Variation in pediatric traumatic brain injury outcomes in the United States.

OBJECTIVE: To ascertain the degree of variation, by state of hospitalization, in outcomes associated with traumatic brain injury (TBI) in a pediatric population. DESIGN: A retrospective cohort study of pediatric patients admitted to a hospital with a TBI. SETTING: Hospitals from states in the United States that voluntarily participate in the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. PARTICIPANTS: Pediatric (age ≤ 19 y) patients hospitalized for TBI (N=71,476) in the United States during 2001, 2004, 2007, and 2010. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Primary outcome was proportion of patients discharged to rehabilitation after an acute care hospitalization among alive discharges. The secondary outcome was inpatient mortality. RESULTS: The relative risk of discharge to inpatient rehabilitation varied by as much as 3-fold among the states, and the relative risk of inpatient mortality varied by as much as nearly 2-fold. In the United States, approximately 1981 patients could be discharged to inpatient rehabilitation care if the observed variation in outcomes was eliminated. CONCLUSIONS: There was significant variation between states in both rehabilitation discharge and inpatient mortality after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the cause of this state-to-state variation, its relationship to patient outcome, and standardizing treatment across the United States.

Incontinence and gait disturbance after intraventricular extension of intracerebral hemorrhage.

OBJECTIVE: We tested the hypothesis that intraventricular hemorrhage (IVH) is associated with incontinence and gait disturbance among survivors of intracerebral hemorrhage (ICH) at 3-month follow-ups. METHODS: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke study was used as the discovery set. The Ethnic/Racial Variations of Intracerebral Hemorrhage study served as a replication set. Both studies performed prospective hot-pursuit recruitment of ICH cases with 3-month follow-up. Multivariable logistic regression analyses were computed to identify risk factors for incontinence and gait dysmobility at 3 months after ICH. RESULTS: The study population consisted of 307 ICH cases in the discovery set and 1,374 cases in the replication set. In the discovery set, we found that increasing IVH volume was associated with incontinence (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.10-2.06) and dysmobility (OR 1.58; 95% CI 1.17-2.15) after controlling for ICH location, initial ICH volume, age, baseline modified Rankin Scale score, sex, and admission Glasgow Coma Scale score. In the replication set, increasing IVH volume was also associated with both incontinence (OR 1.42; 95% CI 1.27-1.60) and dysmobility (OR 1.40; 95% CI 1.24-1.57) after controlling for the same variables. CONCLUSION: ICH subjects with IVH extension are at an increased risk for developing incontinence and dysmobility after controlling for factors associated with severity and disability. This finding suggests a potential target to prevent or treat long-term disability after ICH with IVH.

Super-villains of the "real world": the political use of the characterization of villains in Chistopher Nolan's "Dark Knight Trilogy"

It is almost a tradition that celluloid (or digital) villains are represented with some characteristics that remind us the real political enemies of the producer country of the film, or even enemies within the country according to the particular ideology that sustains the film. The case of Christopher Nolan The Dark Knight trilogy, analyzed here, is representative of this trend for two reasons. First, because it gets marked by political radicalization conducted by the US government after the attack of September 11, 2001. Secondly, because it offers a profuse gallery of villains who are outside the circle of friends as the new doctrine “either with us or against us” opened by George Bush for the XXI century. This gallery includes from the very terrorists who justify the War on Terror (Ra's al Ghul, the Joker), to the “radical left” (Bane, Talia al Ghul) including liberal politicians (Harvey Dent), and corrupt that take advantage of the softness of the law to commit crimes with impunity (Dr. Crane, the Scarecrow).

CCD photometry of distant comets II

R band CCD photometric observations of short period Jupiter family comets in the heliocentric region of 2.11 AU less than or equal to R-h less than or equal to 5.63 AU were performed using the 4.2 m William Herschel Telescope on La Palma in December 1998. 22 comets were targeted, including the comet- asteroid transition object 49P/Arend-Rigaux. Out of a total of ten detected comets. six were seen to display substantial outgassing (48P, 65P, 74P, 103Pt 128P, and 139P), with the remaining four comets (7P. 9P, 22P. and 49P) being stellar in appearance. Nuclear radius measurements and relative dust production rates in terms of Af rho were measured for these comets, along with upper limits for the remaining twelve undetected comets (6P, 44P, 51P, 54P, 57P: 63P, 71P, 73P, 79P, 86P, 87P, and 100P). The inactive comets had nuclear radii in the range 1.8 km less than or equal to r(N) less than or equal to 4.4 km, while upper limits for the active and undetected comets (assuming they all lay within the held of view) were between 0.6 km and 12.7 km, for an assumed albedo of 0.04. Even if one applies the previously measured maximum axis ratio of 2.6:1 and the minimum measured albedo of 0.02 to the undetected comets. their projected semi-major axes are all constrained to below 8 km. For the active comets, photometric profiles of their dust comae were measured and are consistent with those of steady state coma models.

Charge exchange emission from solar wind helium ions

Charge exchange X-ray and far-ultraviolet (FUV) aurorae can provide detailed insight into the interaction between solar system plasmas. Using the two complementary experimental techniques of photon emission spectroscopy and translation energy spectroscopy, we have studied state-selective charge exchange in collisions between fully ionized helium and target gasses characteristic of cometary and planetary atmospheres (H2O, CO2, CO, and CH4). The experiments were performed at velocities typical for the solar wind (200-1500 km s(-1)). Data sets are produced that can be used for modeling the interaction of solar wind alpha particles with cometary and planetary atmospheres. These data sets are used to demonstrate the diagnostic potential of helium line emission. Existing Extreme Ultraviolet Explorer (EUVE) observations of comets Hyakutake and Hale-Bopp are analyzed in terms of solar wind and coma characteristics. The case of Hale-Bopp illustrates well the dependence of the helium line emission to the collision velocity. For Hale-Bopp, our model requires low velocities in the interaction zone. We interpret this as the effect of severe post-bow shock cooling in this extraordinary large comet.

Cyclin G associated kinase interacts with interleukin 12 receptor beta2 and suppresses interleukin 12 induced IFN-gamma production.

BACKGROUND: Although severe encephalopathy has been proposed as a possible contraindication to the use of noninvasive positive-pressure ventilation (NPPV), increasing clinical reports showed it was effective in patients with impaired consciousness and even coma secondary to acute respiratory failure, especially hypercapnic acute respiratory failure (HARF). To further evaluate the effectiveness and safety of NPPV for severe hypercapnic encephalopathy, a prospective case-control study was conducted at a university respiratory intensive care unit (RICU) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) during the past 3 years. METHODS: Forty-three of 68 consecutive AECOPD patients requiring ventilatory support for HARF were divided into 2 groups, which were carefully matched for age, sex, COPD course, tobacco use and previous hospitalization history, according to the severity of encephalopathy, 22 patients with Glasgow coma scale (GCS) <10 served as group A and 21 with GCS = 10 as group B. RESULTS: Compared with group B, group A had a higher level of baseline arterial partial CO2 pressure ((102 +/- 27) mmHg vs (74 +/- 17) mmHg, P <0.01), lower levels of GCS (7.5 +/- 1.9 vs 12.2 +/- 1.8, P <0.01), arterial pH value (7.18 +/- 0.06 vs 7.28 +/- 0.07, P <0.01) and partial O(2) pressure/fraction of inspired O(2) ratio (168 +/- 39 vs 189 +/- 33, P <0.05). The NPPV success rate and hospital mortality were 73% (16/22) and 14% (3/22) respectively in group A, which were comparable to those in group B (68% (15/21) and 14% (3/21) respectively, all P > 0.05), but group A needed an average of 7 cm H2O higher of maximal pressure support during NPPV, and 4, 4 and 7 days longer of NPPV time, RICU stay and hospital stay respectively than group B (P <0.05 or P <0.01). NPPV therapy failed in 12 patients (6 in each group) because of excessive airway secretions (7 patients), hemodynamic instability (2), worsening of dyspnea and deterioration of gas exchange (2), and gastric content aspiration (1). CONCLUSIONS: Selected patients with severe hypercapnic encephalopathy secondary to HARF can be treated as effectively and safely with NPPV as awake patients with HARF due to AECOPD; a trial of NPPV should be instituted to reduce the need of endotracheal intubation in patients with severe hypercapnic encephalopathy who are otherwise good candidates for NPPV due to AECOPD.

William Herschel Telescope observations of distant comets

We present results from broad-band V- and R-filter observations obtained at the 4.2-m William Herschel Telescope on La Palma on 2002 July 12-14. A total of six comets were imaged, and their heliocentric distances ranged from 2.8 to 6.1 au. The comets observed were 43P/Wolf-Harrington, 129P/Shoemaker-Levy 3, 133P/Elst-Pizarro, 143P/Kowal-Mrkos, P/1998 U4 (Spahr) and P/2001 H5 (NEAT). A detailed surface brightness profile analysis indicates that three of the targeted comets (43P/Wolf-Harrington, 129P/Shoemaker-Levy 3 and P/1998 U4) were visibly active, and the remaining three comets were stellar in appearance. Further analysis shows that for the three `stellar-like' comets the possible coma contribution to the observed flux does not exceed 12.2 per cent, and in the case of comet 143P/Kowal-Mrkos the coma contribution is expected to be as low as 1 per cent, and so the resulting photometry most likely represents that of the projected nucleus surface. Effective radii for the inactive comets range from 1.02 to 4.56 km, and the effective radius upper limits for the active comets range from 1.94 to 4.15 km. We assume an albedo and phase coefficient of 0.04 and 0.035 mag deg-1, respectively, with the exception of comets 133P/Elst-Pizarro and 143P/Kowal-Mrkos for which phase coefficients were previously measured. These values are compared with previous measurements, and for comet 43P/Wolf-Harrington we find that the nucleus axial ratio a/b could be as large as 2.44. For the active comets we measured dust production levels in terms of the Af? quantity. Spectral gradients were extracted for two of the inactive comets from their measured broad-band colour indices, and compared with the rest of the comet population for which (V-R) colour and spectral gradient values exist. We find a spectral gradient for 143P/Kowal-Mrkos of 9.9 +/- 8.1 per cent/100 nm, which is very typical of Jupiter-family comets, the majority of which have reflectivity gradients in the range 0-13 per cent (100 nm)-1. The spectral gradient for comet 133P/Elst-Pizarro is amongst the bluest yet measured. We measure a (V-R) colour index value of 0.14 +/- 0.11 for the nucleus of 133P/Elst-Pizarro which is considerably lower than previous measurements. A possible explanation for this difference is considered.

A randomised, controlled trial of conventional versus automated weaning from mechanical ventilation using SmartcareTM/PS

Objective
Preliminary assessment of an automated weaning system (SmartCare™/PS) compared to usual management of weaning from mechanical ventilation performed in the absence of formal protocols.


Design and setting
A randomised, controlled pilot study in one Australian intensive care unit.


Patients
A total of 102 patients were equally divided between SmartCare/PS and Control.

Interventions
The automated system titrated pressure support, conducted a spontaneous breathing trial and provided notification of success (“separation potential”).

Measurements and results
The median time from the first identified point of suitability for weaning commencement to the state of “separation potential” using SmartCare/PS was 20 h (interquartile range, IQR, 2–40) compared to 8 h (IQR 2–43) with Control (log-rank P = 0.3). The median time to successful extubation was 43 h (IQR 6–169) using SmartCare/PS and 40 (14–87) with Control (log-rank P = 0.6). Unadjusted, the estimated probability of reaching “separation potential” was 21% lower (95% CI, 48% lower to 20% greater) with SmartCare/PS compared to Control. Adjusted for other covariates (age, gender, APACHE II, SOFAmax, neuromuscular blockade, corticosteroids, coma and elevated blood glucose), these estimates were 31% lower (95% CI, 56% lower to 9% greater) with SmartCare/PS. The study groups showed comparable rates of reintubation, non-invasive ventilation post-extubation, tracheostomy, sedation, neuromuscular blockade and use of corticosteroids.

Conclusions
Substantial reductions in weaning duration previously demonstrated were not confirmed when the SmartCare/PS system was compared to weaning managed by experienced critical care specialty nurses, using a 1:1 nurse-to-patient ratio. The effect of SmartCare/PS may be influenced by the local clinical organisational context.

Resting energy expenditure in non-ventilated, non-sedated patients recovering from serious traumatic brain injury: Comparison of prediction equations with indirect calorimetry values

Background & aims: Little is known about energy requirements in brain injured (TBI) patients, despite evidence suggesting adequate nutritional support can improve clinical outcomes. The study aim was to compare predicted energy requirements with measured resting energy expenditure (REE) values, in patients recovering from TBI.

Methods: Indirect calorimetry (IC) was used to measure REE in 45 patients with TBI. Predicted energy requirements were determined using FAO/WHO/UNU and Harris–Benedict (HB) equations. Bland– Altman and regression analysis were used for analysis.

Results: One-hundred and sixty-seven successful measurements were recorded in patients with TBI. At an individual level, both equations predicted REE poorly. The mean of the differences of standardised areas of measured REE and FAO/WHO/UNU was near zero (9 kcal) but the variation in both directions was substantial (range 591 to þ573 kcal). Similarly, the differences of areas of measured REE and HB demonstrated a mean of 1.9 kcal and range 568 to þ571 kcal. Glasgow coma score, patient status, weight and body temperature were signi?cant predictors of measured REE (p < 0.001; R²⁼ 0.47).

Conclusions: Clinical equations are poor predictors of measured REE in patients with TBI. The variability in REE is substantial. Clinicians should be aware of the limitations of prediction equations when estimating energy requirements in TBI patients.

SuperWASP observations of the 2007 outburst of Comet 17P/Holmes

We present wide-field imaging of the 2007 outburst of Comet 17P/Holmes obtained serendipitously by SuperWASP-North on 17 nights over a 42-night period beginning on the night (2007 October 22-23) immediately prior to the outburst. Photometry of 17P's unresolved coma in SuperWASP data taken on the first night of the outburst is consistent with exponential brightening, suggesting that the rapid increase in the scattering cross-section of the coma could be largely due to the progressive fragmentation of ejected material produced on a very short time-scale at the time of the initial outburst, with fragmentation time-scales decreasing from tfrag ~ 2 × 103 to ~1 × 103 s over our observing period. Analysis of the expansion of 17P's coma reveals a velocity gradient suggesting that the outer coma was dominated by material ejected in an instantaneous, explosive manner. We find an expansion velocity at the edge of the dust coma of vexp = 0.55 +/- 0.02 kms -1 and a likely outburst date of t0 = 2007 October 23.3 +/- 0.3, consistent with our finding that the comet remained below SuperWASP's detection limit of mV ~ 15mag until at least 2007 October 23.3. Modelling of 17P's gas coma indicates that its outer edge, which was observed to extend past the outer dust coma, is best explained with a single pulse of gas production, consistent with our conclusions concerning the production of the outer dust coma.

Effect of Bauxol on properties of cement pastes

This paper presents the results of an experimental investigation carried out to evaluate the influence of Bauxsol, an artificially neutralised bauxite refinery residue (NBRR), on various properties of cement pastes. It was found that the NBRR does not have any pozzolanic properties and hence cannot be used as a supplementary cementitious material in concrete. In order to evaluate the effect of adding the product to Portland cement (PC) pastes, fresh properties (i.e. standard consistency and slump), setting time and heat of hydration were measured. In addition, its influence on chemical changes and compressive strength was investigated. It was found that the addition of this NBRR resulted in a decrease in compressive strength beyond 7 days. The setting time decreased with an increase in NBRR content in PC pastes. The rate of heat evolution for NBRR pastes was greater than that of the PC pastes, but a corresponding increase in the quantity of calcium hydroxide was not found. Therefore, it was concluded that unidentified hydration products when Bauxsol was used in PC pastes might have been the reason for the decrease in setting times.

Discovery of Main-Belt Comet P/2006 VW139 by Pan-STARRS 1

The main-belt asteroid (300163) 2006 VW139 (later designated P/2006 VW139) was discovered to exhibit comet-like activity by the Pan-STARRS1 (PS1) survey telescope using automated point-spread-function analyses performed by PS1's Moving Object Processing System. Deep follow-up observations show both a short (~10'') antisolar dust tail and a longer (~60'') dust trail aligned with the object's orbit plane, similar to the morphology observed for another main-belt comet (MBC), P/2010 R2 (La Sagra), and other well-established comets, implying the action of a long-lived, sublimation-driven emission event. Photometry showing the brightness of the near-nucleus coma remaining constant over ~30 days provides further evidence for this object's cometary nature, suggesting it is in fact an MBC, and not a disrupted asteroid. A spectroscopic search for CN emission was unsuccessful, though we find an upper limit CN production rate of Q CN 100 Myr, while a search for a potential asteroid family around the object reveals a cluster of 24 asteroids within a cutoff distance of 68 m s-1. At 70 m s-1, this cluster merges with the Themis family, suggesting that it could be similar to the Beagle family to which another MBC, 133P/Elst-Pizarro, belongs.

Observational and Dynamical Characterization of Main-belt Comet P/2010 R2 (La Sagra)

We present observations of the recently discovered comet-like main-belt object P/2010 R2 (La Sagra) obtained by Pan-STARRS1 and the Faulkes Telescope-North on Haleakala in Hawaii, the University of Hawaii 2.2 m, Gemini-North, and Keck I telescopes on Mauna Kea, the Danish 1.54 m telescope (operated by the MiNDSTEp consortium) at La Silla, and the Isaac Newton Telescope on La Palma. An antisolar dust tail is observed to be present from 2010 August through 2011 February, while a dust trail aligned with the object's orbit plane is also observed from 2010 December through 2011 August. Assuming typical phase darkening behavior, P/La Sagra is seen to increase in brightness by >1 mag between 2010 August and December, suggesting that dust production is ongoing over this period. These results strongly suggest that the observed activity is cometary in nature (i.e., driven by the sublimation of volatile material), and that P/La Sagra is therefore the most recent main-belt comet to be discovered. We find an approximate absolute magnitude for the nucleus of HR = 17.9 ± 0.2 mag, corresponding to a nucleus radius of ~0.7 km, assuming an albedo of p = 0.05. Comparing the observed scattering surface areas of the dust coma to that of the nucleus when P/La Sagra was active, we find dust-to-nucleus area ratios of Ad /AN = 30-60, comparable to those computed for fellow main-belt comets 238P/Read and P/2008 R1 (Garradd), and one to two orders of magnitude larger than for two other main-belt comets (133P/Elst-Pizarro and 176P/LINEAR). Using optical spectroscopy to search for CN emission, we do not detect any conclusive evidence of sublimation products (i.e., gas emission), finding an upper limit CN production rate of Q CN 100 Myr, suggesting that it is likely native to its current location and that its composition is likely representative of other objects in the same region of the main belt, though the relatively close proximity of the 13:6 mean-motion resonance with Jupiter and the (3,-2,-1) three-body mean-motion resonance with Jupiter and Saturn mean that dynamical instability on larger timescales cannot be ruled out.

Search for the Return of Activity in Active Asteroid 176P/LINEAR

We present the results of a search for the reactivation of active asteroid 176P/LINEAR during its 2011 perihelion passage using deep optical observations obtained before, during, and after that perihelion passage. Deep composite images of 176P constructed from data obtained between 2011 June and 2011 December show no visible signs of activity, while photometric measurements of the object during this period also show no significant brightness enhancements similar to that observed for 176P between 2005 November and 2005 December when it was previously observed to be active. An azimuthal search for dust emission likewise reveals no evidence for directed emission (i.e., a tail, as was previously observed for 176P), while a one-dimensional surface brightness profile analysis shows no indication of a spherically symmetric coma at any time in 2011. We conclude that 176P did not in fact exhibit activity in 2011, at least not on the level on which it exhibited activity in 2005, and suggest that this could be due to the devolatization or mantling of the active site responsible for its activity in 2005.

Outgassing Behavior of C/2012 S1 (ISON) from 2011 September to 2013 June

We report photometric observations for comet C/2012 S1 (ISON) obtained during the time period immediately after discovery (r = 6.28 AU) until it moved into solar conjunction in mid-2013 June using the UH2.2 m, and Gemini North 8 m telescopes on Mauna Kea, the Lowell 1.8 m in Flagstaff, the Calar Alto 1.2 m telescope in Spain, the VYSOS-5 telescopes on Mauna Loa Hawaii and data from the CARA network. Additional pre-discovery data from the Pan STARRS1 survey extends the light curve back to 2011 September 30 (r = 9.4 AU). The images showed a similar tail morphology due to small micron sized particles throughout 2013. Observations at submillimeter wavelengths using the James Clerk Maxwell Telescope on 15 nights between 2013 March 9 (r = 4.52 AU) and June 16 (r = 3.35 AU) were used to search for CO and HCN rotation lines. No gas was detected, with upper limits for CO ranging between 3.5-4.5 × 1027 molecules s-1. Combined with published water production rate estimates we have generated ice sublimation models consistent with the photometric light curve. The inbound light curve is likely controlled by sublimation of CO2. At these distances water is not a strong contributor to the outgassing. We also infer that there was a long slow outburst of activity beginning in late 2011 peaking in mid-2013 January (r ~ 5 AU) at which point the activity decreased again through 2013 June. We suggest that this outburst was driven by CO injecting large water ice grains into the coma. Observations as the comet came out of solar conjunction seem to confirm our models.