Duration of Posttraumatic Amnesia Predicts Neuropsychological and Global Outcome in Complicated Mild Traumatic Brain Injury.

OBJECTIVES: Examine the effects of posttraumatic amnesia (PTA) duration on neuropsychological and global recovery from 1 to 6 months after complicated mild traumatic brain injury (cmTBI). PARTICIPANTS: A total of 330 persons with cmTBI defined as Glasgow Coma Scale score of 13 to 15 in emergency department, with well-defined abnormalities on neuroimaging. METHODS: Enrollment within 24 hours of injury with follow-up at 1, 3, and 6 months. MEASURES: Glasgow Outcome Scale-Extended, California Verbal Learning Test II, and Controlled Oral Word Association Test. Duration of PTA was retrospectively measured with structured interview at 30 days postinjury. RESULTS: Despite all having a Glasgow Coma Scale Score of 13 to 15, a quarter of the sample had a PTA duration of greater than 7 days; half had PTA duration of 1 of 7 days. Both cognitive performance and Extended Glasgow Outcome Scale outcomes were strongly associated with time since injury and PTA duration, with those with PTA duration of greater than 1 week showing residual moderate disability at 6-month assessment. CONCLUSIONS: Findings reinforce importance of careful measurement of duration of PTA to refine outcome prediction and allocation of resources to those with cmTBI. Future research would benefit from standardization in computed tomographic criteria and use of severity indices beyond Glasgow Coma Scale to characterize cmTBI

Field Programmable Gate Array Failure Rate Estimation Guidelines for Launch Vehicle Fault Tree Models

Today's launch vehicles complex electronic and avionic systems heavily utilize the Field Programmable Gate Array (FPGA) integrated circuit (IC). FPGAs are prevalent ICs in communication protocols such as MIL-STD-1553B, and in control signal commands such as in solenoid/servo valves actuations. This paper will demonstrate guidelines to estimate FPGA failure rates for a launch vehicle, the guidelines will account for hardware, firmware, and radiation induced failures. The hardware contribution of the approach accounts for physical failures of the IC, FPGA memory and clock. The firmware portion will provide guidelines on the high level FPGA programming language and ways to account for software/code reliability growth. The radiation portion will provide guidelines on environment susceptibility as well as guidelines on tailoring other launch vehicle programs historical data to a specific launch vehicle

Real-Time Risk and Fault Management in the Mission Evaluation Room for the International Space Station

Effective anomaly resolution in the Mission Evaluation Room (MER) of the International Space Station (ISS) requires consideration of risk in the process of identifying faults and developing corrective actions. Risk models such as fault trees from the ISS Probabilistic Risk Assessment (PRA) can be used to support anomaly resolution, but the functionality required goes significantly beyond what the PRA could provide. Methods and tools are needed that can systematically guide the identification of root causes for on-orbit anomalies, and to develop effective corrective actions that address the event and its consequences without undue risk to the crew or the mission. In addition, an overall information management framework is needed so that risk can be systematically incorporated in the process, and effectively communicated across all the disciplines and levels of management within the space station program. The commercial nuclear power industry developed such a decision making framework, known as the critical safety function approach, to guide emergency response following the accident at Three Mile Island in 1979. This report identifies new methods, tools, and decision processes that can be used to enhance anomaly resolution in the ISS Mission Evaluation Room. Current anomaly resolution processes were reviewed to identify requirements for effective real-time risk and fault management. Experience gained in other domains, especially the commercial nuclear power industry, was reviewed to identify applicable methods and tools. Recommendations were developed for next-generation tools to support MER anomaly resolution, and a plan for implementing the recommendations was formulated. The foundation of the proposed tool set will be a ''Mission Success Framework'' designed to integrate and guide the anomaly resolution process, and to facilitate consistent communication across disciplines while focusing on the overriding importance of mission success

The quest for sustained multiple morbidity reduction in very low-birth-weight infants: the Antifragility project.

OBJECTIVE: Can a comprehensive, explicitly directive evidence-based guideline for all therapies that might affect the major morbidities of very low-birth-weight (VLBW) infants help a neonatal intensive care unit (NICU) further improve generally favorable morbidity rates? Can Antifragility principles of provider adaptive growth from stressors, enhanced infant risk assessment and adherence to effective therapies minimize unproven treatments and reduce all morbidities? STUDY DESIGN: Prospectively planned observational trial in VLBW infants: control group born October 2011 to September 2013 and study group October 2013 to September 2015. Multi-disciplinary evidence-based review assigned all NICU treatments into one of four distinct categories: (1) always employ this therapy for VLBW infants, (2) never use this therapy, (3) employ this questionable therapy thoughtfully, only in certain circumstances and (4) this therapy has insufficient evidence of efficacy and safety. Extensive staff education emphasized evidence-based potentially better practice (PBP) selection with compliance checks, appreciation of intertwined co-morbidities and prioritizing infant risk reduction strategies. RESULTS: Control included 221 infants, mean (s.d.) age 29 (2.6) weeks, birth weight 1129 (257) g and Study included 197 infants, 29 (2.7) weeks, 1093 (292) g. One hundred and four distinct therapies were placed into categories 1 to 4, with 32 specific compliance checks. Overall mean compliance with the process checks during the second era was 70%, high: 100% (exclusive breast milk use), low: 24% (correct pulse oximetry alarm settings). Morbidity and mortality rates did not significantly change during the second era. CONCLUSIONS: In our NICU with favorable morbidity rates, an expanded effort using a comprehensive therapy guideline for VLBW infants did not further improve outcomes. We need deeper understanding of continuous quality improvement (CQI) fundamentals, therapy compliance, co-morbidity relationships and enhanced sensitivity of risk assessment. Our innovative Antifragility PBP guideline could be useful to other NICUs seeking improvement in VLBW infant morbidities, as we offer a reasoned and concise template of a broad array of therapies categorized efficiently for transparency and review, designed to enhance responsible CQI decision-making

Association between ambient temperature, particulate air pollution and emergency room visits for conjunctivitis

BACKGROUND: Numerous studies have confirmed the association of ambient temperature and air pollution with a higher risk of morbidities, yet few have addressed their effect on the ocular system. The purpose of this study was to assess the association between temperature, air pollution, and emergency room visits for conjunctivitis. METHODS: In this case-crossover study, the records of all emergency room visits to Soroka University Medical Center (SUMC) from 2009 to 2014 were reviewed for patients with conjunctivitis. Daily exposure to fine and coarse particulate matter and temperature were determined by a hybrid model involving satellite sensors. Mean relative humidity was obtained from the Ministry of Environmental Protection meteorological monitoring station located in Beer-Sheva. RESULTS: Six hundred one patients were diagnosed with conjunctivitis in the SUMC emergency room. We discovered a positive association between temperature increments and incidence of conjunctivitis. The strongest effect was found during summer and autumn, with an immediate (lag0) incidence increase of 8.1% for each 1 degrees C increase in temperature (OR = 1.088, 95%CI: 1.046-1.132) between 24 and 28 degrees C in the summer and 7.2% for each 1 degrees C increase in temperature (OR = 1.072, 95%CI: 1.036-1.108) between 13 and 23 degrees C in the autumn. There was no statistically significant association between fine and coarse particulate matter and conjunctivitis incidence. CONCLUSION: Temperature increases during summer and autumn are significantly associated with an increased risk of conjunctivitis. Conjunctivitis is not associated with non-anthropogenic air pollution. These findings may help community clinics and hospital emergency rooms better predict conjunctivitis cases and will hopefully lead to improved prevention efforts that will lower the financial burden on both the individual and the public

NIK Stabilization in Osteoclasts Results in Osteoporosis and Enhanced Inflammatory Osteolysis

Maintenance of healthy bone requires the balanced activities of osteoclasts (OCs), which resorb bone, and osteoblasts, which build bone. Disproportionate action of OCs is responsible for the bone loss associated with postmenopausal osteoporosis and rheumatoid arthritis. NF-κB inducing kinase (NIK) controls activation of the alternative NF-κB pathway, a critical pathway for OC differentiation. Under basal conditions, TRAF3-mediated NIK degradation prevents downstream signaling, and disruption of the NIK:TRAF3 interaction stabilizes NIK leading to constitutive activation of the alternative NF-κB pathway.Using transgenic mice with OC-lineage expression of NIK lacking its TRAF3 binding domain (NT3), we now find that alternative NF-κB activation enhances not only OC differentiation but also OC function. Activating NT3 with either lysozyme M Cre or cathepsinK Cre causes high turnover osteoporosis with increased activity of OCs and osteoblasts. In vitro, NT3-expressing precursors form OCs more quickly and at lower doses of RANKL. When cultured on bone, they exhibit larger actin rings and increased resorptive activity. OC-specific NT3 transgenic mice also have an exaggerated osteolytic response to the serum transfer model of arthritis.Constitutive activation of NIK drives enhanced osteoclastogenesis and bone resorption, both in basal conditions and in response to inflammatory stimuli

Trends in Severity of Illness on ICU Admission and Mortality among the Elderly

Background: There is an increase in admission rate for elderly patients to the ICU. Mortality rates are lower when more liberal ICU admission threshold are compared to more restrictive threshold. We sought to describe the temporal trends in elderly admissions and outcomes in a tertiary hospital before and after the addition of an 8-bed medical ICU. Methods: We conducted a retrospective analysis of a comprehensive longitudinal ICU database, from a large tertiary medical center, examining trends in patients’ characteristics, severity of illness, intensity of care and mortality rates over the years 2001–2008. The study population consisted of elderly patients and the primary endpoints were 28 day and one year mortality from ICU admission. Results: Between the years 2001 and 2008, 7,265 elderly patients had 8,916 admissions to ICU. The rate of admission to the ICU increased by 5.6% per year. After an eight bed MICU was added, the severity of disease on ICU admission dropped significantly and crude mortality rates decreased thereafter. Adjusting for severity of disease on presentation, there was a decreased mortality at 28- days but no improvement in one- year survival rates for elderly patient admitted to the ICU over the years of observation. Hospital mortality rates have been unchanged from 2001 through 2008. Conclusion: In a high capacity ICU bed hospital, there was a temporal decrease in severity of disease on ICU admission, more so after the addition of additional medical ICU beds. While crude mortality rates decreased over the study period, adjusted one-year survival in ICU survivors did not change with the addition of ICU beds. These findings suggest that outcome in critically ill elderly patients may not be influenced by ICU admission. Adding additional ICU beds to deal with the increasing age of the population may therefore not be effective

Trends in Severity of Illness on ICU Admission and Mortality among the Elderly

Background: There is an increase in admission rate for elderly patients to the ICU. Mortality rates are lower when more liberal ICU admission threshold are compared to more restrictive threshold. We sought to describe the temporal trends in elderly admissions and outcomes in a tertiary hospital before and after the addition of an 8-bed medical ICU. Methods: We conducted a retrospective analysis of a comprehensive longitudinal ICU database, from a large tertiary medical center, examining trends in patients’ characteristics, severity of illness, intensity of care and mortality rates over the years 2001–2008. The study population consisted of elderly patients and the primary endpoints were 28 day and one year mortality from ICU admission. Results: Between the years 2001 and 2008, 7,265 elderly patients had 8,916 admissions to ICU. The rate of admission to the ICU increased by 5.6% per year. After an eight bed MICU was added, the severity of disease on ICU admission dropped significantly and crude mortality rates decreased thereafter. Adjusting for severity of disease on presentation, there was a decreased mortality at 28- days but no improvement in one- year survival rates for elderly patient admitted to the ICU over the years of observation. Hospital mortality rates have been unchanged from 2001 through 2008. Conclusion: In a high capacity ICU bed hospital, there was a temporal decrease in severity of disease on ICU admission, more so after the addition of additional medical ICU beds. While crude mortality rates decreased over the study period, adjusted one-year survival in ICU survivors did not change with the addition of ICU beds. These findings suggest that outcome in critically ill elderly patients may not be influenced by ICU admission. Adding additional ICU beds to deal with the increasing age of the population may therefore not be effective

Effect of Electrode Composition and Microstructure on Impendancemetric nitric oxide sensors based on YSZ Electrolyte

The role of metal (Au, Pt, and Ag) electrodes in yttria-stabilized zirconia (YSZ) electrolyte-based impedancemetric nitric oxide (NO) sensors is investigated using impedance spectroscopy and equivalent circuit analysis. Focus on the metal/porous YSZ interface is based on previous studies using a symmetric cell (metal/YSZporous/YSZdense/YSZporous/metal) and attempts to further elucidate the important processes responsible for sensing. The current test cell consists of a rectangular slab of porous YSZ with two metal-wire loop electrodes (metal/YSZporous/metal), both exposed to the same atmosphere. Of the electrode materials, only Au was sensitive to changes in NO concentration. The impedance behavior of porous Au electrodes in a slightly different configuration was compared with dense Au electrodes and was also insensitive to NO. Although the exact mechanism is not determined, the composition and microstructure of the metal electrode seem to alter the rate-limiting step of the interfering O2 reaction. Impedance behavior of the O2 reaction that is limited by processes occurring away from the triple-phase boundary may be crucial for impedancemetric NO sensing