The Code White protocol: a mixed somatic-psychiatric protocol for managing psychomotor agitation in the ED

Objectives: Clinical management of patients presenting with acute psycho­motor agitation is difficult, often because there is no predefined protocol for dealing with it. The main objective of this article is to describe our ­institution’s Code White mixed somatic-psychiatric protocol for managing acute agitation in an emergency department. Its second objective is to ­present data on how long it took to initiate and complete treatment. Methods: We retrospectively analysed 250 clinical situations over 3 years (2014–2016) from the hospital emergency department in the canton of Neuchâtel, Switzerland. Results: The median time from emergency department arrival to treatment initiation was 7 minutes; the median duration of treatment was 119 minutes. The rate of hospitalisation after emergency department treatment was 49.2%. Conclusion: This mixed somatic-psychiatric protocol seemed to reduce both the time before treatment initiation and treatment duration for ­patients presenting with acute psychomotor agitation in an emergency ­department. Implications for practice: The Code White protocol improved the emergency department’s ability to keep acutely agitated patients flowing smoothly and efficiently through it to other units or to discharge. On the qualitative level, it also improved staff safety and peace of mind, allowing them to carry out their many tasks more calmly

Patients' Needs for Care in Public Mental Health: Unity and Diversity of Self-Assessed Needs for Care.

PURPOSE: Needs assessment is recognized to be a key element of mental health care. Patients tend to present heterogeneous profiles of needs. However, there is no consensus in previous research about how patients' needs are organized. This study investigates both general and specific dimensions of patients' needs for care. METHODS: Patients' needs were assessed with ELADEB, an 18-domain self-report scale. The use of a self-assessment scale represents a unique way of obtaining patients' perceptions. A patient-centered psychiatric practice facilitates empowerment as it is based on the patients' personal motivations, needs, and wants. Four seventy-one patients' profiles were analyzed through exploratory factor analysis. RESULTS: A four-factor bifactor model, including one general factor and three specific factors of needs, was most adequate. Specific factors were (a) "finances" and "administrative tasks"; (b) "transports," "public places," "self-care," "housework," and "food"; and (c) "family," "children," "intimate relationships," and "friendship." CONCLUSION: As revealed by the general factor, patients expressing urgent needs in some domains are also more susceptible to report urgent needs in several other domains. This general factor relates to high versus low utilizers of public mental healthcare. Patients also present specific needs in life domains, which are organized in three dimensions: management, functional disabilities, and familial and interpersonal relationships. These dimensions relate to the different types of existing social support described in the literature

Prehospital triage accuracy in a criteria based dispatch centre.

BACKGROUND: Priority dispatch accuracy is a key issue in optimizing the match between patients' medical needs and pre-hospital resources. This study measures the accuracy of a Criteria Based Dispatch (CBD) system, by evaluating discrepancies between dispatch priorities and ambulance crews' severity evaluations. METHODS: This is a retrospective study conducted from January 2011 to December 2011. We ruled that a National Advisory Committee for Aeronautics (NACA) score > 3 (injuries/diseases which can possibly lead to deterioration of vital signs) to 7 (lethal injuries/ diseases) should require a priority dispatch with lights and siren (L&S), while NACA scores < 4 should require a priority dispatch without L&S. Over triage was defined as the proportion of L&S dispatches with a NACA score < 4, and under triage as the proportion of dispatches without L&S with a NACA score > 3. RESULTS: There were 29,008 primary missions in 2011, 1122 were excluded. Of the 15,749 L&S missions, 12,333 patients had a NACA score < 4, leading to an over triage rate of 78 %; 561 missions out of 12,137 missions without L&S had a NACA score > 3, leading to an under triage rate of 4.6 %. Sensitivity was 86 % (95 % confidence interval: 85.6-86.4 %), specificity 48 % (47.4-48.6 %), positive predictive value 21.7 % (21.2-22.2 %), and negative predictive value 95.4 % (95.2-95.6 %). CONCLUSION: The rates of over triage and under triage in our CBD are 78 and 4.6 % respectively. The lack of consistent or universal metrics is perhaps the most important limitation in dispatch accuracy research. This is mainly due to the large heterogeneity of dispatch systems and prehospital emergency system

Replica Field Theory for Deterministic Models (II): A Non-Random Spin Glass with Glassy Behavior

We introduce and study a model which admits a complex landscape without containing quenched disorder. Continuing our previous investigation we introduce a disordered model which allows us to reconstruct all the main features of the original phase diagram, including a low $T$ spin glass phase and a complex dynamical behavior.Comment: 35 pages with uu figures, Roma 102

Upregulation of peroxisome proliferator-activated receptor gamma coactivator gene ( PGC1A ) during weight loss is related to insulin sensitivity but not to energy expenditure

Aims/hypothesis: We investigated whether skeletal muscle peroxisome proliferator-activated receptor gamma coactivator-1 (PGC1A; also known as PPARGC1A) and its target mitofusin-2 (MFN2), as well as carnitine palmitoyltransferase-1 (CPT1; also known as carnitine palmitoyltransferase 1A [liver] [CPT1A]) and uncoupling protein (UCP)3, are involved in the improvement of insulin resistance and/or in the modification of energy expenditure during surgically induced massive weight loss. Materials and methods: Seventeen morbidly obese women (mean BMI: 45.9 ± 4kg/m2) were investigated before, and 3 and 12months after, Roux-en-Y gastric bypass (RYGB). We evaluated insulin sensitivity by the euglycaemic-hyperinsulinaemic clamp, energy expenditure and substrate oxidation by indirect calorimetry, and muscle mRNA expression by PCR. Results: Post-operatively, PGC1A was enhanced at 3 (p = 0.02) and 12months (p = 0.03) as was MFN2 (p = 0.008 and p = 0.03 at 3 and 12months respectively), whereas UCP3 was reduced (p = 0.03) at 12months. CPT1 did not change. The expression of PGC1A and MFN2 were strongly (p < 0.0001) related. Insulin sensitivity, which increased after surgery (p = 0.002 at 3, p = 0.003 at 12months), was significantly related to PGC1A and MFN2, but only MFN2 showed an independent influence in a multiple regression analysis. Energy expenditure was reduced at 3months post-operatively (p = 0.001 vs before RYGB), remaining unchanged thereafter until 12months. CPT1 and UCP3 were not significantly related to the modifications of energy expenditure or of lipid oxidation rate. Conclusions/interpretation: Weight loss upregulates PGC1A, which in turn stimulates MFN2 expression. MFN2 expression significantly and independently contributes to the improvement of insulin sensitivity. UCP3 and CPT1 do not seem to influence energy expenditure after RYG

Effects of a Weight Loss Program on Metabolic Syndrome, Eating Disorders and Psychological Outcomes: Mediation by Endocannabinoids?

To evaluate the effects of weight loss on endocannabinoids, cardiometabolic and psychological parameters, eating disorders (ED) as well as quality of life (QoL) and to elucidate the role of endocannabinoids in metabolic syndrome (MS). In total, 114 patients with obesity were prospectively included in a 12-month weight loss program. Plasma endocannabinoids were measured by mass spectrometry; ED, psychological and QoL-related parameters were evaluated by self-reported questionnaires; physical activity was measured by accelerometer. Nutritional assessment was done by a 3-day food diary. Among completers (n = 87), body weight decreased in 35 patients (-9.1 ± 8.6 kg), remained stable in 39 patients, and increased in 13 patients (+5.8 ± 3.4 kg). 75% of patients with MS at baseline were free of MS at follow-up, and their baseline plasma N-palmitoylethanolamide (PEA) values were significantly lower when compared to patients with persisting MS. At baseline, there was a positive relationship between PEA and waist circumference (p = 0.005, R2 = 0.08), fasting glucose (p &lt; 0.0001, R2 = 0.12), total cholesterol (p = 0.001, R2 = 0.11), triglycerides (p = 0.001, R2 = 0.11), LDL-cholesterol (p = 0.03, R2 = 0.05) as well as depression score (p = 0.002, R2 = 0.29). Plasma PEA might play a role in metabolic improvement after weight loss. Even in subjects without weight loss, a multidisciplinary intervention improves psychological outcomes, ED, and QoL

Influence of the disorder on tracer dispersion in a flow channel

Tracer dispersion is studied experimentally in periodic or disordered arrays of beads in a capillary tube. Dispersion is measured from light absorption variations near the outlet following a steplike injection of dye at the inlet. Visualizations using dye and pure glycerol are also performed in similar geometries. Taylor dispersion is dominant both in an empty tube and for a periodic array of beads: the dispersivity $l\_d$ increases with the P\'eclet number $Pe$ respectively as $Pe$ and $Pe^{0.82}$ and is larger by a factor of 8 in the second case. In a disordered packing of smaller beads (1/3 of the tube diameter) geometrical dispersion associated to the disorder of the flow field is dominant with a constant value of $l\_d$ reached at high P\'eclet numbers. The minimum dispersivity is slightly higher than in homogeneous nonconsolidated packings of small grains, likely due heterogeneities resulting from wall effects. In a disordered packing with the same beads as in the periodic configuration, $l\_d$ is up to 20 times lower than in the latter and varies as $Pe^\alpha$ with $\alpha = 0.5$ or $= 0.69$ (depending on the fluid viscosity). A simple model accounting for this latter result is suggested.Comment: available online at http://www.edpsciences.org/journal/index.cfm?edpsname=epjap&niv1=contents&niv2=archive

Diversifying selection and color-biased dispersal in the asp viper.

BACKGROUND: The presence of intraspecific color polymorphism can have multiple impacts on the ecology of a species; as a consequence, particular color morphs may be strongly selected for in a given habitat type. For example, the asp viper (Vipera aspis) shows a high level of color polymorphism. A blotched morph (cryptic) is common throughout its range (central and western Europe), while a melanistic morph is frequently found in montane populations, presumably for thermoregulatory reasons. Besides, rare atypical uniformly colored individuals are known here and there. Nevertheless, we found in a restricted treeless area of the French Alps, a population containing a high proportion (&gt;50%) of such specimens. The aim of the study is to bring insight into the presence and function of this color morph by (i) studying the genetic structure of these populations using nine microsatellite markers, and testing for (ii) a potential local diversifying selection and (iii) differences in dispersal capacity between blotched and non-blotched vipers. RESULTS: Our genetic analyses support the occurrence of local diversifying selection for the non-blotched phenotype. In addition, we found significant color-biased dispersal, blotched individuals dispersing more than atypical individuals. CONCLUSION: We hypothesize that, in this population, the non-blotched phenotype possess an advantage over the typical one, a phenomenon possibly due to a better background matching ability in a more open habitat. In addition, color-biased dispersal might be partly associated with the observed local diversifying selection, as it can affect the genetic structure of populations, and hence the distribution of color morphs

The effect of insulin on cardiac autonomic balance predicts weight reduction after gastric bypass

Aims/hypothesis: The aim of this study was to assess the predictive role of autonomic reactivity in body weight loss induced by gastric bypass. Methods: A group of 22 morbidly obese subjects, who were due to undergo a gastric bypass, were submitted, before surgery, to a euglycaemic-hyperinsulinaemic clamp, during which a continuous recording of the ECG was performed. The effect of insulin on cardiac autonomic balance was evaluated by performing power spectral analysis of heart rate variability. The low-to-high frequency ratio was calculated before and during the clamp and its modifications were expressed as % delta low-to-high frequency ratio (%Δ L: H). Results: Preoperative %Δ L: H showed a significant (p=0.0009, r 2=0.43), positive relationship to the reduction of body weight, measured 1 year after surgery and expressed as % excess weight loss (% EWL). Preoperative BMI was also significantly (p=0.0009, r 2=0.43) negatively related to the 12-month % EWL. In a multiple regression analysis, %Δ L: H remained a significant (p=0.003), independent predictor of body weight loss, even when preoperative BMI or age, % fat mass, insulinaemia and glucose disposal were taken into account. Conclusions/interpretation: The best correction of excess body weight was achieved by those obese subjects who had a preserved capacity to shift their cardiac autonomic balance towards a sympathetic prevalence in response to an euglycaemic-hyperinsulinaemic clamp. Further studies are needed to elucidate the mechanisms through which the autonomic nervous system influences weight reductio

Landscape statistics of the low autocorrelated binary string problem

The statistical properties of the energy landscape of the low autocorrelated binary string problem (LABSP) are studied numerically and compared with those of several classic disordered models. Using two global measures of landscape structure which have been introduced in the Simulated Annealing literature, namely, depth and difficulty, we find that the landscape of LABSP, except perhaps for a very large degeneracy of the local minima energies, is qualitatively similar to some well-known landscapes such as that of the mean-field 2-spin glass model. Furthermore, we consider a mean-field approximation to the pure model proposed by Bouchaud and Mezard (1994, J. Physique I France 4 1109) and show both analytically and numerically that it describes extremely well the statistical properties of LABSP