Mean Transfer Time Research Articles

Clinico-demographical differences and seven years management performance of acute coronary syndrome in Bali, Indonesia

BackgroundThe geographical diversity and clinical presentation differences of acute coronary syndrome (ACS) patients in Bali significantly influence the management performance and intervention outcomes. Bali, an island with varied geography, presents unique challenges for timely access to percutaneous coronary intervention (PCI) facilities, which are concentrated in South Bali. This study aims to describe annually the clinical characteristics of ACS patients in Bali, focusing on geographical factors and management performance. MethodsThe regional data from the Indonesia Acute Coronary Syndrome Registry (One ACS) were utilized in this study. The study population consisted of patients aged over 18 years who were treated for ACS from 2017 to 2023 at Prof. Dr. I.G.N.G Ngoerah Central General Hospital in Denpasar, Bali. Several outcomes were described, including baseline characteristics, transfer time, door-to-balloon time (DTB), door-to-wire time (DTW), ambulance transport time, patient transport time, and major adverse cardiac event (MACE) outcomes. ResultsA total of 4588 ACS patients based in Bali were included from 2017 to 2023. The majority of ACS patients originated from Denpasar city (44.1 %), followed by Badung (19.2 %) and Gianyar (8.5 %). More than half of the patients (57.9 %) were referred from primary healthcare, with a mean transfer time of 247.45 ± 698.26 min. Mortality rates were high, with significant numbers of cardiac arrests, heart failure, and cardiogenic shock. On multivariate analysis, shortness of breath, chest pain during light activity, patients seeking first medical contact (FMC) in Karangasem, and self-admission to the hospital were independently associated with mortality. ConclusionsThe geographical challenges of Bali, particularly the limited distribution of PCI-capable facilities, contribute to delays in treatment and varied outcomes for ACS patients. Improvements in healthcare systems across Bali are required to conform with current guidelines and enhance intervention outcomes.

Clinical characteristics and outcome of critically ill children referred to a tertiary hospital in Indonesia: a prospective observational study

BackgroundThe clinical characteristics of pediatric critically ill patients who need referral to a tertiary hospital is often unknown in resource limited settings where constraints in diagnosis capacity, resources, and infrastructures are common. There is a need to increase insight in the characteristics of these patients for capacity building strengthening and appropriate resource allocation. The aim of this study was to describe the clinical characteristics and outcomes of critically ill children who are referred to a tertiary referral teaching hospital in Yogyakarta.MethodsA prospective observasional study was carried out from July 1st, 2022 -January 31st, 2023 which included all critically ill pediatric patients who were referred through the Integrated Referral System (SISRUTE) to the Pediatric Intensive Care Unit (PICU) of dr. Sardjito hospital. We excluded patients who were referred with a request for admission to the PICU, but were not admitted to the PICU due to their stable condition and lack of the need for intensive care.ResultDuring the study period, we received 1046 emergency referral requests for pediatric patients via SISRUTE, of those, 562 (53.7%) patients were critically ill. The reasons of PICU referral request were the need of solely intensive care 504 (89.7%), the need of multidisciplinary team care, including intensive care 57 (10.1%) and parents request 1 (0.3%). The pre-referral emergency diagnosis was shock 226 (40.3%), respiratory distress/failure 151 (26.7%), central nervous system (CNS) dysfunction 135 (24.1%), trauma 33 (5.9%) and sepsis 17 (3%). Of the 562 critically ill PICU referral requests, 473 (84.2%) requests were accepted. One hundred and eighty-one (58.7%) patients were finally admitted to the PICU, 125 (40.3%) admitted to our regular ward due to stable condition, 4 (1.3%) patients died in Emergency Departement (ED). The remaining accepted patients on request did not arrive in our facility due to various reasons. The mean (SD) response time was 9.1 (27.6) minutes. The mean (SD) transfer time was 6.45 (4.73) hours. Mean (SD) PICU and hospital length of stay was 6.7 (8.3) days and 10.2 (9.2) days respectively. PICU and hospital mortality was 24.3% and 29.7%, respectively.ConclusionThe mortality rate for critically ill pediatric patients referred to a tertiary PICU still high, with shock being the most common pre-referral emergency diagnosis. There is a discrepancy between the referring hospital’s and the referral hospital’s indication for PICU admission. The time required to reach the referral hospital is quite lengthy.

Are geriatric transfer patients with traumatic brain injury at risk for worse outcomes compared to non-geriatric? Propensity-matched study

ABSTRACT Objective To compare outcomes between geriatric andnon-geriatric patients with traumatic brain injury (TBI) transferred to traumacenter and effects of anticoagulants/antiplatelets (AC/AP) and reversaltherapy. Methods A retrospective review of 1,118 patients with TBI transferred from acute care facilities tolevel 1 trauma center compared in groups: geriatric versus non-geriatric,geriatric with AC/AP therapy versus without, and geriatric AC/AP with AC/APreversal therapy versus without. Results Patients with TBI constituted 54.4% oftrauma transfers. Mean transfer time was 3.9 h. Propensity matched byInjury Severity Score and Abbreviated Injury Score (AIS) head geriatriccompared to non-geriatric patients had more AC/AP use (53.9% vs 8.8%), repeathead computed tomography (93.7% vs 86.1%), intensive care unit (ICU) admissions(57.4% vs 45.7%) and mortality (9.8% vs 3.2%), all p < 0.004. Patients onAC/AP versus without had more ICU admissions (69.1% vs 51.8%, p < 0.001).Patients with AC/AP reversals compared to without reversals had more AIS head 5(32.0% vs 13.1%), brain surgeries (17.8% vs 3.5%) and ICU admissions (84.8% vs57.1%), all p < 0.001. Conclusion TBI constituted half of trauma transfers and10% required surgery. Based on higher ICU admissions, mortality, and prevalenceof AC/AP therapy requiring reversal, geriatric patients with TBI onanticoagulants/antiplatelets should be considered for direct trauma centeradmission.

Delays in transferring patients from prisons to secure psychiatric hospitals: An international systematic review.

Transfer to a psychiatric hospital of prisoners who need inpatient treatment for a mental disorder is an important part of prison healthcare in the UK. It is an essential factor in ensuring the principle of equivalence in the treatment of prisoners. In England and Wales, delays in transferring unwell prisoners to hospital were identified by the 2009 Bradley Report. There has been no subsequent systematic review of progress in so doing nor a corresponding appraisal of transfer arrangements in other parts of the world. To conduct a systematic review of international literature about transfers of mentally unwell individuals from prison to hospital for the treatment of mental disorder since 2009. Eight databases were searched for data-based publications using terms for prison and transfer to hospital from 1 January 2009 to 4 August 2022. Inclusion criteria limited transfer to arrangements for pre-trial and sentenced prisoners going to a health service hospital, excluding hospital orders made on the conclusion of criminal hearing. In England, four articles were identified, all showing that transfer times remain considerably longer than the national targets of 14days (range, 14days to >9months); one study from Scotland found shorter mean transfer times, but more patients had been transferred to psychiatric intensive care units than to secure forensic hospitals. There were only two studies that investigated prison to hospital transfers for mental disorder from outside the UK and only one reported time-to-transfer data. Findings from this literature review highlight failures to resolve transfer delays in England and provide little evidence about the problem elsewhere. Given the lack of data, it is unclear whether other countries do not have this problem or simply that there has been no research interest in it. A possible confounding factor here is that, in some countries, all treatment for prisoners' mental disorders occurs in prison. However, the principle that prisons are not hospitals seems important when people need inpatient care. Prospective, longitudinal cohort studies are urgently needed to map transfer times and outcomes.

Design and Implementation of IoT Gateway with MQTT and IEC 61850 MMS Protocol

With microgrids deployed in multiple areas, communication technologies that control devices and collect data play an important role. Microgrid environments are similar to the internet of things (IoT) environment, where multiple devices exchange information. Recent studies have attempted to utilize IoT protocols as communication protocols for microgrids. Studies have also begun on interworking IoT protocols with IEC 61850, an existing protocol for power utility. In this study, we designed an IoT gateway that maps message queuing telemetry transport (MQTT), an IoT protocol, to the IEC 61850 data model. We built a testbed and performed a verification using TShark to verify that MQTT and IEC 61850 MMS traffic are properly generated and mapped by the IoT gateway. We also used IEEE 1588 to perform time synchronization between Raspberry Pi units, which are IoT devices. Performance analysis was conducted by measuring the mean transfer time of the MQTT and IEC 61850 MMS traffic for various Ethernet speeds and Wi-Fi protocols.

Surgical guides versus augmented reality to transfer a virtual surgical plan for open cranial vault reconstruction: A pilot study

Virtual surgical planning of an open cranial vault reconstruction enables a faster, safer and better surgical procedure for craniosynostosis patients. However, transfer a virtual surgical plan to the patient remains challenging. Although 3D-printed surgical guides can be used, their production is rather time-consuming and expensive. Since augmented reality (AR), allows the user to directly visualize a virtual planning onto the patient, it can be used as an alternative.By using AR-glasses (HoloLens), a new AR-based workflow was developed and compared with surgical guides to transfer the surgical plans on 3D-prints of 10 patients suffering from different types of craniosynostosis.An accuracy of 2.1 mm and a mean transfer time of 8.24 min were reported with the AR workflow as compared to an accuracy of 0.9 mm and a mean transfer time of 50 s for surgical guides.Surgical guides were the most fitting method to transfer virtual surgical plans. The relatively large outliers in the AR workflow meant that the mean accuracy was just outside the clinically acceptable margin. However, the low cost and simplicity make the AR workflow a promising alternative.

Application Value of CT Perfusion Imaging in Patients with Posterior Circulation Hyperacute Cerebral Infarction

Objectives: This study aims to evaluate the application value of computed tomography perfusion (CTP) imaging in patients with posterior circulation cerebral infarction in the hyperacute phase. Methods: The changes in CTP parameters, such as time to peak (TTP), mean transfer time (MTT), cerebral blood flow (CBF) and the cerebral blood volume (CBV) of ischemic region, as well as the ischemic penumbra, infarction core at the affected side and normal brain tissue at the uninjured side, of 168 patients with suspected posterior circulation acute ischemic stroke were analyzed. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of each parameter map of CTP in displaying the cerebral infarction size in each part of the posterior circulation were evaluated. Results: The CTP results revealed that CBF and CBV in the infarction area significantly decreased, and MTT and TTP in the blood supply area of cerebellum, thalamus and posterior cerebral artery (PCA) were significantly delayed. These were statistically different from those in the surrounding penumbra and normal brain tissue (P &lt; 0.05). Furthermore, the CBF of the penumbra in each part slightly decreased, and the delay of MTT and TTP was statistically different from that in normal brains (P &lt; 0.05). The CBV of the penumbra in the pons, midbrain and thalamus decreased, which was statistically different from that in normal brain tissue and simple cerebral ischemia tissue (P &lt; 0.05). The changes in CBF and MTT of the simple cerebral ischemia in each part, and TTP, except for the cerebellum, were statistically different from those of cerebral infarction and normal brain tissue (P &lt; 0.05). The total sensitivity, specificity and accuracy for the posterior circulation cerebral infarction was 77.2%, 98.6% and 94.9%, respectively, according to the CTP evaluation. Conclusion: The CTP parameter map can reflect the difference between an ischemic penumbra and an infraction core in the posterior circulation. It has high sensitivity, specificity and accuracy in the CTP evaluation of posterior circulation cerebral infarctions.

Effectiveness and Safety of P2Y12 Inhibitors Pretreatment in Primary Percutaneous Coronary Intervention with Long Transfer Times

Early initiation of a new P2Y12 inhibitor in ST-elevation myocardial infarction (STEMI) patients prior to primary percutaneous coronary intervention (PCI) is recommended over clopidogrel. However, comparative data remain limited, especially in semi-rural regions with subsequent longer transfer times. We aimed to assess the determinants, effectiveness, and safety of pretreatment with new P2Y12 inhibitors compared with clopidogrel in a primary PCI regional network. Outcomes of 1235 primary PCI patients pretreated with new P2Y12 inhibitors (n=1050) or clopidogrel (n=185) were evaluated using a prospective registry. Primary effectiveness endpoint was the composite of death, recurrent myocardial infarction, stroke, or new revascularization. Serious bleedings were defined as Bleeding Academic Research Consortium ≥ 2. Clopidogrel was more likely to be used in older and female patients with more comorbidities. Mean transfer time was longer in the clopidogrel group (123.3 ± 67.3 vs. 102.3 ± 57.2 min; p < 0.01). The primary endpoint was less frequent with new P2Y12 inhibitors compared with clopidogrel (14.9 vs. 30.3%; odds ratio 0.58, 95% confidence interval [CI] 0.39-0.87; p < 0.01), mostly driven by a reduced rate of death (4.5 vs. 26% respectively; hazard ratio 0.25, 95% CI 0.16-0.38; p < 0.01). Bleeding rates did not differ between groups (1 vs. 0.5%, respectively; p=0.96). Compared with clopidogrel, pretreatment with new P2Y12 inhibitors seems to be associated with lower risks of mortality and ischemic outcomes, and similar risks of bleeding in a real-world registry. Our results are in line with the guidelines recommending the preferential pre-PCI administration of new P2Y12 inhibitors in STEMI patients referred for primary PCI.

Abstract 114: Spoke-administered Thrombolysis Improves Large Vessel Occlusion Early Reperfusion And Inter-hospital Transfer Time For Mechanical Thrombectomy In A Hub-and-spoke Telestroke Network.

Introduction: The utility of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke is controversial. Low early recanalization (ER) rates and potential delays to MT may support bypassing IVT before MT. Recent trials suggest MT alone is reasonable for LVO patients presenting directly to MT-capable centers. However, bypassing IVT has not been evaluated for patients first presenting to “spoke” hospitals capable of administering IVT but requiring transfer to a “hub” hospital for MT. Here we examined how spoke IVT influences LVO ER and spoke-to-hub transfer time (TT) within our hub-and-spoke network. Methods: Patients presenting to 25 spoke hospitals before hub transfer from 2018 to 2020 who were considered possible EVT candidates with pre-transfer CTA-defined LVO and ASPECTS ≥6 were identified from a prospectively maintained database. ER was determined by chart review of vessel imaging on hub arrival. TT was prospectively recorded. Statistics were performed using permutation resampling and linear regression in R. Results: Of 177 patients included, 76 received IVT. Baseline characteristics, NIHSS, and intracerebral hemorrhage were similar between groups. Spoke IVT improved ER frequency [12/76 (15.8%) vs. 3/101 (3.0%), P&lt;0.0001]. Further, spoke IVT was associated with improved ER (aOR=5.9, 95% CI=1.3,33.7, p=0.02), independent of last known well. Patients receiving IVT had decreased mean TT by 25 minutes (139±59 min vs. 164±71 min, p=0.01). Patients with ER had NIHSS interval improvement from spoke to hub [median -2 (IQR 0.0, -3.5) vs. 0 (1.0, -0.4), p=0.02]. IVT was associated with improved 90d mRS ≤2 independent of age, NIHSS, and MT treatment (OR=2.5, 95% CI=1.1, 6.1, p=0.04). Conclusion: Within our network, IVT significantly increases ER and decreases TT, which may contribute to improved 90-day outcomes. This retrospective study supports following current recommendations that IVT be given to all eligible patients at spoke hospitals prior to transfer for MT consideration.

Neurotrauma admissions and COVID-19: a National Centre experience.

BackgroundTo investigate the impact of COVID-19 on trauma admissions to a National Neurosurgical Centre in Ireland.MethodsRetrospective analysis of a prospectively maintained database of all trauma admissions to the National Neurosurgical Centre at Beaumont Hospital, Dublin, during the period March 1 to May 31, 2019 and 2020. Primary outcome was 30-day mortality rate. Secondary outcomes included time transfer time, time from admission to time of surgery, and intensive care unit (ICU) admissions. Patients under the age of 16 were excluded.ResultsA total of 32 and 39 patients were admitted to the National Neurosurgical Centre following trauma over the 3-month period in 2020 and 2019 respectively, giving a 17.9% reduction in admissions. The 30-day mortality rate increased from 7.7% in 2019 to 15.6% on 2020 (p = 0.45). Mean transfer time was 4 h 58 min in 2019 and 3 h 55 min in 2020 (0.22). Mean time from admission to time of surgery was 9 h 10 min in 2019 and 5 h 37 min in 2020 respectively (p = 0.35). In 2019, 20 patients (51.3%) were admitted to ICU. This increased to 23 patients (69.7%) in 2020 (p = 0.08).ConclusionsTraumatic brain injury 30-day mortality rates increased during the first COVID-19 lockdown period. Trauma admission rates to ICU remained unchanged despite an overall reduction in trauma admissions. Transfer time, time to surgery, and length of stay were impacted by COVID-19. Despite the challenges COVID-19 has posed, it is important to maintain a fully functioning neurosurgical and neurocritical care service during the pandemic.

The Scope and Impact of a Novel, Urban, Rapid Patient Interhospital Transfer System to Improve Neuroemergent Care: The Design and Development of the Neuroemergency Transfer Program

Background: Access to neuroemergent care in the United States represents a significant public health concern, with limited neurosurgery and/ or neurocritical care coverage in both rural and urban settings. Inadequate access to neuroemergent providers, even in urban settings, may result in prolonged patient transfer time, associated neurological decline and translate into increased morbidity and mortality. Methods: A single center retrospective analysis of prospectively collected data of interhospital patient transfers to a neuroscience ICU between 2008-2018 was performed. Results: 9637 patients were included for analysis. A substantial increase in transfer requests were observed, 610 to 1221 from 2008 to 2018 respectively, with concurrent increase in the number and geographic distribution of referral centers. Ultimately, 7726 (80.2%) patients were discharged home or to outpatient or acute rehabilitation while 1820 (18.9%) were discharged to a long-term acute care facility (LTAC), hospice, or expired during the index admission. The leading diagnoses for transfer were: 1. intracerebral hemorrhage, 2. subarachnoid hemorrhage, 3. ischemic stroke, 4. subdural hematoma and 5. brain tumor. Transfer from an ED or ICU constituted 93.3% of requests. Mean total transfer time between 2012-2018 was &lt; 155 minutes annually (range 128-155 minutes). In 2018, 91.5% of patients had health insurance with 68.7% covered by some form of Medicaid or Medicare. Conclusions: The ongoing evolution and overall success of the NTP draws chiefly from the designation of an easily accessible central operator to orchestrate transfer, establishing a network of community referral centers and optimization of regional patient transportation - all with the solitary goal of improving patient outcomes.

Optimization of the Transwell® System for Assessing the Dissolution Behavior of Orally Inhaled Drug Products through In Vitro and In Silico Approaches.

The aim of this study was to further evaluate and optimize the Transwell® system for assessing the dissolution behavior of orally inhaled drug products (OIDPs), using fluticasone propionate as a model drug. Sample preparation involved the collection of a relevant inhalable dose fraction through an anatomical mouth/throat model, resulting in a more uniform presentation of drug particles during the subsequent dissolution test. The method differed from previously published procedures by (1) using a 0.4 µm polycarbonate (PC) membrane, (2) stirring the receptor compartment, and (3) placing the drug-containing side of the filter paper face downwards, towards the PC membrane. A model developed in silico, paired with the results of in vitro studies, suggested that a dissolution medium providing a solubility of about 5 µg/mL would be a good starting point for the method’s development, resulting in mean transfer times that were about 10 times longer than those of a solution. Furthermore, the model suggested that larger donor/receptor and sampling volumes (3, 3.3 and 2 mL, respectively) will significantly reduce the so-called “mass effect”. The outcomes of this study shed further light on the impact of experimental conditions on the complex interplay of dissolution and diffusion within a volume-limited system, under non-sink conditions.

604 Epidemiology and Microbiologic Profile of Pediatric Burn Patients: Eight-years’ Experience in a Tertiary Hospital

Abstract Introduction Burn injury is major morbidity and is the third most common cause of mortality among the pediatric population. Methods This study retrospectively analyzed pediatric burn admissions from a tertiary hospital in an 8-year period from 2009–2016. A total of 218 pediatric patients were reviewed for demographics, burn incidence, characteristics, cause of burn and microbiologic profile. Results There were 107(49.08%) Infants, 47 (21.56%)Toddlers, 32 (14.68%) Preschoolers, 17 (7.79%) belonged to school age and 15 (6.88%) were adolescent. Most of the admitted patients were within the city 122 (56%) while 96 (44%) were from other localities outside the city. Scald burn was the most common cause of burn with 160 (73.39%) cases and was highest in the infant age group (49.8%). The mean total body surface area was 10%, the highest being caused by flame burn at 13% TBSA among toddlers and preschoolers having the highest total body surface area involved (12%). The most commonly involved body area is the chest (13.6%). The mean transfer time from injury to the admission of patients coming from within and outside the city was 8.8 and 28 hours respectively. The mean length of hospital stay was 9.08 days. There was also a decrease in mean transfer time and hospital stay from 2009 to 2016. Flame burn accounted for the longest hospital stay at 20.27 days. Microbiologic profile of burn wound cultures showed a predominance of gram-negative rods (90%) with Enterobacter cloacae and Klebsiella pneumonia as common isolates. Culture studies also showed amoxicillin-clavulanic, ampicillin-sulbactam, and cefuroxime have the highest resistance, while most isolates are still susceptible to Amikacin, Ertapenem, Meropenem, and Ciprofloxacin. Conclusions Patients belonging to the school-age group has the highest mean number of hospital days (27.3 days). On review of culture study results from wound tissue samples, Gram-negative rods were the most common and Enterobacter cloacae were the most common isolate. Antibiotics such as Amoxicillin clavulanic, ampicillin-sulbactam, cefuroxime, and ceftazidime had high resistance rates and therefore should not be initially used for patients suspecting of the infected burn wound.

Assessing the Usefulness of Instant Feedback and the Hawthorne Effect: An Audit of Time Indexes of Ems Missions in Tehran

Introduction It has been well established that if a person is aware that they are being monitored their commitment and effort will be maximised (the Hawthorne effect), which then leads to efficiency increase and optimal workflow. Objective Our aim was to evaluate the efficacy of instant feedback and the Hawthorne effect of this intervention on pre-hospital time indexes during emergency medical service (EMS) missions. Methods This is a cross-sectional auditing study on the missions of the Tehran EMS Center (performed over a 12-month period) in three phases: pre-intervention, instant feedback, and monitoring without feedback. The measured time indexes were the different parts of mission times. To collect data, a pre-prepared checklist was set up. For the first phase, data were extracted from the database of the Tehran EMS Center. In the second and third phases, the data were entered into the relevant forms for each mission by the researcher and executive colleagues. Results The data of 229,847 missions were analysed. In the instant feedback phase, compared to the pre-intervention phase, the mean activation time, response time, scene time, transfer time and hospital delay time were decreased. When we compared the mean time indexes in the monitoring phase compared to the instant feedback phase, we saw that the average activation time, response time and transfer time were increased but they were still less than that in the pre-intervention phase. However, the scene time and hospital delay time were not changed compared to the instant feedback phase but were lower than that in the pre-intervention phase. Conclusion Auditing was effective in reducing the total time of missions and this effect was largely maintained in the monitoring phase under the Hawthorne effect.

Mental Health Act transfers from prison to psychiatric hospital over a six-year period in a region of England

Purpose There are high levels of psychiatric morbidity amongst people in prisons. In England and Wales, prisoners who present with the most acute mental health needs can be transferred to hospital urgently under part III of the Mental Health Act 1983. This project reviewed all such transfers within one region of England, with an emphasis on differences across levels of security. Design/methodology/approach Over a six-year period (2010–2016) within one region of England, 930 psychiatric referrals were received from seven male prisons. From these referrals, 173 (18.5%) secure hospital transfers were required. Diagnostic and basic demographic information were analysed, along with hospital security categorisation (high secure, medium secure, low secure, psychiatric intensive care unit and other) and total time to transfer in days. Findings There were substantial delays to urgent hospital transfer across all levels of hospital security. Prisoners were transferred to the following units: medium security (n = 98, 56.9%); psychiatric intensive care units (PICUs) (n = 34, 19.7%); low secure conditions (n = 20, 11.6%); high secure conditions (n = 12, 6.9%); other (n = 9, 5.2%). Mean transfer times were as follows: high secure = 159.6 days; other = 68.8 days; medium secure = 58.6 days; low secure = 54.8 days; and psychiatric intensive care = 16.1 days. Research limitations/implications In keeping with the wider literature in this area, transfers of prisoners to hospital were very delayed across all levels of secure psychiatric hospital care. Mean transfer times were in breach of the national 14-day timescale, although transfers to PICUs were quicker than to other units. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved. Originality/value This paper extends the available literature on the topic of transferring prisoners with mental illness who require compulsory treatment. There is a small but developing literature in this area, and this paper largely confirms that delays to hospital transfer remain a serious problem in England and Wales. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved. This could include different referral and transfer models as a component of service-based and pathways research or combining referral pathways across units to improve their efficacy.

Carbon allocation to the root system of tropical tree Ceiba pentandra using 13C pulse labelling in an aeroponic facility.

Despite the important role of tropical forest ecosystems in the uptake and storage of atmospheric carbon dioxide (CO2), the carbon (C) dynamics of tropical tree species remains poorly understood, especially regarding belowground roots. This study assessed the allocation of newly assimilated C in the fast-growing pioneer tropical tree species Ceiba pentandra (L.), with a special focus on different root categories. During a 5-day pulse-labelling experiment, 9-month-old (~3.5-m-tall) saplings were labelled with 13CO2 in a large-scale aeroponic facility, which allowed tracing the label in bulk biomass and in non-structural carbohydrates (sugars and starch) as well as respiratory CO2 from the canopy to the root system, including both woody and non-woody roots. A combined logistic and exponential model was used to evaluate 13C mean transfer time and mean residence time (MRT) to the root systems. We found 13C in the root phloem as early as 2h after the labelling, indicating a mean C transfer velocity of 2.4±0.1mh-1. Five days after pulse labelling, 27% of the tracers taken up by the trees were found in the leaves and 13% were recovered in the woody tissue of the trunk, 6% in the bark and 2% in the root systems, while 52% were lost, most likely by respiration and exudation. Larger amounts of 13C were found in root sugars than in starch, the former also demonstrating shorter MRT than starch. Of all investigated root categories, non-woody white roots (NRW) showed the largest 13C enrichment and peaked in the deepest NRW (2-3.5m) as early as 24±2h after labelling. In contrast to coarse woody brown roots, the sink strength of NRW increased with root depth. The findings of this study improve the understanding of C allocation in young tropical trees and provide unique insights into the changing contributions of woody and non-woody roots to C sink strengths with depth.

Efficacy of 0.5 mg/kg of propofol at the end of anesthesia to reduce the incidence of emergence agitation in children undergoing general anesthesia with sevoflurane.

Background and Aims:Emergence agitation (EA) is a common transient behavioral disturbance after inhalational anesthesia and may cause harm to the patient. This study evaluated the efficacy of 0.5 mg/kg of propofol administered at the end of anesthesia to reduce the incidence of EA in children undergoing general inhalational anesthesia.Material and Methods:This double-blind randomized clinical trial was done in children aged 1–5 years undergoing general anesthesia with sevoflurane. One hundred and eight subjects were included using consecutive sampling method and randomized into two equal groups. Propofol in the dose of 0.5 mg/kg was administered at the end of anesthesia to children in the propofol group, while those in the control group did not receive any intervention at the end of anesthesia. Incidence of EA, transfer time, postoperative hypotension, desaturation, and nausea-vomiting were observed. Aono and Pediatric Anesthesia Emergence Delirium scale were used to assess EA.Results:Incidence of EA was 25.9% in the propofol group compared to 51.9% in the control group (RR = 0.500; 95% CI 0.298–0.840; P = 0.006). Mean transfer time in propofol group was longer (9.5 ± 3.9 min) than control group (7.8 ± 3.6 min) (mean difference 1.71 min; 95% CI 0.28–3.14; P = 0.020). Hypotension was found in one patient (1.9%) in propofol group, while in control group there was none. Nausea-vomiting was found in five patients (9.3%) in propofol group and eight patients (14.8%) in control. There was no desaturation in both the groups.Conclusion:Administration of 0.5 mg/kg of propofol at the end of anesthesia effectively reduces the incidence of EA in children undergoing general inhalational anesthesia with sevoflurane.

Geographic access to emergency obstetric services: a model incorporating patient bypassing using data from Mozambique

IntroductionTargeted approaches to further reduce maternal mortality require thorough understanding of the geographic barriers that women face when seeking care. Common measures of geographic access do not account for the...

Safety of transfer, type of procedure, and factors predictive of limb salvage in a modern series of acute limb ischemia

ObjectiveThe primary objective was to evaluate the safety of transfer, type of procedure, and factors associated with limb salvage in patients with acute limb ischemia (ALI) treated at a quaternary referral center. MethodsA retrospective review of all patients with ALI secondary to thrombotic or embolic occlusion at a quaternary referral hospital from 2013 to 2016 was conducted. Patients were transferred from throughout Washington and Alaska by ambulance, helicopter, or fixed-wing modes of transportation. Demographics, transport and operative timing, Rutherford classification, level of occlusion, procedural information, and fasciotomy characteristics were reviewed. Outcomes measured included limb salvage rates, discharge disposition, and mortality. ResultsOne hundred twelve patients with ALI were identified, with 82% due to thrombosis and 18% due to arterial embolization. Fifty-seven percent of patients were transferred from a referring hospital with low mean transfer times (1.9 hours for embolic, 2.7 hours for thrombotic). Although the initial operative strategy varied according to the etiology, with 50% of thrombotic occlusions treated with endovascular therapies and 80% of embolic occlusions treated with open thrombectomy, the rates of limb salvage did not vary based on operative approach (92% endovascular first, 90% open first). Further, limb salvage rates were identical between transferred and nontransferred patients (77%). Limb salvage was successful in 91% of patients with Rutherford class 1 and 2 disease, but only 8% in patients with Rutherford class 3 disease. In-hospital and 30-day mortality rates were not different based on ischemic etiology (5%), although patients with Rutherford class 3 disease had significantly higher mortality rates (15%) compared with patients with class 1 (6%), class 2a (6%), and class 2b (2%) disease. Fasciotomy was performed in 29% of patients, with 59% of fasciotomy wounds closed primarily. Predictors of amputation include multiple attempts at limb salvage, higher Rutherford class, multilevel occlusion, more proximal levels of occlusion, and nonviable muscle seen after fasciotomy, with ischemic times trending toward higher amputation rates without statistical significance. There was no difference in discharge disposition based on ischemic etiology. ConclusionsThe modern treatment of patients with ALI is effective, with high rates of limb salvage and low mortality regardless of transfer status, etiology, or initial operation performed. In situations where compartment syndrome is unclear, fasciotomy should not be withheld because it provides valuable predictive information regarding limb salvage.

Abstract TP272: Air versus Ground Transport for Interhospital Transfer Prior to Endovascular Stroke Treatment

Introduction: Interhospital transfer for endovascular treatment of large vessel occlusion (LVO) stroke results in significant delays and worse outcomes. We hypothesized that interhospital patient transfer using air transport would result in shorter transit times compared to ground ambulance. Methods: Subjects from the STRATIS registry that underwent interhospital transfer for endovascular treatment were separated by air transport vs. ground ambulance transport and analyzed by transfer distance. The primary endpoint was transfer-time, calculated as the time from imaging at the initial hospital to arrival at the treating hospital. Also assessed was travel-time, calculated as time of departure from the initial hospital to arrival at the treating hospital. Results: There were 232 subjects from 41 sites. Mean transfer-time for all air subjects (n=118) was 147.1 min, and for all ground subjects (n=114) was 130.0 min (p=0.019). Mean travel-time was 45.0 min for air transport and 40.2 min for ground transport (p=0.239); though the average travel distance was longer for air (65.5 miles) vs. ground (27.6 miles; p&lt;0.001). When analyzed by distance, there was no difference between air and ground transfer-time except transfers less than 20 miles, which favored ground transportation (154.4 min vs. 119.5 min; p=0.015; see table). The lack of advantage for air transport may be accounted for by the time between imaging and departure from the initial hospital (mean 89.4 vs. 101.6 min; p=0.075), reflecting additional logistics and/or reduced availability of air transport. Conclusions: In this large, real-world study, interhospital transfer via air transport did not result in faster transfer times compared to ground ambulance. In fact, there was an advantage to ground transportation for distances of less than 20 miles. These results suggest that ground ambulance should routinely be used for interhospital transfer of stroke patients for travel less than 20 miles.