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Throughout the world, past and present, social organizations develop to cope with restricted water sources. Relying on traditional archaeology, labor estimates, and ethnographic data, the Palenque Pool Project set out to better understand a series of interconnected artificial water features located in the western sector of this Classic Maya site. Here, we detail our 2014–2015 fieldwork. First, there is consideration that the Picota Group was a civic-ceremonial center first established in the Early Classic period (a.d. 250–500), one km to the west of the “downtown” nucleus of the site. A review of labor estimates for the construction of architectural features of the Picota Group follows. We then explore the ethnographic component, comparing similar pool configurations investigated in the highland Tzotzil community of Chamula in 2015. The article concludes with a theoretical discussion of how and why social organizations evolve to manage water resources in the region, with reference to ethnographic information from highland Tzotzil communities.
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.
The effect of transportation and lairage on the faecal shedding and post-slaughter contamination of carcasses with Escherichia coli O157 and O26 in young calves (4–7-day-old) was assessed in a cohort study at a regional calf-processing plant in the North Island of New Zealand, following 60 calves as cohorts from six dairy farms to slaughter. Multiple samples from each animal at pre-slaughter (recto-anal mucosal swab) and carcass at post-slaughter (sponge swab) were collected and screened using real-time PCR and culture isolation methods for the presence of E. coli O157 and O26 (Shiga toxin-producing E. coli (STEC) and non-STEC). Genotype analysis of E. coli O157 and O26 isolates provided little evidence of faecal–oral transmission of infection between calves during transportation and lairage. Increased cross-contamination of hides and carcasses with E. coli O157 and O26 between co-transported calves was confirmed at pre-hide removal and post-evisceration stages but not at pre-boning (at the end of dressing prior to chilling), indicating that good hygiene practices and application of an approved intervention effectively controlled carcass contamination. This study was the first of its kind to assess the impact of transportation and lairage on the faecal carriage and post-harvest contamination of carcasses with E. coli O157 and O26 in very young calves.
Introduction: The decision as to whether to end resuscitation for pre-hospital cardiac arrest (CA) patients in the field or in the emergency department (ED) is commonly made based upon standard criteria. We studied the reliability of several easily determined criteria as predictors of resuscitation outcomes in a population of adults in CA transported to the ED. Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19. Multiple data were abstracted from charts using a standardized form. Regression analysis was used to compare criteria that predicted return of spontaneous circulation (ROSC) and survival to hospital admission (SHA). Results: 264 patients met the study inclusion criteria. Logistic regression was used to identify predictors of ROSC and SHA. The criteria that emerged as significant predictors for ROSC included; longer ED resuscitation time (Odds ratio 1.11 (1.06- 1.18)), witnessed arrest (Odds ratio 9.43 (2.58- 53.0)) and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 3.23 (1.07-9.811)) over Asystole. Receiving point of care ultrasound (PoCUS; Odds ratio 0.22 (0.07-0.69)); and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 4.10 (1.43-11.88)) were the significant predictors for SHA. Longer times for ED resuscitation was close to reaching significance for predicting SHA Conclusion: Our results suggest that both fixed and adaptable factors, including increasing resuscitation time, and PoCUS use in the ED were important independent predictors of successful resuscitation. Several commonly used criteria were unreliable predictors.
Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR), a method of cardiopulmonary bypass, is increasingly being used to supplement traditional CPR to improve outcomes for cardiac arrest (CA). CA and particularly out of hospital CA (OHCA) have poor outcomes. Prior to development of a 3 phase ECPR program in a Canadian regional hospital, we wished to identify and optimize a practical selection process (inclusion and exclusion criteria) for patients who may benefit from ECPR. Methods: Using a locally modified Delphi technique, we followed a literature review to construct a proposed set of evidence based criteria with a questionnaire, where inclusion and exclusion criteria were scored by a selected group of 13 experts. Following 3 rounds, and additional review by an international expert in the field of ECPR, consensus was achieved for patient selection criterion. Results: First round responses achieved 87.5% agreement for selection of exclusion criteria. Inclusion criteria had agreement 62.5%. Responses to the second round for selection of inclusion criteria were unanimous at 100% with the exception of age parameters (<65 years vs. <70 years). The third and final set of criteria achieved 100% consensus though subsequent expert review refined a single exclusion criteria (asystole). Agreed inclusion criteria were: witnessed CA, age <70, refractory arrest, no flow time <10min, total downtime <60min, and a cardiac or select non-cardiac etiology (PE, drug OD, poisoning, hypothermia). Exclusion criteria were : unwitnessed arrest, asystole, certain etiologies (uncontrolled bleeding, irreversible brain damage, trauma), and comorbidities (severe disability limiting ADLs, standing DNR, palliation). Simplified criteria for EMS transport included witnessed OHCA, age, and no flow time. Conclusion: Selection criteria of candidates for ECPR are important components for any program. Expert consensus review of current evidence is an effective method for development of ECPR selection criteria.
Introduction: Traditionally, out of hospital cardiac arrests (CA) have poor outcomes. Incorporation of extracorporeal cardiopulmonary resuscitation (ECPR) is being used increasingly to supplement ACLS to provide better outcomes for patients. Current literature suggests potentially improved outcomes, including neurological function. We assessed the feasibility of introduction of ECPR to a regional hospital using a 4-phase study. We report phase-1, an estimation of the number of potential candidates for ECPR in our setting. Methods: Following development and agreement on local criteria for selection of patients for ECPR using a modified Delphi Technique, inclusion and exclusion criteria were applied retrospectively, to a database comprising 4 years of emergency department (ED) cardiac arrests (n=395). This provided estimates of the number of patients who would have qualified for EMS transport for ECPR and initiation of ECPR in the ED. Results: Application of criteria would result in 20.0% (95% CI 16.2-24.3%) of CA being transported to the ED for ECPR (mean 18.5 patients per year). In the ED 4.6% (95% CI 2.83-7.26%) would be eligible to receive ECPR (4.3 patients per year). Incorporating downtime criteria, 3.0% (95% CI 1.6-5.3%) qualify. After considering local in-house cardiac catheterization hours 9.4% (95% CI 6.8-12.9%) and 5.4% (95% CI 3.5-8.2%), without and with EMS rhythm assumptions respectively, would be eligible for transport. For placement on pump, 3.0% (95% CI 1.6-5.3%) and 2.4% (95% CI 1.2-4.6%), without and with use of total downtime respectively, were eligible. Conclusion: If historical patterns of CA were to continue, we believe that an ECPR program may be feasible in our regional hospital setting, with a small number of selected cardiac arrest patients meeting eligibility for transportation and initiation of ECPR. These numbers suggest that an ECPR program would not be resource intensive, yet would be sufficiently busy to maintain adequate team competency.
Introduction: Electrocardiographic (ECG) rhythms are used during resuscitation (ACLS) to guide resuscitation, and often to determine futility. Survival rates to hospital discharge have been reported to be higher for patients with PEA than asystole in out-of-hospital cardiac arrest. This study examines how well the initial ECG cardiac rhythm represents actual cardiac activity as determined by point of care ultrasound (PoCUS). Methods: A database review was completed for patients arriving to a tertiary ED in asystole or PEA arrest, from 2010 to 2014. Patients under 19y or with a previous DNR were excluded. Patients were grouped into those with cardiac activity (PEA) and asystole on ECG; as well as whether cardiac activity was seen on PoCUS during the arrest. Data was analyzed for visualized cardiac activity on PoCUS. Results: 186 patients met the study criteria. Those with asystole on ECG were more likely to have no cardiac activity than those with PEA (Odds 7.21 for initial PoCUS; 5.45 for any PoCUS). The sensitivity of ECG rhythm was 80.49% and 82.12%, specificity was 77.91% and 54.28%, positive predictive value was 94.28% and 88.57%, and negative predictive value was 30.43% and 41.30% for cardiac activity on initial PoCUS and on any PoCUS respectively. The positive and negative likelihood ratios for ECG were 3.47 and 0.25 for activity on initial PoCUS. The positive and negative likelihood ratios for activity on any PoCUS were 1.78 and 0.33. Conclusion: Our results suggest that although most patients with asystole on ECG demonstrate no cardiac activity, a small number actually had activity on PoCUS. This supports the use of PoCUS during cardiac arrest, in addition to ECG, to identify patients with ongoing mechanical cardiac activity.
Introduction: With hospital occupancy rates frequently approaching 100%, even small variations in daily admission numbers can have a large impact. The ability to predict variance in emergency admission rates would provide administrators with a significant advantage in managing hospital daily bed requirements. There is a growing interest in patterns of hospital admissions, and many EDs utilize historical admission patterns to attempt to predict daily bed requirements. Previous studies have utilized patient demographics and past medical history to develop an admission likelihood model. We wished to examine the predictive strength of individual CEDIS presenting complaints (PC) on admission likelihood Methods: Using a database analysis of over 285,000 ED presentations (2013-2017), we calculated visit frequencies and admission rates by PC. Using a logistic regression analysis PCs were ordered from high to medium predictive strength. Results: Of 285,155 presentations, there were 38,090 hospital admissions, a rate of 13.36%. Based on the number of visit frequencies and admission rates, the PCs demonstrating high predictive strength were Direct Referral (effect=0.36, binomial CI: 0.28 to 0.44); Shortness of Breath (0.32: 0.26 to 0.41); General Weakness; Weakness/Query CVA; & Chest Pain Cardiac Features (each 0.30: 0.25 to 0.42); Altered level of consciousness (0.24: 0.16 to 0.31); and Confusion (0.18: 0.08 to 0.26). With our sample size, all remaining CEDIS PCs had low predictive value (the effect is <0.1), or were not predictive at all. Conclusion: We have demonstrated that, for our population, certain PCs are associated with an increased likelihood of admission and have quantified this effect using logistic regression analysis. Variance from the average daily admission rate may be predicted, in our population, by identifying these PCs at registration.We plan to develop a tool, based on this data and implemented at registration, to predict cumulative likely daily admission requirements as patients present over a 24hr period.
Introduction: Situational Awareness is the ability to identify, process, and comprehend the critical elements of information about the patient condition, stability, the operational environment and an appropriate clinical course. The Situational Awareness Global Assessment Tool (SAGAT) is a validated tool for measuring situational awareness. The SAGAT tool was measured during a series of standardized high fidelity advanced airway management simulations in multidisciplinary teams in New Brunswick Emergency Departments delivered by two simulation programs Methods: Thirty eight simulated emergency airway cases were performed in situ in Emergency Departments and in learning centers in Southern New Brunswick from September 2015 to October 2017. Eight standardized cases were used whose educational objectives were to develop the optimization of critically ill patients prior to induction, to deliver patient-centered anesthesia and to choose an appropriate airway strategy. Learner profiles collected. Cases were divided into two groups; those that contained critical errors and those that did not based on video assessment. Critical errors were defined as failure of 1) Oxygenation 2) Shock correction 3) Induction dose estimation 4) Choice of airway management paradigm. The SAGAT has a maximum score of 13 and was assessed by research nurses after each case for all participants. SAGAT scores were non-normally distributed, so results were expressed as medians with interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. Results: Results. Of the 38 cases, 14 contained one more critical errors. The median SAGAT score in the group that contained critical errors was 8 +/− 2 (IQR). The median SAGAT Score in the group that contained no critical errors was 11 +/− 2 (IQR). The median scores we significantly different with a p-value of 0.02. Conclusion: In this study in simulated emergency cases, higher SAGAT scores were associated with teams leaders that did not commit safety critical errors. This work is the initial analysis to develop standards for Simulated team performance in Emergency Department teams.
Introduction: Situational awareness (SA) is the team understanding patient stability, presenting illness and future clinical course. Losing SA has been shown to increase safety-critical events in multiple industries. SA can be measured by the previously validated Situational Awareness Global Assessment Tool (SAGAT). Checklists are used in many safety-critical industries to reduce errors of omission and commission. An RSI checklist was developed from case review and published evidence.The New Brunswick Trauma Program supports an inter-professional simulation-based medical education program Methods: Simulations were facilitated in three hospitals in New Brunswick from April 2017 to October 2017. Learner profiles were collected. The SAGAT tool was completed by a research nurse at the end of each scenario. SAGAT scores were non-normally distributed, so results were expressed as medians and interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. To understand the effect of the of an RSI checklist a comparison was made between SAGAT scores at baseline in scenario 1, and the same first scenario completed after a washout period. A Poisson regression analysis will be used to account for the effect of confounding variables in further analyses. Results: The group was composed of Registered Nurses (8), Physicians (7), and Respiratory Therapists (2). Situational awareness increased significantly with the use of an RSI checklist after 1 day of 4 simulations. The washout period ranged between 5 weeks and 8 weeks. The baseline situational awareness of the whole group during scenario 1 was 9 +/− 0.5 (median, IQR), and with the RSI checklist was 12 +/−1 (median, IQR). The difference was highly statistically significant, p=< 0.001. This level of situational awareness using checklist is comparable to the SAGAT scores after 10 scenarios. Conclusion: In this provisional analysis, the use of an RSI checklist was associated with an increase in measured situational awareness. Higher levels of situational awareness are associated with greater patient safety. A Poisson regression model will be used to understand the confounding effects of user expertise and the likely interaction with simulation exposure.
Although Saturn's broad A, B, and C rings epitomize the concept of “planetary rings” in the minds of most people, much of our detailed knowledge of ring dynamics has come from the investigation of smaller-scale features such as density and bending waves, the numerous narrow gaps and their embedded ringlets, and the sharp edges which often demarcate various ring regions. In the case of Uranus, almost all of the ring mass is in the form of narrow rings. Narrow ringlets and gaps, and their associated sharp edges (including those of broad rings) form the subject of this chapter, along with the dynamical theories their study has spawned and the puzzles that continue to surround them.
Examples of several narrow gaps and ringlets in Saturn's rings, as well as the very prominent sharp outer edge of the B ring, are shown in Figure 11.1, from French et al. (2016b). Here one can see a total of eight narrow gaps in the region known as the Cassini Division, ranging in width from 5 km to 360 km, as well as four narrow ringlets. At least six more narrow gaps are found in the outer A ring and in the C ring, while three additional narrow ringlets occur in the C ring. The present chapter will cover all of these features, as well as the ten narrow Uranian rings. Recently a pair of narrow, dense rings has been discovered around the centaur object, Chariklo (Braga-Ribas et al., 2014). These are discussed separately in Chapter 7. We also do not discuss the more tenuous and dusty Jovian and Neptunian ring systems, nor the dusty ringlets found at Saturn and Uranus, all of which are covered in Chapter 12. The complex and unique F ring is described in Chapter 13.
We begin with a short overview of the relevant observations and their limitations in Section 11.2, before reviewing the kinematics, systematic width variations and internal structure of narrow ringlets in Section 11.3. In Section 11.4 we discuss the gaps in Saturn's rings, including searches for any embedded satellites. Section 11.5 deals with individual ringlet and gap edges, especially those that are controlled by resonances with external satellites and those that show evidence for local perturbations by unseen, embedded objects.
Introduction/Innovation Concept: University Departments of Emergency Medicine are responsible for the supervision of research and other scholarly projects for fellows, residents and students, though often lack resources to provide adequate input and oversight. Many departments cover large geographical areas and several programs. We piloted new research committee structures and processes to improve oversight and output of research projects. Methods: We created an interactive group supervision tool based around formation of a collaborative research committee, with rotating chairs from each program, to provide supervision and face to face interaction, and direction for research learners. Included were all Dalhousie University adult and pediatric emergency medicine residency and fellowship programs, as well as trauma and EMS programs across Nova Scotia, New Brunswick, and Prince Edward Island. In addition to providing expertise in clinical trial coordination, database management, research administration, grant applications and Research Ethics Board submissions, we have completed a 2-year pilot of our interactive group supervision tool for research projects. Curriculum, Tool, or Material: The interactive tool consists of a structured PICOD form; allocation of topic and research mentors; standardized yearly milestones from project development through presentation and publication; and regular video-conferenced and in-person interactive group sessions involving several project leads, as well as program research directors, researchers, and co-ordinators. To date, all participating program learners have engaged with the tool, with positive feedback from learners, supervisors and program directors. Conclusion: We report our development of a regional collaborative interactive group supervision tool, that maximizes expert resources in the provision of research and scholarly project supervision.
Introduction: Point of care ultrasound (US) is a key adjunct in the management of trauma patients, in the form of the extended focused assessment with sonography in trauma (E-FAST) scan. This study assessed the impact of adding an edus2 ultrasound simulator on the diagnostic capabilities of resident and attending physicians participating in simulated trauma scenarios. Methods: 12 residents and 20 attending physicians participated in 114 trauma simulations utilizing a Laerdal 3G mannequin. Participants generated a ranked differential diagnosis list after a standard assessment, and again after completing a simulated US scan for each scenario. We compared reports to determine if US improved diagnostic performance over a physical exam alone. Standard statistical tests (χ2 and Student t tests) were performed. The research team was independent of the edus2 designers. Results: Primary diagnosis improved significantly from 53 (46%) to 97 (85%) correct diagnoses with the addition of simulated US (χ2=37.7, 1df; p=<0.0001). Of the 61 scenarios where an incorrect top ranked diagnosis was given, 51 (84%) improved following US. Participants were assigned a score from 1 to 5 based on where the correct diagnosis was ranked, with a 5 indicating a correct primary diagnosis. Median scores significantly increased from 3.8 (IQR 3, 4.9) to 5 (IQR 4.7, 5; W=219, p<0.0001).Participants were significantly more confident in their diagnoses after using the US simulator, as shown by the increase in their mean confidence in the correct diagnosis from 53.1% (SD 22.8) to 83.5% (SD 19.1; t=9.0; p<0.0001)Additionally, participants significantly narrowed their differential diagnosis lists from an initial medium count of 3.5 (IQR 2.9, 4.4) possible diagnoses to 2.4 (IQR 1.9, 3; W=-378, p<0.0001) following US. The performance of residents was compared to that of attending physicians for each of the above analyses. No differences in performance were detected. Conclusion: This study showed that the addition of ultrasound to simulated trauma scenarios improved the diagnostic capabilities of resident and attending physicians. Specifically, participants improved in diagnostic accuracy, diagnostic confidence, and diagnostic precision. Additionally, we have shown that the edus2 simulator can be integrated into high fidelity simulation in a way that improves diagnostic performance.
As endemic measles is eliminated through immunization, countries must determine the risk factors for the importation of measles into highly immunized populations to target control measures. Despite eliminating endemic measles, New Zealand suffers from outbreaks after introductions from abroad, enabling us to use it as a model for measles introduction risk. We used a generalized linear model to analyze risk factors for 1137 measles cases from 2007 to June 2014, provide estimates of national immunity levels, and model measles importation risk. People of European ethnicity made up the majority of measles cases. Age is a positive risk factor, particularly 0–2-year-olds and 5–17-year-old Europeans, along with increased wealth. Pacific islanders were also at greater risk, but due to 0–2-year-old cases. Despite recent high measles, mumps, and rubella vaccine immunization coverage, overall population immunity against measles remains ~90% and is lower in people born between 1982 and 2005. Greatest measles importation risk is during December, and countries predicted to be sources have historical connections and highest travel rates (Australia and UK), followed by Asian countries with high travel rates and higher measles incidences. Our results suggest measles importation due to travel is seeding measles outbreaks, and immunization levels are insufficient to continue to prevent outbreaks because of heterogeneous immunity in the population, leaving particular age groups at risk.
The prevalence and spatial distribution of Escherichia coli serogroups O26, O103, O111 and O145 in calves <7 days old in New Zealand and their relationship with serum IgG, weight and sex was determined by collecting recto-anal mucosal swabs (RAMS) (n = 299) and blood samples (n = 299) from two slaughter plants in the North Island. Real-time PCR of RAMS enrichment cultures revealed that 134/299 samples were positive for O26, 68/299 for O103 and 47/299 for O145, but none were positive for O111. Processing of positive enrichment cultures resulted in 49 O26, four O103 and five O145 isolates. Using multiplex PCR 25/49 (51%) O26 isolates were positive for stx1, eae, ehxA, 17/49 (34·7%) for eae, ehxA and 7/49 (14·2%) for eae only. All O103 and O145 isolates were positive for eae, ehxA only. O26 isolates were grouped into four clusters (>70% similarity) using pulsed field gel electrophoresis. Mapping of the farms showed the presence of farms positive for O26, O103 and O145 in three important dairy producing regions of the North Island. Calves positive for O103 were more likely to be positive for O26 and vice versa (P = 0·04). Similarly, calves positive for O145 were more likely to be positive for O103 and vice versa (P = 0·03). This study demonstrates that non-O157 E. coli serogroups of public health and economic importance containing clinically relevant virulence factors are present in calves in the North Island of New Zealand.
Introduction: The use of cardiac point of care ultrasound (PoCUS) to assess cardiac arrest patients is widespread, although not mandated by advanced cardiac life support (ACLS) guidelines. This study aims to examine if the use of ultrasound, along with the findings on ultrasound are associated with a difference in outcomes of cardiac arrest patients in the emergency department (ED). Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in asystole or PEA cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19, or with a previous DNR order. Patients were grouped based on whether PoCUS was used during ACLS (PoCUS group) and those without PoCUS (control group). Multiple data were abstracted from charts using a standardized form. Data was analyzed for the return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD), as well as initial cardiac activity findings on PoCUS. Results: 230 patients met the study inclusion criteria, with 44 (19%) in the control group, and 186 (81%) in the PoCUS group. In the PoCUS group 20 (11%) had cardiac activity (Positive PoCUS) and 166 (89%) had no cardiac activity recorded. The control group had a higher rate of SHA than the PoCUS group (27%; 95% CI 15-43% vs. 10%: 6-15%, p = 0.0046), however there was no difference in frequency of ROSC (control: 37%; 24-55% vs. PoCUS 26%; 20-33%, p = 0.1373) or SHD (control: 7%, 95% CI 1-19%; PoCUS: 2%, 95% CI 0-5%, p = 0.0858). Positive PoCUS patients had a higher frequency of ROSC (75%; 50-91% vs. 20%; 15-27%, p < 0.001) and SHA (25%; 9-49% vs. 8%; 4-13%, p = 0.0294) than patients with no PoCUS cardiac activity, however there was no difference in the rate of SHD between the positive PoCUS patients (0%; 0-17%) and patients with no PoCUS cardiac activity (2%; 0-5%, p = 1.0000). Conclusion: Our results suggest that there is no difference in survival between cardiac arrest patients receiving PoCUS and those who do not. Although finding positive cardiac activity on PoCUS is associated with greater ROSC and survival to hospital admission, it does not identify patients with a final outcome of survival to hospital discharge.
Introduction: The use of cardiac point of care ultrasound (PoCUS) to assess cardiac arrest patients is widespread, although not mandated by advanced cardiac life support (ACLS) guidelines. This study aims to examine if the use of ultrasound is associated with a difference in the length of resuscitation and the frequency of interventions during ACLS in the emergency department (ED). Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19, or with a previous DNR order. Patients were grouped based on whether PoCUS was used during ACLS (PoCUS group) and those without PoCUS (control group). Multiple data were abstracted from charts using a standardized form. Data was analyzed for the length of resuscitation, frequency of common ACLS interventions such as endotracheal intubation, administration of epinephrine, and defibrillation, as well as initial cardiac activity findings on PoCUS. Results: 263 patients met the study inclusion criteria, with 51 (19%) in the control group, and 212 (81%) in the PoCUS group. In the PoCUS group 23 (11%) had cardiac activity (Positive PoCUS) and 189 (89%) had no cardiac activity recorded. Positive PoCUS patients had longer mean resuscitation times (26.13 min, 95% CI 17.80-34.46 min) compared to patients with no PoCUS cardiac activity (12.63 min, 95% CI 11.07-14.19 min, p < 0.05) as well as to the control group (14.20 min, 95% CI 10.30-18.09 min, p < 0.05). Positive PoCUS patients were more likely to receive endotracheal intubation (91%, 95% CI 72-99%), and epinephrine (100%, 95% CI 85-100%) than patients with no PoCUS cardiac activity (ET: 47%, 95% CI 40-54%, p < 0.0001; Epi: 81%, 95% CI 75-86%, p < 0.0172) and than the control group (ET: 65%, 95% CI 50-78%, p < 0.0227; Epi: 80%, 95% CI 67-90%, p < 0.0258). There was no difference in numbers receiving defibrillation between groups. Conclusion: Our results suggest emergency physicians may be making increased resuscitative effort for patients with positive cardiac activity findings on PoCUS compared to those with negative findings or when no PoCUS was performed.
Introduction: Survival to hospital discharge is better for PEA than asystole in out-of-hospital cardiac arrest. Point of care ultrasound (PoCUS) is widely used in cardiac arrest, although not mandated by ACLS guidelines. This study examines if initial PoCUS findings combined with cardiac rhythm are predictive of outcomes including return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and hospital discharge (SHD). Methods: A database review was completed for patients arriving to a tertiary ED in asystole or PEA arrest from 2010 to 2014. Patients under 19y or with a previous DNR were excluded. Patients were grouped into those with cardiac activity on PoCUS and PEA on ECG (Positive group); those with no cardiac activity recorded on PoCUS and asystole on ECG (Negative group); and those with a mix of positive and negative findings (Indeterminate group). Data was analyzed for the frequency of ROSC, SHA, and SHD. Results: 186 patients met the study criteria, with 14 (8%) in the positive group, 134 (72%) in the negative group, and 38 (20%) in the indeterminate group. The positive group had significantly better initial outcomes than the negative group: ROSC: 78% (95% CI 49-95%) vs 17% (11-25%); OR 17.70 (4.57-168.5; p < 0.0001) and SHA: 29% (8-58%) vs 7% (3-12%); OR 5.56 (1.45-21.28; p = 0.022), and then the combined negative and indeterminate groups: ROSC: 22% (16-29%), OR 12.93 (3.43-48.73; p < 0.0001; SHA: 8% (5-13%); OR 4.51 (1.25-16.27; p = 0.033). There was no difference between the positive group and either the negative or combined groups for final outcome of SHD: 0% (0-23%) vs 1% (0-5%); OR 1.83 (0.08-39.97; p = 1.00; and vs 1% (0-5%); OR 1.67 (0.08-33.96; p = 1.00). The negative group had worse initial outcomes than the combined positive and indeterminate groups: ROSC 17% (11-25%) vs. 50% (36-64%) OR 0.21 (0.10-0.42; p < 0.0001); SHA 6% (3-12%) vs. 8% (5-13%) OR 0.34 (0.13-0.92; p = 0.0490). There was no difference in SHD: 1% (0-5%) vs. 1% (0-5%) OR 0.77 (0.07-8.71; p = 1.00). Conclusion: Our results suggest that although finding positive cardiac activity on ECG (PEA) and also on PoCUS is associated with greater ROSC and SHA, it does not identify patients with a final outcome of SHD.
Nationwide prevalence and risk factors for faecal carriage of Escherichia coli O157 and O26 in cattle were assessed in a 2-year cross-sectional study at four large slaughter plants in New Zealand. Recto-anal mucosal swab samples from a total of 695 young (aged 4–7 days) calves and 895 adult cattle were collected post-slaughter and screened with real-time polymerase chain reaction (PCR) for the presence of E. coli O157 and O26 [Shiga toxin-producing E. coli (STEC) and non-STEC]. Co-infection with either serogroup of E. coli (O157 or O26) was identified as a risk factor in both calves and adult cattle for being tested real-time PCR-positive for E. coli O157 or O26. As confirmed by culture isolation and molecular analysis, the overall prevalence of STEC (STEC O157 and STEC O26 combined) was significantly higher in calves [6·0% (42/695), 95% confidence interval (CI) 4·4–8·1] than in adult cattle [1·8% (16/895), 95% CI 1·1–3·0] (P < 0·001). This study is the first of its kind in New Zealand to assess the relative importance of cattle as a reservoir of STEC O157 and O26 at a national level. Epidemiological data collected will be used in the development of a risk management strategy for STEC in New Zealand.