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Using physiological markers to detect patients at risk of deterioration is common. Deaths at music festivals in Australia prompted scrutiny of tools to identify critically unwell patients for transport to hospital. This study evaluated initial physiological parameters to identify patients selected for transport to hospital from a music festival.
Methods:
A retrospective audit of 2045 presentations at music festivals in Victoria, Australia, was performed. Presentation heart rate, systolic blood pressure, respiratory rate, oxygen saturation, temperature, and Glasgow Coma Scale were assessed using area under the receiver operating characteristic curve (AUROC) analysis, with a prespecified threshold of 0.7.
Results:
The only measured variable to exceed the prespecified cutpoint was initial systolic blood pressure, with an AUROC of 0.72 and optimal cutpoint of 122 mmHg. Using commonly accepted cutpoints for variables did not improve detection performance to acceptable levels, nor did using combination systems of cutpoints.
Conclusions:
Initial physiological variables are poor predictors of the decision to transport to hospital from music festivals. Systolic blood pressure was significant, but only at a clinically insignificant value. Decisions on which patients to transport from an event site should incorporate more information than initial physiology. Senior clinicians should lead decision-making about hospital transport from music festivals.
Serotonin and sympathomimetic toxicity (SST) after ingestion of amphetamine-based drugs can lead to severe morbidity and death. There have been evaluations of the safety and efficacy of on-site treatment protocols for SST at music festivals.
Problem:
The study aimed to examine the safety and efficacy of treating patients with SST on-site at a music festival using a protocol adapted from hospital-based treatment of SST.
Methods:
The study is an audit of presentations with SST over a one-year period. The primary outcome was need for ambulance transport to hospital. The threshold for safety was prospectively defined as less than 10% of patients requiring ambulance transport to hospital.
The protocol suggested patients be treated with a combination of benzodiazepines; cold intravenous (IV) fluid; specific therapies (cyproheptadine, chlorpromazine, and clonidine); rapid sequence intubation; and cooling with ice, misted water, and convection techniques.
Results:
One patient of 13 (7.7%) patients with mild or moderate SST required ambulance transport to hospital. Two of seven further patients with severe SST required transport to hospital.
Conclusions:
On-site treatment may be a safe, efficacious, and efficient alternative to urgent transport to hospital for patients with mild and moderate SST. The keys to success of the protocol tested included inclusive and clear education of staff at all levels of the organization, robust referral pathways to senior clinical staff, and the rapid delivery of therapies aimed at rapidly lowering body temperature. Further collaborative research is required to define the optimal approach to patients with SST at music festivals.
In this chapter, we review and discuss academic programs in technology and public policy, focusing on those that are either located in an engineering college or have a strong engineering focus. We consider what constitutes technically focused research in programs melding engineering and policy, where and how this work is done, the focus of these programs at the undergraduate and graduate levels, and the challenges of building and sustaining such programs.
Many academic programs in the United States and elsewhere focus on the social studies aspects of science, technology, and public policy- Indeed, most programs listed in the original American Association for the Advancement of Science guide to graduate education in science, engineering, and public policy were in this category (Levey, 1995). Few programs combine deep technical education and understanding with modern social science and policy-analytical skills and knowledge.
Immersion of patients in a body bag filled with ice and water is recommended as prehospital management of severe hyperthermia. Experienced paramedics have raised a number of concerns about the use of this technique; particularly, whether cardiac monitoring equipment would remain functional once immersed. This test showed that monitoring equipment does remain functional and provides advice about safety considerations. The test should reassure practitioners that such an approach is feasible.
The hot ISM in early-type galaxies (ETGs) plays a crucial role in understanding their formation and evolution. The structural features of the hot gas identified by Chandra observations point to key evolutionary mechanisms, (e.g., kim12). In our Chandra Galaxy Atlas (CGA) project, taking full advantage of the Chandra capabilities, we systematically analyzed the archival Chandra data of 72 ETGs and produced uniform data products of the hot gas properties. The main data products include spatially resolved 2D spectral maps of the hot gas from individual galaxies. We emphasize that new features can be identified in the spectral maps which are not easily visible in the surface brightness maps. The high-level images can be viewed at the dedicated CGA website, and the CGA data products can be downloaded to compare with other wavelength data and to perform user-specific analyses. Utilizing our data products, we will further address focused science topics.
It is expected that most massive stars have companions and thus that some core-collapse supernovae should have a runaway companion. The precise astrometry and photometry provided by Gaia allows for the systematic discovery of these runaway companions. We combine a prior on the properties of runaway stars from binary evolution with data from TGAS and APASS to search for runaway stars within ten nearby supernova remnants. We strongly confirm the existing candidate HD 37424 in S147, propose the Be star BD+50 3188 to be associated with HB 21, and suggest tentative candidates for the Cygnus and Monoceros Loops.
The proboscidean Gomphotherium is reported here from the Alajuela Formation of Panama. Gomphotherium was widespread throughout Holarctica during the Miocene, and the Panama fossil represents the extreme southernmost occurrence of this genus in the New World. Allocation of the Panama Gomphotherium to a valid species is impossible given both the fragmentary material represented and the taxonomic complexity of species assigned to this genus. In North America, Gomphotherium has a relatively long biochronological range from the middle Miocene (~15 Ma) to early Pliocene (~5 Ma). Based on morphological comparisons, the Panama Gomphotherium is either middle Miocene, thus representing the earliest-known entry of this genus into Central America, or late Miocene/early Pliocene, which challenges the currently accepted middle Miocene age of the Alajuela Formation as it has been previously reported from Panama.
This paper reviews recent developments in the production and use of unconventional natural gas in the United States with a focus on water and greenhouse gas emission implications. If unconventional natural gas in the U.S. is produced responsibly, transported and distributed with little leakage, and incorporated into integrated energy systems that are designed for future resiliency, it could play a significant role in realizing a more sustainable energy future; however, the increased use of natural gas as a substitute for more carbon intensive fuels will alone not substantially alter world carbon dioxide concentration projections.
This paper reviews recent developments in the production and use of unconventional natural gas in the United States with a focus on environmental impacts. Specifically, we focus on water management and greenhouse gas emission implications. If unconventional natural gas in the United States is produced responsibly, transported and distributed with little leakage, and incorporated into integrated energy systems that are designed for future resiliency, it could play a significant role in realizing a more sustainable energy future. The cutting-edge of industry water management practices gives a picture of how this transition is unfolding, although much opportunity remains to minimize water use and related environmental impacts. The role of natural gas to mitigate climate forcing is less clear. While natural gas has low CO2 emissions upon direct use, methane leakage and long term climate effects lead to the conclusion that increased use of natural gas as a substitute for more carbon intensive fuels will not substantially alter world carbon dioxide concentration projections, and that other zero or low carbon energy sources will be needed to limit GHG concentrations. We conclude with some possible avenues for further work.
Severe traumatic brain injury (TBI) is the most common cause of brain injury in the Western world and leads to physical, cognitive and emotional deficits that reduce independence. Changes to psychosocial function are the most disruptive, resulting in vocational difficulties, family stress and deteriorating relationships, and are a major target for remediation. But rehabilitation is expensive and its evidence base is limited. Thus, new collaborative initiatives are needed. This article details the development of ‘Moving Ahead’, a model for a Centre of Research Excellence (CRE) for Traumatic Brain Injury Rehabilitation. This CRE offers several major innovations. First, it provides an integrated, multi-faceted approach to addressing psychosocial difficulties embracing different clinical standpoints (e.g., psychological, speech pathology, occupational therapy) and levels of investigation (e.g., basic science to community function) across the lifespan. It is based upon a close relationship with clinicians to ensure transfer of research to practice and, conversely, to ensure that research is clinically meaningful. It provides an integrated platform with which to support and train new researchers in the field via scholarships, postdoctoral fellowships, websites, meetings, mentoring and across-site training, and thus build workforce capacity for individuals with TBI and their families. It has input from the international community to contextualise research more broadly and ensure scientific rigour. Finally, it provides collaboration across sites to facilitate research and data collection.
Renewable energy can provide a host of benefits to society. In addition to the reduction of carbon dioxide (CO2) emissions, governments have enacted renewable energy (RE) policies to meet a number of objectives including the creation of local environmental and health benefits; facilitation of energy access, particularly for rural areas; advancement of energy security goals by diversifying the portfolio of energy technologies and resources; and improving social and economic development through potential employment opportunities. Energy access and social and economic development have been the primary drivers in developing countries whereas ensuring a secure energy supply and environmental concerns have been most important in developed countries.
An increasing number and variety of RE policies–motivated by a variety of factors–have driven substantial growth of RE technologies in recent years. Government policies have played a crucial role in accelerating the deployment of RE technologies. At the same time, not all RE policies have proven effective and efficient in rapidly or substantially increasing RE deployment. The focus of policies is broadening from a concentration almost entirely on RE electricity to include RE heating and cooling and transportation.
RE policies have promoted an increase in RE capacity installations by helping to overcome various barriers. Barriers specific to RE policymaking (e.g., a lack of information and awareness), to implementation (e.g., a lack of an educated and trained workforce to match developing RE technologies) and to financing (e.g., market failures) may further impede deployment of RE.
Mandatory active surveillance culturing of all patients admitted to Veterans Affairs (VA) hospitals carries substantial economic costs. Clinical prediction rules have been used elsewhere to identify patients at high risk of colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE). We aimed to derive and evaluate the clinical efficacy of prediction rules for MRSA and VRE colonization in a VA hospital.
Design and Setting.
Prospective cohort of adult inpatients admitted to the medical and surgical wards of a 119-bed tertiary care VA hospital.
Methods.
Within 48 hours after admission, patients gave consent, completed a 44-item risk factor questionnaire, and provided nasal culture samples for MRSA testing. A subset provided perirectal culture samples for VRE testing.
Results.
Of 598 patients enrolled from August 30, 2007, through October 30, 2009, 585 provided nares samples and 239 provided perirectal samples. The prevalence of MRSA was 10.4% (61 of 585) (15.0% in patients with and 5.6% in patients without electronic medical record (EMR)-documented antibiotic use during the past year; P < .01). The prevalence of VRE was 6.3% (15 of 239) (11.3% in patients with and 0.9% in patients without EMR-documented antibiotic use; P < .01 ). The use of EMR-documented antibiotic use during the past year as the predictive rule for screening identified 242.8 (84%) of 290.6 subsequent days of exposure to MRSA and 60.0 (98%) of 61.0 subsequent days of exposure to VRE, respectively. EMR documentation of antibiotic use during the past year identified 301 (51%) of 585 patients as high-risk patients for whom additional testing with active surveillance culturing would be appropriate.
Conclusions.
EMR documentation of antibiotic use during the year prior to admission identifies most MRSA and nearly all VRE transmission risk with surveillance culture sampling of only 51% of patients. This approach has substantial cost savings compared with the practice of universal active surveillance.
Gastroenteritis, broadly defined, refers to any inflammatory process of the stomach or intestinal mucosal surface. However, the term usually refers to acute infectious diarrhea, a diarrheal syndrome of less than 2 weeks' duration that may be accompanied by fever, nausea, vomiting, abdominal pain, dehydration, and weight loss. This chapter provides an overview of the infectious enteritides. Other chapters consider food poisoning, traveler's diarrhea, antibiotic-associated diarrhea, sexually transmitted enteric infections, and Helicobacter pylori disease.
In developed countries, gastroenteritis, similar to upper respiratory infections, is common and annoying, but it usually does not require a physician visit, laboratory evaluation, or antibiotic treatment. Globally, it is the second-leading cause of mortality, after cardiovascular disease. Gastroenteritis is the leading worldwide cause of childhood death and of years of productive life lost, with approximately 12 600 deaths per day. Annual per-person attack rates range from 1 to 5 in the United States and Europe and up to 5 to 20 in the developing world. There are approximately 100 million cases per year among adults in the United States, nearly 50% of which require subjects to limit their activities for more than 24 hours, whereas 8% require consultation with a physician and fewer than 0.3% result in hospitalization.