Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes.

OBJECTIVES: Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. METHODS: This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). RESULTS: Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. CONCLUSIONS: In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.

Effectiveness of a Novel Rapid Infusion Device and Clinician Education for Early Fluid Therapy by Emergency Medical Services in Sepsis Patients: A Pre-Post Observational Study.

OBJECTIVE: Emergency medical services (EMS) clinicians are tasked with early fluid resuscitation for patients with sepsis. Traditional methods for prehospital fluid delivery are limited in speed and ease-of-use. We conducted a comparative effectiveness study of a novel rapid infusion device for prehospital fluid delivery in suspected sepsis patients. METHODS: This pre-post observational study evaluated a hand-operated, rapid infusion device in a single large EMS system from July 2021-July 2022. Prior to device deployment, EMS clinicians completed didactic and simulation-based device training. Data were extracted from the EMS electronic health record. Eligible patients included adults with suspected sepsis treated by EMS with intravenous fluids. The primary outcome was the proportion of patients receiving goal fluid volume (at least 500 mL) prior to hospital arrival. Secondary outcomes included in-hospital mortality, disposition, and length of stay. Multivariable logistic regression was used to compare outcomes between 6-month pre- and post-implementation periods (July-December 2021 and February-July 2022, respectively), adjusting for patient demographics, abnormal prehospital vital signs, and EMS transport interval. RESULTS: Of 1,180 eligible patients (552 in the pre-implementation period; 628 in the post-implementation period), the mean age was 72 years old, 45% were female, and 25% were minority race-ethnicity. Median (interquartile range) fluid volume (in mL) increased between the pre- and post-implementation periods (600 [400,1,000] and 850 [500-1,000], respectively). Goal fluid volume was achieved in 70% of pre-implementation patients and 82% of post-implementation patients. In adjusted analysis, post-implementation patients were significantly more likely to receive goal fluid volume than pre-implementation patients (adjusted odds ratio (aOR) 2.00, 95% confidence interval (CI) 1.51-2.66). Pre-post in-hospital mortality was not significantly different (aOR 0.91, 95% CI 0.59-1.39). CONCLUSION: In a single EMS system, sepsis education and introduction of a rapid infusion device was associated with achieving goal fluid volume for suspected sepsis. Further research is needed to assess the clinical effectiveness of infusion device implementation to improve sepsis patient outcomes.

Characteristics of sudden death by clinical criteria.

Sudden death is a leading cause of deaths nationally. Definitions of sudden death vary greatly, resulting in imprecise estimates of its frequency and incomplete knowledge of its risk factors. The degree to which time-based and coronary artery disease (CAD) criteria impacts estimates of sudden death frequency and risk factors is unknown. Here, we apply these criteria to a registry of all-cause sudden death to assess its impact on sudden death frequency and risk factors. The sudden unexpected death in North Carolina (SUDDEN) project is a registry of out of-hospital, adjudicated, sudden unexpected deaths attended by Emergency Medical Services. Deaths were not excluded by time since last seen or alive or by prior symptoms or diagnosis of CAD. Common criteria for sudden death based on time since last seen alive (both 24 hours and 1 hour) and prior diagnosis of CAD were applied to the SUDDEN case registry. The proportion of cases satisfying each of the 4 criteria was calculated. Characteristics of victims within each restrictive set of criteria were measured and compared to the SUDDEN registry. There were 296 qualifying sudden deaths. Application of 24 hour and 1 hour timing criteria compared to no timing criteria reduced cases by 25.0% and 69.6%, respectively. Addition of CAD criteria to each timing criterion further reduced qualifying cases, for a total reduction of 81.8% and 90.5%, respectively. However, characteristics among victims meeting restrictive criteria remained similar to the unrestricted population. Timing and CAD criteria dramatically reduces estimates of the number of sudden deaths without significantly impacting victim characteristics.

Prehospital Fluid Administration for Suspected Sepsis in a Large EMS System: Opportunities to Improve Goal Fluid Delivery.

OBJECTIVES: Despite EMS-implemented screening and treatment protocols for suspected sepsis patients, prehospital fluid therapy is variable. We sought to describe prehospital fluid administration in suspected sepsis patients, including demographic and clinical factors associated with fluid outcomes. METHODS: A retrospective cohort of adult patients from a large, county-wide EMS system from January 2018-February 2020 was identified. Patient care reports for suspected sepsis were included, as identified by EMS clinician impression of sepsis, or keywords "sepsis" or "septic" in the narrative. Outcomes were the proportions of suspected sepsis patients for whom intravenous (IV) therapy was attempted and those who received ≥500 mL IV fluid if IV access was successful. Associations between patient demographics and clinical factors with fluid outcomes were estimated with multivariable logistic regression adjusting for transport interval. RESULTS: Of 4,082 suspected sepsis patients identified, the mean patient age was 72.5 (SD 16.2) years, 50.6% were female, and 23.8% were Black. Median (interquartile range [IQR]) transport interval was 16.5 (10.9-23.2) minutes. Of identified patients, 1,920 (47.0%) had IV fluid therapy attempted, and IV access was successful in 1,872 (45.9%). Of those with IV access, 1,061 (56.7%) received ≥500mL of fluid from EMS. In adjusted analyses, female (versus male) sex (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.69-0.90), Black (versus White) race (OR 0.57, 95% CI 0.49-0.68), and end stage renal disease (OR 0.51, 95% CI 0.32-0.82) were negatively associated with attempted IV therapy. Systolic blood pressure (SBP) <90 mmHg (OR 3.89, 95% CI 3.25-4.65) and respiratory rate >20 (OR 1.90, 95% CI 1.61-2.23) were positively associated with attempted IV therapy. Female sex (OR 0.72, 95% CI 0.59-0.88) and congestive heart failure (CHF) (OR 0.55, 95% CI 0.40-0.75) were negatively associated with receiving goal fluid volume while SBP <90 mmHg (OR 2.30, 95% CI 1.83-2.88) and abnormal temperature (>100.4 F or <96 F) (OR 1.41, 95% CI 1.16-1.73) were positively associated. CONCLUSIONS: Fewer than half of EMS sepsis patients had IV therapy attempted, and of those, approximately half met fluid volume goal, especially when hypotensive and no CHF. Further studies are needed on improving EMS sepsis training and prehospital fluid delivery.

Emergency medical services professional behaviors with violent encounters: A prospective study using standardized simulated scenarios.

Introduction: To evaluate emergency medical services (EMS) professional response to escalating threats of violence during simulated patient encounters and describe differences in behaviors by characteristics. Methods: EMS professionals of a large county-based system participated in 1 of 4 standardized patient care scenarios. Each 8-minute scenario included escalated threats of violence such that EMS personnel should escape the scene for safety. Trained evaluators recorded EMS professionals' performance using standardized data elements. Outcomes included EMS personnel escape and verbal de-escalation attempts. Descriptive statistics and univariable odds ratios (OR) with 95% confidence intervals (95% CI) are reported. Results: There were 270 EMS professionals evaluated as individual members of 2-person crews. Overall, 54% escaped the unsafe scene and 54% made an adequate de-escalation attempt; 20% did not make an adequate de-escalation attempt nor escape the unsafe scene. Paramedics demonstrated lower odds of escaping compared to emergency medical technicians (OR: 0.40; 95% CI: 0.17-0.94), yet greater odds of adequate de-escalation (OR: 3.17, 95% CI: 1.38-7.31). EMS professionals with more than 20 years of experience (OR: 0.32, 95% CI: 0.13-0.79, ref:2 years or less) and those with military experience (OR: 0.37; 95% CI: 0.17-0.81) demonstrated reduced odds of escaping. Crisis intervention team (CIT) training was associated with reduced odds of escape (OR: 0.38; 95% CI: 0.21-0.69), but increased odds of adequate de-escalation (OR: 2.19; 95% CI: 1.19-4.04). Conclusions: Nearly half of EMS professionals did not remove themselves from a simulated patient care scenario with an escalating threat of physical violence. EMS-specific training for de-escalation as a first-line technique, recognizing imminent violence, and leaving a dangerous environment is needed.

Performance of the vision, aphasia, neglect (VAN) assessment within a single large EMS system.

BACKGROUND: There is limited evidence on the performance of emergent large-vessel occlusion (LVO) stroke screening tools when used by emergency medical services (EMS) and emergency department (ED) providers. We assessed the validity and predictive value of the vision, aphasia, neglect (VAN) assessment when completed by EMS and in the ED among suspected stroke patients. METHODS: We conducted a retrospective study of VAN performed by EMS providers and VAN inferred from the National Institutes of Health Stroke Scale performed by ED nurses at a single hospital. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAN by EMS and in the ED for LVO and a combined LVO and intracerebral hemorrhage (ICH) outcome. RESULTS: From January 2018 to June 2020, 1,547 eligible patients were identified. Sensitivity and specificity of ED VAN were similar for LVO (72% and 74%, respectively), whereas EMS VAN was more sensitive (84%) than specific (68%). PPVs were low for both EMS VAN (26%) and ED VAN (21%) to detect LVO. Due to several VAN-positive ICHs, PPVs were substantially higher for both EMS VAN (44%) and ED VAN (39%) to detect LVO or ICH. EMS and ED VAN had high NPVs (97% and 96%, respectively). CONCLUSIONS: Among suspected stroke patients, we found modest sensitivity and specificity of VAN to detect LVO for both EMS and ED providers. Moreover, the low PPV in our study suggests a significant number of patients with non-LVO ischemic stroke or ICH could be over-triaged with VAN.

Putative poison gland in the thorny catfish Acanthodoras spinosissimus (Siluriformes: Doradidae) / Suposta glândula de veneno no bagre rebeca Acanthodoras spinosissimus (Siluriformes: Doradidae)

Acanthodoras is the only genus of catfish known to secrete a conspicuous and abundant milky-looking substance through an axillary pore located just below the base of the posterior cleithral process. Despite this remarkable feature, there is no published information on the anatomical structures that produce the secretion and its possible biological/ecological functions. Dissection and histological analysis of preserved specimens of A. spinosissimus revealed the presence of a saccular axillary gland with large, binuclear secretory cells, similar to those found in other poisonous catfish. Secretory cells near the lumen appear to lose nuclei and become filled with secretory products, possibly with proteinaceous elements, as indicated by their eosinophilic appearance. As far as we know, the saccular morphology of the gland appears to constitute a unique characteristic of Acanthodoras among Doradidae catfishes. Further studies are necessary to determine the chemical composition of the secretion, as well as its possible uses by the catfish in its natural environment.

Acanthodoras é o único gênero de bagre conhecido por secretar uma substância de aparência leitosa conspícua e abundante através de um poro axilar localizado logo abaixo da base do processo cleitral posterior. Apesar dessa característica marcante, não há informações publicadas sobre as estruturas anatômicas que produzem a secreção, nem sobre suas possíveis funções biológicas/ecológicas. A dissecção e análise histológica de espécimes preservados de A. spinosissimus revelaram a presença de uma glândula axilar sacular com células secretoras binucleares, semelhantes às encontradas em outros bagres venenosos. As células secretoras próximas ao lúmen parecem perder os núcleos e são preenchidas com produtos secretores, possivelmente com elementos proteicos, conforme indicado por sua aparência eosinofílica. Até onde sabemos, a morfologia sacular da glândula parece constituir uma característica única de Acanthodoras entre os bagres Doradidae. Mais estudos são necessários para determinar a composição química da secreção, bem como seus possíveis usos pelo bagre em seu ambiente natural.

Putative poison gland in the thorny catfish Acanthodoras spinosissimus (Siluriformes: Doradidae)

ABSTRACT Acanthodoras is the only genus of catfish known to secrete a conspicuous and abundant milky-looking substance through an axillary pore located just below the base of the posterior cleithral process. Despite this remarkable feature, there is no published information on the anatomical structures that produce the secretion and its possible biological/ecological functions. Dissection and histological analysis of preserved specimens of A. spinosissimus revealed the presence of a saccular axillary gland with large, binuclear secretory cells, similar to those found in other poisonous catfish. Secretory cells near the lumen appear to lose nuclei and become filled with secretory products, possibly with proteinaceous elements, as indicated by their eosinophilic appearance. As far as we know, the saccular morphology of the gland appears to constitute a unique characteristic of Acanthodoras among Doradidae catfishes. Further studies are necessary to determine the chemical composition of the secretion, as well as its possible uses by the catfish in its natural environment.

RESUMO Acanthodoras é o único gênero de bagre conhecido por secretar uma substância de aparência leitosa conspícua e abundante através de um poro axilar localizado logo abaixo da base do processo cleitral posterior. Apesar dessa característica marcante, não há informações publicadas sobre as estruturas anatômicas que produzem a secreção, nem sobre suas possíveis funções biológicas/ecológicas. A dissecção e análise histológica de espécimes preservados de A. spinosissimus revelaram a presença de uma glândula axilar sacular com células secretoras binucleares, semelhantes às encontradas em outros bagres venenosos. As células secretoras próximas ao lúmen parecem perder os núcleos e são preenchidas com produtos secretores, possivelmente com elementos proteicos, conforme indicado por sua aparência eosinofílica. Até onde sabemos, a morfologia sacular da glândula parece constituir uma característica única de Acanthodoras entre os bagres Doradidae. Mais estudos são necessários para determinar a composição química da secreção, bem como seus possíveis usos pelo bagre em seu ambiente natural.

Symptoms prior to sudden death.

BACKGROUND: Sudden death accounts for up to 15% of all deaths among working age adults. A better understanding of victims' medical care and symptoms reported at their last medical encounter may identify opportunities for interventions to prevent sudden deaths. METHODS: From 2013-15, all out-of-hospital deaths, ages 18-64 reported by Emergency Medical Services (EMS) in Wake County, North Carolina were screened and adjudicated to identify 399 victims of sudden death, 264 of whom had available medical records. Demographic and clinical characteristics and prescribed medications were compared between victims with versus without a medical encounter within one month preceding death with chi-square tests and t-tests, as appropriate. Symptoms reported in medical encounters within one month preceding death were analyzed. RESULTS: Among the 264 victims with available medical records, 73 (27.7%) had at least one encounter within a month preceding death. These victims were older and more likely to have multiple chronic illnesses, yet most were not prescribed evidence-based medicines. Of these 73 victims, 30 (41.1%) reported cardiac symptoms including dyspnea, edema, and chest pain. CONCLUSIONS: Many victims seek medical care and report cardiac symptoms in the month prior to sudden death. However, medications that might prevent sudden death are under prescribed. These findings suggest that there are opportunities for intervention to prevent sudden death.

Opportunities for Emergency Medical Services Intervention to Prevent Opioid Overdose Mortality.

OBJECTIVES: The opioid crisis is a growing cause of mortality in the United States and may be mitigated by innovative approaches to identifying individuals at-risk of fatal opioid overdose. We examined Emergency Medical Services (EMS) utilization among a cohort of individuals who died from opioid overdose in order to identify potential opportunities for intervention. Methods: Individuals who died of unintentional opioid overdose in a large North Carolina county between 01/01/2014 and 12/31/2016 were studied in a retrospective cohort. Death records obtained from North Carolina Vital Records were linked to EMS patient care records obtained from the county EMS System in order to describe the EMS encounters of each decedent in the year preceding their death. Patient demographics and EMS encounters were assessed to identify encounter characteristics that may be targeted for intervention. Chi-square tests and odds ratios were used to evaluate and characterize the statistical significance of differences in EMS utilization. Results: Of the 218 individuals who died from unintentional opioid overdose in the study interval, 30% (n = 66) utilized EMS in the year before their death and 17% (n = 38) had at least one EMS encounter with documented drug or alcohol use (i.e. "drug-related encounter"). The mean age at death was 38 (range 19-74) years, 30% were female, 89% were White, and 8% were Black/African American. Factors associated with higher incidence of EMS utilization included age (P<.001), gender (P=.006), and race (P<.001). Decedents aged 56-65 had the highest EMS utilization (47%) and patients aged <25 and 25-35 had more drug-related EMS encounters (29% and 20%, respectively). The most common reasons for EMS utilization were "other medical" (27%), "non-traumatic pain" (20%), "traumatic injury" (16%), and "poisoning/drug ingestion" (14%). Drug or alcohol use was documented by EMS in 33% of all encounters and an opioid prescription was reported in 22% of encounters. Conclusions: Nearly one-third of individuals who died from accidental opioid overdose utilized EMS in the year before their death and nearly one-fifth had a drug-related encounter. EMS encounters may present an opportunity to identify individuals at-risk of opioid overdose and, ultimately, reduce overdose mortality.

Predictive Utility of End-Tidal Carbon Dioxide on Defibrillation Success in Out-of-Hospital Cardiac Arrest.

INTRODUCTION: The likelihood of survival from ventricular fibrillation (VF) declines 7%-10% per minute until successful defibrillation. When VF duration is prolonged, immediate defibrillation of the ischemic myocardium is less likely to result in ROSC, and repeated unsuccessful defibrillations are associated with post-resuscitation myocardial dysfunction. Thus, the timing of defibrillation should be based upon the probability of shock success-a function of VF duration. Unfortunately, VF duration is often unknown in out-of-hospital cardiac arrest (OHCA) and a better predictor of shock success is needed. OBJECTIVE: To assess the ability of end-tidal carbon dioxide (EtCO2) to predict successful defibrillation in OHCA. METHODS: This retrospective study included adult patients among four EMS systems who experienced non-traumatic OHCA from August, 2015-July, 2017 and received one or more defibrillations. First and succedent shocks were analyzed separately. First shocks represented EMS-attempted defibrillation of patients who had not received a prior AED shock, whereas succedent shocks included all shocks subsequent to the first. Logistic regression provided odds ratios (OR) for first shocks resulting in ROSC, while a generalized estimating equation was used to analyze succedent shocks. RESULTS: Among 324 patients, 869 shocks were delivered by EMS (153 first and 716 succedent shocks). Layperson CPR was performed in 48.1% of cases and 21.6% received an AED shock before EMS arrival. First defibrillation ROSC was more likely with layperson CPR (OR = 4.41;p = 0.01) and increasing EtCO2 (OR = 1.03/mmHg;p = 0.01). No other variables were statistically significant. Notably, only one patient with EtCO2 < 20 mmHg was successfully defibrillated on the first shock. The probability of ROSC was higher with increasing values of EtCO2 when layperson CPR was provided, yet remained relatively unchanged across all values of EtCO2 ≥ 20 mmHg without layperson CPR. The optimal threshold first shock EtCO2 was 27 and 32 mmHg for those with/without layperson CPR, respectively. EtCO2 was not a predictor of ROSC for succedent shocks. CONCLUSIONS: An optimal defibrillation threshold EtCO2 of 27 and 32 mmHg was observed for patients with and without layperson CPR, respectively. Further studies are warranted to verify these results and to evaluate the clinical effect of delaying defibrillation in favor of chest compressions until these values are attained.

COVID-19 Pandemic: The Role of EMS Physicians in a Community Response Effort.

The COVID-19 pandemic is a worldwide historical event that will continue to affect nearly every aspect of ordinary life, including affecting our economic, political, and healthcare eco-systems. An effective pandemic response demands a coordinated and integrated response across community healthcare stakeholders, including Public Health and Emergency Management Officials. EMS systems are in a unique position and perform an essential role on the frontlines of COVID-19, including facilitating coordination of response efforts to COVID-19 within their communities while supporting public health mitigation efforts to slow the spread of the SARS-CoV-2. EMS physicians serve their communities at a unique intersection as clinical leaders, population health experts, and advocates. This paper examines and recommends crucial roles for EMS physician leaders as communities work together in pandemic response.

Influence of density and salinity on larval development of salt-adapted and salt-naïve frog populations.

Environmental change and habitat fragmentation will affect population densities for many species. For those species that have locally adapted to persist in changed or stressful habitats, it is uncertain how density dependence will affect adaptive responses. Anurans (frogs and toads) are typically freshwater organisms, but some coastal populations of green treefrogs (Hyla cinerea) have adapted to brackish, coastal wetlands. Tadpoles from coastal populations metamorphose sooner and demonstrate faster growth rates than inland populations when reared solitarily. Although saltwater exposure has adaptively reduced the duration of the larval period for coastal populations, increases in densities during larval development typically increase time to metamorphosis and reduce rates of growth and survival. We test how combined stressors of density and salinity affect larval development between salt-adapted ("coastal") and nonsalt-adapted ("inland") populations by measuring various developmental and metamorphic phenotypes. We found that increased tadpole density strongly affected coastal and inland tadpole populations similarly. In high-density treatments, both coastal and inland populations had reduced growth rates, greater exponential decay of growth, a smaller size at metamorphosis, took longer to reach metamorphosis, and had lower survivorship at metamorphosis. Salinity only exaggerated the effects of density on the time to reach metamorphosis and exponential decay of growth. Location of origin affected length at metamorphosis, with coastal tadpoles metamorphosing slightly longer than inland tadpoles across densities and salinities. These findings confirm that density has a strong and central influence on larval development even across divergent populations and habitat types and may mitigate the expression (and therefore detection) of locally adapted phenotypes.

Novel Use of Telemedicine by Hurricane Evacuation Shelters.

Introduction: Hurricane Florence made landfall in North Carolina as a Category 1 hurricane on September 14, 2018 causing catastrophic flooding throughout much of eastern North Carolina. Large numbers of evacuees were housed in evacuation shelters established by state emergency management and county governments. The purpose of this study was to evaluate the implementation of a telemedicine service in evacuation shelters to determine whether the presence of telemedicine could alter EMS and ED utilization. Methods: We conducted a cross-sectional study that described the EMS and Emergency Department utilization of patients housed in disaster shelters during a 12 day period following Hurricane Florence. Subjects were those shelter residents in Wake or Orange counties utilizing emergency services. Data were collected from Wake County EMS, Orange County EMS, and RelyMD, the telemedicine service utilized in the shelters. Data included subject demographics, chief complaint, case disposition, telemedicine processing times, and an after-call survey to assess satisfaction and emergency department avoidance rates. De-identified data were compiled into Excel spread sheets. Results: There were a total of 194 combined telemedicine and EMS patient encounters, including 63 EMS transports, 25 refusals, 13 referrals (Wake County EMS), and 93 telemedicine patient encounters. Of the telemedicine encounters, 64 evaluations took place in Wake County shelters and 29 evaluations in the Orange County shelter. Average patient age was 49 years old; 67% were female. Forty three patients (46%) utilized the telemedicine service for obtaining medication refills, of whom 19 (44%) indicated they would have otherwise utilized an ED to refill their medication. Forty patients (43%) indicated they would have otherwise gone to an ED for care had the service not been provided, with the needs of 33 (83%) of these patients successfully managed without evaluation in an ED. Only 9 (9.7%) patients were referred by the telemedicine service to an ED for an evaluation, with 3 (3.2%) being admitted. Conclusion: Our descriptive findings suggest telemedicine can be effectively utilized in a general population evacuation shelter to reduce EMS and ED utilization and address the medical needs of the population. Further studies should be performed to assess applicability to other disaster settings.

Therapeutic systemic hypothermia for a pediatric patient with an isolated cervical spinal cord injury.

Context: While uncommon, spinal cord injuries most frequently occur in adolescent and young adult males. Established treatment options are limited and focused on supportive care. Therapeutic systemic hypothermia is an emerging experimental treatment currently undergoing clinical trials in adults.Findings: Here we report a case of a 13-year-old male with an American Spinal Injury Association Impairment Scale grade C traumatic cervical spinal cord injury treated with 48 hours of therapeutic systemic hypothermia who made a complete neurological recovery. To our knowledge, this is the youngest such case report.Clinical relevance: This case suggests that consideration should be given to including pediatric patients in future clinical trials of therapeutic hypothermia for spinal cord injury.

Power-optimized, time-reversal pulse sequence for a robust recovery of signals from rigid segments using time domain NMR.

Time domain NMR (TD-NMR) has been widely used on the analysis of liquids or liquid components in heterogeneous materials such as food, biological tissues, synthetic and bio polymers, oil-bearing rocks, biomasses and cement-based materials. The use of TD-NMR for studying solid and soft mater has been growing in number and variety of applications, mostly for organic systems where the detection of 1H signals is highly advantageous. However, the strong 1H-1H dipolar interactions in solids make the 1H FID to decay in the same order of the dead time of most commercially available NMR probe heads. Thus, solid echoes are often used for recovering signals from solid components. In this article we reinvestigate the time-reversal solid-echo pulse sequence proposed by Rhim and Kessemeier, seeking for optimal pulse power and timing conditions that maximize its efficiency on recovering 1H signals from rigid segments. We show that under these optimized conditions, which we denote as Rhim and Kessemeier - Radiofrequency Optimized Solid-Echo (RK-ROSE), the experiment can be more efficient than its most popular counterparts Solid-Echo (SE) and mixed-Magic Sandwich Echoes (mixed-MSE). Our results also suggest that, despite the finite pulse power, with current probe technology the RK-ROSE experiment is potentially able to provide an accurate estimation of rigid components, without relying on an external calibration using multiple standard samples, as usually done in SFC analysis of the FID signal. At last, we demonstrate that RK-ROSE can be adapted as a simple filter to supress signals from mobile segments in heterogeneous materials.

Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review.

BACKGROUND: Antibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes. METHODS: A multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015-2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes. RESULTS: Of 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (>1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P < .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22). CONCLUSIONS: Antibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.

Reducing inappropriate outpatient antibiotic prescribing: normative comparison using unblinded provider reports.

Importance: Antibiotic resistance is a global health issue. Up to 50% of antibiotics are inappropriately prescribed, the majority of which are for acute respiratory tract infections (ARTI). Objective: To evaluate the impact of unblinded normative comparison on rates of inappropriate antibiotic prescribing for ARTI. Design: Non-randomised, controlled interventional trial over 1 year followed by an open intervention in the second year. Setting: Primary care providers in a large regional healthcare system. Participants: The test group consisted of 30 primary care providers in one geographical region; controls consisted of 162 primary care providers located in four other geographical regions. Intervention: The intervention consisted of provider and patient education and provider feedback via biweekly, unblinded normative comparison highlighting inappropriate antibiotic prescribing for ARTI. The intervention was applied to both groups during the second year. Main outcomes and measures: Rate of inappropriate antibiotic prescription for ARTI. Results: Baseline inappropriate antibiotic prescribing for ARTI was 60%. After 1 year, the test group rate of inappropriate antibiotic prescribing decreased 40%, from 51.9% to 31.0% (p<0.0001), whereas controls decreased 7% (61.3% to 57.0%, p<0.0001). In year 2, the test group decreased an additional 47% to an overall prescribing rate of 16.3%, and the control group decreased 40% to a prescribing rate of 34.5% after implementation of the same intervention. Conclusions and relevance: Provider and patient education followed by regular feedback to provider via normative comparison to their local peers through unblinded provider reports, lead to reductions in the rate of inappropriate antibiotic prescribing for ARTI and overall antibiotic prescribing rates.

Mechanically robust cationic cellulose nanofibril 3D scaffolds with tuneable biomimetic porosity for cell culture.

3D foam scaffolds were produced in a "bottom-up" approach from lyophilised cationic cellulose nanofibril (CCNF) dispersions and emulsions (CCNF degree of substitution 23.0 ± 0.9%), using a directional freezing/lyophilisation approach, producing internal architectures ranging from aligned smooth walled micro channels, mimicking vascularised tissue, to pumice-like wall textures, reminiscent of porous bone. The open, highly porous architecture of these biomimetic scaffolds included mesopores within the walls of the channels. A combination of SEM and NMR cryoporometry and relaxometry was used to determine the porosity at different length scales: CCNF foams with aligned channels had an average macropore (channel) size of 35 ± 9 µm and a mesopore (wall) diameter of 26 ± 2 nm, while CCNF foams produced from directional freezing and lyophilisation of Pickering emulsions had mesoporous walls (5 ± 3 µm) in addition to channels (54 ± 20 µm). Glyoxal crosslinking both enhanced robustness and stiffness, giving Young's moduli of 0.45 to 50.75 MPa for CCNF foams with degrees of crosslinking from 0 to 3.04 mol%. Porosity and channels are critical scaffold design elements for transport of nutrients and waste products, as well as O2/CO2 exchange. The viability of MG-63 cells was enhanced on crosslinked, mechanically stiff scaffolds, indicating that these exquisitely structured, yet robust, foams could provide biomaterial scaffolds suitable for industrial applications requiring 3D cell culturing.

Investigating Nutrient Limitation Role on Improvement of Growth and Poly(3-Hydroxybutyrate) Accumulation by Burkholderia sacchari LMG 19450 From Xylose as the Sole Carbon Source.

Burkholderia sacchari LMG19450, a non-model organism and a promising microbial platform, was studied to determine nutrient limitation impact on poly(3-hydroxybutyrate) [P(3HB)] production and bacterial growth from xylose, a major hemicellulosic residue. Nitrogen and phosphorus limitations have been studied in a number of cases to enhance PHA accumulation, but not combining xylose and B. sacchari. Within this strategy, it was sought to understand how to control PHA production and even modulate monomer composition. Nitrogen-limited and phosphorus-limited fed-batch experiments in bioreactors were performed to evaluate each one's influence on cell growth and poly(3-hydroxybutyrate) production. The mineral medium composition was defined based on yields calculated from typical results so that nitrogen was available during phosphorus limitation and residual phosphorus was available when limiting nitrogen. Sets of experiments were performed so as to promote cell growth in the first stage (supplied with initial xylose 15 g/L), followed by an accumulation phase, where N or P was the limiting nutrient when xylose was fed in pulses to avoid concentrations lower than 5 g/L. N-limited fed-batch specific cell growth (around 0.19 1/h) and substrate consumption (around 0.24 1/h) rates were higher when compared to phosphorus-limited ones. Xylose to PHA yield was similar in both conditions [0.37 gP(3HB)/gxyl]. We also described pst gene cluster in B. sacchari, responsible for high-affinity phosphate uptake. Obtained phosphorus to biomass yields might evidence polyphosphate accumulation. Results were compared with studies with B. sacchari and other PHA-producing microorganisms. Since it is the first report of the mentioned kinetic parameters for LMG 19450 growing on xylose solely, our results open exciting perspectives to develop an efficient bioprocess strategy with increased P(3HB) production from xylose or xylose-rich substrates.