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Introduction: There is increasing evidence supporting ultrasonography for the determination of optimal chest compression location during cardiac arrest. Radiological studies have demonstrated that in up to 1/3 of patients the aortic root or outflow tract is being compressed during standard CPR. Out-of-hospital-cardiac-arrests (OHCA) could benefit from cardiac localization, undertaken with scaled-down ultrasound equipment by which the largest fluid filled structure in the chest (the heart) is identified to guide optimal compression location. We intend to evaluate 1) where the left ventricle is in supine patients, 2) the accuracy and precision as well as 3) the feasibility and reliability of cardiac localization with a scaled down ultrasound device (bladder scanners). Methods: We are recruiting men and women over the age of 40. The scanning protocol involves using a bladder scanner on a 15-point grid over the subject's left chest and parasternal, midclavicular, and anterior axillary intercostal spaces 3-7. Detected volumes will be recorded, with the presumption that the intercostal space with the largest measured volume is centered over the heart. Echocardiography will then be used to confirm the bladder scanner accuracy and to better describe the patient's internal chest anatomy. Having assessed procedural feasibility on 3 pilot subjects, we are now recruiting 100 participants, with planned interim analysis at 50 participants for sample size reassessment. Maximal volume location frequencies from the echocardiograms will be described and assessed for variation utilizing the goodness-of-fit test. The proportion of agreement across the two modalities regarding the maximal volume location will also be examined. Results: Among the 3 volunteers (pilot study), the scanner identified fluid in 4-8 of 15 intercostal spaces. In each of the three pilot study patients, the maximal volume identified by the bladder scanner was found to be at the parasternal location of the 6th intercostal space. This was also the location of the mid left ventricular diameter on echocardiography. Conclusion: Our literature review and pilot study data support the premise that lay persons and emergency medical personnel may improve compressions (and thus outcomes) during OHCA by using a scaled-down ultrasound to identify the location of optimal compression. We are currently enrolling patients in our study.
OBJECTIVES/SPECIFIC AIMS: Dissemination of research findings through the published literature is a complex but critical part of the scholarly communication process. Additionally, this time point on the translational spectrum is a key objective of the National Clinical Association for Advancing Translational Sciences (NCATS). Tracking the dissemination of research outputs can be difficult to identify and evaluate. The purpose of this case study was 2-fold: (1) identify tools and resources available freely to the public and through university subscriptions used to assess research output; and (2) compare the effectiveness of these tools oat tracking output at different levels of granularity. METHODS/STUDY POPULATION: The authors, Spectrum staff (D.A.) and School of Medicine librarian (M.B.), attended webinars hosted by other Academic Medical Center libraries conducting work on impact tracking and learned from vendor product managers about available tools and resources during on-site campus visits. Publications from Stanford’s Clinical and Translational Science Award (CTSA) were used to track the diffusion of research outputs (e.g., number of citations, document types, research areas, relative citation ratio, CTSAs collaboration) via library subscription services (e.g., Web of Science and Scopus) and freely available tools (e.g., iCite and PubMed). RESULTS/ANTICIPATED RESULTS: The authors found certain tools were more inclusive in retrieving grant funded research outputs. For example, in the case of UL1 grant (UL1TR001085, UL1TR000093, UL1RR025744), on a grant-level output, there were discrepancies in the number of publications retrieved: (1) PubMed found 644 outputs; (2) Web of Science found 497 outputs; and (3) Scopus found 190 outputs. After de-duplication, the search across Web of Science (WoS), Scopus, and PubMed yielded 899 publications. In total, 389 outputs were unique to PubMed; 165 were unique to WoS; and 90 were unique to Scopus. Future analysis will be conducted to identify the source of unique outputs from each database (e.g., conference proceeding, specific journals). Additional analysis based on other units of research outputs (e.g., author-level outputs and article-level outputs) are expected to yield similar discrepancies. DISCUSSION/SIGNIFICANCE OF IMPACT: Citation analysis is a valuable method of assessing research output and, to a larger extent, research impact in a given field. It can help investigators illustrate qualifications for undertaking new projects, highlight collaborations across schools and departments, justify a grant renewal, and/or highlight accomplishments for promotion. However, systematic and comprehensive evaluations are needed in tandem with citation analysis/bibliometric analysis to assess the translation and uptake of research outputs and activities that result in research impact. Furthermore, both investigators and staff need adequate time and training to process research outputs/activities and to effectively organize them in easily understood visualizations.
In a 2015 report, the Institute of Medicine (IOM; Washington, DC USA), now the National Academy of Medicine (NAM; Washington, DC USA), stated that the field of Emergency Medical Services (EMS) exhibits signs of fragmentation; an absence of system-wide coordination and planning; and a lack of federal, state, and local accountability. The NAM recommended clarifying what roles the federal government, state governments, and local communities play in the oversight and evaluation of EMS system performance, and how they may better work together to improve care.
This systematic literature review and environmental scan addresses NAM’s recommendations by answering two research questions: (1) what aspects of EMS systems are most measured in the peer-reviewed and grey literatures, and (2) what do these measures and studies suggest for high-quality EMS oversight?
To answer these questions, a systematic literature review was conducted in the PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Web of Science (Thomson Reuters; New York, New York USA), SCOPUS (Elsevier; Amsterdam, Netherlands), and EMBASE (Elsevier; Amsterdam, Netherlands) databases for peer-reviewed literature and for grey literature; targeted web searches of 10 EMS-related government agencies and professional organizations were performed. Inclusion criteria required peer-reviewed literature to be published between 1966-2016 and grey literature to be published between 1996-2016. A total of 1,476 peer-reviewed titles were reviewed, 76 were retrieved for full-text review, and 58 were retained and coded in the qualitative software Dedoose (Manhattan Beach, California USA) using a codebook of themes. Categorizations of measure type and level of application were assigned to the extracted data. Targeted websites were systematically reviewed and 115 relevant grey literature documents were retrieved.
A total of 58 peer-reviewed articles met inclusion criteria; 46 included process, 36 outcomes, and 18 structural measures. Most studies applied quality measures at the personnel level (40), followed by the agency (28) and system of care (28), and few at the oversight level (5). Numerous grey literature articles provided principles for high-quality EMS oversight.
Limited quality measurement at the oversight level is an important gap in the peer-reviewed literature. The grey literature is ahead in this realm and can guide the policy and research agenda for EMS oversight quality measurement.
TaymourRK, AbirM, ChamberlinM, DunneRB, LowellM, WahlK, ScottJ. Policy, Practice, and Research Agenda for Emergency Medical Services Oversight: A Systematic Review and Environmental Scan. Prehosp Disaster Med. 2018;33(1):89–97.
We sought to identify and review published studies that discuss the ethical considerations, from a physician’s perspective, of managing a hunger strike in a prison setting.
A database search was conducted to identify relevant publications. We included case studies, case series, guidelines and review articles published over a 20-year period. Non-English language publications were translated.
The review found 23 papers from 12 jurisdictions published in five languages suitable for inclusion.
Key themes from included publications are identified and summarised in the context of accepted guidelines from the World Medical Association. Whilst there seems to be an overall consensus favouring autonomy over beneficence, tensions along this fine balance are magnified in jurisdictions where legislation leads to a dual loyalty conflict for the physician.
To search for studies on tongue–lip adhesion and tongue repositioning used as isolated treatments for obstructive sleep apnoea in children with Pierre Robin sequence.
A systematic literature search of PubMed/Medline and three additional databases, from inception through to 8 July 2016, was performed by two authors.
Seven studies with 90 patients (59 tongue–lip adhesion and 31 tongue repositioning patients) met the inclusion criteria. Tongue–lip adhesion reduced the mean (± standard deviation) apnoea/hypopnoea index from 30.8 ± 22.3 to 15.4 ± 18.9 events per hour (50 per cent reduction). The apnoea/hypopnoea index mean difference for tongue–lip adhesion was −15.28 events per hour (95 per cent confidence interval = −30.70 to 0.15; p = 0.05). Tongue–lip adhesion improved the lowest oxygen saturation from 75.8 ± 6.8 to 84.4 ± 7.3 per cent. Tongue repositioning reduced the apnoea/hypopnoea index from 46.5 to 17.4 events per hour (62.6 per cent reduction). Tongue repositioning improved the mean oxygen saturation from 90.8 ± 1.2 to 95.0 ± 0.5 per cent.
Tongue–lip adhesion and tongue repositioning can improve apnoea/hypopnoea index and oxygenation parameters in children with Pierre Robin sequence and obstructive sleep apnoea.
All governments, in various ways, regulate and control nonprofit organizations. Nongovernmental organizations (NGOs), while hopeful of supportive regulatory environments, are simultaneously seeking greater autonomy both to provide services and to advocate for policy change. In part to counter increasing statutory regulation, there is a global nonprofit sector movement towards greater grassroots regulation - what the authors call self-regulation - through codes of conduct and self-accreditation processes. This book drills down to the country level to study both sides of this equation, examining how state regulation and nonprofit self-regulation affect each other and investigating the causal nature of this interaction. Exploring these issues from historical, cultural, political, and environmental perspectives, and in sixteen jurisdictions (Australia, China, Brazil, Ecuador, England and Wales, Ethiopia, Ireland, Israel, Kenya, Malawi, Mexico, Tanzania, Uganda, Scotland, United States, and Vietnam), the authors analyze the interplay between state control and nonprofit self-regulation to better understand broader emerging trends.
With the UK population ageing, deciding upon a satisfactory and sustainable system for the funding of people’s long-term care (LTC) needs has long been a topic of political debate. Phase 1 of the Care Act 2014 (“the Act”) brought in some of the reforms recommended by the Dilnot Commission in 2011. However, the Government announced during 2015 that Phase 2 of “the Act” such as the introduction of a £72,000 cap on Local Authority care costs and a change in the means testing thresholds1 would be deferred until 2020. In addition to this delay, the “freedom and choice” agenda for pensions has come into force. It is therefore timely that the potential market responses to help people pay for their care within the new pensions environment should be considered. In this paper, we analyse whether the proposed reforms meet the policy intention of protecting people from catastrophic care costs, whilst facilitating individual understanding of their potential care funding requirements. In particular, we review a number of financial products and ascertain the extent to which such products might help individuals to fund the LTC costs for which they would be responsible for meeting. We also produce case studies to demonstrate the complexities of the care funding system. Finally, we review the potential impact on incentives for individuals to save for care costs under the proposed new means testing thresholds and compare these with the current thresholds. We conclude that:
∙Although it is still too early to understand exactly how individuals will respond to the pensions freedom and choice agenda, there are a number of financial products that might complement the new flexibilities and help people make provision for care costs.
∙The new care funding system is complex making it difficult for people to understand their potential care costs.
∙The current means testing system causes a disincentive to save. The new means testing thresholds provide a greater level of reward for savers than the existing thresholds and therefore may increase the level of saving for care; however, the new thresholds could still act as a barrier since disincentives still exist.
The Vacuum Solar Telescope has been described elsewhere by Dunn (1964, 1969). A brief summary of its characteristics is included here as background for discussing the computer control of this instrument.
This telescope is altazimuth in design. Image rotation is accomplished by rotating the inner tube structure together with all the auxiliary instruments. Azimuth and elevation torque motors drive the two mirrors at the top of the tower to track the sun automatically. The input to the servo is derived from a photoelectric guider. When clouds intervene, the servos are switched from the photoelectric guider to an electromechanical coordinate converter that also generates the signal for the rotation of the table. An elaborate 25: 1 synchro system connects the mirror servos to the coordinate converter.
To compare the state of chemical hazard preparedness in emergency departments (EDs) in Michigan, USA between 2005 and 2012.
This was a longitudinal study involving a 30 question survey sent to ED directors at each hospital listed in the Michigan College of Emergency Physician (MCEP) Directory in 2005 and in 2012. The surveys contained questions relating to chemical, biological, radiological, nuclear, and explosive events with a focus on hazardous material capabilities.
One hundred twelve of 139 EDs responded to the 2005 survey compared to 99/136 in 2012. Ten of 27 responses were statistically significant, all favoring an enhancement in disaster preparedness in 2012 when compared to 2005. Questions with improvement included: EDs with employees participating in the Michigan voluntary registry; EDs with decontamination rooms; MARK 1 and cyanide kits available; those planning to use dry decontamination, powered air purifiers, surgical masks, chemical gloves, and surgical gowns; and those wishing for better coordination with local and regional resources. Forty-two percent of EDs in 2012 had greater than one-half of their staff trained in decontamination and 81% of respondents wished for more training opportunities in disaster preparedness. Eighty-four percent of respondents believed that they were more prepared in disaster preparedness in 2012 versus seven years prior.
Emergency departments in Michigan have made significant advances in chemical hazard preparedness between 2005 and 2012 based on survey responses. Despite these improvements, staff training in decontamination and hazardous material events remains a weakness among EDs in the state of Michigan.
BelskyJB, KlausnerHA, KarsonJ, DunneRB. Survey of Emergency Department Chemical Hazard Preparedness in Michigan, USA: A Seven Year Comparison. Prehosp Disaster Med. 2016;31(2):224–227.
The Sac Peak magnetograph (DZA) has been modified from Evans' original scheme so that it measures the displacement of the right and left hand circularly polarized lines separately. The computer reduction calculates the Zeeman and radial velocity signals. A grating servo system has been added to correct for slow temperature drifts in the spectrograph. A paper-tape reader controls the raster scan and the formatting of data on to magnetic tape.
A number of observers have noted the presence of bright structures near the cores of the chromospheric rosettes when observed in the far wings of the Hα line (eg Hα ±7/8 Å). Dunn and Zirker observed these bright structures with the highest possible resolution using the Sacramento Peak vacuum solar telescope. They find that these bright regions exhibit a very intricate fine structure which can be followed out much further into the Hα line wing (eg Hα + 2 Å) and even into the continuum. They called this fine structure ‘solar filigree’, the name referring mainly to the collective appearance of the fine structure elements. The elements themselves appear as dot-like structures and frequently also as small wiggly structures called ‘crinkles’. The properties of the filigree structure are summarized as follows:
(i)Size: Measured diameter of the crinkles and dots equals 0.25, 0.40 and 0.60″ at Hα + 2 Å, Hα ± 7/8 Å and Hα ±5/8 Å respectively. The telescope resolution equals 0.22″ so that at Hα + 2 Å the structure is extremely small. The drawings in Figure 1 show typical sizes of the crinkles and network patterns in the filigree.
(ii)Contrast: Filigree is enhanced in the blue wing of the Hα line. Measured contrast, uncorrected for seeing, equals 5–10%.
(iii)Relation to the Granulation: The filigree structures tend to lie between the granules. This is, however, not a strict rule. It seems that in the course of their lifetime the granules move the filigree structures around with velocities of about 1.5 km s-1. Some of the crinkles also seem to wash out temporarily until compressed again by a new granule. The detailed structure of the filigree, therefore, changes significantly over times comparable to the granule lifetime. The overall structure is, however, preserved over much longer periods of time. The granulation pattern when observed in the continuum well outside the Hα line appears very peculiar in that it has substantially decreased in contrast. It appears ‘soft’ similar to granulation washed-out by seeing. This abnormal granulation can be traced over long times (> 30 min) and coincides in location to the filigree location. It is, therefore, definitely real.
(iv)Relation to the spicules: The filigree structure falls near the center of the Hα chromospheric rosettes. These rosettes consist of dark elongated mottles which should probably be identified with spicules. There is, therefore, at least a coarse relation between the occurrence of spicules and the filigree. There is no clear evidence that variations in the filigree pattern are related to the generation of spicules. Some spicules seem to originate from the spaces between the crinkles. Too few, however, to conclude a definite relation.
(v)Relation to the magnetic field: Beckers studied the filigree with the Universal Birefringent Filter in the magnesium b1 and b2 lines. It is very well visible in the far wing of the lines (eg. b1 ±0.8 Å). When traced into the line core the structures increase somewhat in size, as they do in Hα, and form structures similar to, and perhaps identical with, the so-called photospheric network. In the magnetically sensitive b2 line one sees a one-to-one correspondence between these network structures and the magnetic field so that, at least in the layers seen near the core of the b2 line, there is a one-to-one correspondence between the filigree structures and the enhancements in the magnetic field. Simon and Zirker (Solar Physics, submitted for publication) using a spectrograph also found that the filigree occurs in regions of enhanced magnetic field. However, in contrast to the filter observations, they found the magnetic field regions to be much more diffuse (2–3″) so that there is not a one-to-one spatial correspondence between filigree and magnetic field structure.
Actors in high-reliability organizations often form meetings to discuss incidents and learn from them. Such after-action reviews (AARs) are structured opportunities for shared retrospective learning, innovation development, and continuous improvement. Research on AARs has examined the meeting-level antecedents and outcomes associated with various elements of AARs, but has generally stopped short of considering how they should influence and respond to the organizations in which they are situated. After connecting the functions of AARs using the theoretical frameworks of collective sensemaking, organizational learning, and knowledge management, this chapter presents an input-process-output model of AAR systems that accounts for a range of extra-meeting factors that influence and are influenced by the content of retrospective discussion. It also describes best practices and directions for future research associated with these inputs, processes, and outputs.