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In cases of mass-casualty incidents (MCIs), triage represents a fundamental tool for the management of and assistance to the wounded, which helps discriminate not only the priority of attention, but also the priority of referral to the most suitable center.
The objective of this study was to evaluate the capacity of different prehospital triage systems based on physiological parameters (Shock Index [SI], Glasgow-Age-Pressure Score [GAP], Revised Trauma Score [RTS], and National Early Warning Score 2 [NEWS2]) to predict early mortality (within 48 hours) from the index event for use in MCIs.
This was a longitudinal prospective observational multi-center study on patients who were attended by Advanced Life Support (ALS) units and transferred to the emergency department (ED) of their reference hospital. Collected were: demographic, physiological, and clinical variables; main diagnosis; and data on early mortality. The main outcome variable was mortality from any cause within 48 hours.
From April 1, 2018 through February 28, 2019, a total of 1,288 patients were included in this study. Of these, 262 (20.3%) participants required assistance for trauma and injuries by external agents. Early mortality within the first 48 hours due to any cause affected 69 patients (5.4%). The system with the best predictive capacity was the NEWS2 with an area under the curve (AUC) of 0.891 (95% CI, 0.84-0.94); a sensitivity of 79.7% (95% CI, 68.8-87.5); and a specificity of 84.5% (95% CI, 82.4-86.4) for a cut-off point of nine points, with a positive likelihood ratio of 5.14 (95% CI, 4.31-6.14) and a negative predictive value of 98.7% (95% CI, 97.8-99.2).
Prehospital scores of the NEWS2 are easy to obtain and represent a reliable test, which make it an ideal system to help in the initial assessment of high-risk patients, and to determine their level of triage effectively and efficiently. The Prehospital Emergency Medical System (PhEMS) should evaluate the inclusion of the NEWS2 as a triage system, which is especially useful for the second triage (evacuation priority).
Social cognition has been associated with functional outcome in patients with first episode psychosis (FEP). Social cognition has also been associated with neurocognition and cognitive reserve. Although cognitive reserve, neurocognitive functioning, social cognition, and functional outcome are related, the direction of their associations is not clear. Therefore, the main aim of this study was to analyze the influence of social cognition as a mediator between cognitive reserve and cognitive domains on functioning in FEP both at baseline and at 2 years.
The sample of the study was composed of 282 FEP patients followed up for 2 years. To analyze whether social cognition mediates the influence of cognitive reserve and cognitive domains on functioning, a path analysis was performed. The statistical significance of any mediation effects was evaluated by bootstrap analysis.
At baseline, as neither cognitive reserve nor the cognitive domains studied were related to functioning, the conditions for mediation were not satisfied. Nevertheless, at 2 years of follow-up, social cognition acted as a mediator between cognitive reserve and functioning. Likewise, social cognition was a mediator between verbal memory and functional outcome. The results of the bootstrap analysis confirmed these significant mediations (95% bootstrapped CI (−10.215 to −0.337) and (−4.731 to −0.605) respectively).
Cognitive reserve and neurocognition are related to functioning, and social cognition mediates in this relationship.
Residual feed intake (RFI) is an alternative measure of feed efficiency (FE) and is calculated as the difference between actual and expected feed intake. The biological mechanisms underlying animal-to-animal variation in FE are not well understood. The aim of this study was to investigate the digestive ability of beef cows selected for RFI divergence as heifers, using two contrasted diets. Fifteen 4-year-old beef cows were selected from a total of 69 heifers based on their RFI following the feedlot test. The selected heifers were ranked into high-RFI (+ 1.02 ± 0.28, n = 8) and low-RFI (−0.73 ± 0.28, n = 7), and a digestibility trial was performed after their first lactation. Both RFI groups were offered two different diets: 100% hay or a fattening diet which consisted of a DM basis of 67% whole-plant maize silage and 33% high starch concentrates over four experimental periods (two per diet). A diet effect was observed on feed intake and apparent digestibility, whereas no diet × RFI interaction was detected (P > 0.05). Intake and apparent digestibility were higher in cows fed the fattening diet than in those fed the hay diet (P < 0.0001). DM intake (DMI) and organic matter apparent digestibility (OMd) were repeatable and positively correlated between the two subsequent periods of measurements. For the hay and fattening diets, the repeatability between periods was r = 0.71 and r = 0.73 for DMI and r = 0.87 and r = 0.48 for OMd, respectively. Moreover, both intake (r = 0.55) and OMd (r = 0.54) were positively correlated (P < 0.05) between the hay and fattening diets. Significant differences between beef cows selected for divergence in RFI as heifers were observed for digestive traits (P < 0.05), DM and organic matter (OM) apparent digestibility being higher for low-RFI cows. Overall, this study showed that apparent digestibility contributes to between-animal variation in FE in beef cows.
Species distribution models (SDMs) are statistical tools used to develop continuous predictions of species occurrence. ‘Integrated SDMs’ (ISDMs) are an elaboration of this approach with potential advantages that allow for the dual use of opportunistically collected presence-only data and site-occupancy data from planned surveys. These models also account for survey bias and imperfect detection through the use of a hierarchical modelling framework that separately estimates the species–environment response and detection process. This is particularly helpful for conservation applications and predictions for rare species, where data are often limited and prediction errors may have significant management consequences. Despite this potential importance, ISDMs remain largely untested under a variety of scenarios. We performed an exploration of key modelling decisions and assumptions on an ISDM using the endangered Baird’s tapir (Tapirus bairdii) as a test species. We found that site area had the strongest effect on the magnitude of population estimates and underlying intensity surface and was driven by estimates of model intercepts. Selecting a site area that accounted for the individual movements of the species within an average home range led to population estimates that coincided with expert estimates. ISDMs that do not account for the individual movements of species will likely lead to less accurate estimates of species intensity (number of individuals per unit area) and thus overall population estimates. This bias could be severe and highly detrimental to conservation actions if uninformed ISDMs are used to estimate global populations of threatened and data-deficient species, particularly those that lack natural history and movement information. However, the ISDM was consistently the most accurate model compared to other approaches, which demonstrates the importance of this new modelling framework and the ability to combine opportunistic data with systematic survey data. Thus, we recommend researchers use ISDMs with conservative movement information when estimating population sizes of rare and data-deficient species. ISDMs could be improved by using a similar parameterization to spatial capture–recapture models that explicitly incorporate animal movement as a model parameter, which would further remove the need for spatial subsampling prior to implementation.
The aim of this study is to investigate the impact of anatomical changes in prostate cancer patients on the target coverage when using 6 MV beams-VMAT therapy and to propose strategies that allow us to evaluate the dose or correct it by normalization without having to perform a new simulation.
Methods and materials:
Ten patients of high-risk prostate cancer were chosen for the study. All test plans were delivered using the same isocenter and monitor units as the original plan and compared against the original unedited plan. The expansion and contraction of body contours due to size changes was mimicked by increasing and decreasing the body contour with depths of −2, −1·5, …, 1·5, 2 cm, in the anterior, and both lateral directions of the patient. A total of 90 plans were evaluated, 9 for each patient. Dose-volume histogram statistics were extracted from each plan and normalized to prescription dose.
Weight changes resulted in considerable dose modifications to the target and critical structures. Plans were found to be varied with 2·9% ± 0·3% per cm SSD change for VMAT treatment with a correlation index close to one. Therefore, doses variations were linear to the changes of depth. Gamma index evaluation was performed for the 10 renormalized plans. All of them passed criteria of 3%/3 mm in at least 98.2% of points. Eight of them passed criteria in 99% points. Gamma index 4%/4 mm passed 100% points in all patients for the chosen region of interest.
The dosimetry estimation presented in this study shows important data for the radiation oncology staff to justify whether a CT rescan is necessary or not when a patient experiences weight changes during treatment. Based on the results of our study, discrepancies between real dose and planned dose were >5% for 1·7 cm of difference in external contour in the anterior and both lateral directions of the patient.
To compare functional endoscopic sinus surgery with a combined approach (functional endoscopic sinus surgery plus Caldwell–Luc procedure) for the treatment of paediatric antrochoanal polyp, in terms of antrochoanal polyp recurrence and safety.
This retrospective case series comprises 27 paediatric patients with recurrent antrochoanal polyp, treated from January 2010 to January 2018.
The average age of the patients at the time of diagnosis was 10.4 ± 2.49 years. The recurrence rate after functional endoscopic sinus surgery alone was 72.9 per cent, compared with 12.5 per cent after functional endoscopic sinus surgery plus the Caldwell–Luc procedure (p < 0.00001). No complications were reported during surgery or follow up.
The correct identification of the origin of the antrochoanal polyp and an adequate returning of maxillary ventilation by widening the ostium can prevent recurrences. Although functional endoscopic sinus surgery continues to be the ‘gold standard’ for antrochoanal polyp treatment, in cases of revision surgery, a combined approach could ensure the complete removal of the polyp through the two openings.
Hernia is defined as the protrusion of one or several internal organs through an opening in the cavity that contains them due to a tissue defect, abdominal wall surgery by means of synthetic meshes is the most common method used for hernia repair, however, postsurgical effects can range from some discomfort, to chronic pain and even the reappearance of the hernia due to a poor mechanical adaptability between the synthetic tissue and the host tissue. The knowledge of the mechanical properties of the materials involved in hernia repair is fundamental in the understanding and subsequent solution of this type of problems. In this work, experimental data were obtained by means of uniaxial tensile tests in two perpendicular directions of commercial meshes used in hernia repair. The tests were carried out on the UniVert® machine of the CellScale® brand. Anisotropic mechanical behavior is observed due to the structure of the mesh and the interaction between each of the yarns that make it up. The data found vary with respect to the direction of traction and also has non-linear hyperelastic behavior, so the adjustment of curves was made through a hyperelastic model in the COMSOL Multiphysics® software through the Levenberg-Marquardt Algorithm for the characterization of these materials.
This paper addresses the chemical synthesis and characterization of a composite formed by Li2O-Al2O3-Al3Fe-Al3Fe5O12/PCL which were obtained by the process of reduction of ferric chloride (FeCl3) with lithium aluminum hydride (LiAlH4) in an open atmosphere. The goal of the development of this hybrid material was to perform a superparamagnetic material with several potential applications. The results of the characterizations by scanning electron microscopy (SEM) and vibrating sample magnetometer showed a Li2O-Al2O3-Al3Fe-Al3Fe5O12 “desert rose stone”-like morphology 3D hierarchical powders formation when particles were sintered at 850 °C. Homogeneous nanometric particles after calcination at 1100 °C were observed. X-ray diffraction analysis were performed to determine their composition. Subsequently, the superparamagnetic powders were added by dispersion in a polycaprolactone (PCL) matrix, and then, were evaluated by SEM for the observation of their morphologies. The composite material presented a polymer network with an opened structure, a well dispersion of the oxides particles into the interstices with irregular topography and reliefs.
Monitoring the effectiveness of knee and hip arthroplasties could be useful at the clinical, economic, and patient levels. In Catalonia, there is currently no systematic monitoring of the different prostheses available. The aims of this study were to propose an approach for the systematic identification of knee and hip prostheses with the highest revision rates, and to identify those with the poorest outcomes.
Data recorded from January 2005 to December 2016 were considered from 53 out of the 61 public hospitals in Catalonia included in the Catalonian Arthroplasty Register (RACat). Specific prostheses were classified by joint, type, fixation, and, in total hip prostheses, the bearing surface. Prostheses with the worst outcomes were identified using a three-step approach, based on previous literature: (i) screening using Poisson models; (ii) comparison of prostheses using adjusted Cox models; and (iii) consensus-based review by a panel of orthopedic surgeons to detect possible sources of bias. After this process, selected prostheses were provisionally labeled as having the poorest outcomes. This process will be repeated periodically within the RACat to definitively classify the prostheses.
After first two steps, ten knee prostheses and eight hip prostheses were identified. After the panel discussion (third step), one knee and one hip prosthesis were excluded from the final list. The knee prosthesis was excluded because it was a unicompartmental implant, while the hip prosthesis was excluded because it was a monoblock implant. Finally, nine knee prostheses and seven hip prostheses were provisionally identified as having the worst results relative to other available prostheses. These results await confirmation in subsequent analyses.
This study contributed to the current need to identify hip and knee prostheses whose outcomes might be worse than expected. This identification could have an impact at the patient, surgeon, industry, and stakeholder levels.
The twenty-first century could well become known as the populist century. No longer confined to Latin America or to the margins of European politics, populism has spread to Africa, Asia, and, with Donald Trump's election, to the cradle of liberal democracy. Even though it is uncertain what impact Trump's populism will have on American democracy, it is worth learning from Latin America, where populists have been in power from the 1930s and 1940s to the present. Even as Latin American populists like Juan Perón and Hugo Chávez included the poor and the nonwhite in the political community, they moved toward authoritarianism by undermining democracy from within. Are the foundations of American democracy and the institutions of civil society strong enough to resist US president Donald Trump's right-wing populism?
Although the Near Threatened jaguar Panthera onca ranges from the south-west USA to central Argentina, populations outside Amazonia are generally small and isolated. One such area, the Sierra Madre de Chiapas in the state of Chiapas, Mexico, is potentially an important area for jaguar conservation but information on the species in this region is limited and its conservation status is unknown. In this study we documented the occurrence and abundance of jaguars in the Sierra Madre de Chiapas complex. We compiled all available records of the species within the region and conducted a camera-trap survey during August 2015–December 2016. Interviews were conducted to determine the perception of the jaguar by cattle owners and to obtain information on any livestock predation. We found that jaguars still occur throughout the Sierra Madre de Chiapas landscape, including the plains on the Pacific Coast of Chiapas, but its abundance in the region is low. On the basis of our findings we have incorporated the Sierra Madre de Chiapas in Mexico's National Jaguar Conservation Strategy, and recommend that international organizations include this area in their priorities for jaguar conservation. To improve coexistence between jaguars and the communities of the Sierra Madre de Chiapas, strategies need to be developed, in collaboration with the local communities, to improve livestock practices for reduction of predation by jaguars, to strengthen government conservation policies and to implement educational and communication programmes about the importance of this species in the region.
To compare the epidemiology, clinical characteristics, and mortality of patients with bloodstream infections (BSI) caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-EC) versus ESBL-producing Klebsiella pneumoniae (ESBL-KP) and to examine the differences in clinical characteristics and outcome between BSIs caused by isolates with CTX-M versus other ESBL genotypes
As part of the INCREMENT project, 33 tertiary hospitals in 12 countries retrospectively collected data on adult patients diagnosed with ESBL-EC BSI or ESBL-KP BSI between 2004 and 2013. Risk factors for ESBL-EC versus ESBL-KP BSI and for 30-day mortality were examined by bivariate analysis followed by multivariable logistic regression.
The study included 909 patients: 687 with ESBL-EC BSI and 222 with ESBL-KP BSI. ESBL genotype by polymerase chain reaction amplification of 286 isolates was available. ESBL-KP BSI was associated with intensive care unit admission, cardiovascular and neurological comorbidities, length of stay to bacteremia >14 days from admission, and a nonurinary source. Overall, 30-day mortality was significantly higher in patients with ESBL-KP BSI than ESBL-EC BSI (33.7% vs 17.4%; odds ratio, 1.64; P=.016). CTX-M was the most prevalent ESBL subtype identified (218 of 286 polymerase chain reaction-tested isolates, 76%). No differences in clinical characteristics or in mortality between CTX-M and non–CTX-M ESBLs were detected.
Clinical characteristics and risk of mortality differ significantly between ESBL-EC and ESBL-KP BSI. Therefore, all ESBL-producing Enterobacteriaceae should not be considered a homogeneous group. No differences in outcomes between genotypes were detected.
In the nuclear sector, turnkey projects can be considered an investment in obtaining information through “learning by doing” to capture rents from the next generation of reactors. As the first U.S. turnkey export project, the first Spanish nuclear power plant served that purpose and paved the way for the subsequent growth of the nuclear sector, for both Spanish and U.S. firms. Making use of archival material, we analyze the networks created by the government, experts, and business leaders, which sought to obtain, accumulate, and learn from the scarce and conflicting information about atomic technology that was available at the time. We also discern how firms on both sides of the Atlantic acquired and perfected the specific capabilities required to build a commercial nuclear reactor.
Zika virus (ZIKV) infection is an emergent worldwide public health problem. Historically, 84 countries have reported vector-borne ZIKV transmission, 61 of which report on-going transmission. It is a Flavivirus transmitted through arthropods belonging to the Aedes genus. Since 2015, ZIKV infections have increased dramatically; with 1.3 million people infected during 2015 in Brazil alone. This paper's objective is to highlight the conjectural epidemiological points of the virus’ dissemination. The digital archives Pubmed, MEDLINE, EMBASE and Cochrane were searched for papers that assessed aspects of ZIKV transmission and epidemiology. The first isolation occurred in Uganda in 1947. Since then, important outbreaks were documented globally. Consequently, an emergent public health problem arose from a rapidly increasing incidence and its association with the development of neurological diseases such as microcephaly and Guillain–Barré syndrome. Key factors in the successful containment of outbreaks include surveillance of mosquitos in the neighbourhood, an early mosquito control treatment, an assertive information campaign, and the involvement of the local population and healthcare workers. As such, while ZIKV seems to be spreading globally in a similar manner to other arboviruses, such as Dengue and Chikungunya viruses, it can also be rapidly contained due to the pre-existing availability of necessary resources and regulatory tools as control measures. This review aims to provide a description of those characteristics of ZIKV infection that may be useful in the construction of effective outbreak control strategies.
Cognitive deficits are a core feature of early stages in schizophrenia. However, the extent to which antipsychotic (AP) have a deleterious effect on cognitive performance remains under debate. We aim to investigate whether anticholinergic loadings and dose of AP drugs in first episode of psychosis (FEP) in advanced phase of remission are associated with cognitive impairment and the differences between premorbid intellectual quotient (IQ) subgroups.
Two hundred and sixty-six patients participated. The primary outcomes were cognitive dimensions, dopaminergic/anticholinergic load of AP [in chlorpromazine equivalents (Eq-CPZ) and the Anticholinergic Risk Scale (ARS), respectively].
Impairments in processing speed, verbal memory and global cognition were significantly associated with high Eq-CPZ and verbal impairment with high ARS score. Moreover, this effect was higher in the low IQ subgroup.
Clinicians should be aware of the potential cognitive impairment associated with AP in advanced remission FEP, particularly in lower premorbid IQ patients.
Hydrogenated microcrystalline Silicon-Germanium (μc-SiGe:H) thin films were deposited using the Plasma Enhanced Chemical Vapor Deposition (PECVD) technique from a gas mixture of SiH4, GeH4, H2 and Ar at a substrate temperature of 200 ° C. The films were deposited at a pressure of 1.5 Torr, while the RF power was varied in the range of 20 W to 35 W. Structural, optical and electrical characterization was performed in the films, Fourier Transform Infrared Spectroscopy (FTIR) was performed in order to analyze the hydrogen bonding of silicon and germanium, while Raman spectroscopy was used in order to analyze the crystallinity of the films. Through the optical and electrical characterization of the films, parameters such as the optical band gap (Eg) and the activation energy (EA) were obtained, respectively. The conductivity of the films changed up two to orders of magnitude from dark conditions to illumination AM 1.5. Finally, the correlation between deposition RF power and the film properties is presented.