Prehospital Fluid Administration for Suspected Sepsis in a Large EMS System: Opportunities to Improve Goal Fluid Delivery.

OBJECTIVES: Despite EMS-implemented screening and treatment protocols for suspected sepsis patients, prehospital fluid therapy is variable. We sought to describe prehospital fluid administration in suspected sepsis patients, including demographic and clinical factors associated with fluid outcomes. METHODS: A retrospective cohort of adult patients from a large, county-wide EMS system from January 2018-February 2020 was identified. Patient care reports for suspected sepsis were included, as identified by EMS clinician impression of sepsis, or keywords "sepsis" or "septic" in the narrative. Outcomes were the proportions of suspected sepsis patients for whom intravenous (IV) therapy was attempted and those who received ≥500 mL IV fluid if IV access was successful. Associations between patient demographics and clinical factors with fluid outcomes were estimated with multivariable logistic regression adjusting for transport interval. RESULTS: Of 4,082 suspected sepsis patients identified, the mean patient age was 72.5 (SD 16.2) years, 50.6% were female, and 23.8% were Black. Median (interquartile range [IQR]) transport interval was 16.5 (10.9-23.2) minutes. Of identified patients, 1,920 (47.0%) had IV fluid therapy attempted, and IV access was successful in 1,872 (45.9%). Of those with IV access, 1,061 (56.7%) received ≥500mL of fluid from EMS. In adjusted analyses, female (versus male) sex (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.69-0.90), Black (versus White) race (OR 0.57, 95% CI 0.49-0.68), and end stage renal disease (OR 0.51, 95% CI 0.32-0.82) were negatively associated with attempted IV therapy. Systolic blood pressure (SBP) <90 mmHg (OR 3.89, 95% CI 3.25-4.65) and respiratory rate >20 (OR 1.90, 95% CI 1.61-2.23) were positively associated with attempted IV therapy. Female sex (OR 0.72, 95% CI 0.59-0.88) and congestive heart failure (CHF) (OR 0.55, 95% CI 0.40-0.75) were negatively associated with receiving goal fluid volume while SBP <90 mmHg (OR 2.30, 95% CI 1.83-2.88) and abnormal temperature (>100.4 F or <96 F) (OR 1.41, 95% CI 1.16-1.73) were positively associated. CONCLUSIONS: Fewer than half of EMS sepsis patients had IV therapy attempted, and of those, approximately half met fluid volume goal, especially when hypotensive and no CHF. Further studies are needed on improving EMS sepsis training and prehospital fluid delivery.

Effectiveness of a Novel Rapid Infusion Device and Clinician Education for Early Fluid Therapy by Emergency Medical Services in Sepsis Patients: A Pre-Post Observational Study.

OBJECTIVE: Emergency medical services (EMS) clinicians are tasked with early fluid resuscitation for patients with sepsis. Traditional methods for prehospital fluid delivery are limited in speed and ease-of-use. We conducted a comparative effectiveness study of a novel rapid infusion device for prehospital fluid delivery in suspected sepsis patients. METHODS: This pre-post observational study evaluated a hand-operated, rapid infusion device in a single large EMS system from July 2021-July 2022. Prior to device deployment, EMS clinicians completed didactic and simulation-based device training. Data were extracted from the EMS electronic health record. Eligible patients included adults with suspected sepsis treated by EMS with intravenous fluids. The primary outcome was the proportion of patients receiving goal fluid volume (at least 500 mL) prior to hospital arrival. Secondary outcomes included in-hospital mortality, disposition, and length of stay. Multivariable logistic regression was used to compare outcomes between 6-month pre- and post-implementation periods (July-December 2021 and February-July 2022, respectively), adjusting for patient demographics, abnormal prehospital vital signs, and EMS transport interval. RESULTS: Of 1,180 eligible patients (552 in the pre-implementation period; 628 in the post-implementation period), the mean age was 72 years old, 45% were female, and 25% were minority race-ethnicity. Median (interquartile range) fluid volume (in mL) increased between the pre- and post-implementation periods (600 [400,1,000] and 850 [500-1,000], respectively). Goal fluid volume was achieved in 70% of pre-implementation patients and 82% of post-implementation patients. In adjusted analysis, post-implementation patients were significantly more likely to receive goal fluid volume than pre-implementation patients (adjusted odds ratio (aOR) 2.00, 95% confidence interval (CI) 1.51-2.66). Pre-post in-hospital mortality was not significantly different (aOR 0.91, 95% CI 0.59-1.39). CONCLUSION: In a single EMS system, sepsis education and introduction of a rapid infusion device was associated with achieving goal fluid volume for suspected sepsis. Further research is needed to assess the clinical effectiveness of infusion device implementation to improve sepsis patient outcomes.

Individual differences in apology acceptance and forgiveness: the influence of handedness.

The purpose of the current study was to determine if the relationship between interhemispheric interaction and cognitive flexibility extends to explanations of forgiveness and apology acceptance. A growing body of research indicates that consistency of handedness may be reflective of an individual's degree of interhemispheric interaction and access to processes of the right hemisphere. As such, individual differences in processing that require interhemispheric interaction, such as belief updating, are associated with consistency of handedness. Participants completed the Edinburgh Handedness Inventory (EHI) and read descriptions of interpersonal transgressions, then rated their willingness to forgive before and after an apology was offered. There was a main effect such that the presence of apology increased forgiveness. However, inconsistent handedness was associated with greater forgiveness prior to apology compared to consistent handedness. A second study was conducted to determine if the individual differences in forgiveness were mediated by different dimensions of empathy (personal distress, perspective taking, empathic concern and fantasy). Participants completed the Interpersonal Reactivity Index, the Forgiveness Scale and the EHI. Results revealed those with inconsistent handedness who scored lower on personal distress reported decreased negative thoughts about transgressors compared to those with consistent handedness.

Dopaminergic polymorphisms associated with medication responsiveness of gait in Parkinson's disease.

BACKGROUND: Gait dysfunction is a common symptom of Parkinson's disease that can cause significant disability and put patients at risk for falls. These symptoms show variable responsiveness to dopaminergic therapy. OBJECTIVE: To determine whether dopaminergic (rs1076560 DRD2 G > T and rs4680 catechole-o-methyltranspherase (COMT) Val158Met) or brain derived neurotrophic factor (rs6265 BDNF Val66Met) genetic polymorphisms are associated with gait function and medication responsiveness in Parkinson's disease. METHOD: Gait function was evaluated on two days for patients (ON and OFF medication in a counterbalanced fashion) and a single session for controls. Investigators were blinded to genotype during data collection. Associations between genotype and medication responsiveness were analyzed using mixed model ANOVAs. A priori hypotheses were tested using GAITRite® electronic mat spatiotemporal gait parameters including step length, step width, velocity, portion of double and single support per gait cycle, and variability of these measures ON and OFF medication. RESULTS: We found that the DRD2 polymorphism, but neither COMT nor BDNF, was consistently associated with gait function and medication responsiveness in the patients. Specifically, Parkinson's disease patients with reduced striatal D2 expression (DRD2 T allele carriers) had worse gait dysfunction and showed greater dopamine responsiveness of gait function compared to patients who were homozygous for the G allele. There was no effect of any of the genetic polymorphisms on gait for controls. CONCLUSIONS AND RELEVANCE: The findings suggest that genetic subgrouping, in particular for DRD2, may be used to identify Parkinson's disease patient subgroups that are more dopamine responsive for gait function.

The time of our lives: life span development of timing and event tracking.

Life span developmental profiles were constructed for 305 participants (ages 4-95) for a battery of paced and unpaced perceptual-motor timing tasks that included synchronize-continue tapping at a wide range of target event rates. Two life span hypotheses, derived from an entrainment theory of timing and event tracking, were tested. A preferred period hypothesis predicted a monotonic slowing of a preferred rate (tempo) of event tracking across the life span. An entrainment region hypothesis predicted a quadratic profile in the range of event rates that produced effective timing across the life span; specifically, age-specific entrainment regions should be narrower in childhood and late adulthood than in midlife. Findings across tasks provide converging support for both hypotheses. Implications of these findings are discussed for understanding critical periods in development and age-related slowing of event timing.

The pattern of striatal dopaminergic denervation explains sensorimotor synchronization accuracy in Parkinson's disease.

The basal ganglia are thought to play a critical role in duration perception and production. However, experimental evidence for impaired temporal processing in Parkinson's disease (PD) patients is mixed. This study examined the association between striatal dopaminergic denervation in PD patients and sensorimotor synchronization. Twenty-eight mild-to-moderate stage PD patients synchronized finger taps to tone sequences of either 500 ms, 1000 ms or 1500 ms time intervals while ON levodopa (l-DOPA) or placebo pill (on separate test days) with the index finger of their more and less affected hands. We measured the accuracy and variability of synchronization. In a separate session, patients underwent (11)C-dihydrotetrabenazine ((11)C-DTBZ) PET scanning to measure in vivo striatal dopaminergic denervation. Patients were less accurate synchronizing to the 500 ms target time interval, compared to the 1000 ms and 1500 ms time intervals, but neither medication state nor hand affected accuracy; medication state, hand nor the target time interval affected synchronization variability. Regression analyses revealed no strong relationships between synchronization accuracy or variability and striatal dopaminergic denervation. We performed a cluster analysis on the degree of dopaminergic denervation to determine whether patient subgroup differences underlie our results. Three patient subgroups showed behavioral differences in synchronization accuracy, but not variability, paralleling their pattern of denervation. These findings provide further evidence for the role of the basal ganglia and dopamine in duration production and suggest that the degree of striatal dopaminergic denervation may explain the heterogeneity of performance between PD patients on the sensorimotor synchronization task.

Picking up the pace: effects of global temporal context on sensitivity to the tempo of auditory sequences.

This article continues a line of research examining factors affecting listeners' auditory tempo sensitivities. Of particular interest is the question of whether listeners are sensitive to the overall (global) pace of their auditory environment and how this sensitivity may affect their perceptions of sequence timing. To address this question, we manipulated the set of sequence tempi (between 300 and 700 msec) that listeners experienced over the course of a 1-h period (i.e., the global temporal context) while they performed a tempo-discrimination task involving standard-comparison pairs of isochronous tone sequences. Overall findings show systematic distortions in perceived tempo that are consistent with the view that listeners adapt to the global pace of their auditory environments. Moreover, general support was found for the hypothesis that increasing the number of equal intervals in a standard sequence produces greater improvements in tempo sensitivity when the standard sequence tempo is different from the global pace than when it is at the global pace. Implications of these findings for models of timing and temporal processing are discussed.

Tempo sensitivity in isochronous tone sequences: the multiple-look model revisited.

Factors affecting tempo sensitivity in isochronous tone sequences were investigated in two experiments. Participants listened to tones in sequence conditions in which the number of time intervals in isochronous standard and comparison sequences was varied, and they were asked to judge the tempo of the comparison relative to the standard. When the duration of the standard interval was held constant, tempo sensitivity was affected by the number of comparison intervals, but not by the number of standard intervals. In contrast, when the duration of the standard interval was varied randomly from trial to trial, tempo sensitivity was affected by the number of intervals in both sequences. The present findings are discussed in the context of a generalized multiple-look model that posits independent contributions of both sequences to tempo sensitivity. Quantitative model fits suggest that the relative contribution of the number of the standard intervals to tempo thresholds depends on (1) the availability of a stable long-term referent for the standard tempo and (2) a priori knowledge about the number of standard intervals.