Triage and Ongoing Care for Critically Ill Patients in the Emergency Department: Results from a National Survey of Emergency Physicians

Introduction: We conducted a cross-sectional study at the Icahn School of Medicine at Mount Sinai to elicit emergency physician (EP) perceptions regarding intensive care unit (ICU) triage decisions and ongoing management for boarding of ICU patients in the emergency department (ED). We assessed factors influencing the disposition decision for critically ill patients in the ED to characterize EPs’ perceptions about ongoing critical care delivery in the ED while awaiting ICU admission.Methods: Through content expert review and pilot testing, we iteratively developed a 25-item written survey targeted to EPs, eliciting current ICU triage structure, opinions on factors influencing ICU admission decisions, and views on caring for critically ill patients “boarding” in the ED for >4-6 hours.Results: We approached 732 EPs at a large, national emergency medicine conference, achieving 93.6% response and completion rate, with 54% academic and 46% community participants. One-fifth reported having formal ICU admission criteria, although only 36.6% reported adherence. Common factors influencing EPs’ ICU triage decisions were illness severity (91.1%), ICU interventions needed (87.6%), and diagnosis (68.2%), while ICU bed availability (13.5%) and presence of other critically ill patients in ED (10.2%) were less or not important. While 72.1% reported frequently caring for ICU boarders, respondents identified high patient volume (61.3%) and inadequate support staffing (48.6%) as the most common challenges in caring for boarding ICU patients.Conclusion: Patient factors (eg, diagnosis, illness severity) were seen as more important than system factors (eg, bed availability) in triaging ED patients to the ICU. Boarding ICU patients is a common challenge for more than two-thirds of EPs, exacerbated by ED volume and staffing constraints

Preferential responses to faces in superior temporal and medial prefrontal cortex in three-year-old children

Perceiving faces and understanding emotions are key components of human social cognition. Prior research with adults and infants suggests that these social cognitive functions are supported by superior temporal cortex (STC) and medial prefrontal cortex (MPFC). We used functional near-infrared spectroscopy (fNIRS) to characterize functional responses in these cortical regions to faces in early childhood. Three-year-old children (n = 88, M(SD) = 3.15(.16) years) passively viewed faces that varied in emotional content and valence (happy, angry, fearful, neutral) and, for fearful and angry faces, intensity (100%, 40%), while undergoing fNIRS. Bilateral STC and MPFC showed greater oxygenated hemoglobin concentration values to all faces relative to objects. MPFC additionally responded preferentially to happy faces relative to neutral faces. We did not detect preferential responses to angry or fearful faces, or overall differences in response magnitude by emotional valence (100% happy vs. fearful and angry) or intensity (100% vs. 40% fearful and angry). In exploratory analyses, preferential responses to faces in MPFC were not robustly correlated with performance on tasks of early social cognition. These results link and extend adult and infant research on functional responses to faces in STC and MPFC and contribute to the characterization of the neural correlates of early social cognition

The utility of cardiac sonography and capnography in predicting outcome in cardiac arrest

Emergency physicians and intensivists are increasingly utilizing capnography and bedside echocardiography during medical resuscitations. These techniques have shown promise in predicting outcomes in cardiac arrest, and no cases of return of spontaneous circulation in the setting of sonographic cardiac standstill and low end-tidal carbon dioxide have been reported. This case report illustrates an example of such an occurrence. Our aims are to report a case of return of spontaneous circulation in a patient with sonographic cardiac standstill, electrocardiographic pulseless electrical activity, and low end-tidal carbon dioxide tensions and to place the case in the context of previous literature on this topic. Case report and brief review of the literature. In 254 cases reported, no patient has survived in the setting of sonographic cardiac standstill and low end-tidal carbon dioxide tension, making the reported case unique. This case should serve to illustrate the utility and limitations of combined cardiac sonography and end-tidal carbon dioxide measurement in determining prognosis during cardiac arrest

Vortex Plastic Flow, B(x,y,H(t)),M(H(t)),Jc(B(t))B(x,y,H(t)), M(H(t)), J_c(B(t)), Deep in the Bose Glass and Mott-Insulator Regimes

We present simulations of flux-gradient-driven superconducting vortices interacting with strong columnar pinning defects as an external field $H(t)$ is quasi-statically swept from zero through a matching field $B_{\phi}$. We analyze several measurable quantities, including the local flux density $B(x,y,H(t))$, magnetization $M(H(t))$, critical current $J_{c}(B(t))$, and the individual vortex flow paths. We find a significant change in the behavior of these quantities as the local flux density crosses $B_{\phi}$, and quantify it for many microscopic pinning parameters. Further, we find that for a given pin density $J_c(B)$ can be enhanced by maximizing the distance between the pins for $B < B_{\phi}$.Comment: 4 pages, 4 PostScript Figure

On the Origins of Starburst and Post-Starburst Galaxies in Nearby Clusters

HST WFPC2 images in B (F450W) and I (F814W) have been obtained for three starburst (SB) and two post-starburst (PSB) galaxies in the Coma cluster, and for three such galaxies in the cluster DC2048-52. V (F555W) and I images for an additional PSB galaxy in Coma have been extracted from the archive. Seven of these galaxies were previously classified as E/S0 on the basis of ground-based images, one as Sa, and the other as an irregular. The HST images reveal these SB/PSB galaxies to be heterogeneous in morphology. Nevertheless a common theme is that many of them, especially the SB galaxies, tend to have centralized spiral structure that appears simply as a bright ``bulge''on ground-based images. In addition, while some PSB galaxies exhibit distinct spiral structure, on the whole they have smoother morphologies than the SB galaxies. The morphologies and luminosity profiles are generally consistent with substantial starbursts in the form of centralized spiral structure (the SB galaxies) which fade into smoother morphologies (the PSB galaxies), with lingering spectroscopic evidence for past central starbursts. An important point is that the PSB galaxies retain disks, i.e, they have not evolved into spheroidal systems.Comment: 32 pages, 10 figures including 3 jpg images. To appear in the January 1999 Astronomical Journa

Insomnia, Psychiatric Disorders and Suicidal Ideation in a National Representative Sample of Active Canadian Forces Members

Background Past research on the association between insomnia and suicidal ideation (SI) has produced mixed findings. The current study explored the relationship between insomnia, SI, and past-year mental health status among a large Canadian Forces (CF) sample. Method Data was obtained from the 2013 Canadian Forces Mental Health Survey (CFMHS), and included a large representative sample of Canadian Regular Forces personnel (N = 6700). A series of univariate logistic regressions were conducted to test individual associations between past-year mental health status, insomnia, and potential confounds and SI. Mental health status included three groups: 0, 1, or two or more probable diagnoses of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD) and alcohol abuse/dependence. Stepwise multivariate logistic regression was used to assess the relationship between insomnia and SI with mental health status as a moderator. Results 40.8% of respondents reported experiencing insomnia. Both insomnia and number of mental health conditions incrementally increased the risk of SI. However, past-year mental health status was a significant moderator of this relationship, such that for CF personnel with either no (AOR = 1.61, 1.37–1.89) or only one past-year mental health condition (AOR = 1.39, 1.12–1.73), an incremental increase in insomnia was associated with an increased likelihood of SI. However, in personnel with two or more past-year mental health disorders, insomnia was no longer significantly associated with SI (AOR = 1.04, 0.81–1.33). Conclusions Insomnia significantly increased the odds of SI, but only among individuals with no or one mental health condition. Findings highlight the importance of assessing insomnia among CF members in order to further suicide prevention efforts

Evidence of a Supermassive Black Hole in the Galaxy NGC 1023 from the Nuclear Stellar Dynamics

We analyze the nuclear stellar dynamics of the SB0 galaxy NGC 1023, utilizing observational data both from the Space Telescope Imaging Spectrograph aboard the Hubble Space Telescope and from the ground. The stellar kinematics measured from these long-slit spectra show rapid rotation (V = 70 km/s at a distance of 0.1 arcsec = 4.9 pc from the nucleus) and increasing velocity dispersion toward the nucleus (where sigma = 295 +/- 30 km/s). We model the observed stellar kinematics assuming an axisymmetric mass distribution with both two and three integrals of motion. Both modeling techniques point to the presence of a central dark compact mass (which presumably is a supermassive black hole) with confidence > 99%. The isotropic two-integral models yield a best-fitting black hole mass of (6.0 +/- 1.4) x 10^7 M_sun and mass-to-light ratio (M/L_V) of 5.38 +/- 0.08, and the goodness-of-fit (chi^2) is insensitive to reasonable values for the galaxy's inclination. The three-integral models, which non-parametrically fit the observed line-of-sight velocity distribution as a function of position in the galaxy, suggest a black hole mass of (3.9 +/- 0.4) x 10^7 M_sun and M/L_V of 5.56 +/- 0.02 (internal errors), and the edge-on models are vastly superior fits over models at other inclinations. The internal dynamics in NGC 1023 as suggested by our best-fit three-integral model shows that the velocity distribution function at the nucleus is tangentially anisotropic, suggesting the presence of a nuclear stellar disk. The nuclear line of sight velocity distribution has enhanced wings at velocities >= 600 km/s from systemic, suggesting that perhaps we have detected a group of stars very close to the central dark mass.Comment: 21 pages, 12 figures, accepted in the Astrophysical Journa

Vortex Plastic Motion in Twinned Superconductors

We present simulations, without electrodynamical assumptions, of $B(x,y,H(t)), M(H(t))$, and $J_c(H(t))$, in hard superconductors, for a variety of twin-boundary pinning potential parameters, and for a range of values of the density and strength of the pinning sites. We numerically solve the overdamped equations of motion of up to 10^4 flux-gradient-driven vortices which can be temporarily trapped at $\sim 10^6$ pinning centers. These simulations relate macroscopic measurements (e.g., M(H), ``flame'' shaped $B(x,y)$ profiles) with the underlying microscopic pinning landscape and the plastic dynamics of individual vortices

Automatic memory processes in normal ageing and Alzheimer’s disease

This study examined the contribution of automatic and controlled uses of memory to stem completion in young, middle-aged and older adults, and compared these data with a study involving patients with Alzheimer’s disease (AD) who performed the same task (Hudson and Robertson, 2007). In an inclusion task participants aimed to complete three-letter word stems with a previously studied word, in an exclusion task the aim was to avoid using studied words to complete stems. Performances under inclusion and exclusion conditions were contrasted to obtain estimates of controlled and automatic memory processes using process-dissociation calculations (Jacoby, 1991). An age-related decline, evident from middle age was observed for the estimate of controlled processing, whereas the estimate of automatic processing remained invariant across the age groups. This pattern stands in contrast to what is observed in AD, where both controlled and automatic processes have been shown to be impaired. Therefore, the impairment in memory processing on stem completion that is found in AD is qualitatively different from that observed in normal ageing

Spatio-temporal dynamics and plastic flow of vortices in superconductors with periodic arrays of pinning sites

We present simulations of flux-gradient-driven superconducting rigid vortices interacting with square and triangular arrays of columnar pinning sites in an increasing external magnetic field. These simulations allow us to quantitatively relate spatio-temporal microscopic information of the vortex lattice with typically measured macroscopic quantities, such as the magnetization $M(H)$. The flux lattice does not become completely commensurate with the pinning sites throughout the sample at the magnetization matching peaks, but forms a commensurate lattice in a region close to the edge of the sample. Matching fields related to unstable vortex configurations do not produce peaks in $M(H)$. We observe a variety of evolving complex flux profiles, including flat terraces or plateaus separated by winding current-carrying strings and, near the peaks in $M(H)$, plateaus only in certain regions, which move through the sample as the field increases