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OBJECTIVES: Airway management is a fundamental skill that Emergency Medical Services (EMS) clinicians must be prepared to perform on patients of any age. We performed one of the first epidemiological studies of out-of-hospital pediatric airway management utilizing the ESO data set. METHODS: We used the 2019 ESO Data Collaborative public release research data set. We performed a descriptive analysis of all patients <18 years receiving at least one of the following airway management interventions: nasopharyngeal airway, oropharyngeal airway, noninvasive positive pressure ventilation (NIPPV), airway suctioning, bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) or surgical airway placement. We determined the success rates for BVM, TI and SGA. RESULTS: Among 7,422,710 911 EMS activations, there were 346,912 pediatric encounters that resulted in patient care. Airway management occurred in 27,071 encounters (7,803 per 100,000 pediatric EMS patient care events). Use of BVM, intubation or supraglottic airway insertion occurred in 3,496 encounters (1,007 per 100,000 pediatric EMS patient care events). Ventilation with BVM occurred in 2,226 encounters (642 per 100,000 pediatric EMS patient care events), TI in 935 pediatric EMS patient care encounters (270 per 100,000 patient care encounters), and supraglottic airway insertion in 335 patient encounters (97 per 100,000 patient care encounters). Overall TI success was 71.4%, rapid sequence intubation success was 86.3%, and SGA success was 87.2%. Overall TI first pass success rate was 63.1%. CONCLUSIONS: In the ESO cohort, advanced airway management of children occurred in only 5.9 in 10,000 911 emergency encounters. Overall and first pass success rates for TI were low. These data provide contemporary perspectives of pediatric prehospital airway management in the United States.
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Indonesia has experienced rapid primary forest loss, second only to Brazil in modern history. We examined the fates of Indonesian deforested areas, immediately after clearing and over time, to quantify deforestation drivers in Indonesia. Using time-series satellite data, we tracked degradation and clearing events in intact and degraded natural forests from 1991 to 2020, as well as land use trajectories after forest loss. While an estimated 7.8 Mha (SE = 0.4) of forest cleared during this period had been planted with oil palms by 2020, another 8.8 Mha (SE = 0.4) remained unused. Of the 28.4 Mha (SE = 0.7) deforested, over half were either initially left idle or experienced crop failure before a land use could be detected, and 44% remained unused for 5 y or more. A majority (54%) of these areas were cleared mechanically (not by escaped fires), and in cases where idle lands were eventually converted to productive uses, oil palm plantations were by far the most common outcome. The apparent deliberate creation of idle deforested land in Indonesia and subsequent conversion of idle areas to oil palm plantations indicates that speculation and land banking for palm oil substantially contribute to forest loss, although failed plantations could also contribute to this dynamic. We also found that in Sumatra, few lowland forests remained, suggesting that a lack of remaining forest appropriate for palm oil production, together with an extensive area of banked deforested land, may partially explain slowing forest loss in Indonesia in recent years.
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Conservação dos Recursos Naturais , Florestas , Indonésia , Árvores/crescimento & desenvolvimento , AgriculturaRESUMO
Leukocyte telomere length (LTL) varies significantly across human populations, with individuals of African ancestry having longer LTL than non-Africans. However, the genetic and environmental drivers of LTL variation in Africans remain largely unknown. We report here on the relationship between LTL, genetics, and a variety of environmental and climatic factors in ethnically diverse African adults (n = 1,818) originating from Botswana, Tanzania, Ethiopia, and Cameroon. We observe significant variation in LTL among populations, finding that the San hunter-gatherers from Botswana have the longest leukocyte telomeres and that the Fulani pastoralists from Cameroon have the shortest telomeres. Genetic factors explain â¼50% of LTL variation among individuals. Moreover, we observe a significant negative association between Plasmodium falciparum malaria endemicity and LTL while adjusting for age, sex, and genetics. Within Africa, adults from populations indigenous to areas with high malaria exposure have shorter LTL than those in populations indigenous to areas with low malaria exposure. Finally, we explore to what degree the genetic architecture underlying LTL in Africa covaries with malaria exposure.
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Malária Falciparum , Telômero , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , África Subsaariana/epidemiologia , População Negra/etnologia , População Negra/genética , Doenças Endêmicas , Leucócitos/metabolismo , Malária Falciparum/genética , Malária Falciparum/epidemiologia , Malária Falciparum/parasitologia , Plasmodium falciparum/genética , Plasmodium falciparum/patogenicidade , População da África Subsaariana , Telômero/genética , Homeostase do Telômero/genética , Botsuana , Tanzânia , Camarões , População da África AustralRESUMO
BACKGROUND AND OBJECTIVES: A better characterization of deaths in children following emergency care is needed to inform timely interventions. This study aimed to describe the timing, location, and causes of death to 1 year among a cohort of injured and medically ill children. METHODS: We conducted a retrospective cohort study of children <18 years requiring emergency care in six states from January 1, 2012, through December 31, 2017, with follow-up through December 31, 2018, for patients who were not discharged from the emergency department (ED). In this cohort, 1-year mortality, time to death within 1 year, and causes of death were assessed from ED, inpatient, and vital status records. RESULTS: There were 546,044 children during the 6-year period. The 1-year mortality rate was 2.2% (n = 1356) for injured children and 1.4% (n = 6687) for medically ill children. Matched death certificates were available for 861 (63.5%) of 1356 deaths in the injury cohort and for 4712 (70.5%) of 6687 deaths in the medical cohort. Among deaths in the injury cohort, 1274 (94.0%) occurred in the ED or hospital. The most common causes of death were motor vehicle collisions, firearm injuries, and pedestrian injuries. Among the 6687 deaths in the medical cohort, 5081 (76.0%) children died in the ED or hospital (primarily in the ED) and 1606 (24.0%) occurred after hospital discharge. The most common causes of death were sudden infant death syndrome, suffocation and drowning, and congenital conditions. CONCLUSIONS: The 1-year mortality of children presenting to an ED is 2.2% for injured children and 1.4% for medically ill children with most deaths occurring in the ED. Future interventional trials, quality improvement efforts, and health policy focused in the ED could have the potential to improve outcomes of pediatric patients.
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Causas de Morte , Serviço Hospitalar de Emergência , Humanos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos Retrospectivos , Feminino , Masculino , Pré-Escolar , Criança , Lactente , Adolescente , Ferimentos e Lesões/mortalidade , Fatores de Tempo , Estados Unidos/epidemiologia , Estudos de Coortes , Recém-NascidoRESUMO
Asymmetric-flow field-flow fractionation (AF4) is a valuable tool to separate and assess different size populations in nanotherapeutics. When coupled with both static light scattering and dynamic light scattering, it can be used to qualitatively assess protein binding to nanoparticles by comparing the shape factors for both non-plasma-incubated samples and plasma-incubated samples. The shape factor is defined as the ratio of the derived root mean square radius (by static light scattering) to the measured hydrodynamic radius (by dynamic light scattering). The shape factor gives an idea of where the center of mass lies in a nanoparticle, and any shift in the shape factor to larger values is indicative of a mass addition to the periphery of the nanoparticle and suggests the presence of protein binding. This protocol will discuss how to set up an experiment to assess protein binding in nanoparticles using AF4, multi-angle light scattering (MALS), and dynamic light scattering (DLS).
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Fracionamento por Campo e Fluxo , Nanopartículas , Difusão Dinâmica da Luz , Ligação Proteica , Tamanho da Partícula , Fracionamento por Campo e Fluxo/métodos , Luz , Espalhamento de RadiaçãoRESUMO
This protocol describes how to measure the size and concentration of individual metallic nanoparticles using inductively coupled plasma-mass spectrometry (ICP-MS) in single-particle (sp) mode. Accurately determining the size of individual nanoparticles on a per-particle basis, both quickly and accurately, is an ever-increasing need within nanoparticle characterization. ICP-MS is capable of measuring a broad range of metallic nanoparticle sizes with high resolution, thus allowing the measurement of multiple particle populations for the quality assessment of nanoformulations. Additionally, spICP-MS can accurately determine particle concentrations without the need for concentration standards.
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Nanopartículas Metálicas , Nanopartículas , Espectrometria de Massas/métodos , Tamanho da Partícula , Nanopartículas Metálicas/química , Nanopartículas/químicaRESUMO
Nanomaterials are inherently polydisperse. Traditional techniques, such as the widely used batch-mode dynamic light-scattering (DLS) analysis, are not ideal nor thoroughly descriptive enough to define the full complexity of these materials. Asymmetric-flow field-flow fractionation (AF4) with various in-line detectors, such as ultraviolet-visible (UV-vis), multi-angle light scattering (MALS), refractive index (RI), and DLS, is an alternative technique that can provide flow-mode analysis of not only size distribution but also shape, drug release/stability, and protein binding.
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Fracionamento por Campo e Fluxo , Nanopartículas , Difusão Dinâmica da Luz , Refratometria , Fracionamento por Campo e Fluxo/métodos , Luz , Tamanho da PartículaRESUMO
A major challenge for group-hunting predators is coordinating movement at high speed. Billfish - large predators with an elongated rostrum (bill) - include some of the fastest animals in the ocean and often form groups when hunting. This presents a challenge: how do fast-moving predators wielding dangerous weaponry reliably coordinate their attacks to avoid injury? We report a possible solution to this problem through rapid colour change in group-hunting striped marlin (Kajikia audax) as they hunt schools of Pacific sardines (Sardinops sagax). By analysing high-resolution drone footage of marlin attacks, we found that individual marlin intensified the contrast of their body stripes immediately prior to striking prey schools, before rapidly decreasing intensity after their attack. This suggests that color change may be a reliable signal of motivation to attack, potentially deterring conspecifics from attacking.
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Caça , Perciformes , Animais , Comportamento Predatório , Peixes , Instituições AcadêmicasRESUMO
Skin color is highly variable in Africans, yet little is known about the underlying molecular mechanism. Here we applied massively parallel reporter assays to screen 1,157 candidate variants influencing skin pigmentation in Africans and identified 165 single-nucleotide polymorphisms showing differential regulatory activities between alleles. We combine Hi-C, genome editing and melanin assays to identify regulatory elements for MFSD12, HMG20B, OCA2, MITF, LEF1, TRPS1, BLOC1S6 and CYB561A3 that impact melanin levels in vitro and modulate human skin color. We found that independent mutations in an OCA2 enhancer contribute to the evolution of human skin color diversity and detect signals of local adaptation at enhancers of MITF, LEF1 and TRPS1, which may contribute to the light skin color of Khoesan-speaking populations from Southern Africa. Additionally, we identified CYB561A3 as a novel pigmentation regulator that impacts genes involved in oxidative phosphorylation and melanogenesis. These results provide insights into the mechanisms underlying human skin color diversity and adaptive evolution.
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Albinismo Oculocutâneo , Melaninas , Pigmentação da Pele , Humanos , Pigmentação da Pele/genética , Melaninas/genética , Alelos , Genômica , Pigmentação/genética , Polimorfismo de Nucleotídeo Único/genética , Proteínas Repressoras/genéticaRESUMO
Motivation: Clusters of hydrophobic residues are known to promote structured protein stability and drive protein aggregation. Recent work has shown that identifying contiguous hydrophobic residue clusters (termed "blobs") has proven useful in both intrinsically disordered protein (IDP) simulation and human genome studies. However, a graphical interface was unavailable. Results: Here, we present the blobulator: an interactive and intuitive web interface to detect intrinsic modularity in any protein sequence based on hydrophobicity. We demonstrate three use cases of the blobulator and show how identifying blobs with biologically relevant parameters provides useful information about a globular protein, two orthologous membrane proteins, and an IDP. Other potential applications are discussed, including: predicting protein segments with critical roles in tertiary interactions, providing a definition of local order and disorder with clear edges, and aiding in predicting protein features from sequence. Availability: The blobulator GUI can be found at www.blobulator.branniganlab.org, and the source code with pip installable command line tool can be found on GitHub at www.GitHub.com/BranniganLab/blobulator.
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Importance: Survival for children with out-of-hospital cardiac arrest (OHCA) remains poor despite improvements in adult OHCA survival. Objective: To characterize the frequency of and factors associated with adverse safety events (ASEs) in pediatric OHCA. Design, Setting, and Participants: This population-based retrospective cohort study examined patient care reports from 51 emergency medical services (EMS) agencies in California, Georgia, Oregon, Pennsylvania, Texas, and Wisconsin for children younger than 18 years with an OHCA in which resuscitation was attempted by EMS personnel between 2013 and 2019. Medical record review was conducted from January 2019 to April 2022 and data analysis from October 2022 to February 2023. Main Outcomes and Measure: Severe ASEs during the patient encounter (eg, failure to give an indicated medication, 10-fold medication overdose). Results: A total of 1019 encounters of EMS-treated pediatric OHCA were evaluated; 465 patients (46%) were younger than 12 months. At least 1 severe ASE occurred in 610 patients (60%), and 310 patients (30%) had 2 or more. Neonates had the highest frequency of ASEs. The most common severe ASEs involved epinephrine administration (332 [30%]), vascular access (212 [19%]), and ventilation (160 [14%]). In multivariable logistic regression, the only factor associated with severe ASEs was young age. Neonates with birth-related and non-birth-related OHCA had greater odds of a severe ASE compared with adolescents (birth-related: odds ratio [OR], 7.0; 95% CI, 3.1-16.1; non-birth-related: OR, 3.4; 95% CI, 1.2-9.6). Conclusions and Relevance: In this large geographically diverse cohort of children with EMS-treated OHCA, 60% of all patients experienced at least 1 severe ASE. The odds of a severe ASE were higher for neonates than adolescents and even higher when the cardiac arrest was birth related. Given the national increase in out-of-hospital births and ongoing poor outcomes of OHCA in young children, these findings represent an urgent call to action to improve care delivery and training for this population.
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Reanimação Cardiopulmonar , Serviços Médicos de Emergência , Parada Cardíaca Extra-Hospitalar , Adulto , Recém-Nascido , Adolescente , Humanos , Criança , Pré-Escolar , Estudos Retrospectivos , Parada Cardíaca Extra-Hospitalar/epidemiologia , Parada Cardíaca Extra-Hospitalar/terapia , OregonRESUMO
Billfish rostra potentially have several functions; however, their role in feeding is unequivocal in some species. Recent work linked morphological variation in rostral micro-teeth to differences in feeding behavior in two billfish species, the striped marlin (Kajikia audax) and the sailfish (Istiophorus platypterus). Here, we present the rostral micro-tooth morphology for a third billfish species, the blue marlin (Makaira nigricans), for which the use of the rostrum in feeding behavior is still undocumented from systematic observations in the wild. We measured the micro-teeth on rostrum tips of blue marlin, striped marlin, and sailfish using a micro-computed tomography approach and compared the tooth morphology among the three species. This was done after an analysis of video-recorded hunting behavior of striped marlin and sailfish revealed that both species strike prey predominantly with the first third of the rostrum, which provided the justification to focus our analysis on the rostrum tips. In blue marlin, intact micro-teeth were longer compared to striped marlin but not to sailfish. Blue marlin had a higher fraction of broken teeth than both striped marlin and sailfish, and broken teeth were distributed more evenly on the rostrum. Micro-tooth regrowth was equally low in both marlin species but higher in sailfish. Based on the differences and similarities in the micro-tooth morphology between the billfish species, we discuss potential feeding-related rostrum use in blue marlin. We put forward the hypothesis that blue marlin might use their rostra in high-speed dashes as observed in striped marlin, rather than in the high-precision rostral strikes described for sailfish, possibly focusing on larger prey organisms.
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Perciformes , Animais , Microtomografia por Raio-X , Perciformes/anatomia & histologia , Comportamento AlimentarRESUMO
Comparisons of Neanderthal genomes to anatomically modern human (AMH) genomes show a history of Neanderthal-to-AMH introgression stemming from interbreeding after the migration of AMHs from Africa to Eurasia. All non-sub-Saharan African AMHs have genomic regions genetically similar to Neanderthals that descend from this introgression. Regions of the genome with Neanderthal similarities have also been identified in sub-Saharan African populations, but their origins have been unclear. To better understand how these regions are distributed across sub-Saharan Africa, the source of their origin, and what their distribution within the genome tells us about early AMH and Neanderthal evolution, we analyzed a dataset of high-coverage, whole-genome sequences from 180 individuals from 12 diverse sub-Saharan African populations. In sub-Saharan African populations with non-sub-Saharan African ancestry, as much as 1% of their genomes can be attributed to Neanderthal sequence introduced by recent migration, and subsequent admixture, of AMH populations originating from the Levant and North Africa. However, most Neanderthal homologous regions in sub-Saharan African populations originate from migration of AMH populations from Africa to Eurasia â¼250 kya, and subsequent admixture with Neanderthals, resulting in â¼6% AMH ancestry in Neanderthals. These results indicate that there have been multiple migration events of AMHs out of Africa and that Neanderthal and AMH gene flow has been bi-directional. Observing that genomic regions where AMHs show a depletion of Neanderthal introgression are also regions where Neanderthal genomes show a depletion of AMH introgression points to deleterious interactions between introgressed variants and background genomes in both groups-a hallmark of incipient speciation.
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Homem de Neandertal , Humanos , Animais , Homem de Neandertal/genética , Genoma Humano , Fluxo Gênico , Genômica , África SubsaarianaRESUMO
Interferons (IFN) are an assemblage of signaling proteins made and released by various host cells in response to stimuli, including viruses. Respiratory syncytial virus (RSV), influenza virus, and SARS-CoV-2 are major causes of respiratory disease that induce or antagonize IFN responses depending on various factors. In this review, the role and function of type I, II, and III IFN responses to respiratory virus infections are considered. In addition, the role of the viral proteins in modifying anti-viral immunity is noted, as are the specific IFN responses that underly the correlates of immunity and protection from disease.
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Importance: Presentation to emergency departments (EDs) with high levels of pediatric readiness is associated with improved pediatric survival. However, it is unclear whether children of all races and ethnicities benefit equitably from increased levels of such readiness. Objective: To evaluate the association of ED pediatric readiness with in-hospital mortality among children of different races and ethnicities with traumatic injuries or acute medical emergencies. Design, Setting, and Participants: This cohort study of children requiring emergency care in 586 EDs across 11 states was conducted from January 1, 2012, through December 31, 2017. Eligible participants included children younger than 18 years who were hospitalized for an acute medical emergency or traumatic injury. Data analysis was conducted between November 2022 and April 2023. Exposure: Hospitalization for acute medical emergency or traumatic injury. Main Outcomes and Measures: The primary outcome was in-hospital mortality. ED pediatric readiness was measured through the weighted Pediatric Readiness Score (wPRS) from the 2013 National Pediatric Readiness Project assessment and categorized by quartile. Multivariable, hierarchical, mixed-effects logistic regression was used to evaluate the association of race and ethnicity with in-hospital mortality. Results: The cohort included 633â¯536 children (median [IQR] age 4 [0-12] years]). There were 557â¯537 children (98â¯504 Black [17.7%], 167â¯838 Hispanic [30.1%], 311â¯157 White [55.8%], and 147â¯876 children of other races or ethnicities [26.5%]) who were hospitalized for acute medical emergencies, of whom 5158 (0.9%) died; 75â¯999 children (12â¯727 Black [16.7%], 21â¯604 Hispanic [28.4%], 44â¯203 White [58.2%]; and 21â¯609 of other races and ethnicities [27.7%]) were hospitalized for traumatic injuries, of whom 1339 (1.8%) died. Adjusted mortality of Black children with acute medical emergencies was significantly greater than that of Hispanic children, White children, and of children of other races and ethnicities (odds ratio [OR], 1.69; 95% CI, 1.59-1.79) across all quartile levels of ED pediatric readiness; but there were no racial or ethnic disparities in mortality when comparing Black children with traumatic injuries with Hispanic children, White children, and children of other races and ethnicities with traumatic injuries (OR 1.01; 95% CI, 0.89-1.15). When compared with hospitals in the lowest quartile of ED pediatric readiness, children who were treated at hospitals in the highest quartile had significantly lower mortality in both the acute medical emergency cohort (OR 0.24; 95% CI, 0.16-0.36) and traumatic injury cohort (OR, 0.39; 95% CI, 0.25-0.61). The greatest survival advantage associated with high pediatric readiness was experienced for Black children in the acute medical emergency cohort. Conclusions and Relevance: In this study, racial and ethnic disparities in mortality existed among children treated for acute medical emergencies but not traumatic injuries. Increased ED pediatric readiness was associated with reduced disparities; it was estimated that increasing the ED pediatric readiness levels of hospitals in the 3 lowest quartiles would result in an estimated 3-fold reduction in disparity for pediatric mortality. However, increased pediatric readiness did not eliminate disparities, indicating that organizations and initiatives dedicated to increasing ED pediatric readiness should consider formal integration of health equity into efforts to improve pediatric emergency care.
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Mortalidade da Criança , Serviço Hospitalar de Emergência , Etnicidade , Mortalidade Hospitalar , Criança , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Estudos de Coortes , Emergências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hispânico ou Latino , Negro ou Afro-Americano , Grupos RaciaisRESUMO
Objective: Although 911 calls for acute shortness of breath are common, the role of emergency medical services (EMS) in acute asthma care is unclear. We sought to characterize the demographics, course, and outcomes of adult emergency department (ED) patients with asthma in the United States receiving initial EMS care. Methods: We analyzed data from the 2016-2019 National Hospital Ambulatory Medical Care Survey (NHAMCS). We included patients aged ≥18 years with an ED visit diagnosis of asthma, stratifying the cases according to initial EMS care. Accounting for the survey design of NHAMCS, we generated nationalized estimates of the number of EMS and non-EMS asthma visits. Using logistic regression, we determined the associations between initial EMS care and patient demographics (age, sex, race, and insurance type), ED course (initial vital signs, triage category, testing, medications), and outcomes (hospital admission, ED length of stay). Results: Of 435 million adult ED visits during 2016-2019, there were ≈5.3 million related to asthma (1.3 million annually, 1.2%; 95% confidence interval [CI], 1.1%-1.4%). A total of 602,569 (150,642 annually, 11.3%; 95% CI, 8.6%-14.8%) ED patients with asthma received initial EMS care. Compared with non-EMS asthma patients, EMS asthma patients were more likely to present with an "urgent" ED triage category (odds ratio [OR], 22.2; 95% CI, 6.6-74.9) and to undergo laboratory (OR, 2.78; 95% CI, 1.41-5.46) or imaging tests (OR, 2.42; 95% CI, 1.21-4.83). ED patients with asthma receiving initial EMS care were almost 3 times more likely to be admitted to the hospital (OR, 2.81; 95% CI, 1.27-6.25). There were no differences in demographics, ED use of ß-agonists or corticosteroids, or ED length of stay between EMS and non-EMS asthma patients. Conclusions: Approximately 1 in 10 adult ED patients with asthma receive initial care by EMS. EMS asthma patients present to the ED with higher acuity, undergo more diagnostic testing in the ED, and are more likely to be admitted. Although limited in information regarding the prehospital course, these findings highlight the more severe illness of asthma patients transported by EMS and underscore the importance of EMS in emergency asthma care.
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Hemodinâmica , Pigmentação da Pele , Humanos , Dedos/irrigação sanguínea , Perfusão , Capilares , PeleRESUMO
Importance: Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective: To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants: This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures: Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures: In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results: This study included 212â¯689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136â¯538 (64.2%) were male, and 127â¯885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105â¯871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36â¯330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance: These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.
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Serviço Hospitalar de Emergência , Centros de Traumatologia , Adulto , Criança , Humanos , Masculino , Feminino , Estudos Retrospectivos , Mortalidade Hospitalar , Análise de SistemasRESUMO
Aim: To identify specific activities associated with high cognitive load during simulated pediatric out-of-hospital cardiac arrest (POHCA) resuscitation using physiological monitoring with functional near-infrared spectroscopy (fNIRS). Methods: We recruited teams of emergency medical services (EMS) responders from fire departments located throughout the Portland, OR metropolitan area to participate in POHCA simulations. Teams consisted of both paramedics and emergency medical technicians (EMTs), with one paramedic serving as the person in charge (PIC). The PIC was outfitted with the OctaMon to collect fNIRS signals from the prefrontal cortex. Signals reported changes in oxygenated and deoxygenated hemoglobin concentrations, which were used to determine moments of increased cognitive activity. Increased cognitive activity was determined by significant increases in oxygenated hemoglobin and decreases in deoxygenated hemoglobin. Significant changes in fNIRS signals were associated with specific concurrent clinical tasks recorded by two independent researchers using video review. Results: We recorded cognitive activity of EMS providers in 18 POHCA simulations. We found that a proportion of PIC's experienced relatively high cognitive load during medication administration, defibrillation, and rhythm checks compared to other events. Conclusion: EMS providers commonly experienced increased cognitive activity during key resuscitation tasks that were related to safely coordinating team members around calculating and administering medications, defibrillation, and rhythm and pulse checks. Understanding more about activities that require high cognitive demand can inform future interventions that reduce cognitive load.
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BACKGROUND: This methodological intersection article demonstrates a method to measure cognitive load in clinical simulations. Researchers have hypothesized that high levels of cognitive load reduce performance and increase errors. This phenomenon has been studied primarily by experimental designs that measure responses to predetermined stimuli and self-reports that reduce the experience to a summative value. Our goal was to develop a method to identify clinical activities with high cognitive burden using physiologic measures. METHODS: Teams of emergency medical responders were recruited from local fire departments to participate in a scenario with a shockable pediatric out-of-hospital cardiac arrest (POHCA) patient. The scenario was standardized with the patient being resuscitated after receiving high-quality CPR and 3 defibrillations. Each team had a person in charge (PIC) who wore a functional near-infrared spectroscopy (fNIRS) device that recorded changes in oxygenated and deoxygenated hemoglobin concentration in their prefrontal cortex (PFC), which was interpreted as cognitive activity. We developed a data processing pipeline to remove nonneural noise (e.g., motion artifacts, heart rate, respiration, and blood pressure) and detect statistically significant changes in cognitive activity. Two researchers independently watched videos and coded clinical tasks corresponding to detected events. Disagreements were resolved through consensus, and results were validated by clinicians. RESULTS: We conducted 18 simulations with 122 participants. Participants arrived in teams of 4 to 7 members, including one PIC. We recorded the PIC's fNIRS signals and identified 173 events associated with increased cognitive activity. [Defibrillation] (N = 34); [medication] dosing (N = 33); and [rhythm checks] (N = 28) coincided most frequently with detected elevations in cognitive activity. [Defibrillations] had affinity with the right PFC, while [medication] dosing and [rhythm checks] had affinity with the left PFC. CONCLUSIONS: FNIRS is a promising tool for physiologically measuring cognitive load. We describe a novel approach to scan the signal for statistically significant events with no a priori assumptions of when they occur. The events corresponded to key resuscitation tasks and appeared to be specific to the type of task based on activated regions in the PFC. Identifying and understanding the clinical tasks that require high cognitive load can suggest targets for interventions to decrease cognitive load and errors in care.