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Prehospital identification of large vessel occlusion (LVO) stroke may expedite treatment by direct transport to comprehensive stroke centers (CSCs) with endovascular capabilities. The Cincinnati Prehospital Stroke Scale (CPSS) is commonly used for prehospital stroke detection. We aimed to assess whether (1) a high CPSS score can identify LVO and (2) an Emergency Medical Service (EMS) redirection protocol based on high CPSS accelerated endovascular treatment (EVT).
A retrospective comparison of patients transported by EMSs for suspected stroke to a high-volume CSC over a 16-month period, before and after implementation of an EMS redirection protocol based on high CPSS score (3/3). Charts were reviewed to determine the presence of LVO. Time to EVT and 3-month outcomes were compared before and after implementation.
A prehospital CPSS 3/3 score was found in 223 (59%) patients, demonstrating positive and negative predictive values for LVO of 29% and 94%, respectively. CPSS-based EMS redirection increased the proportion of EVT performed after direct transport to CSC [before: 21 (36%), after: 45 (63%), p < 0.01] and decreased median first door-to-groin puncture time by 28 minutes [109 (interquartile range (IQR) 64–116) versus 81 (IQR 56–130), p = 0.03]. At 3 months, the proportion of patients achieving functional independence (modified Rankin score 0–2) went from 20/57 (35%) to 29/68 (43%) (p = 0.39) following implementation.
CPSS-based EMS redirection accelerated identification of LVO strokes in the out-of-hospital setting and decreased time to EVT. Nevertheless, this protocol was also associated with high rates of non-LVO stroke. Impact on clinical outcomes should be evaluated in a larger cohort.
Introduction: Risk-stratification of patients requiring endotracheal intubation and mechanical ventilation in the Emergency Department (ED) is necessary for informed discussions with patients regarding goals-of-care. Frailty is a clinical state characterized by reduced physiologic reserve, and resulting from accumulation of physiological stresses and comorbid disease. Frailty is increasingly being identified as an important independent predictor of outcome among critically ill patients. Our objective was to identify the impact of clinical frailty (defined by the Clinical Frailty Scale [CFS]) on in-hospital mortality and resource utilization of ED patients requiring endotracheal intubation and mechanical ventilation. Methods: We analyzed a prospectively collected registry (2011-2016) of patients requiring endotracheal intubation in the ED at two academic hospitals and six community hospitals. We included all patients ≥18 years of age, who survived to the point of ICU admission. All patient information, outcomes, and resource utilization were stored in the registry. CFS scores were obtained through chart abstraction by two blinded reviewers. The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model, controlling for confounding variables (including patient sex, comorbidities, and illness severity). We defined “frailty” as a CFS ≥ 5. Results: 4,622 patients were included. Mean age was 61.2 years (SD: 17.5), and 2,614 (56.6%) were male. Frailty was associated with increased risk of in-hospital mortality, as compared to those who were not frail (adjusted odds ratio [OR] 2.21 [1.98-2.51]). Frailty was also associated with higher likelihood of discharge to long-term care (adjusted OR 1.78 [1.56-2.01]) among patients initially from a home setting. Frail patients were more likely to fail extubation during their hospitalization (adjusted OR 1.81 [1.67-1.95]) and were more likely to require tracheostomy (adjusted OR 1.41 [1.34-1.49]). Conclusion: Presence of frailty among ED patients requiring endotracheal intubation and mechanical ventilation was associated with increased in-hospital mortality, discharge to long-term care, extubation failure, and tracheostomy. ED physicians should consider the impact of frailty on patient outcomes, and discuss associated prognosis with patients prior to intubation.
OBJECTIVES/SPECIFIC AIMS: The goals of this study were (1) to evaluate the effect of proarrhythmic drugs on calcium transient and (2) to use three-dimensional human engineered cardiac tissue (hECT) technology to evaluate cardiac contractile properties in response to pharmacological challenge with proarrhythmic drugs. METHODS/STUDY POPULATION: Calcium transient was measured in subject-specific iPSC-CMs by using the IonOptix system in Sotalol treated vs. untreated conditions. We fabricated human engineered cardiac tissues (hECT) in a custom designed bioreactor using low- and high-sentitive subject-specific iPSC-CMs. Contractile function of the hECT was evaluated at baseline and after Sotalol [300 µM] administration. The change in beat rate was recorded under spontaneous beating conditions; changes in other twitch parameters, including time to relaxation, were recorded under electrical stimulation. Time to relaxation served as an indicator of action potential duration (APD), which has a temporal correlation with the QT interval. RESULTS/ANTICIPATED RESULTS: The low-sensitive iPSC-CM showed a considerable drop in overall peak height of the calcium transient, in the presence of 100 µM Sotalol. The high-sensitive line, however, showed a more pronounced drop in peak height. Sotalol treatment also induced a more pronounced increase in the exponential decay time constant (tau) in the high-sensitive line compared to the low-sensitive line. The hECT fabricated with high sensitive hiPSC-CM showed a larger decrease in spontaneous beat rate in response to Sotalol (0.41 vs 0.23 fold decrease), with a higher increase in time to relaxation (1.8 vs 1.3 fold increase), compared to hECT from low sensitive hiPSC-CM. Moreover, while the low-sensitive hECT showed a positive correlation between time to relaxation and developed force, as expected after Sotalol stimulation; the high-sensitive hECT failed to show a positive inotropic response. DISCUSSION/SIGNIFICANCE OF IMPACT: Our findings suggest subject-specific iPSC-CMs and hECT, can be used to model functional abnormalities observed in diLQTS in response to Sotalol, and offer novel insights into human-based screening assays for toxic drug reactions. Success of this study may help identify key components underlying diLQT susceptibility to ultimately develop novel therapeutic agents.
Anti-retroviral therapy (ART) regimes for HIV are associated with raised levels of circulating triglycerides (TGs) in western populations. However, there are limited data on the impact of ART on cardiometabolic risk in sub-Saharan African (SSA) populations.
Pooled analyses of 14 studies comprising 21 023 individuals, on whom relevant cardiometabolic risk factors (including TG), HIV and ART status were assessed between 2003 and 2014, in SSA. The association between ART and raised TG (>2.3 mmol/L) was analysed using regression models.
Among 10 615 individuals, ART was associated with a two-fold higher probability of raised TG (RR 2.05, 95% CI 1.51–2.77, I2 = 45.2%). The associations between ART and raised blood pressure, glucose, HbA1c, and other lipids were inconsistent across studies.
Evidence from this study confirms the association of ART with raised TG in SSA populations. Given the possible causal effect of raised TG on cardiovascular disease (CVD), the evidence highlights the need for prospective studies to clarify the impact of long term ART on CVD outcomes in SSA.
The use of technology for workplace and occupational testing blossomed in the early years of this century. This book offers a demonstration that the first generation of these technologies have now been implemented long enough to observe the patterns and issues that emerge when these approaches evolve through technical advancement and successive application. A new set of issues and opportunities has emerged and the next generation of these applications is now coming of age. This book reflects on the last few decades of this evolutionary process from a vantage point of global experience across a wide range of workplace applications, including employment selection, development, and occupational certification. The themes and issues that arise as this broad treatment unfolds provide an essential foundation for students, researchers, and professionals who are involved with the assessment of human capability and potential in organizational and workplace contexts
Measurements of the electrical conductivity of subglacial water provide a useful complement to measurements of pressure and turbidity. In the summer season, fluctuations of conductivity can be attributed to changes in water transport, water provenance and subglacial residence time. These explanations are unlikely to apply during the winter season because surface melt sources are not active and the subglacial water system is predominantly unconnected. Thus, fluctuations in water conductivity during the winter months seem paradoxical. To introduce a quantitative basis for comprehending such phenomena, we develop an interpretative model of the hydrochemical interaction between a water-filled borehole and a subglacial aquifer. The electrical conductivity of water near the borehole–aquifer contact is affected not only by diffusion but also by advective transport of solute between the two reservoirs in response to pressure forcing of the system. Using records of ice strain, water pressure and electrical conductivity from unconnected boreholes in Trapridge Glacier, we demonstrate that changes in borehole geometry caused by ice-strain events provide a plausible mechanism for at least some of the observed fluctuations of electrical conductivity. Conductivity records provide information regarding advective coupling of the borehole–aquifer system that is not available from pressure records alone.
Radio-glaciological parameters from the Moore’s Bay region of the Ross Ice Shelf, Antarctica, have been measured. The thickness of the ice shelf in Moore’s Bay was measured from reflection times of radio-frequency pulses propagating vertically through the shelf and reflecting from the ocean, and is found to be 576 ± 8 m. Introducing a baseline of 543 ± 7m between radio transmitter and receiver allowed the computation of the basal reflection coefficient, R, separately from englacial loss. The depth-averaged attenuation length of the ice column, 〈L〉 is shown to depend linearly on frequency. The best fit (95% confidence level) is 〈L(ν)〉= (460±20) − (180±40)ν m (20 dB km−1), for the frequencies ν = [0.100–0.850] GHz, assuming no reflection loss. The mean electric-field reflection coefficient is (1.7 dB reflection loss) across [0.100–0.850] GHz, and is used to correct the attenuation length. Finally, the reflected power rotated into the orthogonal antenna polarization is <5% below 0.400 GHz, compatible with air propagation. The results imply that Moore’s Bay serves as an appropriate medium for the ARIANNA high-energy neutrino detector.
Open-water swimming is increasingly popular, often in water not considered safe for bathing. Limited evidence exists on the associated health risks. We investigated gastrointestinal illness in 1100 swimmers in a River Thames event in London, UK, to describe the outbreak and identify risk factors. We conducted a retrospective cohort study. Our case definition was swimmers with any: diarrhoea, vomiting, abdominal cramps lasting ⩾48 h, nausea lasting ⩾48 h, with onset within 9 days after the event. We used an online survey to collect information on symptoms, demographics, pre- and post-swim behaviours and open-water experience. We tested associations using robust Poisson regression. We followed up case microbiological results. Survey response was 61%, and attack rate 53% (338 cases). Median incubation period was 34 h and median symptom duration 4 days. Five cases had confirmed microbiological diagnoses (four Giardia, one Cryptosporidium). Wearing a wetsuit [adjusted relative risk (aRR) 6·96, 95% confidence interval (CI) 1·04–46·72] and swallowing water (aRR 1·42, 95% CI 1·03–1·97) were risk factors. Recent river-swimming (aRR 0·78, 95% CI 0·67–0·92) and age >40 years (aRR 0·83, 95% CI 0·70–0·98) were protective. Action to reduce risk of illness in future events is recommended, including clarification of oversight arrangements for future swims to ensure appropriate risk assessment and advice is provided.
Galaxies are born and grow within a cosmic ecosystem, in which they receive material from surrounding intergalactic gas via gravitationally-driven inflows and expel material via powerful galactic outflows. These processes, collectively referred to as the baryon cycle, are increasingly believed to govern galaxy growth over cosmic time. I discuss new insights on the baryon cycle using analytic models and hydrodynamical simulations of galaxy evolution, particularly emphasizing how galaxy outskirts are the prime locale within which to observe these processes in action by examining observational tracers such as rest-ultraviolet absorption lines and the neutral and molecular gas content of galaxies.