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Objectives: COVID-19 infections in the community have the potential to overwhelm both prehospital and in-hospital resources. Transport of well-appearing patients, in the absence of available emergency department treatment capacity, increases strain on the hospital and EMS system. In May of 2020, the Connecticut Office of EMS issued a voluntary, EMS-initiated, non-transport protocol for selected low-risk patients with symptoms consistent with COVID-19. We evaluated the implementation of this non-transport protocol in a mixed urban/suburban EMS system. Methods: We conducted a retrospective review of contemporaneously recorded quality improvement documentation for uses of the Connecticut COVID-19 non-transport protocol by EMS clinicians within our EMS system during two implementations: from 12/14/2020 to 5/1/21, and again from 1/3/22 to 2/18/22, which coincided with large COVID-19 case surges in our region. Results: The vast majority of patients treated under the non-transport protocol were not reevaluated by EMS or in our emergency departments in the subsequent 24 hours. There was reasonable adherence to the protocol, with 83% of cases appropriate for the non-transport protocol. The most common reasons for protocol violations were age outside of protocol scope (pediatric patients), failure of documentation, or vital signs outside of the established protocol parameters. We did not find an increased 24-hour ED visit rate in patients who were inappropriately triaged to the protocol. Of patients who had ED visits within 24 hours, only two were admitted, none to higher levels of care. Conclusion: Within this small study, EMS clinicians in our system were able to safely and accurately apply a non-transport protocol for patients presenting with symptoms consistent with COVID-19. This is consistent with previous literature suggesting that EMS-initiated non-transport is a viable strategy to reduce the burden on health systems.

Adenosine has been safely used by paramedics for the treatment of stable supraventricular tachycardia since the mid-1990s. However, there continues to be variability in paramedics' ability to identify appropriate indications for adenosine administration. As the first of a planned series of studies aimed at improving the accuracy of SVT diagnosis and successful administration of adenosine by paramedics, this study details the current usage patterns of adenosine by paramedics.This cross-sectional retrospective study investigated adenosine use within a large northeast EMS region from January 1, 2019, through September 30, 2021. Excluding pediatric and duplicate case reports, we created a dataset containing patient age, sex, and vital signs before, during, and after adenosine administration; intravenous line location; and coded medical history from paramedic narrative documentation, including a history of atrial fibrillation, suspected arrhythmia diagnosis, and effect of adenosine. In cases with available prehospital electrocardiograms (EKGs) for review, two physicians independently coded the arrhythmia diagnosis and outcome of adenosine administration. Statistical analysis included interrater reliability with Cohen's kappa statistic.One hundred eighty-three cases were included for final analysis, 84 did not have a documented EKG for review. Categorization of presenting rhythms in these cases occurred by a physician reviewing EMS narrative and documentation. Forty of these 84 cases (48%) were adjudicated as SVT likely, 32 (38%) as SVT unlikely and 12 (14%) as uncategorized due to lack of supporting documentation. Of the 99 cases with EKGs available to review, there was substantial agreement of arrhythmia diagnosis interpretation between physician reviewers (Cohen's kappa 0.77-1.0); 54 cases were adjudicated as SVT by two physician reviewers. Other identified cardiac rhythms included atrial fibrillation (16), sinus tachycardia (11), and ventricular tachycardia (2). Adenosine cardioversion occurred in 47 of the 99 cases with EKGs available for physician review (47.5%). Adenosine cardioversion was also deemed to occur in 87% (47/54) of cases when the EKG rhythm was physician adjudicated SVT.This study supports the use of adenosine as a prehospital treatment for SVT while highlighting the need for continued efforts to improve paramedics' identification and management of tachyarrhythmias.

It is generally understood that sorting logs based on grade generates maximum value for all stakeholders. However, the benefits of sorting logs may depend on the location of a timber sale and distances to manufacturing mills. The objective is to quantify the potential value of log sorting through scenario-based analysis in different areas with divergent forest and mill types. An optimization model was developed to allocate logs from the timber sale to the highest profit-yielding mills. Factors considered by the model included logging and transportation cost, timber sale tract-to-mill distances, mills’ acceptance criteria, and price at the mill gate. Four timber sales from across Wisconsin were selected for the study. Three scenarios were tested, with each scenario yielding different proportions of log sorts. The results showed that log sorting increased profit by up to $41.10 per cord in certain locations but was not profitable in other locations. Study Implications The methods proposed in this study can help foresters and landowners increase the value of harvested timber. Practitioners can use the proposed method to systematically assess the gain or loss in profit associated with log sorting at each timber sale. It also provides directives on the best mill for each log sort to be sent. The proposed method should be adopted to minimize underutilization of timber, especially in areas where profits are marginal.

An improved understanding of the human lung necessitates advanced systems models informed by an ever-increasing repertoire of molecular omics, cellular, imaging, and pathological datasets. To centralize and standardize information across broad lung research efforts we expanded the LungMAP.net website into a new gateway portal. This portal connects a broad spectrum of research networks, bulk and single-cell multi-omics data and a diverse collection of image data that span mammalian lung development, and disease. The data are standardized across species and technologies using harmonized data and metadata models that leverage recent advances including those from the Human Cell Atlas, diverse ontologies, and the LungMAP CellCards initiative. To cultivate future discoveries, we have aggregated a diverse collection of single-cell atlases for multiple species (human, rhesus, mouse), to enable consistent queries across technologies, cohorts, age, disease, and drug treatment. These atlases are provided as independent and integrated queryable datasets, with an emphasis on dynamic visualization, figure generation, re-analysis, cell-type curation, and automated reference-based classification of user-provided single-cell genomics datasets (Azimuth). As this resource grows, we intend to increase the breadth of available interactive interfaces, supported data types, data portals and datasets from LungMAP and external research efforts.

The Irish traditional music festival ‘Fleadh Cheoil na hÉireann’ was first held in Drogheda, Co. Louth in August 2018 and subsequently in August 2019. The host town benefitted not only economically during the festival, but also from enhanced investment in infrastructure and marketing. This created a legacy that has outlasted the event itself. Irish traditional music has typically been associated with the west of Ireland and narratives and marketing related to the tradition typically involves reference to rurality. As an urban place on the east coast near the border with Northern Ireland, Drogheda presented a new location and new spaces for the festivalisation of Irish traditional music culture while simultaneously requiring organisers to consider the use of urban public space for festival activities. The local authority was a significant stakeholder in Fleadh Cheoil na hÉireann in Drogheda and utilised the opportunity to create and disseminate an identity for the town and region that would have a legacy for tourism beyond the staging of the event. Using reflective ethnography and interviews with local authority representatives and the festival organisers, this study critically considers how towns are thinking about their public spaces in terms of outdoor staging, public congregation and access. This chapter focuses on the use of such public space during the festival and the development of an identity for Drogheda as a place of festivals. The chapter highlights the importance of urban 'public spaces' and their utilisation as something both local government policymakers and festival audiences are looking for. Such 'public spaces' once re-imagined are now seen as 'experience spaces' in which the quantity and variety of festival experience possibilities are vital.

Objective: The management of patients with ST-elevation myocardial infarction (STEMI) is time-critical, with a focus on early reperfusion to decrease morbidity and mortality. It is imperative that ...

MicroRNAs (miRNAs) are short non-coding RNAs, highly conserved between species, that are powerful regulators of gene expression. Aberrant expression of miRNAs alters biological processes and pathways linked to human disease. miR-486-5p is a muscle-enriched miRNA localized to the cytoplasm and nucleus, and is highly abundant in human plasma and enriched in small extracellular vesicles. Studies of malignant and non-malignant diseases, including kidney diseases, have found correlations with circulating miR-486-5p levels, supporting its role as a potential biomarker. Pre-clinical studies of non-malignant diseases have identified miR-486-5p targets that regulate major signaling pathways involved in cellular proliferation, migration, angiogenesis, and apoptosis. Validated miR-486-5p targets include phosphatase and tensin homolog (PTEN) and FoXO1, whose suppression activates phosphatidyl inositol-3-kinase (PI3K)/Akt signaling. Targeting of Smad1/2/4 and IGF-1 by miR-486-5p inhibits transforming growth factor (TGF)-β and insulin-like growth factor-1 (IGF-1) signaling, respectively. Other miR-486-5p targets include matrix metalloproteinase-19 (MMP-19), Sp5, histone acetyltransferase 1 (HAT1), and nuclear factor of activated T cells-5 (NFAT5). In this review, we examine the biogenesis, regulation, validated gene targets and biological effects of miR-486-5p in non-malignant diseases.

Background: COVID-19 was first reported in the United States in January 2020. Its spread throughout the country required EMS systems to rapidly adapt to patient needs while protecting EMS personnel. EMS agencies developed protocols requiring personnel to don enhanced personal protective equipment prior to patient contact. We hypothesized that the Patient Access Interval (PAI), defined as the time from wheels stopped on scene to initial patient contact, had increased during the COVID pandemic. This had the potential to affect patient outcomes, particularly in time-sensitive emergencies such as cardiac arrest or respiratory distress. Methods: This retrospective cohort study used commercial ambulance data from the four largest cities in Connecticut at two different time points: (Pre-COVID) March-May 2019, and (COVID) March-May 2020. PAI was calculated from contemporaneously reported scene times. Total cases were analyzed, and sub-analyses performed for calls located at extended care facilities (ECFs), for all emergent (Echo/Delta) calls, and for medical cardiac arrest calls. Results: 92,846 total cases were evaluated: 50,083 from 2019, and 42,763 from 2020. Cases that did not include necessary time data for PAI were removed, yielding 75,796 total cases (41,852 from 2019, 33,944 from 2020). The average PAI increased from 1 minute 55 seconds (1 m:55s) Pre-COVID to 2 m:18s COVID. ECF PAI increased from 2 m:39s to 3 m:42s. Echo/Delta PAI increased from 1 m:42s to 2 m:07s. Medical cardiac arrest PAI increased from 1 m:27s to 2 m:04s, and ECF cardiac arrest PAI increased from 2 m:18s to 4 m:35s (all comparisons p < 0.01). Conclusions: There were statistically significant increases in all studied PAIs during COVID. The 23 second increase in PAI for all calls may not have been clinically significant in most cases; however, for life-threatening patient presentations, the increase may have been particularly relevant. The increased PAI was compounded in the ECF environment, possibly due to state-mandated screening and temperature checks of EMS personnel before entering facilities. This was highlighted in the ECF cardiac arrest data, which demonstrated a clinically significant increase in PAI of 2m:17s. While this study was limited by the accuracy of contemporaneous time reports by EMS, the results support our hypothesis that PAI had increased during the COVID pandemic.

Objectives: The COVID-19 epidemic in the United States has hit in the midst of the opioid overdose crisis. Emergency medical services (EMS) clinicians may limit their use of intranasal naloxone due to concerns of novel coronavirus infection. We sought to determine changes in overdose events and naloxone administration practices by EMS clinicians. Methods: Between April 29, 2020 and May 15, 2020, we surveyed directors of EMS fellowship programs across the US about how overdose events and naloxone administration practices had changed in their catchment areas since March 2020. Results: Based on 60 respondents across all regions of the country, one fifth of surveyed communities have experienced an increase in opioid overdoses and events during which naloxone was administered, and 40% have experienced a decrease. The findings varied by region of the country. Eighteen percent of respondents have discouraged or prohibited the use of intranasal naloxone with 10% encouraging the use of intramuscular naloxone. Conclusions: These findings may provide insight into changes in opioid overdose mortality during this time and assist in future disaster planning.

We present PrVM, a framework for scheduling real-time VMs on multicore hardware. It addresses the intersection of the following problems: probabilistic real-time scheduling, VM scheduling, and full virtualization. Though each of these problems have been studied, their intersection - motivated by the need to consolidate multiple real-time software stacks, whose applications can be defined via probabilistic timing properties, onto a single embedded platform - is empty. PrVM uses a probabilistic model and timeliness optimality criterion. PrVM schedules VMs as server-like processes, computes time budgets using probabilistic methods, and aggregates task time budgets into VM time budgets. Experimental evaluations, using simulations and a concrete implementation, confirm the framework's effectiveness for synthetic benchmarks and multimedia applications.

Digital Copilot is a prototype information system providing cognitive assistance to pilots in general aviation. This paper presents the methods and results of an analysis quantifying the expected s...

In July 2017, fever and sepsis developed in 3 recipients of solid organs (1 heart and 2 kidneys) from a common donor in the United States; 1 of the kidney recipients died. Tularemia was suspected only after blood cultures from the surviving kidney recipient grew Francisella species. The organ donor, a middle-aged man from the southwestern United States, had been hospitalized for acute alcohol withdrawal syndrome, pneumonia, and multiorgan failure. F. tularensis subsp. tularensis (clade A2) was cultured from archived spleen tissue from the donor and blood from both kidney recipients. Whole-genome multilocus sequence typing indicated that the isolated strains were indistinguishable. The heart recipient remained seronegative with negative blood cultures but had been receiving antimicrobial drugs for a medical device infection before transplant. Two lagomorph carcasses collected near the donor's residence were positive by PCR for F. tularensis subsp. tularensis (clade A2). This investigation documents F. tularensis transmission by solid organ transplantation.

Background: Implemented in September 2017, the "nurse navigator program" identified the preferred emergency department (ED) destination within a single healthcare system using real-time assessment of hospital and ED capacity and crowding metrics. Objective: The primary objective of the navigator program was to improve load-balancing between two closely situated emergency departments, both of which feed into the same inpatient facilities of a single healthcare system. A registered nurse in the hospital command center made real-time recommendations to emergency medical services (EMS) providers via radio, identifying the preferred destination for each transported patient based on such factors as chief complaint, ED volume, and waiting room census. The destination decision was made via the utilization of various real-time measures of health system capacity in conjunction with existing protocols dictating campus-specific clinical service availability. The objective of this study was to evaluate the efficacy of this real-time ambulance destination direction program as reflected in changes to emergency medical services (EMS) turnaround time and the incidence of intercampus transports. Methods: A before-and-after time series was performed to determine if program implementation resulted in a change in EMS turnaround time or incidence of intercampus transfers. Results: Implementation of the nurse navigator program was associated with a statistically significant decrease in EMS turnaround times for all levels of dispatch and transport at both hospital campuses. Intercampus transfers also showed significant improvement following implementation of the intervention, although this effect lagged behind implementation by several months. Conclusion: A proactive approach to EMS destination control using a nurse navigator with access to real-time hospital and ED capacity metrics appears to be an effective method of decreasing EMS turnaround time.

Introduction: Thoracic ultrasound is frequently used in the emergency department (ED) to determine the etiology of dyspnea, yet its use is not widespread in the prehospital setting. We sought to investigate the feasibility and diagnostic performance of paramedic acquisition and assessment of thoracic ultrasound images in the prehospital environment, specifically for the detection of B-lines in congestive heart failure (CHF). Methods: This was a prospective observational study of a convenience sample of adult patients with a chief complaint of dyspnea. Paramedics participated in a didactic and hands-on session instructing them how to use a portable ultrasound device. Paramedics assessed patients for the presence of B-lines. Sensitivity and specificity for the presence of bilateral B-lines and any B-lines were calculated based on discharge diagnosis. Clips archived to the ultrasound units were reviewed and paramedic interpretations were compared to expert sonologist interpretations. Results: A total of 63 paramedics completed both didactic and hands-on training, and 22 performed ultrasounds in the field. There were 65 patients with B-line findings recorded and a discharge diagnosis for analysis. The presence of bilateral B-lines for diagnosis of CHF yielded a sensitivity of 80.0% (95% confidence interval [CI], 51.4–94.7%) and specificity of 72.0% (95% CI, 57.3–83.3), while presence of any B-lines was 93.3% sensitive (95% CI, 66.0–99.7%), and 50% specific (95% CI, 35.7–64.2%) for CHF. Paramedics archived 117 ultrasound clips of which 63% were determined to be adequate for interpretation. Comparison of paramedic and expert sonologist interpretation of images showed good inter-rater agreement for detection of any B-lines (k = 0.60; 95% CI, 0.36–0.84). Conclusion: This observational pilot study suggests that prehospital lung ultrasound for B-lines may aid in identifying or excluding CHF as a cause of dyspnea. The presence of bilateral B-lines as determined by paramedics is reasonably sensitive and specific for the diagnosis of CHF and pulmonary edema, while the absence of B lines is likely to exclude significant decompensated heart failure. The study was limited by being a convenience sample and highlighted some of the difficulties related to prehospital research. Larger funded trials will be needed to provide more definitive data.

© 2016 The Author(s) Published by the Royal Society. All rights reserved. Despite recent efforts to characterize innovative individuals within a species, we still know very little about the ontogeny of innovation ability. A number of studies have found that innovation rates are correlated with personality traits, such as neophilia and exploration. Juvenile birds are frequently more neophilic and explorative, yet few studies have found evidence of age-related differences in innovative problem-solving success. Here,we showconsistently higher innovation efficiency in juveniles of a wild, omnivorous parrot species across a variety of tasks and contexts.We tested 104 kaka (Nestor meridionalis), ranging in age from four months to 13 years. Twenty-four individuals participated in all three of our problem-solving tasks, two of which involved a familiar feeder and one an entirely novel apparatus. Juveniles were the most efficient problem-solvers in all three tasks. By contrast, the adults’ success was context dependent and limited to the novel apparatus, which did not require modification of a pre-learned behavioural response. This suggests greater behavioural flexibility in the juvenile birds, who also showed higher persistence and exploratory diversity than adults. These traits may enable young kaka to discover efficient foraging techniques, which are then maintained throughout adulthood.

© 2019 Elsevier Ltd Despite decades of comparative research, how selection shapes the evolution of cognitive traits remains poorly understood [1–3]. Several lines of evidence suggest that natural selection acts on spatial memory in food-caching species [3–6]. However, a link between reproductive fitness and spatial memory ability has yet to be demonstrated in any caching species [1, 3, 6]. Here, we show that memory performance influences reproductive success differentially for males and females in a caching songbird, the New Zealand robin (Petroica longipes). Males’ memory performance in a spatial task during winter influenced their subsequent breeding success; individuals with more accurate performance produced more fledglings and independent offspring per nesting attempt. Males with superior memory performance also provided an increased proportion of large prey items to chicks in the nest and spent less time flying while foraging and provisioning. No such effects were found for females. Previous research reveals that trade-offs may constrain selection and act to maintain variation in cognitive traits [7]. The gender dimorphism in the reproductive benefits of robin memory performance suggests an additional role for divergent selection between the sexes in constraining runaway selection on male memory ability [8], ultimately maintaining variation in this cognitive trait. Shaw et al. investigate whether spatial memory performance influences reproductive success in a food-caching bird, the New Zealand robin. The sexes differ in the reproductive and behavioral consequences of memory performance, suggesting that divergent selection between the sexes may constrain selection and maintain cognitive variation in the wild.