Min Of Period Research Articles

Association of Ambulance Diversion Policy on EMS Transport and Ambulance Patient Offload Times: A Comparison of Three Strategies

Objectives Despite limited supporting data, hospitals continue to apply ambulance diversion (AD). Thus, we examined the impact of three different diversion policies on diversion hours, transport time (TT; leaving scene to arrival at the hospital), and ambulance patient offload time (APOT; arrival at the hospital to patient turnover to hospital staff) for 9-1-1 transports in a 22-hospital county Emergency Medical Services (EMS) system. Methods This retrospective study evaluated metrics during periods of three AD policies, each 27 days long: hospital-initiated (Period 1), complete suspension (Period 2), and County EMS-initiated (Period 3). We described the median transports and diversion hours, and compared the daily average and daily 90th percentile TT and APOT during the three study periods. Results Over the study period, there were 50,992 total transports in the county; Period 3 had fewer median transports per day than Period 1 (581 vs 623, p < 0.001), while Period 2 was similar to Period 1 (606 vs 623, p = 0.108). Median average daily diversion hours decreased from 98.1 h during Period 1 to zero hours during both Periods 2 (p < 0.001) and 3 (p < 0.001). Median daily average TT decreased from 18.3 min in Period 1 to 16.9 min in both Periods 2 (p < 0.001) and 3 (p < 0.001). Median daily 90th percentile TT showed a similar decrease from 30.2 min in Period 1 to 27.5 in Period 2 (p < 0.001), and to 28.1 in Period 3 (p = 0.001). Median average daily APOT was 26.0 min during Period 1, similar at 25.2 min during Period 2 (p = 0.826) and decreased to 20.4 min during Period 3 (p < 0.001). The median daily 90th percentile APOT was 53.9 min during Period 1, similar at 51.7 min during Period 2 (p = 0.553) and decreased to 40.3 min during Period 3 (p < 0.001). Conclusions Compared to hospital-initiated AD, enacting no AD or County EMS-initiated AD was associated with less diversion time; TT and APOT showed statistically significant improvement without hospital-initiated AD but were of unclear clinical significance. EMS-initiated AD was difficult to interpret as that period had significantly fewer transports. EMS systems should consider these findings when developing strategies to improve TT, APOT, and system use of diversion.

Effects of the establishment of a trauma center and a new protocol on patients with hemodynamically unstable pelvic fractures at a single institution in Korea.

The aim of this study was to determine whether the outcomes of patients with hemodynamically unstable pelvic bone fractures changed after the introduction of a protocol including extraperitoneal pelvic packing (EPP) and the establishment of a trauma center. We analyzed data of adult patients (≥ 18years old) with hemodynamically unstable pelvic bone fractures who visited a single trauma center from February 2009 to October 2016. In July 2014, a new protocol for pelvic fractures was implemented, and a trauma center was established. Therefore, patient outcomes were compared by period (period I: pre-protocol vs. period II: post-protocol). Seventy-nine patients with hemodynamically unstable pelvic bone fractures were recruited. The time to angiographic embolization after arrival at the emergency room decreased significantly in period II when compared to period I (182.9 vs. 268.9min, respectively, p < 0.001). The time required to intervention, including EPP, also decreased, from 268.9 ± 132.4min in period I to 141.9 ± 79.9min in period II (p < 0.001). The overall mortality rate decreased from 47.2% in period I to 23.3% in period II (p = 0.033), and mortality related to hemorrhagic shock in particular, was significantly lowered, from 27.8% in period I to 4.7% in period II (p = 0.009). The establishment of a trauma center and the implementation of a new protocol that included EPP were effective in the treatment of patients with hemodynamically unstable pelvic fractures.

Effect of an acute care surgical service on the timeliness of care

In the spring of 2008, St. Boniface General Hospital in Winnipeg, Man., created an acute care surgical service (ACSS) designed to improve care for emergent, nontrauma surgical patients. We sought to assess the effect of the ACSS on patient care timeliness. We retrospectively examined the time intervals in care for patients admitted with acute appendicitis, acute cholecystitis and small bowel obstruction in 3 study periods: pre-ACSS, newly formed ACSS and established ACSS. There was a 2-fold increase in patient volume after the ACSS was created. Patient characteristics were similar in all 3 groups. Time from triage to surgical consultation was also similar. The ACSS significantly reduced the duration of the surgical consultation (1 h 43 min in period 1 v. 62 min in period 2 and 49 min in period 3, p = 0.029). Time from admission to operation was similar despite a significant increase in patient load after the ACSS was created. Total length of hospital stay was similar except in the subgroup analysis (appendicitis + cholecystitis only), where the length of stay was reduced after creation of the ACSS (2 d 15 h pre- v. 1 d 19 h post-ACSS, p = 0.009). Most operations occurred between 4 pm and midnight. With the implementation of an ACSS, the number of surgical patients assessed and treated doubled. Despite the increased volume, consultations were completed significantly faster, there was no significant difference in time to operation, and on subgroup analysis length of hospital stay was significantly faster.

Impact of the learning curve on outcomes after percutaneous mitral valve repair with MitraClip ® and lessons learned after the first 75 consecutive patients

Mitral valve regurgitation plays a significant role in the aetiology and course of heart failure. We investigated the impact of the learning curve on outcomes after percutaneous mitral valve repair with MitraClip. Outcomes of the first 75 consecutive patients treated with MitraClip at our centre were stratified by subsequent treatment periods (25 patients each). Median total procedure time and device time decreased from 180 and 105 min in period 1 to 95 and 55 min in period 3 (P < 0.005 each). There was an excess of total safety events in period 1 (n = 16) that decreased in periods 2 and 3 (n = 6 and 3, P = 0.0003). Acute procedural success [APS; clip successfully placed and mitral regurgitation (MR) grade ≤2+ at discharge] was 80% in periods 1 and 2, but 92% in period 3 (P = 0.46). At 6 months, improvement in durability and completeness of mitral valve repair was evident: 89.4% of patients in period 3 and 65.0% in period 1 had MR ≤2+ at 6 months (P = 0.03). Within 30 days, no patient sustained myocardial infarction or stroke, and mortality was 2.7% for all patients without significant differences regarding periods. Furthermore, while treatment period did not affect mid-term survival and hospitalization for heart failure, failure of APS, STS (Society of Thoracic Surgeons) score ≥15%, and overt right heart failure at baseline predicted increased mortality. MitraClip showed a learning curve regarding mid-term durability and completeness of mitral valve repair, and APS predicted mortality. Recently published studies should be interpreted in consideration of these findings.

2010 Chilean Tsunami Observed by GPS-mounted Buoy Network on Tohoku to Shikoku Coast, Japan

The 2010 Chilean Tsunami has been observed by a line of the eleven GPS-mounted buoys of NOWPHAS, drifting on the sea surface at the location of 100- 300m in depth on the Tohoku to Shikoku Coast, Japan. The maximum tsunami anomaly was 0.1-0.3m and the predominant period was longer than 50min. The tsunami components of longer than 30 min in period were significantly amplified from the GPS-mounted buoys to the seabed wave gauges near the GPS-mounted buoys, installed at spots of 30-50m in depth, and then the short components of 10-20min were amplified to the coastal tide gauges due to the local bathymetry. Such the significant amplification was observed from the seabed wave gauges to the coastal tide gauges in three tsunamis in 2003 to 2006.

Coordinated observation of field line resonance in the mid-tail

Abstract. Standing Alfvén waves of 1.1 mHz (~15 min in period) were observed by the Cluster satellites in the mid-tail during 06:00-07:00 UT on 8 August 2003. Pulsations with the same frequency were also observed at several ground stations near Cluster's footpoint. The standing wave properties were determined from the electric and magnetic field measurements of Cluster. Data from the ground magnetometers indicated a latitudinal amplitude and phase structure consistent with the driven field line resonance (FLR) at 1.1 mHz. Simultaneously, quasi-periodic oscillations at different frequencies were observed in the post-midnight/early morning sector by GOES 12 (l0≈8.7), Polar (l0≈11-14) and Geotail (l0≈9.8). The 8 August 2003 event yields rare and interesting datasets. It provides, for the first time, coordinated in situ and ground-based observations of a very low frequency FLR in the mid-tail on stretched field lines.

Ultrasonographic Monitoring of Gallbladder Dynamics during Fasting and Feeding Conditions in Sheep

Romaƒski K. W.: Ultrasonographic Monitoring of Gallbladder Dynamics during Fasting and Feeding Conditions in Sheep. Acta Vet. Brno 2004, 73: 29-35. The aim of this study was to evaluate the use of real-time ultrasonography for long-term studies of ovine gallbladder motor function and the assessment of the dynamics of gallbladder contractility in various fasting conditions and as the consequence of feeding with hay and grain mixture. Five adult sheep were selected in order to find the gallbladder shape suitable for the application of the ellipsoid method to estimate the gallbladder volume. In these animals, the ultrasonographic maximal-size gallbladder images were obtained every 10 min for periods of 3-5 h. Seven series of gallbladder length and height measurements were performed on each animal and the results were used to estimate the gallbladder volume utilizing the ellipsoid method. In animals fasted for 2 days, the gallbladder volume changed significantly (from 12.4 ± 1.2 to 24.2 ± 2.1 ml) in the fashion of cycles lasting usually longer than 100 min. In 1-day fasted animals, the fluctuations of gallbladder volume were less clear than in 2-day fasted animals and ranged from 16.3 ± 2.2 to 26.8 ± 4.3 ml. Feeding significantly lowered the gallbladder volume which gradually returned to values similar to those during the pre-feeding period. In non-fasted animals, feeding with hay evoked a longer contractile effect (control 30.6 ± 2.9 ml, feeding 14.2 ± 1.1 ml, p < 0.001) than feeding with a grain mixture (control 31.0 ± 3.3 ml, feeding 15.9 ± 3.2 ml, p < 0.05). Thus, the ultrasonographic method for gallbladder motility examination is useful in sheep and may provide important basic and clinical information. Furthermore, the results indicate that pre-duodenal mechanoreceptors and/or chemoreceptors can play a role in the control of gallbladder motility in sheep.

Sound exposure as a measure against driver drowsiness

Twelve lorry drivers participated in a field study, including in total 110 tests of a waking sound system. The system was based on a time and frequency varied sound, generated at intervals between 1 and 15 min for periods of 3 – 7 s. The waking effect of the sound was analysed through subjective ratings. Exposure to the sounds was correlated to improvements of the immediate as well as the longterm self-reported changes in wakefulness. The results of the study show consistently positive assessments concerning the applied waking system, both regarding the system as a measure for raised wakefulness, increased road safety and the interest in having the system installed in the vehicle. The waking sounds were in no case felt to be annoying. Analyses of the wakefulness and other factors and the interaction related to fatigue and driving are included in the investigation.

Plasma concentrations of testosterone and luteinizing hormone in rutting reindeer bulls (Rangifer tarandrus)

Concentrations of plasma testosterone and luteinizing hormone (LH) were measured in peripheral plasma from semidomestic, rutting reindeer bulls. Although the concentrations of plasma testosterone were high and showed large variations, those of LH were low and only a few episodic bursts could be detected in hourly samples taken throughout a 48-h period. The mean testosterone concentration in three bulls differed significantly and ranked the animals according to their position in a fighting hierarchy. The mean concentrations of LH did not differ significantly. Plasma samples from one reindeer bull sampled every 20 min for periods of 3 h indicated that an increment in LH concentration preceded a peak in testosterone. No diurnal pattern in testosterone concentrations could be detected, but testosterone peaks seemed to appear about every 3–4 h. The present study thus demonstrates that a series of plasma samples throughout the day is necessary to determine a true "testosterone level" in the reindeer bull.

Ineffectiveness of protamine zinc somatostatin as a long-acting inhibitor of insulin and growth hormone secretion.

The present studies examined the duration of inhibitory action of a preparation of cyclic somatostatin (SRIF) in suspension with protamine zinc (PZ) on (1) physiologic growth hormone (GH) and immunoreactive insulin (IRI) secretion during feeding in the rat and (2) plasma IRI levels in a 10-year-old boy with idiopathic hyperinsulinemic hypoglycemia. Chronically cannulated adult male rats were administered 250 microgram PZ-SRIF subcutaneously twice daily at 12-h intervals for 7 days. Control animals received the PZ vehicle on the same schedule. On the test day, blood samples were obtained every 15 min for periods of 6 h following a single PZ-SRIF injection 1.5 h prior to sampling. Prominent GH secretory bursts were still evident in all PZ-SRIF-treated rats and these pulses occurred at the predictable time in relation to the light-dark cycle. Plasma IRI levels were typically elevated in response to feeding and no significant differences were observed in the mean 6-h GH, IRI, and glucose levels of PZ-SRIF-treated rats when compared with PZ-treated controls. In the boy with idiopathic hyperinsulinemic hypoglycemia, subcutaneous injection of 200 microgram PZ-SRIF depressed plasma IRI levels for only 30 min. These results suggest that PZ is not the agent of choice for significant prolongation of the inhibitory action of SRIF on IRI and GH secretion.

Control of insulin secretion during fasting hyperglycemia in adult diabetics and in nondiabetic subjects during infusion of glucose.

In obese adult diabetics, the concentration of insulin in venous plasma was unrelated to the degree of hyperglycemia after an overnight fast. However, in these subjects, insulin rose and fell in proportion to the magnitude of change in plasma glucose induced by small intravenous infusions of glucose. The minimal dose of glucose to cause a significant rise in insulin above the fasting level was similar in normal subjects, obese nondiabetic subjects, and in obese, hyperglycemic adult diabetics. This dose lay between infusion of 60 and 100 mg of glucose per min for 30 min. These results suggested that the secretion of insulin was under regulation by changes in blood glucose but was not stimulated in proportion to the stable raised blood glucose concentration of the hyperglycemic diabetic. Artificial hyperglycemia was induced in fasting normal subjects by constant intravenous infusion of glucose at rates of 100-250 mg of glucose per min for periods up to 8 hr. Plasma glucose rose during the 1st hr of infusion and then remained constantly elevated for up to 8 hr. The concentration of plasma insulin paralleled that of plasma glucose. During the period of constant hyperglycemia and elevated insulin, superimposition of a brief additional glucose load resulted in a prompt rise in glucose and insulin, both returning to the previous elevated levels. Thus in normals as well as obese diabetics, stable hyperglycemia does not produce a pancreatic response sufficient to return the blood glucose to an arbitrary normal fasting concentration, yet the beta cells remain readily responsive to a change in plasma glucose. These data suggest that the beta cells do not operate as a control system with an absolute reference point when presented with systemic hyperglycemia. The behavior of the beta cells during hyperglycemia in the fasting obese adult diabetic suggests that the regulation of the basal insulin secretion may not be determined by factors directly related to the prevailing concentration of glucose. It is postulated that the beta cells adapt to hyperglycemia perhaps through the operation of controls directed toward a normal delivery of free fatty acids or some other cellular metabolic substrate during fasting.

The use of labelled vitamin B12 in the measurement of glomerular filtration rate.

1. Two preparations of radioactive vitamin B(12) labelled respectively with (57)Co and (58)Co have been employed in the estimation of the glomerular filtration rate (G.F.R.) in dogs. The intravenous injection of these preparations at an interval of 20 min resulted in a changing ratio of their activities in plasma and urine and so permitted a relation in time to be established between the urine and the plasma from which it was filtered.2. When urine and plasma were sampled at short intervals an effective renal delay or transit time could be derived from their isotope ratio curves and used as a correction in the clearance equation. This allowed serial clearances of either isotope to be calculated despite a falling plasma concentration.3. This method was applied to the study of the G.F.R. in fourteen dogs using short urine collections of 2 or 4 min for periods up to 80 min. The results under stable conditions and with deliberately induced changes in the G.F.R. are illustrated and discussed.4. Application of the technique in four patients undergoing differential renal function studies gave results comparable with those in the experimental work.5. The plasma binding of administered vitamin B(12) in serial blood samples in dogs and man was investigated.