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CRISPR therapy for hematological disease has proven effective for transplant dependent beta thalassemia and sickle cell anemia, with additional disease targets in sight. The success of these therapies relies on high rates of CRISPR-induced double strand DNA breaks in hematopoietic stem and progenitor cells (HSPC). To achieve these levels, CRISPR complexes are typically delivered by electroporation ex vivo which is toxic to HSPCs. HSPCs are then cultured in stimulating conditions that promote error-prone DNA repair, requiring conditioning with chemotherapy to facilitate engraftment after reinfusion. In vivo delivery by nanocarriers of CRISPR gene editing tools has the potential to mitigate this complexity and toxicity and make this revolutionary therapy globally available. To achieve in vivo delivery, the inherent restriction factors against oligonucleotide delivery into HSPCs, that make ex vivo manipulation including electroporation and stimulation essential, must be overcome. To this end, our group developed a CRISPR carrying gold nanoparticle (CRISPR-AuNP) capable of delivering either Cas9 or Cas12a CRISPRs as ribonucleoprotein complexes (RNP) without compromising HSPC fitness. However, the most commonly used CRISPR, Cas9, demonstrated inconsistent activity in this delivery system, with lower activity relative to Cas12a. Investigation of Cas9 RNP biophysics relative to Cas12a revealed duplex RNA instability during the initial loading onto Au cores, resulting in undetectable Cas9 loading to the particle surface. Here we demonstrate preformation of RNP before loading, coupled with optimization of the loading chemistry and conditions, resulted in 39.6 ± 7.0 Cas9 RNP/AuNP without compromising RNP activity in both in vitro assays and primary human HSPC. The same alterations improved Cas12a RNP/AuNP loading 10-fold over previously reported levels. To achieve particle stability, the reported polyethyleneimine outer coating was altered to include PEGylation and the resulting 2nd generation CRISPR-AuNP demonstrates favorable nanoformulation characteristics for in vivo administration, with a hydrophilic, more neutral nanoparticle surface. Direct treatment of HSPC in vitro showed 72.5 ± 7.37% uptake of 2nd generation CRISPR-AuNP in primary human HSPC, but with endosomal accumulation and low rates of gene editing consistent with low levels of endosomal escape.

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BACKGROUND: People with opioid use disorder (OUD) are high-risk for short-term mortality and morbidity. Emergency department (ED) interventions can reduce those risks, but benefits wane without ongoing community follow-up. OBJECTIVE: To evaluate an ED-based intensive community outreach program. METHODS: At two urban EDs between October 2019 and March 2020, we enrolled patients with OUD not currently on opioid agonist therapy (OAT) in a prospective cohort study evaluating a one-year intensive community outreach program, which provided ongoing addictions care, housing resources, and community support. We surveyed patients at intake and at scheduled outreach encounters at one, two, six, and twelve months. Follow-up surveys assessed OAT uptake, addictions care engagement, housing status, quality of life scores, illicit opioid use, and outreach helpfulness. We used descriptive statistics for each period and conducted sensitivity and subgroup analyses to account for missing data. RESULTS: Of 84 baseline participants, 29% were female and 32% were housed, with a median age of 33. Sixty participants (71%) completed at least one follow-up survey. Survey completion rates were 37%, 38%, 39%, and 40% respectively at one, two, six, and twelve months. Participants had a median of three outreach encounters. Among respondents, OAT was 0% at enrolment and ranged from 38% to 56% at follow-up; addictions care engagement was 22% at enrolment and ranged from 65% to 81% during follow-up; and housing was 40% at enrolment and ranged from 48% to 59% during follow-up. Improvements from baseline to follow-up occurred for all time periods. OAT and engagement in care benefits were maintained in sensitivity and subgroup analyses. Respondents rated the outreach program as helpful at all time periods, CONCLUSION: An ED-initiated intensive outreach program for patients with OUD not yet on OAT was associated with a persistent increase in OAT use and engagement in care, as well as housing.

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OBJECTIVE: To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs. METHODS: We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence. RESULTS: We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup. CONCLUSIONS: Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

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In environmental research, it is critical to understand how toxins impact invertebrate eggs and egg banks, which, due to their tiny size, are very challenging to study by conventional nuclear magnetic resonance (NMR) spectroscopy. Microcoil technology has been extensively utilized to enhance the mass-sensitivity of NMR. In a previous study, 5-axis computer numerical control (CNC) micromilling (shown to be a viable alternative to traditional microcoil production methods) was used to create a prototype copper slotted-tube resonator (STR). Despite the excellent limit of detection (LOD) of the resonator, the quality of the line shape was very poor due to the magnetic susceptibility of the copper resonator itself. This is best solved using magnetic susceptibility-matched materials. In this study, approaches are investigated that improve the susceptibility while retaining the versatility of coil milling. One method involves machining STRs from various copper/aluminum alloys, while the other involves machining ones from an aluminum 2011 alloy and electroplating them with copper. In all cases, combining copper and aluminum to produce resonators resulted in improved line shape and SNR compared to pure copper resonators due to their reduced magnetic susceptibility. However, the copper-plated aluminum resonators showed optimal performance from the devices tested. The enhanced LOD of these STRs allowed for the first 1H-13C heteronuclear multiple quantum coherence (HMQC) of a single intact 13C-labeled Daphnia magna egg (∼4 µg total biomass). This is a key step toward future screening programs that aim to elucidate the toxic processes in aquatic eggs.

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Many key building blocks of life contain nitrogen moieties. Despite the prevalence of nitrogen-containing metabolites in nature, 15N nuclei are seldom used in NMR-based metabolite assignment due to their low natural abundance and lack of comprehensive chemical shift databases. However, with advancements in isotope labeling strategies, 13C and 15N enriched metabolites are becoming more common in metabolomic studies. Simple multidimensional nuclear magnetic resonance (NMR) experiments that correlate 1H and 15N via single bond 1JNH or multiple bond 2-3JNH couplings using heteronuclear single quantum coherence (HSQC) or heteronuclear multiple bond coherence are well established and routinely applied for structure elucidation. However, a 1H-15N correlation spectrum of a metabolite mixture can be difficult to deconvolute, due to the lack of a 15N specific database. In order to bridge this gap, we present here a broadband 15N-edited 1H-13C HSQC NMR experiment that targets metabolites containing 15N moieties. Through this approach, nitrogen-containing metabolites, such as amino acids, nucleotide bases, and nucleosides, are identified based on their 13C, 1H, and 15N chemical shift information. This approach was tested and validated using a [15N, 13C] enriched Daphnia magna (water flea) metabolite extract, where the number of clearly resolved 15N-containing peaks increased from only 11 in a standard HSQC to 51 in the 15N-edited HSQC, and the number of obscured peaks decreased from 59 to just 7. The approach complements the current repertoire of NMR techniques for mixture deconvolution and holds considerable potential for targeted metabolite NMR in 15N, 13C enriched systems.

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OBJECTIVES: Many emergency department (ED) patients with opioid use disorder are candidates for home buprenorphine/naloxone initiation with to-go packs. We studied patient opinions and acceptance of buprenorphine/naloxone to-go packs, and factors associated with their acceptance. METHODS: We identified patients at two urban EDs in British Columbia who met opioid use disorder criteria, were not presently on opioid agonist therapy and not in active withdrawal. We offered patients buprenorphine/naloxone to-go as standard of care and then administered a survey to record buprenorphine/naloxone to-go acceptance, the primary outcome. Survey domains included current substance use, prior experience with opioid agonist therapy, and buprenorphine/naloxone related opinions. Patient factors were examined for association with buprenorphine/naloxone to-go acceptance. RESULTS: Of the 89 patients enrolled, median age was 33 years, 27% were female, 67.4% had previously taken buprenorphine/naloxone, and 19.1% had never taken opioid agonist therapy. Overall, 78.7% believed that EDs should dispense buprenorphine/naloxone to-go packs. Thirty-eight (42.7%) patients accepted buprenorphine/naloxone to-go. Buprenorphine/naloxone to-go acceptance was associated with lack of prior opioid agonist therapy, less than 10 years of opioid use and no injection drug use. Reasons to accept included initiating treatment while in withdrawal; reasons to reject included prior unsatisfactory buprenorphine/naloxone experience and interest in other treatments. CONCLUSION: Although less than half of our study population accepted buprenorphine/naloxone to-go when offered, most thought this intervention was beneficial. In isolation, ED buprenorphine/naloxone to-go will not meet the needs of all patients with opioid use disorder. Clinicians and policy makers should consider buprenorphine/naloxone to-go as a low-barrier option for opioid use disorder treatment from the ED when integrated with robust addiction care services.

RéSUMé: OBJECTIFS: De nombreux patients des services d'urgence (SU) atteints d'un trouble lié à la consommation d'opioïdes sont des candidats à l'initiation à la buprénorphine/naloxone à domicile avec des trousses à emporter. Nous avons étudié les opinions des patients et l'acceptation des paquets de buprénorphine/naloxone à emporter, ainsi que les facteurs associés à leur acceptation. MéTHODES: Nous avons identifié des patients à deux urgences urbaines de la Colombie-Britannique qui répondaient aux critères relatifs aux troubles liés à l'utilisation d'opioïdes, qui ne suivaient pas actuellement un traitement aux agonistes des opioïdes et qui n'étaient pas en sevrage actif. Nous avons offert aux patients la buprénorphine/naloxone à emporter comme norme de soins, puis nous avons administré une enquête pour enregistrer l'acceptation de la buprénorphine/naloxone à emporter, le critère de jugement principal. Les domaines d'enquête comprenaient la consommation actuelle de substances, l'expérience antérieure avec le traitement aux agonistes opioïdes et les opinions liées à la buprénorphine/naloxone. Les facteurs du patient ont été examinés pour déterminer l'association avec l'acceptation de la buprénorphine/naloxone à emporter. RéSULTATS: Sur 89 patients inscrits, l'âge médian était de 33 ans, 27,0% étaient des femmes, 67,4% avaient déjà pris de la buprénorphine/naloxone et 19,1% n'avaient jamais pris de traitement aux agonistes opioïdes. Dans l'ensemble, 78,7% des répondants étaient d'avis que les SU devraient distribuer des paquets de buprénorphine/naloxone à emporter. Trente-huit (42,7%) patients ont accepté la buprénorphine/naloxone à emporter. L'acceptation de la buprénorphine/naloxone à emporter était associée à l'absence de traitement antérieur par agonistes opioïdes, à moins de 10 ans d'utilisation d'opioïdes et à l'absence de consommation de drogues injectables. Les raisons d'accepter comprenaient le fait de commencer un traitement pendant le sevrage; les raisons de rejeter comprenaient une expérience antérieure insatisfaisante de buprénorphine/naloxone et un intérêt pour d'autres traitements. CONCLUSION: Bien que moins de la moitié de notre population à l'étude ait accepté la buprénorphine/naloxone à emporter lorsqu'elle lui était offerte, la plupart ont pensé que cette intervention était bénéfique. Isolément, la buprénorphine/naloxone à emporter à l'urgence ne répondra pas aux besoins de tous les patients atteints de troubles liés à l'utilisation d'opioïdes. Les cliniciens et les décideurs devraient considérer la buprénorphine/naloxone à emporter comme une option à faible barrière pour le traitement des troubles liés à la consommation d'opioïdes par l'urgence lorsqu'elle est intégrée à de solides services de soins de la toxicomanie.

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BACKGROUND: Approximately one-quarter of emergency department (ED) visits for alcohol withdrawal result in unscheduled 1-week ED return visits, but it is unclear what patient and clinical factors may impact this outcome METHODS: From January 1, 2015, to December 31, 2018, at three urban EDs in Vancouver, Canada, we studied patients who were discharged with a primary or secondary diagnosis of alcohol withdrawal. We performed a structured chart review to ascertain patient characteristics, ED treatments, and the outcome of an ED return within 1 week of discharge. We used univariable and multivariable Bayesian binomial regression to identify characteristics associated with being in the upper quartile of 1-week ED revisits. RESULTS: We collected 935 ED visits among 593 unique patients. Median age was 45 years (interquartile range 34 to 55 years) and 71% were male. The risk of a 1-week ED revisit was 15.0% (IQR 12.3; 19.5%). After adjustment, factors independently associated with a high risk for return included any prior ED visit within 30 days, no fixed address, initial blood alcohol level > 45 mmol/L, and initial Clinical Institute Withdrawal Assessment-alcohol revised score > 23. These factors explained 41% of the overall variance in revisits. CONCLUSION: Among discharged ED patients with alcohol withdrawal, we describe high-risk patient characteristics associated with 1-week ED revisits, and these findings may assist clinicians to facilitate appropriate discharge planning with access to integrated follow-up support.

RéSUMé: CONTEXTE: Environ un quart des visites aux urgences pour sevrage alcoolique se traduit par un retour non programmé aux urgences pendant une semaine, mais les facteurs cliniques et relatifs aux patients qui peuvent avoir une incidence sur ce résultat ne sont pas clairs. MéTHODES: Du 1er janvier 2015 au 31 décembre 2018, dans trois urgences urbaines de Vancouver, au Canada, nous avons étudié les patients qui sont sortis avec un diagnostic primaire ou secondaire de sevrage alcoolique. Nous avons procédé à une analyse structurée des dossiers afin de déterminer les caractéristiques des patients, les traitements aux urgences et l'issue d'un retour aux urgences dans la semaine suivant la sortie. Nous avons utilisé une régression binomiale bayésienne univariable et multivariable pour identifier les caractéristiques associées au fait d'être dans le quartile supérieur des visites aux urgences à une semaine. RéSULTATS: Nous avons recueilli 935 visites aux urgences parmi 593 patients uniques. L'âge médian était de 45 ans (intervalle interquartile de 34 à 55 ans) et 71 % étaient des hommes. Le risque d'une nouvelle visite aux urgences à une semaine était de 15,0% (IQR 12,3 ; 19,5%). Après ajustement, les facteurs indépendamment associés à un risque élevé de retour comprenaient toute visite antérieure à l'urgence dans les 30 jours, aucune adresse fixe, le taux d'alcoolémie initial > 45 mmol/L, et l'évaluation initiale du sevrage de l'Institut clinique ­ cote d'alcoolémie révisée > 23. Ces facteurs expliquaient 41 % de la variance globale des visites. CONCLUSIONS: Parmi les patients sortants des urgences en sevrage alcoolique, nous décrivons les caractéristiques des patients à haut risque associés à la réadmission aux urgences après une semaine de sevrage alcoolique. Ces résultats peuvent aider les cliniciens à planifier de manière appropriée la sortie de l'hôpital et à accéder à un suivi intégré.

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Genetic editing of hematopoietic stem and progenitor cells can be employed to understand gene-function relationships underlying hematopoietic cell biology, leading to new therapeutic approaches to treat disease. The ability to collect, purify, and manipulate primary cells outside the body permits testing of many different gene editing approaches. RNA-guided nucleases, such as CRISPR, have revolutionized gene editing based simply on Watson-Crick base-pairing, employed to direct activity to specific genomic loci. Given the ease and affordability of synthetic, custom RNA guides, testing of precision edits or large random pools in high-throughput screening studies is now widely available. With the ever-growing number of CRISPR nucleases being discovered or engineered, researchers now have a plethora of options for directed genomic change, including single base edits, nicks or double-stranded DNA cuts with blunt or staggered ends, as well as the ability to target CRISPR to other cellular oligonucleotides such as RNA or mitochondrial DNA. Except for single base editing strategies, precise rewriting of larger segments of the genetic code requires delivery of an additional component, templated DNA oligonucleotide(s) encoding the desired changes flanked by homologous sequences that permit recombination at or near the site of CRISPR activity. Altogether, the ever-growing CRISPR gene editing toolkit is an invaluable resource. This chapter outlines available technologies and the strategies for applying CRISPR-based editing in hematopoietic stem and progenitor cells.

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Granulomas are the hallmark of Mycobacterium tuberculosis (Mtb) infection. Cytokine-mediated signaling can modulate immune function; thus, understanding the cytokine milieu in granulomas is critical for understanding immunity in tuberculosis (TB). Interferons (IFNs) are important immune mediators in TB, and while type 1 and 2 IFNs have been extensively studied, less is known about type 3 IFNs (IFNλs) in TB. To determine if IFNλs are expressed in granulomas, which cells express them, and how granuloma microenvironments influence IFNλ expression, we investigated IFNλ1 and IFNλ4 expression in macaque lung granulomas. We identified IFNλ expression in granulomas, and IFNλ levels negatively correlated with bacteria load. Macrophages and neutrophils expressed IFNλ1 and IFNλ4, with neutrophils expressing higher levels of each protein. IFNλ expression varied in different granuloma microenvironments, with lymphocyte cuff macrophages expressing more IFNλ1 than epithelioid macrophages. IFNλ1 and IFNλ4 differed in their subcellular localization, with IFNλ4 predominantly localizing inside macrophage nuclei. IFNλR1 was also expressed in granulomas, with intranuclear localization in some cells. Further investigation demonstrated that IFNλ signaling is driven in part by TLR2 ligation and was accompanied by nuclear translocation of IFNλR1. Our data indicate that IFNλs are part of the granuloma cytokine milieu that may influence myeloid cell function and immunity in TB.

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OBJECTIVES: To examine the association between specialist consultation and risk of 30-day ED revisit in emergency department (ED) patients with recent-onset uncomplicated atrial fibrillation or flutter (AF/AFL). METHODS: As a secondary analysis of a previously published trial, clinical experts identified predictors of consultation including age and sex, ED sinus conversion, thromboembolic risk, heart rate, rate control medication use, coronary artery disease and anti-platelet use, and chronic obstructive pulmonary disease. These were included in a propensity-matched hierarchical Bayesian model accounting for hospital site as a random effect, with 30-day ED revisit as the primary outcome. We also measured ED length of stay for consulted and non-consulted patients. RESULTS: We analyzed data from 11 sites for 829 ED patients with AF/AFL, of whom 364 (44%) had specialist consultation. A total of 128 patients (15.4%) had an ED revisit, 78 (16.8%) from the no consult group and 50 (13.7%) from the consult group. Consultation rates ranged from 8.8 to 71% between sites. Median length of stay was 591 min (interquartile range [IQR] 359-1024) for consulted patients and 300 min (IQR 212-409) for patients without consultation. After propensity-matching, consulted patients had a 0.6% (IQR - 4 to 3%) lower risk of 30-day revisits than non-consulted patients (probability of lower risk 55%). CONCLUSIONS: In ED patients with uncomplicated AF/AFL, there was substantial between-site variation in specialist consultations; such consultation was unlikely to influence revisits within 30 days while ED length of stay was nearly double. ED specialist consultations may not be necessary for uncomplicated patients.

RéSUMé: OBJECTIFS: Examiner l'association entre la consultation d'un spécialiste et le risque d'une nouvelle visite aux urgences à 30 jours chez les patients des urgences souffrant de fibrillation auriculaire ou de flutter non compliqué d'apparition récente (FA/AFL). MéTHODES: Dans le cadre d'une analyse secondaire d'un essai précédemment publié, des experts cliniques ont identifié les facteurs prédictifs de la consultation, notamment l'âge et le sexe, la conversion sinusale des urgences, le risque thromboembolique, la fréquence cardiaque, l'utilisation de médicaments pour contrôler la fréquence cardiaque, la maladie coronarienne et l'utilisation d'antiplaquettaires, et la maladie pulmonaire obstructive chronique. Ceux-ci ont été inclus dans un modèle bayésien hiérarchique apparié en fonction de la propension, qui tient compte du site de l'hôpital comme effet aléatoire, le critère principal étant le retour aux urgences à 30 jours. Nous avons également mesuré la durée de séjour aux urgences des patients consultés et non consultés. RéSULTATS: Nous avons analysé les données de 11 sites pour 829 patients du service d'urgence atteints de FA/AFL, dont 364 (44 %) avaient consulté un spécialiste. Un total de 128 patients (15,4 %) ont eu une nouvelle visite à l'urgence, 78 (16,8 %) du groupe sans consultation et 50 (13,7 %) du groupe de consultation. Les taux de consultation variaient de 8,8 % à 71 % selon les sites. La durée médiane du séjour était de 591 minutes (intervalle interquartile [IQR] 359-1024) pour les patients consultés et de 300 min (IQR 212-409) pour les patients sans consultation. Après appariement par propension, les patients consultés avaient un risque inférieur de 0,6 % (IQR -4 % à 3 %) de revisites à 30 jours par rapport aux patients non consultés (probabilité de risque inférieur de 55 %). CONCLUSIONS: Chez les patients des urgences atteints de FA/AFL non compliquée, il y avait une variation substantielle entre les sites dans les consultations de spécialistes ; il était peu probable qu'une telle consultation influence les visites dans les 30 jours alors que la durée du séjour aux urgences était presque le double. Les consultations de spécialistes des urgences peuvent ne pas être nécessaires pour les patients sans complication.

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OBJECTIVES: The primary objective of this study was to measure the risk of return Emergency Department (ED) visits in patients presenting to the ED with a diagnosis of substance-induced psychosis. Secondary objectives included: (1) describing the characteristics of patients returning within 30 days to the ED with substance-induced psychosis, and (2) identifying risk factors associated with such ED return. METHODS: At two urban sites from January 1, 2018 to December 31, 2019, we included consecutive patients presenting to the ED with substance-induced psychosis defined by their ED discharge diagnosis of psychosis and clinical evidence of substance use. We described ED resources utilized by this patient population including ED time and disposition then subsequently described return visits within 30 days and characteristics among those patients who returned. RESULTS: We identified 611 unique patients presenting with substance-induced psychosis, with 813 total ED visits. The median age was 35 years (IQR 28-45), 71.4% (n = 436) were male, and 44.8% (n = 274) were homeless. The median ED length of stay was 619 min (IQR 313-898), and 48.4% (n = 296) were admitted to hospital. Forty percent of patients (n = 237) returned to the ED within 30 days of the index substance-induced psychosis visit, 116 (18.9%) returning more than once. Of these return visits, 74 (31.2%) were for recurrent substance-induced psychosis. Younger age, female gender, no opioid use, and no prior history of bipolar disorder were identified as common characteristics among those returning to the ED with substance-induced psychosis. CONCLUSIONS: In ED patients with substance-induced psychosis, nearly half of all patients were admitted to hospital, 40% had a 30 days return ED visit, and one-third of those were for substance-induced psychosis. We identified clinically relevant factors common to those returning with recurrent substance-induced psychosis.

RéSUMé: OBJECTIFS: L'objectif principal de cette étude était de mesurer le risque de retour aux urgences chez les patients se présentant aux urgences avec un diagnostic de psychose induite par une substance. Les objectifs secondaires comprenaient : 1) décrire les caractéristiques des patients qui retournent aux urgences dans les 30 jours avec une psychose induite par la substance, et 2) déterminer les facteurs de risque associés à ce retour aux urgences. MéTHODES: Dans deux sites urbains, du 1er janvier 2018 au 31 décembre 2019, nous avons inclus des patients consécutifs se présentant aux urgences avec une psychose induite par une substance, définie par leur diagnostic de psychose à la sortie des urgences et des preuves cliniques de consommation de substances. Nous avons décrit les ressources des urgences utilisées par cette population de patients, notamment le temps passé aux urgences et les dispositions prises, puis nous avons décrit les visites de retour dans les 30 jours et les caractéristiques des patients qui sont revenus. RéSULTATS: Nous avons identifié 611 patients uniques présentant une psychose induite par une substance, avec un total de 813 visites aux urgences. L'âge médian était de 35 ans (IQR 28-45), 71,4 % (n = 436) étaient des hommes et 44,8 % (n = 274) étaient sans domicile fixe. La durée médiane du séjour aux urgences était de 619 minutes (IQR 313-898), et 48,4 % (n = 296) ont été hospitalisés. Quarante pour cent des patients (n = 237) sont retournés aux urgences dans les 30 jours suivant la visite de référence pour une psychose due à une substance, 116 (18,9 %) y étant retournés plus d'une fois. Parmi ces visites de retour, 74 (31,2 %) concernaient une psychose récurrente induite par une substance. Un âge plus jeune, le sexe féminin, l'absence de consommation d'opioïdes et d'antécédents de troubles bipolaires ont été identifiés comme des caractéristiques communes chez les personnes revenant aux urgences pour une psychose induite par une substance. CONCLUSIONS: Chez les patients des urgences souffrant de psychose due à une substance, près de la moitié des patients ont été hospitalisés, 40 % sont revenus aux urgences dans les 30 jours, dont un tiers pour une psychose due à une substance. Nous avons identifié des facteurs cliniquement pertinents communs à ceux qui reviennent avec une psychose récurrente induite par une substance.

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Comprehensive multiphase-nuclear magnetic resonance (CMP-NMR) is a non-invasive approach designed to observe all phases (solutions, gels, and solids) in intact samples using a single NMR probe. Studies of dead and living organisms are important to understand processes ranging from biological growth to environmental stress. Historically, such studies have utilized 1H-based phase editing for the detection of soluble/swollen components and 1H-detected 2D NMR for metabolite assignments/screening. However, living organisms require slow spinning rates (∼500 Hz) to increase survivability, but at such low speeds, complications from water sidebands and spectral overlap from the modest chemical shift window (∼0-10 ppm) make 1H NMR challenging. Here, a novel 13C-optimized E-Free magic angle spinning CMP probe is applied to study all phases in ex vivo and in vivo samples. This probe consists of a two-coil design, with an inner single-tuned 13C coil providing a 113% increase in 13C sensitivity relative to a traditional multichannel single-CMP coil design. For organisms with a large biomass (∼0.1 g) like the Ganges River sprat (ex vivo), 13C-detected full spectral editing and 13C-detected heteronuclear correlation (HETCOR) can be performed at natural abundance. Unfortunately, for a single living shrimp (∼2 mg), 13C enrichment was still required, but 13C-detected HETCOR shows superior data relative to heteronuclear single-quantum coherence at low spinning speeds (due to complications from water sidebands in the latter). The probe is equipped with automatic-tuning-matching and is compatible with automated gradient shimming─a key step toward conducting multiphase screening of dead and living organisms under automation in the near future.

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The Amazon forest has the highest biodiversity on Earth. However, information on Amazonian vertebrate diversity is still deficient and scattered across the published, peer-reviewed, and gray literature and in unpublished raw data. Camera traps are an effective non-invasive method of surveying vertebrates, applicable to different scales of time and space. In this study, we organized and standardized camera trap records from different Amazon regions to compile the most extensive data set of inventories of mammal, bird, and reptile species ever assembled for the area. The complete data set comprises 154,123 records of 317 species (185 birds, 119 mammals, and 13 reptiles) gathered from surveys from the Amazonian portion of eight countries (Brazil, Bolivia, Colombia, Ecuador, French Guiana, Peru, Suriname, and Venezuela). The most frequently recorded species per taxa were: mammals: Cuniculus paca (11,907 records); birds: Pauxi tuberosa (3713 records); and reptiles: Tupinambis teguixin (716 records). The information detailed in this data paper opens up opportunities for new ecological studies at different spatial and temporal scales, allowing for a more accurate evaluation of the effects of habitat loss, fragmentation, climate change, and other human-mediated defaunation processes in one of the most important and threatened tropical environments in the world. The data set is not copyright restricted; please cite this data paper when using its data in publications and we also request that researchers and educators inform us of how they are using these data.

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OBJECTIVE: Clinical trials for patients with shock-refractory out-of-hospital cardiac arrest (OHCA), including the Amiodarone, Lidocaine or Placebo (ALPS) trial, have been unable to demonstrate definitive benefit after treatment with antiarrhythmic drugs. A Bayesian approach, combining the available evidence, may yield additional insights. METHODS: We conducted a reanalysis of the ALPS trial comparing treatment with amiodarone or lidocaine with placebo in patients with OHCA following shock-refractory ventricular fibrillation or ventricular tachycardia (VF/VT). We used Bayesian regression to assess the probability of improved survival or improved neurological outcome on the 7-point modified Rankin Scale. We derived weak, moderate and strong priors from a previous clinical trial. RESULTS: The original ALPS trial randomised 3026 adult patients with OHCA to amiodarone (n=974, survival to hospital discharge 24.4%), lidocaine, (n=993, survival 23.7%) or placebo (n=1059, survival 21.0%). In our reanalysis the probability of improved survival from amiodarone ranged from 83% (strong prior) to 95% (weak prior) compared with placebo and from 78% (strong) to 90% (weak) for lidocaine-an estimated improvement in survival of 2.9% (IQR 1.4%-3.8%) for amiodarone and 1.7% (IQR 0.84%-3.2%) for lidocaine over placebo (moderate prior). The probability of improved neurological outcome from amiodarone ranged from 96% (weak) to 99% (strong) compared with placebo and from 88% (weak) to 96% (strong) for lidocaine. CONCLUSIONS: In a Bayesian reanalysis of patients with shock-resistant VF/VT OHCA, treatment with amiodarone had high probabilities of improved survival and neurological outcome, while treatment with lidocaine had a more modest benefit.

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Microcoils provide a cost-effective approach to improve detection limits for mass-limited samples. Single-sided planar microcoils are advantageous in comparison to volume coils, in that the sample can simply be placed on top. However, the considerable drawback is that the RF field that is produced by the coil decreases with distance from the coil surface, which potentially limits more complex multi-pulse NMR pulse sequences. Unfortunately, 1 H NMR alone is not very informative for intact biological samples due to line broadening caused by magnetic susceptibility distortions, and 1 H-13 C 2D NMR correlations are required to provide the additional spectral dispersion for metabolic assignments in vivo or in situ. To our knowledge, double-tuned single-sided microcoils have not been applied for the 2D 1 H-13 C analysis of intact 13 C enriched biological samples. Questions include the following: Can 1 H-13 C 2D NMR be performed on single-sided planar microcoils? If so, do they still hold sensitivity advantages over conventional 5 mm NMR technology for mass limited samples? Here, 2D 1 H-13 C HSQC, HMQC, and HETCOR variants were compared and then applied to 13 C enriched broccoli seeds and Daphnia magna (water fleas). Compared to 5 mm NMR probes, the microcoils showed a sixfold improvement in mass sensitivity (albeit only for a small localized region) and allowed for the identification of metabolites in a single intact D. magna for the first time. Single-sided planar microcoils show practical benefit for 1 H-13 C NMR of intact biological samples, if localized information within ~0.7 mm of the 1 mm I.D. planar microcoil surface is of specific interest.

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BACKGROUND: Extended periods awaiting an inpatient bed in the emergency department (ED) may exacerbate the state of patients with acute psychiatric illness, increasing the time it takes to stabilise their acute problem in hospital. Therefore, we assessed the association between boarding time and hospital length of stay for psychiatric patients. METHODS: ED clinical records were linked to inpatient administrative records for all patients with a primary psychiatric diagnosis admitted to a Calgary, Alberta hospital between April 2014 and March 2018. The primary exposure was boarding time (admission decision to inpatient bed transfer), and primary outcome was inpatient length of stay. Confounders for this relationship, including indicators of illness severity, were selected a priori then the association was assessed using hierarchical Bayesian Poisson regression, which accounts for repeat observations of the same patient and differences between hospital sites. Changes in length of stay were measured using a rate ratio (ie, expected change in length of stay for each 1 hour increase in boarding time). RESULTS: A total of 19 212 admissions (14 261 unique patients) were included in the analysis. The average boarding time was 14 hours (range: 0-186 hours). Patients who were boarded for greater than 14 hours more frequently required a high-observation bed (14% vs 3.5%), received an antipsychotic (44% vs 14%) or received sedation (55% vs 33%) while in the ED. The probability that boarding time increased hospital length of stay (rate ratio: >1) was 92%, with a median increase for a patient boarded for 24 hours of 0.01 days. CONCLUSION: Boarding in the ED was associated with a high probability of increasing the hospital length of stay for psychiatric patients; however, the absolute increase is minimal. Although slight, this signal for longer length of stay may be a sign of increased morbidity for psychiatric patients held in the ED.

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Soil and water contaminations are caused by rare earth elements (REEs) due to mining and industrial activities, that threaten the ecosystem and human health. Therefore, phytoremediation methods need to be developed to overcome this problem. To date, little research has been conducted concerning the phytoremediation potential of Salix for REEs. In this study, two Salix species (Salix myrsinifolia and Salix schwerinii) and two Salix cultivars (Klara and Karin) were hydroponically exposed to different concentrations of six-REE for 4 weeks. The treatments were: T1 (Control: tap water), T2 (La: 50 mg/L) and T3 (La 11.50 + Y 11 + Nd 10.50 + Dy 10 + Ce 12 and Tb 11.50 in mg L-1). The effects of the REE on Salix growth indicators (height, biomass, shoot diameter and root length), concentrations of REE in the produced biomass, and accumulation of REE in different parts of the Salix (stem, root, and leaf) tissues, were determined. In addition, the retention of REE in ashes following Salix combustion (800 and 1000 °C) was determined. The result indicates that with La and REE exposure, the height growth, dry biomass, shoot diameter and root length of all Salix remained equivalent to the control treatment excluding Klara, which displayed relatively higher growth in all parameters. Further, among the REE studied, the highest La concentration (8404 µg g-1 DW) and La accumulation (10,548 µg plant-1) were observed in Karin and Klara root respectively. Translocations and bioconcentration factors were discovered at <1 for all Salix, which indicates their phytostabilization potential. The total REE concentrations in bottom ashes varied between 7 and 8% with retention rates between 85 and 89%. This study demonstrates that Salix are suitable candidates for REE phytostabilization and the remediation of wastewater sites to limit metals percolating to the water layers in the ecosystem.

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Comprehensive multiphase (CMP) NMR, first described in 2012, combines all of the hardware components necessary to analyze all phases (solid, gel, and solution) in samples in their natural state. In combination with spectral editing experiments, it can fully differentiate phases and study the transfer of chemical species across and between phases, providing unprecedented molecular-level information in unaltered natural systems. However, many natural samples, such as swollen soils, plants, and small organisms, contain water, salts, and ionic compounds, making them electrically lossy and susceptible to RF heating, especially when using high-strength RF fields required to select the solid domains. While dedicated reduced-heating probes have been developed for solid-state NMR, to date, all CMP-NMR probes have been based on solenoid designs, which can lead to problematic sample heating. Here, a new prototype CMP probe was developed, incorporating a loop gap resonator (LGR) for decoupling. Temperature increases are monitored in salt solutions analogous to those in small aquatic organisms and then tested in vivo on Hyalella azteca (freshwater shrimp). In the standard CMP probe (solenoid), 80% of organisms died within 4 h under high-power decoupling, while in the LGR design, all organisms survived the entire test period of 12 h. The LGR design reduced heating by a factor of ∼3, which allowed 100 kHz decoupling to be applied to salty samples with generally ≤10 °C sample heating. In addition to expanding the potential for in vivo research, the ability to apply uncompromised high-power decoupling could be beneficial for multiphase samples containing true crystalline solids that require the strongest possible decoupling fields for optimal detection.

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OBJECTIVE: In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure. METHODS: We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5 mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60 days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group. RESULTS: Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk. CONCLUSIONS: Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.

RéSUMé: OBJECTIF: Chez les patients des services d'urgence (SU) atteints de colique urétérale, la valeur pronostique de l'hydronéphrose n'est pas claire. Notre objectif était de déterminer si l'hydronéphrose peut différencier les patients à faible risque appropriés pour l'essai de passage spontané de ceux qui ont des calculs cliniquement importants susceptibles de subir un échec de passage. MéTHODES: Nous avons utilisé des données administratives et un examen structuré des dossiers pour évaluer une cohorte consécutive de patients atteints de calculs urétéraux qui avaient subi une tomodensitométrie dans neuf hôpitaux canadiens de deux villes. Nous avons utilisé la tomodensitométrie, l'étalon-or pour l'imagerie des calculs, pour évaluer l'hydronéphrose et la taille des calculs. Nous avons décrit la précision de la classification de la gravité de l'hydronéphrose pour la détection de gros calculs (> 5 mm). Chez les patients tentant un passage spontané, nous avons utilisé la régression bayésienne hiérarchique pour déterminer l'association de l'hydronéphrose avec l'échec du passage, défini par le besoin d'intervention de sauvetage dans les 60 jours. Pour illustrer l'utilité pronostique, nous avons signalé la probabilité d'échec de passage avant le test chez tous les patients admissibles (sans directives sur l'hydronéphrose) à la probabilité d'échec de passage post-test dans chaque groupe d'hydronéphrose. RéSULTATS: Sur 3251 patients, 70% d'hommes et d'âge moyen 51 ans, 38% avaient un gros calcul, dont 23%, 29%, 53% et 72% avec une hydronéphrose absente, légère, modérée et sévère. Les taux d'échec au passage étaient de 15%, 20%, 28% et 43% dans les catégories d'hydronéphrose respectives et de 23% dans l'ensemble. L'hydronéphrose « absente ou légère ¼ a permis d'identifier un sous-ensemble important de patients (64%) présentant de faibles taux d'échec au passage. Une hydronéphrose modérée prédisait un risque d'échec de passage légèrement plus élevé, et une hydronéphrose sévère un risque sensiblement plus élevé. CONCLUSIONS: L'absence d'hydronéphrose et une hydronéphrose légère permettent d'identifier les patients à faible risque, peu susceptibles d'avoir un échec de passage, qui peuvent être appropriés pour un essai de passage spontané sans imagerie CT. Une hydronéphrose modérée est faiblement associée à des calculs plus gros mais pas à un échec de passage significativement plus important. L'hydronéphrose sévère est une constatation importante qui justifie une imagerie définitive et une référence. Différencier l'hydronéphrose « modérée-sévère ¼ de l'« absence-légère ¼ fournit une valeur de stratification du risque. Un classement plus granulaire de l'hydronéphrose n'est pas utile sur le plan pronostique.

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Comprehensive multiphase NMR combines the ability to study and differentiate all phases (solids, gels, and liquids) using a single NMR probe. The general goal of CMP-NMR is to study intact environmental and biological samples to better understand conformation, organization, association, and transfer between and across phases/interfaces that may be lost with conventional sample preparation such as drying or solubilization. To date, all CMP-NMR studies have used 4 mm probes and rotors. Here, a larger 7 mm probehead is introduced which provides ∼3 times the volume and ∼2.4 times the signal over a 4 mm version. This offers two main advantages: (1) the additional biomass reduces experiment time, making 13C detection at natural abundance more feasible; (2) it allows the analysis of larger samples that cannot fit within a 4 mm rotor. Chicken heart tissue and Hyalella azteca (freshwater shrimp) are used to demonstrate that phase-based spectral editing works with 7 mm rotors and that the additional biomass from the larger volumes allows detection with 13C at natural abundance. Additionally, a whole pomegranate seed berry (aril) and an intact softgel capsule of hydroxyzine hydrochloride are used to demonstrate the analysis of samples too large to fit inside a conventional 4 mm CMP probe. The 7 mm version introduced here extends the range of applications and sample types that can be studied and is recommended when 4 mm CMP probes cannot provide adequate signal-to-noise (S/N), or intact samples are simply too big for 4 mm rotors.

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