Background: Accurate etiologic diagnoses are needed in patients with rapidly progressive dementia (RPD) to ensure access to symptomatic and disease-modifying therapies when available. Methods: Patients with RPD were prospectively enrolled and evaluated at Washington University (Saint Louis, MO; 2016-2019) and Mayo Clinic (Jacksonville, FL; 2020-2021). Etiologic diagnoses were independently assigned by two dementia specialists integrating clinical features and the results of diagnostic tests; disagreements were resolved via blinded review by a third specialist. Results: 160 RPD patients were enrolled and followed. Average age-at-symptom onset was 60.0±15.9 years; 50% were female. Inter-rater reliability (91% agreement; Cohen’s κ=0.88, p<0.001) and clinicopathologic correlation were excellent (100% agreement in 24 patients with neuropathologic data). Autoimmune encephalitis was the leading cause of RPD (39%), followed by Alzheimer disease and related dementias (29%), Creutzfeldt-Jakob disease (15%), and other causes (15%). Patients with potentially treatable causes of RPD were younger (54.5±18.2 than those with neurodegenerative causes (67.3±9.5; p<0.001), and more likely to present with altered levels of consciousness, seizures, or CSF pleocytosis (p<0.05). Conclusions: Etiologic diagnoses can be reliably established in RPD patients using available clinical data. The prevalence of autoimmune encephalitis in this series justifies routine screening for potentially treatment-responsive causes of RPD, particularly in younger patients.

Substantial progress has been made in the standardization of nomenclature for paediatric and congenital cardiac care. In 1936, Maude Abbott published her Atlas of Congenital Cardiac Disease, which was the first formal attempt to classify congenital heart disease. The International Paediatric and Congenital Cardiac Code (IPCCC) is now utilized worldwide and has most recently become the paediatric and congenital cardiac component of the Eleventh Revision of the International Classification of Diseases (ICD-11). The most recent publication of the IPCCC was in 2017. This manuscript provides an updated 2021 version of the IPCCC.

The International Society for Nomenclature of Paediatric and Congenital Heart Disease (ISNPCHD), in collaboration with the World Health Organization (WHO), developed the paediatric and congenital cardiac nomenclature that is now within the eleventh version of the International Classification of Diseases (ICD-11). This unification of IPCCC and ICD-11 is the IPCCC ICD-11 Nomenclature and is the first time that the clinical nomenclature for paediatric and congenital cardiac care and the administrative nomenclature for paediatric and congenital cardiac care are harmonized. The resultant congenital cardiac component of ICD-11 was increased from 29 congenital cardiac codes in ICD-9 and 73 congenital cardiac codes in ICD-10 to 318 codes submitted by ISNPCHD through 2018 for incorporation into ICD-11. After these 318 terms were incorporated into ICD-11 in 2018, the WHO ICD-11 team added an additional 49 terms, some of which are acceptable legacy terms from ICD-10, while others provide greater granularity than the ISNPCHD thought was originally acceptable. Thus, the total number of paediatric and congenital cardiac terms in ICD-11 is 367. In this manuscript, we describe and review the terminology, hierarchy, and definitions of the IPCCC ICD-11 Nomenclature. This article, therefore, presents a global system of nomenclature for paediatric and congenital cardiac care that unifies clinical and administrative nomenclature.

The members of ISNPCHD realize that the nomenclature published in this manuscript will continue to evolve. The version of the IPCCC that was published in 2017 has evolved and changed, and it is now replaced by this 2021 version. In the future, ISNPCHD will again publish updated versions of IPCCC, as IPCCC continues to evolve.

Introduction: CAEP recently developed the acute atrial fibrillation (AF) and flutter (AFL) [AAFF] Best Practices Checklist to promote optimal care and guidance on cardioversion and rapid discharge of patients with AAFF. We sought to assess the impact of implementing the Checklist into large Canadian EDs. Methods: We conducted a pragmatic stepped-wedge cluster randomized trial in 11 large Canadian ED sites in five provinces, over 14 months. All hospitals started in the control period (usual care), and then crossed over to the intervention period in random sequence, one hospital per month. We enrolled consecutive, stable patients presenting with AAFF, where symptoms required ED management. Our intervention was informed by qualitative stakeholder interviews to identify perceived barriers and enablers for rapid discharge of AAFF patients. The many interventions included local champions, presentation of the Checklist to physicians in group sessions, an online training module, a smartphone app, and targeted audit and feedback. The primary outcome was length of stay in ED in minutes from time of arrival to time of disposition, and this was analyzed at the individual patient-level using linear mixed effects regression accounting for the stepped-wedge design. We estimated a sample size of 800 patients. Results: We enrolled 844 patients with none lost to follow-up. Those in the control (N = 316) and intervention periods (N = 528) were similar for all characteristics including mean age (61.2 vs 64.2 yrs), duration of AAFF (8.1 vs 7.7 hrs), AF (88.6% vs 82.9%), AFL (11.4% vs 17.1%), and mean initial heart rate (119.6 vs 119.9 bpm). Median lengths of stay for the control and intervention periods respectively were 413.0 vs. 354.0 minutes (P < 0.001). Comparing control to intervention, there was an increase in: use of antiarrhythmic drugs (37.4% vs 47.4%; P < 0.01), electrical cardioversion (45.1% vs 56.8%; P < 0.01), and discharge in sinus rhythm (75.3% vs. 86.7%; P < 0.001). There was a decrease in ED consultations to cardiology and medicine (49.7% vs 41.1%; P < 0.01), but a small but insignificant increase in anticoagulant prescriptions (39.6% vs 46.5%; P = 0.21). Conclusion: This multicenter implementation of the CAEP Best Practices Checklist led to a significant decrease in ED length of stay along with more ED cardioversions, fewer ED consultations, and more discharges in sinus rhythm. Widespread and rigorous adoption of the CAEP Checklist should lead to improved care of AAFF patients in all Canadian EDs.

Little is known about the experiences of people living alone with dementia in the community and their non-resident relatives and friends who support them. In this paper, we explore their respective attitudes and approaches to the future, particularly regarding the future care and living arrangements of those living with dementia. The study is based on a qualitative secondary analysis of interviews with 24 people living alone with early-stage dementia in North Wales, United Kingdom, and one of their relatives or friends who supported them. All but four of the dyads were interviewed twice over 12 months (a total of 88 interviews). In the analysis, it was observed that several people with dementia expressed the desire to continue living at home for ‘as long as possible’. A framework approach was used to investigate this theme in more depth, drawing on concepts from the existing studies of people living with dementia and across disciplines. Similarities and differences in the future outlook and temporal orientation of the participants were identified. The results support previous research suggesting that the future outlook of people living with early-stage dementia can be interpreted in part as a response to their situation and a way of coping with the threats that it is perceived to present, and not just an impaired view of time. Priorities for future research are highlighted in the discussion.

Brain-derived neurotrophic factor (BDNF) gene variants may potentially influence behaviour. In order to test this hypothesis, we investigated the relationship between BDNF Val66Met polymorphism and aggressive behaviour in a population of schizophrenic patients. Our results showed that increased number of BDNF Met alleles was associated with increased aggressive behaviour.

Introduction: Biphasic anaphylactic reactions are a concern in emergency medicine. Risk factors associated with this type of reaction remain ill-defined. The aim of this study was to investigate elements associated with biphasic anaphylactic reactions and to determine the impact of anaphylaxis treatments on biphasic reactions. Methods: From the multicenter Cross-Canada Anaphylaxis Registry prospective cohort, we selected adults (≥18 years) with a visit to the emergency department (ED) of Sacré-Cœur Hospital, an urban tertiary-care hospital. Then, a structured chart review was done to collect additional information on types and timing of treatments for the initial anaphylactic reaction, presence and treatment of biphasic reactions during the initial ED visit or upon patients’ return. Biphasic reactions were defined by the recurrence of any anaphylaxis symptoms within 72 hours of a resolved anaphylaxis episode. Potential factors associated with biphasic reactions were studied using Chi-Square and Mann-Whitney tests. Results: Patients with anaphylaxis were enrolled between April 2014 and February 2018. From the cohort, 401 adult patients were identified. We found 37 patients who developed a biphasic reaction. Amongst them, 33 received treatments and 9 required more than one dose of intramuscular epinephrine. None of the biphasic reaction patients required intravenous epinephrine, other vasopressors, ICU admission, or endotracheal intubation. Biphasic reactions appeared in a median time of 13.3h after the initial reaction ranging from 1.1h to 69.6h (IQR 30.2). There was no difference in age or gender of patients who developed a biphasic reaction compared those who did not. Pertinent past medical history, daily medications, mean of arrival to the ED, allergen type, ingestion route, or initial symptoms during the anaphylaxis episode were not significantly different in the two groups. Treatment with corticosteroids was similar in the two groups (9.0% vs. 8.1% p = 0.82). Treatment, dose and route of administration of epinephrine was not different in the two groups but longer delays before treatment with the first dose of epinephrine was more frequent in biphasic reaction patients (median delay of 64 minutes, p = 0.015). Conclusion: No patient characteristic, allergen, route of ingestion, symptom, nor treatment with corticosteroids has shown to be significantly different in patients with and without biphasic reactions. Delayed treatment with epinephrine is significantly associated with biphasic reactions.

The flow of a suspension through a bifurcating channel is studied experimentally and by computational methods. The geometry considered is an ‘asymmetric T’, as flow in the entering branch divides to either continue straight or to make a right angle turn. All branches are of the same square cross-section of side length $D$, with inlet and outlet section lengths $L$ yielding $L/D=58$ in the experiments. The suspensions are composed of neutrally buoyant spherical particles in a Newtonian liquid, with mean particle diameters of $d=250~\unicode[STIX]{x03BC}\text{m}$ and $480~\unicode[STIX]{x03BC}\text{m}$ resulting in $d/D\approx 0.1$ to $d/D\approx 0.2$ for $D=2.4~\text{mm}$. The flow rate ratio $\unicode[STIX]{x1D6FD}=Q_{\Vert }/Q_{0}$, defined for the bulk, fluid and particles, is used to characterize the flow behaviour; here $Q_{\Vert }$ and $Q_{0}$ are volumetric flow rates in the straight outlet branch and inlet branch, respectively. The channel Reynolds number $Re=(\unicode[STIX]{x1D70C}DU)/\unicode[STIX]{x1D702}$ was varied over $0<Re<900$, with $\unicode[STIX]{x1D70C}$ and $\unicode[STIX]{x1D702}$ the fluid density and viscosity, respectively, and $U$ the mean velocity in the inlet channel; the inlet particle volume fraction was $0.05\leqslant \unicode[STIX]{x1D719}_{0}\leqslant 0.30$. Experimental and numerical results for single-phase Newtonian fluid both show $\unicode[STIX]{x1D6FD}$ increasing with $Re$, implying more material tending toward the straight branch as the inertia of the flow increases. In suspension flow at small $\unicode[STIX]{x1D719}_{0}$, inertial migration of particles in the inlet branch affects the flow rate ratio for particles ($\unicode[STIX]{x1D6FD}_{\mathit{particle}}$) and suspension ($\unicode[STIX]{x1D6FD}_{\mathit{suspension}}$). The flow split for the bulk suspension satisfies $\unicode[STIX]{x1D6FD}>0.5$ for $\unicode[STIX]{x1D719}_{0}<0.16$ while $\unicode[STIX]{x1D719}_{0}=0.16$ crosses from $\unicode[STIX]{x1D6FD}\approx 0.5$ to $\unicode[STIX]{x1D6FD}>0.5$ at $Re\approx 100$. For $\unicode[STIX]{x1D719}_{0}\geqslant 0.2$, $\unicode[STIX]{x1D6FD}<0.5$ at all $Re$ studied. A complex dependence of the mean solid fraction in the downstream branches upon inlet fraction $\unicode[STIX]{x1D719}_{0}$ and $Re$ is observed: for $\unicode[STIX]{x1D719}_{0}<0.1$, the solid fraction in the straight downstream branch initially decreases with $Re$, before increasing to surpass the inlet fraction at large $Re$ ($Re\approx 500$ for $\unicode[STIX]{x1D719}_{0}=0.05$). At $\unicode[STIX]{x1D719}_{0}>0.1$, the solid fraction in the straight branch satisfies $\unicode[STIX]{x1D719}_{\Vert }/\unicode[STIX]{x1D719}_{0}>1$, and this ratio grows with $Re$. Discrete-particle simulations employing immersed boundary and lattice-Boltzmann techniques are used to analyse these phenomena, allowing rationalization of aspects of this complex behaviour as being due to particle migration in the inlet branch.

The discovery of the first electromagnetic counterpart to a gravitational wave signal has generated follow-up observations by over 50 facilities world-wide, ushering in the new era of multi-messenger astronomy. In this paper, we present follow-up observations of the gravitational wave event GW170817 and its electromagnetic counterpart SSS17a/DLT17ck (IAU label AT2017gfo) by 14 Australian telescopes and partner observatories as part of Australian-based and Australian-led research programs. We report early- to late-time multi-wavelength observations, including optical imaging and spectroscopy, mid-infrared imaging, radio imaging, and searches for fast radio bursts. Our optical spectra reveal that the transient source emission cooled from approximately 6 400 K to 2 100 K over a 7-d period and produced no significant optical emission lines. The spectral profiles, cooling rate, and photometric light curves are consistent with the expected outburst and subsequent processes of a binary neutron star merger. Star formation in the host galaxy probably ceased at least a Gyr ago, although there is evidence for a galaxy merger. Binary pulsars with short (100 Myr) decay times are therefore unlikely progenitors, but pulsars like PSR B1534+12 with its 2.7 Gyr coalescence time could produce such a merger. The displacement (~2.2 kpc) of the binary star system from the centre of the main galaxy is not unusual for stars in the host galaxy or stars originating in the merging galaxy, and therefore any constraints on the kick velocity imparted to the progenitor are poor.

Introduction: A 2008 survey found that 1.9% of the entire US population was using prescription pain medication non-medically and that 56% obtained them from a friend or relatives. Diversion of pain medication may occur when a portion of the prescription is unused for pain relief after an ED visit. We hypothesized that at least 10 pills (~40%) of an opioid prescription 2 weeks after an ED visit, will not be consumed and become available for potential misuse. Objective: Determine the quantity of unused opioids pills for common acute pain diagnoses, 2 weeks after an ED visit for acute pain. Methods: Prospective observational cohort study of consecutive ED patients from a tertiary academic urban hospital with 60,000 ED visits annually. Inclusion criteria: aged ≥18 years, acute pain conditions present ≤2 weeks, pain intensity at triage of ≥4 (on a 0-10 numeric rating scale; NRS), and discharged with a new opioid prescription. ED physicians identified (24/7) eligible patients. They recorded the pain complaint/location, the final diagnosis, the quantity and type of prescribed pain medication. Discharged patients completed paper or electronic 14-day diary (REDCap database) to document their pain medication consumption. As a mitigation strategy, they were also contacted by phone at 2 weeks for the same information. A paired t-test was used to test the difference between the amounts of opioids prescribed and consumed. Results: 350 patients were recruited. Mean age 50 (SD ±16) and 54.2% were men. Painful diagnosis: fracture (18.2%), acute back pain (15.3%), renal colic (15.3%), Sprain (excluding back/neck pain) (6.9%), Contusion (6.4%), acute neck pain (5.8%), abdominal pain (4.9%), and other (27.2%). Opioids prescribed: oxycodone (47%), morphine (37%) and hydromorphone (16%). Means quantity of opioid pills prescribed: 24 (IC95%: 23-26). Filled opioid prescription: 92%. Means quantity of opioid pills consumed: 8 (IC95%: 7-9). Means quantity of unused opioids pills: 16. Opioid pills available for misuse in our cohort: 5,600 pills. Conclusion: After an ED visit for acute pain a significant portion of opioids prescribed is unused and available for misuse. A large pragmatic study should be done to confirm that an opioid prescription strategy based on our results will limit unused opioid pills while maintaining pain relief.

Introduction: Trauma remains the primary cause of death in people under 40 in Québec. Although trauma care has dramatically improved in the last decade, no empirical data on the effectiveness of trauma care in rural Québec are available. This study aims to establish a portrait of trauma and trauma-related mortality in rural versus urban pre-hospital and hospital settings. Methods: Data for all trauma victims treated in the 26 rural hospitals and 32 Level-1 and Level-2 urban trauma centres was obtained from Québec’s trauma registry (2009-2013). Rural hospitals were located in rural small towns (Statistics Canada definition), provided 24/7 physician coverage and admission capabilities. Study population was trauma patients who accessed eligible hospitals. Transferred patients were excluded. Descriptive statistics were used to compare rural with urban trauma case frequency, severity and mortality and descriptive data collected on emergency department (ED) characteristics. Using logistic regression analysis we compared rural to urban in-hospital mortality (pre-admission and during ED stay), adjusting for age, sex, severity (ISS), injury type and mode of transport. Results: Rural hospitals (N=26) received on average 490 000 ED visits per year and urban trauma centres (N=32), 1 550 000. Most rural hospitals had 24/7 coverage and diagnostic equipment e.g. CT scanners (74 %), intensive care units (78 %) and general surgical services (78 %), but little access to other consultants. About 40% of rural hospitals were more than 300 km from a Level-1 or Level-2 trauma centre. Of the 72 699 trauma cases, 4703 (6.5%) were treated in rural and 67 996 (93.5%) in urban hospitals. Rural versus urban case severity was similar: ISS rural: 8.6 (7.1), ISS urban: 7.2 (7.2). Trauma mortality was higher in rural than urban pre-hospital settings: 7.5% vs 2.6%. Reliable pre-hospital times were available for only a third of eligible cases. Rural mortality was significantly higher than urban mortality during ED stays (OR (95% IC): 2.14 (1.61-2.85)) but not after admission (OR (95% IC): 0.87 (0.74-1.02)). Conclusion: Rural hospitals treat equally severe trauma cases as do urban trauma centres but with fewer resources. The higher pre-hospital and in-ED mortality is of grave concern. Longer rural transport times may be a factor. Lack of reliable pre-hospital times precluded further analysis.

The WR stellar population can be distinguished, at least partially, from other stellar populations by broad-band IR colour selection. We present the use of a machine learning classifier to quantitatively improve the selection of Galactic Wolf-Rayet (WR) candidates. These methods are used to separate the other stellar populations which have similar IR colours. We show the results of the classifications obtained by using the 2MASS J, H and K photometric bands, and the Spitzer/IRAC bands at 3.6, 4.5, 5.8 and 8.0μm. The k-Nearest Neighbour method has been used to select Galactic WR candidates for observational follow-up. A few candidates have been spectroscopically observed. Preliminary observations suggest that a detection rate of 50% can easily be achieved.

Over the past 15 years, the molecular complex Sgr C has been repeatedly observed with both XMM-Newton and Chandra. These observations reveal new features indicating that the region might be more complex than previously thought. We find that its strong iron line emission at 6.4 keV varies significantly over time, which supports the X-ray reflection scenario.

The late-type stellar population in the Galactic Center was first predicted to reside in a dynamically relaxed cusp (power law slope ranging from 3/2 to 7/4). However, other works - which rely on models to correct for projection effects - have suggested a flat distribution instead. The need for this correction is due to the lack of information regarding the line-of-sight distances. With a two decade long baseline in astrometric measurements, we are now able to measure significant projected radial accelerations, six of which are newly reported here, which directly constrain line-of-sight distances. Here we present a statistical approach to take advantage of this information and more accurately constrain the shape of the radial density profile of the late-type stellar population in the Galactic Center.

A K-band (18-25 GHz) reflected-wave ruby maser (Moore and Clauss 1979) has been borrowed from the National Radio Astronomy Observatory for radio astronomy use on the NASA 64-m antenna of the Deep Space Network at the Tidbinbilla Tracking Station, near Canberra. The purpose of the installation is to provide additional sensitive spectral line, continuum, and VLBI capabilities in the southern hemisphere. Previous measurements at 22.3 GHz (λ = 13.5 mm) determined that the Tidbinbilla 64-m antenna has a peak aperture efficiency of ˜22%, a well-behaved beam shape and consistent pointing (Fourikis and Jauncey 1979). Before installing the maser on the antenna a cooled (circulator) switch was added to provide a beam-switching capability, and a spectral line receiver following the maser was incorporated. The system was assembled and tested at JPL in late 1980 and installed at Tidbinbilla early in 1981. We give here a brief description and present some of the first line observations made in February and March 1981. Extensive line and continuum observations are planned with the present system and a program is under way to determine the telescope pointing characteristics.