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Background: Bamlanivimab and casirivimab/imdevimab are recombinant neutralizing monoclonal antibodies that decrease viral load in patients with coronavirus disease 2019 (COVID-19) and can decrease hospitalizations. Few data exist comparing these two therapies. Objective: Our aim was to compare the efficacy and safety of bamlanivimab and casirivimab/imdevimab in emergency department (ED) patients with COVID-19 who met criteria for monoclonal antibody therapy. Methods: We performed a single-center, open-label, prospective study in adult ED patients with confirmed COVID-19 and high-risk features for hospitalization. Enrolled patients received bamlanivimab or casirivimab/imdevimab, depending on the day of the week that they arrived. We observed patients for post–infusion-related reactions and contacted them on days 5, 10, and 30. The primary outcome was the number of hospitalizations through day 30. In addition, we compared groups with regard to return visits to the ED, symptom improvement, antibody-induced adverse events, and deaths. Results: Between December 17, 2020 and January 17, 2021, 321 patients completed the study. We found no statistically significant difference in the rate of subsequent hospitalization between groups (bamlanivimab: n = 18 of 201 [8.9%] and casirivimab/imdevimab: n = 13 of 120 [10.8%]; p = 0.57). In addition, we found no statistically significant differences between groups regarding return visits to the ED or symptom improvement. One patient had a possible adverse reaction to the treatment, and 1 patient died. Both of these events occurred in the bamlanivimab group. Conclusions: We found no statistically significant differences in rates of subsequent hospitalization or other outcomes for ED patients with COVID-19 when they received bamlanivimab as opposed to casirivimab/imdevimab. Adverse events were rare in both groups.

Some experts have promoted the use of rapid testing for COVID-19. However, with the current technologies available, continuing to replace laboratory-based, real-time reverse transcription polymerase chain reaction tests with rapid (point-of-care) tests may lead to an increased number of false negative tests. Moreover, the more rapid dissemination of false negative results that can occur with the use of rapid tests for COVID-19 may lead to increased spread of the novel coronavirus if patients do not understand the concept of false negative tests. One means of combatting this would be to tell patients who have a "negative" rapid COVID-19 test that their test result was "indeterminate."

Objective Advanced Trauma Life Support guidelines recommend only 1 L of intravenous (IV) crystalloid before transitioning to blood products. We sought to determine if receiving >1 L of IV crystalloid during the initial resuscitation is associated with worse outcomes. We also sought to determine if receiving no crystalloids is associated with better outcomes. Methods We performed a single center retrospective study using trauma registry data, which was supplemented by manual chart review. We only included patients who had an initial heart rate ≥ 100 beats/min or a systolic blood pressure ≤ 90 mmHg. For each patient, we determined the total amount of IV crystalloid administered in the first 3 h after arrival to the hospital plus prehospital crystalloid. We performed multivariate regression analyses to determine if there is an association between the administration of >1 L of crystalloids or no crystalloids with in-hospital mortality, hospital length of stay (LOS), or packed red blood cells (PRBCs) transfused. Results Between January 1, 2018 and September 30, 2019, there were 878 who met criteria for enrollment. Among those, 55.0% received ≤1 L of IV crystalloids, and 45.0% received >1 L. Multivariate analyses showed no significant association between receiving >1 L and mortality (p = 0.61) or PRBCs transfused (p = 0.29), but patients who received >1 L had longer hospital LOS (p = 0.04). We found no association between receiving no crystalloids and mortality, PRBCs transfused, or LOS. Conclusion On a multivariate analysis of trauma patients, we did not find an association between the administration of >1 L of IV crystalloid and in-hospital mortality or the volume of PRBCs transfused. However, receiving >1 L of crystalloids was associated with a longer hospital LOS. We found no benefit to completely withholding crystalloids.

Background Physiologic hyperglycemia of puberty is a major contributor to poor glycemic control in youth with type 1 diabetes (T1D). This study’s aim was to determine the effectiveness of continuous glucose monitoring (CGM) to improve glycemic control in pubertal youth with T1D compared to a non-CGM cohort after controlling for age, sex, BMI, duration, and insulin delivery methodology. The hypothesis is that consistent CGM use in puberty improves compliance with diabetes management, leading to increased percentage (%) time in range (TIR70–180 mg/dL) of glycemia, and lowering of HbA1c. Methods A longitudinal, retrospective, case-controlled study of 105 subjects consisting of 51 T1D controls (60.8% male) age 11.5 ± 3.8 y; and 54 T1D subjects (48.1% male) age 11.1 ± 5.0 y with confirmed CGM use for 12 months. Pubertal status was determined by Tanner staging. Results were adjusted for baseline HbA1c and diabetes duration. Results HbA1c was similar between the controls and the CGM group at baseline: 8.2 ± 1.1% vs 8.3 ± 1.2%, p=0.48 respectively; but was significantly lower in the CGM group 12 months later, 8.2 ± 1.1% vs. 8.7 ± 1.4%, p=0.035. Longitudinal change in HbA1c was similar in the prepubertal cohort between the control- and CGM groups: −0.17 ± 0.98% vs. 0.38 ± 1.5%, p=0.17. In contrast, HbA1c increased with advancing age and pubertal status in the pubertal controls but not in the pubertal CGM group: 0.55 ± 1.4 vs −0.22 ± 1.1%, p=0.020. Percent TIR was inversely related to HbA1c in the CGM group, r=-0.6, p=0.0004, for both prepubertal and pubertal subjects. Conclusions CGM use significantly improved glycemic control in pubertal youth with T1D compared to non-CGM users.

This review identifies two cognitive benefits of social hierarchy that may contribute to hierarchy maintenance. First, research indicates that people pay attention to hierarchies automatically, early, and accurately. As a result, hierarchies feel easy to process, which increases liking and support of hierarchy. Second, through their clear, predictable structures and the opportunities they provide for personal agency, hierarchies help people satisfy their need for control, which may lead people to seek out and maintain hierarchy, especially if they currently hold a high rank or believe in social mobility. These cognitive benefits of ease and control may have effects on the performance of hierarchies and on people's willingness to change unfair structures.

Purpose Many experts recommend ordering an ultrasound and a urinalysis on all patients with scrotal pain. While the ultrasound may help diagnose a number of potential causes of scrotal pain, the urinalysis primarily has value in assessing for epididymo-orchitis. This study sought to evaluate the utility of these diagnostic tests for patients who presented to the emergency department (ED) with acute scrotal pain and possible epididymo-orchitis. Patients and methods This was a single-center chart review of patients presenting to the ED with scrotal pain. Trained research assistants reviewed charts to obtain urinalysis and ultrasound results as well as diagnoses and treatments provided. Using the final diagnosis as a gold standard, the sensitivity and specificity of ultrasound and urinalysis were calculated for the diagnosis of epididymo-orchitis. Also, through a prespecified definition of "changed management," we estimated the percentage of cases in which a urinalysis changed management of patients with acute scrotal pain. Results We identified 663 adult and pediatric patients who presented with scrotal pain during 2016. All patients had an ultrasound performed, and 458 (69.1%) had a urinalysis done. The sensitivity of urinalysis for epididymo-orchitis was 58.2% (95% CI 48.9% to 67.1%), and the specificity was 85.1% (95% CI 80.8% to 88.7%). For ultrasound, the sensitivity was 78.8% (95% CI 71.4% to 85.0%) and the specificity was 98.1% (95% CI 96.4% to 99.1%). In 24 of 458 cases (5.2% [95% CI 3.4% to 7.7%]) where a urinalysis was obtained, its results may have changed management of the patient. Conclusion The diagnosis of patients who present to the ED with scrotal pain is primarily driven by the ultrasound results. While the urinalysis may occasionally provide some benefit in the evaluation of patients with suspected epididymo-orchitis, the reflexive ordering of a urinalysis in patients with scrotal pain may be unnecessary.

ImportanceThere is no consensus on the impact of the 2020 COVID-19 pandemic lockdown on glycemic control in children and adolescents with type 1 diabetes (T1D) in the US.AimTo determine the impact of the pandemic lockdown of March 15th through July 6th, 2020 on glycemic control after controlling for confounders.Subjects and MethodsAn observational study of 110 subjects of mean age 14.8 ± 4.9 years(y), [male 15.4 ± 4.0y, (n=57); female 14.1 ± 3.8y, (n=53), p=0.07] with T1D of 6.31 ± 4.3y (95% CI 1.0-19.7y). Data were collected at 1-4 months before the lockdown and 1-4 months following the lifting of the lockdown at their first post-lockdown clinic visit.ResultsThere was no significant change in A1c between the pre- and post-pandemic lockdown periods, 0.18 ± 1.2%, (95% CI -0.05 to 0.41), p=0.13. There were equally no significant differences in A1c between the male and female subjects, -0.16 ± 1.2 vs -0.19 ± 1.2%, p=0.8; insulin pump users and non-pump users, -0.25 ± 1.0 vs -0.12 ± 1.4%, p=0.5; and pubertal vs prepubertal subjects, 0.18 ± 1.3 vs -0.11 ± 0.3%, p=0.6. The significant predictors of decrease in A1c were pre-lockdown A1c (pConclusionsThere was no change in glycemic control during the pandemic lockdown of 2020 in US children.

Concrete is one of the most common structural materials in the world. The quality of concrete is affected by various conditions and properties. Water-cement ratio (w/c ratio) and curing conditions are two of the most important factors that influence the quality of concrete. Hence, monitoring of the quality of curing is essential for all concrete structures to have information about the concrete condition and prevent errors that can lead to high maintenance costs. Performing non-destructive tests instead of conventional destructive tests is important to save time and high testing costs. Each material in the world has its own special hyperspectral signature that can be considered as a fingerprint. These signatures are provided by recording the reflectance of the light reflected from the specimen, and analyzing this reflectance in a larger wavelength range than human eyes can see. Nowadays, hyperspectral imaging technology is used in many working areas such as in agriculture, food processing, medicine, surveillance, astronomy and so forth. Likewise, some research has been done to identify concrete properties by using this technology. Mixtures with different w/c ratio and different curing treatments were prepared for this project. The effects of the different curing conditions and different w/c ratios on hyperspectral signatures were investigated by comparing the hyperspectral data that were taken on different days after concreting. This project aims to determine an easily implementable, low cost, fast, reliable and non-destructive in-situ testing method to investigate curing quality by using the hyperspectral imaging method.

Importance The physiologic changes in lipids during puberty in type 1 diabetes (T1D) are unclear because subjects in previous studies were not stratified by partial clinical remission status. Aim To determine the effect of partial clinical remission on lipid changes during puberty in youth with T1D. Subjects and Methods A retrospective cross-sectional study of 194 subjects consisting of 71 control subjects of age 12.9 ± 1.3 years and 123 subjects with T1D stratified into remitters (n = 44; age, 13.0 ± 0.8 years) and nonremitters (n = 79; age, 11.2 ± 0.6 years). Partial clinical remission was defined as insulin-dose adjusted HbA1c of ≤9. Pubertal status was determined by Tanner staging. Results Among the pubertal cohort, low-density lipoprotein cholesterol concentration was significantly higher in the nonremitters compared with remitters (91.1 ± 25.6 vs 77.2 ± 25.8 mg/dL, P = 0.018) and with normal-weight control subjects (91.1 ± 25.6 vs 70.4 ± 22.9 mg/dL, P = 0.009) but was similar between overweight/obese control subjects and nonremitters (89.7 ± 28.9 vs 91.1± 25.6 mg/dL, P = 0.81) and between normal-weight control subjects and remitters (70.4 ± 22.9 vs 77.2 ± 25.8 mg/dL, P = 0.39). Total cholesterol was also significantly higher in nonremitters compared with remitters (167.8 ± 30.5 vs 149.8 ± 32.1 mg/dL, P = 0.012) and with normal-weight control subjects (167.8 ± 30.5 vs 143.2 ± 30.1 mg/dL, P = 0.011) but was similar between nonremitters and overweight/obese control subjects (P = 0.098) and between remitters and normal-weight control subjects (P = 0.51). Non–high-density lipoprotein cholesterol was equally significantly higher in nonremitters compared with remitters (111.3 ± 30.1 vs 95.9 ± 29.1 mg/dL, P = 0.028) and normal-weight control subjects (111.3 ± 30.1 vs 86.2 ± 32.2 mg/dL, P = 0.028) but was similar between nonremitters and overweight/obese control subjects (P = 0.48) and between remitters vs normal-weight control subjects (P = 0.39). Conclusions Puberty-related reductions in low-density lipoprotein, total cholesterol, and non–high-density lipoprotein occur in remitters and normal-weight control subjects but not in nonremitters and overweight/obese control subjects.

Objectives The is no consensus on the early patterns of lipid-based cardiovascular disease (CVD) risk in youth with either type 1 diabetes (T1D) or type 2 diabetes (T2D). The aim was todetermine the differences in CVD risk, using lipid profiles, in children and adolescents with either T1D or T2D at the time of their first lipid assessment, after stratifying the T1D cohort into remitters and non-remitters based on their honeymoon history. Methods A cross-sectional study of 249 subjects consisting of 73 controls, 53 T2D subjects, and 123 T1D subjects stratified into remitters (n=44), and non-remitters (n=79). Partial clinical remission (PCR) was defined as insulin-dose adjusted HbA1c of ≤9. Pubertal status was determined by Tanner staging. Results After adjusting for age, sex, BMI, race, and pubertal status, T2D patients had significantly higher LDL-C compared to the controls (p=0.022), the remitters (p=0.029), but not the non-remitters (103.1 ± 5.9 mg/dL vs. 91.4 ± 4.2 mg/dL, p=0.49). Similarly, T2D patients had significantly higher non-HDL-C compared to the controls (p=0.006), the remitters (p=0.0002), but not the non-remitters (137.6 ± 7.1 mg/dL vs. 111.71 ± 5.0 mg/dL, p=0.053). Total cholesterol was also significantly higher in T2D patients compared to the controls (p=0.0005), the remitters (p=0.006) but not the non-remitters (183.5 ± 6.6 mg/dL vs. 166.2 ± 4.8 mg/dL, p=0.27). Conclusions Lack of the honeymoon phase in children and adolescents with T1D confers early and significantly increased lipid-based cardiovascular risk to these patients that is similar to the elevated cardiovascular risk seen in T2D.

Many public officials are calling for increased testing for the 2019 novel coronavirus disease (COVID-19), and some governments have taken extraordinary measures to increase the availability of testing. However, little has been published about the sensitivity and specificity of the reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swabs that are commonly used for testing. This narrative review evaluates the literature regarding the accuracy of these tests, and makes recommendations based on this literature. In brief, a negative RT-PCR nasopharyngeal swab test is insufficient to rule out COVID-19. Thus, over-reliance on the results of the test may be dangerous, and the push for widespread testing may be overstated.

Background Some experts recommend using a 1-h sepsis bundle, but clinical data supporting this strategy are lacking. Objectives We aimed to determine the rate of, and clinical predictors for, bacteremia for patients undergoing a 1-h sepsis bundle, and to determine the percentage of “code sepsis” patients who are ultimately diagnosed with sepsis or a bacterial infection. Methods This retrospective chart review evaluated code sepsis patients from three emergency departments (EDs) that utilize a 1-h sepsis bundle. The primary outcome was the rate of true-positive blood cultures. Secondarily, we analyzed various clinical factors using logistic regression analysis to determine which are associated with bacteremia. Results Of the 544 code sepsis patients analyzed, 33.8% (95% confidence interval [CI] 29.9–38.0%) were ultimately diagnosed with sepsis, and 54.6% (95% CI 50.3–58.8%) were diagnosed with a bacterial infection. Exactly 7.0% (95% CI 5.0–9.5%) of the blood cultures performed were true positives. On multivariate logistic regression analysis, temperature > 38°C (100.4°F) or 4 mmol/L, and indwelling line/device were found to be positively associated with true-positive blood cultures. Conclusion In a group of code sepsis patients from facilities that use a 1-h sepsis bundle, the majority were ultimately not diagnosed with sepsis, and nearly half did not have a bacterial infection. A small minority of patients had bacteremia. Restricting blood culture ordering in patients with possible sepsis to only those who have increased risk for bacteremia could lead to a more judicious use of blood cultures.

Background Serum lactate increases in states of severe sepsis and shock, but its interpretation may be subject to confounders. Lactated Ringer's solution (LR) is used in the resuscitation of septic patients and contains 28 mmol/L of sodium lactate. Objectives We sought to determine if a bolus of 30 mL/kg of LR increases serum lactate levels. Methods In this double-blind, randomized controlled trial, 30 volunteers were assigned to receive either 30 mL/kg of intravenous LR or normal saline (NS). Serum lactate was measured before and after the fluid bolus. The primary outcome was the difference in the change in lactate between the LR and NS groups. Secondarily, we assessed the change in pH, bicarbonate, sodium, and chloride in each group. Results After 30 mL/kg of intravenous LR, the mean serum lactate level increased by 0.93 mmol/L (95% confidence interval 0.42–1.44 mmol/L). However, there was also a small increase in the mean serum lactate level in the NS group of 0.37 mmol/L (95% confidence interval −0.26 mmol/L to 1.00 mmol/L), such that there was not a statistically significant difference in the change in lactate when comparing the LR group to the NS group (p = 0.2). The NS group saw larger declines in pH and bicarbonate and greater increases in chloride compared with the LR group. Conclusion In healthy individuals, a modest but significant rise in mean serum lactate was seen after a 30 cc/kg LR bolus. There was no difference in mean serum lactate when comparing a 30 mL/kg bolus of NS to LR.

Background Urgent care centers (UCCs) can offer a cheap alternative to emergency departments (EDs) for some patients with acute complaints. However, if patients who initially present to a UCC are unnecessarily transferred to an ED, those patients may suffer undue financial harm. The group of patients transferred from UCCs to EDs have never previously been studied. Objectives The primary objective of this study was to determine the fraction of transfers from a UCC to an ED that were unnecessary. We also assessed the frequency with which these patients were discharged from the ED, and tried to determine which groups of patients were most likely to be unnecessarily transferred. Methods This was a retrospective chart review performed on patients transferred from UCCs to our ED. If the transferred patient had no advanced imaging tests, advanced procedures, or specialty consultations in the ED, and was not admitted, we considered the transfer to be unnecessary. Patients were stratified by age (adult vs. pediatric) and type of insurance. Results We identified 3232 patients who were transferred from UCCs to our ED over a 1-year period. Among those, 1159 (35.9%; 95% confidence interval [CI] 34.2–37.5%) met our criteria as unnecessary, and 2075 (64.2%; 95% CI 62.5–65.8%) were discharged from the ED. Notably, pediatric patients were more likely than adult patients to be unnecessarily transferred. Patients without medical insurance were not more likely to be transferred than those with private insurance. Conclusion Most patients transferred to our ED from a UCC were discharged, and many transfers were unnecessary, especially those involving pediatric patients. These transfers may represent an economic burden to our society.

An exploratory study for verifying regional geographical origin of carrots from specific production regions in Austria (“Genussregionen”) was performed by combining chemical fingerprinting methods, namely n(86Sr)/n(87Sr) isotope amount ratios, multi-elemental and metabolomic pattern. Chemometric classification models were built on individual and combined datasets using (data-driven) soft independent modelling of class analogies and (orthogonal) projections to latent structures-discriminant analysis to characterise and differentiate carrots grown in five regions in Austria. A predictive ability of 97% or better (depending on the classification technique) was obtained using combined Sr isotope amount ratios and multi-elemental data. The use of data fusion strategies, in particular the mid-level option (fusion of selected variables from the different analytical platforms), allowed highly efficient (99–100%, except soft independent modelling of class analogy with 97%) and correct classification of carrot samples.

Portable spectroscopic instruments are an interesting alternative for in-field and on-line measurements. However, the practical implementation of visible-near infrared (VIS-NIR) portable sensors in the forest sector is challenging due to operation in harsh environmental conditions and natural variability of wood itself. The objective of this work was to use spectroscopic methods as an alternative to visual grading of wood quality. Three portable spectrometers covering visible and near infrared range were used for the detection of selected naturally occurring wood defects, such as knots, decay, resin pockets and reaction wood. Measurements were performed on wooden discs collected during the harvesting process, without any conditioning or sample preparation. Two prototype instruments were developed by integrating commercially available micro-electro-mechanical systems with for-purpose selected lenses and light source. The prototype modules of spectrometers were driven by an Arduino controller. Data were transferred to the PC by USB serial port. Performance of all tested instruments was confronted by two discriminant methods. The best performing was the microNIR instrument, even though the performance of custom prototypes was also satisfactory. This work was an essential part of practical implementation of VIS-NIR spectroscopy for automatic grading of logs directly in the forest. Prototype low-cost spectrometers described here formed the basis for development of a prototype hyperspectral imaging solution tested during harvesting of trees within the frame of a practical demonstration in mountain forests.

Alteplase is the only Food and Drug Administration-approved intravenous (IV) thrombolytic medication for acute ischemic stroke. However, multiple recent studies comparing tenecteplase and alteplase suggest that tenecteplase is at least as efficacious as alteplase with regards to neurologic improvement. When given at 0.25 milligrams per kilogram (mg/kg), tenecteplase may have less bleeding complications than alteplase as well. This narrative review evaluates the literature and addresses the practical issues with regards to the use of tenecteplase versus alteplase for acute ischemic stroke, and it recommends that physicians consider tenecteplase rather than alteplase for thrombolysis of acute ischemic stroke.

BackgroundMany emergency physicians use an intravenous fluid bolus as part of a ‘cocktail’ of therapies for patients with headache, but it is unclear if this is beneficial. The objective of this study was to determine if an intravenous fluid bolus helps reduce pain or improve other outcomes in patients who present to the ED with a benign headache.MethodsThis was a randomised, single-blinded, clinical trial performed on patients aged 10–65 years old with benign headaches who presented to a single ED in Las Vegas, Nevada, from May 2017 to February 2019. All patients received prochlorperazine and diphenhydramine, and they were randomised to also receive either 20 mL/kg up to 1000 mL of normal saline (the fluid bolus group) or 5 mL of normal saline (the control group). The primary outcome was the difference between groups in mean pain reduction 60 min after the initiation of treatment. Secondarily, we compared groups with regards to pain reduction at 30 min, nausea scores, the use of rescue medications and disposition.ResultsWe screened 67 patients for enrolment, and 58 consented. Of those, 35 were randomised to the fluid bolus group and 23 to the control group. The mean pain score dropped by 48.3 mm over 60 min in the fluid bolus group, compared with 48.7 mm in the control group. The between groups difference of 0.4 mm (95% CI −16.5 to 17.3) was not statistically significant (p=0.96). Additionally, no statistically significant difference was found between groups for any secondary outcome.ConclusionThough our study lacked statistical power to detect small but clinically significant differences, ED patients who received an intravenous fluid bolus for their headache had similar improvements in pain and other outcomes compared with those who did not.Trial registration numberNCT03185130.

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Within the last few decades, we have witnessed a dramatic rise in the use of AI surveillance technology in organizations. In this paper, we answer calls from management scholars to investigate the ...

OBJECTIVES The objectives were to determine if nebulized albuterol causes an increase in the serum lactate level compared to placebo and, secondarily, to confirm that albuterol decreases serum potassium levels compared to placebo in patients with normokalemia. METHODS This was a randomized, double-blind, placebo-controlled trial. Twenty-eight healthy adult volunteers were assigned to receive either 10 mg of nebulized albuterol or placebo (nebulized saline) over 1 hour. Serum lactate was measured prior to treatment and at 30 and 70 minutes after the start of treatment. Serum potassium level was measured prior to treatment and at 70 minutes. The primary outcome was the degree of change in lactate level. The secondary outcome was the degree of change in potassium level. RESULTS In the 14 subjects who received albuterol, the mean increase in lactate was 0.77 mmol/L (95% confidence interval [CI] = 0.52 to 1.02 mmol/L), and the mean decrease in potassium level was 0.5 mEq/L (95% CI = -0.72 to -0.28 mEq/L). Among the subjects who received placebo, the lactate level decreased by 0.15 mmol/L (95% CI = -0.39 to 0.09 mmol/L) and there was no change in potassium level at (0.0 mEq/L [95% CI = -0.21 to 0.21 mEq/L]). These differences are statistically significant (p < 0.0001 and p = 0.003, respectively). CONCLUSION Nebulized albuterol increases lactate levels and decreases potassium levels in healthy adults.

Background Recent data have challenged the notion that rapid intravenous fluid administration results in adverse neurologic outcomes in children with diabetic ketoacidosis (DKA). While many physicians still administer a cautious 10 cc/kg bolus of intravenous fluids for pediatric DKA patients, there may be benefits to using a larger bolus. Methods This was a retrospective chart review of all pediatric patients with DKA presenting to a single emergency department (ED) between 2013 and 2015. Patients who received a bolus of 10 cc/kg or less in the ED were compared to patients who received >10 cc/kg of fluids. The primary outcome was the difference in hospital length-of-stay between the two groups. Secondarily, we compared groups with regards to the time to bicarbonate normalization. Results In sum, 170 pediatric DKA ED visits were analyzed. Patients who received a 10 cc/kg bolus or less of fluids in the ED had a mean hospital length-of-stay > that was 0.38 days longer (95% CI: 0.006 to 0.75 days) than those who received >10 cc/kg. On multivariable regression analysis, the difference between groups was diminished and no longer statistically significant. The time to bicarbonate normalization was 0.12 days longer (95% CI -0.029 to 0.27) in the 10 cc/kg or less group than the >10 cc/kg group. Conclusions After adjustment for confounders, no statistically significant differences in outcomes were seen in pediatric DKA patients who received a 10 cc/kg bolus or less compared to those who received a larger initial bolus.

Author(s): Marshall, Travis; Chen, Nae Meng; Nguyen, Eric; Slattery, David E.; Zitek, Tony | Abstract: Introduction: Computed tomography pulmonary angiography (CTPA) is the test of choice for diagnosis of pulmonary embolism (PE) in the emergency department (ED), but this test may be indeterminate for technical reasons such as inadequate contrast filling of the pulmonary arteries. Many hospitals have requirements for intravenous (IV) catheter size or location for CTPAs to reduce the chances of inadequate filling, but there is a lack of clinical data to support these requirements. The objective of this study was to determine if a certain size or location of IV catheter used for contrast for CTPA is associated with an increased chance of an indeterminate CTPA. Methods: This was a retrospective chart review of patients who underwent CTPA in the emergency department. A CTPA was considered indeterminate if the radiology report indicated it was inadequate to exclude a pulmonary embolism. The reason for the study being indeterminate, and the size and location of the IV catheter were abstracted. The rate of inadequate contrast filling of the pulmonary vasculature was calculated and compared for various IV catheter sizes and locations. In particular, 20-gauge or larger IV catheters in the antecubital fossa or forearm were compared to all other sizes and locations. Results: A total of 19.3% of the 1500 CTPA reports reviewed met our criteria as indeterminate, and 51.6% of those were due to inadequate filling. Patients with a 20-gauge IV catheter or larger placed in the antecubital fossa or forearm had inadequate filling 9.2% of the time compared to 13.2% for patients who had smaller IVs or IVs in other locations (difference: 4.0% [95% CI -1.7% to 9.7%]). There were also no statistically significant differences in the rates of inadequate filling when data were further stratified by IV catheter location and size. Conclusion: We did not detect any statistically significant differences in the rate of inadequate contrast filling based on IV catheter locations or sizes. While small differences not detected in this study may exist, it seems prudent to proceed with CTPA in patients with difficult IV access who need emergent imaging even if they have a small or distally located IV.

Author(s): Zitek, Tony; Busby, Elizabeth; Hudson, Heather; McCourt, John D.; Baydoun, Jamie; Slattery, David E. | Abstract: Introduction: The peripheral internal jugular (IJ), also called the “easy IJ,” is an alternative to peripheral venous access reserved for patients with difficult intravenous (IV) access. The procedure involves placing a single-lumen catheter in the IJ vein under ultrasound (US) guidance. As this technique is relatively new, the details regarding the ease of the procedure, how exactly it should be performed, and the safety of the procedure are uncertain. Our primary objective was to determine the success rate for peripheral IJ placement. Secondarily, we evaluated the time needed to complete the procedure and assessed for complications.Methods: This was a prospective, single-center study of US-guided peripheral IJ placement using a 2.5-inch, 18-gauge catheter on a convenience sample of patients with at least two unsuccessful attempts at peripheral IV placement by nursing staff. Peripheral IJ lines were placed by emergency medicine (EM) attending physicians and EM residents who had completed at least five IJ central lines. All physicians who placed lines for the study watched a 15-minute lecture about peripheral IJ technique. A research assistant monitored each line to assess for complications until the patient was discharged. Results: We successfully placed a peripheral IJ in 34 of 35 enrolled patients (97.1%). The median number of attempts required for successful cannulation was one (interquartile range (IQR): 1 to 2). The median time to successful line placement was 3 minutes and 6 seconds (IQR: 59 seconds to 4 minutes and 14 seconds). Two lines failed after placement, and one of the 34 successfully placed peripheral IJ lines (2.9%) had a complication – a local hematoma. There were, however, no arterial punctures or pneumothoraces. Although only eight of 34 lines were placed using sterile attire, there were no line infections. Conclusion: Our research adds to the growing body of evidence supporting US-guided peripheral internal jugular access as a safe and convenient procedure alternative for patients who have difficult IV access.

This paper deals with the concept of differentiated knowledge bases, an area related to the study of the regional innovation systems. The concept explores the ways in which knowledge is involved in innovation processes and knowledge flows within and between organisations. Some limitation of this concept can be the fact that there is no clear methodology for identification of knowledge bases in regions. The aim of this paper is to propose appropriate indicators and methodology to empirically identify the knowledge base of a region. The second aim of this paper is to use this methodology for the identification of knowledge bases in the Czech regions. Based on this typology, the Czech regions are classified into four groups - those with a prevailing analytical, synthetic, analytical-synthetic, and synthetic-analytical knowledge base. The methods used for the classification include the point method and cluster analysis, which allows aggregating regions with similar characteristics. The Capital City of Prague, the South Bohemian Region, and the South Moravian Region were among the ones with an analytical base. A synthetic knowledge base was identified in the Liberec Region, the Zlin Region, and the Vysocina Region. One of the two transitional types was found in the remaining regions. In real-life practice the findings can be applied, above all, to the implementation of regional innovation policies, which should always respect the characteristics of the given region. DOI: http://dx.doi.org/10.5755/j01.ee.27.5.14276

ObjectiveThe primary goal of this study was to compare paramedic first pass success rate between two different video laryngoscopes and direct laryngoscopy (DL) under simulated prehospital conditions in a cadaveric model.MethodsThis was a non-randomized, group-controlled trial in which five non-embalmed, non-frozen cadavers were intubated under prehospital spinal immobilization conditions using DL and with both the GlideScope Ranger (GL; Verathon Inc, Bothell, Washington USA) and the VividTrac VT-A100 (VT; Vivid Medical, Palo Alto, California USA). Participants had to intubate each cadaver with each of the three devices (DL, GL, or VT) in a randomly assigned order. Paramedics were given 31 seconds for an intubation attempt and a maximum of three attempts per device to successfully intubate each cadaver. Confirmation of successful endotracheal intubation (ETI) was confirmed by one of the six on-site physicians.ResultsSuccessful ETI within three attempts across all devices occurred 99.5% of the time overall and individually 98.5% of the time for VT, 100.0% of the time for GL, and 100.0% of the time for DL. First pass success overall was 64.4%. Individually, first pass success was 60.0% for VT, 68.8% for GL, and 64.5% for DL. A chi-square test revealed no statistically significant difference amongst the three devices for first pass success rates (P=.583). Average time to successful intubation was 42.2 seconds for VT, 38.0 seconds for GL, and 33.7 for seconds for DL. The average number of intubation attempts for each device were as follows: 1.48 for VT, 1.40 for GL, and 1.42 for DL.ConclusionThe was no statistically significant difference in first pass or overall successful ETI rates between DL and video laryngoscopy (VL) with either the GL or VT (adult).HodnickR, ZitekT, GalsterK, JohnsonS, BledsoeB, EbbsD. A comparison of paramedic first pass endotracheal intubation success rate of the VividTrac VT-A 100, GlideScope Ranger, and direct laryngoscopy under simulated prehospital cervical spinal immobilization conditions in a cadaveric model. Prehosp Disaster Med. 2017;32(6):621–624.

Study objective Intravenous subdissociative-dose ketamine has been shown to be effective for pain management, but has not been specifically studied for headaches in the emergency department (ED). For this reason, we designed a study to compare standard treatment (prochlorperazine) with ketamine in patients with benign headaches in the ED. Methods This study was a multicenter, double-blind, randomized, controlled trial with a convenience sample of patients presenting to the ED with benign headaches. Patients were randomized to receive either prochlorperazine and diphenhydramine or ketamine and ondansetron. Patients' headache severity was measured on a 100-mm visual analog scale (VAS) at 0, 15, 30, 45, and 60 minutes. Nausea, vomiting, anxiety, and the need for rescue medications were also tracked. Patients were contacted at 24 to 48 hours posttreatment to rate their satisfaction and to determine whether they were still experiencing a headache. Results There were a total of 54 subjects enrolled. Two patients in the ketamine group and one in the prochlorperazine group withdrew because of adverse effects of the medications. In regard to the primary outcome, at 60 minutes, the prochlorperazine group had a mean improvement in VAS pain scores of 63.5 mm compared with 43.5 mm in the ketamine group, corresponding to a between-groups difference of 20.0 mm (95% confidence interval [CI] 2.8 to 37.2 mm) and a P value of .026. At 45 minutes, the prochlorperazine group had a mean improvement in pain scores of 56.1 mm compared with 38.0 mm in the ketamine group, a difference of 18.1 mm (95% CI 1.0 to 35.2 mm). At 24- to 48-hour follow-up, the mean satisfaction score was 8.3 of 10 for prochlorperazine and 4.9 of 10 for ketamine, a difference of 3.4 (95% CI 1.2 to 5.6). There was not a statistically significant difference in the percentage of patients who had a headache at follow-up or in other secondary outcomes. Conclusion Prochlorperazine appears to be superior to ketamine for the treatment of benign headaches in the ED.

In the pediatric population, cardiac tamponade may present with altered mental status without any clear signs of trauma. Bedside ultrasound is essential to the early diagnosis of this condition. We describe the case of a 5-year-old boy who sustained a potentially fatal, unrecognized trauma to his chest resulting in cardiac tamponade.

The DynaLearn interactive learning environment enables learning by having learners create conceptual models of system's behavior. This paper reports on exploratory evaluation studies using the DynaLearn software, carried out with learners studying environmental science. Two three-day modeling sessions were conducted in two consecutive years with two students exploring the evolving prototype of the software. The learners worked on assignments designed to achieve specific learning goals. To investigate conceptual changes on behalf of the learner, a set of parameters was applied for semantic text analysis of written pre- and posttests. The evaluation results show key changes occurring in knowledge structure and content in both years for both students. Indications of an effect of prior knowledge on the magnitude of conceptual change were found. The results confirm the potential of DynaLearn for inducing causal and interlinked understanding of environmental systems.

Deep vein thrombosis (DVT) is a serious condition that is difficult to diagnose clinically. Venography has long been held as the gold standard for diagnosis of DVT. Ultrasonography has a sensitivity and specificity that approaches that of venography, and has nearly replaced venography for the diagnosis of DVT. Traditionally DVT ultrasounds have been performed by technologists and interpreted by radiologists. These tests generally consist of full leg compression and Doppler studies, which may take over 15 min to perform. However, several recent studies have demonstrated that simplified versions of these ultrasound protocols, such as two-point compression or three-point compression, can be performed at the bedside with sensitivities and specificities that are comparable to those of the more comprehensive formal studies. These studies allow emergency medicine and critical care physicians to rapidly diagnose DVT at the bedside, and some studies suggest that these bedside studies are as accurate as formal studies.

Although advances have been made in the approach to airway management, intubating critically ill patients in the Emergency Department (ED) can still be perilous. In some cases, poor peripheral perfusion may preclude obtaining a consistent or reliable pulse oximetry waveform, and the intubator will not accurately know when the patient begins to desaturate. We describe a case of a patient requiring intubation in whom we were unable to obtain a consistent pulse oximetry waveform. We utilized a novel technique in which a Biphasic Cuirass Ventilation (BCV) device was applied to maintain oxygenation and ventilation during the performance of rapid sequence intubation (RSI). This technique has the potential to improve the safety of RSI, especially in the critically ill patient.

The potential to discriminate between wild and hatchery trout [Salmo trutta f. fario L. and Oncorhynchus mykiss (Walbaum)] by chronological microchemical patterns of different otolith regions was tested. Central and rim regions of otoliths were analysed for life stage specific elemental patterns of strontium (Sr), sodium (Na) and calcium (Ca) as well as of 87Sr/86Sr ratios using laser ablation inductively coupled plasma mass spectrometry (LA-ICP-MS). Classification to life stage specific habitats was achieved with 100% accuracy by 88Sr/43Ca, 23Na/43Ca and 87Sr/86Sr ratios resulting in a discrimination of hatchery fish from wild fish. 87Sr/86Sr ratios and Sr concentration in otoliths were positively correlated with the ratio and amount in the water. Na content in otoliths did not directly reflect the concentration in the water, although the 23Na/43Ca ratio in otoliths contributed to the discrimination. Clear differences in otolith chemistry were found for fish experiencing different geological units or a groundwater-fed environment in a hatchery. Natural chronological microchemical patterns in otoliths proved to be a valuable tool for discriminating wild and hatchery fish without the necessity to use marking methods. LA-ICP-MS is well suited for this application because of its limited need for sample preparation, its potentially high sample throughput and the possibility of simultaneous measurement of multiple elemental and isotopic fingerprints.

Due to the world wide degradation of river catchments and their related aquatic resources the development of integrated management strategies has become an important issue. Tools and processes are required that support the integration of science, the needs of stakeholders and the local population, within existing political frameworks to achieve a sustainable catchment development. In this paper the potential of qualitative reasoning (QR) models for sustainable catchment management is evaluated by students and domain experts. This evaluation yields promising results. The evaluated QR models were found to represent complex knowledge in an understandable manner. Most people ‘largely or fully agreed’ that the presented QR models may significantly contribute to the understanding of students and stakeholders, concerning which entities and processes drive a sustainable development of a riverine landscape, and therefore enhances their decision-making capabilities. Due to its potential to integrate quantitative and qualitative knowledge, to build causal models, and to run dynamic simulations, the presented QR approach has great potential to become an important contribution to integrated catchment management at multiple levels of the implementation process thereof (such as education, decision-making, social learning, integration of different scientific disciplines, and communication).

Introduction: Two-point compression ultrasound is purportedly a simple and accurate means to diagnose proximal lower extremity deep vein thrombosis (DVT), but the pitfalls of this technique have not been fully elucidated. The objective of this study is to determine the accuracy of emergency medicine resident-performed two-point compression ultrasound, and to determine what technical errors are commonly made by novice ultrasonographers using this technique. Methods: This was a prospective diagnostic test assessment of a convenience sample of adult emergency department (ED) patients suspected of having a lower extremity DVT. After brief training on the technique, residents performed two-point compression ultrasounds on enrolled patients. Subsequently a radiology department ultrasound was performed and used as the gold standard. Residents were instructed to save videos of their ultrasounds for technical analysis. Results: Overall, 288 two-point compression ultrasound studies were performed. There were 28 cases that were deemed to be positive for DVT by radiology ultrasound. Among these 28, 16 were identified by the residents with two-point compression. Among the 260 cases deemed to be negative for DVT by radiology ultrasound, 10 were thought to be positive by the residents using two-point compression. This led to a sensitivity of 57.1% (95% CI [38.8-75.5]) and a specificity of 96.1% (95% CI [93.8-98.5]) for resident-performed two-point compression ultrasound. This corresponds to a positive predictive value of 61.5% (95% CI 42.8% to 80.2%) and a negative predictive value of 95.4% (95% CI 92.9% to 98.0%). The positive likelihood ratio is 14.9 (95% CI 7.5 to 29.5) and the negative likelihood ratio is 0.45 (95% CI 0.29 to 0.68). Video analysis revealed that in four cases the resident did not identify a DVT because the thrombus was isolated to the superior femoral vein (SFV), which is not evaluated by two-point compression. Moreover, the video analysis revealed that the most common mistake made by the residents was inadequate visualization of the popliteal vein. Conclusion: Two-point compression ultrasound does not identify isolated SFV thrombi, which reduces its sensitivity. Moreover, this technique may be more difficult than previously reported, in part because novice ultrasonographers have difficulty properly assessing the popliteal vein.

The article describes an experimental device that is placed in the KKE labs. This is a single stage axial air turbine situated in the compressor suction. The device is intended for research of turbine flow path. Currently being tested reaction bladed in cooperation with an industrial partner Doosan Skoda Power.

Research and development represent an important source for the introduction of new innovation, in particular technical innovation. Individual regions differ considerably in the level of their research activity and in their preconditions for it. The aim of this paper is to compare the level of research activity in Czech and Slovak regions. The analysis is carried out at the NUTS3 regions level; therefore, it involves 14 regions in the Czech Republic and 8 regions in Slovakia. Our analysis is focused on expenditures on R&D and human resources in R&D. We analyze the source of financing (public, business), field of science (technical and natural sciences), type of research (basic, applied), and the number of R&D personnel in full time equivalent. The attention is also paid to the institutions responsible for support of R&D in both countries. The level of research activity in the Czech Republic is significantly higher than in Slovakia. In both countries the research is concentrated in the capital cities and the South Moravian Region in the case of the Czech Republic. Big differences between capital cities and other regions were observed. This work is licensed under aCreative Commons Attribution-NonCommercial 4.0 International License.

When subordinates break a rule, authority figures have to decide whether to be strict and make the subordinates face the consequences or be lenient and overlook the violation. Five studies examined...