Objective To evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or ...emergency care settings.Design Systematic review of randomised and quasi-randomised controlled trials, and meta-analysis.Data sources Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews.Review methods Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors.Data extraction Outcomes were number of fallers, fall related injuries, fall rate, death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement. Results 19 studies, of variable methodological quality, were included. The combined risk ratio for the number of fallers during follow-up among 18 trials was 0.91 (95% confidence interval 0.82 to 1.02) and for fall related injuries (eight trials) was 0.90 (0.68 to 1.20). No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral.Conclusions Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates.
Abstract Introduction This study reports the epidemiology and outcomes from out-of-hospital cardiac arrest (OHCA) in England during 2014. Methods Prospective observational study from the national ...OHCA registry. The incidence, demographic and outcomes of patients who were treated for an OHCA between 1st January, 2014 and 31st December 2014 in 10 English ambulance service (EMS) regions, serving a population of almost 54 million, are reported in accordance with Utstein recommendations. Results 28,729 OHCA cases of EMS treated cardiac arrests were reported (53 per 100,000 of resident population). The mean age was 68.6 (SD = 19.6) years and 41.3% were female. Most (83%) occurred in a place of residence, 52.7% were witnessed by either the EMS or a bystander. In non-EMS witnessed cases, 55.2% received bystander CPR whilst public access defibrillation was used rarely (2.3%). Cardiac aetiology was the leading cause of cardiac arrest (60.9%). The initial rhythm was asystole in 42.4% of all cases and was shockable (VF or pVT) in 20.6%. Return of spontaneous circulation at hospital transfer was evident in 25.8% (n = 6302) and survival to hospital discharge was 7.9%. Conclusion Cardiac arrest is an important cause of death in England. With less than one in ten patients surviving, there is scope to improve outcomes. Survival rates were highest amongst those who received bystander CPR and public access defibrillation.
We update and evaluate the treatment of nitrate aerosols in the Geophysical Fluid Dynamics Laboratory (GFDL) atmospheric model (AM3). Accounting for the radiative effects of nitrate aerosols ...generally improves the simulated aerosol optical depth, although nitrate concentrations at the surface are biased high. This bias can be reduced by increasing the deposition of nitrate to account for the near-surface volatilization of ammonium nitrate or by neglecting the heterogeneous production of nitric acid to account for the inhibition of N2O5 reactive uptake at high nitrate concentrations. Globally, uncertainties in these processes can impact the simulated nitrate optical depth by up to 25 %, much more than the impact of uncertainties in the seasonality of ammonia emissions (6 %) or in the uptake of nitric acid on dust (13 %). Our best estimate for fine nitrate optical depth at 550 nm in 2010 is 0.006 (0.005–0.008). In wintertime, nitrate aerosols are simulated to account for over 30 % of the aerosol optical depth over western Europe and North America. Simulated nitrate optical depth increases by less than 30 % (0.0061–0.010) in response to projected changes in anthropogenic emissions from 2010 to 2050 (e.g., −40 % for SO2 and +38 % for ammonia). This increase is primarily driven by greater concentrations of nitrate in the free troposphere, while surface nitrate concentrations decrease in the midlatitudes following lower concentrations of nitric acid. With the projected increase of ammonia emissions, we show that better constraints on the vertical distribution of ammonia (e.g., convective transport and biomass burning injection) and on the sources and sinks of nitric acid (e.g., heterogeneous reaction on dust) are needed to improve estimates of future nitrate optical depth.
Abstract
Large-scale quantum networks require quantum memories featuring long-lived storage of non-classical light together with efficient, high-speed and reliable operation. The concurrent ...realization of these features is challenging due to inherent limitations of matter platforms and light–matter interaction protocols. Here, we propose an approach to overcome this obstacle, based on the implementation of the Autler–Townes-splitting (ATS) quantum-memory protocol on Bose–Einstein condensate (BEC) platform. We demonstrate a proof-of-principle of this approach by storing short pulses of single-photon-level light as a collective spin-excitation in a rubidium-BEC. For 20 ns long-pulses, we achieve an ultra-low-noise memory with an efficiency of 30% and lifetime of 15
μ
s. The non-adiabatic character of the ATS protocol (leading to high-speed and low-noise operation) in combination with the intrinsically large atomic densities and ultra-low temperatures of the BEC platform (offering highly efficient and long-lived storage) opens up a new avenue toward high-performance quantum memories.
•Lunar impact monitoring has been used to determine the flux of meteoroids in the 30g to a few kilograms size range.•A catalog of 126 photometrically calibrated impact flashes is presented.•A ...rigorous approach for photometric calibration of impact flash observations and calculation of flash energy is described.•Rates of observed flashes are correlated with meteor showers.•A large impact flash in March 2013 gave crater size estimates consistent with the crater measured by LRO.
The flashes from meteoroid impacts on the Moon are useful in determining the flux of impactors with masses as low as a few tens of grams. A routine monitoring program at NASA’s Marshall Space Flight Center has recorded over 300 impacts since 2006. A selection of 126 flashes recorded during periods of photometric skies was analyzed, creating the largest and most homogeneous dataset of lunar impact flashes to date. Standard CCD photometric techniques were applied to the video and the luminous energy, kinetic energy, and mass are estimated for each impactor. Shower associations were determined for most of the impactors and a range of luminous efficiencies was considered. The flux to a limiting energy of 2.5×10−6kT TNT or 1.05×107J is 1.03×10−7km−2h−1 and the flux to a limiting mass of 30g is 6.14×10−10m−2yr−1 at the Moon. Comparisons made with measurements and models of the meteoroid population indicate that the flux of objects in this size range is slightly lower (but within the error bars) than flux at this size from the power law distribution determined for the near Earth object and fireball population by Brown et al. (Brown, P.G., Spalding, R., ReVelle, D., Tagliaferri, E., Worden, S. 2002. Nature 420, 294–296). Size estimates for the crater detected by Lunar Reconnaissance Orbiter from a large impact observed on March 17, 2013 are also briefly discussed.
Summary Background Mechanical chest compression devices have the potential to help maintain high-quality cardiopulmonary resuscitation (CPR), but despite their increasing use, little evidence exists ...for their effectiveness. We aimed to study whether the introduction of LUCAS-2 mechanical CPR into front-line emergency response vehicles would improve survival from out-of-hospital cardiac arrest. Methods The pre-hospital randomised assessment of a mechanical compression device in cardiac arrest (PARAMEDIC) trial was a pragmatic, cluster-randomised open-label trial including adults with non-traumatic, out-of-hospital cardiac arrest from four UK Ambulance Services (West Midlands, North East England, Wales, South Central). 91 urban and semi-urban ambulance stations were selected for participation. Clusters were ambulance service vehicles, which were randomly assigned (1:2) to LUCAS-2 or manual CPR. Patients received LUCAS-2 mechanical chest compression or manual chest compressions according to the first trial vehicle to arrive on scene. The primary outcome was survival at 30 days following cardiac arrest and was analysed by intention to treat. Ambulance dispatch staff and those collecting the primary outcome were masked to treatment allocation. Masking of the ambulance staff who delivered the interventions and reported initial response to treatment was not possible. The study is registered with Current Controlled Trials, number ISRCTN08233942. Findings We enrolled 4471 eligible patients (1652 assigned to the LUCAS-2 group, 2819 assigned to the control group) between April 15, 2010 and June 10, 2013. 985 (60%) patients in the LUCAS-2 group received mechanical chest compression, and 11 (<1%) patients in the control group received LUCAS-2. In the intention-to-treat analysis, 30 day survival was similar in the LUCAS-2 group (104 6% of 1652 patients) and in the manual CPR group (193 7% of 2819 patients; adjusted odds ratio OR 0·86, 95% CI 0·64–1·15). No serious adverse events were noted. Seven clinical adverse events were reported in the LUCAS-2 group (three patients with chest bruising, two with chest lacerations, and two with blood in mouth). 15 device incidents occurred during operational use. No adverse or serious adverse events were reported in the manual group. Interpretation We noted no evidence of improvement in 30 day survival with LUCAS-2 compared with manual compressions. On the basis of ours and other recent randomised trials, widespread adoption of mechanical CPR devices for routine use does not improve survival. Funding National Institute for Health Research HTA – 07/37/69.
Summary Background Severe ankle sprains are a common presentation in emergency departments in the UK. We aimed to assess the effectiveness of three different mechanical supports (Aircast brace, ...Bledsoe boot, or 10-day below-knee cast) compared with that of a double-layer tubular compression bandage in promoting recovery after severe ankle sprains. Methods We did a pragmatic, multicentre randomised trial with blinded assessment of outcome. 584 participants with severe ankle sprain were recruited between April, 2003, and July, 2005, from eight emergency departments across the UK. Participants were provided with a mechanical support within the first 3 days of attendance by a trained health-care professional, and given advice on reducing swelling and pain. Functional outcomes were measured over 9 months. The primary outcome was quality of ankle function at 3 months, measured using the Foot and Ankle Score; analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN37807450. Results Patients who received the below-knee cast had a more rapid recovery than those given the tubular compression bandage. We noted clinically important benefits at 3 months in quality of ankle function with the cast compared with tubular compression bandage (mean difference 9%; 95% CI 2·4–15·0), as well as in pain, symptoms, and activity. The mean difference in quality of ankle function between Aircast brace and tubular compression bandage was 8%; 95% CI 1·8–14·2, but there were little differences for pain, symptoms, and activity. Bledsoe boots offered no benefit over tubular compression bandage, which was the least effective treatment throughout the recovery period. There were no significant differences between tubular compression bandage and the other treatments at 9 months. Side-effects were rare with no discernible differences between treatments. Reported events (all treatments combined) were cellulitis (two cases), pulmonary embolus (two cases), and deep-vein thrombosis (three cases). Interpretation A short period of immobilisation in a below-knee cast or Aircast results in faster recovery than if the patient is only given tubular compression bandage. We recommend below-knee casts because they show the widest range of benefit. Funding National Co-ordinating Centre for Health Technology Assessment.
Background: Anthropogenic climate change presents a major global health threat. However, the very provision of healthcare itself is associated with a significant environmental impact. Carbon ...footprinting techniques are increasingly used outside of the healthcare sector to assess greenhouse gas emissions and inform strategies to reduce them. Aim: This study represents the first assessment of the carbon footprint of an individual specialty service to include both direct and indirect emissions. Methods: This was a component analysis study. Activity data were collected for building energy use, travel and procurement. Established emissions factors were applied to reconcile this data to carbon dioxide equivalents (CO2eq) per year. Results: The Dorset Renal Service has a carbon footprint of 3006 tonnes CO2eq per annum, of which 381 tonnes CO2eq (13% of overall emissions) result from building energy use, 462 tonnes CO2eq from travel (15%) and 2163 tonnes CO2eq (72%) from procurement. The contributions of the major subsectors within procurement are: pharmaceuticals, 1043 tonnes CO2eq (35% of overall emissions); medical equipment, 753 tonnes CO2eq (25%). The emissions associated with healthcare episodes were estimated at 161 kg CO2eq per bed day for an inpatient admission and 22 kg CO2eq for an outpatient appointment. Conclusions: These results suggest that carbon-reduction strategies focusing upon supply chain emissions are likely to yield the greatest benefits. Sustainable waste management and strategies to reduce emissions associated with building energy use and travel will also be important. A transformation in the way that clinical care is delivered is required, such that lower carbon clinical pathways, treatments and technologies are embraced. The estimations of greenhouse gas emissions associated with outpatient appointments and inpatient stays calculated here may facilitate modelling of the emissions of alternative pathways of care.
We assessed the convergent validity of commonly applied metrics of cerebral autoregulation (CA) to determine the extent to which the metrics can be used interchangeably. To examine between-subject ...relationships among low-frequency (LF; 0.07-0.2 Hz) and very-low-frequency (VLF; 0.02-0.07 Hz) transfer function coherence, phase, gain, and normalized gain, we performed retrospective transfer function analysis on spontaneous blood pressure and middle cerebral artery blood velocity recordings from 105 individuals. We characterized the relationships (n = 29) among spontaneous transfer function metrics and the rate of regulation index and autoregulatory index derived from bilateral thigh-cuff deflation tests. In addition, we analyzed data from subjects (n = 29) who underwent a repeated squat-to-stand protocol to determine the relationships between transfer function metrics during forced blood pressure fluctuations. Finally, data from subjects (n = 16) who underwent step changes in end-tidal P(CO2) (P(ET)(CO2) were analyzed to determine whether transfer function metrics could reliably track the modulation of CA within individuals. CA metrics were generally unrelated or showed only weak to moderate correlations. Changes in P(ET)(CO2) were positively related to coherence LF: β = 0.0065 arbitrary units (AU)/mmHg and VLF: β = 0.011 AU/mmHg, both P < 0.01 and inversely related to phase (LF: β = -0.026 rad/mmHg and VLF: β = -0.018 rad/mmHg, both P < 0.01) and normalized gain (LF: β = -0.042%/mmHg(2) and VLF: β = -0.013%/mmHg(2), both P < 0.01). However, Pet(CO(2)) was positively associated with gain (LF: β = 0.0070 cm·s(-1)·mmHg(-2), P < 0.05; and VLF: β = 0.014 cm·s(-1)·mmHg(-2), P < 0.01). Thus, during changes in P(ET)(CO2), LF phase was inversely related to LF gain (β = -0.29 cm·s(-1)·mmHg(-1)·rad(-1), P < 0.01) but positively related to LF normalized gain (β = 1.3% mmHg(-1)/rad, P < 0.01). These findings collectively suggest that only select CA metrics can be used interchangeably and that interpretation of these measures should be done cautiously.
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