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Background The Ontario Health Teams (OHT) model is a form of integrated care that seeks to provide coordinated delivery of care to communities across Ontario, Canada. Primary care is positioned at heart of the Ontario Health Teams model, yet physician participation and representation has been severely challenged at planning and governance tables. Methods The purpose of this multiple case study is to examine 1) processes and structures to enable family physician participation in OHTs and 2) describe prevalent challenges to family physician participation. We conducted semi-structured interviews with stakeholders (administrators, physicians) from OHT communities and carried out an analysis of internal and external documents to contextualize interview findings. Thematic analysis was first applied within case and then between cases. Results Four OHT communities participated in this study. Thirty-nine participants (17 family physicians; 22 other stakeholders) participated in the study. Over 60 documents were provided and analyzed. The study took place between June and December 2021. Conclusions Within-case analysis found that structures and processes should be formalized and established to facilitate physician participation. Skepticism, burnout, heavy workload, and the COVID-19 pandemic were challenges to participation. Between-case analysis found that participation varied amongst cases. Face-to-face communication processes were favoured in all cases and history of collaboration facilitated relationship-building. All cases faced similar challenges to physician participation despite regional differences.

Background In Canada, Ontario Health Teams (OHTs) are a new model for integrated healthcare. Core to OHTs are family physicians (FPs) and their ability to collaborate with other FPs and healthcare providers. Whereas the factors for intra-organizational collaboration have been well-studied, inter-organizational collaboration between FPs and other healthcare organizations as an integrated care network, are less understood. This paper aims to explore the structural factors, processes, and theoretical frameworks that support FPs’ collaboration for integrated healthcare. Methods A scoping review was undertaken based on Joanna Briggs Institute (JBI) methodology for scoping review and using the Preferred Reporting Items for Systematic Review and Meta-Analysis for Scoping Review (PRISMA_ScR) checklist. A search for academic and relevant grey literature published between 2000–2021 was conducted across databases (MEDLINE, EMBASE, EBSCOhost).Thematic analysis was used to identify the key findings of the selected studies. Results Thirty-two studies were included as eligible for this review. Three structural components were identified as critical to FPs’ successful participation in inter-organizational partnerships: (1) shared vision/values, (2) leadership by FPs, and (3) defined decision-making procedures. Also, three processes were identified: (1) effective communication, (2) a collective sense of motivation for change, and (3) relationships built on trust. Three theoretical frameworks provided insight into collaborative initiatives: (1) Social Identity Approach, (2) framework of interprofessional collaboration, and (3) competing values framework. Conclusion FPs hold unique positions in healthcare and this review is the first to synthesize the best evidence for building collaborations between FPs and other healthcare sectors. These findings will inform collaboration strategies for healthcare integration, including with OHTs.

Patient-centred care is a key priority for governments, providers and stakeholders, yet little is known about the care preferences of patient groups. We completed a scoping review that yielded 193 articles for analysis. Five health states were used to account for the diversity of possible preferences based on health needs. Five broad themes were identified and expressed differently across the health states, including personalized care, navigation, choice, holistic care and care continuity. Patients' perspectives must be considered to meet the diverse needs of targeted patient groups, which can inform health system planning, quality improvement initiatives and targeting of investments.

Background Down syndrome (DS) is the most common chromosomal abnormality encountered by primary care physicians. The demands of families with DS children are significantly high with possible burdens on their primary caregivers. Objective To assess the burden of DS children on their family primary caregivers and to identify the variables associated with caregiver burden. Methods A cross-sectional study was conducted in Mansoura, Egypt from March 2019 to March 2020 including 457 family primary caregivers and their DS children. Socio-demographic and clinical data were collected through direct interviews. Caregiver burden was assessed by Zarit Burden Interview (ZBI-22) scale. The associations between categorical variables were tested using chi-square test, crude odds ratio and 95% confidence interval. Logistic regression analysis was carried out to detect the variables independently associated with caregiver burden. Results More than half (51.9%) of caregivers had no or little burden, 40.7% had mild to moderate burden and 7.4% had moderate to severe burden. Female caregiving, single parent status and DS children of age less than 6 years old, female gender and having congenital heart diseases were the variables independently associated with mild to severe burden with adjusted odds ratios of 4.2, 2.5, 1.5, 2.1 and 1.7, respectively. Conclusions Less than half of family primary caregivers of DS children in Mansoura, Egypt suffered from mild to severe burden. Primary care physicians could recognize caregivers at risk of burden using ZBI-22 scale, and provide appropriate social, medical and psychological care for parents and DS children to mitigate this burden.

Sleep is an essential part of human life and in one way or another, the dreams that occur in it also have a significant place in human lives. Dreams, especially the good dreams, are also mentioned in Qur'an and Hadith. It is proven that the Holy Prophet Muhammad ﷺ himself used to interpret them and his ﷺ holy companions and followers followed his ﷺ lead. In the context of subcontinent, the written literature of the region contains a considerable material (especially from the eleventh and twelfth centuries AH) on Muslim scholars’ explanation and interpretation of dreams. This article investigates the ways dreams were interpreted in the epistles of the religious scholars of that time. How did those scholars inform the addressees of their spiritual states and how did they guide them well through the written interpretation of the addressees’ dreams. Keywords: Sleep, Dreams, Muslim Scholars, Subcontinent, Epistles

Background The benefits of early antibiotics for sepsis have recently been questioned. Evidence for this mainly comes from observational studies. The only randomized trial on this subject, the Prehospital Antibiotics Against Sepsis (PHANTASi) trial, did not find significant mortality benefits from early antibiotics. That subgroups of patients benefit from this practice is still plausible, given the heterogeneous nature of sepsis. Research Question Do subgroups of sepsis patients experience 28-day mortality benefits from early administration of antibiotics in a prehospital setting? And what key traits drive these benefits? Study Design and Methods We used machine learning to conduct exploratory partitioning cluster analysis to identify possible subgroups of sepsis patients who may benefit from early antibiotics. We further tested the influence of several traits within these subgroups, using a logistic regression model. Results We found a significant interaction between age and benefits of early antibiotics (P = .03). When we adjusted for this interaction and several other confounders, there was a significant benefit of early antibiotic treatment (OR = 0.07; 95%CI = 0.01-0.79; P = .03). Interpretation An interaction between age and benefits of early antibiotics for sepsis has not been reported before. When validated, it can have major implications for clinical practice. This new insight into benefits of early antibiotic treatment for younger sepsis patients may enable more effective care.

Objective To understand the theoretical framework of how information, motivation, and behavioral skills (IMB) independently and collectively affect cervical cancer screening and testing adherence. Study design Qualitative study. Methods Data collected from three focus groups and seven individual interviews, with 33 healthcare providers, ranging from community health navigators, Ob-Gyn MD’s, nurses, care coordinators, medical assistants, and outpatient managers, representing a grassroots community health agency, a large cancer center, and a public sector health clinic. We recruited providers over a five-month period in the summer to fall of 2019. Provider interviews and focus groups were structured with four to eleven participants per group and were audio-recorded. This study was rooted in grounded theory, analyzing data using the iterative process of Coding, Consensus, Co-occurrence, and Comparison to identify common themes. Results Emerging qualitative findings include the relevance of information, the interaction between information and motivation, the role of behavioral skills, and the symbiotic relationship between information, motivation, and behavioral skills (IMB). Most notable is this interdependency between IMB components, with the core of this relationship being the critical link of coordinating adherence. Conclusion This knowledge will help advance and expand IMB intervention components to improve time to cervical cancer screening and follow-up adherence among at-risk communities. Particularly given COVID-19 barriers, which disproportionately affect at-risk women, this study has practice implications that inform the development of cervical cancer screening practice interventions and strategies to improve adherence, while ensuring safety for both patients and providers.

In this study, the antioxidant potentials and protective effect of ethanolic extract of monkey fruits (Artocarpus lakoocha) (AL) was investigated against paracetamol-induced toxicity in rats. AL which contains high concentration of polyphenols, flavonoids, tannins and protein, exhibited high radical scavenging activity and ferric reducing antioxidant power. Administration of paracetamol (500 mg/kg) for seven consecutive days caused severe oxidative stress in liver and kidney, as observed by the significantly higher level of Lipid Peroxidation (LPO) and the associated biochemical markers compared to control rats. Pre-treatment with AL at 250, 500 and 1000 mg/kg prior to paracetamol administration for 30 days significantly improved hepatic and renal parameters in a dose-dependent manner. Silymarin (100 mg/kg) was administered as a standard drug for comparison over a similar treatment period. Moreover, AL exhibited the highest protective effect when administered at the highest dose, by lowering serum levels of alanine transaminase (28.25%), aspartate transaminase (29.0%), alkaline phosphatase (27.87%), lactate dehydrogenase (7.51%), γ-glutamyltransferase (31.0%), total bilirubin (69.38%), cholesterol (14.80%), triglycerides (27.52%), low-density lipoprotein cholesterol (76.12%), creatinine (36.84%), urea (41.08%) and uric acid (34.88%), In addition, significantly increased total protein (50.0%) and high-density lipoprotein cholesterol (55.79%) with administration of AL was seen when compared with paracetamol-controlled group. Decreased LPO levels in the liver (45.55%) and kidneys (32.0%) confirmed the hepatorenal protective effects of AL, as further confirmed by the histopathological findings. Overall, AL fruit is an excellent source of natural antioxidants and possess hepatorenal protective activity against paracetamol-induced liver and kidney injuries.

Background A wide array of early warning scores (EWS) have been developed and are used in different settings to detect which patients are at risk of deterioration. The aim of this review is to provide an overview of studies conducted on the value of EWS on predicting intensive care (ICU) admission and mortality in the emergency department (ED) and acute medical unit (AMU). Methods A literature search was conducted in the bibliographic databases PubMed and EMBASE, from inception to April 2017. Two reviewers independently screened all potentially relevant titles and abstracts for eligibility. Results 42 studies were included. 36 studies reported on mortality as an endpoint, 13 reported ICU admission and 9 reported the composite outcome of mortality and ICU admission. For mortality prediction National Early Warning Score (NEWS) was the most accurate score in the general ED population and in those with respiratory distress, Mortality in Emergency Department Sepsis score (MEDS) had the best accuracy in patients with an infection or sepsis. ICU admission was best predicted with NEWS, however in patients with an infection or sepsis Modified Early Warning Score (MEWS) yielded better results for this outcome. Conclusion MEWS and NEWS generally had favourable results in the ED and AMU for all endpoints. Many studies have been performed on ED and AMU populations using heterogeneous prognostic scores. However, future studies should concentrate on a simple and easy to use prognostic score such as NEWS with the aim of introducing this throughout the (pre-hospital and hospital) acute care chain.

Sepsis is a major health care issue and sepsis survivors are often confronted with long-term complications after admission to the intensive care unit (ICU) which may negatively influence their health related quality of life (HRQOL). This study aimed to systematically evaluate the outcome in terms of HRQOL in patients with sepsis after ICU discharge. A literature search was conducted in the bibliographic databases PubMed, EMBASE, and CINAHL, including reference lists of published guidelines, reviews and associated articles. Sixteen studies were included, thirteen (81.3%) reported that sepsis survivors suffer from impaired HRQOL in physical and mental domains which persist from months to years after a sepsis episode. More focus on improving long-term outcomes for patients surviving sepsis and the ICU is needed.

Background Acute healthcare chains in the Netherlands are increasingly under pressure because of rising emergency department (ED) admissions, relative bed shortages and government policy changes. In order to improve acute patient flow and quality of care through hospitals, an acute medical unit (AMU) might be a solution, as demonstrated in the UK. However, limited information is available concerning AMUs in the Netherlands. Therefore, the aims of this study were to (1) Systematically provide an overview of current international literature regarding the effectiveness of AMUs (2) Give an overview of the current situation in the Netherlands (3) Make recommendations that could be used for future Dutch AMU guidelines Methods A systematic literature search was performed searching 3 electronic databases: PubMed, Cochrane and EMBASE. All 106 hospitals in the Netherlands were contacted, inquiring about the status of an ED, the AMU or future plans to start one. Results The literature search resulted in 31 studies that met inclusion criteria. In general, these studies reported significant benefits on number of admissions, hospital length of stay (LOS), mortality, other wards and readmissions. Among the Dutch hospitals with an ED, 33 out of 93 implemented an AMU or similar ward, these are however organized heterogeneously. Following current trends, more AMUs are expected to be realized in the future. Conclusion In order to improve the current strain on the Dutch acute healthcare system, an AMU could potentially provide benefits. However, uniform guideline is warranted to optimize and compare quality of care throughout the Netherlands.

Nine commercial cultivars of okra were evaluated for a number of agro-botanical traits. The analysis of variance for all the traits showed highly significant variations among the genotypes. The phenotypic coefficient of variation (PCV) was found higher than the genotypic coefficient of variation (GCV) for all characters. Maximum GCV and PCV were observed for branches/plant (42.54 and 42.60) and leaves/plant (27.93 and 27.99) respectively. Heritability as well as genetic advance was found maximum for branches/plant recorded as 99.72 and 87.50 respectively. Based on D2 statistics 9 genotypes were grouped into 4 clusters, namely cluster I, II, III and IV. Highest inter-cluster distance (1.18) was observed between cluster II and cluster IV. The genotypes of cluster IV possessed heterogeneous nature and showed highest intra-cluster distance (0.65). Titanic-1, BARI Derosh-1 and Green Finger genotypes were found superior to the rest of the genotypes due to their highest cluster mean for yield/plant (955.8g), plant height (208cm), leaves/plant (60.8) and fruits/plant (31.4). These information could be useful in recombination breeding programme.Jahangirnagar University J. Biol. Sci. 3(2): 25-32, 2014 (December)

Background Due to the rise in incidence, the long term effect of sepsis are becoming more evident. There is increasing evidence that sepsis may result in an impaired health related quality of life. The aim of this study was to investigate whether health related quality of life is impaired in sepsis survivors and which clinical parameters are associated with the affected health related quality of life. Methods We analyzed 880 Short Form 36 (SF-36) questionnaires that were sent to sepsis survivors who participated in the Prehospital Antibiotics Against Sepsis (PHANTASi) trial. These questionnaires were sent by email, 28 days after discharge. Data entry and statistical analyses were performed in SPSS. The data from the general Dutch population, was obtained from the Netherlands Cancer Institute (NKI-AVL) and served as a control group. Subsequently, 567 sepsis survivors were matched to 567 controls. Non-parametric Wilcoxon signed-rank test was performed to compare these two groups. Within the group, we sought to explain the diminished health related quality of life by factor analysis. Results We found that sepsis survivors have a worse health related quality of life compared to the general Dutch population. This negative effect was more evident for the physical component than the mental component of health related quality of life. We found that health related quality of life was significantly altered by advancing age and female sex. We also found that the total length of stay (in the hospital) and (previous) comorbidity negatively affect the physical component of health related quality of life. Conclusion In our study we found that health related quality of life in sepsis survivors, 28 days after discharge, is severely diminished in comparison with the general Dutch population. The physical domain is severely affected, whereas the mental domain is less influenced. The length of stay, comorbidity, advancing age and female sex all have a negative effect on the Physical Component Scale of the health related quality of life.

BACKGROUND: Blood cultures remain the gold standard for detecting bacteremia despite their limitations. The current practice of blood culture collection is still inefficient with low yields. Limited focus has been given to the association between timing of specimen collection at different time points during admission and their yield.METHODS: We carried out a retrospective observational study by analyzing all 3,890 sets of cultures collected from the 1,962 admitted patients over the seven-month period of this study. We compared the blood culture yield between the early group (≤24 hours after admission) and the late group (> 24 hours of admission). We also investigated the effect of prehospital oral antibiotics and pre-analytical time on the first cultures in the emergency department. Epidemiology and efficiency of blood cultures were studied for each medical specialty.RESULTS: In total, 3,349(86.1%) blood cultures were negative and 541(13.9%) were positive for one or more microorganisms. After correcting for contamination, the overall yield was 290 (7.5%). The early group (n = 1,490) yielded significantly more true-positive cultures (10.1% versus 5.8%, PCONCLUSION: This study showed that blood cultures are inefficient in detecting bacteremia. Cultures collected during 24 hours after admission yielded more positive results than those collected later. Significant variations in blood culture epidemiology and efficiency per specialty suggest that guidelines should be reevaluated. Future studies should aim at improving blood culture yield, implementing educational programs to reduce contamination and cost-effective application of modern molecular diagnostic technologies.

Diabetes mellitus (DM) is one of the most common endocrine metabolic disorders. In addition to exercise and diet, oral anti-diabetic drugs have been used as a part of the management strategy worldwide. Unfortunately, none of the conventional anti-diabetic drugs are without side effects, and these drugs pose an economic burden. Therefore, the investigation of novel anti-diabetic regimens is a major challenge for researchers, in which nature has been the primary resource for the discovery of potential therapeutics. Many plants have been shown to act as anti-diabetic agents, in which the main active constituents are believed to be polyphenols. Natural products containing high polyphenol levels can control carbohydrate metabolism by various mechanisms, such as protecting and restoring beta-cell integrity, enhancing insulin releasing activity, and increasing cellular glucose uptake. Blackberries, red grapes, apricots, eggplant and popular drinks such as coffee, cocoa and green tea are all rich in polyphenols, which may dampen insulin resistance and be natural alternatives in the treatment of diabetes. Therefore, the aim of this review is to report on the available anti-diabetic polyphenols (medicinal plants, fruits and vegetables), their mechanisms in the various pathways of DM and their correlations with DM. Additionally, this review emphasizes the types of polyphenols that could be potential future resources in the treatment of DM via either novel regimens or as supplementary agents.

Introduction: Sepsis is one of the most frequent reasons for referral to emergency departments (EDs) worldwide. Sepsis becomes more serious when left untreated with a high mortality rate, exceeding even those of myocardial infarction and stroke. Therefore, much effort has been put in to start with appropriate therapy as early as possible. Emergency medical services (EMS) personnel have already made a significant difference in improving care for patients with acute coronary syndrome, multiple trauma and stroke. Patients with severe sepsis or septic shock could also benefit from timely prehospital care. Earlier recognition and initiation of treatment by EMS personnel may improve survival of these critically ill patients. Methods and analysis: The Prehospital Antibiotics against Sepsis (PHANTASi) trial is an investigator- initiated, multicentre, randomized controlled open-label clinical trial nested within a step wedge design. This study compares the effects of usual care to that of training EMS personnel in recognizing and initiating treatment in the prehospital setting together with early administration of antibiotics for patients suspected of (severe) sepsis and septic shock. Primary outcome is 28 day mortality. Secondary outcomes include, length of hospital stay and admission to intensive care units. Ethics and dissemination: This study has been approved by the research ethics committee of VU University Medical Centre, Amsterdam, The Netherlands (Protocol 2013.458/ NL 42001.029.13). The results of the study will be disseminated at several research conferences and international peer reviewed journals. The study will be implemented and reported in line with the CONSORT statement.

Honey is a popular natural food product with a very complex composition mainly consisting of both organic and inorganic constituents. The composition of honey is strongly influenced by both natural and anthropogenic factors, which vary based on its botanical and geographical origins. Although minerals and heavy metals are minor constituents of honey, they play vital role in determining its quality. There are several different analytical methods used to determine the chemical elements in honey. These methods are typically based on spectroscopy or spectrometry techniques (including atomic absorption spectrometry, atomic emission spectrometry, inductively coupled plasma mass spectrometry, and inductively coupled plasma optical emission spectrometry). This review compiles available scientific information on minerals and heavy metals in honey reported from all over the world. To date, 54 chemical elements in various types of honey have been identified and can be divided into 3 groups: major or macroelements (Na, K, Ca, Mg, P, S, Cl), minor or trace elements (Al, Cu, Pb, Zn, Mn, Cd, Tl, Co, Ni, Rb, Ba, Be, Bi, U, V, Fe, Pt, Pd, Te, Hf, Mo, Sn, Sb, La, I, Sm, Tb, Dy, Sd, Th, Pr, Nd, Tm, Yb, Lu, Gd, Ho, Er, Ce, Cr, As, B, Br, Cd, Hg, Se, Sr), and heavy metals (trace elements that have a specific gravity at least 5 times higher than that of water and inorganic sources). Chemical elements in honey samples throughout the world vary in terms of concentrations and are also influenced by environmental pollution.

This study was conducted to investigate the effects of different honey processing parameters (temperature, light, gamma irradiation, evaporation and sachet packaging) on the physical, biochemical and antioxidant characteristics of Tualang honey samples that have been stored for 1 year. The protein and proline contents doubled following radiation and evaporation. Radiation and evaporation also developed the honey quality by decreasing the moisture content and improving the antioxidant parameters (ferric reducing antioxidant power [FRAP] and color intensity), and maintaining the total dissolved solids and electrical conductivity of the honey within the recommended levels. Cold temperature storage maintained the moisture contents and 5-hydroxymethylfurfural levels within safe levels. However, in case of sachet honey, cold temperature storage is not recommendable as room temperature improved the protein, proline and FRAP content. Irradiation and evaporation of honey samples are recommended as these processes tend to improve the physical, biochemical and antioxidant properties and increase the protein and proline contents of honey. Practical Applications As the physicochemical, biochemical and antioxidant potentials of honey have seen to be improved significantly after irradiation and evaporation, these can be potential techniques to improve the quality of honey prior to consumption.

BACKGROUND: Emergency medical services (EMS) personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and myocardial infarction. Patients with sepsis could also benefit from timely prehospital care.METHODS: After training EMS personnel in recognising sepsis, we did a randomised controlled open-label trial in ten large regional ambulance services serving 34 secondary and tertiary care hospitals in the Netherlands. We compared the effects of early administration of antibiotics in the ambulance with usual care. Eligible patients were randomly assigned (1:1) using block-randomisation with blocks of size 4 to the intervention (open-label intravenous ceftriaxone 2000 mg in addition to usual care) or usual care (fluid resuscitation and supplementary oxygen). Randomisation was stratified per region. The primary outcome was all-cause mortality at 28 days and analysis was by intention to treat. To assess the effect of training, we determined the average time to antibiotics (TTA) in the emergency department and recognition of sepsis by EMS personnel before and after training. The trial is registered at ClinicalTrials.gov, number NCT01988428.FINDINGS: 2698 patients were enrolled between June 30, 2014, and June 26, 2016. 2672 patients were included in the intention-to-treat analysis: 1535 in the intervention group and 1137 in the usual care group. The intervention group received antibiotics a median of 26 min (IQR 19-34) before arriving at the emergency department. In the usual care group, median TTA after arriving at the emergency department was 70 min (IQR 36-128), compared with 93 min (IQR 39-140) before EMS personnel training (p=0·142). At day 28, 120 (8%) patients had died in the intervention group and 93 (8%) had died in the usual care group (relative risk 0·95, 95% CI 0·74-1·24). 102 (7%) patients in the intervention group and 119 (10%) in the usual care group were re-admitted to hospital within 28 days (p=0·0004). Seven mild allergic reactions occurred, none of which could be attributed to ceftriaxone.INTERPRETATION: In patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity.FUNDING: The NutsOhra Foundation, Netherlands Society of Internal Medicine (NIV).

We read, with interest, the letters to editor by Rello et al . (1) and Bolliger et al . (2) in response to our Prehospital Antibiotics Against Sepsis (PHANTASi) trial which was recently published in the Lancet Respiratory Medicine (3).

The antihyperglycemic, antidiabetic, and antioxidant potentials of the methanolic extract ofGarcinia pedunculata(GP) fruit in rats were investigated. The acute antihyperglycemic effect of different doses of GP was studied in normal male Wistar rats. Diabetes was induced by streptozotocin (STZ) injection in another cohort of male Wistar rats and they showed significantly higher blood glucose and glycated hemoglobin (HbA1c) levels, altered lipid profiles, and lower insulin levels compared to nondiabetic control animals. There were increased lipid peroxidation and reduced levels of cellular antioxidant enzymes in different tissues of diabetic rats. However, oral administration of GP extracts, especially the highest dose (1000 mg/kg), significantly ameliorated hyperglycemia (42%); elevated insulin levels (165%); decreased HbA1c (29.4%); restored lipid levels (reduction in TG by 25%, TC by 15%, and LDL-C by 75% and increase in HDL-C by 4%), liver and renal function markers, and lipid peroxidation (reduction by 52% in the liver, 39% in the kidney, 44% in the heart, and 46% in the pancreas); and stimulated tissue antioxidant enzymes to near normalcy. Overall, the findings suggest that GP fruit is effective against hyperglycemia and could be used in the treatment of diabetes and its complications and other oxidative stress-mediated pathological conditions.

The present study was designed to investigate the cardioprotective effects of Sundarban honey (SH) in rats with isoproterenol- (ISO-) induced myocardial infarction. Adult male Wistar Albino rats were pretreated with Sundarban honey (5 g/kg) daily for a period of 6 weeks. After the treatment period, ISO (85 mg/kg) was subcutaneously injected into the rats at 24 h intervals for 2 days. ISO-induced myocardial damage was indicated by increased serum cardiac specific troponin I levels and cardiac marker enzyme activities including creatine kinase-MB, lactate dehydrogenase, aspartate transaminase, and alanine transaminase. Significant increases in serum total cholesterol, triglycerides, and low-density lipoprotein-cholesterol levels were also observed, along with a reduction in the serum high-density lipoprotein-cholesterol level. In addition to these diagnostic markers, the levels of lipid peroxide products were significantly increased. The activities of antioxidant enzymes such as superoxide dismutase, glutathione peroxidase, and glutathione reductase were significantly decreased in the hearts after ISO-induced myocardial infarction. However, pretreatment of ischemic rats with Sundarban honey brought the biochemical parameters to near normalcy, indicating the protective effect of Sundarban honey against ISO-induced ischemia in rats. Histopathological findings of the heart tissues further confirmed the biochemical findings, indicating that Sundarban honey confers protection against ISO-induced oxidative stress in the myocardium.

This study was conducted to evaluate the effects of evaporation, gamma irradiation and temperature on the total polyphenols, flavonoids and 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical-scavenging activities of Tualang honey samples (n = 14) following storage over three, six or twelve months. The mean polyphenol concentrations of the six gamma irradiated honey samples at three, six and twelve months, respectively, were 96.13%, 98.01% and 102.03% higher than the corresponding values of the eight non-gamma irradiated samples. Similarly, the mean values for flavonoids at three, six and twelve months were 111.52%, 114.81% and 110.04% higher, respectively, for the gamma irradiated samples. The mean values for DPPH radical-scavenging activities at three, six and twelve months were also 67.09%, 65.26% and 44.65% higher, respectively, for the gamma irradiated samples. These data indicate that all gamma irradiated honey samples had higher antioxidant potential following gamma irradiation, while evaporation and temperature had minor effects on antioxidant potential.

Withania somnifera (L.) Dunal (Solanaceae), also known as ashwagandha, is an important medicinal plant that is widely used as a home remedy for several diseases in the Indian subcontinent and other parts of the world. W. somnifera is a dietary supplement composed of various nutrients, polyphenols and alkaloids that have free radical scavenging capacity, as well as other chemical constituents that possess anti-inflammatory, antitumor, anti-stress, antioxidant, immunomodulatory, and rejuvenating properties. The mechanism of action for these properties are not fully understood. W. somnifera also appears to influence the endocrine, cardiopulmonary and central nervous systems. Toxicity studies reveal that W. somnifera can be used without side effects. The findings presented in this review are very encouraging and indicate that this herb should be studied more extensively to confirm these results and to reveal other potential therapeutic effects.

I was happy to see Dr. Dutton and colleagues add Canadian data to the literature supporting prioritization and investment in social care.[1][1] I agree that social determinants of health can have as important an impact as health care on life expectancy — sometimes more. I also agree that using

Little is known about the epidemiology of sepsis in the Netherlands. In addition, information regarding the ability of emergency medical services (EMS) personnel to recognize sepsis is lacking. The aim of this study is to determine epidemiological characteristics of sepsis and the recognition of sepsis by EMS personnel in an urban area in the Netherlands. We conducted a retrospective cohort study using transport information from EMS Amsterdam and admission diagnoses at the emergency department gathered through discharge data from two academic hospitals in Amsterdam for the year 2012. A total of 253 patients with sepsis were evaluated, of which 131 were transported by ambulance. The in-hospital mortality rate of the total population was 21% and a mean length of hospital stay was of 13.5 days. Sixty-seven patients (26.5%) were admitted to the intensive care unit. Almost half of the patients were assigned to the internal medicine ward (117; 46.2%). The most common site of infection was the urinary tract (30%). E. coli was the most frequent cause of infections. EMS staff recognized 18/131 (13.7%) transported patients with (severe) sepsis or septic shock. In 52 cases (39.7%) sepsis went unrecognized, probably due to an incomplete primary survey. In 60 cases (45.8%) sepsis went unrecognized, although enough systemic inflammatory response syndrome criteria were present at initial presentation. Recognition of sepsis by EMS staff in the Netherlands is low, probably due to a lack of awareness of the syndrome and infrequent measurement of temperature and respiratory rate. As early initiation of treatment is crucial, the EMS staff, general practitioners, and other specialties could benefit from more education on this critical illness.

Introduction: General practitioners (GPs) and the emergency medical services (EMS) personnel have a pivotal role as points of entry into the acute care chain. This study was conducted to investigate the recognition of sepsis by GPs and EMS personnel and to evaluate the associations between recognition of sepsis in the pre-hospital setting and patient outcomes. Methods Design: prospective, observational study during a 12 week period in the emergency department (ED) of two academic hospitals. Study population: Patients >18 years presenting with sepsis at the ED. The information available in the ED discharge letter and the ED charts was used to make a definite diagnosis of sepsis, severe sepsis and septic shock Outcome measures: primary: recognition/documentation of sepsis. Secondary: ED arrival time to antibiotic administration, in-hospital mortality, hospital length of stay (LOS) and intensive care unit (ICU) admission. Results: A total of 301 patients were included in the study. GPs and EMS personnel correctly identified and documented 31.6% (n=114) and 41.4% of all sepsis patients (n=140) respectively. Recognition and documentation of sepsis improved with increasing severity. The mean time to administration of antibiotics (TTA) was nearly halved for the group of patients where sepsis was documented (GP: 66,4 minutes, EMS: 65,6 minutes) compared to the group in which sepsis was not documented (GP: 123,9 minutes, EMS: 101,5 minutes; p= 0.365 and p= 0.024 respectively). Conclusions: There is room for improvement in the recognition of sepsis, severe sepsis and septic shock by practitioners working in the pre-hospital setting. Documentation of sepsis prior to arrival in hospital led to a reduced time delay in administration of antibiotics.

We investigated the protective role ofWithania somniferaleaf extract (WSLEt) on isoproterenol- (ISO-) induced myocardial infarction (MI) in rats. Subcutaneous injection of ISO (85 mg/kg body weight (b.w.)) administered to rats for two consecutive days caused a significant increase in cardiac troponin I (cTnI) levels and serum lipid profiles, as well as the activities of some marker enzymes. In addition to these diagnostic markers, there were increased levels of lipid peroxidation (LPO) and decreased activities of enzymatic antioxidants (superoxide dismutase (SOD), glutathione peroxidase (GPx), glutathione reductase (GRx), and glutathione-S-transferase (GST)) in the myocardium. However, oral pretreatment (100 mg/kg b.w.) with WSLEt for 4 weeks elicited a significant cardioprotective activity by lowering the levels of cTnI, lipid profiles, and marker enzymes. The levels of LPO products were also significantly decreased. Elevated activities of antioxidant enzymes were also observed in rats pretreated with WSLEt. As further confirmed histopathologically, our findings strongly suggest that the cardioprotective effect of WSLEt on myocardium experiencing ISO-induced oxidative damage may be due to an augmentation of the endogenous antioxidant system and an inhibition of LPO in the myocardial membrane. We conclude that WSLEt confers some protection against oxidative damage in ISO-induced MI in rats.

A long completion time in the Emergency Department (ED) is associated with higher morbidity and in-hospital mortality. A completion time of more than four hours is a frequently used cut-off point. Mostly, older and sicker patients exceed a completion time of four hours on the ED. The primary aim was to examine which factors currently contribute to overcrowding and a time to completion of more than four hours on the EDs of two different hospitals, namely: the VU Medical Center (VUmc), an academic level 1 trauma centre and the St. Antonius Hospital, a large community hospital in Nieuwegein. In addition, we compared the differences between these hospitals.In this observational study, the time steps in the process of diagnosing and treatment of all patients visiting the EDs of the two hospitals were measured for four weeks. Patients triaged as Emergency Severity Index (ESI) category 2/3 or Manchester Triage System (MTS) orange/yellow were followed more closely and prospectively by researchers for detailed information in the same period from 12.00-23.00 hrs.In the VUmc, 89% of the patients had a completion time of less than four hours. The average completion time (n = 2262) was 2:10 hours, (median 1:51 hours, range: 0:05-12:08). In the St. Antonius Hospital, 77% of patients had a completion time shorter than four hours (n = 1656). The average completion time in hours was 2:49 (n = 1655, median 2:34, range: 0:08-11:04). In the VUmc, a larger percentage of ESI 1, 2 and 3 patients did not achieve the 4-hour target (14%, 20% and 19%) compared with ESI 4 and 5 patients (2.7% and 0%), p0.001. At the St. Antonius Hospital, a greater percentage of orange and yellow categorised patients exceeded four hours on the ED (32% and 28%) compared with red (8%) and green/blue (13%), p0.001. For both hospitals there was a significant dependency between exceeding four hours on the ED and the following: whether a consultation was performed (p0.001), the number of radiology tests performed (p0.001), and an age above 65 years.Factors leading to ED stagnation were similar in both hospitals, namely old age, treatment by more than one speciality and undergoing radiological tests. Uniform remedial measures should be taken on a nationwide level to deal with these factors to reduce stagnation in the EDs.

Honey is a popular natural food product with a very complex composition mainly consisting of both organic and inorganic constituents. The composition of honey is strongly influenced by both natural and anthropogenic factors, which vary based on its botanical and geographical origins. Although minerals and heavy metals are minor constituents of honey, they play vital role in determining its quality. There are several different analytical methods used to determine the chemical elements in honey. These methods are typically based on spectroscopy or spectrometry techniques (including atomic absorption spectrometry, atomic emission spectrometry, inductively coupled plasma mass spectrometry, and inductively coupled plasma optical emission spectrometry). This review compiles available scientific information on minerals and heavy metals in honey reported from all over the world. To date, 54 chemical elements in various types of honey have been identified and can be divided into 3 groups: major or macroelements (Na, K, Ca, Mg, P, S, Cl), minor or trace elements (Al, Cu, Pb, Zn, Mn, Cd, Tl, Co, Ni, Rb, Ba, Be, Bi, U, V, Fe, Pt, Pd, Te, Hf, Mo, Sn, Sb, La, I, Sm, Tb, Dy, Sd, Th, Pr, Nd, Tm, Yb, Lu, Gd, Ho, Er, Ce, Cr, As, B, Br, Cd, Hg, Se, Sr), and heavy metals (trace elements that have a specific gravity at least 5 times higher than that of water and inorganic sources). Chemical elements in honey samples throughout the world vary in terms of concentrations and are also influenced by environmental pollution.

Background Several triage systems have been developed for use in the emergency department (ED), however they are not designed to detect deterioration in patients. Deteriorating patients may be at risk of going undetected during their ED stay and are therefore vulnerable to develop serious adverse events (SAEs). The National Early Warning Score (NEWS) has a good ability to discriminate ward patients at risk of SAEs. The utility of NEWS had not yet been studied in an ED. Objective To explore the performance of the NEWS in an ED with regard to predicting adverse outcomes. Design A prospective observational study. Patients Eligible patients were those presenting to the ED during the 6 week study period with an Emergency Severity Index (ESI) of 2 and 3 not triaged to the resuscitation room. Intervention NEWS was documented at three time points: on arrival (T0), hour after arrival (T1) and at transfer to the general ward/ICU (T2). The outcomes of interest were: hospital admission, ICU admission, length of stay and 30 day mortality. Results A total of 300 patients were assessed for eligibility. Complete data was able to be collected for 274 patients on arrival at the ED. NEWS was significantly correlated with patient outcomes, including 30 day mortality, hospital admission, and length of stay at all-time points. Conclusion The NEWS measured at different time points was a good predictor of patient outcomes and can be of additional value in the ED to longitudinally monitor patients throughout their stay in the ED and in the hospital.