviews. Results: The Kisii consider female genital cut a cultural identifier inherited from past generations and whose main value is a rite of passage from girlhood to womanhood. Majority (63%) had heard of the health risks associated with female genital cut including transmission of infections, excessive bleeding and pain. But most of the community did not seem to know the long-term health consequences associated with female genital cut. Even though knowledge on the campaigns to eradicate the practice was found to be wide spread, the community’s response toward the campaigns was less than positive. Conclusions: The authors conclude that female genital cut continues to persist in this community because of its value as a rite of passage, which currently has no substitute. This cultural demand by far outweighs the health risks associated with female genital cut, which are being mitigated through medicalization of the practice. For intervention programmes to succeed a more culturally sensitive campaign that is acceptable or appropriate alternative rite of passage is required.

Quality of life in the elderly: Psychometric properties of the WHOQOL-OLD module in Mexico

The purpose was to examine and compare the psychometric properties of a Mexican Spanish version of the WHOQOL-OLD module. The instrument was applied to 285 individuals aged over 60 years (mean = 69.26, SD = 6.52). All participants completed a demographic data sheet, the WHOQOL-OLD, the Beck Depression Inventory (BDI), and the Geriatric Depression Scale (GDS);182 of the 285 participants also completed a quality of life questionnaire for diabetic patients (DQOL). Acceptable levels of reliability were found, with Cronbach’s alpha values between 0.70 and 0.90 for overall quality of life and all domains except for autonomy, where the alpha value was low. The exploratory factor analysis carried out to examine the construct validity of the instrument yielded six domains: sensory abilities, autonomy, past/present/future activities, social participation, death and dying, and intimacy (explained variance of 62.95%). The mean overall quality of life score was 94.86 (SD = 13.68, range 50 to 120). The WHOQOL-OLD module showed criterion validity and concurrent validity with respect to the BDI (r = -0.516, p = 0.034), the GDS (r = -0.336, p = 0.002), and the DQOL (n = 182, r = 0.159, p = 0.032). Discriminant validity was also confirmed with respect to self-perceived health (t = 2.701, d.f. = 225, p = 0.007) and education (F(3, 280) = 9.015, p p > 0.05). We conclude that the Mexican Spanish version of the WHOQOL-OLD module has adequate psychometric properties.

Parkinson’s Disease: Examining the Role of the Pedunculopontine Nucleus via Animal Models

Parkinson’s disease is a neurodegenerative disease that spreads rapidly through the brain, and can influence a number of vital systems. The cause of this disease appears to be brought on by the progressive inability to produce adequate dopamine in the brain. People that suffer with Parkinson’s have reported REM sleep disruption at the onset of the condition. This paper reviews several animal model lesion studies related to the Pedunculopontine Nucleus, and how it plays a role in sleep regulation following a decline in dopamine production in those with parkinsonian conditions. The goal of this paper is to elucidate the functioning of the PPN and explain the nuclei’s possible role in the onset and progression of parkinsonian conditions in animal models.

A nonlinear neural population coding theory of quantum cognition and decision making

Mathematical frameworks of quantum theory have recently been adopted in cognitive and behavioral sciences, to explain the violations of normative decision theory and anomalies in cognition. However, to date, no study has attempted to explore neural implementations of such “quantum-like” information processing in the brain. This study demonstrates that neural population coding of information with nonlinear neural response functions can account for such “quantum” information processing in decision-making and cognition. It is also shown that quantum decision theory is a special case of more general population vector cording theory. Future applications of the present theory in the rapidly evolving field of “psychophysical neuroeconomics” are also discussed.

Factors Associated with Compliance with Infection Control Guidelines in the Management of Labour by Healthcare Workers at Mulago Hospital, Uganda

Globally, infections acquired during childbirth contribute to one tenth of the maternal deaths annually [1] [2]. Factors predisposing to high risks of puerperal infections include non-compliance with Standard Precautions of Infection Control (SPIC), unhygienic births by unskilled birth attendants, multiple vaginal examinations, prolonged labour and premature rapture of membranes [1]. The main purpose of this study was to determine factors associated with compliance to standard precautions of infection control the management of labour by healthcare workers in Mulago Hospital to generate information, which may be used in infection control and prevention practices. A cross-sectional study utilizing a quantitative approach was conducted among 115 healthcare workers. Consecutive sampling was done to include respondents in the study. Data were collected by direct observation and researcher administered questionnaires. Data were coded and entered into the computer using SPSS version 20 with programmed quality control checks. Descriptive data analyses, frequencies, cross tabulations and logistic regression analysis were the major statistical methods used. 103 healthcare workers were involved in the study, where 74% were females. Overall compliance was at 52%, although it varied across domains. The majority of the healthcare workers (95.1%) did not comply with hand hygiene. Being a male was associated with low compliance scores a cross most domains. One of the hospital factors which was significantly associated with compliance to hand hygiene was having had an in-service training with p = 0.008 and p = 0.012 at multivariate analysis. Overall compliance to standard precautions of infection control was low compared to the Centre for Disease Control (CDC) recommendation. The findings in this study provide insight into individual and hospital related factors associated with compliance with standard precautions of infection control in the management of labour. There is an urgent need to put up interventions to improve on compliance with SPIC in management of labour among all healthcare workers.

An Experimental Comparison of Quantum Decision Theoretical Models of Intertemporal Choice for Gain and Loss

In mathematical physics and psychology, “quantum decision theory” has been proposed to explain anomalies in human decision-making. One of such quantum models has been proposed to explain time inconsistency in human decision over time. In this study, we conducted a behavioral experiment to examine which quantum decision models best account for human intertemporal choice. We observed that a q-exponential model developed in Tsallis’ thermodynamics (based on Takahashi’s (2005) nonlinear time perception theory) best fit human behavioral data for both gain and loss, among other quantum decision models.

Reducing the Prevalence of Catheter-Related Infections by Quality Improvement: Six-Year Follow-Up Study

Background: Peripheral venous catheter (PVC) insertion is a crucial nursing action during life support. Several factors that increase the risk of thrombophlebitis associated with PVCs have been reported. Objective: We wish to evaluate the impact of a quality improvement regarding PVC treatment for patients with coronary heart diseases. Method: A longitudinal, quantitative observational study was carried out in 2008 and 2013 in a hospital in southern Sweden with 360 consecutive patients suffering from acute chest pain. New routines for PVC treatment were included in the hospital with daily inspection according to a checklist. A structured observation protocol was used to survey the prevalence of thrombophlebitis between 2008 and 2013. Also, we examined the relationship between the location and luminal diameters of PVCs. Results: The student’s t-test showed significant differences between 2008 and 2013 with respect to luminal diameter of PVCs (p = 0.002), prevalence of thrombophlebitis (p = 0.003) and number of days with PVC left in situ (p < 0.001). Conclusion: These findings emphasize the value of using systematic daily inspections and checklists to achieve quality and safety in patients with acute chest pain having PVC-based treatment.

Veterans utilizing a federally qualified health center: a clinical snapshot

Dear Editor,Te Veterans Health Administration(VHA)provides healthcare for over 9 million enrolled veterans with approximately 2.7 million of those residing in rural areas[1].Te MISSION Act of 2018 emphasizes VHA collaboration with Federally Qualifed Healthcare Centers(FQHC)to serve rural residing veterans and nearly all existing collaborations involve arrangement of payment for community-based care by VHA to FQHCs.Unfortunately,there is a paucity of descriptive clinical data on existing cross-system collaborations which may help characterize these veterans and aid understanding of conditions for which they may receive treatment across systems.Such data has implications for workforce training,development,and resource allocation[2].Te objective of this report is to describe diferent clinical profles between two mutually exclusive samples:veterans engaged in FQHC only use,and VHA-enrolled veterans engaged in dual VHA and FQHC use.

华蟾素治疗肝癌、肺癌、胰腺癌的Ⅰ期临床研究:初步报道

背景与目的:华蟾素目前广泛应用于肿瘤的治疗中,由于在80年代上市,未进行临床Ⅰ期研究,无法确定其最大耐受剂量。因此本文旨在观察华蟾素治疗肝细胞癌、肺癌和胰腺癌的最大耐受剂量和不良反应,同时评价治疗疗效。方法:Ⅲ、Ⅳ期肝细胞癌、非小细胞肺癌和胰腺癌接受华蟾素治疗,采用静脉滴注,连续14 d,21 d为一疗程。如果没有出现剂量限制性毒性,治疗将持续2个疗程。剂量递增的方案为:10、20、40、60、90和120 m l/(m2.d)。结果:入组15例患者(每个剂量组为3例)中,11例为肝癌,2例胰腺癌和2例肺癌。第五剂量组结束时没有发现剂量限制性毒性(DLT)。其中14例患者可评价疗效,6例(42.9%)为SD,8例(57.1%)为PD。在第一剂量组中,1例肝癌患者肿瘤缩小20%并维持11个月。结论:本研究最高剂量达到常规剂量的8倍,尚未出现剂量限制性毒性。部分患者获得了肿瘤缩小或稳定的疗效。