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Introduction: Previous systematic reviews suggest early mobilization in the intensive care unit (ICU) population is feasible, safe, and may improve outcomes. Only one review investigated mobilization specifically in trauma ICU patients and failed to identify any relevant articles. The objective of the present systematic review was to conduct an up-to-date search of the literature to assess the effect of early mobilization in adult trauma ICU patients on mortality, length of stay (LOS) and duration of mechanical ventilation. Methods: We performed a systematic search of four electronic databases (Ovid MEDLINE, Embase, CINAHL, Cochrane Library) and the grey literature. To be included, studies must have compared early mobilization to delayed or no mobilization among trauma patients admitted to the ICU. Meta-analysis was performed to determine the effect of early mobilization on mortality, hospital LOS, ICU LOS, and duration of mechanical ventilation. Results: The search yielded 2,975 records from the 4 databases and 7 records from grey literature and bibliographic searches; of these, 9 articles met all eligibility criteria and were included in the analysis. There were 7 studies performed in the United States, 1 study from China and 1 study from Norway. Study populations included neurotrauma (3 studies), blunt abdominal trauma (2 studies), mixed injury types (2 studies) and burns (1 study). Cohorts ranged in size from 15 to 1,132 patients (median, 63) and varied in inclusion criteria. Most studies used some form of stepwise progressive mobility protocol. Two studies used simple ambulation as the mobilization measure, and 1 study employed upright sitting as their only intervention. Time to commencement of the intervention was variable across studies, and only 2 studies specified the timing of mobilization initiation. We did not detect a difference in mortality with early mobilization, although the pooled risk ratio (RR) was reduced (RR 0.90, 95% CI 0.74 to 1.09). Hospital LOS and ICU LOS were decreased with early mobilization, though this difference did not reach significance. Duration of mechanical ventilation was significantly shorter in the early mobilization group (mean difference −1.18. 95% CI −2.17 to −0.19). Conclusion: Our review identified few studies that examined mobilization of critically ill trauma patients in the ICU. On meta-analysis, early mobilization was found to reduce duration of mechanical ventilation, but the effects on mortality and LOS were not significant.
Introduction: Long-term immobility has detrimental effects for critically ill patients admitted to the intensive care unit (ICU) including ICU-acquired weakness. Early mobilization of patients admitted to ICU has been demonstrated to be a safe, feasible and effective strategy to improve patient outcomes. The optimal mobilization of trauma ICU patients has not been extensively studied. Our objective was to determine the impact of an early mobilization protocol on outcomes among trauma patients admitted to the ICU. Methods: We analyzed all adult trauma patients ( > 18 years old) admitted to ICU over a 2-year period prior to and following implementation of an early mobilization protocol, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared patient characteristics and outcomes (mortality, length of stay [LOS], ventilator days) between the pre- and post-implementation groups. Associations between early mobilization and clinical outcomes were estimated using binary and linear regression models. Results: Overall, there were 526 patients included in the analysis (292 pre-implementation, 234 post-implementation). The study population ranged in age from 18 to 92 years (mean age 49.0 ± 20.4 years) and 74.3% of all patients were male. The pre- and post-implementation groups were similar in age, sex, and injury severity. In-hospital mortality was reduced in the post-implementation group (25.3% vs. 17.5%; p = 0.031). In addition, there was a reduction in ICU mortality in the post-implementation group (21.6% vs. 12.8%; p = 0.009). We did not observe any difference in overall hospital LOS, ICU LOS, or ventilator days between the two groups. Compared to the pre-implementation period, trauma patients admitted to the ICU following protocol implementation were less likely to die in-hospital (OR = 0.52, 95% CI 0.30-0.91; p = 0.021) or in the ICU (OR = 0.40, 95% CI 0.21- 0.76, p = 0.005). Results were similar following a sensitivity analysis limited to patients with blunt or penetrating injuries. There was no difference between the pre- and post-implementation groups with respect to in-hospital LOS, ICU LOS, or the number of ventilator days. Conclusion: We found that trauma patients admitted to ICU during the post-implementation period had decreased odds of in-hospital mortality and ICU mortality. Ours is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol.
Films of borophosphosilicate glass (BPSG) or phosphosilicate glass (PSG) are deposited on single crystal Si (100) wafers (typically 4 to 6 inches in diameter) by chemical vapor deposition processes during the fabrication of radiation-hardened microcircuits. These films act as insulator and as passivation layers. Since the P content of the glass layer is critical because of fluidity and corrosion problems, careful certification is required. The certification analysis has been accomplished here previously by empirical energy dispersive (ED) X-ray fluorescence (XRF) methods which use a set of expensive and fragile PSG wafer calibration standards. The results obtained were uncertain and the standards were sometimes broken.
Most patients admitted to the hospital via the emergency department (ED) do so with a peripheral intravenous catheter/cannula (PIVC). Many PIVCs develop postinsertion failure (PIF).
To determine the independent factors predicting PIF after PIVC insertion in the ED.
We analyzed data from a prospective clinical cohort study of ED-inserted PIVCs admitted to the hospital wards. Independent predictors of PIF were identified using Cox proportional hazards regression modeling.
In 391 patients admitted from 2 EDs, the rate of PIF was 31% (n=118). The types of PIF identified were infiltration, occlusion, pain and/or peripheral intravenous assessment score >2 (ie, the hospital’s assessment of PIVC phlebitis), and dislodgement (ie, accidental securement device failure or purposeful removal). Of the PIVCs that failed, infiltration and occlusion combined were the most common causes of PIF (n=55, 47%). The median PIVC dwell time was 28.5 hours (interquartile range [IQR], 17.4–50.8 hours). The following variables were associated with increased risk of PIF: being an older patient (for a 1-year increase, hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01–1.03; P=.0001); having an Australian Triage Scale score of 1 or 2 compared to a score of 3, 4, or 5 (HR, 2.04; 95% CI, 1.39–3.01; P=.0003); having an ultrasound-guided PIVC (HR, 6.52; 95% CI, 2.11–20.1; P=.0011); having the PIVC inserted by a medical student (P=.0095); infection prevention breaches at insertion (P=.0326); and PIVC inserted in the ante cubital fossa or the back of hand compared to the upper arm (P=.0337).
PIF remains at an unacceptable level in both traditionally inserted and ultrasound-inserted PIVCs.
Clinical trial registration
Australian and New Zealand Trials Registry (ANZCTRN12615000588594).
The European Southern Observatory Faint Object Spectrograph and Camera v2 is one of the workhorse instruments on ESO’s New Technology Telescope, and is one of the most popular instruments at La Silla observatory. It is mounted at a Nasmyth focus, and therefore exhibits strong, wavelength and pointing-direction-dependent instrumental polarisation. In this document, we describe our efforts to calibrate the broadband imaging polarimetry mode, and provide a calibration for broadband B, V, and R filters to a level that satisfies most use cases (i.e. polarimetric calibration uncertainty ~0.1%). We make our calibration codes public. This calibration effort can be used to enhance the yield of future polarimetric programmes with the European Southern Observatory Faint Object Spectrograph and Camera v2, by allowing good calibration with a greatly reduced number of standard star observations. Similarly, our calibration model can be combined with archival calibration observations to post-process data taken in past years, to form the European Southern Observatory Faint Object Spectrograph and Camera v2 legacy archive with substantial scientific potential.
The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting.
A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.
A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.
Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.
Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted.
Field studies of grazing management have frequently concluded that the magnitude and direction of vegetation response is dependent on initial vegetation condition. On upland heath, this dependence reflects the importance of small-scale ecological processes (e.g. plant competition), and local neighbourhood effects (e.g. spatial distribution of plant species), in driving the vegetation dynamics. These small-scale effects, together with variation in grazing patterns, increase the difficulty of deriving general rules about the effect of grazing on vegetation change from field studies. However, we need to determine the impacts of such grazing-related vegetation change upon biodiversity, (e.g. birds). For many bird species it is impractical to use experimental approaches due to low breeding densities, and the influence of other site and management effects (e.g. predator control). To predict the effect of management changes on them requires an accurate assessment of the large-scale effects of grazing management on the ecological landscape using data from small-scale field studies. This paper sets out an approach that integrates field studies with theoretical models to investigate the large-scale effects of grazing management on plant and bird communities on upland heath.
To determine the scope, source, and mode of transmission of a multifacility outbreak of extensively drug-resistant (XDR) Acinetobacter baumannii.
SETTING AND PARTICIPANTS
Residents and patients in skilled nursing facilities, long-term acute-care hospital, and acute-care hospitals.
A case was defined as the incident isolate from clinical or surveillance cultures of XDR Acinetobacter baumannii resistant to imipenem or meropenem and nonsusceptible to all but 1 or 2 antibiotic classes in a patient in an Oregon healthcare facility during January 2012–December 2014. We queried clinical laboratories, reviewed medical records, oversaw patient and environmental surveillance surveys at 2 facilities, and recommended interventions. Pulsed-field gel electrophoresis (PFGE) and molecular analysis were performed.
We identified 21 cases, highly related by PFGE or healthcare facility exposure. Overall, 17 patients (81%) were admitted to either long-term acute-care hospital A (n=8), or skilled nursing facility A (n=8), or both (n=1) prior to XDR A. baumannii isolation. Interfacility communication of patient or resident XDR status was not performed during transfer between facilities. The rare plasmid-encoded carbapenemase gene blaOXA-237 was present in 16 outbreak isolates. Contact precautions, chlorhexidine baths, enhanced environmental cleaning, and interfacility communication were implemented for cases to halt transmission.
Interfacility transmission of XDR A. baumannii carrying the rare blaOXA-237 was facilitated by transfer of affected patients without communication to receiving facilities.
Great technological advances have been made in Precision Agriculture (PA) in the past decade, yet adoption of PA in intensive grassland areas in North West Europe is low. This is despite the fact that in these areas the market structures are suitable and there are highly developed agricultural and food industries offering great potential for the application of new technology. Specific inefficiencies in plant nutrient management in soil exist, which are not only limiting grass yields but are also causing environmental deterioration. Soil nutrient management efficiency could be greatly improved using PA techniques, but the complexity of grassland systems, coupled with a lack of calibration of sensors specific to grassland, together with local barriers, appear to be the reasons why PA adoption is poor in these areas. This paper reviews new and existing technology including soil and crop sensors, navigation devices, remote sensing and unmanned aerial vehicles. The suitability and readiness of these technologies for adoption in grassland areas is discussed, along with data interpretation issues, future perspectives and research opportunities.
The Numeniini is a tribe of 13 wader species (Scolopacidae, Charadriiformes) of which seven are Near Threatened or globally threatened, including two Critically Endangered. To help inform conservation management and policy responses, we present the results of an expert assessment of the threats that members of this taxonomic group face across migratory flyways. Most threats are increasing in intensity, particularly in non-breeding areas, where habitat loss resulting from residential and commercial development, aquaculture, mining, transport, disturbance, problematic invasive species, pollution and climate change were regarded as having the greatest detrimental impact. Fewer threats (mining, disturbance, problematic native species and climate change) were identified as widely affecting breeding areas. Numeniini populations face the greatest number of non-breeding threats in the East Asian-Australasian Flyway, especially those associated with coastal reclamation; related threats were also identified across the Central and Atlantic Americas, and East Atlantic flyways. Threats on the breeding grounds were greatest in Central and Atlantic Americas, East Atlantic and West Asian flyways. Three priority actions were associated with monitoring and research: to monitor breeding population trends (which for species breeding in remote areas may best be achieved through surveys at key non-breeding sites), to deploy tracking technologies to identify migratory connectivity, and to monitor land-cover change across breeding and non-breeding areas. Two priority actions were focused on conservation and policy responses: to identify and effectively protect key non-breeding sites across all flyways (particularly in the East Asian- Australasian Flyway), and to implement successful conservation interventions at a sufficient scale across human-dominated landscapes for species’ recovery to be achieved. If implemented urgently, these measures in combination have the potential to alter the current population declines of many Numeniini species and provide a template for the conservation of other groups of threatened species.
Windpumping has been identified as a process that could potentially enhance sublimation of surface snow at high forcing frequency and spawn air movement deeper in firn at lower frequencies. We performed an experiment to examine the relationship between high-frequency wind and pressure measurements within the top meter of an alpine snowpack and compared experimental results with two theoretical predictions. We find that both theoretical predictions underestimate high-frequency perturbation pressure attenuation with depth in the near-surface snowpack and the discrepancy between theory and measurement increases with perturbation pressure frequency. The impact of this result for near-surface snow is that potential enhanced sublimation will occur over a shallower snow depth than these two theories predict. Correspondingly, interstitial air mixing at depth in firn will be driven by lower frequencies than these two theories predict. While direct measurement of these energy-rich lower frequencies is beyond the scope of this paper, stationary pressure measurements validate the presence of a pressure field that could drive near-surface circulation.
Cenozoic sediments of Florida contain one of the most highly fossiliferous sequences of extinct sirenians in the world. Sirenians first occur in Florida during the Eocene (ca. 40 Ma), have their peak diversity during the late Oligocene–Miocene (including the widespread dugongid Metaxytherium), and become virtually extinct by the late Miocene (ca. 8 Ma). Thereafter during the Pliocene and Pleistocene, sirenians are represented in Florida by abundant remains of fossil manatees (Trichechus sp.). Stable isotopic analyses were performed on 100 teeth of fossil sirenians and extant Trichechus manatus from Florida in order to reconstruct diets (as determined from δ13C values) and habitat preferences (as determined from δ18O values) and test previous hypotheses based on morphological characters and associated floral and faunal remains. A small sample (n = 6) of extant Dugong dugon from Australia was also analyzed as an extant model to interpret the ecology of fossil dugongs.
A pilot study of captive manatees and their known diet revealed an isotopic enrichment (ɛ∗) in δ13C of 14.0‰, indistinguishable from previously reported ɛ∗ for extant medium to large terrestrial mammalian herbivores with known diets. The variation in δ18OV-SMOW reported here is interpreted to indicate habitat preferences, with depleted tooth enamel values (≈25‰) representing freshwater rivers and springs, whereas enriched values (≈30‰) indicate coastal marine environments. Taken together, the Eocene to late Miocene sirenians (Protosirenidae and Dugongidae) differ significantly in both δ13C and δ18O from Pleistocene and Recent manatees (Trichechidae). In general, Protosiren and the fossil dugongs from Florida have carbon isotopic values that are relatively positive (mean δ13C = −0.9‰) ranging from −4.8‰ to 5.6‰, interpreted to represent a specialized diet of predominantly seagrasses. The oxygen isotopic values (mean δ18O = 29.2‰) are likewise relatively positive, indicating a principally marine habitat preference. These interpretations correlate well with previous hypotheses based on morphology (e.g., degree of rostral deflection) and the known ecology of modern Dugong dugon from the Pacific Ocean. In contrast, the fossil and extant Trichechus teeth from Florida have relatively lower carbon isotopic values (mean δ13C = −7.2‰) that range from −18.2‰ to 1.7‰, interpreted as a more generalized diet ranging from C3 plants to seagrasses. The relatively lower oxygen isotopic values (mean δ18O = 28.1 ‰) are interpreted as a more diverse array of freshwater and marine habitat preferences than that of Protosiren and fossil dugongs. This study of Cenozoic sirenians from Florida further demonstrates that stable isotopes can test hypotheses previously based on morphology and associated floral and faunal remains. All these data sets taken together result in a more insightful approach to reconstructing the paleobiology of this interesting group of ancient aquatic mammalian herbivores.
Terrestrial meteorite ages indicate that some ice at the Allan Hills blue ice area (AH BIA) may be as old as 2.2 Ma. As such, ice from the AH BIA could potentially be used to extend the ice core record of paleoclimate beyond 800 ka. We collected samples from 5 to 10 cm depth along a 5 km transect through the main icefield and drilled a 225 m ice core (S27) at the midpoint of the transect to develop the climate archive of the AH BIA. Stable water isotope measurements (δD) of the surface chips and of ice core S27 yield comparable signals, indicating that the climate record has not been significantly altered in the surface ice. Measurements of 40Aratm and δ18Oatm taken from ice core S27 and eight additional shallow ice cores constrain the age of the ice to approximately 90–250 ka. Our findings provide a framework around which future investigations of potentially older ice in the AH BIA could be based.
A new technology to size nanoparticles in liquids is presented. The technique is based on aerosol technology coupled to a nanoparticle nebulizer. This allows number concentration measurements in the size range ca. 5 to 500 nm with high peak resolution.