There are numerous challenges pertaining to epilepsy care across Ontario, including Epilepsy Monitoring Unit (EMU) bed pressures, surgical access and community supports. We sampled the current clinical, community and operational state of Ontario epilepsy centres and community epilepsy agencies post COVID-19 pandemic. A 44-item survey was distributed to all 11 district and regional adult and paediatric Ontario epilepsy centres. Qualitative responses were collected from community epilepsy agencies. Results revealed ongoing gaps in epilepsy care across Ontario, with EMU bed pressures and labour shortages being limiting factors. A clinical network advising the Ontario Ministry of Health will improve access to epilepsy care.

Introduction: Paramedics commonly administer intravenous dextrose to severely hypoglycemic patients. Typically, the treatment provided is a 25g ampule of 50% dextrose (D50). This dose of D50 is meant to ensure a return to consciousness. However, this dose may be unnecessary and lead to harm or difficulties regulating blood glucose post treatment. We hypothesize that a lower dose such as dextrose 10% (D10) or titrating the D50 to desired level of consciousness may be optimal and avoid adverse events. Methods: We systematically searched Medline, Embase, CINAHL and Cochrane Central on June 5th 2019. PRISMA guidelines were followed. The GRADE methods and risk of bias assessments were applied to determine the certainty of the evidence. We included primary literature investigating the use of intravenous dextrose in hypoglycemic diabetic patients presenting to paramedics or the emergency department. Outcomes of interest were related to the safe and effective reversal of symptoms and blood glucose levels (BGL). Results: 660 abstracts were screened, 40 full text articles, with eight studies included. Data from three randomized controlled trials and five observational studies were analyzed. A single RCT comparing D10 to D50 was identified. The primary significant finding of the study was an increased post-treatment glycemic profile by 3.2 mmol/L in the D50 group; no other outcomes had significant differences between groups. When comparing pooled data from all the included studies we find higher symptom resolution in the D10 group compared to the D50 group; at 99.8% and 94.9% respectively. However, the mean time to resolution was approximately 4 minutes longer in the D10 group (4.1 minutes (D50) and 8 minutes (D10)). There was more need for subsequent doses in the D10 group at 23.0% versus 16.5% in the D50 group. The post treatment glycemic profile was lower in the D10 group at 5.9 mmol/L versus 8.5 mmol/L in the D50 group. Both treatments had nearly complete resolution of hypoglycemia; 98.7% (D50) and 99.2% (D10). No adverse events were observed in the D10 group (0/871) compared to 12/133 adverse events in the D50 group. Conclusion: D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia. Although the desired effect can take several minutes longer there appear to be fewer adverse events. The post treatment glycemic profile may facilitate less challenging ongoing glucose management by the patients.

Introduction: The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated Emergency Medical Services (EMS) evidence repository. This summary describes the research evidence for the identification and management of adult patients suffering from sepsis syndrome or septic shock. Methods: PubMed was searched in a systematic manner. One author reviewed titles and abstracts for relevance and two authors appraised each study selected for inclusion. Primary outcomes were extracted. Studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and a three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing findings based on the studies’ primary outcome for each intervention). LOE and DOE of each intervention were plotted on an evidence matrix (DOE x LOE). Results: Eighty-eight studies were included for 15 interventions listed in PEP. The interventions with the most evidence were related to identification tools (ID) (n = 26, 30%) and early goal directed therapy (EGDT) (n = 21, 24%). ID tools included Systematic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA) and other unique measures. The most common primary outcomes were related to diagnosis (n = 30, 34%), mortality (n = 40, 45%) and treatment goals (e.g. time to antibiotic) (n = 14, 16%). The evidence rank for the supported interventions were: supportive-high quality (n = 1, 7%) for crystalloid infusion, supportive-moderate quality (n = 7, 47%) for identification tools, prenotification, point of care lactate, titrated oxygen, temperature monitoring, and supportive-low quality (n = 1, 7%) for vasopressors. The benefit of prehospital antibiotics and EGDT remain inconclusive with a neutral DOE. There is moderate level evidence opposing use of high flow oxygen. Conclusion: EMS sepsis interventions are informed primarily by moderate quality supportive evidence. Several standard treatments are well supported by moderate to high quality evidence, as are identification tools. However, some standard in-hospital therapies are not supported by evidence in the prehospital setting, such as antibiotics, and EGDT. Based on primary outcomes, no identification tool appears superior. This evidence analysis can guide selection of appropriate prehospital therapies.

A pollen profile obtained from lake sediments at Lunkaransar, Rajasthan, in northwest India was used along with a pollen-climate calibration function to estimate past precipitation. Between 10,500 and 3500 yr B.P., the estimated precipitation was about 500 mm/yr, or about 200 mm/yr above the modern value. A model was used for the energy and hydrologic budget of a lake basin and lake at Sambhar (located 240 km SE of Lunkaransar) to calculate that a 200 mm/yr increase in rainfall above the modern amount would have raised the lake level about 20 m above the modern level. Topographic charts and satellite imagery provided some evidence in support of an enlarged paleolake of that elevation, but field exploration would be required to confirm the size and date of a former lake. After about 3500 yr B.P., the Lunkaransar profile indicated a desiccated lake bed; because no pollen was preserved, the pollen-climate calibration function was of no use for estimating the amount of the precipitation decline. A reduction of precipitation of about 200 mm/yr below the modern amount was estimated from the energy and hydrologic budget for paleolake Sambhar by assuming that the lake was one-tenth of its present size during the dry interval.

Four cores from Lake Mendota in the Yahara River valley of south-central Wisconsin provide pollen, charcoal, and sediment-year. Derived estimates of stratigraphic evidence of a middle Holocene dry period in the northern Midwest. The lake level was lower between about 6500 and 3500 yr B.P. indicating that runoff from the upper Yahara River basin may have ceased during the drier seasons of the precipitation between 6500 and 3500 yr B.P. indicate a decrease of about 10% (down to about 700 mm) from the present precipitation value of 800 mm. A warming between 6500 and 3500 yr B.P. is also interpreted based on a change of vegetation from rich mesophytic forest before 6500 yr B.P. to Quercus savanna, with increased charcoal abundances after that time. After 3500 yr B.P., a closed Quercus forest and decreased charcoal suggest a cooler and wetter climate. The qualitative paleoecological interpretations, quantitative precipitation reconstructions based on pollen from the region (including the Lake Mendota data), and estimates of hydrologic budget based on lake-level changes, all show indications of a dry and warm middle Holocene. Evidence from a large regional array of sites also supports these interpretations.

The energy transfer by stimulated Brillouin backscatter from a long pump pulse (15 ps) to a short seed pulse (1 ps) has been investigated in a proof-of-principle demonstration experiment. The two pulses were both amplified in different beamlines of a Nd:glass laser system, had a central wavelength of 1054 nm and a spectral bandwidth of 2 nm, and crossed each other in an underdense plasma in a counter-propagating geometry, off-set by $\def \xmlpi #1{}\def \mathsfbi #1{\boldsymbol {\mathsf {#1}}}\let \le =\leqslant \let \leq =\leqslant \let \ge =\geqslant \let \geq =\geqslant \def \Pr {\mathit {Pr}}\def \Fr {\mathit {Fr}}\def \Rey {\mathit {Re}}10^\circ $. It is shown that the energy transfer and the wavelength of the generated Brillouin peak depend on the plasma density, the intensity of the laser pulses, and the competition between two-plasmon decay and stimulated Raman scatter instabilities. The highest obtained energy transfer from pump to probe pulse is 2.5%, at a plasma density of $0.17 n_{cr}$, and this energy transfer increases significantly with plasma density. Therefore, our results suggest that much higher efficiencies can be obtained when higher densities (above $0.25 n_{cr}$) are used.

Length 2.5 mm., width 1.1 mm. Pronotum and elytra equal in width, sides straight and parallel, elytra arcuately narrowed on the caudal third, very broadly obtuse behind; dark reddish brown; pubescence sparse, erect and yellow, more evident about the apex of the pronotum and on the elytral declivity.

The head has the frons broadly, feebly convex, the median line feebly carinate with a narrow, transverse epistomal impression, the entire surface subopaque from minute reticulations, marked with sparse, coarse, shallow punctures with minute setae on the caudal half, more finely and closely granulatepunctate in front, the punctures bearing long yellow hairs erect on the frons, longer and recumbent from the transverse impression, forming the epistomal fringe, the epistomal margin smooth, narrow and feebly elevated; the eyes with a deep triangular emargination.