Impact of Prehospital Pain Management on Emergency Department Management of Injured Children.

OBJECTIVE: Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS. METHODS: This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions. RESULTS: We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care. CONCLUSIONS: We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.

Machine learning prediction of electron density and temperature from He I line ratios.

We propose to utilize machine learning to predict the electron density, ne, and temperature, Te, from He I line intensity ratios. In this approach, training data consist of measured He I line ratios as input and ne and Te measured using other diagnostic(s) as desired output, which is a Langmuir probe in our study. Support vector machine regression analysis is, then, performed with the training data to develop a predictive model for ne and Te, separately. It is confirmed that ne and Te predicted using the developed models agree well with those from the Langmuir probe in the ranges of 0.28 × 1018 ≤ ne (m-3) ≤ 3.8 × 1018 and 3.2 ≤ Te (eV) ≤ 7.5. The developed models are, further, examined with an evaluation data, which are not included in the training data, and are found to well reproduce absolute values and radial profiles of probe-measured ne and Te.

New application of hyperspectral imaging to steady-state plasma observations.

A new application of hyperspectral imaging (HSI) to steady-state plasma emission observations is proposed because of its prominent feature: an HSI camera records a two-dimensional image, and each spatial pixel contains spectral data typically with more than a hundred bands, while conventional digital cameras have only three bands. The characterization of an HSI camera (Specim IQ) has been performed during steady-state plasma-material interaction experiments using the linear plasma device PISCES-A. By easily subtracting the background/continuum emission in contrast to conventional filter cameras, two-dimensional images of multiple emission lines at different wavelengths are simultaneously obtained during a single measurement, demonstrating the advantage in plasma emission observations.

Effect of low and moderate dose FEIBA to reverse major bleeding in patients on direct oral anticoagulants.

OBJECTIVE: Management of acute, major or life threatening bleeding in the presence of direct acting oral anticoagulants (DOAC) is unclear. In the absence of a specific antidote, or in situations where there is a need for adjunctive therapy, the ideal prothrombin complex concentrate and dose is unclear. The goal of our study was to evaluate the outcomes of our reduced dosing strategy with FEIBA in patients experiencing a DOAC-related bleeding event. DESIGN: Retrospective analysis of patients treated with FEIBA for a DOAC-related bleeding event. SETTING: Academic medical center PATIENTS: Consecutive patients between May 2011 and April 2017 receiving FEIBA for a DOAC-related bleed INTERVENTIONS: None MEASUREMENTS & MAIN RESULTS: Of the 64 patients included in this analysis, 38 patients received low dose FEIBA (mean 10.0 ±â€¯3.6 units/kg) and 26 received moderate dose (mean 24.3 ±â€¯2.1 units/kg) FEIBA; an additional dose was requested in 6 patients. Six dabigatran patients received idarucizumab. 30 day event rates included 5 thromboembolic events (8%) and 9 (14%) patients expired. Follow-up CT-imaging for ICH, endoscopy/colonoscopy, or interventional radiology exams did not reveal any clinically concerning active bleeding or hematoma expansion except in 2 ICH patients with slight expansion between imaging sessions. CONCLUSIONS: Low (<20 units/kg) to moderate (20-30 units/kg) doses of FEIBA, with the option for a repeat dose, may be an effective management strategy for obtaining hemostasis in DOAC-related major bleeding events.

Development of a LIBS system for in situ surface measurements during plasma exposure in PISCES-A.

A laser-induced breakdown spectroscopy (LIBS) system has been developed with a Q-switched Nd:YAG laser (wavelength = 1064 nm and pulse width ∼5 ns) to conduct in situ surface measurements during plasma exposure in the PISCES-A linear divertor plasma simulator. The LIBS signal enhancement is obtained with both the magnetic field normal to the surface of a target and steady-state background plasma. Migration of sputtered Ta impurities onto the neighboring Cr surface is identified during He plasma exposure, only when cone structures are formed on the Cr surface. D retention in W during D plasma exposure is observed to decrease with increasing the sample temperature. The temporal evolution of D outgassing from W is measured in a time range of ∼10-420 s right after D plasma exposure. A power law fit, t -α , yields α ∼ 0.34 ± 0.09, which is nearly consistent with calculated and measured values.

The Accuracy of an Electronic Pulmonary Embolism Severity Index Auto-Populated from the Electronic Health Record: Setting the stage for computerized clinical decision support.

BACKGROUND: The Pulmonary Embolism (PE) Severity Index identifies emergency department (ED) patients with acute PE that can be safely managed without hospitalization. However, the Index comprises 11 weighted variables, complexity that can impede its integration into contextual workflow. OBJECTIVE: We designed a computerized version of the PE Severity Index (e-Index) to automatically extract the required variables from discrete fields in the electronic health record (EHR). We tested the e-Index on the study population to determine its accuracy compared with a gold standard generated by physician abstraction of the EHR on manual chart review. METHODS: This retrospective cohort study included adults with objectively-confirmed acute PE in four community EDs from 2010-2012. Outcomes included performance characteristics of the e-Index for individual values, the number of cases requiring physician editing, and the accuracy of the e-Index risk category (low vs. higher). RESULTS: For the 593 eligible patients, there were 6,523 values automatically extracted. Fifty one of these needed physician editing, yielding an accuracy at the value-level of 99.2% (95% confidence interval [CI], 99.0%-99.4%). Sensitivity was 96.9% (95% CI, 96.0%-97.9%) and specificity was 99.8% (95% CI, 99.7%-99.9%). The 51 corrected values were distributed among 47 cases: 43 cases required the correction of one variable and four cases required the correction of two. At the risk-category level, the e-Index had an accuracy of 96.8% (95% CI, 95.0%-98.0%), under-classifying 16 higher-risk cases (2.7%) and over-classifying 3 low-risk cases (0.5%). CONCLUSION: Our automated extraction of variables from the EHR for the e-Index demonstrates substantial accuracy, requiring a minimum of physician editing. This should increase user acceptability and implementation success of a computerized clinical decision support system built around the e-Index, and may serve as a model to automate other complex risk stratification instruments.

Observation of turbulent-driven shear flow in a cylindrical laboratory plasma device.

An azimuthally symmetric radially sheared plasma fluid flow is observed to spontaneously form in a cylindrical magnetized helicon plasma device with no external sources of momentum input. A turbulent momentum conservation analysis shows that this shear flow is sustained by the Reynolds stress generated by collisional drift turbulence in the device. The results provide direct experimental support for the basic theoretical picture of drift-wave-shear-flow interactions.

The proliferative and antiapoptotic effects of substance P are facilitated by formation of a beta -arrestin-dependent scaffolding complex.

A requirement for scaffolding complexes containing internalized G protein-coupled receptors and beta-arrestins in the activation and subcellular localization of extracellular signal-regulated kinases 1 and 2 (ERK1/2) has recently been proposed. However, the composition of these complexes and the importance of this requirement for function of ERK1/2 appear to differ between receptors. Here we report that substance P (SP) activation of neurokinin-1 receptor (NK1R) stimulates the formation of a scaffolding complex comprising internalized receptor, beta-arrestin, src, and ERK1/2 (detected by gel filtration, immunoprecipitation, and immunofluorescence). Inhibition of complex formation, by expression of dominant-negative beta-arrestin or a truncated NK1R that fails to interact with beta-arrestin, inhibits both SP-stimulated endocytosis of the NK1R and activation of ERK1/2, which is required for the proliferative and antiapoptotic effects of SP. Thus, formation of a beta-arrestin-containing complex facilitates the proliferative and antiapoptotic effects of SP, and these effects of SP could be diminished in cells expressing truncated NK1R corresponding to a naturally occurring variant.