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Introduction: Emergency department (ED) crowding and hospital diversion times are increasing nationwide, with negative effects on patient safety and an association with increased mortality. Crowding in referral centers makes transfer of complex or critical patients by rural emergency physicians (EP) more complicated and difficult. We present a case requiring an unorthodox transfer method to navigate extensive hospital diversion and obtain life-saving neurosurgical care.Case Report: We present the case of a previously healthy 21-year-old male with two hours of headache and rapid neurologic decompensation en route to and at the ED. Computed tomography revealed obstructive hydrocephalus recognized by the EP, who medically managed the increased intracranial pressure (ICP) and began the transfer process for neurosurgical evaluation and management. After refusal by six referral centers in multiple states, all of which were on diversion, the EP initiated an unorthodox transfer procedure to the institution at which he trained, ultimately transferring the patient by air. Bilateral external ventricular drains were placed in the receiving ED, and the patient ultimately underwent neurosurgical resection of an obstructive colloid cyst.Conclusion: First, our case illustrates the difficulties faced by rural EPs when attempting to transfer critical patients when large referral centers are refusing transfers and the need for improvements in facilitating timely transfers of critically ill, time-sensitive patients. Second, EPs should be aware of colloid cysts as a rare but potentially catastrophic cause of rapid neurologic decline due to increased ICP, and the ED management thereof, which we review.

Purpose The heterogeneity in sepsis is held responsible, in part, for the lack of precision treatment. Many attempts to identify subtypes of sepsis patients identify those with shared underlying biology or outcomes. To date, though, there has been limited effort to determine overlap across these previously identified subtypes. We aimed to determine the concordance of critically ill patients with sepsis classified by four previously described subtype strategies. Methods This secondary analysis of a multicenter prospective observational study included 522 critically ill patients with sepsis assigned to four previously established subtype strategies, primarily based on: (i) clinical data in the electronic health record ([alpha], [beta], [gamma], and [delta]), (ii) biomarker data (hyper- and hypoinflammatory), and (iii-iv) transcriptomic data (Mars1-Mars4 and SRS1-SRS2). Concordance was studied between different subtype labels, clinical characteristics, biological host response aberrations, as well as combinations of subtypes by sepsis ensembles. Results All four subtype labels could be adjudicated in this cohort, with the distribution of the clinical subtype varying most from the original cohort. The most common subtypes in each of the four strategies were [gamma] (61%), which is higher compared to the original classification, hypoinflammatory (60%), Mars2 (35%), and SRS2 (54%). There was no clear relationship between any of the subtyping approaches (Cramer's V = 0.086-0.456). Mars2 and SRS1 were most alike in terms of host response biomarkers (p = 0.079-0.424), while other subtype strategies showed no clear relationship. Patients enriched for multiple subtypes revealed that characteristics and outcomes differ dependent on the combination of subtypes made. Conclusion Among critically ill patients with sepsis, subtype strategies using clinical, biomarker, and transcriptomic data do not identify comparable patient populations and are likely to reflect disparate clinical characteristics and underlying biology., Author(s): Rombout B. E. van Amstel [sup.1] [sup.2], Jason N. Kennedy [sup.3], Brendon P. Scicluna [sup.4] [sup.5], Lieuwe D. J. Bos [sup.1] [sup.2], Hessel Peters-Sengers [sup.6] [sup.7], Joe M. Butler [...]

Video games are a ubiquitous form of entertainment that also have the potential to fulfil the socialisation needs of players. In recent years, policy makers and healthcare providers have voiced growing concerns regarding the potential for video gaming to negatively impact mental health and foster social isolation. However, empirical data regarding the potential relationship between time spent gaming, loneliness, and mental health outcomes is lacking. Therefore, the present study aimed to examine this potential relationship using three nationwide COVID-19 lockdowns as models of increased risk of loneliness and poor mental health, across three individual studies. Time spent gaming had no direct relationship with either mental health or loneliness measures taken during lockdown, and this relationship was not moderated by loneliness. While lockdown alone did not impact mental health, loneliness was consistently associated with poor mental health outcomes during lockdown. Our results add to the existing body of literature on the relationship between video gaming and mental health and emphasise the need for targeted public mental health interventions to improve public mental health during periods of isolation. Data and analysis code associated with this project is accessible at: . [ABSTRACT FROM AUTHOR]

Purpose There is limited knowledge on how the source of infection impacts the host response to sepsis. We aimed to compare the host response in sepsis patients with a single, known source at admission (< 24 h) to the intensive care unit. Methods From the molecular diagnosis and risk stratification of sepsis (MARS) prospective cohort, we measured 16 plasma host response biomarkers reflective of key host response pathways in 621 sepsis patients. In a subgroup (n = 335), blood leukocyte transcriptomes were compared between the sources. Differences in clinical patient profiles and survival were compared in the whole sepsis cohort (n = 2019). Results The plasma biomarker cohort was categorized into sepsis originating from the respiratory tract (n = 334, 53.8%), abdomen (n = 159, 25.6%), urinary tract (n = 44, 7.1%), cardiovascular (n = 41, 6.6%), central nervous system (CNS) (n = 18, 2.9%), or skin (n = 25, 4%). This analysis revealed stronger inflammatory and cytokine responses, loss of vascular integrity and coagulation activation in abdominal sepsis relative to respiratory. Endothelial cell activation was prominent in urinary, cardiovascular and skin infections, while CNS infection was associated with the least host response aberrations. The leukocyte transcriptional response showed the largest overlap between abdominal and pulmonary infections (76% in common); notable differences between the sources were detected regarding hemostasis, cytokine signaling, innate and adaptive immune, and metabolic transcriptional pathways. After adjustment for confounders, the source of infection remained an independent contributor to 30-day mortality (unadjusted p = 0.001, adjusted p = 0.028). Conclusion Sepsis heterogeneity is partly explained by source-specific host response dysregulations and should be considered when selecting patients for trials testing immune modulatory drugs., Author(s): Hessel Peters-Sengers [sup.1] [sup.2], Joe M. Butler [sup.1] [sup.2], Fabrice Uhel [sup.1] [sup.2], Marcus J. Schultz [sup.3] [sup.4] [sup.5] [sup.6], Marc J. Bonten [sup.7] [sup.8], Olaf L. Cremer [sup.9], [...]

Caltrans has traditionally focused on designing, building, and maintaining California’s large freeway network. Lately, a stronger focus is being placed on real time transportation network operation, which requires the use of real time data and decision support software tools. This transition represents a cultural shift for Caltrans, and its organizational structures and staffing processes are not yet in place to support the effort. This report explores major impediments to hiring data analysts and software engineers, including lack of understanding among current management personnel in regard to the need for data analysts and software engineers, barriers for Caltrans Operations to directly hire IT/software personnel, lack of interest among Caltrans engineering unions to include software engineers as members, a general belief that software engineers are not “real” engineers, and concern that the state will not be able to hire software engineers due to high salary demands. Opportunities for addressing barriers include developing appropriate recruitment strategies for software related positions, educating agency personnel on the need for data analysis and software skills, changing the requirements for positions in Caltrans traffic operations, and establishing a management team to coordinate and support these efforts.

Author(s): Michiel Schinkel [sup.1], Brent Appelman [sup.1], Joe Butler [sup.1], Alex Schuurman [sup.1], W. Joost Wiersinga [sup.1] [sup.2], Renee A. Douma, Joop P. van den Bergh, Tom Dormans, Auke C. [...]

The Mobile Millennium project provided a platform for aggregating traffic information across various sources, including infrastructure sensors, commercial data feeds, probe vehicles, and probe cell phones. The Networked Traveler project provided the California PATH instrumented research vehicle platform used to both deliver vehicle probe data back to the infrastructure and to generate Advanced Driver Assistance Systems (ADAS) alerts to the drivers of those vehicles. The main theme of this collaboration project was to demonstrate the potential to create Enhanced Probe Vehicles (EPVs) by merging vehicle CAN-bus data with the typical GPS data that is provided by normal probe vehicles. The first goal of this project was integrate the two systems, allowing the instrumented research vehicles to communicate with the Mobile Millennium traffic aggregation servers. The second goal was to enhance the data gathered and stored by the Mobile Millennium traffic aggregation server to include the enhanced information provided by the EPVs, specifically, to include hazard warning light activation events. The third and final goal of this project was to integrate the information provided by the EPVs to the traffic server into soft-safety alerts that could be provided to the drivers of the EPVs and demonstrate the prototype system. This report documents the systems that were built for the demonstration, and provides a short analysis of the system performance from data gathered through both a simulation and an on-the-road vehicle test