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Introduction: Atrial fibrillation (AF) is the most common sustained arrhythmia affecting 1-2% of the population. Oral anticoagulation (OAC) reduces stroke risk by 60-80% in AF patients, but only 50% of indicated patients receive OAC. Many patients present to the ED with AF due to arrhythmia symptoms, however; lack of OAC prescription in the ED has been identified as a significant gap in the care of AF patients. Methods: This was a multi-center, pragmatic, three-phase before-after study, in three Canadian sites. Patients who presented to the ED with electrocardiographically (ECG) documented, nonvalvular AF and were discharged home were included. Phase 1 was a retrospective chart review to determine OAC prescription of AF patients in each ED; Phase 2 was a low-intensity knowledge translation intervention where a simple OAC-prescription tool for ED physicians with subsequent short-term OAC prescription was used, as well as an AF patient education package and a letter to family physicians; phase 3 incorporated Phase 2 interventions, but added immediate follow-up in a community AF clinic. The primary outcome of the study was the rate of new OAC prescriptions at ED discharge in AF patients who were OAC eligible and were not on OAC at presentation. Results: A total of 632 patients were included from June, 2015-November, 2016. ED census ranged from 30000-68000 annual visits. Mean age was 71±15, 67±12, 67±13 years, respectively. 47.5% were women, most responsible ED diagnosis was AF in 75.8%. The mean CHA2DS2-VASc score was 2.6±1.8, with no difference amongst groups. There were 266 patients eligible for OAC and were not on this at presentation. In this group, the prescription of new OAC was 15.8% in Phase 1 as compared to 54% and 47%, in Phases 2 and 3, respectively. After adjustment for center, components of the CHA2DS2-VASc score, prior risk of bleeding and most responsible ED diagnosis, the odds ratio for new OAC prescription was 8.0 (95%CI (3.5,18.3) p<0.001) for Phase 3 vs 1, and 10.0 (95%CI (4.4,22.9) p<0.001), for Phase 2 vs 1). No difference in OAC prescription was seen between Phases 2 and 3. Conclusion: Use of a simple OAC-prescription tool was associated with an increase in new OAC prescription in the ED for eligible patients with AF. Further testing in a rigorous study design to assess the effect of this practice on stroke prevention in the AF patients who present to the ED is indicated.
A 10-year descriptive analysis of morbidity and mortality associated with water-related activities in the Top End, Northern Territory (NT), Australia.
An outdoor, water-orientated lifestyle characterises the Top End due to its tropical climate, lengthy coastline, many inland-waterways, and common domestic-pool ownership. However, the water holds many dangers: from drowning to the prospect of crocodile attacks.
Data were retrospectively collected from two sources: the Trauma Registry (TR), Royal Darwin Hospital, NT and the National Coronial Information System. Inclusion criteria: all mortality or injury with an Injury Severity Score (ISS) ≥9 from water-related activity in the Top End. Exclusion criteria: envenomation. Data included: demographics, geographical location, time/mechanism of injury, injury narrative/outcome, alcohol consumption, ISS, and Indigenous race.
Ninety-five deaths occurred from 1/1/2005–12/31/2014; 87 prehospital (92%). The leading three mechanisms of injury for the 138 TR admissions were drowning (40%), falling/diving (35%), and watercraft events (14%). Median age 27 (0-90); 78% males. There were 74 children (<16 years) including 20 deaths. Indigenous Australians represent 30% of the NT population, but had 43% of deaths and 12% of admissions. Deaths from crocodile attacks are increasing with 14 deaths from 2005-2014, compared to 10 deaths from 1971-2004 (Caldicutt). Alcohol was recorded in 31% of admissions and 52% of deaths in those age >16. The Top End’s crude rate of drowning averaged over 10 years was 4.36/100,000/annum, compared to 1.31/100,000/annum in Australia.
Alcohol plays a major role in the Top End’s water-related harm, associated with all mechanisms and over one-half of adult deaths. Also striking is increasing crocodile fatalities, possibly caused by population recovery from endangered to plentiful, since hunting ceased in 1971. Local authorities/advocates push water-safety and crocodile-awareness programs. However, the lure of tropical waters combined with alcohol remains a risk to life and limb. Further public health campaigns focusing on these issues are called for.
There is increasing recognition that perinatal anxiety disorders are both common and potentially serious for mother and child. Obsessive–compulsive disorder (OCD) can be triggered or exacerbated in the postpartum period, with mothers reporting significant effects on parenting tasks. However, there is little evidence concerning their effective treatment or the impact of successful treatment on parenting.
A total of 34 mothers with OCD and a baby of 6 months old were randomized into either time-intensive cognitive–behaviour therapy (iCBT) or treatment as usual (TAU). iCBT took place after randomization at 6 months postpartum and was completed by 9 months. Maternal symptomatology, sensitivity in mother–infant interactions and parenting were assessed at baseline and reassessed at 12 months postpartum. At 12 months attachment was also assessed using Ainsworth's Strange Situation Procedure. A healthy control group of mothers and infants (n = 37) underwent the same assessments as a benchmark.
iCBT was successful in ameliorating maternal symptoms of OCD (controlled effect size = 1.31–1.90). However, mother–infant interactions were unchanged by treatment and remained less sensitive in both OCD groups than a healthy control group. The distribution of attachment categories was similar across both clinical groups and healthy controls with approximately 72% classified as secure in each group.
iCBT is an effective intervention for postpartum OCD. Sensitive parenting interactions are affected by the presence of postpartum OCD and this is not improved by successful treatment of OCD symptoms. However, the overall attachment bond appears to be unaffected. Longitudinal studies are needed to explore the impact of postpartum OCD as the child develops.
Direct detection of 14C using the Harwell 6MV Tandem accelerator has been achieved using a gaseous ion source. The implications of our results for the use of such sources in this role and for the machine, in general, are discussed.
The technique of image sharpening which allows high resolution images to be produced from ground-based telescopes is applied to the problem of photometry in crowded field regions - such as close to the cores of globular clusters. The conditions for image sharpening are discussed and the technique is demonstrated using simple objects (close double stars). Preliminary results from image sharpening of M15 are presented.
Bungowannah virus was discovered following an outbreak of stillbirths and sudden death in young pigs. Affected animals consistently showed a myocardopathy with signs of cardiac failure. After virus isolation and PCR investigations were unsuccessful, direct fetal inoculation was undertaken. Nucleic acid purified from serum from infected fetuses was subjected to sequence-independent single-primer amplification and nucleic acid sequencing. Sequences consistent with a pestivirus were obtained. The entire genome was identified but was genetically remote from the recognized pestivirus species. This virus was not recognized by pan-pestivirus reactive monoclonal antibodies but was subsequently detected in cell cultures by immunoperoxidase staining using convalescent sow serum. Experimental infections of sows at different stages of gestation reproduced the myocarditis syndrome. Pre-weaning losses of 70 and 29% were observed following infection at days 35 and 90, respectively. Piglets infected at day 35 were shown to be persistently infected, while chronic infections were observed after fetal infection at day 55. Chronically infected piglets showed growth retardation and were viremic for up to 7 months. Myocarditis was associated with infection in late gestation (day 90). Non-pregnant sheep and cattle have been experimentally infected but with no evidence of disease. Infection of pregnant cattle in early gestation resulted in both maternal and fetal infection, but all infected fetuses mounted an antibody response to the virus. Analysis of the nucleic acid sequence confirmed that Bungowannah has a number of changes not observed in other pestiviruses. Genes encoding some of the structural proteins remain fully functional when inserted into a bovine viral diarrhea virus (BVDV) backbone. Cell culture-based studies have shown that Bungowannah virus will grow in cells extending from humans to bats as well as farm animals.
The rapid rise in syphilis cases has prompted a number of public health campaigns to assist men who have sex with men (MSM) recognize and present early with symptoms. This study aimed to investigate the temporal trend of the duration of self-report symptoms and titre of rapid plasma reagin (RPR) in MSM with infectious syphilis. Seven hundred and sixty-one syphilis cases in MSM diagnosed at the Melbourne Sexual Health Centre (MSHC) from 2007–2013 were reviewed. Median duration of symptoms and RPR titres in each year were calculated. The median durations of symptoms with primary and secondary syphilis were 9 [interquartile range (IQR) 6–14] days and 14 (IQR 7–30) days, respectively. The overall median titre of RPR in secondary syphilis (median 128, IQR 64–256) was higher than in primary syphilis (median 4, IQR 1–32) and in early latent syphilis (median 32, IQR 4–64). The median duration of symptoms for primary syphilis, secondary syphilis and titre of RPR level did not change over time. Public health campaigns were not associated with a significant shorter time from onset of symptoms to treatment. Alternative strategies such as more frequent testing of MSM should be promoted to control the syphilis epidemic in Australia.
Data were extracted from the case records of UK patients admitted with laboratory-confirmed influenza A(H1N1)pdm09. White and non-White patients were characterized by age, sex, socioeconomic status, pandemic wave and indicators of pre-morbid health status. Logistic regression examined differences by ethnicity in patient characteristics, care pathway and clinical outcomes; multivariable models controlled for potential confounders. Whites (n = 630) and non-Whites (n = 510) differed by age, socioeconomic status, pandemic wave of admission, pregnancy, recorded obesity, previous and current smoking, and presence of chronic obstructive pulmonary disease. After adjustment for a priori confounders non-Whites were less likely to have received pre-admission antibiotics [adjusted odds ratio (aOR) 0·43, 95% confidence interval (CI) 0·28–0·68, P < 0·001) but more likely to receive antiviral drugs as in-patients (aOR 1·53, 95% CI 1·08–2·18, P = 0·018). However, there were no significant differences by ethnicity in delayed admission, severity at presentation for admission, or likelihood of severe outcome.
Due to multiple issues, integrated interdisciplinary palliative care teams in a neonatal intensive care unit (NICU) may be difficult to access, sometimes fail to be implemented, or provide inconsistent or poorly coordinated care. When implementing an effective institution-specific neonatal palliative care program, it is critical to include stakeholders from the clinical, operational, and financial worlds of healthcare. In this study, researchers sought to gain a multidisciplinary perspective into issues that may impact the implementation of a formal neonatal palliative care program at a tertiary regional academic medical center.
In this focused ethnography, the primary researcher conducted semistructured interviews that explored the perspectives of healthcare administrators, finance officers, and clinicians about neonatal palliative care. The perspectives of 39 study participants informed the identification of institutional, financial, and clinical issues that impact the implementation of neonatal palliative care services at the medical center and the planning process for a formal palliative care program on behalf of neonates and their families.
Healthcare professionals described experiences that influenced their views on neonatal palliative care. Key themes included: (a) uniqueness of neonatal palliative care, (b) communication and conflict among providers, (c) policy and protocol discrepancies, and (d) lack of administrative support.
Significance of results:
The present study highlighted several areas that are challenging in the provision of neonatal palliative care. Our findings underscored the importance of recognizing and procuring resources needed simultaneously from the clinical, operational, and financial worlds in order to implement and sustain a successful neonatal palliative care program.
The sorption behaviour of I−, Cs+, Ni2+, Eu3+, Th4+ and UO2+2on NRVB (Nirex reference vault backfill) a possible vault backfill, at pH 12.8 was studied. Sorption isotherms generated were compared to results obtained in the presence of cellulose degradation products (CDP). Whereas Cs was not affected by the presence of the organic compounds, a notable reduction in the sorption of Th and Eu to cement was observed. The results also indicated limited removal of Ni from solution (with or without an organic ligand) by sorption, the concentration in solution seemingly being determined solely by solubility processes. In the case of uranium, the presence of CDP increased the sorption to cement by almost one order of magnitude. Further studies into the uptake of CDP by cement are being undertaken to identify the mechanism(s) responsible.
In this paper we report the use of a device based on two multilayered a-SiC:H/a-Si:H stacked heterostructures to photodetect and demultiplex optical signals of the visible spectrum. Both heterostructures were optimized for the detection of short and long wavelengths within the visible range. The optoelectronic characterization of the device includes spectral response measurements under reverse bias and using different optical steady state light conditions to soak the device. Results show that the device photocurrent signal measured using appropriate steady state optical bias, allows the separate detection of the input transmitted signals which enables the demultiplexing task. A numerical simulation, gives insight into the transduction mechanism to explain the device wavelength selective behavior.
Tunable WDM converters based on amorphous SiC multilayer photonic active filters are analyzed. The manipulation of the magnitude is achieved through appropriated front and back backgrounds. Transfer function characteristics are studied. Results show that the light-activated device combines the demultiplexing operation with the simultaneous photodetection and self amplification of an optical signal. Depending on the wavelength of the external background and irradiation side, it acts either as a short- or a long- pass band filter or as a band-stop filter. A combinational logic function is mapped onto an active two stage optoelectronic logic circuit. An algorithm to decode the multiplex signal is established. An optoelectronic model supports the optoelectronic logic architecture.
Substrate-selective, low-temperature chemical vapor deposition of high quality gold filmswas obtained with the new precursor ethyl(trimethylphosphine)gold(I) in an ultrahigh vacuum reactor designed to handle wafers up to 3 inches in diameter. Growth behavior at temperatures as low as room temperature as well as substrate pre-cleaning procedures are presented. Activation energies of 35.1 ± 0.4 kcal mol−1 and 18.3 ± 0.7 kcal mol−1 were found for growth of gold films on gold and copper substrates, respectively.
Existing work in the mechanical behavior of thin films focuses mainly on measurement of macroscopic properties without strong correlation to microstructural features. We used transmission electron microscopy (TEM) to characterize the microstructures of free-standing copper thin films both before and after monotonic tensile deformation in an ex-situ thin film tensile testing system, as well as during in-situ loading in the TEM. The defect structures contributing to plastic deformation were investigated with an emphasis on comparison to mechanisms known to operate in bulk copper. The thin film exhibited much lower ductility (approximately 1%) than that normally observed in bulk form (greater than 40%). The predominant plastic deformation mechanisms did not include the typical dislocation activity that occurs in bulk copper, but rather greatly inhibited dislocation interactions typical of stages I and II hardening only. The absence of those structures normally found in tensile-deformed bulk copper is attributed to the differences in characteristic sizes of features within the microstructure available for deformation in bulk versus evaporated thin film material, that is, grain size and film thickness. The thin film ductility is an order of magnitude lower than what has been observed in bulk, ultrafine-grained copper, implying that a pure thin film effect on ductility exists and is significant. Microstructural features both near to and far from the fracture surface regions will be presented.
Protein adsorption to ceramic surfaces is an important early step in the function of implants. The types and amounts of adsorbed protein and the resulting conformational changes could mediate subsequent cell adhesion and inorganic deposition. Microporous silicoalumino-phosphates, which allow variations in surface composition within the same crystal structure, have been used as model surfaces. Effects of surface composition on adsorption isotherms, elutability, and biological activity of the adsorbed protein layer have been studied using lysozyme, a model protein. Control over protein adsorption mechanisms using well-characterized surface properties could be used to predict the biological properties of surfaces, and engineer coatings for a desired response.
Strains in GaN nanowires with InGaN quantum wells (QW) were measured from transmission electron microscope (TEM) images. The nanowires, all from a single growth run, are single crystals of the wurtzite structure that grow along the <0001> direction, and are approximately 1000 nm long and 60 nm to 130 nm wide with hexagonal cross-sections. The In concentration in the QWs ranges from 12 to 15 at %, as determined by energy dispersive spectroscopy in both the transmission and scanning electron microscopes. Fourier transform (FT) analyses of <0002> and <1100> lattice images of the QW region show a 4 to 10 % increase of the c-axis lattice spacing, across the full specimen width, and essentially no change in the a-axis value. The magnitude of the changes in the c-axis lattice spacing far exceeds values that would be expected by using a linear Vegard's law for GaN – InN with the measured In concentration. Therefore the increases are considered to represent tensile strains in the <0001> direction. Visual representations of the location and extent of the strained regions were produced by constructing inverse FT (IFT) images from selected regions in the FT covering the range of c-axis lattice parameters in and near the QW. The present strain values for InGaN QW in nanowires are larger than any found in the literature to date for other forms of InxGa1-xN (QW)/GaN.