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Most inpatient clinicians have little problem recognizing classic mania, as it presents with a familiar complex of signs and symptoms: elation, expansiveness, rapid speech with flight of ideas, grandiosity, spending sprees, and hypersexuality . A manic episode can usually be differentiated from a psychotic break in schizophrenia in that many manic patients will exhibit people-seeking behavior as well as an overall quality of overactivation (Table 3.1). However, this pattern of acute euphoric mania may be less common than in the past. Increasingly, patients require hospitalization for manic symptoms combined with irritability, suicidal preoccupations, and dysphoric mood (in the older literature, in fact, this syndrome was termed “dysphoric mania”). This is the so-called mixed state, which – depending on one’s definition – 40% of bipolar patients will experience at some point in their clinical course .
Cricothyrotomy is an intervention performed to salvage “can't intubate, can't ventilate” situations. Studies have shown poor accuracy with landmarking the cricothyroid membrane, particularly in female patients by surgeons and anesthesiologists. This study examines the perceived versus actual success rate of landmarking the cricothyroid membrane by resident and staff emergency physicians using obese and non-obese models.
Five male and female volunteers were models. Each model was placed supine, and a point-of-care ultrasound expert landmarked the borders of each cricothyroid membrane; 20 residents and 15 staff emergency physicians were given one attempt to landmark five models. Overall accuracy and accuracy stratified by sex and obesity status were calculated.
Overall landmarking accuracy amongst all participants was 58% (SD 18%). A difference in accuracy was found for obese males (88%) versus obese females (40%) (difference = 48%, 95% CI = 30–65%, p < 0.0001), and non-obese males (77%) versus non-obese females (46%) (difference = 31%, 95% CI = 12–51%, p = 0.004). There was no association between perceived difficulty and success (correlation = 0.07, 95% CI = −0.081–0.214, p = 0.37). Confidence levels overall were higher amongst staff physicians (3.0) than residents (2.7) (difference = 0.3, 95% CI = 0.1–0.6, p = 0.02), but there was no correlation between confidence in an attempt and its success (p = 0.33).
We found that physicians demonstrate significantly lower accuracy when landmarking cricothyroid membranes of females. Emergency physicians were unable to predict their own accuracy while landmarking, which can potentially lead to increased failed attempts and a longer time to secure the airway. Improved training techniques may reduce failed attempts and improve the time to secure the airway.
Since the introduction of the logarithmic law of the wall more than 80 years ago, the equation for the mean velocity profile in turbulent boundary layers has been widely applied to model near-surface processes and parameterize surface drag. Yet the hypothetical turbulent eddies proposed in the original logarithmic law derivation and mixing length theory of Prandtl have never been conclusively linked to physical features in the flow. Here, we present evidence that suggests these eddies correspond to regions of coherent streamwise momentum known as uniform momentum zones (UMZs). The arrangement of UMZs results in a step-like shape for the instantaneous velocity profile, and the smooth mean profile results from the average UMZ properties, which are shown to scale with the friction velocity and wall-normal distance in the logarithmic region. These findings are confirmed across a wide range of Reynolds number and surface roughness conditions from the laboratory scale to the atmospheric surface layer.
We study the optimization of collisionless shock acceleration of ions based on hydrodynamic modelling and simulations of collisional shock waves in gaseous targets. The models correspond to the specifications required for experiments with the
laser at the Accelerator Test Facility at Brookhaven National Laboratory and the Vulcan Petawatt system at Rutherford Appleton Laboratory. In both cases, a laser prepulse is simulated to interact with hydrogen gas jet targets. It is demonstrated that by controlling the pulse energy, the deposition position and the backing pressure, a blast wave suitable for generating nearly monoenergetic ion beams can be formed. Depending on the energy absorbed and the deposition position, an optimal temporal window can be determined for the acceleration considering both the necessary overdense state of plasma and the required short scale lengths for monoenergetic ion beam production.
Dental pulp derived cells are pluripotent stem cells which can be differentiated along odontogenic, osteogenic, adipogenic, or neurogenic lineages. Odontogenic and osteogenic differentiation, in the absence of dexamethasone, have been shown to be highly dependent on substrate morphology and mechanics. Here we focus on neurogenic differentiation, using the protocol described by A. Arthur et al., and its dependence on substrate nature. DPSCs were cultured on PLA, a biodegradable polymer approved for internal use. The upregulation of genetic markers was compared with that of cells plated on standard TCP. The role of substrate morphology was investigated by plating on electrospun fibers approximately 2.0 ± 1.0 μm in diameter and on spin-cast thin films. The influence of graphene was investigated through the addition of 3% and 10% graphene nanoparticles to the films and fibers respectively.
The aspect ratio of the cells was measured using confocal microscopy. Cells grown on graphene containing substrates had larger aspect ratios than their non-graphene counterparts, and cells grown on microfibers were longer than their counterparts on the flat films. But the cell aspect ratio did not necessarily correlate with genetic differentiation. The results after 21 days of incubation indicated that early markers (TBP, β-III tubulin), decreased uniformly on all substrates relative to day 0, with the largest decrease occurring on the PLA flat film with graphene. The late stage marker, NEFM, which indicates differentiation, was upregulated to a significantly larger extent on all PLA substrates. No difference was observed between the fibers and the flat film in the absence of graphene, thus morphology did not play a significant role on this polymer. Addition of graphene did not affect the outcome on the fibers, but significantly suppressed the gene expression on the flat films. These results indicate that PLA is a promising scaffold material for neurogenic differentiation.
The recent NAP 5 report in the UK showed that many of the cases of awareness associated with TIVA were due to poor technique and inadequate dosing. In short, we don’t teach TIVA as well as we do inhalational anaesthesia. Yes, we have those occasional lectures and workshops built into our curriculum for trainees, covering pharmacokinetics/pharmacodynamics (PK/PD) and TIVA. However, trainees learn from watching their seniors from day to day in the operating room (OR). The vast majority of this training is gas based; it’s easy to use, everything is set up, the vaporiser is full and you’re ready to go as soon as you reach the OR. Why bother going to all the work of setting up for TIVA: surely that’s just for specialised cases? Thus our trainees are rarely exposed to TIVA and, in turn, become the gaseous trainers of the future. No wonder that when called upon to use TIVA in those circumstances where there is no alternative, even experienced anaesthetists can have difficulty. It’s often our trainees who are called upon to provide sedation for patients transferring between locations, or provide anaesthesia and sedation in remote sites without the infrastructure to support inhalational anaesthesia. These same trainees have often not learned TIVA in a practical way and are then struggling to remember, was it mg.kg−1.h−1, or µg.kg−1.min−1? How can we transfer the knowledge and skills that we have learned, over many years of passing the gas, to the art of TIVA?
Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM).
Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators.
Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology.
This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.
Ocular complaints prompt a significant number of emergency department (ED) visits, and they can range from benign to sight-threatening. Detailed fundoscopic examination is difficult, even for experienced providers. Point-of-care ultrasound (POCUS) is increasingly utilized in the ED for numerous applications, including ocular evaluation. We present a case in which ocular POCUS was used to diagnose a submacular hemorrhage in a patient who presented with acute painless loss of vision. Ocular POCUS can be readily employed to assess for myriad clinically significant pathologies.
Bovine trichomoniasis is a notifiable, reproductive disease of cattle caused by the parasite Tritrichomonas foetus. Culturing with modified Diamond's medium (MDM) is required to increase the low number of organisms received from a preputial sample, but is limited in application to remote areas as it requires continuous cold chain storage. This study utilized lyophilization to sustain the viability of MDM during transport in lieu of a continuous cold chain. All lyophilized MDM was able to sustain T. foetus after storage for 42 days at 24 °C, and the results demonstrated that lyophilized MDM was equally as viable as refrigerated liquid MDM. Storage of lyophilized MDM at room temperature for 1 and 7 days did not impact T. foetus yield, both with and without exposure to light. A limitation of the lyophilized MDM was demonstrated with a significant decrease in T. foetus yield when the media was stored at 37 and 58 °C. The lyophilization of MDM provides a robust method of transporting and storing medium prior to reconstitution and inoculation, for use in T. foetus diagnosis and surveillance in remote areas.
OBJECTIVES/SPECIFIC AIMS: 1. Identify the extent of CD implementation for trained childcare teachers. 2. Explore teacher perspectives on the impact of CD. 3. Explore teacher perspectives on barriers and facilitators to full implementation of CD. METHODS/STUDY POPULATION: We conducted a survey with 267 childcare teachers who had been trained in CD across the state, representing early childhood educational environments in urban and rural settings. Specific questions were asked related to level of CD implementation, perceived benefit, and facilitators/barriers to full implementation. A random subset of the sample (8 teachers) participated in a subsequent focus group to explore survey themes in greater depth. Focus group members were asked about their rationale for attending CD training, CD implementation (including barriers/facilitators to full implementation), and perceived impact on their classrooms. The focus group was recorded and transcribed to capture questions and comments. RESULTS/ANTICIPATED RESULTS: Objective 1: 1. 30% of teachers reported full implementation of CD. 2. 50% of teachers reported partial implementation of CD. Objective 2: 1. The vast majority of teachers (95%) agreed that CD had a positive impact on their classroom, including better structure and enhanced relationships with the children. 2. The vast majority of teachers (85%) agreed that CD had a positive impact on the children in their classroom, including increases in problem-solving abilities and self-control. Objective 3: 1. Most teachers (71%) reported experiencing barriers to CD implementation, with the majority of those surveyed (93%) stating that additional implementation support would be helpful. 2. The top three barriers to implementation elicited in survey and focus groups included uncertainty regarding how to begin implementing CD in the classroom, lacking materials for CD implementation, and lacking time to focus on applying knowledge from training into the classroom. 3. The top three facilitators for implementation elicited in survey and focus groups included coaching support for teachers, training agency leadership in CD, and greater perceived impact of CD. DISCUSSION/SIGNIFICANCE OF IMPACT: Childhood disruptive behaviors are among the most frequent reasons for referral to specialized services in and out of the classroom (Sukhodolsky, Smith, McCauley, Ibrahim, & Piasecka, 2016). Disruptive and aggressive behaviors are problematic, not only for victims of children who are aggressive but also for aggressive children as they age. Although effective treatments exist, the level of effective implementation of these interventions are understudied. These results demonstrate that 2/3 of teachers trained in CD are not fully implementing the model and provides concrete barriers and facilitators to current implementation. These data will provide the initial foundation for the development of a targeted implementation strategy that supports full implementation of CD within early childhood education settings.
Carbon nanotubes (CNTs) possess impressive properties along with low density. Integration of CNTs in the form of fabrics or other preformed assemblies simplifies their handling and allows for the higher CNT content needed to better leverage their properties in multifunctional structures. Here we describe production of non-woven CNT-polyurethane fabrics made from industrial-grade CNTs via a one-step filtration method. Individual sheets were scaled to 30 cm x 30 cm size and subsequently used to fabricate thicker composites, including via lamination with itself to produce simple panels and with other materials to further tailor the nanocomposite properties and address several example applications including electrical heating, fire resistance, electromagnetic shielding, and a skin for stretchable morphing structures.
A fine-grained, up to 3-m-thick tephra bed in southwestern Saskatchewan, herein named Duncairn tephra (Dt), is derived from an early Pleistocene eruption in the Jemez Mountains volcanic field of New Mexico, requiring a trajectory of northward tephra dispersal of ~1500 km. An unusually low CaO content in its glass shards denies a source in the closer Yellowstone and Heise volcanic fields, whereas a Pleistocene tephra bed (LSMt) in the La Sal Mountains of Utah has a very similar glass chemistry to that of the Dt, supporting a more southerly source. Comprehensive characterization of these two distal tephra beds along with samples collected near the Valles caldera in New Mexico, including grain size, mineral assemblage, major- and trace-element composition of glass and minerals, paleomagnetism, and fission-track dating, justify this correlation. Two glass populations each exist in the Dt and LSMt. The proximal correlative of Dt1 is the plinian Tsankawi Pumice and co-ignimbritic ash of the first ignimbrite (Qbt1g) of the 1.24 Ma Tshirege Member of the Bandelier Tuff. The correlative of Dt2 and LSMt is the co-ignimbritic ash of Qbt2. Mixing of Dt1 and Dt2 probably occurred during northward transport in a jet stream.
Vulnerability to depression can be measured in different ways. We here examine how genetic risk factors are inter-related for lifetime major depression (MD), self-report current depressive symptoms and the personality trait Neuroticism.
We obtained data from three population-based adult twin samples (Virginia n = 4672, Australia #1 n = 3598 and Australia #2 n = 1878) to which we fitted a common factor model where risk for ‘broadly defined depression’ was indexed by (i) lifetime MD assessed at personal interview, (ii) depressive symptoms, and (iii) neuroticism. We examined the proportion of genetic risk for MD deriving from the common factor v. specific to MD in each sample and then analyzed them jointly. Structural equation modeling was conducted in Mx.
The best fit models in all samples included additive genetic and unique environmental effects. The proportion of genetic effects unique to lifetime MD and not shared with the broad depression common factor in the three samples were estimated as 77, 61, and 65%, respectively. A cross-sample mega-analysis model fit well and estimated that 65% of the genetic risk for MD was unique.
A large proportion of genetic risk factors for lifetime MD was not, in the samples studied, captured by a common factor for broadly defined depression utilizing MD and self-report measures of current depressive symptoms and Neuroticism. The genetic substrate for MD may reflect neurobiological processes underlying the episodic nature of its cognitive, motor and neurovegetative manifestations, which are not well indexed by current depressive symptom and neuroticism.
Gambling disorder (GD), recognized in Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-5) as a behavioral addiction, is associated with a range of adverse outcomes. However, there has been little research on the genetic and environmental influences on the development of this disorder. This study reports results from the largest twin study of GD conducted to date.
Replication and combined analyses were based on samples of 3292 (mean age 31.8, born 1972–79) and 4764 (mean age 37.7, born 1964–71) male, female, and unlike-sex twin pairs from the Australian Twin Registry. Univariate biometric twin models estimated the proportion of variation in the latent GD liability that could be attributed to genetic, shared environmental, and unique environmental factors, and whether these differed quantitatively or qualitatively for men and women.
In the replication study, when using a lower GD threshold, there was evidence for significant genetic (60%; 95% confidence interval (CI) 45–76%) and unique environmental (40%; 95% CI 24–56%), but not shared environmental contributions (0%; 95% CI 0–0%) to GD liability; this did not significantly differ from the original study. In the combined analysis, higher GD thresholds (such as one consistent with DSM-5 GD) and a multiple threshold definitions of GD yielded similar results. There was no evidence for quantitative or qualitative sex differences in the liability for GD.
Twin studies of GD are few in number but they tell a remarkably similar story: substantial genetic and unique environmental influences, with no evidence for shared environmental contributions or sex differences in GD liability.
Balloon atrial septostomy is performed in infants with dextro-transposition of the great arteries to improve oxygenation before surgery. It is performed in the catheterisation laboratory with fluoroscopy or at the bedside using echocardiography. It is unclear whether procedural safety and efficacy is superior in one location versus the other, although the bedside procedure may improve resource utilisation and present an opportunity for reducing cost. This study compares safety and efficacy of atrial septostomy performed at the patient’s bedside versus the catheterisation laboratory.
Neonates with dextro-transposition of the great arteries who underwent balloon atrial septostomy from October, 2000 to January, 2014 were included. Medical and procedural records, echocardiograms, and catheterisation data were reviewed. Comparisons between the two procedural locations included patient demographics, pre- and post-procedure oxygen saturations, and outcomes. Complications reviewed included bleeding, arrhythmia, cardiac trauma, stroke, and death. Coronary artery evaluations were recorded. T-tests were used for continuous variables, and Fisher’s exact tests were used for all categorical variables. Wilcoxon rank sum and analysis of covariance modelling were used for time variables and oxygen saturation, respectively.
A total of 88 infants met the inclusion criteria. Among them, 53 underwent septostomy at the bedside and 35 underwent septostomy in the catheterisation laboratory. No safety or outcome benefit was identified between the two procedural locations.
Septostomy performed at the bedside and in the catheterisation laboratory had similar outcomes and efficacy. Further, bedside septostomy has the advantage of no radiation exposure, and obviating risks with patient transfer from the ICU to the catheterisation laboratory.
The calibration hardware system of the Large Synoptic Survey Telescope (LSST) is designed to measure two quantities: a telescope’s instrumental response and atmospheric transmission, both as a function of wavelength. First of all, a “collimated beam projector” is designed to measure the instrumental response function by projecting monochromatic light through a mask and a collimating optic onto the telescope. During the measurement, the light level is monitored with a NIST-traceable photodiode. This method does not suffer from stray light effects or the reflections (known as ghosting) present when using a flat-field screen illumination, which has a systematic source of uncertainty from uncontrolled reflections. It allows for an independent measurement of the throughput of the telescope’s optical train as well as each filter’s transmission as a function of position on the primary mirror. Second, CALSPEC stars can be used as calibrated light sources to illuminate the atmosphere and measure its transmission. To measure the atmosphere’s transfer function, we use the telescope’s imager with a Ronchi grating in place of a filter to configure it as a low resolution slitless spectrograph. In this paper, we describe this calibration strategy, focusing on results from a prototype system at the Cerro Tololo Inter-American Observatory (CTIO) 0.9 meter telescope. We compare the instrumental throughput measurements to nominal values measured using a laboratory spectrophotometer, and we describe measurements of the atmosphere made via CALSPEC standard stars during the same run.
Living alongside predators can entail substantial costs both in terms of livelihoods and personal safety. Negative interactions with predators can lead to negative attitudes and behavioural intentions such as retaliatory or pre-emptive killing. As a result, conservation strategies are increasingly adopting human–wildlife coexistence approaches aimed at minimizing the costs associated with living with predators by providing direct or indirect benefits. This is done in the hope that people will foster positive attitudes and behavioural intentions towards predators. However, people's attitudes and their behavioural intentions are not necessarily linked, and both need to be understood for conservation actions to be effective. We conducted 747 semi-structured interviews with community members in the Maasai Mara, Kenya, to determine which factors influenced people's attitudes and behavioural intentions towards predators and whether the two were linked. Most interviewees (57.52%) had a positive attitude towards predators as measured by their assertion that people, livestock and predators should coexist. Their attitude was dependent on benefits, occupation, conservancy membership and perceived community ownership of predators, but was not influenced by the costs of livestock depredation. Most respondents who were members of a conservancy had positive attitudes towards predators but this differed by conservancy, suggesting that, in addition to benefits, conservation politics could influence attitudes. In total, 10.3% of respondents said that they would kill a predator if it killed their livestock. This behavioural intention was only influenced by the respondent's attitude. Understanding the factors that influence attitudes and behavioural intentions will aid future management and coexistence strategies.
Assessment of the extent of civilian casualties during times of conflict presents significant challenges in data collection, quantitative methods, interpretation, and presentation. In this article, we briefly consider the motivation and use of casualty accounting and review historical approaches to these questions with illustrative comments on the US Civil War, World War I, World War II, and other conflicts. We provide an overview of several accounting methodologies including excess mortality, epidemiologic surveys, direct and indirect counts, multiple list estimation, and crowdsourcing. We reflect on the evolution toward modern approaches to casualty assessments, permitted by both a deeper understanding of human rights and by contemporaneous technological advances in data collection techniques. Our goal is to introduce several areas of research that deserve attention from social science historians and statisticians.