Mean Transport Time Research Articles

Fast processing of gynecologic cancer tissue in Danish Cancer Biobank makes them well-suited for biomarker studies.

Gynecologic cancers remain a frequent and deadly diagnosis. Historically, treatment has focused on a "one size fits all" approach, but there is an urgent need for more personal medicine. Hence, to enhance personal medicine, new biomarkers are needed. Samples from the Danish Cancer Biobank (DCB) may be well-suited for biomarker studies, as the biobank contains samples from more than 100.000 cancer patients, and the samples are annotated with pre-analytical variables. The aim of this study was to investigate if the recorded pre-analytical variables indicate the gynecologic tissue in DCB are suited for biomarker studies. Data on processing time, transport time, and registration- and verification status were extracted from all patients with a gynecologic tissue sample collected between 2020 and 2022 in DCB. The mean processing time across centers was found to be 1.03 h (SD = 0.71), and the mean transport time was found to be 0.32 h (SD = 0.70). In total, 69% of the tissue samples were pathologically examined, and 91.5% of the pathologically examined samples were found to be concordant with the patient's final diagnosis. While differences were observed, 98% of the samples were processed within 3 h, indicating the majority of gynecologic tissue samples in DCB are of high quality and optimal for biomarker studies.

An assessment of turnaround times of infant Deoxyribonucleic acid-Polymerase Chain Reaction testing and the associated factors in Western Kenya: A mixed methods study.

The HIV/AIDS continues being a significant global public health priority in the 21st century with social and economic consequences Mother-to-child transmission (MTCT) occurs when an HIV-infected woman passes the virus to her infant and about 90% of these MTCT infections occurs in Africa where children and infants are still dying of HIV. Early definitive diagnosis using Deoxyribonucleic acid reaction of HIV infection in infants is critical to ensuring that HIV-infected infants receive appropriate and timely care and treatment to reduce HIV related morbidity and mortality. To assess the Infant Deoxyribonucleic acid-Polymerase Chain Reaction (DNA-PCR) Turnaround Time (TAT) of dry blood spots and associated factors in Vihiga, Bungoma, Kakamega and Busia counties, in Kenya. A mixed methods study using a) retrospectively collected data from Ministry of Health Laboratory registers, Early Infant Diagnosis (EID) database from 28 health facilities and b) 9 key informant interviews with laboratory in-charges were conducted. A total of 2,879 HIV exposed babies' data were abstracted from January 2012 to June 2013. The mean TAT from specimen collection and results received back at the facilities was 46.90 days, Vihiga county having the shortest mean duration at 33.7days and Kakamega county having the longest duration at 51.7days (p = 0.001). In addition, the mean transport time from specimen collection and receipt at Alupe Kenya Medical Research Institute (KEMRI) reference Laboratory was 16.50 days. Vihiga County had the shortest transport time at 13.01 days while Busia had the longest at 18.99 days (p = 0.001). Longer TAT was due to the batching of specimens at the peripheral health facilities and hubbing to the nearest referral hospitals. The TAT for DNA-PCR specimen was 46.90 days with Vihiga County having the shortest TAT due to lack of specimen batching and hubbing. Discourage specimen batching/hubbing and support point-of-care early infant diagnosis (EID) tests.

National Beef Quality Audit-2022: Transportation, mobility, live cattle, and hide assessments to determine producer-related defects that affect animal welfare and the value of market cows and bulls at processing facilities.

The National Beef Quality Audit (NBQA)-2022 serves as a benchmark of the current market cow and bull sectors of the U.S. beef industry and allows comparison to previous audits as a method of monitoring industry progress. From September 2021 through May 2022, livestock trailers (n = 125), live animals (n = 5,430), and post-slaughter hide-on animals (n = 6,674) were surveyed at 20 commercial beef processing facilities across the U.S. Cattle were transported in a variety of trailer types for an average distance of 490.6 km and a mean transport time of 6.3h. During transit, cattle averaged 2.3 m2 of trailer space per animal indicating sufficient space was provided according to industry guidelines. Of all trailers surveyed, 55.3% transported cattle from an auction barn to a processing facility. When surveyed, 63.6% of all truck drivers reported to be Beef Quality Assurance certified. The majority (77.0%) of cattle were sound when evaluated for mobility. Mean body condition scores (9-point scale) for beef cows and bulls were 3.8 and 4.4, respectively, whereas mean body condition scores (5-point scale) for dairy cows and bulls were 2.3 and 2.6, respectively. Of the cattle surveyed, 45.1% had no visible live animal defects, and 37.9% had only a single defect. Of defects present in cows, 64.6% were attributed to an udder problem. Full udders were observed in 47.5% of all cows. Nearly all cattle were free of visible abscesses and knots (97.9% and 98.2%, respectively). No horns were observed in 89.4% of all cattle surveyed. Beef cattle were predominantly black-hided (68.9% and 67.4% of cows and bulls, respectively). Holstein was the predominant dairy animal observed and accounted for 85.7% of the cows and 98.0% of the bulls. Only 3.1% of all animals had no form of identification. Findings from the NBQA-2022 show improvements within the industry and identify areas that require continued education and research to improve market cow and bull welfare and beef quality.

Impact of Community Socioeconomic Characteristics on Emergency Medical Service Delays in Responding to Fatal Vehicle Crashes

This study aimed to determine the impact of community socioeconomic status on emergency medical services' response time for fatal vehicle crashes. Authors used the 2019 National Highway Traffic Safety Administration Fatality Analysis Reporting System and 2019-2020 Area Health Resource Files to obtain emergency medical services' time intervals and county socioeconomic characteristics (e.g., median household income, availability of trauma centers, and rurality), generating a study sample of 18,540 individuals involved in fatal vehicle crashes between January and December 2019. Generalized linear models with log-link and Gamma-family were used to obtain estimates, and other variables were adjusted in the model. Both the mean time of the emergency medical service arrival to the site of the crash and the mean transport time from the crash site to hospital varied by county SES. Counties with a higher mean household income had 12% shorter emergency medical services' arrival times and up to 7% shorter emergency medical services' hospital transport times than counties with lower SES. The emergency medical services' hospital transport times by emergency medical services also varied by proximity to trauma centers and were 15% shorter in counties that had ≥2 trauma centers than in counties without trauma centers. This study shows socioeconomic disparities in emergency medical service rescue time for fatal vehicle crashes. Community characteristics play a major role in emergency medical services' arrival time intervals. Prior research demonstrated a strong link between the timeliness of emergency medical service response and the likelihood of survival in fatal motor vehicle accidents. These findings showing that socioeconomically disadvantaged areas and those lacking trauma facilities had slower emergency medical service rescue times, suggest that socioeconomic status may be a predictor of mortality in fatal motor vehicle accidents. Effective emergency medical services are essential to reduce the morbidity and mortality among motor vehicle crash victims; however, disparities exist in the timeliness of these services by geographic and socioeconomic county characteristics. Further research is urgently needed to inform policy interventions.

Comparison of hemodynamic consequences of hand ventilation versus machine ventilation for transportation of post-operative pediatric cardiac patients.

Hemodynamic monitoring during in-hospital transport of intubated patients is vital; however, no prospective randomized trials have evaluated the hemodynamic consequences of hand versus machine ventilation during transport among pediatric patients' post-cardiac surgery. The authors hypothesized that manual ventilation after pediatric cardiac surgery would alter hemodynamic and arterial blood gas (ABG) parameters during transport compared to mechanical ventilation. A prospective randomized trial. Tertiary cardiac care hospital. Pediatric cardiac surgery patients. One hundred intubated pediatric patients were randomized to hand or machine ventilation immediately post-cardiac surgery during transport from the operating room to the pediatric post-operative intensive care unit (PICU). Hemodynamic variables, including end-tidal CO2 (ETCO2), oxygen saturation, heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), peak airway pressure (Ppeak), and mean airway pressure (Pmean), were measured at origin, during transport, and at the destination. ABG was measured before and upon arrival in the PICU, and adverse events were recorded. The Chi-square test and independent t-test were used for comparison of categorical and continuous parameters, respectively. The mean transport time was comparable between hand-ventilated (5.77 ± 1.46 min) and machine-ventilated (5.96 ± 1.19 min) groups (P = 0.47). ETCO2 consistently dropped during transport and after shifting in the hand-ventilated group, with significantly higher ETCO2 excursion than in machine-ventilated patients (P < 0.05). SBP and DBP significantly decreased during transport (at 5 and 6 min intervals) and after shifting in hand-ventilated patients than in the other group (P < 0.05). Additionally, after shifting, a significant increase in Ppeak (P < 0.001), Pmean (P < 0.001), and pH (P < 0.001), and a decrease in pCO2 (P = 0.0072) was observed in hand-ventilated patients than machine-ventilated patients. No adverse event was noted during either mode of ventilation. Hand ventilation leads to more significant variation in ABG and hemodynamic parameters than machine ventilation in pediatric patients during transport post-cardiac surgery. Therefore, using a mechanical ventilator is the preferred method for transporting post-operative pediatric cardiac patients.

Experimental Implementation of NSER Mobile App for Efficient Real-Time Sharing of Prehospital Patient Information With Emergency Departments: Interrupted Time-Series Analysis.

BackgroundWith the aging society, the number of emergency transportations has been growing. Although it is important that a patient be immediately transported to an appropriate hospital for proper management, accurate diagnosis in the prehospital setting is challenging. However, at present, patient information is mainly communicated by telephone, which has a potential risk of communication errors such as mishearing. Sharing correct and detailed prehospital information with emergency departments (EDs) should facilitate optimal patient care and resource use. Therefore, the implementation of an app that provides on-site, real-time information to emergency physicians could be useful for early preparation, intervention, and effective use of medical and human resources.ObjectiveIn this paper, we aimed to examine whether the implementation of a mobile app for emergency medical service (EMS) would improve patient outcomes and reduce transportation time as well as communication time by phone (ie, phone-communication time).MethodsWe performed an interrupted time-series analysis (ITSA) on the data from a tertiary care hospital in Japan from July 2021 to October 2021 (8 weeks before and 8 weeks after the implementation period). We included all patients transported by EMS. Using the mobile app, EMS can send information on patient demographics, vital signs, medications, and photos of the scene to the ED. The outcome measure was inpatient mortality and transportation time, as well as phone-communication time, which was the time for EMS to negotiate with ED staffs for transport requests.ResultsDuring the study period, 1966 emergency transportations were made (n=1033, 53% patients during the preimplementation period and n=933, 47% patients after the implementation period). The ITSA did not reveal a significant decrease in patient mortality and transportation time before and after the implementation. However, the ITSA revealed a significant decrease in mean phone-communication time between pre- and postimplementation periods (from 216 to 171 seconds; −45 seconds; 95% CI −71 to −18 seconds). From the pre- to postimplementation period, the mean transportation time from EMS request to ED arrival decreased by 0.29 minutes (from 36.1 minutes to 35.9 minutes; 95% CI −2.20 to 1.60 minutes), without change in time trends. We also introduced cases where the app allowed EMS to share accurate and detailed prehospital information with the emergency department, resulting in timely intervention and reducing the burden on the ED.ConclusionsThe implementation of a mobile app for EMS was associated with reduced phone-communication time by 45 seconds (22%) without increasing mortality or overall transportation time despite the implementation of new methods in the real clinical setting. In addition, real-time patient information sharing, such as the transfer of monitor images and photos of the accident site, could facilitate optimal patient care and resource use.

Interfacility Transport of Mechanically Ventilated Patients with Suspected COVID-19 in the Prone Position

Objective Prone positioning during mechanical ventilation in patients with severe respiratory failure is an important intervention with both physiologic and empiric rationale for its use. This study describes a consecutive cohort of patients with severe hypoxemic respiratory failure due to COVID-19 who were transported in the prone position in order to determine the incidence of serious adverse events (SAEs) during transport. Methods This retrospective study used prospectively collected data from a provincial air and land critical care transport system where specially trained critical care paramedic crews transported intubated and mechanically ventilated patients with COVID-19 in the prone position. SAEs were determined a priori, and included markers of new hemodynamic or respiratory instability, new resuscitative measures, and equipment or vehicle malfunction. Two authors independently reviewed each patient care record to identify SAEs during transport, and the ability of the crews to successfully manage such events. Results From April 2020 to June 2021, 127 intubated and mechanically ventilated patients were transported in the prone position. Of these, 117 were transported by land vehicle, 7 by rotor-wing, and 3 by fixed wing aircraft. 67 (52.8%) were vasopressor-dependent, 5 (3.9%) were receiving inhaled vasodilators, 9 (7.1%) were hypoxic (SpO2 < 88%), and 3 (2.4%) were hypotensive (SBP < 90 or MAP < 65 mm Hg) when the transport crew made patient contact at the sending hospital. Of the 122 (96.1%) patients in which a pre-transport PaO2/FiO2 ratio was available, the mean (median; range) was 86.7 (81; 47–144), with 27 patients greater having a ratio greater than 100. The mean (median; range) transport time was 49 (45; 14–176) minutes. There were 19 SAEs in 18 (14.2%) patients during transport, the most common of which was new hypoxia requiring ventilator adjustments (15 of 18 patients). All SAEs were successfully managed by the transport crews. No patient experienced tracheal tube obstruction, unintentional extubation, cardiac arrest, or died during transport. Conclusion Patients with severe hypoxemic respiratory failure due to COVID-19 can be safely transported in the prone position by specially trained critical care paramedic crews.

Expeditionary Mechanical Ventilation in Conjunction With Extracorporeal Life Support During Ground Transport.

We assessed the use of an FDA-cleared transport ventilator with limited functions and settings during ground transport in a swine model of ground evacuation. We hypothesized that when used as an adjunct to extracorporeal life support (ECLS), the device would enable safe mobile ventilatory support during ground evacuation. Female Yorkshire swine (n = 11; mean, 52.4 ± 1.3 kg) were sedated and anesthetized and received mechanical ventilation (MV) with a standard intensive care unit (ICU) ventilator and were transitioned to the Simplified Automated Ventilator II (SAVe II; AutoMedx) during ground transport. MV served as an adjunct to ECLS in all animals. Ventilator performance was assessed in the uninjured state on day 1 and after bilateral pulmonary contusion on day 2. Data were collected pre- and post-transport on both days. During 33 transports, the SAVe II provided similar ventilation support as the ICU ventilator. Mean total transport time was 38.8 ± 2.1 minutes. The peak inspiratory pressure (PIP) limit was the only variable to show consistent differences pre- and post-transport and between ventilators. No adverse events occurred. As an adjunctive supportive device during ground transport, the SAVe II performed adequately without failure or degradation in subject status. Further testing is warranted to elucidate the clinical limits of this device during standalone use.

Characterizing the performance of emergency medical transport time metrics in a residentially segregated community.

To derive and characterize the performance of various metrics of emergency transport time in assessing for sociodemographic disparities in the setting of residential segregation. Secondarily to characterize racial disparities in emergency transport time of suspected stroke patients in Austin, Texas. We used a novel dataset of 2518 unique entries with detailed spatial and temporal information on all suspected stroke transports conducted by a public emergency medical service in Central Texas between 2010 and 2018. We conducted one-way ANOVA tests with post-hoc pairwise t-tests to assess how mean hospital transport times varied by patient race. We also developed a spatially-independent metric of emergency transport urgency, the ratio of expected duration of self-transport to a hospital and the measured transport time by an ambulance. We calculated ambulance arrival and destination times using sequential temporospatial coordinates. We excluded any entries in which patient race was not recorded. We also excluded entries in which ambulances' routes did not pass within 100 m of either the patient's location or the documented hospital destination. We found that mean transport time to a hospital was 2.5 min shorter for black patients compared to white patients. However, white patients' transport times to a hospital were found to be, on average, 4.1 min shorter than expected compared to 3.4 min shorter than expected for black patients. One-way ANOVA testing for the spatially-independent index of emergency transport urgency was not statistically significant, indicating that average transport time did not vary significantly across racial groups when accounting for variations in transport distance. Using a novel transport urgency index, we demonstrate that these findings represent race-based variation in spatial distributions rather than racial bias in emergency medical transport. These results highlight the importance of closely examining spatial distributions when utilizing temporospatial data to investigate geographically-dependent research questions.

Effect of delayed transport on clinical outcomes among patients with cardiac arrest during the coronavirus disease 2019 pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has prompted many changes. Revised cardiopulmonary resuscitation (CPR) recommendations were issued including increased requirement for personal protective equipment (PPE) during CPR and isolation rooms. We hypothesized that these changes might have affected transport times and distance. Accordingly, we investigated any differences in transport time and distance and their effect on patient neurologic outcomes at hospital discharge. MethodsThis retrospective study was conducted among patients who experienced cardiopulmonary arrest and were admitted to an emergency department during specific periods — pre-COVID-19 (January 1 to December 31, 2019) and COVID-19 (March 1, 2020, to February 28, 2021). ResultThe mean transport distance was 3.5 ± 2.1 km and 3.7 ± 2.3 km during the pre-COVID-19 and COVID-19 periods, respectively (p = 0.664). The mean total transport time was 30.3 ± 6.9 min and 35.6 ± 9.3 min during the pre-COVID-19 and COVID-19 periods, respectively (p < 0.001). The mean activation time was 1.5 ± 2.2 min and 2.9 ± 4.5 min during the pre-COVID-19 and COVID-19 periods, respectively (p = 0.003). The mean transport time was 9.3 ± 3.5 min and 11.5 ± 6 min during the pre-COVID-19 and COVID-19 periods, respectively (p = 0.001). ConclusionTotal transport time, including activation time for out-of-hospital cardiac arrest patients, increased owing to increased PPE requirements. However, there was no significant difference in the neurological outcome at hospital discharge.

Abstract 10319: Community Socioeconomic and Urban-Rural Differences in Emergency Medical Services Time Intervals for Suspected Stroke Patients in North Carolina

Introduction: Rapid emergency medical services (EMS) response, care, and transport of acute stroke patients increases the likelihood of receiving time-sensitive treatment. There is limited research on the relationship of community factors with prehospital delays in EMS management of stroke. We compared EMS prehospital time intervals for suspected stroke patients by community socioeconomic status (SES) and urban-rural status in North Carolina (NC). Methods: We analyzed 2019 NC EMS encounter data collected in the National EMS Information System Version 3 standard. Eligible patients were adults requiring a 911 call response by EMS for stroke-like symptoms and transport to the hospital. Incident street addresses were geocoded to census tracts using ArcGIS Pro and linked to SES data from the American Community Survey and rural-urban commuting area (RUCA) codes. Community SES was defined as high, medium, or low based on tertiles of the AHRQ SES index. Urban, suburban, and rural tracts were defined by RUCA codes 1, 2-6, and 7-10, respectively. Differences in mean times by community SES and urban-rural status were evaluated using Kruskal Wallis tests. Results: We identified 17,117 eligible EMS encounters of suspected stroke (65% (11,121 of 17,117) 65+ years old; 55% (9,330 of 17,117) female; 70% (11,839 of 17,117) White) from 2,028 tracts. Median response, scene, and transport times were 8 (interquartile range, IQR 6-11) min, 16 (IQR 12-20) min, and 14 (IQR 9-22) min, respectively. Mean transport times were shorter in low SES (16 min) than in medium and high SES communities (17 min, p&lt;.0001). Mean transport times were longer in rural (21 min) and suburban (19 min) than in urban tracts (14 min, p&lt;.0001). Conclusions: EMS transport times were on average longer for suspected stroke patients in rural but not in low SES tracts. Further research is needed on the role of community socioeconomic deprivation and rurality in contributing to delays in prehospital stroke care.

Factors associated with delays in the search for care in under-5 deaths in Yucatán, Mexico.

We examined delays during the search for care and associations with mother, child, or health services characteristics, and with symptoms reported prior to death. Cross-sectional study compris-ing household interviews with 252 caregivers of children under-5 who died in the state of Yucatán, Mexico, during 2015-2016. We evaluated the three main delays: 1) time to identify symptoms and start search for care, 2) transport time to health facility, and 3) wait time at health facility. Children faced important delays including a mean time to start the search for care of 4.1 days. The mean transport time to the first facility was longer for children enrolled in Seguro Popular and there were longer wait times at public facilities, especially among children who also experienced longer travel time. Providing resources to enable caregiv-ers to access health services in a timely manner may reduce delays in seeking care.

Abstract P169: Assessing Racial Disparity in Emergency Medical Transport of Suspected Stroke Patients

Introduction: Numerous studies have found evidence of disparities in the treatment and health outcomes of patients with acute ischemic stroke. As minimizing time to treatment is essential in acute ischemic stroke management, we aimed to assess for racial disparities in emergency stroke transport. Emergency transport times are dependent on the geographic distribution of patients and hospitals, but previous studies have not controlled for racial variation in spatial distributions when assessing for disparity. Methods: Using a novel dataset of 2,518 unique entries with detailed spatial and temporal information on all suspected stroke transports conducted by a public emergency medical service in Central Texas over eight years, we conducted one-way ANOVA tests with post-hoc pairwise t-tests to assess how mean hospital transport time varied by patient race and developed a spatially-independent metric of emergency transport urgency. Results: Results are reported as means with standard errors and p-values from post-hoc pairwise testing. We found that mean transport time to a hospital was 2.5 minutes shorter for black patients (10.9 +/- 0.274 minutes) compared to white patients (13.4 +/- 0.174 minutes) with p &lt; 0.0001. However, white patients’ transport times to a hospital were found to be, on average, 4.1 +/- 0.085 minutes shorter than expected compared to 3.4 +/- 0.124 minutes shorter than expected for black patients (p = 0.00015). Using a novel transport urgency index, we demonstrate that these findings represent race-based variation in spatial distributions rather than racial bias in emergency medical transport. Conclusion: In summary, these results highlight the importance of closely examining spatial distributions when utilizing spatial data to investigate geographically-dependent research questions.

Emergency Medical Service Transport Time and Trauma Outcomes at an Urban Level 1 Trauma Center: Evaluation of Prehospital Emergency Medical Service Response.

The use of helicopter emergency medical services (HEMS) for trauma patients has been debated since its introduction. We aim to compare outcomes for trauma patients transported by ground EMS (GEMS) vs. HEMS using raw and adjusted mortality in a level 1 trauma center. A 6-year retrospective cohort study utilizing our level 1 trauma center registry for patients transferred by GEMS or HEMS was performed. Demographics and outcome measures were compared. Raw and adjusted mortality was evaluated. Adjusted mortality was determined incorporating confounders, including patient demographics, comorbid conditions, mechanism of injury, injury severity score (ISS), Glasgow Coma Scale score, and EMS transport time. Chi-square, multivariable logistic regression, and independent sample T-test were utilized with significance, defined as P < .05. Of 12633 patients, 10656 were transported via GEMS and 1977 with HEMS. Mean age was 55 for GEMS and 40 for HEMS (P < .001). Mean ISS was 9.29 and 11.73 for GEMS and HEMS (P < .001). Mean Revised Trauma Score was higher (less severe) for GEMS vs. HEMS (7.6 vs. 7.12, P < .001). Mean transport times for GEMS and HEMS was 39.45 vs. 47.29minutes (P = .02). Raw mortality was 2.55% (307/10656) for GEMS and 6.78% (134/1977) for HEMS. Adjusted mortality revealed a 16.6% increased mortality for GEMS compared to HEMS (adjusted odds ratio = 1.166, 95% CI: .815-1.668). Air-lifted trauma patients were younger, more severely injured, and more hemodynamically unstable and required longer transport time but experienced lower adjusted mortality. Future research is needed to investigate whether reducing transport times and augmenting the advanced care already implemented by HEMS crews can improve outcomes.

Reconstruction of massive tibial bone and soft tissue defects by trifocal bone transport combined with soft tissue distraction: experience from 31 cases

BackgroundLarge post-traumatic tibial bone defects combined with soft tissue defects are a common orthopedic clinical problem associated with poor outcomes when treated using traditional surgical methods. The study was designed to investigate the safety and efficacy of trifocal bone transport (TFT) and soft-tissue transport with the Ilizarov technique for large posttraumatic tibial bone and soft tissue defects.MethodsWe retrospectively reviewed 31 patients with massive posttraumatic tibial bone and soft tissue defects from May 2009 to May 2016. All of the eligible patients were managed by TFT and soft-tissue transport. The median age was 33.4 years (range, 2–58 years). The mean defect of bone was 11.87 cm ± 2.78 cm (range, 8.2–18.2 cm) after radical resection performed by TFT. The soft tissue defects ranged from 7 cm × 8 cm to 24 cm × 12 cm. The observed results included bone union time, wound close time and true complications. The Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system was used to assess bone and functional results and postoperative complications were evaluated by Paley classification.ResultsThe mean duration of follow-up after frame removal was 32 months (range, 12–96 months). All cases achieved complete union in both the elongation sites and the docking sites, and eradication of infection. The mean bone transport time was 94.04 ± 23.33 days (range, 63.7–147 days). The mean external fixation time was 22.74 ± 6.82 months (range, 14–37 months), and the mean external fixation index (EFI) was 1.91 ± 0.3 months/cm (range, 1.2–2.5 months/cm). The bone results were excellent in 6 patients, good in 14 patients, fair in 8 patients and poor in 3 patients. The functional results were excellent in 8 patients, good in 15 patients, fair in 5 patients and poor in 3 patients. Conclusion: TFT, in conjunction with soft tissue transport technique, can give good results in most patients (in this article, good and excellent results were observed in 64% of patients). Soft tissue transport is a feasible method in providing good soft tissue coverage on the bone ends. Although it has no advantages over microvascular techniques, it might be an good alternative in the absence of an experienced flap surgeon. Nonetheless, high-quality controlled studies are needed to assess its long-term safety and efficacy.

Numerical impacts on tracer transport: A proposed intercomparison test of Atmospheric General Circulation Models

AbstractThe transport of trace gases by the atmospheric circulation plays an important role in the climate system and its response to external forcing. Transport presents a challenge for Atmospheric General Circulation Models (AGCMs), as errors in both the resolved circulation and the numerical representation of transport processes can bias their abundance. In this study, two tests are proposed to assess transport by the dynamical core of an AGCM. To separate transport from chemistry, the tests focus on the age‐of‐air, an estimate of the mean transport time by the circulation. The tests assess the coupled stratosphere–troposphere system, focusing on transport by the overturning circulation and isentropic mixing in the stratosphere, or Brewer–Dobson Circulation, where transport time‐scales on the order of months to years provide a challenging test of model numerics. Four dynamical cores employing different numerical schemes (finite‐volume, pseudo‐spectral, and spectral‐element) and discretizations (cubed sphere versus latitude–longitude) are compared across a range of resolutions. The subtle momentum balance of the tropical stratosphere is sensitive to model numerics, and the first intercomparison reveals stark differences in tropical stratospheric winds, particularly at high vertical resolution: some cores develop westerly jets and others easterly jets. This leads to substantial spread in transport, biasing the age‐of‐air by up to 25% relative to its climatological mean, making it difficult to assess the impact of the numerical representation of transport processes. This uncertainty is removed by constraining the tropical winds in the second intercomparison test, in a manner akin to specifying the Quasi‐Biennial Oscillation in an AGCM. The dynamical cores exhibit qualitative agreement on the structure of atmospheric transport in the second test, with evidence of convergence as the horizontal and vertical resolution is increased in a given model. Significant quantitative differences remain, however, particularly between models employing spectral versus finite‐volume numerics, even in state‐of‐the‐art cores.

Paramedic Pain Management Practice with Introduction of a Non-opiate Treatment Protocol.

IntroductionThere is concern about the initiation of opiates in healthcare settings due to the risk of future misuse. Although opiate medications have historically been at the core of prehospital pain management, several states are introducing non-opiate alternatives to prehospital care. Prior studies suggest that non-opiate analgesics are non-inferior to opiates for many acute complaints, yet there is little literature describing practice patterns of pain management in prehospital care. Our goal was to describe the practice patterns and attitudes of paramedics toward pain management after the introduction of non-opiates to a statewide protocol.MethodsThis study was two-armed. The first arm employed a pre/post retrospective chart review model examining medication administrations reported to the Massachusetts Ambulance Trip Information System between January 1, 2017–December 31, 2018. We abstracted instances of opiate and non-opiate utilizations along with patients’ clinical course. The second arm consisted of a survey administered to paramedics one year after implementation of non-opiates in the state protocol, which used binary questions and Likert scales to describe beliefs pertaining to prehospital analgesia.ResultsPain medications were administered in 1.6% of emergency medical services incidents in 2017 and 1.7% of incidents in 2018. The rate of opiate analgesic use was reduced by 9.4% in 2018 compared to 2017 (90.6% vs 100.0%). The absolute reduction in opiate use in 2018 was 3.6%. Women were less likely (odds ratio [OR] = 0.78, 95% confidence interval [CI], 0.69–0.89) and trauma patients were more likely to receive opiates (OR = 2.36, CI, 1.96–2.84). Mean transport times were longer in opiate administration incidents (36.97 vs 29.35 minutes, t = 17.34, p<0.0001). We surveyed 100 paramedics (mean age 41.98, 84% male). Compositely, 85% of paramedics planned to use non-opiates and 35% reported having done so. Participants planning to use non-opiates were younger and less experienced. Participants indicated that concern about adverse effects, efficacy, and time to effect impacted their practice patterns.ConclusionThe introduction of non-opiate pain medication to state protocols led to reduced opiate administration. Men and trauma patients were more likely to receive opiates. Paramedics reported enthusiasm for non-opiate medications. Beliefs about non-opioid analgesics pertaining to adverse effects, onset time, and efficacy may influence their utilization.

The Impact of Prehospital Transport Mode on Mortality of Penetrating Trauma Patients

ObjectiveThe optimal mode of transport of trauma patients from the scene to the hospital remains unknown. We aimed to study the impact of different prehospital modes of transport of penetrating trauma patients on hospital mortality. MethodsUsing the Trauma Quality Improvement Program 2010 to 2016 database, we identified all adults with a penetrating injury. Univariate then multivariable logistic regression analyses were performed to study the correlation between the mode of transport and in-hospital mortality, adjusting for several covariates. ResultsA total of 92,427 subjects were included. The overall mean transport time for patients transported by a ground ambulance, helicopter, fixed wing ambulance, and police/private vehicle were 32.2, 61.2, 68.9, and 28.2 minutes, respectively. Multivariable analyses revealed that compared with ground ambulance, helicopter transport was associated with a 34% decrease in the odds of mortality (odds ratio = 0.66, P < .0001), whereas police transport and private vehicle transport were associated with a 52% decrease in the odds of mortality (odds ratio = 0.48, P < .0001). ConclusionHelicopter, police, and private vehicle transports are associated with a decreased odds of mortality compared with ground ambulance. Further research should examine the variation in levels of care within different modes of prehospital transport.

Determinants of lost theatre capacity.

Secondary care Trusts nationwide are continuing to fail the 18-week referral to treatment (RTT) target despite several initiatives to improve theatre efficiency (2018 NHS England review). A limitation of wasted theatre productivity is required to alleviate pressures on waiting lists. Productivity, which is a measure of treatment time as a proportion of available/allocated time, takes into consideration variations in operator performance, early (non-funded) theatre starts, and over-run, and its analysis enables the determination of theatre downtime and lost theatre capacity. We monitored productivity over a 12-week period and performed downtime analysis as reported in the NHS Improvement national audit (NHSI). Results showed a marked but predictable variation in productivity connected to turnaround and session list scheduling. Productivity and booking efficiency correlated uniformly (Pearson's r=0.82). Theatre downtime was analysed with respect to three components defined in the NHSI national audit: late starts, early finish, and turnaround. We found that lost theatre time was predominantly due to early finishes; late starts were infrequent. Transport time correlated unfavourably with productivity (Pearson's r=-0.29, p=0.037) and over-run (r=0.44), and prolonged transport times were shorter when surgery was performed in a dedicated day surgery unit. Calculating the mean transport times for lists with high compared with low productivity helped us set a benchmark for patient transport times for future audit.

Free flap transfer combined with the Ilizarov technique for type IIIB and IIIC open fracture of extremities: Experience with 8 cases

Severe open fractures of the limbs caused by high-energy events are common. Orthopaedic surgeons are often confused when making treatment protocols for these injuries. A case series of 8 patients with type IIIB and IIIC open fractures of the extremities managed with free tissue transfer combined with the Ilizarov technique is presented. This is a retrospective study of 8 patients with Gustilo type IIIB and IIIC open fractures of the extremities treated with free tissue transfer and the Ilizarov technique. The bone and functional outcomes were evaluated using the Association for the Study and Application of the Method of Ilizarov (ASAMI) classification, and the complications were classified according to the Paley criteria. The mean follow-up duration was 22.5 ​± ​6.85 months (range, 13–36 months). All patients achieved complete union in both soft tissue and bone defects. The limb length of the 8 patients was completely restored. The mean bone defect was 9.4 ​± ​2.0 ​cm (range, 6.5–13.3 ​cm). The mean bone union time was 11.1 ​± ​2.3 months (range, 7.0–15.0 months). The mean bone transport time was 113.9 ​± ​17.7 days (range, 87–136 days). The mean soft tissue defect was 109.5 ​± ​78.8 ​cm2 (range, 98–299 ​cm2). The mean healing time of the soft tissue defects was 2.5 ​± ​2.3 months (range, 1.0–8.0 months). The mean external fixation time was 17.1 ​± ​3.48 months (range, 10–21 months), and the mean external fixation index (EFI) was 2.1 ​± ​0.7 ​months/cm (range, 1.1–3.5 ​months/cm). The bone outcomes were excellent in five patients, good in two patients, and fair in one patient. The functional outcomes were excellent in three patients, good in three patients, and fair in two patients. There were five problems, 13 obstacles, and one true complication according to the Paley criteria. Performing free tissue transfer combined with the Ilizarov technique in patients with Gustilo type IIIB and IIIC open fractures of the extremities is safe and effective. Our data suggest performing free tissue transfer combined with the Ilizarov technique in patients with Gustilo type IIIB and IIIC open fractures of the extremities is safe and effective.