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Current American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) and European Society of Cardiology (ESC) guidelines recommend different strategies to avoid low-yield admissions in patients with syncope.The purpose of this study was to directly compare the safety and efficacy of applying admission criteria of both guidelines to patients presenting with syncope to the emergency department in 2 multicenter studies.The international BASEL IX (BAsel Syncope EvaLuation) study (median age 71 years) and the U.S. SRS (Improving Syncope Risk Stratification in Older Adults) study (median age 72 years) were investigated. Primary endpoints were sensitivity/specificity for the adjudicated diagnosis of cardiac syncope (BASEL IX only) and 30-day major adverse cardiovascular events (30d-MACE).Among 2560 patients in the BASEL IX and 2085 in SRS studies, ACC/AHA/HRS and ESC criteria recommended admission for a comparable number of patients in BASEL IX (27% vs 28%), but ACC/AHA/HRS criteria less often in SRS (19% vs 32%; P.01). Recommendations were discordant in ∼25% of patients. In BASEL IX, sensitivity for cardiac syncope and 30d-MACE among patients without admission criteria was comparable for ACC/AHA/HRS and ESC criteria (64% vs 65%, P = .86; and 67% vs 71%, P = .15, respectively). In SRS, sensitivity for 30d-MACE was lower with ACC/AHA/HRS (54%) vs ESC criteria (88%; P.001). Similarly, specificity for cardiac syncope and 30d-MACE in BASEL IX was comparable for both guidelines, but in SRS the ACC/AHA/HRS guidelines showed a higher specificity for 30d-MACE than the ESC guidelines.ACC/AHA/HRS and ESC guidelines showed disagreement regarding admission for 1 in 4 patients and had only modest sensitivity, all indicating possible opportunities for improvements.

OBJECTIVE: We evaluated the acceptability of the Pediatric Quality of Life Inventory (PedsQL) and other outcomes as the primary outcomes for a pediatric hemorrhagic trauma trial (TIC-TOC) among clinicians. METHODS: We conducted a mixed-methods study that included an electronic questionnaire followed by teleconference discussions. Participants confirmed or rejected the PedsQL as the primary outcome for the TIC-TOC trial and evaluated and proposed alternative primary outcomes. Responses were compiled and a list of themes and representative quotes was generated. RESULTS: 73 of 91 (80%) participants completed the questionnaire. 61 (84%) participants agreed that the PedsQL is an appropriate primary outcome for children with hemorrhagic brain injuries. 32 (44%) participants agreed that the PedsQL is an acceptable primary outcome for children with hemorrhagic torso injuries, 27 (38%) participants were neutral, and 13 (18%) participants disagreed. Several themes were identified from responses, including that the PedsQL is an important and patient-centered outcome but may be affected by other factors, and that intracranial hemorrhage progression assessed by brain imaging (among patients with brain injuries) or blood product transfusion requirements (among patients with torso injuries) may be more objective outcomes than the PedsQL. CONCLUSIONS: The PedsQL was a well-accepted proposed primary outcome for children with hemorrhagic brain injuries. Traumatic intracranial hemorrhage progression was favored by a subset of clinicians. A plurality of participants also considered the PedsQL an acceptable outcome for selection for pediatric trauma clinical trial children with hemorrhagic torso injuries. Blood product transfusion requirement was favored by fewer participants.

STUDY OBJECTIVE:In the current era of frequent chest computed tomography (CT) for adult blunt trauma evaluation, many minor injuries are diagnosed, potentially rendering traditional teachings obsolete. We seek to update teachings in regard to thoracic spine fracture by determining how often such fractures are observed on CT only (ie, not visualized on preceding trauma chest radiograph), the admission rate, mortality, and hospital length of stay of thoracic spine fracture patients, and how often thoracic spine fractures are clinically significant. METHODS:This was a preplanned analysis of prospectively collected data from the NEXUS Chest CT study conducted from 2011 to 2014 at 9 Level I trauma centers. The inclusion criteria were older than 14 years, blunt trauma occurring within 6 hours of emergency department (ED) presentation, and chest imaging (radiography, CT, or both) during ED evaluation. RESULTS:Of 11,477 enrolled subjects, 217 (1.9%) had a thoracic spine fracture; 181 of the 198 thoracic spine fracture patients (91.4%) who had both chest radiograph and CT had their thoracic spine fracture observed on CT only. Half of patients (49.8%) had more than 1 level of thoracic spine fracture, with a mean of 2.1 levels (SD 1.6 levels) of thoracic spine involved. Most patients (62%) had associated thoracic injuries. Compared with patients without thoracic spine fracture, those with it had higher admission rates (88.5% versus 47.2%; difference 41.3%; 95% confidence interval 36.3% to 45%), higher mortality (6.3% versus 4.0%; difference 2.3%; 95% confidence interval 0 to 6.7%), and longer length of stay (median 9 versus 6 days; difference 3 days; P

Background The NEXUS Chest CT clinical decision rules (CDRs) have been proposed to safely guide selective chest CT use in blunt trauma evaluation. We conducted a cost-effectiveness analysis of the NEXUS Chest CT CDR to determine its impact on missed injuries, cost, and radiation exposure. Methods We constructed a decision model comparing two strategies: implementation of the NEXUS Chest CDR vs. usual care in the evaluation of adults with blunt trauma. We derived probabilities, clinical outcomes, effective radiation dose (ERD) from the NEXUS Chest CT validation cohort and costs from the Charge-master at the primary study site. Our primary outcomes were cost and effective radiation dose (ERD) per missed clinically significant injury (CSI). Results Using a hypothetical cohort of 1000 adults with blunt chest trauma in each arm, the base case model projected that the implementation of the CDR would result in 161 fewer chest CTs, 0.08 additional missed CSIs, a cost savings of $136,432 and a decrease in 1435 mSv, as compared to Usual Care. To detect one additional CSI, the Usual Care strategy would require 2015 more chest CTs with a cost of $1.8 million and 17,934 mSv more radiation. Conclusions Compared to usual care, implementation of the NEXUS Chest CT Major CDR in the evaluation of adults with blunt trauma would greatly reduce CT associated costs and radiation exposure with a slight increased risk of missed CSIs.

BackgroundOlder adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care.Materials and methodsWe analyzed patients ≥50y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs.ResultsAmong 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry

A search for Weakly Interacting Massive Particles (WIMPs) was conducted with the single-phase liquid-xenon detector XMASS through inelastic scattering in which $^{129}$Xe nuclei were excited, using an exposure ($\rm 327\; kg \times 800.0 \; days$) 48 times larger than that of our previous study. The inelastic excitation sensitivity was improved by detailed evaluation of background, event classification based on scintillation timing that distinguished $\gamma$-rays and $\beta$-rays, and simultaneous fitting of the energy spectra of $\gamma$-like and $\beta$-like samples. No evidence of a WIMP signal was found. Thus, we set the upper limits of the inelastic channel cross section at 90\% confidence level, for example, $4.1\times 10^{-39} \;{\rm cm^2}$ for a $200\; {\rm GeV}/c^2$ WIMP. This result provides the most stringent limits on the SD WIMP-neutron interaction and is better by a factor of 7.7 at $200\;{\rm GeV}/c^2$ than the existing experimental limit., Comment: 8 pages, 10 figures

Tranexamic acid improves survival in severely injured adults. However, its effectiveness on overall functional outcome is unknown. We hypothesized that tranexamic acid improves overall functional outcome compared with placebo in severely injured adults and conduct an exploratory analysis of the Clinical Randomization of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) data to investigate this hypothesis.We included injured adults from the CRASH-2 trial who were randomized 3 hours or less from injury. The primary outcome measure was functional status at hospital discharge or on day 28 if the subject was still in the hospital. Functional status was measured with the modified Oxford Handicap Scale, a 6-category ordinal functional outcome scale. We conducted 3 separate analyses using 3 different outcome measures to evaluate the effectiveness of tranexamic acid versus placebo on functional outcomes, including the mean utility-weighted modified Oxford Handicap Scale score (overall functional outcome), the area under the curve (based on functional outcome and rate of recovery), and a sliding dichotomy analysis (favorable versus unfavorable functional outcome) stratified by baseline mortality risk (stratified analysis).There were 13,432 patients (6,679 randomized to placebo and 6,753 to tranexamic acid) included in the study cohort. The mean utility-weighted modified Oxford Handicap Scale score was 0.66 (SD 0.33) for patients randomized to tranexamic acid compared with a mean of 0.64 (SD 0.34) for those randomized to placebo (mean difference 0.02; 95% confidence interval [CI] 0.01 to 0.03). The area under the curve analysis demonstrated that patients randomized to tranexamic acid had a higher 28-day mean utility-weighted modified Oxford Handicap Scale score compared with those randomized to placebo (mean score 0.55 [SD 0.30] versus 0.53 [SD 0.31]; mean difference 0.02 [95% CI 0.01 to 0.03]). The sliding dichotomy analysis demonstrated heterogeneity of treatment effects across risk groups. The overall proportion of patients with favorable functional outcomes was higher in the tranexamic acid group (5,360/6,753 [79.4%]; 95% CI 78.4% to 80.3%) compared with the placebo group (5,174/6,679 [77.5%]; 95% CI 76.5% to 78.5%; difference 1.9% [95% CI 0.5% to 3.3%]; number needed to treat=52). When each risk group was tested separately, only the lowest-risk group (6% baseline mortality risk) demonstrated a statistically significant effect of tranexamic acid toward favorable functional outcomes (tranexamic acid versus placebo adjusted odds ratio 0.78; 95% CI 0.67 to 0.90). There were no differences between tranexamic acid and placebo in the other risk groups.Across 3 exploratory analyses, severely injured adult patients randomized within 3 hours from injury demonstrated better functional outcomes with tranexamic acid compared with placebo. When heterogeneity of treatment effects across risk groups was evaluated, only the lowest-risk group demonstrated a significant effect of tranexamic acid toward favorable outcomes. Given the overall safety and cost-effectiveness of tranexamic acid use in injured adults, our results further support the use of tranexamic acid for this population. Future trauma trials that evaluate tranexamic acid use should also consider functional status as an important outcome.

Study objective The prevalence of pulmonary embolism among patients with syncope is understudied. In accordance with a recent study with an exceptionally high pulmonary embolism prevalence, some advocate evaluating all syncope patients for pulmonary embolism, including those with another clear cause for their syncope. We seek to evaluate the pulmonary embolism prevalence among emergency department (ED) patients with syncope. Methods We combined data from 2 large prospective studies enrolling adults with syncope from 17 EDs in Canada and the United States. Each study collected the results of pulmonary embolism–related investigations (ie, D-dimer, ventilation-perfusion scan, or computed tomography [CT] pulmonary angiography) and 30-day adjudicated outcomes: pulmonary embolism or nonpulmonary embolism outcome (arrhythmia, myocardial infarction, serious hemorrhage, and death). Results Of the 9,374 patients enrolled, 9,091 (97.0%; median age 66 years, 51.9% women) with 30-day follow-up were analyzed: 547 (6.0%) were evaluated for pulmonary embolism (278 [3.1%] had D-dimer, 39 [0.4%] had ventilation-perfusion scan, and 347 [3.8%] had CT pulmonary angiography). Overall, 874 patients (9.6%) experienced 30-day serious outcomes: 818 patients (9.0%) with nonpulmonary embolism serious outcomes and 56 (prevalence 0.6%; 95% confidence interval 0.5% to 0.8%) with pulmonary embolism (including 8 [0.2%] out of 3521 patients diagnosed during the index hospitalization and 7 [0.1%] diagnosed after the index visit). Eighty-six patients (0.9%) died, and 4 deaths (0.04%) were related to pulmonary embolism. Only 11 patients (0.1%) with a nonpulmonary embolism serious condition had a concomitant pulmonary embolism. Conclusion The prevalence of pulmonary embolism is very low among ED patients with syncope, including those hospitalized after syncope. Although an underlying pulmonary embolism may cause syncope, clinicians should be cautious about indiscriminate investigations for pulmonary embolism.

Almost 20% of patients with syncope will experience another event. It is unknown whether recurrent syncope is a marker for a higher or lower risk etiology of syncope. The goal of this study is to determine whether older adults with recurrent syncope have a higher likelihood of 30-day serious clinical events than patients experiencing their first episode. METHODS: This study is a pre-specified secondary analysis of a multicenter prospective, observational study conducted at 11 emergency departments in the US. Adults 60 years or older who presented with syncope or near syncope were enrolled. The primary outcome was occurrence of 30-day serious outcome. The secondary outcome was 30-day serious cardiac arrhythmia. In multivariate analysis, we assessed whether prior syncope was an independent predictor of 30-day serious events. RESULTS: The study cohort included 3580 patients: 1281 (35.8%) had prior syncope and 2299 (64.2%) were presenting with first episode of syncope. 498 (13.9%) patients had 1 prior episode while 771 (21.5%) had more than 1 prior episode. Those with recurrent syncope were more likely to have congestive heart failure, coronary artery disease, previous diagnosis of arrhythmia, and an abnormal ECG. Overall, 657 (18.4%) of the cohort had a serious outcome by 30 days after index ED visit. In multivariate analysis, we found no significant difference in risk of events (adjusted odds ratio 1.09; 95% confidence interval 0.90–1.31; p=0.387). CONCLUSION: In older adults with syncope, a prior history of syncope within the year does not increase the risk for serious 30-day events. TRIAL REGISTRATION NUMBER

Syncope is a common chief complaint in the ED, and the electrocardiogram (ECG) is a routine diagnostic tool in the evaluation of syncope. We assessed whether increasingly prolonged QTc intervals are associated with composite 30-day serious outcomes in older adults presenting to the ED with syncope.This is a secondary analysis of a prospective, observational study at 11 EDs in adults 60 years or older who presented with syncope or near syncope. We excluded patients presenting without an ECG, measurement of QTc, non-sinus rhythm, bundle branch block or those without 30-day follow-up. We categorized QTc cutoffs into values of451; 451-470; 471-500, and500 ms. We determined the rate of composite 30-day serious outcomes including ED serious outcomes and 30-day arrhythmias not identified in ED.The study cohort included 2609 patients. There were 1678 patients (64.3%) that had QTc intervals451 ms; 544 (20.8%) were 451-470 ms; 302 (11.6%) were 471-500 ms, and 85 (3.3%) had intervals500 ms. Composite 30-day serious outcomes was associated with increasingly prolonged QTc intervals (13.0%, 15.3%, 18.2%, 22.4%, p = 0.01), but this association did not persist in multivariate analysis.In a cohort of older patients presenting with syncope, increased QTc interval was a marker of but was not independently predictive of composite 30-day serious outcomes.

XMASS-I is a single-phase liquid xenon detector whose purpose is direct detection of dark matter. To achieve the low background requirements necessary in the detector, a new model of photomultiplier tubes (PMTs), R10789, with a hexagonal window was developed based on the R8778 PMT used in the XMASS prototype detector. We screened the numerous component materials for their radioactivity. During development, the largest contributions to the reduction of radioactivity came from the stem and the dynode support. The glass stem was exchanged to the Kovar alloy one and the ceramic support were changed to the quartz one. R10789 is the first model of Hamamatsu Photonics K. K. that adopted these materials for low background purposes and provided a groundbreaking step for further reductions of radioactivity in PMTs. Measurements with germanium detectors showed 1.2$\pm$0.3 mBq/PMT of $^{226}$Ra, less than 0.78 mBq/PMT of $^{228}$Ra, 9.1$\pm$2.2 mBq/PMT of $^{40}$K, and 2.8$\pm$0.2 mBq/PMT of $^{60}$Co. In this paper, the radioactive details of the developed R10789 are described together with our screening methods and the components of the PMT., Comment: 7 pages, 3 figures

Hidden photons and axion-like particles are candidates for cold dark matter if they were produced non-thermally in the early universe. We conducted a search for both of these bosons using 800 live-days of data from the XMASS detector with 327 kg of liquid xenon in the fiducial volume. No significant signal was observed, and thus we set constraints on the $\alpha' / \alpha$ parameter related to kinetic mixing of hidden photons and the coupling constant $g_{Ae}$ of axion-like particles in the mass range from 40 to 120 keV/$c^2$, resulting in $\alpha' / \alpha < 6 \times 10^{-26}$ and $g_{Ae} < 4 \times 10^{-13}$. These limits are the most stringent derived from both direct and indirect searches to date., Comment: 18 pages, 5 figures

Detection of low-intensity light relies on the conversion of photons to photoelectrons, which are then multiplied and detected as an electrical signal. To measure the actual intensity of the light, one must know the factor by which the photoelectrons have been multiplied. To obtain this amplification factor, we have developed a procedure for estimating precisely the signal caused by a single photoelectron. The method utilizes the fact that the photoelectrons conform to a Poisson distribution. The average signal produced by a single photoelectron can then be estimated from the number of noise events, without requiring analysis of the distribution of the signal produced by a single photoelectron. The signal produced by one or more photoelectrons can be estimated experimentally without any assumptions. This technique, and an example of the analysis of a signal from a photomultiplier tube, are described in this study., Comment: 18 pages, 6 figures

We performed a search for event bursts in the XMASS-I detector associated with 11 gravitational-wave events detected during LIGO/Virgo’s O1 and O2 periods. Simple and loose cuts were applied to the data collected in the full 832 kg xenon volume around the detection time of each gravitational-wave event. The data were divided into four energy regions ranging from keV to MeV. Without assuming any particular burst models, we looked for event bursts in sliding windows with various time width from 0.02 to 10 s. The search was conducted in a time window between − 400 and + 10 , 000 s from each gravitational-wave event. For the binary neutron star merger GW170817, no significant event burst was observed in the XMASS-I detector and we set 90% confidence level upper limits on neutrino fluence for the sum of all the neutrino flavors via coherent elastic neutrino-nucleus scattering. The obtained upper limit was (1.3–2.1) × 10 11 cm − 2 under the assumption of a Fermi-Dirac spectrum with average neutrino energy of 20 MeV. The neutrino fluence limits for mono-energetic neutrinos in the energy range between 14 and 100 MeV were also calculated. Among the other 10 gravitational wave events detected as the binary black hole mergers, a burst candidate with a 3.0 σ significance was found at 1801.95–1803.95 s in the analysis for GW151012. However, no significant deviation from the background in the reconstructed energy and position distributions was found. Considering the additional look-elsewhere effect of analyzing the 11 GW events, the significance of finding such a burst candidate associated with any of them is 2.1 σ .

The coherent elastic neutrino-nucleus scattering (CEvNS) plays a crucial role at the final evolution of stars. The detection of it would be of importance in astroparticle physics. Among all available neutrino sources, galactic supernovae give the highest neutrino flux in the MeV range. Among all liquid xenon dark matter experiments, XMASS has the largest sensitive volume and light yield. The possibility to detect galactic supernova via the CEvNS-process on xenon nuclei in the current XMASS detector was investigated. The total number of events integrated in about 18 seconds after the explosion of a supernova 10~kpc away from the Earth was expected to be from 3.5 to 21.1, depending on the supernova model used to predict the neutrino flux, while the number of background events in the same time window was measured to be negligible. All lead to very high possibility to detect CEvNS experimentally for the first time utilizing the combination of galactic supernovae and the XMASS detector. In case of a supernova explosion as close as Betelgeuse, the total observable events can be more than ten thousand, making it possible to distinguish different supernova models by examining the evolution of neutrino event rate in XMASS., Comment: 6 pages, 5 figures

© 2015 American College of Emergency Physicians Study objective The NEXUS chest decision instrument identifies a very-low-risk population of patients with blunt trauma for whom chest imaging can be avoided. However, it requires that all 7 National Emergency X-Ray Utilization Study (NEXUS) chest criteria be absent. To inform patient and physician shared decisionmaking about imaging, we describe the test characteristics of individual criteria of the NEXUS chest decision instrument and provide the prevalence of injuries when 1, 2, or 3 of the 7 criteria are present. Methods We conducted this secondary analysis of 2 prospectively collected cohorts of patients with blunt trauma who were older than 14 years and enrolled in NEXUS chest studies between December 2009 and January 2012. Physicians at 9 US Level I trauma centers recorded the presence or absence of the 7 NEXUS chest criteria. We calculated test characteristics of each criterion and combinations of criteria for the outcome measures of major clinical injuries and thoracic injury observed on chest imaging. Results We enrolled 21,382 patients, of whom 992 (4.6%) had major clinical injuries and 3,135 (14.7%) had thoracic injuries observed on chest imaging. Sensitivities of individual test characteristics ranged from 15% to 56% for major clinical injury and 14% to 53% for thoracic injury observed on chest imaging, with specificities varying from 71% to 84% for major clinical injury and 67% to 84% for thoracic injury observed on chest imaging. Individual criteria were associated with a prevalence of major clinical injury between 1.9% and 3.8% and of thoracic injury observed on chest imaging between 5.3% and 11.5%. Conclusion Patients with isolated NEXUS chest criteria have low rates of major clinical injury. The risk of major clinical injury for patients with 2 or 3 factors range from 1.7% to 16.6%, depending on the combination of criteria. Criteria-specific risks could be used to inform shared decisionmaking about the need for imaging by patients and their physicians.

A search for dark matter was conducted by looking for an annual modulation signal due to the Earth's rotation around the Sun using XMASS, a single phase liquid xenon detector. The data used for this analysis was 359.2 live days times 832 kg of exposure accumulated between November 2013 and March 2015. When we assume Weakly Interacting Massive Particle (WIMP) dark matter elastically scattering on the target nuclei, the exclusion upper limit of the WIMP–nucleon cross section 4.3×10−41 cm2 at 8 GeV/c$^{2}$ was obtained and we exclude almost all the DAMA/LIBRA allowed region in the 6 to 16 GeV/c$^{2}$ range at ∼10$^{−40}$ cm$^{2}$. The result of a simple modulation analysis, without assuming any specific dark matter model but including electron/γ events, showed a slight negative amplitude. The p-values obtained with two independent analyses are 0.014 and 0.068 for null hypothesis, respectively. We obtained 90% C.L. upper bounds that can be used to test various models. This is the first extensive annual modulation search probing this region with an exposure comparable to DAMA/LIBRA.

We present a real-time supernova neutrino burst monitor at Super-Kamiokande (SK). Detecting supernova explosions by neutrinos in real time is crucial for giving a clear picture of the explosion mechanism. Since the neutrinos are expected to come earlier than light, a fast broadcasting of the detection may give astronomers a chance to make electromagnetic radiation observations of the explosions right at the onset. The role of the monitor includes a fast announcement of the neutrino burst detection to the world and a determination of the supernova direction. We present the online neutrino burst detection system and studies of the direction determination accuracy based on simulations at SK., 15 pages, 8 figures, accepted for publication in Astroparticle Physics

Double electron capture is a rare nuclear decay process in which two orbital electrons are captured simultaneously in the same nucleus. Measurement of its two-neutrino mode would provide a new reference for the calculation of nuclear matrix elements whereas observation of its neutrinoless mode would demonstrate lepton number violation. A search for two-neutrino double electron capture on $^{124}$Xe is performed using 165.9 days of data collected with the XMASS-I liquid xenon detector. No significant excess above background was observed and we set a lower limit on the half-life as $4.7 \times 10^{21}$ years at 90% confidence level. The obtained limit has ruled out parts of some theoretical expectations. We obtain a lower limit on the $^{126}$Xe two-neutrino double electron capture half-life of $4.3 \times 10^{21}$ years at 90% confidence level as well., 6 pages, 3 figures, accepted for publication in Physics Letters B

Background Although pulmonary contusion (PC) is traditionally considered a major injury requiring intensive monitoring, more frequent detection by chest CT in blunt trauma evaluation may diagnose clinically irrelevant PC. Objectives We sought to determine (1) the frequency of PC diagnosis by chest CT versus chest X-ray (CXR), (2) the frequency of PC-associated thoracic injuries, and (3) PC patient clinical outcomes (mortality, length of stay [LOS], and need for mechanical ventilation), considering patients with PC seen on chest CT only (SOCTO) and isolated PC (PC without other thoracic injury). Methods Focusing primarily on patients who had both CXR and chest CT, we conducted a pre-planned analysis of two prospectively enrolled cohorts with the following inclusion criteria: age >14 years, blunt trauma within 24 h of emergency department presentation, and receiving CXR or chest CT during trauma evaluation. We defined PC and other thoracic injuries according to CT reports and followed patients through their hospital course to determine clinical outcomes. Results Of 21,382 enrolled subjects, 8661 (40.5%) had both CXR and chest CT and 1012 (11.7%) of these had PC, making it the second most common injury after rib fracture. PC was SOCTO in 739 (73.0%). Most (73.5%) PC patients had other thoracic injury. PC patients had higher admission rates (91.9% versus 61.7%; mean difference 30.2%; 95% confidence interval [CI] 28.1–32.1%) and mortality (4.7% versus 2.0%: mean difference 2.8%; 95% CI 1.6–4.3%) than non-PC patients, but mortality was restricted to patients with other injuries (injury severity scores > 10). Patients with PC SOCTO had low rates of associated mechanical ventilation (4.6%) and patients with isolated PC SOCTO had low mortality (2.6%), comparable to that of patients without PC. Conclusions PC is commonly diagnosed under current blunt trauma imaging protocols and most PC are SOCTO with other thoracic injury. Given that they are associated with low mortality and uncommon need for mechanical ventilation, isolated PC and PC SOCTO may be of limited clinical significance.

XMASS is a multipurpose liquid-xenon detector that currently aims to directly detect dark matter. In this paper, we describe the fabrication and characterization of reference sources used for the energy calibration and position reconstruction of the present XMASS detector. Several gamma-ray sources were produced in the form of a sealed needle-source. A thin-wall tube with a diameter of approximately 0.2 mm was sealed at both ends, with the 241 Am or 57 Co source material contained inside. The active region of the source was observed to be 1–2 mm long, close to the tip of the needle. These sources were tested in the XMASS detector, and the results were compared with Monte-Carlo simulations.

A search for Supernova Relic Neutrinos $\bar{\nu}_e$'s is first conducted via inverse-beta-decay by tagging neutron capture on hydrogen at Super-Kamiokande-IV. The neutron tagging efficiency is determined to be $(17.74\pm0.04_{stat.}\pm1.05_{sys.})%$, while the corresponding accidental background probability is $(1.06\pm0.01_{stat.}\pm 0.18_{sys.})$%. Using 960 days of data, we obtain 13 inverse-beta-decay candidates in the range of $E_{\bar{\nu}_e}$ between 13.3 MeV and 31.3 MeV. All of the observed candidates are attributed to background. Upper limits at 90% C.L. are calculated in the absence of a signal., Comment: 6 pages, 4 figures

Objective The antifibrinolytic agent tranexamic acid (TXA) has demonstrated clinical benefit in trauma patients with severe bleeding, but its effectiveness in patients with traumatic brain injury (TBI) is unclear. We conducted a systematic review to evaluate the following research question: In ED patients with or at risk of intracranial hemorrhage (ICH) secondary to TBI, does TXA compared to placebo improve patients' outcomes? Methods MEDLINE, EMBASE, CINAHL, and other databases were searched for randomized controlled trial (RCT) or quasi-RCT studies that compared the effect of TXA to placebo on outcomes of TBI patients. The main outcomes of interest included mortality, neurologic function, hematoma expansion, and adverse effects. We used “Grading quality of evidence and strength of recommendations” to assess the quality of trials. Two authors independently abstracted data using a data collection form. Results from studies were pooled when appropriate. Results Of 1030 references identified through the search, 2 high-quality RCTs met inclusion criteria. The effect of TXA on mortality had a pooled relative risk of 0.64 (95% confidence interval [CI], 0.41-1.02); on unfavorable functional status, a relative risk of 0.77 (95% CI, 0.59-1.02); and on ICH progression, a relative risk of 0.76 (95% CI, 0.58-0.98). No serious adverse effects (such as thromboembolic events) associated with TXA group were reported in the included trials. Conclusion Pooled results from the 2 RCTs demonstrated statistically significant reduction in ICH progression with TXA and a nonstatistically significant improvement of clinical outcomes in ED patients with TBI. Further evidence is required to support its routine use in patients with TBI.

Objective: Mild traumatic brain injury (mTBI) patients are frequently admitted to high levels of care despite limited evidence suggesting benefit. Such decisions may contribute to the significant cost of caring for mTBI patients. Understanding the factors that drive disposition decision making and how disposition is associated with outcomes is necessary for developing an evidence-base supporting disposition decisions. We evaluated factors associated with emergency department triage of mTBI patients to 1 of 3 levels of care: home, inpatient floor, or intensive care unit (ICU). Methods: This multicenter, prospective, cohort study included patients with isolated head trauma, a cranial computed tomography as part of routine care, and a Glasgow Coma Scale (GCS) score of 13 to 15. Data analysis was performed using multinomial logistic regression. Results: Of the 304 patients included, 167 (55%) were discharged home, 76 (25%) were admitted to the inpatient floor, and 61 (20%) were admitted to the ICU. In the multivariable model, admission to the ICU, compared with floor admission, varied by study site, odds ratio (OR) 0.18 (95% confidence interval [CI], 0.06-0.57); antiplatelet/anticoagulation therapy, OR 7.46 (95% CI, 1.79-31.13); skull fracture, OR 7.60 (95% CI, 2.44-23.73); and lower GCS, OR 2.36 (95% CI, 1.05-5.30). No difference in outcome was observed between the 3 levels of care. Conclusion: Clinical characteristics and local practice patterns contribute to mTBI disposition decisions. Level of care was not associated with outcomes. Intracranial hemorrhage, GCS 13 to 14, skull fracture, and current antiplatelet/anticoagulant therapy influenced disposition decisions. (C) 2014 Elsevier Inc. All rights reserved.

Many low background experiments using xenon need to remove radioactive radon to improve their sensitivities. However, no method of continually removing radon from xenon has been described in the literature. We studied a method to remove radon from xenon gas through an activated charcoal trap. From our measurements we infer a linear relationship between the mean propagation velocity vRn of radon and vXe of xenon in the trap with vRn=vXe ¼ð 0:967 0:10 Þ� 10

Study objective Cardiac arrhythmia is a life-threatening condition in older adults who present to the emergency department (ED) with syncope. Previous work suggests the initial ED ECG can predict arrhythmia risk; however, specific ECG predictors have been variably specified. Our objective is to identify specific ECG abnormalities predictive of 30-day serious cardiac arrhythmias in older adults presenting to the ED with syncope. Methods We conducted a prospective, observational study at 11 EDs in adults aged 60 years or older who presented with syncope or near syncope. We excluded patients with a serious cardiac arrhythmia diagnosed during the ED evaluation from the primary analysis. The outcome was occurrence of 30-day serous cardiac arrhythmia. The exposure variables were predefined ECG abnormalities. Independent predictors were identified through multivariate logistic regression. The sensitivities and specificities of any predefined ECG abnormality and any ECG abnormality identified on adjusted analysis to predict 30-day serious cardiac arrhythmia were also calculated. Results After exclusion of 197 patients (5.5%; 95% confidence interval [CI] 4.7% to 6.2%) with serious cardiac arrhythmias in the ED, the study cohort included 3,416 patients. Of these, 104 patients (3.0%; 95% CI 2.5% to 3.7%) had a serious cardiac arrhythmia within 30 days from the index ED visit (median time to diagnosis 2 days [interquartile range 1 to 5 days]). The presence of nonsinus rhythm, multiple premature ventricular conductions, short PR interval, first-degree atrioventricular block, complete left bundle branch block, and Q wave/T wave/ST-segment abnormalities consistent with acute or chronic ischemia on the initial ED ECG increased the risk for a 30-day serious cardiac arrhythmia. This combination of ECG abnormalities had a similar sensitivity in predicting 30-day serious cardiac arrhythmia compared with any ECG abnormality (76.9% [95% CI 67.6% to 84.6%] versus 77.9% [95% CI 68.7% to 85.4%]) and was more specific (55.1% [95% CI 53.4% to 56.8%] versus 46.6% [95% CI 44.9% to 48.3%]). Conclusion In older ED adults with syncope, approximately 3% receive a diagnosis of a serious cardiac arrhythmia not recognized on initial ED evaluation. The presence of specific abnormalities on the initial ED ECG increased the risk for 30-day serious cardiac arrhythmias.

A high performance distillation system to remove krypton from xenon was constructed, and a purity level of Kr/Xe = $\sim 3 \times 10^{-12}$ was achieved. This development is crucial in facilitating high sensitivity low background experiments such as the search for dark matter in the universe., Comment: 15 pages, 11 figures

The intensity of scintillation light emission from liquid xenon at room temperature was measured. The scintillation light yield at 1 deg. was measured to be 0.64 +/- 0.02 (stat.) +/- 0.06 (sys.) of that at -100 deg. Using the reported light yield at -100 deg. (46 photons/keV), the measured light yield at 1 deg. corresponds to 29 photons/keV. This result shows that liquid xenon scintillator gives high light yield even at room temperature., Comment: 16pages,12figures

A subset of neutrino-induced upward through-going muons in the Super-Kamiokande detector consists of high energy muons which lose energy through radiative processes such as bremsstrahlung, e^{+} e^{-} pair production and photonuclear interactions. These ``upward showering muons'' comprise an event sample whose mean parent neutrino energy is approximately 1 TeV. We show that the zenith angle distribution of upward showering muons is consistent with negligible distortion due to neutrino oscillations, as expected of such a high-energy neutrino sample. We present astronomical searches using these high energy events, such as those from WIMP annihilations in the Sun, Earth and Galactic Center, some suspected point sources, as well as searches for diffuse flux from the interstellar medium., Comment: Submitted for publication to Astroparticle Physics. Fig 12 has slightly higher resolution in the version submitted to the journal

Reminiscences of Pauli and of the PauIi group or his last contribution to neutrino physics are briefly described.

We show that Pauli's spin-statistics relation remains valid in noncommutative quantum field theories (NC QFT), with the exception of some peculiar cases of noncommutativity between space and time. We also prove that, while the individual symmetries C and T, and in some cases also P, are broken, the CPT theorem still holds in general for noncommutative field theories, in spite of the inherent nonlocality and violation of Lorentz invariance., Comment: 5 pages, latex, no figures

Super-Kamiokande is the world's largest water Cherenkov detector, with net mass 50,000 tons. During the period April, 1996 to July, 2001, Super-Kamiokande I collected 1678 live-days of data, observing neutrinos from the Sun, Earth's atmosphere, and the K2K long-baseline neutrino beam with high efficiency. These data provided crucial information for our current understanding of neutrino oscillations, as well as setting stringent limits on nucleon decay. In this paper, we describe the detector in detail, including its site, configuration, data acquisition equipment, online and offline software, and calibration systems which were used during Super-Kamiokande I.

CANGAROO-III is an Imaging Atmospheric Cherenkov Telescope (IACT) array of four 10 m telescopes for very high energy (sub-TeV) gamma-ray astronomy. A design study of the CANGAROO-III telescope system was carried out using the Monte Carlo technique in order to optimize the pixel size and the telescope spacing. Studies were also made of observations at low elevation angles.

The KEK to Kamioka long-baseline neutrino experiment (K2K) has begun its investigation of neutrino oscillations suggested by atmospheric neutrino observations. Twenty-eight neutrino events have been detected in coincidence with the expected arrival time of the beam in the 22.5 kt fiducial volume of Super--Kamiokande, the far detector at 250 km distance. The expectation is 37.8+3.5-3.8, derived using measurements of neutrino interactions in a near detector and extrapolation using a beam simulation validated by a measurement of pion kinematics after production and focusing. The background is of order 10^-3 events., Comment: 6 pages, 3 embedded figures, LaTeX with RevTeX style, submitted to PRL. This version is As Submitted

From an exposure of 25.5~kiloton-years of the Super-Kamiokande detector, 900 muon-like and 983 electron-like single-ring atmospheric neutrino interactions were detected with momentum $p_e > 100$ MeV/$c$, $p_\mu > 200$ MeV/$c$, and with visible energy less than 1.33 GeV. Using a detailed Monte Carlo simulation, the ratio $(\mu/e)_{DATA}/(\mu/e)_{MC}$ was measured to be $0.61 \pm 0.03(stat.) \pm 0.05(sys.)$, consistent with previous results from the Kamiokande, IMB and Soudan-2 experiments, and smaller than expected from theoretical models of atmospheric neutrino production.

Effluent from the FCC process contains considerable concentrations of phenol, sulfide and ammonium ions. The pH of the effluent is around 9. In the present study, the possibility of the application of anion exchange membranes for its removal and recovery, was investigated. The equilibrium constant between phenol and hydroxide ions and the ion exchange capacity of a commercial anion exchange membrane were determined. The membrane was sandwiched between two glass cells filled with a phenol solution at pH 9, fed and withdrawn continuously to keep the phenol concentration constant, and a sodium hydroxide solution at various pH, respectively. The permeation rate increased with pH and reached a plateau at above pH 13. The permeation rate was measured for various concentrations of phenol in the feed side, keeping the pH of the strip side at 13. The rate linearly increased with the phenol concentration and reached a plateau at concentration greater than 1 mol/m3. The apparent diffusion coefficient of phenol in the membrane was determined from the plateau value. At a concentration of less than 1 mol/m3, the rate was found to be controlled by boundary film resistance. It was also found that the permeation rate of phenol was suppressed by the sulfide ion at a concentration comparable to or larger than that of phenol.

BackgroundThe prevalence of tranexamic acid (TXA) use for trauma and other conditions in children is unknown.ObjectivesThe objective of this study was to describe the use of TXA in United States (US) children's hospitals for children in general, and specifically for trauma.MethodsWe conducted a secondary analysis of a large, administrative database of 36 US children's hospitals. We included children

Data from the Kamiokande detector were used to study the atmospheric (v μ + v μ ) (v e + v e ) ratio in the multi-GeV energy range. The observed ratio of μ-like to e-like events relative to the calculated ratio, ( μ /e) data /( μ /e) MC = 0.57 -0.07 +0.08 ± 0.07, suggests that the atmospheric (v μ + v μ ) (v e + v e ) ratio is smaller than expected for these neutrino energies. Also studied was the zenith-angle dependence of the above ratio. Results of an analysis of neutrino oscillations are presented.

To derive a clinical decision rule to identify adult emergency department (ED) patients with traumatic intracranial haemorrhage (tICH) who are at low risk for requiring critical care resources during hospitalization.This is a retrospective cohort study of patients (≥ 18 years) with tICH presenting to the ED. The need for intensive care unit (ICU) admission was defined as the presence of a critical care intervention including: intubation, neurosurgical intervention, blood product transfusion, vasopressor or inotrope administration, invasive monitoring for haemodynamic instability, emergent treatment for arrhythmia, therapeutic angiography, and cardiopulmonary resuscitation. The decision rule was derived using binary recursive partitioning.A total of 432 patients were identified (median age 48 years) of which 174 patients (40%) had a critical care intervention. We performed binary recursive partitioning with Classification and Regression Trees (CART) software to develop the clinical decision rule. Patients with a normal mental status (Glasgow Coma Score=15), isolated head injury, and age65 were considered low risk for a critical care intervention. The derived rule had a sensitivity of 98% (95% confidence interval [CI] 94-99), a specificity of 50% (95% CI 44-56), a positive predictive value of 57% (95% CI 51-62), and a negative predictive value of 97% (95% CI 93-99). The area under the curve for the decision rule was 0.74 (95% CI 0.70-0.77).This clinical decision rule identifies low risk adult ED patients with tICH who do not need ICU admission. Further validation and refinement of these findings would allow for more appropriate ICU resource utilisation.

A hadron calorimeter for investigating relativistic heavy ion reactions, filled with liquid argon doped with allene, has been tested for 1 GeV/n neon and iron ions, and 1.7 GeV/n helium, neon and iron ions. The electrode system of the calorimeter consists of G-10 plates placed in the first, second and third parts, 2 mm thick iron plates in the second part and 6 mm thick iron plates in the third part with a liquid argon gap of 3.5 mm. Some of the ions were stopped inside the calorimeter without fragmentation, which were treated separately. The calorimeter shows a good linear response to the total incident energy of ions for fragmented and stopped ions. The absolute yields of collected charge are consistent with the calculated values. An energy resolution in FWHM of 2–5% is obtained for stopped ions. For fragmented ions, the energy resolution in FWHM is given by [ 0.9+81.1 √E( GeV ) ]% for all relativistic ions and if the datum of helium ions is excluded, the resolution can be expressed by [ 4.8 + 53.2 √E( GeV ) ]% . The present energy resolution is better than those recently obtained with scintillation calorimeters at BNL and CERN.

A modified indicator gas washout method was developed to measure functional residual capacity (FRC) during high-frequency oscillatory ventilation (HFOV) without interruption of HFOV. A hot-wire flowmeter and medical gas analyzer measured the flow rate and argon concentration, respectively, at the expiratory end of the respiratory circuit. Upstream of the hot-wire flowmeter, two heat-and-moisture exchangers for resistance and a rubber balloon for capacitance were placed to convert the oscillating expiratory flow to an almost continuous flow. This made it possible to measure FRC during HFOV without interrupting HFOV. To measure the volume of the entire respiratory circuit, a 10 percent argon in 90 percent oxygen gas mixture was initially used as a bias flow, and after equilibration, the test gas was switched to 100 percent oxygen. By electrical integration of the product of the expiratory flow rate and argon concentration, the total amount of argon equilibrated in the entire respiratory circuit was calculated. The volume of the circuit was calculated by dividing the total amount of argon by the initial argon concentration. Functional residual capacity plus the volume of the respiratory circuit was similarly calculated and the difference was estimated as FRC. The accuracy and reproducibility of our method were evaluated by using a one-compartment lung model. There was a high correlation between the volume setting of the model lung and the estimated FRC. This method can be used to estimate FRC in a one-compartment lung model during HFOV, and it is potentially useful in clinical situations.

There are many kinds of humidifying devices. We evaluated six humidifiers from the viewpoint of AWLs. The AWL was obtained by calculating the area difference between pressure-volume tracings obtained without and with humidifiers. To examine the effect of pressure monitoring sites on AWL when a humidifier is placed, we measured AWL at three different pressure monitoring sites. The AWL was affected significantly by the pressure monitoring site for the ventilator. When a pressure monitor sensor was placed on the inspiratory limb between the inspiratory valve and humidifiers, the ventilator was not able to compensate for the pressure drop caused by impedance characteristics of the humidifier equipment. This resulted in significant inspiratory AWL on the patient. Thus, humidifying devices should be carefully selected from the viewpoint of not only humidifying capability but also AWL. Furthermore, we must recognize the importance of the pressure monitoring site for the ventilator.

Methods: Insulin was fixed at pre-trial dose for 16 weeks; after which insulin was titrated up to 36 weeks. Primary endpoint: change in HbA1c after 16 weeks. Results: In total, 257 subjects were randomised (mean [±SD] age 60.5±11.2; body mass index 25.6±4.5 kg/m2, HbA1c 8.8±0.9%). Lira reduced HbA1c more than placebo (p