33 research outputs found

    Defining levels of care in cardiogenic shock

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    BackgroundExpert opinion and professional society statements have called for multi-tier care systems for the management of cardiogenic shock (CS). However, little is known about how to pragmatically define centers with different levels of care (LOC) for CS.MethodsEleven of 23 hospitals within our healthcare system sharing a common electronic health record were classified as different LOC according to their highest mechanical circulatory support (MCS) capabilities: Level 1 (L-1)—durable left ventricular assist device, Level 1A (L-1A)—extracorporeal membrane oxygenation, Level 2 (L-2)—intra-aortic balloon pump and percutaneous ventricular assist device; and Level 3 (L-3)—no MCS. All adult patients treated for CS (International Classification of Diseases, ICD-10 code R57.0) between 2016 and 2022 were included. Etiologies of CS were identified using associated diagnostic codes. Management strategies and outcomes across LOC were compared.ResultsHigher LOC centers had higher volumes: L-1 (n = 1): 2,831 patients, L-1A (n = 4): 3,452, L-2 (n = 1): 340, and L-3 (n = 5): 780. Emergency room admissions were more common in lower LOC (96% at L-3 vs. 46% L-1; p < 0.001), while hospital transfers were predominant at higher LOC (40% at L-1 vs. 2.7% at L-3; p < 0.001). Men comprised 61% of the cohort. Patients were younger in the higher LOC [69 (60–78) years at L-1 vs. 77 (67–85) years at L-3; p < 0.001]. Patients with acute myocardial infarction (AMI)-CS and acute heart failure (AHF)-CS were concentrated in higher LOC centers while other etiologies of CS were more common in L-2 and L-3 (p < 0.001). Cardiac arrest on admission was more prevalent in lower LOC centers (L-1: 2.8% vs. L-3: 12.1%; p < 0.001). Patients with AMI-CS received more percutaneous coronary intervention in lower LOC (51% L-2 vs. 29% L-1; p < 0.01) but more coronary arterial bypass graft surgery at higher LOC (L-1: 42% vs. L-1A: 23%; p < 0.001). MCS use was consistent across levels for AMI-CS but was more frequent in higher LOC for AHF-CS patients (L-1: 28% vs. L-2: 10%; p < 0.001). Despite increasing in-hospital mortality with decreasing LOC, no significant difference was seen after multivariable adjustment.ConclusionThis is the first report describing a pragmatic classification of LOC for CS which, based on MCS capabilities, can discriminate between centers with distinct demographics, practice patterns, and outcomes. This classification may serve as the basis for future research and the creation of CS systems of care

    Semi-device-independent self-testing of unsharp measurements

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    Unsharp quantum measurements provide a resource in scenarios where one faces the trade-off between information gain and disturbance. In this work we introduce a prepare-transform-measure scenario in which two-outcome unsharp measurements outperform their sharp counterparts, as well as any stochastic strategy involving dichotomic projective measurements. Based on that, we propose a scheme for semi-device-independent self-testing of unsharp measurements and show that all two-outcome qubit measurements can be characterized in a robust way. Along with the main result, in this work we introduce a method, based on semidefinite programming, for bounding quantum correlations in scenarios with sequential measurements of length 2. This method can also be applied to refine security analysis of the semi-device-independent one-way quantum key distribution. We also present an information gain–disturbance relation for pairs of dichotomic measurements

    Feedback on Terrorist Attacks on November 13, 2015. Organization of Reinforcements by Provinces Medical Emergency Services

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    International audienceThe Parisian terrorist attacks of last November 13, 2015 highlighted the need for a structured organization of the answer of the health system in which out-of-hospital emergency medicine occupies a dominating place. In addition to the Ile-de-France organization, bordering medical emergency services quickly engaged reinforcements, in order to make safe the medical answer on the assumption of an increase in the number of victims. This operational strategy rests at the preestablished plans which are recommended to be updated on the basis of mutual assistance more formalized between the emergency medical services, mainly in the provinces where the medical teams are fewers

    Hepatitis C Virus Core Protein Inhibits Interferon Production by a Human Plasmacytoid Dendritic Cell Line and Dysregulates Interferon Regulatory Factor-7 and Signal Transducer and Activator of Transcription (STAT) 1 Protein Expression

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    <div><p>Plasmacytoid Dendritic Cells (pDCs) represent a key immune cell population in the defense against viruses. pDCs detect viral pathogen associated molecular patterns (PAMPs) through pattern recognition receptors (PRR). PRR/PAMP interactions trigger signaling events that induce interferon (IFN) production to initiate local and systemic responses. pDCs produce Type I and Type III (IFNL) IFNs in response to HCV RNA. Extracellular HCV core protein (Core) is found in the circulation in chronic infection. This study defined how Core modulates PRR signaling in pDCs. Type I and III IFN expression and production following exposure to recombinant Core or β-galactosiade was assessed in human GEN2.2 cells, a pDC cell line. Core suppressed type I and III IFN production in response to TLR agonists and the HCV PAMP agonist of RIG-I. Core suppression of IFN induction was linked with decreased IRF-7 protein levels and increased non-phosphorylated STAT1 protein. Circulating Core protein interferes with PRR signaling by pDCs to suppress IFN production. Strategies to define and target Core effects on pDCs may serve to enhance IFN production and antiviral actions against HCV.</p></div

    Paradigm Model of HCV Core acting on pDCs.

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    <p>A) pDCs respond to TLR stimulation and HCV PAMP to produce IFNs Type I and IFNLs. However, in the presence of HCV core (B), there is increased STAT1 but decreased IFNs production. The decreased IFN results in decreased IRF-7, which is an ISG.</p

    rCore inhibits TLR stimulation.

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    <p>Gene fold increases in GEN2.2-pDCs following rCore pretreatment and TLR stimulation with Loxoribine (A) or CpGA (B). C) Kinetics of IFN mRNA after pretreatment with rCore or β-galactosidase (β-gal) and HCV pU/UC RNA stimulation. D) Levels of protein by ELISA when cells were treated with rCore or β-gal for 24 h then stimulated with the HCV PAMP RNA for 24 h. E) IFNβ promoter activity following 24 hours of rCore/β-gal pretreatment and 24 hour transfection of pU/UC RNA and IFNβ –firefly luciferase reporter plasmid. Units are shown as Relative Light Units (RLU) and represent the light units measured of firefly luciferase (driven by the IFNβ promoter) divided by the light units of renilla luciferase (transfection control; driven by the CMV promoter). Combined data for 3 (A, B, D & E) or 8 (C) independent experiments. P values are results of Mann-Whitney comparison of the bars indicated. *p<0.05 **p<0.01 ***p<0.001 #p≤0.0001. Mean +/− SEM.</p
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