Introduction: When a patient is incapable of making medical decisions for themselves, choices are made according to the patient's previously expressed, wishes, values, and beliefs by a substitute decision maker (SDM). While interventions to engage patients in their own advance care planning exist, little is known about public readiness to act as a SDM on behalf of a loved one. This mixed-methods survey aimed to describe attitudes, enablers and barriers to preparedness to act as a SDM, and support for a population-level curriculum on the role of an SDM in end-of-life and resuscitative care. Methods: From November 2017 to June 2018, a mixed-methods street intercept survey was conducted in Ottawa, Canada. Descriptive statistics and logistic regression analysis were used to assess predictors of preparedness to be a SDM and understand support for a high school curriculum. Responses to open-ended questions were analyzed using inductive thematic analysis. Results: The 430 respondents were mostly female (56.5%) with an average age of 33.9. Although 73.0% of respondents felt prepared to be a SDM, 41.0% of those who reported preparedness never had a meaningful conversation with loved ones about their wishes in critical illness. The only predictors of SDM preparedness were the belief that one would be a future SDM (OR 2.36 95% CI 1.34-4.17), and age 50-64 compared to age 16-17 (OR 7.46 95% CI 1.25-44.51). Thematic enablers of preparedness included an understanding of a patient's wishes, the role of the SDM and strong familial relationships. Barriers included cultural norms, family conflict, and a need for time for high stakes decisions. Most respondents (71.9%) believed that 16 year olds should learn about SDMs. They noted age appropriateness, potential developmental and societal benefit, and improved decision making, while cautioning the need for a nuanced approach respectful of different maturity levels, cultures and individual experiences. Conclusion: This study reveals a concerning gap between perceived preparedness and actions taken in preparation to be an SDM for loved ones suffering critical illness. The results also highlight the potential role for high school education to address this gap. Future studies should further explore the themes identified to inform development of resources and curricula for improved health literacy in resuscitation and end-of-life care.

Introduction: Oxygen is commonly administered to prehospital patients presenting with acute myocardial infarction (AMI). We conducted a systematic review to determine if oxygen administration, in AMI, impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central, clinicaltrials.gov and ISRCTN for relevant randomized controlled trials and observational studies comparing oxygen administration and no oxygen administration. The outcomes of interest were: mortality (≤30 days, in-hospital, and intermediate 2-11 months), infarct size, and major adverse cardiac events (MACE). Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. A meta-analysis was performed using RevMan 5 software. Results: Our search yielded 1192 citations of which 48 studies were reviewed as full texts and a total of 8 studies were included in the analysis. All evidence was considered low or very low quality. Five studies reported on mortality finding low quality evidence of no benefit or harm. Low quality evidence demonstrated no benefit or harm from supplemental oxygen administration. Similarly, no benefit or harm was found in MACE or infarct size (very low quality). Normoxia was defined as oxygen saturation measured via pulse oximetry at ≥90% in one recent study and ≥94% in another. Conclusion: We found low and very low quality evidence that the administration of supplemental oxygen to normoxic patients experiencing AMI, provides no clear harm nor benefit for mortality or MACE. The evidence on infarct size was inconsistent and warrants further prospective examination.

Introduction: Opioids are routinely administered for analgesia to prehospital patients experiencing chest discomfort from acute myocardial infarction (AMI). We conducted a systematic review to determine if opioid administration impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central and Clinicaltrials.gov for relevant randomized controlled trials and observational studies comparing opioid administration in AMI patients from 1990 to 2017. The outcomes of interest were: all-cause short-term mortality (≤30 days), major adverse cardiac events (MACE), platelet activity and aggregation, immediate adverse events, infarct size, and analgesia. Included studies were hand searched for additional citations. Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. Results: Our search yielded 3001 citations of which 19 studies were reviewed as full texts and a total of 9 studies were included in the analysis. The studies predominantly reported on morphine as the opioid. Five studies reported on mortality (≤30 days), seven on MACE, four on platelet activity and aggregation, two on immediate adverse events, two on infarct size and none on analgesic effect. We found low quality evidence suggesting no benefit or harm in terms of mortality or MACE. However, low quality evidence indicates that opioids increase infarct size. Low-quality evidence also shows reduced serum P2Y12 (eg: clopidogrel and ticagrelor) active metabolite levels and increased platelet reactivity in the first several hours post administration following an increase in vomiting. Conclusion: We find low and very low quality evidence that the administration of opioids in STEMI may be adversely related to vomiting and some surrogate outcomes including increased infarct size, reduced serum P2Y12 levels, and increased platelet activity. We found no clear benefit or harm on patient-oriented clinical outcomes including mortality.

Thermal analysts have exploited the sensitivity of carbonate mineral decomposition to furnace atmosphere as a diagnostic tool for identifying and quantifying these minerals in mixtures and solid solutions (1-3). However, thermal analysis techniques alone cannot reveal information about the reaction products after each thermal event. In-situ high temperature x-ray diffraction is one technique that can identify these products. Using this technique, Kissinger et al. (4) identified the reaction products of the thermal decomposition of reagent grade FeCO3 (siderite) and MgCO3 (magnesite). However, the thermal behavior of analytical reagent grade carbonates differs from natural minerals (1). Milodowski and Morgan (5) used in-situ XRD to investigate the thermal behavior of the dolomite-ankerite series.

The synchrotron x-ray source provides a unique opportunity to observe many “in-situ” processes. The formation of the “short-lived” intermediate species, Ta2C, during the combustion synthesis of TaC, has been observed and reported by monitoring the Bragg diffraction peaks of the reactants and products, Similarly, the synthesis of the ferroelectric material, BaTiO3, and subsequent phase transfonnation from cubic to tetragonal have also been investigated. These experiments would not have been possible without the high incident x-ray flux available at a synchrotron source.

Angiostrongylus cantonensis (rat lungworm), a parasitic nematode, is expanding its distribution. Human infection, known as angiostrongyliasis, may manifest as eosinophilic meningitis, an emerging infectious disease. The range and incidence of this disease are expanding throughout the tropics and subtropics. Recently, the Hawaiian Islands have experienced an increase in reported cases. This study addresses factors affecting the parasite's distribution and projects its potential future distribution, using Hawaii as a model for its global expansion. Specimens of 37 snail species from the Hawaiian Islands were screened for the parasite using PCR. It was present on five of the six largest islands. The data were used to generate habitat suitability models for A. cantonensis, based on temperature and precipitation, to predict its potential further spread within the archipelago. The best current climate model predicted suitable habitat on all islands, with greater suitability in regions with higher precipitation and temperatures. Projections under climate change (to 2100) indicated increased suitability in regions with estimated increased precipitation and temperatures, suitable habitat occurring increasingly at higher elevations. Analogously, climate change could facilitate the spread of A. cantonensis from its current tropical/subtropical range into more temperate regions of the world, as is beginning to be seen in the continental USA.

The present experimental investigation characterises the dynamic response and wake structure of a sinusoidally rotating circular cylinder with a low mass ratio (defined as the ratio of the total oscillating mass to the displaced fluid mass) undergoing cross-stream flow-induced vibration (FIV). The study covers a wide parameter space spanning the forcing rotary oscillation frequency ratio $0\leqslant f_{r}^{\ast }\leqslant 4.5$ and the forcing rotation speed ratio $0\leqslant \unicode[STIX]{x1D6FC}_{r}^{\ast }\leqslant 2.0$ , at reduced velocities associated with the vortex-induced vibration (VIV) upper and lower amplitude response branches. Here, $f_{r}^{\ast }=f_{r}/f_{nw}$ and $\unicode[STIX]{x1D6FC}_{r}^{\ast }=\unicode[STIX]{x1D6FA}_{o}D/(2U)$ , where $f_{r}$ is the forcing rotary oscillation frequency, $f_{nw}$ is the natural frequency of the system in quiescent fluid (water), $\unicode[STIX]{x1D6FA}_{o}$ is the peak angular rotation speed, $D$ is the cylinder diameter and $U$ is the free-stream velocity; the reduced velocity is defined by $U^{\ast }=U/(\,f_{nw}D)$ . The fluid–structure system was modelled using a low-friction air-bearing system in conjunction with a free-surface recirculating water channel, with axial rotary motion provided by a microstepping motor. The cylinder was allowed to vibrate with only one degree of freedom transverse to the oncoming free-stream flow. It was found that in specific ranges of $f_{r}^{\ast }$ , the body vibration frequency may deviate from that seen in the non-rotating case and lock onto the forcing rotary oscillation frequency or its one-third subharmonic. The former is referred to as the ‘rotary lock-on’ (RLO) region and the latter as the ‘tertiary lock-on’ (TLO) region. Significant increases in the vibration amplitude and suppression of VIV could both be observed in different parts of the RLO and TLO regions. The peak amplitude response in the case of $U^{\ast }=5.5$ (upper branch) was observed to be $1.2D$ , an increase of approximately $50\,\%$ over the non-rotating case, while in the case of $U^{\ast }=8.0$ (lower branch), the peak amplitude response was $2.2D$ , a remarkable increase of $270\,\%$ over the non-rotating case. Notably, the results showed that the amplitude responses at moderate Reynolds numbers ( $Re=UD/\unicode[STIX]{x1D708}=2060$ and $2940$ , where $\unicode[STIX]{x1D708}$ is the kinematic viscosity of the fluid) in the present study showed significant differences from those of a previous low-Reynolds-number ( $Re=350$ ) numerical study at similar reduced velocities by Du & Sun (Phys. Fluids, vol. 14 (8), 2015, pp. 2767–2777). Remarkably, in an additional study examining the cylinder vibration as a function of $U^{\ast }$ while the fixed forcing rotary oscillation parameters were kept constant at $(f_{r}^{\ast },\unicode[STIX]{x1D6FC}_{r}^{\ast })=(1.0,1.0)$ , the cylinder experienced substantially larger oscillations than in the non-rotating case, and a rotation-induced galloping response was observed for $U^{\ast }>12$ , where the amplitude increased monotonically to reach approximately $3.0D$ at the highest reduced velocity ( $U^{\ast }=20$ ) tested. Furthermore, new wake modes were identified in the RLO and TLO regions using particle image velocimetry measurements at selected points in the $f_{r}^{\ast }-\unicode[STIX]{x1D6FC}_{r}^{\ast }$ parameter space.

The main goal of this paper is to provide insights into swash flow dynamics, generated by a non-breaking solitary wave on a steep slope. Both laboratory experiments and numerical simulations are conducted to investigate the details of runup and rundown processes. Special attention is given to the evolution of the bottom boundary layer over the slope in terms of flow separation, vortex formation and the development of a hydraulic jump during the rundown phase. Laboratory experiments were performed to measure the flow velocity fields by means of high-speed particle image velocimetry (HSPIV). Detailed pathline patterns of the swash flows and free-surface profiles were also visualized. Highly resolved computational fluid dynamics (CFD) simulations were carried out. Numerical results are compared with laboratory measurements with a focus on the velocities inside the boundary layer. The overall agreement is excellent during the initial stage of the runup process. However, discrepancies in the model/data comparison grow as time advances because the numerical model does not simulate the shoreline dynamics accurately. Introducing small temporal and spatial shifts in the comparison yields adequate agreement during the entire rundown process. Highly resolved numerical solutions are used to study physical variables that are not measured in laboratory experiments (e.g. pressure field and bottom shear stress). It is shown that the main mechanism for vortex shedding is correlated with the large pressure gradient along the slope as the rundown flow transitions from supercritical to subcritical, under the developing hydraulic jump. Furthermore, the bottom shear stress analysis indicates that the largest values occur at the shoreline and that the relatively large bottom shear stress also takes place within the supercritical flow region, being associated with the backwash vortex system rather than the plunging wave. It is clearly demonstrated that the combination of laboratory observations and numerical simulations have indeed provided significant insights into the swash flow processes.

Background: Recruiting family physicians into primary care research studies requires researchers to continually manage information coming in, going out, and coming in again. In many research groups, Microsoft Excel and Access are the usual data management tools, but they are very basic and do not support any automation, linking, or reminder systems to manage and integrate recruitment information and processes. Objective: We explored whether a commercial customer relationship management (CRM) software program – designed for sales people in businesses to improve customer relations and communications – could be used to make the research recruitment system faster, more effective, and more efficient. Findings: We found that while there was potential for long-term studies, it simply did not adapt effectively enough for our shorter study and recruitment budget. The amount of training required to master the software and our need for ongoing flexible and timely support were greater than the benefit of using CRM software for our study.

While flow-induced vibration of bluff bodies has been extensively studied over the last half-century, only limited attention has been given to flow-induced vibration of elastically mounted rotating cylinders. Since recent low-Reynolds-number numerical work suggests that rotation can enhance or suppress the natural oscillatory response, the former could find applications in energy harvesting and the latter in vibration control. The present experimental investigation characterises the dynamic response and wake structure of a rotating circular cylinder undergoing vortex-induced vibration at a low mass ratio ( $m^{\ast }=5.78$ ) over the reduced velocity range leading to strong oscillations. The experiments were conducted in a free-surface water channel with the cylinder vertically mounted and attached to a motor that provided constant rotation. Springs and an air-bearing system allow the cylinder to undertake low-damped transverse oscillations. Under cylinder rotation, the normalised frequency response was found to be comparable to that of a freely vibrating non-rotating cylinder. At reduced velocities consistent with the upper branch of a non-rotating transversely oscillating cylinder, the maximum oscillation amplitude increased with non-dimensional rotation rate up to $\unicode[STIX]{x1D6FC}\approx 2$ . Beyond this, there was a sharp decrease in amplitude. Notably, this critical value corresponds approximately to the rotation rate at which vortex shedding ceases for a non-oscillating rotating cylinder. Remarkably, at $\unicode[STIX]{x1D6FC}=2$ there was approximately an 80 % increase in the peak amplitude response compared to that of a non-rotating cylinder. The observed amplitude response measured over the Reynolds-number range of ( $1100\lesssim Re\lesssim 6300$ ) is significantly different from numerical predictions and other experimental results recorded at significantly lower Reynolds numbers.

Objectives: The present study examined differences in neurocognitive outcomes among non-Hispanic Black and White stroke survivors using the NIH Toolbox-Cognition Battery (NIHTB-CB), and investigated the roles of healthcare variables in explaining racial differences in neurocognitive outcomes post-stroke. Methods: One-hundred seventy adults (91 Black; 79 White), who participated in a multisite study were included (age: M=56.4; SD=12.6; education: M=13.7; SD=2.5; 50% male; years post-stroke: 1–18; stroke type: 72% ischemic, 28% hemorrhagic). Neurocognitive function was assessed with the NIHTB-CB, using demographically corrected norms. Participants completed measures of socio-demographic characteristics, health literacy, and healthcare use and access. Stroke severity was assessed with the Modified Rankin Scale. Results: An independent samples t test indicated Blacks showed more neurocognitive impairment (NIHTB-CB Fluid Composite T-score: M=37.63; SD=11.67) than Whites (Fluid T-score: M=42.59, SD=11.54; p=.006). This difference remained significant after adjusting for reading level (NIHTB-CB Oral Reading), and when stratified by stroke severity. Blacks also scored lower on health literacy, reported differences in insurance type, and reported decreased confidence in the doctors treating them. Multivariable models adjusting for reading level and injury severity showed that health literacy and insurance type were statistically significant predictors of the Fluid cognitive composite (p<.001 and p=.02, respectively) and significantly mediated racial differences on neurocognitive impairment. Conclusions: We replicated prior work showing that Blacks are at increased risk for poorer neurocognitive outcomes post-stroke than Whites. Health literacy and insurance type might be important modifiable factors influencing these differences. (JINS, 2017, 23, 640–652)

As part of a multi-wavelength study, we report on a 50 ks Chandra/ACIS observation of the Guitar Nebula, a bow shock nebula associated with the radio pulsar B2224+65. We see a “hot spot” at the tip of the bow shock. We also notice a “jet” of X-ray emission at position angle (PA) −69°. However, the proper motion of the pulsar and the axis of optical emission is at PA 52°.1. We discuss the resulting interpretations of the relativistic pulsar wind and the surrounding ISM.

Plasmodium knowlesi a simian malaria parasite is currently affecting humans in Southeast Asia. Malaysia has reported the most number of cases and P. knowlesi is the predominant species occurring in humans. The vectors of P. knowlesi belong to the Leucosphyrus group of Anopheles mosquitoes. These are generally described as forest-dwelling mosquitoes. With deforestation and changes in land-use, some species have become predominant in farms and villages. However, knowledge on the distribution of these vectors in the country is sparse. From a public health point of view it is important to know the vectors, so that risk factors towards knowlesi malaria can be identified and control measures instituted where possible. Here, we review what is known about the knowlesi malaria vectors and ascertain the gaps in knowledge, so that future studies could concentrate on this paucity of data in-order to address this zoonotic problem.

Carbapenem-resistant Acinetobacter baumannii (CRAB) with diverse multilocus sequence typing emerged among our nursing home residents (6.5%) with a high background rate of MRSA (32.2%). Rectal swabs yielded a higher rate of CRAB detection than axillary or nasal swabs. Bed-bound status, use of adult diapers, and nasogastric tube were risk factors for CRAB colonization.

Infect Control Hosp Epidemiol 2016;37:983–986

The use of computer simulations in professional rehabilitation counselling training has received considerable attention in recent years. Most notably, computer-based rehabilitation case management simulations have been developed for teaching and evaluating clinical problem solving skills of rehabilitation counselling trainees. However, a major problem confronting the use of computer simulations in professional rehabilitation training is the lack of quantification procedures for measuring performance on computer simulations. A current approach involves the computation of proficiency and efficiency indices as performance feedback measures. The purpose of this paper, however, is to demonstrate the potential problems with using these two indices as feedback mechanisms in computer simulations and to present an alternative quantification procedure for measuring and providing feedback about trainee performance on computer-based case management simulations.