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Cricothyrotomy and chest needle decompression (NDC) have a high failure and complication rate. This article sought to determine whether paramedics can correctly identify the anatomical landmarks for cricothyrotomy and chest NDC.
A prospective study using human models was performed. Paramedics were partnered and requested to identify the location for cricothyrotomy and chest NDC (both mid-clavicular and anterior axillary sites) on each other. A board-certified or board-eligible emergency medicine physician timed the process and confirmed location accuracy. All data were collected de-identified. Descriptive analysis was performed on continuous data; chi-square was used for categorical data.
A total of 69 participants were recruited, with one excluded for incomplete data. The paramedics had a range of six to 38 (median 14) years of experience. There were 28 medical training officers (MTOs) and 41 field paramedics. Cricothyroidotomy location was correctly identified in 56 of 68 participants with a time to identification range of 2.0 to 38.2 (median 8.6) seconds. Chest NDC (mid-clavicular) location was correctly identified in 54 of 68 participants with a time to identification range of 3.4 to 25.0 (median 9.5) seconds. Chest NDC (anterior axillary) location was correctly identified in 43 of 68 participants with a time to identification range of 1.9 to 37.9 (median 9.6) seconds. Chi-square (2-tail) showed no difference between MTO and field paramedic in cricothyroidotomy site (P = .62), mid-clavicular chest NDC site (P = .21), or anterior axillary chest NDC site (P = .11). There was no difference in time to identification for any procedure between MTO and field paramedic.
Both MTOs and field paramedics were quick in identifying correct placement of cricothyroidotomy and chest NDC location sites. While time to identification was clinically acceptable, there was also a significant proportion that did not identify the correct landmarks.
To determine the effect on decisional-related and clinical outcomes of decision aids for depression treatment in adults in randomised clinical trials. In January 2019, a systematic search was conducted in five databases. Study selection and data extraction were performed in duplicate. Meta-analyses were performed, and standardised and weighted mean differences were calculated, with corresponding 95% confidence intervals. The certainty of the evidence was evaluated with GRADE methodology.
Six randomised clinical trials were included. The pooled estimates showed that decision aids for depression treatment had a beneficial effect on patients’ decisional conflict, patient knowledge and information exchange between patient and health professional. However, no statistically significant effect was found for doctor facilitation, treatment adherence or depressive symptoms. The certainty of the evidence was very low for all outcomes.
Using decision aids to choose treatment in patients with depression may have a a beneficial effect on decisional-related outcomes, but it may not translate into an improvement in clinical outcomes.
Altered levels of phenylalanine and its metabolites in blood and cerebrospinal fluid have previously been reported in schizophrenia. This study attempted to examine whether phenylalanine kinetics is altered in schizophrenia using the 13C-phenylalanine breath test (13C-PBT).
Subjects were 20 patients with schizophrenia and the same number of controls. 13C-phenylalanine was administered and then 13CO2 concentration in breath was monitored for 120 minutes. The Δ 13CO2 at each collecting time, the maximal Δ 13CO2 (Cmax), the time to reach Cmax (Tmax), the area under the curve of time course of Δ13CO2 (AUC), the cumulative recovery rate (CRR) at each collecting time of the 13C-PBT were calculated for each subject.
Body weight (BW) and diagnostic status were significant predictors for Cmax. BW, age and diagnostic status were significant predictors for AUC and CRR at 120 minutes (CRR0-120). A repeated measures ANCOVA controlling for age and BW revealed a different pattern of change in CRR over time between the patients and controls and that Δ13CO2 in schizophrenia were lower than that in healthy control at all sampling point during 120 min, with an overall significant differences between healthy control and schizophrenia. The ANCOVA controlling for age and BW, showed that Cmax, AUC and CRR0-120 were significantly lower in schizophrenics than in controls.
Our data indicate the different change of Δ13CO2 and CRR over time and the decreased Cmax, AUC and CRR0-120 of 13C-PBT in schizophrenia patients compared to healthy controls, suggesting the altered phenylalanine kinetics in schizophrenia.
Attention deficit/hyperactivity disorder (ADHD) often presents as an impairing lifelong condition in adults, yet it is currently under-diagnosed and under-treated in many European countries.
To establish the characteristics of the European (EU) adult ADHD patient relative to adult patients outside the EU (OEU).
To compare the baseline characteristics of patients with ADHD in regions where adult ADHD is relatively well established (e.g., USA), with EU adult ADHD patients.
Baseline data was used from the open-label acute treatment period of a multicenter, randomized, withdrawal trial of atomoxetine in adult patients with ADHD (N = 2017; EU, n = 1217; OEU, n = 800). All enrolled patients were included in the baseline analyses.
The demographics for patients in the EU region and regions OEU were comparable. Patients in the EU region had a somewhat lower percentage of prior exposure to psychostimulants compared to the region OEU (32.7% versus 38.9%, p = .005). Conners’ Adult ADHD Rating Scale-Investigator Rated: Screening Version with adult ADHD prompts (18 item total, inattentive and hyperactive/impulsive subscales, and index) were comparable. The adult ADHD Quality of Life life outlook and life productivity domain scores were different between groups (p ≤ .0004). The EuroQol-5 Dimension UK and US population-based Index score, and health state score were comparable between groups.
There were some subtle differences between study groups; however, overall, the adult ADHD patients were not substantially different between the EU region and regions OEU, suggesting that baseline features of ADHD in adult EU patients manifest comparable to those in patients OEU.
In recent years, the discovery of massive quasars at
has provided a striking challenge to our understanding of the origin and growth of supermassive black holes in the early Universe. Mounting observational and theoretical evidence indicates the viability of massive seeds, formed by the collapse of supermassive stars, as a progenitor model for such early, massive accreting black holes. Although considerable progress has been made in our theoretical understanding, many questions remain regarding how (and how often) such objects may form, how they live and die, and how next generation observatories may yield new insight into the origin of these primordial titans. This review focusses on our present understanding of this remarkable formation scenario, based on the discussions held at the Monash Prato Centre from November 20 to 24, 2017, during the workshop ‘Titans of the Early Universe: The Origin of the First Supermassive Black Holes’.
The COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) project is a large international collaborative effort to analyze individual-level phenotype data from twins in multiple cohorts from different environments. The main objective is to study factors that modify genetic and environmental variation of height, body mass index (BMI, kg/m2) and size at birth, and additionally to address other research questions such as long-term consequences of birth size. The project started in 2013 and is open to all twin projects in the world having height and weight measures on twins with information on zygosity. Thus far, 54 twin projects from 24 countries have provided individual-level data. The CODATwins database includes 489,981 twin individuals (228,635 complete twin pairs). Since many twin cohorts have collected longitudinal data, there is a total of 1,049,785 height and weight observations. For many cohorts, we also have information on birth weight and length, own smoking behavior and own or parental education. We found that the heritability estimates of height and BMI systematically changed from infancy to old age. Remarkably, only minor differences in the heritability estimates were found across cultural–geographic regions, measurement time and birth cohort for height and BMI. In addition to genetic epidemiological studies, we looked at associations of height and BMI with education, birth weight and smoking status. Within-family analyses examined differences within same-sex and opposite-sex dizygotic twins in birth size and later development. The CODATwins project demonstrates the feasibility and value of international collaboration to address gene-by-exposure interactions that require large sample sizes and address the effects of different exposures across time, geographical regions and socioeconomic status.
Growth mixture modeling with a sample of 749 Mexican heritage families identified parallel trajectories of adolescents’ and their mothers’ heritage cultural values and parallel trajectories of adolescents’ and their fathers’ heritage cultural values from Grades 5 to 10. Parallel trajectory profiles were then used to test cultural gap-distress theory that predicts increased parent–adolescent conflict and adolescent psychopathology over time when adolescents become less aligned with Mexican heritage values compared to their parents. Six similar parallel profiles were identified for the mother–youth and father–youth dyads, but only one of the six was consistent with the hypothesized problem gap pattern in which adolescents’ values were declining over time to become more discrepant from their parents. When compared to families in the other trajectory groups as a whole, mothers in the mother–adolescent problem gap trajectory group reported higher levels of mother–adolescent conflict in the 10th grade that accounted for subsequent increases in internalizing and externalizing symptoms assessed in 12th grade. Although the findings provided some support for cultural gap-distress predictions, they were not replicated with adolescent report of conflict nor with the father–adolescent trajectory group analyses. Exploratory pairwise comparisons between all six mother–adolescent trajectory groups revealed additional differences that qualified and extended these findings.
We aimed to verify the effectiveness of real-time reverse transcription (rRT) polymerase chain reaction (PCR) for detecting cases of modified measles (M-Me) and for predicting super-spreader candidates through the experience of a measles outbreak dominated by M-Me in Yamagata, Japan, during March–April 2017. We applied rRT-PCR to specimens from 35 cases of M-Me, nine cases of typical measles (T-Me) and nine cases of prodromal stage of T-Me (P-Me). From rRT-PCR among the M-Me cases, peripheral blood mononuclear cells (PBMC) showed the highest positive rate (80.0%), followed by throat swab (48.6%), urine (33.3%) and serum (3.1%). The negative result of PBMC in M-Me cases was recovered by the result of a throat swab. In specimens of PBMC, throat swab and urine, M-Me group showed the significantly higher cycle of threshold (i.e., lower viral load) in the rRT-PCR than T-Me and P-Me groups, respectively. Furthermore, three super-spreaders in T-Me or P-Me showed an extremely low cycle of threshold in their throat swab specimens. rRT-PCR using PBMC and throat swab might be helpful for clinical management and measles control by certain detection of M-Me cases and by predicting super-spreading events resulting from measles cases with the high viral load.
The “Stop the Bleed” campaign advocates for non-medical personnel to be trained in basic hemorrhage control. However, it is not clear what type of education or the duration of instruction needed to meet that requirement. The objective of this study was to determine the impact of a brief hemorrhage control educational curriculum on the willingness of laypersons to respond during a traumatic emergency.
This “Stop the Bleed” education initiative was conducted by the University of Texas Health San Antonio Office of the Medical Director (San Antonio, Texas USA) between September 2016 and March 2017. Individuals with formal medical certification were excluded from this analysis. Trainers used a pre-event questionnaire to assess participants knowledge and attitudes about tourniquets and responding to traumatic emergencies. Each training course included an individual evaluation of tourniquet placement, 20 minutes of didactic instruction on hemorrhage control techniques, and hands-on instruction with tourniquet application on both adult and child mannequins. The primary outcome in this study was the willingness to use a tourniquet in response to a traumatic medical emergency.
Of 236 participants, 218 met the eligibility criteria. When initially asked if they would use a tourniquet in real life, 64.2% (140/218) responded “Yes.” Following training, 95.6% (194/203) of participants responded that they would use a tourniquet in real life. When participants were asked about their comfort level with using a tourniquet in real life, there was a statistically significant improvement between their initial response and their response post training (2.5 versus 4.0, based on 5-point Likert scale; P<.001).
In this hemorrhage control education study, it was found that a short educational intervention can improve laypersons’ self-efficacy and reported willingness to use a tourniquet in an emergency. Identified barriers to act should be addressed when designing future hemorrhage control public health education campaigns. Community education should continue to be a priority of the “Stop the Bleed” campaign.
RossEM, RedmanTT, MappJG, BrownDJ, TanakaK, CooleyCW, KharodCU, WamplerDA. Stop the Bleed: The Effect of Hemorrhage Control Education on Laypersons’ Willingness to Respond During a Traumatic Medical Emergency. Prehosp Disaster Med. 2018;33(2):127–132.
We calculate the luminosity of the synchrotron radiation from the vicinity of the light cylinder. We find that even if the thermal emission from the entire surface is included as the seed photon, the γ-ray to X-ray flux ratio for young pulsars is significantly higher than the observations. For these pulsars, most of γ-ray photons may be absorbed in the magnetosphere.
The standard shock acceleration model of pulsar wind nebulae (PWNe) does not account for the hard spectrum in radio wavelengths. The origin of the radio-emitting particles is also important to determine the pair production efficiency in the pulsar magnetosphere. Here, we propose a possible resolution for the particle energy distribution in PWNe; the radio-emitting particles are not accelerated at the pulsar wind termination shock but are stochastically accelerated by turbulence inside PWNe. We upgrade our past one-zone spectral evolution model including the energy diffusion, i.e., the stochastic acceleration, and apply to the Crab Nebula. For a particle injection to the stochastic acceleration process, we consider the continuous injection from the supernova ejecta or the impulsive injection associated with supernova explosion. The observed broadband spectrum and the decay of the radio flux are reproduced by tuning the amount of the particle injected to the stochastic acceleration process. Our results imply that some unveiled mechanisms, such as back reaction to the turbulence, are required to make the energies of stochastically and shock accelerated particles comparable.
The influence of baseline severity has been examined for antidepressant
medications but has not been studied properly for cognitive–behavioural
therapy (CBT) in comparison with pill placebo.
To synthesise evidence regarding the influence of initial severity on
efficacy of CBT from all randomised controlled trials (RCTs) in which
CBT, in face-to-face individual or group format, was compared with
pill-placebo control in adults with major depression.
A systematic review and an individual-participant data meta-analysis
using mixed models that included trial effects as random effects. We used
multiple imputation to handle missing data.
We identified five RCTs, and we were given access to individual-level
data (n = 509) for all five. The analyses revealed that
the difference in changes in Hamilton Rating Scale for Depression between
CBT and pill placebo was not influenced by baseline severity (interaction
P = 0.43). Removing the non-significant interaction
term from the model, the difference between CBT and pill placebo was a
standardised mean difference of –0.22 (95% CI –0.42 to –0.02,
P = 0.03, I2 = 0%).
Patients suffering from major depression can expect as much benefit from
CBT across the wide range of baseline severity. This finding can help
inform individualised treatment decisions by patients and their
Silicified beyrichiocopid and podocopid ostracods from limestone nodules derived from the middle part of the Ichinotani Formation within the Hida Gaien Terrane of central Honshu Island, Japan, are associated with fusulinid foraminifera that indicate strata of the middle Moscovian (Pennsylvanian, Carboniferous). This is a rare record of ostracods from the Palaeozoic of Japan and the first systematic description of ostracods from the Carboniferous of the Hida Gaien Terrane. The fauna comprises six ostracod species (two new) assigned to the genera Amphissites, Kirkbya, Bairdia, Aechmina and Healdia, and additional material of possible cavellinids. The numerical dominance of ornamented beyrichiocopids such as Kirkbya and Amphissites, along with smaller numbers of smooth podocopids such as Bairdia, indicates an ‘Eifelian mega-assemblage’ ecotype (sensu G. Becker), that is typical of mid Palaeozoic shallow marine, high-energy environments in a fore-reef ecosystem.
Major depressive disorder (MDD) is moderately heritable, however genome-wide association studies (GWAS) for MDD, as well as for related continuous outcomes, have not shown consistent results. Attempts to elucidate the genetic basis of MDD may be hindered by heterogeneity in diagnosis. The Center for Epidemiological Studies Depression (CES-D) scale provides a widely used tool for measuring depressive symptoms clustered in four different domains which can be combined together into a total score but also can be analysed as separate symptom domains.
We performed a meta-analysis of GWAS of the CES-D symptom clusters. We recruited 12 cohorts with the 20- or 10-item CES-D scale (32 528 persons).
One single nucleotide polymorphism (SNP), rs713224, located near the brain-expressed melatonin receptor (MTNR1A) gene, was associated with the somatic complaints domain of depression symptoms, with borderline genome-wide significance (pdiscovery = 3.82 × 10−8). The SNP was analysed in an additional five cohorts comprising the replication sample (6813 persons). However, the association was not consistent among the replication sample (pdiscovery+replication = 1.10 × 10−6) with evidence of heterogeneity.
Despite the effort to harmonize the phenotypes across cohorts and participants, our study is still underpowered to detect consistent association for depression, even by means of symptom classification. On the contrary, the SNP-based heritability and co-heritability estimation results suggest that a very minor part of the variation could be captured by GWAS, explaining the reason of sparse findings.
Here we discuss requirements for high performance and solution processable organic semiconductors, by presenting a systematic investigation of 7-alkyl-2-phenylbenzothieno[3,2-b]benzothiophenes (Ph-BTBT-Cn’s). We found that the solubility and thermal properties of Ph-BTBT-Cn’s depend systematically on the substituted alkyl-chain length n. The observed features are well understood in terms of the change of molecular packing motif with n: The compounds with n ≤ 4 do not form independent alkyl chain layers, whereas those with n ≥ 5 form isolated alkyl chain layers. The latter compounds afford a series of isomorphous bilayer-type crystal structures that form two-dimensional carrier transport layers within the crystals. We also show that the Ph-BTBT-C10 afford high performance single-crystalline field-effect transistors the mobility of which reaches as high as 15.9 cm2/Vs. These results demonstrate a crucial role of the substituted alkyl chain length for obtaining high performance organic semiconductors and field-effect transistors.
The transport of relativistic electron beam in compressed cylindrical targets was studied from a numerical and experimental point of view. In the experiment, cylindrical targets were imploded using the Gekko XII laser facility of the Institute of Laser Engineering. Then the fast electron beam was created by shooting the LFEX laser beam. The penetration of fast electrons was studied by observing Kα emission from tracer layers in the target.
Heptavalent pneumococcal conjugate vaccine (PCV7) was introduced to Japan in 2010. We investigated the impact of PCV7 on childhood community-acquired pneumonia (CAP) and pneumococcal pneumonia (PP). Children aged <5 years living in Chiba city, Japan, who were admitted to hospitals were enrolled to estimate the incidence of CAP based on the mid-year population. PP was determined by the presence of Streptococcus pneumoniae in cultured blood and/or sputum samples of CAP patients. The incidence of CAP and S. pneumoniae isolated from PP patients was compared before (April 2008–March 2009) and after (April 2012–March 2013) the introduction of PCV7 immunization. The annual incidence of CAP was reduced [incidence rate ratio 0·81, 95% confidence interval (CI) 0·73–0·90]. When comparing post-vaccine with pre-vaccine periods, the odds ratio for PP incidence was 0·60 (95% CI 0·39–0·93, P = 0·024). PCV7-covered serotypes markedly decreased (66·6% in pre-vaccine vs. 15·6% in post-vaccine, P < 0·01), and serotypes 6C, 15A, 15C and 19A increased. Multidrug-resistant international clones in the pre-vaccine period (Spain6B-2/ST90, Taiwan19F-14/ST236) decreased, while Sweden15A-25/ST63 was the dominant clone in the post-vaccine period. A significant reduction in the incidence of both CAP hospitalizations and culture-confirmed PP of vaccine serotypes was observed at 2 years after PCV7 vaccination.
The Proterozoic carbonate stromatolites of the Pahrump Group from the Crystal Spring formation exhibit interesting layering patterns. In continuous vertical formations, there are sections of chevron-shaped stromatolites alternating with sections of simple horizontal layering. This apparent cycle of stromatolite formation and lack of formation repeats several times over a vertical distance of at least 30 m at the locality investigated. Small representative samples from each layer were taken and analysed using X-ray diffraction (XRD), X-ray fluorescence (XRF), environmental scanning electron microscopy – energy dispersive X-ray spectrometry, and were optically analysed in thin section. Optical and spectroscopic analyses of stromatolite and of non-stromatolite samples were undertaken with the objective of determining the differences between them. Elemental analysis of samples from within each of the four stromatolite layers and the four intervening layers shows that the two types of layers are chemically and mineralogically distinct. In the layers that contain stromatolites the Ca/Si ratio is high; in layers without stromatolites the Ca/Si ratio is low. In the high Si layers, both K and Al are positively correlated with the presence and levels of Si. This, together with XRD analysis, suggested a high K-feldspar (microcline) content in the non-stromatolitic layers. This variation between these two types of rocks could be due to changes in biological growth rates in an otherwise uniform environment or variations in detrital influx and the resultant impact on biology. The current analysis does not allow us to choose between these two alternatives. A Mars rover would have adequate resolution to image these structures and instrumentation capable of conducting a similar elemental analysis.