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In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.
The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.
This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP’s physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.
The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.
State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.
Background: Cervical spondylotic myelopathy (CSM) is the leading cause of spinal cord impairment. In a public healthcare system, wait times to see spine specialists and eventually access surgical treatment for CSM can be substantial. The goals of this study were to determine consultation wait times (CWT) and surgical wait times (SWT), and identify predictors of wait time length. Methods: Consecutive patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) prospective and observational CSM study from March 2015 to July 2017 were included. A data-splitting technique was used to develop and internally validate multivariable models of potential predictors. Results: A CSORN query returned 264 CSM patients for CWT. The median was 46 days. There were 31% mild, 35% moderate, and 33% severe CSM. There was a statistically significant difference in median CWT between moderate and severe groups; 207 patients underwent surgical treatment. Median SWT was 42 days. There was a statistically significant difference in SWT between mild/moderate and severe groups. Short symptom duration, less pain, lower BMI, and lower physical component score of SF-12 were predictive of shorter CWT. Only baseline pain and medication duration were predictive of SWT. Both CWT and SWT were shorter compared to a concurrent cohort of lumbar stenosis patients (p <0.001). Conclusions: Patients with shorter duration (either symptoms or medication) and less neck pain waited less to see a spine specialist in Canada and to undergo surgical treatment. This study highlights some of the obstacles to overcome in expedited care for this patient population.
Objectives: The Tower of London (TOL) test has probably become the most often used task to assess planning ability in clinical and experimental settings. Since its implementation, efforts were made to provide a task version with adequate psychometric properties, but extensive normative data are not publicly available until now. The computerized TOL-Freiburg Version (TOL-F) was developed based on theory-grounded task analyses, and its psychometric adequacy has been repeatedly demonstrated in several studies but often with small and selective samples. Method: In the present study, we now report reliability estimates and normative data for the TOL-F stratified for age, sex, and education from a large population-representative sample collected in the Gutenberg Health Study in Mainz, Germany (n=7703; 40–80 years). Results: The present data confirm previously reported adequate indices of reliability (>.70) of the TOL-F. We also provide normative data for the TOL-F stratified for age (5-year intervals), sex, and education (low vs. high education). Conclusions: Together, its adequate reliability and the representative age-, sex-, and education-fair normative data render the computerized TOL-F a suitable diagnostic instrument to assess planning ability. (JINS, 2019, 25, 520–529)
Fomesafen is a protoporphyrinogen oxidase–inhibitor herbicide with an alternative mode of action that provides PRE weed control in strawberry [Fragaria×ananassa (Weston) Duchesne ex Rozier (pro sp.) [chiloensis×virginiana]] produced in a plasticulture setting in Florida. Plasticulture mulch could decrease fomesafen dissipation and increase crop injury in rotational crops. Field experiments were conducted in Balm, FL, to investigate fomesafen persistence and movement in soil in Florida strawberry systems for the 2014/2015 and 2015/2016 production cycles. Treatments included fomesafen preplant at 0, 0.42, and 0.84 kg ai ha−1. Soil samples were taken under the plastic from plots treated with fomesafen at 0.42 kg ha−1 throughout the production cycle. Fomesafen did not injure strawberry or decrease yield. Fomesafen concentration data for the 0.0- to 0.1-m soil depth were described using a three-parameter logistic function. The fomesafen 50% dissipation times were 37 and 47 d for the 2014/2015 and 2015/2016 production cycles, respectively. At the end of the study, fomesafen was last detected in the 0.0- to 0.1-m depth soil at 167 and 194 d after treatment in the 2014/2015 and 2015/2016 production cycles, respectively. Fomesafen concentration was less than 25 ppb on any sampling date for 0.1- to 0.2-m and 0.2- to 0.3-m depths. Fomesafen concentration decreased significantly after strawberry was transplanted and likely leached during overhead and drip irrigation used during the crop establishment.
We present Phantom, a fast, parallel, modular, and low-memory smoothed particle hydrodynamics and magnetohydrodynamics code developed over the last decade for astrophysical applications in three dimensions. The code has been developed with a focus on stellar, galactic, planetary, and high energy astrophysics, and has already been used widely for studies of accretion discs and turbulence, from the birth of planets to how black holes accrete. Here we describe and test the core algorithms as well as modules for magnetohydrodynamics, self-gravity, sink particles, dust–gas mixtures, H2 chemistry, physical viscosity, external forces including numerous galactic potentials, Lense–Thirring precession, Poynting–Robertson drag, and stochastic turbulent driving. Phantom is hereby made publicly available.
Chondrules and matrix from carbonaceous chondrites exhibit complementary nucleosynthetic W isotope anomalies that result from the depletion of a metallic s-process carrier in the chondrules, and the enrichment of this carrier in the matrix. The complementarity is difficult to reconcile with an origin of chondrules in protoplanetary impacts and also with models in which chondrules and matrix formed independently of each other in distinct regions of the disk. Instead, the complementarity indicates that chondrules formed by localized melting of dust aggregates in the solar nebula. The Hf–W ages for metal-silicate fractionation in CV and CR chondrites are 2.2 ± 0.8 Ma and 3.6 ± 0.6 Ma after formation of Ca-Al-rich inclusions, and are indistinguishable from Al–Mg ages for CV and CR chondrules. The good agreement between these ages strongly suggests that 26Al was homogeneously distributed in the solar protoplanetary disk and that therefore Al–Mg ages are chronologically meaningful. The concordant Al–Mg and Hf–W ages reveal that chondrule formation (as dated by Al–Mg) was associated with metal-silicate fractionation (as dated by Hf–W), both within a given chondrite but also among the different subgroups of ordinary chondrites. These age data indicate that chondrules from a given chondrite group formed in a narrow time interval of <1 Ma, and that chondrule formation and chondrite accretion were closely linked in time and space. The rapid accretion of chondrules into a chondrite parent body is consistent with the isotopic complementarity, which requires that neither chondrules nor matrix were lost prior to chondrite accretion. Combined, these observations suggest that chondrule formation was an important step in the accretion of planetesimals.
Interventions to reduce disability from acute orthopedic injuries require a primary assessment of knowledge and need. There are no previous studies to assess this need in the remote provincial islands of the Philippines, an area recurrently affected by natural disaster.
A preliminary assessment of orthopedic knowledge and need was performed to be expanded for regional or national implementation.
Two independent surveys were conducted of households and mid-level providers who represent the first contact of care. The goal of the survey was to describe the local health care system, to identify barriers to care, and to assess gaps in knowledge for acute traumatic orthopedic injuries. Both surveys were conducted in June of 2015.
Population proportional sampling assessed a total of 100 households from 25 local Barangay communities. Questions focused on existing knowledge of acute traumatic orthopedic injuries and barriers to care.
The mid-level provider survey focused on knowledge and barriers to care regarding acute traumatic orthopedic injuries. A total of 10 school nurses and Barangay midwives representing 25 local Barangay were surveyed.
In the household population survey, 84% of respondents reported cost was either always or sometimes a barrier to care; 73% cited transportation as a barrier to care. A total of 68% of respondents reported that they would seek care at the provincial hospital for a suspected broken bone; 28% percent of respondents did not believe broken bones making an arm or leg crooked could be corrected without surgery. Only 55% percent believed care should be sought within six hours of injury, and 37% stated that more than three days after an injury was an appropriate timeframe to seek care.
Of the mid-level providers surveyed, 90% reported that they would refer possible broken bones to a higher level of care. Aggregate ranking of barriers to care from greatest to least were: cost, transportation, knowledge of time sensitive nature of treatment, religious beliefs, and other (not specified). In all, 100% reported that an education initiative regarding acute orthopedic injuries would increase the number of patients seeking care within 12 hours.
The survey describes perceived barriers to care and gaps in knowledge for acute orthopedic injuries. With some modification, this survey tool could be expanded and utilized on a regional or national level to assess gaps in knowledge and barriers to acute orthopedic care.
CourtneyCS, KirschTD. Orthopedic Knowledge and Need in the Provincial Philippines: Pilot Study of a Population-Based Survey. Prehosp Disaster Med. 2018;33(3):293–298.
Direct ink writing of silicone elastomers enables printing with precise control of porosity and mechanical properties of ordered cellular solids, suitable for shock absorption and stress mitigation applications. With the ability to manipulate structure and feedstock stiffness, the design space becomes challenging to parse to obtain a solution producing a desired mechanical response. Here, we derive an analytical design approach for a specific architecture. Results from finite element simulations and quasi-static mechanical tests of two different parallel strand architectures were analyzed to understand the structure-property relationships under uniaxial compression. Combining effective stiffness-density scaling with least squares optimization of the stress responses yielded general response curves parameterized by resin modulus and strand spacing. An analytical expression of these curves serves as a reduced order model, which, when optimized, provides a rapid design capability for filament-based 3D printed structures. As a demonstration, the optimal design of a face-centered tetragonal architecture is computed that satisfies prescribed minimum and maximum load constraints.
Fomesafen is a protoporphyrinogen oxidase (PROTOX) inhibitor that has the potential to be used as an alternative mechanism of action for PRE nutsedge and broadleaf weed control in Florida production of small fruit and vegetables. Fumigation in the raised-bed plasticulture system may increase herbicide persistence. Fomesafen persistence could dissuade Florida growers from using the herbicide for fear of injury to subsequent susceptible crops. Field experiments were conducted in Balm, FL, in 2015 and 2016 to investigate the effect of fumigation on fomesafen dissipation, eggplant tolerance, and purple nutsedge control. Treatments included fomesafen at 0.42 kg ai ha−1, S-metolachlor at 1.06 kg ai ha−1, and a nontreated control in either a fumigated bed injected with a combination of 39% 1,3-dichloropropene and 59.6% chloropicrin at 336 kg ha−1 or no fumigant. Fomesafen concentration in the soil decreased by 83% and 96% from application to harvest in 2015 and 2016, respectively. Fumigation did not affect fomesafen dissipation in either year. At 2 wk after transplant (WATr), fomesafen caused 14% eggplant injury. Injury decreased to less than 5% at 6 WATr. Fomesafen and S-metolachlor treatments did not reduce eggplant height or yields compared with the nontreated control. Fumigation and fomesafen did not decrease purple nutsedge density; however, S-metolachlor applications resulted in a 48% reduction. Further research is needed to assess efficacy on broadleaf and grass weeds.
Martian Meteorite ALH84001 contains four unusual features which have been interpreted as possible signatures of relic biogenic activity. After six years of intense study by the world's scientific community, the current status of the biogenic hypothesis is reviewed and shown to still be valid. Furthermore additional features have been observed in two younger Martian meteorites. The strongest argument for possible evidence of biogenic activity within the ALH84001 meteorite is the presence of truncated hexa-octahedral magnetite crystals which are only known on Earth to be the products of biology.
We report the discovery in the Greenland ice sheet of a discrete layer of free nanodiamonds (NDs) in very high abundances, implying most likely either an unprecedented influx of extraterrestrial (ET) material or a cosmic impact event that occurred after the last glacial episode. From that layer, we extracted n-diamonds and hexagonal diamonds (lonsdaleite), an accepted ET impact indicator, at abundances of up to about 5×106 times background levels in adjacent younger and older ice. The NDs in the concentrated layer are rounded, suggesting they most likely formed during a cosmic impact through some process similar to carbon-vapor deposition or high-explosive detonation. This morphology has not been reported previously in cosmic material, but has been observed in terrestrial impact material. This is the first highly enriched, discrete layer of NDs observed in glacial ice anywhere, and its presence indicates that ice caps are important archives of ET events of varying magnitudes. Using a preliminary ice chronology based on oxygen isotopes and dust stratigraphy, the ND-rich layer appears to be coeval with ND abundance peaks reported at numerous North American sites in a sedimentary layer, the Younger Dryas boundary layer (YDB), dating to 12.9 ± 0.1 ka. However, more investigation is needed to confirm this association.
Mulches used in plasticulture systems could decrease dissipation of fomesafen, a protoporphyrinogen oxidase inhibitor, and dissuade producers from using the herbicide for fear of crop injury in subsequent growing seasons. Field experiments were conducted in Balm, FL, in 2015 and 2016 to investigate the effect of different plastic mulches on fomesafen dissipation, squash tolerance, and efficacy on purple nutsedge. Squash was injured less than 5% from fomesafen applications. The use of plastic mulches reduced purple nutsedge density at transplant by 60% compared with the no-mulch treatment. At transplant, treatments with low-density polyethylene mulch (LDPE), virtually impermeable film (VIF), and totally impermeable film (TIF) mulch had greater than 2-fold the fomesafen concentrations than treatments with clear or no mulch. At harvest in 2015, LDPE, VIF, and TIF treatments had greater fomesafen concentrations than clear and no-mulch treatments; however, concentrations in 2016 were similar for all treatments. Fomesafen can persist at high concentrations throughout the growing season in Florida plasticulture possibly limiting producer options for crop rotation and the use of cover crops.
Three-dimensional (3D) printing has expanded beyond the mere patterned deposition of melted solids, moving into areas requiring spatially structured soft matter—typically materials composed of polymers, colloids, surfactants, or living cells. The tunable and dynamically variable rheological properties of soft matter enable the high-resolution manufacture of soft structures. These rheological properties are leveraged in 3D printing techniques that employ sacrificial inks and sacrificial support materials, which go through reversible solid–fluid transitions under modest forces or other small perturbations. Thus, a sacrificial material can be used to shape a second material into a complex 3D structure, and then discarded. Here, we review the sacrificial materials and related methods used to print soft structures. We analyze data from the literature to establish manufacturing principles of soft matter printing, and we explore printing performance within the context of instabilities controlled by the rheology of soft matter materials.
Catheter-associated urinary tract infections (CAUTIs) are among the most common hospital-acquired infections (HAIs). Reducing CAUTI rates has become a major focus of attention due to increasing public health concerns and reimbursement implications.
To implement and describe a multifaceted intervention to decrease CAUTIs in our ICUs with an emphasis on indications for obtaining a urine culture.
A project team composed of all critical care disciplines was assembled to address an institutional goal of decreasing CAUTIs. Interventions implemented between year 1 and year 2 included protocols recommended by the Centers for Disease Control and Prevention for placement, maintenance, and removal of catheters. Leaders from all critical care disciplines agreed to align routine culturing practice with American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines for evaluating a fever in a critically ill patient. Surveillance data for CAUTI and hospital-acquired bloodstream infection (HABSI) were recorded prospectively according to National Healthcare Safety Network (NHSN) protocols. Device utilization ratios (DURs), rates of CAUTI, HABSI, and urine cultures were calculated and compared.
The CAUTI rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. The DUR was 0.7 in 2013 and 0.68 in 2014. The HABSI rates per 1,000 patient days decreased from 2.8 in 2013 to 2.4 in 2014.
Effectively reducing ICU CAUTI rates requires a multifaceted and collaborative approach; stewardship of culturing was a key and safe component of our successful reduction efforts.
Papyri 10012A and 10012B from Illahun, Egypt, provide the earliest astro-chronological datum in history and, while calculated to various years in the 19th century BCE, have never been independently verified. As this datum enables the Middle Kingdom (MK) section of Egyptian historical chronology to be anchored in absolute time, it establishes the principal calendrical timeline for the eastern Mediterranean Bronze Age in the first half of the 2nd millennium BCE. AMS radiocarbon measurements of Papyrus 10012B establish its date range to 1886–1750 BCE, confirming the astronomical calculations and the essential reliability of Egyptian historical chronology for this period. Furthermore, all three leading estimates for the calendar year attribution of the document are supported by this analysis, with the role of a possible growing season effect determining which is most favored.
New radiocarbon calibration curves, IntCal04 and Marine04, have been constructed and internationally ratified to replace the terrestrial and marine components of IntCal98. The new calibration data sets extend an additional 2000 yr, from 0–26 cal kyr BP (Before Present, 0 cal BP = AD 1950), and provide much higher resolution, greater precision, and more detailed structure than IntCal98. For the Marine04 curve, dendrochronologically-dated tree-ring samples, converted with a box diffusion model to marine mixed-layer ages, cover the period from 0–10.5 cal kyr BP. Beyond 10.5 cal kyr BP, high-resolution marine data become available from foraminifera in varved sediments and U/Th-dated corals. The marine records are corrected with site-specific 14C reservoir age information to provide a single global marine mixed-layer calibration from 10.5–26.0 cal kyr BP. A substantial enhancement relative to IntCal98 is the introduction of a random walk model, which takes into account the uncertainty in both the calendar age and the 14C age to calculate the underlying calibration curve (Buck and Blackwell, this issue). The marine data sets and calibration curve for marine samples from the surface mixed layer (Marine04) are discussed here. The tree-ring data sets, sources of uncertainty, and regional offsets are presented in detail in a companion paper by Reimer et al. (this issue).