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Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.
Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.
A compact X-ray energy spectrometer has been developed consisting essentially of a radioisotope X-ray source, a lithium-drifted silicon (or germanium) detector and a small computer. Interchangeable sources enable efficient excitation of K X-rays from Na to U and L X-rays from about Ag to U. Energy resolution of K X-rays from adjacent elements down to Na is possible. Depending on the source and the part of the spectrum examined, the characteristic X-rays from up to about 15 elements can be simultaneously excited and measured, for either qualitative or quantitative multi-element analysis. The computer stores detected spectra and performs simple data processing such as peak recognition, background subtraction, peak integration, ratioing and solution of linear equations.
The analysis reported in this paper is the determination of V, Cr, Fe, Co, W and Mo in tool steels and is intended to illustrate the capabilities of the radioisotope X-ray fluorescence analysis technique, and the instrument, for multi-element analysis of a system having fairly complex interelement effects.
A 100 mCi Pu-238 source was used to excite the K X-rays of V, Cr, Fe, Co and Mb and the L X-rays of W. The count time used was five minutes per sample. Data reduction consisted essentially of peak integration, background subtraction and solution of sixth order linear matrices of a modified Criss-Birks type. The 36 matrix coefficients were determined using six standards, and were then used to analyze seven other analyzed specimens which were treated as unknowns. The measured values of concentration were in very good agreement with the quoted values. An iteration technique was employed to reduce errors in the matrix inversioiis.
Laser-based compact MeV X-ray sources are useful for a variety of applications such as radiography and active interrogation of nuclear materials. MeV X rays are typically generated by impinging the intense laser onto ~mm-thick high-Z foil. Here, we have characterized such a MeV X-ray source from 120 TW (80 J, 650 fs) laser interaction with a 1 mm-thick tantalum foil. Our measurements show X-ray temperature of 2.5 MeV, flux of 3 × 1012 photons/sr/shot, beam divergence of ~0.1 sr, conversion efficiency of ~1%, that is, ~1 J of MeV X rays out of 80 J incident laser, and source size of 80 m. Our measurement also shows that MeV X-ray yield and temperature is largely insensitive to nanosecond laser contrasts up to 10−5. Also, preliminary measurements of similar MeV X-ray source using a double-foil scheme, where the laser-driven hot electrons from a thin foil undergoing relativistic transparency impinging onto a second high-Z converter foil separated by 50–400 m, show MeV X-ray yield more than an order of magnitude lower compared with the single-foil results.
The Greek author Dionysius of Halicarnassus came to Rome in 30/29 BC. He learnt Latin, developed a network of students, patrons and colleagues, and started to teach rhetoric. He published a history of early Rome (Roman Antiquities), and essays on rhetoric and literary criticism, including On the Ancient Orators, On Composition, and several letters. This volume examines how Dionysius' critical and rhetorical works are connected with his history of Rome, and the complex ways in which both components of this dual project - rhetorical criticism and historiography - fit into the social, intellectual, literary, cultural and political world of Rome under Augustus. How does Dionysius' interpretation of the earliest Romans resonate with the political reality of the Principate? And how do his views relate to those of Cicero, Livy and Horace? This volume casts new light on ancient rhetoric, literary criticism, historiography and the literary culture of Augustan Rome.
Although the need for pigs to lie down on long journeys is not in question, there is evidence that they may not choose to do so on journeys of less than 3h (Hunter et al., 1994). These observations were undertaken to determine how pigs in the 95 to 100 kg weight range behaved on short journeys. A three-tier floating-deck vehicle with weld-mesh flooring was used because the popularity of three-deck vehicles is increasing (Riches et al., 1996).
Interest in planting mixtures of cover crop species has grown in recent years as farmers seek to increase the breadth of ecosystem services cover crops provide. As part of a multidisciplinary project, we quantified the degree to which monocultures and mixtures of cover crops suppress weeds during the fall-to-spring cover crop growing period. Weed-suppressive cover crop stands can limit weed seed rain from summer- and winter-annual species, reducing weed population growth and ultimately weed pressure in future cash crop stands. We established monocultures and mixtures of two legumes (medium red clover and Austrian winter pea), two grasses (cereal rye and oats), and two brassicas (forage radish and canola) in a long fall growing window following winter wheat harvest and in a shorter window following silage corn harvest. In fall of the long window, grass cover crops and mixtures were the most weed suppressive, whereas legume cover crops were the least weed suppressive. All mixtures also effectively suppressed weeds. This was likely primarily due to the presence of fast-growing grass species, which were effective even when they were seeded at only 20% of their monoculture rate. In spring, weed biomass was low in all treatments due to winter kill of summer-annual weeds and low germination of winter annuals. In the short window following silage corn, biomass accumulation by cover crops and weeds in the fall was more than an order of magnitude lower than in the longer window. However, there was substantial weed seed production in the spring in all treatments not containing cereal rye (monoculture or mixture). Our results suggest that cover crop mixtures require only low seeding rates of aggressive grass species to provide weed suppression. This creates an opportunity for other species to deliver additional ecosystem services, though careful species selection may be required to maintain mixture diversity and avoid dominance of winter-hardy cover crop grasses in the spring.