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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 aim of this report was to evaluate the methods used to test the efficacy of complementary and alternative veterinary medicine. A general review of available literature in this area was carried out and experimental design of 26 reported trials was analysed in detail. Quantitative evidence must form the basis of medicinal treatments, whether they fall under the traditional western medicine genre or whether they are seen as complementary or alternative therapies. Results from the quantitative characterisation of publications showed that within the ‘animal’ sector, the majority of work published is nonexperimental. Medline PubMed, for the years 1975 to 2005 returned a total of 400 review papers incorporating work from the human sector in alternative animal therapy in comparison to only 75 papers on experimental work. Of the 26 alternative veterinary medicine papers reviewed in detail 19 trials used a control group to assess the efficacy of the therapy tested. The experimental designs applied in clinical trials within this area are acceptable, using high levels of control and quantitative measurements. Improvements could be made through increased use of blind and double blind designs. Although there is lack of scientific evidence for alternative therapies, the application of these is continuously growing. This imbalance should be acknowledged and rectified.
During early lactation, when requirements for energy and protein are high, tissue protein requirements cannot be fulfilled by microbial protein alone and the opportunity arises to feed protected protein as a supplement to provide UDP which will compensate for the deficit between tissue protein requirements and microbial protein supplied by RDP.
We report the discovery of widespread millimeter-wavelength Class I methanol maser emission associated with protostellar molecular outflows in the massive (proto)cluster G11.92−0.61. Our ~0.5″-resolution SMA and ALMA observations of the 229 GHz and 278 GHz Class I transitions reveal seven and twelve candidate masers, respectively: all 229 GHz masers have 278 GHz counterparts, and five are also coincident with 44 GHz Class I masers previously detected with the VLA. For paired masers, the peak intensities at 229 GHz and 278 GHz are correlated. We also find tentative evidence for a correlation between the strength of millimeter-wavelength Class I maser emission and the energy of the associated molecular outflow.
We present Kitty, an unprecedented and near simultaneous flaring event in ten transitions (6 hydroxyl, 1 water and 3 methanol), that began on 1 January 2015 in the massive star-forming region NGC6334F located in the Cat’s Paw Nebula. The brightest components in each transition increased by factors of 20 to 70 in line with a factor of ~70 increase in dust emission luminosity for the source MM1. We also report the detection of only the fifth known 4.660 GHz hydroxyl maser and that it varied in a correlated fashion with 1.720, 6.031, and 6.035 GHz hydroxyl counterparts. We postulate that if Kitty, and two historical flares in 1965 & 1999, are accretion events and are caused by the successive passages of a secondary star disrupting the accretion disk, where the frequency of occurrence is cycling down at a rate of ~2.2, it is possible another event will occur in 2022.
Surface electroencephalogram (EEG) recording remains the gold standard for noninvasive assessment of electrical brain activity. It is the most efficient way to diagnose and classify epilepsy syndromes as well as define the localization of the epileptogenic zone. The EEG is useful for management decisions and for establishing prognosis in some types of epilepsy. Electroencephalography is an evolving field in which new methods are being introduced. The Canadian Society of Clinical Neurophysiologists convened an expert panel to develop new national minimal guidelines. A comprehensive evidence review was conducted. This document is organized into 10 sections, including indications, recommendations for trained personnel, EEG yield, paediatric and neonatal EEGs, laboratory minimal standards, requisitions, reports, storage, safety measures, and quality assurance.
This is a status report on a continuing program using the Hubble Space Telescope (HST) Wide–Field Camera (WFC) to probe the stellar population of the Galactic bulge to fainter magnitudes. We seek the mean age of the stars and the initial mass function (IMF). Galactic bulge stars offer the only opportunity to investigate the IMF of a super metal–rich population. They are 100 times closer than the next nearest sample.
Enlist™ cotton contains the aad-12 and pat genes that confer resistance to 2,4-D and glufosinate, respectively. Thirty-three field trials were conducted focused on Enlist cotton injury from glufosinate as affected by cotton growth stage, application rate, and single or sequential applications. Maximum injury from a single application of typical 1X (542 g ae ha-1) and 2X use rates was 3 and 13%, respectively, regardless of growth stage. Injury from sequential applications of 1X or 2X rates was equivalent to single applications. Similar injury was observed with four commercial formulations of glufosinate. Cotton yield was never affected by glufosinate. This research demonstrates Enlist™ cotton has robust resistance to glufosinate at rates at least twice the typical use rate when applied once or twice at growth stages ranging from 2 to 12 leaves.
Introduction: Point of care ultrasonography (PoCUS) is an established tool in the initial management of hypotensive patients in the emergency department (ED). It has been shown rule out certain shock etiologies, and improve diagnostic certainty, however evidence on benefit in the management of hypotensive patients is limited. We report the findings from our international multicenter RCT assessing the impact of a PoCUS protocol on diagnostic accuracy, as well as other key outcomes including mortality, which are reported elsewhere. Methods: Recruitment occurred at 4 North American and 3 Southern African sites. Screening at triage identified patients (SBP<100 mmHg or shock index >1) who were randomized to either PoCUS or control groups. Scans were performed by PoCUS-trained physicians. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. Final chart review was blinded to initial impressions and PoCUS findings. Categorical data was analyzed using Fishers two-tailed test. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. The perceived shock category changed more frequently in the PoCUS group 20/127 (15.7%) vs. control 7/125 (5.6%); RR 2.81 (95% CI 1.23 to 6.42; p=0.0134). There was no significant difference in change of diagnostic impression between groups PoCUS 39/123 (31.7%) vs control 34/124 (27.4%); RR 1.16 (95% CI 0.786 to 1.70; p=0.4879). There was no significant difference in the rate of correct category of shock between PoCUS (118/127; 93%) and control (113/122; 93%); RR 1.00 (95% CI 0.936 to 1.08; p=1.00), or for correct diagnosis; PoCUS 90/127 (70%) vs control 86/122 (70%); RR 0.987 (95% CI 0.671 to 1.45; p=1.00). Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We found that the use of PoCUS did change physicians’ perceived shock category. PoCUS did not improve diagnostic accuracy for category of shock or diagnosis.
Introduction: Point of care ultrasound (PoCUS) is an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). While PoCUS protocols have been shown to improve early diagnostic accuracy, there is little published evidence for any mortality benefit. We report the findings from our international multicenter randomized controlled trial, assessing the impact of a PoCUS protocol on survival and key clinical outcomes. Methods: Recruitment occurred at 7 centres in North America (4) and South Africa (3). Scans were performed by PoCUS-trained physicians. Screening at triage identified patients (SBP<100 or shock index>1), randomized to PoCUS or control (standard care and no PoCUS) groups. Demographics, clinical details and study findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. The primary outcome measure was 30-day/discharge mortality. Secondary outcome measures included diagnostic accuracy, changes in vital signs, acid-base status, and length of stay. Categorical data was analyzed using Fishers test, and continuous data by Student T test and multi-level log-regression testing. (GraphPad/SPSS) Final chart review was blinded to initial impressions and PoCUS findings. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no difference between groups for the primary outcome of mortality; PoCUS 32/129 (24.8%; 95% CI 14.3-35.3%) vs. Control 32/129 (24.8%; 95% CI 14.3-35.3%); RR 1.00 (95% CI 0.869 to 1.15; p=1.00). There were no differences in the secondary outcomes; ICU and total length of stay. Our sample size has a power of 0.80 (α:0.05) for a moderate effect size. Other secondary outcomes are reported separately. Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We did not find any mortality or length of stay benefits with the use of a PoCUS protocol, though a larger study is required to confirm these findings. While PoCUS may have diagnostic benefits, these may not translate into a survival benefit effect.
Introduction: Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for emergency department (ED) patients with undifferentiated non-traumatic hypotension. While PoCUS has been shown to improve early diagnosis, there is a minimal evidence for any outcome benefit. We completed an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key resuscitation markers in this group. We report diagnostic impact and mortality elsewhere. Methods: The SHoC-ED1 study compared the addition of PoCUS to standard care within the first hour in the treatment of adult patients presenting with undifferentiated hypotension (SBP<100 mmHg or a Shock Index >1.0) with a control group that did not receive PoCUS. Scans were performed by PoCUS-trained physicians. 4 North American, and 3 South African sites participated in the study. Resuscitation outcomes analyzed included volume of fluid administered in the ED, changes in shock index (SI), modified early warning score (MEWS), venous acid-base balance, and lactate, at one and four hours. Comparisons utilized a T-test as well as stratified binomial log-regression to assess for any significant improvement in resuscitation amount the outcomes. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no significant difference in mean total volume of fluid received between the control (1658 ml; 95%CI 1365-1950) and PoCUS groups (1609 ml; 1385-1832; p=0.79). Significant improvements were seen in SI, MEWS, lactate and bicarbonate with resuscitation in both the PoCUS and control groups, however there was no difference between groups. Conclusion: SHOC-ED1 is the first RCT to compare PoCUS to standard of care in hypotensive ED patients. No significant difference in fluid used, or markers of resuscitation was found when comparing the use of a PoCUS protocol to that of standard of care in the resuscitation of patients with undifferentiated hypotension.
Introduction: Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). Current established protocols (e.g. RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. Recently the SHoC Protocol was published, recommending 3 core scans; cardiac, lung, and IVC; plus other scans when indicated clinically. We report the abnormal ultrasound findings from our international multicenter randomized controlled trial, to assess if the recommended 3 core SHoC protocol scans were chosen appropriately for this population. Methods: Recruitment occurred at seven centres in North America (4) and South Africa (3). Screening at triage identified patients (SBP<100 or shock index>1) who were randomized to PoCUS or control (standard care with no PoCUS) groups. All scans were performed by PoCUS-trained physicians within one hour of arrival in the ED. Demographics, clinical details and study findings were collected prospectively. A threshold incidence for positive findings of 10% was established as significant for the purposes of assessing the appropriateness of the core recommendations. Results: 138 patients had a PoCUS screen completed. All patients had cardiac, lung, IVC, aorta, abdominal, and pelvic scans. Reported abnormal findings included hyperdynamic LV function (59; 43%); small collapsing IVC (46; 33%); pericardial effusion (24; 17%); pleural fluid (19; 14%); hypodynamic LV function (15; 11%); large poorly collapsing IVC (13; 9%); peritoneal fluid (13; 9%); and aortic aneurysm (5; 4%). Conclusion: The 3 core SHoC Protocol recommendations included appropriate scans to detect all pathologies recorded at a rate of greater than 10 percent. The 3 most frequent findings were cardiac and IVC abnormalities, followed by lung. It is noted that peritoneal fluid was seen at a rate of 9%. Aortic aneurysms were rare. This data from the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients, supports the use of the prioritized SHoC protocol, though a larger study is required to confirm these findings.
The stability of a tidewater terminus is controlled by glacial dynamics, calving processes and sedimentary processes at the grounding line. An investigation of grounding-line sediment dynamics and morainal-bank sediment budgets in Glacier Bay, Alaska, U.S.A., has yielded data that enable us to determine the debris fluxes of Grand pacific, Margerie and Muir Glaciers. Debris flux ranges from 105 to 106 m3 a−1, one to two orders of magnitude lower than the glacifluvial sediment fluxes (106−107 m3 a−1). Combined, these fluxes represent the highest yields known for glacierized basins. Large debris fluxes reflect the combined effects of rapid glacier flow, driven by the maritime climate of southeast Alaska, and highly erodible bedrock. Englacial-debris distribution is affected by valley width and relief, both of which control the availability of sediment. The number of tributaries controls the distribution and volume of debris in englacial and supraglacial moraines. At the terminus, iceberg-rafting removes up to two orders of magnitude more sediment from the ice-proximal environment than is deposited by melt-out or is dumped during calving events. Rough estimates of the sediment flux by deforming beds suggests that soft-bed deformation may deliver up to an order of magnitude more sediment to the terminus than is released from within the glacier ice.
Investigations of grounding-line sedimentation in front of tidewater termini of temperate valley glaciers demonstrate that sediment yields and dynamics provide a second-order control on glacier stability by influencing water depth at the grounding line. Sediment is delivered to the grounding line by two routes: (1) debris transported in, on and beneath the glacier, and (2) sediment transported in glacial outwash streams. Glacial streams in Glacier Bay, Alaska, U.S.A., deliver 106 to 107 m3 year−1 of sediment to the grounding lines. The glacial debris flux transports 105 to 106 m3 year−1 of debris to the ice cliffs, where approximately 10% is released at the grounding line, the remainder being transported downfjord by iceberg-rafting. An additional 105 m3 year−1 of sediment may be transported to the grounding line by shearing and advection of a deformable bed.
EGRET, the high-energy γ-ray telescope on the Compton Gamma-Ray Observatory, has the sensitivity, angular resolution, and background rejection necessary to study diffuse γ-ray emission from the interstellar medium (ISM). High-energy γ rays produced in cosmic-ray (CR) interactions in the ISM can be used to determine the CR density and calibrate the CO line as a tracer of molecular mass. Dominant production mechanisms for γ rays of energies ∼30 MeV–30 GeV are the decay of pions produced in collisions of CR protons with ambient matter and Bremsstrahlung scattering of CR electrons.
Jovian auroral emissions are observed at infrared, visible, ultraviolet, and x-ray wavelengths. As at Earth, pitch-angle scattering of energetic particles into the atmospheric loss cone and the acceleration of current-carrying electrons in field-aligned currents both play a role in exciting the auroral emissions. The x-ray aurora is believed to result principally from heavy ion precipitation, while the ultraviolet aurora is produced predominantly by precipitating energetic electrons. The magnetospheric processes responsible for the aurora are driven primarily by planetary rotation. Acceleration of Iogenic plasma by rotationally-induced electric fields results in both the formation of the energetic ions that are scattered and the formation of strong, field-aligned currents that communicate the torques from the ionosphere. In addition to rotation-driven processes, solar-wind-modulated processes in the outer magnetosphere may lead to highly, time-dependent acceleration and thus also contribute to jovian auroral activity. Observational evidence for both sources will be presented. See Waite et al. (2001, Nat., 410, 787).