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Introduction: Trauma and injury play a significant role in the population's burden of disease. Limited research exists evaluating the role of trauma bypass protocols. The objective of this study was to assess the impact and effectiveness of a newly introduced prehospital field trauma triage (FTT) standard, allowing paramedics to bypass a closer hospital and directly transport to a trauma centre (TC) provided transport times were within 30 minutes. Methods: We conducted a 12-month multi-centred health record review of paramedic call reports and emergency department health records following the implementation of the 4 step FTT standard (step 1: vital signs and level of consciousness, step 2: anatomical injury, step 3: mechanism and step 4: special considerations) in nine paramedic services across Eastern Ontario. We included adult trauma patients transported as an urgent transport to hospital, that met one of the 4 steps of the FTT standard and would allow for a bypass consideration. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions. The primary outcome was the rate of appropriate triage to a TC, defined as any of the following: injury severity score ≥12, admitted to an intensive care unit, underwent non-orthopedic operation, or death. We report descriptive and univariate analysis where appropriate. Results: 570 adult patients were included with the following characteristics: mean age 48.8, male 68.9%, attended by Advanced Care Paramedic 71.8%, mechanisms of injury: MVC 20.2%, falls 29.6%, stab wounds 10.5%, median initial GCS 14, mean initial BP 132, prehospital fluid administered 26.8%, prehospital intubation 3.5%, transported to a TC 74.6%. Of those transported to a TC, 308 (72.5%) had bypassed a closer hospital prior to TC arrival. Of those that bypassed a closer hospital, 136 (44.2%) were determined to be “appropriate triage to TC”. Bypassed patients more often met the step 1 or step 2 of the standard (186, 66.9%) compared to the step 3 or step 4 (122, 39.6%). An appropriate triage to TC occurred in 104 (55.9%) patients who had met step 1 or 2 and 32 (26.2%) patients meeting step 3 or 4 of the FTT standard. Conclusion: The FTT standard can identify patients who should be bypassed and transported to a TC. However, this is at a cost of potentially burdening the system with poor sensitivity. More work is needed to develop a FTT standard that will assist paramedics in appropriately identifying patients who require a trauma centre.
Improving access to tuberculosis (TB) care and ensuring early diagnosis are two major aims of the WHO End TB strategy and the Collaborative TB Strategy for England. This study describes risk factors associated with diagnostic delay among TB cases in England. We conducted a retrospective cohort study of TB cases notified to the Enhanced TB Surveillance System in England between 2012 and 2015. Diagnostic delay was defined as more than 4 months between symptom onset and treatment start date. Multivariable logistic regression was used to identify demographic and clinical factors associated with diagnostic delay. Between 2012 and 2015, 22 422 TB cases were notified in England and included in the study. A third (7612) of TB cases had a diagnostic delay of more than 4 months. Being female, aged 45 years and older, residing outside of London and having extra-pulmonary TB disease were significantly associated with a diagnostic delay in the multivariable model (aOR = 1.2, 1.2, 1.2, 1.3, 1.8, respectively). This study identifies demographic and clinical factors associated with diagnostic delay, which will inform targeted interventions to improve access to care and early diagnosis among these groups, with the ultimate aim of helping reduce transmission and improve treatment outcomes for TB cases in England.
Prolonged periods of stress have been associated with impaired immune function; the experiment reported here investigates a potential link between level of metabolic load and immune function in lactating dairy cattle. A group of 111 Holstein-Friesian dairy cows was used. The cows belonged to one of two genetic lines: a selection line (S) with high genetic merit for fat plus protein yield and an unselected control line (C). The cows were offered one of two silage-based total mixed diets containing either 200 g (LC) or 450 g (HC) of concentrate per kg dry matter. Combination of genetic selection and food gave four groups: S-LC, S-HC, C-LC and C-HC. All cows were inoculated with a live attenuated BHV-1 vaccine soon after parturition and the primary antibody response in whey monitored. The number of BHV-1 antibody positive cows was not significantly different between the four groups; but, the initial antibody response was lower in cows of high genetic merit which were given a low concentrate diet. Statistical analysis demonstrated that the contribution of diet to this effect was highly significant. One year later, again after parturition, the experiment was repeated, this time using serum as the test sample. The average antibody response of the BHV-1 antibody positive cows was not significantly different between the four groups but the number of antibody positive cows was group-dependent. In conclusion, diet type but not genetic merit for high fat plus protein yield made a highly significant contribution to the antibody response of dairy cows to BHV-1 vaccination, both initially and a year later.
Established methods of recruiting population controls for case–control studies to investigate gastrointestinal disease outbreaks can be time consuming, resulting in delays in identifying the source or vehicle of infection. After an initial evaluation of using online market research panel members as controls in a case–control study to investigate a Salmonella outbreak in 2013, this method was applied in four further studies in the UK between 2014 and 2016. We used data from all five studies and interviews with members of each outbreak control team and market research panel provider to review operational issues, evaluate risk of bias in this approach and consider methods to reduce confounding and bias. The investigators of each outbreak reported likely time and cost savings from using market research controls. There were systematic differences between case and control groups in some studies but no evidence that conclusions on the likely source or vehicle of infection were incorrect. Potential selection biases introduced by using this sampling frame and the low response rate are unclear. Methods that might reduce confounding and some bias should be balanced with concerns for overmatching. Further evaluation of this approach using comparisons with traditional methods and population-based exposure survey data is recommended.
There has been growing public concern with regard to the effects of heavy metals excreted by animals on the environment. Heavy metals can be lost from manure and slurry to ground and surface waters, and subsequently affect water quality (Van Horn et al., 1996). In regions of high domestic livestock production, farmers are therefore seeking means to reduce the quantity of heavy metals excreted by animals and subsequently onto the land (Van Horn et al., 1996). The objective of this study was to establish the effect of two levels of dietary Zn inclusion in two different forms (organically chelated vs. inorganic) on apparent absorption and retention in dairy cattle.
An adequate intake of colostrum by the newborn piglet allows the piglet to acquire passive immunity and develop active immunity. Many studies have looked at the uptake of IgG by piglets in artificial situations rather than by natural suckling. Therefore we investigated the uptake of IgG by piglets whilst suckling naturally and estimated the time of gut closure.
A total of 8 multiparous sows (Newsham - Large White x Landrace) were induced to farrow on day 114 of gestation. Colostrum/milk was sampled, using oxytocin where necessary, at 0, 4, 8, 12, 16, 20, 24h and 2, 5 and 7 days after farrowing. Female piglets (average 3 per litter) were fitted with umbilical catheters to allow blood sampling at 0, 4, 8, 12, 16, 20, 24 and 48h; samples were taken at 5 and 7 days of age by venepuncture.
Background: Cerebral palsy (CP) is a debilitating disorder (1). Based on neuromotor impairments it is divided to spastic, dyskinetic and ataxic types (2). Inborn Errors of Metabolism (IEMs), monogenic and chromosomal disorders mimic CP (3). We aimed to identify causal genetic variants in patients with atypical dyskinetic CP in whom known IEMs were ruled out. Timely diagnosis is essential for proper management, especially in conditions that mimic CP and are treatable. Methods: We enrolled 23 patients with unexplained atypical dyskinetic CP, for whole exome sequencing. Variants were filtered against public and in-house databases to identify variants predicted as damaging (in silico tools and ACMG criteria). We applied a virtual gene panel of known and suspected CP and movement disorder genes and investigated each sample. Results: The participants presented with symptoms including: spasticity, dystonia, choera-athetosis, ataxia and cognitive delays. We identified 23 diagnoses: 13 dominant,6 recessive and 4 X-linked. 12 patients had movement disorders. In 4, the diagnoses enabled targeted treatment (neurotransmitter supplements in Unverricht Lundborg diseases (CSTB) and PAK3 deficiency, deep brain stimulation in GNAO1 deficiency, medical diet in Glutaric Aciduria (GCDH). Conclusions: Whole Exome Sequencing contributes to establishing diagnosis in patients with atypical dyskinetic CP resulting in precision medicine and improved health outcomes.
Introduction: The Canadian C-Spine Rule (CCR) was validated by emergency physicians and triage nurses to determine the need for radiography in alert and stable Emergency Department trauma patients. It was modified and validated for use by paramedics in 1,949 patients. The prehospital CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 4 low-risk criteria. This study evaluated the impact and safety of the implementation of the CCR by paramedics. Methods: This single-centre prospective cohort implementation study took place in Ottawa, Canada. Advanced and primary care paramedics received on-line and in-person training on the CCR, allowing them to use the CCR to evaluate eligible patients and selectively transport them without immobilization. We evaluated all consecutive eligible adult patients (GCS 15, stable vital signs) at risk for neck injury. Paramedics were required to complete a standardized study data form for each eligible patient evaluated. Study staff reviewed paramedic documentation and corresponding hospital records and diagnostic imaging reports. We followed all patients without initial radiologic evaluation for 30 days for referral to our spine service, or subsequent visit with radiologic evaluation. Analyses included sensitivity, specificity, kappa coefficient, t-test, and descriptive statistics with 95% CIs. Results: The 4,034 patients enrolled between Jan. 2011 and Aug. 2015 were: mean age 43 (range 16-99), female 53.3%, motor vehicle collision 51.9%, fall 23.8%, admitted to hospital 7.0%, acute c-spine injury 0.8%, and clinically important c-spine injury (0.3%). The CCR classified patients for 11 important injuries with sensitivity 91% (95% CI 58-100%), and specificity 67% (95% CI 65-68%). Kappa agreement for interpretation of the CCR between paramedics and study investigators was 0.94 (95% CI 0.92-0.95). Paramedics were comfortable or very comfortable using the CCR in 89.8% of cases. Mean scene time was 3 min (15.6%) shorter for those not immobilized (17 min vs. 20 min; p=0.0001). A total of 2,569 (63.7%) immobilizations were safely avoided using the CCR. Conclusion: Paramedics could safely and accurately apply the CCR to low-risk trauma patients. This had a significant impact on scene times and the number of prehospital immobilizations.
Introduction: In Ottawa, STEMI patients are transported directly to percutaneous coronary intervention (PCI) by advanced care paramedics (ACPs), primary care paramedics (PCPs), or transferred from PCP to ACP crew (ACP-intercept). PCPs have a limited skill set to address complications during transport.The objective of this study was to determine what clinically important events (CIEs) occurred in STEMI patients transported for primary PCI via a PCP crew, and what proportion of such events could only be treated by ACP protocols. Methods: We conducted a health record review of STEMI patients transported for primary PCI from Jan 1, 2011-Dec 21, 2015. Ottawa has a single PCI center and its EMS system employs both PCP and ACP paramedics. We identified consecutive STEMI bypass patients transported by PCP-only and ACP-intercept using the dispatch database. A data extraction form was piloted and used to extract patient demographics, transport times, and primary outcomes: CIEs and interventions performed during transport, and secondary outcomes: hospital diagnosis, and mortality. CIEs were reviewed by two investigators to determine if they would be treated differently by ACP protocols. We present descriptive statistics. Results: We identified 967 STEMI bypass cases among which 214 (118 PCP-only and 96 ACP-intercept) met all inclusion criteria. Characteristics were: mean age 61.4 years, 78% male, 31.8% anterior and 44.4% inferior infarcts, mean response time 6 min, total paramedic contact time 29 min, and in cases of ACP-intercept 7 min of PCP-only contact time.A CIE occurred in 127 (59%) of cases: SBP<90 mmHg 26.2%, HR<60 30.4%, HR>100 20.6%, malignant arrhythmias 7.5%, altered mental status 6.5%, airway intervention 2.3%, 2 patients (0.9%) arrested, both survived. Of the CIE identified, 54 (42.5%) could be addressed differently by ACP vs PCP protocols (25.2% of total cases). The majority related to fluid boluses for hypotension (44 cases; 35% of CIE). ACP intervention for CIEs within the ACP intercept group was 51.6%. There were 6 in-hospital deaths (2.8%) with no difference in transport crew type. Conclusion: CIEs are common in STEMI bypass patients however a smaller proportion of such CIE would be addressed differently by ACP protocols compared to PCP protocols. The vast majority of CIE appeared to be transient and of limited clinical significance.
Considered as a less hazardous piezoelectric material, potassium sodium niobate (KNN) has been in the fore of the search for replacement of lead (Pb) zirconate titanate for piezoelectrics applications. Here, we challenge the environmental credentials of KNN due to the presence of ~60 wt% Nb2O5, a substance much less toxic to humans than Pb oxide, but whose mining and extraction cause significant environmental damage.
Although only three antennas of the Australia Telescope Compact Array are currently operational, we have made use of the technique of bandwidth synthesis to make an image of the radio galaxy 2152 – 69. The three baselines were used to observe the source at three different frequencies, effectively resulting in nine baselines, which have been used to produce an image with a surprisingly high dynamic range, and with a slightly higher resolution than any existing image.
The production of such a worthwhile result, despite being made with a small subset of the capabilities of the Australia Telescope, bodes well for the future operation of the instrument.
Several extragalactic HI surveys using a λ21 cm 13-beam focal plane array will begin in early 1997 using the Parkes 64 m telescope. These surveys are designed to detect efficiently nearby galaxies that have failed to be identified optically because of low optical surface brightness or high optical extinction. We discuss scientific and technical aspects of the multibeam receiver, including astronomical objectives, feed, receiver and correlator design and data acquisition. A comparison with other telescopes shows that the Parkes multibeam receiver has significant speed advantages for any large-area λ21 cm galaxy survey in the velocity range range 0–14000 km s−1.
PKS 1830–211 is the strongest known radio gravitational lens by almost an order of magnitude and has the potential to provide a measurement of H0, provided the lensing system can be parameterized. Attempts to identify optical counterparts, to measure redshifts, have so far proved unsuccessful and this has lead to radio and millimetre spectral line observations. We present our discovery of an absorption system at z = 0.19. A brief description is also made of our ATCA observations to measure the lensing time delay for this source.
Children in care often have poor outcomes. There is a lack of evaluative
research into intervention options.
To examine the efficacy of Multidimensional Treatment Foster Care for
Adolescents (MTFC-A) compared with usual care for young people at risk in
foster care in England.
A two-arm single (assessor) blinded randomised controlled trial (RCT)
embedded within an observational quasi-experimental case–control study
involving 219 young people aged 11–16 years (trial registration: ISRCTN
68038570). The primary outcome was the Child Global Assessment Scale
(CGAS). Secondary outcomes were ratings of educational attendance,
achievement and rate of offending.
The MTFC-A group showed a non-significant improvement in CGAS outcome in
both the randomised cohort (n = 34, adjusted mean
difference 1.3, 95% CI −7.1 to 9.7, P = 0.75) and in the
trimmed observational cohort (n = 185, adjusted mean
difference 0.95, 95% CI −2.38 to 4.29, P = 0.57). No
significant effects were seen in secondary outcomes. There was a possible
differential effect of the intervention according to antisocial
There was no evidence that the use of MTFC-A resulted in better outcomes
than usual care. The intervention may be more beneficial for young people
with antisocial behaviour but less beneficial than usual treatment for
The effects of low energy ions from a biased electron cyclotron resonance plasma during growth of Al2O3 and La2O3 are used to modify the density and crystalline quality of these oxide films. The type of phase formed for Al2O3 is varied with the ion-assisted growth from amorphous to crystalline γA12O3. The photoluminescence (PL) properties of different Er-doped Al- and La-oxide phases are examined, and through comparison of the PL spectra, the local environment of Er in these oxide materials is discussed.