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In the intensive care setting, delirium is a common occurrence; however, the impact of the level of alertness has never been evaluated. Therefore, this study aimed to assess the delirium characteristics in the drowsy, as well as the alert and calm patient.
In this prospective cohort study, 225 intensive care patients with Richmond Agitation and Sedation Scale (RASS) scores of −1 — drowsy and 0 — alert and calm were evaluated with the Delirium Rating Scale-Revised-1998 (DRS-R-98) and the Diagnostic and Statistical Manual 4th edition text revision (DSM-IV-TR)-determined diagnosis of delirium.
In total, 85 drowsy and 140 alert and calm patients were included. Crucial items for the correct identification of delirium were sleep–wake cycle disturbances, language abnormalities, thought process alterations, psychomotor retardation, disorientation, inattention, short- and long-term memory, as well as visuo-spatial impairment, and the temporal onset. Conversely, perceptual disturbances, delusions, affective lability, psychomotor agitation, or fluctuations were items, which identified delirium less correctly. Further, the severities of inattentiveness and visuo-spatial impairment were indicative of delirium in both alert- or calmness and drowsiness.
Significance of results
The impairment in the cognitive domain, psychomotor retardation, and sleep–wake cycle disturbances correctly identified delirium irrespective of the level alertness. Further, inattentiveness and — to a lesser degree — visuo-spatial impairment could represent a specific marker for delirium in the intensive care setting meriting further evaluation.
The aim of this study was to describe individuals seeking care for injury at a major emergency department (ED) in southern Puerto Rico in the months after Hurricane Maria on September 20, 2017.
After informed consent, we used a modified version of the Natural Disaster Morbidity Surveillance Form to determine why patients were visiting the ED during October 16, 2017–March 28, 2018. We analyzed visits where injury was reported as the primary reason for visit and whether it was hurricane-related.
Among 5 116 patients, 573 (11%) reported injury as the primary reason for a visit. Of these, 10% were hurricane-related visits. The most common types of injuries were abrasions, lacerations, and cuts (43% of all injury visits and 50% of hurricane-related visits). The most common mechanisms of injury were falls, slips, trips (268, 47%), and being hit by/or against an object (88, 15%). Most injury visits occurred during the first 3 months after the hurricane.
Surveillance after Hurricane Maria identified injury as the reason for a visit for about 1 in 10 patients visiting the ED, providing evidence on the patterns of injuries in the months following a hurricane. Public health and emergency providers can use this information to anticipate health care needs after a disaster.
In this study, we examine how the Guri catfish Genidens genidens uses estuarine and freshwater habitats along the largest South American coastal lagoon, through the chemical analysis of otoliths and microscopic analysis of gonads. Chemical composition (Sr:Ca) of otolith edges allowed distinguishing between individuals who used the estuarine or freshwater compartments of the lagoon. The analysis of core-to-edge chemical profiles of each individual otolith revealed that the population may present two different patterns of habitat use along the lagoon. The ‘type 1’ pattern (89.5%) includes fish who appear to have been born in estuarine waters, whereas ‘type 2’ (9.5%) includes those fish born in fresh water. Nevertheless, juveniles from both patterns appear to migrate to estuarine waters. The gonad analysis shows G. genidens may reproduce in fresh water, as nearly 57% of all sampled fish were found to spawn in the freshwater portion of the lagoon. Also, the otolith core of many adult fish presented freshwater signatures, thus suggesting consistent fresh water use during early life. Our findings based on otolith and gonadal analyses challenge the previous classification of G. genidens as an estuarine resident. Rather, our results allow the suggestion that this species should be placed in the ‘estuarine and fresh water’ guild, which includes both fish completing their life cycles within the estuary and fish who consistently use freshwater habitats.
We report comprehensive rock-magnetic and archaeointensity investigations from 21 well-constrained pottery fragments from the Catamarca province of northwest Argentina. The absolute ages of the studied sites are ascertained by several high-quality radiometric ages and range between 1940 to 114014C yr BP. Magnetic mineralogy experiments indicates that the remanence is carried by thermally stable Ti-poor titanomagnetites. Forty-seven samples belonging to 11 out of 98 studied potsherds yielded reliable absolute intensity determinations judging from the quality parameters associated with the Thellier double-heating experiments. Moreover, we analyzed the available absolute geomagnetic intensities associated with the radiometric ages to construct the first intensity paleosecular variation curve (PSVC) for South America using thermoremanent magnetization carried by burned archaeological artifacts obtained in the present investigation and 79 other selected archaeointensities (out of 213 published in the literature). The dataset is used to build the PSVC reference curve by combined bootstrap and temporal P-spline methods. The variation curve shows significant differences with the global prediction model SHA.DIF.14k mainly based on the GEOMAGIA database. This intensity PSVC curve shows reasonably good agreement with paleosecular variation curves for Europe between 850 through 1150 BC and for Asia between 1000 and 1500 BC. This regional curve may be used as most reliable archaeomagnetic dating tool for the major part of South America (Peru, Brazil, Argentina, Chile, and Bolivia) for the last two millennia.
A novel process for Boron doping of ultrananocrystalline diamond (UNCD) films, using thermal diffusion, is described. Hall measurements show an increase in carrier concentration from 1013 to 1020 cm−3. Ultraviolet Photoelectron Spectroscopy and x-ray Photoelectron Spectroscopy show a band gap of 4.4 eV, a work function of 5.1 eV and a Fermi level at 2.0 eV above the valence band. Boron atoms distribution through UNCD films, was measured by Secondary Ion Mass Spectrometry, revealing Boron atoms diffusivity of about 10−14 cm2/s. Raman spectroscopy and x-ray Diffraction analysis revealed that UNCD films did not suffer graphitization nor structural damage during annealing.
The importance of the proper identification of delirium, with its high incidence and adversities in the intensive care setting, has been widely recognized. One common screening instrument is the Intensive Care Delirium Screening Checklist (ICDSC); however, the symptom profile and key features of delirium dependent on the level of sedation have not yet been evaluated.
In this prospective cohort study, the ICDSC was evaluated versus the Diagnostic and Statistical Manual, 4th edition, text revision, diagnosis of delirium set as standard with respect to the symptom profile, and correct identification of delirium. The aim of this study was to identify key features of delirium in the intensive care setting dependent on the Richmond Agitation and Sedation Scale levels of sedation: drowsiness versus alert and calmness.
The 88 delirious patients of 225 were older, had more severe disease, and prolonged hospitalization. Irrespective of the level of sedation, delirium was correctly classified by items related to inattention, disorientation, psychomotor alterations, inappropriate speech or mood, and symptom fluctuation. In the drowsy patients, inattention reached substantial sensitivity and specificity, whereas psychomotor alterations and sleep-wake cycle disturbances were sensitive lacked specificity. The positive prediction was substantial across items, whereas the negative prediction was only moderate. In the alert and calm patient, the sensitivities were substantial for psychomotor alterations, sleep-wake cycle disturbances, and symptom fluctuations; however, these fluctuations were not specific. The positive prediction was moderate and the negative prediction substantial. Between the nondelirious drowsy and alert, the symptom profile was similar; however, drowsiness was associated with alterations in consciousness.
Significance of results
In the clinical routine, irrespective of the level of sedation, delirium was characterized by the ICDSC items for inattention, disorientation, psychomotor alterations, inappropriate speech or mood and symptom fluctuation. Further, drowsiness caused altered levels of consciousness.
A large collection of maize macro-specimens has been gathered from archaeological sites across the American continent, but only a few have been directly dated by accelerator mass spectrometry (AMS). We recently conducted two new excavations in several rock shelters of Tehuacán valley (San Marcos, Coxcatlán, and Purrón) and uncovered 132 non-manipulated macro-specimens of maize suitable for morphological and paleogenomic analysis, including many complete cobs, stalks, internodes, and leaves. Direct AMS dates for 43 samples found in San Marcos or Coxcatlán confirm the previously reported chronologies for these sites. By contrast, a cob found in Purrón was dated to 3060±30 before present (3360–3180 cal BP) (2σ), demonstrating that maize was present at that site at least 1500 calendar years earlier than previously expected, and suggesting that other specimens of similar age are still likely to be found in the southeastern region of the Tehuacán valley. A global comparison of macro-specimen chronology across the continent shows that the current archaebotanical record does not yet reflect the chronology of dispersal from central Mexico to northern or southern regions, opening the possibility for finding the missing links in subsequent expeditions within Mexico and Central America.
To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Approach (IMA) and the INICC Surveillance Online System (ISOS) on central line-associated bloodstream infection (CLABSI) rates in 14 intensive care units (ICUs) in Argentina from January 2014 to April 2017.
This prospective, pre–post surveillance study of 3,940 ICU patients was conducted in 11 hospitals in 5 cities in Argentina. During our baseline evaluation, we performed outcome and process surveillance of CLABSI applying Centers for Disease Control and Prevention/National Health Safety Network (CDC/NHSN) definitions. During the intervention, we implemented the IMA through ISOS: (1) a bundle of infection prevention practice interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback on CLABSI rates and consequences, and (6) performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using a logistic regression model to estimate the effect of the intervention on the CLABSI rate.
During the baseline period, 5,118 CL days and 49 CLABSIs were recorded, for a rate of 9.6 CLABSIs per 1,000 central-line (CL) days. During the intervention, 15,659 CL days and 68 CLABSIs were recorded, for a rate of 4.1 CLABSIs per 1,000 CL days. The CLABSI rate was reduced by 57% (incidence density rate: 0.43; 95% confidence interval, 0.34–0.6; P<.001).
Implementing IMA through ISOS was associated with a significant reduction in the CLABSI rate in ICUs in Argentina.
We analyze Sun-as-a-star observations spanning over solar cycles 22 – 24 from the ground-based network BiSON and solar cycles 23 – 24 collected by the space-based VIRGO and GOLF instruments on board the SoHO satellite. Using simultaneous observations from all three instruments, our analysis suggests that the structural and magnetic changes responsible for modifying the frequencies remained comparable between cycle 23 and cycle 24 but differ from cycle 22. Thus we infer that the magnetic layer of the Sun has become thinner since the beginning of cycle 23 and continues during the current cycle.
This paper is focused on explaining the radiation test in temperature performed on the Engineering and Qualification Model of the Medium Gain Antenna Radiofrequency (MGA-RFA) Assembly of ESA's BepiColombo mission. The goal of this program is to observe and study Mercury and its surroundings in a very demanding environment in terms of temperature and radiation. The MGA is an X-band two-axis steerable horn, which provides bidirectional communications between spacecraft and Earth as backup of the High Gain Antenna and also operates as primary communication link at several mission stages or conditions. The paper presents the measurement set-up for the qualification campaign of the antenna, where it was necessary to characterize the antenna in a representative thermal environment, and the results obtained from this test. Results of test up to 150°C show how gain and radiation pattern shapes are slightly affected by thermal stress, but without jeopardizing mission requirements. In addition, by analyzing correlation of this test with RF analysis in the same thermal conditions, it becomes possible to accurately extrapolate the MGA-RFA behavior up to temperatures of more than 500°C. This fact allowed the successful space qualification of this model.
Similar to delirium, its subsyndromal form has been recognized as the cause of diverse adverse outcomes. Nonetheless, the nature of this subsyndromal delirium remains vastly understudied. Therefore, in the following, we evaluate the phenomenological characteristics of this syndrome versus no and full-syndromal delirium.
In this prospective cohort study, we evaluated the Delirium Rating Scale–Revised, 1998 (DRS–R–98) versus the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM–IV–TR) diagnostic criteria and examined the diagnosis of delirium with respect to phenomenological distinctions in the intensive care setting.
Out of 289 patients, 36 with subsyndromal delirium versus 86 with full-syndromal and 167 without delirium were identified. Agreement with respect to the DSM–IV–TR diagnosis of delirium was perfect. The most common subtype in those with subsyndromal delirium was hypoactive, in contrast to mixed subtype in those with full-syndromal delirium versus no motor alterations in those without delirium. By presence and severity of delirium symptoms, subsyndromal delirium was intermediate. The ability of the DRS–R–98 items to discriminate between either form of delirium was substantial. Between subsyndromal and no delirium, the cognitive domain and sleep–wake cycle were more impaired and allowed a distinction with no delirium. Further, between full- and subsyndromal delirium, the prevalence and severity of individual DRS–R–98 items were greater. Although the differences between these two forms of delirium was substantial, the items were not very specific, indicating that the phenomenology of subsyndromal delirium is closer to full-syndromal delirium.
Significance of results:
Phenomenologically, subsyndromal delirium was found to be distinct from and intermediate between no delirium and full-syndromal delirium. Moreover, the greater proximity to full-syndromal delirium indicated that subsyndromal delirium represents an identifiable subform of full-syndromal delirium.
In the intensive care setting, delirium is a common occurrence that comes with subsequent adversities. Therefore, several instruments have been developed to screen for and detect delirium. Their validity and psychometric properties, however, remain controversial.
In this prospective cohort study, the Confusion Assessment Method for the Intensive Care Unit (CAM–ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) were evaluated versus the DSM–IV–TR in the diagnosis of delirium with respect to their validity and psychometric properties.
Out of some 289 patients, 210 with matching CAM–ICU, ICDSC, and DSM–IV–TR diagnoses were included. Between the scales, the prevalence of delirium ranged from 23.3% with the CAM–ICU, to 30.5% with the ICDSC, to 43.8% with the DSM–IV–TR criteria. The CAM–ICU showed only moderate concurrent validity (Cohen's κ = 0.44) and sensitivity (50%), but high specificity (95%). The ICDSC also reached moderate agreement (Cohen's κ = 0.60) and sensitivity (63%) while being very specific (95%). Between the CAM–ICU and the ICDSC, the concurrent validity was again only moderate (Cohen's κ = 0.56); however, the ICDSC yielded higher sensitivity and specificity (78 and 83%, respectively).
Significance of Results:
In the daily clinical routine, neither the CAM–ICU nor the ICDSC, common tools used in screening and detecting delirium in the intensive care setting, reached sufficient concurrent validity; nor did they outperform the DSM–IV–TR diagnostic criteria with respect to sensitivity or positive prediction, but they were very specific. Thus, the non-prediction by the CAM–ICU or ICDSC did not refute the presence of delirium. Between the CAM–ICU and ICDSC, the ICDSC proved to be the more accurate instrument.
The management of and prognosis for delirium are affected by its subtype: hypoactive, hyperactive, mixed, and none. The DMSS–4, an abbreviated version of the Delirium Motor Symptom Scale, is a brief instrument for the assessment of delirium subtypes. However, it has not yet been evaluated in an intensive care setting.
We performed a prospective/descriptive cohort study in order to determine the internal consistency, reliability, and validity of the relevant items of the DMSS–4 versus the Delirium Rating Scale–Revised-98 (DRS–R-98) and the original DMSS in a surgical intensive care setting.
A total of 289 elderly, predominantly male patients were screened for delirium, and 122 were included in our sample. The internal consistency of the DMSS–4 items was excellent (Cronbach's α = 0.92), and between the DMSS–4 and DRS–R-98 the overall concurrent validity was substantial (Cramer's V = 0.67). Within individual motor subtypes, concurrent validity remained at least substantial (Cohen's κ = 0.65–0.81) and sensitivity high (69.8 to 82.2%), in contrast to those of the no-motor subtype, with less validity and sensitivity (κ = 0.28, 22%). Similarly, total concurrent validity between the DMSS–4 and the original DMSS reached perfection (Cramer's V = 0.83), as did agreement between the subtypes (κ = 0.83–0.92), while sensitivity remained high (88.2–100%). Only in those with delirium with no-motor subtype was agreement moderate (κ = 0.56) and sensitivity lower (67%). Specificity was high across all subtypes (91.2–99.1%). The DMSS–4 yielded very sensitive ratings, particularly for hypoactive and hyperactive motor symptoms, and interrater agreement was excellent (Fleiss's κ = 0.83).
Significance of Results:
We found the DMSS–4 to be a most reliable and valid brief assessment of delirium in characterizing the subtypes of delirium in an intensive care setting, with increased sensitivity to hypoactive and hyperactive motor alterations.
Early Archaic human skeletal remains found in a burial context in Lapa do
Santo in east-central Brazil provide a rare glimpse into the lives of
hunter-gatherer communities in South America, including their rituals for
dealing with the dead. These included the reduction of the body by means of
mutilation, defleshing, tooth removal, exposure to fire and possibly
cannibalism, followed by the secondary burial of the remains according to
strict rules. In a later period, pits were filled with disarticulated bones
of a single individual without signs of body manipulation, demonstrating
that the region was inhabited by dynamic groups in constant transformation
over a period of centuries.
Our commentary articulates some of the commonalities between Baumeister et
al.'s theory of socially differentiated roles and Strategic
Differentiation-Integration Effort. We expand upon the target article's
position by arguing that differentiating social roles is contextual and driven
by varying ecological pressures, producing character displacement not only among
individuals within complex societies, but also across social systems and
multiple levels of organization.
We discuss the early evolution of beryllium and oxygen in our Galaxy by comparing abundances of these elements for halo and disk metal-poor stars. Both, O and Be rise as we go progressively to more metal-rich stars, showing a slope 0.41 ± 0.09 ([Be/O] vs [Fe/H]) for stars with [Fe/H]≤ —1. This relationship provides an observational constraint to the actually proposed Galactic Cosmic Ray theories.
We have obtained the oxygen abundance in a sample of 44 F-type dwarfs in the Ursa Major group and the Hyades open cluster, using an NLTE analysis of the O I infrared triplet at λλ 7771-7775 Å. These clusters show the “lithium gap” in the F spectral range, and it has been suggested that if this phenomenon were due to microscopic diffusion, their Li-depleted stars could also show oxygen and/or nitrogen depletion. Our results here show a substantial measure of uniformity in the oxygen abundances. The data might indicate a very small dip (< 0.1 dex) in the O abundance for stars located in the Li gap. Microscopic diffusion seems to be the only known mechanism able to produce an oxygen dip. If this mechanism were responsible for the Li gap, it would have to account for a depletion of up to two orders of magnitude in Li and, at the same time, less than 0.1 dex in oxygen. We note that turbulent mixing could modify a microscopic diffusion pattern in order to yield the observed abundances of the two elements.
We present new beryllium abundances for three unevolved stars with [Fe/H] in the range −0.4 to −1.6. The Be II doublet is detected in the three stars. A spectral synthesis analysis has been conducted to derive the abundances. We briefly discuss their Be and Li abundances, together with a wide sample of stars from the literature, in the context of mixing processes below the convection zone.
We present results based on the analysis of lithium abundances in a sample of ~ 50 pre-main sequence stars covering a wide range of masses (from 2 to 0.3 M⊙) and luminosities (corresponding to ages of 1-100 Myr). Stars with masses estimated to be ≳ 1 M⊙show lithium abundances close to cosmic with little scatter (± 0.3 dex). Stars with masses less than Solar present a wide range of lithium abundances, with a clear trend to lower abundances for lower luminosities (greater age). The observed Li abundances constrain theoretical predictions of lithium depletion in rotating pre-main sequence stars.
Oxygen abundances have been derived in a sample of very metal-poor stars using the O I triplet at λλ 7771-5 Å and OH lines in the near UV. A detailed NLTE analysis of iron lines has been carried out for one of the observed stars, BD +23° 3130, providing consistent values of effective temperature and surface gravity that are in very good agreement with independent estimates from the infrared flux method and Hipparcos parallaxes, respectively. These parameters, especially the higher gravity obtained with respect to previous analyses, reduce the discrepancies claimed between the oxygen abundances determined from OH, O I triplet and [O I] λ 6300 Å lines, and give consistent abundances to within 0.16 dex for BD +23° 3130 ([Fe/H]NLTE = −2.43). The oxygen abundances derived for this new sample confirm previous findings for a progressive linear increase in the oxygen-to-iron ratio with a slope −0.33 ± 0.02 (including NLTE corrections to the iron abundances for all the stars considered) from solar metallicity to [Fe/H]∼ −3, and [O/Fe] values as high as ∼ 1.1 for stars with [Fe/H]≾ −2.5. These results can be interpreted as evidence for oxygen overproduction in the very early epoch of the formation of the Galactic halo, possibly associated with supernova events with very massive progenitor stars.