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Prehospital identification of large vessel occlusion (LVO) stroke may expedite treatment by direct transport to comprehensive stroke centers (CSCs) with endovascular capabilities. The Cincinnati Prehospital Stroke Scale (CPSS) is commonly used for prehospital stroke detection. We aimed to assess whether (1) a high CPSS score can identify LVO and (2) an Emergency Medical Service (EMS) redirection protocol based on high CPSS accelerated endovascular treatment (EVT).
A retrospective comparison of patients transported by EMSs for suspected stroke to a high-volume CSC over a 16-month period, before and after implementation of an EMS redirection protocol based on high CPSS score (3/3). Charts were reviewed to determine the presence of LVO. Time to EVT and 3-month outcomes were compared before and after implementation.
A prehospital CPSS 3/3 score was found in 223 (59%) patients, demonstrating positive and negative predictive values for LVO of 29% and 94%, respectively. CPSS-based EMS redirection increased the proportion of EVT performed after direct transport to CSC [before: 21 (36%), after: 45 (63%), p < 0.01] and decreased median first door-to-groin puncture time by 28 minutes [109 (interquartile range (IQR) 64–116) versus 81 (IQR 56–130), p = 0.03]. At 3 months, the proportion of patients achieving functional independence (modified Rankin score 0–2) went from 20/57 (35%) to 29/68 (43%) (p = 0.39) following implementation.
CPSS-based EMS redirection accelerated identification of LVO strokes in the out-of-hospital setting and decreased time to EVT. Nevertheless, this protocol was also associated with high rates of non-LVO stroke. Impact on clinical outcomes should be evaluated in a larger cohort.
On October 1, 2017, a gunman fired on a festival in Las Vegas, Nevada, killing 58 people and wounding over 500. Multiple casualties were received at two nearby hospitals that sponsor residency programs: Sunrise Hospital and Medical Center and University Medical Center.
To evaluate the impact of the most lethal mass-shooting event in US history on graduate medical education (GME) at the involved hospitals.
Anonymized surveys were sent to 210 physicians at SMC and 110 physicians at UMC. Surveys incorporated 4 validated instruments: The Post Traumatic Growth Inventory (PTGI), The Impact of Events Scale-Revised (IES-R), The Multidimensional Scale of Perceived Social Support (MSPSS), and The Team Cohesion Factor (TCF).
Sixty-six physicians completed the surveys (38 attendings; 17 residents). 10% of physicians scored in the likely posttraumatic stress disorder (PTSD) range and 15% found themselves avoiding or struggling with managing similar patients, though overall survey response rate was low. The majority of physicians did not believe the event impacted their specific GME activities. No attending physician rated the event as negative in terms of global impact on GME, and 34% rated it as positive. However, 12 of 17 residents rated the event as a hurdle in its GME impact. A regression model predicting the IES-R score demonstrated a trend that those with higher pre-event stress and lower social support reported more adverse impact (p<0.06).
We believe our study is the first to examine the impact of mass casualty traumatic events on graduate medical education. Attendings and residents differ in their global perception of the impact, with attendings viewing it as a positive event and residents as a challenge. Pre-event level of stress and perceived social support predicted the impact of the event and may partially explain these results if residents and attendings vary on these parameters.
A quarter of the global population meets diagnostic criteria for metabolic syndrome (MetS). MetS prevalence stratifies by socioeconomic status (SES), such that low SES is associated with higher MetS risk starting in childhood. Despite this trend, some low-SES children maintain good metabolic health across the life span, but the factors responsible for their resilience are not well understood. This study examined the role of threat vigilance as either a moderator or a mediator of the effects of low early life SES on adult metabolic risk. Three hundred twenty-five Canadians aged 15–55 participated (M = 36.4 years, SD = 10.7; 55.4% female). We coded parental occupational status between the ages of 0 and 5 to index early life SES. We used the International Diabetes Federation case definition for MetS based on waist circumference, blood pressure, triglyceride levels, HDL cholesterol, and glycosylated hemoglobin measures. Threat vigilance was assessed using the Weapons Identification Procedure, a visual discrimination paradigm that captures implicit perceptions of threat. Analyses supported the moderator hypothesis: low early life SES was associated with MetS diagnosis exclusively among those with high levels of threat vigilance. This suggests that low early life SES environments that heighten vigilance to threat might be particularly detrimental for metabolic health. Conversely, low threat vigilance may buffer against the metabolic risks associated with socioeconomic disadvantage.
Malnutrition is common in children with CHD and is likely to place them at an increased risk for adverse surgical outcomes. We sought to evaluate the impact of preoperative malnutrition on outcomes after paediatric cardiac surgery.
We conducted a retrospective analysis of patients from age 0 to 5 years undergoing cardiac surgery at Seattle Children’s Hospital from 2006 to 2015. We used regression modelling to examine the impact of malnutrition on surgical outcomes.
We found a non-linear relationship between low height-for-age and weight-for-age z-scores and mortality after surgery. In the range of z-score ⩽−2, each additional unit decrease in height-for-age or weight-for-age z-score was associated with a 2.9 or 2.1% increased risk for mortality, respectively. Each unit decrease in height-for-age z-score was associated with a 1.2% increased risk for cardiac arrest, 1.1% increased risk for infection, and an average of 1.7 additional hours of mechanical ventilation, 6 hours longer ICU stay, and 13 hours longer hospital stay. Each unit decrease in weight-for-age z-score was associated with a 0.7% increased risk for cardiac arrest, 0.8% increased risk for infection, and an average of 1.9 additional hours of mechanical ventilation and 5.3 additional hours of ICU stay.
This study is unique in demonstrating a significant association between malnutrition and 30-day mortality and other adverse outcomes after paediatric cardiac surgery in a mixed population of CHD patients. By evaluating nutritional status as a continuous variable, we were able to clearly distinguish the point at which malnutrition begins to affect mortality.
A diverse millipede (diplopod) fauna has been recovered from the earliest Carboniferous (Tournaisian) Ballagan Formation of the Scottish Borders, discovered by the late Stan Wood. The material is generally fragmentary; however, six different taxa are present based on seven specimens. Only one displays enough characters for formal description and is named Woodesmus sheari Ross, Edgecombe & Clark gen. & sp. nov. The absence of paranota justifies the erection of Woodesmidae fam. nov. within the Archipolypoda. The diverse fauna supports the theory that an apparent lack of terrestrial animal fossils from ‘Romer's Gap' was due to a lack of collecting and suitable deposits, rather than to low oxygen levels as previously suggested.
Accumulating evidence suggests that the experience of early life adversity is a risk factor for a range of poor outcomes across development, including poor physical health in adulthood. The biological embedding model of early adversity (Miller, Chen, & Parker, 2011) suggests that early adversity might become embedded within immune cells known as monocytes/macrophages, programming them to be overly aggressive to environmental stimuli and insensitive to inhibitory signals, creating a “proinflammatory phenotype” that increases vulnerability to chronic diseases across the life span. We tested this hypothesis in the present study. Adolescent girls (n = 147) had blood drawn every 6 months across a 2.5-year period. To assess inflammatory responses to challenge, their monocytes were stimulated in vitro with a bacterial product, and production of the cytokine interleukin-6 was quantified. Hydrocortisone was added to cultures to assess the cells’ sensitivity to glucocorticoids’ anti-inflammatory signal. Using cluster analyses, we found that early life adversity was associated with greater odds of displaying a proinflammatory phenotype characterized by relatively larger interleukin-6 responses and relatively less sensitivity to glucocorticoids. In contrast, ongoing social stress was not associated with increasing odds of being categorized in the proinflammatory cluster. These findings suggest that early life adversity increases the probability of developing a proinflammatory phenotype, which, if sustained, could forecast risk for health problems later in life.
Using a sequential in vitro/in vivo approach, we tested the ability of botanical extracts to influence biomarkers associated with bone resorption and bone formation. Pomegranate fruit and grape seed extracts were found to exhibit anti-resorptive activity by inhibiting receptor activator of nuclear factor-κB ligand (RANKL) expression in MG-63 cells and to reduce IL-1β-stimulated calvarial 45Ca loss. A combination of pomegranate fruit and grape seed extracts were shown to be effective at inhibiting bone loss in ovariectomised rats as demonstrated by standard histomorphometry, biomechanical and bone mineral density measurements. Quercetin and licorice extract exhibited bone formation activity as measured by bone morphogenetic protein-2 (BMP-2) promoter activation, increased expression of BMP-2 mRNA and protein levels, and promotion of bone growth in cultured mouse calvariae. A combination of quercetin and licorice extract demonstrated a potential for increasing bone mineral density in an intact female rat model as compared with controls. The results from this sequential in vitro/in vivo research model yielded botanical extract formulas that demonstrate significant potential benefits for bone health.
Research shows that poor social ties increase risks of morbidity and mortality from cardiovascular disease (CVD). However, little is known about the nature of everyday social encounters that give rise to this association, or when in the course of development they begin to shape disease-relevant biological processes. In this study, 122 adolescent females recorded the qualities of their everyday social interactions using electronic diaries. At the same time we measured components of the metabolic syndrome, a precursor to CVD that includes central adiposity, high blood pressure, insulin resistance, and lipid dysregulation. Metabolic symptoms were reassessed 12 and 24 months later. Hierarchical linear modeling revealed an association between negative social interactions and metabolic symptom trajectories. To the extent that participants had more intense negative social encounters in daily life, they showed increasing scores on a composite indicator of metabolic risk over 2 years. This association was independent of a variety of potential confounders, and persisted when symptoms of depression and broader personality traits were controlled. There was no association between positive social encounters and metabolic risk trajectories. These findings suggest that even in otherwise healthy adolescents, abrasive social encounters may accelerate the progression of early stages of CVD.
Here we describe the evolution through winter of a layer of in situ supercooled water beneath the sea ice at a site close to the McMurdo Ice Shelf. From early winter (May), the temperature of the upper water column was below its surface freezing point, implying contact with an ice shelf at depth. By late winter the supercooled layer was c. 40 m deep with a maximum supercooling of c. 25 mK located 1–2 m below the sea ice-water interface. Transitory in situ supercooling events were also observed, one lasting c. 17 hours and reaching a depth of 70 m. In spite of these very low temperatures the isotopic composition of the water was relatively heavy, suggesting little glacial melt. Further, the water's temperature-salinity signature indicates contributions to water mass properties from High Salinity Shelf Water produced in areas of high sea ice production to the north of McMurdo Sound. Our measurements imply the existence of a heat sink beneath the supercooled layer that extracts heat from the ocean to thicken and cool this layer and contributes to the thickness of the sea ice cover. This sink is linked to the circulation pattern of the McMurdo Sound.
The last decade of excavations at Çadır Höyük, in the north-central region of the Anatolian plateau, has revealed a well-established Late Chalcolithic community with continuous occupation into the Early Bronze I period (mid fourth to early third millennium BC). While the Late Chalcolithic town was prosperous, with well-made houses and objects, and even monumental construction, the stability of the settlement had slipped by the Early Bronze I phase. We summarise here the results from ten seasons of work at the site and profile how the findings contribute to our understanding of Çadır's role in a larger regional context. We also offer possible explanations for the changing nature of the Çadır occupation during the periods detailed here.
Uncertainty is a basic fact of life. Despite uncertainty, people must make predictions about the world. Will the car you are considering buying be reliable? Will you like the food you order? When you see an animal in the woods, what should you do? One source of information that reduces uncertainty is category membership. Although all Toyota Camrys are not exactly the same, they are similar enough that you can predict with some confidence that the new Camry you are considering will be reliable. Kansas City style barbecue ribs are not identical, but they taste more similar to one another than they do to roast chicken or “tofu surprise.” Knowing the category of an entity therefore serves to reduce the uncertainty associated with it, and the category reduces uncertainty to the degree that the category members are uniform with respect to the prediction you want to make. This category-based induction is one of the main ways that categories are useful to us in everyday life.
Unfortunately, this reduction of uncertainty is limited by the uncertainty of category membership itself. If you go to the Toyota dealership and order a Camry, you can be close to 100% sure that your new car is going to be a Camry. But in many other situations, you cannot be 100% sure.
To assess the safety and efficacy of a chlorine dioxide water treatment system in controlling Legionella in a hospital water supply.
For 17 months following installation of the system, we performed regular water cultures throughout the building, assessed chlorine dioxide and chlorite levels, and monitored metal corrosion.
Sites that grew Legionella species decreased from 41% at baseline to 4% (P = .001). L. anisa was the only species recovered and it was found in samples of both hot and cold water. Levels of chlorine dioxide and chlorite were below Environmental Protection Agency (EPA) limits for these chemicals in potable water. Further, enhanced carbon filtration effectively removed the chemicals, even at chlorine dioxide levels of more than twice what was used to treat the water. After 9 months, corrosion of copper test strips exposed to the chlorine dioxide was not higher than that of control strips. During the evaluation period, there were no cases of nosocomial Legionella in the building with the system, whereas there was one case in another building.
Our results indicate that operation of a chlorine dioxide system effectively removed Legionella species from a hospital water supply. Furthermore, we found that the system was safe, as levels of chlorine dioxide and chlorite were below EPA limits. The system did not appear to cause increased corrosion of copper pipes. Our results indicate that chlorine dioxide may hold promise as a solution to the problem of Legionella contamination of hospital water supplies.
Numerical and experimental techniques were used to study the physics of flow
separation for steady internal flow in a 45° junction geometry, such as that observed
between two pipes or between the downstream end of a bypass graft and an artery.
The three-dimensional Navier–Stokes equations were solved using a validated finite
element code, and complementary experiments were performed using the photochromic
dye tracer technique. Inlet Reynolds numbers in the range 250 to 1650 were considered.
An adaptive mesh refinement approach was adopted to ensure grid-independent
solutions. Good agreement was observed between the numerical results and the
experimentally measured velocity fields; however, the wall shear stress agreement was less
satisfactory. Just distal to the ‘toe’ of the junction, axial flow separation was observed
for all Reynolds numbers greater than 250. Further downstream (approximately 1.3
diameters from the toe), the axial flow again separated for Re [ges ] 450. The location and
structure of axial flow separation in this geometry is controlled by secondary flows,
which at sufficiently high Re create free stagnation points on the model symmetry
plane. In fact, separation in this flow is best explained by a secondary flow boundary
layer collision model, analogous to that proposed for flow in the entry region of a
curved tube. Novel features of this flow include axial flow separation at modest Re (as
compared to flow in a curved tube, where separation occurs only at much higher Re),
and the existence and interaction of two distinct three-dimensional separation zones.