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Introduction: Emergency Department (ED) overcrowding has been shown to delay time sensitive tests and therapies. North American guidelines call for Door-to ECG (DTE) times to be <10min in patients presenting with chest pain as delays have been shown to lead to poorer patient outcomes. We hypothesize that increased ED crowding will increase the DTE times. Methods: This was a retrospective cohort study from July 2015-May 2016 at a single tertiary care Canadian ED (53000 visits per year). Data were extracted from the ED information system (EDIS) which contains an organized record of ED activity for each visit. Our selection criteria screened for patients presenting with complaints that included chest pain, chest heaviness, chest tightness and chest burning. The primary outcome of the study was the association between ED occupancy and DTE time, which was measured using a non-parametric Spearman correlation. Multivariable linear regression models controlling for age and sex were developed for both time in minutes, and the log transformed time in minutes. Results: There were 2479 ECGs done on patients presenting with chest pain that met inclusion criteria. The median DTE time was 55.1 minutes. There was a significant positive association between DTE time and ED occupancy (rho=.133, p<0.001). DTE time increased by 0.64 minutes (or approximately 0.4%) for each additional patient in the ED, p<0.001. Additionally, younger age and female sex were also associated with increased DTE time. Conclusion: Increased ED occupancy was correlated with longer DTE times at a single Canadian ED, even after controlling for age and sex. This study provides an example of the negative consequences of ED overcrowding.
Introduction: Despite strong evidence that antithrombotic drugs in atrial fibrillation/flutter (AF) patients reduce stroke risk, previous emergency department (ED) pre-novel anticoagulant (NOAC) studies have shown that most discharged patients are not optimally treated. This study sought to determine baseline antithrombotic management in AF patients, and appropriate antithrombotic prescription upon ED discharge since the introduction of NOACs. Methods: Consecutive AF patients discharged by the ED physician from three academic EDs in Toronto, Canada were retrospectively identified using ECG data. Primary AF was defined as AF in patients ≥18 years without congenital heart disease or other acute medical conditions. All management and disposition decisions were left to the discretion of the emergency doctor. Results: From July 2012 to October 2014, 691 patients with primary AF were identified. Of these, 34.4% (n=238) had new onset AF and 66.4% (n=459) were discharged home directly from the ED. Of those with previously known AF (n= 453), 44.2% (n=200) were on anticoagulation at ED arrival (warfarin 59.5%, dabigatran 23.0%, rivaroxaban 11.5%); 25.6% (n=116) on antiplatelets, and 29 (6.4%) on both. Based on 2012 Canadian AF guidelines, 60.1% of those who should have received anticoagulation were receiving it. In discharged patients meeting de novo criteria for anticoagulation (n=130), 20.0% (n=26) were started on anticoagulation and 23.1% (n=30) on antiplatelets. In patients with CHADS2 score ≥ 2 (n=61), 26.2% (n=16) were started on anticoagulation. Warfarin (73.1%) was most commonly prescribed followed by dabigatran (15.4%) and rivaroxaban (11.5%). Age was the only inverse independent predictor for appropriate anticoagulation (OR 0.92 per 5 year of age 95% CI 0.89-0.95, p <0.0001) i.e. older patients were less likely to be anticoagulated. The CHADS2 score was not an independent predictor of appropriate anticoagulation. Conclusion: Our study shows a persistent gap in the antithrombotic treatment of ED AF patients irrespective of their risk.
How does one communicate in a multilingual society with staggering linguistic diversity? To best characterize the multifaceted dimensions of multilingual communication in India, this chapter will focus on the contemporary and historical study of Hindi–Urdu and Indian English, and their spread in intranational diasporic contexts (e.g., from North to South India) and international diasporic contexts (particularly in South-East Asia). The chapter argues that multilingualism in India is shaped primarily by natural forces of networking and communication (e.g., media, literature, trade, multiple identities, etc.) rather than being the result of exclusive and externally imposed models based on government planning. Shaped by such natural forces, linguistic accommodation with multiple dimensions plays a key role in the formation of the linguistic and transactional characteristics of Hindi–Urdu in intranational and international contexts (as well as English).
Soybean is a leading oilseed crop in India, which contains about 40% of protein and 20% of oil. Core collection will accelerate the management and utilization of soybean genetic resources in breeding programmes. In the present study, eight agromorphological traits of 3443 soybean germplasm were analysed for the development of core collection using the principal component score (PCS) strategy and the power core method. The PCS strategy yielded core collection (CC1) of 576 accessions, which accounted for 16.72% of the entire collection (EC). The analysis based on the power core programme resulted in CC2 of 402 accessions, which accounted for 11.67% of the EC. Statistical analysis showed similar trends for the mean and range estimated in both core collections and EC. In addition, the variance, standard deviation and coefficient of variance were in general higher in core collections than in the EC. The correlations observed in the EC in general were preserved in core collections. A total of 311 and 137 unique accessions were found in CC1 and CC2 in addition to 265 accessions that were found to be common in both core collections. These 265 common accessions were the most diverse core sets, which accounted for 7.64% of the EC. We proposed to constitute an integrated core collection (ICC) by integrating both common and unique accessions. The ICC comprised 713 accessions, which accounted for about 20.62% of the EC. Statistical analysis indicated that the ICC captured maximum variation than CC1 and CC2. Therefore, the ICC can be extensively evaluated for a large number of economically important traits for the identification of desirable genotypes and for the development of mini core collection in soybean.
Nano-graphite oxide has been synthesized from graphite flakes using modified Hummer’s method. Fourier transform infrared (FT-IR) data, x-ray diffraction (XRD) and transmission electron microscopy (TEM) revealed functionalization of the synthesised nano-graphitic platelets with oxygenated bonds. Using thermal embedding technique for the fabrication of self-assembled films, electrodes of nano-graphite oxide have been fabricated for enzyme free detection of cholesterol electrochemically. The electrodes provided a linear response for the enzyme less detection in the range of 50mg/dl to 500mg/dl with a correlation coefﬁcient, R, of 0.99784 and sensitivity of 1.0587 µA/mg.
We studied the safety of use of acute reperfusion therapies in patients with stroke- on- awakening using a computed tomographic angiography (Cta) based large vessel occlusion-good scan paradigm in clinical routine.
the Cta database of the Calgary stroke program was reviewed for the period January 2003-March 2010. patients with stroke-on-awakening with large artery occlusions on Cta, who received conservative, iV thrombolytic and/or endovascular treatment at discretion of the attending stroke neurologist were analyzed. time of onset was defined by the time last seen or known to be normal. Baseline non-contrast Ct scan (nCCt) alberta Stroke program early Ct Score (aSpeCtS) > 7 was considered a good scan. hemorrhage was defined on follow-up brain imaging using eCaSS 3 criteria. independence (mrS≤2) at three months was considered a good clinical outcome. Standard descriptive statistics and multivariable analysis were done.
among 532 patients with large artery occlusions, 70 patients with stroke-on-awakening (13.1%) were identified. the median age was 69.5 (iQr 24) and 41 (58.6%) were female; 41 (58.6%) received anti-platelets only and 29 (41.4%) received thrombolytic treatment [iV-12 (17.1%), iV/ia-12 (17.1%) and ia-5(7.1%)]. unadjusted analysis showed that baseline nCCt aSpeCtS ≤ 7 (p=0.002) and higher nihSS scores (p=0.018) were associated with worse outcomes. there were no ph2 hemorrhages in the iV thrombolytic or endovascular treated group. functional outcome was not different by treatment.
When carefully selected using Ct –Cta, by a good scan (aSpeCtS > 7) occlusion paradigm, acute reperfusion therapies in patients with stroke-on-awakening can be performed safely in clinical routine.
For over three decades, bone conduction hearing aids have been changing the lives of patients with impaired hearing. The size, appearance and fitting discomfort of early generations of bone conduction hearing aids made them unpopular. The advent of bone-anchored hearing aids in the 1970s offered patients improved sound quality and fitting comfort, due to the application of osseointegration. However, the issue of post-operative peri-abutment pin tract wound infection persisted. The Bonebridge system incorporates the first active bone conduction device, and aims to resolve peri-abutment issues. Implantation of this system in an Asian patient is presented.
The objective of this work is to examine the feasibility of electrically conductive hydrogel composites as scaffolds in tissue engineering and tissue regeneration, and to understand the properties of the composites as a growth matrix for clinically relevant cell lines. The composite is comprised of carbon nanobrushes embedded in a biocompatible poloxamer gel. This work assesses the ability of such composite gels to support the growth of fibroblasts and myocytes and eventually serve as a matrix to stimulate wound closure. In such a model, fibroblasts and myocytes are seeded on the hydrogel and bathed in culture medium. The experimental model assesses the ability of fibroblasts and myocytes to grow into and adhere to the gel. The work demonstrates that carbon nanobrushes can be dispersed within poloxamer gels, and that fibroblasts and myocytes can proliferate within homogenously dispersed carbon nanobrush-containing poloxamer gels. This work also examines the effects of carbon nanobrush content on the rheological properties of the poloxamer gel matrix and shows an improvement in several areas in the presence of carbon nanobrushes. Future work will examine the effects of design parameters such as carbon nanobrush content and matrix structure on wound healing, as well as the growth of tendons and other cell lines within the hydrogel composites. This work has relevance for tissue and cellular engineering and tissue regeneration in clinical medicine.
The concept of Business English has undergone some major shifts in the last few years because of a number of developments, such as advances in genre theory and the coming together of English for Business Purposes and Business Communication, inspired by the realization that there is a gap to be bridged between the academy and the globalized business world. Drawing on advances in the analysis of business discourses, especially in applied genre analysis, this state-of-the-art review revisits the frameworks currently used in English for Business Purposes and Business Communication (or, more generally, Professional Communication) to suggest an integration of the two approaches for the design of English for Business Communication (EBC) programmes. The study incorporates an extensive review of much of the relevant published work in all the three areas mentioned above to identify some of the main issues in EBC, and illustrates a gradual shift in the rationale for the design and implementation of EBC programmes.
We describe the fabrication and structure of nanoscale thin films of β phase shape memory alloys with the nominal atomic stoichiometry Au7Cu5Al4 (corresponding to 5.8 wt% Al). These alloys possess properties that suggest they could be used in nanoscale actuators. The films described here are between 20 and 50 nm thick which is below the thickness at which some other shape memory alloys cease to transform. However, microstructural and X-ray studies confirm that the coatings still exhibit the displacive transformations that are a prerequisite for the shape memory effect.
The integration of simulation into a medical postgraduate curriculum requires informed implementation in ways that take advantage of simulation's unique ability to facilitate guided application of new knowledge. It requires review of all objectives of the training program to ensure that each of these is mapped to the best possible learning method. To take maximum advantage of the training enhancements made possible by medical simulation, it must be integrated into the learning environment, not simply added on. This requires extensive reorganization of the resident didactic schedule.
Simulation planning is supported by clear learning objectives that define the goals of the session, promote learner investment in active participation and allow for structured feedback for individual growth. Teaching to specific objectives using simulation requires an increased time commitment from teaching faculty and careful logistical planning to facilitate flow of learners through a series of simulations in ways that maximize learning. When applied appropriately, simulation offers a unique opportunity for learners to acquire and apply new knowledge under direct supervision in ways that complement the rest of the educational curriculum. In addition, simulation can improve the learning environment and morale of residents, provide additional methods of resident evaluation, and facilitate the introduction of new technologies and procedures into the clinical environment.
The effects of neutral gas friction, on the Rayleigh–Taylor instability of an infinitely conducting plasma of variable density, with ion viscosity and Hall currents, are investigated. For an ambient horizontal magnetic field, it is shown that the solution is characterized by a variational principle. Making use of the existence of this, proper solutions are obtained for a semi-infinite plasma, in which the density is stratified exponentially along the vertical, confined between two planes. In the simultaneous presence of the effects of ion viscosity and Hall currents, it is found that the potentially unstable stratification is unstable for all wavenumber perturbations, irrespective of whether or not the effects of neutral gas friction are included. Further, it is found that the growth rate increases with both Hall currents and neutral gas friction, and decreases with ion viscosity. The influence of the Hall currents and the neutral gas friction, therefore, is destabilizing, while that of ion viscosity is stabilizing. In the absence of Hall currents, it is found that the viscous plasma is stable, even for a potentially unstable stratification, for perturbations confined to a cone about the magnetic field vector. The angle of the cone of stable propagation of an inviscid plasma,. however, decreases with both Hall currents and effects of neutral gas friction.
The gravitational instability of a two-component plasma has been studied here to include simultaneously the effects of neutral gas friction, finite ion Larmor radius, magnetic resistivity and Hall currents. The viscosities of the two components of the plasma have also been taken into account. The mode of the transverse as well as the longitudinal wave propagation have been discussed. The dispersion relations have been obtained for both these cases and numerical calculations have been performed to obtain the dependence of the growth rate of the gravitationally unstable mode on the various physical parameters involved. For the transverse mode of propagation, it is found that the growth rate of the unstable mode increases with magnetic resistivity and with the ratio of the densities of two components. The influence of the magnetic resistivity is, therefore, destabilizing on this mode of wave propagation. The viscosities of the two components are found to have a stabilizing influence on the growth rate in this case since it is found that the increase of hte viscosity effects reduces the growth rate. For the longitudinal mode also it is found that the effects of viscosities as well as that of neutral gas friction are stabilizing. The magnetic resistivity does not affect the growth rate since the equation determining the growth rate is found to be independent of this effect.
The energetic anti-loss-cone electrons can drive a low-frequency electrostatic instability, propagating transverse to the ambient magnetic field, in the presence of a cold plasma. The typical real frequency and growth rates associated with this instabifity are respectively, of the order of (ωp being the proton cyclotron frequency). The instability has a transverse wavelength ⋍10ρe (ρe being the Larmor radius of energetic electrons). For the parameters pertinent to auroral plasma at 1RE, the quasi-linear analysis shows that the instability can give rise to an oscillating electric field Esat ⋍0.5−25 mV/ m and an increase of 100–103 K in the temperature of cold electrons. The instability may be relevant to recent observations of low-frequency turbulence on the auroral field lines.
It is shown that both lower hybrid and modified electron acoustic instabilities can be excited in a hot anti-loss-cone plasma co-existing with a rarefied cold plasma, provided the anti-loss-cone factor, ρ, exceeds a value Tm/Tt, where Tm and Tt are the parallel temperatures of missing and trapped electrons respectively. These instabilities are excited in a bounded range of wavenumbers and the growth rates are enhanced with the increase of cold plasma density. For
Tm/Tt < ρ > (Tm/Tt)½
both the instabilities are of resonant type whereas for ρ > (Tm/Tt)½ both may be converted into non-resonant types. These instabilities are expected to give rise to the heating of protons as well as electrons in the magnetosphere beyond the plasmapause.
The dynamic stability of a stratified layer of partially ionized compressible plasma is discussed to investigate the effects of finite electrical conductivity and ion viscosity. The prevailing magnetic field is assumed to be uniform and vertical. For a semi-infinite plasma having a one-dimensional exponential density gradient along the vertical, the dispersion relation has been obtained by variational methods. It is found that the ion viscosity and ion–neutral collisions, whether included jointly or separately, do not change the stability criterion of the perfectly conducting system. Their inclusion, however, has a tendency to reduce the growth rate of the unstable perturbations showing that they have a stabilizing influence. On the other hand the inclusion of the effects of finite resistivity and compressibility of the medium is found to be destabilizing as the wavenumber range over which the plasma would otherwise be stable, becomes unstable.