Spanish vs USA cohort comparison of prehospital trauma scores to predict short-term mortality

BACKGROUND

This study aimed to evaluate three prehospital early warning scores (EWSs): RTS, MGAP and MREMS, to predict short-term mortality in acute life-threatening trauma and injury/illness by comparing United States (US) and Spanish cohorts.

METHODS

A total of 8,854 patients, 8,598/256 survivors/nonsurvivors, comprised the unified cohort. Datasets were randomly divided into training and test sets. Training sets were used to analyse the discriminative power of the scores in terms of the area under the curve (AUC), and the score performance was assessed in the test set in terms of sensitivity (SE), specificity (SP), accuracy (ACC) and balanced accuracy (BAC).

RESULTS

The three scores showed great discriminative power with AUCs>0.90, and no significant differences between cohorts were found. In the test set, RTS/MREMS/MGAP showed SE/SP/ACC/BAC values of 86.0/89.9/89.6/87.1%, 91.0/86.9/87.5/88.5%, and 87.7/82.9/83.4/85.2%, respectively.

CONCLUSIONS

All EWSs showed excellent ability to predict the risk of short-term mortality, independent of the country.

Cardiac output estimation using ballistocardiography: a feasibility study in healthy subjects

There is no reliable automated non-invasive solution for monitoring circulation and guiding treatment in prehospital emergency medicine. Cardiac output (CO) monitoring might provide a solution, but CO monitors are not feasible/practical in the prehospital setting. Non-invasive ballistocardiography (BCG) measures heart contractility and tracks CO changes. This study analyzed the feasibility of estimating CO using morphological features extracted from BCG signals. In 20 healthy subjects ECG, carotid/abdominal BCG, and invasive arterial blood pressure based CO were recorded. BCG signals were adaptively processed to isolate the circulatory component from carotid (CCc) and abdominal (CCa) BCG. Then, 66 features were computed on a beat-to-beat basis to characterize amplitude/duration/area/length of the fluctuation in CCc and CCa. Subjects' data were split into development set (75%) to select the best feature subset with which to build a machine learning model to estimate CO and validation set (25%) to evaluate model's performance. The model showed a mean absolute error, percentage error and 95% limits of agreement of 0.83 L/min, 30.2% and - 2.18-1.89 L/min respectively in the validation set. BCG showed potential to reliably estimate/track CO. This method is a promising first step towards an automated, non-invasive and reliable CO estimator that may be tested in prehospital emergencies.

Desorption and ablation regimes in UV-MALDI: the critical fluence

Although MALDI is a widely used technique, there is so far no theoretical description able to reproduce some critical aspects of the experimental results. For example, there is experimental as well as theoretical controversy regarding the minimum laser fluence, i.e., the so-called fluence threshold (F _T), required to evaporate a sample. Furthermore, although the different processes involved in ion production have been the focus of many investigations, the fact is that the primary process for ion formation in MALDI is not desorption but ablation. In this work, we present a new phenomenological approach for understanding MALDI results based on a simple, but physically intuitive, idea consisting of limiting the laser-matter interaction process to three layers. This description allows us to consider the different processes that dominate ion formation, i.e., heat dissipation, as well as the different existing regimes. Concretely, we present the results for three different matrices, i.e., DHB, ferulic acid (FA) and α-cyano-4-hydroxycinnamic acid (CHCA), in the limit of low fluence. The simulations we carried out show great qualitative and pseudo-quantitative agreement with the experimental results. Also, based on the simulation results, it is possible to distinguish clearly between the two dominant regimes, i.e., desorption and ablation, and it is possible, therefore, to estimate the critical fluence (F _C) that defines the transition from one regime to another.

Hereditary angioedema: 24 years of experience in a Portuguese Reference Center

Summary

Hereditary angioedema (HAE) poses a high burden of disease, being its epidemiological and clinical data heterogeneous among countries, with no recent published studies concerning Portuguese patients. Therefore, we aimed to raise awareness of HAE and to contribute to clinical knowledge. An observational, descriptive, retrospective, and cross-sectional study was performed, that included a cohort of 126 patients followed in a single Portuguese Center. We observed a high prevalence of HAE-C1-INH type II (45.2% of patients). Most HAE patients (67.4%) presented the initial manifestations of the disease before adulthood, at a mean age of 12.6 ± 8.4 years. However, we found a long delay in HAE diagnosis, especially in those without family history (mean 20.7 ± 17.3 years). Stress was the most common trigger, followed by trauma and infection. Symptoms involving different systems were increasingly reported with increased disease duration. Cutaneous symptoms (95.0%) were more frequent, followed by gastrointestinal (80.7%), and respiratory symptoms (50.4%). HAE symptoms led to abdominal surgery in 22 (17.5%) patients and induced laryngeal edema requiring intubation/tracheostomy in 8 (6.3%) patients. Most patients were under long-term prophylaxis, mainly with attenuated androgens (62.7% of patients).The correct distinction between HAE and other common causes of angioedema is critical, allowing reduction of diagnostic delay, improvement of adequate management, and ultimately improving outcomes and quality of life of HAE patients.

Novel nonylphenol-degrading bacterial strains isolated from sewage sludge: Application in bioremediation of sludge

Nonylphenol (NP) is an anthropogenic pollutant frequently found in sewage sludge due to the insufficient degrading effectiveness of conventional WWTPs and has attracted attention as an endocrine disruptor. The aim of this study was to isolate specific NP-degrading bacteria from sewage sludge to be used in the degradation of this contaminant through bioaugmentation processes in aqueous solution and sewage sludge. Up to eight different bacterial strains were isolated, six of them not previously described as NP degraders. Bacillus safensis CN12 presented the best NP degradation in solution, and glucose used as an external carbon source increased its effect, reaching DT₅₀ degradation values (time to decline to half the initial concentration of the pollutant) of only 0.9 days and a complete degradation in <7 days. Four NP metabolites were identified throughout the biodegradation process, showing higher toxicity than the parent contaminant. In sewage sludge suspensions, the endogenous microbiota was capable of partially degrading NP, but a part remained adsorbed as bound residue. Bioaugmentation was used for the first time to remove NP from sewage sludge to obtain more environmentally friendly biosolids. However, B. safensis CN12 was not able to degrade NP due to its high adsorption on sludge, but the use of a cyclodextrin (HPBCD) as availability enhancer allowed us to extract NP and degrade it in solution. The addition of glucose as an external carbon source gave the best results since the metabolism of the sludge microbiota was activated, and HPBCD was able to remove NP from sewage sludge to the solution to be degraded by B. safensis CN12. These results indicate that B. safensis CN12 can be used to degrade NP in water and sewage sludge, but the method must be improved using consortia of B. safensis CN12 with other bacterial strains able to degrade the toxic metabolites produced.

Airway Strategy and Ventilation Rates in the Pragmatic Airway Resuscitation Trial

BACKGROUND

We sought to describe ventilation rates during out-of-hospital cardiac arrest (OHCA) resuscitation and their associations with airway management strategy and outcomes.

METHODS

We analyzed continuous end-tidal carbon dioxide capnography data from adult OHCA enrolled in the Pragmatic Airway Resuscitation Trial (PART). Using automated signal processing techniques, we determined continuous ventilation rate for consecutive 10-second epochs after airway insertion. We defined hypoventilation as a ventilation rate <6 breaths/min. We defined hyperventilation as a ventilation rate >12 breaths/min. We compared differences in total and percentage post-airway hyper- and hypoventilation between airway interventions (laryngeal tube (LT) vs. endotracheal intubation (ETI). We also determined associations between hypo-/hyperventilation and OHCA outcomes (ROSC, 72-hour survival, hospital survival, hospital survival with favorable neurologic status).

RESULTS

Adequate post-airway capnography were available for 1,010 (LT n=714, ETI n=296) of 3,004 patients. Median ventilation rates were: LT 8.0 (IQR 6.5-9.6) breaths/min, ETI 7.9 (6.5-9.7) breaths/min. Total duration and percentage of post-airway time with hypoventilation were similar between LT and ETI: median 1.8 vs. 1.7 minutes, p=0.94; median 10.5% vs. 11.5%, p=0.60. Total duration and percentage of post-airway time with hyperventilation were similar between LT and ETI: median 0.4 vs. 0.4 minutes, p=0.91; median 2.1% vs. 1.9%, p=0.99. Hypo- and hyperventilation exhibited limited associations with OHCA outcomes.

CONCLUSION

In the PART Trial, EMS personnel delivered post-airway ventilations at rates satisfying international guidelines, with only limited hypo- or hyperventilation. Hypo- and hyperventilation durations did not differ between airway management strategy and exhibited uncertain associations with OCHA outcomes.

Methodology and framework for the analysis of cardiopulmonary resuscitation quality in large and heterogeneous cardiac arrest datasets

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) data debriefing and clinical research often require the retrospective analysis of large datasets containing defibrillator files from different vendors and clinical annotations by the emergency medical services.

AIM

To introduce and evaluate a methodology to automatically extract cardiopulmonary resuscitation (CPR) quality data in a uniform and systematic way from OHCA datasets from multiple heterogeneous sources.

METHODS

A dataset of 2236 OHCA cases from multiple defibrillator models and manufacturers was analyzed. Chest compressions were automatically identified using the thoracic impedance and compression depth signals. Device event time-stamps and clinical annotations were used to set the start and end of the analysis interval, and to identify periods with spontaneous circulation. A manual audit of the automatic annotations was conducted and used as gold standard. Chest compression fraction (CCF), rate (CCR) and interruption ratio were computed as CPR quality variables. The unsigned error between the automated procedure and the gold standard was calculated.

RESULTS

Full-episode median errors below 2% in CCF, 1 min^-1 in CCR, and 1.5% in interruption ratio, were measured for all signals and devices. The proportion of cases with large errors (>10% in CCF and interruption ratio, and >10 min^-1 in CCR) was below 10%. Errors were lower for shorter sub-intervals of interest, like the airway insertion interval.

CONCLUSIONS

An automated methodology was validated to accurately compute CPR metrics in large and heterogeneous OHCA datasets. Automated processing of defibrillator files and the associated clinical annotations enables the aggregation and analysis of CPR data from multiple sources.

Airway strategy and chest compression quality in the Pragmatic Airway Resuscitation Trial

BACKGROUND

Chest compression (CC) quality is associated with improved out-of-hospital cardiopulmonary arrest (OHCA) outcomes. Airway management efforts may adversely influence CC quality. We sought to compare the effects of initial laryngeal tube (LT) and initial endotracheal intubation (ETI) airway management strategies upon chest compression fraction (CCF), rate and interruptions in the Pragmatic Airway Resuscitation Trial (PART).

METHODS

We analyzed CPR process files collected from adult OHCA enrolled in PART. We used automated signal processing techniques and a graphical user interface to calculate CC quality measures and defined interruptions as pauses in chest compressions longer than 3 s. We determined CC fraction, rate and interruptions (number and total duration) for the entire resuscitation and compared differences between LT and ETI using t-tests. We repeated the analysis stratified by time before, during and after airway insertion as well as by successive 3-min time segments. We also compared CC quality between single vs. multiple airway insertion attempts, as well as between bag-valve-mask (BVM-only) vs. ETI or LT.

RESULTS

Of 3004 patients enrolled in PART, CPR process data were available for 1996 (1001 LT, 995 ETI). Mean CPR analysis duration were: LT 22.6 ± 10.8 min vs. ETI 25.3 ± 11.3 min (p < 0.001). Mean CC fraction (LT 88% vs. ETI 87%, p = 0.05) and rate (LT 114 vs. ETI 114 compressions per minute (cpm), p = 0.59) were similar between LT and ETI. Median number of CC interruptions were: LT 11 vs. ETI 12 (p = 0.001). Total CC interruption duration was lower for LT than ETI (LT 160 vs. ETI 181 s, p = 0.002); this difference was larger before airway insertion (LT 56 vs. ETI 78 s, p < 0.001). There were no differences in CC quality when stratified by 3-min time epochs.

CONCLUSION

In the PART trial, compared with ETI, LT was associated with shorter total CC interruption duration but not other CC quality measures. CC quality may be associated with OHCA airway management.

Pediatric chest x-ray in covid-19 infection

BACKGROUND

The outbreak of COVID-19 has become pandemic. Pediatric population has been less studied than adult population and prompt diagnosis is challenging due to asymptomatic or mild episodes. Radiology is an important complement to clinical and epidemiological features.

OBJECTIVE

To establish the most common CXR patterns in children with COVID-19, evaluate interobserver correlation and to discuss the role of imaging techniques in the management of children.

MATERIALS AND METHODS

Forty-four patients between 0 and 16 years of age with confirmed SARS-Cov-2 infection and CXR were selected. Two paediatric radiologists independently evaluated the images and assessed the type of abnormality, distribution and evolution when available.

RESULTS

Median age was 79.8 months (ranging from 2 weeks to 16 years of age). Fever was the most common symptom (43.5 %). 90 % of CXR showed abnormalities. Peribronchial cuffing was the most common finding (86.3 %) followed by GGOs (50 %). In both cases central distribution was more common than peripheral. Consolidations accounted for 18.1 %. Normal CXR, pleural effusion, and altered cardiomediastinal contour were the least common.

CONCLUSION

The vast majority of CXR showed abnormalities in children with COVID-19. However, findings are nonspecific. Interobserver correlation was good in describing consolidations, normal x-rays and GGOs. Imaging techniques have a role in the management of children with known or suspected COVID-19, especially in those with moderate or severe symptoms or with underlying risk factors.

Thoracic outlet syndrome in adolescents: a case series

OBJECTIVE

Thoracic Outlet Syndrome (TOS) is caused by a compression of the brachial plexus and the subclavian vessels in their passage to the upper limb. It mostly occurs in women aged 20-50, so it is infrequent in children. We present our results in the diagnosis and management of pediatric TOS.

MATERIAL AND METHODS

Retrospective study of patients diagnosed with TOS between December 2017 and June 2018. Clinical, radiological, surgical, and evolution variables were assessed.

RESULTS

Five TOS were diagnosed in 4 patients - one TOS was bilateral. Mean age at diagnosis was 12.5 years (7-15), and there was a delay in diagnosis of 153 days (10-36). TOS was either venous (3) or neurogenic (2). Patients presented with pain (5/5), edema (4/5), hypoesthesia (3/5), decreased strength (3/5), and cervical pain (2/5). One patient presented with sport-related pain. Neurophysiological study was normal in three cases. Two patients presented bone anomalies at CT-scan. Three surgeries were performed in two patients using the supraclavicular approach with resection of the anomalous first rib and scalenectomy. One patient refused surgery, and another patient remained expectant without reappearance of symptoms. Postoperative follow-up was 9 months (6-12), with progressive improvement of symptoms.

CONCLUSIONS

TOS may occur in adolescents in the form of upper limb pain and edema. Imaging tests are recommended to detect abnormal anatomical structures. The supraclavicular approach represents a safe and effective technique in decompressing the thoracic outlet.

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Convolutional Recurrent Neural Networks to Characterize the Circulation Component in the Thoracic Impedance during Out-of-Hospital Cardiac Arrest

Pulse detection during out-of-hospital cardiac arrest remains challenging for both novel and expert rescuers because current methods are inaccurate and time-consuming. There is still a need to develop automatic methods for pulse detection, where the most challenging scenario is the discrimination between pulsed rhythms (PR, pulse) and pulseless electrical activity (PEA, no pulse). Thoracic impedance (TI) acquired through defibrillation pads has been proven useful for detecting pulse as it shows small fluctuations with every heart beat. In this study we analyse the use of deep learning techniques to detect pulse using only the TI signal. The proposed neural network, composed by convolutional and recurrent layers, outperformed state of the art methods, and achieved a balanced accuracy of 90% for segments as short as 3 s.

Haemodynamic profile of Spanish adults with Down syndrome

OBJECTIVES

Although the reasons are unknown, the prevalence of arterial hypertension and atherosclerotic cardiovascular events in the adult population with Down syndrome (SD) is anecdotal. To better understand this finding, we evaluated the haemodynamic characteristics of a cohort of adults with SD.

METHODS

We conducted a cross-sectional study of adults with SD recruited consecutively from the outpatient clinics of an internal medicine department between June and November 2018. We collected demographic, clinical and laboratory variables and employed a thoracic bioimpedance device (HOTMAN® System) for the haemodynamic measures. Outpatient blood pressure monitoring (OBPM) was conducted on a subgroup of participants.

RESULTS

Twenty-six participants (mean age, 45±11years) participated in the study (50% men). The sample's mean blood pressure (BP) was 109/69±11/9mmHg, with a mean heart rate of 60±12bpm. None of the participants had hypertension. The predominant haemodynamic profile consisted of normal dynamism (65%), normal BP (96%), hypochronotropism (46%), normal inotropism (50%) and hypervolaemia (54%), with normal peripheral vascular resistance values (58%). Twelve participants underwent OBPM (46%). The mean 24-h systolic BP, diastolic BP, mean BP and mean heart rate were 105±11mmHg, 67±11mmHg, 80±11mmHg and 61±6bpm, respectively.

CONCLUSIONS

The most common haemodynamic profile observed in adults with SD consisted of hypochronotropism and hypervolaemia, with normal values for peripheral vascular resistance and optimal mean BP values. There were no participants with hypertension in our sample.

Impedance Based Automatic Detection of Ventilations During Mechanical Cardiopulmonary Resuscitation

Monitoring ventilation rate is key to improve the quality of cardiopulmonary resuscitation (CPR) and increase the probability of survival in the event of an out-of-hospital cardiac arrest (OHCA). Ventilations produce discernible fluctuations in the thoracic impedance signal recorded by defibrillators. Impedance-based detection of ventilations during CPR is challenging due to chest compression artifacts. This study presents a method for an accurate detection of ventilations when chest compressions are delivered using a piston-driven mechanical device. Data from 223 OHCA patients were analyzed and 399 analysis segments totaling 3101 minutes of mechanical CPR were extracted. A total of 18327 ventilations were annotated using concurrent capnogram recordings. An adaptive least mean squares filter was used to remove compression artifacts. Potential ventilations were detected using a greedy peak detector, and the ventilation waveform was characterized using 8 waveform features. These features were used in a logistic regression classifier to discriminate true ventilations from false positives produced by the greedy peak detector. The classifier was trained and tested using patient wise 10-fold cross validation (CV), and 100 random CV partitions were created to statistically characterize the performance metrics. The peak detector presented a sensitivity (Se) of 99.30%, but a positive predictive value (PPV) of 54.43%. The best classifier configuration used 6 features and improved the mean (sd) Se and PPV of the detector to 93.20% (0.06) and 94.43% (0.04), respectively. When used to measure per minute ventilation rates for feedback to the rescuer, the mean (sd) absolute error in ventilation rate was 0.61 (1.64) min^-1. The first impedance-based method to accurately detect ventilations and give feedback on ventilation rate during mechanical CPR has been demonstrated.

Capnography: A support tool for the detection of return of spontaneous circulation in out-of-hospital cardiac arrest

BACKGROUND

Automated detection of return of spontaneous circulation (ROSC) is still an unsolved problem during cardiac arrest. Current guidelines recommend the use of capnography, but most automatic methods are based on the analysis of the ECG and thoracic impedance (TI) signals. This study analysed the added value of EtCO₂ for discriminating pulsed (PR) and pulseless (PEA) rhythms and its potential to detect ROSC.

MATERIALS AND METHODS

A total of 426 out-of-hospital cardiac arrest cases, 117 with ROSC and 309 without ROSC, were analysed. First, EtCO₂ values were compared for ROSC and no ROSC cases. Second, 5098 artefact free 3-s long segments were automatically extracted and labelled as PR (3639) or PEA (1459) using the instant of ROSC annotated by the clinician on scene as gold standard. Machine learning classifiers were designed using features obtained from the ECG, TI and the EtCO₂ value. Third, the cases were retrospectively analysed using the classifier to discriminate cases with and without ROSC.

RESULTS

EtCO₂ values increased significantly from 41 mmHg 3-min before ROSC to 57 mmHg 1-min after ROSC, and EtCO₂ was significantly larger for PR than for PEA, 46 mmHg/20 mmHg (p < 0.05). Adding EtCO₂ to the machine learning models increased their area under the curve (AUC) by over 2 percentage points. The combination of ECG, TI and EtCO₂ had an AUC for the detection of pulse of 0.92. Finally, the retrospective analysis showed a sensitivity and specificity of 96.6% and 94.5% for the detection of ROSC and no-ROSC cases, respectively.

CONCLUSION

Adding EtCO₂ improves the performance of automatic algorithms for pulse detection based on ECG and TI. These algorithms can be used to identify pulse on site, and to retrospectively identify cases with ROSC.

Increase of germ cell nuclear factor expression in globozoospermic Gopc-/- knockout mice

BACKGROUND

Golgi-associated PDZ and coiled-coil motif-containing protein (GOPC) is a Golgi protein that plays a role in vesicular transport and intracellular protein trafficking and degradation. Mice deficient in GOPC protein have globozoospermia and are infertile. The germ cell nuclear factor (GCNF) is a member of the nuclear receptor superfamily which is expressed in male germ cells, from spermatocytes and spermatids, both in the nucleus and the acrosomal region. It is not known if its expression could be altered in Gopc^-/- mice with defective acrosomes.

OBJECTIVES

The aim of the present work was to analyze the distribution of GCNF protein in spermatids of Gopc^-/- knockout mice.

MATERIALS AND METHODS

We have analyzed the expression and distribution during spermatogenesis of GCNF and its deregulation in Gopc^-/- mutant mice by RT-qPCR, Western blot, immunohistochemistry and immunogold.

RESULTS

Germ cell nuclear factor was localized in the nucleus of all the cell types in the seminiferous tubules. Despite being a nuclear protein, it was also located in the acrosome and in the manchette of elongating spermatids. We have found that in the absence of GOPC, the expression of GCNF was increased in the nucleus of spermatocytes, mainly in leptotene, and in the nucleus and the manchette during the spermatid elongation.

DISCUSSION AND CONCLUSION

Gopc^-/- mice have defective acrosome and manchette. The manchette is involved in the transport of proteins through the cytoplasm and the nucleus. Considering that the GCNF protein is normally transported to the acrosome and the nucleus, it can be thought that transport deficiencies in Gopc^-/- mice are responsible for the increased expression of this protein.

A Machine Learning Shock Decision Algorithm for Use During Piston-Driven Chest Compressions

GOAL

Accurate shock decision methods during piston-driven cardiopulmonary resuscitation (CPR) would contribute to improve therapy and increase cardiac arrest survival rates. The best current methods are computationally demanding, and their accuracy could be improved. The objective of this work was to introduce a computationally efficient algorithm for shock decision during piston-driven CPR with increased accuracy.

METHODS

The study dataset contains 201 shockable and 844 nonshockable ECG segments from 230 cardiac arrest patients treated with the LUCAS-2 mechanical CPR device. Compression artifacts were removed using the state-of-the-art adaptive filters, and shock/no-shock discrimination features were extracted from the stationary wavelet transform analysis of the filtered ECG, and fed to a support vector machine (SVM) classifier. Quasi-stratified patient wise nested cross-validation was used for feature selection and SVM hyperparameter optimization. The procedure was repeated 50 times to statistically characterize the results.

RESULTS

Best results were obtained for a six-feature classifier with mean (standard deviation) sensitivity, specificity, and total accuracy of 97.5 (0.4), 98.2 (0.4), and 98.1 (0.3), respectively. The algorithm presented a five-fold reduction in computational demands when compared to the best available methods, while improving their balanced accuracy by 3 points.

CONCLUSIONS

The accuracy of the best available methods was improved while drastically reducing the computational demands.

SIGNIFICANCE

An efficient and accurate method for shock decisions during mechanical CPR is now available to improve therapy and contribute to increase cardiac arrest survival.

ECG-based pulse detection during cardiac arrest using random forest classifier

Sudden cardiac arrest is one of the leading causes of death in the industrialized world. Pulse detection is essential for the recognition of the arrest and the recognition of return of spontaneous circulation during therapy, and it is therefore crucial for the survival of the patient. This paper introduces the first method based exclusively on the ECG for the automatic detection of pulse during cardiopulmonary resuscitation. Random forest classifier is used to efficiently combine up to nine features from the time, frequency, slope, and regularity analysis of the ECG. Data from 191 cardiac arrest patients was used, and 1177 ECG segments were processed, 796 with pulse and 381 without pulse. A leave-one-patient out cross validation approach was used to train and test the algorithm. The statistical distributions of sensitivity (SE) and specificity (SP) for pulse detection were estimated using 500 patient-wise bootstrap partitions. The mean (std) SE/SP for nine-feature classifier was 88.4 (1.8) %/89.7 (1.4) %, respectively. The designed algorithm only requires 4-s-long ECG segments and could be integrated in any commercial automated external defibrillator. The method permits to detect the presence of pulse accurately, minimizing interruptions in cardiopulmonary resuscitation therapy, and could contribute to improve survival from cardiac arrest.

A Multistage Algorithm for ECG Rhythm Analysis During Piston-Driven Mechanical Chest Compressions

GOAL

An accurate rhythm analysis during cardiopulmonary resuscitation (CPR) would contribute to increase the survival from out-of-hospital cardiac arrest. Piston-driven mechanical compression devices are frequently used to deliver CPR. The objective of this paper was to design a method to accurately diagnose the rhythm during compressions delivered by a piston-driven device.

METHODS

Data was gathered from 230 out-of-hospital cardiac arrest patients treated with the LUCAS 2 mechanical CPR device. The dataset comprised 201 shockable and 844 nonshockable ECG segments, whereof 270 were asystole (AS) and 574 organized rhythm (OR). A multistage algorithm (MSA) was designed, which included two artifact filters based on a recursive least squares algorithm, a rhythm analysis algorithm from a commercial defibrillator, and an ECG-slope-based rhythm classifier. Data was partitioned randomly and patient-wise into training (60%) and test (40%) for optimization and validation, and statistically meaningful results were obtained repeating the process 500 times.

RESULTS

The mean (standard deviation) sensitivity (SE) for shockable rhythms, specificity (SP) for nonshockable rhythms, and the total accuracy of the MSA solution were: 91.7 (6.0), 98.1 (1.1), and 96.9 (0.9), respectively. The SP for AS and OR were 98.0 (1.7) and 98.1 (1.4), respectively.

CONCLUSIONS

The SE/SP were above the 90%/95% values recommended by the American Heart Association for shockable and nonshockable rhythms other than sinus rhythm, respectively.

SIGNIFICANCE

It is possible to accurately diagnose the rhythm during mechanical chest compressions and the results considerably improve those obtained by previous algorithms.

Oral Immunotherapy for Food Allergy: A Spanish Guideline. Immunotherapy Egg and Milk Spanish Guide (ITEMS Guide). Part I: Cow Milk and Egg Oral Immunotherapy: Introduction, Methodology, Rationale, Current State, Indications, Contraindications, and Oral Immunotherapy Build-up Phase

BACKGROUND AND OBJECTIVE

Cow milk and egg are the most frequent causes of food allergy in the first years of life. Oral immunotherapy (OIT) has been investigated as an alternative to avoidance diets. No clinical practice guidelines on the management of OIT with milk and egg are currently available. Objectives: To develop clinical guidelines for OIT based on available scientific evidence and the opinions of experts.

METHODS

A review was made of studies published between 1984 and June 2016, doctoral theses published in Spain, summaries of communications at scientific meetings (SEAIC, SEICAP, EAACI, and AAAAI), and the consensus of opinion established by a group of experts from the scientific societies SEICAP and SEAIC.

RESULTS

Recommendations were established regarding the indications, requirements and practical aspects of the different phases of OIT, as well as special protocols for patients at high risk of adverse reactions.

CONCLUSIONS

Clinical practice guidelines based on the consensus reached between Spanish experts are presented for the management of OIT with milk and egg.

Oral immunotherapy for food allergy: A Spanish guideline. Immunotherapy egg and milk Spanish guide (items guide). Part I: Cow milk and egg oral immunotherapy: Introduction, methodology, rationale, current state, indications contraindications and oral immunotherapy build-up phase

INTRODUCTION

Cow's milk and egg are the most frequent causes of food allergy in the first years of life. Treatments such as oral immunotherapy (OIT) have been investigated as an alternative to avoidance diets. No clinical practice guides on the management of OIT with milk and egg are currently available.

OBJECTIVES

To develop a clinical guide on OIT based on the available scientific evidence and the opinions of experts.

METHODS

A review was made of studies published in the period between 1984 and June 2016, Doctoral Theses published in Spain, and summaries of communications at congresses (SEAIC, SEICAP, EAACI, AAAAI), with evaluation of the opinion consensus established by a group of experts pertaining to the scientific societies SEICAP and SEAIC.

RESULTS

Recommendations have been established regarding the indications, requirements and practical aspects of the different phases of OIT, as well as special protocols for patients at high risk of suffering adverse reactions.

CONCLUSIONS

A clinical practice guide is presented for the management of OIT with milk and egg, based on the opinion consensus of Spanish experts.

A multiscale approach to assess geomorphological processes in a semiarid badland area (Ebro Depression, Spain)

In this paper, three methods (Terrestrial Laser Scanner (TLS), terrestrial Structure from Motion photogrammetry (SfM) and aerial SfM photogrammetry with an Unmanned Aerial Vehicle (UAV)) were evaluated and compared to produce high resolution point clouds and Digital Elevation Models (DEMs) in a semiarid, complex badland area (Los Aguarales) with tourism activities. Geomorphological processes and dynamics were studied at different spatial scales. The preliminary results showed the possibilities of a multiscale approach, using various non-invasive techniques, to assess geomorphological processes. The high resolution of the point clouds, obtained with TLS and terrestrial SfM photogrammetry, allowed preliminary identification of numerous spatial details, although no relevant topographical changes were detected during a short, wet spring period (with rainfall of 200 mm). UAV images allowed work at larger scales (catchment), mapping piping features, and could be seen as a worthwhile tool for time-effective data acquisition from larger areas. The application of different technologies and a multiscale approach to generate high resolution DEMs is a useful technique when carrying out geomorphological studies in semiarid badland areas. However, long term studies will be necessary to verify the suitability of these techniques in such complex landscapes, and quantify topographical changes and erosion rates. Finally, the information obtained with these tools could be used to promote the study area as an interesting geomorphosite with opportunities for tourism.

Oral Immunotherapy for Food Allergy: A Spanish Guideline. Egg and Milk Immunotherapy Spanish Guide (ITEMS GUIDE). Part II: Maintenance Phase of Cow Milk (CM) and Egg Oral Immunotherapy (OIT), Special Treatment Dosing Schedules. Models of Dosing Schedules of OIT With CM and Egg

BACKGROUND AND OBJECTIVE

Cow milk and egg are the most frequent causes of food allergy in the first years of life. Oral immunotherapy (OIT) has been investigated as an alternative to avoidance diets. No clinical practice guidelines on the management of OIT with milk and egg are currently available. Objectives: To develop clinical guidelines for OIT based on available scientific evidence and the opinions of experts.

METHODS

A review was made of studies published between 1984 and June 2016, doctoral theses published in Spain, summaries of communications at scientific meetings (SEAIC, SEICAP, EAACI, and AAAAI), and the consensus of opinion established by a group of experts from the scientific societies SEICAP and SEAIC.

RESULTS

Recommendations were established regarding the indications, requirements and practical aspects of the different phases of OIT, as well as special protocols for patients at high risk of adverse reactions.

CONCLUSIONS

Clinical practice guidelines based on the consensus reached between Spanish experts are presented for the management of OIT with milk and egg.

Biomonitoring of 21 endocrine disrupting chemicals in human hair samples using ultra-high performance liquid chromatography-tandem mass spectrometry

Rapid industrial growth has increased human exposure to a large variety of chemicals with adverse health effects. These industrial chemicals are usually present in the environment, foods, beverages, clothes and personal care products. Among these compounds, endocrine disrupting chemicals (EDCs) have raised concern over the last years. In the present work, the determination of 21 EDCs in human hair samples is proposed. An analytical method based on the digestion of the samples with a mixture of acetic acid/methanol (20:80, v/v) followed by a solid-liquid microextraction and analysis by ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) was developed and validated. The most influential parameters affecting the extraction method were optimized. The method was validated using matrix-matched calibration and recovery assays. Limits of detection ranged from 0.2 to 4 ng g^-1, limits of quantification from 0.5 to 12 ng g^-1, and inter- and intra-day variability was under 15% in all cases. Recovery rates for spiked samples ranged from 92.1 to 113.8%. The method was applied for the determination of the selected compounds in human hair. Samples were collected weekly from six randomly selected volunteers (three men and three women) over a three-month period. All the analyzed samples tested positive for at least one of the analyzed compounds.

Milk and blood biomarkers associated to the clinical efficacy of a probiotic for the treatment of infectious mastitis

Previous studies have shown the efficacy of oral administration of selected lactobacilli strains to treat mastitis. The objective of this study was to find microbiological, biochemical and/or immunological biomarkers of the probiotic effect. Women with (n=23) and without (n=8) symptoms of mastitis received three daily doses (10(9) cfu) of Lactobacillus salivarius PS2 for 21 days. Samples of milk, blood and urine were collected before and after the probiotic intervention, and screened for a wide spectrum of microbiological, biochemical and immunological parameters. In the mastitis group, L. salivarius PS2 intake led to a reduction in milk bacterial counts, milk and blood leukocyte counts and interleukin (IL)-8 level in milk, an increase in those of immunoglobulin (Ig)E, IgG3, epidermal growth factor and IL-7, a modification of the milk electrolyte profile, and a reduction of some oxidative stress biomarkers. Such biomarkers will be useful in future clinical studies involving a larger cohort.

Non-linear photoelectron effect contributes to the formation of negative matrix ions in UV-MALDI

The mechanism of negative ion formation in matrix-assisted laser desorption/ionization (MALDI) is less well understood than that of positive ions: electron capture, disproportionation, and liberation of negatively charged sample molecules or clusters have been proposed to produce the initial anions in MALDI.