Secondary Transfers Research Articles

Is Secondary Lower Trapezius Tendon Transfer After Rotator Cuff Repair Failure Effective? A Comparative Study with Primary Lower Trapezius Tendon Transfer

BackgroundLower trapezius tendon (LTT) transfer has emerged as a promising surgical intervention for addressing posterosuperior irreparable rotator cuff tears (PSIRCTs) in the absence of glenohumeral arthritis. However, comparative studies evaluating primary versus secondary LTT transfers following rotator cuff repair failure are limited. MethodsThis retrospective study analyzed 103 patients who underwent LTT transfer for PSIRCTs without glenohumeral arthritis. Patients were categorized into Group Primary (no prior shoulder surgeries, n=83) and Group Secondary (previous rotator cuff repairs failure, n=20). Clinical outcomes were assessed using Visual Analog Scale (VAS), Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) score, and Single Assessment Numeric Evaluation (SANE) score. Radiological evaluations included acromiohumeral distance (AHD) and Hamada classification. Incidences of complications such as retears and infections were documented. ResultsThe mean age for the Group Primary and the Group Secondary was 63.3 ± 6.3 years and 61.5 ± 4.8 years, respectively, with mean follow-up periods of 37.4 ± 15.7 months and 42.9 ± 16.8 months, respectively. Both Group Primary and Group Secondary demonstrated significant postoperative improvements in VAS, Constant, ASES, UCLA, and SANE scores, with no statistically significant differences observed between the groups. Radiologically, both groups showed a slight progression of glenohumeral arthritis with no significant differences between the groups. Retears of transferred tendon occurred at a similar rate in each group, with 18% in Group Primary and 20% in the Group Secondary ConclusionSecondary LTT transfer following rotator cuff repair failure represents an effective surgical approach for managing PSIRCTs, demonstrating comparable improvements in clinical and radiological outcomes to primary LTT transfer. These findings support the consideration of LTT transfer irrespective of prior rotator cuff repair history. Long-term follow-up studies are essential to evaluate the durability and functional outcomes over extended periods.

Potential consequences of the German hospital reform and the resolution of the Federal Joint Committee on the treatment of proximal femoral fractures for the Federal State of Saxony : Improvement or hazard for the quality of care?

The German hospital landscape is undergoing comprehensive changes due to the increasing aging population and staff shortages in the healthcare sector. These changes are driven by the current hospital reform and the guidelines of the Federal Joint Committee (G-BA) for the treatment of proximal femoral fractures. To investigate the effects of the hospital reform and the implementation of the G‑BA guidelines for the treatment of proximal femoral fractures in Saxony. Based on the number of proximal femoral fracture surgeries performed in all certified trauma centers in Saxony (East Saxony/West Saxony Trauma Network) in 2019 and 2022, asimulation was conducted to visualize the implementation of the G‑BA guidelines and the hospital reform. Applying the criteria of the G‑BA resolution results in areduction of hospitals treating proximal femoral fractures in Saxony from 42to 28(-33%). The implementation of the planned hospital reform further reduces the number of such hospitals to 15(-64%). This reduction leads to asignificant increase in case numbers in the remaining hospitals (twofold to threefold) and up to a fourfold increase by 2030. This comes with an increased need for operating capacities (1.2operating rooms per week) and about 7400 secondary transfers per year. In the districts of North Saxony, Bautzen, Central Saxony, and the Erzgebirge District, no hospital would be available to treat geriatric proximal femoral fractures. The planned reform and the current implementation of the G‑BA resolution pose ahigh risk to create gaps in care in Saxony with a markedly reduced number of hospitals involved in treatment of proximal femoral fractures. The necessary operating resources and inpatient capacities in the remaining hospitals are insufficient to care for the expected number of patients given the personnel and capacity shortages.

High-energy blunt pelvic ring injuries and pre-hospital pelvic binder applications – A retrospective assessment based on a prospective registry

IntroductionApplication of a pelvic binder in the pre-hospital settings is a crucial step of high-energy blunt pelvic ring injury (PRI) management protocols. The aim of this retrospective cohort study was to evaluate the percentage of pre-hospital pelvic binder's applications in high-energy blunt type B or C PRI patients managed at a single level I trauma center, and to assess its impact on the medical resource requirements and patients' outcomes. MethodsThe institutional Severely Injured Patients’ Registry was screened for patients meeting the following inclusion criteria: (1) high-energy blunt PRI; (2) admission between 2014.01.01 and 2022.12.31; (3) age ≥16 years; and (4) available computed tomography of the pelvis. Exclusion criteria were: (1) death before admission; (2) low-energy injury; (3) penetrating, blast and electrical injuries; and (4) secondary transfers. Study variables, including pre-hospital application of a pelvic binder and demographic, clinical, management and outcome data were extracted from the registry. Additionally, AO/OTA classifications were determined. ResultsA consecutive series of 262 patients was included into the final analysis. Of these, 58.8 % received a pre-hospital pelvic binder (PPB), increasing from type A (45.1 %) to type B (57.8 %) and type C (73.7 %). Pre-hospital hemodynamic instability was a major factor triggering the use of PPB in high-energy blunt type B PRI patients with PPB in 76.9 % of the cases with hemodynamic instability vs. 51.3 % of the cases without hemodynamic instability (p = 0.009). This difference was not statistically significant for high-energy blunt type C PRI patients (82.8 % vs. 64.3 %, p = 0.200). The presence of a physician on the trauma site contributed to the increased percentage of PRI managed with PPB from 43.5 % to 67.3 % in type B PRI (p = 0.011), and from 50 % to 77.1 % in type C PRI (p = 0.257).This study showed an increased need for packed red blood cells (PRBC) transfusions in subgroups treated with PPB and no statistically significant differences in term of intensive care unit (ICU) and total hospital length of stay and complications between high-energy blunt type B or C PRI patients with or without PPB.Comparison of mortality rates in patients with and without PPB showed a trend towards lower mortality rates with PPB in patients with AIS extremity participating in at least 50 % of the total ISS. ConclusionIn the ideal pre-hospital scenario, every high-energy blunt type B or C PRI patient should be managed with a PPB. Continuous pre-hospital team training and information is crucial to achieve this goal. The preparation of Emergency Department and ICU who admit a patient with PPB should include a sufficient number of PRBC ready for transfusion. Mortality rates did not seem to be affected by PPB, except for a trend towards lower mortality rates in patients in whom their PRI was the major component of the global severity of their injury. This might point out the critical and positive effect of PPB in high-energy blunt PRI patients.

Retrospective Evaluation of Falls From Height Cases Admitted to the Pre-Hospital Emergency Healthcare System

Aim: The aim of this study is to analyze the demographic characteristics, timing aspects (time of occurrence, emergency response time, ambulance arrival time), and hospital arrival times in pre-hospital cases of falls in Ankara. Material and Methods: This cross-sectional observational epidemiological study examined data from patients who received pre-hospital emergency care due to fall-related trauma in Ankara between January 1, 2019, and December 31, 2023. Patients were identified through calls made to the central 112 Call Center and documented in the Emergency Health Automation System. Demographic details, injury epidemiology (ICD-10 codes, injury mechanism, incident timing), and emergency response times (command response time, time from ambulance dispatch to scene arrival, transport time) were collected. Results: This study includes 16,136 patients, of whom 6,346 are female and 9,790 are male, with an average age of 38.3 ± 24.3 years. The predominant ICD-10 diagnosis codes are W03, W10, W12, W13, W14, W17, Y30, and X80. The year 2019 saw the highest number of incidents (n=4,014), with a decrease observed in 2020 (n=2,790). The highest number of falls occurred in July, while the lowest was in February, with the fewest falls reported in winter and the most in summer throughout the five years. Most incidents occurred between 08:00 and 15:59 (n=8,366), followed by 16:00 to 23:59 (n=6,456); 1,314 incidents occurred between 00:00 and 07:59. Falls occurred most frequently during working hours (61.9%, n=9,983). The average command center response time was 216.4 ± 203.6 seconds, station response time was 39.6 ± 47.8 seconds, and transport time was 371.6 ± 249.9 seconds. Most patients were transported to Training and Research Hospital (n=7,827), followed by State Hospital (n=3,422), University Hospital (n=2,210), and Private Hospital (n=249). Secondary transfers were mostly related to Training and Research Hospital (n=1,387), primarily for specialist needs (n=1,165). There were 32 patients who received on-scene intervention and 231 patients who died. Significantly increased response times were observed from 2019 to 2023 (p

Emergency Medical Retrieval Services in Remote Indigenous Islands: Experiences in Lanyu, Taiwan

Abstract: Emergency medical retrieval services (EMRS) in remote Indigenous islands is rarely investigated. We analyzed the characteristics of patients who underwent EMRS in Lanyu, an offshore island of Taiwan, from January 1, 2014 to December 31, 2021. The need for EMRS for Lanyu Indigenous residents (N=132, 3.83‰) was almost 1.5-fold and 100-fold for non-Indigenous residents (N=16, 2.64‰) and tourists (N=40, 0.04‰), respectively. The resident group had a longer hospitalization (12.0 ± 12.9 vs. 5.9 ± 11.7 days, p=.007). The tourist group had more near-drowning or decompression sickness (44.0% vs. 3.0%, p<.001) and secondary transfers (20.0% vs. 5.4%, p=.003). All the patients (N=12) that required multiple retrievals were Lanyu Indigenous residents. The Lanyu Indigenous residents, compared with the non-Indigenous residents, had fewer admissions to intensive care units (47.7% vs. 80.0%) and more in-hospital mortalities (10.6% vs. 0.0%). Multifaceted approaches should be initiated to improve the health care system in remote Indigenous islands.

From frequented environments to the crime scene: Evaluating findings of fibre comparisons in complex transfer scenarios.

The evaluation of the results from a fibre comparison given activity level propositions is well established when considering only a single group of potential primary transfers. However, secondary transfers are less prevalent in the literature despite their potential value, especially in cases where the primary transfers are not sufficiently informative. In particular, one can consider the fibres from frequented environments of the person of interest (POI) identified in a struggle. If the POI did struggle with the complainant, these fibres can potentially be recovered in small quantities on the surface of the complainant as a result of secondary or higher order transfers. Therefore, these fibres may provide useful information that can resolve competing propositions involving struggles, as well as forensic intelligence in the form of linkages or investigative leads. If a non-differentiation is indeed found between recovered fibres and fibres from the frequented environments of the POI, these results need to be properly interpreted. In this paper, a model, based on an object oriented Bayesian network (OOBN), for evaluating such findings along with its implementation is proposed. Using available data from the literature and other sources, the model was then used to assess a few hypothetical scenarios involving secondary transfers. The results provided useful insights into secondary transfer that help to validate the model and demonstrate the potential utility that can be gained by considering transfers beyond the primary order. Moreover, these results can be used to help guide future research by identifying gaps in the literature. Finally, the direct application to a case study was conducted to demonstrate the practical aspects of such a model.

Secondary Ambulance Transfers During the Mass-Casualty Terrorist Attack in Israel on October 7, 2023.

On October 7, 2023, Israel experienced the worst terror attack in its history - 1,200 people were killed, 239 people were taken hostage, and 1,455 people were wounded. This mass-casualty event (MCE) was more specifically a mega terrorist attack. Due to the overwhelming number of victims who arrived at the two closest hospitals, it became necessary to implement secondary transfers to centers in other areas of the country. Historically, secondary transfer has been implemented in MCEs but usually for the transfer of critical patients from a Level 2 or Level 3 Trauma Center to a Level 1 Center. Magen David Adom (MDA), Israel's National Emergency Pre-Hospital Medical Organization, is designated by the Health Ministry as the incident command at any MCE. On October 7, in addition to the primary transport of victims by ambulance to hospitals throughout Israel, they secondarily transported patients from the two closest hospitals - the Soroka Medical Center (SMC; Level 1 Trauma Center) in Beersheba and the Barzilai Medical Center (BMC; Level 2 Trauma Center) in Ashkelon. Secondary transport began five hours after the event started and continued for approximately 12 hours. During this time, the terrorist infiltration was still on-going. Soroka received 650 victims and secondarily transferred 26, including five in Advanced Life Support (ALS) ambulances. Barzilai received 372 and secondarily transferred 38. These coordinated secondary transfers helped relieve the overwhelmed primary hospitals and are an essential component of any MCE strategy.

Utilizing a Second Flap to Address the Effect of Postradiotherapy Soft Tissue Fibrosis in Head and Neck Malignancy.

Background Late effects of adjuvant radiation therapy (RT) on soft tissues can lead to hair loss, pigmentary changes, loss of tissue volume, and fibrosis, which appear months to years after the treatment. These changes are often progressive and are because of tissue hypoxia due to radiation-induced capillary endothelial damage. Tissue hypoxia may be compounded by subclinical infection following minor trauma, exposed hardware, or associated osteoradionecrosis. The combined effect of these factors causes significant deformities in soft tissue, affecting both function and appearance. Such changes are also seen in primarily transferred flaps, which have been radiated, resulting in severe, progressive soft tissue fibrosis, compromising function and aesthetics. In selected cases, a second flap may be needed to restore function and volume. Methods Data of patients who underwent secondary soft tissue transfers for postradiotherapy-related soft tissue changes were collected from the hospital electronic medical records, from January 2019 to 2023. Details regarding the primary surgery, dose, duration of adjuvant RT, time interval between adjuvant RT and secondary soft tissue transfer, indications, and the choice of the second flap were analyzed. Results Twenty-one patients had undergone secondary soft tissue transfer for extensive soft tissue fibrosis. In addition, associated compounding features like exposed implant and volume loss were observed. Two patients with osteoradionecrosis also had associated extensive soft tissue fibrosis necessitating replacement. Out of these 21 patients, 13 had undergone free tissue transfers, while 7 locoregional tissue transfers. Conclusion Late sequelae of adjuvant RT changes usually present from 6 months onwards. The radiated hypoxic tissue, due to capillary damage, leads to a chronic progressive fibrotic stage, causing loss of soft tissue volume and fibrosis. Replacing this tissue with a vascularized flap helps to restore volume and correct these secondary changes, improving overall quality of life.

Abstract WMP43: Disparities in Large Vessel Occlusion Stroke Imaging and Endovascular Treatment Metrics, and Procedural Exclusions in the Global Registry of Stroke Care Quality (Res-Q)

Introduction: Global access to mechanical thrombectomy for large vessel occlusion (LVO) stroke is low and disparate between regions. Comparative global data on time metrics for imaging and endovascular treatment (EVT) performance, as well as the reasons for excluding EVT, are lacking. Methods: This is a cross-sectional study using quality metrics from the Res-Q registry on patients presenting directly to the hospital with acute ischemic stroke from January 1, 2022, to December 31, 2022, in countries with 200 or more cases. We used descriptive statistical methods to study the time metrics of interest including door to imaging and door to puncture. Additionally, reasons for not performing thrombectomy in patients with LVO were collected (Table 1). Results: Among the 153,181 patients from 912 hospitals across 67 countries enrolled in the Res-Q registry, 125,390 had an acute ischemic stroke. After excluding secondary transfers (n=26,648), patients with missing or erroneous data (n=42,232), and countries with less than 200 cases (n=1,626), data from a total of 54,884 patients from 631 hospitals across 30 countries were analyzed. CT angiography (CTA) was performed in 24,215 (44.1%) patients and EVT was done in 3,649 (6.6%) patients. For patients who had simultaneous CT+CTA, the median door-to-CTA time was 27.5 min (IQR 22.5-33.9) and the median door-to-puncture time was 98.5 (IQR 79.8-129.3) minutes. The most prevalent specific reason for excluding EVT in patients with LVO on CTA/MRA was the presentation in the late time window (42.0%). Only 11 (36.7%) countries achieved a median door-to-puncture time within 90 minutes (Table 1). Conclusions: The performance of acute imaging for LVO detection and time metrics for EVT appear to be disparate between countries and warrant further study. Additional data from global stroke care quality registries are needed to set benchmarks, compare regional stroke systems of care, and identify gaps to mobilize resources appropriately.

Abstract WMP38: Access to Acute Stroke Care: Global Perspective From Registry of Stroke Care Quality (RES-Q)

Introduction: Disparities in access to acute stroke care represents a major global challenge. Addressing such challenges requires a comprehensive understanding of the variations in stroke care quality between nations. Methods: We used data from the global Registry of Stroke Care Quality (RES-Q). RES-Q is web-based quality monitoring platform for the management of stroke care. Key quality metrics on patients with acute ischemic stroke admitted in 2022 were calculated: patients percentage arriving by Emergency Medical Services (EMS); patients percentage admitted to the Stroke Unit/Intensive Care Unit (ICU); Door-to-Imaging Time (DIT), Door-to-Needle Time (DNT) for intravenous thrombolysis. Results: Of 153 181 patients across 912 hospitals in 67 countries enrolled in the register, 125 390 had acute ischemic stroke. After excluding secondary transfers (n=26 648), missing or erroneous data (n=45 526), and countries with <200 cases (n=1 410), a total of 51,806 patients from 696 hospitals and in 30 countries were analyzed. The percentage of patients arriving at healthcare facilities by EMS varied from 3% to 98% (median 51%; IQR 26-87) and admitted to the Stroke Units/ICUs from 25% to 99% (median 78%; IQR 47-89). The median DIT was 32; IQR 21-39, with range 10-60 minutes. The median DNT was 44; IQR 31-52, with range 20-71 minutes. Median DNT of patients admitted directly to the CT scanner was 24 minutes (IQR 15-38), and, if admitted to the emergency department, DNT was 39 minutes (IQR 25-55). Data by quartiles (best is blue, worst is red) from each country are presented in a detailed Table below. Conclusion: Our study underscores the critical role of the global registry in enabling cross-national comparative analyses of acute stroke care quality. The findings highlight disparities and variations in critical aspects of acute stroke care, paving the way for targeted interventions, policy reforms, and enhanced collaboration among stakeholders to improve stroke care globally.

Unfavorable clinical outcomes in patients with good collateral scores following endovascular treatment for acute ischemic stroke of the anterior circulation: The UNCLOSE study

Background Patients with acute ischemic stroke secondary to large vessel occlusions and good collaterals are frequently associated with favorable outcomes after mechanical thrombectomy, although poor outcomes are observed also in this subgroup. We aimed to investigate the factors associated with unfavorable outcomes (modified Rankin Scale3–6) in this specific subgroup of patients. Methods In total, 219 patients (117 females) with anterior circulation stroke and good collaterals (American Society for Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grades 3–4), treated by mechanical thrombectomy between 2016 and 2021 at our institution were included in this study. Clinical files and neuroimaging were retrospectively reviewed. Univariate and multivariate analyses were performed to identify the predictors of unfavorable outcomes in the overall population (primary endpoint). Secondary endpoints focused on the analysis of the predictors of unfavorable outcomes in the subgroup of successfully recanalized patients, mortality, and symptomatic intracerebral hemorrhages in the overall population. Results Poor outcome was observed in 47% of the patients despite the presence of good collaterals. Older age ( p < 0.001), higher baseline National Institute of Health stroke scale ( p < 0.001), no intravenous thrombolysis administration ( p = 0.004), > 3 passes ( p = 0.01), and secondary transfers ( p < 0.001) were associated with the primary endpoint. The multivariate analysis showed a predictive effect of modified treatment in cerebral infarction 2b-3 and of first pass effect on symptomatic intracerebral hemorrhage. Conclusions Despite good collaterals, defined through the American Society for Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale, poor outcomes occurred in almost half of the patients. Patients with good collaterals not receiving intravenous thrombolysis were significantly associated with unfavorable outcomes, whereas first pass effect was not significantly correlated with clinical outcome in this specific cohort of patients. Different methods to assess collaterals should also be investigated.

Impact of a ground intermediate transport from the helicopter landing site at a hospital on transport duration and patient safety

BackgroundHelicopter emergency medical service provides timely care and rapid transport of severely injured or critically ill patients. Due to constructional or regulatory provisions at some hospitals, a remote helicopter landing site necessitates an intermediate ground transport to the emergency department by ambulance which might lengthen patient transport time and comprises the risk of disconnection or loss of vascular access lines, breathing tubes or impairment of other relevant equipment during the loading processes. The aim of this study was to evaluate if a ground intermediate transport at the hospital site prolonged patient transport times and operating times or increases complication rates.MethodsA retrospective analysis of all missions of a German air rescue service between 2012 and 2020 was conducted. Need of a ground transport at the accepting hospital, transfer time from the helipad to the hospital, overall patient transport time from the emergency location or the referring hospital to the accepting hospital and duration of the mission were analyzed. Several possible confounders such as type of mission, mechanical ventilation of the patient, use of syringe infusion pumps (SIPs), day- or nighttime were considered.ResultsOf a total of 179,003 missions (92,773 (51,8%) primary rescue missions, 10,001 (5,6%) polytrauma patients) 86,230 (48,2%) secondary transfers) an intermediate transport by ambulance occurred in 40,459 (22,6%) cases. While transfer times were prolonged from 6.3 to 8.8 min for primary rescue cases (p < 0.001) and from 9.2 to 13.5 min for interhospital retrieval missions (p < 0.001), the overall patient transport time was 14.8 versus 15.8 min (p < 0.001) in primary rescue and 23.5 versus 26.8 min (p < 0.001) in interhospital transfer. Linear regression analysis revealed a mean time difference of 3.91 min for mechanical ventilation of a patient (p < 0.001), 7.06 min for the use of SIPs (p < 0.001) and 2.73 min for an intermediate ambulance transfer (p < 0.001). There was no relevant difference of complication rates seen.ConclusionsAn intermediate ground transport from a remote helicopter landing site to the emergency department by ambulance at the receiving hospital had a minor impact on transportation times and complication rates.

Assessment of embodied carbon transfer in China’s interregional gas–electricity–heat trade based on multi-stream and multi-node model

With the implementation of the national ”dual carbon” goal, fully and effectively evaluating the spatial carbon transfer of regional natural gas–electricity–heat trade flows will help to better clarify the regional carbon emission reduction responsibilities and improve the efficiency of regional coordinated emission reduction. Therefore, this paper adopts an accounting system based on production and consumption, constructs a multi-stream and multi-node carbon transfer assessment model of regional natural gas–electricity–heat chain, calculates the embodied carbon transfer of natural gas–electricity–heat trade transmission, and analyzes the path of spatial transfer of implied carbon emissions between regions in China. The results show that the implicit spatial carbon transfer pattern of China’ s gas, electricity and heat cross-regional trade shows that Beijing, Tianjin and coastal developed areas have gradually become the main carbon inflows, and the NWC, NEC and other regions with rich resources but underdeveloped areas have become the main carbon outflows; the path of regional carbon transfer is roughly from upstream underdeveloped regions to downstream regions with better economic development, of which the secondary and tertiary transfers of embodied carbon from natural gas account for 6.1% and 0.8% of the total transfer.

Paediatric Major Trauma: A Retrospective Observational Comparison of Mortality in Prehospital Bypass and Secondary Transfer in the East of England.

Background More than half of seriously injured children are not initially treated at a major trauma centre (MTC). Children may be transported by private vehicle to a trauma unit (TU). Children may also be transported by emergency medical services (EMS) to the nearest TU with approximately one in five of these undergoing secondary transfer to an MTC. Most trauma networks permit TU bypass to an MTC. However, the evidence on outcomes between transfer and bypass is limited. This study aimed to evaluate the use of the trauma network by comparing outcomes between paediatric major trauma patients by the method of presentation. Methods In this retrospective observational study, a consecutive sample of paediatric (<16 years old) major trauma patients transported to the regional MTC (Cambridge University Hospitals NHS Foundation Trust (CUH)) between 1st January 2015 and 31st December 2020 was included. Patients were excluded if they arrived at the MTC >24 hours post-injury or were transported to the MTC as the nearest hospital. Patients were divided into four groups: self-presented to MTC, MTC as nearest hospital, bypass and secondary transfer. Results A total of 315 patients (28 'self-presented', 55 'nearest', 58 'bypass' and 174 'secondary transfers') were included. The median age was 9.4 [3.7-13.6] years, and n=209 (66.3%) were male. The median Injury Severity Score (ISS) was 16.0 [9.0-25.0] and n=190 (60.3%) had an ISS >15. There was no difference in 30-day mortality between the 'bypass' and 'secondary transfer' groups.There was a significantly longer hospital and intensive care unit length of stay (LOS) in the bypass group compared to other groups, both p<0.001. The median time to definitive care was five hours greater in the secondary transfer group compared to 'bypass'(bypass 117.6 minutes [100.8-136.6], secondary transfer 418.8 minutes [315.6-529.8]). Conclusion There was no significant difference in 30-day mortality of paediatric major trauma patients who underwent secondary transfer compared to those transported directly from the scene to the MTC, despite significant time delays in reaching definitive care.

The Hunter-8 Scale Prehospital Triage Workflow for Identification of Large Vessel Occlusion and Brain Haemorrhage

Objective The Hunter-8 prehospital stroke scale predicts large vessel occlusion in hyperacute ischemic stroke patients (LVO) at hospital admission. We wished to test its performance in the hands of paramedics as part of a prehospital triage algorithm. We aimed to determine (a) the proportion of patients identified by the Hunter-8 algorithm, receiving reperfusion therapies, (b) whether a call to stroke team improved this, and (c) performance for LVO detection using an expanded LVO definition. Methods A prehospital workflow combining pre-morbid functional status, time from symptom onset, and the Hunter-8 scale was implemented from July 2019. A telephone call to the stroke team was prompted for potential treatment candidates. Classic LVO was defined as a proximal middle cerebral artery (MCA-M1), terminal internal carotid artery, or tandem occlusion. Extended LVO added proximal MCA-M2 and basilar occlusions. Results From July 2019 to April 2021, there were 363 Hunter-8 activations, 320 analyzed: 181 (56.6%) had confirmed ischemic strokes, 13 (4.1%) transient ischemic attack, 91 (28.5%) stroke mimics, and 35 (10.9%) intracranial hemorrhage. Fifty-two patients (16.3%) received reperfusion therapies, 35 with Hunter-8 ≥ 8. The stroke doctor changed the final destination for 76 patients (23.7%), and five received reperfusion therapies. The AUCs for classic and extended LVO were 0.73 (95% CI 0.66–0.79) and 0.72 (95% CI 0.65–0.77), respectively. Conclusion The Hunter-8 workflow resulted in 28.7% of confirmed ischemic stroke patients receiving reperfusion therapies, with no secondary transfers to the comprehensive stroke center. The role of communication with stroke team needs to be further explored.

Bypass of Primary Stroke Centers Compared With Secondary Transfer for Endovascular Thrombectomy

Background Our stroke network operates a hybrid organizational structure, with patients with potential large‐vessel occlusion taken to the local primary stroke center (PSC) during office hours, and directly bypassed to the endovascular thrombectomy–capable stroke center (EVT‐SC) after hours. We aimed to compare the 2 methods of transfer. Methods Consecutive patients with anterior large‐vessel occlusion treated with EVT between August 2017 and February 2021 were identified. Patients who had EVT puncture within 6 hours of last known normal were included for analysis. Patients were grouped into method of presentation: direct bypass to EVT‐SC (“EVT‐SC direct”) or taken to local PSC with secondary transfer to EVT‐SC (“PSC‐transfer”). The primary outcome was 3‐month functional independence (modified Rankin scale score 0–2). Secondary outcomes included mortality at 7 days and at 3 months. Results A total of 259 patients (109 women; mean±SD age, 66.8±15.2 years) were included; there were 91 (35.1%) EVT‐SC direct and 168 (64.9%) PSC‐transfer patients. The EVT‐SC direct patients had shorter median times from last known normal to thrombolysis (120 versus 147 minutes; P =0.004) and puncture (190 versus 230 minutes; P &lt;0.001). Multivariable logistic regression analysis found that EVT‐SC direct patients had greater 3‐month functional independence (odds ratio [OR], 2.04 [95% CI, 1.12–3.73]; P =0.02) and lower 3‐month mortality (OR, 0.33 [95% CI, 0.12–0.91]; P =0.03). For every 100 patients directly bypassed to EVT‐SC, there were 14 more patients functionally independent and 9 fewer who had died, at 3 months. Conclusions In this comparison of 2 organizational paradigms in patients with a PSC as the closest stroke center, direct bypass to EVT‐SC resulted in significantly better process times and clinical outcomes compared with secondary transfers from PSCs.

Machine learning-based prediction of emergency neurosurgery within 24 h after moderate to severe traumatic brain injury

BackgroundRapid referral of traumatic brain injury (TBI) patients requiring emergency neurosurgery to a specialized trauma center can significantly reduce morbidity and mortality. Currently, no model has been reported to predict the need for acute neurosurgery in severe to moderate TBI patients. This study aims to evaluate the performance of Machine Learning-based models to establish to predict the need for neurosurgery procedure within 24 h after moderate to severe TBI.MethodsRetrospective multicenter cohort study using data from a national trauma registry (Traumabase®) from November 2011 to December 2020. Inclusion criteria correspond to patients over 18 years old with moderate or severe TBI (Glasgow coma score ≤ 12) during prehospital assessment. Patients who died within the first 24 h after hospital admission and secondary transfers were excluded. The population was divided into a train set (80% of patients) and a test set (20% of patients). Several approaches were used to define the best prognostic model (linear nearest neighbor or ensemble model). The Shapley Value was used to identify the most relevant pre-hospital variables for prediction.Results2159 patients were included in the study. 914 patients (42%) required neurosurgical intervention within 24 h. The population was predominantly male (77%), young (median age 35 years [IQR 24–52]) with severe head injury (median GCS 6 [3–9]). Based on the evaluation of the predictive model on the test set, the logistic regression model had an AUC of 0.76. The best predictive model was obtained with the CatBoost technique (AUC 0.81). According to the Shapley values method, the most predictive variables in the CatBoost were a low initial Glasgow coma score, the regression of pupillary abnormality after osmotherapy, a high blood pressure and a low heart rate.ConclusionMachine learning-based models could predict the need for emergency neurosurgery within 24 h after moderate and severe head injury. Potential clinical benefits of such models as a decision-making tool deserve further assessment. The performance in real-life setting and the impact on clinical decision-making of the model requires workflow integration and prospective assessment.

Anthropogenic pressure leads to more introductions: Marine traffic and artificial structures in offshore islands increases non-indigenous species

Anthropogenic pressures such as the introduction of non-indigenous species (NIS) have impacted global biodiversity and ecosystems. Most marine species spreading outside their natural biogeographical limits are promoted and facilitated by maritime traffic through ballast water and hull biofouling. Propagule pressure plays a primary role in invasion success mixed with environmental conditions of the arrival port. Moreover, with the current ocean sprawl, new substrates are offered for potential NIS recruits. Here, differences in the fouling assemblages thriving inside three different ports/marinas facilities in Madeira Island were assessed for comparison. The locations showed significant differences concerning assemblage structure. Most NIS were detected in plastic floating pontoons. Funchal harbour receives most of the marine traffic in Madeira, acting as the main hub for primary NIS introductions, being recreational boating involved in NIS secondary transfers. Our results highlight the need for future management actions in island ecosystems, particularly monitoring and sampling of recreational boating.

Nexus of ambient flow and squall line via turbulence in the March 2018 meso-scale convective system over Southeast China

On March 4, 2018, an extremely strong squall line occurs suddenly over Southeast China, incurring devastatingly strong surface winds. In this study, we first present a high-resolution model simulation, then apply the recently developed theory of canonical transfer, which bears a form reminiscent of the Poisson bracket in Hamiltonian mechanics, to investigate the underlying dynamical processes. Using a recently developed functional analysis apparatus, multiscale window transform, the fields are reconstructed onto three scale windows, namely, ambient flow window, squall line-scale window, and turbulence window, which for convenience are denoted as windows 0, 1, 2, respectively. It is found that, among all the canonical transfers of kinetic energy (KE), only that between windows 0 and 2, and that between windows 1 and 2, are significant, and the two correspond remarkably well in space, except for opposite signs. Specifically, at the leading edge, KE is first transferred from the ambient flow over the spectrum all the way to the turbulence scale processes, and then goes to window 1 to form the squall line. At the trailing edge, this process is reversed. While the downscale cascading at the leading edge and upscale transfer at the trailing edge are expected in the classical shock hypothesis of squall lines, the existence of the secondary upscale and downscale transfers, respectively, at the leading and trailing edge, are not seen before. Most importantly, these secondary canonical transfers make the turbulence-scale window function like a hub, bridging the ambient flow and the squall line. To our knowledge, such an energetic scenario, i.e., the nexus of two adjacent scales in a spectrum via a “remote mediator” is not seen before in the literature. This study testifies to the importance of turbulent flows in the maintenance of squall lines, and may yield a clue to a better simulation.

Transición de las fuentes de ingresos agropecuarios en economías rurales de México

Traditionally, agriculture has been the main economic activity of rural communities, however, there are other sources of income that contribute to expenditures on family well-being. Nevertheless, the dynamics of these flows are unknown due to the absence of official statistics for small populations, which makes it difficult to analyze them in relation to poverty. Through an econometric model, the objective was to analyze the transition of income from agricultural production to sources in the service sector and remittances. It was taken as a study case, "Eleodoro Dávila" town from Filomeno Mata municipality, Veracruz, Mexico. Randomly, a questionnaire was applied to 33.33% of the population and an econometric model of expenditures on family well-being was built with data obtained. The dependent variable was expenditures on family well-being, while the independent variables were the diversity of sources of income. In addition, the elasticities of the independent variables were estimated from the econometric model. Primary and secondary activities, subsidies and household transfers were found to contribute to family well-being. In addition, it was found that a 1% increase in income from livestock production generates a 0.05% change in spending on family well-being, while agricultural production generates 0.16%. Trade, international and national remittances generate the greatest effects with 0.81%, 0.71% and 0.48% respectively. The situation that prevailed during 2019-2020 in the study community allows us to conclude that the agricultural sector has lost preponderance as the main source of income.