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BACKGROUND Most patients living with serious illness value spending time at home. Emerging data suggest that days alive and at home (DAH) may be a useful metric, however more research is needed. We aimed to assess the concurrent validity of DAH with respect to clinically significant changes in patient- and caregiver-reported outcomes (PROs). METHODS We drew data from a study that compared two models of home-based palliative care among seriously ill patients and their caregivers in two Kaiser Permanente regions (Southern California and Northwest). We included participants aged 18 years or older (n = 3533) and corresponding caregivers (n = 463). We categorized patients and caregivers into three groups based on whether symptom burden (Edmonton Symptom Assessment System, ESAS) or caregiving preparedness (Preparedness for Caregiving Scale, CPS) showed improvements, deterioration, or no change from baseline to 1 month later. We measured DAH across four time windows: 30, 60, 90, and 180 days, after admission to home palliative care. We used two-way ANOVA to compare DAH across the PRO groups. RESULTS Adjusted pairwise comparisons showed that DAH was highest for patients whose ESAS scores improved or did not change compared with those with worsening symptoms. Although the mean differences ranged from less than a day to about 3 weeks, none exceeded 0.3 standard deviations. ESAS change scores had weak negative correlations (r = -0.11 to -0.21) with DAH measures. CPS change scores also showed weak, positive correlations (r = 0.23-0.24) with DAH measures. CONCLUSION DAH measures are associated, albeit weakly, with clinically important improvement or maintenance of patient symptom burden in a diverse, seriously ill population.

Organic-inorganic hybrid superlattices (OIHSLs) hold attractive physical and chemical properties, while the construction of single-crystal covalent OIHSLs has not been achieved. Herein a coordination assembly strategy was proposed to create a single-crystal covalent OIHSL PbBDT (BDT=1,4-benzenedithiolate), where layered [PbS 2 ] sublattice covalently connects with benzene sublattice. The covalent bonding offers better thermo-/chemi-stability, inter-sublattice electron transport, and unique organic-group-functionalized surface, which may enable better performances in chemical applications than non-covalent OIHSL. These features endow PbBDT with the highest sensitivity, the lowest detection limit and excellent selectivity towards NO 2 at room temperature among all chemiresistive gas-sensing materials with reported response time less than 2 min without the need of light assistance.

Background Although we previously proposed a nomogram to predict malignancy in intraductal papillary mucinous neoplasms (IPMN) and validated it in an external cohort, its application is challenging without data on tumor markers. Moreover, existing nomograms have not been compared. This study aimed to develop a nomogram based on radiologic findings and to compare its performance with previously proposed American and Korean/Japanese nomograms. Methods We recruited 3708 patients who underwent surgical resection at 31 tertiary institutions in eight countries, and patients with main pancreatic duct > 10 mm were excluded. To construct the nomogram, 2606 patients were randomly allocated 1:1 into training and internal validation sets, and area under the receiver operating characteristics curve (AUC) was calculated using 10-fold cross validation by exhaustive search. This nomogram was then validated and compared to the American and Korean/Japanese nomograms using 1102 patients. Results Among the 2606 patients, 90 had main-duct type, 900 had branch-duct type, and 1616 had mixed-type IPMN. Pathologic results revealed 1628 low-grade dysplasia, 476 high-grade dysplasia, and 502 invasive carcinoma. Location, cyst size, duct dilatation, and mural nodule were selected to construct the nomogram. AUC of this nomogram was higher than the American nomogram (0.691 vs. 0.664, p = 0.014) and comparable with the Korean/Japanese nomogram (0.659 vs 0.653, p = 0.255). Conclusions A novel nomogram based on radiologic findings of IPMN is competitive for predicting risk of malignancy. This nomogram would be clinically helpful in circumstances where tumor markers are not available. The nomogram is freely available at http://statgen.snu.ac.kr/software/nomogramIPMN.

This paper investigates interval observer‐based controller design for switched linear systems involving additional disturbance and measurement noise, whose modes need not to be cooperative. First, by giving the upper bound and the lower bound of the disturbance and the measurement noise, we construct hybrid interval observer for the considered switched linear system by means of a switched coordinate transformation, which can transform the observer error systems into cooperative ones. The interval observer can supply certain state information at any instant. Compared with the interval observer design for switched systems with arbitrary switching sequences or dwell time switching based on common Lyapunov function, the difficulty consists in characterizing the jump of the multiple Lyapunov functions. Then, by using the multiple Lyapunov functions method and average dwell time scheme, some sufficient conditions are derived and applied to build the interval observer‐based state feedback controller. Finally, we provide an example to illustrate the validity of the derived results.

The combination of transition-metal catalysis and organocatalysis increasingly offers chemists opportunities to realize diverse unprecedented chemical transformations. By combining iridium with chiral thiourea catalysis, direct enantioselective reductive cyanation and phosphonylation of secondary amides have been accomplished for the first time for the synthesis of enantioenriched chiral α-aminonitriles and α-aminophosphonates. The protocol is highly efficient and enantioselective, providing a novel route to the synthesis of optically active α-functionalized amines from the simple, readily available feedstocks. In addition, the reactions are scalable and the thiourea catalyst can be recycled and reused.

Sepsis is a major public health problem. Understanding the epidemiology of sepsis subtypes is important to quantify the magnitude of the problem and identify targets for system wide treatment strategies. We sought to describe the current national epidemiology of community-acquired (CAS), hospital-acquired (HAS) and healthcare-associated sepsis (HCAS) hospitalizations among academic medical centers in the United States using current discharge diagnosis taxonomies.Retrospective analysis of patient discharge data from the Vizient Clinical Data Base/Resource Manager. We identified sepsis hospitalizations using four ICD-10 coding strategies: (1) "Martin" sepsis codes (21 ICD-10 codes), (2) "Angus" sepsis codes (ICD-10 infection + ICD-10 organ dysfunction), (3) Medicare "SEP-1" codes (28 ICD-10 codes), and (4) "explicit sepsis" codes (ICD-10 R65.20 and R65.21). Using present-on-admission flags for each diagnosis, we also distinguished: (1) community-acquired sepsis (CAS), (2) hospital-acquired sepsis (HAS), and (3) healthcare associated sepsis (HCAS).Among 22,655,240 hospitalizations, the number and incidence of sepsis hospitalizations were: (1) Martin (n = 1,718,257, 75.8 per 1000 hospitalizations), (2) Angus (n = 2,749,163, 121.3 per 1000), (3) SEP-1 (n = 1,624,909, 71.7 per 1000), and (4) explicit sepsis (n = 655,853, 28.9 per 1000). CAS was the most common sepsis subtype. HAS exhibited higher adjusted mortality than CAS. ICU admission was highest for HAS (Martin, 1.5%; Angus, 1.5%; SEP-1, 1.6%; Explicit, 1.9%).These results illustrate the prevalence of sepsis at US academic medical centers using the most current sepsis classification taxonomies and discharge diagnosis codes. These results highlight important considerations when using hospital discharge data to characterize the epidemiology of sepsis.

Sleep disorders have been observed among patients with heart failure. The aim of this study was to investigate whether acute sleep deprivation (SD) aggravates left heart function. Male C57B/L6 mice were assigned to four experimental groups. Ligation of the left anterior descending branch (LAD) caused myocardial infarction (MI) in mice in the LAD group and the LAD+SD group, while mice in the sham and sham+SD groups underwent the same surgery without ligation. Echocardiography was performed before and 8 weeks after ligation of the LAD to evaluate the left ventricular internal diameter at diastole (LVIDd), left ventricular internal diameter at systole (LVIDs), ejection fraction (EF), and fractional shortening (FS). Seven days of sleep deprivation induced using the modified single platform method resulted in a lower EF and FS and a higher LVIDd and LVIDs, as well as increased expression of the IL-1β, IL-18, and IL-10 mRNAs in the left ventricular tissue of MI mice. ELISA also indicated higher levels of IL-1β and IL-10 in the LAD+SD group. It was concluded that acute sleep deprivation induced cardiovascular alterations in cardiac structure and function in HF mice, accompanied by increased levels of inflammatory cytokines.

Desmoplastic myxoid tumor (DMT), SMARCB1 mutant is a recently proposed new entity that mainly occurs in the pineal region and has epigenetic features similar to those of atypical teratoid/rhabdoid tumors (AT/RT)-MYC and poorly differentiated chordomas. Herein, we present a new case of a 33-year-old man with headaches, dizziness, nausea, vomiting, and blurred vision, who was initially found to have a suspicious germinoma on imaging. After surgical removal of the lesion, the postoperative pathological diagnosis was DMT, SMARCB1 mutant. To the best of our knowledge, this is the first case reported in China. Our findings also extend the range of the immunohistochemical phenotype of this rare tumor.

Background Shock from medical and traumatic conditions can result in organ injury and death. Limited data describe out‐of‐hospital treatment of shock. We sought to characterize adult out‐of‐hospital shock care in a national emergency medical services (EMS) cohort. Methods This cross‐sectional study used 2018 data from ESO, Inc. (Austin, TX), a national EMS electronic health record system, containing data from 1289 EMS agencies in the United States. We included adult (age ≥18 years) non‐cardiac arrest patients with shock, defined as initial systolic blood pressure ≤80 mm Hg. We compared patient demographics, clinical characteristics, and response (defined as systolic blood pressure increase) between medical and traumatic shock patients, looking at systolic blood pressure trends over the first 90 minutes of care. Results Among 6,156,895 adult 911 responses, shock was present in 62,867 (1.02%; 95% confidence interval [CI] = 1.01%–1.03%); 54,239 (86.3%) medical and 5978 (9.5%) traumatic, and 2650 unknown. Medical was more common than traumatic shock in women and older patients. The most common injuries associated with traumatic shock were falls (37.6%) and motor vehicle crashes (18.7%). Mean initial and final medical systolic blood pressure were 71 ± 10 mm Hg and 99 ± 24 mm Hg. Systolic blood pressure increased in 88.8% and decreased or did not change in 11.0%. Mean initial and final trauma systolic blood pressure were 71 ± 13 mm Hg and 105 ± 28 mm Hg; systolic blood pressure increased in 90.4% and decreased/did not change in 9.6%. On fractional polynomial modeling, systolic blood pressure changes were greater and faster for trauma than medical shock. Conclusions In this national series, 1 of every 100 EMS encounters involved shock. These findings highlight the current course and care of shock in the out‐of‐hospital setting.

Background The national incidence and characteristics of out‐of‐hospital cardiac arrest in the United States is unclear. We sought to describe the national characteristics of adult out‐of‐hospital cardiac arrest reported in the National Emergency Medical Services Information System (NEMSIS). Methods We used 2016 NEMSIS data, consisting of most emergency medical services (EMS) responses from 46 states and territories. We limited the analysis to adult (age ≥18 years) emergency “9‐1‐1” events. We defined out‐of‐hospital cardiac arrest as: (1) patient condition reported as cardiac arrest, (2) EMS reported attempted resuscitation of cardiac arrest, (3) EMS performance of cardiopulmonary resuscitation (CPR), or (4) EMS performance of defibrillation. We determined the incidence of adult out‐of‐hospital cardiac arrest among EMS responses. We also determined patient demographics (age, sex, race, ethnicity, location, US census region, and urbanicity), response characteristics (dispatch complaint and elapsed time) and clinical interventions (medications and procedures) of adult out‐of‐hospital cardiac arrest. We analyzed the data using descriptive techniques, calculating binomial proportions with exact 95% confidence intervals (CI). Results Among 18,679,873 adult 9‐1‐1 responses, there were 224,992 with patient condition cardiac arrest, 344,274 with EMS‐reported attempted cardiac arrest resuscitation, 149,775 with EMS performance of CPR, and 185,388 cases with EMS performance of defibrillation, resulting in a total of 574,824 out‐of‐hospital cardiac arrest (incidence 30.8 per 1000 EMS 9‐1‐1 responses, 95% CI = 30.69–30.85). Among identified out‐of‐hospital cardiac arrest responses, most involved patients who were older (mean = 62.4 ± 20.1 years). Most out‐of‐hospital cardiac arrest occurred at home (58.8%), in the South census region (65.4%), and in urban settings (79.8%). The most commonly reported medications used in out‐of‐hospital cardiac arrest were: epinephrine (22.5%), amiodarone (2.9%), sodium bicarbonate (6.2%), glucose (3.0%), and naloxone (5.1%). Commonly reported procedures included CPR (26.1%), orotracheal intubation (14.2%), bag‐valve‐mask ventilation (10.1%), manual defibrillation (29.3%) and automated external defibrillation (5.6%). Out‐of‐hospital cardiac arrest EMS treatment times were: elapsed response time (median = 7 minutes [interquartile range (IQR) = 5–10]), scene time (median = 17 minutes [IQR = 12–25]), and elapsed transport time (median = 11 minutes [IQR = 6–17]). Conclusions Using information available in the 2016 NEMSIS data, we estimate that there were over 570,000 reported adult out‐of‐hospital cardiac arrests in the United States. These results highlight the challenges of characterizing the epidemiology of adult out‐of‐hospital cardiac arrest in the United States.

Background While emergency medical services (EMS) often use endotracheal intubation (ETI) or supraglottic airways (SGA), some patients receive only bag-valve-mask (BVM) ventilation during out-of-hospital cardiac arrests (OHCA). Our objective was to compare patient characteristics and outcomes for BVM ventilation to advanced airway management (AAM) in adults with OHCA. Methods Using data from the Pragmatic Airway Resuscitation Trial, we identified patients receiving AAM (ETI or a SGA), BVM ventilation only (BVM-only), and BVM ventilation as a rescue after at least one failed attempt at advanced airway placement (BVM-rescue). The outcomes were return of spontaneous circulation (ROSC), 72-hour survival, survival to hospital discharge, neurologically intact survival (Modified Rankin Scale ≤ 3), and the presence of aspiration on a chest radiograph. Comparisons were made using generalized mixed-effects models while adjusting for age, sex, initial rhythm, EMS-witnessed status, bystander cardiopulmonary resuscitation, response time, study cluster, and advanced life support first on scene. Results Of 3,004 patients enrolled, there were 282 BVM-only, 2,129 AAM, and 156 BVM-rescue patients with complete covariates. Shockable initial rhythms (34% vs. 18.6%) and EMS-witnessed arrests (21.6% vs. 11.3%) were more likely in BVM-only than AAM but similar between BVM-rescue and AAM. Compared to AAM, BVM-only patients had similar ROSC (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 0.96 to 1.73), but higher 72-hour survival (OR = 1.96, 95% CI = 1.42 to 2.69), survival to discharge (OR = 4.47, 95% CI = 3.03 to 6.59), and neurologically intact survival (OR = 7.05, 95% CI = 4.40 to 11.3). Compared to AAM, BVM-rescue patients had similar ROSC (OR = 0.73, 95% CI = 0.47 to 1.12) and 72-hour survival (OR = 1.08, 95% CI = 0.66 to 1.77) but higher survival to discharge (OR = 2.15, 95% CI = 1.17 to 3.95) and neurologically intact survival (OR = 2.64, 95% CI = 1.20 to 5.81). Aspiration incidence was similar. Conclusions Bag-valve-mask-only ventilation is associated with improved OHCA outcomes. Despite similar rates of ROSC and 72-hour survival, BVM-rescue ventilation was associated with improved survival to discharge and neurologically intact survival compared to successful AAM.

Dunaliella salina is well known for its ability to accumulate large amounts of β-carotene. Myo-inositol (MI) enhances the biomass production of D. salina, but the underlying mechanisms were unclear. The present study showed that the concentration of exogenous MI decreased gradually and reached a constant level at the 4th day of cultivation. MI enhanced the contents of total colored carotenoids and the activity of photosystem II. Metabolic profiles were significantly changed after the addition of exogenous MI, as revealed by multivariate statistical analysis. The metabolites could be categorized into four groups based on the relative levels in different samples. Exogenous MI increased the levels of most detected sugars, amino acids, and total saturated and unsaturated fatty acids. Based on the physiological and metabolic analyses, a hypothetical growth-promoting model that MI promotes the growth of D. salina TG by increasing the levels of key metabolites and possibly enhancing photosynthesis, was proposed. This study provides valuable information for understanding the growth-promoting mechanisms of MI in D. salina from the metabolic perspective.

Urinary tract infections (UTIs) are the most common bacterial infection in young infants. The American Academy of Pediatrics' (AAP) clinical practice guideline for UTIs focuses on febrile children age 2-24 months, with no guideline for infants

The ability to manipulate the mammalian hair cycle will lead to novel therapies and strategies to combat all forms of alopecia. Thus, in addition to the epithelial-mesenchymal interactions in the hair follicle, niche and microenvironmental signals that accompany the phases of growth, regression and rest need to be scrutinized. Immune cells are well-described in skin homeostasis and wound healing, and have recently been shown to play an important role in the mammalian hair cycle. In this review, we will summarize our current knowledge of the role of immune cells in hair cycle control, and discuss their relevance to human hair cycling disorders. Increased attention to this aspect of the hair cycle will provide new avenues to manipulate hair regeneration in humans, and provide better insight into developing better ex vivo models of hair growth.

Objectives The predictive accuracy and clinical role of the focused assessment with sonography for trauma (FAST) exam in pediatric blunt abdominal trauma are uncertain. This study investigates the performance of the emergency department (ED) FAST exam to predict early surgical intervention and subsequent free fluid (FF) in pediatric trauma patients. Methods Pediatric level 1 trauma patients ages 0 to 15 years with blunt torso trauma at a single trauma center were retrospectively reviewed. After stratification by initial hemodynamic (HD) instability, the association of a positive FAST with (1) early surgical intervention, defined as operative management (laparotomy or open pericardial window) or angiography within 4 hours of ED arrival and (2) presence of FF during early surgical intervention was determined. Results Among 508 salvageable pediatric trauma patients with an interpreted FAST exam, 35 (6.9%) had HD instability and 98 (19.3%) were FAST positive. A total of 42 of 508 (8.3%) patients required early surgical intervention, and the sensitivity and specificity of FAST predicting early surgical intervention were 59.5% and 84.3%, respectively. The specificity and positive predictive value of FF during early surgical intervention in FAST‐positive HD unstable patients increased from 50% and 90.9% at 4 hours after ED arrival to 100% and 100% at 2 hours after ED arrival, respectively. Conclusions In this large series of injured children, a positive FAST exam improves the ability to predict the need for early surgical intervention, and accuracy is greater for FF in HD unstable patients 2 hours after arrival to the ED.

In an effort to identify improvement opportunities for earlier dementia detection and care within a large, integrated health care system serving diverse Medicare Advantage (MA) beneficiaries, we examined where, when, and by whom Alzheimer's disease and related dementias (ADRD) diagnoses are recorded as well as downstream health care utilization and life care planning.Patients 65 years and older, continuously enrolled in the Kaiser Foundation health plan for at least 2 years, and with a first ADRD diagnosis between January 1, 2015, and December 31, 2018, comprised the incident cohort. Electronic health record data were used to identify site and source of the initial diagnosis (clinic vs hospital-based, provider type), health care utilization in the year before and after diagnosis, and end-of-life care.ADRD prevalence was 5.5%. A total of 25,278 individuals had an incident ADRD code (rate: 1.2%) over the study period-nearly half during a hospital-based encounter. Hospital-diagnosed patients had higher comorbidities, acute care use before and after diagnosis, and 1-year mortality than clinic-diagnosed individuals (36% vs 11%). Many decedents (58%-72%) received palliative care or hospice. Of the 55% diagnosed as outpatients, nearly two-thirds were diagnosed by dementia specialists; when used, standardized cognitive assessments indicated moderate stage ADRD. Despite increases in advance care planning and visits to dementia specialists in the year after diagnosis, acute care use also increased for both clinic- and hospital-diagnosed cohorts.Similar to other MA plans, ADRD is under-diagnosed in this health system, compared to traditional Medicare, and diagnosed well beyond the early stages, when opportunities to improve overall outcomes are presumed to be better. Dementia specialists function primarily as consultants whose care does not appear to mitigate acute care use. Strategic targets for ADRD care improvement could focus on generating pragmatic evidence on the value of proactive detection and tracking, care planning, and the role of specialists in chronic care management.

Background Emergency medical services (EMS) patients with acute dyspnea require prompt treatment. Limited data describe out‐of‐hospital dyspnea treatment with non‐invasive, positive‐pressure ventilation (NIPPV), including continuous positive airway pressure (CPAP) or bi‐level positive air pressure (BPAP). We sought to determine the course and outcomes of out‐of‐hospital acute dyspnea patients treated with NIPPV. Methods We analyzed retrospective data on 1289 EMS agencies from the ESO Data Collaborative (ESO, Inc., Austin, TX) between January and December 2018. We defined acute dyspnea as adults with an initial respiratory rate ≥ 30 breaths/min (bpm), with a primary or secondary EMS subjective impression of a respiratory condition, who received oxygen and/or a respiratory medication and had 2 or more recordings of respiratory rate (RR). We excluded patients with trauma and those with altered mental status. We identified cases receiving care with and without NIPPV. The primary outcome was change in respiratory rate (RR), censored at 90 minutes of treatment. We compared baseline characteristics between NIPPV and non‐NIPPV patients. We compared RR changes between NIPPV and non‐NIPPV patients at 20 and 40 minutes of treatment. Using mixed linear, fractional polynomial, and multiple spline models, we examined the association of out‐of‐hospital NIPPV with overall change in RR. Secondary outcomes included whether the patient received advanced airway treatment (intubation, supraglottic airway device, and/or cricothyroidotomy). Results We analyzed 33,585 EMS encounters for patients with acute dyspnea, including 8,750 (26.1%) NIPPV and 24,835 (73.9%) non‐NIPPV encounters. Median treatment duration was similar between NIPPV and non‐NIPPV (23.3 minutes vs 23.6 minutes, rank‐sum P = 0.266). Common concurrent treatments included albuterol (NIPPV, 48.8%; non‐NIPPV, 46.2%), ipratropium bromide (27.9%, 24.8%), and methylprednisolone (24.9%, 18.5%). At 20 minutes, mean RR change was slightly lower for the NIPPV group than non‐NIPPV; −6.0 versus −6.8 breaths/min. At 40 minutes, mean RR change was similar between NIPPV and non‐NIPPV groups; −7.7 versus −7.9 breaths/min. On linear mixed modeling adjusted for age, sex, incident location, race, ethnicity, agency type, initial RR, and medication use, NIPPV was associated with a smaller RR decrease across time than NIPPV; [NIPPV × time] interaction P

Objective Mental health emergencies among young people are increasing. There is growing pressure for emergency departments to screen patients for mental health needs even when it is not their chief complaint. We hypothesized that young people with an initial non‐specific condition and emergency department (ED) revisits have increased mental health needs. Methods Retrospective, observational study of the California Office of Statewide Health Planning and Development Emergency Department Discharge Dataset (2010–2014) of young people (11–24 years) with an index visit for International Classification of Diseases, Ninth Revision diagnostic codes of “Symptoms, signs, and ill‐defined conditions” (Non‐Specific); “Diseases of the respiratory system” (Respiratory) and “Unintentional injury” (Trauma) who were discharged from a California ED. Patients were excluded if they had a prior mental health visit, chronic disease, or were pregnant. ED visit frequency was counted over 12 months. Regression models were created to analyze characteristics associated with a mental health visit. Results Patients in the Non‐Specific category compared to the Respiratory category had 1.2 times the odds of a future mental health visit (OR 1.20; 95% CI 1.17–1.24). Patients with ≥1 ED revisit, regardless of diagnostic category, had 1.3 times the odds of a future mental health visit. Patients with both a Non‐Specific index visit and 1, 2, and 3 or more revisits with non‐specific diagnoses had increasing odds of a mental health visit (OR 1.38; 95% CI 1.29–1.47; OR 1.70; 95% CI 1.46–1.98; OR 2.20; 95% CI 1.70–2.87, respectively.) Conclusions Young people who go to the ED for non‐specific conditions and revisits may benefit from targeted ED mental health screening.

Airway management is an important intervention during resuscitation of out‐of‐hospital cardiac arrest (OHCA). Endotracheal intubation is commonly used by emergency medical services paramedics in the advanced airway management of OHCA, but numerous studies question its safety and effectiveness. Furthermore, there is now increasing use of supraglottic airway devices. In this review, we provide an overview of 3 recent randomized clinical trials of advanced airway management (Pragmatic Airway Resuscitation Trial [PART], AIRWAYS‐2, and Cardiac Arrest Airway Management [CAAM]) and highlight new information that is available to guide OHCA airway management practices.

In response to ever-increasing application requirements in lighting and displays, a tremendous emphasis is being placed on single-component white-light emission. Single-component inorganic borates doped with rare earth metal ions have shown prominent achievements in white-light emission. The first environmentally friendly defect-induced white-light emitting crystalline inorganic borate, Ba2 [Sn(OH)6 ][B(OH)4 ]2 , has been prepared. Additionally, it is the first borate-stannate without a Sn-O-B linkage. Notably, Ba2 [Sn(OH)6 ][B(OH)4 ]2 shows Commission Internationale de l'Eclairage (CIE) chromaticity coordinates of (0.42, 0.38), an ultrahigh color rendering index (CRI) of 94.1, and an appropriate correlated color temperature (CCT) of 3083 K. Such a promising material will provide a new approach in the development of white-light emitting applications.

Heterostructured metal-organic framework (MOF)-on-MOF thin films have the potential to cascade the various properties of different MOF layers in a sequence to produce functions that cannot be achieved by single MOF layers. An integration method that relies on van der Waals interactions, and which overcomes the lattice-matching limits of reported methods, has been developed. The method deposits molecular sieving Cu-TCPP (TCPP=5,10,15,20-tetrakis(4-carboxyphenyl)porphyrin) layers onto semiconductive Cu-HHTP (HHTP=2,3,6,7,10,11-hexahydrotriphenylene) layers to obtain highly oriented MOF-on-MOF thin films. For the first time, the properties in different MOF layers were cascaded in sequence to synergistically produce an enhanced device function. Cu-TCPP-on-Cu-HHTP demonstrated excellent selectivity and the highest response to benzene of the reported recoverable chemiresistive sensing materials that are active at room temperature. This method allows integration of MOFs with cascading properties into advanced functional materials.

OBJECTIVE Clinical trial investigators often assemble internal study monitoring committees (SMCs) to measure individual or group adherence with trial performance benchmarks. We examined the processes and results of study monitoring in an international trial of out-of-hospital cardiac arrest. METHODS We studied SMC operations for the Resuscitation Outcomes Consortium (ROC) Continuous Chest Compressions (CCC) trial, which compared continuous with interrupted chest compressions upon survival after out-of-hospital cardiac arrest. The SMC defined trial performance benchmarks, which included compliance with the intervention, cardiopulmonary resuscitation (CPR) process data availability and timely data completion. Trial investigators received monthly performance reports. We determined rates of trial noncompliance and suspension from the trial. RESULTS ROC-CCC enrolled a total of 23,711 subjects in the primary analysis population. Across 113 enrolling agencies, the SMC monitored performance for a total 2,367 agency-months. Emergency medical services agencies were on probation for a total of 178 (7.5%) agency-months. Fifty-five agencies were placed on probation at least once, of which 78% improved their performance and were approved for continued participation in the trial. A total of 12 agencies were suspended from trial participation. Data monitoring resulted in high-quality CPR (mean chest compression fraction = 0.80), 87% CPR process availability and timely data completion (75th and 95th percentiles prehospital data = 22 and 57 days; hospital data = 58 and 118 days). CONCLUSIONS Study monitoring procedures may play an important role in ensuring the performance quality in acute care clinical trials.

Objectives The current evidence base regarding the effectiveness of home-based palliative care (HomePal) on outcomes of importance to multiple stakeholders remains limited. The purpose of this study was to compare end-of-life care in decedents who received HomePal with two cohorts that either received hospice only (HO) or did not receive HomePal or hospice (No HomePal-HO). Design Retrospective cohorts from an ongoing study of care transition from hospital to home. Data were collected from 2011 to 2016. Setting Kaiser Permanente Southern California. Participants Decedents 65 and older who received HomePal (n = 7177) after a hospitalization and two comparison cohorts (HO only = 25 102; No HomePal-HO = 22 472). Measurements Utilization data were extracted from administrative, clinical, and claims databases, and death data were obtained from state and national indices. Days at home was calculated as days not spent in the hospital or in a skilled nursing facility (SNF). Results Patients who received HomePal were enrolled for a median of 43 days and had comparable length of stay on hospice as patients who enrolled only in hospice (median days = 13 vs 12). Deaths at home were comparable between HomePal and HO (59% vs 60%) and were higher compared with No HomePal-HO (16%). For patients who survived at least 6 months after HomePal admission (n = 2289), the mean number of days at home in the last 6 months of life was 163 ± 30 vs 161 ± 30 (HO) vs 149 ± 40 (No HomePal-HO). Similar trends were also noted for the last 30 days of life, 25 ± 8 (HomePal, n = 5516), 24 ± 8 (HO), and 18 ± 11 (No HomePal-HO); HomePal patients had a significantly lower risk of hospitalizations (relative risk [RR] = .58-.87) and SNF stays (RR = .32-.77) compared with both HO and No HomePal-HO patients. Conclusion Earlier comprehensive palliative care in patients' home in place of or preceding hospice is associated with fewer hospitalizations and SNF stays and more time at home in the final 6 months of life. J Am Geriatr Soc, 2019.

Background Our objective was to assess the association between intensive care unit (ICU)‐free days and patient outcomes in pediatric prehospital care and to evaluate whether ICU‐free days is a more sensitive outcome measure for emergency medical services research in this population. Methods This study used data from a previous pediatric prehospital trial. The original study enrolled patients ≤12 years of age and compared bag‐valve‐mask‐ventilation (BVM) versus endotracheal intubation (ETI) during prehospital resuscitation. For the current study, we defined ICU‐free days as 30 minus the number of days in the ICU (range, 0–30 days) and assigned 0 ICU‐free days for death within 30 days. We compared ICU‐free days between the original study treatment groups (BVM vs ETI) and with the original trial outcomes of survival to hospital discharge and Pediatric Cerebral Performance Category (PCPC). Results Median ICU‐free days for the BVM group (n = 404) versus ETI group (n = 416) was not statistically different: 0 ICU‐free days (interquartile range, 0–10) versus 0 (0–0), P = 0.219. Median ICU‐free days were greater for BVM group in 3 subgroups: foreign body aspiration 30 (0–30) versus 0 (0–21), P = 0.028; child maltreatment 0 (0–14.2) versus 0 (0‐0), P = 0.004; and respiratory arrest 25 (1–29) versus 7.5 (0–27.7), P = 0.015. In the original trial, neither survival nor PCPC demonstrated differences in all 3 subgroups—survival was greater with BVM for child maltreatment and respiratory arrest and favorable PCPC was greater with BVM for foreign body aspiration. Overall, in the current study, patients with more ICU‐free days also had greater survival to hospital discharge and more favorable PCPC scores. Conclusions This initial study of the association between ICU‐free days and patient outcomes during prehospital pediatric resuscitation appears to support the use of ICU‐free days as a clinical endpoint in this population. ICU‐free days may be more sensitive than either mortality or PCPC alone while capturing aspects of both measures.

Objective With a significant proportion of individuals with opioid use disorder not currently receiving treatment, it is critical to find novel ways to engage and retain patients in treatment. Our objective is to describe the feasibility and preliminary outcomes of a program that used emergency physicians to initiate a bridge treatment, followed by peer support services, behavioral counseling, and ongoing treatment and follow‐up. Methods We developed a program called the Houston Emergency Opioid Engagement System (HEROES) that provides rapid access to board‐certified emergency physicians for initiation of buprenorphine, plus at least 1 behavioral counseling session and 4 weekly peer support sessions over the course of 30 days. Follow‐ups were conducted by phone and in person to obtain patient‐reported outcomes. Primary outcomes included percentage of patients who completed the 30‐day program and the percentage for successful linkage to more permanent ongoing treatment after the initial program. Results There were 324 participants who initiated treatment on buprenorphine from April 2018 to July 2019, with an average age of 36 (±9.6 years) and 52% of participants were males. At 30 days, 293/324 (90.43%) completed the program, and 203 of these (63%) were successfully connected to a subsequent community addiction medicine physician. There was a significant improvement (36%) in health‐related quality of life. Conclusion Lack of insurance is a predictor for treatment failure. Implementation of a multipronged treatment program is feasible and was associated with positive patient‐reported outcomes. This approach holds promise as a strategy for engaging and retaining patients in treatment.

Objective Intravenous fluid administration is a main component of sepsis therapy, but physicians are cautious about giving fluids to end‐stage renal disease (ESRD) patients out of concern for causing volume overload. We compared the outcomes of septic shock patients with and without ESRD and evaluated the association between early intravenous fluid administration and outcomes. Methods We analyzed patients enrolled in the Protocolized Care for Early Septic Shock (PROCESS) trial, which studied different resuscitation strategies for early septic shock. Stratifying for ESRD, we compared patient characteristics, course of care, and outcomes between ESRD and non‐ESRD. Using multivariable logistic regression, we determined the association between 6‐hour total fluid volume (> = 30 mL/kg vs = 30 mL/kg (66.6% vs 86.7% P = 30 mL/kg intravenous fluid did not alter any outcome. For non‐ESRD patients, receiving ≥30 mL/kg of intravenous fluid was associated with increased 90‐day mortality (adjusted odds ratio = 1.64; 95% confidence interval, 1.03‐2.61). Conclusions In the PROCESS trial, ESRD patients had similar outcomes to non‐ESRD patients. Although ESRD patients received less intravenous fluid administration, most received over 30 mL/kg in the first 6 hours. In contrast to non‐ESRD patients, receiving ≥30 mL/kg of intravenous fluid was not associated with worse outcomes in ESRD.

BACKGROUND AND OBJECTIVES The purpose of this study was to determine charges following unilateral mastectomy (UM) and bilateral mastectomy (BM) for patients with unilateral breast cancer (UBC). We hypothesized that BM may be associated with fewer charges over time. METHODS A retrospective review was conducted of patients with UBC treated between 2006 and 2010 with UM and BM in a large healthcare system. Institutional billing data were investigated for 5 years postoperatively to calculate the immediate and subsequent charges of all inpatient and outpatient breast-related care associated with the initial diagnosis for a subset of patients identified using propensity score matching method. RESULTS A subset of matched patients (n = 320) undergoing UM (n = 160) or BM (n = 160) were included in this analysis. At 1 year, there was a trend toward lower total charges following UM as compared with BM (median, $125 230 vs $138 467; P = .6075). However, during years 2 to 5, total charges were significantly higher following UM vs BM ($22 128 vs $13 478; P = .0116). CONCLUSIONS While initially higher, overall charges for BM are lower than UM between 2 and 5 years out from surgery. Further study is necessary to determine if this trend is sustained over the long term. These data can inform patient decision making regarding mastectomy for their breast cancer.