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Purpose Many normotensive patients with acute pulmonary embolism (PE) are admitted to an intensive care unit (ICU) to monitor for hemodynamic decompensation. We investigated the incidence and causes of early hemodynamic decompensation in normotensive patients admitted to an ICU with PE. Materials and methods This was a single-center, retrospective study of normotensive patients admitted to an ICU with primary diagnosis of PE between 2010 and 2017. The primary outcome was hemodynamic decompensation, defined as need for vasopressors within 48 h of ICU admission. Results Of 293 patients included in the study, hemodynamic decompensation occurred in 8 patients (2.7%). The two most common precipitants of hemodynamic decompensation were acute hemorrhage and PE-related right ventricular dysfunction — each contributing to hemodynamic decompensation in 3 patients. Conclusions Among patients admitted to the ICU with acute normotensive PE, early hemodynamic decompensation was rare. In patients who experienced decompensation, major bleeding and thrombotic complications were equally likely to have been the precipitant— highlighting the risks of diagnostic anchoring in this population. As our results suggest that ICU-level care may not be necessary for many of these patients, additional tools are needed to assist in the triage of normotensive patients with PE.

INTRODUCTION: Vitamin C deficiency has been described in patients with sepsis. The post-cardiac arrest syndrome shares similarities to sepsis, however vitamin C levels in post-arrest patients have been incompletely characterized. We assessed vitamin C levels in a post-arrest population. METHODS: This was a retrospective observational study at a tertiary care center. A convenience sample of post-arrest, sepsis, and healthy control patients was selected from prior studies. Vitamin C levels were measured from samples obtained within 6-hours of emergency department admission. A subset of cardiac arrest patients had vitamin C levels additionally measured at 24-hours later. RESULTS: A total of 84 patients (34 healthy controls, 25 post-arrest, and 25 septic patients) were included. The median baseline vitamin C level in cardiac arrest patients was 0.33 mg/dL (0.05–0.83), as compared to 0.91mg/dL (0.69–1.48) in the healthy control group (p

The Jezreel Valley Regional Project (JVRP) is a long-term multidisciplinary project investigating human activity in the Jezreel Valley through all periods through the modern era. This research incorporates extensive and intensive archaeological survey and excavation at several spatial scales, and utilizes a number of methodological approaches to documentation and spatial analysis. One of the major challenges of this project has been coping with a high volume of data, and integrating cutting-edge technology into our workflow to solve the problems that many archaeologists face. This paper will present an overview of our field-based methods of data acquisition, particularly by means of 3D photogrammetry, remote sensing, and high-precision ground control. When integrated through our data management system and used in GIS applications, these data not only produce plans and imagery far more precise than conventional approaches, but the methods used are incredibly time-efficient, cost-effective, and produce archival digital data. Furthermore, we will report on results of spatial analysis of archaeological activity in the Jezreel Valley in conjunction with digital terrain and hydrological modelling of the landscape. These digital techniques allow us to study human and environmental changes in the landscape like never before.

INTRODUCTION: There is no standard for categorizing reasons for death in those who achieve return of spontaneous circulation (ROSC) after cardiac arrest but die before hospital discharge. Categorization is important for comparing outcomes across studies, assessing benefits of interventions, and developing quality-improvement initiatives. We developed and tested a method for categorizing reasons for death after cardiac arrest in both in-hospital (IHCA) and out-of-hospital (OHCA) arrests.METHODS: Single-center, retrospective, cohort study of patients with ROSC after IHCA or OHCA between 2008 and 2017 who died before hospital discharge. Traumatic arrests and patients with "do-not-resuscitate" orders prior to their arrest were excluded. Two investigators assigned each patient to one of five predefined reasons for death. Interrater reliability was assessed using Fleiss' kappa. For final categorization, discrepancies were resolved by a third investigator.RESULTS: There were 182 IHCA and 226 OHCA included. There was substantial agreement between raters (kappa of 0.62 and 0.61 for IHCA and OHCA, respectively). Reasons for death for IHCA and OHCA were: neurological withdrawal of care (27% vs 73%), comorbid withdrawal of care (36% vs 4%), refractory hemodynamic shock (25% vs 17%), respiratory failure (1% vs 3%), and sudden cardiac death (11% vs 4%). The differences in reasons for death among the two groups were significant (p-value CONCLUSIONS: Categorizing reasons for death after cardiac arrest with ROSC is feasible using our proposed categories, with substantial inter-rater agreement. Neurologic withdrawal of care is much less common in IHCA than OHCA, which may have implications for further research.

Baseline and post-concussion neurocognitive testing is useful in managing concussed athletes. Attention deficit hyperactivity disorder (ADHD) and stimulant medications are recognized as potential modifiers of performance on neurocognitive testing by the Concussion in Sport Group. Our goal was to assess whether individuals with ADHD perform differently on post-concussion testing and if this difference is related to the use of stimulants.Retrospective case-control study in which 4373 athletes underwent baseline and post-concussion testing using the ImPACT battery. 277 athletes self-reported a history of ADHD, of which, 206 reported no stimulant treatment and 69 reported stimulant treatment. Each group was matched with participants reporting no history of ADHD or stimulant use on several biopsychosocial characteristics. Non-parametric tests were used to assess ImPACT composite score differences between groups.Participants with ADHD had worse verbal memory, visual memory, visual motor speed, and reaction time scores than matched controls at baseline and post-concussion, all with p ≤ .001 and |r|≥ 0.100. Athletes without stimulant treatment had lower verbal memory, visual memory, visual motor speed, and reaction time scores than controls at baseline (p ≤ 0.01, |r|≥ 0.100 [except verbal memory, r = -0.088]) and post-concussion (p = 0.000, |r|0.100). Athletes with stimulant treatment had lower verbal memory (Baseline: p = 0.047, r = -0.108; Post-concussion: p = 0.023, r = -0.124) and visual memory scores (Baseline: p = 0.013, r = -0.134; Post-concussion: p = 0.003, r = -0.162) but equivalent visual motor speed and reaction time scores versus controls at baseline and post-concussion.ADHD-specific baseline and post-concussion neuropsychological profiles, as well as stimulant medication status, may need to be considered when interpreting ImPACT test results. Further investigation into the effects of ADHD and stimulant use on recovery from sport-related concussion (SRC) is warranted.

Introduction: There is no standard method for reporting reasons for death in cardiac arrest patients. Categorizing reasons for death is important for comparing outcomes across cardiac arrest trials, assessing the benefits of targeted interventions in in-hospital (IHCA) and out-of-hospital (OHCA) cardiac arrest patients, and developing quality-improvement initiatives. We developed and tested a method for categorizing reasons for death in post-cardiac arrest patients, assessed inter-rater reliability, and compared reasons for death between IHCA and OHCA. Methods: Single-center, retrospective, cohort study of patients who had return of spontaneous circulation (ROSC) after an OHCA or IHCA between 2008 and 2017, but died before hospital discharge. Traumatic arrests and patients with a “do-not-resuscitate” order prior to their initial arrest were excluded. Two independent investigators reviewed medical records and assigned each patient to one of five predefined categories of reasons for death. Inter-rater reliability was assessed using Fleiss Kappa. For final categorization, discrepancies were resolved by discussion with a third investigator. Categorical data was compared by Fisher’s Exact Test, and continuous data by Wilcoxon Rank-Sum Test. Results: There were 182 IHCA and 227 OHCA included, with the initial rhythm being non-shockable in 77% and 69% of cases (p=0.07), respectively. Median time to ROSC was shorter in IHCA compared to OHCA (10 [IQR: 6-20] vs 30 [IQR: 21-42] min, p Conclusion: Five categories for reasons for death in post-cardiac arrest patients were developed. The primary reason for death was neurological withdrawal of care after OHCA and comorbid withdrawal of care after IHCA. Categorizing reasons for death may be important for investigators when targeting an IHCA vs an OHCA population.

Karst aquifers that are dominated by conduit recharge are at high risk of contamination because there is little filtration or sorption of contaminants in the water. Identifying flow paths through conduit aquifers is required in order to delineate basin boundaries and potential areas at risk from groundwater contamination. In this study we report on the first continuous (~1 year) discharge and water quality data set ever collected from the Boils spring on the Highland Rim of middle Tennessee. The Boils drains the Roaring River-Spring Creek system, a State Scenic River and Wildlife Management Area. We also report on the results of a quantitative dye trace that was done to identify surface contributions to this spring. At the Boils, we measured discharge, temperature, and specific conductance for an approximate one-year period. The average annual discharge of the Boils during 2015 was 2.1 m3/s, with storm discharge reaching as much as 14 m3/s. Conductivity at the Boils spring ranged from 310 μS at baseflow to 290 μS during storm events. Water temperature of the spring varied seasonally from 9 to 22 °C. The dye trace revealed a direct connection to the Boils from a sink located 9 km away (straight-line distance), with a travel time of about 12 h. A second trace at another sink covered a straight-line distance of 1.5 km in 4 h. The rapid travel times suggest that this aquifer is dominated by conduit flow and that further research to sample water quality is warranted. Our data help to fill an important gap in data about major spring discharge and water quality in Tennessee.

Emergency department (ED) crowding is associated with patient safety concerns, increased patients left without being seen (LWBS), low patient satisfaction, and lost ED revenue. The objective was to measure the impact of a revised triage process on ED throughput.This study took place at an urban, university-affiliated, adult ED with an annual census of 70,000 and admission rate of 34%. The revised triage approach included: identifying eligible patients at triage based on complaint, comorbidities, and illness acuity; and reallocating a nurse practitioner (NP) into our triage area. We trialed the intervention from 1100-2300 on weekdays from January 13-26, 2016. Adult patients who were not likely to require intensive evaluations were eligible. Primary outcomes were throughput measures including: time to provider, ED length of stay (LOS), and LWBS. Pre- and post-intervention metrics were compared using the Mann-Whitney U test, given the non-normal distribution of the metrics.The NP evaluated 120 patients of which 101 (84%) were discharged, 3 (2.5%) admitted, and 16 (13%) required more intense evaluation. Time to provider decreased from a median (IQR) of 42 (16, 114) to 27 (12.4, 81.5) minutes (p0.01) and ED LOS from 290 (194.8, 405.6) to 257 (171.2, 363.4) minutes (p0.01) for all patients not admitted and not requiring a consult. LWBS decreased from a pre-trial 4.6% to 2.2% (p0.01).The revised triage intervention was associated with improvements in several ED throughput metrics and a reduction in LWBS.

The melanocortin 3 receptor (MC3R) is involved in regulation of energy homeostasis. However, its transcript structure is not well understood. We therefore studied initiation and termination sites for hypothalamic murine Mc3r and human MC3R transcripts. Rapid Amplification of cDNA Ends (RACE) was performed for the 5′ and 3′ ends of murine and human hypothalamic RNA. 5′ RACE experiments using hypothalamic murine RNA indicated mouse hypothalamus expresses two major Mc3r transcription start sites: one with a 5′ UTR approximately 368 bases in length and another previously unknown transcript with a 5′ UTR approximately 440 bases in length. 5′ RACE experiments using human hypothalamic RNA identified a 5′ UTR beginning 533 bases upstream of the start codon with a 248 base splice. 3′ RACE experiments using hypothalamic murine RNA indicated the 3′ UTR terminates approximately 1286 bases after the translational stop codon, with a previously unknown 787 base splice between consensus splice donor and acceptor sites. 3′ RACE experiments using human MC3R transcript indicated the 3′ UTR terminates approximately 115–160 bases after the translational stop codon. These data provide insight into melanocortin 3 receptor transcript structure.

Basketball is a physical game played on a hardwood floor among high-jumping athletes at risk for injury. It is currently unknown how sport-related concussion (SRC) affects player performance after injury among professional basketball players. The objective of this study was to explore the impact of SRC on basketball performance among National Basketball Association (NBA) players.A retrospective, archival cohort study was performed that compared NBA player performance following concussion to pre-concussive performance. A comprehensive NBA injury database, compiled from publically available sources, was queried for NBA players who suffered concussion from 2005-06 to 2014-15 (10 seasons). Intra-and inter-player analyses were performed against a matched control group of players who missed playing time for personal reasons.Following application of inclusion/exclusion criteria and a matching process, 51 concussed players and 51 control players were included in analysis. There were no statistically significant decrements in baseline to post-concussion performance metrics in intra-player or player vs. controls after 5 return games.Our findings suggest that at the NBA level, an athlete's performance in the initial 5 games following injury does not suffer from the after-effects of concussive injury. These results may be useful in counseling professional athletes following a concussion.

Dynamics of histones under tension in the pericentromere depends on RSC and ISW2 chromatin remodeling. The underlying pericentromeric chromatin forms a platform that is required to maintain kinetochore structure when under spindle-based tension., Nucleosome positioning is important for the structural integrity of chromosomes. During metaphase the mitotic spindle exerts physical force on pericentromeric chromatin. The cell must adjust the pericentromeric chromatin to accommodate the changing tension resulting from microtubule dynamics to maintain a stable metaphase spindle. Here we examine the effects of spindle-based tension on nucleosome dynamics by measuring the histone turnover of the chromosome arm and the pericentromere during metaphase in the budding yeast Saccharomyces cerevisiae. We find that both histones H2B and H4 exhibit greater turnover in the pericentromere during metaphase. Loss of spindle-based tension by treatment with the microtubule-depolymerizing drug nocodazole or compromising kinetochore function results in reduced histone turnover in the pericentromere. Pericentromeric histone dynamics are influenced by the chromatin-remodeling activities of STH1/NPS1 and ISW2. Sth1p is the ATPase component of the Remodels the Structure of Chromatin (RSC) complex, and Isw2p is an ATP-dependent DNA translocase member of the Imitation Switch (ISWI) subfamily of chromatin-remodeling factors. The balance between displacement and insertion of pericentromeric histones provides a mechanism to accommodate spindle-based tension while maintaining proper chromatin packaging during mitosis.

Background The risk of sport-related concussion (SRC) has emerged as a major public health concern. In rare instances, sport-related head injuries can be even more severe, such as subdural hemorrhage, epidural hemorrhage, or malignant cerebral edema. Unlike SRCs, sport-related structural brain injury (SRSBI) is rare, may require neurosurgical intervention, and can lead to permanent neurologic deficit or death. Data characterizing SRSBI are limited, and many have recognized the need to better understand these catastrophic brain injuries. The goal of the current series is to describe, in detail, the presentation, management, and outcomes of examples of these rare injuries. Case Description During the fall of 2015, three high school football players presented with acute subdural hemorrhages following in-game collisions and were treated at our institution within a span of 2 months. For the 2 athletes who required surgical intervention, a previous SRC was sustained within 4 weeks before the catastrophic event. One year after injury, 2 players have returned to school, though with persistent deficits. One patient remains nonverbal and wheelchair bound. None of the athletes has returned to sports. Conclusions Acute subdural hemorrhage resultant from an in-game football collision is rare. The temporal proximity of the reported SRSBIs to recent SRCs emphasizes the importance of return-to-play protocols and raises questions regarding the possibility of second impact syndrome. Although epidemiologic conclusions cannot be drawn from this small sample, these cases provide a unique opportunity to demonstrate the presentation, management, and long-term outcomes of SRSBI in American high school football.

Aerial image mask inspection tools are effective in qualifying masks based upon printability assessments using scanner-based actinic (193nm) illumination conditions. Aerial imaging inspection application is relevant for masks that are at final process steps or resemble a completed mask. However, maskshops perform inspections at additional, intermediary, mask manufacturing stages, as well as on masks designed for 248nm scanners. In both of these cases, aerial image inspection using scanner-based actinic (193nm) illumination conditions was not considered relevant. This paper demonstrates that aerial imaging inspection tools can be easily configured to perform inspections using various non-aerial illumination modes, owing to their inherently flexible optical design. Aerial image mask inspection tools, running in these optical modes, are effective for detecting defects at various stages of the mask manufacturing process and even for inspecting 248nm masks. Accordingly, MP Mask has adopted the first and second generation aerial imaging mask inspection tools of Applied Materials for all of the following applications: Advanced front end reticle qualification, low and high transmission PSM masks, and immersion and non-immersion plates from 65nm to 45nm technology nodes for DRAM and flash products. A simple cost of ownership comparison of aerial image mask inspection tools with traditional inspection methodology indicates that these inspection tools are well-qualified for use on a wide spectrum of masks and process points. This paper presents qualification procedures and results obtained with this new tool based on a set of masks representing several exposure wavelengths, mask types, technology nodes, product families, and inspection points.