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The indications for shunting after vascular injury include damage control for patients in extremis, the presence of associated fractures requiring fixation, the need for transportation to specialized centers for definitive reconstruction, or injury occurrence in an austere environment with limited resources.
There are a number of commercially available vascular shunts. Improvised shunts can be constructed out of any plastic tubing that has the adequate diameter to match the corresponding vessel, such as chest tubes, intravenous tubing, and feeding tubes. Improvised shunts must be rigid enough that when they are tied into position, the sutures do not collapse the lumen of the shunt.
When selecting the shunt size for temporary bypass, the largest size of shunt that fits into the injured vessel without forcing it into place should be selected. This will maximize distal blood flow.
Commercially made shunts should not be trimmed. The edges of commercially made shunts are smooth and designed to avoid trauma to the intima of the artery.
Improvised shunts should be left long, with redundant length in both the proximal and distal vessel. This will reduce the risk of inadvertent shunt dislodgement.
The maximum length of time that a vascular shunt can remain in situ is unknown. It is important to perform definitive repair as soon as the patient’s physiology and other circumstances allow. Most shunts remain patent for 24–48 hours. The patency of the shunt is confirmed by the presence of a distal palpable pulse or dopplerable signal.
The vertebral artery (VA) is the first cephalad branch of the subclavian artery. From a trauma surgery perspective, the VA is divided into three parts. Part I runs from its origin at the subclavian artery to C6, where it enters the transverse foramen. Part II courses in the bony vertebral canal, formed by the transverse foramen of C6 to C1. Part III runs outside the vertebral canal, from C1 to the base of the skull. The VA enters the skull through the foramen magnum, piercing the dura mater. It joins the contralateral VA to form the basilar artery, which is part of the circle of Willis.
The first part of the VA can be landmarked externally by the triangle formed by the sternal and clavicular heads of the sternocleidomastoid (SCM) muscle and the clavicle. It runs upward and backward between the anterior scalene and longus colli muscles, before entering the vertebral canal at the C6 level.
The carotid sheath is anterior and medial to the first part of the VA.
The external landmark of C6, where the VA enters into the vertebral canal and the second part of the VA begins, is the cricoid cartilage.
The cartilaginous and bony structures of the larynx include the hyoid bone as well as the thyroid and cricoid cartilages. The trachea begins below the cricoid cartilage.
The hyoid bone, thyroid cartilage, and tracheal cartilages are incomplete rings, with posterior membranous walls. In contrast, the cricoid cartilage is a complete ring, forming an important structural attachment for muscles and ligaments of the larynx. The cricoid cartilage ensures airway patency by stenting the larynx open.
The cricothyroid membrane is situated between the thyroid and cricoid cartilages in the midline anteriorly. It is located directly beneath the skin, providing direct and easy access to the airway. This membrane is bordered superiorly by the thyroid cartilage, inferiorly by the cricoid cartilage, and laterally by the paired cricothyroid muscles. In adults, it is approximately 1 cm tall and 2–3 cm wide.
The vocal cords are enclosed within the thyroid cartilage, approximately 1 cm from the upper border of the cricothyroid membrane.
The cricothyroid membrane is about four fingerbreadths from the suprasternal notch.
The Personality Assessment Inventory (PAI; Morey, 1991) is a 344-item self-administered questionnaire that assesses a variety of psychopathology and personality domains. The PAI consists of twenty-two non-overlapping scales, including four validity scales, eleven clinical scales, five treatment scales, and two interpersonal scales. Ten of the scales are further organized into subscales intended to assure breadth of coverage within diagnostic constructs. PAI scale and subscale raw scores are linearly transformed to T-scores (mean of 50, standard deviation of 10) to provide interpretation relative to a community standardization sample. Each item on the PAI is rated using a four-alternative scale, ranging from False, Not at all True (F), to Very True (VT). The PAI has practical applications across a variety of assessment specialties, including diagnostic decision-making, treatment planning, forensic evaluation, and personnel selection.
Serotonin and sympathomimetic toxicity (SST) after ingestion of amphetamine-based drugs can lead to severe morbidity and death. There have been evaluations of the safety and efficacy of on-site treatment protocols for SST at music festivals.
The study aimed to examine the safety and efficacy of treating patients with SST on-site at a music festival using a protocol adapted from hospital-based treatment of SST.
The study is an audit of presentations with SST over a one-year period. The primary outcome was need for ambulance transport to hospital. The threshold for safety was prospectively defined as less than 10% of patients requiring ambulance transport to hospital.
The protocol suggested patients be treated with a combination of benzodiazepines; cold intravenous (IV) fluid; specific therapies (cyproheptadine, chlorpromazine, and clonidine); rapid sequence intubation; and cooling with ice, misted water, and convection techniques.
One patient of 13 (7.7%) patients with mild or moderate SST required ambulance transport to hospital. Two of seven further patients with severe SST required transport to hospital.
On-site treatment may be a safe, efficacious, and efficient alternative to urgent transport to hospital for patients with mild and moderate SST. The keys to success of the protocol tested included inclusive and clear education of staff at all levels of the organization, robust referral pathways to senior clinical staff, and the rapid delivery of therapies aimed at rapidly lowering body temperature. Further collaborative research is required to define the optimal approach to patients with SST at music festivals.
Pain control is an important element of care for patients after surgery, leading to better outcomes, quicker transitions to recovery, and improvement in quality of life. The purpose of this study was to evaluate the safety and efficacy of non-steroidal anti-inflammatory drugs in children after cardiac surgery
Materials and Methods:
Patients between the ages of 1 month and 18 years of age, who received intravenous or oral non-steroidal anti-inflammataory drugs after cardiac surgery, from November 2015 until September 2017 were included in this study. The primary endpoints were non-steroidal anti-inflammataory drug-associated renal dysfunction and post-operative bleeding. Secondary endpoints examined the effect of non-steroidal anti-inflammataory drug use on total daily dose of narcotics, number of intravenous PRN narcotic doses received, and pain assessment score. Data were analysed using descriptive statistics for frequencies and ranges. Multivariate analysis was performed to measure the association of all predictors and outcomes. Wilcoxon singed-rank test was performed for secondary outcomes.
There was no association between the incidence of renal dysfunction and the use of or duration of non-steroidal anti-inflammataory drugs; in addition no association was found with increased chest tube output. There was a statistically significant reduction of patients’ median Face, Legs, Activity, Cry, Consolability (FLACC) scores (2–0; p = 0.003), seen within first 24 hours after initiation of ketorolac, and a significant reduction of morphine requirements seen from day 1 to day 2 (0.3 mg/kg versus 0.1 mg/kg; p < 0.001) and number of as-needed doses.
Non-steroidal anti-inflammataory drugs in paediatric cardiac surgery patients are safe and effective for post-operative pain management.
In this chapter, we review and discuss academic programs in technology and public policy, focusing on those that are either located in an engineering college or have a strong engineering focus. We consider what constitutes technically focused research in programs melding engineering and policy, where and how this work is done, the focus of these programs at the undergraduate and graduate levels, and the challenges of building and sustaining such programs.
Many academic programs in the United States and elsewhere focus on the social studies aspects of science, technology, and public policy- Indeed, most programs listed in the original American Association for the Advancement of Science guide to graduate education in science, engineering, and public policy were in this category (Levey, 1995). Few programs combine deep technical education and understanding with modern social science and policy-analytical skills and knowledge.
We have detected 27 new supernova remnants (SNRs) using a new data release of the GLEAM survey from the Murchison Widefield Array telescope, including the lowest surface brightness SNR ever detected, G 0.1 – 9.7. Our method uses spectral fitting to the radio continuum to derive spectral indices for 26/27 candidates, and our low-frequency observations probe a steeper spectrum population than previously discovered. None of the candidates have coincident WISE mid-IR emission, further showing that the emission is non-thermal. Using pulsar associations we derive physical properties for six candidate SNRs, finding G 0.1 – 9.7 may be younger than 10 kyr. Sixty per cent of the candidates subtend areas larger than 0.2 deg2 on the sky, compared to < 25% of previously detected SNRs. We also make the first detection of two SNRs in the Galactic longitude range 220°–240°.
This work makes available a further
of the GaLactic and Extragalactic All-sky Murchison Widefield Array (GLEAM) survey, covering half of the accessible galactic plane, across 20 frequency bands sampling 72–231 MHz, with resolution
. Unlike previous GLEAM data releases, we used multi-scale CLEAN to better deconvolve large-scale galactic structure. For the galactic longitude ranges
$345^\circ < l < 67^\circ$
$180^\circ < l < 240^\circ$
, we provide a compact source catalogue of 22 037 components selected from a 60-MHz bandwidth image centred at 200 MHz, with RMS noise
and position accuracy better than 2 arcsec. The catalogue has a completeness of 50% at
, and a reliability of 99.86%. It covers galactic latitudes
towards the galactic centre and
for other regions, and is available from Vizier; images covering
for all longitudes are made available on the GLEAM Virtual Observatory (VO).server and SkyView.
We examined the latest data release from the GaLactic and Extragalactic All-sky Murchison Widefield Array (GLEAM) survey covering 345° < l < 60° and 180° < l < 240°, using these data and that of the Widefield Infrared Survey Explorer to follow up proposed candidate Supernova Remnant (SNR) from other sources. Of the 101 candidates proposed in the region, we are able to definitively confirm ten as SNRs, tentatively confirm two as SNRs, and reclassify five as H ii regions. A further two are detectable in our images but difficult to classify; the remaining 82 are undetectable in these data. We also investigated the 18 unclassified Multi-Array Galactic Plane Imaging Survey (MAGPIS) candidate SNRs, newly confirming three as SNRs, reclassifying two as H ii regions, and exploring the unusual spectra and morphology of two others.
A higher incidence of psychotic disorders has been consistently reported among black and other minority ethnic groups, particularly in northern Europe. It is unclear whether these rates have changed over time.
We identified all individuals with a first episode psychosis who presented to adult mental health services between 1 May 2010 and 30 April 2012 and who were resident in London boroughs of Lambeth and Southwark. We estimated age-and-gender standardised incidence rates overall and by ethnic group, then compared our findings to those reported in the Aetiology and Ethnicity of Schizophrenia and Other Psychoses (ÆSOP) study that we carried out in the same catchment area around 10 years earlier.
From 9109 clinical records we identified 558 patients with first episode psychosis. Compared with ÆSOP, the overall incidence rates of psychotic disorder in southeast London have increased from 49.4 (95% confidence interval (CI) 43.6–55.3) to 63.1 (95% CI 57.3–69.0) per 100 000 person-years at risk. However, the overall incidence rate ratios (IRR) were reduced in some ethnic groups: for example, IRR (95% CI) for the black Caribbean group reduced from 6.7 (5.4–8.3) to 2.8 (2.1–3.6) and the ‘mixed’ group from 2.7 (1.8–4.2) to 1.4 (0.9–2.1). In the black African group, there was a negligible difference from 4.1 (3.2–5.3) to 3.5 (2.8–4.5).
We found that incidence rates of psychosis have increased over time, and the IRR varied by the ethnic group. Future studies are needed to investigate more changes over time and determinants of change.
While social connectedness is heralded as a key enabler of positive health and social outcomes for older people, rarely have they themselves had the opportunity to express their views about the concept. Working with a diverse group of Pacific, Māori, Asian and New Zealand European older adults, this paper explores what matters to older people when discussing social connectedness? We draw from individual, in-depth interviews with 44 older adults, and three group interviews comprising 32 older adults. Data were analysed using thematic and narrative analyses. The three themes identified were: getting out of the house, ability to connect and feelings of burden. Fundamental to social connectedness was participants’ desire to be recognised as resourceful agents able to foster relationships on the basis of mutual respect. Social connectedness was conceptualised as multi-levelled: relating to interpersonal relationships as much as neighbourhoods and wider society. Alongside these similarities we also discuss important differences. Participants preferred to socialise with people from similar cultural backgrounds where they shared taken-for-granted social customs and knowledges. This is in the context where racism, poverty and inequalities clearly impeded already minoritised participants’ sense of social connection. Key structural ways to improve social connectedness should focus on factors that enable cohesion between levels of connection, including stable neighbourhoods serviced with accessible public transport, liveable pensions and inclusivity of cultural diversity.
Co-occurrence of common mental disorders (CMD) with psychotic experiences is well-known. There is little research on the public mental health relevance of concurrent psychotic experiences for service use, suicidality, and poor physical health. We aim to: (1) describe the distribution of psychotic experiences co-occurring with a range of non-psychotic psychiatric disorders [CMD, depressive episode, anxiety disorder, probable post-traumatic stress disorder (PTSD), and personality dysfunction], and (2) examine associations of concurrent psychotic experiences with secondary mental healthcare use, psychological treatment use for CMD, lifetime suicide attempts, and poor self-rated health.
We linked a prospective cross-sectional community health survey with a mental healthcare provider database. For each non-psychotic psychiatric disorder, patients with concurrent psychotic experiences were compared to those without psychotic experiences on use of secondary mental healthcare, psychological treatment for CMD, suicide attempt, physical functioning, and a composite multimorbidity score, using logistic regression and Cox regressions.
In all disorders except for anxiety disorder, concurrent psychotic experiences were accompanied by a greater odds of all outcomes (odds ratios) for a unit change in composite multimorbidity score ranged between 2.21 [95% confidence interval (CI) 1.49–3.27] and 3.46 (95% CI 1.52–7.85). Hazard ratios for secondary mental health service use for non-psychotic disorders with concurrent psychotic experiences, ranged from 0.53 (95% CI 0.15–1.86) for anxiety disorders with psychotic experiences to 4.99 (95% CI 1.22–20.44) among those with PTSD with psychotic experiences.
Co-occurring psychotic experiences indicate greater public mental health burden, suggesting psychotic experiences could be a marker for future preventive strategies improving public mental health.
Artificial linguistic systems can offer researchers test tube-like models of second language (L2) acquisition through which specific questions can be examined under tightly controlled conditions. This paper examines what research with artificial linguistic systems has revealed about the neural mechanisms involved in L2 grammar learning. It first considers the validity of meaningful and non-meaningful artificial linguistic systems. Then it contextualizes and synthesizes neural artificial linguistic system research related to questions about age of exposure to the L2, type of exposure, and online L2 learning mechanisms. Overall, using artificial linguistic systems seems to be an effective and productive way of developing knowledge about L2 neural processes and correlates. With further validation, artificial linguistic system paradigms may prove an important tool more generally in understanding how individuals learn new linguistic systems as they become bilingual.
Human-centered design provides a means to help designers create products or systems with ‘people’ as the focus. Compassionate Design (CD), introduced in this paper, is an approach that addresses niche sensitive needs and involves a way of thinking where designers pay special attention to the users’ sense of dignity, empowerment, and security. These niche needs surfaced as a result of analyses of 12 cases situated in sensitive contexts where the users felt vulnerable, had a high level of emotional engagement and were negatively affected by the situation. The designers described their deep concern for the users in various talks and interviews. This paper explains the conception of CD and its development that resulted from iteratively and qualitatively analyzing these cases in which designers were intuitively focusing on niche user needs. Dignity, empowerment and security form the basis of CD and have been contextualized in Maslow’s hierarchy of needs after they emerged as a result of the analysis of data. This research sets the platform for a design approach that can help designers to consider the often unarticulated user needs of dignity, empowerment and security, in a more intentional manner and not be left to chance.
We examined Clostridioides difficile infection (CDI) prevention practices and their relationship with hospital-onset healthcare facility-associated CDI rates (CDI rates) in Veterans Affairs (VA) acute-care facilities.
From January 2017 to February 2017, we conducted an electronic survey of CDI prevention practices and hospital characteristics in the VA. We linked survey data with CDI rate data for the period January 2015 to December 2016. We stratified facilities according to whether their overall CDI rate per 10,000 bed days of care was above or below the national VA mean CDI rate. We examined whether specific CDI prevention practices were associated with an increased risk of a CDI rate above the national VA mean CDI rate.
All 126 facilities responded (100% response rate). Since implementing CDI prevention practices in July 2012, 60 of 123 facilities (49%) reported a decrease in CDI rates; 22 of 123 facilities (18%) reported an increase, and 41 of 123 (33%) reported no change. Facilities reporting an increase in the CDI rate (vs those reporting a decrease) after implementing prevention practices were 2.54 times more likely to have CDI rates that were above the national mean CDI rate. Whether a facility’s CDI rates were above or below the national mean CDI rate was not associated with self-reported cleaning practices, duration of contact precautions, availability of private rooms, or certification of infection preventionists in infection prevention.
We found considerable variation in CDI rates. We were unable to identify which particular CDI prevention practices (i.e., bundle components) were associated with lower CDI rates.
The relationship between criminogenic risk and mental illness in justice involved persons with mental illness is complex and poorly understood by clinicians, researchers, administrators, and policy makers alike. Historically, when providing services to justice involved persons with mental illness, clinicians have emphasized mental health recovery (eg, psychiatric rehabilitation) at the exclusion of treatments targeted at criminogenic risk. More recently, however, researchers have demonstrated with great clarity that criminogenic risk not only contributes but is likely the leading factor in the criminal behavior committed by persons with mental illness. Yet, we still do not know the nature of this criminogenic-mental illness relationship, how this relationship impacts treatment needs, and of ultimate concern, what this relationship means in terms of individual and societal outcomes. In this paper we briefly define criminogenic risk and the research that demonstrates the role of criminogenic risk in criminal justice involvement of persons with mental illness. We also review prevalence rates of persons with mental illness justice involvement, and then discuss important factors to be considered when assessing risk to include both criminogenic and mental illness risk. We conclude this paper by reviewing treatment and management strategies for persons with mental illness that are criminal justice involved particularly reviewing and building off the recommendations put forth by Bartholomew & Morgan.