Unnecessary Transport Research Articles

RNA-seq reveals the gene expression in patterns in Populus × euramericana 'Neva' plantation under different precision water and fertilizer-intensive management.

Populus spp. is a crucial fast-growing and productive tree species extensively cultivated in the mid-latitude plains of the world. However, the impact of intensive cultivation management on gene expression in plantation remains largely unexplored. Precision water and fertilizer-intensive management substantially increased key enzyme activities of nitrogen transport, assimilation, and photosynthesis (1.12-2.63 times than CK) in Populus × euramericana 'Neva' plantation. Meanwhile, this management approach had a significant regulatory effect on the gene expression of poplar plantations. 1554 differential expression genes (DEGs)were identified in drip irrigation (ND) compared with conventional irrigation. Relative to ND, 2761-4116 DEGs, predominantly up-regulated, were identified under three drip fertilization combinations, among which 202 DEGs were mainly regulated by fertilization. Moreover, drip irrigation reduced the expression of cell wall synthesis-related genes to reduce unnecessary water transport. Precision drip and fertilizer-intensive management promotes the synergistic regulation of carbon and nitrogen metabolism and up-regulates the expression of major genes in nitrogen transport and assimilation processes (5 DEGs), photosynthesis (15 DEGs), and plant hormone signal transduction (11 DEGs). The incorporation of trace elements further enhanced the up-regulation of secondary metabolic process genes. In addition, the co-expression network identified nine hub genes regulated by precision water and fertilizer-intensive management, suggesting a pivotal role in regulating the growth of poplar. Precision water and fertilizer-intensive management demonstrated the ability to regulate the expression of key genes and transcription factor genes involved in carbon and nitrogen metabolism pathways, plant hormone signal transduction, and enhance the activity of key enzymes involved in related processes. This regulation facilitated nitrogen absorption and utilization, and photosynthetic abilities such as light capture, light transport, and electron transport, which faintly synergistically regulate the growth of poplar plantations. These results provide a reference for proposing highly efficient precision intensive management to optimize the expression of target genes.

Pallet Loading Problem: A Case Study in the Automotive Industry Applying a Simplified Mathematical Model

Logistics and the supply chain are areas of great importance within organizations. Due to planning gaps, an increase in extra and unnecessary transport costs is usually observed in several companies due to their commercial commitments and need to comply with the delivery time and the batch quantity of products, leading to a negative economic impact. Thus, the objective of this work was to adjust an optimization model to maximize the shipments usually carried out by the companies. To validate the model, an automotive components manufacturer was selected, allowing us to apply the model to a real case study and evaluate the advantages and drawbacks of this tool. It was found that the company to validate the model exports most of its products, and most pallets sent are not fully optimized, generating excessive expense for the company in terms of urgent transport. To solve this problem, two mathematical optimization models were used for the company’s current reality, optimizing the placement of boxes per pallet and customer. With the use of the new tool, it was possible to determine that five pallets should be sent to the customer weekly, which correspond to their needs, and that have the appropriate configurations so that the pallet is sent completely.

Development and validation of a prehospital termination of resuscitation (TOR) rule for out - of hospital cardiac arrest (OHCA) cases using general purpose artificial intelligence (AI)

BackgroundPrehospital identification of futile resuscitation efforts (defined as a predicted probability of survival lower than 1%) for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transport. Reliable prediction variables for OHCA 'termination of resuscitation' (TOR) rules are needed to guide treatment decisions. The Universal TOR rule uses only three variables (Absence of Prehospital ROSC, Event not witnessed by EMS and no shock delivered on the scene) has been externally validated and is used by many EMS systems. Deep learning, an artificial intelligence (AI) platform is an attractive model to guide the development of TOR rule for OHCA. The purpose of this study was to assess the feasibility of developing an AI-TOR rule for neurologically favorable outcomes using general purpose AI and compare its performance to the Universal TOR rule. Methods: We identified OHCA cases of presumed cardiac etiology who were 18 years of age or older from 2016 to 2019 in the All-Japan Utstein Registry. We divided the dataset into 2 parts, the first half (2016–2017) was used as a training dataset for rule development and second half (2018–2019) for validation. The AI software (Prediction One®) created the model using the training dataset with internal cross-validation. It also evaluated the prediction accuracy and displayed the ranking of influencing variables. We performed validation using the second half cases and calculated the prediction model AUC. The top four of the 11 variables identified in the model were then selected as prognostic factors to be used in an AI-TOR rule, and sensitivity, specificity, positive predictive value, and negative predictive value were calculated from validation cohort. This was then compared to the performance of the Universal TOR rule using same dataset. ResultsThere were 504,561 OHCA cases, 18 years of age or older, 302,799 cases were presumed cardiac origin. Of these, 149,425 cases were used for the training dataset and 153,374 cases for the validation dataset. The model developed by AI using 11 variables had an AUC of 0.969, and its AUC for the validation dataset was 0.965. The top four influencing variables for neurologically favorable outcome were Prehospital ROSC, witnessed by EMS, Age (68 years old and younger) and nonasystole. The AUC calculated using the 4 variables for the AI-TOR rule was 0.953, and its AUC for the validation dataset was 0.952 (95%CI 0.949 –0.954). Of 80,198 patients in the validation cohort that satisfied all four criteria for the AI-TOR rule, 58 (0.07%) had a neurologically favorable one-month survival. The specificity of AI-TOR rule was 0.990, and the PPV was 0.999 for predicting lack of neurologically favorable survival, both the specificity and PPV were higher than that achieved with the universal TOR (0.959, 0.998). ConclusionsThe accuracy of prediction models using AI software to determine outcomes in OHCA was excellent and the AI-TOR rule’s variables from prediction model performed better than the Universal TOR rule. External validation of our findings as well as further research into the utility of using AI platforms for TOR prediction in clinical practice is needed.

Frequency and characteristics of interventions by community paramedics on people in need of care : Analysis of 2,410 deployment protocols for people aged 65+ years

The aim of this study was to obtain a differentiated view of interventions delivered by community paramedics (Gemeindenotfallsanitäter, G‑NFS) in older people in need of care living in nursing homes and at home. Aretrospective analysis of G‑NFS documentation from 2021 with afocus on patients aged ≥65years was performed. Data were grouped into callouts to nursing homes or private homes. Interventions, urgency, transport, and further recommendations were analyzed descriptively. Of 5,900G-NFS protocols, 43.0% (n = 2,410) were related to elderly people (mean age 80.8years, 49.7% female). A total of 20.6% of these callouts involved nursing home residents, 38.4% (n = 926) were homecare patients, and 41% (n = 988) of callouts were to persons who did not rely on care. No specific interventions except advice were given to 48.4% of nursing home residents, and to even 82.1% of those in homecare and 83.7% of those without care needs. About 60% of the G‑NFS interventions were classified as non-urgent. Transport was waived for 63.1% of nursing home residents, for 58.1% in homecare, and for 60.6% of persons without care needs. A visit to the emergency department was recommended to 29.4% of nursing home residents, 37.6% of homecare patients, and 33.6% of persons without need of care. Measures related to urine catheters were documented much more often in nursing homes (38.5%) than in patients in homecare (15.1%) or without need of care (9.3%). Community paramedics perform primary care tasks and can contribute to a reduction in unnecessary transport. It should be discussed whether the emergency medical service is responsible for such interventions and how older people in need of care can be cared for according to their needs in the future.

Social Needs in the Prehospital Setting (SNIPS): EMS Attitudes Toward Addressing Patient Social Needs.

There has been interest in utilizing EMS to address patients' social determinants of health, which are thought to be the cause of many unnecessary transports, particularly for "super-utilizing" patients. However, existing research is limited regarding EMS clinicians' understanding of social determinants of health and attitudes toward potential interventions. This cross-sectional study was conducted using an internet-based survey of EMS clinicians across the United States with multiple methods of recruitment. Descriptive statistics and Chi Square Tests analyzed the data. A total of 1,112 EMTs and paramedics completed the survey with 43.4% reporting familiarity with the term, "social determinants of health," and 87.7% screening positive for burnout. Greater than 60% reported willingness to use proposed interventions to address patient social needs. Those who reported familiarity with the term, "social determinants of health," were more likely to indicate willingness to utilize interventions and to believe they were responsible for addressing their patients' social needs. Burnout had no effect on clinicians' willingness to use resources. Respondents showed substantial interest in using the proposed resources to address patient social needs, suggesting that EMS clinicians may be receptive to expanding their scope of responsibility to include socioeconomic interventions. EMS clinicians familiar with the term "social determinants of health" were more likely to believe they were responsible for addressing patient social needs and more willing to use interventions, suggesting a potential benefit to more education on the topic. Burnout among EMS clinicians may not be a barrier to implementing such interventions. Our survey suggests that EMS clinicians may be interested in helping to address their patients' social needs. EMS clinicians should be offered education on social determinants of health in their initial training and through continuing education. Partnerships with human services agencies will be important to ensure the effectiveness of prehospital interventions.

Evaluation of a Portable Blood Gas Analyzer for Prehospital Triage in Carbon Monoxide Poisoning: Instrument Validation Study.

Carbon monoxide (CO) poisoning is an important cause of morbidity and mortality worldwide. Symptoms are mostly aspecific, making it hard to identify, and its diagnosis is usually made through blood gas analysis. However, the bulkiness of gas analyzers prevents them from being used at the scene of the incident, thereby leading to the unnecessary transport and admission of many patients. While multiple-wavelength pulse oximeters have been developed to discriminate carboxyhemoglobin (COHb) from oxyhemoglobin, their reliability is debatable, particularly in the hostile prehospital environment. The main objective of this pilot study was to assess whether the Avoximeter 4000, a transportable blood gas analyzer, could be considered for prehospital triage. This was a monocentric, prospective, pilot evaluation study. Blood samples were analyzed sequentially with 2 devices: the Avoximeter 4000 (experimental), which performs direct measurements on blood samples of about 50 µL by analyzing light absorption at 5 different wavelengths; and the ABL827 FLEX (control), which measures COHb levels through an optical system composed of a 128-wavelength spectrophotometer. The blood samples belonged to 2 different cohorts: the first (clinical cohort) was obtained in an emergency department and consisted of 68 samples drawn from patients admitted for reasons other than CO poisoning. These samples were used to determine whether the Avoximeter 4000 could properly exclude the diagnosis. The second (forensic) cohort was derived from the regional forensic center, which provided 12 samples from documented CO poisoning. The mean COHb level in the clinical cohort was 1.7% (SD 1.8%; median 1.2%, IQR 0.7%-1.9%) with the ABL827 FLEX versus 3.5% (SD 2.3%; median 3.1%, IQR 2.2%-4.1%) with the Avoximeter 4000. Therefore, the Avoximeter 4000 overestimated COHb levels by a mean difference of 1.8% (95% CI 1.5%-2.1%). The consistency of COHb readings by the Avoximeter 4000 was excellent, with an intraclass correlation coefficient of 0.97 (95% CI 0.93-0.99) when the same blood sample was analyzed repeatedly. Using prespecified cutoffs (5% in nonsmokers and 10% in smokers), 3 patients (4%) had high COHb levels according to the Avoximeter 4000, while their values were within the normal range according to the ABL827 FLEX. Therefore, the specificity of the Avoximeter 4000 in this cohort was 95.6% (95% CI 87%-98.6%), and the overtriage rate would have been 4.4% (95% CI 1.4%-13%). Regarding the forensic samples, 10 of 12 (83%) samples were positive with both devices, while the 2 remaining samples were negative with both devices. The limited difference in COHb level measurements between the Avoximeter 4000 and the control device, which erred on the side of safety, and the relatively low overtriage rate warrant further exploration of this device as a prehospital triage tool.

Stabilizing Li1.3Al0.3Ti1.7(PO4)3|Li Metal Anode Interface in Solid‐State Batteries by Kevlar Aramid Nanofiber‐Based Protective Coating

AbstractLi1.3Al0.3Ti1.7(PO4)3 (LATP) solid‐state electrolyte has garnered considerable interest owing to its competitive room‐temperature Li‐ion conductivity, air stability, and economic nature. Nevertheless, the successful implementation of LATP in next‐generation Li‐metal solid‐state batteries (SSBs) is impeded by its high incompatibility with Li metal. Herein, combining the Kevlar aramid nanofiber (KANF) membrane with a solidified electrolyte (SE) formed via in situ polymerization, the SE@KANF protective layer for LATP can be constructed. Such a protective layer not only effectively prevents Li metal from reducing LATP but also provides intimate interface contact and limits unnecessary electron transport. Consequently, Li symmetric battery incorporating SE@KANF layer enables an ultrahigh critical current density of 1.4 mA cm−2 and stably cycles for over 2000 h at 0.2 mA cm−2. Moreover, the full SSB coupling with LiFePO4 cathode delivers a capacity retention of 95% after 180 cycles at 0.1 C at 30 °C. The present study underscores the importance of the protective interface layer in stabilizing the LATP|Li interface.

Auswirkungen der komplexen Modellintervention CoCare auf die medizinische Versorgung in deutschen Pflegeheimen: eine Übersicht über die Ergebnis- und Prozessevaluation

IntroductionMore and more people are being cared for in nursing homes these days. Multimorbidity results in frequent but sometimes unnecessary patient transports and hospitalisations. The CoCare intervention was developed as a nursing home-based intervention to improve coordination of medical care and GP and specialist care in long-term care homes. The project aimed to reduce avoidable hospital admissions and ambulance transportation, minimise costs through the resulting better collaboration and improving the quality of life of nursing home residents. This article presents the results of the process and outcome evaluation of the intervention in an integrated way and assesses them against the background of the project objectives. MethodsIntervention and data collection started in January 2018 and ended in September 2020. A mixed-methods design was chosen for the evaluation. The (cost) effectiveness of the intervention was tested by a controlled observational study, comparing intervention (IG) and control group (CG). As part of the evaluation of the results, claims data from health insurance funds and a questionnaire-based survey among nursing staff, physicians and nursing home residents were analysed. As part of the process evaluation, subjectively perceived changes in care and implementation difficulties were recorded with the help of focus groups and telephone interviews conducted quarterly. ResultsFrom the point of view of the health economic evaluation, with a decrease in total costs of € 468.56 (p<.001) per nursing home resident and quarter, an advantageous cost-benefit ratio can be assumed. Thus, the significant increase in outpatient care for nursing home residents goes along with a reduction of ambulance transportation by 0.19 (p=.049) and hospitalization rates by 0.08 (p=.001). In the nursing staff sample, a significant positive difference between IG (T1) and CG was observed with regard to communication and cooperation. In addition, pre-post comparison showed a significant improvement in the nursing staff's assessment of interprofessional cooperation in IG at T1 compared to T0. Both nursing staff and physicians perceived positive changes in care and positively assessed the benefit of the intervention. While practitioners experienced an intensification and improvement of communication and cooperation through the implementation of the CoCare measures, these changes were not perceived by residents. DiscussionThe CoCare intervention lowered the barriers for nursing homes to contact general practitioners, specifically in unclear situations and can thus be seen as an effective tool to reduce potentially avoidable hospital admissions and costs. It is conceivable that results can be transferred to other regions in Germany and to similar care scenarios. It should be examined to what extent approaches of this new form of care can be transferred to standard care and whether adjustments to facilitate the implementation of coordinated care approaches across occupational groups in inpatient care facilities can be proposed within the framework of legislative procedures.

P69: ECMO mobilizing device

Extracorporeal Membrane Oxygenation (ECMO) is a temporary lifesaving treatment for critically ill patients suffering from severe respiratory and/or cardiac failure. Studies have demonstrated the feasibility of mobilization in ECMO patients within the hospital during their bridge to recovery or transplantation. Ambulatory ECMO is a comprehensive form of mobilization aimed at preventing neuromuscular weakness and impaired physical functioning during and after treatment. Despite more compact and mobile ECMO devices, the implementation of ambulatory ECMO remains a labour-intensive, complex, and challenging operation. Ambulatory ECMO requires a large multidisciplinary team to carry all the equipment, to monitor and physically support the patient, and to provide a back-up wheelchair in case of patient fatigue. Additionally, current device configuration contributes to unnecessary device transport. Moreover, there is no adequate solution for ensuring the stability of the patient’s cannula and circuit management during ambulation. We developed a system that contributes to the improvement and innovation of current ambulatory ECMO patient programs and combines: (1) A modular cart-in-cart system (A) consisting of two distinct carts - the stationary cart (B) and the ambulatory cart (C). The stationary cart carries the devices (e.g. heater-cooler) not required during ambulation and remains in the ICU next to the patient’s bed. The ambulatory cart carries all the necessary devices during ambulation and features an extendable walking frame (D) that ensures safe walking support for the patient. A foldable seat (E) allows the patient to sit and facilitates transport back to the ICU in case of patient fatigue. Additionally, a safety brake system prevents unintentional movement of the ambulatory cart. Devices on both carts can be (dis)connected through a multi-connector hub, enabling easy configuration of necessary fluids, gases, and electricity. The connection between the stationary and ambulatory cart is maintained by a foot pedal-controlled lift mechanism that prevents accidental disconnection of the multi-connector and enables transport of both carts simultaneously. The system also features a gas switching device that allows for convenient switching between wall-mounted gas and bottled gas. (2) A universal-sized shoulder brace (F) with integrated blood tubing connector that can be adjusted to the patient via Velcro closure, facilitates secure fixation of the blood tubing, and minimizes strain on the cannula. At the time of writing, the project is undergoing design optimization. Subsequently, a physical prototype will be constructed and subjected to verification and validation processes. Internal testing will be performed to assess compliance with the user requirements. The prototype will then be evaluated in a simulated ICU environment to determine its suitability for use in a clinical setting. The patent for this invention has been filed and is currently pending.

Low Carbon Timber® - European best practice in climate-friendly chains

Low Carbon Timber® - European best practice in climate-friendly chains The current reports of the IPCC on climate change are alarming and show that the development is not only far worse than feared but also that the efforts of the global community and the European Union must be drastically intensified to avert an existential threat to the environment, the economy, and the people. A considerable yet untapped reduction potential lies in a reduction of transport in the supply chains. With 22%, transport is the second highest cause of European greenhouse gas emissions, ahead of the "buildings" and "agriculture" sectors. Against this background, the avoidance of unnecessary transport is an essential instrument for reducing emissions in the transport sector. The transnational initiative and environmental label HOLZ VON HIER®, or LOW CARBON TIMBER® in non-German-speaking countries, represents a European best practice example that can be used directly by municipalities, companies, planners, and customers to make an immediate contribution to climate protection.

A Design Thinking Approach: Applying 5S Methodology Effectively in an Industrial Work Environment

Lean thinking, tools and methods can improve and change companies’ internal processes, cultural norms, and shared values to achieve a stronger state of operational excellence and bring companies greater competitive advantage. 5S is a Lean tool that aims for a well-organized and safe working environment, increased quality, and productivity optimization by organizing the manufacturing processes to be waste-free by maintaining and organizing the workplace using the 5S concept. Even tough 5S concept and its implementation processes are often well documented, the actual translation work of the 5S concept into functional and successful solutions in a production environment that has pre-existing value systems and processes is still lacking more profound and nuanced investigation. Additionally, engineers responsible for the 5S implementation process have a need for precise tools and methods to understand the user experience and ensure customer-centricity in their decision-making. To understand more profoundly the connection between the 5S concept and user centricity, this article applies Design Thinking method and tools to a 5S implementation process. The goal of combining these two methods is to investigate what is a functional and user-friendly way to eliminate non-value adding activities and improve safety, functionality, and productivity in a production cell using 5S methodology. The results of this research show that the floor surface area that is required to store hoisting motor buffer has decreased by 80%. Also, the waste in form of unnecessary transport in that buffer area has decreased to a fifth when compared to the original situation. The results of this research show that the Design Thinking method and its tools not only fit, but also foster 5S implementation processes.

The paramedic-general practitioner relationship: a scoping review.

Health services internationally are implementing programs that increase working ties between paramedics and general practitioners (GPs) to reduce unnecessary transport to emergency departments (EDs) and improve access to primary health care. As paramedic involvement in primary health care develops, there is increasing focus on the GP-paramedic collaborative relationship. Resulting issues regarding professional boundaries may occur, as paramedics practice in fields that were previously solely in the GP scope. An effective paramedic-GP working relationship will be an essential foundation to the success of future strategies. A search of three electronic databases was completed (Ovid MEDLINE, Embase Classic+Embase and CINAHL Plus). Eligibility for inclusion required analysis of the relationship between paramedics and GPs. All processes were completed by two independent reviewers. After removal of duplicates, 4995 titles were screened by title and/or abstract. After full-text review, 15 studies were included. Five themes were identified that contribute significantly to the strengths and weaknesses of the relationship - the importance of communication, understanding scope of practice, leadership roles, responsibility for patient care and interdisciplinary training. Issues identified included significant variation in the structure of different emergency medical services and varying standards of education requirements for paramedics worldwide. There were no published Australian studies that had the primary aim of examining the paramedic-GP relationship. The depth of research on this topic is lacking, despite increased interest over the past decade. The relevance of the international literature to the Australian setting is questionable.

Age Friendly Emergency Medicine Services: Integrating What Matters, Medications, Mobility, and Mentation into Emergency Response.

Our population is aging. The Age Friendly Health System (AFHS) initiative by the Institute of Healthcare Improvement (IHI) includes the 4 M's of What Matters, Medications, Mobility, and Mentation, and is at the forefront of older adult health care. When applying the 4M's to emergency medical services (EMS), the benefits include avoiding unnecessary transports and helping the patient stay healthy and safe in their home setting. The University of North Texas Health Science Center and other partnerships aspired to designate MedStar the first AFHS in the country within EMS practice. The Plan-Do-Study-Act (PDSA) cycle aimed at various changes with the AFHS components of What Matters and Medications within an electronic medical record (EMR) algorithm for emergency medical paramedics. Additionally, previously piloted geriatric practice leadership institute projects embedded Mentation and Mobility by including specific screenings in the EMR. The preliminary result in the PDSA described showed 52% of older adults answered health when asked What Matters most to them today. However, updated data as of January 2022, showed an overwhelming 6732 (69%) patients out of 9685 patients, answered health when asked What Matters most to them today. Additionally, the EMR identifies high-risk medications. Paramedics can now verify potential risks and develop a care plan based on the identified high-risk medications. Implementing AFHS components allows for better care delivery and outcomes as our older population is growing and embraces more complexities. The data is still novel but promising, requiring longitudinal information before conclusions can be considered. IHI is currently reviewing opportunities to expand its models of care into emergency medicine, behavioral health, and other settings. MedStar sets the example that EMS can practice the AHFS approach serving as a model for the EMS environment. We are currently awaiting feedback from IHI regarding our request to designate MedStar the first AFHS EMS practice in the country.

Abstract 206: Easily Created Prediction Model Using Deep Learning For Termination Of Resuscitation (tor) In Out Of Hospital Cardiac Arrest (ohca) Cases: The All-japan Utstein Registry Experience.

Background: Correct identification of futile prehospital resuscitation in out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transports. Reliable prediction variables are needed for 'termination of resuscitation' (TOR) rules in OHCA. However, making such prediction models requires a large number of samples and time-consuming statistical analysis. Deep learning (DL), a form of artificial intelligence (AI), is attractive for building such prediction models. We made a TOR prediction model using a DL software, Prediction One (Sony Network Communications Inc., Tokyo, Japan). The purpose of this study was to evaluate the efficacy of this predictive model using general purpose AI compared to the Universal TOR rule for out - of hospital cardiac arrest. Methods: A retrospective, population-based review of OHCA victims without prehospital ROSC from January 1, 2010 to December 31, 2017 in the All-Japan Utstein Registry. We divided half (2010-2014) as a training dataset and half (2015-2017) as an external validation dataset. Prediction one made the prediction model using the training dataset with internal cross-validation. We used both the created model and the Universal TOR rule to predict outcomes using the external validation set. Results: 989,929 OHCA cases, 18 years of age or older, were registered in the All-Japan Utstein Registry and 575,346 cases were of presumed cardiac origin. Of these, 354,356 cases were used as the training dataset and 220,990 cases were used as the external validation dataset. The model made by Prediction One using 11 variables had AUC of 0.969 and F value of 0.969, and its AUC for the validation cohort was 0.964 (95%CI 0.963-0.966) with 99.3% accuracy. The model made by Prediction One using three variables of universal TOR rule had AUC of 0.948 and F value 0.967, and its AUC for the validation cohort was 0.939 (95%CI 0.936-0.942) with 99.1% accuracy. Conclusions: The accuracy of prediction models using Prediction One was good. More research into the utility of using AI for TOR prediction is required.

Carbonylative Ring Expansion of Epoxides to β‐Lactones Using Inorganic Salt as Catalytic Species Precursor

AbstractTransition‐metal‐catalyzed carbonylative transformation is a well‐established and indispensable tool in organic chemistry, partially due to that CO is a cheap and readily available C1‐building block. The β‐lactone products via carbonylative ring expansion of epoxide are particularly attractive, because they feature broad utility in organic and polymer chemistry. One of the major challenges for this promising reaction is the usage of toxic, moderately air sensitive, unstable and pyrophoric low‐valent cobalt catalysts. Inorganic salts feature high abundance in nature, and the generation of catalytic species from in situ reduction of divalent cobalt(II) salt has received intense attention, which avoids the unnecessary storage and transport of sensitive low‐valent cobalt compounds. Herein, we have employed this strategy for the selectively carbonylative ring expansion of epoxides under an extremely mild condition, e. g. 40 °C and 1 atm CO pressure. This method eliminates the usage of extremely sensitive cobalt carbonyl catalyst. In addition, this reaction is tolerant to a variety of epoxides, and up to 15 examples of β‐lactones with excellent functionality have been isolated in moderate to excellent yields and selectivity.

Telemedicine in pediatric cardiology: pros and cons.

The aim of this article is to review recent uses of telemedicine in pediatric cardiology, highlighting merits, challenges, and future directions. The COVID-19 pandemic accelerated telemedicine use, which has had a positive impact with respect to providers, patients, and their caregivers. Recent data have demonstrated the feasibility and effectiveness of telemedicine through expediting needed care and reducing healthcare utilization, including unnecessary emergency department visits, transports, and hospitalizations. With increasing complexity of cardiac care, telecardiology allows for establishing a medical home, improving access, and continuity of care. Great potential also exists for telecardiology to permit more consistent preventive care, possibly resulting in improved health equity, reduced morbidity and mortality, and associated costs. Challenges to optimal implementation of telecardiology, which are all surmountable, include the currently unaccounted additional workload and administrative burden, licensing restrictions, disparities in access to care, insurance reimbursement, and potential fraud and abuse. Telecardiology allows for efficient, quality, effective, collaborative care and is foundational to creating innovative, high-value care models. Through integration with accelerating technology and in-person visits, a sustainable hybrid model of optimal care can be achieved. Addressing barriers to progress in telecardiology is critical.

Utilization and Effect of Direct Medical Oversight during Out-of-Hospital Cardiac Arrest

Study Objective Direct medical oversight (DMO), where emergency medical services (EMS) clinicians contact a physician for real-time medical direction, is used by many EMS systems across the United States. Our objective was to characterize the recommendations made by DMO during out-of-hospital cardiac arrests (OHCA) and to determine their effect on EMS transport decisions and patient outcomes. Methods This is a secondary analysis of DMO call recordings from OHCA cases in the Portland, Oregon metropolitan area from January 1, 2018 to February 28, 2021. Data extracted from the audio recordings were linked to OHCA cases in the Portland Cardiac Arrest Epidemiologic Registry (PDX Epistry). The primary outcomes are recommendations made by DMO: transport, continued field resuscitation, or termination of resuscitation (TOR). Secondary outcomes include EMS transport decisions, survival to hospital admission, and survival to hospital discharge. We used descriptive statistics, unpaired t-tests, and chi-square tests as appropriate for data analysis. Results There were 239 OHCA cases for which DMO was contacted by EMS. The median time from EMS arrival to DMO contact was 25.6 min, and EMS requested TOR for 72.0% of patients. Compared to patients where EMS requested further treatment advice, patients for whom EMS requested TOR had poor prognostic signs including older age, asystole as an initial rhythm, and lower rates of transient return of spontaneous circulation prior to DMO call compared with cases where EMS did not request TOR. DMO recommended transport, continued field resuscitation, or TOR in 21.8%, 18.0%, and 60.2% of patients, respectively. Of the 239 patients, 59 (24.7%) were ultimately transported by EMS to the hospital, 14 (5.9%) survived to admission, and only 1 patient (0.4%) survived to hospital discharge and had an acceptable neurologic outcome (Cerebral Performance Category score of 2). Conclusions Patients for whom EMS contacts DMO for further treatment advice or requesting field TOR after prolonged OHCA resuscitation have poor outcomes, even when DMO recommends transport or further resuscitation, and may represent opportunities to reduce unnecessary DMO contact or patient transports. More research is needed to determine which OHCA patients benefit from DMO contact.

Forecasting worldwide empty container availability with machine learning techniques

Due to imbalances in the global transport of containerised goods, liner shipping companies go to great lengths to match the regional supply and demand for empty containers by transporting equipment from surplus to deficit regions. Making accurate forecasts of regional empty container availability could support liner companies and other involved actors by making better relocation decisions, thus avoiding unnecessary transport costs of empty equipment. Previously proposed container availability prediction models are limited to the application in individual regions and typically characterized by a high degree of temporal aggregation. Against this background, this paper introduces two novel approaches based on machine learning and probabilistic techniques to predict the future weekly availability of empty containers for more than 280 locations worldwide. The machine learning and probabilistic prediction models are built by analysing a unique data set of more than 100 million events from past container journeys. These events represent different stages during the transport process of a container. Both models use a two-step forecast logic. First, the expected future location of a container is predicted. Second, the expected timestamp for arriving at that location is estimated. The machine learning model uses artificial neural networks and mixture density networks to forecast the movements of containers. The models are quantitatively assessed and compared to the actual availability of containers and two more conventional forecasting approaches. The results indicate that the probabilistic prediction approach can keep up with conventional approaches while the neural network approach significantly outperforms the other approaches concerning every evaluation metric.

Prehospital Release of Patients After Treatment in an Anesthesiologist-Staffed Mobile Emergency Care Unit

Prehospital treatment and release of patients may reduce unnecessary transports to the hospital and may improve patient satisfaction. However, the safety of patients should be paramount. To determine the extent of unplanned emergency department (ED) contacts, short-term mortality, and diagnostic patterns in patients treated and released by a prehospital anesthesiologist supervising a mobile emergency care unit (MECU). This retrospective cohort study used a manual review of prehospital and in-hospital medical records to investigate all living patients who were treated and released by an MECU in Odense, Denmark, between January 1, 2011, and December 31, 2020. Patients were followed up for 30 days after initial contact with the prehospital service. Primary outcome measures included unplanned contacts with the emergency department less than 48 hours after prehospital treatment and prehospital assigned diagnosis. Secondary outcomes consisted of mortality at 48 hours and 7 and 30 days. A total of 3141 patients were identified; 384 were excluded and 2757 were included in the analysis. The median patient age was 40 (IQR, 14-66) years; 1296 (47.0%) were female and 1461 (53.0%) were male. Two hundred thirty-nine patients (8.7% [95% CI, 7.6%-9.8%]) had unplanned contact with the ED within 48 hours; this rate was doubled for patients with respiratory diseases (37 of 248 [14.9% (95% CI, 10.7%-20.0%)]). Fifty-nine of 60 patients who died within 48 hours of release had terminal illness. Excluding these patients, the mortality rates were 0.04% at 48 hours, 0.8% at 7 days, and 2.4% at 30 days. Two thousand sixty-one patients (74.8%) had primarily nondefinitive observational diagnoses. The findings of this cohort study suggest that prehospital treatment and subsequent release at the scene is safe. One patient in 12 attended the ED within the ensuing 48 hours. However, for patients with respiratory diseases, this rate was doubled. Hospital admission could be avoided for some patients in the end stage of a terminal illness.

Redirecting emergency medical services patients with unmet primary care needs: the perspective of paramedics on feasibility and acceptance of an alternative care path in a qualitative investigation from Berlin, Germany

BackgroundAgainst the backdrop of emergency department (ED) overcrowding, patients’ potential redirection to outpatient care structures is a subject of current political debate in Germany. It was suggested in this context that suitable lower-urgency cases could be transported directly to primary care practices by emergency medical services (EMS), thus bypassing the ED. However, practicality is discussed controversially. This qualitative study aimed to capture the perspective of EMS personnel on potential patient redirection concepts.MethodsWe conducted qualitative, semi-structured phone interviews with 24 paramedics. Interviews were concluded after attainment of thematic saturation. Interviews were transcribed verbatim, and qualitative content analysis was performed.ResultsTechnical and organizational feasibility of patients’ redirection was predominantly seen as limited (theme: “feasible, but only under certain conditions”) or even impossible (theme: “actually not feasible”), based on a wide spectrum of potential barriers. Prominently voiced reasons were restrictions in personnel resources in both EMS and ambulatory care, as well as concerns for patient safety ascribed to a restricted diagnostic scope. Concerning logistics, alternative transport options were assessed as preferable. Regarding acceptance by stakeholders, the potential for releasing ED caseload was described as a factor potentially promoting adoption, while doubt was raised regarding acceptance by EMS personnel, as their workload was expected to conversely increase. Paramedics predominantly did not consider transporting lower-urgency cases as their responsibility, or even as necessary. Participants were markedly concerned of EMS being misused for taxi services in this context and worried about negative impact for critically ill patients, as to vehicles and personnel being potentially tied up in unnecessary transports. As to acceptance on the patients’ side, interview participants surmised a potential openness to redirection if this would be associated with benefits like shorter wait times and accompanied by proper explanation.ConclusionsInterviews with EMS staff highlighted considerable doubts about the general possibility of a direct redirection to primary care as to considerable logistic challenges in a situation of strained EMS resources, as well as patient safety concerns. Plans for redirection schemes should consider paramedics’ perspective and ensure a provision of EMS with the resources required to function in a changing care environment.