An Analysis of Helicopter EMS Accidents using HFACS: 2000-2012

In 1972, the first hospital based civilian helicopter emergency medical service (HEMS) in the United States began operations. While the use of helicopters to transport medical casualties started decades previously, St. Anthony Flight for Life represented the start of an industry that would grow rapidly in the years to follow, both in the US and around the world (Flight for Life Colorado, n.d.). Helicopters provide a valuable contribution to the field of medicine. They are faster than ground-based transportation and able to reach areas considered otherwise remote or impassible. They are highly manoeuvrable, unhindered by traffic, and can land in confined spaces. Further advancements, such as the use of advanced life support equipment and flight medical personnel have further improved patient outcomes. After a decade of growth, a disturbing trend emerged in the air ambulance sector. In the early 1980s, the National Transportation Safety Board (NTSB) observed a marked rise in aviation accidents involving ambulance helicopters. Since then it has been observed that there are a disproportionate number of accidents in HEMS flying compared to other types of flying, including fixed-wing EMS. This phenomenon has been the subject of numerous articles, government reports, and news stories (e.g. NTSB, 1988; Harris, 1994; Wright, 2004; Veilette, 2005; and Negroni, 2009). By its nature, HEMS operations pose more risks than other types of flying. Unscheduled flights into unfamiliar areas and semi-prepared landing surfaces ostensibly increase the chance of an accident or incident. However, examination of HEMS operations in other countries show that the risk is more pronounced in the US than other countries (Table 1). The US had an accident rate in 2000-09 that was both higher than other countries and the previous decade. It also has the highest fatal accident rate, considering that the Australian rate in 2000-09 was the result of a single HEMS crash in 2003

M–M Bond-Stretching Energy Landscapes for M_2(dimen)_(4)^(2+) (M = Rh, Ir; dimen = 1,8-Diisocyanomenthane) Complexes

Isomers of Ir_2(dimen)_(4)^(2+) (dimen = 1,8-diisocyanomenthane) exhibit different Ir–Ir bond distances in a 2:1 MTHF/EtCN solution (MTHF = 2-methyltetrahydrofuran). Variable-temperature absorption data suggest that the isomer with the shorter Ir–Ir distance is favored at room temperature [K = ~8; ΔH° = −0.8 kcal/mol; ΔS° = 1.44 cal mol^(–1) K^(–1)]. We report calculations that shed light on M_2(dimen)_(4)^(2+) (M = Rh, Ir) structural differences: (1) metal–metal interaction favors short distances; (2) ligand deformational-strain energy favors long distances; (3) out-of-plane (A_(2u)) distortion promotes twisting of the ligand backbone at short metal–metal separations. Calculated potential-energy surfaces reveal a double minimum for Ir_2(dimen)_(4)^(2+) (4.1 Å Ir–Ir with 0° twist angle and ~3.6 Å Ir–Ir with ±12° twist angle) but not for the rhodium analogue (4.5 Å Rh–Rh with no twisting). Because both the ligand strain and A_(2u) distortional energy are virtually identical for the two complexes, the strength of the metal–metal interaction is the determining factor. On the basis of the magnitude of this interaction, we obtain the following results: (1) a single-minimum (along the Ir–Ir coordinate), harmonic potential-energy surface for the triplet electronic excited state of Ir_2(dimen)_(4)^(2+) (R_(e,Ir–Ir) = 2.87 Å; F_(Ir–Ir) = 0.99 mdyn Å^(–1)); (2) a single-minimum, anharmonic surface for the ground state of Rh_2(dimen)_(4)^(2+) (R_(e,Rh–Rh) = 3.23 Å; F_(Rh–Rh) = 0.09 mdyn Å^(–1)); (3) a double-minimum (along the Ir–Ir coordinate) surface for the ground state of Ir_2(dimen)_(4)^(2+) (R_(e,Ir–Ir) = 3.23 Å; F_(Ir–Ir) = 0.16 mdyn Å^(–1))

Flexibility in the receptor-binding domain of the enzymatic colicin E9 is required for toxicity against Escherichia coli cells

The events that occur after the binding of the enzymatic E colicins to Escherichia coli BtuB receptors that lead to translocation of the cytotoxic domain into the periplasmic space and, ultimately, cell killing are poorly understood. It has been suggested that unfolding of the coiled-coil Mull receptor binding domain of the E colicins may be an essential step that leads to the loss of immunity protein from the colicin and immunity protein complex and then triggers the events of translocation. We introduced pairs of cysteine mutations into the receptor binding domain of colicin E9 (ColE9) that resulted in the formation of a disulfide bond located near the middle or the top of the R domain. After dithiothreitol reduction, the ColE9 protein with the mutations L359C and F412C (ColE9 L359C-F412C) and the ColE9 protein with the mutations Y324C and L447C (ColE9 Y324C-L447C) were slightly less active than equivalent concentrations of ColE9. On oxidation with diamide, no significant biological activity was seen with the ColE9 L359C-F412C and the ColE9 Y324C-L447C mutant proteins; however diamide had no effect on the activity of ColE9. The presence of a disulfide bond was confirmed in both of the oxidized, mutant proteins by matrix-assisted laser desorption ionization-time of flight mass spectrometry. The loss of biological activity of the disulfide-containing mutant proteins was not due to an indirect effect on the properties of the translocation or DNase domains of the mutant colicins. The data are consistent with a requirement for the flexibility of the coiled-coil R domain after binding to BtuB

Cosmic Texture from a Broken Global SU(3) Symmetry

We investigate the observable consequences of creating cosmic texture by breaking a global SU(3) symmetry, rather than the SU(2) case which is generally studied. To this end, we study the nonlinear sigma model for a totally broken SU(3) symmetry, and develop a technique for numerically solving the classical field equations. This technique is applied in a cosmological context: the energy of the collapsing SU(3) texture field is used as a gravitational source for the production of perturbations in the primordial fluids of the early universe. From these calculations, we make predictions about the appearance of the anisotropies in the cosmic microwave background radiation (CMBR) which would be present if the large scale structure of the universe was gravitationally seeded by the collapse of SU(3) textures.Comment: 28 pages, latex, 11 figures, submitted to Phys. Rev.

No effect of arm exercise on diaphragmatic fatigue or ventilatory constraint in Paralympic athletes with cervical spinal cord injury

Cervical spinal cord injury (CSCI) results in a decrease in the capacity of the lungs and chest wall for pressure, volume, and airflow generation. We asked whether such impairments might increase the potential for exercise-induced diaphragmatic fatigue and mechanical ventilatory constraint in this population. Seven Paralympic wheelchair rugby players (mean ± SD peak oxygen uptake = 16.9 ± 4.9 ml·kg–1·min–1) with traumatic CSCI (C5–C7) performed arm-crank exercise to the limit of tolerance at 90% of their predetermined peak work rate. Diaphragm function was assessed before and 15 and 30 min after exercise by measuring the twitch transdiaphragmatic pressure (Pdi,tw) response to bilateral anterolateral magnetic stimulation of the phrenic nerves. Ventilatory constraint was assessed by measuring the tidal flow volume responses to exercise in relation to the maximal flow volume envelope. Pdi,tw was not different from baseline at any time after exercise (unpotentiated Pdi,tw = 19.3 ± 5.6 cmH2O at baseline, 19.8 ± 5.0 cmH2O at 15 min after exercise, and 19.4 ± 5.7 cmH2O at 30 min after exercise; P = 0.16). During exercise, there was a sudden, sustained rise in operating lung volumes and an eightfold increase in the work of breathing. However, only two subjects showed expiratory flow limitation, and there was substantial capacity to increase both flow and volume (<50% of maximal breathing reserve). In conclusion, highly trained athletes with CSCI do not develop exercise-induced diaphragmatic fatigue and rarely reach mechanical ventilatory constraint

Susceptibility Provision Enhances Effective De-escalation (SPEED): utilizing rapid phenotypic susceptibility testing in Gram-negative bloodstream infections and its potential clinical impact

Abstract Objectives We evaluated the performance and time to result for pathogen identification (ID) and antimicrobial susceptibility testing (AST) of the Accelerate Pheno™ system (AXDX) compared with standard of care (SOC) methods. We also assessed the hypothetical improvement in antibiotic utilization if AXDX had been implemented. Methods Clinical samples from patients with monomicrobial Gram-negative bacteraemia were tested and compared between AXDX and the SOC methods of the VERIGENE® and Bruker MALDI Biotyper® systems for ID and the VITEK® 2 system for AST. Additionally, charts were reviewed to calculate theoretical times to antibiotic de-escalation, escalation and active and optimal therapy Results ID mean time was 21 h for MALDI-TOF MS, 4.4 h for VERIGENE® and 3.7 h for AXDX. AST mean time was 35 h for VITEK® 2 and 9.0 h for AXDX. For ID, positive percentage agreement was 95.9% and negative percentage agreement was 99.9%. For AST, essential agreement was 94.5% and categorical agreement was 93.5%. If AXDX results had been available to inform patient care, 25% of patients could have been put on active therapy sooner, while 78% of patients who had therapy optimized during hospitalization could have had therapy optimized sooner. Additionally, AXDX could have reduced time to de-escalation (16 versus 31 h) and escalation (19 versus 31 h) compared with SOC. Conclusions By providing fast and reliable ID and AST results, AXDX has the potential to improve antimicrobial utilization and enhance antimicrobial stewardship

Interferometry with Photon-Subtracted Thermal Light

We propose and implement a quantum procedure for enhancing the sensitivity with which one can determine the phase shift experienced by a weak light beam possessing thermal statistics in passing through an interferometer. Our procedure entails subtracting exactly one (which can be generalized to m) photons from the light field exiting an interferometer containing a phase-shifting element in one of its arms. As a consequence of the process of photon subtraction, and somewhat surprisingly, the mean photon number and signal-to-noise ratio of the resulting light field are thereby increased, leading to enhanced interferometry. This method can be used to increase measurement sensitivity in a variety of practical applications, including that of forming the image of an object illuminated only by weak thermal light

Waste Management Options for Long-Duration Space Missions: When to Reject, Reuse, or Recycle

The amount of waste generated on long-duration space missions away from Earth orbit creates the daunting challenge of how to manage the waste through reuse, rejection, or recycle. The option to merely dispose of the solid waste through an airlock to space was studied for both Earth-moon libration point missions and crewed Mars missions. Although the unique dynamic characteristics of an orbit around L2 might allow some discarded waste to intersect the lunar surface before re-impacting the spacecraft, the large amount of waste needed to be managed and potential hazards associated with volatiles recondensing on the spacecraft surfaces make this option problematic. A second option evaluated is to process the waste into useful gases to be either vented to space or used in various propulsion systems. These propellants could then be used to provide the yearly station-keeping needs at an L2 orbit, or if processed into oxygen and methane propellants, could be used to augment science exploration by enabling lunar mini landers to the far side of the moon

Phase 1b/2a trial of the superoxide dismutase mimetic GC4419 to reduce chemoradiotherapy-induced oral mucositis in patients with oral cavity or oropharyngeal carcinoma

PURPOSE: To assess the safety of the superoxide dismutase mimetic GC4419 in combination with radiation and concurrent cisplatin for patients with oral cavity or oropharyngeal cancer (OCC) and to assess the potential of GC4419 to reduce severe oral mucositis (OM). PATIENTS AND METHODS: Patients with locally advanced OCC treated with definitive or postoperative intensity modulated radiation therapy (IMRT) plus cisplatin received GC4419 by 60-minute intravenous infusion, ending \u3c60 minutes before IMRT, Monday through Friday for 3 to 7 weeks, in a dose and duration escalation study. Oral mucositis was assessed twice weekly during and weekly after IMRT. RESULTS: A total of 46 patients received GC4419 in 11 separate dosing and duration cohorts: dose escalation occurred in 5 cohorts receiving 15 to 112 mg/d over 3 weeks (n=20), duration escalation in 3 cohorts receiving 112 mg/d over 4 to 6 weeks (n=12), and then 3 additional cohorts receiving 30 or 90 mg/d over 6 to 7 weeks (n=14). A maximum tolerated dose was not reached. One dose-limiting toxicity (grade 3 gastroenteritis and vomiting with hyponatremia) occurred in each of 2 separate cohorts at 112 mg. Nausea/vomiting and facial paresthesia during infusion seemed to be GC4419 dose-related. Severe OM occurred through 60 Gy in 4 of 14 patients (29%) dosed for 6 to 7 weeks, with median duration of only 2.5 days. CONCLUSIONS: The safety of GC4419 concurrently with chemoradiation for OCC was acceptable. Toxicities included nausea/vomiting and paresthesia. Doses of 30 and 90 mg/d administered for 7 weeks were selected for further study. In an exploratory analysis, severe OM seemed less frequent and briefer than expected