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Introduction: Optimizing naloxone dosing in the context of increasing fentanyl and ultra-potent opioid (UPO) prevalence is an important consideration for emergency health care providers. The goal of this systematic review was to evaluate the association between initial and cumulative naloxone doses on effective reversal and adverse events in undifferentiated and fentanyl/UPO overdoses. Methods: We searched Embase, MEDLINE, Cochrane Central Register of Controlled Trials, DARE, CINAHL, Science Citation Index, reference lists, toxicology websites, and conference proceedings from July to October 2018 and back to 1972. Our search included pertinent indexing terms for UPOs. We included interventional and observational studies reporting on naloxone administration for opioid toxicity reversal in people ≥12 years old. Additionally, we accessed non-traditional evidence sources (case reports and series) given this rapidly changing field. We conducted inclusion screens, data extraction and quality assessments in duplicate. We summarized study characteristics and where reported, analyzed number of patients with clinical response. Response was defined as not receiving further naloxone doses and remaining alive. Results: We included 174 studies (108 case reports and series, 55 observational, 9 interventional) with 26,660 subjects (median age 35.1; 74.2% male). We observed lower response among patients exposed to fentanyl/UPO versus heroin for initial naloxone doses ≤0.4mg (56.8% versus 80.2%) and > 0.4mg (27.0% versus 82.1%). Mean cumulative doses were higher for fentanyl/UPO (2.10 mg, SD 1.80 mg) versus heroin (1.48 mg, SD 1.68 mg) overdoses. In North American studies the median cumulative dose used was higher for fentanyl/UPO versus heroin overdoses. A dose-response curve for fentanyl/UPO studies showed marked variability in doses among responders, indicating heterogeneity. Adverse events reporting was inconsistent; 10% of subjects experienced withdrawal based on studies in which they were reported. Conclusion: This is the first systematic review to summarize proportion of patients with clinical response by naloxone dose provided. While variable reporting, study quality, heterogeneity, and our outcome definitions limit the conclusions we can draw, it appears that higher initial doses and in some cases, higher cumulative naloxone doses were used and may be necessary to reverse toxicity due to fentanyl/UPO compared to other opioids. High-quality prospective studies assessing effectiveness and safety are needed.
Techniques were developed and statistically evaluated for the determination of both the homogeneity and the elemental compositions of columbium alloy ingots. X-ray fluorescent spectrography and automatic data handling systems are utilized. Sample preparation is discussed in detail from the consumable-electrode arc-melt process to the final physical form suitable for X-ray fluorescent spectrography. Arrangements of apparatus for obtaining, recording, processing, and interpreting data, with specific attention to limitations for various matrices, are treated at length.
The method has been applied to specific cases with, for example, a correlation of the degree of variation of homogeneity of columbium alloy ingots with remelting practice. An attempt is made to provide a preliminary basis for determining the value of the technique as a possible means of quality control.
Reciprocal space mapping can be efficiently carried out using a position-sensitive x-ray detector (PSD) coupled to a traditional double-axis diffractometer. The PSD offers parallel measurement of the total scattering angle of all diffracted x-rays during a single rocking-curve scan. As a result, a two-dimensional reciprocal space map can be made in a very short time similar to that of a one-dimensional rocking-curve scan. Fast, efficient reciprocal space mapping offers numerous routine advantages to the x-ray diffraction analyst. Some of these advantages arc the explicit differentiation of lattice strain from crystal orientation effects in strain-relaxed heteroepitaxial layers; the nondestructive characterization of the size, shape and orientation of nanocrystalline domains in ordered-alloy epilayers; and the ability to measure the average size and shape of voids in porous epilayers. Here, the PSD-based diffractometer is described, and specific examples clearly illustrating the advantages of complete reciprocal space analysis are presented.
Haberle et al. (1996) and Joshi, Haberle & Reynolds (1997) demonstrated that for a planet receiving Earth-level insolation, a 100 mb pure CO2 atmosphere would carry enough heat flux to the dark side of a synchronously rotating planet (SRP) to prevent the atmosphere freezing out there. For a 1,500 mb pure CO2 atmosphere and 0.8 Earth insolation, liquid water could survive over much of the planet. Such high partial pressures of CO2 may seem like special pleading, but in fact, they are not essential for habitable conditions. The effective grey optical depth of the present terrestrial atmosphere (with just 350 ppm CO2, and H2O as the principal greenhouse gas) is approximately 0.9, as against 1.0 for a 1,000 mb pure CO2 atmosphere, so the latter serves merely as a useful approximation (for a truly Earth-type atmosphere, temperatures would be a few degrees lower over the lit hemisphere). Heath et al. (1999) concluded that even forest-habitable conditions, suitable for Earth-like trees (Heath 1996) were not to be ruled out on the basis of present knowledge. Recent work by Joshi (2004) has modelled the range of climatic options for certain land-sea distributions, and these leave the door open for further investigations of combinations of geography and insolation compatible with forest-habitability.
Whole apples have not been previously implicated in outbreaks of foodborne bacterial illness. We investigated a nationwide listeriosis outbreak associated with caramel apples. We defined an outbreak-associated case as an infection with one or both of two outbreak strains of Listeria monocytogenes highly related by whole-genome multilocus sequence typing (wgMLST) from 1 October 2014 to 1 February 2015. Single-interviewer open-ended interviews identified the source. Outbreak-associated cases were compared with non-outbreak-associated cases and traceback and environmental investigations were performed. We identified 35 outbreak-associated cases in 12 states; 34 (97%) were hospitalized and seven (20%) died. Outbreak-associated ill persons were more likely to have eaten commercially produced, prepackaged caramel apples (odds ratio 326·7, 95% confidence interval 32·2–3314). Environmental samples from the grower's packing facility and distribution-chain whole apples yielded isolates highly related to outbreak isolates by wgMLST. This outbreak highlights the importance of minimizing produce contamination with L. monocytogenes. Investigators should perform single-interviewer open-ended interviews when a food is not readily identified.
Introduction: Non-trauma centers (NTC) and community hospitals commonly deliver medical care during the “golden hour” of trauma, which has significant implications on the health outcomes of patients. The Niagara Health System (NHS) and its 3 community NTC hospitals provide trauma care to over 100 patients annually during this critical period. NTCs lack standardized resources commonly found in trauma centers. Checklists and bundles have been effective in streamlining process to ensure health care providers provide the right care, at the right time and address critical points during patient care. A trauma care bundle was designed and implemented in the NHS as a means to improve trauma care and patient outcomes. Methods: A quality improvement (QI) approach was used to design, implement and evaluate a trauma care bundle at one of the NHS’s community hospitals. These interventions were adapted and modified for community trauma care purposes. We piloted the trauma care bundle using rapid cycle improvements, known as Plan-Do-Study-Act (PDSA) cycles. We assessed outcome and process measures through a chart audit of all trauma care patients in the NHS from July 2015-December 2015. A safety attitudes questionnaire (SAQ) was administered to health system staff who were involved in the pilot to assess balancing measures. Results: Improvements to the bundle and its implementation from 4 PDSA cycles resulted in increased utilization. This continuous monitoring of the bundle and ongoing, conscious efforts to improve the intervention were used to spread and scale across all 3 sites of the NHS. 30% of patients received the trauma care bundle during phase 1 of the pilot from July 1- October 31, 2015. We are presently analyzing preliminary data to understand how the trauma care bundle impacts health outcomes and process and will present a comparative analysis between patient groups. Conclusion: Trauma care bundles may foster safer and more efficient patient care in community hospitals where the golden hour of trauma often occurs. This community trauma care bundle shows promising results for streamlining the care process to ensure patients receive appropriate care during the golden hour. Spread and scale of this bundle across other community hospitals will likely yield similar improvements in patient care.
In most mental illnesses, onset occurs before the age of 25 and the earliest stages are critical. The youth bear a large share of the burden of disease associated with mental illnesses. Yet, Canadian youths with mental health difficulties face delayed detection; long waiting lists; inaccessible, unengaging services; abrupt transitions between services; and, especially in remoter regions, even a complete lack of services. Responding to this crisis, the Canadian Institutes of Health Research announced a 5-year grant that was awarded to ACCESS, a pan-Canadian network of youths, families, clinicians, researchers, policymakers, community organisations and Indigenous communities. Using strategies developed collaboratively by all stakeholders, ACCESS will execute a youth mental healthcare transformation via early detection, rapid access and appropriate, high-quality care. The project includes an innovative, mixed-methods service research component. Similar in many respects to other national youth mental health initiatives, ACCESS also exhibits important differences of scale, scope and approach.
Legionella pneumophila is the main pathogen responsible for outbreaks of Legionnaires' disease, which can be related to contaminated water supplies such as cooling towers or water pipes. We combined conventional molecular methods and whole genome sequence (WGS) analysis to investigate an outbreak of L. pneumophila in a large Australian hospital. Typing of these isolates using sequence-based typing and virulence gene profiling, was unable to discriminate between outbreak and non-outbreak isolates. WGS analysis was performed on isolates during the outbreak, as well as on unlinked isolates from the Public Health Microbiology reference collection. The more powerful resolution provided by analysis of whole genome sequences allowed outbreak isolates to be distinguished from isolates that were temporally and spatially unassociated with the outbreak, demonstrating that this technology can be used in real-time to investigate L. pneumophila outbreaks.
The association between depression after myocardial infarction and increased risk of mortality and cardiac morbidity may be due to cardiac disease severity.
To combine original data from studies on the association between post-infarction depression and prognosis into one database, and to investigate to what extent such depression predicts prognosis independently of disease severity.
An individual patient data meta-analysis of studies was conducted using multilevel, multivariable Cox regression analyses.
Sixteen studies participated, creating a database of 10 175 post-infarction cases. Hazard ratios for post-infarction depression were 1.32 (95% CI 1.26–1.38, P<0.001) for all-cause mortality and 1.19 (95% CI 1.14–1.24, P<0.001) for cardiovascular events. Hazard ratios adjusted for disease severity were attenuated by 28% and 25% respectively.
The association between depression following myocardial infarction and prognosis is attenuated after adjustment for cardiac disease severity. Still, depression remains independently associated with prognosis, with a 22% increased risk of all-cause mortality and a 13% increased risk of cardiovascular events per standard deviation in depression z-score.
A heuristic greedy algorithm is developed for efficiently tiling spatially dense redshift surveys. In its first application to the Galaxy and MassAssembly (GAMA) redshift survey we find it rapidly improves the spatial uniformity of our data, and naturally corrects for any spatial bias introduced by the 2dF multi-object spectrograph. We make conservative predictions for the final state of the GAMA redshift survey after our final allocation of time, and can be confident that even if worse than typical weather affects our observations, all of our main survey requirements will be met.
Hydrogenated amorphous silicon-germanium alloy thin films (a-Si1-xGex:H) were deposited using reactive magnetron sputtering. Dual targets of silicon and germanium were sputtered in an argon + hydrogen atmosphere using rf excitation. Films with x = 0.4 were deposited as a function of substrate temperature and hydrogen partial pressure, and were evaluated by dark and photoconductivity, infrared absorption, and optical transmission. Photosensitivity reached a maximum value of about 5000 between 150 and 200 °C. Using the stretching modes in the region of 2000 cm-1, the hydrogen bonding was characterized in terms of the preferential attachment ratio (PA), which represents the ratio of H bonded to silicon to that bonded to germanium. The PA shows a systematic increase with increasing temperature, independent of hydrogen partial pressure. The interplay between thermodynamic and kinetics effects in determining PA and film quality will be discussed.
The effect of the dietary n-3 long-chain PUFA, DHA (22 : 6n-3), on the growth of pre-term infants is controversial. We tested the effect of higher-dose DHA (approximately 1 % dietary fatty acids) on the growth of pre-term infants to 18 months corrected age compared with standard feeding practice (0·2–0·3 % DHA) in a randomised controlled trial. Infants born < 33 weeks gestation (n 657) were randomly allocated to receive breast milk and/or formula with higher DHA or standard DHA according to a concealed schedule stratified for sex and birth-weight ( < 1250 and ≥ 1250 g). The dietary arachidonic acid content of both diets was constant at approximately 0·4 % total fatty acids. The intervention was from day 2 to 5 of life until the infant's expected date of delivery (EDD). Growth was assessed at EDD, and at 4, 12 and 18 months corrected age. There was no effect of higher DHA on weight or head circumference at any age, but infants fed higher DHA were 0·7 cm (95 % CI 0·1, 1·4 cm; P = 0·02) longer at 18 months corrected age. There was an interaction effect between treatment and birth weight strata for weight (P = 0·01) and length (P = 0·04). Higher DHA resulted in increased length in infants born weighing ≥ 1250 g at 4 months corrected age and in both weight and length at 12 and 18 months corrected age. Our data show that DHA up to 1 % total dietary fatty acids does not adversely affect growth.
Substrate temperature during film growth is an important processing parameter for vapor deposited films of the high Tc superconductors. In this paper we describe a novel, non-contact optical thermometry technique in which the temperature of a transparent substrate or “temperature sensor” is determined from its thermal expansion and refractive index change measured by laser interferometry. The technique is easy to implement and extremely accurate. Temperatures measured with this technique are reported for MgO substrates in varying degrees of thermal contact with a heated backing plate and compared to those measured conventionally by optical pyrometry or thermocouples in close proximity to the sample. The effect of the deposited film on the temperature of radiatively heated substrates will also be discussed.
Uniform keV ion irradiation causes a morphological instability known to result in the spontaneous formation of topographic ripple and dot patterns. The degree of order of these patterns, which has important implications for non-lithographic patterning applications, varies markedly with fabrication conditions. We investigate the influence of systematic variations of fabrication conditions, including current density, ion fluence and ion energy, on the degree of order of argon ion bombarded Si(111) surfaces. For quantifying order in sputter rippled topographic images, we develop an algorithm that evaluates the density of topological defects, such as ripple bifurcations and terminations, and suitably normalizes the result in order to present a scalar figure of merit: the normalized defect density. We discuss fabrication conditions that lead to extremely well ordered dot and ripple patterns upon irradiation.
Thin film interactions between a-(Ni-Nb) and polycrystalline Au over-layers have been studied with high depth resolution (≤1.7nm) Rutherford backscattering (RBS) and TEM to obtain information on the early stages of reaction at the interface. The RBS spectra from Au indicated that the interdiffused samples consisted of two layers: an Au-Nb binary layer on the surface and a ternary Au-Ni-Nb compound layer beneath the binary layer. The growth kinetics of the ternary compound layer differed in samples which had been relaxed prior to Au deposition from the kinetics for unrelaxed samples. Furthermore, cross section TEM micrographs showed that relaxed and unrelaxed samples exhibit different microstructures after the early stages, of annealing. We interpret this result to indicate that the reaction stages in relaxed samples are not as advanced as those in the unrelaxed samples.
Reactive magnetron sputtering (RMS) is a versatile technique for the production of alloy thin film coatings such as hydrides, nitrides, oxides, etc. RMS provides control over (i) film stoichiometry, via the partial pressure of “reactive” gas (H2, N2, etc.) injected, and (ii) film microstructure, via the bombardment of the growing surface by fast neutral or accelerated ionic species. However, few details are known about the fluxes reaching the film surface, and their reactions with it.
This paper reports comprehensive measurements for the RMS growth of hydrogenated amorphous silicon (a-Si:H). The analysis techniques are in situ double modulation mass spectroscopy, plasma probes, isotope replacement experiments, and Monte-Carlo simulations of sputtered particle transport. We determine (i) the composition, energy and angular distributions of the incident flux, (ii) the H coverage of the growing surface, and (iii) the release of H2 from the growing film. For conditions which produce electronic quality a-Si:H, the total H flux arriving at the substrate varies between 0.5–2 times the depositing Si flux; about half of the H flux reflects. The growth surface has excess H varying between 0.5–2 × 1015/cm2, and this surface H coverage is linearly related to the bulk H incorporation. We also find evidence that film density varies with the energy of the arriving sputtered Si atoms.