To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Introduction: For rhythm control of acute atrial fibrillation (AAF) in the emergency department (ED), choices include initial drug therapy or initial electrical cardioversion (ECV). We compared the strategies of pharmacological cardioversion followed by ECV if necessary (Drug-Shock), and ECV alone (Shock Only). Methods: We conducted a randomized, blinded, placebo-controlled trial (1:1 allocation) comparing two rhythm control strategies at 11 academic EDs. We included stable adult patients with AAF, where onset of symptoms was <48 hours. Patients underwent central web-based randomization stratified by site. The Drug-Shock group received an infusion of procainamide (15mg/kg over 30 minutes) followed 30 minutes later, if necessary, by ECV at 200 joules x 3 shocks. The Shock Only group received an infusion of saline followed, if necessary, by ECV x 3 shocks. The primary outcome was conversion to sinus rhythm for ≥30 minutes at any time following onset of infusion. Patients were followed for 14 days. The primary outcome was evaluated on an apriori-specified modified intention-to-treat (MITT) basis excluding patients who never received the study infusion (e.g. spontaneous conversion). Data were analyzed using chi-squared tests and logistic regression. Our target sample size was 374 evaluable patients. Results: Of 395 randomized patients, 18 were excluded from the MITT analysis; none were lost to follow-up. The Drug-Shock (N = 198) and Shock Only (N = 180) groups (total = 378) were similar for all characteristics including mean age (60.0 vs 59.5 yrs), duration of AAF (10.1 vs 10.8 hrs), previous AF (67.2% vs 68.3%), median CHADS2 score (0 vs 0), and mean initial heart rate (119.9 vs 118.0 bpm). More patients converted to normal sinus rhythm in the Drug-Shock group (97.0% vs 92.2%; absolute difference 4.8%, 95% CI 0.2-9.9; P = 0.04). The multivariable analyses confirmed the Drug-Shock strategy superiority (P = 0.04). There were no statistically significant differences for time to conversion (91.4 vs 85.4 minutes), total ED length of stay (7.1 vs 7.7 hours), disposition home (97.0% vs 96.1%), and stroke within 14 days (0 vs 0). Premature discontinuation of infusion was more common in the Drug-Shock group (8.1% vs 0.6%) but there were no serious adverse events. Conclusion: Both the Drug-Shock and Shock Only strategies were highly effective and safe in allowing AAF patients to go home in sinus rhythm. A strategy of initial cardioversion with procainamide was superior to a strategy of immediate ECV.
Introduction: Redirecting low acuity patients from emergency departments to primary care walk-in clinics has been identified as a priority by many health authorities. Promoting family physicians for the management of ambulatory patients with urgent health concerns reflects the assumption that primary care facilities can offer high-quality and more affordable ambulatory emergency care. However, no performance assessment framework has been developed for ambulatory emergency care and consequently, quality of care provided in these alternate settings has never been formally compared. Primary objective: To identify structure, process and outcome indicators for ambulatory emergency care. Methods: We will identify and develop quality indicators (QIs) for ambulatory emergency care using a RAND/UCLA Appropriateness Method (RAM) composed of three different steps. First, we will perform a scoping literature review to inventory 1) all previously recommended QIs assessing care provided to ambulatory emergency patients in the ED or the primary care settings; 2) all conditions evaluated with the retrieved QIs; and 3) all outcomes measured by the same QIs. Second, a steering committee composed of the research team and of international experts in performance assessment in emergency and primary care will be presented with the lists of QI-related conditions and outcomes. They will be asked to identify potential outcome indicators for ambulatory emergency care by generating any relevant combinations of one condition and one outcome (e.g. acute asthma exacerbation/re-consultation). Committee members will be given the latitude to use and pair any conditions or outcomes not included in the lists as long as they think the resulting indicators are compatible with the study objectives. Using a structured nominal group approach, they will combine their suggestions and refine the list of potential QIs. This list of potential outcome indicators composed of pairs “condition/outcome” will be merged with the list of already published QIs identified during the literature review. Third, as per the RAM standards, we will assemble an international multidisciplinary panel (n=20) of patients, emergency and primary care providers, researchers and decision makers, after recommendations from international emergency and primary care associations, and from the Canadian Strategy for Patient-Oriented Research (SPOR) Support Units. Through iterative rounds of ratings using both web-based survey tools and videoconferencing, panelists will independently assess all candidate QIs. They will be asked to rate on a nine-level scale to what extent each QI is a relevant and useful measure of ambulatory emergency care quality. From one round to the next, QIs with a median panelist rating score of one to three will be excluded. Those with a median score of seven or more will be automatically included in the final list. QIs with median score of four to six will be retained for future deliberations among the panelists. Rounds of ratings will be conducted until all QIs are classified. Impact: The QIs identified will be used to develop a performance assessment framework for ambulatory emergency care. This will represent an essential step toward testing the assumption that EDs and primary care walk-in clinics provide equivalent care quality to low acuity patients.
(Solar Phys.). High spectral, temporal and spatial resolution observations were obtained with the 60-channel Utrecht solar radio spectrograph (160–320 MHz) and the 169 MHz Nançay solar radioheliograph. From a large number of type III bursts the average height was found to be 0.37 solar radius above the photosphere, corresponding to approximately the Newkirk streamer density, if the bursts are emitted at the harmonic of the local plasma frequency. No center-to-limb variation, nor east-west asymmetry was observed. All double bursts, double humped bursts, precursor-type III had exactly the same position and general shape for both members of the pair. From this it was concluded that fundamental-harmonic pairs are very rare at frequencies above 160 MHz (Mercier and Rosenberg, 1974).
Background: Debate persists in Canada about the cost and benefit of vagal nerve stimulation in patients with refractory epilepsy. The aim of our study was to evaluate the impact of a vagal nerve stimulator on the seizure frequency and the admission rate of children with refractory epilepsies over five years of follow-up. Methods: 52 patients were implanted between 2000-2013. Of these, 37 were followed at CHU Sainte-Justine and 21 kept seizure diaries. Seizure frequency was compared to the baseline at 6 months, 12 months, 24 months and 60 months of follow up using a multivariate ANOVA analysis. The hospitalization rate was calculated as the mean difference between the number of hospitalizations prior to and after the implantation. Results: Seizure frequency decreased by 58% at 6 months, by 61% at 12 months, by 53% at 24 months and by 63% at 60 months of follow up respectively compared to the baseline (p<0.001). The hospitalization rate decreased by 50.87% after surgery (p<0.001). Conclusion: In our population, vagal nerve stimulation has a sustained impact on seizure frequency and hospitalization rates. This supports previous data from our group and others on cost-effectiveness of the technique in children with refractory epilepsy.
The factorial approach to assess the amino acid (AA) requirements of pigs is based on the assumption that the AA composition of body protein is constant. However, there are indications that this assumption may not be valid because the AA composition of body protein can be affected by the AA supply. The extent to which different tissues are affected by an AA deficiency is unknown. The objective of this study was to investigate the effect of feeding pig diets with a deficient or sufficient total sulfur AA supply (TSAA; Met+Cys) from 6 to 23 weeks of age on tissue composition and meat quality. The deficient diet (TSAA–) provided 24% Met : Lys and 51% TSAA : Lys on a standardized ileal digestible basis, which are 19% and 16% below the recommended requirements, respectively. The sufficient diet (TSAA+) provided 33% Met : Lys and 60% TSAA : Lys. Diets were offered slightly below the ad libitum feed intake capacity of the pigs. Pigs offered diet TSAA– had a lower average daily gain, lower weights of the longissimus dorsi (LM) and rhomboideus muscles (RM), and of selected skin sections (P<0.05). The weight of different sections of the small intestine and the liver was not affected by the diet. The protein content of the LM and RM decreased in pigs offered diet TSAA– (P<0.05), whereas the protein content of other tissues was not affected. The TSAA supply affected the AA composition (g/16 g N) of protein in all tissues, but the Met content was changed only in the liver (P<0.05). Pigs receiving diet TSAA– had a lower Cys content in the RM and in the distal jejunum and ileum (P<0.01). The deficient TSAA supply resulted in a lower carcass weight and higher muscle glycogen stores (P<0.05), but did not affect other meat quality traits. The results of this study indicate that the muscles, jejunum and ileum respond more to a prolonged AA deficiency than the liver. In addition, the observed changes in AA composition of tissue protein question the use of a constant AA profile of retained protein to assess AA requirements.
Carrying the apoE ε4 allele (E4+) is the most important genetic risk for Alzheimer's disease. Unlike non-carriers (E4 − ), E4+ seem not to be protected against Alzheimer's disease when consuming fish. We hypothesised that this may be linked to a disturbance in n-3 DHA metabolism in E4+. The aim of the present study was to evaluate [13C]DHA metabolism over 28 d in E4+v. E4 − . A total of forty participants (twenty-six women and fourteen men) received a single oral dose of 40 mg [13C]DHA, and its metabolism was monitored in blood and breath over 28 d. Of the participants, six were E4+ and thirty-four were E4 − . In E4+, mean plasma [13C]DHA was 31 % lower than that in E4 − , and cumulative β-oxidation of [13C]DHA was higher than that in E4 − 1–28 d post-dose (P≤ 0·05). A genotype × time interaction was detected for cumulative β-oxidation of [13C]DHA (P≤ 0·01). The whole-body half-life of [13C]DHA was 77 % lower in E4+ compared with E4 − (P≤ 0·01). In E4+ and E4 − , the percentage dose of [13C]DHA recovered/h as 13CO2 correlated with [13C]DHA concentration in plasma, but the slope of linear regression was 117 % steeper in E4+ compared with E4 − (P≤ 0·05). These results indicate that DHA metabolism is disturbed in E4+, and may help explain why there is no association between DHA levels in plasma and cognition in E4+. However, whether E4+ disturbs the metabolism of 13C-labelled fatty acids other than DHA cannot be deduced from the present study.
The growing number of spastic ataxia of Charlevoix-Saguenay (SACS) gene mutations reported worldwide has broadened the clinical phenotype of autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS). The identification of Quebec ARSACS cases without two known SACS mutation led to the development of a multi-modal genomic strategy to uncover mutations in this large gene and explore phenotype variability.
Search for SACS mutations by combining various methods on 20 cases with a classical French-Canadian ARSACS phenotype without two mutations and a group of 104 sporadic or recessive spastic ataxia cases of unknown cause. Western blot on lymphoblast protein from cases with different genotypes was probed to establish if they still expressed sacsin.
A total of 12 mutations, including 7 novels, were uncovered in Quebec ARSACS cases. The screening of 104 spastic ataxia cases of unknown cause for 98 SACS mutations did not uncover carriers of two mutations. Compounds heterozygotes for one missense SACS mutation were found to minimally express sacsin.
The large number of SACS mutations present even in Quebec suggests that the size of the gene alone may explain the great genotypic diversity. This study does not support an expanding ARSACS phenotype in the French-Canadian population. Most mutations lead to loss of function, though phenotypic variability in other populations may reflect partial loss of function with preservation of some sacsin expression. Our results also highlight the challenge of SACS mutation screening and the necessity to develop new generation sequencing methods to ensure low cost complete gene sequencing.
In this paper, we present the first laboratory experiments that show the generation of internal solitary waves by the impingement of a quasi-two-dimensional internal wave beam on a pycnocline. These experiments were inspired by observations of internal solitary waves in the deep ocean from synthetic aperture radar (SAR) imagery, where this so-called mechanism of ‘local generation’ was argued to be at work, here in the form of internal tidal beams hitting the thermocline. Nonlinear processes involved here are found to be of two kinds. First, we observe the generation of a mean flow and higher harmonics at the location where the principal beam reflects from the surface and pycnocline; their characteristics are examined using particle image velocimetry (PIV) measurements. Second, we observe internal solitary waves that appear in the pycnocline, detected with ultrasonic probes; they are further characterized by a bulge in the frequency spectrum, distinct from the higher harmonics. Finally, the relevance of our results for understanding ocean observations is discussed.
Investigations describing the utilization pattern and comparing the outcome from emergency and mass casualty situations are limited by the lack of a reliable and valid patient classification system. In this study we briefly describe the use of APACHE (Acute Physiology and Chronic Health Evaluation), a physiologically based classification system for measuring severity of illness in groups of critically ill patients, as a tool in comparing outcomes of 1437 ICU admissions from eight European and five American hospitals. Because of the successful results from this pilot effort, we believe that APACHE could be used to compare the performance of hospitals in an emergency or mass casualty situation.
For space weather applications, it is important to understand filaments evolution and especially their eruptions associated with coronal mass ejections. In view of the cadence and continuity of SDO observations, AIA and HMI offer a unique tool for such a program. Because of the data volume and the requirement of short latency, only an automated detection can be worked out. We present a new method for the automated detection and tracking of filaments, based on the analysis of AIA 30.4 nm He ii images, with the capability to use also the magnetic field measured by HMI.
We present results from quiet sun observations in the metric range. Solar images where obtained through rotational aperture synthesis at a number of frequencies, using the Nançay radioheliograph in its latest version, from 2004 to 2011. The main morphology is described, and compared to the magnetic field topology. We also measured on-disk spectra, of the average sun and of coronal holes, and equatorial and polar limb profiles. From these measurements, simple temperature/density atmospheric models are derived and briefly discussed.
We compared 2 data sources—antimicrobial orders and bar-coded medication administration (BCMA)—for calculating the number of grams used, grams used based on defined daily dose, and days of therapy at one Veterans Affairs Medical Center for 2009-2010. The number of grams used calculated from BCMA data provided the most informative antimicrobial utilization measure.
Using systematic review methodology, global research reporting the frequency of zoonotic bacterial pathogens, antimicrobial use (AMU) and antimicrobial resistance (AMR) in ornamental fish, and human illness due to exposure to ornamental fish, was examined. A survey was performed to elicit opinions of aquaculture-allied personnel on the frequency of AMU and AMR in ornamental fish. The most commonly reported sporadic human infections were associated with Mycobacterium marinum, while Salmonella Paratyphi B var. Java was implicated in all reported outbreaks. Aeromonas spp. were most frequently investigated (n=10 studies) in 25 studies surveying ornamental fish from various sources. High levels of resistance were reported to amoxicillin, penicillin, tetracycline and oxytetracycline, which was also in agreement with the survey respondents' views. Studies on AMU were not found in our review. Survey respondents reported frequent use of quinolones, followed by tetracyclines, nitrofurans, and aminoglycosides. Recommendations for future surveillance and public education efforts are presented.
In a rapid thermal processing system working at a total pressure of a few Torr, we have obtained selective epitaxial growth of silicon at temperatures as low as 650°C. When using SiH2Cl2 (DCS) as the reactive gas, no addition of HCl is needed. Nevertheless, using SiH4 below 950°C a small amount of HCl should be added.
Some kinetic aspects of the two systems, DCS/HCI/H2 and SiH4/HCl/H2, are presented and discussed. For the DCS system, we show that the rate-limiting reactions are slightly different from those commonly accepted in the literature, where the results are from systems working at atmospheric pressure or in the 20-100 Torr range.
Our model is based on the main decomposition of DCS, SiH2Cl→SiHCl + HCl, instead of the widely accepted reaction SiH2Cl2→SiCl2 + H2. This is the main reason why no extra HCl is required in the DCS/H2 system to obtain full selectivity from above 1000°C down to 650°C.
Spin-on glass organosilicate films are promising Ultra Low-ĸ (ULK) interlevel dielectric candidates in which porosity can be created by incorporating thermally labile porogens. The as-deposited film (called the hybrid film) consists of a methylsilsesquioxane (MSQ) matrix and an organic porogen. The standard porogen removal step consists of a 450°C thermal annealing. However, it leaves polymeric residues suspected to cause an incomplete matrix crosslinking and, consequently, to be detrimental to the porous film's electrical and mechanical properties. In this work, a supercritical fluid (SCF) treatment, performed on a 200 mm tool, was added before the thermal annealing with the intent of improving the dielectric properties. Electrical and mechanical properties were greatly enhanced: the dielectric constant was reduced from 2.5 to 2.1 and the Young's modulus was increased from 2 GPa to 3 GPa. Porogen residue removal and cross-linking improvements were investigated by Fourier Transform Infrared (FTIR) spectroscopy in transmission and multiple internal reflection (MIR) mode.
The Saghro Cenozoic lavas form a bimodal suite of nephelinites (with carbonatite xenoliths) and phonolites emplaced in the Anti-Atlas belt of Morocco. Despite the paucity of samples with intermediate composition between the two main types of lava (only one phonotephrite flow is reported in this area), whole-rock major element modelling shows that the two main lithologies can be linked by fractional crystallization. The most primitive modelled cumulates are calcite-bearing olivine clinopyroxenites, whereas the final stages of differentiation are characterized by the formation of nepheline-syenite cumulates. This evolution trend is classically observed in plutonic alkaline massifs associated with carbonatites. Late-stage evolution is responsible for the crystallization of hainite- and delhayelite-bearing microdomains, for the transformation of aegirine-augite into aegirine (or augite into aegirine-augite), and for the crystallization of lorenzenite and a eudialyte-group mineral as replacement products of titanite. These phases were probably formed, either by crystallization from late residual peralkaline melts, or by reaction of pre-existing minerals with such melt, or hydrothermal peralkaline fluid.
The Amalaoulaou Neoproterozoic island-arc massif belongs to the Gourma belt in Mali. The metagabbros and pyroxenites forming the main body of this arc root show the pervasive development of garnet. In the pyroxenites, the latter has grown by reaction between pyroxene and spinel during isobaric cooling. By contrast, in the metagabbros, garnet textures and relations to felsic veins exclude an origin through solid-state reactions only. It is proposed that garnet has grown following dehydration and localized melting of amphibole-bearing gabbros at the base of the arc. The plagioclase-saturated melts represented by anorthositic veins in the metagabbros and by trondhjemites in the upper part of the massif provide evidence for melting in the deep arc crust, which locally generated high-density garnet–clinopyroxene–rutile residues. Garnet growth and melting began around 850 °C at 10 kbar and the tonalitic melts were most probably generated around 1050 °C at P ≥ 10 kbar. This HT granulitic imprint can be related to arc maturation, leading to a P–T increase in the deep arc root and dehydration and/or dehydration-melting of amphibole-bearing gabbros. Observation of such features in the root of this Neoproterozoic island arc has important consequences, as it provides a link to models concerning the early generation of continental crust.
The hunting methods of the Neanderthals are rarely evident in detail in the archaeological record. Here, the rare and important discovery of a fragment of broken Levallois point, embedded in the neck-bones of a wild ass, provokes plenty of discussion of the methods of hafting and killing game in the Middle Palaeolithic of Syria.