Assessment of different pedestrian communication strategies for improving driver behavior at marked crosswalks on free channelized right turns.

INTRODUCTION: Previous studies have indicated low driver yielding rates to pedestrians in various countries. This study analyzed four different strategies to improve driver yielding rates at marked crosswalks on channelized right turn lanes at signalized intersections. METHOD: A sample of 5,419 drivers was collected for four gestures using field experiments for males and females in the State of Qatar. The experiments were conducted in daytime and nighttime on weekends at three different locations; two sites are located in an urban area and the third is located in non-urban area. The effect of pedestrians' and drivers' demographic characteristics, gestures, approach speed, time of the day, location of the intersection, car type, and driver distractions on yielding behavior is investigated using logistic regression analysis. RESULTS: It was found that for the base gesture, only 2.00% of drivers yielded to the pedestrians, while for hand, attempt, and vest-attempt gestures the yielding percentages were considerably higher, 12.81%, 19.59%, and 24.60%, respectively. The results also showed that females received significantly higher yielding rates compared to males. In addition, the probability of a driver yielding increased 2.8 times when drivers approached at slower speed compared to a higher speed. Further, drivers' age group, accompanied, and distractions were not significant in determining drivers' probability of yielding.

Clinical and biochemical spectrum of metabolic cardiomyopathy in Egyptian children.

Background: Inborn errors of metabolism (IEMs) commonly present with pediatric cardiomyopathy. Identification of the underlying cause is necessary as it may lead to improved outcomes. Objectives: We aimed to investigate the diagnostic rate, the clinical, and biochemical spectra of IEMs among Egyptian pediatric patients presenting with cardiomyopathy, and their outcome measures. Methods: We retrospectively analyzed the clinical, biochemical, and radiological data of 1512 children diagnosed with cardiomyopathy at Cairo University Children's Hospital over a 5-year duration. Results: Two hundred twenty-nine children were clinically suspected as IEMs and underwent metabolic workup. Nineteen different IEMs were confirmed in 57 (24.4%) of the suspected children. Their median age at presentation was 2.6 years and the majority had extra-cardiac manifestations. Hypertrophic cardiomyopathy represented 43/57 (75.4%) of confirmed cases, while dilated cardiomyopathy represented 13/57 (22.8%), and one patient presented with a mixed phenotype. Twenty- six patients (45.6%) survived, while 31 patients (54%) either died or were lost to follow up and assumed deceased. Conclusions: We developed for the first time a database and a diagnostic scheme for metabolic cardiomyopathies in Egyptian children. With the recent introduction of enzyme replacement therapy, many metabolic disorders became treatable, thus establishing an early and accurate diagnosis is extremely important.

Ultrasound-assisted catheter-directed thrombolysis versus anticoagulation alone for management of submassive pulmonary embolism.

BACKGROUND: Patients with submassive pulmonary embolism (PE) are vulnerable to sudden deterioration, recurrent PE, and progression to pulmonary hypertension and chronic right ventricular (RV) dysfunction. Previous studies have suggested a clinical benefit of using ultrasound-assisted catheter-directed thrombolysis (USCDT) to invasively manage patients with submassive PE. However, there is sparse data comparing the clinical outcomes of these patients when treated with USCDT versus anticoagulation (AC) alone. We sought to compare the outcomes of USCDT versus AC alone in the management of submassive PE. METHODS: 192 consecutive patients who underwent USCDT for submassive PE between January 2013 and February 2019 were identified. ICD9/ICD10 codes were used to detect 2554 patients diagnosed with PE who did not undergo thrombolysis. Propensity matching identified 192 patients with acute PE treated with AC alone. Clinical outcomes were compared between the two groups. Baseline demographics, laboratory values, and pulmonary embolism severity index scores were similar between the two cohorts. RESULTS: There was a significant reduction in mean systolic pulmonary artery pressure (sPAP) in the USCDT group compared to the AC group (∆11 vs ∆3.9 mmHg, p < 0.001). There was significant improvement in proportion of RV dysfunction in all patients, but the difference was larger in the USCDT group (∆43.3% vs ∆17.3%, p < 0.001). Patients who underwent USCDT had lower 30-day (4.3% vs 10.5%, p = 0.03), 90-day (5.5% vs 12.4%, p = 0.03), and 1-year mortality (6.2% vs 14.2%, p = 0.03). CONCLUSIONS: In patients with acute submassive PE, USCDT was associated with improved 30-day, 90-day, and 1 year mortality as compared to AC alone. USCDT also improved RV function and reduced sPAP to a greater degree than AC alone. Further studies are needed to verify these results in both short- and long-term outcomes.

Serious illness conversations in pulmonary hypertension.

Pulmonary arterial hypertension has evolved from a fatal disease with few treatment options to a chronic condition with improved survival. This improvement is possible through development of effective therapies as well as the expansion of risk stratification scores to assist clinical decision making. Despite improved disease control, quality of life, and overall prognosis, many challenges remain. The treatment itself is burdensome, with significant impact on quality of life. Many patients with pulmonary arterial hypertension still present with advanced, often end-stage disease. Increased use of mechanical circulatory support and catheter-based interventions have expanded use of extracorporeal life support and right ventricle assist devices. For these reasons as well as the long-term relationships pulmonary hypertension physicians have with patients and their families, navigating the course of the illness in a considered, proactive way is essential. Understanding individual goals and revisiting them as they change over time requires comfort with the conversation itself. There are many barriers and challenges to having effective, compassionate conversations in the clinical setting with time constraints being the most often cited. Compressed visits are necessarily focused on the clinical aspects, therapy and medication adherence and tolerance. Clinicians are sometimes wary of diminishing hope in the face of ongoing treatment. Having sufficient experience and comfort with these discussions can be empowering. In this paper, we discuss the challenges involved and propose a framework to assist in incorporating these discussions into clinical care.

Improving transitions of care for critically ill adult patients on pulmonary arterial hypertension medications.

PURPOSE: The purpose of this report is to describe the activities of critical care and ambulatory care pharmacists in a multidisciplinary transitions-of-care (TOC) service for critically ill patients with pulmonary arterial hypertension (PAH) receiving PAH medications. SUMMARY: Initiation of medications for treatment of PAH involves complex medication access steps. In the ambulatory care setting, multidisciplinary teams often have a process for completing these steps to ensure access to PAH medications. Patients with PAH are frequently admitted to an intensive care unit (ICU), and their home PAH medications are continued and/or new medications are initiated in the ICU setting. Inpatient multidisciplinary teams are often unfamiliar with the medication access steps unique to PAH medications. The coordination and completion of medication access steps in the inpatient setting is critical to ensure access to medications at discharge and prevent delays in care. A PAH-specific TOC bundle for patients prescribed a PAH medication who are admitted to the ICU was developed by a multidisciplinary team at an academic teaching hospital. The service involves a critical care pharmacist completing a PAH medication history, assessing for PAH medication access barriers, and referring patients to an ambulatory care pharmacist for postdischarge telephone follow-up. In collaboration with the PAH multidisciplinary team, a standardized workflow to be initiated by the critical care pharmacist was developed to streamline completion of PAH medication access steps. Within 3 days of hospital discharge, the ambulatory care pharmacist calls referred patients to ensure access to PAH medications, provide disease state and medication education, and request that the patient schedule a follow-up office visit to take place within 14 days of discharge. CONCLUSION: Collaboration by a PAH multidisciplinary team, critical care pharmacist, and ambulatory care pharmacist can improve TOC related to PAH medication access for patients with PAH. The PAH TOC bundle serves as a model that may be transferable to other health centers.

Effects of dissolved organic phase composition and salinity on the engineered sulfate application in a flow-through system.

Engineered sulfate application has been proposed as an effective remedy to enhance the rate-limited biodegradation of petroleum-hydrocarbon-contaminated subsurface environments, but the effects of dissolved organic phase composition and salinity on the efficiency of this method are unknown. A series of flow-through experiments were conducted for 150 days and dissolved benzene, toluene, naphthalene, and 1-methylnaphthalene were injected under sulfate-reducing and three different salinity conditions for 80 pore volumes. Then, polycyclic aromatic hydrocarbons (PAHs) were omitted from the influent solution and just dissolved benzene and toluene were injected to investigate the influence of dissolved phase composition on treatment efficiency. A stronger sorption capacity for PAHs was observed and the retardation of the injected organic compounds followed the order of benzene < toluene < naphthalene < 1-methylnaphthalene. Mass balance analyses indicated that 50 and 15% of toluene and 1-methlynaphtalene were degraded, respectively. Around 5% of the injected naphthalene degraded after injecting > 60 PVs influent solution, and benzene slightly degraded following the removal of PAH compounds. The results showed substrate interactions and composition can result in rate-limited and insufficient biodegradation. Similar reducing conditions and organic utilization were observed for different salinity conditions in the presence of the multi-component dissolved organic phase. This was attributed to the dominant microbial community involved in toluene degradation that exerted catabolic repression on the simultaneous utilization of other organic compounds and were not susceptible to changes in salinity.

Uso de ecocardiografia junto ao leito para medir índices cardíaco e de resistência vascular sistêmica em pacientes pediátricos com choque séptico / The use of bedside echocardiography for measuring cardiac index and systemic vascular resistance in pediatric patients with septic shock

RESUMO Objetivo: Acompanhar o índice cardíaco e o índice de resistência vascular sistêmica até a ressuscitação. Métodos: Por meio de ecocardiografia junto ao leito, obteve-se um conjunto de parâmetros hemodinâmicos, inclusive débito cardíaco, volume sistólico, índice cardíaco, índice de resistência vascular sistêmica, integral velocidade-tempo, índice de desempenho miocárdico, tempo de reenchimento capilar e frequência cardíaca no momento zero após infusão de fluidos em bolo, e início e utilização de fármacos inotrópicos, com seguimento até 6 horas e 24 horas. Resultados: Incluíram-se 45 pacientes com choque séptico adquirido na comunidade. Os focos de infecção foram gastrenterite (24%), perfuração intestinal com necessidade de cirurgia emergencial (24%), pneumonia (20%), infecção do sistema nervoso central (22%) e infecção de tecidos moles (8%). Os isolados mais frequentes foram de Klebsiella e Enterobacter. Estimamos os fatores que afetaram o índice cardíaco: pressão venosa central elevada no momento zero (r = 0,33; p = 0,024) e persistência de frequência cardíaca elevada após 6 horas (r = 0,33; p = 0,03). O índice de resistência vascular sistêmica foi alto na maioria dos pacientes no momento zero e após 24 horas, e por ocasião da ressuscitação, afetando inversamente o índice cardíaco, assim como a integral velocidade-tempo (r = -0,416; -0,61; 0,55 e -0,295). O tempo de reenchimento capilar aumentado foi preditor clínico de valores baixos de integral velocidade-tempo após 24 horas (r = -0,4). O índice de mortalidade foi de 27%. Nos pacientes que não sobreviveram, observaram-se índices de resistência vascular sistêmica mais baixos e débitos cardíacos mais altos. Conclusão: O índice de resistência vascular sistêmica esteve persistentemente elevado em pacientes com choque frio, o que influenciou no índice de volume sistólico, no índice cardíaco e na integral velocidade-tempo. O uso de ecocardiografia para obtenção de mensurações hemodinâmicas é importante em pacientes pediátricos com choque séptico, para que se possam ajustar as doses de vasodilatadores e vasopressores, e obter os objetivos da ressuscitação em tempo apropriado.

ABSTRACT Objective: Follow-up of cardiac index and systemic vascular resistance index by bedside echocardiography until resuscitation. Methods: A set of hemodynamic parameters was obtained, including cardiac output, stroke volume, cardiac index, systemic vascular resistance index, velocity time integral, myocardial performance index, capillary refill time, and heart rate at 0 hours after fluid boluses before the start of inotropes, and followed up after 6 hours and 24 hours. Results: Included were 45 patients with community-acquired septic shock. Septic foci were gastroenteritis (24%), intestinal perforation requiring emergency surgery (24%), pneumonia (20%), central nervous system infection (22%) and soft tissue infection (8%). Klebsiella and Enterobacter were the most frequent isolates. We estimated the factors affecting the cardiac index: high central venous pressure at zero time (r = 0.33, p = 0.024) and persistently high heart rate at hour 6 (r = 0.33, p = 0.03). The systemic vascular resistance index was high in most patients at 0 and 24 hours and at the time of resuscitation and inversely affected the cardiac index as well as affecting the velocity time integral (r = -0.416, -0.61, 0.55 and -0.295). Prolonged capillary refill time was a clinical predictor of the low velocity time integral at 24 hours (r = -0.4). The mortality was 27%. Lower systemic vascular resistance index and higher cardiac output were observed in nonsurviving patients. Conclusion: There was a persistently high systemic vascular resistance index in cold shock patients that influenced the stroke volume index, cardiac index, and velocity time integral. The use of echocardiograms for hemodynamic measurements is important in pediatric septic shock patients to adjust dilators, and vasopressor doses and achieve resuscitation targets in a timely manner.

The use of bedside echocardiography for measuring cardiac index and systemic vascular resistance in pediatric patients with septic shock. / Uso de ecocardiografia junto ao leito para medir índices cardíaco e de resistência vascular sistêmica em pacientes pediátricos com choque séptico.

OBJECTIVE: Follow-up of cardiac index and systemic vascular resistance index by bedside echocardiography until resuscitation. METHODS: A set of hemodynamic parameters was obtained, including cardiac output, stroke volume, cardiac index, systemic vascular resistance index, velocity time integral, myocardial performance index, capillary refill time, and heart rate at 0 hours after fluid boluses before the start of inotropes, and followed up after 6 hours and 24 hours. RESULTS: Included were 45 patients with community-acquired septic shock. Septic foci were gastroenteritis (24%), intestinal perforation requiring emergency surgery (24%), pneumonia (20%), central nervous system infection (22%) and soft tissue infection (8%). Klebsiella and Enterobacter were the most frequent isolates. We estimated the factors affecting the cardiac index: high central venous pressure at zero time (r = 0.33, p = 0.024) and persistently high heart rate at hour 6 (r = 0.33, p = 0.03). The systemic vascular resistance index was high in most patients at 0 and 24 hours and at the time of resuscitation and inversely affected the cardiac index as well as affecting the velocity time integral (r = -0.416, -0.61, 0.55 and -0.295). Prolonged capillary refill time was a clinical predictor of the low velocity time integral at 24 hours (r = -0.4). The mortality was 27%. Lower systemic vascular resistance index and higher cardiac output were observed in nonsurviving patients. CONCLUSION: There was a persistently high systemic vascular resistance index in cold shock patients that influenced the stroke volume index, cardiac index, and velocity time integral. The use of echocardiograms for hemodynamic measurements is important in pediatric septic shock patients to adjust dilators, and vasopressor doses and achieve resuscitation targets in a timely manner.

OBJETIVO: Acompanhar o índice cardíaco e o índice de resistência vascular sistêmica até a ressuscitação. MÉTODOS: Por meio de ecocardiografia junto ao leito, obteve-se um conjunto de parâmetros hemodinâmicos, inclusive débito cardíaco, volume sistólico, índice cardíaco, índice de resistência vascular sistêmica, integral velocidade-tempo, índice de desempenho miocárdico, tempo de reenchimento capilar e frequência cardíaca no momento zero após infusão de fluidos em bolo, e início e utilização de fármacos inotrópicos, com seguimento até 6 horas e 24 horas. RESULTADOS: Incluíram-se 45 pacientes com choque séptico adquirido na comunidade. Os focos de infecção foram gastrenterite (24%), perfuração intestinal com necessidade de cirurgia emergencial (24%), pneumonia (20%), infecção do sistema nervoso central (22%) e infecção de tecidos moles (8%). Os isolados mais frequentes foram de Klebsiella e Enterobacter. Estimamos os fatores que afetaram o índice cardíaco: pressão venosa central elevada no momento zero (r = 0,33; p = 0,024) e persistência de frequência cardíaca elevada após 6 horas (r = 0,33; p = 0,03). O índice de resistência vascular sistêmica foi alto na maioria dos pacientes no momento zero e após 24 horas, e por ocasião da ressuscitação, afetando inversamente o índice cardíaco, assim como a integral velocidade-tempo (r = -0,416; -0,61; 0,55 e -0,295). O tempo de reenchimento capilar aumentado foi preditor clínico de valores baixos de integral velocidade-tempo após 24 horas (r = -0,4). O índice de mortalidade foi de 27%. Nos pacientes que não sobreviveram, observaram-se índices de resistência vascular sistêmica mais baixos e débitos cardíacos mais altos. CONCLUSÃO: O índice de resistência vascular sistêmica esteve persistentemente elevado em pacientes com choque frio, o que influenciou no índice de volume sistólico, no índice cardíaco e na integral velocidade-tempo. O uso de ecocardiografia para obtenção de mensurações hemodinâmicas é importante em pacientes pediátricos com choque séptico, para que se possam ajustar as doses de vasodilatadores e vasopressores, e obter os objetivos da ressuscitação em tempo apropriado.

Assessment of Left Ventricular Volume and Function Using Real-Time 3D Echocardiography versus Angiocardiography in Children with Tetralogy of Fallot.

BACKGROUND: Evaluation of left ventricular (LV) size and function is one of the important reasons for performing echocardiography. Real time three dimensional echocardiography (RT3DE) is now available for a precise non-invasive ventricular volumetry. Aim of work was to validate RT3DE as a non-invasive cardiac imaging method for measurement of LV volumes using cardiac angiography as the reference technique. METHODS: Prospective study on 40 consecutive patients with tetralogy of Fallot (TOF) referred for cardiac catheterization for preoperative assessment. Biplane cineangiography, conventional 2 dimensional echocardiography (2DE) and RT3DE were performed for the patients. A control group of 18 age and sex matched children was included and 2DE and RT3DE were performed for them. RESULTS: The mean LV end diastolic volume (LVEDV) and LVEDV index (LVEDVI) measured by RT3DE of patients were lower than controls (p value = 0.004, 0.01, respectively). There was strong correlation between the mean value of the LVEDV and the LVEDVI measured by RT3DE and angiography (r = 0.97, p < 0.001). The mean value of LV ejection fraction measured by RT3DE was lower than that assessed by 2DE (50 ± 6.2%, 65 ± 4.6%, respectively, p value < 0.001) in the studied TOF cases. There was good intra- and inter-observer reliability for all measurements. CONCLUSION: RT3DE is a noninvasive and feasible tool for measurement of LV volumes that strongly correlates with LV volumetry done by angiography in very young infants and children, and further studies needed.

Risk factors of prolonged hospital stay in children with viral severe acute respiratory infections.

INTRODUCTION: Severe acute lower respiratory infections (SARIs) are one of the major causes of morbidity and mortality in young children, especially in developing countries. The present study focused on detection of risk factors for prolonged hospital stays among children with viral SARIs. METHODOLOGY: A sentinel surveillance study was conducted at Cairo University Hospital (CUH) between February 2010 and May 2011. Nasopharyngeal (NP) and oropharyngeal (OP) swabs were collected from all children admitted with SARIs. Viruses were identified using reverse transcription polymerase chain reaction (RT-PCR). RESULTS: Out of 1,046 children, 380 (36%) were positive for one or more viruses; these included respiratory syncytial virus (RSV) (22.9%), adenovirus (6.2%), parainfluenza viruses (PIVs1-3) (5.1%), human metapneumovirus (HMPV) (4.5%), influenza A (1.4%), and influenza B (0.6%). Viral etiology was mainly detected in children under one year of age (88.9%). Prolonged length of stay was independently associated with the presence of cyanosis and underlying chronic illness (OR 7.4, CI: 1.8-30.32 [p = 0.005], OR 2.5, CI: 1.36-4.64 [p = 0.004], respectively). Virus type did not affect the length of hospital stay (p > 0.05). Oxygen therapy was required in 91% of the patients. A total of 43 patients (11.6%) required intensive care admission. Twenty-one patients (5.5%) died, and 15 of them (71.4%) had an underlying chronic illness. CONCLUSIONS: The study demonstrated the important burden of respiratory viruses as a cause of SARI in hospitalized children in a tertiary Egyptian hospital. Cyanosis and underlying chronic illness were significantly associated with prolonged length of stay.

Morbidity and outcome of severe respiratory syncytial virus infection.

BACKGROUND: Respiratory syncytial virus (RSV) is the main cause of severe acute respiratory infection (SARI) in infants and young children. This study aimed to identify risk factors for intensive care unit (ICU) admission, prolonged length of stay (PLOS), and mortality in patients hospitalized with SARI caused by RSV. METHODS: This prospective cohort study included children hospitalized with SARI (according to the World Health Organization definition) and whose laboratory results proved RSV infection during the period from February 2010 to May 2011. RESULTS: Out of 240 enrolled patients, 24 patients (10%) were admitted to the ICU, 57 patients (24.3%) had a PLOS of >9 days and 12 patients (5%) died. The presence of cyanosis (P = 0.000; OR, 351.7) and lung consolidation (P = 0.006, OR, 9.3) were independent risk factors associated with ICU admission. The need for ICU admission (P = 0.000; OR, 6.1) and lung consolidation (P = 0.008, OR, 2.46) were independent risk factors associated with PLOS. The presence of an underlying congenital heart disease (P = 0.03, OR, 18.3), thrombocytopenia (P = 0.04, OR, 32.86) and mechanical ventilation (P = 0.000; OR, 449.4) were the only independent risk factors associated with mortality in our study. CONCLUSIONS: Early recognition of risk factors for complicated RSV disease on admission prompts early interventions and early ICU admissions for these children.