UPMC Altoona

BACKGROUND: After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting. METHODS: To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days. RESULTS: A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, -9.8 percentage points; 95% confidence interval, -18.6 to -1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan-Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients' arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury-acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions. CONCLUSIONS: In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427 .).

Journal Article Consilience: the Unity of Knowledge Get access Consilience: The Unity of Knowledge. By Edward O. Wilson. New York: Knopf, 1998. 332 pp. Cloth $26.00. Ian Marshall Ian Marshall Penn State Altoona Search for other works by this author on: Oxford Academic Google Scholar ISLE: Interdisciplinary Studies in Literature and Environment, Volume 6, Issue 1, Winter 1999, Pages 168–170, https://doi.org/10.1093/isle/6.1.168 Published: 01 January 1999

Avian diversification has been influenced by global climate change, plate tectonic movements, and mass extinction events. However, the impact of these factors on the diversification of the hyperdiverse perching birds (passerines) is unclear because family level relationships are unresolved and the timing of splitting events among lineages is uncertain. We analyzed DNA data from 4,060 nuclear loci and 137 passerine families using concatenation and coalescent approaches to infer a comprehensive phylogenetic hypothesis that clarifies relationships among all passerine families. Then, we calibrated this phylogeny using 13 fossils to examine the effects of different events in Earth history on the timing and rate of passerine diversification. Our analyses reconcile passerine diversification with the fossil and geological records; suggest that passerines originated on the Australian landmass ∼47 Ma; and show that subsequent dispersal and diversification of passerines was affected by a number of climatological and geological events, such as Oligocene glaciation and inundation of the New Zealand landmass. Although passerine diversification rates fluctuated throughout the Cenozoic, we find no link between the rate of passerine diversification and Cenozoic global temperature, and our analyses show that the increases in passerine diversification rate we observe are disconnected from the colonization of new continents. Taken together, these results suggest more complex mechanisms than temperature change or ecological opportunity have controlled macroscale patterns of passerine speciation.

A committee of the Mars Exploration Program Analysis Group (MEPAG) has reviewed and updated the description of Special Regions on Mars as places where terrestrial organisms might replicate (per the COSPAR Planetary Protection Policy). This review and update was conducted by an international team (SR-SAG2) drawn from both the biological science and Mars exploration communities, focused on understanding when and where Special Regions could occur. The study applied recently available data about martian environments and about terrestrial organisms, building on a previous analysis of Mars Special Regions (2006) undertaken by a similar team. Since then, a new body of highly relevant information has been generated from the Mars Reconnaissance Orbiter (launched in 2005) and Phoenix (2007) and data from Mars Express and the twin Mars Exploration Rovers (all 2003). Results have also been gleaned from the Mars Science Laboratory (launched in 2011). In addition to Mars data, there is a considerable body of new data regarding the known environmental limits to life on Earth-including the potential for terrestrial microbial life to survive and replicate under martian environmental conditions. The SR-SAG2 analysis has included an examination of new Mars models relevant to natural environmental variation in water activity and temperature; a review and reconsideration of the current parameters used to define Special Regions; and updated maps and descriptions of the martian environments recommended for treatment as "Uncertain" or "Special" as natural features or those potentially formed by the influence of future landed spacecraft. Significant changes in our knowledge of the capabilities of terrestrial organisms and the existence of possibly habitable martian environments have led to a new appreciation of where Mars Special Regions may be identified and protected. The SR-SAG also considered the impact of Special Regions on potential future human missions to Mars, both as locations of potential resources and as places that should not be inadvertently contaminated by human activity.

Deformed wing virus (DWV) of honeybees (Apis mellifera) is closely associated with characteristic wing deformities, abdominal bloating, paralysis, and rapid mortality of emerging adult bees. The virus was purified from diseased insects, and its genome was cloned and sequenced. The genomic RNA of DWV is 10,140 nucleotides in length and contains a single large open reading frame encoding a 328-kDa polyprotein. The coding sequence is flanked by a 1,144-nucleotide 5' nontranslated leader sequence and a 317-nucleotide 3' nontranslated region, followed by a poly(A) tail. The three major structural proteins, VP1 (44 kDa), VP2 (32 kDa), and VP3 (28 kDa), were identified, and their genes were mapped to the N-terminal section of the polyprotein. The C-terminal part of the polyprotein contains sequence motifs typical of well-characterized picornavirus nonstructural proteins: an RNA helicase, a chymotrypsin-like 3C protease, and an RNA-dependent RNA polymerase. The genome organization, capsid morphology, and sequence comparison data indicate that DWV is a member of the recently established genus Iflavirus.

The construct of engagement provides a holistic lens for understanding how children interact with learning activities, with distinct behavioral, emotional-affective, and cognitive components forming a multidimensional engagement profile for each child. As the understanding of engagement and recognition of its complexity grow, a pressing need has emerged for a synthetic, coherent review that simultaneously integrates extant literature and clarifies the conceptualization of engagement, identifies its key facilitators and consequences, and proffers a theoretical framework that elaborates on how engagement functions. Using a developmental-contextual approach, this article integrates empirical and theoretical scholarship to illustrate how engagement is produced by developmental and relational processes involving transactions across multiple ecologies. The integrative model of engagement offers a comprehensive perspective on the multiple pathways-psychological, cognitive, social, and cultural-underlying the development of children's engagement. Conceptualizing engagement as a multidimensional construct shaped by interactions between an individual and the environment enriches the field's understanding of the personal, contextual, and sociocultural factors that foster or undermine engagement. This framing also enhances understanding of the psychosocial mechanisms through which learning environments influence engagement. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Importance: Both military and civilian clinical practice guidelines include early plasma transfusion to achieve a plasma to red cell ratio approaching 1:1 to 1:2. However, it was not known how early plasma should be given for optimal benefit. Two recent randomized clinical trials were published, with apparently contradictory results. The Prehospital Air Medical Plasma (PAMPer) clinical trial showed a nearly 30% reduction in mortality with plasma transfusion in the prehospital environment, while the Control of Major Bleeding After Trauma (COMBAT) clinical trial showed no survival improvement. Objective: To facilitate a post hoc combined analysis of the COMBAT and PAMPer trials to examine questions that could not be answered by either clinical trial alone. We hypothesized that prehospital transport time influenced the effects of prehospital plasma on 28-day mortality. Design, Setting, and Participants: A total of 626 patients in the 2 clinical trials were included. Patients with trauma and hemorrhagic shock were randomly assigned to receive either standard care or 2 U of thawed plasma followed by standard care in the prehospital environment. Data analysis was performed between September 2018 and January 2019. Interventions: Prehospital transfusion of 2 U of plasma compared with crystalloid-based resuscitation. Main Outcomes and Measures: The main outcome was 28-day mortality. Results: In this post hoc analysis of 626 patients (467 men [74.6%] and 159 women [25.4%]; median [interquartile range] age, 42 [27-57] years) who had trauma with hemorrhagic shock, a Cox regression analysis showed a significant overall survival benefit for plasma (hazard ratio [HR], 0.65; 95% CI, 0.47-0.90; P = .01) after adjustment for injury severity, age, and clinical trial cohort (COMBAT or PAMPer). A significant association with prehospital transport time was detected (from arrival on scene to arrival at the trauma center). Increased mortality was observed in patients in the standard care group when prehospital transport was longer than 20 minutes (HR, 2.12; 95% CI, 1.05-4.30; P = .04), while increased mortality was not observed in patients in the prehospital plasma group (HR, 0.78; 95% CI, 0.40-1.51; P = .46). No serious adverse events were associated with prehospital plasma transfusion. Conclusions and Relevance: These data suggest that prehospital plasma is associated with a survival benefit when transport times are longer than 20 minutes and that the benefit-risk ratio is favorable for use of prehospital plasma. Trial Registration: ClinicalTrials.gov identifiers: NCT01838863 (COMBAT) and NCT01818427 (PAMPer).

BACKGROUND: With the rapid growth of minority populations in the United States, the need to train healthcare providers to give culturally competent care has never been greater. Extensive research on cultural competence of healthcare providers has been conducted, but no systematic review specifically focused on the effect of cultural competence training on patient satisfaction of clients from minority groups. AIMS: To search and critically appraise published research articles that evaluated the effectiveness of cultural competence training of healthcare providers on improving patient satisfaction of clients from minority groups. METHODS: Using MeSH entry terms: Competency, Cultural; Cultural Competencies; Cultural Competence; Competence, Cultural; Satisfaction, Patient; and non-MeSh text words: Cultural Awareness, Cultural Sensitivity, Cultural Competence Training, Cultural Sensitivity Training, and Cultural Awareness Training, a comprehensive literature search of peer-reviewed articles from 2002 to 2014 in CINAHL, Cochrane, PsycINFO, PubMed, and Web of Science databases was conducted. Original studies that reported cultural competence training and measured its impact on patient satisfaction were included. Quality of the reviewed studies was assessed on the basis of methodological limitations related to experimental design, sample size and sampling approaches, and ethnic spread of the participants. RESULTS: Seven studies met the inclusion criteria. Six studies revealed that cultural competence training intervention significantly increased the cultural competence level of healthcare providers. Five studies demonstrated that cultural competence training of healthcare providers was significantly associated with increased patient satisfaction. LINKING EVIDENCE TO ACTION: Cultural competence training is an effective intervention that enables healthcare providers to give culturally competent care that increases satisfaction of patients from minority groups. However, more research with better research designs, large sample sizes, and validated standardized cultural competence and patient satisfaction assessment tools is needed to unequivocally attribute cultural competence training to patient satisfaction.

In this mixed-methods study, we use a postcolonial framework to investigate how state standards represent Indigenous histories and cultures. The research questions that guided this study include: (a) What is the frequency of Indigenous content (histories, cultures, current issues) covered in state-level U.S. history standards for K–12? (b) What is the difference between the frequency of inclusion of pre-1900 Indigenous content and post-1900 Indigenous content in U.S. history standards for K–12? (c) How do the standards depict Indigenous Peoples in U.S. history? U.S. history curriculum standards from all 50 states and the District of Columbia were analyzed using within-case analysis and quantified to represent each state’s depiction of Indigenous content. Findings reveal that standards overwhelmingly present Indigenous Peoples in a pre-1900 context and relegate the importance and presence of Indigenous Peoples to the distant past.

OBJECTIVE: The aim of this study was to determine whether prehospital blood products reduce 30-day mortality in patients at risk for hemorrhagic shock compared with crystalloid only resuscitation. SUMMARY OF BACKGROUND DATA: Hemorrhage is the primary cause of preventable death after injury. Large volume crystalloid resuscitation can be deleterious. The benefits of prehospital packed red blood cells (PRBCs), plasma, or transfusion of both products among trauma patients is unknown compared with crystalloid. METHODS: Secondary analysis of the multicenter PAMPer trial was performed on hypotensive injured patients from the scene. The trial randomized 27 helicopter bases to prehospital plasma or standard resuscitation. Standard resuscitation at the sites was equally divided between crystalloid and crystalloid + PRBC. This led to 4 prehospital resuscitation groups: crystalloid only; PRBC; plasma; and PRBC+plasma. Cox regression determined the association between resuscitation groups and risk-adjusted 30-day mortality. The dose effect of resuscitation fluids was also explored. RESULTS: Four hundred seven patients were included. PRBC+plasma had the greatest benefit [hazard ratio (HR) 0.38; 95% confidence interval (95% CI) 0.26-0.55, P < 0.001], followed by plasma (HR 0.57; 95% CI 0.36-0.91, P = 0.017) and PRBC (HR 0.68; 95% CI 0.49-0.95, P = 0.025) versus crystalloid only. Mortality was lower per-unit of PRBC (HR 0.69; 95% CI 0.52-0.92, p = 0.009) and plasma (HR 0.68; 95% CI 0.54-0.88, P = 0.003). Crystalloid volume was associated with increased mortality among patients receiving blood products (HR 1.65; 95% CI 1.17-2.32, P = 0.004). CONCLUSION: Patients receiving prehospital PRBC+plasma had the greatest mortality benefit. Crystalloid only had the worst survival. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably PRBC+plasma. Prehospital whole blood may be ideal in this population.

This study examined prospective elementary teachers' learning about scientific inquiry in the context of an innovative life science course. Research questions included: (1) What do prospective elementary teachers learn about scientific inquiry within the context of the course? and (2) In what ways do their experiences engaging in science investigations and teaching inquiry‐oriented science influence prospective elementary teachers' understanding of science and science learning and teaching? Eleven prospective elementary teachers participated in this qualitative, multi‐participant case study. Constant comparative analysis strategies attempted to build abstractions and explanations across participants around the constructs of the study. Findings suggest that engaging in scientific inquiry supported the development more appropriate understandings of science and scientific inquiry, and that prospective teachers became more accepting of approaches to teaching science that encourage children's questions about science phenomena. Implications include careful consideration of learning experiences crafted for prospective elementary teachers to support the development of robust subject matter knowledge.

<h3>Importance</h3> Recovery after concussion varies, with adolescents taking longer (approximately 30 days) than adults. Many factors have been reported to influence recovery, including preinjury factors, perceptions about recovery, comorbid conditions, and sex. However, 1 factor that may play a role in recovery but has received little attention from researchers is the timeliness of clinical evaluation and care. <h3>Objective</h3> To investigate the association of time since injury with initiation of clinical care on recovery time following concussion. <h3>Design, Setting, and Participants</h3> This retrospective, cross-sectional study was conducted in a sports medicine clinic between August 2016 and March 2018. Eligible participants were aged 12 to 22 years and had a diagnosed, symptomatic concussion; patients were excluded if recovery data were incomplete. Participants were divided into 2 groups: those seen within 7 days of the injury (early) vs between 8 and 20 days of the injury (late). Data were analyzed between June 2019 and August 2019. <h3>Exposures</h3> Time from injury (concussion) to initiation of clinical care. <h3>Main Outcomes and Measures</h3> Recovery time; testing with the Post-Concussion Symptom Scale, Immediate Post-Concussion Assessment and Cognitive Testing, and Vestibular/Ocular Motor Screening instruments; demographic factors, medical history, and injury information. <h3>Results</h3> A total of 416 individuals were eligible, and 254 (61.1%) were excluded, leaving 162 (38.9%) in analyses. The early group (98 patients) and late group (64 patients) did not differ in age (mean [SD] age, early, 15.3 [1.6] years; late, 15.4 [1.6] years), number of female patients (early, 51 of 98 [52.0%]; late, 40 of 64 [62.5%]), or other demographic, medical history, or injury information. The groups also were similar on symptom severity, cognitive, ocular, and vestibular outcomes at the first clinic visit. Results from a logistical regression supported being in the late group (adjusted odds ratio, 5.8 [95% CI, 1.9-17.6];<i>P</i> = .001) and visual motion sensitivity symptoms greater than 2 (adjusted odds ratio, 4.5 [95% CI, 1.1-18.0];<i>P</i> = .04) as factors significantly associated with recovery time. <h3>Conclusions and Relevance</h3> Findings suggest that earlier initiation of clinical care is associated with faster recovery after concussion. Other factors may also influence recovery time. Further research is needed to determine the role of active rehabilitation and treatment strategies, as well as demographic factors, medical history, and injury characteristics on the current findings.

PURPOSE: We know very little about how transgender people create their families and the issues involved in these decisions. This qualitative study explored the parenting intentions and desires of 32 self-identified transgender individuals who want to become parents in the future. METHODS: Data were collected using an open-ended survey with 32 transgender men and transgender women regarding when and how they want to become parents in the future. RESULTS: We found that transgender individuals expressed specific desires for parenthood, such as biological relatedness and barriers to parenthood, such as physical limitations or lack of legal protections, which influence how transgender individuals choose to become parents in the future. For example, many participants described wanting to be biologically related to a future child and how this can be complicated by being transgender due to hormonal treatments, surgeries, or not having the biological means of become a parent using "traditional" methods. CONCLUSIONS: The barriers and desires discussed provide invaluable insight into the parenting intentions and reproductive health of transgender people. This study revealed numerous examples where healthcare professionals could benefit from this new knowledge, such as increasing communication with patients about these desires and issues related to treatment and reproduction.

Abstract There is now unequivocal evidence for global climate change; however, its potential impacts on evolutionary processes remain unclear. Many species have responded to contemporary climate change through shifts in their geographic range. This could lead to increased sympatry between recently diverged species; likely increasing the potential for hybridization. Recently, following a series of warm winters, southern flying squirrels ( Glaucomys volans ) in Ontario, Canada rapidly expanded their northern range limit resulting in increased sympatry with the closely related northern flying squirrel ( Glaucomys sabrinus ). This provided the opportunity to test the prediction that contemporary climate change can act as a catalyst creating conditions for the formation of hybrid zones. Following extensive sampling and molecular analyses (nuclear and mitochondrial DNA), we identified the occurrence of hybridization between sympatric G. sabrinus and G. volans . There was evidence of backcrossing but not of extensive introgession, consistent with the hypothesis of recent rather than historic hybridization. To our knowledge, this is the first report of hybrid zone formation following a range expansion induced by contemporary climate change. This is also the first report of hybridization between North American flying squirrel species.

Diurnal and seasonal rhythms of cortisol, testosterone, and DHEA were examined, as little is known about the relationship between these rhythmicities and pubertal development. Salivary samples were obtained from 60 boys and 60 girls at approximately 07:45, 08:00, 08:30, 12:00, 16:50, and 21:00 h. The participants' ages ranged from 8-14 yrs, and each participant was tested three times at six-month intervals. The study was conducted at a General Clinical Research Center (GCRC) and at the homes of the participants. All hormones showed diurnal fluctuations. The acrophase (peak time) of cortisol occurred earlier than for testosterone or DHEA and showed a seasonal effect, with the acrophase occurring earlier in spring than in summer. The cortisol acrophase also occurred later in the day for boys than for girls during later puberty. Seasonal effects were found only for cortisol with higher concentrations in the spring and summer. Cortisol concentrations were relatively stable across pubertal maturation, but significantly lower concentrations were observed at pubertal stage 3 compared to the other stages. Morning cortisol levels were also higher in boys at pubertal stage 2. Testosterone concentrations were higher in boys at pubertal stages 3 and 4, and DHEA was lower at pubertal stage 1 than 3 and 4 for both boys and girls. For the total sample, there was a positive correlation between DHEA and testosterone during early puberty (stages 1-3) but not later puberty (stages 4-5). Awakening secretory activity correlated with daytime secretory activity for testosterone and DHEA, but not for cortisol. These data provide novel chronobiological information on cortisol, testosterone, and DHEA as it relates to sexual maturation and encourage further study on both normal and abnormal endocrine rhythms.

We investigate the magnetorheological (MR) properties of suspensions containing iron microwires with 260 nm diameter and two distinct length distributions of 5.4 ± 5.2 µm and 7.6 ± 5.1 µm suspended in silicone oil (0.45 Pa s). The rheological properties of these fluids were determined using a parallel plate rheometer equipped with a variable strength electromagnet. The shear stress was measured as a function of shear rate for increasing applied magnetic fields. These results were modeled using the Bingham-plastic constitutive model to determine the apparent yield stress and viscosity as a function of increasing volume fraction and length of microwires. At a saturated magnetic flux density, the yield stress using the 5.4 µm microwires was found to be 0.65, 2.23, and 4.76 kPa for the 2, 4, and 6 vol% suspensions, respectively. For the 7.6 µm wires, the yield stress increases to 8.2 kPa for the 6 vol% suspension. Compared with conventional MR fluids employing spherical particles, the degree of settling is markedly decreased in the microwire-based fluids. At 6 vol%, conventional fluids display appreciable settling whereas the microwire-based fluids display no discernable settling. Moreover, the rod-shaped microwires are shown to increase the yield stress of the fluids and enhance the MR performance.

We present a systematic study of the absorption, heating behavior, and microstructure evolution of porous copper powder metal compacts subjected to 2.45 GHz microwave radiation and explain our observations using known physical mechanisms. Using a single-mode microwave system, we place the compacts in pure electric (E) or magnetic (H) fields and compare the heating trends. We also investigate the effect of particle size on the same. The observed trends and the differences between E- and H-field heating are reflected in the dramatic changes in the conductivity, permittivity, and permeability of the samples. These property changes are effected by the microstructure evolution during heating in the two types of fields. We also find that the observed dependence of the initial microwave heating on particle size is suggestive of single-particle behavior.

Narcissism research is poorly calibrated across fields of study in part due to confusion over how to integrate normal and pathological descriptions of narcissism. We argue that pathological and normal narcissism can be integrated in a single model that organizes around self-regulation mechanisms. We present theoretical and empirical support for this interpretation, and demonstrate that modeling pathological and normal narcissism as 2 dimensions underlying the narcissistic character can help to resolve some of the inconsistencies in the field regarding how to best assess adaptive and maladaptive expressions of narcissism.

Purpose In today's complex and highly competitive marketplace, universities and colleges, realizing a need to develop sustainable strategies, have turned to branding as a solution. However, because of their unique service characteristics, universities' branding attempts may not always result in success. The aim of this paper is to present a brand ecosystem framework in order to develop branding strategies for colleges and universities. Design/methodology/approach The key elements of the framework include: student experiences as the driving force of the university branding strategies, academic services as the core value creation activities in delivering student learning experiences that are co‐created with students and faculty, and supporting activities that are important in creating the core value. Findings The framework suggests that both core and supporting value‐creating activities are dynamically inter‐related and work jointly in creating student learning experiences, and ultimately, a strong university brand. Originality/value The paper presents the crucial elements and the relationships among them for building successful brands in higher education.

Methanogenic archaea have a unique role in Earth's global carbon cycle as producers of the greenhouse gas methane (CH4 ). However, despite the fact that ice covers 11% of Earth's continental landmass, evidence for methanogenic activity in subglacial environments has yet to be clearly demonstrated. Here we present genetic, biochemical and geochemical evidence indicative of an active population of methanogens associated with subglacial sediments from Robertson Glacier (RG), Canadian Rockies. Porewater CH4 was quantified in two subglacial sediment cores at concentrations of 16 and 29 ppmv. Coenzyme M (CoM), a metabolic biomarker for methanogens, was detected at a concentration of 1.3 nmol g sediment(-1) corresponding to ∼3 × 10(3) active cells g sediment(-1) . Genetic characterization of communities associated with subglacial sediments indicated the presence of several archaeal 16S rRNA and methyl CoM reductase subunit A (mcrA) gene phylotypes, all of which were affiliated with the euryarchaeal order Methanosarcinales. Further, CH4 was produced at 9-51 fmol g dry weight sediment(-1) h(-1) in enrichment cultures of RG sediments incubated at 4°C. Collectively, these findings have important implications for the global carbon cycle in light of recent estimates indicating that the Earth's subglacial biome ranges from 10(4) to 10(6) km(3) sediment.