Drone-facilitated real-time video-guided feedback helps to improve the quality of lay bystander basic life support. A randomized controlled simulation trial

Objectives: Telephone instructions are commonly used to improve cardiopulmonary resuscitation (CPR) by lay bystanders. This usually implies an audio but no visual connection between the provider and the emergency medical telecommunicator. We aimed to investigate whether video-guided feedback via a camera drone enhances the quality of CPR.Methods: We used a randomized controlled simulation trial. Lay rescuers performed 8 minutes of CPR on an objective feedback manikin. Participants were randomized to receive telephone instructions with (intervention group) or without (control group) a drone providing a visual connection with the telecommunicator after a 2-minute run-in phase. Performed work (total compression depth minus total lean depth) was the primary outcome. Secondary outcomes were the proportion of effective chest compressions, average compression depth, subjective physical strain every two minutes, and dexterity in the nine-hole peg test after the scenario. Outcomes were compared using the t- and Mann Whitney-U tests. A two-sided p-value of <0.05 was considered significant.Results: We included 27 individuals (14 (52%) female, mean age 41 ± 14 years). Performed work was greater in the drone than in the control group (41.3 ± 7.0 vs. 33.9 ± 10.9 m; absolute difference 7.5, 95% CI 1.4 to 14.8; p = 0.046), with higher average compression depth (49 ± 7 vs. 40 ± 13 mm; p = 0.041), and higher proportions of adequate chest compressions (43 (IQR 14-60) vs. 3 (0-29) %; p = 0.041). We did not find any significant differences regarding the remaining secondary outcomes.Conclusion: Video-guided feedback via drones might be a helpful tool to enhance the quality of telephone-assisted CPR in lay bystanders.

The COVID-19 pandemic and children with PANS/PANDAS: an evaluation of symptom severity, telehealth, and vaccination hesitancy

The current study assessed the impact of the COVID-19 pandemic on children with PANS/PANDAS, a condition characterized by sudden-onset obsessive-compulsive, tic, or restrictive eating symptoms following infection. We conducted an anonymous survey between February and June 2021 of 254 self-reported caregivers of minors with PANS/PANDAS. Caregivers answered questions regarding PANS/PANDAS symptoms, telehealth care, and intention to vaccinate their child against COVID-19. PANS/PANDAS symptoms during COVID-19 infections were assessed when applicable. Children's OCD symptoms and coercive behaviors towards caregivers, along with the caregivers' mental health, relationship satisfaction, and burden, were assessed using standardized questionnaires. A majority of respondents endorsed a negative impact on their child's friendships, relationships with extended family, hobbies, and academic skills due to the pandemic. Children with suspected or diagnosed COVID-19 experienced new or worsened psychiatric symptoms, particularly mood lability, OCD, and anxiety. Telehealth care was the preferred treatment modality if the child had mild symptoms of PANS/PANDAS. A majority of caregivers reported high levels of relationship dissatisfaction and caregiver burden. As expected, these data suggest an overall negative impact of the COVID-19 pandemic on children with PANS/PANDAS and their caregivers.

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey

Background

Socioeconomic factors and the COVID-19 pandemic influence children's physical and mental health. We aimed to investigate the association between a census tract's median household income [MHI in United States Dollars ($)] and pediatric intoxications in Rhode Island, the smallest state in the United States of America. Geographical hotspots, as well as interactions with the COVID-19 pandemic, should be identified.

Methods

This study is a retrospective analysis of ambulance calls for pediatric (<18 years) intoxication in Rhode Island between March 1st, 2018, and February 28th, 2022. March 1st, 2020 was considered the beginning of the COVID-19 pandemic. Prehospital data were joined with information from the United States Census Bureau. The census tracts' case counts and MHI were examined using Poisson regression. Geographical clusters were identified with the Global Moran's I and local indicators of spatial association tests in ArcGIS Pro (Esri Corporation, Redlands, CA).

Results

Inclusion criteria were met by 208 incidents (48% female, median age 16 (IQR 15 to 17) years). The regression model showed a 0.6% increase (IRR 1.006, 95% CI [1.002, 1.01], p = 0.003) in pediatric intoxications for every $ 1,000 increase in MHI. Interaction analysis showed that the effect of MHI was less pronounced during the pandemic (IRR 0.98, 95% CI [0.964, 0.997], p = 0.02). Thirty-four (14%) of the 244 census tracts contributed to geographical clusters, which changed after the onset of the pandemic.

Conclusion

Higher median household income could be a risk factor for pediatric intoxications. Geographical hotspots changed with the pandemic.

Socioeconomic Risk Factors for Pediatric Out-of-hospital Cardiac Arrest: A Statewide Analysis

INTRODUCTION

Economic hardship is a major threat to children's health, implying that pediatric out-of-hospital cardiac arrest (pOHCA) might be promoted by lower incomes and child poverty. To target resources, it is helpful to identify geographical hotspots. Rhode Island is the smallest state by area in the United States of America. It has one million inhabitants and is comparable to many larger cities worldwide. We aimed to investigate the possible associations of pOHCA with economic factors and the coronavirus 2019 (COVID-19) pandemic. Our goal was to identify high-risk areas and evaluate whether the COVID-19 pandemic had an influence on delays in prehospital care.

METHODS

We analyzed all pOHCA cases (patients <18 years of age) in Rhode Island between March 1, 2018-February 28, 2022. We performed Poisson regression with pOHCA as dependent and economic risk factors (median household income [MHI] and child poverty rate from the US Census Bureau) as well as the COVID-19 pandemic as independent variables. Hotspots were identified using local indicators of spatial association (LISA) statistics. We used linear regression to assess the association of emergency nedical services-related times with economic risk factors and COVID-19.

RESULTS

A total of 51 cases met our inclusion criteria. Lower MHIs (incidence-rate ratio [IRR]) 0.99 per $1,000 MHI; P=0.01) and higher child poverty rates (IRR 1.02 per percent; P=0.02) were significantly associated with higher numbers of ambulance calls due to pOHCA. The pandemic did not have a significant influence (IRR 1.1; P=0.7). LISA identified 12 census tracts as hotspots (P<0.01). The pandemic was not associated with delays in prehospital care.

CONCLUSION

Lower median household income and higher child poverty rate are associated with higher numbers of pediatric out-of-hospital cardiac arrest.

Calls of Despair: An EMS Perspective on Suicide and Overdose in Rhode Island during COVID-19

In 2020, Americans suffered marked increases in overdose deaths and self-reported suicidal ideation, widely attributed to COVID-19. However, the recent pandemic's full effect on suicide and drug overdose, two of the "deaths of despair", remains poorly understood. This study aims to illustrate the impact of COVID-19 on suicide and overdose calls to emergency medical services (EMS) in Rhode Island using syndromic analysis as a novel public health surveillance tool. Utilizing computer algorithms, suicide and overdose EMS calls were identified during the pre-pandemic (March 2019-February 2020) and pandemic (March 2020-February 2021) years. Versus the prior year, pandemic year mean monthly call volume declined significantly for opioid (-16.2%), overdose (-15.5%), and suicide ideation (-6.2%) syndromes. Given elevated national overdose deaths and suicidality, our results suggest that hesitancy to call 911 amid COVID-19 hampered EMS intervention on suicide and overdose patients, potentially compounding their despair and the acuity of their eventual presentation.

Efficient and fabrication error tolerant grating couplers on the InP membrane on silicon platform

In order to couple light between photonic integrated circuits and optical fibers, grating couplers are commonly employed. This paper describes the design and fabrication of deep and shallow-etched grating couplers with a metal back-reflector with record low insertion losses in InP-based platforms. The measured insertion losses for deep and shallow-etched gratings are 2.4 and 2.6 dB, respectively. Additionally, fabrication error tolerances in shallow etched grating couplers have been examined experimentally, which showed high tolerance of this structure toward the grating period and fill factor.

A 3D image-based modelling approach for understanding spatiotemporal processes in phosphorus fertiliser dissolution, soil buffering and uptake by plant roots

Phosphorus (P) is a key yield-limiting nutrient for crops, but the main source of P fertiliser is finite. Therefore, efficient fertilisation is crucial. Optimal P application requires understanding of the dynamic processes affecting P availability to plants, including fertiliser dissolution rate and soil buffer power. However, standard soil testing methods sample at fixed time points, preventing a mechanistic understanding of P uptake variability. We used image-based modelling to investigate the effects of fertiliser dissolution rate and soil buffer power on P uptake by wheat roots imaged using X-ray CT. We modelled uptake based on 1-day, 1-week, and 14-week dissolution of a fixed quantity of total P for two common soil buffer powers. We found rapid fertiliser dissolution increased short-term root uptake, but total uptake from 1-week matched 1-day dissolution. We quantified the large effects root system architecture had on P uptake, finding that there were trade-offs between total P uptake and uptake per unit root length, representing a carbon investment/phosphorus uptake balance. These results provide a starting point for predictive modelling of uptake from different P fertilisers in different soils. With the addition of further X-ray CT image datasets and a wider range of conditions, our simulation approach could be developed further for rapid trialling of fertiliser-soil combinations to inform field-scale trials or management.

In-hospital predictors of 60-day readmission in COVID-19 patients

Introduction

Preventing hospital readmissions can improve a patient's quality of life and decrease healthcare costs. While prior work has focused on pre-existing comorbidities to predict COVID-19 readmissions, the prognostic role of in-hospital data and complications has been less studied.

Methods

Data was collected on adult patients diagnosed with COVID-19 and admitted to a multicenter hospital system in Illinois between March and November 2020. Our cohort consisted of COVID-19 hospitalization survivors excluding those discharged to hospice care. Major adverse events (MAEs) were defined as venous thromboembolism (VTE), myocardial injury (troponin greater than upper limit of normal), stroke, new requirement for renal replacement therapy (RRT), life-threatening arrhythmia, or acute heart failure exacerbation. The primary outcome was readmission within 60 days of initial hospitalization.

Results

From the 1406 survivors of the index hospitalization, 223 (15.9%) patients were readmitted within 60 days. Those readmitted were older and more likely to have underlying comorbidities including atrial fibrillation, coronary artery disease, and hypertension (Table 1). Length of stay between the readmission and non-readmission groups was trending towards statistical significance (10.52 days vs 8.95 days, p=0.053).

Those with one or more MAE during their index hospitalization, when adjusted for age and body mass index, were at an increased risk of readmission (adjusted odds ratio [aOR] 1.90, p&lt;0.01). Readmitted patients were more likely to have VTE during their index hospitalization than those not readmitted (7.2% vs 3.7%, p&lt;0.05). The incidence of new RRT (4.9% vs 2.5%, p=0.083) and myocardial injury (3.6% vs 1.5%, p=0.067) between the groups was also trending towards statistical significance (Table 1). No statistical difference was present between the other individual MAEs; however, this is limited by small sample sizes of certain MAEs. Of the 322 patients with echocardiography during the index admission, 82 (25.5%) were readmitted. In this cohort, left ventricular ejection fraction (LVEF) that was reduced (LVEF &lt;50%) or hyperdynamic (LVEF &gt;65%) was not a statistically significant predictor of readmission (Figure 1).

Lastly, discharge disposition was predictive of readmission as those being sent to acute rehab (OR 2.04, p&lt;0.01), long-term acute care (OR 2.58, p&lt;0.01), or skilled nursing facility (OR 2.67, p&lt;0.001) were at higher risk compared to those who were discharged to home (Figure 1).

Conclusion

In this cohort, the occurrence of any MAE during index COVID-19 hospitalization, particularly VTE, RRT, and myocardial injury, can be used to predict 60-day readmission. Furthermore, discharge disposition, but not LVEF, demonstrated prognostic value in our cohort. Identifying high risk patients prior to discharge helps health care providers focus resources on patients most likely to be readmitted.

Funding Acknowledgement

Type of funding sources: None.

Cardiac arrest in patients hospitalized for COVID-19: a tertiary medical center retrospective cohort study

Background/Introduction

Patients with COVID-19 are at increased risk for mortality during hospitalization. Better definition of the incidence, predictors, and outcomes of cardiac arrest during hospitalization for COVID-19 may support early identification and intervention.

Purpose

To estimate the incidence of in-hospital cardiac arrest in patients with COVID-19, describe the temporal trends in incidence of and survival after cardiac arrest, summarise characteristics of those who experienced a cardiac arrest, and compare the characteristics of survivors versus non-survivors of cardiac arrest.

Methods

We conducted a retrospective cohort study of patients admitted for COVID-19 to a tertiary medical center comprising three hospitals between March and November 2020. Data entry is ongoing for more than 2000 patients admitted through 2021. Clinical variables extracted via review of electronic medical records included age, sex, race/ethnicity, body mass index, history of cardiovascular disease (ie., coronary artery disease, congestive heart failure, atrial fibrillation, or cerebrovascular event), other comorbidities included in the Charlson comorbidity index, date of admission, duration of hospitalization, all cardiac arrest events during hospitalization, presenting rhythm during first cardiac arrest, and death. Data were described using summary statistics. Multivariable logistic regression was used to evaluate associations.

Results

Among 1666 patients, 107 (6.4%) experienced at least one in-hospital cardiac arrest event during hospitalization for COVID-19, of which 25 (23%) survived to hospital discharge. From March to October 2020, there was a decrease in estimated cardiac arrest incidence in-hospital from 8.2% to 3%, whereas estimated survival to hospital discharge after an arrest remained similar at approximately 20% (Figure). Compared to those who did not, patients who experienced in-hospital cardiac arrest were older and more likely to have existing cardiovascular disease, as well as other comorbidities. Similar factors were associated with lower chance of survival after cardiac arrest (Table). Patients with pulseless ventricular tachycardia/fibrillation (VT/VF) as presenting rhythm in cardiac arrest had better survival to hospital discharge compared to those with other rhythms (OR 3.3, p=0.02). Younger age (per 10 years, OR=0.7, p=0.03) and fewer comorbidities (per one fewer comorbidity, OR=1.5, p=0.05) were associated with better survival after cardiac arrest in multivariable logistic regression.

Conclusion

There was a decline in estimated incidence of cardiac arrest during hospitalization for COVID-19 since beginning of pandemic, with survival to hospital discharge after cardiac arrest estimated to be stable at around 20%. Younger age and fewer comorbidities especially cardiovascular disease were associated with better survival after an in-hospital cardiac arrest.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Rush University Medical Center Figure 1Table 1

Clinical characteristics and disease burden in prurigo nodularis

BACKGROUND

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intense pruritus, but information on patient experience and impact on quality of life (QoL) remains understudied.

AIM

To characterize disease characteristics and QoL in a global sample of patients with PN.

METHODS

An anonymous survey was distributed via patient support groups for PN.

RESULTS

In total, 231 members responded to the survey. The majority of respondents reported itch localized both to nodules and to intervening skin (67.0%). Associated symptoms included prickling, pain, stinging and burning. The extensor lower legs (69% right, 67.3% left) and flexor forearms (66.1% right, 62% left) were the most common sites of itch. Participants reported frequent healthcare utilization, with 36.3% visiting a doctor ≥ 10 times in the past year. Physician-diagnosed anxiety (45.4%), depression (16.4%) and the atopic triad (18.7%) were commonly reported. Patients with PN had mean scores of 16.4, 11.6 and 16.8 on the Dermatology Life Quality Index, Pittsburgh Sleep Quality Index and 5-Dimensions Itch, respectively.

CONCLUSIONS

Severe pruritus with accompanying pain, stinging and burning is characteristic of PN, with the majority of patients experiencing itch in both nodular and interlesional skin. Patients further report decreased QoL scores and impaired sleep. Patient experiences should guide future management of PN.

Image-based quantification of soil microbial dead zones induced by nitrogen fertilization

Microbial communities in agricultural soils underpin many ecosystem services including the maintenance of soil structure, food production, water purification and carbon storage. However, the impact of fertilization on the health of microbial communities is not well understood. This study investigates the spatial and temporal dynamics of nitrogen (N) transport away from a fertilizer granule with pore scale resolution. Specifically, we examined how soil structure and moisture content influence fertilizer derived N movement through the soil pore network and the subsequent impact of on soil microbial communities. We develop a mathematical model to describe N transport and reactions in soil at the pore-scale. Using X-ray Computed Tomography scans, we reconstructed a microscale description of a soil-pore geometry as a computational mesh. Solving two-phase water/air model produced pore-scale water distributions at 15, 30 and 70% water-filled pore volume. The N-speciation model considered ammonium (NH₄⁺), nitrate (NO₃^-) and dissolved organic N (DON), and included N immobilization, ammonification and nitrification processes, as well as diffusion in soil solution. We simulated the dissolution of a fertilizer pellet and a pore scale N cycle at three different water saturations. To aid interpretation of the model results, microbial activity at a range of N concentrations was measured. The model showed that the diffusion and concentration of N in water films is critically dependent upon soil moisture and N species. We predict that the maximum NH₄⁺ and NO₃^- concentrations in soil solution around the pellet under dry conditions are in the order of 1 × 10³ and 1 × 10⁴ mol m^-3 respectively, and under wet conditions 2 × 10² and 1 × 10³ mol m^-3, respectively. Supporting experimental evidence suggests that these concentrations would be sufficient to reduce microbial activity in the short-term in the zone immediately around the fertilizer pellet (ranging from 0.9 to 3.8 mm), causing a major loss of soil biological functioning. This model demonstrates the importance of pore-scale processes in regulating N movement and their interactions with the soil microbiome.

Review of Leucospilomutilla Ashmead and Description of the New Genus Atlantilla (Hymenoptera: Mutillidae)

The new genus Atlantilla Williams & Bartholomay, gen. nov. (type species Mutilla auriculata Gerstaecker, 1874), is proposed based on the combination of previously undescribed males from the Atlantic Forest and females of Traumatomutilla auriculata (Gerstaecker, Arch Naturgesch 40:41-77, 1874). This genus is similar to Leucospilomutilla Ashmead, 1903, which is also reviewed here. The previously unknown male of L. staurogastra Suárez, 1973 is described. Keys and illustrations are provided for each of the three known Leucospilomutilla species.

Spatial and Seasonal Distribution of Forensically Important Blow Flies (Diptera: Calliphoridae) in Makhanda, Eastern Cape, South Africa

The seasonal activity of adults of eight forensically important blow fly species [Calliphora croceipalpis (Diptera: Calliphoridae), Jaennicke, Lucilia sericata (Meigen) (Diptera: Calliphoridae), L. cuprina (Wiedemann) (Diptera: Calliphoridae), Chrysomya chloropyga (Wiedemann) (Diptera: Calliphoridae), Ch. albiceps (Wiedemann) (Diptera: Calliphoridae), Ch. marginalis (Wiedemann) (Diptera: Calliphoridae), Ch. putoria (Wiedemann) (Diptera: Calliphoridae), Ch. megacephala (Fabricius) (Diptera: Calliphoridae)] was quantified from collections in Makhanda, South Africa. Flies were collected in traps baited with chicken liver and placed in the field at eight locations for four consecutive days each fortnight for 14 mo. The seasonal distribution of each species compared well to published seasonal distributions of these blow flies elsewhere in South Africa, with evidence of year-to-year variation within seasons that might be explained by weather. This information is important for determining when and where certain species are likely to occur and will be of use in forensic investigations and myiasis management plans.

Comparison of EMS Provider In-Transit Performance and Exertion with Standard and Experimental Resuscitation Protocols during Simulated Out-of-Hospital Cardiac Arrest

OBJECTIVE

To assess the effect of a device-assisted out- of-hospital cardiac arrest (OHCA) resuscitation approach on provider performance during simulated transport.

METHODS

BLS and ALS providers were randomized into control and experimental teams. Subjects were fitted with wireless heart rate (HR) monitors. Control teams simulated with standard protocols and equipment; experimental teams with resuscitation-automating devices and goal-directed protocols. Chest compression quality, pulmonary ventilation, defibrillation, and medication administration tasks were monitored; subjects' HR's were continuously recorded.

RESULTS

Ten control and ten experimental teams completed the study (20 EMT-B's; 1 EMT-I, 8 EMT-C's, 11 EMT-P's) with similar resting HR's and age-predicted maximal HR's (mHR). All exhibited suboptimal in-transit resuscitation quality during initial simulations; HR did not differ significantly between the groups. Experimental teams exhibited improved chest compression and ventilation quality during transport along with lower subject HR.

CONCLUSION

OHCA resuscitation automation improved the in-simulation quality of critical in-transit tasks and reduced provider exertion.

Model and experimental validation of a unidirectional phase modulator

A unidirectional phase modulator consisting of tandem phase modulators is studied in detail for use as an integral part of an integrated optical isolator. The effects of non-linearity and residual amplitude modulation in the modulators, as well as the effect of the RF driving signals are captured in a phenomenological model for the first time. The model has been verified experimentally using a device realized in a generic InP based photonic integration platform and is used to study the operating range of the device. Design parameters of the modulator are derived such that modulation side bands in the forward propagating light are less than 40 dB, while isolation is maximized.

Rate-equation theory of a feedback insensitive unidirectional semiconductor ring laser

For our recently designed continuous-wave and single-frequency ring laser with intra-cavity isolator, we have formulated a rate-equation theory which accounts for two sources of mutual back-scattering between the clockwise and counterclockwise modes, i.e. induced by side-wall irregularities and due to inversion-grating-induced spatial hole burning. With this theory we first confirm that for a ring laser without intra-cavity isolation, from sufficiently large pumping strength on, the inversion-grating-induced bistable operation (i.e. either clockwise or counterclockwise) will overrule the back-reflection-induced coupled-mode operation (i.e. both clockwise and counterclockwise). We then analyze the robustness of unidirectional operation in case of intra-cavity isolation against the intra-cavity back-reflection mechanism and grating-induced mode coupling and derive for this case an explicit expression for the directionality in the presence of external optical feedback, valid for sufficiently strong isolation. The predictions posed in the second reference remain unaltered in the presence of the mode coupling mechanisms here considered.

Evaluation of Malaise and Yellow Pan Trap Performance to Assess Velvet Ant (Hymenoptera: Mutillidae) Diversity in a Neotropical Savanna

Given the global biodiversity crisis, it is crucial to identify methods best suited for conducting inventories. We evaluated the relative merits of Malaise traps (MT) and ground-level yellow pan traps (YPT) to sample male velvet ants (Hymenoptera: Mutillidae) in a Neotropical savanna biodiversity hotspot. We compared richness, number of captures, evenness, composition, and body size of male velvet ants (Hymenoptera: Mutillidae) sampled with both methods in four sites at Parque Nacional da Chapada dos Veadeiros, central Brazil, during 19 d. We expected reduced diversity and smaller body size of velvet ants sampled with YPT, because they target visually oriented insects that are active closer to the ground, whereas MT represent a passive method that intercepts insects flying at different heights. Richness, total number of captures, and evenness of species and genera were significantly higher in MT. The body size of velvet ants captured with MT was significantly larger than those found in YPT. Generalized linear model and nonmetric multidimensional scaling analyses revealed a clear difference in the patterns of abundances and composition of velvet ants sampled with MT and YPT, especially for the genera Darditilla, Traumatomutilla, Lomachaeta, Pseudomethoca, Tallium, and Ephuta. YPT were effective at capturing few species that were rare in MT but, overall, MT were much more effective than YPT. We found similar patterns when using either species or genus for assessing samples obtained with MT or YPT, suggesting that ecological studies on Neotropical velvet ants may not require taxonomic resolution to the species level.

Dendritic and mast cell involvement in the inflammatory response to primary malignant bone tumours

Background

A chronic inflammatory cell infiltrate is commonly seen in response to primary malignant tumours of bone. This is known to contain tumour-associated macrophages (TAMs) and lymphocytes; dendritic cells (DCs) and mast cells (MCs) have also been identified but whether these and other inflammatory cells are seen commonly in specific types of bone sarcoma is uncertain.

Methods

In this study we determined the nature of the inflammatory cell infiltrate in 56 primary bone sarcomas. Immunohistochemistry using monoclonal antibodies was employed to assess semiquantitatively CD45+ leukocyte infiltration and the extent of the DC, MC, TAM and T and B lymphocyte infiltrate.

Results

The extent of the inflammatory infiltrate in individual sarcomas was very variable. A moderate or heavy leukocyte infiltrate was more commonly seen in conventional high-grade osteosarcoma, undifferentiated pleomorphic sarcoma and giant cell tumour of bone (GCTB) than in Ewing sarcoma, chordoma and chondrosarcoma. CD14+/CD68+ TAMs and CD3+ T lymphocytes were the major components of the inflammatory cell response but (DC-SIGN/CD11c+) DCs were also commonly noted when there was a significant TAM and T lymphocyte infiltrate. MCs were identified mainly at the periphery of sarcomas, including the osteolytic tumour-bone interface.

Discussion

Our findings indicate that, although variable, some malignant bone tumours (e.g. osteosarcoma, GCTB) are more commonly associated with a pronounced inflammatory cell infiltrate than others (e.g. chondrosarcoma. Ewing sarcoma); the infiltrate is composed mainly of TAMs but includes a significant DC, T lymphocyte and MC infiltrate.

Conclusion

Tumours that contain a heavy inflammatory cell response, which includes DCs, TAMs and T lymphocytes, may be more amenable to immunomodulatory therapy. MCs are present mainly at the tumour edge and are likely to contribute to osteolysis and tumour invasion.

Abstract P5-16-01: Implementation of routine genomic and proteomic profiling of metastatic breast cancer patients in a community cancer center

Background: The optimal treatment strategy for patients with metastatic breast cancer (MBC) is currently unknown. Resistance to standard therapies, including anthracyclines and taxanes, limit the number of treatment options in many patients to a small number of non-cross resistant regimens. Rational combination approaches that are selected based upon genomic and proteomic analysis represents a possible advance that warrants extensive exploration.

Methods: Single center analysis of 77 consecutive metastatic breast cancer patients seen over a 12 month period (June 2014 through May 2015). All patients were referred for sequencing and the metastatic disease was rebiopsied. All samples were sent for standard pathologic, genomic (FoundationOne), and proteomic (TheraLink) analysis.

Results: Genomic and proteomic analysis yielded actionable targets in a majority of cases (89%). The most common pathways involved were the following: PI3K/Akt/mTOR (73%), MAPK (46%), ErbB (36%), FGFR (25%), and Jak/STAT (11%). Over 100 unique molecular aberrations were identified in 40 evaluable patients. Current outcomes are summarized in Table 1. The overall response rate was 45%, with another 43% of patients with stable disease. Average number of prior therapies was over 4, with a range of 1-11.

Table 1ER+/HER2-CR = 3PR = 8SD = 15PD = 2NE = 20ER+/HER2+CR = 2PR = 2SD = 1PD = 0NE = 9ER-/HER2+CR = 0PR = 1SD = 1PD = 1NE = 2Triple NegativeCR = 0PR = 2SD = 0PD = 2NE = 6Total evaluable patients = 40Overall CR = 13%Overall PR = 33%Overall SD = 43%Overall PD = 13%Total Not Evaluable = 37 pts (48%)Overall Response Rate (ORR) = 45%     CR = complete response PR = partial response SD = stable disease PD = progressive disease NE = not evaluable

Conclusion: Since current literature suggests that an overall response rate of approximately 10% or less is expected for patients that have received greater than 4 previous lines of therapy, the ORR seen in this analysis is quite remarkable. Most patients in this analysis were treated with FDA approved drugs off label, which provided additional challenges and was the primary reason that many patients were not evaluable. Patients were only evaluable if they received the recommended therapy and were measured for outcome. Our initial data provides growing evidence that it is critical to incorporate genomic and proteomic analysis (preferably as early as possible in the disease course) to allow for the best chance of disease response.

Citation Format: Williams CB, Krie A, De P, Dey N, Klein J, Williams KA, Hoogeveen M, Solomon B, Leyland-Jones B. Implementation of routine genomic and proteomic profiling of metastatic breast cancer patients in a community cancer center. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-16-01.

Integrated remotely tunable optical delay line for millimeter-wave beam steering fabricated in an InP generic foundry

A compact and fabrication-tolerant integrated remotely tunable optical delay line is proposed for millimeter-wave beam steering and is fabricated in an InP generic foundry. The proposed delay line is based on a spectrally cyclic-arrayed waveguide grating feedback loop. Its major features include the tolerant architecture with reduced chip size, and bi-directional operation with simplified remote tuning. Moreover, its cyclic feature guarantees further cascaded operations either for 2D radio beam steering or for high-resolution delay generation. The experimental results show less than 6.5-dB insertion loss of the integrated delay line. Five different delays from 0 to 71.6 ps are generated with less than 0.67-ps delay errors.

Detection and Measurement of Unhealthy, Environment-Derived Aerosol Materials in an Emergency Department

OBJECTIVE

To measure unhealthy aerosol materials in an Emergency Department (ED) and identify their sources for mitigation efforts.

BACKGROUND

Based on pilot findings of elevated ED particulate matter (PM) levels, investigators hypothesized that unhealthy aerosol materials derive from exogenous (vehicular) sources at ambulance receiving entrances.

METHODS

The Aerosol Environmental Toxicity in Healthcare-related Exposure and Risk program was conducted as an observational study. Calibrated sensors monitored PM and toxic gases at Ambulance Triage Exterior (ATE), Ambulance Triage Desk (ATD), and control Public Triage Desk (PTD) on a 3/3/3-day cycle. Cassette sampling characterized PM; meteorological and ambulance traffic data were logged. Descriptive and multiple linear regression analyses assessed for interactions between aerosol material levels, location, temporal variables, ambulance activity, and meteorological factors.

RESULTS

Sensors acquired 93,682 PM0.3, 90,250 PM2.5, and 93,768 PM5 measurements over 366 days to generate a data set representing at least 85.6% of planned measurements. PM0.3, PM2.5, and PM5 mean counts were lowest in PTD; 56%, 224%, and 223% higher in ATD; and 996%, 200%, and 63% higher in ATE, respectively (all p < .001). Qualitative analyses showed similar PM compositions in ATD and ATE. On multiple linear regression analysis, PM0.3 counts correlated primarily with location; PM2.5 and PM5 counts correlated most strongly with location and ambulance presence. PM < 2.5 and toxic gas concentrations at ATD and PTD patient care areas did not exceed hazard levels; PM0.3 counts did not have formal safety thresholds for comparison.

CONCLUSIONS

Higher levels of PM were linked with ED ambulance areas, although their health impact is unclear.

Surgical manoeuvres to reduce the impact of corneal allograft rejection

Allograft rejection is the major obstacle to successful corneal transplantation in high-risk cases. The risk factors are well recognized. Within the high-risk group, surgeons can influence graft survival by MHC antigen matching, by immunosuppression, by decreasing the number of antigen-presenting cells gaining access to the graft, and by avoiding up-regulation of MHC expression through the suppression of post-operative inflammation.

Monolithic 16-wavelength selector based on a chain of passband-flattened cyclic AWGs and optical switches

An InP monolithically integrated wavelength selector based on combinations of integrated AWGs and SOAs selects one out of up to 16 input channels. Loss-compensated, error-free WDM channel selection operation with <2.3  dB penalties is reported, with an OSNR of up to 32.5  dB/0.1  nm.

Matching for Human Leukocyte Antigens (HLA) in corneal transplantation - to do or not to do

As many patients with severe corneal disease are not even considered as candidates for a human graft due to their high risk of rejection, it is essential to find ways to reduce the chance of rejection. One of the options is proper matching of the cornea donor and recipient for the Human Leukocyte Antigens (HLA), a subject of much debate. Currently, patients receiving their first corneal allograft are hardly ever matched for HLA and even patients undergoing a regraft usually do not receive an HLA-matched graft. While anterior and posterior lamellar grafts are not immune to rejection, they are usually performed in low risk, non-vascularized cases. These are the cases in which the immune privilege due to the avascular status and active immune inhibition is still intact. Once broken due to infection, sensitization or trauma, rejection will occur. There is enough data to show that when proper DNA-based typing techniques are being used, even low risk perforating corneal transplantations benefit from matching for HLA Class I, and high risk cases from HLA Class I and probably Class II matching. Combining HLA class I and class II matching, or using the HLAMatchmaker could further improve the effect of HLA matching. However, new techniques could be applied to reduce the chance of rejection. Options are the local or systemic use of biologics, or gene therapy, aiming at preventing or suppressing immune responses. The goal of all these approaches should be to prevent a first rejection, as secondary grafts are usually at higher risk of complications including rejections than first grafts.

Quality improvement in EMS: a unique and challenging necessity

Quality Improvement (QI) is required in all aspects of the healthcare field. Emergency Medical Services (EMS) poses unique QI challenges. This article explores some of these challenges and provides some points to consider when performing QI in EMS services.

An overview of prehospital emergency medical services

Prehospital emergency medical services (EMS) provide lifesaving care daily in the United States. This article outlines the development of this vital public safety endeavor and highlights the characteristics of the Rhode Island system.

Physician medical direction of emergency medical services

Emergency medical services (EMS) bring the practice of emergency medicine directly to the homes of patients. Physician guidance of system development and provider practice can enhance the quality of care. This article provides an overview of issues in the development of EMS system oversight in the United States in general, and in Rhode Island.

Critical care transport

Critical care transport (CCT) is the segment of the Emergency Medical Services (EMS) system that transports patients who are critically ill or injured. Nearly 1,000 medical helicopters affiliated with over 300 transport programs, hundreds of fixed-wing aircraft, and many, many ground ambulances assisting adult, pediatric and neonatal CCT teams are operating in the United States.1 This article reviews the history of and indications for CCT, team qualifications, vehicle options, safety, CCT system design, and physician involvement in CCT. It concludes with a brief review of CCT services in Rhode Island.

Emergency medical technician education and training

Emergency Medical Services (EMS) training and education are vital and vibrant aspects of a young and evolving profession. This article provides a perspective on this effort in the United States and reviews current activity in Rhode Island.

The Rhode Island Life Saving Score (RILSS)--a proposed life-saving definition for EMS and emergency medicine

Emergency Medical Services (EMS) and Emergency Medicine staff are often described as life-saving providers, but there is no generally accepted objective definition of a life saved by these providers. Therefore, a proposed definition is described. Development of this definition began with conceptual rules, followed by a survey of physician EMS medical directors, and then by the development of a tool to implement the definition, and measure its validity and reliability through a review of 100 critical care transport EMS patient charts.

Numerical and experimental study of a high port-density WDM optical packet switch architecture for data centers

Data centers have to sustain the rapid growth of data traffic due to the increasing demand of bandwidth-hungry internet services. The current intra-data center fat tree topology causes communication bottlenecks in the server interaction process, power-hungry O-E-O conversions that limit the minimum latency and the power efficiency of these systems. In this paper we numerically and experimentally investigate an optical packet switch architecture with modular structure and highly distributed control that allow configuration times in the order of nanoseconds. Numerical results indicate that the candidate architecture scaled over 4000 ports, provides an overall throughput over 50 Tb/s and a packet loss rate below 10(-6) while assuring sub-microsecond latency. We present experimental results that demonstrate the feasibility of a 16x16 optical packet switch based on parallel 1x4 integrated optical cross-connect modules. Error-free operations can be achieved with 4 dB penalty while the overall energy consumption is of 66 pJ/b. Based on those results, we discuss feasibility to scale the architecture to a much larger port count.

Monolithic active-passive 16 × 16 optoelectronic switch

We present what is to our knowledge the first active-passive monolithically integrated 16×16 switch. The active InP/InGaAsP elements provide semiconductor optical amplifier gates in a multistage rearrangeably nonblocking switch design. Thirty-two representative connections, including the shortest, longest, and comprehensive range of intermediate paths have been assessed across the switch circuit. The 10 Gb/s signal routing is demonstrated with an optical signal-to-noise ratio up to 28.3 dB/0.1 nm and a signal extinction ratio exceeding 50 dB.

Blue light (470 nm) effectively inhibits bacterial and fungal growth

Blue light (470 nm) LED antimicrobial properties were studied alone against bacteria and with or without the food grade photosensitizer, erythrosine (ERY) against filamentous fungi. Leuconostoc mesenteroides (LM), Bacillus atrophaeus (BA) or Pseudomonas aeruginosa (PA) aliquots were exposed on nutrient agar plates to Array 1 (AR1, 0·2 mW cm(-2)) or Array 2 (AR2, 80 mW cm(-2)), which emitted impure or pure blue light (0-300 J cm(-2)), respectively. Inoculated control (room light only) plates were incubated (48 h) and colonies enumerated. The antifungal properties of blue light combined with ERY (11·4 and 22·8 μmol l(-1)) on Penicillium digitatum (PD) and Fusarium graminearum (FG) conidia were determined. Conidial controls consisted of: no light, room light-treated conidia and ERY plus room light. Light-treated (ERY + blue light) conidial samples were exposed only to AR2 (0-100 J cm(-2)), aliquots spread on potato dextrose agar plates, incubated (48 h, 30°C) and colonies counted. Blue light alone significantly reduced bacterial and FG viability. Combined with ERY, it significantly reduced PD viability. Blue light is lethal to bacteria and filamentous fungi although effectiveness is dependent on light purity, energy levels and microbial genus.

SIGNIFICANCE AND IMPACT OF THE STUDY

Light from two arrays of different blue LEDs significantly reduced bacterial (Leuconostoc mesenteroides, Bacillus atrophaeus and Pseudomonas aeruginosa) viabilities. Significant in vitro viability loss was observed for the filamentous fungi, Penicillium digitatum and Fusarium graminearum when exposed to pure blue light only plus a photosensitizer. F. graminearum viability was significantly reduced by blue light alone. Results suggest that (i) the amount of significant loss in bacterial viability observed for blue light that is pure or with traces of other wavelengths is genus dependent and (ii) depending on fungal genera, pure blue light is fungicidal with or without a photosensitizer.

Non-prescription medicine supply: protocols and practice

Focal points

The influence of rejection episodes in recipients of bilateral corneal grafts

We investigated whether a rejection episode in one graft was associated with rejection in the other graft, in recipients with bilateral corneal transplants. In a prospectively maintained, national register of 14,865 followed corneal grafts, 1476 patients with bilateral penetrating corneal grafts were identified. Occurrence of rejection was a risk factor for graft failure (p < 0.0001). Logistic regression was used to calculate the adjusted odds ratio for rejection in one eye following rejection in the other eye. In the subset of 1118 patients with bilateral grafts but no history of previous grafts or rejections in either eye, the adjusted odds ratio for a rejection episode in the first eye following rejection in the second was 3.27 (95% confidence interval, CI 1.85, 5.79; p < 0.001). The adjusted odds ratio was 2.04 (95% CI 1.07, 3.91; p = 0.03) for rejection in the second eye following rejection in the first. The median time between the first rejection episode in one eye and the first rejection episode in the other eye was 15 months. Patients with bilateral corneal grafts who suffer a graft rejection episode in one eye are at significantly greater odds of suffering a rejection episode in the other corneal transplant.

A steroid-inducible promoter for the cornea

AIM

Topical glucocorticosteroids are administered to virtually every corneal transplant recipient, but irreversible immunological rejection remains the leading cause of graft failure. Ex vivo gene therapy of the donor cornea has been shown to modulate graft rejection in experimental models. The efficacy of a glucocorticosteroid-inducible promoter was assessed in controlling transgene expression following lentivirus-mediated gene transfer to ovine and human corneas.

METHODS

A glucocorticosteroid response element (GRE5) was cloned into a lentiviral vector (LV-GRE-IL10) encoding the model transgene interleukin 10. Transgene expression by LV-GRE-IL10-transduced A549 cells, ovine corneas and human corneas cultured with or without dexamethasone was quantified by an IL10-specific enzyme-linked immunosorbent assay.

RESULTS

IL10 levels were 30-40-fold higher in supernatants from LV-GRE-IL10-transduced A549 cells cultured with dexamethasone than in controls. Dexamethasone withdrawal resulted in restoration of baseline IL10 levels. Supernatants from LV-GRE-IL10-transduced ovine and human corneas cultured in dexamethasone contained nine to 10 times more IL10 than supernatants from transduced corneas cultured without dexamethasone.

CONCLUSION

The GRE5 promoter in a lentiviral vector drove rapid, sustained and inducible transgene expression in both ovine and human corneas in the presence of dexamethasone. A steroid-inducible promoter may be useful for controlling transgene expression in gene-modified donor corneal allografts.

Mechanisms of corneal allograft rejection and regional immunosuppression

Corneal transplantation has not matched the improvements in outcome seen with other clinical transplantation procedures. The therapeutic strategies, which have improved the outcomes of solid vascularised organs are not applicable to corneal transplantation. Corneal transplantation is different with respect to relevant transplantation biology and the clinical context in which it is practiced. New approaches need to be developed which provide regional rather than systemic immunosuppression. The accessibility of the cornea makes it particularly suitable for topical medication and for gene therapy approaches. Engineered antibodies, small enough to pass through the cornea, and directed at key molecules in the allograft response have been developed. Gene therapy had been developed using viral vectors to transfect the corneal endothelium with the genes for immunosuppressive lymphokines. Both approaches show promise.

Educational and research implications of portable human patient simulation in acute care medicine

Advanced medical simulation has become widespread. One development, the adaptation of simulation techniques and manikin technologies for portable operation, is starting to impact the training of personnel in acute care fields such as emergency medicine (EM) and trauma surgery. Unencumbered by cables and wires, portable simulation programs mitigate several limitations of traditional (nonportable) simulation and introduce new approaches to acute care education and research. Portable simulation is already conducted across multiple specialties and disciplines. In situ medical simulations are those carried out within actual clinical environments, while off-site portable simulations take place outside of clinical practice settings. Mobile simulation systems feature functionality while moving between locations; progressive simulations are longer-duration events using mobile simulations that follow a simulated patient through sequential care environments. All of these variants have direct applications for acute care medicine. Unique training and investigative opportunities are created by portable simulation through four characteristics: 1) enhancement of experiential learning by reframing training inside clinical care environments, 2) improving simulation accessibility through delivery of training to learner locations, 3) capitalizing on existing care environments to maximize simulation realism, and 4) provision of improved training capabilities for providers in specialized fields. Research agendas in acute care medicine are expanded via portable simulation's introduction of novel topics, new perspectives, and innovative methodologies. Presenting opportunities and challenges, portable simulation represents an evolutionary progression in medical simulation. The use of portable manikins and associated techniques may increasingly complement established instructional measures and research programs at acute care institutions and simulation centers.

Embolic phenomena during computer-assisted and conventional total knee replacement

Systemic emboli released during total knee replacement have been implicated as a cause of peri-operative morbidity and neurological dysfunction. We undertook a prospective, double-blind, randomised study to compare the cardiac embolic load sustained during computer-assisted and conventional, intramedullary-aligned, total knee replacement, as measured by transoesophageal echocardiography. There were 26 consecutive procedures performed by a single surgeon at a single hospital. The embolic load was scored using the modified Mayo grading system for echogenic emboli.

Fourteen patients undergoing computer-assisted total knee replacement had a mean embolic score of 4.89 (3 to 7) and 12 undergoing conventional total knee replacement had a mean embolic score of 6.15 (4 to 8) on release of the tourniquet. Comparison of the groups using a two-tailed t-test confirmed a highly significant difference (p = 0.004).

This study demonstrates that computer-assisted knee replacement results in the release of significantly fewer systemic emboli than the conventional procedure using intramedullary alignment.

Lentivirus-mediated gene transfer to the rat, ovine and human cornea

Gene therapy of the cornea shows promise for modulating corneal transplant rejection but the most appropriate vector for gene transfer has yet to be determined. We investigated a lentiviral vector (LV) for its ability to transduce corneal endothelium. A lentivector expressing enhanced yellow fluorescent protein (eYFP) under the control of the Simian virus type 40 early promoter (LV-SV40-eYFP) transduced 80-90% of rat, ovine and human corneal endothelial cells as detected by fluorescence microscopy. The kinetics of gene expression varied among species, with ovine corneal endothelium showing a relative delay in detectable reporter gene expression compared with the rat or human corneal endothelium. Vectors containing the myeloproliferative sarcoma virus promoter or the phosphoglycerate kinase promoter were not significantly more effective than LV-SV40-eYFP. The stability of eYFP expression in rat and ovine corneas following ex vivo transduction of the donor cornea was assessed following orthotopic corneal transplantation. Following transduction ex vivo, eYFP expression was maintained in corneal endothelial cells for at least 28 days after corneal transplantation in the sheep and >60 days in the rat. Thus, rat, ovine and human corneal endothelial cells were efficiently transduced by the LV, and gene expression appeared stable over weeks in vivo.

Fetal and neonatal exposure to AZT and low-protein diet affects glucose homeostasis: a model with implications for AIDS prevention

Zidovudine (AZT) lowers the perinatal transmission of HIV but can impair mitochondrial function by depleting mitochondrial DNA (mtDNA). AZT therapy and perinatal nutritional deprivation affect the body fat distribution, which influences glucose tolerance. We sought to model intrauterine exposure to AZT in humans to determine whether it interacts with low-protein diet (LPD) to impact on birth weight and glucose homeostasis in the offspring. Pregnant dams and their offspring were given AZT, an LPD, or AZT and an LPD (LPD + AZT). AZT reduced mtDNA copy number in liver and birth weight in the offspring and increased their fasting glucose and insulin (P = 0.021, 0.03, 0.001, and 0.011 respectively) at 6-8 wk of age. LPD decreased litter size and birth weight (P = 0.01 and 0.012). In the LPD + AZT group, birth weight and litter size were reduced compared with untreated controls, and fasting blood glucose and insulin were raised. There was a significant interaction between LPD and AZT on fasting insulin levels (P = 0.025). Islet size was not significantly affected, but the mean beta-cell area/islet was reduced in the LPD + AZT group compared with controls (P < 0.05). Early exposure to AZT interacts with LPD to impair fetal development in this model. This combination appeared to impair the supply of insulin and, hence, glucose homeostasis, perhaps as a result of impaired mitochondrial function. Although it is not certain that this can be extrapolated to humans, maternal nutritional deprivation combined with AIDS therapy could influence both birth weight and onset of diabetes.