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A test unit has been developed by Rolls-Royce for the U.S. Navy to use in evaluating fuel thermal deposition typically found in various aircraft engine components. Although the current Jet Fuel Thermal Oxidation Tester (JFTOT) provides a qualitative thermal stability evaluation, it may not be able to predict in-service problems. Conditioning and testing of the fuel under realistic conditions is crucial if one is to predict deposit formations accurately. Engine fuel deposit evaluations and evidence from unpublished Rolls-Royce laboratory rig tests were used to help design a test unit that would address fuel stability problems in current or future aircraft. The Aviation Fuel Thermal Stability (AFTS) test unit embodies test modules that were selected with extensive fuel systems experience to enable the evaluation of thermal deposition in various fuel components using properly conditioned fuel. The test modules are controlled and results are recorded by a computer. This paper includes a review of the AFTS test unit design and preliminary test results thereof.

INTRODUCTION: Paramedics often encounter patients with difficult airways requiring emergent airway management. OBJECTIVE: The purpose of this study was to compare intubation utilizing the Airtraq with direct laryngoscopy (DL) in the manikin model. We evaluated the number of attempts, the time to successful intubation, and the Airtraq's learning curve. METHODS: This was a randomized, crossover study involving paramedics. Each participant was given a standardized lecture and a demonstration of the Airtraq device. After a 5-minute practice session on a Laerdal Airway Management Trainer with the Airtraq and DL, participants managed the following four scenarios on a Laerdal SimMan manikin: 1) normal airway; 2) tongue edema; 3) cervical spine immobilization; and 4) repeated normal airway. Results were analyzed using the Wilcoxon signed rank test. RESULTS: Thirty paramedics participated in this study. For scenario 1, there were no significant differences in either the number of attempts or the time to ventilation between the devices. For scenario 2, the mean time to ventilation was significantly faster, and fewer intubation attempts were observed with the Airtraq when compared with DL. For scenario 3, there were no significant differences in number of attempts and time to ventilation. Scenario 4 demonstrated significantly less time to ventilation and fewer intubation attempts with the Airtraq. A significant decrease in time to ventilation was observed with the Airtraq when comparing scenarios 1 and 4. CONCLUSIONS: The Airtraq was shown to be equal to or faster than DL. The Airtraq has a rapid learning curve demonstrated by a significantly decreased time to ventilation between scenarios 1 and 4. [ABSTRACT FROM AUTHOR]

Objectives: This study examines B-type natriuretic peptide (BNP) levels in patients with systolic versus non-systolic dysfunction presenting with shortness of breath.Background: Preserved systolic function is increasingly common in patients presenting with symptoms of congestive heart failure (CHF) but is still difficult to diagnose.Methods: The Breathing Not Properly Multinational Study was a seven-center, prospective study of 1,586 patients who presented with acute dyspnea and had BNP measured upon arrival. A subset of 452 patients with a final adjudicated diagnosis of CHF who underwent echocardiography within 30 days of their visit to the emergency department (ED) were evaluated. An ejection fraction of greater than 45% was defined as non-systolic CHF.Results: Of the 452 patients with a final diagnosis of CHF, 165 (36.5%) had preserved left ventricular function on echocardiography, whereas 287 (63.5%) had systolic dysfunction. Patients with non-systolic heart failure (NS-CHF) had significantly lower BNP levels than those with systolic heart failure (S-CHF) (413 pg/ml vs. 821 pg/ml, p < 0.001). As the severity of heart failure worsened by New York Heart Association class, the percentage of S-CHF increased, whereas the percentage of NS-CHF decreased. When patients with NS-CHF were compared with patients without CHF (n = 770), a BNP value of 100 pg/ml had a sensitivity of 86%, a negative predictive value of 96%, and an accuracy of 75% for detecting abnormal diastolic dysfunction. Using Logistic regression to differentiate S-CHF from NS-CHF, BNP entered first as the strongest predictor followed by oxygen saturation, history of myocardial infarction, and heart rate.Conclusions: We conclude that NS-CHF is common in the setting of the ED and that differentiating NS-CHF from S-CHF is difficult in this setting using traditional parameters. Whereas BNP add modest discriminatory value in differentiating NS-CHF from S-CHF, its major role is still the separation of patients with CHF from those without CHF. [ABSTRACT FROM AUTHOR]

In 2019, Connecticut launched an opioid overdose-monitoring program to provide rapid intervention and limit opioid overdose-related harms. The Connecticut Statewide Opioid Response Directive (SWORD)-a collaboration among the Connecticut State Department of Public Health, Connecticut Poison Control Center (CPCC), emergency medical services (EMS), New England High Intensity Drug Trafficking Area (HIDTA), and local harm reduction groups-required EMS providers to call in all suspected opioid overdoses to the CPCC. A centralized data collection system and the HIDTA overdose mapping tool were used to identify outbreaks and direct interventions. We describe the successful identification of a cluster of fentanyl-contaminated crack cocaine overdoses leading to a rapid public health response. On June 1, 2019, paramedics called in to the CPCC 2 people with suspected opioid overdose who reported exclusive use of crack cocaine after being resuscitated with naloxone. When CPCC specialists in poison information followed up on the patients' status with the emergency department, they learned of 2 similar cases, raising suspicion that a batch of crack cocaine was mixed with an opioid, possibly fentanyl. The overdose mapping tool pinpointed the overdose nexus to a neighborhood in Hartford, Connecticut; the CPCC supervisor alerted the Connecticut State Department of Public Health, which in turn notified local health departments, public safety officials, and harm reduction groups. Harm reduction groups distributed fentanyl test strips and naloxone to crack cocaine users and warned them of the dangers of using alone. The outbreak lasted 5 days and tallied at least 22 overdoses, including 6 deaths. SWORD's near-real-time EMS reporting combined with the overdose mapping tool enabled rapid recognition of this overdose cluster, and the public health response likely prevented additional overdoses and loss of life.

Background: The goal of root canal therapy depends on chemomechanical debridement and three-dimensional filling of the root canal system.[1]., Aim: The aim of this study is to assess the effect of NaOCl + Ethylenediaminetetraacetic acid (EDTA) and Twin Kleen as a final irrigating solution on the depth of penetration of AH Plus and Perma Evolution sealers into the dentinal tubules., Materials and Methods: Forty mandibular premolars were decoronated and instrumented up to size 30. Moreover, randomly assigned into two groups based on final rinse Group A ( n = 20): 5.25% NaOCl + 17% EDTA. Group B ( n = 20): Twin Kleen solution. Resin sealers were labeled with few grains of fluorescent rhodamine B dye and subdivided into two subgroups, Subgroup A1and B1 ( n 1 = 10): AH Plus; Subgroup A2 and B2 ( n 2 = 10): Perma Evolution and obturated. Confocal laser scanning microscopy was used to examine the sections taken 2, 5, and 8 mm from the apex. Images were exported to Image J software to determine the sealer penetration depth., Statistical Analysis: Independent t -test and one-way analysis of variance followed by Tukey's HSD post hoc test., Results: Maximum depth of sealer penetration was seen in Twin Kleen in all sections. Perma Evolution showed highest sealer penetration at the middle and apical third region of root canal for both groups., Conclusions: Final irrigation with Twin Kleen produced highest sealer penetration than with EDTA., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Conservative Dentistry.)

Tactical emergency medical support (TEMS) is a critical component of the out-of-hospital response to domestic high-threat incidents such as hostage scenarios, warrant service, active shooter or violent incidents, terrorist attacks, and other intentional mass casualty-producing acts. From its grass-roots inception in the form of medical support of select law enforcement special weapons and tactics (SWAT) units in the 1980s, the TEMS subspecialty of prehospital care has rapidly grown and evolved over the past 40 years. The National TEMS Initiative and Council (NTIC) competencies and training objectives are the only published recommendations of their kind and offer the opportunity for national standardization of TEMS training programs and a future accreditation process. Building on the previous work of the NTIC and the creation of acknowledged competency domains for TEMS and the acknowledged civilian translation of TCCC by the Committee for Tactical Emergency Casualty Care (C-TECC), the Joint Review Committee (JRC) has created an opportunity to bring forward the work in a form that could be operationally useful in an all-hazards and whole of community format., (2016.)

There is a major gap in the security of the critical infrastructure - civilian medical response to atypical emergencies. Clear evidence demonstrates that, despite ongoing improvements to the first-responder system, there exists an inherent delay in the immediate medical care at the scene of an emergency. This delay can only be reduced through a societal shift in reliance on police and fire response and by extending the medical system into all communities. Additionally, through analysis of military data, it is known that immediately addressing the common injury patterns following a traumatic event will save lives. The predictable nature of these injuries, coupled with an unavoidable delay in the arrival of first responders, necessitates the need for immediate care on scene. Initial care is often rendered by bystanders, typically armed only with basic first-aid training based on medical emergencies and does not adequately address the traumatic injury patterns seen in disasters. Implementing an approach similar to the American Cardiac Arrest Act can improve outcomes to traumatic events. This paper analyses the latest data on active shooter incidents and proposes that the creation of a network of trauma-trained medic extenders would improve all communities' resilience to catastrophic disaster.

Objective: We sought to categorize and characterize the utilization of statewide emergency medical services (EMS) protocols as well as state recognition of specialty receiving facilities for trauma and time-sensitive conditions in the United States., Methods: A survey of all state EMS offices was conducted to determine which states use mandatory or model statewide EMS protocols and to characterize these protocols based on the process for authorizing such protocols. The survey also inquired as to which states formally recognize specialty receiving facilities for trauma, STEMI, stroke, cardiac arrest, and burn as well as whether or not states have mandatory or model statewide destination protocols for these specialty centers., Results: Thirty-eight states were found to have either mandatory or model statewide EMS protocols. Twenty-one states had mandatory statewide EMS protocols at either the basic life support (BLS) or advanced life support (ALS) level, and in 16 of these states, mandatory protocols covered both BLS and ALS levels of care. Seventeen states had model statewide protocols at either the BLS or ALS level, and in 14 of these states, the model protocols covered both BLS and ALS levels of care. Twenty states had separate protocols for the care of pediatric patients, while 18 states combined pediatric and adult care within the same protocols. When identified, the median age used to consider a patient for pediatric care was ≤14 years (range ≤8 to ≤17 years). Three states' protocols used a child's height based on a length-based dosage tool as the threshold for identifying a pediatric patient for care using their pediatric protocols. States varied in recognition of receiving centers for EMS patients with special medical needs: 46 recognized trauma centers, 25 recognized burn centers, 22 recognized stroke centers, 11 recognized centers capable of percutaneous coronary intervention for ST-elevation myocardial infarction, and 3 recognized centers for patients surviving cardiac arrest., Conclusion: Statewide mandated EMS treatment protocols exist in 21 states, and optional model protocol guidelines are provided by 17 states. There is wide variation in the format and characteristics of these protocols and the recognition of specialty receiving centers for patients with time-sensitive illnesses.

Introduction: Tactical teams are at high risk of sustaining injuries. Caring for these casualties in the field involves unique requirements beyond what is provided by traditional civilian emergency medical services (EMS) systems. Despite this need, the training objectives and competencies are not uniformly agreed to or taught., Methods: An expert panel was convened that included members from the Departments of Defense, Homeland Security, Justice, and Health and Human Services, as well as federal, state, and local law-enforcement officers who were recruited through requests to stakeholder agencies and open invitations to individuals involved in Tactical Emergency Medical Services (TEMS) or its oversight. Two face-to-face meetings took place. Using a modified Delphi technique, previously published TEMS competencies were reviewed and updated., Results: The original 17 competency domains were modified and the most significant changes were the addition of Tactical Emergency Casualty Care (TECC), Tactical Familiarization, Legal Aspects of TEMS, and Mass Casualty Triage to the competency domains. Additionally, enabling and terminal learning objectives were developed for each competency domain., Conclusion: This project has developed a minimum set of medical competencies and learning objectives for both tactical medical providers and operators. This work should serve as a platform for ensuring minimum knowledge among providers, which will serve enhance team interoperability and improve the health and safety of tactical teams and the public., (2014.)

Objectives: Assess the association of helmet use with motorcycle crash mortality and identify characteristics of riders who do not wear helmets in Connecticut crashes., Methods: Police crash data for Connecticut motorcycle crashes 2001-2007 were analyzed. Bivariate analysis and multivariable logistic regressions were performed including age, gender, seating position, road type, season, time of day, and recklessness., Results: Of the 9,214 crashes with helmet use data available, helmets were worn in 4072 (44.2%). Non-helmeted riders, age > or =18, riding interstate or state roads, in the evening or at night, and who were riding recklessly were associated with higher odds of fatality. Predictors of nonhelmet use included males, passengers, age <18 or 30 to 59, and riding in the summer, eveningor at night, and on U.S., state, and localroads., Conclusion: Current crash data affirm that helmets reduce fatal crashes in Connecticut. A set of factors help predict nonhelmeted riders to whom safety training could be targeted.

Introduction: Paramedics often encounter patients with difficult airways requiring emergent airway management., Objective: The purpose of this study was to compare intubation utilizing the Airtraq with direct laryngoscopy (DL) in the manikin model. We evaluated the number of attempts, the time to successful intubation, and the Airtraq's learning curve., Methods: This was a randomized, crossover study involving paramedics. Each participant was given a standardized lecture and a demonstration of the Airtraq device. After a 5-minute practice session on a Laerdal Airway Management Trainer with the Airtraq and DL, participants managed the following four scenarios on a Laerdal SimMan manikin: 1) normal airway; 2) tongue edema; 3) cervical spine immobilization; and 4) repeated normal airway. Results were analyzed using the Wilcoxon signed rank test., Results: Thirty paramedics participated in this study. For scenario 1, there were no significant differences in either the number of attempts or the time to ventilation between the devices. For scenario 2, the mean time to ventilation was significantly faster, and fewer intubation attempts were observed with the Airtraq when compared with DL. For scenario 3, there were no significant differences in number of attempts and time to ventilation. Scenario 4 demonstrated significantly less time to ventilation and fewer intubation attempts with the Airtraq. A significant decrease in time to ventilation was observed with the Airtraq when comparing scenarios 1 and 4., Conclusions: The Airtraq was shown to be equal to or faster than DL. The Airtraq has a rapid learning curve demonstrated by a significantly decreased time to ventilation between scenarios 1 and 4.

In a naturalistic setting, sildenafil may affect quality, satisfaction, and the desire for intercourse in young asymptomatic men. Healthy men 21 years old or older having sex with a steady female partner for at least 6 months and intercourse frequency of at least twice a week were eligible. Subjects received 4 capsules of sildenafil powder 50 mg to take home for one 2-week period, to use one hour before sexual activity. For a second 2-week period, they received 4 identical placebo capsules. Ten subjects aged 22 to 34 were studied. The effects found in this study were small and of borderline statistical significance. The findings may be analogous to those with antidepressants, where major effects are seen only in clinically depressed patients, however, normal volunteers have subtle and difficult-to-measure effects.

Objectives: To assess the reliability and interobserver agreement of stroke identification on neuroimaging in patients presenting with dementia., Design: Comparison study between neurologists, radiology reports, and autopsy., Setting: Dementia registry within a health maintenance organization., Participants: Dementia patients with computed tomography (CT) scans obtained near the time of diagnosis and postmortem neuropathological examinations (N=99)., Measurements: Three neurologists independently read CT scans for the presence and locations of strokes. Radiology reports from these scans were reviewed. The results from neurologists, radiologists, and autopsies were compared., Results: The positive predictive value for CT-observed strokes compared with their presence on autopsy was 0.44 to 0.49, regardless of the specialty of the observer. Strokes were present at autopsy in 46 of 99 cases. Agreement between neurologists on the presence of strokes was fair to moderate (kappa=0.27-0.56). Less agreement was found between neurologists and radiologists (kappa=0.00-0.11). Results improved slightly when each case was evaluated as any stroke present versus no stroke on imaging (kappa=0.34-0.75) or for the presence of multiple strokes (kappa=0.17-0.69)., Conclusion: There is only fair to moderate agreement between observers regarding the identification of strokes on CT scans in patients presenting with dementia. Furthermore, strokes identified on imaging were present on pathology only half the time.

Background: The inhabitants of 3 different types of population centers in Israel were assessed as to stress-related symptomatology during 2003 and 2004. These centers have been exposed to 2 distinct forms of violence-sporadic, large-scale terror attacks in the metropolitan areas in the heart of Israel and daily "war-zone" conditions in the settlements beyond the 1967 borders of Israel., Method: A semistructured interview and questionnaire survey of a random sample of 314 inhabitants of a suburb of Tel-Aviv, a settlement in the West Bank (Kiryat-Arba), and the Gush-Katif settlement cluster in the Gaza Strip was performed. Symptoms of acute stress and chronic (posttraumatic) stress as well as symptoms of general psychopathology and distress were assessed., Results: The inhabitants of Gush-Katif, in spite of firsthand daily exposure to violent attacks, reported the fewest and least severe symptoms of stress-related complaints, the least sense of personal threat, and the highest level of functioning of all 3 samples. The most severely symptomatic and functionally compromised were the inhabitants of the Tel-Aviv suburb, who were the least frequently and least directly affected by exposure to violent attacks. Because the Gush-Katif population is exclusively religious, the data were reassessed according to religiousness. The religious inhabitants of Kiryat-Arba had almost the same symptom profile as the Gush-Katif population, whereas secular inhabitants of Kiryat-Arba reported faring worse than did either population in the Tel-Aviv suburb., Conclusion: Deeply held belief systems affecting life-views may impart significant resilience to developing stress-related problems, even under extreme conditions. Religiousness combined with common ideological convictions and social cohesion was associated with substantial resilience as compared to a secular metropolitan urban population.

Objective: Diabetes has been implicated in reduced myocardial compliance and changes in the intercellular matrix of the myocardium. We determined the effect of diabetes on B-type natriuretic peptide (BNP) concentrations in patients presenting to the emergency department with dyspnea., Research Design and Methods: The Breathing Not Properly Multinational Study was a prospective evaluation of 1,586 patients. A subset of 922 patients was obtained and subdivided into the following groups: group 1 (n = 324), neither diabetes nor heart failure; group 2 (n = 107), diabetes and no heart failure; group 3 (n = 247), no diabetes and heart failure; group 4 (n = 183), both diabetes and heart failure; group 5 (n = 41), heart failure history with no diabetes; and group 6 (n = 20), heart failure history with diabetes. Patients from groups 1, 3, and 5 were matched to groups 2, 4, and 6, respectively, to have the same mean age, sex distribution, BMI, renal function, and New York Heart Association (NYHA) classification (for heart failure)., Results: There was no significant difference in median BNP levels between diabetes and no diabetes among no heart failure patients (32.4 vs.32.9 pg/ml), heart failure patients (587 vs. 494 pg/ml), and those with a heart failure history (180 vs. 120 pg/ml). Receiver-operating characteristic curve analysis of the area under the curve for BNP was not different in diabetic versus nondiabetic patients (0.888 vs. 0.878, respectively). However, in a multivariate model, diabetes was an independent predictor of a final diagnosis of heart failure (odds ratio 1.51, 95% CI 1.03-2.02; P < 0.05)., Conclusions: History of diabetes does not impact BNP levels measured in patients with acute dyspnea in the emergency department. Despite the impact of diabetes on the cardiovascular system, diabetes does not appear to confound BNP levels in the emergency department diagnosis of heart failure., (Copyright 2004 American Diabetes Association)

Two polyclonal B cell activators, lipopolysaccharide (LPS) and poly I:C, have been used to induce interferon (IFN) production by murine B cell populations. The results show that splenic B cell-enriched fractions, isolated by wheat germ agglutination followed by C-dependent anti-Thy 1.2 cytolysis, respond to treatment with poly I:C + DEAE-dextran by IFN production at levels comparable on a per cell basis to unfractionated spleen cells. By contrast, the LPS-stimulated IFN response of these same B cell fractions is either undetectable or substantially lower than that of spleen cells; although the B cell fractions appear fully capable of LPS-induced proliferation. Consistent with this pattern of splenic B cell IFN responses, two antibody-secreting hybridoma lines and two myeloma cell lines (including the parental myeloma of the hybrid) can be stimulated by poly I:C + DEAE-dextran to produce IFN; yet these same B cell lines do not synthesize IFN in response to LPS at doses from 1-100 micrograms/ml. The level of poly I:C-induced IFN secreted by the hybridomas are approximately 10-fold greater than that produced by the unfused parental myeloma cells. Not only do these results directly demonstrate that murine lymphocytes of the B cell lineage produce IFN in response to the B cell activator poly I:C, but these observations also strongly suggest that the IFN responses of the B cell tumor lines model the IFN producing capacity of splenic B cells. Moreover, since the hybridoma cell lines and one of the myeloma lines synthesize specific antibody molecules, these observations show that the progeny of a single B cell clone can synthesize and secrete both IFN and immunoglobulin.