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Intubation of patients suspected of having coronavirus disease 2019 (COVID-19) is considered to be a high-risk procedure due to the aerosolization of viral particles. In an effort to minimize the risk of exposure and optimize patient care, we sought to develop, test, provide training, and implement a standardized algorithm for intubating these high-risk patients at our institution. We developed an initial intubation algorithm, incorporating strategic use of equipment and incorporating emerging best practices. By combining simulation-based training sessions and rapid-cycle improvement methodology with physicians, nurses, and respiratory therapists, and incorporating their feedback into the development, we were able to optimize the process prior to implementation. Training sessions also enabled the participants to practice the algorithm as a team. Upon completion of each training session, participants were invited to complete a brief online survey about their overall experience. An algorithm and training system vetted by simulation and actual practice were developed. A training video and dissemination package were made available for other emergency departments to adopt. Survey results were overall positive, with 97.92% of participants feeling confident in their role in the intubation process, and many participants citing the usefulness of the multidisciplinary approach to the training. A multidisciplinary, team-based approach to the development and training of a standardized intubation algorithm combining simulation and rapid-cycle improvement methodology is a useful, effective process to respond to rapidly evolving clinical information and experiences during a global pandemic.

On Saturday, October 27, 2018, a man with anti-Semitic motivations entered Tree of Life synagogue in the Squirrel Hill section of Pittsburgh, Pennsylvania; he had an AR-15 semi-automatic rifle and three handguns, opening fire upon worshippers. Eventually 11 civilians died at the scene and eight people sustained non-fatal injuries, including five police officers. Each person injured but alive at the scene received care at one of three local level-one trauma centers. The injured had wounds often seen in war-settings, with the signature of high velocity weaponry. We describe the scene response, specific elements of our hospital plans, the overall out-of-hospital preparedness in Pittsburgh, and the lessons learned.

This study describes 11,920 in-flight medical emergencies on the basis of consultations from five major airlines to a physician-directed communications center. In nearly half the emergencies, physicians on board provided assistance, and in 7.3%, the aircraft was diverted. Commercial airlines serve approximately 2.75 billion passengers worldwide annually. When in-flight medical emergencies occur, access to care is limited. Physicians and other medical professionals are often called on to assist when traveling, despite limited training or experience with these situations. 1 Airlines partner with health care institutions to deliver real-time medical advice from an emergency call center to airline personnel, in an effort to improve the quality of care provided to passengers. There is limited information on the incidence and characteristics of in-flight medical emergencies. 2 Although previous studies of these events have characterized the incidence, categories of symptoms, rates of aircraft . . .

Background Distal medium vessel occlusions (DMVOs) contribute substantially to the incidence of acute ischemic strokes (AIS) and pose distinct challenges in clinical management and prognosis. Neuroimaging techniques, such as Fluid Attenuation Inversion Recovery (FLAIR) imaging and cerebral blood volume (CBV) index derived from perfusion imaging, have significantly improved our ability to assess the impact of strokes and predict their outcomes. The primary objective of this study was to investigate relationship between follow-up infarct volume (FIV) as assessed by FLAIR imaging in patients with DMVOs. Methods This prospectively collected, retrospective reviewed cohort study included patients from two comprehensive stroke centers within the Johns Hopkins Medical Enterprise, spanning August 2018–October 2022. The cohort consisted of adults with AIS attributable to DMVO. Detailed imaging analyses were conducted, encompassing non-contrast CT, CT angiography (CTA), CT perfusion (CTP), and FLAIR imaging. Univariable and multivariable linear regression models were employed to assess the association between different factors and FIV. Results The study included 79 patients with DMVO stroke with a median age of 69 years (IQR, 62–77 years), and 57% ( n  = 45) were female. There was a negative correlation between the CBV index and FIV in a univariable linear regression analysis (Beta =  – 16; 95% CI,  – 23 to  – 8.3; p  < 0.001) and a multivariable linear regression model (Beta =  – 9.1 per 0.1 change; 95% CI,  – 15 to  – 2.7; p  = 0.006). Diabetes was independently associated with larger FIV (Beta = 46; 95% CI, 16 to 75; p  = 0.003). Additionally, a higher baseline ASPECTS was associated with lower FIV (Beta =  – 30; 95% CI,  – 41 to  – 20; p  < 0.001). Conclusion Our findings underscore the CBV index as an independent association with FIV in DMVOs, which highlights the critical role of collateral circulation in determining stroke outcomes in this patient population. In addition, our study confirms a negative association of ASPECTS with FLAIR FIV and identifies diabetes as independent factor associated with larger FIV. These insights pave the way for further large-scale, prospective studies to corroborate these findings, thereby refining the strategies for stroke prognostication and management.

Background and purpose Acute ischemic stroke due to anterior circulation large‐vessel occlusion (AIS‐LVO) remains a leading cause of disability despite successful reperfusion therapies. Prolonged venous transit (PVT) has emerged as a potential prognostic imaging biomarker in AIS‐LVO. We aimed to investigate whether PVT is associated with a decreased likelihood of excellent functional outcome (modified Rankin Scale [mRS] score of 0–1 at 90 days) after successful reperfusion. Methods In our prospectively collected, retrospectively reviewed database, we analyzed data from 104 patients with AIS‐LVO who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b/2c/3) between September 2017 and September 2022. PVT was defined as a time to maximum (Tmax) of ≥10 s in the superior sagittal sinus and/or torcula on computed tomography perfusion (CTP) imaging. Patients were categorized into PVT‐positive (PVT+) and PVT‐negative (PVT–) groups. The primary outcome was excellent functional recovery at 90 days. Results Of the 104 patients, 30 (29%) were PVT+. Excellent functional outcome was achieved in 38 patients (37%). PVT+ patients had a significantly lower rate of excellent recovery compared to PVT– patients (11% vs. 39%; p < 0.001). After adjusting for possible confounders, PVT positivity was independently associated with lower odds of excellent recovery (adjusted odds ratio 0.11, 95% confidence interval 0.02 to 0.48; p = 0.006). Conclusions Among patients with AIS‐LVO who achieved successful reperfusion, PVT positivity was independently associated with a decreased likelihood of excellent functional outcome at 90 days. Assessment of PVT on CTP may provide valuable prognostic information and aid in clinical decision making for patients with AIS‐LVO.

Objective Venous outflow (VO) impairment predicts unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS‐LVO). Prolonged venous transit (PVT), a visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps, has been associated with unfavorable 90‐day functional outcomes despite successful reperfusion. This study investigates the association between PVT and percent change on the National Institutes of Health Stroke Scale (NIHSS) among AIS‐LVO patients who have undergone successful reperfusion. Methods We performed a retrospective analysis of prospectively collected data from consecutive adult AIS‐LVO patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s in the superior sagittal sinus, torcula, or both. The primary outcome was continuous NIHSS percent change and dichotomous NIHSS percent change ≥70%. Regression analyses were performed to assess the effect of PVT on NIHSS percent change. Results In 119 patients of median (IQR) age 71 (63–81) years, the admission and discharge NIHSS scores were significantly higher in PVT+ patients compared to PVT− patients (17 [14–23.5] vs. 13 [9.5–19], p = 0.011, and 7.5 [4–12] vs. 3 [1–7], p < 0.001, respectively). After adjusting for age, sex, hypertension, diabetes, atrial fibrillation, administration of intravenous thrombolysis (IVT), Alberta Stroke Program Early CT Scores (ASPECTS), mTICI 2c and/or 3, Tmax >6 s volume, and hemorrhagic transformation, PVT+ was significantly associated with lower NIHSS percent change (B = −0.163, 95%CI −0.326 to −0.001, p = 0.049) and was less likely to achieve higher than 70% NIHSS improvement (OR = 0.331, 95% CI 0.127–0.863, p = 0.024). Interpretation PVT+ was significantly associated with reduced neurological improvement despite successful reperfusion in AIS‐LVO patients, highlighting the critical role of VO impairment in short‐term functional outcomes. These findings further validate PVT as a valuable adjunct imaging biomarker derived from CTP for assessing VO profiles in AIS‐LVO.

Diverse microbial ecosystems underpin life in the sea. Among these microbes are many unicellular eukaryotes that span the diversity of the eukaryotic tree of life. However, genetic tractability has been limited to a few species, which do not represent eukaryotic diversity or environmentally relevant taxa. Here, we report on the development of genetic tools in a range of protists primarily from marine environments. We present evidence for foreign DNA delivery and expression in 13 species never before transformed and for advancement of tools for eight other species, as well as potential reasons for why transformation of yet another 17 species tested was not achieved. Our resource in genetic manipulation will provide insights into the ancestral eukaryotic lifeforms, general eukaryote cell biology, protein diversification and the evolution of cellular pathways. This Resource describes genetic tools for microbial eukaryotes, providing a roadmap for developing genetically tractable organisms.

Logged and disturbed forests are often viewed as degraded and depauperate environments compared with primary forest. However, they are dynamic ecosystems 1 that provide refugia for large amounts of biodiversity 2 , 3 , so we cannot afford to underestimate their conservation value 4 . Here we present empirically defined thresholds for categorizing the conservation value of logged forests, using one of the most comprehensive assessments of taxon responses to habitat degradation in any tropical forest environment. We analysed the impact of logging intensity on the individual occurrence patterns of 1,681 taxa belonging to 86 taxonomic orders and 126 functional groups in Sabah, Malaysia. Our results demonstrate the existence of two conservation-relevant thresholds. First, lightly logged forests (<29% biomass removal) retain high conservation value and a largely intact functional composition, and are therefore likely to recover their pre-logging values if allowed to undergo natural regeneration. Second, the most extreme impacts occur in heavily degraded forests with more than two-thirds (>68%) of their biomass removed, and these are likely to require more expensive measures to recover their biodiversity value. Overall, our data confirm that primary forests are irreplaceable 5 , but they also reinforce the message that logged forests retain considerable conservation value that should not be overlooked. An analysis of the impact of logging intensity on biodiversity in tropical forests in Sabah, Malaysia, identifies a threshold of tree biomass removal below which logged forests still have conservation value.

BackgroundChildren vaccination is a key intervention for their survival, especially among refugees. Yet, children vaccination registration is done manually in refugees camps and there is no possibility to send reminders to parents to come back on time. We aimed to boost the parental registration of children’s vaccination records on a Children Immunization app (CIMA) while also availing the parents with useful parenting skills under COVID-19-related stress.MethodsWe incorporated United Nations Office on Drugs and Crime (UNODC) Parenting Skills under COVID-19 information material, through CIMA in Arabic and English languages. We recruited 1100 children in February–March 2021, through a community health promotion dissemination approach. A team of two nurses from the local population and two volunteers (one trained nurse and one trained social worker), from the camp, was formed. They promoted the CIMA app at two clinics and through households visits in Zaatari refugee camp. Qualitative data on impressions and observations of the interactions with the Zaatari camp community were also collected.ResultsA total of 1100 children, up to 15 months of age, eligible for vaccination were enrolled in CIMA, whereby the staff explained the content of the app in terms of vaccination schedule, health promotion materials for vaccination and parenting skills to their caregivers. During the household visits, the volunteers identified a total of 70 children that have incomplete history of vaccination records (n = 42/70 girls, 60%). Also, opportunities and challenges for scaling the app were documented.ConclusionThe scaling of CIMA as an innovative means of dissemination of risk and health information in challenging context such as refugee camps was feasible. In the context of vaccination needs for children, in refugee settings, such a need is more eminent, particularly in the context of COVID-19.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.An amendment to this paper has been published and can be accessed via a link at the top of the paper.