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Introduction: Transcutaneous cardiac pacing (TCP) is recommended for the treatment of symptomatic bradycardia, a life-threatening condition. Although TCP is taught in ACLS (advanced cardiac life support) courses, it is a difficult skill to master for junior residents. The main objective of this study is to measure the impact of having access to a checklist on successful TCP implementation. Our hypothesis was that the availability of a CL would improve performance of junior residents in the management of symptomatic bradycardia by facilitating TCP. Methods: We conducted a prospective, randomized, single-site study. First-year residents entering postgraduate programs and taking a mandatory ACLS course were enrolled. Students had didactic sessions on the management of symptomatic bradycardia followed by hands-on teaching on a low-fidelity manikin (ALS® simulator, Laerdal) using a CL conceived for this project as a teaching tool. Study participants were then assessed with a simulation scenario requiring TCP. Participants were randomly assigned to groups with and without CL accessibility. Performances were graded on six critical tasks. The primary outcome was the successful use of TCP, defined as having completed all tasks. Participants then completed a post-test questionnaire. Sample size estimation was based on a previous project (Ranger et al., 2018). Accepting an alpha error of 0.05 and a power of 80%, 45 participants in each group would permit the detection of 26.5% in performance gain. Results: Of 250 residents completing the ACLS course in 2017, 85 voluntary participants were randomized to a control group (no CL available during testing, n = 42) or an experimental group (CL available during testing, n = 43). Six participants in the experimental group adequately used TCP compared to five participants in the control group (p = 0.81, chi-squared test). Out of the 43 participants who had access to the CL, only 2 (5%) used it. Reasons why the CL was infrequently used were stated as the following: 24 participants (56%) mentioned not realizing it was available, 8 (19%) considered it was of little to no utility and 5 (19%) forgot a CL existed. Conclusion: Availability of a checklist previously used during simulation teaching did not increase junior residents’ capacity to correctly apply TCP. Non-recognition of CL availability and decreased perceived need for it were the main reasons for marginal use. Our results suggest that there are many limiting factors to CL effectiveness.
Important ear problems can affect the outer ear, the middle ear and the inner ear. Globally, the greatest burden of disease is due to ear conditions that are associated with otorrhoea and hearing loss.
This study reviewed the literature on the prevention and treatment of common ear conditions that are most relevant to settings with high rates of ear disease and limited resources. The grading of recommendations assessment, development and evaluation (‘GRADE’) approach was utilised to assess interventions.
Accurate diagnosis of ear disease is challenging. Much of the preventable burden of ear disease is associated with otitis media. Nine otitis media interventions for which there is moderate to high certainty of effect were identified. While most interventions only provide modest benefit, the impact of treatment is more substantial in children with acute otitis media with perforation and chronic suppurative otitis media.
Disease prevention through good hygiene practices, breastfeeding, reducing smoke exposure, immunisation and limiting noise exposure is recommended. Children with acute otitis media with perforation, chronic suppurative otitis media, complications of otitis media, and significant hearing loss should be prioritised for medical treatment.
Serious mental illness (SMI) is profoundly stigmatised, such that there is even an impact on relatives of people with SMI.
To develop and validate a scale to comprehensively measure self-stigma among first-degree relatives of individuals with SMI.
We conducted group interviews focusing on self-stigma with first-degree relatives (n = 20) of people with SMI, from which 74 representative quotations were reframed as Likert-type items. Cognitive interviews with relatives (n = 11) identified 30 items for the Self-Stigma in Relatives of people with Mental Illness (SSRMI) scale. Relatives (n = 195) completed the scale twice, a month apart, together with four external correlate scales.
The 30-item SSRMI was reliable, with scores stable over time. Its single-factor structure allowed generation of a 10-item version. Construct validity of 30- and 10-item versions was supported by expected relationships with external correlates.
Both versions of the SSRMI scale are valid and reliable instruments appropriate for use in clinical and research contexts.
Rapid or explosive heating of electrically conductive films has several applications, and the use of reactive laminates to increase output energy is an intriguing concept. Past studies have shown electrically heated aluminum/nickel (Al/Ni) nano-laminate films to augment this energy by an amount approximately equivalent to the expected heat of mixing between the two elements, which for most intermetallics is a significant fraction of the total heat of reaction (86% for Al/Ni). In this study, we investigate the use of sputtered aluminum/boron (Al/B) laminates to determine whether a similar increase, as measured by the velocity of an ejected flyer layer, occurs. However, observed velocities in any samples containing boron were 38% to 45% lower than samples without boron, despite much higher heats of reaction reported in the literature for Al/B. We attributed this reduction to the vaporization temperature of boron being much higher than that of Al, and because Al electrical resistivity at elevated temperatures was still much lower than boron, boron heating was less efficient as vaporized Al expanded and drove the ejected flyer. These results and analysis give insight into other reactive material combinations in which one of the constituents is an electrical insulator.
The discovery of the first electromagnetic counterpart to a gravitational wave signal has generated follow-up observations by over 50 facilities world-wide, ushering in the new era of multi-messenger astronomy. In this paper, we present follow-up observations of the gravitational wave event GW170817 and its electromagnetic counterpart SSS17a/DLT17ck (IAU label AT2017gfo) by 14 Australian telescopes and partner observatories as part of Australian-based and Australian-led research programs. We report early- to late-time multi-wavelength observations, including optical imaging and spectroscopy, mid-infrared imaging, radio imaging, and searches for fast radio bursts. Our optical spectra reveal that the transient source emission cooled from approximately 6 400 K to 2 100 K over a 7-d period and produced no significant optical emission lines. The spectral profiles, cooling rate, and photometric light curves are consistent with the expected outburst and subsequent processes of a binary neutron star merger. Star formation in the host galaxy probably ceased at least a Gyr ago, although there is evidence for a galaxy merger. Binary pulsars with short (100 Myr) decay times are therefore unlikely progenitors, but pulsars like PSR B1534+12 with its 2.7 Gyr coalescence time could produce such a merger. The displacement (~2.2 kpc) of the binary star system from the centre of the main galaxy is not unusual for stars in the host galaxy or stars originating in the merging galaxy, and therefore any constraints on the kick velocity imparted to the progenitor are poor.
Gold, palladium, and platinum aerogels were prepared by a rapid, direct solution-based reduction synthesis with densities of 0.54, 0.065, and 0.055 g/cm3, respectively. Salt solutions were reduced at 1:1 (v/v) with dimethylamine borane and sodium borohydride to rapidly form gels within seconds to minutes above a threshold salt concentration and were then rinsed and freeze dried. Au, Pd, and Pt aerogels had no presence of oxide phases confirmed by X-ray diffractometry. Specific surface areas determined with gas physisorption were 3.06, 15.43, and 20.56 m2/g for Au, Pd, and Pt. Electrochemically determined specific capacitances using electrochemical impedance spectroscopy and cyclic voltammetry were 2.18, 4.13, and 4.20 F/g, and 2.67, 7.99, and 5.12 F/g for Au, Pd, and Pt, respectively. The rapid synthesis, high solvent accessible specific surface area, conductivity, and capacitance make these noble metal aerogels candidates for many of catalytic, energy, and sensor applications.
Circumstellar SiO masers can be observed in red giant evolved stars throughout the Galaxy. Since stellar masers are not affected by non-gravitational forces, they serve as point-mass probes of the gravitational potential and form an excellent sample for studies of the Galactic structure and dynamics. Compared to optical studies, the non-obscured masers are in particular valuable when observed close to the highly obscured Galactic Bulge and Plane. Their line-of-sight velocities can easily be obtained with high accuracy, proper motions can be measured and distances can be estimated. Furthermore, when different mass and metallicity effects can be accounted for, such a large sample will highlight asymmetries and evolutionary traces in the sample. In our Bulge Asymmetries and Dynamic Evolution (BAaDE) survey we have searched 20,000 infrared selected evolved stars for 43 GHz SiO masers with the VLA in the northern Bulge and Plane and are in the process of observing another 10,000 stars for 86 GHz SiO masers with ALMA in the southern Bulge. Our instantaneous detection rate in the Bulge is close to 70%, both at 43 and 86 GHz, with occasionally up to 7 simultaneous SiO transitions observed in a single star. Here we will outline the BAaDE survey, its first results and some of the peculiar maser features we have observed. Furthermore we will discuss the prospects for obtaining proper motions and parallaxes for individual maser stars to reconstruct individual stellar orbits.
The Bulge Asymmetries and Dynamical Evolution (BAaDE) project aims to map the positions and velocities of up to ~20,000 late-type stars with SiO maser emission along the full Galactic plane, with a large concentration in the Galactic Bulge and inner Galaxy. Both J = 1 → 0 and J = 2 → 1 transitions using the Very Large Array (VLA) and the Atacama Large Millimeter Array (ALMA) are being observed. In the VLA observing setup, in addition to the 28SiO, v = 1 and v = 2J = 1 → 0 maser transitions, the bandwidth was wide enough to include the J = 1 → 0 transitions of the rare isotopologues of the SiO molecule in both the ground and vibrationally excited states: 29SiO, v = 0, 30SiO, v = 0, 29SiO, v = 1, and 29SiO, v = 2. Approximately 10% of the initial ~3500 targets of the project show maser emission from at least one of these lines. Some of these stars (with isotopic maser emission) show high radial velocities which implies that they are indeed in the Galactic Bulge or inner Galaxy (i.e. not foreground objects). We present line profiles, refined detection statistics, and the implications of the detection of the isotopic maser emission on pumping schemes that have been previously presented.
Introduction/Innovation Concept: Feedback provided to residents by physicians emphasize the medical expertise competency and may limit the attention paid to other CanMEDS competencies. Recent years have seen the emergence of the concept of multisource feedback, a process through which different members of the care team assess and provide feedback to residents. This approach is considered one of the best for providing relevant feedback on competencies that are less often addressed by physicians. To date, very few studies have explored emergency residents’ perceptions following feedback from their physicians, nurses with whom they have worked, and patients they have treated. Methods: In the emergency department of a tertiary-care university hospital, 10 emergency medicine residents participated, on a voluntary basis, in individual and semi-structured group interviews, three months after having received multisource feedback. Two researchers then qualitatively analyzed the data collected in those interviews. Thematic content analysis using QDA Miner identified dominant themes in the residents’ perceptions. Curriculum, Tool, or Material: Multisource feedback tool: Three questionnaires were designed to gather assessment from different sources: physicians, nurses, and patients. The questionnaires were adapted from those created by Joshi and colleagues for use in a study of residents’ competency in interpersonal and communication skills. During a nine months period, the residents distributed questionnaires to physicians, nurses, and patients with whom they felt they had enough interactions during their clinical shifts. Data from the questionnaires were compiled by two educators that prepared individual feedback reports for each resident. An educator was asked to conduct individual meetings with each resident to present the feedback report and discuss its content. Conclusion: Each source provided relevant comments that differed significantly in their content. Physicians focused primarily on medical expertise, whereas nurses addressed competencies related to management, collaboration, and communication, and patients commented on the competencies of professionalism and communication. Residents concluded that obtaining feedback from nurses and patients was not only acceptable but useful in their training. Several reported modifying certain behaviours after receiving the multisource feedback. Multisource feedback appears to have obvious teaching potential to provide feedback on competencies other than medical expertise in emergency residents.
Introduction: Transcutaneous cardiac pacing (TCP), a skill taught in Advanced Cardiovascular Life Support (ACLS) courses, is recommended to treat unstable bradycardia. Training manikins currently available fail to reproduce key features of TCP and might be suboptimal to teach this procedure.The objective of this study was to measure the impact of a modified high-fidelity manikin on junior residents’ TCP competency during an ACLS course. We hypothesized that the use of this high-fidelity manikin improves junior residents’ performances. Methods: This prospective cohort study was conducted at the Université de Montréal in July 2015 and 2016. First-year residents undergoing their mandatory ACLS course were enrolled. The control group (2015) received the traditional curriculum, which includes hands-on teaching on Advanced Life Support manikins. The intervention group (2016) received a similar curriculum, but used a modified high-fidelity manikin that reproduces key features of TCP (e.g. use of multifunction pads, TCP induced patient twitching, ECG artifacts). Cohorts were tested with a simulation scenario requiring TCP. Performances were graded based on six critical tasks: turns on pacer function, applies multifunction pads, recognizes TCP is ineffective, achieves captures, verifies mechanical capture and prescribes sedation. Our primary outcome was successful use of TCP defined as having completed all tasks. Secondary outcomes were the success rates for each task. These were compared using Pearson’s chi-squared test. We anticipated that the success rate of TCP would increase from 20% to 50%. To obtain a power of more than 90%, 48 participants were needed in both cohorts. Results: A total of 50 residents were recruited in both cohorts. No resident that received the traditional curriculum was able to successfully establish TCP while 18 residents trained on the modified high-fidelity manikin succeeded (0 vs 36%, P<0.001). Furthermore, the latter were more likely to recognize when pacing was inefficient (12 vs 86%, P<0.001), obtain ventricular capture (2 vs 48%, P<0.001), and check for a pulse rate to confirm capture (0 vs 48%, P<0.001). Conclusion: Successful use of TCP is a difficult skill to master for junior residents. A modified high-fidelity manikin during ACLS training significantly improves their ability to establish effective pacing.
Rapid weight gain in infancy and low levels of n-3 long chain polyunsaturated fatty acids (LCPUFA) at birth are associated with increased adiposity later in life. The association between placental LCPUFA delivery and weight gain in infancy is poorly understood. We sought to determine the relationships between maternal phenotype, placental fatty acid transporter expression and offspring growth patterns over the first 6 months. Placental tissue and cord blood were collected at term delivery from women with uncomplicated pregnancies. Offspring body composition measurements were recorded 1 day and 6 months after birth. Body mass index (BMI) z-scores were determined using World Health Organization 2006 reference data. Body phenotype patterns were compared among offspring who had an increase in BMI z-score and those who had a decrease. High skinfold thickness at birth and positive change in BMI z-scores during infancy were associated with low neonatal n-3 LCPUFA plasma levels (r=−0.46, P=0.046) and high saturated fatty acids levels (r=0.49, P=0.034). Growth of skinfolds over 6 months of age was associated with placental fatty acid transporter gene expression. Change in BMI z-score in the first 6 months of life correlated with arm muscle area growth, a measure of lean mass (r=0.62, P=0.003), but not with growth in skinfold thickness. Early infancy weight gain was associated with poor plasma LCPUFA status at birth, and fat deposition in infancy was related to changes in placental lipid handling. Thus, neonatal fatty acid profiles may influence the trajectory of infant growth and fat and lean mass deposition.
Environmental exposures during pregnancy may increase breast cancer risk for mothers and female offspring. Tumor tissue assays may provide insight regarding the mechanisms. This study assessed the feasibility of obtaining tumor samples and pathology reports from mothers (F0) who were enrolled in the Child Health and Development Studies during pregnancy from 1959 to 1967 and their daughters (F1) who developed breast cancer over more than 50 years of follow-up. Breast cancer cases were identified through linkage to the California Cancer Registry and self-report. Written consent was obtained from 116 F0 and 95 F1 breast cancer survivors to access their pathology reports and tumor blocks. Of those contacted, 62% consented, 13% refused and 24% did not respond. We obtained tissue samples for 57% and pathology reports for 75%, and if diagnosis was made ⩽10 years we obtained tissue samples and pathology reports for 91% and 79%, respectively. Obtaining pathology reports and tumor tissues of two generations is feasible and will support investigation of the relationship between early-life exposures and molecular tumor markers. However, we found that more recent diagnosis increased the accessibility of tumor tissue. We recommend that cohorts request consent for obtaining future tumor tissues at study enrollment and implement real-time tissue collection to enhance success of collecting tumor samples and data.
Because individuals develop dementia as a manifestation of neurodegenerative or neurovascular disorder, there is a need to develop reliable approaches to their identification. We are undertaking an observational study (Ontario Neurodegenerative Disease Research Initiative [ONDRI]) that includes genomics, neuroimaging, and assessments of cognition as well as language, speech, gait, retinal imaging, and eye tracking. Disorders studied include Alzheimer’s disease, amyotrophic lateral sclerosis, frontotemporal dementia, Parkinson’s disease, and vascular cognitive impairment. Data from ONDRI will be collected into the Brain-CODE database to facilitate correlative analysis. ONDRI will provide a repertoire of endophenotyped individuals that will be a unique, publicly available resource.
Late Medieval Castles is a companion to Anglo-Norman Castles (2003), a volume that brought together a series of historiographically significant articles on castles and castle-building in the period from the Norman Conquest to the early thirteenth century. The format and themes of the present collection are broadly comparable with the earlier book, but with the focus on those castles dating to the period c.1250–1500.
In the course of bringing Anglo-Norman Castles to publication the somewhat arbitrary cut-off date of c.1225 seemed unsatisfactory for a number of reasons. On a practical level, there were highly relevant articles that could not be included because the subject matter fell outside the chronological range of the volume. A more scholarly concern was the fact that a number of issues pertinent to castle-building in the eleventh and twelfth centuries could not be satisfactorily addressed without reference to subsequent developments in the thirteenth and fourteenth. Allied to this, a focus on Anglo-Norman building (no matter how justifiable in historical terms) does perhaps contribute, albeit unwittingly, to the erroneous idea that the eleventh and twelfth centuries are the most important centuries for castle-building, a time when the ‘true’ castle is to be found, and that the period that follows, particularly after 1300, is something of an anti-climax. The present volume should therefore be seen as a continuation of the broad themes discussed in the introduction to Anglo-Norman Castles, with the aim of pursuing them in a late medieval context.
In the years since 2003 there have been a number of important publications in the field of castle studies, and castles continue to be a source of controversy and to provoke debate. Despite the fact that the availability of some secondary material has been made easier through electronic access, I have been consistently reminded by academic colleagues that a compilation such as this is worthwhile, both for the student reader and those seeking a path into the specialist secondary literature. This author at least also believes that there is value in bringing together in one place a series of important contributions that have defined the subject and which also illustrate a diversity of approaches.