Suspect severe gastroenteritis associated with ingestion of caterpillar setae fragments in a cat.

A 6-month-old male neutered Domestic Shorthair cat was assessed for a 24-h history of anorexia, lethargy, depressed mentation, mild abdominal pain and persistent bradycardia. Abdominal ultrasound revealed marked thickening of the gastric wall, gastric distension, free abdominal fluid, distension and corrugation of the small intestine. Full-thickness histopathological biopsy of the gastric wall demonstrated intralesional chitinous structures whose morphology (size and presence of obvious barbs) supports these structures being urticating hairs (setae). A processionary caterpillar is considered most likely as these are the most common urticating caterpillars in Australia. This is the first case of suspected severe gastroenteritis associated with the ingestion of caterpillar setae fragments in a cat.

Decision Regret among Patients with Early-stage Lung Cancer Undergoing Radiation Therapy or Surgical Resection.

AIMS: Clinical equipoise exists regarding early-stage lung cancer treatment among patients as trials comparing stereotactic body radiation therapy (SBRT) and surgical resection are unavailable. Given the potential differences in treatment effectiveness and side-effects, we sought to determine the associations between treatment type, decision regret and depression. MATERIALS AND METHODS: A multicentre, prospective study of patients with stage IA-IIA non-small cell lung cancer (NSCLC) with planned treatment with SBRT or surgical resection was conducted. Decision regret and depression were measured using the Decision Regret Scale (DRS) and Patient Health Questionnaire-4 (PHQ-4) at 3, 6 and 12 months post-treatment, respectively. Mixed linear regression modelling examined associations between treatment and decision regret adjusting for patient sociodemographics. RESULTS: Among 211 study participants with early-stage lung cancer, 128 (61%) patients received SBRT and 83 (39%) received surgical resection. The mean age was 73 years (standard deviation = 8); 57% were female; 79% were White non-Hispanic. In the entire cohort at 3 months post-treatment, 72 (34%) and 57 (27%) patients had mild and severe decision regret, respectively. Among patients who received SBRT or surgery, 71% and 46% of patients experienced at least mild decision regret at 3 months, respectively. DRS scores increased at 6 months and decreased slightly at 12 months of follow-up in both groups. Higher DRS scores were associated with SBRT treatment (adjusted mean difference = 4.18, 95% confidence interval 0.82 to 7.54) and depression (adjusted mean difference = 3.49, 95% confidence interval 0.52 to 6.47). Neither patient satisfaction with their provider nor decision-making role concordance was associated with DRS scores. CONCLUSIONS: Most early-stage lung cancer patients experienced at least mild decision regret, which was associated with SBRT treatment and depression symptoms. Findings suggest patients with early-stage lung cancer may not be receiving optimal treatment decision-making support. Therefore, opportunities for improved patient-clinician communication probably exist.

The 2019-2020 volcanic eruption of Late'iki (Metis Shoal), Tonga.

Late'iki (previously known as Metis Shoal) is a highly active volcano in the Tofua arc with at least four temporary island-building eruptions and one submarine eruption in the last 55 years. The most recent eruption, commencing in October 2019, resulted in lava effusion and subsequent phreatic explosions, the construction of a short-lived island that was quickly eroded by wave action and possibly further phreatic activity that continued into January 2020. The two-pyroxene dacite from the 2019 eruption is similar to the 1967/8 eruptions suggesting the magma is residual from earlier eruptions and has not undergone further differentiation in the last 50 years. New observations of the 2019 eruption site confirm the lava-dominant character of the volcano summit but a thin veneer of wave-reworked, finely fragmented lava material remains that is interpreted to have been produced by phreatic explosions from hot rock-water interactions during the effusive eruption. A notable absence of quench-fragmented hyaloclastite breccias suggests that non-explosive quench fragmentation processes were minimal at these shallow depths or that hyaloclastite debris has resedimented to greater depths beyond our summit survey area.

Electrostatic frequency reduction: A negative stiffness mechanism for measuring dissipation in a mechanical oscillator at low frequency.

Broadband seismometers and gravitational wave detectors make use of mechanical resonators with a high quality factor to reduce Brownian noise. At low frequency, Brownian noise is ultimately dominated by internal friction in the suspension, which has a 1/f noise compared with the white noise arising from viscous dissipation. Internal friction is typically modeled as a frequency-dependent loss and can be challenging to measure reliably through experiment. In this work, we present the physics and experimental implementation of electrostatic frequency reduction (EFR) in a mechanical oscillator-a method to measure dissipation as a function of frequency. By applying a high voltage to two parallel capacitor plates, with the center plate being a suspended mass, an electrostatic force is created that acts as a negative stiffness mechanism to reduce the system's resonance frequency. Through EFR, the loss angle can be measured as a function of frequency by measuring amplitude decay response curves for a range of applied voltages. We present experimental measurements of the loss angle for three metal helical extension springs in the nominal frequency range 0.7-2.9 Hz at 0.2 Hz intervals, demonstrating the possibility for fine adjustment of the resonance frequency for loss angle measurements. A quality factor proportional to the resonance frequency squared was measured, an indication that internal friction and other non-viscous dissipation elements, such as electrostatic damping, were the prominent loss mechanisms in our experiments. Finally, we consider the implications of Brownian noise arising from internal friction on a low 1/f noise seismometer.

On Recent Large Antarctic Ozone Holes and Ozone Recovery Metrics.

The 2015 and 2020 ozone holes set record sizes in October-December. We show that these years, as well as other recent large ozone holes, still adhere to a fundamental recovery metric: the later onset of early spring ozone depletion as chlorine and bromine diminishes. This behavior is also captured in the Whole Atmosphere Chemistry Climate Model. We quantify observed recovery trends of the onset of the ozone hole and in the size of the September ozone hole, with good model agreement. A substantial reduction in ozone hole depth during September over the past decade is also seen. Our results indicate that, due to dynamical phenomena, it is likely that large ozone holes will continue to occur intermittently in October-December, but ozone recovery will still be detectable through the later onset, smaller, and less deep September ozone holes: metrics that are governed more by chemical processes.

Sleep duration and bone health measures in older men.

The associations between objective measures of sleep duration and bone outcomes in older men are unknown. No consistent, significant association was identified between sleep duration and bone mineral density (BMD) in the current analysis. However, future research should determine if vitamin D status modifies this relationship. INTRODUCTION: Prior studies, predominantly in women, reported that long and short self-reported sleep duration are associated with lower BMD. Associations between actigraphy-determined sleep duration and BMD or bone turnover markers (BTMs) in older men are unknown. METHODS: Men in The Osteoporotic Fractures in Men (MrOS) Study with wrist actigraphy and concurrent BMD assessment but without comorbidities affecting bone health were included. Sleep duration was considered as a continuous (N = 1926) and dichotomized variable where men were classified as getting the recommended (7-8 h/night; N = 478) or short (< 6 h/night; N = 577) sleep. The cross-sectional association between BMD, BTMs, and sleep duration was examined using a t test or linear regression, where appropriate, in unadjusted and adjusted models. RESULTS: There were no clinically or statistically significant differences in BMD at the L-spine, total hip, or femoral neck between men getting the recommended vs. short sleep duration, using actigraphy or self-reported sleep duration (all p ≥ 0.07). When sleep duration was considered as a continuous variable, femoral neck BMD was higher in men with longer self-reported sleep duration (ß = 0.006 ±0.003, p = 0.02), but this was not significant after further adjustment. In men with low 25OHD (< 20 ng/mL), longer actigraphy-determined sleep duration was associated with higher total hip BMD (ß = 0.016 ± 0.008; p = 0.04). Sleep duration and BTMs were not associated. CONCLUSION: Sleep duration was not associated with hip or L-spine BMD or BTMs in older men. Future research should determine if vitamin D status or other factors modify this relationship.

Low Protein Intake Irrespective of Source is Associated with Higher Mortality Among Older Community-dwelling Men.

OBJECTIVES: Our aim was to determine the association between protein intake (overall and by source) and all-cause and cause-specific mortality among older men. DESIGN: Prospective cohort study. SETTING: 5790 ambulatory community-dwelling older men from multicenter Osteoporotic Fractures in Men (MrOS) study. MEASUREMENTS: Total energy and protein intake, and protein intake by source (dairy, non-dairy animal, plant) were assessed using a 69-item food frequency questionnaire. We included up to 10-year follow-up with adjudicated cardiovascular, cancer and other mortality outcomes. We used time-to-event analysis with protein exposures, mortality outcome, and adjusted for possible confounders including age, center, education, race, smoking, alcohol use, physical activity, weight, total energy intake (TEI), and comorbidities. Hazard ratios were expressed per each unit=2.9% TEI decrement for all protein intake variables. RESULTS: The mean (SD) baseline age of 5790 men was 73.6 (5.8) y. There were 1611 deaths and 211 drop-outs prior to 10 years, and 3868 men who were alive at the 10-year follow-up. The mean (SD) total protein intake was 64.7 (25.8) g/d, while the mean (SD) intake expressed as percent of total energy intake (%TEI) was 16.1 (2.9) %TEI. Lower protein intake was associated with an increased risk of death, with unadjusted HR=1.11 (95% CI: 1.06, 1.17) and adjusted HR=1.09 (95% CI: 1.04, 1.14) and the associations for protein intake by source were similar. The adjusted HR for cancer mortality was HR=1.13 (95% CI: 1.03, 1.25) while the association for CVD mortality was HR=1.08 (95% CI: 0.99, 1.18). CONCLUSIONS: Low protein intake, irrespective of source, was associated with a modest increase in risk of all-cause and cause-specific mortality among older men. Special consideration should be given to level of protein intake among older adults.

Processes of consent in research for adults with impaired mental capacity nearing the end of life: systematic review and transparent expert consultation (MORECare_Capacity statement).

BACKGROUND: Involving adults lacking capacity (ALC) in research on end of life care (EoLC) or serious illness is important, but often omitted. We aimed to develop evidence-based guidance on how best to include individuals with impaired capacity nearing the end of life in research, by identifying the challenges and solutions for processes of consent across the capacity spectrum. METHODS: Methods Of Researching End of Life Care_Capacity (MORECare_C) furthers the MORECare statement on research evaluating EoLC. We used simultaneous methods of systematic review and transparent expert consultation (TEC). The systematic review involved four electronic databases searches. The eligibility criteria identified studies involving adults with serious illness and impaired capacity, and methods for recruitment in research, implementing the research methods, and exploring public attitudes. The TEC involved stakeholder consultation to discuss and generate recommendations, and a Delphi survey and an expert 'think-tank' to explore consensus. We narratively synthesised the literature mapping processes of consent with recruitment outcomes, solutions, and challenges. We explored recommendation consensus using descriptive statistics. Synthesis of all the findings informed the guidance statement. RESULTS: Of the 5539 articles identified, 91 met eligibility. The studies encompassed people with dementia (27%) and in palliative care (18%). Seventy-five percent used observational designs. Studies on research methods (37 studies) focused on processes of proxy decision-making, advance consent, and deferred consent. Studies implementing research methods (30 studies) demonstrated the role of family members as both proxy decision-makers and supporting decision-making for the person with impaired capacity. The TEC involved 43 participants who generated 29 recommendations, with consensus that indicated. Key areas were the timeliness of the consent process and maximising an individual's decisional capacity. The think-tank (n = 19) refined equivocal recommendations including supporting proxy decision-makers, training practitioners, and incorporating legislative frameworks. CONCLUSIONS: The MORECare_C statement details 20 solutions to recruit ALC nearing the EoL in research. The statement provides much needed guidance to enrol individuals with serious illness in research. Key is involving family members early and designing study procedures to accommodate variable and changeable levels of capacity. The statement demonstrates the ethical imperative and processes of recruiting adults across the capacity spectrum in varying populations and settings.

Aeromedical retrieval of trauma patients: Impact of flight path model on estimates of population coverage.

BACKGROUND: The aim of this study was to compare the impact of different flight path models on the calculated population coverage of aeromedical retrieval systems, using the state of Alabama as a case study. METHODS: Geospatial analysis of U.S. Census Bureau population data using helicopter bases and trauma centers as foci of either circular or elliptical coverage areas. RESULTS: Circular isochrone models around helicopter bases or trauma centers suggest that the entire population of Alabama could reach a level I or II trauma center within 60 min. Elliptical isochrones, incorporating outbound and inbound flights, suggest that only 78.8% of the population have ready access to level I or II trauma centers. CONCLUSION: While all three flight path models described have some validity and utility, simplistic circular flight time isochrones around trauma centers and helicopter bases provide overly optimistic estimates of population coverage. The elliptical model provides a more realistic evaluation.

Cerebrospinal fluid opening pressure: The effect of body mass index and body composition.

OBJECTIVES: Idiopathic intracranial hypertension (IIH) is strongly related to obesity. The relationship between intracranial pressure, body mass index (BMI), percentage body fat and distribution of body fat in non-IIH patients remains less clear. The aim of this study was to examine the relationship between intracranial pressure and body type in non-IIH patients. PATIENTS AND METHODS: Lumbar puncture manometry was used to measure cerebrospinal fluid opening pressure (CSFOP). BMI, in addition to neck, waist and hip circumferences were calculated. Air displacement plethysmography (BODPOD) was used to assess body composition. RESULTS: Data was collected from 100 subjects. 11 subjects with conditions known to cause raised intracranial pressure were excluded from analysis. According to Pearson correlation factors displaying a significant relationship with CSFOP included: BMI (R = 0.635, p < 0.0001); waist circumference (R = 0.498, p < 0.0001), hip circumference (R = 0.513, p < 0.0001) and percentage body fat (R = 0.435, p < 0.001). Multivariate analysis indicated that BMI was the only independent factor which predicted CSFOP. Sub-analysis according to gender indicated that BMI was predictive in females and percentage body fat was predictive in males. We did not identify any differences in BMI, percentage body fat or distribution of body fat in 7 IIH patients and 7 wt-matched non-IIH patients. CONCLUSION: BMI and percentage body fat both positively correlated with CSFOP, but BMI was more predictive in women and percentage body fat was more predictive in men. We did not find a relationship between distribution of body fat and CSFOP.

Heightened sleep propensity: a novel and high-risk sleep health phenotype in older adults.

OBJECTIVES: To reveal sleep health phenotypes in older adults and examine their associations with time to 5-year all-cause and cardiovascular mortality. DESIGN: Prospective longitudinal cohorts. SETTING: The Study of Osteoporotic Fractures and Outcomes of Sleep Disorders in Older Men Study. PARTICIPANTS: N = 1722 men and women aged ≥65 years matched 1:1 on sociodemographic and clinical measures. MEASUREMENTS: Self-reported habitual sleep health characteristics (satisfaction, daytime sleepiness, timing, efficiency, and duration) measured at an initial visit and longitudinal follow-up for mortality. RESULTS: Latent class analysis revealed 3 sleep health phenotypes: (1) heightened sleep propensity (HSP; medium to long duration, high sleepiness, high efficiency/satisfaction; n = 322), (2) average sleep (AS; medium duration, average efficiency, high satisfaction, low sleepiness; n = 1,109), and (3) insomnia with short sleep (ISS; short to medium duration, low efficiency/satisfaction, moderate sleepiness; n = 291). Phenotype predicted time to all-cause mortality (χ2 = 9.4, P = .01), with HSP conferring greater risk than AS (hazard ratio [95% confidence interval] = 1.48 [1.15-1.92]) or ISS (1.52 [1.07-2.17]), despite ISS reporting the poorest mental and physical health. Although sex did not formally moderate the relationship between phenotype and mortality, subgroup analyses indicated that these findings were driven primarily by women. Phenotype did not predict cardiovascular mortality. CONCLUSIONS: These analyses support the utility of examining multidimensional sleep health profiles by suggesting that the combination of long sleep, high efficiency/satisfaction, and daytime sleepiness-previously identified as independent risk factors-may be components of a single high-risk sleep phenotype, HSP. Further investigation of sex differences and the mechanisms underlying mortality risk associated with HSP is warranted.

Large impacts, past and future, of ozone-depleting substances on Brewer-Dobson circulation trends: A multi-model assessment.

Substantial increases in the atmospheric concentration of well-mixed greenhouse gases (notably CO2), such as those projected to occur by the end of the 21st century under large radiative forcing scenarios, have long been known to cause an acceleration of the Brewer-Dobson circulation (BDC) in climate models. More recently, however, several single-model studies have proposed that ozone-depleting substances might also be important drivers of BDC trends. As these studies were conducted with different forcings over different periods, it is difficult to combine them to obtain a robust quantitative picture of the relative importance of ozone-depleting substances as drivers of BDC trends. To this end we here analyze - over identical past and future periods - the output from 20 similarly-forced models, gathered from two recent chemistry-climate modeling intercomparison projects. Our multi-model analysis reveals that ozone-depleting substances are responsible for more than half of the modeled BDC trends in the two decades 1980-2000. We also find that, as a consequence of the Montreal Protocol, decreasing concentrations of ozone-depleting substances in coming decades will strongly decelerate the BDC until the year 2080, reducing the age-of-air trends by more than half, and will thus substantially mitigate the impact of increasing CO2. As ozone-depleting substances impact BDC trends, primarily, via the depletion/recovery of stratospheric ozone over the South Pole, they impart seasonal and hemispheric asymmetries to the trends which may offer opportunities for detection in coming decades.

Population Coverage of Trauma Systems: What Do Helicopters Add?

Trauma is a time-critical condition. Helicopters are thought to enhance the accessibility to trauma centers, but this benefit is poorly quantified. The aim of this study was to conduct a geographical analysis of the added benefit provided by helicopters, over ground transport. This study uses geospatial analysis. Helicopter bases and Level I and II designated trauma centers were geocoded. 60-minute drive-time and elliptical flight-time isochrones were mapped with ArcGIS™ (Esri, Redlands, CA). Calculations included allowance for mission ground time (MGT). We compared the proportion of the population that could be taken to Level I and II trauma centers, within 60 minutes, by road and by air. Using a 30-minute MGT model, helicopters permit 279,317 additional residents (5.8%) access to a Level I trauma center within 60 minutes. Using the 20-minute MGT model, 1,089,177 more residents (22.8%) would have access to Level I trauma center care. The benefits were marginally greater for access to Level I and II trauma center care. Helicopters enhance access to specialist trauma center care, but the benefit is small and dependent on MGT. Consideration should be given to the siting of helicopters, particularly in relation to trauma patients, MGT, and the timely response of EMS when determining the triage for helicopter transport.

Effects and moderators of exercise on sleep in adults with cancer: Individual patient data and aggregated meta-analyses.

OBJECTIVES: To evaluate the effects of exercise interventions on sleep disturbances and sleep quality in patients with mixed cancer diagnoses, and identify demographic, clinical, and intervention-related moderators of these effects. METHODS: Individual patient data (IPD) and aggregated meta-analyses of randomized controlled trials (RCTs). Using data from the Predicting OptimaL cAncer RehabIlitation and Supportive care project, IPD of 2173 adults (mean age = 54.8) with cancer from 17 RCTs were analyzed. A complementary systematic search was conducted (until November 2018) to study the overall effects and test the representativeness of analyzed IPD. Effect sizes of exercise effects on self-reported sleep outcomes were calculated for all included RCTs. Linear mixed-effect models were used to evaluate the effects of exercise on post-intervention outcome values, adjusting for baseline values. Moderator effects were studied by testing interactions for demographic, clinical and intervention-related characteristics. RESULTS: For all 27 eligible RCTs from the updated search, exercise interventions significantly decreased sleep disturbances in adults with cancer (g = -0.09, 95% CI [-0.16; -0.02]). No significant effect was obtained for sleep quality. RCTs included in IPD analyses constituted a representative sample of the published literature. The intervention effects on sleep disturbances were not significantly moderated by any demographic, clinical, or intervention-related factor, nor by sleep disturbances. CONCLUSIONS: This meta-analysis provides some evidence that, compared to control conditions, exercise interventions may improve sleep disturbances, but not sleep quality, in cancer patients, although this effect is of a small magnitude. Among the investigated variables, none was found to significantly moderate the effect of exercise interventions on sleep disturbances.

Use of helicopters for retrieval of trauma patients: A geospatial analysis.

BACKGROUND: Helicopters are widely used to facilitate the transport of trauma patients, from the scene of an incident to the hospital. However, the use of helicopters may not always be appropriate. The aim of this project was to conduct a geospatial analysis of helicopter transport to a Level I trauma center. METHODS: Retrospective geospatial analysis of trauma registry data, 2013 to 2018. We included all adult (≥16) trauma patients brought to the trauma center directly from the scene. Data were geocoded and analyzed using arcGIS. Drive times and flight times were calculated using Google Maps. Flight times included the time required to reach the incident location. RESULTS: Two thousand eight hundred ninety-three patients were identified, and 1,911 had incident locations recorded and were therefore included in the analysis. The median age was 41 years (interquartile range [IQR], 27-58 years). Twenty-four percent of the patients had suffered severe injuries (Injury Severity Score [ISS], 16-25), 17% very severe injuries (ISS > 25), 24% moderately severe injuries, and 36% minor injuries (ISS, 1-8). The overall geographical distribution was centroidal, although with a concentration of case volume in the vicinity, and to the northeast, of the trauma center. Median flight time was 60 minutes (IQR, 52-69 minutes), and median drive time 65 minutes (IQR, 54-86 minutes). In 33% of the patients, the calculated drive time to the trauma center was shorter than the calculated flight time when considering the time for the helicopter to reach the scene. CONCLUSION: The majority of patients taken to our level I trauma center by helicopter are injured in relatively close proximity. One in four patients is severely or very severely injured, but one third of the patients have only minor injuries. Over a quarter of trauma patients might have reached hospital more quickly if they had been taken by road, rather than helicopter. LEVEL OF EVIDENCE: Epidemiological/geographical study, level V.

Beam emittance preservation using Gaussian density ramps in a beam-driven plasma wakefield accelerator.

A current challenge that is facing the plasma wakefield accelerator (PWFA) community is transverse beam emittance preservation. This can be achieved by balancing the natural divergence of the beam against the strong focusing force provided by the PWFA plasma source in a scheme referred to as beam matching. One method to accomplish beam matching is through the gradual focusing of a beam with a plasma density ramp leading into the bulk plasma. Here, the beam dynamics in a Gaussian plasma density ramp are considered, and an empirical formula is identified that gives the ramp length and beam vacuum waist location needed to achieve near-perfect matching. The method uses only the beam vacuum waist beta function as an input. Numerical studies show that the Gaussian ramp focusing formula is robust for beta function demagnification factors spanning more than an order of magnitude with experimentally favourable tolerances for future PWFA research facilities. This article is part of the Theo Murphy meeting issue 'Directions in particle beam-driven plasma wakefield acceleration'.

Association between objective sleep duration and bone mineral density in older postmenopausal women from the Study of Osteoporotic Fractures (SOF).

Methodological limitations preclude determination of the association between sleep duration and bone mineral density (BMD) from existing literature. This was the first study to use objective sleep duration to determine its association with BMD. Nocturnal sleep duration, assessed objectively (actigraphy) or subjectively (questionnaire), was not independently associated with BMD in postmenopausal women. INTRODUCTION: Both long and short self-reported sleep durations are associated with low bone mineral density (BMD) in men and women. The association between sleep duration measured by actigraphy and BMD in postmenopausal women is unknown. METHODS: The Study of Osteoporotic Fractures (SOF) ancillary sleep study was used to determine the association between sleep duration and BMD at the total hip and femoral neck in postmenopausal women ≥ 75 years old. Sleep duration was assessed by wrist actigraphy (average 4 nights) and questionnaire. BMD was compared between postmenopausal women with short (< 6 h/night) vs. NIH-recommended (7-8 h/night) sleep durations. Data were analyzed using a 2-sample t test (unadjusted) and multivariate regression model (adjusted). Simple linear regression was used to estimate the difference in BMD per additional hour of sleep when sleep duration was considered as a continuous, rather than dichotomized, variable. RESULTS: Total hip BMD was higher in women with actigraphically assessed shorter sleep duration in unadjusted models only. No clinically or statistically significant differences in total hip or femoral neck BMD were observed according to nocturnal sleep duration after adjusting for body mass index (BMI) in dichotomized (N = 874) or continuous (N = 1624) sleep duration models or when subjective sleep duration was used. When sleep duration included daytime naps, longer sleep duration was associated with lower total hip BMD (ß = - 0.005, p = 0.04). CONCLUSIONS: Nocturnal sleep duration, whether assessed objectively (actigraphy) or subjectively (questionnaire), was not independently associated with BMD in older postmenopausal women.

The effects of 4 weeks normobaric hypoxia training on microvascular responses in the forearm flexor.

Intermittent exposure to hypoxia can lead to improved endurance performance. Currently, it is unclear whether peripheral adaptions play a role in improving oxygen delivery and utilization following both training and detraining. This study aimed to characterize skeletal muscle blood flow (mBF), oxygen consumption (mV̇O2), and perfusion adaptations to i) 4-weeks handgrip training in hypoxic and normoxic conditions, and ii) following 4-weeks detraining. Using a randomised crossover design, 9 males completed 30-min handgrip training four times a week in hypoxic (14% FiO2 ~ 3250m altitude) and normoxic conditions. mBF, mV̇O2 and perfusion were assessed pre, post 4-weeks training, and following 4-weeks detraining. Hierarchical linear modelling found that mV̇O2 increased at a significantly faster rate (58%) with hypoxic training (0.09 mlO2·min-1 · 100g-1 per week); perfusion increased at a significantly (69%) faster rate with hypoxic training (3.72 µM per week). mBF did not significantly change for the normoxic condition, but there was a significant increase of 0.38 ml· min-1 · 100ml-1 per week (95% CI: 0.35, 0.40) for the hypoxic condition. During 4-weeks detraining, mV̇O2 and perfusion significantly declined at similar rates for both conditions, whereas mBF decreased significantly faster following hypoxic training. Four weeks hypoxic training increases the delivery and utilisation of oxygen in the periphery.

Bleeding emergencies in neonatal and paediatric patients: improving the quality of care using simulation.

OBJECTIVES: Using a multidisciplinary approach and simulation, a massive transfusion process (MTP) was developed to care for patients in need of emergency transfusion. It was then assessed for effectiveness. BACKGROUND: After a series of sentinel emergency bleeding events, a reliable process for hospital staff to deliver appropriate blood products and obtain relevant laboratory tests to guide therapy for patients with emergency bleeding was needed. METHODS: To determine the feasibility of the new MTP, multidisciplinary teams participated in simulation events. Each simulation event helped refine the MTP. A special laboratory testing panel was devised. To judge the effectiveness and timeliness of the MTP, process measures and patient survival was retrospectively evaluated during the time period before and after MTP implementation. RESULTS: A new emergency bleeding panel of laboratory tests significantly decreased the turn-around time for fibrinogen, haematocrit, International normalised ratio (INR) and platelet count. The speed of commencing the first red blood cells transfusion was also improved (2:00 h vs 0:20 min, P = 0·001). Of 78 patients, there was no change in survival before (n = 31, 48·4%) and after (n = 47, 42·6%; P = 0·6478) MTP implementation. However, there was significant improvement in survival associated with MTP events on the weekdays. CONCLUSIONS: A reliable emergency transfusion process consists of an automatic chain of events that keeps decision-making to a minimum and leads to the fast procurement of blood products and salient test results. This work shows that a multidisciplinary iterative process using simulation increases the efficiency of clinical care delivery for bleeding paediatric and neonatal patients.