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To review the management of temporal bone fractures at a major trauma centre and introduce an evidence-based protocol.
A review of reports of head computed tomography performed for trauma from January 2012 to July 2018 was conducted. Recorded data fields included: mode of trauma, patient age, associated intracranial injury, mortality, temporal bone fracture pattern, symptoms and intervention.
Of 815 temporal bone fracture cases, records for 165 patients met the inclusion criteria; detailed analysis was performed on the records of these patients.
Temporal bone fractures represent high-energy trauma. Initial management focuses on stabilisation of the patient and treatment of associated intracranial injury. Acute ENT intervention is directed towards the management of facial palsy and cerebrospinal fluid leak, and often requires multidisciplinary team input. The role of nerve conduction assessment for immediate facial palsy is variable across the UK. The administration of high-dose steroids in patients with temporal bone fracture and intracranial injury is not advised. A robust evidence-based approach is introduced for the management of significant ENT complications associated with temporal bone fractures.
Research on producer willingness to adopt individual best pasture management practices (BMPs) is extensive, but less attention has been paid to producers simultaneously adopting multiple, complementary BMPs. Applications linking primary survey data on BMP adoption to water quality biophysical models are also limited. A choice-experiment survey of livestock producers is analyzed to determine willingness to adopt pasture BMPs. Sediment abatement curves are derived by linking estimates of producer responsiveness to incentives to adopt rotational grazing with a biophysical simulation model. Current cost share rates of $24/acre should yield a 12% decrease in sediment loading from pastures.
We determined how pasture and grazing management practices affected the number of days hay was fed to cattle by season. Data were collected from a survey of Tennessee cattle producers. Days of cattle on hay varied across seasons because of variations in forage production and weather. The number of days hay was fed to cattle varied with pasture-animal management practices such as rotating pastures, forage mixtures, and weed management strategies. Having mixtures of cool- and warm-season grasses reduced the number of days on hay in the winter, spring, and summer months indicating benefits from diversified forages.
Using existing data from clinical registries to support clinical trials and other prospective studies has the potential to improve research efficiency. However, little has been reported about staff experiences and lessons learned from implementation of this method in pediatric cardiology.
We describe the process of using existing registry data in the Pediatric Heart Network Residual Lesion Score Study, report stakeholders’ perspectives, and provide recommendations to guide future studies using this methodology.
The Residual Lesion Score Study, a 17-site prospective, observational study, piloted the use of existing local surgical registry data (collected for submission to the Society of Thoracic Surgeons-Congenital Heart Surgery Database) to supplement manual data collection. A survey regarding processes and perceptions was administered to study site and data coordinating center staff.
Survey response rate was 98% (54/55). Overall, 57% perceived that using registry data saved research staff time in the current study, and 74% perceived that it would save time in future studies; 55% noted significant upfront time in developing a methodology for extracting registry data. Survey recommendations included simplifying data extraction processes and tailoring to the needs of the study, understanding registry characteristics to maximise data quality and security, and involving all stakeholders in design and implementation processes.
Use of existing registry data was perceived to save time and promote efficiency. Consideration must be given to the upfront investment of time and resources needed. Ongoing efforts focussed on automating and centralising data management may aid in further optimising this methodology for future studies.
Introduction: Oxygen is commonly administered to prehospital patients presenting with acute myocardial infarction (AMI). We conducted a systematic review to determine if oxygen administration, in AMI, impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central, clinicaltrials.gov and ISRCTN for relevant randomized controlled trials and observational studies comparing oxygen administration and no oxygen administration. The outcomes of interest were: mortality (≤30 days, in-hospital, and intermediate 2-11 months), infarct size, and major adverse cardiac events (MACE). Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. A meta-analysis was performed using RevMan 5 software. Results: Our search yielded 1192 citations of which 48 studies were reviewed as full texts and a total of 8 studies were included in the analysis. All evidence was considered low or very low quality. Five studies reported on mortality finding low quality evidence of no benefit or harm. Low quality evidence demonstrated no benefit or harm from supplemental oxygen administration. Similarly, no benefit or harm was found in MACE or infarct size (very low quality). Normoxia was defined as oxygen saturation measured via pulse oximetry at ≥90% in one recent study and ≥94% in another. Conclusion: We found low and very low quality evidence that the administration of supplemental oxygen to normoxic patients experiencing AMI, provides no clear harm nor benefit for mortality or MACE. The evidence on infarct size was inconsistent and warrants further prospective examination.
Introduction: Opioids are routinely administered for analgesia to prehospital patients experiencing chest discomfort from acute myocardial infarction (AMI). We conducted a systematic review to determine if opioid administration impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central and Clinicaltrials.gov for relevant randomized controlled trials and observational studies comparing opioid administration in AMI patients from 1990 to 2017. The outcomes of interest were: all-cause short-term mortality (≤30 days), major adverse cardiac events (MACE), platelet activity and aggregation, immediate adverse events, infarct size, and analgesia. Included studies were hand searched for additional citations. Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. Results: Our search yielded 3001 citations of which 19 studies were reviewed as full texts and a total of 9 studies were included in the analysis. The studies predominantly reported on morphine as the opioid. Five studies reported on mortality (≤30 days), seven on MACE, four on platelet activity and aggregation, two on immediate adverse events, two on infarct size and none on analgesic effect. We found low quality evidence suggesting no benefit or harm in terms of mortality or MACE. However, low quality evidence indicates that opioids increase infarct size. Low-quality evidence also shows reduced serum P2Y12 (eg: clopidogrel and ticagrelor) active metabolite levels and increased platelet reactivity in the first several hours post administration following an increase in vomiting. Conclusion: We find low and very low quality evidence that the administration of opioids in STEMI may be adversely related to vomiting and some surrogate outcomes including increased infarct size, reduced serum P2Y12 levels, and increased platelet activity. We found no clear benefit or harm on patient-oriented clinical outcomes including mortality.
Introduction: Point-of-Care Ultrasound (PoCUS) is being increasingly utilized during cardiac arrests for prognosis. Following the publication of recent studies, the goal of this study was to systematically review and analyze the literature to evaluate the accuracy of PoCUS in predicting return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and survival to hospital discharge (SHD) in adult patients with non-traumatic, non- shockable out- of-hospital or emergency department cardiac arrest. Methods: A systematic review and meta-analysis was completed. A search of Medline, EMBASE, Cochrane, CINAHL, ClinicalTrials.gov and the World Health Organization Registry was completed from 1974 until August 24th 2018. Adult randomized controlled trials and observational studies were included. The QUADAS-2 tool was applied by two independent reviewers. Data analysis was completed according to PRISMA guidelines and with a random effects model for the meta-analysis. Heterogeneity was assessed using I-squared statistics. Results: Ten studies (1,485 participants) were included. Cardiac activity on PoCUS had a pooled sensitivity of 59.9% (95% confidence interval 36.5%-79.4%) and specificity of 91.5% (80.8%-96.5%) for ROSC; 74.7% (58.3%-86.2%) and 80.5% (71.7%-87.4%) for SHA; and 69.4% (45.5%-86.0%) and 74.6% (59.8%-85.3%) for SHD. The sensitivity of cardiac activity on PoCUS for predicting ROSC was 24.7%(6.8%-59.4%) in the asystole subgroup compared with 77% (59.4%-88.5%) within the PEA subgroup. Cardiac activity on PoCUS, compared to an absence had an odd ratio of 15.9 (5.9-42.5) for ROSC, 9.8 (4.9-19.4) for SHA and 5.7 (2.1-15.6) for SHD. Positive likelihood ratio (LR) was 6.65 (3.16-14.0) and negative LR was 0.27 (0.12-0.61) for ROSC. Conclusion: Cardiac activity on PoCUS was associated with improved odds for ROSC, SHA, and SHD among adults with non-traumatic asystole and PEA. We report lower sensitivity and higher negative likelihood ratio, but with greater heterogeneity compared to previous systematic reviews. PoCUS may provide valuable information in the management of non-traumatic PEA or asystole, but should not be viewed as the sole predictor in determining outcomes in these patients.
Children with congenital heart disease are at high risk for malnutrition. Standardisation of feeding protocols has shown promise in decreasing some of this risk. With little standardisation between institutions’ feeding protocols and no understanding of protocol adherence, it is important to analyse the efficacy of individual aspects of the protocols.
Adherence to and deviation from a feeding protocol in high-risk congenital heart disease patients between December 2015 and March 2017 were analysed. Associations between adherence to and deviation from the protocol and clinical outcomes were also assessed. The primary outcome was change in weight-for-age z score between time intervals.
Increased adherence to and decreased deviation from individual instructions of a feeding protocol improves patients change in weight-for-age z score between birth and hospital discharge (p = 0.031). Secondary outcomes such as markers of clinical severity and nutritional delivery were not statistically different between groups with high or low adherence or deviation rates.
High-risk feeding protocol adherence and fewer deviations are associated with weight gain independent of their influence on nutritional delivery and caloric intake. Future studies assessing the efficacy of feeding protocols should include the measures of adherence and deviations that are not merely limited to caloric delivery and illness severity.
OBJECTIVES/SPECIFIC AIMS: Our primary objective was to understand the relationship between incident or recent stressful events and adherence to HIV care in the context of other person, environment, and HIV-specific stressors in a sample of Black women living with HIV (WLWH). METHODS/STUDY POPULATION: Thirty in-depth interviews were conducted with Black women living with HIV who receive care at an academic HIV primary care clinic in the Southern region of the United States to elicit stressful events influencing adherence to HIV care. Semi-structured interview guides were used to facilitate discussion regarding stressful events and adherence to HIV care. Interviews were audiotaped and transcribed verbatim. Transcripts were independently coded using a theme-based approach by two experienced coders, findings were compared, and discrepancies were resolved by discussion. RESULTS/ANTICIPATED RESULTS: Participants described frequently experiencing incident stressful events including death or serious illness of a close friend or family member, and relationship, financial, and employment difficulties. Furthermore, participants reported experiencing traumatic events such as sexual and physical abuse during childhood and adolescents. While experiencing traumatic events such as sexual and physical abuse during childhood and adolescence may be distressing, these events did not influence adherence to HIV care. However, incident stressful events as defined above did influence adherence to HIV care for some participants, but not for others. For participants who reported that stressful events did not influence adherence to HIV care, factors such as personal motivation, access to social support, and adaptive coping strategies facilitated their engagement in care. DISCUSSION/SIGNIFICANCE OF IMPACT: Experiencing stressful events, incident or traumatic, is common among Black WLWH and have the potential to negatively influence adherence to HIV care. Thus, Interventions aimed at identifying and addressing stress, social support, and coping are essential to improve adherence to HIV care behaviors.
Lowering protein level in diets for piglets urge to have knowledge on the piglet’s requirements for essential amino acids (AA) and their interactions. The present studies aimed to determine the interaction between the dietary level of valine (Val) and tryptophan (Trp) and the effect of AA imbalance at two levels of dietary Val on the growth performance of post-weaning piglets. In Experiment 1 (duration 4 weeks), the effects of supplementation of free l-Val (1.0 g/kg) and/or l-Trp (0.5 g/kg) in a low-CP diet (CP 17.7%), marginal in Trp and Val, was studied in a 2×2 factorial design and using an additional reference treatment (CP 19.5%). In Experiment 2 (duration 5 weeks), the influence of a stepwise increase in excess supply of isoleucine (Ile), histidine (His) and leucine (Leu), up to 10, 10% and 30% relative to their requirement values respectively, was evaluated at 60% or 70% standardized ileal digestible (SID) Val relative to SID lysine, using a 3×2 factorial design. In Experiment 1, over the whole experimental period, feed intake (FI) was affected by dietary Trp level (P<0.05) and feed conversion ratio (FCR) by both the level of Trp and Val in the diet (both P<0.05). Increasing Trp level increased FI and decreased FCR while increasing dietary Val level reduced FI and increased FCR. For BW gain (BWG), there was an interaction between dietary level of Trp and Val (P<0.05). Valine supplementation decreased BWG using a diet marginal in Trp, whereas it increased BWG when using a Trp sufficient diet. Piglets fed the low-CP diet with adequate levels of Val and Trp showed at least same performance compared to piglets fed the high CP reference diet. In Experiment 2, increasing dietary Val improved FI and BWG (P<0.001) and tended to improve FCR. Dietary AA excess for Ile, His and Leu reduced FI and BWG (P<0.05) and only affected FCR (P<0.01) in the 1st week of the study. Dietary level of Val and AA excess did not show interactive effects, except for FCR over the final 2 weeks of the study (P<0.05). In conclusion, an interaction exists between dietary supply of Val and Trp on the zootechnical performance of post-weaning piglets and dietary AA excess for Ile, Leu and His, reduces growth performance of piglets in low-protein diets, independent of the dietary level of Val.
In order to control and optimize chicken quality products, it is necessary to improve the description of the responses to dietary amino acid (AA) concentration in terms of carcass composition and meat quality, especially during the finishing period. The aim of this study was to investigate the effects of Lysine (Lys, i.e. a limiting AA used as reference in AA nutrition) and AA other than Lys (AA effect). In total, 12 experimental diets were formulated with four levels of digestible Lys content (7, 8.5, 10 and 11.5 g/kg) combined with either a low (AA−), adequate control (AAc) and high (AA+) amount of other essential AA (EAA) expressed as a proportion of Lys. They were distributed to male Ross PM3 from 3 to 5 weeks of age. No significant AA×Lys interaction was found for growth performance or carcass composition. Body weight and feed conversion ratio were significantly improved by addition of Lys but were impaired in broilers receiving the AA− diets, whereas breast meat yield and abdominal fat were only affected by Lys. No additional benefit was found when the relative amount of other EAA was increased. There was a significant AA×Lys interaction on most of the meat quality traits, including ultimate pH, color and drip loss, with a significant effect of both AA and Lys. For example, AA− combined with reduced Lys level favored the production of meat with high ultimate pH (>6.0), dark color and low drip loss whereas more acid, light and exudative meat (<5.85) was produced with AA+ combined with a low Lys level. In conclusion, growth performance, carcass composition and meat quality are affected by the levels of dietary Lys and AA in finishing broilers. In addition, interactive responses to Lys and AA are found on meat quality traits, leading to great variations in breast pHu, color and drip loss according AA balance or imbalance.
The Single Ventricle Reconstruction trial randomised neonates with hypoplastic left heart syndrome to a systemic-to-pulmonary-artery shunt strategy. Patients received care according to usual institutional practice. We analysed practice variation at the Stage II surgery to attempt to identify areas for decreased variation and process control improvement.
Prospectively collected data were available in the Single Ventricle Reconstruction public-use database. Practice variation across 14 centres was described for 397 patients who underwent Stage II surgery. Data are centre-level specific and reported as interquartile ranges across all centres, unless otherwise specified.
Preoperative Stage II median age and weight across centres were 5.4 months (interquartile range 4.9–5.7) and 5.7 kg (5.5–6.1), with 70% performed electively. Most patients had pre-Stage-II cardiac catheterisation (98.5–100%). Digoxin was used by 11/14 centres in 25% of patients (23–31%), and 81% had some oral feeds (68–84%). The majority of the centres (86%) performed a bidirectional Glenn versus hemi-Fontan. Median cardiopulmonary bypass time was 96 minutes (75–113). In aggregate, 26% of patients had deep hypothermic circulatory arrest >10 minutes. In 13/14 centres using deep hypothermic circulatory arrest, 12.5% of patients exceeded 10 minutes (8–32%). Seven centres extubated 5% of patients (2–40) in the operating room. Postoperatively, ICU length of stay was 4.8 days (4.0–5.3) and total length of stay was 7.5 days (6–10).
In the Single Ventricle Reconstruction Trial, practice varied widely among centres for nearly all perioperative factors surrounding Stage II. Further analysis may facilitate establishing best practices by identifying the impact of practice variation.
With a high affinity to carbon comparable to titanium and an electrically conductive carbide, zirconium has potential to form ohmic contact on boron doped diamond. In this work, formation of ohmic contacts on boron doped diamond using zirconium is studied in comparison to titanium. Boron doped diamond epitaxial layers have been grown by microwave plasma enhanced chemical vapour deposition with various B/C ratio. Circular Transmission Line Model structures were fabricated using standard micro-fabrication technologies. Specific contact resistance of fabricated contacts was determined for different boron concentrations and for various annealing temperatures. Ohmic contacts using zirconium are formed after annealing at 400 °C. Specific contact resistance steadily decreases with high temperature annealing down to a value of ca. 1 mΩ.cm2 after annealing at 700 °C for highly boron doped diamond. In comparison, titanium contact fabricated on highly doped diamond appears not stable under high temperature annealing.
Pertussis morbidity is highest in infants too young to be fully protected by routine vaccination schedules. Alternate vaccine strategies are required to maximise protection in this age-group. To understand baseline pertussis epidemiology prior to the introduction of the maternal pertussis vaccination program in 2014, we conducted a retrospective case series analyses of 53 901 notifications and temporal trends from 1997 to 2014. Notifications were highest in infants younger than 4 months of age and highest annual notification rates in infants younger than 1 month of age (308/100 000 per year). Amongst Aboriginal and Torres Strait Islander infants aged younger than 1 month, this rate was 576/100 000 per year. Notification rates were 40% higher amongst women 15–44 years, 62·4/100 000 population compared with men (44·5/100 000) and 90% higher in Aboriginal and Torres Strait Islander women of the same age (38·2/100 000) compared with men (19·7/100 000). Six infant deaths were identified, all younger than 2 months of age. Monitoring epidemiology in at-risk groups – infants too young to be vaccinated, women of childbearing age and Aboriginal and Torres Strait Islander peoples – following implementation of the maternal pertussis vaccination program will be important to assess its impact and safety.
Children with hypoplastic left heart syndrome are at a risk for neurodevelopmental delays. Current guidelines recommend systematic evaluation and management of neurodevelopmental outcomes with referral for early intervention services. The Single Ventricle Reconstruction Trial represents the largest cohort of children with hypoplastic left heart syndrome ever assembled. Data on life events and resource utilisation have been collected annually. We sought to determine the type and prevalence of early intervention services used from age 1 to 4 years and factors associated with utilisation of services.
Data from 14-month neurodevelopmental assessment and annual medical history forms were used. We assessed the impact of social risk and geographic differences. Fisher exact tests and logistic regression were used to evaluate associations.
Annual medical history forms were available for 302 of 314 children. Greater than half of the children (52–69%) were not receiving services at any age assessed, whereas 20–32% were receiving two or more therapies each year. Utilisation was significantly lower in year 4 (31%) compared with years 1–3 (with a range from 40 to 48%) (p<0.001). Social risk factors were not associated with the use of services at any age but there were significant geographic differences. Significant delay was reported by parents in 18–43% of children at ages 3 and 4.
Despite significant neurodevelopmental delays, early intervention service utilisation was low in this cohort. As survival has improved for children with hypoplastic left heart syndrome, attention must shift to strategies to optimise developmental outcomes, including enrolment in early intervention when merited.
We performed a spatial-temporal analysis to assess household risk factors for Ebola virus disease (Ebola) in a remote, severely-affected village. We defined a household as a family's shared living space and a case-household as a household with at least one resident who became a suspect, probable, or confirmed Ebola case from 1 August 2014 to 10 October 2014. We used Geographic Information System (GIS) software to calculate inter-household distances, performed space-time cluster analyses, and developed Generalized Estimating Equations (GEE). Village X consisted of 64 households; 42% of households became case-households over the observation period. Two significant space-time clusters occurred among households in the village; temporal effects outweighed spatial effects. GEE demonstrated that the odds of becoming a case-household increased by 4·0% for each additional person per household (P < 0·02) and 2·6% per day (P < 0·07). An increasing number of persons per household, and to a lesser extent, the passage of time after onset of the outbreak were risk factors for household Ebola acquisition, emphasizing the importance of prompt public health interventions that prioritize the most populated households. Using GIS with GEE can reveal complex spatial-temporal risk factors, which can inform prioritization of response activities in future outbreaks.
This study measures willingness to pay (WTP) for extrinsic attributes (Angus, local, DNA traceable, raised carbon friendly, and humanely treated cattle) in steak and ground beef using choice-based experiments from a national consumer survey. Belief that survey responses could have consequences on beef products offered by the steak and ground beef industry is investigated, as well as its effect on attribute WTP. For most attributes, belief in consequentiality increases WTP. Results suggest that although consequentiality believers tend to place greater importance on certain food industry issues, they are less certain about the attribute's provision actually effecting change in the industry.
The effect of animal characteristics and placement decisions on retained ownership profitability of Tennessee cattle from 2005 to 2015 was determined using a mixed model regression. Ex post simulation analysis examined retained ownership profitability by placement season under different animal characteristic and corn price scenarios. Regression results indicate that placement weight, placement season, days on feed, animal health, and animal sex affect retained ownership profitability. Simulation results indicate that winter placement of cattle in feedlots had the highest expected retained ownership profits. Results provide risk-averse producers information regarding the profitability of retained ownership.