Inclined position is associated with improved first pass success and laryngoscopic view in prehospital endotracheal intubations.

PURPOSE: In hospital-based studies, patients intubated by physicians while in an inclined position compared to supine position had a higher rate of first pass success and lower rate of peri-intubation complications. We evaluated the impact of patient positioning on prehospital endotracheal intubation in an EMS system with rapid sequence induction capability. We hypothesized that patients in the inclined position would have a higher first-pass success rate. METHODS: Prehospital endotracheal intubation cases performed by paramedics between 2012 and 2017 were prospectively collected in airway registries maintained by a metropolitan EMS system. We included all adult (age ≥ 18 years) non-traumatic, non-arrest patients who received any attempt at intubation. Patients were categorized according to initial positioning: supine or inclined. The primary outcome measure was first pass success with secondary outcomes of laryngoscopic view and challenges to intubation. RESULTS: Of the 13,353 patients with endotracheal intubation attempted by paramedics during the study period, 4879 were included for analysis. Of these, 1924 (39.4%) were intubated in the inclined position. First pass success was 86.3% among the inclined group versus 82.5% for the supine group (difference 3.8%, 95% CI: 1.5%-6.1%). First attempt laryngeal grade I view was 62.9% in the inclined group versus 57.1% for the supine group (difference 5.8%, 2.0-9.6). Challenges to intubation were more frequent in the supine group (42.3% versus 38.8%, difference 3.5%, 0.6-6.3). CONCLUSION: Inclined positioning was associated with a better grade view and higher rate of first pass success. The technique should be considered as a viable approach for prehospital airway management.

Advances in breeding phenology outpace latitudinal and elevational shifts for North American birds tracking temperature.

Terrestrial species can respond to a warming climate in multiple ways, including shifting in space (via latitude or elevation) and time (via phenology). Evidence for such shifts is often assessed independent of other temperature-tracking mechanisms; critically, no study has compared shifts across all three spatiotemporal dimensions. Here we used two continental-scale monitoring databases to estimate trends in the breeding latitude (311 species), elevation (251 species) and phenology (111 species) of North American landbirds over 27 years, with a shared pool of 102 species. We measured the magnitude of shifts and compared them relative to average regional warming (that is, shift ratios). Species shifted poleward (1.1 km per year, mean shift ratio 11%) and to higher elevations (1.2 m per year, mean shift ratio 17%), while also shifting their breeding phenology earlier (0.08 days per year, mean shift ratio 28%). These general trends belied substantial variation among species, with some species shifting faster than climate, whereas others shifted more slowly or in the opposite direction. Across the three dimensions (n = 102), birds cumulatively tracked temperature at 33% of current warming rates, 64% of which was driven by advances in breeding phenology as opposed to geographical shifts. A narrow focus on spatial dimensions of climate tracking may underestimate the responses of birds to climate change; phenological shifts may offer an alternative for birds-and probably other organisms-to conserve their thermal niche in a warming world.

Geomagnetic disturbance associated with increased vagrancy in migratory landbirds.

Rare birds known as "accidentals" or "vagrants" have long captivated birdwatchers and puzzled biologists, but the drivers of these rare occurrences remain elusive. Errors in orientation or navigation are considered one potential driver: migratory birds use the Earth's magnetic field-sensed using specialized magnetoreceptor structures-to traverse long distances over often unfamiliar terrain. Disruption to these magnetoreceptors or to the magnetic field itself could potentially cause errors leading to vagrancy. Using data from 2 million captures of 152 landbird species in North America over 60 years, we demonstrate a strong association between disruption to the Earth's magnetic field and avian vagrancy during fall migration. Furthermore, we find that increased solar activity-a disruptor of the avian magnetoreceptor-generally counteracts this effect, potentially mitigating misorientation by disabling the ability for birds to use the magnetic field to orient. Our results link a hypothesized cause of misorientation to the phenomenon of avian vagrancy, further demonstrating the importance of magnetoreception among the orientation mechanisms of migratory birds. Geomagnetic disturbance may have important downstream ecological consequences, as vagrants may experience increased mortality rates or facilitate range expansions of avian populations and the organisms they disperse.

Traits shaping urban tolerance in birds differ around the world.

As human density increases, biodiversity must increasingly co-exist with urbanization or face local extinction. Tolerance of urban areas has been linked to numerous functional traits, yet few globally consistent patterns have emerged to explain variation in urban tolerance, which stymies attempts at a generalizable predictive framework. Here, we calculate an Urban Association Index (UAI) for 3,768 bird species in 137 cities across all permanently inhabited continents. We then assess how this UAI varies as a function of ten species-specific traits and further test whether the strength of trait relationships vary as a function of three city-specific variables. Of the ten species traits, nine were significantly associated with urban tolerance. Urban-associated species tend to be smaller, less territorial, have greater dispersal ability, broader dietary and habitat niches, larger clutch sizes, greater longevity, and lower elevational limits. Only bill shape showed no global association with urban tolerance. Additionally, the strength of several trait relationships varied across cities as a function of latitude and/or human population density. For example, the associations of body mass and diet breadth were more pronounced at higher latitudes, while the associations of territoriality and longevity were reduced in cities with higher population density. Thus, the importance of trait filters in birds varies predictably across cities, indicating biogeographic variation in selection for urban tolerance that could explain prior challenges in the search for global patterns. A globally informed framework that predicts urban tolerance will be integral to conservation as increasing proportions of the world's biodiversity are impacted by urbanization.

Evidence for Expanding Invasive Mediastinal Staging for Peripheral T1 Lung Tumors.

BACKGROUND: Guidelines recommend invasive mediastinal staging for patients with non-small cell lung cancer and a "central" tumor. However, there is no consensus definition for central location. As such, the decision to perform invasive staging largely remains on an empirical foundation. RESEARCH QUESTION: Should patients with peripheral T1 lung tumors undergo invasive mediastinal staging? STUDY DESIGN AND METHODS: All participants with a screen-detected cancer with a solid component between 8 and 30 mm were identified from the National Lung Screening Trial. After translation of CT data, cancer location was identified and the X, Y, Z coordinates were determined as well as distance from the main carina. A multivariable logistic regression model was constructed to evaluate for predictors associated with lymph node metastasis. RESULTS: Three hundred thirty-two participants were identified, of which 69 had lymph node involvement (20.8%). Of those with lymph node metastasis, 39.1% were N2. There was no difference in rate of lymph node metastasis based on tumor size (OR, 1.03; P = .248). There was also no statistical difference in rate of lymph node metastasis based on location, either by distance from the carina (OR, 0.99; P = .156) or tumor coordinates (X: P = .180; Y: P = .311; Z: P = .292). When adjusted for age, sex, histology, and smoking history, there was no change in the magnitude of the risk, and tests of significance were not altered. INTERPRETATION: Our data indicate a high rate of N2 metastasis among T1 tumors and no significant relationship between tumor diameter or location. This suggests that patients with small, peripheral lung cancers may benefit from invasive mediastinal staging.

An individual-based model for the dispersal of Ixodes scapularis by ovenbirds and wood thrushes during fall migration.

Ixodes scapularis is responsible for the transmission of a variety of pathogens in North America, including Borrelia burgdorferi sensu stricto, Anaplasma phagocytophilum and Babesia microti. Songbirds have previously been described as agents of tick dispersal, and a combination of empirical data and modeling efforts have implicated songbirds in the range expansion of I. scapularis northward into Canada during spring bird migration. The role of fall bird migration has received comparatively less attention, particularly at a continental scale. The aim of the current research was to use a novel individual-based modeling approach (IBM) to investigate the role of southward migrating songbirds in the dispersal of I. scapularis within the continental United States. The IBM used in this research explicitly models dispersal by two extensively studied migrating songbird species, wood thrush Hylocichla mustelina and ovenbird Seiurus aurocapillus. Our IBM predicts the annual dispersal of more than four million ticks by H. mustelina and S. aurocapillus, notably into areas as far west as the Dakotas, and as far south as Central Alabama. Predicted dispersal locations include areas where the southern phenotype of I. scapularis dominates, suggestive of a possible mechanism for previously described unidirectional gene flow from north to south. In addition, the model demonstrates that three species-specific songbird traits - breeding range, migration timing, and propensity for tick attachment - each play a major role in the relative magnitude of tick dispersal by different songbird species. The pattern of I. scapularis dispersal predicted by this model suggests that migrating songbirds may have contributed to the range expansion of the tick historically, and may continue to do so presently and into the future, particularly as climate changes the geographic areas that are suitable for I. scapularis. Ultimately, widespread tick dispersal by migrating songbirds likely increases the human risk of Lyme disease and other tick-borne diseases in the United States.