Impact on costs of a case management intervention for emergency department frequent users

Background: In most of the emergency departments (ED) in developed countries, a subset of patients visits the ED frequently. Despite their small numbers, these patients are the source of a disproportionally high number of all ED visits, and use a significant proportion of healthcare resources. They place a heavy economic burden on hospital and healthcare system budgets overall. In order to improve the management of these patients, the University hospital of Lausanne, Switzerland implemented a case management intervention (CM) between May 2012 and July 2013. In this randomized controlled trial, 250 frequent ED users (visits>5 during previous 12 months) were allocated to either the CM group or the standard ED care (SC) group and followed up for 12 months. The first result of the CM was to reduce significantly the ED visits. The present study examined whether the CM intervention also reduced the costs generated by the ED frequent users not only from the hospital perspective, but also from the healthcare system perspective. Methods: Cost data were obtained from the hospital's analytical accounting system and from health insurances. Multivariate linear models including a fixed effect "group" and socio-demographic characteristics and health-related variables were run.

Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study.

BACKGROUND: Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability's different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability. METHODS: A controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson's Chi-squared test and Fisher's exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used. RESULTS: We compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2). CONCLUSIONS: Frequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.

Helicopter emergency medical rescue for the traumatized: experience in the metropolitan region of Campinas, Brazil

OBJECTIVE: To analyze the profile of patients served by the air medical rescue system in the Metropolitan Region of Campinas, evaluating: triage and mobilization criteria; response time; on-site care and transport time; invasive procedures performed in the Pre-Hospital Care (PHC); severity of patients; morbidity and mortality.METHODS: We conducted a prospective, descriptive study in which we analyzed medical records of patients rescued between July 2010 and December 2012. During this period, 242 victims were taken to the HC-Unicamp. Of the 242 patients, 22 were excluded from the study.RESULTS: of the 220 cases evaluated, 173 (78.6%) were male, with a mean age of 32 years. Blunt trauma was the most prevalent (207 cases - 94.1%), motorcycle accidents being the most common mechanisms of injury (66 cases - 30%), followed by motor vehicle collisions (51 cases - 23.2%). The average response time was 10 ± 4 minutes and the averaged total pre-hospital time was 42 ± 11 minutes. The mean values of the trauma indices were: RTS = 6.2 ± 2.2; ISS = 19.2 ± 12.6; and TRISS = 0.78 ± 0.3. Tracheal intubation in the pre-hospital environment was performed in 77 cases (35%); 43 patients (19.5%) had RTS of 7.84 and ISSd"9, being classified as over-triaged. Of all patients admitted, the mortality was 15.9% (35 cases).CONCLUSION: studies of air medical rescue in Brazil are required due to the investments made in the pre-hospital care in a country without an organized trauma system. The high rate of over-triage found highlights the need to improve the triage and mobilization criteria.

Analysis of emergency braking performance with particular consideration of temperature effects on brakes

During vehicle deceleration due to braking there is friction between the lining surface and the brake drum or disc. In this process the kinetic energy of vehicle is turned into thermal energy that raises temperature of the components. The heating of the brake system in the course of braking is a great problem, because besides damaging the system, it may also affect the wheel and tire, which can cause accidents. In search of the best configuration that considers the true conditions of use, without passing the safety limits, models and formulations are presented with respect to the brake system, considering different braking conditions and kinds of brakes. Some modeling was analyzed using well-known methods. The flat plate model considering energy conservation was applied to a bus, using for this a computer program. The vehicle is simulated to undergo an emergency braking, considering the change of temperature on the lining-drum. The results include deceleration, braking efficiency, wheel resistance, normal reaction on the tires and the coefficient of adhesion. Some of the results were compared with dynamometer tests made by FRAS-LE and others were compared with track tests made by Mercedes-Benz. The convergence between the results and the tests is sufficient to validate the mathematical model. The computer program makes it possible to simulate the brake system performance in the vehicle. It assists the designer during the development phase and reduces track tests.

Climate Change and Ethics of Geoengineering -- Implications Of Climate Emergency Ethics

Global climate change and intentional climate modification, i.e. geoengineering include various ethical problems which are entangled as a complex ensemble of questions regarding the future of the biosphere. The possibilities of catastrophic effects of climate change which are also called “climate emergency” have led to the emergence of the idea of modifying the atmospheric conditions in the form of geoengineering. The novel issue of weather ethics is a subdivision of climate ethics, and it is interested in ethical and political questions surrounding weather and climate control and modification in a restricted spatio-temporal scale. The objective of geoengineering is to counterbalance the adverse effects of climate change and its diverse corollaries in various ways on a large scale. The claim of this dissertation is that there are ethical justifications to claim that currently large-scale interventions to the climate system are ethically questionable. The justification to pursue geoengineering on the basis of considering its pros and cons, is inadequate. Moral judgement can still be elaborated in cases where decisions have to be made urgently and the selection of desirable choices is severely limited. The changes needed to avoid severe negative impacts of climate change requires commitment to mitigation as well as social changes because technical solutions cannot address the issue of climate change altogether. The quantitative emphasis of consumerism should shift to qualitative focus on the aspiration for simplicity in order to a move towards the objective of the continuation of the existence of humankind and a flourishing, vital biosphere.

Genetic programming for the RoboCup Rescue Simulation System

The Robocup Rescue Simulation System (RCRSS) is a dynamic system of multi-agent interaction, simulating a large-scale urban disaster scenario. Teams of rescue agents are charged with the tasks of minimizing civilian casualties and infrastructure damage while competing against limitations on time, communication, and awareness. This thesis provides the first known attempt of applying Genetic Programming (GP) to the development of behaviours necessary to perform well in the RCRSS. Specifically, this thesis studies the suitability of GP to evolve the operational behaviours required of each type of rescue agent in the RCRSS. The system developed is evaluated in terms of the consistency with which expected solutions are the target of convergence as well as by comparison to previous competition results. The results indicate that GP is capable of converging to some forms of expected behaviour, but that additional evolution in strategizing behaviours must be performed in order to become competitive. An enhancement to the standard GP algorithm is proposed which is shown to simplify the initial search space allowing evolution to occur much quicker. In addition, two forms of population are employed and compared in terms of their apparent effects on the evolution of control structures for intelligent rescue agents. The first is a single population in which each individual is comprised of three distinct trees for the respective control of three types of agents, the second is a set of three co-evolving subpopulations one for each type of agent. Multiple populations of cooperating individuals appear to achieve higher proficiencies in training, but testing on unseen instances raises the issue of overfitting.

The potential utility of age, triage score, and disposition data contained in emergency department electronic records for influenza-like illness surveillance in Montreal

La surveillance de l’influenza s’appuie sur un large spectre de données, dont les données de surveillance syndromique provenant des salles d’urgences. De plus en plus de variables sont enregistrées dans les dossiers électroniques des urgences et mises à la disposition des équipes de surveillance. L’objectif principal de ce mémoire est d’évaluer l’utilité potentielle de l’âge, de la catégorie de triage et de l’orientation au départ de l’urgence pour améliorer la surveillance de la morbidité liée aux cas sévères d’influenza. Les données d’un sous-ensemble des hôpitaux de Montréal ont été utilisées, d’avril 2006 à janvier 2011. Les hospitalisations avec diagnostic de pneumonie ou influenza ont été utilisées comme mesure de la morbidité liée aux cas sévères d’influenza, et ont été modélisées par régression binomiale négative, en tenant compte des tendances séculaires et saisonnières. En comparaison avec les visites avec syndrome d’allure grippale (SAG) totales, les visites avec SAG stratifiées par âge, par catégorie de triage et par orientation de départ ont amélioré le modèle prédictif des hospitalisations avec pneumonie ou influenza. Avant d’intégrer ces variables dans le système de surveillance de Montréal, des étapes additionnelles sont suggérées, incluant l’optimisation de la définition du syndrome d’allure grippale à utiliser, la confirmation de la valeur de ces prédicteurs avec de nouvelles données et l’évaluation de leur utilité pratique.

An in vitro study of the probiotic potential of a bile-salt-hydrolyzing Lactobacillus fermentum strain, and determination of its cholesterol-lowering properties

This study evaluated the use of a bile-salt-hydrolyzing Lactobacillus fermentum strain as a probiotic with potential hypocholesterolemic properties. The effect of L. fermentum on representative microbial populations and overall metabolic activity of the human intestinal microbiota was investigated using a three-stage continuous culture system. Also, the use of galactooligosaccharides as a prebiotic to enhance growth and/or activity of the Lactobacillus strain was evaluated. Administration of L. fermentum resulted in a decrease in the overall bifidobacterial population (ca. 1 log unit). In the in vitro system, no significant changes were observed in the total bacterial, Lactobacillus, Bacteroides, and clostridial populations through L. fermentum supplementation. Acetate production decreased by 9 to 27%, while the propionate and butyrate concentrations increased considerably (50 to 90% and 52 to 157%, respectively). A general, although lesser, increase in the production of lactate was observed with the administration of the L. fermentum strain. Supplementation of the prebiotic to the culture medium did not cause statistically significant changes in either the numbers or the activity of the microbiota, although an increase in the butyrate production was seen (29 to 39%). Results from this in vitro study suggest that L.Fermentum KC5b is a candidate probiotic which may affect cholesterol metabolism. The short-chain fatty acid concentrations, specifically the molar proportion of propionate and/or bile salt deconjugation, are probably the major mechanism involved in the purported cholesterol-lowering properties of this strain.

Cancellation of siren noise from two way voice communications inside emergency vehicles

Sirens used by police, fire and paramedic vehicles have been designed so that they can be heard over large distances, but unfortunately the siren noise enters the vehicle and corrupts intelligibility of voice communications from the emergency vehicle to the control room. Often the siren needs to be turned off to enable the control room to hear what is being said. This paper discusses a siren noise filter system that is capable of removing the siren noise picked up by the two-way radio microphone inside the vehicle. The removal of the siren noise improves the response time for emergency vehicles and thus save lives. To date, the system has been trialed within a fire tender in a non-emergency situation, with good results.

Cancellation of siren noise from two-way voice communication inside emergency vehicles

The development of an adaptive filter system, capable of reducing significantly the effect of siren noise within the cab of an emergency vehicle, is described. The system is capable of removing the siren noise picked up by the radio microphone inside the vehicle, without degrading the wanted voice signal, thus allowing the siren to be used at all times.

The application of affine projection to the development of a siren noise cancellation system

Emergency vehicles use high-amplitude sirens to warn pedestrians and other road users of their presence. Unfortunately, the siren noise enters the vehicle and corrupts the intelligibility of two-way radio voice com-munications from the emergency vehicle to a control room. Often the siren has to be turned off to enable the control room to hear what is being said which subsequently endangers people's lives. A digital signal processing (DSP) based system for the cancellation of siren noise embedded within speech is presented. The system has been tested with the least mean square (LMS), normalised least mean square (NLMS) and affine projection algorithm (APA) using recordings from three common types of sirens (two-tone, wail and yelp) from actual test vehicles. It was found that the APA with a projection order of 2 gives comparably improved cancellation over the LMS and NLMS with only a moderate increase in algorithm complexity and code size. Therefore, this siren noise cancellation system using the APA offers an improvement in cancellation achieved by previous systems. The removal of the siren noise improves the response time for the emergency vehicle and thus the system can contribute to saving lives. The system also allows voice communication to take place even when the siren is on and as such the vehicle offers less risk of danger when moving at high speeds in heavy traffic.

Results of a DSP based adaptive cancellation filter system for the chirp, pulsar and localiser sirens

Sirens’ used by police, fire and paramedic vehicles generate noise that propagates inside the vehicle cab that subsequently corrupts intelligibility of voice communications from the emergency vehicle to the control room. It is even common for the siren to be turned off to enable the control room to hear what is being said. Both fixed filter and adaptive filter systems have previously been developed to help cancel the transmission of the siren noise over the radio. Previous cancellation systems have only concentrated on the traditional 2-tone, wail and yelp sirens. This paper discusses an improvement to a previous adaptive filter system and presents the cancellation results to three new types of sirens; being chirp pulsar and localiser. A siren noise filter system has the capability to improve the response time for an emergency vehicle and thus help save lives. To date, this system has been tested using live recordings taken from a nonemergency situation with good results.

Formal theory building for the avalanche game: explaining counter-intuitive behaviour of a complex system using geometrical and human behavioural/physiological effects

In 'Avalanche', an object is lowered, players staying in contact throughout. Normally the task is easily accomplished. However, with larger groups counter-intuitive behaviours appear. The paper proposes a formal theory for the underlying causal mechanisms. The aim is to not only provide an explicit, testable hypothesis for the source of the observed modes of behaviour-but also to exemplify the contribution that formal theory building can make to understanding complex social phenomena. Mapping reveals the importance of geometry to the Avalanche game; each player has a pair of balancing loops, one involved in lowering the object, the other ensuring contact. For more players, sets of balancing loops interact and these can allow dominance by reinforcing loops, causing the system to chase upwards towards an ever-increasing goal. However, a series of other effects concerning human physiology and behaviour (HPB) is posited as playing a role. The hypothesis is therefore rigorously tested using simulation. For simplicity a 'One Degree of Freedom' case is examined, allowing all of the effects to be included whilst rendering the analysis more transparent. Formulation and experimentation with the model gives insight into the behaviours. Multi-dimensional rate/level analysis indicates that there is only a narrow region in which the system is able to move downwards. Model runs reproduce the single 'desired' mode of behaviour and all three of the observed 'problematic' ones. Sensitivity analysis gives further insight into the system's modes and their causes. Behaviour is seen to arise only when the geometric effects apply (number of players greater than degrees of freedom of object) in combination with a range of HPB effects. An analogy exists between the co-operative behaviour required here and various examples: conflicting strategic objectives in organizations; Prisoners' Dilemma and integrated bargaining situations. Additionally, the game may be relatable in more direct algebraic terms to situations involving companies in which the resulting behaviours are mediated by market regulations. Finally, comment is offered on the inadequacy of some forms of theory building and the case is made for formal theory building involving the use of models, analysis and plausible explanations to create deep understanding of social phenomena.

A feasible study of EEG-driven assistive robotic system for stroke rehabilitation

Stroke is a medical emergency and can cause a neurological damage, affecting the motor and sensory systems. Harnessing brain plasticity should make it possible to reconstruct the closed loop between the brain and the body, i.e., association of the generation of the motor command with the somatic sensory feedback might enhance motor recovery. In order to aid reconstruction of this loop with a robotic device it is necessary to assist the paretic side of the body at the right moment to achieve simultaneity between motor command and feedback signal to somatic sensory area in brain. To this end, we propose an integrated EEG-driven assistive robotic system for stroke rehabilitation. Depending on the level of motor recovery, it is important to provide adequate stimulation for upper limb motion. Thus, we propose an assist arm incorporating a Magnetic Levitation Joint that can generate a compliant motion due to its levitation and mechanical redundancy. This paper reports on a feasibility study carried out to verify the validity of the robot sensing and on EEG measurements conducted with healthy volunteers while performing a spontaneous arm flexion/extension movement. A characteristic feature was found in the temporal evolution of EEG signal in the single motion prior to executed motion which can aid in coordinating timing of the robotic arm assistance onset.

A police state? The Nyasaland emergency and colonial intelligence.

The Nyasaland Emergency in 1959 proved a decisive turning point in the history of the Federation of Rhodesia and Nyasaland, which from 1953 to 1963 brought together the territories of Northern Rhodesia (Zambia), Southern Rhodesia (Zambia) and Nyasaland (Malawi) under a settler-dominated federal government. The British and Nyasaland governments defended the emergency by claiming to have gathered intelligence which showed that the Nyasaland African Congress was preparing a campaign of sabotage and murder. The Devlin Commission, appointed to investigate the emergency, dismissed the evidence of a ‘murder plot’, criticised the Nyasaland government's handling of the Emergency and, notoriously, described Nyasaland as a ‘police state’. This article has two principal aims. First, using the recently declassified papers of the Intelligence and Security Department (ISD) of the Colonial Office, it seeks to provide the first detailed account of what the British government knew of the intelligence relating to the ‘murder plot’ and how they assessed it, prior to the outbreak of the emergency. It demonstrates that officials in the ISD and members of the Security Service adopted a far more cautious attitude towards the intelligence than did Conservative ministers, and had greater qualms about allowing it into the public domain to justify government policy. Second, the article examines the implications of Devlin's use of the phrase ‘police state’ for Nyasaland and for the late colonial state in general. It contrasts Devlin's use of the term with that of security experts in the ISD, who routinely applied it to policing systems that diverged from their own preferred model. Hence, whereas Devlin compared policing in Nyasaland unfavourably with that in Southern Rhodesia, implying, ironically, that Nyasaland was ‘under-policed’ (because there were fewer police per head of population in Nyasaland than in Southern Rhodesia), the ISD regarded the intensive system of policing operated by the British South Africa Police in Southern Rhodesia as characteristic of a ‘police state’. The article suggests that the frequent use of the term ‘police state’ was indicative of broader anxieties about what Britain's legacy would be for the post-independence African state.