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Background Social media use has become a mainstay of communication and with that comes the exchange of factual and non-factual information. Social media has given many people the opportunity to speak their opinions without repercussions and create coalitionS of like-minded people. This also has led to the development of a community know as anti-vaxxers or vaccine deniers. This research explores the extent to which vaccine knowledge has reached on social media. Methods This cross sectional research explored the relationship between the spread of information regarding vaccines in relation to social media use. A sample of 2515 people over the age of 18 around the world completed the survey via a link distributed on Twitter, Facebook and Instagram. A series of questions on vaccine knowledge and beliefs were compounded to create an individual’s “knowledge score” and a “belief score”. Knowledge scores were ranked from low knowledge to high knowledge with increasing scores. Belief scores were ranked from belief in myths to disbelief in myths with higher scores. This score was then analysed, using a Welch test and post hoc testing when applicable, across demographics and questions relating to social media use. Results Significant relations were found in both the knowledge and belief categories, many of which were similar findings between the two. North Americans had significantly lower knowledge and belief scores compared to all other continents. While the majority of people primarily use Facebook, Twitter users were significantly more knowledgeable. It was also found that higher education was correlated with higher knowledge and belief scores. Conclusions Overall, these correlations are important in determining ways to intervene into the anti-vax movement through the use of social media. Cross demographics were not analysed in this study but could be in future studies. To better understand the social media exposures related to vaccine information a follow up structured interview research study would be beneficial. Note that due to the cross sectional nature of this study, causal relationships could not be made.

Lipoprotein(a) (Lp(a)) is a prothrombotic and anti-fibrinolytic lipoprotein, whose role has not been clearly defined in the pathogenesis of coronavirus disease 2019 (COVID-19). In this prospective observational study, serum Lp(a) as well as outcomes were measured in 50 COVID-19 patients and 30 matched sick controls. Lp(a) was also assessed for correlation with a wide panel of biomarkers. Serum Lp(a) did not significantly differ between COVID-19 patients and sick controls, though its concentration was found to be significantly associated with severity of COVID-19 illness, including acute kidney failure stage (r = 0.380, p = 0.007), admission disease severity (r = 0.355, p = 0.013), and peak severity (r = 0.314; p = 0.03). Lp(a) was also positively correlated with interleukin (IL)-8 (r = 0.308; p = 0.037), fibrinogen (r = 0.344; p = 0.032) and creatinine (r = 0.327; p = 0.027), and negatively correlated with ADAMTS13 activity/VWF:Ag (r = − 0.335; p = 0.021); but not with IL-6 (r = 0.241; p = 0.106). These results would hence suggest that adverse outcomes in patients with COVID-19 may be aggravated by a genetically determined hyper-Lp(a) state rather than any inflammation induced elevations. Supplementary Information The online version contains supplementary material available at 10.1007/s11239-021-02597-y.

Complement system hyperactivation has been proposed as a potential driver of adverse outcomes in severe acute respiratory syndrome coronavirus 2 infected patients, given prior research of complement deposits found in tissue and blood samples, as well as evidence of clinical improvement with anticomplement therapy. Its role in augmenting thrombotic microangiopathy mediated organ damage has also been implicated in coronavirus disease 2019 (COVID‐19). This study aimed to examine associations between complement parameters and progression to severe COVID‐19 illness, as well as correlations with other systems. Blood samples of COVID‐19 patients presenting to the emergency department (ED) were analyzed for a wide panel of complement and inflammatory biomarkers. The primary outcome was COVID‐19 severity at index ED visit, while the secondary outcome was peak disease severity over the course of illness. Fifty‐two COVID‐19 patients were enrolled. C3a (p = 0.018), C3a/C3 ratio (p = 0.002), and sC5b‐9/C3 ratio (p = 0.021) were significantly elevated in with severe disease at ED presentation. Over the course of illness, C3a (p = 0.028) and C3a/C3 ratio (p = 0.003) were highest in the moderate severity group. In multivariate regression controlled for confounders, complement hyperactivation failed to predict progression to severe disease. C3a, C3a/C3 ratio, and sC5b‐9/C3 ratio were correlated positively with numerous inflammatory biomarkers, fibrinogen, and VWF:Ag, and negatively with plasminogen and ADAMTS13 activity. We found evidence of complement hyperactivation in COVID‐19, associated with hyperinflammation and thrombotic microangiopathy. Complement inhibition should be further investigated for potential benefit in patients displaying a hyperinflammatory and microangiopathic phenotype.

BackgroundThe mechanism by which SARS-CoV-2 triggers cell damage and necrosis are yet to be fully elucidated. We sought to quantify epithelial cell death in patients with COVID-19, with an estimation of relative contributions of apoptosis and necrosis.MethodsBlood samples were collected prospectively from adult patients presenting to the emergency department. Circulating levels of caspase-cleaved (apoptosis) and total cytokeratin 18 (CK-18) (total cell death) were determined using M30 and M65 enzyme assays, respectively. Intact CK-18 (necrosis) was estimated by subtracting M30 levels from M65.ResultsA total of 52 COVID-19 patients and 27 matched sick controls (with respiratory symptoms not due to COVID-19) were enrolled. Compared with sick controls, COVID-19 patients had higher levels of M65 (p = 0.046, total cell death) and M30 (p = 0.0079, apoptosis). Hospitalised COVID-19 patients had higher levels of M65 (p= 0.014) and intact CK-18 (p= 0.004, necrosis) than discharged patients. Intensive care unit (ICU)-admitted COVID-19 patients had higher levels of M65 (p= 0.004), M30 (p= 0.004) and intact CK-18 (p= 0.033) than hospitalised non-ICU admitted patients. In multivariable logistic regression, elevated levels of M65, M30 and intact CK-18 were associated with increased odds of ICU admission (OR=22.05, p=0.014, OR=19.71, p=0.012 and OR=14.12, p=0.016, respectively).ConclusionNecrosis appears to be the main driver of hospitalisation, whereas apoptosis and necrosis appear to drive ICU admission. Elevated levels CK-18 levels are independent predictors of severe disease, and could be useful for risk stratification of COVID-19 patients and in assessment of therapeutic efficacy in early-phase COVID-19 clinical trials.

This2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendationsfor advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

PURPOSE: Although basic objective measures (e.g., knee laxity, strength, and hop tests) have been related to subjective measures of function, associations between knee-specific objective and subjective measures have yet to be completed. The objective was to determine if knee joint contact and ligament forces differ between pre- and post-anterior cruciate ligament (ACL) reconstructed states and if these forces relate to their patient's respective subjective functional ability scores. METHODS: Twelve patients performed a hopping task before and after reconstruction. Magnetic resonance images and OpenSim were used to develop patient-specific models in static optimization and joint reaction analyses. Questionnaires concerning each patient's subjective functional ability were also collected and correlated with knee joint contact and ligament forces. RESULTS: No significant differences were observed between deficient and reconstructed groups with respect to knee joint contact or ligament forces. Nevertheless, there were several significant (P < 0.05) moderate to strong correlations between subjective and objective measures including Tegner activity level to contact force in both states (r = 0.67-0.76) and International Knee Documentation Committee to compressive and anterior shear forces (r = 0.64-0.66). CONCLUSION: Knee-specific objective measures of a patient's functional capacity can represent their subjective ability, which explains this relationship to a greater extent than past anatomical and gross objective measures of function. This consolidation is imperative for improving the current rehabilitation schema as it allows for external validation of objective and subjective functional measures. With poor validation of subjective function against objective measures of function, the reinjury rate is unlikely to diminish, continuing the heavy financial burden on health care systems.

PURPOSE This study aimed to quantify the relationship between objective and subjective measures of functional ability and determine if measures in the deficient (ACLd) state were correlated to, and capable of predicting a patient's objective and subjective measures in the reconstructed (ACLr) state. METHODS Twenty ACL-injured participants completed hop and side cut movements prior to and 10 months post-reconstruction. Their subjective measures (Tegner, Lysholm, IKDC, KOOS, and KNEEs) were related to objective measures of functional ability (peak knee flexion, peak knee extensor moment, stiffness, knee joint center excursion (KJCE), and knee joint center boundary). Correlations were used to determine relationships between variables whereas regressions were used to identify ACLd score's predictive ability of an ACLr score. RESULTS Relationships between objective and subjective measures were task and ACL status dependent with KJCE and stiffness most commonly being related to subjective scores. The greatest correlation was between knee stiffness and Tegner in the ACLr group during the side cut (r = 0.69). Peak knee flexion angle (adj. R2 = 0.4-0.66) was the best objective predictor between ACLd and ACLr states while KOOS-ADL had the strongest correlations (r = 0.70-0.77) and Tegner had the greatest predictive power (odds ratio: 1.46-1.86) between states in both tasks. CONCLUSION Objective measures show a wide range of correlation to subjective measures with some being quite strong. Furthermore, objective measures in the ACLd state are more correlated and more often capable of predicting ACLr scores than the subjective measures of functional ability.

BackgroundSARS-CoV-2 viral entry may disrupt angiotensin II (Ang II) homeostasis in part via ACE2 downregulation, potentially contributing to COVID-19 induced lung injury. Preclinical models of viral pneumonias that utilize ACE2 demonstrate Ang II type 1 receptor (AT1R) blockade mitigates lung injury, though observational COVID-19 data addressing the effect of AT1R blockade remain mixed.MethodsMulticenter, blinded, placebo-controlled randomized trial of losartan (50 mg PO twice daily for 10 days) versus placebo. Hospitalized patients with COVID-19 and a respiratory sequential organ failure assessment score of at least 1 and not already taking a renin-angiotensin-aldosterone system (RAAS) inhibitor were eligible. The primary outcome was the imputed partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio at 7 days. Secondary outcomes included ordinal COVID-19 severity, oxygen, ventilator, and vasopressor-free days, and mortality. Losartan pharmacokinetics (PK) and RAAS components [Ang II, angiotensin-(1–7) (Ang-(1–7)), ACE, ACE2] were measured in a subgroup of participants.FindingsFrom April 2020 - February 2021, 205 participants were randomized, 101 to losartan and 104 to placebo. Compared to placebo, losartan did not significantly affect PaO2/FiO2 ratio at 7 days [difference of -24.8 (95% -55.6 to 6.1; p=0.12)]. Losartan did not improve any secondary clinical outcome, but worsened vasopressor-free days. PK data were consistent with appropriate steady-state concentrations, but we observed no significant effect of losartan on RAAS components.InterpretationInitiation of orally administered losartan to hospitalized patients with COVID-19 and acute lung injury does not improve PaO2 / FiO2 ratio at 7 days. These data may have implications for ongoing clinical trials.Trial RegistrationLosartan for Patients With COVID-19 Requiring Hospitalization (NCT04312009), https://clinicaltrials.gov/ct2/show/NCT04312009

Background Anterior cruciate ligament (ACL) rupture is a debilitating knee injury associated with sequela such as joint instability and progressive degeneration. Unfortunately, following surgical ACL reconstruction in adolescents the rates of either ACL graft failure or contralateral ACL rupture ranges from 17–30%. A contributing factor to the high re-injury rate in this population may be the limited evidence regarding appropriate criteria for allowing unrestricted return-to-activities (RTA) post-operatively. Several systematic reviews have already sought to develop a consensus on what criteria should be utilized for releasing patients to unrestricted sports activities; however, these reviews have focused on adult populations, a group at much lower risk for re-injury. Our objective is to systematically examine the literature and identify the criteria used in existing research when determining unrestricted RTA following an ACL reconstruction in an adolescent population. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search will be performed of the Medline/PubMed, Cochrane, Embase, CINAHL, and SPORTDiscus electronic database. Searches will be conducted from January 1st, 2000 until submission of the final review. Studies will be identified that include adolescent patients (≤ 18 years old) undergoing a primary ACL reconstruction, and which have specified the criteria used to determine RTA. Each article will be independently screened by two reviewers. To supplement the electronic database search, citations within all included studies will be manually reviewed. Reviewers will record the RTA assessment utilized and the rates of ACL re-injury through a standardized data extraction sheet. Reviewers will resolve full-text screening and data extraction disagreements through discussion. Synthesis of the collected data will focus on compiling and mapping the most commonly used types of RTA criteria. Discussion This systematic review will clarify the existing evidence on RTA in adolescent patients post-ACL reconstruction. This will help future interventions build more effective adolescent-specific RTA assessments through the validation of current RTA criteria as well as the implementation of new criteria according to the identified literature gaps.

Background and aims Reduction of atherogenic lipoproteins is often the ultimate goal of nutritional interventions, however this is complicated given that hypolipidemia is frequently observed in coronavirus disease 2019 (COVID-19) patients. We aimed to explore the association of hypolipidemia with patient outcomes in terms of immunothrombosis and multiorgan injury, focusing on specialized apolipoproteins apo A1 and apo B. Methods Lipid profiles of 50 COVID-19 patients and 30 sick controls presenting to the Emergency Department (ED) were measured in this prospective observational study. The primary outcome was development of severe acute kidney injury (AKI). Need for hospitalization and ICU admission were secondary outcomes. Lipoproteins were analyzed for independent association with serum creatinine (SCr) increase ratio and correlated with a wide panel of biomarkers. Results COVID-19 cohort had significantly lower apo A1 (p = 0.006), and higher apo B/apo A1 ratio (p = 0.041). Patients developing severe AKI had significantly lower LDL-C (p = 0.021). Apo B/apo A1 was associated with 2.25-fold decrease in serum SCr increase ratio, while LDL-C with a 1.5% decrease. Hypolipidemia correlated with low plasminogen, ADAMTS13 activity/VWF:Ag, and high inflammatory biomarkers (CRP, IL-6, IL-8, IL-10), plasminogen activator inhibitor-1 (PAI-1), ED creatinine, and SCr increase ratio. Conclusion Although favored in dietetics, findings of a low LDL-C in COVID-19 patients should be alarming in light of our observations. Low apo B/apo A1 ratio and LDL-C are predictive of renal deterioration in COVID-19 patients, and low LDL-C in particular may potentially serve to indicate COVID-19 related AKI driven by disrupted fibrinolysis and a secondary thrombotic microangiopathy-like process.

Objectives Severe coronavirus disease 2019 (COVID-19) is associated with a dysregulated immune state. While research has focused on the hyperinflammation, little research has been performed on the compensatory anti-inflammatory response. The aim of this study was to evaluate the anti-inflammatory cytokine response to COVID-19, by assessing interleukin-10 (IL-10) and IL-10/lymphocyte count ratio and their association with outcomes. Methods Adult patients presenting to the emergency department (ED) with laboratory-confirmed COVID-19 were recruited. The primary endpoint was maximum COVID-19 severity within 30 days of index ED visit. Results A total of 52 COVID-19 patients were enrolled. IL-10 and IL-10/lymphocyte count were significantly higher in patients with severe disease (p Conclusions The hyperinflammatory response to COVID-19 is accompanied by a simultaneous anti-inflammatory response, which is associated with poor outcomes and may increase the risk of new positive bacterial cultures. IL-10 and IL-10/lymphocyte count at ED presentation were independent predictors of COVID-19 severity. Moreover, elevated IL-10 was more strongly associated with outcomes than pro-inflammatory IL-6 or IL-8. The anti-inflammatory response in COVID-19 requires further investigation to enable more precise immunomodulatory therapy against SARS-CoV-2.

Introduction Severe COVID‐19 is often compounded by a prothrombotic state that is associated with poor outcomes. In this investigation, we aimed to evaluate ADAMTS13 activity, von Willebrand factor level (VWF:Ag), and the corresponding ADAMTS13 activity/VWF:Ag ratio, in patients with COVID‐19 and for associations with disease progression and acute kidney injury (AKI). Methods Patients presenting to the emergency department (ED) with COVID‐19 were enrolled in this prospective, observational study. ADAMTS13 activity and VWF:Ag were measured at index ED visit. The primary endpoint was severe AKI defined by KDIGO stage 2 + 3 criteria, while the secondary endpoint was peak 30‐day COVID‐19 severity. Results A total of 52 adult COVID‐19 patients were enrolled. Overall, we observed that 23.1% of the cohort had a relative deficiency in ADAMTS13 activity, while 80.8% had elevated VWF:Ag. The ADAMTS13 activity/VWF:Ag ratio was significantly lower in patients with severe AKI (P = .002) and those who developed the severe form of COVID‐19 (P = .020). The ADAMTS13 activity/VWF:Ag ratio was negatively correlated with age (P

The American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend ventilation rates of eight to ten breaths per minute or two ventilations every 30 compressions, and tidal volumes between 500-600 ml. However, compliance with these guidelines is mainly unknown. The objective of this study is to estimate the proportion of simulated adult OHCA cases that meet guideline-based ventilation targets.We conducted a blinded prospective observational study of standardized simulated cases of EMS-witnessed adult OHCA. During scheduled training sessions, resuscitations were performed by high-quality CPR trained EMS teams composed of four on-duty, full-time EMT/Paramedics from a large urban fire-based EMS agency. A high-fidelity simulation center allowed complete audio and video monitoring from a control room. Rescuers were unaware of the study, or that ventilation practices were being observed. All interventions, including airway and ventilation strategies, were at the discretion of the clinical team. A calibrated Laerdal SimMan 3 G manikin and associated Laerdal Debrief Viewer software recorded ventilation rate, tidal volume, and minute ventilation. Simulations achieving median ventilation rate 7-10 breaths/min, tidal volume 500-600 ml, and minute ventilation 3.5-6 liters/min were considered meeting guideline-based targets.A total of 106 EMS teams were included in the study. Only 3/106 [2.8% (95% CI: 0.6-8.0)] of the EMS teams demonstrated ventilation characteristics meeting all guideline-based targets. The median ventilation rate was 5.8 breaths/min (IQR 4.4-7.7 breaths/min) with 26/106 [24.5% (95% CI: 17.2-33.7)] between 7-10 breaths/min. The median tidal volume was 413.5 ml (IQR 280.5-555.4 ml), with 18/106 [17.0% (95% CI: 10.9-25.5)] between 500-600 ml. The median minute ventilation was 2.4 L/min (IQR 1.2-3.6 L/min) with 16/106 [15.1% (95% CI: 9.4-23.3)] between 3.5-6.0 L/min.During simulated adult OHCA resuscitation attempts, ventilation practices rarely met guideline-based targets, despite being performed by well-trained EMS providers. Methods should be developed to monitor and ensure high-quality ventilation during actual OHCA resuscitation attempts.

ObjectivesSevere coronavirus disease 2019 (COVID-19) is associated with a dysregulated immune state, called cytokine storm. While research has focused on the hyperinflammation, little research has been performed on the compensatory anti-inflammatory response which if severe may lead to a state of functional immunoparalysis. The aim of this study was to evaluate the anti-inflammatory response to COVID-19, by assessing interleukin-10 (IL-10) and IL-10/lymphocyte count ratio and their association with patient outcomes.MethodsAdult patients presenting to the emergency department (ED) with laboratory-confirmed COVID-19 were recruited. The primary endpoint was peak COVID-19 severity within 30 days of index ED visit. Additional endpoints included COVID-19 severity at ED disposition, development of severe acute kidney injury (AKI) or secondary bacterial infections.ResultsA total of 52 COVID-19 patients were enrolled. IL-10 and IL-10/lymphocyte count were significantly higher in patients with severe disease at both time points (all pConclusionsThe hyperinflammatory response to COVID-19 is accompanied by a simultaneous anti-inflammatory response, which is associated with poor outcomes and may increase the risk of secondary bacterial infections. IL-10 and IL-10/lymphocyte ratio at ED presentation were independent predictors of COVID-19 severity. Functional immunoparalysis in COVID-19 requires further investigation to enable more precise immunomodulatory therapy against SARS-CoV-2.

Background Out-of-hospital cardiac arrest (OHCA) studies have focused on the benefits and harms of placing an intra-arrest advanced airway, but few studies have evaluated the benefits and harms after successful placement. We hypothesize that increased time in the tumultuous prehospital environment after intra-arrest advanced airway placement results in reduced patient survival. Methods This was a secondary analysis of adult, non-traumatic, OHCA patients with an advanced airway placed in the PRIMED trial. The exposure variable was the time interval between successful advanced airway placement and Emergency Department (ED) arrival. The outcome was cerebral performance category (CPC) 1 or 2 at hospital discharge. Multivariable logistic regression, adjusted for Utstein variables and resuscitation-associated time intervals, was used to estimate adjusted odds ratios (aOR). Results The cohort of complete cases included 4779 patients. The median time exposed to a prehospital advanced airway was 27 min (IQR 20–35). The total prehospital time was 39.4 min (IQR 32.3−48.1). An advanced airway was placed intra-arrest in 3830 cases (80.1%) and post-return of spontaneous circulation (post-ROSC) in 949 cases (19.9%). Overall, 486 (10.2%) of the cohort achieved the CPC outcome, but this was higher in the post-ROSC (21.7%) versus intra-arrest (7.5%) cohort. CPC was not associated with the time interval from advanced airway placement to ED arrival in the intra-arrest airway cohort (aOR 0.98, 95%CI 0.94−1.01). Conclusions In OHCA patients who receive an intra-arrest advanced airway, longer time intervals exposed to a prehospital advanced airway are not associated with reduced patient survival.

Anterior cruciate ligament (ACL) injury rates in female adolescents are increasing. Irrespective of treatment options, approximately 1/3 will suffer secondary ACL injuries following their return to activity (RTA). Despite this, there are no evidence-informed RTA guidelines to aid clinicians in deciding when this should occur. The first step towards these guidelines is to identify relevant and feasible measures to assess the functional status of these patients. The purpose of this study was therefore to evaluate tests frequently used to assess functional capacity following surgery using a Reduced Error Pruning Tree (REPT). Thirty-six healthy and forty-two ACLinjured adolescent females performed a series of functional tasks. Motion analysis along with spatiotemporal measures were used to extract thirty clinically relevant variables. The REPT reduced these variables down to two limb symmetry measures (maximum anterior hop and maximum lateral hop), capable of classifying injury status between the healthy and ACL injured participants with a 69% sensitivity, 78% specificity and kappa statistic of 0.464. We, therefore, conclude that the REPT model was able to evaluate functional capacity as it relates to injury status in adolescent females. We also recommend considering these variables when developing RTA assessments and guidelines.Clinical Relevance- Our results indicate that spatiotemporal measures may differentiate ACL-injured and healthy female adolescents with moderate confidence using a REPT. The identified tests may reasonably be added to the clinical evaluation process when evaluating functional capacity and readiness to return to activity.

Highlights • No clear pattern of leukocyte abnormalities is seen in children with COVID-19. • Leukocyte counts may not be a reliable marker of pediatric COVID-19 severity. • C-Reactive Protein and Lactate Dehydrogenase are frequently elevated in severe cases. • Procalcitonin is often elevated and may reflect bacterial co-infection. • Elevated creatine kinase-MB is seen in one-third of children with mild COVID-19., Limited data exists to-date on the laboratory findings in children with COVID-19, warranting the conduction of this study, in which we pool the currently available literature data on the laboratory findings seen in children with mild and severe COVID-19. Following an extensive literature search, we identified 24 eligible studies, including a total of 624 pediatric cases with laboratory-confirmed COVID-19, which report data on 27 different biomarkers. We then performed a meta-analysis to calculate the pooled prevalence estimates (PPE) for these laboratory abnormalities in mild COVID-19. As data was too limited for children with severe COVID-19 to allow pooling, results were presented descriptively in a summary of findings table. Our data show an inconsistent pattern of change in the leukocyte index of mild and severe cases of COVID-19 in children. Specifically, changes in leukocyte counts were only observed in 32% of the mild pediatric cases (PPE: 13% increase, 19% decrease). In mild disease, creatine kinase-MB (CK-MB) was frequently elevated, with a PPE of 33%. In severe disease, c-reactive protein (CRP), procalcitonin (PCT), and lactate dehydrogenase (LDH) were frequently elevated. Based on data obtained from early COVID-19 studies, leukocyte indices in children appear inconsistent, differing from those reported in adults that highlight specific leukocyte trends. This brings into question the utility and reliability of such parameters in monitoring disease severity in the pediatric population. Instead, we suggest physicians to serially monitor CRP, PCT, and LDH to track the course of illness in hospitalized children. Finally, elevated CK-MB in mild pediatric COVID-19 cases is indicative of possible cardiac injury. This highlights the importance of monitoring cardiac biomarkers in hospitalized patients and the need for further investigation of markers such as cardiac troponin in future studies.

Background The introduction of video laryngoscopy (VL) may impact emergency medicine (EM) residents' intubation practices. Methods We analyzed 14,313 intubations from 11 EM training sites, July 1, 2002, to December 31, 2012, assessing the likelihood of first-attempt success and likelihood of having a second attempt, by rank and device. We determined whether direct laryngoscopy (DL) first-attempt success decreased as VL became more prevalent using a logistic regression model with proportion of encounters initiated with VL at that center in the prior 90 and 365 days as predictors of DL first-attempt success. Results First-attempt success by PGY-1s was 71% (95% confidence interval [CI] = 63% to 78%); PGY-2s, 82% (95% CI = 78% to 86%); and PGY-3+, 89% (95% CI = 85% to 92%). Residents' first-attempt success rate was higher with the C-MAC video laryngoscope (C-MAC) versus DL, 92% versus 84% (risk difference [RD] = 8%, 95% CI = 4% to 11%), but there was no statistical difference between the GlideScope video laryngoscope (GVL) and DL, 80% versus 84% (RD = -4%, 95% CI = -10% to 1%). PGY-1s were more likely to have a second intubation attempt after first-attempt failure with VL versus DL: 32% versus 18% (RD = 14%, 95% CI = 5% to 23%). DL first-attempt success rates did not decrease as VL became more prevalent. Conclusions First-attempt success increases with training. Interns are more likely to have a second attempt when using VL. The C-MAC may be associated with increased first-attempt success for EM residents compared with DL or GVL. The increasing prevalence of VL is not accompanied by a decrease in DL success.

IMPORTANCE: Coronavirus disease 2019 (COVID-19) has become a pandemic, and it is unknown whether a combination of public health interventions can improve control of the outbreak. OBJECTIVE: To evaluate the association of public health interventions with the epidemiological features of the COVID-19 outbreak in Wuhan by 5 periods according to key events and interventions. DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, individual-level data on 32 583 laboratory-confirmed COVID-19 cases reported between December 8, 2019, and March 8, 2020, were extracted from the municipal Notifiable Disease Report System, including patients’ age, sex, residential location, occupation, and severity classification. EXPOSURES: Nonpharmaceutical public health interventions including cordons sanitaire, traffic restriction, social distancing, home confinement, centralized quarantine, and universal symptom survey. MAIN OUTCOMES AND MEASURES: Rates of laboratory-confirmed COVID-19 infections (defined as the number of cases per day per million people), across age, sex, and geographic locations were calculated across 5 periods: December 8 to January 9 (no intervention), January 10 to 22 (massive human movement due to the Chinese New Year holiday), January 23 to February 1 (cordons sanitaire, traffic restriction and home quarantine), February 2 to 16 (centralized quarantine and treatment), and February 17 to March 8 (universal symptom survey). The effective reproduction number of SARS-CoV-2 (an indicator of secondary transmission) was also calculated over the periods. RESULTS: Among 32 583 laboratory-confirmed COVID-19 cases, the median patient age was 56.7 years (range, 0-103; interquartile range, 43.4-66.8) and 16 817 (51.6%) were women. The daily confirmed case rate peaked in the third period and declined afterward across geographic regions and sex and age groups, except for children and adolescents, whose rate of confirmed cases continued to increase. The daily confirmed case rate over the whole period in local health care workers (130.5 per million people [95% CI, 123.9-137.2]) was higher than that in the general population (41.5 per million people [95% CI, 41.0-41.9]). The proportion of severe and critical cases decreased from 53.1% to 10.3% over the 5 periods. The severity risk increased with age: compared with those aged 20 to 39 years (proportion of severe and critical cases, 12.1%), elderly people (≥80 years) had a higher risk of having severe or critical disease (proportion, 41.3%; risk ratio, 3.61 [95% CI, 3.31-3.95]) while younger people (

Up to 44% of out-of-hospital cardiac arrest (OHCA) patients will rearrest in the immediate post-return of spontaneous circulation (post-ROSC) period, and rearrest is associated with decreased survival. Cardiac arrest guidelines are often equivocal regarding what post-ROSC care should be provided in the prehospital setting and when hospital transport should be initiated. Prehospital protocols must balance the benefit of time-dependent hospital-based care with the risk of early rearrest. We sought to describe current prehospital protocols for post-ROSC care in the treatment of OHCA.A single trained abstractor systematically reviewed a purposeful sample of prehospital protocols for adult non-traumatic cardiac arrest from the United States using anWe identified and reviewed 82 prehospital protocols from 46 states and the District of Columbia. Seven protocols were excluded due to the revision date, leaving 75 protocols included in the study. Six protocols (8%; CI 3.7-16%) provide no guidance on prehospital post-ROSC care. 12-lead electrocardiogram (ECG) acquisition (63/75 [84%; CI 73-91%]) and transport to percutaneous coronary intervention-capable hospitals (55/75 [73%; CI 62-83%]) are common, although not ubiquitous. Of those that do require a 12-lead ECG, 40% [CI 27-54%] required the presence of an ST-elevation myocardial infarction to inform their transport decision. Only 9 (12%; CI 6.4-22%) provide any guidance on when to initiate transport post-ROSC, with 4 (5%; CI 2-13%) requiring a post-ROSC stabilization period prior to transport.Prehospital treatment and transport protocols for post-ROSC care are highly variable across the United States.

Purpose: Physical activity level is a prognostic variable for patients with injuries. Self-report questionnaires exist to obtain these measures; however, they are not accessible to all populations because of language barriers. Therefore, the purpose of this study was to translate and validate the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) for francophones. Method: We translated the HSS Pedi-FABS using the forward–reverse translation approach and validated it among bilingual adults and an expert panel before administering it to a paediatric population. A repeated-measures crossover design was used: forty-three middle school students, aged 13.1 (SD 0.75) years, were randomly administered either the English or the French questionnaire. Two days later, all participants completed the other version. The translated questionnaire was assessed for its convergent validity (Spearman’s r correlation coefficients [ rs]), internal consistency (Cronbach’s α), and reliability (standard error of measurement [SEM]). Results: All assessments had a significance level of p s = 0.911). The overall scores for the questionnaire and the individual items of the questionnaire revealed excellent internal consistency (α = 0.868) and reliability (SEM = 0.334). Conclusions: The validated and reliable translated questionnaire can be used by researchers and clinicians to assess physical activity levels in French paediatric populations.

Anterior cruciate ligament injury (ACLi) reduces mechanical knee joint stability. Differences in muscle activation patterns are commonly identified between ACLi individuals and uninjured controls (CON); however, how and which of these differences are adaptations to protect the knee or adversely increase risk of joint instability remain unclear. Since the neuromuscular system integrates activity of all muscles crossing the knee to create a moment-of-force that opposes an external load, this study sought to quantify differences in individual muscle electromyography (EMG)-moment relationships between ACLi and CON. Participants isometrically modulated ground reaction forces during a standing force matching protocol to elicit combinations of sagittal, frontal and transverse plane moments. Partial least squares regressions determined which internal joint moment(s) predicted activation of 10 leg muscles for each group. Compared to CON, ACLi demonstrated greater contribution of rectus femoris to knee extension, semitendinosus and gastrocnemii to knee flexion, and lateral gastrocnemii to knee external rotation moments. ACLi also showed lower contributions of biceps femoris to knee flexion, medial gastrocnemius to internal rotation, and varied hip muscle contributions to frontal plane hip moments. Between group differences in EMG-moment relationships during static conditions suggest neuromuscular contributions to sagittal plane stability increases after ACL injury, while knee stability during knee abduction and external rotation is reduced. Clinical Significance: Clinical assessments of ACLi should account for deficits in frontal and rotational plane stability by including tasks that elicit such loads. Improving hamstring muscle balance, hip abductor and gastrocnemius function may benefit ACLi rehabilitation interventions and should be studied further. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Background Sex-related neuromuscular differences have been linked to greater risk of anterior cruciate ligament injuries in females. Despite this, it remains unclear if sex-related differences are present after injury. This study sought to determine if sex differences are present in the functional roles of knee joint muscles in an anterior cruciate ligament deficient population. Methods An isometric, weight-bearing, force-generation protocol required injured and healthy males and females to modulate ground reaction forces. Electromyography was used to classify the functional role of 10 lower limb muscles in their contribution to knee joint stability during various loading directions. These roles were compared between the four groups at 12 loading directions using a directional analysis. Findings Functional muscle roles were different between groups, except for injured males and healthy females. Healthy males had either joint actuators or specific joint stabilisers, but no general stabilisers; the vastus medialis and lateralis of injured males and healthy females were classified as general stabilisers while injured females added the gluteus medialis and medial gastrocnemius as general stabilisers. Interpretation A population-based hierarchy in functional muscle roles was discovered. Healthy males demonstrated the most specific muscle roles, which can be viewed as more adaptive to variable loading conditions. The more generalised stabilisation strategies seen in injured males and females would alter joint loading which may be detrimental to the knee joint health over time. In summary, (1) these injuries alter muscle roles; (2) these alterations are sex-specific; (3) rehabilitation might be optimised if sex-differences are considered.

Neuromuscular control is critical for maintaining dynamic joint stability and mitigating the risk of anterior cruciate ligament (ACL) injury. Given the increased risk of ACL injury in females, sex-based differential muscle activation strategies are often associated with this risk. For example, the quadriceps-dominant muscle activation strategy sometimes observed in females has been discussed as a cause of their increased risk of ACL injury. However, there has been no synthesised knowledge on sex differences in muscle activation patterns associated with ACL injuries. Therefore, the purpose of this review was to synthesise sex differences in muscle activation patterns in movements associated with ACL injuries in both adult and adolescent populations. A systematic electronic database search was conducted. Thirty studies were included in the review. Females demonstrated higher pre- and post-landing activation of the quadriceps and lower activation of the hamstrings in 15 studies. Females also had higher quadriceps-to-hamstring co-contraction ratios during pre- and post-landing phases compared to their male counterparts in 4 of 9 studies that considered co-contraction. While some studies supported the quadriceps-dominant activation strategies in females, no consensus can be drawn due to methodological inconsistencies and limitations. Also, despite the importance of ACL injury prevention in children and adolescents, the evidence on sex difference in muscle activation patterns in this population is insufficient to draw meaningful conclusions.

The forward lunge (FL) may be a promising movement to assess functional outcome after ACL reconstruction. Thus, we aimed to investigate the FL movement pattern before and after ACL reconstruction with a comparison to healthy controls to determine if differences were present. Twenty-eight ACL injured participants and 28 matched healthy controls were included. They performed FL movements while sagittal plane biomechanics of the knee and electromyography (EMG) of nine leg muscles was assessed. The ACL injured group was tested before and 10 months after surgery. The perceived knee function and activity level was assessed by questionnaires. The ACL injured group performed the FL significantly slower than the controls before surgery (mean difference: 0.41 s [95%CI: 0.04-0.79 s; p

Females aged between 13 and 17 years old possess the highest non-contact ACL injury incidence of any sex-age strata. Considering that energy absorption strategies have been associated with a reduced risk for sustaining an ACL injury, evaluating landing performance in youth athletes requires investigations beyond the kinematic level. The purpose of this study was to identify sex-specific energy absorption strategies in adolescent males and females, including the relationship between strength and the observed strategies. Thirty-one healthy adolescent athletes completed unanticipated single-leg drop-jump landings on their dominant limb. Sex-specific kinematics and lower-limb contributions to energy absorption were then compared over the landing phase for each jump. Pearson and Spearman correlation coefficients determined the relationship between isometric joint strength and the observed kinematics and energy absorption. Female participants absorbed a larger proportion of the landing energy at the ankle (p = 0.046, d = 0.75) and smaller proportion at the hip (p = 0.028, d = 0.85) compared to males. Females also reached larger peak negative joint power in their knee (p = 0.001, d = 1.1) and ankle (p = 0.04, d = 0.79). Hip extension strength was positively correlated with trunk flexion (r = 0.559, p = 0.001) and negatively correlated with forward pelvic tilt (r = -0.513, p = 0.003). Females adopted an energy absorption strategy which utilized the distal joints to absorb a larger portion of the landing forces and tended to absorb the forces later in the landing phase relative to males. The greater reliance on distal joints is correlated to reduced hip strength and may increase the risk for sustaining an ACL injury.

Introduction/Background Endometrial cancer (EC) is the most frequent gynecological malignancy and studies have shown that demographic attributes could influence quality of care. We aim to review their impact on compliance to standard treatment guidelines in EC with already published quality metrics. Methodology Using the Surveillance Epidemiology and End Results (SEER) database 1988–2013 we identified 151,752 patients treated for EC in the United States. The quality indicators (QI) were extracted from a Belgian study on quality of care in EC. Ten QI were selected because of their relevance and applicability to the SEER. These QI either evaluated the surgical management, the adjuvant treatment decision, or the outcome in EC. We examined the association between socio-demographic characteristics (race, age, insurance status, income, and marital status) and quality of care using a logistic regression model. Results Concerning the six surgical QI, one was accurately met (>80% population received the recommended treatment), three were moderately met (50–79%) and two were poorly met ( Conclusion The 10 Belgian QI used to assess quality of care in the United States showed an overall correct compliance to standard treatment. Demographic discrepancies persist in the management of EC, impacting evidence-based care. Disclosure Nothing to disclose

Introduction/Background Surgical assessment of lymph nodes for endometrial cancer staging at primary surgery is one of the most varied practices worldwide and controversies remain about the need for and the extent of para-aortic lymph node dissection in all patient. This study aimed to determine whether a pelvic and para-aortic lymphadenectomy improves survivals compared with a pelvic lymphadenectomy alone in patients with endometrial cancer. Methodology Data from all women with operated on for endometrial cancer between January 1998 and December 2013 were extracted from the Surveillance, Epidemiology and End Results database. Women treated with pelvic lymphadenectomy were matched with women treated with pelvic and para-aortic lymphadenectomy according to age and risk of recurrence. The primary and secondary endpoints were overall and disease-specific survivals respectively. Results One to one matching enabled to compare the outcome of 1015 patients who underwent pelvic lymphadenectomy with 1015 patients who underwent pelvic and para-aortic lymphadenectomy. The 3-years overall survival probabilities for patients at intermediate and high risk of recurrence were similar in the pelvic and para-aortic lymphadenectomy group and the pelvic only group (91.2 and 86.4% respectively, p=0.07). Multivariate analysis of prognostic factors showed that in patients with an intermediate or high risk of recurrence, pelvic and para-aortic lymphadenectomy did not reduce the risk of death compared with pelvic lymphadenectomy (HR 1.08, 95% CI 0.69–1.69; p=0.74). Conclusion The present study suggests that for patients with endometrial cancer at intermediate or high risk of recurrence, the extent of lymphadenectomy does not impact overall and disease-free survivals. Disclosure Nothing to disclose.

The purpose of this study was to describe neuromuscular and kinematic differences during failed and successful drop-vertical jumps in a pediatric population. Healthy young athletes (n = 32) completed single-leg drop vertical jump landings where the required landing leg was unanticipated. Trials were categorized as failed if the participant shifted their base of support during the landing. Joint kinematics and muscle activation amplitudes were time normalized over the flight and landing phases. Statistical parametric mapping (SPM) was used to compare landings and a moving average convergence divergence oscillator was then calculated to determine where failed and successful waveforms began to diverge prior to reaching statistical significance. SPM determined that participants performed the failed trials with reduced pelvic tilt towards the landing limb during 41–69% of the flight phase, greater trunk flexion angle during 31–100% of the landing phase and greater trunk tilt away from the landing limb during 3–13% and 21–90% of the landing phase. Greater rectus femoris activation during the failed trials was identified during 88–100% of the flight phase, as well as 1–4% and 71–97% of the landing phase. Greater gluteus medius and biceps femoris activation was also identified in the failed trials during 54–72% and 76–89% of the landing phase respectively. These findings indicate that the control of proximal joints has an important role in determining if a participant will fail a landing; and that how athletes prepare for a landing may be more relevant than the kinematics following ground contact.

La chirurgie bariatrique est actuellement le traitement de reference pour l’obesite morbide. La gastrectomie en manchon (sleeve gastrectomy (SG)) est l’intervention la plus pratiquee en France car il s’agit d’une technique ne necessitant pas de court circuit intestinal permettant ainsi de maintenir un acces au tube digestif par voie endoscopique. Par contre, avec un recul croissant, le reflux gastrooesophagien (RGO) apparait comme une complication a long terme de la SG. Nous rapportons ici un cas de RGO invalidant survenu tardivement chez un patient obese morbide opere d’une SG cinq ans auparavant et nous en discutons le traitement chirurgical.

Objective Externally applied abduction and rotational loads are major contributors to the knee joint injury mechanism; yet, how muscles work together to stabilize the knee against these loads remains unclear. Our study sought to evaluate lower limb functional muscle synergies in healthy young adults such that muscle activation can be directly related to internal knee joint moments. Methods Concatenated non-negative matrix factorization extracted muscle and moment synergies of 22 participants from electromyographic signals and joint moments elicited during a weight-bearing force matching protocol. Results Two synergy sets were extracted: Set 1 included four synergies, each corresponding to a general anterior, posterior, medial, or lateral force direction. Frontal and transverse moments were coupled during medial and lateral force directions. Set 2 included six synergies, each corresponding to a moment type (extension/flexion, ab/adduction, internal/external rotation). Hamstrings and quadriceps dominated synergies associated with respective flexion and extension moments while quadriceps-hamstring co-activation was associated with knee abduction. Rotation moments were associated with notable contributions from hamstrings, quadriceps, gastrocnemius, and hip ab/adductors, corresponding to a general co-activation muscle synergy. Conclusion Our results highlight the importance of muscular co-activation of all muscles crossing the knee to support it during injury-inducing loading conditions such as externally applied knee abduction and rotation. Functional muscle synergies can provide new insight into the relationship between neuromuscular control and knee joint stability by directly associating biomechanical variables to muscle activation.

Background: Advanced airways (endotracheal tubes, supraglottic airways) are frequently placed by Emergency Medical Services (EMS) in patients with out-of-hospital cardiac arrest (OHCA). However, if an airway is to be placed, it is unknown whether this should occur early or late in the sequence of resuscitation events. This study evaluated the association between the timing of airway placement and the minute-to-minute probability of achieving return of spontaneous circulation (ROSC). Methods: This secondary analysis of Resuscitation Outcomes Consortium Prehospital Resuscitation using an Impedance Valve and Early versus Delayed (ROC PRIMED) study data included adult, non-traumatic, witnessed OHCA patients with airway placement by EMS before ROSC. The primary exposure variable was time from EMS arrival to advanced airway placement. The outcome was prehospital ROSC. Since resuscitations occur over time, a Cox proportional hazards model was fit to estimate the probability of ROSC as a function of the airway timing, adjusting for Utstein variables. Results: A total of 7,547 patients were included. Time to airway placement was 0–5 minutes in 12% of the cohort, >5–10 (36%), >10–15 (29%), >15–20 (14%), >20–25 (5%), >25–30 (2%), and >30 (2%). ROSC occurred in 43%. Time to airway had a statistically significant impact on ROSC. A negative association between the time to airway placement and the hazard of ROSC was observed, such that increasing intervals between EMS arrival and airway placement were associated with decreasing probabilities of ROSC, regardless of initial cardiac rhythm. Conclusions: EMS advanced airway placement has a time-dependent association with ROSC. In witnessed OHCA patients receiving advanced airways, early airway placement is associated with increased probability of ROSC.

Background: The vast majority of ACL injuries in adolescents occur during non-contact injuries, in particular single-leg landings. The magnitude of energy absorption about each joint during theses landings influences the internal and external forces acting on the joints of the lower extremity. Understanding the biomechanics of landing in adolescent male and female athletes may provide insight into these non-contact injury mechanisms. Hypothesis/Purpose: This study set out to identify sex-specific energy absorption strategies during single-leg landing and determine the relationship between joint strength and the observed strategies. To better represent real-world conditions, we developed a novel unanticipated drop-jump landing protocol for this population. Methods: Thirty-one healthy youth athletes completed unanticipated single-leg drop-jump landings on their dominant limb. Kinematics and lower-limb contributions to energy absorption were calculated over the landing phase for each jump. Independent t-tests as well as Mann-Whitney U tests determined the presence of statistical differences between sexes. Pearson and Spearman correlation coefficients determined the relationship between isometric joint strength and the observed kinematics and energy absorption. Results: Females participants absorbed a larger proportion of the landing forces at the ankle and smaller proportion at the hip compared to males. Females also reached larger peak negative joint power in their knee and ankle. Both hip extension and ankle plantar flexion strength were correlated with greater spine flexion and less pelvic flexion. Conclusion: Females adopted an energy absorption strategy which utilized distal joints to absorb a larger portion of the landing forces and tended to absorb the forces later relative to males. A greater reliance on the distal joints is related to reduced hip strength and may increase the risk for sustaining an ACL injury.

Background Voluntary activation deficit of the quadriceps muscle group is a common symptom in populations with knee joint injury. Musculoskeletal modeling and simulations can improve our understanding of pathological conditions; however, they are mathematically complex which can limit their clinical application. A practical subject-specific modeling framework is introduced to evaluate knee extensor inhibition and muscle force contributions to isometric knee joint torques in healthy adults with and without experimentally induced quadriceps muscle pain. Methods A randomized cross-over placebo controlled study design was used. Subject-specific maximum knee joint extension torque and quadriceps electromyographic data from 13 uninjured young adults were combined in a modeling framework to determine optimal muscle strength scaling parameters and ideal torque. Strength deficit ratios (experimental torque/ideal torque) and individual muscle contribution to experimental torque was computed before and after intramuscular hypertonic (pain inducing) and isotonic (sham) saline was injected to the vastus medialis. Findings Decreased experimental knee extension torque (−8%) and vastus medialis electromyography (−26%) amplitude pre- to post- hypertonic injection was observed. Correspondingly, significant decreases in the knee extensor strength deficit ratio (−18%) and percent contribution of vastus medialis to experimental torque (−24%) was observed pre- to post- hypertonic injection. No differences were observed with isotonic injections, confirming the validity of the model. Interpretation Our practical method to estimate strength ratios can be easily implemented within a musculoskeletal modeling framework to improve the validity of model estimates. This, in turn, can increase our understanding of the relationship between neuromuscular deficits and functional outcomes in patient populations.

Background There is a lack of objective dynamic knee joint control measures that can be related to the status of the anterior cruciate ligament (ACL). The purpose of this study was to introduce two novel measures and apply a third to determine how dynamic knee joint control changes in relation to ACL status during dynamic movements. Methods Twenty patients (13 male) were tested pre- (ACLd) and 10-months post- (ACLr) ACL reconstructive surgery and matched to an uninjured participant (CON). Kinetic and kinematic data were synchronously recorded with a force platform and motion capture system. Three objective control measures including dynamic angular stiffness, knee joint center excursion (KJCE), and knee joint center boundary (KJCB) were assessed for each participant when completing the side cut and hop tasks. Results During the side cut, stiffness was found to be significantly lower in ACLd (0.06 ± 0.01 Nm/kg/°) and ACLr (0.07 ± 0.02 Nm/kg/°) compared to CON (0.08 ± 0.02 Nm/kg/°), while there were no differences in stiffness during the hop. No significant differences were observed in the KJCE during the side cut, while KJCE was significantly greater (p = 0.006) during the hop in CON compared to the ACLd. There were no differences in KJCB. Conclusions These high-functioning ACL injured in both ACLd and ACLr phases, aside from reduced stiffness, were able to complete both tasks with similar dynamic control as the CON. Although improvements in self-perceived control between ACLd and ACLr have been observed, this lack of improvement in objective control demonstrates a gap between a patient's self-efficacy and the level of control.

Background American Stroke Association guidelines for prehospital acute ischemic stroke recommend against bypassing an intravenous tPA-ready hospital (IRH), if additional transportation time to an endovascular-ready hospital (ERH) exceeds 15-20 min. However, it is unknown when the benefit of potential endovascular therapy at an ERH outweighs the harm from delaying intravenous therapy at a closer IRH, especially since large vessel occlusion (LVO) status is initially unknown. We hypothesized that current time recommendations for IRH bypass are too short to achieve optimal outcomes for certain patient populations. Methods A decision analysis model was constructed using population-based databases, a detailed literature review, and interventional trial data containing time-dependent modified Rankin Scale distributions. The base case was triaged by Emergency Medical Services (EMS) 110 min after stroke onset and had a 23.6% LVO rate. Base case triage choices were (1) transport to the closest IRH (12 min), (2) transport to the ERH (60 min) bypassing the IRH, or (3) apply the Cincinnati Stroke Triage Assessment Tool and transport to the ERH if positive for LVO. Outcomes were assessed using quality-adjusted life years (QALYs). Sensitivity analyses were performed for all major variables, and alternative prehospital stroke scales were assessed. Results In the base case, transport to the IRH was the optimal choice with an expected outcome of 8.47 QALYs. Sensitivity analyses demonstrated that transport to the ERH was superior until bypass time exceeded 44 additional minutes, or when the onset to EMS triage interval exceeded 99 min. As the probability of LVO increased, ERH transport was optimal at longer onset to EMS triage intervals. The optimal triage strategy was highly dependent on specific interactions between the IRH transportation time, ERH transportation time, and onset to EMS triage interval. Conclusions No single time difference between IRH and ERH transportation optimizes triage for all patients. Allowable IRH bypass time should be increased and acute ischemic stroke guidelines should incorporate the onset to EMS triage interval, IRH transportation time, and ERH transportation time.

Advanced airway management – such as endotracheal intubation (ETI) or supraglottic airway (SGA) insertion – is one of the most prominent interventions in out-of-hospital cardiac arrest (OHCA) resuscitation. While randomized controlled trials are currently in progress to identify the best advanced airway technique in OHCA, the mechanisms by which airway management may influence OHCA outcomes remain unknown. We provide a conceptual model describing potential mechanisms linking advanced airway management with OHCA outcomes.

The insertion of a silent period (or gap) in a frequently occurring standard stimulus elicits a negative-going event-related potential (ERP), called the Deviant-Related Negativity (DRN). This is often studied using a single-deviant paradigm. To study the effects of gaps with multiple durations, a different sequence would be required for each gap. A more time-efficient multi-deviant paradigm has been developed in which stimuli of various gap widths are included in a single sequence. In the present study, 14 young adults watched a silent video while ignoring an auditory sequence. A single run of a multi-deviant sequence was presented in which 6 different rare deviants alternated with a standard stimulus. The standard was a 200-ms white noise burst. The deviants were constructed by inserting a gap in the standard. The duration of the 6 gaps ranged from 2 to 40 ms. Participants were also presented with multiple runs of single-deviant sequences. Each of the 3 deviants was run in a separate sequence. The amplitude of the DRN elicited by the deviant increased as gap duration became longer, although it did plateau for the longer duration gaps. The amplitudes of the DRNs were larger in the single-deviant paradigm than in the multi-deviant paradigm. However, the difference was only significant when the mastoid reference was used. Behavioural data showed a mean d’ of 2.1 for the 5-ms gap. None of the participants were able to detect the 2-ms gap. There was no correlation between d’ and the DRN amplitude. Still, the effects of gap duration on the amplitude of the DRN were similar between the single and multi-deviant sequences. This makes the multi-deviant paradigm a possible time-saving alternative to the single-deviant paradigm.

The purpose of this study was to identify high-functioning anterior cruciate ligament-deficient patients and assess the effects of reconstruction on their self-reported functionality, muscle activations and biomechanical properties. Twenty young and active patients participated pre- (11.5 ± 14.3 months post-injury) and again 10.5 ± 1.7 months post-reconstruction and were individually matched to 20 healthy controls. Participants completed hop and side cut movements while patient-related outcome measures, lower limb electromyography, kinetic, and whole body kinematic data were collected. One-dimensional statistical parametric mapping was used to test for group differences (healthy vs deficient; deficient vs reconstructed; reconstructed vs healthy). When comparing healthy to anterior cruciate ligament-deficient participants, all questionnaires indicated significant lower subjective function while the only substantial biomechanical difference between these participants was a decreased knee extensor moment in both the hop (peak difference: 0.63 Nm/kg, p