OBJECTIVES:The emergency department is an important venue for initial sepsis recognition and care. We sought to determine contemporary estimates of the epidemiology of U.S. emergency department ...visits for sepsis.
DESIGN:Analysis of data from the National Hospital Ambulatory Medical Care Survey.
SETTING:U.S. emergency department visits, 2009–2011.
PATIENTS:Adult (age, ≥ 18 yr) emergency department sepsis patients. We defined serious infection as an emergency department diagnosis of a serious infection or a triage temperature greater than 38°C or less than 36°C. We defined three emergency department sepsis classifications1) original emergency department sepsis—serious infection plus emergency department diagnosis of organ dysfunction, endotracheal intubation, or systolic blood pressure less than or equal to 90 mm Hg or explicit sepsis emergency department diagnoses; 2) quick Sequential Organ Failure Assessment emergency department sepsis—serious infection plus presence of at least two “quick” Sequential Organ Failure Assessment criteria (Glasgow Coma Scale ≤ 14, respiratory rate ≥ 22 breaths/min, or systolic blood pressure ≤ 100 mm Hg); and 3) revised emergency department sepsis—original or quick Sequential Organ Failure Assessment emergency department sepsis.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:We used survey design and weighting variables to produce national estimates of annual adult emergency department visits using updated sepsis classifications. Over 2009–2011, there were 103,257,516 annual adult emergency department visits. The estimated number of emergency department sepsis visits were as follows1) original emergency department sepsis 665,319 (0.64%; 95% CI, 0.57–0.73); 2) quick Sequential Organ Failure Assessment emergency department sepsis 318,832 (0.31%; 95% CI, 0.26–0.37); and 3) revised emergency department sepsis 847,868 (0.82%; 95% CI, 0.74–0.91).
CONCLUSIONS:Sepsis continues to present a major burden to U.S. emergency departments, affecting up to nearly 850,000 emergency department visits annually. Updated sepsis classifications may impact national estimates of emergency department sepsis epidemiology.
Accurate triage assessment by emergency nurses is essential for prioritizing patient care and providing appropriate treatment. Undertriage and overtriage remain an ongoing issue in care of patients ...who present to the emergency department. The purpose of this literature review was to examine factors associated with triage accuracy in the emergency department.
We conducted an evidence-based literature review using the Cumulative Index to Nursing and Allied Health Literature, PubMed, and Embase. The search focused on peer-reviewed articles in English, available in full text, published between January 2011 and December 2021.
A total of 14 articles met inclusion criteria and revealed the following 3 themes for triage accuracy: triage nurse characteristics, patient characteristics, and work environment. Triage nurses' accuracy rates ranged from 59.3% to 82%, with experience in triage associated with higher accuracy. Patient characteristics influenced triage accuracy, with nontrauma patients being undertriaged and trauma patients often overtriaged. The work environment played a role, as accuracy rates varied based on shift time and patient volume. Competing systems between prehospital and ED triage posed challenges and affected accuracy during fluctuations in patient volumes.
This review underscores the complex nature of ED triage accuracy. It highlights the importance of nurse experience, training programs, patient characteristics, and the work environment in enhancing triage decision making. Enhanced understanding of these factors can inform strategies to optimize triage accuracy and improve patient outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Uncontrolled trauma-related hemorrhage remains the primary preventable cause of death among those with critical injury.
The purpose of this investigation was to evaluate the types of trauma ...associated with critical injury and trauma-related hemorrhage, and to determine the time to definitive care among patients treated at major trauma centers who were predicted to require massive transfusion.
A secondary analysis was performed of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) trial data (N = 680). All patients included were predicted to require massive transfusion and admitted to one of 12 North American trauma centers. Descriptive statistics were used to characterize patients, including demographics, type and mechanism of injury, source of bleeding, and receipt of prehospital interventions. Patient time to definitive care was determined using the time from activation of emergency services to responder arrival on scene, and time from scene departure to emergency department (ED) arrival. Each interval was calculated and then summed for a total time to definitive care.
Patients were primarily white (63.8%), male (80.3%), with a median age of 34 (IQR 24-51) years. Roughly one-half of patients experienced blunt (49.0%) versus penetrating (48.2%) injury. The most common types of blunt trauma were motor vehicle injuries (83.5%), followed by falls (9.3%), other (3.6%), assaults (1.8%), and incidents due to machinery (1.8%). The most common types of penetrating injuries were gunshot wounds (72.3%), stabbings (24.1%), other (2.1%), and impalements (1.5%). One-third of patients (34.5%) required some prehospital intervention, including intubation (77.4%), chest or needle decompression (18.8%), tourniquet (18.4%), and cardiopulmonary resuscitation (CPR; 5.6%). Sources of bleeding included the abdomen (44.3%), chest (20.4%), limb/extremity (18.2%), pelvis (11.4%), and other (5.7%). Patients waited for a median of six (IQR4-10) minutes for emergency responders to arrive at the scene of injury and traveled a median of 27 (IQR 19-42) minutes to an ED. Time to definitive care was a median of 57 (IQR 44-77) minutes, with a range of 12-232 minutes. Twenty-four-hour mortality was 15% (n = 100) with 81 patients dying due to exsanguination or hemorrhage.
Patients who experience critical injury may experience lengthy times to receipt of definitive care and may benefit from bystander action for hemorrhage control to improve patient outcomes.
Bacterial spot disease of pepper and tomato is caused by four distinct Xanthomonas species and is a severely limiting factor on fruit yield in these crops. The genetic diversity and the type III ...effector repertoires of a large sampling of field strains for this disease have yet to be explored on a genomic scale, limiting our understanding of pathogen evolution in an agricultural setting. Genomes of 67 Xanthomonas euvesicatoria (Xe), Xanthomonas perforans (Xp), and Xanthomonas gardneri (Xg) strains isolated from diseased pepper and tomato fields in the southeastern and midwestern United States were sequenced in order to determine the genetic diversity in field strains. Type III effector repertoires were computationally predicted for each strain, and multiple methods of constructing phylogenies were employed to understand better the genetic relationship of strains in the collection. A division in the Xp population was detected based on core genome phylogeny, supporting a model whereby the host-range expansion of Xp field strains on pepper is due, in part, to a loss of the effector AvrBsT. Xp-host compatibility was further studied with the observation that a double deletion of AvrBsT and XopQ allows a host range expansion for Nicotiana benthamiana. Extensive sampling of field strains and an improved understanding of effector content will aid in efforts to design disease resistance strategies targeted against highly conserved core effectors.
Fieldwork is a critical tool for scientific research, particularly in applied disciplines. Yet fieldwork is often unsafe, especially for members of historically marginalized groups and people whose ...presence in scientific spaces threatens traditional hierarchies of power, authority, and legitimacy. Research is needed to identify interventions that prevent sexual harassment and assault from occurring in the first place. We conducted a quasi-experiment assessing the impacts of a 90-min interactive training on field-based staff in a United States state government agency. We hypothesized that the knowledge-based interventions, social modeling, and mastery experiences included in the training would increase participants' sexual harassment and assault prevention knowledge, self-efficacy, behavioural intention, and behaviour after the training compared to a control group of their peers. Treatment-control and pre-post training survey data indicate that the training increased participants' sexual harassment and assault prevention knowledge and prevention self-efficacy, and, to a lesser extent, behavioural intention. These increases persisted several months after the training for knowledge and self-efficacy. While we did not detect differences in the effect of the training for different groups, interestingly, post-hoc tests indicated that women and members of underrepresented racial groups generally scored lower compared to male and white respondents, suggesting that these groups self-assess their own capabilities differently. Finally, participants' likelihood to report incidents increased after the training but institutional reports remained low, emphasizing the importance of efforts to transform reporting systems and develop better methods to measure bystander actions. These results support the utility of a peer-led interactive intervention for improving workplace culture and safety in scientific fieldwork settings. PROTOCOL REGISTRATION: "The stage 1 protocol for this Registered Report was accepted in principle on August 24, 2022. The protocol, as accepted by the journal, can be found at: https://doi.org/10.6084/m9.figshare.21770165 .
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
In addition to amyloid-β plaque and tau neurofibrillary tangle deposition, neuroinflammation is considered a key feature of Alzheimer's disease pathology. Inflammation in Alzheimer's disease is ...characterized by the presence of reactive astrocytes and activated microglia surrounding amyloid plaques, implicating their role in disease pathogenesis. Microglia in the healthy adult mouse depend on colony-stimulating factor 1 receptor (CSF1R) signalling for survival, and pharmacological inhibition of this receptor results in rapid elimination of nearly all of the microglia in the central nervous system. In this study, we set out to determine if chronically activated microglia in the Alzheimer's disease brain are also dependent on CSF1R signalling, and if so, how these cells contribute to disease pathogenesis. Ten-month-old 5xfAD mice were treated with a selective CSF1R inhibitor for 1 month, resulting in the elimination of ∼80% of microglia. Chronic microglial elimination does not alter amyloid-β levels or plaque load; however, it does rescue dendritic spine loss and prevent neuronal loss in 5xfAD mice, as well as reduce overall neuroinflammation. Importantly, behavioural testing revealed improvements in contextual memory. Collectively, these results demonstrate that microglia contribute to neuronal loss, as well as memory impairments in 5xfAD mice, but do not mediate or protect from amyloid pathology.
Although critical illness has been associated with SARS-CoV-2-induced hyperinflammation, the immune correlates of severe COVID-19 remain unclear. Here, we comprehensively analyzed peripheral blood ...immune perturbations in 42 SARS-CoV-2 infected and recovered individuals. We identified extensive induction and activation of multiple immune lineages, including T cell activation, oligoclonal plasmablast expansion, and Fc and trafficking receptor modulation on innate lymphocytes and granulocytes, that distinguished severe COVID-19 cases from healthy donors or SARS-CoV-2-recovered or moderate severity patients. We found the neutrophil to lymphocyte ratio to be a prognostic biomarker of disease severity and organ failure. Our findings demonstrate broad innate and adaptive leukocyte perturbations that distinguish dysregulated host responses in severe SARS-CoV-2 infection and warrant therapeutic investigation.
Nurses’ preparedness to provide hemorrhage control aid outside of the patient care setting has not been thoroughly evaluated. We evaluated nurses’ preparedness to provide hemorrhage control in the ...prehospital setting after a proof-of-concept training event.
We performed a secondary analysis of evaluations from a voluntary hemorrhage control training offered to a group of experienced nurses. Education was provided by a nurse certified in Stop the Bleed training and using the Basic Bleeding Control 2.0 materials. The training lasted approximately 1 hour and included a didactic portion followed by hands-on practice with task trainer legs. Participants were surveyed after training to assess their preparedness to provide hemorrhage control aid using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree); comments and feedback were also requested. Mean (SD) was used to analyze Likert scale data. Content analysis was performed to identify common themes in qualitative data.
Forty-five experienced nurses participated in the voluntary training. Nursing experience included obstetrics, pediatrics, critical care, acute care, community health, and psychiatric/mental health. Only 39% of participants reported having previously completed a similar course. After training completion, participants reported an increase in their preparedness to provide hemorrhage control aid (mean 3.47 SD = 1.40 vs mean 4.8 SD .04, P < .01). Major themes identified included wanting to feel prepared to help others, refreshing skills, and knowing how to respond in an emergency.
Regardless of background and experience, nurses may benefit from more advanced hemorrhage control education to prepare them to provide aid in prehospital emergency settings.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
IMPORTANCE: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hour requirements beyond those established in 2003, leading to concerns about the ...effects on patient care and resident training. OBJECTIVE: To determine if the 2011 ACGME duty hour reform was associated with a change in general surgery patient outcomes or in resident examination performance. DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental study of general surgery patient outcomes 2 years before (academic years 2009-2010) and after (academic years 2012-2013) the 2011 duty hour reform. Teaching and nonteaching hospitals were compared using a difference-in-differences approach adjusted for procedural mix, patient comorbidities, and time trends. Teaching hospitals were defined based on the proportion of cases at which residents were present intraoperatively. Patients were those undergoing surgery at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). General surgery resident performance on the annual in-training, written board, and oral board examinations was assessed for this same period. EXPOSURES: National implementation of revised resident duty hour requirements on July 1, 2011, in all ACGME accredited residency programs. MAIN OUTCOMES AND MEASURES: Primary outcome was a composite of death or serious morbidity; secondary outcomes were other postoperative complications and resident examination performance. RESULTS: In the main analysis, 204 641 patients were identified from 23 teaching (n = 102 525) and 31 nonteaching (n = 102 116) hospitals. The unadjusted rate of death or serious morbidity improved during the study period in both teaching (11.6% 95% CI, 11.3%-12.0% to 9.4% 95% CI, 9.1%-9.8%, P < .001) and nonteaching hospitals (8.7% 95% CI, 8.3%-9.0% to 7.1% 95% CI, 6.8%-7.5%, P < .001). In adjusted analyses, the 2011 ACGME duty hour reform was not associated with a significant change in death or serious morbidity in either postreform year 1 (OR, 1.12; 95% CI, 0.98-1.28) or postreform year 2 (OR, 1.00; 95% CI, 0.86-1.17) or when both postreform years were combined (OR, 1.06; 95% CI, 0.93-1.20). There was no association between duty hour reform and any other postoperative adverse outcome. Mean (SD) in-training examination scores did not significantly change from 2010 to 2013 for first-year residents (499.7 85.2 to 500.5 84.2, P = .99), for residents from other postgraduate years, or for first-time examinees taking the written or oral board examinations during this period. CONCLUSIONS AND RELEVANCE: Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance. The implications of these findings should be considered when evaluating the merit of the 2011 ACGME duty hour reform and revising related policies in the future.
Vaccine-mediated immunity often relies on the generation of protective antibodies and memory B cells, which commonly stem from germinal center (GC) reactions. An in-depth comparison of the GC ...responses elicited by SARS-CoV-2 mRNA vaccines in healthy and immunocompromised individuals has not yet been performed due to the challenge of directly probing human lymph nodes. Herein, through a fine-needle aspiration-based approach, we profiled the immune responses to SARS-CoV-2 mRNA vaccines in lymph nodes of healthy individuals and kidney transplant recipients (KTXs). We found that, unlike healthy subjects, KTXs presented deeply blunted SARS-CoV-2-specific GC B cell responses coupled with severely hindered T follicular helper cell, SARS-CoV-2 receptor binding domain-specific memory B cell, and neutralizing antibody responses. KTXs also displayed reduced SARS-CoV-2-specific CD4 and CD8 T cell frequencies. Broadly, these data indicate impaired GC-derived immunity in immunocompromised individuals and suggest a GC origin for certain humoral and memory B cell responses following mRNA vaccination.
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•Human GC responses to SARS-CoV-2 vaccines are restricted to draining lymph nodes•Vaccine-induced GC responses are associated with SARS-CoV-2 neutralizing antibodies•Kidney transplant recipients lack GC responses to SARS-CoV-2 vaccines•Vaccines expand S+RBD− memory B cells in healthy donors and transplant recipients
Fine-needle aspiration of lymph nodes in humans reveals that SARS-CoV-2 vaccination induces neutralizing antibody-producing germinal centers, enhanced by repeated vaccination. Conversely, in patients receiving immunosuppressant medication, this process is disrupted, resulting in stunted protective immune responses, highlighting issues about vaccine and booster efficacy in patients with compromised immune systems.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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