Prehospital Systolic Blood Pressure Thresholds: A Community‐based Outcomes Study

Objectives Emergency medical services (EMS) personnel commonly use systolic blood pressure ( sBP ) to triage and treat acutely ill patients. The definition of prehospital hypotension and its associated outcomes are poorly defined. The authors sought to determine the discrimination of prehospital sBP thresholds for 30‐day mortality and to compare patient classification by best‐performing thresholds to traditional cutoffs. Methods In a community‐based cohort of adult, nontrauma, noncardiac arrest patients transported by EMS between 2002 and 2006, entries to state hospital discharge data and death certificates were linked. Prehospital sBP thresholds between 40 and 140 mm Hg in derivation ( n =  132,624) and validation ( n =  22,020) cohorts and their discrimination for 30‐day mortality, were examined. Cutoffs were evaluated using the 0/1 distance, Youden index, and adjusted Z‐statistics from multivariable logistic regression models. Results In the derivation cohort, 1,594 (1.2%) died within 24 hours, 7,404 (6%) were critically ill during hospitalization, and 6,888 (5%) died within 30 days. The area under the receiver operating characteristic (ROC) curve for sBP was 0.60 (95% confidence interval [CI] = 0.59, 0.61) for 30‐day mortality and 0.64 (95% CI = 0.62 0.66) for 24‐hour mortality. The 0/1 distance, Youden index, and adjusted Z‐statistics found best‐performing sBP thresholds between 110 and 120 mm Hg. When compared to an sBP ≤ 90 mm Hg, a cutoff of 110 mm Hg would identify 17% ( n =  137) more deaths at 30 days, while overtriaging four times as many survivors. Conclusions Prehospital sBP is a modest discriminator of clinical outcomes, yet no threshold avoids substantial misclassification of 30‐day mortality among noninjured patients. Resumen Los Umbrales de la Presión Arterial Sistólica Prehospitalaria: Un Estudio de Base Comunitaria Acerca de la Evolución de los Pacientes Objetivos El personal de los sistemas de emergencias médicas ( SEM ) usa frecuentemente la presión arterial sistólica ( PAS ) para clasificar y tratar a los pacientes agudos. Las definiciones de hipotensión prehospitalaria y sus resultados asociados están pobremente definidos. Se determinó la discriminación de los umbrales de PAS prehospitalaria para la mortalidad a los 30 días, y se comparó la clasificación del paciente por los mejores umbrales con los puntos de corte tradicionales. Metodología Estudio de cohorte de base comunitaria de pacientes adultos no traumatológicos ni con paradas cardiorrespiratorias transportados por los SEM entre 2002 y 2006, cuyas historias estaban vinculadas con los datos de alta hospitalaria y los certificados de mortalidad. Se examinaron los umbrales de PAS prehospitalaria entre 40 mm Hg y 140 mm Hg en las cohortes de derivación ( n =  132.624), y validación ( n =  22,020), y su discriminación para la mortalidad a los 30 días. Los puntos de corte se evaluaron usando la distancia 0/1, el índice de Youden y los estadísticos Z ajustados de los modelos de regresión logística multivariable. Resultados: En la cohorte de derivación, 1.594 (1,2%) fallecieron en las primeras 24 horas, 7.404 (6%) estuvieron críticamente enfermos durante el ingreso y 6.888 (5%) fallecieron en los 30 primeros días. El área bajo la curva de la ROC para PAS fue 0,60 ( IC 95% = 0,59–0,61) para la mortalidad a los 30 días y 0,64 ( IC 95% = 0,62–0,66) para la mortalidad a las 24 horas. La distancia 0/1, el índice de Youden y las estadísticas Z ajustadas hallaronque los mejores umbrales de PAS estaban entre 110 y 120 mm Hg. Cuando se comparó con una PAS ≤ 90 mm Hg, un punto de corte de 110 mm Hg identificaría un 17% ( n =  137) más de muertes a los 30 días, mientras que sobreclasificaría cuatro veces más a los supervivientes. Conclusiones La presión arterial sistólica es un discriminador modesto de resultados clínicos. No obstante, ningún umbral evita una mala clasificación de la mortalidad a los 30 días entre los pacientes no traumatológicos.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/1/acem12142-sup-0002-DataSupplementS2_FigS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/2/acem12142-sup-0007-DataSupplementS7_FigS4.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/3/acem12142-sup-0006-DataSupplementS6_FigS3.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/4/acem12142-sup-0009-DataSupplementS9_TableS3.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/5/acem12142-sup-0003-DataSupplementS3.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/6/acem12142-sup-0008-DataSupplementS8_TableS2.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/7/acem12142-sup-0004-DataSupplementS4_TableS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/8/acem12142-sup-0001-DataSupplementS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/9/acem12142.pd

Conservatives and the Constabulary in Great Britain: cross-dressing conundrums

Purpose This chapter is devoted to analysing the historical peculiarity of the contemporary British politics of policing. Methodology/approach Research is based on an analysis of policy statements and debates, news reports, and official statistics, in the light of historical studies of the earlier politics of policing. Findings The Conservative government’s police reform programme severely diminishes the resources, powers, status and independence of the police, reversing the Tory’s traditional unquestioning support of the police. The package is shown to reflect broader changes in political economy and culture under neoliberalism. Originality/value There has been no previous academic analysis bringing together the various aspects of the reform programme, contrasting it with previous historical understanding of the politics of policing, and linking it to broader contemporary change

Radio observations of the XMM-Newton/Chandra 13hr deep survey field

Our VLA observations of the XMM-Newton/Chandra 13hr deep survey field (see Page et al., this proceedings) result in one of the two deepest 1.4GHz radio maps ever made. Within the 15' radius field covered by the deep X-ray data (0.19 sq deg), a total of 556 radio sources are detected, down to a 4 sigma flux limit of 28uJy. Of the 214 Chandra sources, 55 have radio counterparts. The sub-arcsecond accuracy of the VLA and Chandra positions enable us to determine with high confidence the sources common to both surveys. Here we present the relationship between the X-ray and radio source populations at the faintest radio flux limits yet probed by such a study. We discuss how the X-ray/radio relationship differs as a function of optical morphology, ie between unresolved `stellar' objects and well resolved galaxies. We then discuss the origin of the X-ray and radio emission, ie AGN, starburst or a mixture of both, in these two classes of object.Comment: Astronomische Nachrichten, in press (Feb 2003). Proceedings of "X-ray Surveys, in the Light of New Observatories", 4-6 September, Santander, Spai

Discovery of a high-z protocluster with tunable filters: the case of 6C0140+326 at z=4.4

We present the first results obtained using a tunable narrowband filter in the search for high-z protoclusters. Using the recently commissioned red tunable filter on the Gran Telescopio Canarias we have searched for Lya emitters in a 75 arcmin^2 field centered on the z=4.413 radio galaxy 6C0140+326. With three different wavelength tunings we find a total of 27 unique candidate Lya emitters. The availability of three different wavelength tunings allows us to make estimates of the redshifts for each of the objects. It also allows us to separate a possible protocluster from structure in the immediate foreground. This division shows that the foreground region contains significantly fewer Lya emitters. Also, the spatial distribution of the objects in the protocluster field deviates from a random distribution at the 2.5 sigma level. The observed redshift distribution of the emitters is different from the expected distribution of a blank field at the ~3 sigma level, with the Lya emitters concentrated near the radio galaxy at z>4.38. The 6C0140+326 field is denser by a factor of 9+/-5 than a blank field, and the number density of Lya emitters close to the radio galaxy is similar to that of the z~4.1 protocluster around TNJ1338-1942. We thus conclude that there is an overdensity of Lya emitters around the radio galaxy 6C0140+326. This is one of few known overdensities at such a high redshift.Comment: 10 pages, 6 figures, accepted for publication in MNRA

Radio Galaxy Zoo: discovery of a poor cluster through a giant wide-angle tail radio galaxy

This article has been accepted for publication in Monthly Notices of the Royal Astronomical Society ©: 2016 J. K. Banfield, H. Andernach, A. D. Kapińska, L. Rudnick, M. J. Hardcastle, G. Cotter, S. Vaughan, T. W. Jones, I. Heywood, J. D. Wing, O. I. Wong, T. Matorny, I. A. Terentev, Á. R. López-Sánchez, R. P. Norris, N. Seymour, S. S. Shabala, and K. W. Willett. Published by Oxford University Press on behalf of the Royal Astronomical Society. All rights reserved. The version of record is available on line at doi: 10.1093/mnras/stw1067We have discovered a previously unreported poor cluster of galaxies (RGZ-CL J0823.2+0333) through an unusual giant wide-angle tail radio galaxy found in the Radio Galaxy Zoo project. We obtained a spectroscopic redshift of $z=0.0897$ for the E0-type host galaxy, 2MASX J08231289+0333016, leading to M$_r = -22.6$ and a $1.4\,$GHz radio luminosity density of $L_{\rm 1.4} = 5.5\times10^{24}$ W Hz$^{-1}$. These radio and optical luminosities are typical for wide-angle tailed radio galaxies near the borderline between Fanaroff-Riley (FR) classes I and II. The projected largest angular size of $\approx8\,$arcmin corresponds to $800\,$kpc and the full length of the source along the curved jets/trails is $1.1\,$Mpc in projection. X-ray data from the XMM-Newton archive yield an upper limit on the X-ray luminosity of the thermal emission surrounding RGZ J082312.9+033301,at $1.2-2.6\times10^{43}$ erg s$^{-1}$ for assumed intra-cluster medium temperatures of $1.0-5.0\,$keV. Our analysis of the environment surrounding RGZ J082312.9+033301 indicates that RGZ J082312.9+033301 lies within a poor cluster. The observed radio morphology suggests that (a) the host galaxy is moving at a significant velocity with respect to an ambient medium like that of at least a poor cluster, and that (b) the source may have had two ignition events of the active galactic nucleus with $10^7\,$yrs in between. This reinforces the idea that an association between RGZ J082312.9+033301, and the newly discovered poor cluster exists.Peer reviewe

Ernst Freund as Precursor of the Rational Study of Corporate Law

Gindis, David, Ernst Freund as Precursor of the Rational Study of Corporate Law (October 27, 2017). Journal of Institutional Economics, Forthcoming. Available at SSRN: https://ssrn.com/abstract=2905547, doi: https://dx.doi.org/10.2139/ssrn.2905547The rise of large business corporations in the late 19th century compelled many American observers to admit that the nature of the corporation had yet to be understood. Published in this context, Ernst Freund's little-known The Legal Nature of Corporations (1897) was an original attempt to come to terms with a new legal and economic reality. But it can also be described, to paraphrase Oliver Wendell Holmes, as the earliest example of the rational study of corporate law. The paper shows that Freund had the intuitions of an institutional economist, and engaged in what today would be called comparative institutional analysis. Remarkably, his argument that the corporate form secures property against insider defection and against outsiders anticipated recent work on entity shielding and capital lock-in, and can be read as an early contribution to what today would be called the theory of the firm.Peer reviewe

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.

OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality