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Emergency Medical Services (EMS) systems have developed protocols for prehospital activation of the cardiac catheterization laboratory for patients with suspected ST-elevation myocardial infarction (STEMI) to decrease first-medical-contact-to-balloon time (FMC2B). The rate of “false positive” prehospital activations is high. In order to decrease this rate and expedite care for patients with true STEMI, the American Heart Association (AHA; Dallas, Texas USA) developed the Mission Lifeline PreAct STEMI algorithm, which was implemented in Los Angeles County (LAC; California USA) in 2015. The hypothesis of this study was that implementation of the PreAct algorithm would increase the positive predictive value (PPV) of prehospital activation.
This is an observational pre-/post-study of the effect of the implementation of the PreAct algorithm for patients with suspected STEMI transported to one of five STEMI Receiving Centers (SRCs) within the LAC Regional System. The primary outcome was the PPV of cardiac catheterization laboratory activation for percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The secondary outcome was FMC2B.
A total of 1,877 patients were analyzed for the primary outcome in the pre-intervention period and 405 patients in the post-intervention period. There was an overall decrease in cardiac catheterization laboratory activations, from 67% in the pre-intervention period to 49% in the post-intervention period (95% CI for the difference, -14% to -22%). The overall rate of cardiac catheterization declined in post-intervention period as compared the pre-intervention period, from 34% to 30% (95% CI, for the difference -7.6% to 0.4%), but actually increased for subjects who had activation (48% versus 58%; 95% CI, 4.6%-15.0%). Implementation of the PreAct algorithm was associated with an increase in the PPV of activation for PCI or CABG from 37.9% to 48.6%. The overall odds ratio (OR) associated with the intervention was 1.4 (95% CI, 1.1-1.8). The effect of the intervention was to decrease variability between medical centers. There was no associated change in average FMC2B.
The implementation of the PreAct algorithm in the LAC EMS system was associated with an overall increase in the PPV of cardiac catheterization laboratory activation.
During the summer of 2016, the Hawaii Department of Health responded to the second-largest domestic foodborne hepatitis A virus (HAV) outbreak in the post-vaccine era. The epidemiological investigation included case finding and investigation, sequencing of RNA positive clinical specimens, product trace-back and virologic testing and sequencing of HAV RNA from the product. Additionally, an online survey open to all Hawaii residents was conducted to estimate baseline commercial food consumption. We identified 292 confirmed HAV cases, of whom 11 (4%) were possible secondary cases. Seventy-four (25%) were hospitalised and there were two deaths. Among all cases, 94% reported eating at Oahu or Kauai Island branches of Restaurant Chain A, with 86% of those cases reporting raw scallop consumption. In contrast, a food consumption survey conducted during the outbreak indicated 25% of Oahu residents patronised Restaurant Chain A in the 7 weeks before the survey. Product trace-back revealed a single distributor that supplied scallops imported from the Philippines to Restaurant Chain A. Recovery, amplification and sequence comparison of HAV recovered from scallops revealed viral sequences matching those from case-patients. Removal of product from implicated restaurants and vaccination of those potentially exposed led to the cessation of the outbreak. This outbreak further highlights the need for improved imported food safety.
The Dark Energy Survey is undertaking an observational programme imaging 1/4 of the southern hemisphere sky with unprecedented photometric accuracy. In the process of observing millions of faint stars and galaxies to constrain the parameters of the dark energy equation of state, the Dark Energy Survey will obtain pre-discovery images of the regions surrounding an estimated 100 gamma-ray bursts over 5 yr. Once gamma-ray bursts are detected by, e.g., the Swift satellite, the DES data will be extremely useful for follow-up observations by the transient astronomy community. We describe a recently-commissioned suite of software that listens continuously for automated notices of gamma-ray burst activity, collates information from archival DES data, and disseminates relevant data products back to the community in near-real-time. Of particular importance are the opportunities that non-public DES data provide for relative photometry of the optical counterparts of gamma-ray bursts, as well as for identifying key characteristics (e.g., photometric redshifts) of potential gamma-ray burst host galaxies. We provide the functional details of the DESAlert software, and its data products, and we show sample results from the application of DESAlert to numerous previously detected gamma-ray bursts, including the possible identification of several heretofore unknown gamma-ray burst hosts.
On 30 May 2012, Surrey and Sussex Health Protection Unit was called by five nurseries reporting children and staff with sudden onset vomiting approximately an hour after finishing their lunch that day. Over the following 24 h 50 further nurseries supplied by the same company reported cases of vomiting (182 children, 18 staff affected). Epidemiological investigations were undertaken in order to identify the cause of the outbreak and prevent further cases. Investigations demonstrated a nursery-level attack rate of 55 out of 87 nurseries (63·2%, 95% confidence interval 52·2–73·3). Microbiological tests confirmed the presence of Bacillus cereus in food and environmental samples from the catering company and one nursery. This was considered microbiologically and epidemiologically consistent with toxin from this bacterium causing the outbreak. Laboratory investigations showed that the conditions used by the caterer for soaking of pearl haricot beans (known as navy bean in the USA) used in one of the foods supplied to the nurseries prior to cooking, was likely to have provided sufficient growth and toxin production of B. cereus to cause illness. This large outbreak demonstrates the need for careful temperature control in food preparation.
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.
The main objectives of our study were to explore reasons for seasonal influenza vaccine acceptance and declination in employees of a large integrated healthcare system and to identify underlying constructs that influence acceptance versus declination. Secondary objectives were to determine whether vaccine acceptance varied by hospital location and to identify facility-level measures that explained variability.
A national health promotion survey of employees was conducted that included items on vaccination in the 2009-2010 influenza season. The survey was administered with two other institutional surveys in a stratified fashion: approximately 40% of participating employees were randomly assigned to complete the health promotion survey.
National single-payer healthcare system with 152 hospitals.
Employees of the healthcare system in 2010 who responded to the survey.
Factor analysis was used to identify underlying constructs that influenced vaccine acceptance versus declination. Mean factor scores were examined in relation to demographic characteristics and occupation. Multilevel logistic regression models were used to determine whether vaccine acceptance varied by location and to identify facility-level measures that explained variability.
Four factors were identified related to vaccine declination and were labeled as (1) “don't care,” (2) “don't want,” (3) “don't believe,” and (4) “don't know.” Significant differences in mean factor scores existed by demographic characteristics and occupation. Vaccine acceptance varied by location, and vaccination rates in the previous year were an important facility-level predictor.
Results should guide interventions that tailor messages on the basis of particular reasons for declination. Occupation-specific and culturally appropriate messaging should be considered. Continued efforts will be taken to better understand how workplace context influences vaccine acceptance.
Pelagic ecosystems and their fisheries are of particular economic and social importance to the countries and territories of the Wider Caribbean for various reasons. In some countries (e.g. Barbados, Grenada) commercial pelagic fisheries already contribute significantly to total landings and seafood export foreign exchange earnings. Ports and postharvest facilities service the vessels, ranging from artisanal canoes to industrial longliners, and their catch which often reaches tourists as well as locals (Mahon and McConney 2004). In other places where the focus has previously been on inshore and demersal fisheries (e.g. Antigua and Barbuda, Belize) there is growing interest in the potential of pelagic fisheries development. This potential lies not only in commercial fisheries, but also in the high-revenue and conservation-aware recreational fisheries well established in a few locations (e.g. Puerto Rico, Costa Rica) and undertaken at a lower level in many others.
Underlying all of this is the complexity due to many of the valued pelagics being migratory or highly migratory shared and straddling stocks falling under the 1995 United Nations Fish Stocks Agreement and subject to several international instruments and management regimes, such as those of the International Commission for the Conservation of Atlantic Tunas (ICCAT). The web of linkages across Caribbean marine jurisdictions and organizations is complex (McConney et al. 2007). The related issues call for an ecosystem approach (McConney and Salas Chapter 7; Schuhmann et al. Chapter 8) and some progress has already been made at multiple levels (Fanning and Oxenford Chapter 16; Singh-Renton et al. Chapter 14).
This synthesis chapter presents the outputs of facilitated symposium sessions specifically related to achieving and implementing a shared vision for the pelagic ecosystem in marine ecosystem based management (EBM) in the Wider Caribbean. The methodology was described in Chapter 1 of this volume. This chapter first describes a vision for the pelagic ecosystem and reports on the priorities assigned to the identified vision elements. It then addresses how the vision might be achieved by taking into account assisting factors (those that facilitate achievement) and resisting factors (those that inhibit achievement). The chapter concludes with guidance on the strategic direction needed to implement the vision, identifying specific actions to be undertaken for each of the vision elements.
While little is known about hawksbill turtles Eretmochelys imbricata in the eastern Pacific Ocean, available information suggests that the population has declined substantially in recent decades and could be near extirpation in the region. To evaluate the current status of the population more effectively and to determine the feasibility of recovery efforts, a workshop of regional marine turtle specialists was held in June 2008 in Los Cóbanos, El Salvador. An international working group, Iniciativa Carey del Pacífico Oriental (ICAPO; Eastern Pacific Hawksbill Initiative in English), was established to consolidate information, promote conservation projects and raise awareness about the species. We present information derived from the workshop and compiled by the ICAPO working group since that time. Considering only records from 1 January 2007 to 31 May 2009 it appears that El Salvador hosts the majority of known hawksbill turtle nesting activity in the eastern Pacific, with 79.6% (n = 430) of all nesting observation records, and Mexico hosts the majority of records of hawksbill turtles at sea, with 60.3% (n = 44) of all in-water observation records. Although current abundance is very low, the pervasiveness of the species in the region suggests potential for conservation and recovery. Despite a historical paucity of research focusing on this population, the relatively large and steadily increasing number of records as a result of concerted efforts demonstrates the viability of the ICAPO network as an instrument to promote conservation of this species in the eastern Pacific.
A cross-sectional study was conducted to investigate risk factors for sporadic Cryptosporidium infection in a paediatric population in Nigeria. Of 692 children, 134 (19·4%) were infected with Cryptosporidium oocysts. Cryptosporidium spp. were identified in 49 positive samples using PCR–restriction fragment length polymorphism and direct sequencing of the glycoprotein60 (GP60) gene. Generalized linear mixed-effects models were used to identify risk factors for all Cryptosporidium infections, as well as for C. hominis and C. parvum both together and separately. Risk factors identified for all Cryptosporidium infections included malaria infection and a lack of Ascaris infection. For C. hominis infections, stunting and younger age were highlighted as risk factors, while stunting and malaria infection were identified as risk factors for C. parvum infection.
Studies were carried out in South America to assess the effect of maternally derived antibody (MDA) on the responsiveness of calves to FMD vaccination. It was found that calves with MDA did not merely fail to respond to vaccination, but that their serum titres were depressed. This depression was proportional to the level of pre-existing MDA at the time of vaccination and following primary vaccination it persisted for a least 60 days. High MDA titres interfered with both primary and secondary responses. Animals with relatively low MDA titres were able to respond to vaccination, or at least to be sensitized so that on revaccination they showed a satisfactory response. The half-life of MDA was shown to be approximately 22 days, suggesting that under field conditions significant MDA titres are likely to persist for 4–5 months. A trial carried out in Brazil in which the primary course of two inoculations, 4 weeks apart, was initiated when the calves were 5–6 months of age, resulted in the reduction of FMD in the calf population from 11% to 0·9% over a 12-month period. The use of vaccination programmes of this type to lessen the incidence of FMD in young bovines is discussed.
Groups of volunteers were immunized subcutaneously with one of three inacti vated influenza virus A/USSR/77 (HlNl) vaccine preparations; a whole virus vaccine, a surface-antigen subunit adsorbed vaccine, or an aqueous surface-antigen subunit vaccine. The reactions to immunization were recorded, and the antibody response was measured 1 month later. A fourth group of volunteers were inoculated intranasally with live attentuated A/USSR/77 (H1N1) influenza virus; the reactions and antibody response of these volunteers were also measured. One month after immunization, the incidence of infection by challenge with homologous live attentuated virus was determined for all groups of volunteers. The results showed that all four vaccines used were relatively non-reactogenic, and that inactivated vaccines induced higher titres of serum antibody than the live attenuated vaccine. All the vaccines induced significant protection against challenge virus infection which was directly related to the level of serum HI antibody response.
Groups of volunteers were immunized with one of three influenza virus vaccines, and the resistance to challenge infection with attenuated influenza A (H1N1) virus was measured 8 months later. The vaccines were aqueous subunit influenza A/USSR/77 (H1N1) vaccine, aqueous subunit influenza B/Hong Kong/73 vaccine, or attenuated influenza virus A (H1N1) vaccine. The B virus vaccine was included as a control to assess the incidence of natural A virus infection during the study period. A proportion of the B virus vaccinees had pre-existing A (H1N1) virus antibody and were used to study the immunity conferred by natural infection to the live virus challenge. The serum antibody responses were measured at 1 and 8 months after immunization. The results showed that all the vaccines induced serum HI antibody in a proportion of the volunteers; however, after 1 month, higher titres of serum antibody were found in volunteers given inactivated A vaccine than in those given live attenuated A virus vaccine. Eight months post-immunization the titres of serum antibody in volunteers given inactivated vaccine had declined significantly, but there were no changes in the antibody titres of those given live virus vaccine. The incidence of infection by the challenge virus at 8 months post-immunization was directly related to the serum antibody titres 1 month post-immunization; no evidence was obtained to suggest that those given live virus vaccine had a more solid immunity than those given inactivated vaccine.
The effects of temperature on reported cases of a number of foodborne illnesses in England and Wales were investigated. We also explored whether the impact of temperature had changed over time. Food poisoning, campylobacteriosis, salmonellosis, Salmonella Typhimurium infections and Salmonella Enteritidis infections were positively associated (P<0·01) with temperature in the current and previous week. Only food poisoning, salmonellosis and S. Typhimurium infections were associated with temperature 2–5 weeks previously (P<0·01). There were significant reductions also in the impact of temperature on foodborne illnesses over time. This applies to temperature in the current and previous week for all illness types (P<0·01) except S. Enteritidis infection (P=0·079). Temperature 2–5 weeks previously diminished in importance for food poisoning and S. Typhimurium infection (P<0·001). The results are consistent with reduced pathogen concentrations in food and improved food hygiene over time. These adaptations to temperature imply that current estimates of how climate change may alter foodborne illness burden are overly pessimistic.
Limitations of access have long restricted exploration and investigation of the cavities beneath ice shelves to a small number of drillholes. Studies of sea-ice underwater morphology are limited largely to scientific utilization of submarines. Remotely operated vehicles, tethered to a mother ship by umbilical cable, have been deployed to investigate tidewater-glacier and ice-shelf margins, but their range is often restricted. The development of free-flying autonomous underwater vehicles (AUVs) with ranges of tens to hundreds of kilometres enables extensive missions to take place beneath sea ice and floating ice shelves. Autosub2 is a 3600 kg, 6.7 m long AUV, with a 1600 m operating depth and range of 400 km, based on the earlier Autosub1 which had a 500 m depth limit. A single direct-drive d.c. motor and five-bladed propeller produce speeds of 1–2 m s−1. Rear-mounted rudder and stern-plane control yaw, pitch and depth. The vehicle has three sections. The front and rear sections are free-flooding, built around aluminium extrusion space-frames covered with glass-fibre reinforced plastic panels. The central section has a set of carbon-fibre reinforced plastic pressure vessels. Four tubes contain batteries powering the vehicle. The other three house vehicle-control systems and sensors. The rear section houses subsystems for navigation, control actuation and propulsion and scientific sensors (e.g. digital camera, upward-looking 300 kHz acoustic Doppler current profiler, 200 kHz multibeam receiver). The front section contains forward-looking collision sensor, emergency abort, the homing systems, Argos satellite data and location transmitters and flashing lights for relocation as well as science sensors (e.g. twin conductivity–temperature–depth instruments, multibeam transmitter, sub-bottom profiler, AquaLab water sampler). Payload restrictions mean that a subset of scientific instruments is actually in place on any given dive. The scientific instruments carried on Autosub are described and examples of observational data collected from each sensor in Arctic or Antarctic waters are given (e.g. of roughness at the underside of floating ice shelves and sea ice).
We measured 10Be and 26Al in 29 sediment samples to infer the history and millennial-scale rates of change down a low-gradient piedmont, a common but enigmatic landform that dominates the Mojave Desert. Nuclide data suggest that a large volume of sediment was deposited on the proximal East Range Road piedmont in Fort Irwin, California, ∼ 75,500 yr ago. Since then, this material has been stable or eroding slowly. In contrast, on the distal piedmont (3.5 km from the upland source basins) soil stratigraphy suggests that there have been alternating periods of surface stability, erosion, and deposition over the last 70,000 yr. Nuclide data from samples amalgamated along cross-piedmont transects suggest that long-term average down-gradient sediment speeds range from 9 cm yr− 1 near the uplands to 22 cm yr− 1 6 km down-piedmont. These speeds are similar to 10Be-estimated sediment speeds down three other piedmonts in the Mojave Desert, suggesting that piedmont surface morphologies dominated by shallow migrating channels have similar sediment transport rates. The timing of surface process change down the East Range Road piedmont is determined by a combination of sediment available in the source basins, sediment transport rates, and the size of the piedmont.
We determined the incidence of cryptosporidiosis in children aged <5 years presenting with diarrhoea in an urban and rural hospital-based setting in Malawi. Stools were collected over a 22-month period during both rainy and dry seasons. A range of microscopic methods were used to determine the presence of Cryptosporidium spp. oocysts. Species determination was by polymerase chain reaction–restriction fragment length polymorphism (PCR–RFLP) of oocyst-extracted DNA using 18S rRNA and COWP gene loci. Cryptosporidium spp. oocysts were seen in 5·9% (50/848) of samples, of which 43 amplified by PCR–RFLP indicated the following species: C. hominis, C. parvum, C. hominis/C. parvum, C. meleagridis and C. andersoni. Seven samples could not be amplified by PCR. Wider species diversity was found in the rural setting, and may be a result of increased malnutrition and zoonotic exposure in this area. Improvements in water, sanitation, household hygiene and animal control are required to reduce the incidence of infection in this population.