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In a recent paper (J. Fluid Mech., vol. 861, 2019, pp. 328–348), Benilov derived equations governing a laminar liquid sheet (a curtain) that emanates from a slot whose centreline is inclined to the vertical. The equations are valid for slender sheets whose characteristic length scale in the direction of flow is much larger than its cross-sectional thickness. For a liquid that leaves a slot with average speed,
, volumetric flow rate per unit width,
, surface tension,
, and density,
, Benilov obtains parametric equations that predict steady-state curtain shapes that bend upwards against gravity provided
. Benilov’s parametric equations are shown to be identical to those derived by Finnicum, Weinstein, and Ruschak (J. Fluid Mech., vol. 255, 1993, pp. 647–665). In the latter form, it is straightforward to deduce an alternative solution of Benilov’s equations where a curtain falls vertically regardless of the slot’s orientation. This solution is consistent with prior experimental and theoretical results that show that a liquid curtain can emerge from a slot at an angle different from that of the slot centreline.
In March 2017, the New Jersey Department of Health received reports of 3 patients who developed septic arthritis after receiving intra-articular injections for osteoarthritis knee pain at the same private outpatient facility in New Jersey. The risk of septic arthritis resulting from intra-articular injection is low. However, outbreaks of septic arthritis associated with unsafe injection practices in outpatient settings have been reported.
An infection prevention assessment of the implicated facility’s practices was conducted because of the ongoing risk to public health. The assessment included an environmental inspection of the facility, staff interviews, infection prevention practice observations, and a medical record and office document review. A call for cases was disseminated to healthcare providers in New Jersey to identify patients treated at the facility who developed septic arthritis after receiving intra-articular injections.
We identified 41 patients with septic arthritis associated with intra-articular injections. Cultures of synovial fluid or tissue from 15 of these 41 case patients (37%) recovered bacteria consistent with oral flora. The infection prevention assessment of facility practices identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, unsafe injection practices, and poor cleaning and disinfection practices. No additional cases were identified after infection prevention recommendations were implemented by the facility.
Aseptic technique is imperative when handling, preparing, and administering injectable medications to prevent microbial contamination.
This investigation highlights the importance of adhering to infection prevention recommendations. All healthcare personnel who prepare, handle, and administer injectable medications should be trained in infection prevention and safe injection practices.
Public health is defined by the UK’s Faculty of Public Health as ‘The science and art of promoting and protecting health and well being, preventing ill health and prolonging life through the organised efforts of society’.
This definition locates the causes of ill health and the remedies in the realms of personal and societal agency, and not only in the remit of health practitioners. Although the latter have a role as members of society to make prevention a reality for themselves, families and communities, they play a special part in preventing further ill health for people who suffer mental illness and are seeking help for it.
Other chapters in this book attend to the relational and social fabric that enables people to flourish; it is made of good and trusting relationships, and material conditions that permit thought about purpose and meaning beyond survival.
Emergency department (ED) access block, the inability to provide timely care for high acuity patients, is the leading safety concern in First World EDs. The main cause of ED access block is hospital access block with prolonged boarding of inpatients in emergency stretchers. Cumulative emergency access gap, the product of the number of arriving high acuity patients and their average delay to reach a care space, is a novel access measure that provides a facility-level estimate of total emergency care delays. Many health leaders believe these delays are too large to be solved without substantial increases in hospital capacity. Our objective was to quantify cumulative emergency access blocks (the problem) as a fraction of inpatient capacity (the potential solution) at a large sample of Canadian hospitals.
In this cross-sectional study, we collated 2015 administrative data from 25 Canadian hospitals summarizing patient inflow and delays to ED care space. Cumulative access gap for high acuity patients was calculated by multiplying the number of Canadian Triage Acuity Scale (CTAS) 1-3 patients by their average delay to reach a care space. We compared cumulative ED access gap to available inpatient bed hours to estimate fractional access gap.
Study sites included 16 tertiary and 9 community EDs in 12 cities, representing 1.79 million patient visits. Median ED census (interquartile range) was 66,300 visits per year (58,700-80,600). High acuity patients accounted for 70.7% of visits (60.9%-79.0%). The mean (SD) cumulative ED access gap was 46,000 stretcher hours per site per year (± 19,900), which was 1.14% (± 0.45%) of inpatient capacity.
ED access gaps are large and jeopardize care for high acuity patients, but they are small relative to hospital operating capacity. If access block were viewed as a “whole hospital” problem, capacity or efficiency improvements in the range of 1% to 3% could profoundly mitigate emergency care delays.
To integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs).
Design, Setting, and Participants
This 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015.
Phase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication.
Overall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3·85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9·06 in phase 1 to 1·65 in phase 4 (relative risk [RR], 0·182; 95% confidence interval [CI], 0·153–0·216; P<·001). New catheters per 1,000 patient days declined from 53·4 in phase 1 to 39·5 in phase 4 (RR, 0·740; 95% CI, 0·730; P<·001), and catheter days per 1,000 patient days decreased from 194·5 in phase 1 to 140·7 in phase 4 (RR, 0·723; 95% CI, 0·719–0·728; P<·001). The reinsertion rate declined from 3·66% in phase 1 to 3·25% in phase 4 (RR, 0·894; 95% CI, 0·834–0·959; P=·0017).
The phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.
The “Stop the Bleed” campaign advocates for non-medical personnel to be trained in basic hemorrhage control. However, it is not clear what type of education or the duration of instruction needed to meet that requirement. The objective of this study was to determine the impact of a brief hemorrhage control educational curriculum on the willingness of laypersons to respond during a traumatic emergency.
This “Stop the Bleed” education initiative was conducted by the University of Texas Health San Antonio Office of the Medical Director (San Antonio, Texas USA) between September 2016 and March 2017. Individuals with formal medical certification were excluded from this analysis. Trainers used a pre-event questionnaire to assess participants knowledge and attitudes about tourniquets and responding to traumatic emergencies. Each training course included an individual evaluation of tourniquet placement, 20 minutes of didactic instruction on hemorrhage control techniques, and hands-on instruction with tourniquet application on both adult and child mannequins. The primary outcome in this study was the willingness to use a tourniquet in response to a traumatic medical emergency.
Of 236 participants, 218 met the eligibility criteria. When initially asked if they would use a tourniquet in real life, 64.2% (140/218) responded “Yes.” Following training, 95.6% (194/203) of participants responded that they would use a tourniquet in real life. When participants were asked about their comfort level with using a tourniquet in real life, there was a statistically significant improvement between their initial response and their response post training (2.5 versus 4.0, based on 5-point Likert scale; P<.001).
In this hemorrhage control education study, it was found that a short educational intervention can improve laypersons’ self-efficacy and reported willingness to use a tourniquet in an emergency. Identified barriers to act should be addressed when designing future hemorrhage control public health education campaigns. Community education should continue to be a priority of the “Stop the Bleed” campaign.
RossEM, RedmanTT, MappJG, BrownDJ, TanakaK, CooleyCW, KharodCU, WamplerDA. Stop the Bleed: The Effect of Hemorrhage Control Education on Laypersons’ Willingness to Respond During a Traumatic Medical Emergency. Prehosp Disaster Med. 2018;33(2):127–132.
The clouded leopard Neofelis nebulosa is a potent ambassador species for conservation, occurring from the Himalayan foothills eastwards to Indochina, between which Myanmar is a biogeographical land bridge. In Myanmar's Northern Forest Complex, the species co-occurs with the tiger Panthera tigris, leopard Panthera pardus, marbled cat Pardofelis marmorata, golden cat Catopuma temminckii and leopard cat Prionailurus bengalensis. We deployed cameras within the Htamanthi Wildlife Sanctuary over 2 consecutive years. In 2014–2015 we deployed 82 camera stations around the Nam Pa Gon stream (Catchment 1) for 7,365 trap days. In 2015–2016 we deployed 80 camera stations around the Nam E Zu stream (Catchment 2) for 7,192 trap days. In Catchment 1 we identified five tigers from 26 detections, five clouded leopards from 41 detections (68 photographs) and 11 marbled cats from 13 detections. Using Bayesian-based spatial capture–recapture we estimated the densities of tigers and clouded leopards to be 0.81 ± SD 0.40 and 0.60 ± SD 0.24 individuals per 100 km2, respectively. In Catchment 2 we identified two tigers from three detections, nine clouded leopards from 55 detections and 12 marbled cats from 37 detections. Densities of clouded leopards and marbled cats were 3.05 ± SD 1.03 and 8.80 ± SD 2.06 individuals per 100 km2, respectively. These differences suggest that human activities, in particular gold mining, are affecting felid populations, and these are a paramount concern in Htamanthi. We demonstrate the importance of Htamanthi within the Northern Forest Complex and highlight the Yawbawmee corridor as a candidate for protection.
Extensive areas of tropical forests have been, and continue to be, disturbed as a result of selective timber extraction. Although such anthropogenic disturbance typically results in the loss of biodiversity, many species persist, and their conservation in production landscapes could be enhanced by a greater understanding of how biodiversity responds to forest management practices. We conducted intensive camera-trap surveys of eight protected forest areas in Sabah, Malaysian Borneo, and developed estimates of Sunda clouded leopard Neofelis diardi population density from spatially explicit capture–recapture analyses of detection data to investigate how the species’ abundance varies across the landscape and in response to anthropogenic disturbance. Estimates of population density from six forest areas were 1.39–3.10 individuals per 100 km2. Our study provides the first evidence that the population density of the Sunda clouded leopard is negatively affected by hunting pressure and forest fragmentation, and that among selectively logged forests, time since logging is positively associated with abundance. We argue that these negative anthropogenic impacts could be mitigated with improved logging practices, such as reducing the access of poachers by effective gating and destruction of road access points, and by the deployment of anti-poaching patrols. By calculating a weighted mean population density estimate from estimates developed here and from the literature, and by extrapolating this value to an estimate of current available habitat, we estimate there are 754 (95% posterior interval 325–1,337) Sunda clouded leopards in Sabah.
Objectives: Medical devices are ubiquitous in modern medical care. However, little is known about the epidemiology of medical devices in the healthcare marketplace, including the rate at which medical devices are subject to recalls or other advisories. We sought to study the epidemiology of medical devices in Canada, focusing on device recalls. In Canada, a recall may signify a variety of events, ranging from relatively minor field safety notifications, to removal of a product from the marketplace.
Methods: We used data from Health Canada to study medical device recalls in Canada from 2005 to 2015. We analyzed the risks of medical device recalls according to the risk class of the device (I lowest; IV highest) and the hazard priority of the recall (Type I highest potential harm; Type III lowest potential harm).
Results: During a 10-year period, there were 7,226 medical device recalls. Most recalls were for intermediate risk class (Class II, 40.1 percent; Class III, 38.7 percent) medical devices. Among recalled devices, 5.0 percent were judged to have a reasonable probability of serious adverse health consequences or death (Type I recall Hazard Priority classification). While the number of medical devices marketed in Canada is not known, over a similar 10-year period, 24,849 new Class II, II, and IV medical device licenses were issued by Health Canada.
Conclusions: Several hundred medical device recalls occur in Canada each year. Further research is needed to characterize the nature of medical device recalls, and to explore how consumers use information about recalls.
Many snow models have been developed for various applications such as hydrology, global atmospheric circulation models and avalanche forecasting. The degree of complexity of these models is highly variable, ranging from simple index methods to multi-layer models that simulate snow-cover stratigraphy and texture. In the framework of the Snow Model Intercomparison Project (SnowMIP), 23 models were compared using observed meteorological parameters from two mountainous alpine sites. The analysis here focuses on validation of snow energy-budget simulations. Albedo and snow surface temperature observations allow identification of the more realistic simulations and quantification of errors for two components of the energy budget: the net short- and longwave radiation. In particular, the different albedo parameterizations are evaluated for different snowpack states (in winter and spring). Analysis of results during the melting period allows an investigation of the different ways of partitioning the energy fluxes and reveals the complex feedbacks which occur when simulating the snow energy budget. Particular attention is paid to the impact of model complexity on the energy-budget components. The model complexity has a major role for the net longwave radiation calculation, whereas the albedo parameterization is the most significant factor explaining the accuracy of the net shortwave radiation simulation.
We sought to evaluate the risk and image quality from cardiovascular CT in patients across all stages of single-ventricle palliation, and to define accuracy by comparing findings with intervention and surgery.
Consecutive CT scans performed in patients with single-ventricle heart disease were retrospectively reviewed at a single institution. Diagnosis, sedation needs, estimated radiation dose, and adverse events were recorded. Anatomical findings, image quality (1–4, 1=optimal), and discrepancy compared with interventional findings were determined. Results are described as medians with their 25th and 75th percentiles.
From January, 2010 to August, 2015, 132 CT scans were performed in single-ventricle patients of whom 20 were neonates, 52 were post-Norwood, 15 were post-Glenn, and 45 were post-Fontan. No sedation was used in 76 patients, 47 were under minimal or moderate sedation, and nine were under general anaesthesia. The median image quality score was 1.2. The procedural dose–length product was 24 mGy-cm, and unadjusted and adjusted radiation doses were 0.34 (0.2, 1.8) and 0.82 (0.55, 1.88) mSv, respectively. There was one adverse event. No major and two minor discrepancies were noted at the time of 79 surgical and 10 catheter-based interventions.
Cardiovascular CT can be performed with a low radiation exposure in patients with single-ventricle heart disease. Its accuracy compared with that of interventional findings is excellent. CT is an effective advanced imaging modality when a non-invasive pathway is desired, particularly if cardiac MRI poses a high risk or is contraindicated.
The strong self-damped Lyman α absorption systems present in the spectra of high redshift QSOs represent a unique population of absorber which has recently been associated with the precursors of current disk galaxies. In a low resolution survey for what we have come to call “Lyman α disk systems” performed at Lick Observatory (Wolfe, et al. 1986, Ap. J. Suppl. 61, 249) approximately 18 systems with confirmed damped Lyman α profiles and rest frame equivalent widths greater than 5 Å were detected in a sample of 68 high redshift QSOs (Smith, Cohen and Bradley 1986, Ap. J. 310, 583). Subsequent higher resolution study has shown these systems to have the following properties (Turnshek, et al. 1988, Ap. J., in press):
2.Low-mixed ionization state. Typically the low ionization states dominate the high ionization states (e.g. CII ≫ CIV). Some enrichment has occurred, −2≲[X/H]⊙ ≲0.
3.Gas density, n ≲ 1 cm−3.
4.The gas shows two components, a quiescent (disk) component, σν ≲ 10 km s−1, and a turbulent (halo) component, σν ≲ 20 km s−1. Some systems show only the low velocity dispersion component.
5.At least one system intervening toward a radio QSO (Pks 0458-020) shows 21-cm absorption. The system shows multiple cloud structure with σν ≈ 6 km s−1, Ts ≈ 100 K, and structure extended over several kpc on the sky.
6.There is evidence that these systems may be self gravitating with scale height of the order of 300 pc.
7.These systems represent a unique population of absorber (distinct from the ‘Lyman a forest’ and heavy element systems) covering approximately 20% of the sky to z ≈ 3 and accounting for all of the baryonic matter at that redshift.
In the early hours of 25 December 2012, an attempt to explore Subglacial Lake Ellsworth, West Antarctica, using a specially designed hot-water drill, was halted. This UK project, involving several universities, the British Antarctic Survey and the National Oceanography Centre, had been in planning for 10 years. The project developed a full blueprint for subglacial lakes research, involving access to the subglacial environment through deep drilling, direct measurement and sampling of water and sediment by the construction of a probe and sediment corer, and environmental protocols to ensure cleanliness in line with international agreements on stewardship and protection of subglacial systems. Drilling was ceased after the main borehole failed to link with a subsurface cavity of water, built up over ∽40 hours. Without this link, insufficient water was available to continue drilling downwards to the lake, ∽3000 m beneath the surface. On return to the UK, an external review of the programme was undertaken to formally assess the reasons for the fieldwork failure, and to make recommendations on the modifications necessary for success. From this review, the Lake Ellsworth programme formulated a pathway along which a second attempt to explore the lake can be developed. Here details of the Lake Ellsworth field experiment, the circumstances that led to its failure and the corrections required are presented. Hot-water drilling is still regarded as the only feasible scheme for assuring clean access to the subglacial environment. The lessons learned from the Lake Ellsworth experience are substantial, however, and demonstrate that considerable technological and methodological advances are necessary for successful future research on subglacial lakes beneath thick (>2 km) ice.
Museum exhibitions possess a long history of serving as useful tools for teaching both paleontology and evolutionary biology to college undergraduates. Yet, they are frequently under-appreciated and underutilized. However, they remain potentially outstanding resources because they can be used to meet a spectrum of learning objectives related to nature of science, real-world relevance, and student interest. Specifically, even small museum displays can provide: 1) authentic specimens, which often are more diverse, of higher quality, and historically more significant than those in teaching collections; 2) specimens in context, with other specimens and/or geological or biological background available; 3) examples of how fossils connect to virtually all of Earth and life sciences (explaining why they have so frequently been at the center of traditional “natural history”); 4) cross-disciplinary experiences, connecting science, art, technology, and history within a social context; and 5) opportunities for students to learn about teaching. A survey of instructor-developed activities performed within a host of natural history museums—with particular attention devoted to the Museum of the Earth, an affiliate of Cornell University—suggests that natural history exhibitions, regardless of size and scope, can complement and strengthen formal education in an undergraduate setting.
The Middle Jurassic is a poorly sampled time interval for non-pelagic neosuchian crocodyliforms, which obscures our understanding of the origin and early evolution of major clades. Here we report a lower jaw from the Middle Jurassic (Bathonian) Duntulm Formation of the Isle of Skye, Scotland, UK, which consists of an isolated and incomplete left dentary and part of the splenial. Morphologically, the Skye specimen closely resembles the Cretaceous neosuchians Pachycheilosuchus and Pietraroiasuchus, in having a proportionally short mandibular symphysis, shallow dentary alveoli and inferred weakly heterodont dentition. It differs from other crocodyliforms in that the Meckelian canal is dorsoventrally expanded posterior to the mandibular symphysis and drastically constricted at the 7th alveolus. The new specimen, together with the presence of Theriosuchus sp. from the Valtos Formation and indeterminate neosuchians from the Kilmaluag Formation, indicates the presence of a previously unrecognised, diverse crocodyliform fauna in the Middle Jurassic of Skye, and Europe more generally. Small-bodied neosuchians were present, and ecologically and taxonomically diverse, in nearshore environments in the Middle Jurassic of the UK.
Since their inception, the Perspectives in Logic and Lecture Notes in Logic series have published seminal works by leading logicians. Many of the original books in the series have been unavailable for years, but they are now in print once again. This volume, the twenty-fifth publication in the Lecture Notes in Logic series, grew from a conference on Nonstandard Methods and Applications in Mathematics held in Pisa, Italy from 12–16 June, 2002. It contains ten peer-reviewed papers that aim to provide something more timely than a textbook, but less ephemeral than a conventional proceedings. Nonstandard analysis is one of the great achievements of modern applied mathematical logic. These articles consider the foundations of the subject, as well as its applications to pure and applied mathematics and mathematics education.