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Air medical transport of trauma patients from the scene of injury plays a critical role in the delivery of severely injured patients to trauma centers. Over-triage of patients to trauma centers reduces the system efficiency and jeopardizes safety of air medical crews.
The objective of this study was to determine which triage factors utilized by Emergency Medical Services (EMS) providers are strong predictors of early discharge for trauma patients transported by helicopter to a trauma center.
A retrospective chart review over a two-year period was performed for trauma patients flown from the injury site into a Level I trauma center by an air medical transport program. Demographic and clinical data were collected on each patient. Prehospital factors such as Glasgow Coma Score (GCS), Revised Trauma Score (RTS), intubation status, mechanism of injury, anatomic injuries, physiologic parameters, and any combinations of these factors were investigated to determine which triage criteria accurately predicted early discharge. Hospital factors such as Injury Severity Score (ISS), length-of-stay (LOS), survival, and emergency department disposition were also collected. Early discharge was defined as a hospital stay of less than 24 hours in a patient who survives their injuries. A more stringent definition of appropriate triage was defined as a patient with in-hospital death, an ISS >15, those taken to the operating room (OR) or intensive care unit (ICU), or those receiving blood products. Those patients who failed to meet these criteria were also used to determine over-triage rates.
An overall early discharge rate of 35% was found among the study population. Furthermore, when the more stringent definition was applied, over-triage rates were as high as 85%. Positive predictive values indicated that patients who met at least one anatomic and physiologic criteria were appropriately transported by helicopter as 94% of these patients had stays longer than 24 hours. No other criteria or combination of criteria had a high predictive value for early discharge.
No individual triage criteria or combination of criteria examined demonstrated the ability to uniformly predict an early discharge. Although helicopter transport and subsequent hospital care is costly and resource consuming, it appears that a significant number of patients will be discharged within 24 hours of their transport to a trauma center. Future studies must determine the impact of eliminating “low-yield” triage criteria on under-triage of scene trauma patients.
Driven by the rapid rise of silicon photonics, optical signaling is moving from the realm of long-distance communications to chip-to-chip, and even on-chip domains. If on-chip signaling becomes optical, we should consider what more we might do with light than just communicate. We might, for example, set goals for the storing and processing of information directly in the optical domain. Doing this might enable us to supplement, or even surpass, the performance of electronic processors, by exploiting the ultrahigh bandwidth and wavelength division multiplexing capabilities offered by optics. In this article, we show how, by using an integrated photonics platform that embeds chalcogenide phase-change materials into standard silicon photonics circuits, we can achieve some of these goals. Specifically, we show that a phase-change integrated photonics platform can deliver binary and multilevel memory, arithmetic and logic processing, as well as synaptic and neuronal mimics for use in neuromorphic, or brain-like, computing—all working directly in the optical domain.
Apolipoprotein E (APOE) E4 is the main genetic risk factor for Alzheimer’s disease (AD). Due to the consistent association, there is interest as to whether E4 influences the risk of other neurodegenerative diseases. Further, there is a constant search for other genetic biomarkers contributing to these phenotypes, such as microtubule-associated protein tau (MAPT) haplotypes. Here, participants from the Ontario Neurodegenerative Disease Research Initiative were genotyped to investigate whether the APOE E4 allele or MAPT H1 haplotype are associated with five neurodegenerative diseases: (1) AD and mild cognitive impairment (MCI), (2) amyotrophic lateral sclerosis, (3) frontotemporal dementia (FTD), (4) Parkinson’s disease, and (5) vascular cognitive impairment.
Genotypes were defined for their respective APOE allele and MAPT haplotype calls for each participant, and logistic regression analyses were performed to identify the associations with the presentations of neurodegenerative diseases.
Our work confirmed the association of the E4 allele with a dose-dependent increased presentation of AD, and an association between the E4 allele alone and MCI; however, the other four diseases were not associated with E4. Further, the APOE E2 allele was associated with decreased presentation of both AD and MCI. No associations were identified between MAPT haplotype and the neurodegenerative disease cohorts; but following subtyping of the FTD cohort, the H1 haplotype was significantly associated with progressive supranuclear palsy.
This is the first study to concurrently analyze the association of APOE isoforms and MAPT haplotypes with five neurodegenerative diseases using consistent enrollment criteria and broad phenotypic analysis.
The Comprehensive Assessment of Neurodegeneration and Dementia (COMPASS-ND) cohort study of the Canadian Consortium on Neurodegeneration in Aging (CCNA) is a national initiative to catalyze research on dementia, set up to support the research agendas of CCNA teams. This cross-country longitudinal cohort of 2310 deeply phenotyped subjects with various forms of dementia and mild memory loss or concerns, along with cognitively intact elderly subjects, will test hypotheses generated by these teams.
The COMPASS-ND protocol, initial grant proposal for funding, fifth semi-annual CCNA Progress Report submitted to the Canadian Institutes of Health Research December 2017, and other documents supplemented by modifications made and lessons learned after implementation were used by the authors to create the description of the study provided here.
The CCNA COMPASS-ND cohort includes participants from across Canada with various cognitive conditions associated with or at risk of neurodegenerative diseases. They will undergo a wide range of experimental, clinical, imaging, and genetic investigation to specifically address the causes, diagnosis, treatment, and prevention of these conditions in the aging population. Data derived from clinical and cognitive assessments, biospecimens, brain imaging, genetics, and brain donations will be used to test hypotheses generated by CCNA research teams and other Canadian researchers. The study is the most comprehensive and ambitious Canadian study of dementia. Initial data posting occurred in 2018, with the full cohort to be accrued by 2020.
Availability of data from the COMPASS-ND study will provide a major stimulus for dementia research in Canada in the coming years.
The cognitive process of worry, which keeps negative thoughts in mind and elaborates the content, contributes to the occurrence of many mental health disorders. Our principal aim was to develop a straightforward measure of general problematic worry suitable for research and clinical treatment. Our secondary aim was to develop a measure of problematic worry specifically concerning paranoid fears.
An item pool concerning worry in the past month was evaluated in 250 non-clinical individuals and 50 patients with psychosis in a worry treatment trial. Exploratory factor analysis and item response theory (IRT) informed the selection of scale items. IRT analyses were repeated with the scales administered to 273 non-clinical individuals, 79 patients with psychosis and 93 patients with social anxiety disorder. Other clinical measures were administered to assess concurrent validity. Test-retest reliability was assessed with 75 participants. Sensitivity to change was assessed with 43 patients with psychosis.
A 10-item general worry scale (Dunn Worry Questionnaire; DWQ) and a five-item paranoia worry scale (Paranoia Worries Questionnaire; PWQ) were developed. All items were highly discriminative (DWQ a = 1.98–5.03; PWQ a = 4.10–10.7), indicating small increases in latent worry lead to a high probability of item endorsement. The DWQ was highly informative across a wide range of the worry distribution, whilst the PWQ had greatest precision at clinical levels of paranoia worry. The scales demonstrated excellent internal reliability, test-retest reliability, concurrent validity and sensitivity to change.
The new measures of general problematic worry and worry about paranoid fears have excellent psychometric properties.
Important Bird and Biodiversity Areas (IBAs) are sites identified as being globally important for the conservation of bird populations on the basis of an internationally agreed set of criteria. We present the first review of the development and spread of the IBA concept since it was launched by BirdLife International (then ICBP) in 1979 and examine some of the characteristics of the resulting inventory. Over 13,000 global and regional IBAs have so far been identified and documented in terrestrial, freshwater and marine ecosystems in almost all of the world’s countries and territories, making this the largest global network of sites of significance for biodiversity. IBAs have been identified using standardised, data-driven criteria that have been developed and applied at global and regional levels. These criteria capture multiple dimensions of a site’s significance for avian biodiversity and relate to populations of globally threatened species (68.6% of the 10,746 IBAs that meet global criteria), restricted-range species (25.4%), biome-restricted species (27.5%) and congregatory species (50.3%); many global IBAs (52.7%) trigger two or more of these criteria. IBAs range in size from < 1 km2 to over 300,000 km2 and have an approximately log-normal size distribution (median = 125.0 km2, mean = 1,202.6 km2). They cover approximately 6.7% of the terrestrial, 1.6% of the marine and 3.1% of the total surface area of the Earth. The launch in 2016 of the KBA Global Standard, which aims to identify, document and conserve sites that contribute to the global persistence of wider biodiversity, and whose criteria for site identification build on those developed for IBAs, is a logical evolution of the IBA concept. The role of IBAs in conservation planning, policy and practice is reviewed elsewhere. Future technical priorities for the IBA initiative include completion of the global inventory, particularly in the marine environment, keeping the dataset up to date, and improving the systematic monitoring of these sites.
Background: Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of pharmacological venous thromboprophylaxis (VTEp) may cause further intracranial hemorrhage. We reviewed the literature to determine the postinjury time interval at which VTEp can be administered without risk of TBI evolution and hematoma expansion. Methods: MEDLINE and EMBASE databases were searched. Inclusion criteria were studies investigating timing and safety of VTEp in TBI patients not previously on oral anticoagulation. Two investigators extracted data and graded the papers’ levels of evidence. Randomized controlled trials were assessed for bias according to the Cochrane Collaboration Tool and Cohort studies were evaluated for bias using the Newcastle-Ottawa Scale. We performed univariate meta-regression analysis in an attempt to identify a relationship between VTEp timing and hemorrhagic progression and assess study heterogeneity using an I2 statistic. Results: Twenty-one studies were included in the systematic review. Eighteen total studies demonstrated that VTEp postinjury in patients with stable head computed tomography scan does not lead to TBI progression. Fourteen studies demonstrated that VTEp administration 24 to 72 hours postinjury is safe in patients with stable injury. Four studies suggested that administering VTEp within 24 hours of injury in patients with stable TBI does not lead to progressive intracranial hemorrhage. Overall, meta-regression analysis demonstrated that there was no relationship between rate of hemorrhagic progression and VTEp timing. Conclusions: Literature suggests that administering VTEp 24 to 48 hours postinjury may be safe for patients with low-hemorrhagic-risk TBIs and stable injury on repeat imaging.
Medusaceratops lokii Ryan, Russell, and Hartman, 2010 is an enigmatic taxon of ceratopsid represented by partial parietals from the Mansfield bonebed in the Campanian Judith River Formation, Montana. Originally, all ceratopsid material collected from this bonebed was referred to the centrosaurine ceratopsid Albertaceratops, but subsequently two parietals were designated the types of the chasmosaurine, M. lokii, in part, because they were interpreted to have three epiparietals bilaterally. Here we describe new material from the bonebed that allows a systematic revision of the taxon. A revised reconstruction of the frill, informed by newly discovered parietals, reveals that M. lokii had a broad midline ramus and at least five epiparietals (ep) around the margin of the frill, both traits that are characteristic of Centrosaurinae. From medial to lateral, the epiparietal ornamentation consists of a small, variably procurving epiparietal (ep 1), an anterolaterally curving pachyostotic hook (ep 2), a smaller pachyostoic process (ep 3), and two small triangular epiparietals (ep 4 and 5). A phylogenetic analysis of ceratopsids, which is the first to include Medusaceratops, indicates that M. lokii is a unique, early centrosaurine ceratopsid taxon that is more closely related to Centrosaurini and Pachyrhinosaurini than Nasutoceratopsini. No unequivocal chasmosaurine bones or diagnostic material from any other ceratopsid could be identified from the Mansfield bonebed, suggesting that it represents one of the oldest occurrences of a monodominant accumulation of a centrosaurine ceratopsid on record.
The Southern Ocean is the largest of the high-nutrient, low-chlorophyll (HNLC) regions of the world ocean. Phytoplankton production fails to utilise completely the pool of inorganic nutrients in the euphotic zone, giving rise to low phytoplankton bio-mass and leaving relatively high summer nutrient concentrations. This enigma is of considerable significance for our understanding of the role of the oceans in the global carbon cycle. Various limiting factors have been considered: low light, low temperature, absence of necessary trace elements, grazing pressure and other means of biomass removal.
The dynamics of nitrogen uptake by phytoplankton are of particular importance. Classically, nitrate mixed into the surface layer during winter provides the nitrogen pool for growth in the spring bloom. Some organic material is exported to depth, whilst the remainder is recycled, providing ammonium and other reduced species as nitrogenous substrates for growth during the remainder of the season. The oxidation state of the inorganic nitrogen supply thus identifies new and recycled carbon fixation. Whilst this is convenient “shorthand” for the nitrogen nutrition of carbon export in much of the ocean, it is an inappropriate model for the Southern Ocean. Here, nitrate and ammonium use are simultaneous, and nitrate is never exhausted by the annual phytoplankton production.
We speculate that a range of environmental factors combine to make the large pool of nitrate partially inaccessible to phytoplankton. in addition to the documented effects of low iron availability and high ammonium concentrations, the low temperatures characteristic of the Southern Ocean may decrease nitrate availability because of the increased energetic overheads in its uptake and reduction. This in turn makes ammonium an important nitrogenous substrate, and its production by zooplankton and heterotrophic microorganisms is an important component of the plankton nitrogen cycle. There is some evidence that ammonium production by large grazing animals may stimulate phytoplankton growth. Microbial removal of nitrogen from sedimenting phytoplankton cells may result in local decoupling between the carbon and nitrogen cycles, allowing some reduced nitrogen to remain in the euphotic zone whilst carbon is exported to depth.
A neurological method for assessment of nasal cavity homologies in extant archosaurs is extended to lambeosaurine hadrosaurids (Dinosauria: Ornithischia) to test functional hypotheses associated with their hypertrophied nasal passages and highly derived cranial crests. The olfactory system and associated cranial nerve pathways that have consistent relationships to soft tissue divisions of the nasal cavity are reconstructed in lambeosaurines on the basis of new paleoneurological data and a comparative phylogenetic approach. The new model of the lambeosaurine olfactory system and nasal cavity shows that a significant portion of nasal cavity proper was located outside the crest cavities and that the primary olfactory region was located rostromedial to the orbits.
All available data indicate that the evolutionary hypertrophy of the nasal cavity occurred predominantly within the non-olfactory nasal vestibule, and that crest development was not causally associated with olfaction. The high level of interspecific and ontogenetic variation in crest shape and nasal vestibule development in lambeosaurine dinosaurs is most consistent with proposed behavioral functions, notably acoustic resonance for intraspecific communication. Despite significant modification to the nasal cavity within Archosauria and its extreme hypertrophy and supraorbital development in Lambeosaurinae, the neural olfactory system and the olfactory region of the nasal cavity proper retain their plesiomorphic positions and associations, suggesting that this system is highly conserved in vertebrate evolution.
Various transmission routes contribute to spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) in hospitalized patients. Patients with readmissions during which CRKP is again isolated (“CRKP readmission”) potentially contribute to transmission of CRKP.
To evaluate CRKP readmissions in the Consortium on Resistance against Carbapenems in K. pneumoniae (CRaCKLe).
Cohort study from December 24, 2011, through July 1, 2013.
Multicenter consortium of acute care hospitals in the Great Lakes region.
All patients who were discharged alive during the study period were included. Each patient was included only once at the time of the first CRKP-positive culture.
All readmissions within 90 days of discharge from the index hospitalization during which CRKP was again found were analyzed. Risk factors for CRKP readmission were evaluated in multivariable models.
Fifty-six (20%) of 287 patients who were discharged alive had a CRKP readmission. History of malignancy was associated with CRKP readmission (adjusted odds ratio [adjusted OR], 3.00 [95% CI, 1.32–6.65], P<.01). During the index hospitalization, 160 patients (56%) received antibiotic treatment against CRKP; the choice of regimen was associated with CRKP readmission (P=.02). Receipt of tigecycline-based therapy (adjusted OR, 5.13 [95% CI, 1.72–17.44], using aminoglycoside-based therapy as a reference in those treated with anti-CRKP antibiotics) was associated with CRKP readmission.
Hospitalized patients with CRKP—specifically those with a history of malignancy—are at high risk of readmission with recurrent CRKP infection or colonization. Treatment during the index hospitalization with a tigecycline-based regimen increases this risk.
Infect. Control Hosp. Epidemiol. 2016;37(3):281–288
To determine the rates of and risk factors for tigecycline nonsusceptibility among carbapenem-resistant Klebsiella pneumoniae (CRKPs) isolated from hospitalized patients
Multicenter prospective observational study
Acute care hospitals participating in the Consortium on Resistance against Carbapenems in Klebsiella pneumoniae (CRaCKle)
A cohort of 287 patients who had CRKPs isolated from clinical cultures during hospitalization
For the period from December 24, 2011 to October 1, 2013, the first hospitalization of each patient with a CRKP during which tigecycline susceptibility for the CRKP isolate was determined was included. Clinical data were entered into a centralized database, including data regarding pre-hospital origin. Breakpoints established by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) were used to interpret tigecycline susceptibility testing.
Of 287 patients included in the final cohort, 155 (54%) had tigecycline-susceptible CRKPs. Of all index isolates, 81 (28%) were tigecycline-intermediate and 51 (18%) were tigecycline resistant. In multivariate modeling, independent risk factors for tigecycline nonsusceptibility were (1) admission from a skilled nursing facility (OR, 2.51; 95% CI, 1.51–4.21; P=.0004), (2) positive culture within 2 days of admission (OR, 1.82; 95% CI, 1.06–3.15; P=.03), and (3) receipt of tigecycline within 14 days (OR, 4.38, 95% CI, 1.37–17.01, P=.02).
In hospitalized patients with CRKPs, tigecycline nonsusceptibility was more frequently observed in those admitted from skilled nursing facilities and occurred earlier during hospitalization. Skilled nursing facilities are an important target for interventions to decrease antibacterial resistance to antibiotics of last resort for treatment of CRKPs.