Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU).
We conducted a ...single-center, pragmatic, multiple-crossover trial comparing balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an ICU. The type of crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month, with the entire emergency department crossing over between balanced crystalloids and saline monthly during the 16-month trial. The primary outcome was hospital-free days (days alive after discharge before day 28). Secondary outcomes included major adverse kidney events within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first.
A total of 13,347 patients were enrolled, with a median crystalloid volume administered in the emergency department of 1079 ml and 88.3% of the patients exclusively receiving the assigned crystalloid. The number of hospital-free days did not differ between the balanced-crystalloids and saline groups (median, 25 days in each group; adjusted odds ratio with balanced crystalloids, 0.98; 95% confidence interval CI, 0.92 to 1.04; P=0.41). Balanced crystalloids resulted in a lower incidence of major adverse kidney events within 30 days than saline (4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P=0.01).
Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital-free days between treatment with balanced crystalloids and treatment with saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SALT-ED ClinicalTrials.gov number, NCT02614040 .).
To identify sensitive periods of postnatal growth for preterm infants relative to neurodevelopment at 18 months' corrected age.
We studied 613 infants born at <33 weeks' gestation who participated in ...the DHA for Improvement of Neurodevelopmental Outcome trial. We calculated linear slopes of growth in weight, length, BMI, and head circumference from 1 week of age to term (40 weeks' postmenstrual age), term to 4 months, and 4 to 12 months, and we estimated their associations with Bayley Scales of Infant Development, 2nd Edition, Mental (MDI) and Psychomotor (PDI) Development Indexes in linear regression.
The median gestational age was 30 (range: 2-33) weeks. Mean ± SD MDI was 94 ± 16, and PDI was 93 ± 16. From 1 week to term, greater weight gain (2.4 MDI points per z score 95% confidence interval (CI): 0.8-3.9; 2.7 PDI points 95% CI: 1.2-.2), BMI gain (1.7 MDI points 95% CI: 0.4-3.1; 2.5 PDI points 95% CI: 1.2-3.9), and head growth (1.4 MDI points 95% CI: -0.0-2.8; 2.5 PDI points 95% CI: 1.2-3.9) were associated with higher scores. From term to 4 months, greater weight gain (1.7 points 95% CI: 0.2-3.1) and linear growth (2.0 points 95% CI: 0.7-3.2), but not BMI gain, were associated with higher PDI. From 4 to 12 months, none of the growth measures was associated with MDI or PDI score.
In preterm infants, greater weight and BMI gain to term were associated with better neurodevelopmental outcomes. After term, greater weight gain was also associated with better outcomes, but increasing weight out of proportion to length did not confer additional benefit.
Dabigatran is approved for stroke risk reduction in patients with nonvalvular atrial fibrillation (NVAF). Data from diverse clinical practice settings will help establish whether the risk:benefit ...ratio seen in clinical trials is comparable with routine clinical care. This study aimed to compare the safety and effectiveness of dabigatran and warfarin in clinical practice. We undertook a propensity score-matched (PSM) cohort study (N=12,793 per group; mean age 74) comparing treatment with dabigatran or warfarin in the US Department of Defense claims database, October 2009 to July 2013. Treatment-naïve patients with first prescription claim for dabigatran (either FDA-approved dose) or warfarin between October 2010 and July 2012 (index) and a diagnosis of NVAF during the 12 months before index date were included. Primary outcomes were stroke and major bleeding. Secondary outcomes included ischaemic and haemorrhagic stroke, major gastrointestinal (GI), urogenital or other bleeding, myocardial infarction (MI) and death. Time-to-event was investigated using Kaplan-Meier survival analyses. Outcomes comparisons were made utilising Cox-proportional hazards models of PSM groups. Dabigatran users experienced fewer strokes (adjusted hazard ratio 95 % confidence intervals 0.73 0.55-0.97), major intracranial (0.49 0.30-0.79), urogenital (0.36 0.18-0.74) and other (0.38 0.22-0.66) bleeding, MI (0.65 0.45-0.95) and deaths (0.64 0.55-0.74) than the warfarin group. Major bleeding (0.87 0.74-1.03) and major GI bleeding (1.13 0.94-1.37) was similar between groups and major lower GI bleeding events were more frequent (1.30 1.04-1.62) with dabigatran. In conclusion, compared with warfarin, dabigatran treatment was associated with a lower risk of stroke and most outcomes measured, but increased incidence of major lower GI bleeding.
Inhibitory control is a key executive function and has been studied extensively using the stop signal task. By applying a simple race model that posits an independent race between a GO process ...responsible for initiation of responses and a STOP process responsible for inhibition of responses, one can estimate how long it takes an individual to inhibit an ongoing response, the stop signal reaction time. Here, we examined how stop signal reaction time can be affected by working memory. Participants engaged in a dual task; they completed a stop signal task under low and high working memory load conditions. Working memory capacity was also measured. We found that the STOP process was lengthened in the high, compared to the low, working memory load condition, as evidenced by differences in stop signal reaction time. The GO process was unaffected and working memory capacity could not account for differences across the load conditions. These results indicate that inhibitory control can be influenced by placing demands on working memory.
Study objective Induction doses of etomidate during rapid sequence intubation cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged ...as an alternative for rapid sequence intubation induction. Among adult trauma patients intubated in the emergency department, we compare clinical outcomes among those induced with etomidate and ketamine. Methods The study entailed a retrospective evaluation of a 4-year (January 2011 to December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing rapid sequence intubation in the emergency department of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression, adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included ICU-free days and ventilator-free days evaluated with multivariable ordered logistic regression using the same covariates. Results The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared with 17.3% among those induced with etomidate (adjusted odds ratio OR 1.41; 95% confidence interval CI 0.92 to 2.16). Patients induced with ketamine had ICU-free days (adjusted OR 0.80; 95% CI 0.63 to 1.00) and ventilator-free days (adjusted OR 0.96; 95% CI 0.76 to 1.20) similar to those of patients induced with etomidate. Conclusion In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard rapid sequence intubation induction agent for adult trauma patients, patient-centered outcomes were similar for patients who received etomidate and ketamine.
There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, ...providing evaluation statuses to guide research and inform implementation into training curricula.
A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias.
Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent.
Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.
Resolving surf-zone bathymetry from high-resolution imagery typically involves measuring wave speeds and performing a physics-based inversion process using linear wave theory, or data assimilation ...techniques which combine multiple remotely sensed parameters with numerical models. In this work, we explored what types of coastal imagery can be best utilized in a 2-dimensional fully convolutional neural network to directly estimate nearshore bathymetry from optical expressions of wave kinematics. Specifically, we explored utilizing time-averaged images (timex) of the surf-zone, which can be used as a proxy for wave dissipation, as well as including a single-frame image input, which has visible patterns of wave refraction and instantaneous expressions of wave breaking. Our results show both types of imagery can be used to estimate nearshore bathymetry. However, the single-frame imagery provides more complete information across the domain, decreasing the error over the test set by approximately 10% relative to using timex imagery alone. A network incorporating both inputs had the best performance, with an overall root-mean-squared-error of 0.39 m. Activation maps demonstrate the additional information provided by the single-frame imagery in non-breaking wave areas which aid in prediction. Uncertainty in model predictions is explored through three techniques (Monte Carlo (MC) dropout, infer-transformation, and infer-noise) to provide additional actionable information about the spatial reliability of each bathymetric prediction.
Abstract
High-eccentricity tidal migration is a possible way for giant planets to be placed in short-period orbits. If this happens often, one would expect to catch proto hot Jupiters on highly ...elliptical orbits undergoing high-eccentricity tidal migration. As of yet, few such systems have been discovered. Here, we introduce TOI-3362b (TIC-464300749b), an 18.1 day, 5
M
Jup
planet orbiting a main-sequence F-type star that is likely undergoing high-eccentricity tidal migration. The orbital eccentricity is 0.815
−
0.032
+
0.023
. With a semimajor axis of 0.153
−
0.003
+
0.002
au, the planet’s orbit is expected to shrink to a final orbital radius of 0.051
−
0.006
+
0.008
au after complete tidal circularization. Several mechanisms could explain the extreme value of the planet’s eccentricity, such as planet–planet scattering and secular interactions. Such hypotheses can be tested with follow-up observations of the system, e.g., measuring the stellar obliquity and searching for companions in the system with precise, long-term radial-velocity observations. The variation in the planet’s equilibrium temperature as it orbits the host star and the tidal heating at periapse make this planet an intriguing target for atmospheric modeling and observation. Because the planet’s orbital period of 18.1 days is near the limit of TESS’s period sensitivity, even a few such discoveries suggest that proto hot Jupiters may be quite common.
Timely observations of nearshore water depths are important for a variety of coastal research and management topics, yet this information is expensive to collect using in situ survey methods. Remote ...methods to estimate bathymetry from imagery include using either ratios of multi-spectral reflectance bands or inversions from wave processes. Multi-spectral methods work best in waters with low turbidity, and wave-speed-based methods work best when wave breaking is minimal. In this work, we build on the wave-based inversion approaches, by exploring the use of a fully convolutional neural network (FCNN) to infer nearshore bathymetry from imagery of the sea surface and local wave statistics. We apply transfer learning to adapt a CNN originally trained on synthetic imagery generated from a Boussinesq numerical wave model to utilize tower-based imagery collected in Duck, North Carolina, at the U.S. Army Engineer Research and Development Center’s Field Research Facility. We train the model on sea-surface imagery, wave conditions, and associated surveyed bathymetry using three years of observations, including times with significant wave breaking in the surf zone. This is the first time, to the authors’ knowledge, an FCNN has been successfully applied to infer bathymetry from surf-zone sea-surface imagery. Model results from a separate one-year test period generally show good agreement with survey-derived bathymetry (0.37 m root-mean-squared error, with a max depth of 6.7 m) under diverse wave conditions with wave heights up to 3.5 m. Bathymetry results quantify nearshore bathymetric evolution including bar migration and transitions between single- and double-barred morphologies. We observe that bathymetry estimates are most accurate when time-averaged input images feature visible wave breaking and/or individual images display wave crests. An investigation of activation maps, which show neuron activity on a layer-by-layer basis, suggests that the model is responsive to visible coherent wave structures in the input images.
The chorioamnionitis associated with preterm delivery is often polymicrobial with ureaplasma being the most common isolate. To evaluate interactions between the different proinflammatory mediators, ...we hypothesized that ureaplasma exposure would increase fetal responsiveness to LPS. Fetal sheep were given intra-amniotic (IA) injections of media (control) or Ureaplasma parvum serovar 3 either 7 or 70 d before preterm delivery. Another group received an IA injection of Escherichia coli LPS 2 d prior to delivery. To test for interactions, IA U. parvum-exposed animals were challenged with IA LPS and delivered 2 d later. All animals were delivered at 124 ± 1-d gestation (term = 150 d). Compared with the 2-d LPS exposure group, the U. parvum 70 d + LPS group had 1) decreased lung pro- and anti-inflammatory cytokine expression and 2) fewer CD3(+) T lymphocytes, CCL2(+), myeloperoxidase(+), and PU.1(+) cells in the lung. Interestingly, exposure to U. parvum for 7 d did not change responses to a subsequent IA LPS challenge, and exposure to IA U. parvum alone induced mild lung inflammation. Exposure to U. parvum increased pulmonary TGF-β1 expression but did not change mRNA expression of either the receptor TLR4 or some of the downstream mediators in the lung. Monocytes from fetal blood and lung isolated from U. parvum 70 d + LPS but not U. parvum 7 d + LPS animals had decreased in vitro responsiveness to LPS. These results are consistent with the novel finding of downregulation of LPS responses by chronic but not acute fetal exposures to U. parvum. The findings increase our understanding of how chorioamnionitis-exposed preterm infants may respond to lung injury and postnatal nosocomial infections.
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