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In March 2020, at the onset of the coronavirus disease 2019 (COVID-19) pandemic in the United States, the Southern California Extracorporeal Membrane Oxygenation (ECMO) Consortium was formed. The consortium included physicians and coordinators from the four ECMO centers in San Diego County. Guidelines were created to ensure that ECMO was delivered equitably and in a resource effective manner across the county during the pandemic. A biomedical ethicist reviewed the guidelines to ensure ECMO utilization would provide maximal community benefit of this limited resource. The San Diego County Health and Human Services Agency further incorporated the guidelines into its plans for the allocation of scarce resources. The consortium held weekly video conferences to review countywide ECMO capacity (including census and staffing), share data, and discuss clinical practices and difficult cases. Equipment exchanges between ECMO centers maximized regional capacity. From March 1 to November 30, 2020, consortium participants placed 97 patients on ECMO. No eligible patients were denied ECMO due to lack of resources or capacity. The Southern California ECMO Consortium may serve as a model for other communities seeking to optimize ECMO resources during the current COVID-19 or future pandemics.
Most patients with World Federation of Neurological Surgeons (WFNS) grade 5 subarachnoid hemorrhage (SAH) have poor outcomes. Accurate assessment of prognosis is important for treatment decisions and conversations with families regarding goals of care. Unjustified pessimism may lead to “self-fulfilling prophecy,” where withdrawal of life-sustaining measures (WLSM) is invariably followed by death.
We performed a cohort study involving consecutive patients with WFNS grade 5 SAH to identify variables with >= 90% and >= 95% positive predictive value (PPV) for poor outcome (1-year modified Rankin Score >= 4), as well as findings predictive of WLSM.
Of 140 patients, 38 (27%) had favorable outcomes. Predictors with >= 95% PPV for poor outcome included unconfounded 72-hour Glasgow Coma Scale motor score <= 4, absence of >= 1 pupillary light reflex (PLR) at 24 hours, and intraventricular hemorrhage (IVH) score of >= 20 (volume >= 54.6 ml). Intracerebral hemorrhage (ICH) volume >= 53 ml had PPV of 92%. Variables associated with WLSM decisions included a poor motor score (p < 0.0001) and radiographic evidence of infarction (p = 0.02).
We identified several early predictors with high PPV for poor outcome. Of these, lack of improvement in motor score during the initial 72 hours had the greatest potential for confounding from “self-fulfilling prophecy.” Absence of PLR at 24 hours, IVH score >= 20, and ICH volume >= 53 ml predicted poor outcome without a statistically significant effect on WLSM decisions. More research is needed to validate prognostic variables in grade 5 SAH, especially among patients who do not undergo WLSM.
Depression is a major public health problem in European countries, and health systems need to ensure access to effective psychological and pharmacological treatments. Research suggests that improvements in depression care require “complex interventions” that implement change in several areas simultaneously.
We describe an observational study of the implementation of a “stepped care” model to provide care for all adults presenting with a new case of depression in a mixed urban-rural area of Scotland with a population of 76,000 people.
A team of 5.2 clinicians provided care for about 1,000 new cases of depression each year. “Guided Self-Help” was the baseline intervention for all patients, supplemented where necessary with pharmacological treatment and Cognitive Behavioural or Interpersonal Therapy.
Service delivery systems were reformed to provide: specialist treatment in primary care settings using primarily non-medical clinicians, comprehensive electronic clinical records, continuous outcome monitoring and intensive investment in staff training and support.
Clinical outcomes (measured by the Personal Health Questionnaire, Social and Work Adjustment Scale and EQ-5D) showed significant improvement despite relatively brief clinician contact (2.5 hours over 4.6 contacts). Savings of more than 50% were made on the antidepressant drug budget. Service user satisfaction ratings were high.
Population needs for depression care can be met using “stepped care” models such as that described above. A randomised controlled study of this approach would be required to fully test the model.
Introduction: Patients with chronic non-cancer pain (CNCP) and opioid-use disorders make up a category of patients who present a challenge to emergency department (ED) providers and healthcare administrators. Their conditions predispose them to frequent ED utilization. This problem has been compounded by a worsening opioid epidemic that has rendered clinicians apprehensive about how they approach pain care. A systematic review has not yet been performed to inform the management of CNCP patients in the ED. As such, the purpose of this project was to identify and describe the effectiveness of interventions to reduce ED visits for high-utilizers with CNCP. Methods: Included participants were high-utilizers presenting with CNCP. All study designs were eligible for inclusion if they examined an intervention aimed at reducing ED utilization. The outcomes of interest were the number of ED visits as well as the amount and type of opioids prescribed in the ED and after discharge. We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, Web of Science, and the grey literature from inception to June 16, 2018. Two independent investigators assessed articles for inclusion following PRISMA guidelines. Risk of bias will be assessed using the Cochrane ROBINS-I and RoB 2 tools for non-randomized and randomized trials, respectively. Results: Following review, 14 of the 5,018 identified articles were included for analysis. These articles assessed a total of 1,670 patients from both urban and rural settings. Interventions included pain protocols or policies (n = 5), individualized care plans (n = 5), ED care coordination (n = 2), a chronic pain management pathway (n = 1), and a behavioural health intervention (n = 1). Intervention effects trended towards the reduction of both ED visits and opioid prescriptions. The meta-analysis is in progress. Conclusion: Preliminary results suggest that interventions aimed at high-utilizers with CNCP can reduce ED visits and ED opioid prescription. ED opioid-restriction policies that sought to disincentivize drug-related ED visits were most successful, especially when accompanied by an electronic medical record (EMR) alert to ensure consistent application of the policy by all clinicians and administrators involved in the care of these patients. This review was limited by inconsistencies in the definition of ‘high-utilizer’ and by the lack of high-powered randomized studies.
Background: NCSE dramatically increases morbidity and mortality. It is clinically subtle, which makes it difficult to diagnose without EEG. StatNet EEG provides a quick alternative to conventional EEG, which is often unavailable after hours. Methods: Each patient received a StatNet EEG by a neurology resident and a conventional EEG by an EEG technologist. Blinded studies were compared for delay between the studies, setup time, artifact, and abnormality detection using conventional EEG as controls. Nonparametric Mann-Whitney two-sample T-test was used. Results are expressed in mean minutes +/- SD. Kappa score assessed inter-observer reliability. Results: 19 patients were collected. Two StatNet EEGs were not interpretable and excluded. The mean delay between studies was 26h53min. Electrode placement is significantly shorter: 13:14±5:24 StatNet EEG vs 18:07±5:35 conventional EEG (p=0.02).
Conclusions: There is high inter-rater reliability between the conventional and StatNet EEG groups (table 1) demonstrating that StatNet is a reliable and effective tool, aiding in early recognition and management of NCSE.
Neighboring tidewater glaciers often exhibit asynchronous dynamic behavior, despite relatively uniform regional atmospheric and oceanic forcings. This variability may be controlled by a combination of local factors, including glacier and fjord geometry, fjord heat content and circulation, and glacier surface melt. In order to characterize and understand contrasts in adjacent tidewater glacier and fjord dynamics, we made coincident ice-ocean-atmosphere observations at high temporal resolution (minutes to weeks) within a 10 000 km2 area near Uummannaq, Greenland. Water column velocity, temperature and salinity measurements reveal systematic differences in neighboring fjords that imply contrasting circulation patterns. The observed ocean velocity and hydrography, combined with numerical modeling, suggest that subglacial discharge plays a major role in setting fjord conditions. In addition, satellite remote sensing of seasonal ice flow speed and terminus position reveal both speedup and slow-down in response to melt, as well as differences in calving style among the neighboring glaciers. Glacier force budgets and modeling also point toward subglacial discharge as a key factor in glacier behavior. For the studied region, individual glacier and fjord geometry modulate subglacial discharge, which leads to contrasts in both fjord and glacier dynamics.
Accurate and complete reporting of study methods, results and interpretation are essential components for any scientific process, allowing end-users to evaluate the internal and external validity of a study. When animals are used in research, excellence in reporting is expected as a matter of continued ethical acceptability of animal use in the sciences. Our primary objective was to assess completeness of reporting for a series of studies relevant to mitigation of pain in neonatal piglets undergoing routine management procedures. Our second objective was to illustrate how authors can report the items in the Reporting guidElines For randomized controLled trials for livEstoCk and food safety (REFLECT) statement using examples from the animal welfare science literature. A total of 52 studies from 40 articles were evaluated using a modified REFLECT statement. No single study reported all REFLECT checklist items. Seven studies reported specific objectives with testable hypotheses. Six studies identified primary or secondary outcomes. Randomization and blinding were considered to be partially reported in 21 and 18 studies, respectively. No studies reported the rationale for sample sizes. Several studies failed to report key design features such as units for measurement, means, standard deviations, standard errors for continuous outcomes or comparative characteristics for categorical outcomes expressed as either rates or proportions. In the discipline of animal welfare science, authors, reviewers and editors are encouraged to use available reporting guidelines to ensure that scientific methods and results are adequately described and free of misrepresentations and inaccuracies. Complete and accurate reporting increases the ability to apply the results of studies to the decision-making process and prevent wastage of financial and animal resources.
Gem minerals at Lava Plains, northeast Queensland, offer further insights into mantle-crustal gemformation under young basalt fields. Combined mineralogy, U-Pb age determination, oxygen isotope and petrological data on megacrysts and meta-aluminosilicate xenoliths establish a geochemical evolution in sapphire, zircon formation between 5 to 2 Ma. Sapphire megacrysts with magmatic signatures (Fe/Mg ∼100–1000, Ga/Mg 3–18) grew with ∼3 Ma micro-zircons of both mantle (δ18O 4.5–5.6%) and crustal (δ18O 9.5–10.1‰) affinities. Zircon megacrysts (3±1 Ma) show mantle and crustal characteristics, but most grew at crustal temperatures (600–800°C). Xenolith studies suggest hydrous silicate melts and fluids initiated from amphibolized mantle infiltrated into kyanite+sapphire granulitic crust (800°C, 0.7 GPa). This metasomatized the sapphire (Fe/Mg ∼50–120, Ga/Mg ∼3–11), left relict metastable sillimanite-corundum-quartz and produced minerals enriched in high field strength, large ion lithophile and rare earth elements. The gem suite suggests a syenitic parentage before its basaltic transport. Geographical trace-element typing of the sapphire megacrysts against other eastern Australian sapphires suggests a phonolitic involvement.
A cardiac source is often implicated in strokes where the deficit includes aphasia. However, less is known about the etiology of isolated aphasia during transient ischemic attack (TIA). Our objective was to determine whether patients with isolated aphasia are likely to have a cardioembolic etiology for their TIA.
We prospectively studied a cohort of TIA patients in eight tertiary-care emergency departments. Patients with isolated aphasia were identified by the treating physician at the time of emergency department presentation. Patients with dysarthria (i.e., a phonation disturbance) were not included. Potential cardiac sources for embolism were defined as atrial fibrillation on history, electrocardiogram, Holter monitor, atrial fibrillation on echocardiography, or thrombus on echocardiography.
Of the 2,360 TIA patients identified, 1,155 had neurological deficits at the time of the emergency physician assessment and were included in this analysis, and 41 had isolated aphasia as their only neurological deficit. Patients with isolated aphasia were older (73.9±10.0 v. 67.2±14.5 years; p=0.003), more likely to have a history of heart failure (9.8% v. 2.6%; p=0.027), and were twice as likely to have any cardiac source of embolism (22.0% v. 10.6%; p=0.037).
Isolated aphasia is associated with a high rate of cardioembolic sources of embolism after TIA. Emergency patients with isolated aphasia diagnosed with a TIA warrant a rapid and thorough assessment for a cardioembolic source.
Antarctic and Southern Ocean science is vital to understanding natural variability, the processes that govern global change and the role of humans in the Earth and climate system. The potential for new knowledge to be gained from future Antarctic science is substantial. Therefore, the international Antarctic community came together to ‘scan the horizon’ to identify the highest priority scientific questions that researchers should aspire to answer in the next two decades and beyond. Wide consultation was a fundamental principle for the development of a collective, international view of the most important future directions in Antarctic science. From the many possibilities, the horizon scan identified 80 key scientific questions through structured debate, discussion, revision and voting. Questions were clustered into seven topics: i) Antarctic atmosphere and global connections, ii) Southern Ocean and sea ice in a warming world, iii) ice sheet and sea level, iv) the dynamic Earth, v) life on the precipice, vi) near-Earth space and beyond, and vii) human presence in Antarctica. Answering the questions identified by the horizon scan will require innovative experimental designs, novel applications of technology, invention of next-generation field and laboratory approaches, and expanded observing systems and networks. Unbiased, non-contaminating procedures will be required to retrieve the requisite air, biota, sediment, rock, ice and water samples. Sustained year-round access to Antarctica and the Southern Ocean will be essential to increase winter-time measurements. Improved models are needed that represent Antarctica and the Southern Ocean in the Earth System, and provide predictions at spatial and temporal resolutions useful for decision making. A co-ordinated portfolio of cross-disciplinary science, based on new models of international collaboration, will be essential as no scientist, programme or nation can realize these aspirations alone.
Here we present the first results from the Siding Spring Southern Seyfert Spectroscopic Snapshot Survey (S7) which aims to investigate the physics of ∼140 radio-detected southern active Galaxies with z<0.02 through Integral Field Spectroscopy using the Wide Field Spectrograph (WiFeS). This instrument provides data cubes of the central 38×25 arc sec. of the target galaxies in the waveband 340–710nm with the unusually high resolution of R=7000 in the red (530–710nm), and R=3000 in the blue (340–560nm). These data provide the morphology, kinematics and the excitation structure of the extended narrow-line region, probe relationships with the black hole characteristics and the host galaxy, measures host galaxy abundance gradients and the determination of nuclear abundances from the HII regions. From photoionisation modelling, we may determine the shape of the ionising spectrum of the AGN, discover whether AGN metallicities differ from nuclear abundances determined from HII regions, and probe grain destruction in the vicinity of the AGN. Here we present some preliminary results and modelling of both Seyfert galaxies observed as part of the survey.
Piglets reared in swine production in the USA undergo painful procedures that include castration, tail docking, teeth clipping, and identification with ear notching or tagging. These procedures are usually performed without pain mitigation. The objective of this project was to develop recommendations for pain mitigation in 1- to 28-day-old piglets undergoing these procedures. The National Pork Board funded project to develop recommendations for pain mitigation in piglets. Recommendation development followed a defined multi-step process that included an evidence summary and estimates of the efficacies of interventions. The results of a systematic review of the interventions were reported in a companion paper. This manuscript describes the recommendation development process and the final recommendations. Recommendations were developed for three interventions (CO2/O2 general anesthesia, non-steroidal anti-inflammatory drugs (NSAIDs), and lidocaine) for use during castration. The ability to make strong recommendations was limited by low-quality evidence and strong certainty about variation in stakeholder values and preferences. The panel strongly recommended against the use of a CO2/O2 general anesthesia mixture, weakly recommended for the use of NSAIDs and weakly recommended against the use of lidocaine for pain mitigation during castration of 1- to 28-day-old piglets.
Coronal Multi-channel Polarimeter (CoMP-S), developed by HAO/NCAR, has been introduced to regular operation at the Lomnicky Peak Observatory (High Tatras in northern Slovakia, 2633 m a.s.l.) of the Astronomical Institute of Slovak Academy of Sciences. We present here the technical parameters of the current version of the instrument and its potential for observations of prominences in the visual and near-IR spectral regions. The first results derived from observations of prominences in the Hα emission line taken during a coordinated observing campaign of several instruments in October 2012 are shown here.
A heuristic greedy algorithm is developed for efficiently tiling spatially dense redshift surveys. In its first application to the Galaxy and MassAssembly (GAMA) redshift survey we find it rapidly improves the spatial uniformity of our data, and naturally corrects for any spatial bias introduced by the 2dF multi-object spectrograph. We make conservative predictions for the final state of the GAMA redshift survey after our final allocation of time, and can be confident that even if worse than typical weather affects our observations, all of our main survey requirements will be met.
Interaction of Greenland’s marine-terminating glaciers with the ocean has emerged as a key term in the ice-sheet mass balance and a plausible trigger for their recent acceleration. Our knowledge of the dynamics, however, is limited by scarcity of ocean measurements at the glacier/ocean boundary. Here data collected near six marine-terminating glaciers (79 North, Kangerdlugssuaq, Helheim and Petermann glaciers, Jakobshavn Isbræ, and the combined Sermeq Kujatdleq and Akangnardleq) are compared to investigate the water masses and the circulation at the ice/ocean boundary. Polar Water, of Arctic origin, and Atlantic Water, from the subtropical North Atlantic, are found near all the glaciers. Property analysis indicates melting by Atlantic Water (AW; found at the grounding line depth near all the glaciers) and the influence of subglacial discharge at depth in summer. AW temperatures near the glaciers range from 4.5˚C in the southeast, to 0.16˚C in northwest Greenland, consistent with the distance from the subtropical North Atlantic and cooling across the continental shelf. A review of its offshore variability suggests that AW temperature changes in the fjords will be largest in southern and smallest in northwest Greenland, consistent with the regional distribution of the recent glacier acceleration.
Tail docking of pigs is a routine procedure on farms to help control tail-biting behavior; however, docking can cause pain. The objective of this research was to evaluate the effect of local or general anesthesia on the physiology (experiment 1) and behavior (experiment 2) of tail docked pigs. Pigs were allocated to one of six treatment groups: (i) sham docking (CON); (ii) docking using conventional cutting (CUT) with side-cutting pliers; (iii) CUT docking plus local anesthesia injected immediately before docking (LA); (iv) CUT docking plus short-acting local anesthesia applied topically to the tail wound (SHORT); (v) CUT docking plus long-acting anesthesia applied topically to the tail wound (LONG) and (vi) CUT docking while the pig was anesthetized with carbon dioxide gas (CO2). In experiment 1, blood samples were collected from pigs (10 pigs per treatment) before and 30, 60 and 120 min after docking to measure leukocyte counts and percentages and cortisol concentrations. In experiment 2, the above treatments were repeated (10 pigs per treatment); the percentage of stress vocalizations were recorded during the administration of the treatments and behavior was recorded for up to 120 min after docking or handling. All pigs were weighed before and 24 h after docking and wound healing was recorded until weaning. The neutrophil/lymphocyte ratio was greater (P < 0.05) in CUT, LA, SHORT and LONG compared with CON pigs. At 30 min, cortisol concentrations were greater (P < 0.05) in CUT, LA, LONG and CO2 compared with CON pigs. Cortisol concentrations did not differ (P > 0.05) between SHORT and CON pigs 30 min after docking. Cortisol concentrations did not differ (P > 0.05) among pigs given pain relief at the time of docking compared with pigs’ docked without pain relief. Body weight change and wound scores did not differ (P > 0.05) among treatments. The percentage of stress vocalizations increased (P < 0.05) in CUT, SHORT and LONG, but not in CON, LA and CO2 pigs in response to docking or handling. The percentage of time pigs spent lying without contact after docking tended to be greater (P = 0.06) in CUT pigs compared with all other docking treatments and CON pigs. In this study, none of the anesthesia treatments tested were effective at significantly changing the physiological or behavioral response to tail docking in pigs.
The relationship between black hole mass and bulge mass (Magorrian et al. 1998; Gebhardt et al. 2000a) indicates a symbiotic relationship between the formation of supermassive black holes and galaxy formation. Silk and Rees (1998) indicated how an isotropic wind from a black hole may interact with the infalling gas in a forming galaxy to provide a natural relationship between black hole mass and bulge mass. Saxton et al. (2005) also showed that jets propagating through an inhomogeneous interstellar medium generate an energy-driven, more or less spherical bubble, different from the bipolar structure that is usually associated with classical radio galaxies. Thus, from our viewpoint, when we consider the interaction between jets and the interstellar medium we naturally think of gigahertz peak spectrum (GPS) and compact steep spectrum (CSS) radio galaxies as well as high redshift radio galaxies. These sources appear to be radio galaxies in the early stages of their evolution in which there is abundant evidence for strong jet–ISM interaction in the form of shock-excited emission lines and anomalous gas velocities. Given that jet power and momentum can be isotropically distributed by an inhomogeneous medium, an important issue to address is the detailed interaction between clouds and outflows in such a medium. The nature of this interaction and in particular the momentum imparted to the gas surrounding the active nucleus is going to be quite different from that envisaged by Silk and Rees (1998) and many other papers since.
Surgical castration of male piglets is a common management practice conducted on commercial swine farms to prevent the occurrence of boar taint and aggressive behavior. However, the procedure of surgical castration causes acute pain-induced distress, which is an animal welfare concern. The objective of this study was to evaluate the use of two topical anesthetics to alleviate the pain caused by castration in piglets as measured by physiological and behavior indices of stress. At 3 days of age, 40 weight-matched piglets were allocated to one of four treatment groups. Treatments included: (i) sham castration (CON), (ii) surgical castration (CAS), (iii) castration and short-acting local anesthetic applied topically to the castration wound (SHORT) and (iv) castration and long-acting local anesthetic applied topically to the castration wound (LONG). Blood samples were collected from piglets before and 30, 60, 120 and 180 min after castration to measure leukocyte and differential counts and cortisol concentrations. The above experiment was repeated without blood collection and behavior was recorded for 30 min before and 180 min after castration or handling. Stress vocalizations were recorded during castration and handling. All piglets were weighed before and 24 h after castration and wound healing was recorded daily for the first 14 days after castration. Leukocyte counts and differentials did not differ (P > 0.05) among any of the treatments. Cortisol concentrations were elevated (P < 0.06) in CAS, SHORT and LONG piglets compared with controls 30 and 60 min after castration. The percentage of stress vocalizations was greater (P < 0.05) among castrated piglets compared with CON piglets, regardless of anesthetic treatment. Piglets that were castrated and not given a topical anesthetic spent more time (P < 0.05) lying without contact compared with piglets castrated and given a topical anesthetic, regardless of the topical anesthetic administered. Body weight change did not differ (P > 0.05) among treatments 24 h after castration or control handling and wound healing scores were greater (P < 0.05) in SHORT compared with CAS and LONG piglets 9 to 14 days after castration. In this study, the use of a short- or long-acting topical anesthetic was not effective in reducing the pain-induced distress caused by castration in piglets. Further research is needed to evaluate alternative practical methods to reduce the pain caused by the on-farm castration of piglets.