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A novel high-power impulse plasma source (HiPIPS) technology that combines atmospheric pressure plasma jets with high-power pulsed direct current generators is described. Pulsed power is applied in microsecond pulses (20 µs) at low duty cycle (10%) and low frequency (0.5 kHz) leading to high peak power densities (10–75 kW) and high peak currents (100–250 A) while maintaining low average power (<40 W) and low processing temperatures (<50 °C). These conditions result in the generation of a highly dense plasma discharge (ne = 6.23 × 1016 cm−3) for surface modification and deposition of coatings. Using HiPIPS, Ar-initiated metallic Ti, CoCr, or Ti–6Al–4V plasma was generated, and the plasma properties were characterized by measuring current–voltage characteristics, electron densities (Langmuir probe), and optical emission spectra. HiPIPS CoCr and Ti–6Al–4V coatings were deposited for proof of concept of the technique. The resulting coatings were examined with scanning electron microscopy, energy-dispersive X-ray spectroscopy, and nanoindentation.
Background: SMA is a neurodegenerative disease caused by biallelic deletion/mutation of the survival motor neuron (SMN1) gene. In the phase 1 trial (NCT02122952), SMN GRT onasemnogene abeparvovec (AVXS-101) improved outcomes of 15 symptomatic SMA1 patients (3 at a lower dose [cohort 1] and 12 at the proposed therapeutic dose [cohort 2]). This report describes long-term follow-up study design and data from the phase 1 study. Methods: Patients in the phase 1 study could rollover into a long-term follow-up study (NCT03421977). The primary objective is to collect long-term safety data (serious adverse events, hospitalizations, and adverse events of special interest). Annual follow-up will occur for 15 years. Additionally, patient record transfers from local clinician(s) will be requested. Safety assessments include medical history and record review, physical examination, clinical laboratory evaluation, and pulmonary assessments. Efficacy assessments include physical examination to assess developmental milestones. Results: As of September 27, 2018, the oldest patients are 59.2 (cohort 1) and 52.1 (cohort 2) months old and free of permanent ventilation. Preliminary data, including survival and developmental milestones, will be presented. Conclusions: Patients treated with a one-time dose of AVXS-101 continue to gain strength, develop, and achieve new milestones, demonstrating a long-term, durable response.
Residency education delivery in the United States has migrated from conventional lectures to alternative educational models that include mini-lectures, small group, and learner lead discussions. As training programs struggle with mandated hours of content, prehospital (EMS) and disaster medicine are given limited focus. While the need for prehospital and disaster medicine education in emergency training is understood, no standard curriculum delivery has been proposed and little research has been done to evaluate the effectiveness of any particular model.
To demonstrate a four-hour multi-modal curriculum that includes lecture based discussions and small group exercises, culminating in an interactive multidisciplinary competition that integrates the previously taught information.
EMS and disaster faculty were surveyed on the previous disaster and prehospital educational day experiences to evaluate course content, level of engagement, and participation by faculty. Based on this feedback, the EMS/Disaster divisions developed a schedule for the four hour EMS and Disaster Day that incorporated vital concepts while addressing the pitfalls previously identified. Sessions included traditional lectures, question and answer sessions, small group exercises, and a tabletop competition. Structured similarly to a strategy board game, the tabletop exercise challenged residents to take into account both medical and ethical considerations during a traditional triage exercise.
Compared to past reviews by emergency medical faculty, residents, and medical students, there was a precipitous increase in satisfaction scores on the part of all participants.
This curriculum deviates from the conventional education model and has been successfully implemented at our 3-year residency program of 66 residents. This EMS and Disaster Day promotes active learning, resident and faculty participation, and retention of important concepts while also fostering relationships between disaster managers and the Department of Emergency Medicine.
Introduction: Abdominal pain is one of the most frequent reasons for an emergency department (ED) visit. Most cases are functional and no therapy has proven effective. Our objective was to determine if hyoscine butylbromide (HBB) (BuscopanTM) is effective for children who present to the ED with functional abdominal pain. Methods: We conducted a randomized, blinded, superiority trial comparing HBB 10 mg plus acetaminophen placebo to oral acetaminophen 15 mg/kg (max 975 mg) plus HBB placebo using a double-dummy approach. We included children 8-17 years presenting to the ED at London Health Sciences Centre with colicky abdominal pain rated >40 mm on a 100 mm visual analog scale (VAS). The primary outcome was VAS pain score at 80 minutes post-administration. Secondary outcomes included adverse effects; caregiver satisfaction with pain management using a five-item Likert scale; recidivism and missed surgical diagnoses within 24-hours of discharge. Analysis was based on intention to treat. Results: We analyzed 225 participants (112 acetaminophen; 113 HBB). The mean (SD) age was 12.4 (3.0) years and 148/225 (65.8%) were females. Prior to enrollment, the median (IQR) duration of pain prior was 2 (4.5) hours and analgesia was provided to 101/225 (44.9%) of participants. The mean (SD) pre-intervention pain scores in the acetaminophen and HBB groups were 62.7 (15.9) mm and 60.3 (17.3) mm, respectively. At 80 minutes, the mean (SD) pain scores in the acetaminophen and HBB groups were 30.1 (28.8) mm and 29.4 (26.4) mm, respectively and there were no significant differences adjusting for pre-intervention scores (p = 0.96). The median (IQR) caregiver satisfaction was high in the acetaminophen [5 (2)] and HBB [5 (1)] groups (p = 0.79). The median (IQR) length of stay between acetaminophen [235 (101)] and HBB [234 (103)] was not significantly different (p = 0.53). The proportion of participants with a return visit for abdominal pain was 4/112 (3.5%) in the acetaminophen group and 6/113 (5.3%) in the HBB group. The most common adverse effect was nausea (9% in each group) and there were no significant differences in adverse effects between acetaminophen (26/112, 23.2%) and HBB (31/113, 27.4%) (p = 0.52). There were no missed surgical diagnoses. Conclusion: For children with presumed functional abdominal pain who present to the ED, both acetaminophen and HBB produce a clinically important (VAS < 30 mm) reduction in pain and should be routinely considered in this clinical setting.
Children with congenital heart disease are at high risk for malnutrition. Standardisation of feeding protocols has shown promise in decreasing some of this risk. With little standardisation between institutions’ feeding protocols and no understanding of protocol adherence, it is important to analyse the efficacy of individual aspects of the protocols.
Adherence to and deviation from a feeding protocol in high-risk congenital heart disease patients between December 2015 and March 2017 were analysed. Associations between adherence to and deviation from the protocol and clinical outcomes were also assessed. The primary outcome was change in weight-for-age z score between time intervals.
Increased adherence to and decreased deviation from individual instructions of a feeding protocol improves patients change in weight-for-age z score between birth and hospital discharge (p = 0.031). Secondary outcomes such as markers of clinical severity and nutritional delivery were not statistically different between groups with high or low adherence or deviation rates.
High-risk feeding protocol adherence and fewer deviations are associated with weight gain independent of their influence on nutritional delivery and caloric intake. Future studies assessing the efficacy of feeding protocols should include the measures of adherence and deviations that are not merely limited to caloric delivery and illness severity.
Numerous studies have been conducted into the microstructural origin of the instability and unpredictability of various energetic materials. Some of these materials are RDX/HMX, Ammonium Perchlorate, Aluminum, etc. Many techniques both destructive and non-destructive have so far been utilized in an attempt to quatify the energetic properties of their composites. These composites may contain one or more energetic constituents in an elastomeric binder. Non-destructive X-ray characterization techniques have been successfully employed to measure several microstructural parameters. Previous studies have shown considerable differences among various production grade RDX. These studies reveal marked differences in the amounts of residual elastic strain and the distribution of dislocations (residual plastic strain) in the constituent RDX phase.
The focus of this study is to develop a technique for quantitative constituent phase analysis of solid-propellant (fuel) composites using conventional diffractometry. The use of a Curved Position Sensitive Detector (CPSD) greatly enhances the technique and allows real time applications in production environments. Through the use of computer based Systems and "user friendly" software the required Operator, skill and training have been considerably reduced. The CPSD System has been successfully used to quantify constituent phases (peak heights) and the amounts of residual elastic strain (peak shifts) in these molecular crystal powder mixtures.
It is envisioned that rapid, automated, non-destructive X-ray characterization techniques will greatly facilitate production based propellant quality control. A thorough understanding of the relationship between the energetics and microstructural parameters can also he obtained.
For the past several years the Boeing Aerospace Company has been implementing advanced nondestructive chemical analysis methods to improve product reliability and reduce material inspection costs. Previous testing of incoming material for conformance to vendor test reports or of production materials for verification of alloy composition, had consisted of either time-consuming destructive testing or nondestructive chemical spot testing, which often was insensitive to differences between alloys of similar chemical properties. Beginning in 1974, development of EDXRF techniques was initiated to provide a rapid nondestructive analysis capability for both laboratory and factory use. For materials containing elements easily excited by EDXRF methods, costly destructive sampling and testing can be avoided. Generally, chips, wire, barstock, sheet or plate can be analyzed using an annular radioactive source. The uniformity of the X-ray flux diminishes sample geometry and surface roughness effects.
Nurses view patient safety as an essential component of their work and have reported a general interest in embracing an antibiotic steward role. However, antibiotic stewardship (AS) functions have not been formally integrated into nursing practice despite nurses’ daily involvement in clinical activities that impact antibiotic decisions (e.g., obtaining specimens for cultures, blood drawing for therapeutic drug monitoring). Recommendations to expand AS programs to include bedside nurses are generating support at a national level, yet a practical guidance on how nurses can be involved in AS activities is lacking. In this review, we provide a framework identifying selected practices where nurses can improve antibiotic prescribing practices through appropriate obtainment of Clostridioides difficile tests, appropriate urine culturing practices, optimal antibiotic administration, accurate and detailed documentation of penicillin allergy histories and through the prompting of antibiotic time outs. We identify reported barriers to engagement of nurses in AS and offer potential solutions that include patient safety principles and quality improvement strategies that can be used to mitigate participation barriers. This review will assist AS leaders interested in advancing the contributions of nurses into their AS programs by discussing education, communication, improvement models, and workflow integration enhancements that strengthen systems to support nurses as valued partners in AS efforts.
As editor in chief of Utilitas, it is my great pleasure to announce the appointment of two new associate editors. Dr. Emmanuelle de Champs is Professor of British History and Civilisation at the University of Cergy-Pontoise. She is the author of Enlightenment and Utility: Bentham in France, Bentham in French (Cambridge University Press, 2015) and La déontologie politique ou La pensée constitutionnelle de Jeremy Bentham (Droz, 2008). Dr. Holly Smith is Distinguished Professor of Philosophy at Rutgers University. Her Making Morality Work has just been published by Oxford University Press. So we have now strengthen our editorial roster in both the history of ideas and contemporary moral philosophy.
Procurement's important role in healthcare decision making has encouraged criticism and calls for greater collaboration with health technology assessment (HTA), and necessitates detailed analysis of how procurement approaches the decision task.
We reviewed tender documents that solicit medical technologies for patient care in Canada, focusing on request for proposal (RFP) tenders that assess quality and cost, supplemented by a census of all tender types. We extracted data to assess (i) use of group purchasing organizations (GPOs) as buyers, (ii) evaluation criteria and rubrics, and (iii) contract terms, as indicators of supplier type and market conditions.
GPOs were dominant buyers for RFPs (54/97) and all tender types (120/226), and RFPs were the most common tender (92/226), with few price-only tenders (11/226). Evaluation criteria for quality were technical, including clinical or material specifications, as well as vendor experience and qualifications; “total cost” was frequently referenced (83/97), but inconsistently used. The most common (47/97) evaluative rubric was summed scores, or summed scores after excluding those below a mandatory minimum (22/97), with majority weight (64.1 percent, 62.9 percent) assigned to quality criteria. Where specified, expected contract lengths with successful suppliers were high (mean, 3.93 years; average renewal, 2.14 years), and most buyers (37/42) expected to award to a single supplier.
Procurement's evaluative approach is distinctive. While aiming to go beyond price in the acquisition of most medical technologies, it adopts a narrow approach to assessing quality and costs, but also attends to factors little considered by HTA, suggesting opportunities for mutual lesson learning.
Nutritional strategies to mitigate the negative effects of heat stress on animal welfare and productivity often involve changes in ration formulation. However, cattle commonly sort their ration in favour of certain components, and it is not clear how feed sorting responds to heat stress. This study investigated the association between heat stress and feed sorting behaviour. Lactating Holstein dairy cows (n = 32; parity = 2.8±1.2; mean±SD) were housed in a free stall barn and milked 3×/day. Cows were fed individually using the Calan Broadbent Feeding System and offered ad libitum access to a total mixed ration (containing on a dry matter basis: 3.3% ryegrass hay, 16.5% ryegrass baleage, 24.7% corn silage, 11.1% brewers grains, 19.7% ground corn, 19.8% concentrate and 4.9% protein/mineral supplement), provided 1×/day. Beginning at 186±60 days in milk, cows were exposed to either: heat stress conditions (HT; n = 15) (average temperature–humidity index: 77.6), or evaporative cooling (CL; n = 17), consisting of misters and fans over the freestall and feed bunks. Data were collected during a 4-day baseline period, and two 4-day experimental periods: starting at 10 days after implementing treatments (defined as acute heat stress for HT cows), and at 62 days after implementing treatments (defined as chronic heat stress for HT cows). Daily feed intake and physiological responses to heat stress (body temperature, respiration rate) were recorded. Samples of fresh and refused feed were collected daily from individual cows for particle size analysis. The particle size separator had three screens (19, 8 and 1.18 mm) and a bottom pan, resulting in 4 fractions (long, medium, short and fine particles). Feed sorting was calculated as the actual intake of each particle size fraction expressed as a percentage of the predicted intake of that fraction. During both heat stress periods, HT cows sorted for long particles more than CL cows (105.0% v. 100.6%; SE = 1.1). During acute heat stress, HT cows sorted to a greater extent than CL cows against medium and short particles, whereas sorting of these fractions did not differ during chronic heat stress. Body temperature and respiration rate were associated across treatments with the extent of sorting for long particles and against short particles during acute heat stress. These results suggest that feed sorting is particularly influenced during acute heat stress, and that sorting for longer particles may increase in heat stress.
Human skeletal remains constitute remarkably informative finds, both biologically and socioculturally. Their recovery, preservation, conservation, storage, and analysis are complex issues that need to be addressed within any given biocultural context. Given the country's geography and the long history of human occupation, Greek field archaeology is intense and ongoing, with both rescue and systematic excavations. Human burials are thus frequently encountered in excavations throughout Greece, resulting in the accumulation of osteological material. Some of the common challenges of bioarchaeological research in Greece consist of insufficient time, funding, and documentation in the field; unmet conservation needs and lack of storage space; as well as the long time-gap between excavation and analysis. Here, we give a brief overview of excavation, curation, and bioarchaeological practice within a Greek archaeological framework. We focus on the newly launched Phaleron Bioarchaeological Project on a vast necropolis from the wider Athens region in order to present our methodological approach. Finally, we consider the role of interdisciplinary collaboration in managing large-scale bioarchaeological projects and serving long-term heritage preservation goals.