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To determine the association between delay in transfer to a central stroke unit from peripheral institutions and outcomes.
Methods:
We conducted a retrospective cohort study of all patients with acute stroke, admitted to a comprehensive stroke center (CSC) from three emergency departments (EDs), between 2016 and 2018. The primary outcomes were length of stay, functional status at 3 months, discharge destination, and time to stroke investigations.
Results:
One thousand four hundred thirty-five patients were included, with a mean age of 72.9 years, and 92.4% ischemic stroke; 663 (46.2%) patients were female. Each additional day of delay was associated with 2.0 days of increase in length of stay (95% confidence interval [CI] 0.8–3.2, p = 0.001), 11.5 h of delay to vascular imaging (95% CI 9.6–13.4, p < 0.0001), 24.2 h of delay to Holter monitoring (95% CI 7.9–40.6, p = 0.004), and reduced odds of nondisabled functional status at 3 months (odds ratio 0.98, 95% CI 0.96–1.00, p = 0.01). Factors affecting delay included stroke onset within 6 h of ED arrival (605.9 min decrease in delay, 95% CI 407.9–803.9, p < 0.0001), delay to brain imaging (59.4 min increase in delay for each additional hour, 95% CI 48.0–71.4, p < 0.0001), admission from an alternative service (3918.7 min increase in delay, 95% CI 3621.2–4079.9, p < 0.0001), and transfer from a primary stroke center (PSC; 740.2 min increase in delay, 95% CI 456.2–1019.9, p < 0.0001).
Conclusion:
Delay to stroke unit admission in a system involving transfer from PSCs to a CSC was associated with longer hospital stay and poorer functional outcomes.
The purpose of this study was to pilot safety and tolerability of a 1-week aerobic exercise program during the post-acute phase of concussion (14–25 days post-injury) by examining adherence, symptom response, and key functional outcomes (e.g., cognition, mood, sleep, postural stability, and neurocognitive performance) in young adults.
Method:
A randomized, non-blinded pilot clinical trial was performed to compare the effects of aerobic versus non-aerobic exercise (placebo) in concussion patients. The study enrolled three groups: 1) patients with concussion/mild traumatic brain injury (mTBI) randomized to an aerobic exercise intervention performed daily for 1-week, 2) patients with concussion/mTBI randomized to a non-aerobic (stretching and calisthenics) exercise program performed daily for 1-week, and 3) non-injured, no intervention reference group.
Results:
Mixed-model analysis of variance results indicated a significant decrease in symptom severity scores from pre- to post-intervention (mean difference = −7.44, 95% CI [−12.37, −2.20]) for both concussion groups. However, the pre- to post-change was not different between groups. Secondary outcomes all showed improvements by post-intervention, but no differences in trajectory between the groups. By three months post-injury, all outcomes in the concussion groups were within ranges of the non-injured reference group.
Conclusions:
Results from this study indicate that the feasibility and tolerability of administering aerobic exercise via stationary cycling in the post-acute time frame following post-concussion (14–25 days) period are tentatively favorable. Aerobic exercise does not appear to negatively impact recovery trajectories of neurobehavioral outcomes; however, tolerability may be poorer for patients with high symptom burden.
This article analyses the religious and other motivations of Robert Hingson and Brother's Brother Foundation in their work on smallpox eradication and international health more broadly. It examines Hingson's development and early usage of the jet injector in mass vaccination campaigns. It also highlights that in offering logistical support to Hingson's efforts in Liberia, the US government participated in smallpox eradication earlier than existing narratives have suggested.
Invasive plants may dramatically impact forest ecosystems by establishing dense populations and suppressing the recruitment of native tree species. One invasive shrub currently spreading throughout eastern deciduous forests of North America, Japanese barberry (Berberis thunbergii DC), may be limiting tree recruitment in stands where it invades. Once established, B. thunbergii becomes densely populated within forest understories and suppresses native plants by competing for limited resources, altering soil conditions, and changing the understory microclimate. To quantify native seedling inhibition caused by B. thunbergii invasion, we conducted an observational study on seedling abundance within forest plots that were either invaded or not invaded by B. thunbergii and used survey data to generate Bayesian models of native seedling densities along gradients of increasing B. thunbergii stem counts and aboveground plant dry mass. Model outputs predicted that B. thunbergii–invaded plots had 82% lower seedling densities compared with uninvaded plots. Native tree seedling densities were very low even in areas with moderate B. thunbergii density, suggesting that reduced tree seedling densities are observed even at low densities of invasion. Our findings indicate that forests invaded with B. thunbergii harbor substantially lower densities of native tree seedlings, with potentially significant long-term consequences for forest ecological integrity, biodiversity, and ecosystem services.
In-situ wafer curvature measurements were used to study the effect of Si doping on intrinsic growth stress during the metalorganic chemical vapor deposition (MOCVD) growth of AlxGa1-xN (x=0-0.62) layers on SiC substrates. Post-growth transmission electron microscopy (TEM) characterization was used to correlate measured changes in stress with changes in film microstructure. Si doping was found to result in the inclination of edge-type threading dislocations (TDs) in AlxGa1-xN which resulted in a relaxation of compressive stress and generation of tensile stress. The experimentally measured stress gradient was similar to that predicted by an effective climb model. Dislocation inclination resulted in a reduction in the TD density for Si-doped layers compared to undoped AlxGa1-xN likely due to increased opportunities for dislocation interaction and annihilation. The TD density, which increased with increasing Al-fraction, was found to significantly alter the stress gradients in the films. Film stress was also observed to play a role in TD inclination. In undoped AlxGa1-xN, TD inclination was observed only when the film grew under a compressive stress while in Si-doped AlxGa1-xN, TD inclination was observed independent of the sign or magnitude of the film stress. Si dopants are believed to alter the concentration of surface vacancies which gives rise to dislocation jog via a surface-mediated climb mechanism.
The inability to reach a substantive concluding document at the Belgrade Meeting and increased Soviet and Eastern European repression of human rights activists in the meeting's wake raised questions about the potential promise of the Helsinki process. What followed was a complicated but important period in which political support for the Helsinki process solidified in the United States, Western allies united around CSCE objectives, and nongovernmental organizations developed a cohesive approach to promoting their agenda, but little progress was made in securing human rights observance in Eastern Europe. The significance of this period lies in the strengthening of the Western commitment to human rights such that Eastern European violations became an important component of East–West diplomacy. As this chapter illustrates, transnational connections forged in advance of and during the Madrid CSCE Review Meeting (1980–3) were a fundamental reason human rights took on such international importance. Western pressure throughout these years did not result in meaningful success but did convince Soviet leaders that progress on other questions such as trade and arms control was connected with their record on human rights. Although the sides remained at a virtual stalemate until 1985, the increasing attention to human rights in the preceding years was an integral part of the human rights reforms that arose once Mikhail Gorbachev came to power.
The official CSCE negotiations began in November 1972, and for two and a half years, thirty-five European and North American states debated what became known as the Helsinki Final Act. By the time the agreement was signed on August 1, 1975, the content bore little resemblance to early Soviet proposals. Instead, the text included a number of unique elements advocated by Western and neutral and nonaligned (NNA) states that led to the CSCE's surprising influence on East–West relations. The agreement's follow-up mechanism, commitment to respect human rights, and provisions for human contacts all fostered the development of a transnational network that played an important role in shaping political and social change in Europe in the late 1980s.
A number of earlier works, predominantly written by diplomats engaged in the CSCE negotiations, have addressed the years of talks that produced the Helsinki Final Act and examined the process by which thirty-five delegations finally reached a consensus. This chapter builds upon their accounts and other more recent scholarship. It begins by explaining why the Soviets lobbied for the conference beginning in 1954, and why Western states ultimately agreed to participate. My discussion, however, focuses more closely on how the NATO caucus succeeded in transforming the CSCE agenda and reshaping it to the West's long-term advantage despite many internal disagreements and an overall lack of foresight as to the significance of the Helsinki Final Act.
The largely peaceful collapse of communism in Eastern Europe in 1989, the reunification of Germany in 1990, and the disintegration of the Soviet Union in 1991 traditionally signify the end of the Cold War, which had dominated international relations for more than forty-five years. The end of the Cold War has been attributed to a multitude of factors including economic decline, imperial overstretch, military competition, nationalism, the transmission of Western culture, scientific and educational contacts, and the personalities of key political leaders, among others. I have argued that the Helsinki process and the transnational network of human rights advocates also contributed to the transformation of Europe, and that the development of this network established human rights as an integral component of international relations. My research shows that the Helsinki process directly and indirectly influenced both Western and Eastern governments to pursue policies that facilitated the rise of organized dissent in Eastern Europe, freedom of movement for East Germans, and improved human rights practices in the Soviet Union – all factors in the end of the Cold War. Finally, I have suggested that January 19, 1989, may be the appropriate date to consider as the end of the Cold War; on that day CSCE representatives agreed to the Vienna Concluding Document, which included legitimate commitments to enhance religious freedom, facilitate the spread of information, and address human rights and human contacts in three subsequent conferences.
In the aftermath of Belgrade, the long-term future of the CSCE at the official level appeared temporarily secure, with the Madrid Review Meeting scheduled to open in 1980 and the United States exerting increased influence in the Helsinki process. The outlook for monitoring groups, however, was far bleaker as repression of Helsinki activists in Eastern Europe escalated. To fill the void and build upon their work, NGOs outside of Eastern Europe were needed to aid the monitoring efforts. Two critical groups emerged: Helsinki Watch, a United States-based group made up of private citizens that became the most influential Western NGO devoted to Helsinki monitoring, and later the International Helsinki Federation for Human Rights, an international umbrella organization for Helsinki groups across CSCE states. Importantly, Helsinki Watch was part of a broader network of human rights organizations developing internationally in the 1970s, and it played a central role in the rising profile of human rights activism. Helsinki Watch and its allies in the IHF used their influence to press Western and neutral CSCE delegations to focus attention on the plight of Eastern Helsinki monitors and abuses of human rights more broadly. The IHF also widened nongovernmental support for Helsinki monitoring by incorporating a broader range of Western voices. It strengthened and formalized diffuse Helsinki monitoring activities, thereby heightening their effectiveness.
Jimmy Carter's election in 1976 transformed United States involvement in the Helsinki process and the government's attitude toward human rights. Carter's focus on human rights, and specifically on Helsinki implementation, integrated both issues into United States foreign policy toward Eastern Europe. At the 1977–8 Belgrade Follow-up Meeting, which would become a turning point for the United States in the Helsinki process, the Carter administration made clear the importance of human rights to its foreign policy while significantly raising its profile within the CSCE negotiations. In part due to this change in United States policy, the CSCE became an ongoing process that held all participants accountable for compliance with the agreement. The new United States approach to the CSCE was essential to the long-term influence of the Helsinki process given that dissidents in Eastern Europe needed high-level allies who could utilize their reports of human rights abuses in an international framework and exert pressure on repressive governments to changes their practices. Furthermore, its emphasis on thorough Helsinki compliance was critical to later change in Eastern Europe, even if it temporarily complicated CSCE discussions.
The Belgrade Follow-up Meeting also proved significant to the development and influence of the transnational Helsinki network. First, the promise to evaluate Helsinki compliance at Belgrade provided a rationale for individual, collective, and governmental efforts to monitor adherence to the Helsinki Final Act; as the previous two chapters have shown, the result was the emergence of a variety of monitoring organizations.
The pace of progress accelerated in the months following the Vienna Meeting, ushering in significant developments in the Helsinki process. Within the CSCE framework, almost all contentious issues were resolved, enabling agreements on such topics as adherence to the principles of pluralistic democracy, market capitalism, and the rule of law. More broadly, stunning changes transformed Eastern and Central Europe between 1989 and 1991, and Helsinki monitors were active in the movements that toppled communist leadership in Czechoslovakia and Poland. The broader Helsinki network was one element in a kaleidoscope that shaped the changes across Eastern Europe and the Soviet Union throughout this period. This chapter, which draws its title from a speech given by Charter 77 activist and Czechoslovak President Václav Havel to Helsinki Watch in February 1990, demonstrates how Helsinki activism influenced the transformation of Europe both directly and indirectly. The steps taken by Gorbachev to ensure the acceptance of the Moscow conference had signaled a momentous shift in Soviet attitudes toward human rights and the CSCE. Concessions such as the release of political prisoners, granting exit visas to long-time refuseniks, and allowing travel to the West were crucial to the broader end of the Cold War. My work suggests the Helsinki process was one factor that shaped Gorbachev's thinking about human rights, self-determination, and nonviolence, all of which contributed to the demise of communism in Eastern Europe and the collapse of the Soviet Union.
The rapid demise of communism in Eastern Europe, the reunification of a long-divided Germany, and finally the disintegration of the Soviet Union stunned almost all observers. These three developments, all within a few years of each other, represent for many the end of the Cold War. Understanding how and why the Cold War concluded is one of the most pressing questions historians face today. Thus far, scholars have considered a range of factors in assessing the end of the Cold War, with the predominant explanations focusing on Soviet economic stagnation, the arms race, the influence of ideas, the power of personality, Eastern European agency, and overextension abroad. Historians generally have underestimated the role of human rights advocacy and the influence of the 1975 Helsinki Final Act, which was the culmination of three years of negotiations at the Conference on Security and Cooperation in Europe (CSCE) and contained principles to govern East–West interactions in Europe. The Helsinki Final Act, however, spurred the development of a transnational network that significantly contributed to the end of the Cold War.
Examining the end of the Cold War through the lens of the CSCE also suggests a less traditional endpoint to the half-century superpower rivalry – January 19, 1989. On that date, the CSCE Vienna Review Meeting ended, representing a substantive end to the divide that had previously characterized Europe and East–West relations.