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A previous efficacy trial found benefit from inhaled budesonide for COVID-19 in patients not admitted to hospital, but effectiveness in high-risk individuals is unknown. We aimed to establish whether inhaled budesonide reduces time to recovery and COVID-19-related hospital admissions or deaths among people at high risk of complications in the community.

Abducens nerve palsy via direct or indirect injury is well described following head trauma likely due to its long anatomical course with several vulnerable segments. However, bilateral abducens palsies due to non-iatrogenic intracranial hypotension is unique. This report describes the case of a male with sequential delayed onset abducens nerve palsies following head and neck trauma due to intracranial hypotension secondary to cerebrospinal fluid (CSF) leak from a dural tear at the C6/7 level. Signs of intracranial hypotension were evident on magnetic resonance imaging (MRI). We hypothesise that the traction effect from ongoing CSF leak resulted in sequential palsies. His clinical course was also complicated by pulmonary embolus and a prolonged period of immobility, the anti-gravity effects of which likely mitigated the CSF leak in the early period. Conservative management was undertaken with bed rest, fluids and caffeine with good response and resolving abducens dysfunction after ten weeks. Further management with epidural blood patch or surgical fixation was not necessary and deemed unlikely to succeed given the location of the dural tear and the need for concurrent anticoagulation. It is important to recognise CSF leak and intracranial hypotension as potential, albeit rare, causes for sequential abducens nerve palsy in patients with head and spinal injuries. Management strategies of this condition range from conservative measures to surgical intervention.

Patients with a history of asthma-related hospitalizations are at high risk of readmission and generally consume a large amount of health-care resources. It is not clear if the secondary care provided by specialists after an episode of asthma-related hospitalization is associated with better outcomes compared with the primary care provided by general practitioners.

IntroductionThe aim of this study was to test the hypothesis that all blunt trauma patients, presenting with a Glasgow coma scale (GCS) score of 15, without intoxication or neurological deficit, and no pain or tenderness on log-roll can have any thoracolumbar fracture excluded without imaging.Materials and MethodsAll patients diagnosed with a thoracolumbar fracture presenting to the emergency department of a major trauma centre and having an initial GCS score of 15 were included in the study. Variables collected included type of fracture, mechanism of injury, the presence of pain or tenderness on log-roll, ethanol levels and prehospital opioid analgesia.ResultsThere were 536 patients with thoracolumbar fractures, of which 508 (94.8%) patients had either pain, tenderness or had received prehospital opioid analgesia. A small subgroup of 28 (5.2%) patients who received no prehospital opioid analgesia, did not complain of pain and had no tenderness to the thoracolumbar spine elicited on log-roll. This subgroup was significantly older (p=0.033) and a high proportion of patients (64.3%) had a concurrent fracture of the cervical spine. Within this subgroup, a clinically significant unstable thoracic fracture was present in three patients, with all three patients exhibiting symptoms and signs of neurological injury or having a concurrent cervical vertebral fracture.ConclusionsIn this population of blunt trauma patients with a GCS score of 15, not under the influence of alcohol or prehospital morphine administration, the absence of pain or tenderness on log-roll can exclude a clinically significant lumbar vertebral fracture, but does not exclude a thoracic fracture.

The authors systematically collated, classified, and evaluated the evidence of intervention studies from recent systematic reviews about the effects of telehealth interventions on COPD and asthma care. Eight electronic databases were searched. Eligible articles were those published between 2001 and 2011 in English. Eleven review articles are included. Asthma and COPD are better controlled when patients use interactive technological tools to monitor their chronic disease. The effects of telehealth interventions on emergency department attendance, specific quality of life, and mortality remained less certain. Only some reviews mentioned if the cost-effectiveness was systematically analyzed. Telehealth promises to be a highly effective intervention in managing chronic lung diseases while also potentially reducing some of the economic burdens of asthma and COPD. New directions in telehealth developments, implementations, and evaluations should be made, in which the exchange of health information should not be over simplified, but rather reflect the different socio-cultural practices of population groups and individuals.

IntroductionInjured patients presenting with hypothermia, acidosis and coagulopathy have been identified at high risk of death. This study aimed to describe the presentation, management and outcome of major trauma patients presenting with the ‘triad of death’ and identify ways to improve survival.MethodsA retrospective, explicit chart review was undertaken on patients presenting to a level I adult major trauma centre with the ‘triad of death’. These patients presented directly from the scene, were coagulopathic (international normalised ratio (INR) >1.5), hypothermic (temperature <35°C) and acidotic (pH <7.2) on arrival.ResultsThere were 90 patients over an 8-year period, with an overall mortality of 47.8%. No significant differences were observed among demographics and injury severity scores between survivors and non-survivors. Extremes of systolic blood pressure and heart rate, a high activated partial thromboplastin time activated partial thromboplastin time, low fibrinogen counts, pH, bicarbonate, base excess and haemoglobin were present among survivors. There were no survivors in our cohort with an initial INR greater than 3.2. Survivors received significantly lower volumes of packed red blood cells.ConclusionsThere has been little change in mortality over time in this subgroup of major trauma patients. While the presence of the triad alone does not determine futility, there were no survivors over 8 years with extreme coagulopathy with concurrent hypothermia and acidosis.

‘Massive’ transfusion is a poorly defined inclusion criteria for studies examining the blood and blood product that are used during trauma resuscitation. We aimed to compare the traditional definition of massive transfusion (≥10 units in 24 h) to a more acute definition of at least 5 units in 4 h.

HYPOTHESIS This project tested the hypothesis that computer-aided decision support during the first 30 minutes of trauma resuscitation reduces management errors. DESIGN Ours was a prospective, open, randomized, controlled interventional study that evaluated the effect of real-time, computer-prompted, evidence-based decision and action algorithms on error occurrence during initial resuscitation between January 24, 2006, and February 25, 2008. SETTING A level I adult trauma center. PATIENTS Severely injured adults. MAIN OUTCOME MEASURES The primary outcome variable was the error rate per patient treated as demonstrated by deviation from trauma care algorithms. Computer-assisted video audit was used to assess adherence to the algorithms. RESULTS A total of 1171 patients were recruited into 3 groups: 300 into a baseline control group, 436 into a concurrent control group, and 435 into the study group. There was a reduction in error rate per patient from the baseline control group to the study group (2.53 to 2.13, P = .004) and from the control group to the study group (2.30 to 2.13, P = .04). The difference in error rate per patient from the baseline control group to the concurrent control group was not statistically different (2.53 to 2.30, P = .21). A critical decision was required every 72 seconds, and error-free resuscitations were increased from 16.0% to 21.8% (P = .049) during the first 30 minutes of resuscitation. Morbidity from shock management (P = .03), blood use (P &lt; .001), and aspiration pneumonia (P = .046) were decreased. CONCLUSIONS Computer-aided, real-time decision support resulted in improved protocol compliance and reduced errors and morbidity. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00164034Arch Surg. 2011;146(2):218-225--

The article explores trends in the newspaper industry. The Newspaper Association of America reports that advertising revenue for the first quarter of 2010 has declined just by 9.7%. In the last six-month reporting period, a report from the Audit Bureau of Circulations states that the decline in circulation has been moderating. Another trend that continue to persist is the decreasing frequency of publishing in print. Still, the author believes newspapers will emerge from the recession with a lowered cost structure and new opportunities.

Collision-induced activation of deprotonated trimethylamine N-oxide yields the two anions [N(CH2)3]– and [ON(CH2)2]– following losses of H2O and CH4, respectively. These two anions decompose by minor losses of H•and H2when collisionally activated: no other fragmentations are noted. Calculations at the CCSD(T)/aug-cc-pVDZ//B3LYP/6-31+G(d) level of theory indicate that these trigonal anions are stable, and should not rearrange following collisional activation. Collisional-induced charge stripping of the anions [N(CH2)3]– and [ON(CH2)2]–, respectively, form N(CH2)3and ON(CH2)2. Some of these neutrals are energised and undergo rearrangement and dissociation. From a consideration of experiment and theory, it is proposed (i) that energised N(CH2)3may cyclise to form the 1-aziridinylcarbinyl radical. This species may ring open to CH2=NCH2CH2which then decomposes to CH2N and C2H4and (ii) energised ON(CH2)2may undergo OC cyclisation followed by ring opening to energised CH2=NCH2O which may fragment to yield CH2N and CH2O.

Right atrial appendage rupture from blunt trauma is exceedingly rare, even more so when no other chest wall injuries are found. Very few cases have been documented with respect to survival from such an injury.

Obturator hernias (OH) are rare, accounting for less than 0.05% of all hernias. The aetiology is usually attributed to chronically raised intra-abdominal pressure or cachexia with poor muscle mass. This case report describes a traumatic obturator hernia, an exceptionally rare aetiology of an already rare surgical condition. There are no previous reports of a traumatic obturator hernia in the current literature.

The article discusses the role of newspapers as a reliable source of recycled and recyclable newsprint. Newspapers are launching total-market-coverage products in response to declining penetrations. "RedEye" has been created by the "Chicago Tribune" to distribute for free at commuter stops and coffee shops. Project Freesheet was founded by a photographer, which targets ridding cities of commuter papers. The irony of freeting over the carbon footprint of free newspapers is also addressed.

The objective of this pilot project was to determine whether engaging critical care unit staff in designing and implementing enhancements to the practice environment would positively impact the clinical environment and staff outcomes. The project used a one-group pre-post test design and a participatory action process. Significant changes in the practice environment were observed in the priority areas identified by the unit staff. Results indicated that team collaboration and respectful work relationships improved following interventions.

HIV is becoming more prevalent in the UK, and is being increasingly detected in asymptomatic women during antenatal screening. Taunton & Somerset Hospital wrote an ICP document for the management of HIV in pregnancy according to their Trust policy, and it is presented here.

The objective of this pilot project was to determine whether engaging critical care unit staff in designing and implementing enhancements to the practice environment would positively impact the clinical environment and staff outcomes. The project used a one-group pre-post test design and a participatory action process. Significant changes in the practice environment were observed in the priority areas identified by the unit staff. Results indicated that team collaboration and respectful work relationships improved following interventions.

Pharmacoepidemiology is a relatively new and evolving science that attempts to quantify mainly adverse drug events and patterns of drug use in a large population. The strength of pharmacoepidemiology over randomized trials is the ability to quantify rare adverse events that may occur over long periods. Recently, discordance in the results of pharmacoepidemiologic studies has made it difficult for clinicians and policy makers to make informed drug‐therapy decisions. This commentary addresses the strength of pharmacoepidemiology and the advances in the methodology of pharmacoepidemiologic studies over the years. We also discuss the potential problem of discordant results and urge pharmacoepidemiologists to develop good practice guidelines for the conduct of pharmacoepidemiologic studies.

Recent work in adaptive importance sampling is applied to Markov chain models for Monte Carlo simulations. When this technique is incorporated into the simulation of physical processes, it can give orders-of-magnitude improvement in convergence times relative to standard approaches. We review the related methodology and illustrate its application.

To evaluate the effectiveness and safety of inhaled salmeterol in patients managed in nonspecialistpractice settings.

Objective:To estimate the prevalence of resistance of Mycobacterium tuberculosisto first-line antituberculosis drugs in Canada. Methods: M. tuberculosisisolates from one third of all culture-positive tuberculosis (TB) cases diagnosed between February 1, 1993 to January 31, 1994 in Canada were collected prospectively. Proportion of drug-resistant isolates and the factors related to drug resistance were measured. Results:Of 458 study cases, 40 (8.7%) had resistance to at least one first-line antituberculosis drug, of which 5–9% had mono-resistance, 0.7% had multidrug-resistance(MDR-TB) — i.e., resistance to at least isoniazid and rifampin — and 2.2% had other patterns. The overall prevalence of resistance among the foreign-born cases was 10.6% with the highest level among those who resided in Canada for less than four years (15.5%). Conclusions:Canada has a relatively low prevalence of antituberculosis drug resistance and a very low prevalence of MDR-TB. Some new immigrants to Canada may be at higher risk for drug resistance and their initial treatment needs to be tailored accordingly. Objectif:Évaluer la prévalence de la résistance du mycobacterium tuberculosiscontre le médicament antituberculeux de première ligne au Canada. Méthodes:Le mycobacterium tuberculosisrepère un tiers de tous les cas de cultures tuberculosis qui ont fait l’objet d’un diagnostic positif entre le 1er février 1993 et le 31 janvier 1994 au Canada; ces données ont été collectées de manière prospective. On a mesuré la proportion de repère des médicaments résistants et les facteurs reliés à la résistance du médicament. Résultats:Sur 458 cas étudiés, 40 (8,7 %) se sont avérés résistants à au moins un médicament antituberculeux de première ligne dont 5,9 % se sont avérés résistants à un seul médicament et 0,7 % ont une résistance à plusieurs médicaments (MDR-TB) — c.-à-d. résistants à au moins deux médicaments: l’isoniazid et le rifampin — et 2,2 % avaient d’autres caractéristiques. La prévalence globale de la résistance parmi les cas venus de l’étranger était de 10,6 % dont le niveau le plus élevé a résidé au Canada pendant moins de quatre ans (15,5 %). Conclusions:Au Canada, la prévalence de la résistance des médicaments antituberculeux est relativement faible. Certains nouveaux arrivants peuvent présenter un risque plus élevé de résistance aux médicaments et leur traitement initial doit être personnalisé en conséquence.

Provides insights into different technologies that produce electricity or usable heat in the 21st century. Solar thermal; Wind; Hydropower; Biomass; Photovoltaics; Geothermal.

Basic lead styphnate RD 1349 forms the primary explosive component of several high temperature fuzehead formulations and percussion primers. A study of its thermal decomposition under controlled conditions near its ignition temperature (521-525 K) shows that it decomposes very rapidly, following a second order autocatalytic rate law. The kinetics of this reaction are initially controlled by the ''nucleation of reactive molecules''occurring on the crystal surfaces or glide planes, by the growth of these nuclei as the reaction proceeds and, in the rate determining step, by their subsequent reaction in the bulk of the material. The rate determining step in this reaction follows Arrhenius kinetics with an activation energy of 197 kJ mol-1 and pre-exponential log10 A (s-1) = 17.9.

This quantitative study evaluates the bacterial leakage beneath crowns cemented with a glass ionomer cement in comparison with those cemented with a polycarboxylate cement or a varnish plus zinc phosphate cement.

Reports of sensitivity and even pulpal death after crown cementation with glass ionomer luting agents have raised concern that these materials, when used as luting agents, may cause pulpal inflammation. Responses o f these agents were measured in this study.

Background: An audit of the management and outcome of major trauma patients was carried out to determine ways in which the system of care may be improved.

2,5-Dipicryl-1,3,4-oxadiazole (DPO) is a thermally stable, high impulse shock sensitive explosive, which decomposes in the solid state at a rate easily followed by isothermal differential scanning calorimetry between 575 K (302°C) and 598 K (325°C). The α-t plots follow a typical sigmoidal profile and the kinetic data has been analysed in terms of the two standard rate laws which characterise many sigmoidal nucleation, growth and decomposition reactions, viz. the Prout-Tompkins rate law and the Avrami-Erofe'ev rate law. Both give an excellent description of the reaction kinetics over the approximate range 0.08 < α <0.80, but the apparent reaction order associated with Avrami-Erofe'ev kinetics is temperature dependent. An Arrhenius plot based on Prout-Tompkins kinetics suggests that the thermal decomposition of DPO proceeds with an activation energy of 218 kJ mol-1 and a pre-exponential, In A(s-1), of 39.83, while that based on Avrami-Erofe'ev kinetic data yields an activation energy of 184 kJ mol-1 and In A(s-1) of 30.92. Ramifications of these results are discussed.

We present the case of a 20-year-old male who was transferred to our Major Trauma Centre following a high-speed motor vehicle rollover. He arrived intubated with a right sided ICC in place. On arrival we elected to replace this ICC due to concerns regarding a superficial position, however 24 h after replacement, a large right sided pneumothorax developed. We suspect that both the pre-hospital ICC, as well as the ICC which we replaced it with, were unusually sited in the intrathoracic but extrapleural position.

Penetrating injuries to the neck present a unique challenge due to the confined space of the thoracic outlet for haemorrhage control and repair. This results in high mortality rates when the major vascular structures of the neck are transected, as well as potential neurological compromise. We present the case of a penetrating injury to the proximal subclavian artery from a broken angle grinder disc which is a unique mechanism of injury that can have fatal consequences. The patient described in this case underwent an emergent median sternotomy for proximal control of the brachiocephalic trunk and ligation of the right vertebral artery to facilitate a primary repair of the injured vessel segment. Post operatively the patient made a complete recovery with no central or peripheral neurologic deficits and requiring no further interventions. The key points from this case are that angle grinders pose a significant injury burden and early specialised medical attention should be sought, rapid control of the proximal neck vessels can be obtained via a median sternotomy and that the vertebral artery can be ligated in an emergent situation without neurological consequence.

The Longitudinal Interprofessional Family-Based Experience (LIFE) was developed to address the need for longitudinal, experiential IPE opportunities that bring students together with real patient-family units with an intentional plan for multiple qualitative and quantitative evaluation measures. LIFE engaged 48 early learners from eight health science schools at a large midwestern university in ongoing team skill-based interactions coupled with real patient experiential learning over 11 weeks. Student teams were introduced and encouraged to apply the socio-ecological model (SEM) and social determinants of health (SDH) while collaboratively exploring the impact of the patient-family’s interface with the healthcare system and community during two consecutive patient-family interviews. A creative collaboration with the health system’s Office of Patient Experience, provided eight patients who had experienced chronic illness and treatment in the healthcare system, who engaged with the learners as both teachers as well as evaluators in this experience. LIFE is a framework model that has applicability and adaptability for designing, implementing, and sustaining experiential IPE. Initial summary data regarding outcomes for students are presented as well as considerations to increase accessible and sustainable authentic IPE experiences through untapped patient and community collaborations.

Whilst post-traumatic respiratory failure is the most common indication for use of VV-ECMO in trauma patients, its use in traumatic thoracic compartment syndrome is not yet well described. Thoracic compartment syndrome, a rare complication of thoracic trauma, occurs in the setting of chest wall injuries, impaired chest wall compliance, pulmonary contusions and subsequent high ventilatory pressures. This in turn impairs venous return and increases risk of circulatory arrest due to obstructive shock.