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Background: Chest tube insertion is a time and safety critical procedure with a significant complication rate (up to 30%). Industry routinely uses Lean and ergonomic methodology to improve systems. This process improvement study used best evidence review, small group consensus, process mapping and prototyping in order to design a lean and ergonomically mindful equipment solution. Aim Statement: By simplifying and reorganising chest tube equipment, we aim to provide users with adequate equipment, reduce equipment waste, and wasted effort locating equipment. Measures & Design: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Necessary equipment was identified. Next, two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student) to refine the equipment list and packaging. A final equipment storage system was produced and evaluated by an interprofessional team during cadaver training using a survey and Likert scales. Evaluation/Results: There were 47 equipment items in the pre-intervention ED chest tube tray. After prototyping 21 items were removed while nine critical items were added. The nine items missing from the original design were found in four different locations in the department. Six physicians and seven RNs participated in cadaver testing and completed an evaluation survey of the new layout. Participants preferred the new storage design (Likert median 5, IQR of 1) over the current storage design (median of 1, IQR of 1). Discussion/Impact: The results suggest that the lean equipment storage is preferred by ED staff compared to the current set-up, may reduce time finding missing equipment, and will reduce waste. Future simulation work will quantitatively understand compliance with safety critical steps, user stress, wasted user time and cost.
Introduction: Chest tube insertion, a critical procedure with a published complication rate (30%), is a required competency for emergency physicians. Microskills training has been shown to identify steps that require deliberate practice. Objectives were: 1. Develop a chest tube insertion microskills checklist to facilitate IPE, 2. Compare the microskills checklist with published best available evidence, 3. Develop an educational video based on the process map, 4. Evaluate the video in an interprofessional team prior to cadaver training as a proof of concept. Methods: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student). A final microskills list was produced and compared to the procedural steps described in consensus publications. An educational video was produced and evaluated by an interprofessional team prior to cadaver training using a survey and Likert scales as a proof of concept. Participants were 7 EM RNs and 6 ATLS trained physicians. Participants were asked to fill out a nine-question survey, using a 5-point Likert Scale (1-strongly disagree to 5 strongly agree). Results: The final process map contained 54 interdisciplinary steps, compared to ATLS that describes 14 main steps and peer reviewed articles that describe 9 main steps. The microskills checklist described, in more detail, the steps that relate to team interaction and the operational environment. Physicians rated the training video were able to apply what they learned in the video with an average of 4.67 (median of 5, mode of 5, and an IQR of 0.75). Conclusion: The development of the process maps and microkills checklists provides interprofessional teams with more information about chest tube insertion than instructions described in commonly available courses and procedural steps derived by consensus.
Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.
Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.
Infants with prenatally diagnosed CHD are at high risk for adverse outcomes owing to multiple physiologic and psychosocial factors. Lack of immediate physical postnatal contact because of rapid initiation of medical therapy impairs maternal–infant bonding. On the basis of expected physiology, maternal–infant bonding may be safe for select cardiac diagnoses.
This is a single-centre study to assess safety of maternal–infant bonding in prenatal CHD.
In total, 157 fetuses with prenatally diagnosed CHD were reviewed. On the basis of cardiac diagnosis, 91 fetuses (58%) were prenatally approved for bonding and successfully bonded, 38 fetuses (24%) were prenatally approved but deemed not suitable for bonding at delivery, and 28 (18%) were not prenatally approved to bond. There were no complications attributable to bonding. Those who successfully bonded were larger in weight (3.26 versus 2.6 kg, p<0.001) and at later gestation (39 versus 38 weeks, p<0.001). Those unsuccessful at bonding were more likely to have been delivered via Caesarean section (74 versus 49%, p=0.011) and have additional non-cardiac diagnoses (53 versus 29%, p=0.014). There was no significant difference regarding the need for cardiac intervention before hospital discharge. Infants who bonded had shorter hospital (7 versus 26 days, p=0.02) and ICU lengths of stay (5 versus 23 days, p=0.002) and higher survival (98 versus 76%, p<0.001).
Fetal echocardiography combined with a structured bonding programme can permit mothers and infants with select types of CHD to successfully bond before ICU admission and intervention.
The effect of transportation and lairage on the faecal shedding and post-slaughter contamination of carcasses with Escherichia coli O157 and O26 in young calves (4–7-day-old) was assessed in a cohort study at a regional calf-processing plant in the North Island of New Zealand, following 60 calves as cohorts from six dairy farms to slaughter. Multiple samples from each animal at pre-slaughter (recto-anal mucosal swab) and carcass at post-slaughter (sponge swab) were collected and screened using real-time PCR and culture isolation methods for the presence of E. coli O157 and O26 (Shiga toxin-producing E. coli (STEC) and non-STEC). Genotype analysis of E. coli O157 and O26 isolates provided little evidence of faecal–oral transmission of infection between calves during transportation and lairage. Increased cross-contamination of hides and carcasses with E. coli O157 and O26 between co-transported calves was confirmed at pre-hide removal and post-evisceration stages but not at pre-boning (at the end of dressing prior to chilling), indicating that good hygiene practices and application of an approved intervention effectively controlled carcass contamination. This study was the first of its kind to assess the impact of transportation and lairage on the faecal carriage and post-harvest contamination of carcasses with E. coli O157 and O26 in very young calves.
Introduction: Situational Awareness is the ability to identify, process, and comprehend the critical elements of information about the patient condition, stability, the operational environment and an appropriate clinical course. The Situational Awareness Global Assessment Tool (SAGAT) is a validated tool for measuring situational awareness. The SAGAT tool was measured during a series of standardized high fidelity advanced airway management simulations in multidisciplinary teams in New Brunswick Emergency Departments delivered by two simulation programs Methods: Thirty eight simulated emergency airway cases were performed in situ in Emergency Departments and in learning centers in Southern New Brunswick from September 2015 to October 2017. Eight standardized cases were used whose educational objectives were to develop the optimization of critically ill patients prior to induction, to deliver patient-centered anesthesia and to choose an appropriate airway strategy. Learner profiles collected. Cases were divided into two groups; those that contained critical errors and those that did not based on video assessment. Critical errors were defined as failure of 1) Oxygenation 2) Shock correction 3) Induction dose estimation 4) Choice of airway management paradigm. The SAGAT has a maximum score of 13 and was assessed by research nurses after each case for all participants. SAGAT scores were non-normally distributed, so results were expressed as medians with interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. Results: Results. Of the 38 cases, 14 contained one more critical errors. The median SAGAT score in the group that contained critical errors was 8 +/− 2 (IQR). The median SAGAT Score in the group that contained no critical errors was 11 +/− 2 (IQR). The median scores we significantly different with a p-value of 0.02. Conclusion: In this study in simulated emergency cases, higher SAGAT scores were associated with teams leaders that did not commit safety critical errors. This work is the initial analysis to develop standards for Simulated team performance in Emergency Department teams.
Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Microskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Surgical cricothyrotomy is a rarely performed safety critical task. Methods: Two doctors and three nurses developed stepwise team microskills checklists from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 30 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. Commonly available airway trainers were retrofitted with the 3-D printed larynx. The microskills checklist was used in four phases: 1. Group discussion of each microskill step; 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback - changes are recorded; 3. Total task run through without interruption - changes are recorded; 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 12/21, RNs 6/12. The commonest changes in practice were equipment preparation (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 5/5). Conclusion: Microskills checklists facilitate cricothyrotomy skill development in interprofessional teams in this provisional analysis.
Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Mircroskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Endotracheal intubation is a complex task with a clinically significant complication and failure rate. Methods: Two doctors and three nurses developed stepwise team microskills checklist from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 36 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. The microskills checklist was used in four phases: 1. Group discussion of each microskill step 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback. Changes are recorded. 3. Total task run though without interruption. Changes are recorded. 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Results. Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 13/30, RNs 7/16. The commonest changes in practice were patient positioning (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 4.8/5). Conclusion: Microskills checklist facilitate endotracheal intubation with a bougie skill development in interprofessional teams in this provisional analysis.
Introduction: Traditionally, out of hospital cardiac arrests (CA) have poor outcomes. Incorporation of extracorporeal cardiopulmonary resuscitation (ECPR) is being used increasingly to supplement ACLS to provide better outcomes for patients. Current literature suggests potentially improved outcomes, including neurological function. We assessed the feasibility of introduction of ECPR to a regional hospital using a 4-phase study. We report phase-1, an estimation of the number of potential candidates for ECPR in our setting. Methods: Following development and agreement on local criteria for selection of patients for ECPR using a modified Delphi Technique, inclusion and exclusion criteria were applied retrospectively, to a database comprising 4 years of emergency department (ED) cardiac arrests (n=395). This provided estimates of the number of patients who would have qualified for EMS transport for ECPR and initiation of ECPR in the ED. Results: Application of criteria would result in 20.0% (95% CI 16.2-24.3%) of CA being transported to the ED for ECPR (mean 18.5 patients per year). In the ED 4.6% (95% CI 2.83-7.26%) would be eligible to receive ECPR (4.3 patients per year). Incorporating downtime criteria, 3.0% (95% CI 1.6-5.3%) qualify. After considering local in-house cardiac catheterization hours 9.4% (95% CI 6.8-12.9%) and 5.4% (95% CI 3.5-8.2%), without and with EMS rhythm assumptions respectively, would be eligible for transport. For placement on pump, 3.0% (95% CI 1.6-5.3%) and 2.4% (95% CI 1.2-4.6%), without and with use of total downtime respectively, were eligible. Conclusion: If historical patterns of CA were to continue, we believe that an ECPR program may be feasible in our regional hospital setting, with a small number of selected cardiac arrest patients meeting eligibility for transportation and initiation of ECPR. These numbers suggest that an ECPR program would not be resource intensive, yet would be sufficiently busy to maintain adequate team competency.
Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR), a method of cardiopulmonary bypass, is increasingly being used to supplement traditional CPR to improve outcomes for cardiac arrest (CA). CA and particularly out of hospital CA (OHCA) have poor outcomes. Prior to development of a 3 phase ECPR program in a Canadian regional hospital, we wished to identify and optimize a practical selection process (inclusion and exclusion criteria) for patients who may benefit from ECPR. Methods: Using a locally modified Delphi technique, we followed a literature review to construct a proposed set of evidence based criteria with a questionnaire, where inclusion and exclusion criteria were scored by a selected group of 13 experts. Following 3 rounds, and additional review by an international expert in the field of ECPR, consensus was achieved for patient selection criterion. Results: First round responses achieved 87.5% agreement for selection of exclusion criteria. Inclusion criteria had agreement 62.5%. Responses to the second round for selection of inclusion criteria were unanimous at 100% with the exception of age parameters (<65 years vs. <70 years). The third and final set of criteria achieved 100% consensus though subsequent expert review refined a single exclusion criteria (asystole). Agreed inclusion criteria were: witnessed CA, age <70, refractory arrest, no flow time <10min, total downtime <60min, and a cardiac or select non-cardiac etiology (PE, drug OD, poisoning, hypothermia). Exclusion criteria were : unwitnessed arrest, asystole, certain etiologies (uncontrolled bleeding, irreversible brain damage, trauma), and comorbidities (severe disability limiting ADLs, standing DNR, palliation). Simplified criteria for EMS transport included witnessed OHCA, age, and no flow time. Conclusion: Selection criteria of candidates for ECPR are important components for any program. Expert consensus review of current evidence is an effective method for development of ECPR selection criteria.
Introduction: Situational awareness (SA) is the team understanding patient stability, presenting illness and future clinical course. Losing SA has been shown to increase safety-critical events in multiple industries. SA can be measured by the previously validated Situational Awareness Global Assessment Tool (SAGAT). Checklists are used in many safety-critical industries to reduce errors of omission and commission. An RSI checklist was developed from case review and published evidence.The New Brunswick Trauma Program supports an inter-professional simulation-based medical education program Methods: Simulations were facilitated in three hospitals in New Brunswick from April 2017 to October 2017. Learner profiles were collected. The SAGAT tool was completed by a research nurse at the end of each scenario. SAGAT scores were non-normally distributed, so results were expressed as medians and interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. To understand the effect of the of an RSI checklist a comparison was made between SAGAT scores at baseline in scenario 1, and the same first scenario completed after a washout period. A Poisson regression analysis will be used to account for the effect of confounding variables in further analyses. Results: The group was composed of Registered Nurses (8), Physicians (7), and Respiratory Therapists (2). Situational awareness increased significantly with the use of an RSI checklist after 1 day of 4 simulations. The washout period ranged between 5 weeks and 8 weeks. The baseline situational awareness of the whole group during scenario 1 was 9 +/− 0.5 (median, IQR), and with the RSI checklist was 12 +/−1 (median, IQR). The difference was highly statistically significant, p=< 0.001. This level of situational awareness using checklist is comparable to the SAGAT scores after 10 scenarios. Conclusion: In this provisional analysis, the use of an RSI checklist was associated with an increase in measured situational awareness. Higher levels of situational awareness are associated with greater patient safety. A Poisson regression model will be used to understand the confounding effects of user expertise and the likely interaction with simulation exposure.
As endemic measles is eliminated through immunization, countries must determine the risk factors for the importation of measles into highly immunized populations to target control measures. Despite eliminating endemic measles, New Zealand suffers from outbreaks after introductions from abroad, enabling us to use it as a model for measles introduction risk. We used a generalized linear model to analyze risk factors for 1137 measles cases from 2007 to June 2014, provide estimates of national immunity levels, and model measles importation risk. People of European ethnicity made up the majority of measles cases. Age is a positive risk factor, particularly 0–2-year-olds and 5–17-year-old Europeans, along with increased wealth. Pacific islanders were also at greater risk, but due to 0–2-year-old cases. Despite recent high measles, mumps, and rubella vaccine immunization coverage, overall population immunity against measles remains ~90% and is lower in people born between 1982 and 2005. Greatest measles importation risk is during December, and countries predicted to be sources have historical connections and highest travel rates (Australia and UK), followed by Asian countries with high travel rates and higher measles incidences. Our results suggest measles importation due to travel is seeding measles outbreaks, and immunization levels are insufficient to continue to prevent outbreaks because of heterogeneous immunity in the population, leaving particular age groups at risk.
This study aimed to review available disaster training options for health care providers, and to provide specific recommendations for developing and delivering a disaster-response-training program for non-disaster-trained emergency physicians, residents, and trainees prior to acute deployment.
A comprehensive review of the peer-reviewed and grey literature of the existing training options for health care providers was conducted to provide specific recommendations.
A comprehensive search of the Pubmed, Embase, Web of Science, Scopus, and Cochrane databases was performed to identify publications related to courses for disaster preparedness and response training for health care professionals. This search revealed 7,681 unique titles, of which 53 articles were included in the full review. A total of 384 courses were found through the grey literature search, and many of these were available online for no charge and could be completed in less than six hours. The majority of courses focused on management and disaster planning; few focused on clinical care and acute response.
There is need for a course that is targeted toward emergency physicians and trainees without formal disaster training. This course should be available online and should utilize a mix of educational modalities, including lectures, scenarios, and virtual simulations. An ideal course should focus on disaster preparedness, and the clinical and non-clinical aspects of response, with a focus on an all-hazards approach, including both terrorism-related and environmental disasters.
HansotiB, KelloggDS, AberleSJ, BroccoliMC, FedenJ, FrenchA, LittleCM, MooreB, SabatoJJr., SheetsT, WeinbergR, ElmesP, KangC. Preparing Emergency Physicians for Acute Disaster Response: A Review of Current Training Opportunities in the US. Prehosp Disaster Med. 2016;31(6):643–647.
We present our analysis of archival Hubble Space Telescope Wide Field Planetary Camera 2 (WFPC2) observations in F450W (~B) and F555W (~V) of the intermediate-age populous star clusters NGC 121, NGC 339, NGC 361, NGC 416, and Kron 3 in the Small Magellanic Cloud. We use published photometry of two other SMC populous star clusters, Lindsay 1 and Lindsay 113, to investigate the age sequence of these seven star clusters in order to improve our understanding of the formation chronology of the SMC. We analyzed the V vs B–V and MV vs (B–V)o color-magnitude diagrams of these populous Small Magellanic Cloud star clusters using a variety of techniques and determined their ages, metallicities, and reddenings. These new data enable us to improve the age-metallicity relation of star clusters in the Small Magellanic Cloud. In particular, we find that a closed-box continuous star-formation model does not reproduce the age-metallicity relation adequately. However, a theoretical model punctuated by bursts of star formation is in better agreement with the observational data. The full details of this analysis are reported in Mighell, Sarajedini, & French (1998, AJ, 116, 2395).
Introduction: In Canada, major trauma is a healthcare priority and in 2014 was responsible for over 15866 deaths, with a total economic burden of 26.8 billion dollars. Numerous factors influence the likelihood of occurrence and outcome from major trauma, including incident factors, host, EMS response, emergency, surgical and critical care. Traditionally trauma registers contained information that mainly concerning hospital treatment and host factors. This collaborative analysis uses matched data from a Provincial Trauma Research Register and records from a Provincial Ambulance Service. Methods: A retrospective observational (registry) study comparing rural and urban adult and pediatric major trauma patients (Injury Severity Score >15) who were injured in a motor vehicle crash (ICD V20-V99) and presented to a level 1 or level 2 trauma centre by EMS by primary or secondary transfer, between April 2011 and March 2013 in a selected province in Canada. Comparisons of the process care times, and patient disposition, were made in an inclusive trauma system. Results: 108 cases meet the inclusion criteria with 78 considered rural and 30 urban using published definitions. The median response times were 16.2 minutes for rural (95% CI: 13.2 -19.8) and 7.8 minutes for urban (95% CI: 7.2 - 10.5) with 60% and 61% meeting response targets respectively. A greater proportion of urban patients are taken initially to level 3-5 centers and require secondary transfer (45% urban vs 24% rural p=<0.01). Median times intervals to surgical care were double for the urban patients (14 rural vs 32 hrs urban p=<0.01). Conclusion: The majority of serious road traffic collisions occur in rural areas. Although rural patients wait longer for an initial EMS response, more rural patients are taken directly to a level 1 or 2 trauma center. Unexpectedly then rural patients have much shorter times to surgical care. The benefits of an inclusive trauma system should be weighed against the benefits of bypass processes in urban environments where the nearest Emergency Department is not a Level 1 or 2 Trauma Center.
Nationwide prevalence and risk factors for faecal carriage of Escherichia coli O157 and O26 in cattle were assessed in a 2-year cross-sectional study at four large slaughter plants in New Zealand. Recto-anal mucosal swab samples from a total of 695 young (aged 4–7 days) calves and 895 adult cattle were collected post-slaughter and screened with real-time polymerase chain reaction (PCR) for the presence of E. coli O157 and O26 [Shiga toxin-producing E. coli (STEC) and non-STEC]. Co-infection with either serogroup of E. coli (O157 or O26) was identified as a risk factor in both calves and adult cattle for being tested real-time PCR-positive for E. coli O157 or O26. As confirmed by culture isolation and molecular analysis, the overall prevalence of STEC (STEC O157 and STEC O26 combined) was significantly higher in calves [6·0% (42/695), 95% confidence interval (CI) 4·4–8·1] than in adult cattle [1·8% (16/895), 95% CI 1·1–3·0] (P < 0·001). This study is the first of its kind in New Zealand to assess the relative importance of cattle as a reservoir of STEC O157 and O26 at a national level. Epidemiological data collected will be used in the development of a risk management strategy for STEC in New Zealand.
Avian diet selection is hypothesized to be sensitive to seasonal changes in breeding status, but few tests exist for frugivorous tropical birds. Frugivorous birds provide an interesting test case because fruits are relatively deficient in minerals critical for reproduction. Here, we quantify annual patterns of fruit availability and diet for two frugivorous hornbill (Bucerotidae) species over a 5.5-y period to test for patterns of diet selection. Data from the lowland tropical rain forest of the Dja Reserve, Cameroon, are used to generate two nutritional indices. One index estimates the nutrient concentration of the diet chosen by Ceratogymna atrata and Bycanistes albotibialis on a monthly basis using 3165 feeding observations combined with fruit pulp sample data. The second index is an estimate of nutrient concentration of a non-selective or neutral diet across the study area based on tree fruiting phenology, vegetation survey and fruit-pulp sample data. Fifty-nine fruit pulp samples representing 40 species were analysed for 16 nutrient categories to contribute to both indices. Pulp samples accounted for approximately 75% of the observed diets. The results support expected patterns of nutrient selection. The two hornbill species selected a diet rich in calcium during the early breeding season (significantly so for B. albotibialis in July and August). Through the brooding and fledging periods, they switched from a calcium-rich diet to one rich in iron and caloric content as well as supplemental protein in the form of invertebrates. Calcium, the calcium to phosphorus ratio and fat concentration were the strongest predictors of breeding success (significant for calcium and Ca:P for B. albotibialis in June). We conclude that hornbills actively select fruit based on nutritional concentration and mineral concentration and that the indices developed here are useful for assessing frugivore diet over time.
In late February and early March 2002, an archaeological watching brief at Lynford Quarry, Mundford, Norfolk revealed a palaeochannel with a dark organic fill containing in situ mammoth remains and associated Mousterian stone tools and debitage buried under 2–3 m of bedded sands and gravels. Well-preserved in situ Middle Palaeolithic open air sites are very unusal in Europe and exceedingly rare within a British context. As such, the site was identified as being of national and international importance, and was subsequently excavated by the Norfolk Archaeological Unit with funding provided by English Heritage through the Aggregates Levy Sustainability Fund.
This report presents some of the initial results of the excavation. It sets out how the site was excavated, outlines the stratigraphic sequence for the site, and presents some provisional findings of the excavation based on the results of the assessment work carried out by project specialists and Norfolk Archaeological Unit staff.
The faecal-pat prevalence (as estimated by culture) of Campylobacter fetus from cattle and sheep on 19 farms in rural Lancashire was investigated using standard Campylobacter culture techniques and PCR during a 2-year longitudinal study. C. fetus was isolated from 9·48% [95% confidence interval (CI) 8·48–10·48] of cattle faecal pats and 7·29% (95% CI 6·21–9·62) of sheep faecal pats. There was evidence of significant differences in shedding prevalence between geographical regions; cows in geographical zone 3 had an increased risk of shedding C. fetus compared to cows in geographical zones 1 and 2 (OR 6·64, 95% CI 1·67–26·5, P = 0·007), as did cows at pasture (OR 1·66, 95% CI 1·01–2·73, P = 0·046) compared to when housed. Multiple logistic regression modelling demonstrated underlying seasonal periodicity in both species.