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Current judgments are systematically biased by priorjudgments. Such biases occur in ways that seem to reflect thecognitive system’s ability to adapt to the statisticalregularities within the environment. These cognitivesequential dependencies have been shown to occur undercarefully controlled laboratory settings as well as more recentstudies designed to determine if such effects occur in realworld scenarios. In this study we use these well-knownfindings to guide our analysis of over 2.2 million businessreview ratings. We explore how both within-reviewer andwithin-business (between reviewer) ratings are influenced byprevious ratings. Our findings, albeit exploratory, suggestthat current ratings are influenced in systematic ways by priorratings. This work is couched within a broader program thataims to determine the validity of laboratory findings usinglarge naturally occurring behavioral data.

BackgroundEpisodes of paroxysmal atrial fibrillation may be precipitated by the rapid ingestion of ice-cold foods and beverages. This condition has received little research attention, and its true prevalence is poorly described. Treating physicians may not identify cold ingestion as a causal factor of paroxysmal atrial fibrillation, thus compromising both history taking and patient education.Case reportWe report a case of a healthy young-adult man who drank a slushed ice beverage that immediately induced atrial fibrillation and a brain freeze headache simultaneously. This occurred on two separate occasions, years apart. During both episodes, the acute brain freeze self-resolved quickly, but the new-onset palpitations occasioned a visit to the emergency department for diagnosis and treatment. The emergency physicians failed to make the causal link between the cold drink and the atrial dysrhythmia. Though the brain freeze headache and paroxysmal atrial fibrillation were both precipitated by rapid ingestion of an ice-cold beverage, the mediating mechanisms are distinct. We review these two cold-induced conditions, their prevalence, and their probable mechanisms.ConclusionsThe recurrent simultaneous occurrence of brain-freeze headache with paroxysmal atrial fibrillation identifies the ingestion of a frozen beverage as the precipitant of the atrial dysrhythmia. Increasing physician awareness of cold ingestion as a cause of paroxysmal atrial fibrillation will improve history taking and patient education.

Over the past 20 years, a significant amount of research has located sports coaching principally as an educational endeavour. In particular, non-linear educative approaches have attracted much attention yet few studies have explored in any real depth the theoretical underpinnings of such practices. Where conceptual analyses have been conducted, the work of Vygotsky has emerged as a useful framework. The aim of the present study was to investigate the extent to which Vygotskian principles of learning and development might be evident within non-linear sports coaching practices and to examine whether embracing these principles might enhance coaching practice both in youth and adult settings. Drawing on qualitative empirical data, this paper explores how six coaches perceived their everyday practice as non-linear. Resultant findings uncover the nuances of both coach and athlete experience in line with three of Vygotsky's key theoretical assertions, namely: Zone of Proximal Development (ZPD), scaffolding and mediation. The paper concludes by suggesting that the application of theoretical ideas has the potential to inform and enhance non-linear pedagogical approaches, yet coaches must remain cognisant of the bespoke nature of the coaching context.

Prochlorperazine is frequently used in the treatment of refractory nausea and migraines. Known side effects include extrapyramidal symptoms such as akathisia and dystonia. We report a pregnant patient taking prochlorperazine for hyperemesis gravidarum who

RationaleStudies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described.ObjectivesTo compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria.MethodsWe conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality.Measurements and main resultsOf 423 adults with acute low-risk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P

Project Goal:Create device to stabilize patient’s lung after suffering a tension pneumothorax Current treatments involve chest tubes that are prone to clotting and infection Can be used in non-sterile environment Can be used in transit and at the hospital Field and Hospital Versions of PAD Danny Baldo Jr., Horacio Estabridis, Vinson Tran, Kelsey Fung, Thanh Chung, Anthony PhamDepartment of Biomedical Engineering, University of California, IrvineFrancis Duhay: Edwards Lifesciences

Some theories of language see it as a complex and highly adaptive system. For example, language may adapt to certainsocial or demographic variables of a linguistic community. If so, language may be used as an indication of certain social influences.Studies have begun to explore how the structure of social-networks contribute to language use. Until recently, datasetslarge enough to test how subtle effects of socio-cultural properties—spanning vast amounts of time and space—influence languagechange have been difficult to obtain. We analyzed over one million online business reviews using network analyses andinformation theory to quantify social connectivity and language structure. Results indicate that sometimes a surprisingly highproportion of variance in individual language use can be accounted for by differences in social structure. We consider how bigdata can be used as an arena for testing the influence of social variables on language use.

BackgroundThe Pulmonary Embolism (PE) Severity Index identifies emergency department (ED) patients with acute PE that can be safely managed without hospitalization. However, the Index comprises 11 weighted variables, complexity that can impede its integration into contextual workflow.ObjectiveWe designed a computerized version of the PE Severity Index (e-Index) to automatically extract the required variables from discrete fields in the electronic health record (EHR). We tested the e-Index on the study population to determine its accuracy compared with a gold standard generated by physician abstraction of the EHR on manual chart review.MethodsThis retrospective cohort study included adults with objectively-confirmed acute PE in four community EDs from 2010-2012. Outcomes included performance characteristics of the e-Index for individual values, the number of cases requiring physician editing, and the accuracy of the e-Index risk category (low vs. higher).ResultsFor the 593 eligible patients, there were 6,523 values automatically extracted. Fifty one of these needed physician editing, yielding an accuracy at the value-level of 99.2% (95% confidence interval [CI], 99.0%-99.4%). Sensitivity was 96.9% (95% CI, 96.0%-97.9%) and specificity was 99.8% (95% CI, 99.7%-99.9%). The 51 corrected values were distributed among 47 cases: 43 cases required the correction of one variable and four cases required the correction of two. At the risk-category level, the e-Index had an accuracy of 96.8% (95% CI, 95.0%-98.0%), under-classifying 16 higher-risk cases (2.7%) and over-classifying 3 low-risk cases (0.5%).ConclusionOur automated extraction of variables from the EHR for the e-Index demonstrates substantial accuracy, requiring a minimum of physician editing. This should increase user acceptability and implementation success of a computerized clinical decision support system built around the e-Index, and may serve as a model to automate other complex risk stratification instruments.

Introduction: Historically, emergency department (ED) patients with pulmonary embolism (PE) have been admitted for several days of inpatient care. Growing evidence suggests that selected ED patients with PE can be safely discharged home after a short length of stay. However, the optimal timing of follow up is unknown. We hypothesized that higher-risk patients with short length of stay (

Prochlorperazine is frequently used in the treatment of refractory nausea and migraines. Known side effects include extrapyramidal symptoms such as akathisia and dystonia. We report a pregnant patient taking prochlorperazine for hyperemesis gravidarum who developed hemidystonia, which triggered an acute code stroke response from prehospital, emergency medicine and neurology providers. We suspect this report to be the first case of prochlorperazine-induced hemidystonia as a stroke mimic.

Introduction: Application of a clinical decision rule for subarachnoid hemorrhage, in combination with cranial computed tomography (CT) performed within six hours of ictus (early cranial CT), may be able to reasonably exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). This study’s objective was to examine the sensitivity of both early cranial CT and a previously validated clinical decision rule among emergency department (ED) patients with aSAH and a normal mental status.Methods: Patients were evaluated in the 21 EDs of an integrated health delivery system between January 2007 and June 2013. We identified by chart review a retrospective cohort of patients diagnosed with aSAH in the setting of a normal mental status and performance of early cranial CT. Variables comprising the SAH clinical decision rule (age >40, presence of neck pain or stiffness, headache onset with exertion, loss of consciousness at headache onset) were abstracted from the chart and assessed for inter-rater reliability. Results: One hundred fifty-five patients with aSAH met study inclusion criteria. The sensitivity of early cranial CT was 95.5% (95% CI [90.9-98.2]). The sensitivity of the SAH clinical decision rule was also 95.5% (95% CI [90.9-98.2]). Since all false negative cases for each diagnostic modality were mutually independent, the combined use of both early cranial CT and the clinical decision rule improved sensitivity to 100% (95% CI [97.6-100.0]). Conclusion: Neither early cranial CT nor the SAH clinical decision rule demonstrated ideal sensitivity for aSAH in this retrospective cohort. However, the combination of both strategies might optimize sensitivity for this life-threatening disease.

Introduction: We evaluated emergency physicians’ (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients.Methods: We administered a survey to all EPs in a large integrated healthcare delivery system. The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We calculated descriptive statistics and post-test probabilities for such a clinical prediction rule.Results: The response rate was 68% (366/535). Respondents’ median practice tenure was eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests’ bedside application (35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to

Accurate gene model annotation of reference genomes is critical for making them useful. The modENCODE project has improved the D. melanogaster genome annotation by using deep and diverse high-throughput data. Since transcriptional activity that has been evolutionarily conserved is likely to have an advantageous function, we have performed large-scale interspecific comparisons to increase confidence in predicted annotations. To support comparative genomics, we filled in divergence gaps in the Drosophila phylogeny by generating draft genomes for eight new species. For comparative transcriptome analysis, we generated mRNA expression profiles on 81 samples from multiple tissues and developmental stages of 15 Drosophila species, and we performed cap analysis of gene expression in D. melanogaster and D. pseudoobscura. We also describe conservation of four distinct core promoter structures composed of combinations of elements at three positions. Overall, each type of genomic feature shows a characteristic divergence rate relative to neutral models, highlighting the value of multispecies alignment in annotating a target genome that should prove useful in the annotation of other high priority genomes, especially human and other mammalian genomes that are rich in noncoding sequences. We report that the vast majority of elements in the annotation are evolutionarily conserved, indicating that the annotation will be an important springboard for functional genetic testing by the Drosophila community.

BACKGROUND: It is unclear whether sex-based differences in cardiovascular outcomes exist in late-onset hypertension. METHODS: This is a population-based cohort study in Ontario, Canada of 266 273 adults, aged ≥66 years with newly diagnosed hypertension. We determined the incidence of the primary composite cardiovascular outcome (myocardial infarction, stroke, and congestive heart failure), all-cause mortality, and cardiovascular death by sex using Cox proportional hazard models adjusted for demographic factors and comorbidities. RESULTS: The mean age of the total cohort was 74 years, and 135 531 (51%) were female. Over a median follow-up of 6.6 (4.7–9.0) years, females experienced a lower crude incidence rate (per 1000 person-years) than males for the primary composite cardiovascular outcome (287.3 versus 311.7), death (238.4 versus 251.4), and cardiovascular death (395.7 versus 439.6), P<0.001. The risk of primary composite cardiovascular outcome was lower among females (adjusted hazard ratio, 0.75 [95% CI, 0.73–0.76]; P<0.001) than in males. This was consistent after adjusting for the competing risk of allcause death with a subdistributional hazard ratio, 0.88 ([95% CI, 0.86–0.91]; P<0.001). CONCLUSIONS: Females had a lower risk of cardiovascular outcomes compared with males within a population characterized by advanced age and new hypertension. Our results highlight that the severity of outcomes is influenced by sex in relation to the age at which hypertension is diagnosed. Further studies are required to identify sex-specific variations in the diagnosis and management of late-onset hypertension due to its high incidence in this group. [ABSTRACT FROM AUTHOR]

BACKGROUND: Noninvasive cardiac testing (NICT) has been associated with decreased long-term risks of major adverse cardiac events (MACEs) among emergency department patients at high coronary risk. It is unclear whether this association extends to patients without evidence of myocardial injury on initial ECG and cardiac troponin testing. METHODS: A retrospective cohort study was conducted of patients presenting with chest pain between 2013 and 2019 to 21 emergency departments within an integrated health care system in Northern California, excluding patients with ST-segment-- elevation myocardial infarction or myocardial injury by serum troponin testing. To account for confounding by indication, we grouped patient encounters by the NICT referral rate of the initially assigned emergency physician relative to local peers within discrete time periods. The primary outcome was MACE within 2 years. Secondary outcomes were coronary revascularization and MACE, inclusive of all-cause mortality. Associations between the NICT referral group (low, intermediate, or high) and outcomes were assessed using risk-adjusted proportional hazards methods with censoring for competing events. RESULTS: Among 144 577 eligible patient encounters, the median age was 58 years (interquartile range, 48--68) and 57% were female. Thirty-day NICT referral was 13.0%, 19.9%, and 27.8% in low, intermediate, and high NICT referral groups, respectively, with a good balance of baseline covariates between groups. Compared with the low NICT referral group, there was no significant decrease in the adjusted hazard ratio of MACE within the intermediate (adjusted hazard ratio, 1.08 [95% CI, 1.02--1.14]) or high (adjusted hazard ratio, 1.05 [95% CI, 0.99--1.11]) NICT referral groups. Results were similar for MACE, inclusive of all-cause mortality, and coronary revascularization, as well as subgroup analyses stratified by estimated risk (history, electrocardiogram, age, risk factors, troponin [HEART] score: percent classified as low risk, 48.2%; moderate risk, 49.2%; and high risk, 2.7%). CONCLUSIONS: Increases in NICT referrals were not associated with changes in the hazard of MACE within 2 years following emergency department visits for chest pain without evidence of acute myocardial injury. These findings further highlight the need for evidence-based guidance regarding the appropriate use of NICT in this population. [ABSTRACT FROM AUTHOR]

Perioperative anxiety is common in surgical patients and linked to poor outcomes. This multicenter randomized controlled trial assessed the effect of the use of a warm weighted blanket on presurgical anxiety and pain, as well as postsurgical restlessness, nausea, and vomiting. Levels of anxiety and pain were measured in adult patients using a 100‐point visual analog scale before elective surgery. Patients received either a warm weighted blanket (n = 74) or a traditional sheet or nonweighted blanket (n = 74). Patients in the intervention group had significantly lower preoperative anxiety scores (mean [SD] = 26.28 [25.75]) compared to the control group (mean [SD] = 38.73 [30.55], P =.008). However, the intervention had no significant effect on presurgical pain or postsurgical nausea, vomiting, or restlessness. These results suggest that weighted blankets reduce preoperative anxiety in adult patients. [ABSTRACT FROM AUTHOR]

The foundation of the family and consumer sciences (FCS) can be traced back to the legendary Ellen Swallows Richards. Richards was the first female to graduate with a chemistry degree from Vassar College and the first female accepted into the Massachusetts Institute of Technology (MIT), where she would eventually become MIT's first female professor (Ford, 2008). Richards would later found the American Home Economics Association, now the American Association of Family & Consumer Sciences. Throughout her lifetime, she would lay the groundwork for the discipline known as "home economics" (now "family and consumer sciences"), and continue to advocate for the application of scientific and management principles in real-world settings both in the home and in the workplace. Many of these original scientific principles have reentered the national educational conversation through the current emphasis on Science, Technology, Engineering, and Mathematics (STEM) education and the need for a STEM-literate population.

Background: The Office of Naval Research (ONR) organized a STEM Challenge initiative to explore how intelligent tutoring systems (ITSs) can be developed in a reasonable amount of time to help students learn STEM topics. This competitive initiative sponsored four teams that separately developed systems that covered topics in mathematics, electronics, and dynamical systems. After the teams shared their progress at the conclusion of an 18-month period, the ONR decided to fund a joint applied project in the Navy that integrated those systems on the subject matter of electronic circuits. The University of Memphis took the lead in integrating these systems in an intelligent tutoring system called "ElectronixTutor." This article describes the architecture of ElectronixTutor, the learning resources that feed into it, and the empirical findings that support the effectiveness of its constituent ITS learning resources. Results: A fully integrated ElectronixTutor was developed that included several intelligent learning resources (AutoTutor, Dragoon, LearnForm, ASSISTments, BEETLE-II) as well as texts and videos. The architecture includes a student model that has (a) a common set of knowledge components on electronic circuits to which individual learning resources contribute and (b) a record of student performance on the knowledge components as well as a set of cognitive and non-cognitive attributes. There is a recommender system that uses the student model to guide the student on a small set of sensible next steps in their training. The individual components of ElectronixTutor have shown learning gains in previous decades of research. Conclusions: The ElectronixTutor system successfully combines multiple empirically based components into one system to teach a STEM topic (electronics) to students. A prototype of this intelligent tutoring system has been developed and is currently being tested. ElectronixTutor is unique in its assembling a group of well-tested intelligent tutoring systems into a single integrated learning environment.

Previous studies show that reading sentences about actions leads to specific motor activity associated with actually performing those actions. We investigate how sign language input may modulate motor activation, using British Sign Language (BSL) sentences, some of which explicitly encode direction of motion, versus written English, where motion is only implied. We find no evidence of action simulation in BSL comprehension (Experiments 1-3), but we find effects of action simulation in comprehension of written English sentences by deaf native BSL signers (Experiment 4). These results provide constraints on the nature of mental simulations involved in comprehending action sentences referring to transfer events, suggesting that the richer contextual information provided by BSL sentences versus written or spoken English may reduce the need for action simulation in comprehension, at least when the event described does not map completely onto the signer's own body.

Introduction: Informed consent is a required process for procedures performed in the emergency department (ED), though it is not clear how often or adequately it is obtained by emergency physicians.Incomplete performance and documentation of informed consent can lead to patient complaints,medico-legal risk, and inadequate education for the patient/guardian about the procedure. Weundertook this study to quantify the incidence of informed consent documentation in the ED setting forlumbar puncture (LP) and to compare rates between pediatric (,18 years) and adult patients.Methods: In this retrospective cohort study, we reviewed the ED electronic health records (EHR) for allpatients who underwent successful LPs in 3 EDs between April 2010 and June 2012. Specific elementsof informed consent documentation were reviewed. These elements included the presence of generalED and LP-specific consent forms, signatures of patient/guardian, witness, and physician,documentation of purpose, risks, benefits, alternatives, and explanation of the LP. We also reviewedthe use of educational material about the LP and LP-specific discharge information.Results: Our cohort included 937 patients; 179 (19.1%) were pediatric. A signed general ED consent form was present in the EHR for 809 (86%) patients. A consent form for the LP was present for 524 (56%) patients, with signatures from 519 (99%) patients/guardians, 327 (62%) witnesses, and 349 (67%) physicians. Documentation rates in the EHR were as follows: purpose (698; 74%), risks (742; 79%), benefits (605; 65%), alternatives (635; 68%), and explanation for the LP (57; 6%). Educational material about the LP was not documented as having been given to any of the patients and LP-specific discharge information was documented as given to 21 (2%) patients. No significant differences were observed in the documentation of informed consent elements between pediatric and adult patients.Conclusion: General ED consent was obtained in the vast majority of patients, but use of a specific LP consent form and documentation of the elements of informed consent for LP in the ED were suboptimal, though comparable between pediatric and adult patients. There is significant opportunity for improvement in many aspects of documenting informed consent for LP in the ED. [West J Emerg Med. 2014;15(3):318–324.]

Introduction: Central venous catheterization (CVC) can be an important component of the management of patients with severe sepsis and septic shock. CVC, however, is a time- and resource-intensive procedure associated with serious complications. The effects of the absence of shock or the presence of relative contraindications on undertaking central line placement in septic emergency department (ED) patients eligible for early goal-directed therapy (EGDT) have not been well described. We sought to determine the association of relative normotension (sustained systolic blood pressure >90 mmHg independent of or in response to an initial crystalloid resuscitation of 20 mL/kg), obesity (body mass index [BMI] ≥30), moderate thrombocytopenia (platelet count

Transportation in ancient Egypt entailed the use of boats and ships for water travel; for landtransportation, attested methods include foot-traffic and the use of draft animals—especiallydonkeys and oxen, but also, from the first millennium BCE onward, camels. Land vehicles,including carts, chariots, sledges, and carrying chairs, were dependent on the existence and natureof suitable routes, some of which may have been improved or paved along at least part of theirextent. The transport of large objects, especially stone blocks, obelisks, and statues, requiredspecialized techniques, infrastructure, and vehicles.