To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Introduction: The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated Emergency Medical Services (EMS) evidence repository. This summary describes the research evidence for the identification and management of adult patients suffering from sepsis syndrome or septic shock. Methods: PubMed was searched in a systematic manner. One author reviewed titles and abstracts for relevance and two authors appraised each study selected for inclusion. Primary outcomes were extracted. Studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and a three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings based on the studies’ primary outcome for each intervention). LOE and DOE of each intervention were plotted on an evidence matrix (DOE x LOE). Results: Eighty-eight studies were included for 15 interventions listed in PEP. The interventions with the most evidence were related to identification tools (ID) (n = 26, 30%) and early goal directed therapy (EGDT) (n = 21, 24%). ID tools included Systematic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA) and other unique measures. The most common primary outcomes were related to diagnosis (n = 30, 34%), mortality (n = 40, 45%) and treatment goals (e.g. time to antibiotic) (n = 14, 16%). The evidence rank for the supported interventions were: supportive-high quality (n = 1, 7%) for crystalloid infusion, supportive-moderate quality (n = 7, 47%) for identification tools, prenotification, point of care lactate, titrated oxygen, temperature monitoring, and supportive-low quality (n = 1, 7%) for vasopressors. The benefit of prehospital antibiotics and EGDT remain inconclusive with a neutral DOE. There is moderate level evidence opposing use of high flow oxygen. Conclusion: EMS sepsis interventions are informed primarily by moderate quality supportive evidence. Several standard treatments are well supported by moderate to high quality evidence, as are identification tools. However, some standard in-hospital therapies are not supported by evidence in the prehospital setting, such as antibiotics, and EGDT. Based on primary outcomes, no identification tool appears superior. This evidence analysis can guide selection of appropriate prehospital therapies.
We assessed whether paternal demographic, anthropometric and clinical factors influence the risk of an infant being born large-for-gestational-age (LGA). We examined the data on 3659 fathers of term offspring (including 662 LGA infants) born to primiparous women from Screening for Pregnancy Endpoints (SCOPE). LGA was defined as birth weight >90th centile as per INTERGROWTH 21st standards, with reference group being infants ⩽90th centile. Associations between paternal factors and likelihood of an LGA infant were examined using univariable and multivariable models. Men who fathered LGA babies were 180 g heavier at birth (P<0.001) and were more likely to have been born macrosomic (P<0.001) than those whose infants were not LGA. Fathers of LGA infants were 2.1 cm taller (P<0.001), 2.8 kg heavier (P<0.001) and had similar body mass index (BMI). In multivariable models, increasing paternal birth weight and height were independently associated with greater odds of having an LGA infant, irrespective of maternal factors. One unit increase in paternal BMI was associated with 2.9% greater odds of having an LGA boy but not girl; however, this association disappeared after adjustment for maternal BMI. There were no associations between paternal demographic factors or clinical history and infant LGA. In conclusion, fathers who were heavier at birth and were taller were more likely to have an LGA infant, but maternal BMI had a dominant influence on LGA.
SNP in the vitamin D receptor (VDR) gene is associated with risk of lower respiratory infections. The influence of genetic variation in the vitamin D pathway resulting in susceptibility to upper respiratory infections (URI) has not been investigated. We evaluated the influence of thirty-three SNP in eleven vitamin D pathway genes (DBP, DHCR7, RXRA, CYP2R1, CYP27B1, CYP24A1, CYP3A4, CYP27A1, LRP2, CUBN and VDR) resulting in URI risk in 725 adults in London, UK, using an additive model with adjustment for potential confounders and correction for multiple comparisons. Significant associations in this cohort were investigated in a validation cohort of 737 children in Manchester, UK. In all, three SNP in VDR (rs4334089, rs11568820 and rs7970314) and one SNP in CYP3A4 (rs2740574) were associated with risk of URI in the discovery cohort after adjusting for potential confounders and correcting for multiple comparisons (adjusted incidence rate ratio per additional minor allele ≥1·15, Pfor trend ≤0·030). This association was replicated for rs4334089 in the validation cohort (Pfor trend=0·048) but not for rs11568820, rs7970314 or rs2740574. Carriage of the minor allele of the rs4334089 SNP in VDR was associated with increased susceptibility to URI in children and adult cohorts in the United Kingdom.
Families of children born with CHD face added stress owing to uncertainty about the magnitude of the financial burden for medical costs they will face. This study seeks to assess the family responsibility for healthcare bills during the first 12 months of life for commercially insured children undergoing surgery for severe CHD.
The MarketScan® database from Truven was used to identify commercially insured infants in 39 states from 2010 to 2012 with an ICD-9 diagnosis code for transposition of the great arteries, tetralogy of Fallot, or truncus arteriosus, as well as the corresponding procedure code for complete repair. Data extraction identified payment responsibilities of the patients’ families in the form of co-payments, deductibles, and co-insurance during the 1st year of life.
There were 481 infants identified who met the criteria. Average family responsibility for healthcare bills during the 1st year of life was $2928, with no difference between the three groups. The range of out-of-pocket costs was $50–$18,167. Initial hospitalisation and outpatient care accounted for the majority of these responsibilities.
Families of commercially insured children with severe CHD requiring corrective surgery face an average of ~$3000 in out-of-pocket costs for healthcare bills during the first 12 months of their child’s life, although the amount varied considerably. This information provides a framework to alleviate some of the uncertainty surrounding healthcare financial responsibilities, and further examination of the origination of these expenditures may be useful in informing future healthcare policy discussion.
Access to transition-related medical interventions (TRMIs) for transgender veterans has been the subject of substantial public interest and debate. To better inform these important conversations, the current study investigated whether undergoing hormone or surgical transition intervention(s) relates to the frequency of recent suicidal ideation (SI) and symptoms of depression in transgender veterans.
This study included a cross-sectional, national sample of 206 self-identified transgender veterans. They self-reported basic demographics, TRMI history, recent SI, and symptoms of depression through an online survey.
Significantly lower levels of SI experienced in the past year and 2-weeks were seen in veterans with a history of both hormone intervention and surgery on both the chest and genitals in comparison with those who endorsed a history of no medical intervention, history of hormone therapy but no surgical intervention, and those with a history of hormone therapy and surgery on either (but not both) the chest or genitals when controlling for sample demographics (e.g., gender identity and annual income). Indirect effect analyses indicated that lower depressive symptoms experienced in the last 2-weeks mediated the relationship between the history of surgery on both chest and genitals and SI in the last 2-weeks.
Results indicate the potential protective effect that TRMI may have on symptoms of depression and SI in transgender veterans, particularly when both genitals and chest are affirmed with one's gender identity. Implications for policymakers, providers, and researchers are discussed.
We assess the gas-phase abundances of Si, C, and Fe from our recent measurements of Si++, C++, and Fe++ in the Orion Nebula by expanding on our earlier “blister” models. The Fe++ 22.9 μm line measured with the KAO yields Fe/H ~ 3 × 10−6 - considerably larger than in the diffuse ISM, where relative to solar, Fe/H is down by ~ 100. However, in Orion, Fe/H is still lower than solar by a factor ~ 10. The C and Si abundances are derived from new IUE high dispersion spectra of the C++ 1907, 1909 Å and Si++ 1883, 1892 Å lines. Gas-phase Si/C = 0.016 in the Orion ionized volume and is particularly insensitive to uncertainties in extinction and temperature structure. The solar value is 0.098. Gas-phase C/H = 3 × 10−4 and Si/H = 4.8 × 10−6. Compared to solar, Si is depleted by 0.135 in the ionized region, while C is essentially undepleted. This suggests that most Si and Fe resides in dust grains even in the ionized volume.
We apply a 2-D, axisymmetric code for modeling H II regions (Rubin Ap. J. 287, 653, 1984) to observations of the Orion Nebula. The model solves for the ionization and thermal structure and radiative transfer for the quasi-equilibrium volume. Assuming that the Orion Nebula is viewed face-on (along the symmetry axis) and that the geometry/density distribution is plane parallel with an exponential density gradient perpendicular to the slab, we use a x2 minimization technique to best fit the radio continuum maps. The best fit to the Schraml and Mezger map (Astrophys. J. 156, 269, 1969) has a density at the star of ∼1800 cm−3, a scale height of ∼0.23 pc, and ∼1.5x1049 ionizing photons s−1 so that ∼ 1/3 of the ionizing photons from the exciting source are escaping the nebula through the frontal density-bounded direction. Our model for Orion requires circular symmetry in the plane of the sky; nonsymmetrical features such as the ionization bar toward the SE cannot be reproduced. Further modeling that compares with line observations has been delayed to incorporate the important role played by recombinations in populating low-lying [O II] levels (Rubin 1985, Astrophys. J., submitted).
We present new far-infrared line observations of the planetary nebulae (PNs) NGC 7027, NGC 7009, NGC 6210, NGC 6543, and IC 4997 obtained with the Kuiper Airborne Observatory (KAO). The bulk of our data are for NGC 7027 and NGC 7009, including [Ne V] 24 μm, [O IV] 26 μm, [O III] (52, 88μm), and [Nm] 57 μm. Our data for [O III] (52, 88) and [N III] 57 in NGC 7027 represent the first measurements of these lines in this source. The large [O III] 52/88 flux ratio implies an electron density (cm–3) of log Ne[O III] = 4.19, the largest Ne ever inferred from these lines. We derive N++/O++ = 0.394±0.062 for NGC 7027 and 0.179±0.043 for NGC 6210. We are able to infer the O+3/O++ ionic ratio from our data. As gauged by this ionic ratio, NGC 7027 is substantially higher ionization than is NGC 7009 – consistent with our observation that the former produces copious [Ne V] emission while the latter does not. These data help characterize the stellar ionizing radiation field.
The remarkable filament system seen in radio observations in the vicinity of the galactic center includes two thin filaments which arch away from the galactic plane (E.G. Yusef-Zadem et al 1984). The brightest part of each of these thermal structures is located at GO.10+0.02 and GO.07+0.04. Morris and Yusef-Zadem (1989) reason that photoionization by OB stars is unlikely on geometrical and morphological grounds. They suggest a magnetohydrodynamic mechanism to account for the radio emission and ionization. Erickson et al. (1968) were able to explain most of their observations of the far infrared (FIR) fine structure line emission from these locations in terms of a photoionization model.
The hybrid procedure is one mode of initial palliation for hypoplastic left heart syndrome. Subsequently, patients proceed with either the “three-stage” pathway – comprehensive second stage followed by Fontan completion – or the “four-stage” pathway – Norwood procedure, hemi-Fontan, or Fontan completion. In this study, we describe somatic growth patterns observed in the hybrid groups and a comparison primary Norwood group.
A retrospective analysis of patients who have undergone hybrid procedure and Fontan completion was performed. Weight-for-age and height-for-age z-scores were recorded at each operation.
We identified 13 hybrid patients – eight in the three-stage pathway and five in the four-stage pathway – and 49 Norwood patients. Weight: three stage: weight decreased from hybrid procedure to comprehensive second stage (−0.4±1.3 versus −2.3±1.4, p<0.01) and then increased to Fontan completion (−0.4±1.5 versus −0.6±1.4, p<0.01); four stage: weight decreased from hybrid procedure to Norwood (−2.0±1.4 versus −3.3±0.9, p=0.06), then stabilised to hemi-Fontan. Weight increased from hemi-Fontan to Fontan completion (−2.7±0.6 versus −1.0±0.7, p=0.01); primary Norwood group: weight decreased from Norwood to hemi-Fontan (p<0.001) and then increased to Fontan completion (p<0.001). Height: height declined from hybrid procedure to Fontan completion in the three-stage group. In the four-stage group, height decreased from hybrid to hemi-Fontan, and then increased to Fontan completion. The Norwood group decreased in height from Norwood to hemi-Fontan, followed by an increase to Fontan completion.
In this study, we show that patients undergoing the hybrid procedure have poor weight gain before superior cavopulmonary connection, before returning to baseline by Fontan completion. This study identifies key periods to target poor somatic growth, a risk factor of morbidity and worse neurodevelopmental outcomes.
At the beginning of this session we proceeded to apply the method of measuring large differences of potential described in former papers, to the investigation of the disruptive discharge through liquid dielectrics. We have now obtained some results for oil of turpentine.
A vessel capable of holding the liquid, and at the same time of forming an electrode, was constructed by fixing on a metal plate to one end of a hollow glass cylinder of diameter slightly less than that of the receiver of the air-pump. The vessel was placed on a metallic support, so as to be in conducting connection with the metal parts of the air-pump, and with the earth. The other electrode, which was either a circular disc, a spherical ball, or a conical point, was screwed on to the brass rod passing through the stuffing-box on the top of the receiver, and was thus capable of being adjusted to various heights in the turpentine. The bottom of the vessel is 16·7 centimetres, and the brass disc, which commonly formed the upper electrode, is 10 centimetres in diameter, and 4 millimetres thick.
The Pioneer-6 and Pioneer-7 space probes carried charged-particle telescopes which measure, for the first time, both the direction of arrival and differential energy spectra of protons and alpha particles. The intensity changes, directional distributions and energy spectra of proton fluxes associated with solar activity are investigated. The data were obtained in the beginning of the new solar cycle (no. 20), when it is possible to unambiguously associate proton-flux increases with specific solar active regions. The origin, possibly long-term storage, and propagation of these proton fluxes are investigated. It was observed that enhanced 0·6–13 MeV proton fluxes associated with specific active regions were present over heliographic longitude ranges as great as ~ 180°. These enhanced fluxes exhibit definite onsets and cut-offs which appear to be associated with the magnetic-sector boundaries observed by Ness on Pioneer-6. Discrete flare-produced intensity increases extending in energy to more than 50 MeV are observed, superposed on the enhanced flux. These increases displayed short transit times and short rise times. Both the enhanced and flare-produced fluxes propagate along the spiral interplanetary magnetic field from the Western hemisphere of the Sun. From these observations we are led to a model in which the magnetic fields from the active region are spread out over a longitude range of 100–180° in the solar corona. The existence of strong unidirectional anisotropies in the initial phases of flare-proton events implies that little scattering occurs between the Sun and spacecraft. However, the gradual approach to an isotropic flux at late times indicates that the decay phase is controlled by the interplanetary magnetic field.
Previous research shows that older men tend to have lower nutritional intakes and higher risk of under-nutrition compared with younger men. The objectives of this study were to describe energy and nutrient intakes, assess nutritional risk and investigate factors associated with poor intake of energy and key nutrients in community-dwelling men aged ≥75 years participating in the Concord Health and Ageing in Men Project – a longitudinal cohort study on older men in Sydney, Australia. A total of 794 men (mean age 81·4 years) had a detailed diet history interview, which was carried out by a dietitian. Dietary adequacy was assessed by comparing median intakes with nutrient reference values (NRV): estimated average requirement, adequate intake or upper level of intake. Attainment of NRV of total energy and key nutrients in older age (protein, Fe, Zn, riboflavin, Ca and vitamin D) was incorporated into a ‘key nutrients’ variable dichotomised as ‘good’ (≥5) or ‘poor’ (≤4). Using logistic regression modelling, we examined associations between key nutrients with factors known to affect food intake. Median energy intake was 8728 kJ (P5=5762 kJ, P95=12 303 kJ), and mean BMI was 27·7 (sd 4·0) kg/m2. Men met their NRV for most nutrients. However, only 1 % of men met their NRV for vitamin D, only 19 % for Ca, only 30 % for K and only 33 % for dietary fibre. Multivariate logistic regression analysis showed that only country of birth was significantly associated with poor nutritional intake. Dietary intakes were adequate for most nutrients; however, only half of the participants met the NRV of ≥5 key nutrients.
Congenital airway obstruction is rare but potentially fatal. We developed a complex airways interventional delivery team to manage such cases. Antenatal imaging detects airway compromise at an early stage and facilitates the planning of delivery procedures (‘ex utero intrapartum treatment’ and ‘operation on placental support’) which maintain feto-placental circulation whilst an airway is secured.
A retrospective review was performed of cases in which ENT input was required at birth for airway obstruction.
Four neonates were delivered before implementation of the service: two were intubated and another two underwent tracheostomy but died in the peri-natal period. Seven neonates were delivered after implementation of the service: six were intubated and one underwent immediate tracheostomy. Five subsequently underwent tracheostomy (three have since been decannulated). One child with multiple congenital anomalies died due to respiratory failure. Airway obstruction was caused by lymphatic malformation, teratoma, costo-craniomandibular syndrome and choristoma.
In the absence of other anomalies, interventional airway delivery led to reduced mortality and improved outcomes.
It is well established that pregnant women are at an increased risk of Plasmodium falciparum infection when compared to non-pregnant individuals and limited epidemiological data suggest Plasmodium vivax risk also increases with pregnancy. The risk of P. falciparum declines with successive pregnancies due to the acquisition of immunity to pregnancy-specific P. falciparum variants. However, despite similar declines in P. vivax risk with successive pregnancies, there is a paucity of evidence P. vivax-specific immunity. Cross-species immunity, as well as immunological and physiological changes that occur during pregnancy may influence the susceptibility to both P. vivax and P. falciparum. The period following delivery, the postpartum period, is relatively understudied and available epidemiological data suggests that it may also be a period of increased risk of infection to Plasmodium spp. Here we review the literature and directly compare and contrast the epidemiology, clinical pathogenesis and immunological features of P. vivax and P. falciparum in pregnancy, with a particular focus on studies performed in areas co-endemic for both species. Furthermore, we review the intriguing epidemiology literature of both P. falciparum and P. vivax postpartum and relate observations to the growing literature pertaining to malaria immunology in the postpartum period.
ITO samples were sputtered at room temperature by ion assisted dual ion beam sputtering using atomic or molecular oxygen. The electrical properties appear to depend on the oxygen flow rate during deposition and the resistivity decreases for samples sputtered at a higher oxygen flow rate (1-5 sccm). The resistivity is lowest at an oxygen flow rate of 4 sccm. The average absorption in the visible part of the spectrum also decreases as a function of the oxygen flow rate and is lower for samples sputtered with atomic oxygen. The figure of merit, i.e. the ratio of the conductivity versus the average absorption in the visible range, increases for higher oxygen flow rates and is typically 20-60% higher for samples sputtered using an atomic oxygen assist beam.