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In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.
The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.
This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP’s physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.
The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.
State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.
An automated- electron microprobe system using an on-line 8,000 word minicomputer has been designed. The general principles and need for such a system is discussed. The microprobe-computer interface hardware consists of computer addressable axis positioners, scalers, timer and a digital to analog converter. The axis positioners are used to position the spectrometers and specimen stage, whereas the digital to analog converter is used to position the electron beam in a 1000 × 1000 point matrix. The digital to analog converter is also used to drive a X-Y recorder for computer plotting of calibration curves, pulse amplitude distributions, X-ray line profiles and wavelength scans. System software is written in the interactive CLASS language which was designed specifically for laboratory instrument control. The language permits large computer programs to be chained through a minicomputer while passing variables from one function to the next. The operating software consists of automatic peak location, sequencing of data collection, statistical analysis of data, and correction of data for fluorescence, absorption and atomic number effects. An automated quantitative analysis of several copper-gold alloys and a computerized test for specimen homogeneity is described to demonstrate system operation. Future automation considerations are also discussed.
Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.
To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.
Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.
A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).
The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.
Declaration of interest
Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
Phenology is a key ecosystem process that reflects climate–vegetation functioning, and is an indicator of global environmental changes. Recently, it has been suggested that land-use change and timber extraction promote differences in forest phenology. We use remote-sensing data to describe regional leaf phenological patterns in combination with field data from 131 plots in old-growth and disturbed forests distributed over subtropical forests of Argentina (54–65°W). We assessed how climate is related to phenological patterns, and analysed how changes in forest structural characteristics such as stock of above-ground biomass relate to the observed phenological signals across the gradient. We found that the first three axes of a principal component analysis explained 85% of the variation in phenological metrics across subtropical forests, ordering plots mainly along indicators of seasonality and productivity. At the regional scale, the relative importance of forest biomass in explaining variation in phenological patterns was about 15%. Climate showed the highest relative importance, with temperature and rainfall explaining Enhanced Vegetation Index metrics related to seasonality and productivity patterns (27% and 47%, respectively). Within forest types, climate explains the major fraction of variation in phenological patterns, suggesting that forest function may be particularly sensitive to climate change. We found that forest biomass contributed to explaining a proportion of leaf phenological variation within three of the five forest types studied, and this may be related to changes in species composition, probably as a result of forest use.
Whether monozygotic (MZ) and dizygotic (DZ) twins differ from each other in a variety of phenotypes is important for genetic twin modeling and for inferences made from twin studies in general. We analyzed whether there were differences in individual, maternal and paternal education between MZ and DZ twins in a large pooled dataset. Information was gathered on individual education for 218,362 adult twins from 27 twin cohorts (53% females; 39% MZ twins), and on maternal and paternal education for 147,315 and 143,056 twins respectively, from 28 twin cohorts (52% females; 38% MZ twins). Together, we had information on individual or parental education from 42 twin cohorts representing 19 countries. The original education classifications were transformed to education years and analyzed using linear regression models. Overall, MZ males had 0.26 (95% CI [0.21, 0.31]) years and MZ females 0.17 (95% CI [0.12, 0.21]) years longer education than DZ twins. The zygosity difference became smaller in more recent birth cohorts for both males and females. Parental education was somewhat longer for fathers of DZ twins in cohorts born in 1990–1999 (0.16 years, 95% CI [0.08, 0.25]) and 2000 or later (0.11 years, 95% CI [0.00, 0.22]), compared with fathers of MZ twins. The results show that the years of both individual and parental education are largely similar in MZ and DZ twins. We suggest that the socio-economic differences between MZ and DZ twins are so small that inferences based upon genetic modeling of twin data are not affected.
Some 25% of women and 8% of men in the United States have experienced childhood sexual abuse (CSA) before the age of 18. For these individuals, healthcare visits and interactions can be retraumatizing due to perceived similarities to past abuse (e.g., pain, undressing, lack of control). However, no prior studies have provided formal qualitative analyses regarding CSA survivors' reactions to cancer treatment. Therefore, our study's objective was to identify key themes pertaining to CSA survivors' cancer treatment experiences.
Male and female members of the Amazon Mechanical Turk (N = 159, mean age = 44.27 years, SD = 10.02) participated in an anonymous online survey study. The inclusion criteria included reporting: history of CSA; a diagnosis of colorectal, gynecological, breast, or skin cancer; and experience of triggers and/or difficulties during cancer treatment. Participants' responses to open-ended questions were analyzed using inductive thematic analysis.
We identified two primary themes describing CSA survivors' experiences: Theme 1: treatment-related triggers (key subthemes: procedure-related, provider-related, and emotional triggers); and Theme 2: questioning the meaning of cumulative trauma (e.g., “Why me again?”).
Significance of results:
For CSA survivors, cancer and its treatment can trigger thoughts and emotions associated with the original abuse as well as negative evaluations of themselves, the world, and their future. Our findings are consistent with past research on CSA survivors' experiences in non-cancer healthcare settings and add to the literature by highlighting their struggles during cancer treatment. The present results can inform further research on trauma survivors' reactions to cancer treatment and give cancer care providers the context they need to understand and sensitively serve a substantial yet often overlooked patient group.
We report recent investigations of the organic chemistry of relatively nearby cold, dark interstellar clouds. Specifically, we confirm the presence of interstellar tricarbon monoxide (C3O) in Taurus Molecular Cloud1 (TMC-1); report the first detection in such regions of acetaldehyde (CH3CHO), the most complex oxygen-containing organic molecule yet found in dark clouds; report the first astronomical detection of several molecular rotational transitions, including the J=18−17 and 14−13 transitions of cyanodiacetylene (HC5N), the 101−000 transition of acetaldehyde, and the J=5−4 transition of C3O; and set a significant upper limit on the abundance of cyanocarbene (HCCN) as a result of the first reported interstellar search for this molecule.
On 1 December 2011 the West Antarctic Ice Sheet (WAIS) Divide ice-core project reached its final depth of 3405 m. The WAIS Divide ice core is not only the longest US ice core to date, but is also the highest-quality deep ice core, including ice from the brittle ice zone, that the US has ever recovered. The methods used at WAIS Divide to handle and log the drilled ice, the procedures used to safely retrograde the ice back to the US National Ice Core Laboratory (NICL) and the methods used to process and sample the ice at the NICL are described and discussed.
To examine variation in antibiotic coverage and detection of resistant pathogens in community-onset pneumonia.
A total of 128 hospitals in the Veterans Affairs health system.
Hospitalizations with a principal diagnosis of pneumonia from 2009 through 2010.
We examined proportions of hospitalizations with empiric antibiotic coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PAER) and with initial detection in blood or respiratory cultures. We compared lowest- versus highest-decile hospitals, and we estimated adjusted probabilities (AP) for patient- and hospital-level factors predicting coverage and detection using hierarchical regression modeling.
Among 38,473 hospitalizations, empiric coverage varied widely across hospitals (MRSA lowest vs highest, 8.2% vs 42.0%; PAER lowest vs highest, 13.9% vs 44.4%). Detection rates also varied (MRSA lowest vs highest, 0.5% vs 3.6%; PAER lowest vs highest, 0.6% vs 3.7%). Whereas coverage was greatest among patients with recent hospitalizations (AP for anti-MRSA, 54%; AP for anti-PAER, 59%) and long-term care (AP for anti-MRSA, 60%; AP for anti-PAER, 66%), detection was greatest in patients with a previous history of a positive culture (AP for MRSA, 7.9%; AP for PAER, 11.9%) and in hospitals with a high prevalence of the organism in pneumonia (AP for MRSA, 3.9%; AP for PAER, 3.2%). Low hospital complexity and rural setting were strong negative predictors of coverage but not of detection.
Hospitals demonstrated widespread variation in both coverage and detection of MRSA and PAER, but probability of coverage correlated poorly with probability of detection. Factors associated with empiric coverage (eg, healthcare exposure) were different from those associated with detection (eg, microbiology history). Providing microbiology data during empiric antibiotic decision making could better align coverage to risk for resistant pathogens and could promote more judicious use of broad-spectrum antibiotics.
The purpose of this study was to quantify the effect of multidrug-resistant (MDR) gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) on mortality following infection, regardless of patient location.
We conducted a retrospective cohort study of patients with an inpatient admission in the US Department of Veterans Affairs (VA) system between October 1, 2007, and November 30, 2010. We constructed multivariate log-binomial regressions to assess the impact of a positive culture on mortality in the 30- and 90-day periods following the first positive culture, using a propensity-score–matched subsample.
Patients identified with positive cultures due to MDR Acinetobacter (n=218), MDR Pseudomonas aeruginosa (n=1,026), and MDR Enterobacteriaceae (n=3,498) were propensity-score matched to 14,591 patients without positive cultures due to these organisms. In addition, 3,471 patients with positive cultures due to MRSA were propensity-score matched to 12,499 patients without positive MRSA cultures. Multidrug-resistant gram-negative bacteria were associated with a significantly elevated risk of mortality both for invasive (RR, 2.32; 95% CI, 1.85–2.92) and noninvasive cultures (RR, 1.33; 95% CI, 1.22–1.44) during the 30-day period. Similarly, patients with MRSA HAIs (RR, 2.77; 95% CI, 2.39–3.21) and colonizations (RR, 1.32; 95% CI, 1.22–1.50) had an increased risk of death at 30 days.
We found that HAIs due to gram-negative bacteria and MRSA conferred significantly elevated 30- and 90-day risks of mortality. This finding held true both for invasive cultures, which are likely to be true infections, and noninvasive infections, which are possibly colonizations.
Laryngeal amyloidosis represents approximately 1 per cent of all benign laryngeal lesions, and can cause variable symptoms depending on anatomical location and size. Treatment ranges from observation through to endoscopic microsurgery, laser excision and laryngectomy.
To highlight the diversity of presentations, increase awareness of paediatric amyloidosis and update the reader on current management.
Five cases are illustrated. Four adult patients were female, and the one child, the second youngest in the literature, was male. Amyloid deposits were identified in all laryngeal areas, including the supraglottis, glottis and subglottis. Treatment consisted of balloon dilatation, endoscopic excision, laser cruciate incision, and resection with carbon dioxide laser, a microdebrider and coblation wands.
Laryngeal amyloidosis remains a rare and clinically challenging condition. Diagnosis should be considered for unusual appearing submucosal laryngeal lesions. Treatment of this disease needs to be evaluated on a case-by-case basis and managed within an appropriate multidisciplinary team.
The CMP challenges for advanced technology nodes are discussed. Global and local uniformity challenges and their cumulative effects are presented. Uniformity improvements for advanced node integration were achieved through slurry, pad and platen optimization, innovative integration schemes, the reduction of incoming variation and the reduction of cumulative effects. We discuss reduction of typical CMP defect types. Defects resulting from simple mechanisms (foreign material, polish residues) and those resulting from chemical and physical interactions (corrosion, chemical attack, scratches, physical migration) and strategies for control are studied. Defectivity reduction measures include new post-CMP clean chemicals, new slurries and pads and reduction of incoming defectivity. Finally we discuss an observed tradeoff between good defectivity and good uniformity.
It is increasingly essential for medical researchers to be literate in statistics, but the requisite degree of literacy is not the same for every statistical competency in translational research. Statistical competency can range from ‘fundamental’ (necessary for all) to ‘specialized’ (necessary for only some). In this study, we determine the degree to which each competency is fundamental or specialized.
We surveyed members of 4 professional organizations, targeting doctorally trained biostatisticians and epidemiologists who taught statistics to medical research learners in the past 5 years. Respondents rated 24 educational competencies on a 5-point Likert scale anchored by ‘fundamental’ and ‘specialized.’
There were 112 responses. Nineteen of 24 competencies were fundamental. The competencies considered most fundamental were assessing sources of bias and variation (95%), recognizing one’s own limits with regard to statistics (93%), identifying the strengths, and limitations of study designs (93%). The least endorsed items were meta-analysis (34%) and stopping rules (18%).
We have identified the statistical competencies needed by all medical researchers. These competencies should be considered when designing statistical curricula for medical researchers and should inform which topics are taught in graduate programs and evidence-based medicine courses where learners need to read and understand the medical research literature.
Parasites of the genera Plasmodium and Haemoproteus (Apicomplexa: Haemosporida) are a diverse group of pathogens that infect birds nearly worldwide. Despite their ubiquity, the ecological and evolutionary factors that shape the diversity and distribution of these protozoan parasites among avian communities and geographic regions are poorly understood. Based on a survey throughout the Neotropics of the haemosporidian parasites infecting manakins (Pipridae), a family of Passerine birds endemic to this region, we asked whether host relatedness, ecological similarity and geographic proximity structure parasite turnover between manakin species and local manakin assemblages. We used molecular methods to screen 1343 individuals of 30 manakin species for the presence of parasites. We found no significant correlations between manakin parasite lineage turnover and both manakin species turnover and geographic distance. Climate differences, species turnover in the larger bird community and parasite lineage turnover in non-manakin hosts did not correlate with manakin parasite lineage turnover. We also found no evidence that manakin parasite lineage turnover among host species correlates with range overlap and genetic divergence among hosts. Our analyses indicate that host switching (turnover among host species) and dispersal (turnover among locations) of haemosporidian parasites in manakins are not constrained at this scale.
Coastal plain stratigraphy is often over looked in paleo–sea-level reconstructions because carbonate sediments do not precisely constrain former sea level. Pacific Island sedimentology provides an invaluable record of geomorphic and environmental consequences of coastal evolution in response to changes in sea level and local tectonics. A series of coastal auger cores obtained from eastern ʻUpolu reveal a subsurface carbonate sand envelope predominately composed of coral and coralline algae derived from the reef framework. Coupling the sedimentological record with geophysical models of Holocene sea level, we identify a critical value (0.3–1.0 m) during the falling phase of the sea-level high stand (1899–2103 cal yr BP) that represents the transition from a transgressive to a regressive environment and initiates coastal progradation. Correlating the critical value with time, we observe nearly a millennium of coastal plain development is required before a small human population is established. Our findings support previous studies arguing that Sāmoa was colonized by small and isolated groups, as post–mid-Holocene drawdown in regional sea level produced coastal settings that were morphologically attractive for human settlement. As future sea level approaches mid-Holocene high stand values, lessons learned from Pacific Island sedimentological records may be useful in guiding future decisions related to coastal processes and habitat suitability.
Courts of last resort in the American states offer researchers considerable leverage to develop and test theories about how institutions influence judicial behavior. One measure critical to this research agenda is the individual judges' preferences, or ideal points, in policy space. Two main strategies for recovering this measure exist in the literature: Brace, Langer, and Hall's (2000, Measuring preferences of state supreme court judges, Journal of Politics 62(2):387–413) Party-Adjusted Judge Ideology and Bonica and Woodruff's (2014, A common-space measure of state supreme court ideology, Journal of Law, Economics, & Organization, doi: 10.1093/jleo/ewu016) judicial CFscores. Here, we introduce a third measurement strategy that combines CFscores with item response (IRT) estimates of judicial voting behavior in all fifty-two state courts of last resort from 1995 to 2010. We show that leveraging two distinct sources of information (votes and CFscores) yields a superior estimation strategy. Specifically, we highlight several key advantages of the combined measure: (1) it is estimated dynamically, allowing for the possibility that judges' ideological leanings change over time and (2) it maps judges into a common space. In a comparison against existing measurement strategies, we find that our measure offers superior performance in predicting judges' votes. We conclude that it is a valuable tool for advancing the study of judicial politics.
We provide an expanded and updated, 2-locus phylogeny (mtSSU, nuLSU) of the lichenized fungal family Trypetheliaceae, with a total of 196 ingroup OTUs, in order to further refine generic delimitations and species concepts in this family. As a result, the following 15 clades are recognized as separate genera, including five newly established genera: Aptrootia, Architrypethelium, Astrothelium (including the bulk of corticate species with astrothelioid ascospores; synonyms: Campylothelium, Cryptothelium, Laurera), Bathelium s. str. (excluding B. degenerans and relatives which fall into Astrothelium), the reinstated Bogoriella (for tropical, lichenized species previously placed in Mycomicrothelia), Constrictolumina gen. nov. (for tropical, lichenized species of Arthopyrenia), Dictyomeridium gen. nov. (for a subgroup of species with muriform ascospores previously placed in Polymeridium), Julella (provisionally, as the type species remains unsequenced), Marcelaria (Laurera purpurina complex), Nigrovothelium gen. nov. (for the Trypethelium tropicum group), Novomicrothelia gen. nov. (for an additional species previously placed in Mycomicrothelia), Polymeridium s. str., Pseudopyrenula, Trypethelium s. str. (T. eluteriae group), and Viridothelium gen. nov. (for the Trypethelium virens group). All recognized genera are phenotypically characterized and a discussion on the evolution of phenotypic features in the family is given. Based on the obtained phylogeny, species delimitations are revised and the importance of characters such as thallus morphology, hymenial inspersion, and secondary chemistry for taxonomic purposes is discussed, resulting in a refined species concept.
The preliminary results of a search for OH/IR stars in the Galactic Centre using the VLA are presented. The goal of this project is to determine the mass density distribution from a few parsecs up to about 120 pc of the Galactic Centre using stellar kinematics. Up to now, 125 OH/IR stars have been found. The distribution of the stars is clearly elongated with the major axis parallel to the galactic equator. The stars show a rotation of 117 km s−1 deg−1 with a dispersion of 90 km s−1. Two preliminary models have been applied in order to determine the enclosed mass, resulting in M(r)=4.0·106·r1.4 Mo, where r is the galactocentric distance in parsecs.
Two studies consisting of six field experiments each were conducted at three locations in southwestern Ontario, Canada, in 2014 and 2015 to evaluate the possible antagonism when dicamba was added to quizalofop-p-ethyl or clethodim for the control of volunteer glyphosate-resistant (GR) corn. At 4 wk after application (WAA), quizalofop-p-ethyl at 24, 30, or 36 g ai ha−1 provided 88, 94, and 95% control of volunteer GR corn, respectively. The addition of dicamba at 300 or 600 g ae ha−1 to quizalofop-p-ethyl (24 g ha−1) reduced the activity of quizalofop-p-ethyl on volunteer GR corn by 12 and 20%. At 4 WAA, clethodim at 30, 37.5, and 45 g ai ha−1 provided 85, 91, and 95% control of volunteer GR corn, respectively. The addition of dicamba at 300 or 600 g ha−1 to clethodim (30 g ha−1) resulted in antagonism, causing a reduction in volunteer GR corn by 12 and 11%, respectively. In general, there was greater antagonism when the high rate of dicamba was tank-mixed with the lower rate of the graminicide. There was no antagonistic effect on soybean yield by tank-mixing dicamba with either graminicide at all rates evaluated. Based on these results, volunteer GR corn can be controlled effectively by increasing the rate of the graminicide when tankmixed with dicamba.