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Filamentary structures can form within the beam of protons accelerated during the interaction of an intense laser pulse with an ultrathin foil target. Such behaviour is shown to be dependent upon the formation time of quasi-static magnetic field structures throughout the target volume and the extent of the rear surface proton expansion over the same period. This is observed via both numerical and experimental investigations. By controlling the intensity profile of the laser drive, via the use of two temporally separated pulses, both the initial rear surface proton expansion and magnetic field formation time can be varied, resulting in modification to the degree of filamentary structure present within the laser-driven proton beam.
To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs).
Descriptive retrospective cohort with nested case-control study.
Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.
Children≤18 years ventilated for≥1 calendar day.
We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria.
Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20–67%; PICU, 0–70%; and NICU, 0–43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test.
Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.
Sepsis – syndrome of infection complicated by organ dysfunction – is responsible for over 750 000 hospitalisations and 200 000 deaths in the USA annually. Despite potential nutritional benefits, the association of diet and sepsis is unknown. Therefore, we sought to determine the association between adherence to a Mediterranean-style diet (Med-style diet) and long-term risk of sepsis in the REasons for Geographic Differences in Stroke (REGARDS) cohort. We analysed data from REGARDS, a population-based cohort of 30 239 community-dwelling adults age ≥45 years. We determined dietary patterns from a baseline FFQ. We defined Med-style diet as a high consumption of fruit, vegetables, legumes, fish, cereal and low consumption of meat, dairy products, fat and alcohol categorising participants into Med-style diet tertiles (low: 0–3, moderate: 4–5, high: 6–9). We defined sepsis events as hospital admission for serious infection and at least two systematic inflammatory response syndrome criteria. We used Cox proportional hazard models to determine the association between Med-style diet tertiles and first sepsis events, adjusting for socio-demographics, lifestyle factors, and co-morbidities. We included 21 256 participants with complete dietary data. Dietary patterns were: low Med-style diet 32·0 %, moderate Med-style diet 42·1 % and high Med-style diet 26·0 %. There were 1109 (5·2 %) first sepsis events. High Med-style diet was independently associated with sepsis risk; low Med-style diet referent, moderate Med-style diet adjusted hazard ratio (HR) 0·93 (95 % CI 0·81, 1·08), high Med-style diet adjusted HR=0·74 (95 % CI 0·61, 0·88). High Med-style diet adherence is associated with lower risk of sepsis. Dietary modification may potentially provide an option for reducing sepsis risk.
Small perturbations to a steady uniform granular chute flow can grow as the material moves downslope and develop into a series of surface waves that travel faster than the bulk flow. This roll wave instability has important implications for the mitigation of hazards due to geophysical mass flows, such as snow avalanches, debris flows and landslides, because the resulting waves tend to merge and become much deeper and more destructive than the uniform flow from which they form. Natural flows are usually highly polydisperse and their dynamics is significantly complicated by the particle size segregation that occurs within them. This study investigates the kinematics of such flows theoretically and through small-scale experiments that use a mixture of large and small glass spheres. It is shown that large particles, which segregate to the surface of the flow, are always concentrated near the crests of roll waves. There are different mechanisms for this depending on the relative speed of the waves, compared to the speed of particles at the free surface, as well as on the particle concentration. If all particles at the surface travel more slowly than the waves, the large particles become concentrated as the shock-like wavefronts pass them. This is due to a concertina-like effect in the frame of the moving wave, in which large particles move slowly backwards through the crest, but travel quickly in the troughs between the crests. If, instead, some particles on the surface travel more quickly than the wave and some move slower, then, at low concentrations, large particles can move towards the wave crest from both the forward and rearward sides. This results in isolated regions of large particles that are trapped at the crest of each wave, separated by regions where the flow is thinner and free of large particles. There is also a third regime arising when all surface particles travel faster than the waves, which has large particles present everywhere but with a sharp increase in their concentration towards the wave fronts. In all cases, the significantly enhanced large particle concentration at wave crests means that such flows in nature can be especially destructive and thus particularly hazardous.
Giant electromagnetic pulses (EMP) generated during the interaction of high-power lasers with solid targets can seriously degrade electrical measurements and equipment. EMP emission is caused by the acceleration of hot electrons inside the target, which produce radiation across a wide band from DC to terahertz frequencies. Improved understanding and control of EMP is vital as we enter a new era of high repetition rate, high intensity lasers (e.g. the Extreme Light Infrastructure). We present recent data from the VULCAN laser facility that demonstrates how EMP can be readily and effectively reduced. Characterization of the EMP was achieved using B-dot and D-dot probes that took measurements for a range of different target and laser parameters. We demonstrate that target stalk geometry, material composition, geodesic path length and foil surface area can all play a significant role in the reduction of EMP. A combination of electromagnetic wave and 3D particle-in-cell simulations is used to inform our conclusions about the effects of stalk geometry on EMP, providing an opportunity for comparison with existing charge separation models.
In this study, we report the characterization of a 304L stainless steel cylindrical projectile produced by additive manufacturing. The projectile was compressively deformed using a Taylor Anvil Gas Gun, leading to a huge strain gradient along the axis of the deformed cylinder. Spatially resolved neutron diffraction measurements on the HIgh Pressure Preferred Orientation time-of-flight diffractometer (HIPPO) and Spectrometer for Materials Research at Temperature and Stress diffractometer (SMARTS) beamlines at the Los Alamos Neutron Science CEnter (LANSCE) with Rietveld and single-peak analysis were used to quantitatively evaluate the volume fractions of the α, γ, and ε phases as well as residual strain and texture. The texture of the γ phase is consistent with uniaxial compression, while the α texture can be explained by the Kurdjumov–Sachs relationship from the γ texture after deformation. This indicates that the material first deformed in the γ phase and subsequently transformed at larger strains. The ε phase was only found in volumes close to the undeformed material with a texture connected to the γ texture by the Shoji–Nishiyama orientation relationship. This allows us to conclude that the ε phase occurs as an intermediate phase at lower strain, and is superseded by the α phase when strain increases further. We found a proportionality between the root-mean-squared microstrain of the γ phase, dominated by the dislocation density, with the α volume fraction, consistent with strain-induced martensite α formation. Knowledge of the sample volume with the ε phase from the neutron diffraction analysis allowed us to identify the ε phase by electron back scatter diffraction analysis, complementing the neutron diffraction analysis with characterization on the grain level.
A comparative study is presented of the chemistry and crystallography of zinc-bearing strunzites from Hagendorf Süd, Bavaria, Germany and the Sitio do Castelo mine, Folgosinho, Portugal. Electron microprobe analyses of samples from the two localities show quite different cation substitutions. The Hagendorf Süd mineral is a Zn-bearing ferristrunzite, with compositional zoning due to Zn2+ replacing predominantly Fe3+ as well as minor Mn2+, whereas the Portugese mineral is a Zn-bearing strunzite, in which Zn2+ replaces Mn2+, with minor replacement of Fe3+ by Mn3+. Zincostrunzite, with dominant Zn in the interlayer octahedrally coordinated site, is a new strunzite-group mineral that has been characterized at both locations. Analysis of single-crystal synchrotron data for zinc-bearing ferristrunzite and zincostrunzite crystals from Hagendorf Süd show that the structures of both minerals contain zeolitic water in the interlayer region. The formula for strunzite-group minerals containing the zeolitic water is MFe23+(PO4)2(OH)2·6.5H2O, M=Fe, Mn, Zn. This formulation agrees with that found for zincostrunzite from the Sitio do Castelo mine, but differs from that reported previously for strunzite, MFe2+(PO4)2(OH)2·6H2O, which has no interlayer water. Interestingly, the zincostrunzites from the two localities differ in the location of the interlayer water molecule, with a corresponding difference in the H bonding.
W49 A is a star-forming region (SFR) found in the constellation of Aquila. It contains 3 active regions: W49 North (W49 N), W49 South West (W49 SW) and W49 South (W49 S). We present preliminary results from two epochs (e-)MERLIN observations of all ground-state OH masers towards the star-forming region (SFR) complex W49 A. The first epoch of observations was done in full-polarization mode with MERLIN in 2005 while the second epoch was obtained only in dual circular polarization during the test observations of the upgraded e-MERLIN in 2013. The overall maser spatial distributions in both epochs are in good agreement. We found several new high velocity maser features up to +34 km s−1 and −28 km s−1. The magnetic field strengths are between 1.1 to 10.8 mG. All three sources show evidence of magnetic field reversal.
Outstanding problems concerning mass-loss from evolved stars include initial wind acceleration and what determines the clumping scale. Reconstructing physical conditions from maser data has been highly uncertain due to the exponential amplification. ALMA and e-MERLIN now provide image cubes for five H2O maser transitions around VY CMa, at spatial resolutions comparable to the size of individual clouds or better, covering excitation states from 204 to 2360 K. We use the model of Gray et al. 2016, to constrain variations of number density and temperature on scales of a few au, an order of magnitude finer than is possible with thermal lines, comparable to individual cloud sizes or locally almost homogeneous regions. We compare results with the models of Decin et al. 2006 and Matsuura et al. 2014 for the circumstellar envelope of VY CMa; in later work this will be extended to other maser sources.
Snow avalanches are typically initiated on marginally stable slopes with a surface layer of fresh snow that may easily be incorporated into them. The erosion of snow at the front is fundamental to the dynamics and growth of snow avalanches and they may rapidly bulk up, making them much more destructive than the initial release. Snow may also deposit at the rear, base and sides of the flow and the net balance of erosion and deposition determines whether an avalanche grows or decays. In this paper, small-scale analogue experiments are performed on a rough inclined plane with a static erodible layer of carborundum grains. The static layer is prepared by slowly closing down a flow from a hopper at the top of the slope. This leaves behind a uniform-depth layer of thickness
at a given slope inclination. Due to the hysteresis of the rough bed friction law, this layer can then be inclined to higher angles provided that the thickness does not exceed
, which is the maximum depth that can be held static on a rough bed. An avalanche is then initiated on top of the static layer by releasing a fixed volume of carborundum grains. Dependent on the slope inclination and the depth of the static layer three different behaviours are observed. For initial deposit depths above
, the avalanche rapidly grows in size by progressively entraining more and more grains at the front and sides, and depositing relatively few particles at the base and tail. This leaves behind a trough eroded to a depth below the initial deposit surface and whose maximal areal extent has a triangular shape. Conversely, a release on a shallower slope, with a deposit of thickness
, leads to net deposition. This time the avalanche leaves behind a levee-flanked channel, the floor of which lies above the level of the initial deposit and narrows downstream. It is also possible to generate avalanches that have a perfect balance between net erosion and deposition. These avalanches propagate perfectly steadily downslope, leaving a constant-width trail with levees flanking a shallow trough cut slightly lower than the initial deposit surface. The cross-section of the trail therefore represents an exact redistribution of the mass reworked from the initial static layer. Granular flow problems involving erosion and deposition are notoriously difficult, because there is no accepted method of modelling the phase transition between static and moving particles. Remarkably, it is shown in this paper that by combining Pouliquen & Forterre’s (J. Fluid Mech., vol. 453, 2002, pp. 133–151) extended friction law with the depth-averaged
-rheology of Gray & Edwards (J. Fluid Mech., vol. 755, 2014, pp. 503–544) it is possible to develop a two-dimensional shallow-water-like avalanche model that qualitatively captures all of the experimentally observed behaviour. Furthermore, the computed wavespeed, wave peak height and stationary layer thickness, as well as the distance travelled by decaying avalanches, are all in good quantitative agreement with the experiments. This model is therefore likely to have important practical implications for modelling the initiation, growth and decay of snow avalanches for hazard assessment and risk mitigation.
Introduction: Effective trauma resuscitation requires a coordinated team approach, yet there is a significant risk for error. These errors can manifest from sequential system-, team- and knowledge based failures, defined as latent safety threats (LSTs). In situ simulation (ISS), a point-of-care training strategy, provides a novel prospective approach to identify factors that impact patient safety. This study quantified and formulated a hierarchy of LSTs during risk-informed ISS trauma resuscitations. Methods: At a Level 1 trauma centre, we conducted 12 multi-disciplinary, unannounced ISSs to prospectively identify trauma-related LSTs. Four, risk-informed scenarios were developed based on 5 recurring themes found within the trauma program’s morbidity and mortality process. The actual, on-call trauma team participated in the study. Simulations were video recorded with 4 cameras, each positioned at a different angle. Using a framework analysis methodology, human factors experts transcribed and coded the videos. Thematic structure was established deductively based on existing literature and inductively based on observed ISS events. All LSTs were prioritized for future patient safety, systems and ergonomic interventions using the Healthcare Failure Mode and Effect Analysis (HFMEA) matrix. Results: We identified 893 LSTs from 12 simulations. LST analysis resulted in 8 themes subcategorized into 43 codes. Themes were associated with team-, knowledge- or system-related issues. The following themes emerged: situational awareness, provider safety, mental model alignment, team/individual responsibility, team resources, equipment considerations, workplace environment and clinical protocols. The HFMEA hazard scoring process identified 13 high priority codes that required urgent attention and intervention to mitigate negative patient outcomes. Conclusion: A prospective, video-based framework analysis represents a novel and robust approach to LST identification within trauma care. Patterns of LSTs within and between simulations provide a high degree of transparency and traceability for an inter-professional trauma program review. Hazard matrix scoring facilitates the classification and prioritization of human factors interventions intended to improve patient safety.
Geophysical granular flows, such as avalanches, debris flows, lahars and pyroclastic flows, are always strongly influenced by the basal topography that they flow over. In particular, localised bumps or obstacles can generate rapid changes in the flow thickness and velocity, or shock waves, which dissipate significant amounts of energy. Understanding how a granular material is affected by the underlying topography is therefore crucial for hazard mitigation purposes, for example to improve the design of deflecting or catching dams for snow avalanches. Moreover, the interactions with solid boundaries can also have important applications in industrial processes. In this paper, small-scale experiments are performed to investigate the flow of a granular avalanche over a two-dimensional smooth symmetrical bump. The experiments show that, depending on the initial conditions, two different steady-state regimes can be observed: either the formation of a detached jet downstream of the bump, or a shock upstream of it. The transition between the two cases can be controlled by adding varying amounts of erodible particles in front of the obstacle. A depth-averaged terrain-following avalanche theory that is formulated in curvilinear coordinates is used to model the system. The results show good agreement with the experiments for both regimes. For the case of a shock, time-dependent numerical simulations of the full system show the evolution to the equilibrium state, as well as the deposition of particles upstream of the bump when the inflow ceases. The terrain-following theory is compared to a standard depth-averaged avalanche model in an aligned Cartesian coordinate system. For this very sensitive problem, it is shown that the steady-shock regime is captured significantly better by the terrain-following avalanche model, and that the standard theory is unable to predict the take-off point of the jet. To retain the practical simplicity of using Cartesian coordinates, but have the improved predictive power of the terrain-following model, a coordinate mapping is used to transform the terrain-following equations from curvilinear to Cartesian coordinates. The terrain-following model, in Cartesian coordinates, makes identical predictions to the original curvilinear formulation, but is much simpler to implement.
Adult ventilator-associated event (VAE) definitions include ventilator-associated conditions (VAC) and subcategories for infection-related ventilator-associated complications (IVAC) and possible ventilator-associated pneumonia (PVAP). We explored these definitions for children.
Pediatric, cardiac, or neonatal intensive care units (ICUs) in 6 US hospitals
Patients ≤18 years old ventilated for ≥1 day
We identified patients with pediatric VAC based on previously proposed criteria. We applied adult temperature, white blood cell count, antibiotic, and culture criteria for IVAC and PVAP to these patients. We matched pediatric VAC patients with controls and evaluated associations with adverse outcomes using Cox proportional hazards models.
In total, 233 pediatric VACs (12,167 ventilation episodes) were identified. In the cardiac ICU (CICU), 62.5% of VACs met adult IVAC criteria; in the pediatric ICU (PICU), 54.2% of VACs met adult IVAC criteria; and in the neonatal ICU (NICU), 20.2% of VACs met adult IVAC criteria. Most patients had abnormal white blood cell counts and temperatures; we therefore recommend simplifying surveillance by focusing on “pediatric VAC with antimicrobial use” (pediatric AVAC). Pediatric AVAC with a positive respiratory diagnostic test (“pediatric PVAP”) occurred in 8.9% of VACs in the CICU, 13.3% of VACs in the PICU, and 4.3% of VACs in the NICU. Hospital mortality was increased, and hospital and ICU length of stay and duration of ventilation were prolonged among all pediatric VAE subsets compared with controls.
We propose pediatric AVAC for surveillance related to antimicrobial use, with pediatric PVAP as a subset of AVAC. Studies on generalizability and responsiveness of these metrics to quality improvement initiatives are needed, as are studies to determine whether lower pediatric VAE rates are associated with improvements in other outcomes.
Background: There are currently no national standards for clinical electromyography (EMG) training for residents in neurology and physiatry in Canada. The purpose of this study was to obtain demographic and qualitative data pertaining to EMG residency training in Canada, with the goal of facilitating discourse that could lead to national standards for EMG training. Methods: An online survey was distributed to senior neurology and physiatry residents (post-graduate years 3-5), at seven tertiary Canadian centres. The study authors, who are trainees and consultants with a broad range of EMG expertise (junior and senior resident, clinical neuromuscular fellows, senior physiatrist and neuromuscular neurologists), developed pertinent demographic and qualitative questions. Results: Thirty-eight residents completed the survey (23 neurology, 15 physiatry). There was inter-program variation in quantity of the training experience, content of the curriculum, access to expertise (including technologists) and goals for future training and practice. Similarly, differences were identified between the training experiences of neurology and physiatry residents. Conclusions: Inter-program variability in EMG training was identified. Additionally, differences were identified between neurology and physiatry resident training. This data provides evidence of training discrepancies across the country and can be used to establish national training standards for EMG in Canada.
Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Among the domains assessed by the CIWA-Ar, tremor is the most objective indicator of withdrawal severity, however, the ability of clinicians to reliably quantify tremor is highly dependent on experience. The objective of this study was to prospectively validate an objective, reliable tool to standardize and quantify the severity of alcohol withdrawal tremor using the built-in accelerometer of an iOS application. Methods: A prospective observational study of patients ≥18 years presenting to an academic emergency department in alcohol withdrawal was conducted from Oct 2014 to Aug 2015. Assessments were videotaped by a research assistant and subsequently reviewed by 3 clinical experts, blinded to the primary clinical assessment. Tremor severity was scored using the 8-point CIWA scale (0=no tremor, 7=severe tremor). Accelerometer derived results were compared to expert assessments of each video. Inter-rater agreement was estimated using Cohen’s kappa (k) statistic. Results: 76 patients with 78 tremor recordings were included. Accelerometer derived tremor scores matched exactly with expert assessor scores in 36 (46.2%) cases, within 1 point for 73 (93.6%) cases and differed by ≥ 2 points in 5 (6.4%) cases. The overall kappa for agreement within 1 point for tremor severity was ‘very good’ 0.92 (95% CI: 0.86, 0.99). Conclusion: iOS accelerometer based assessment of the tremor component of the CIWA-Ar score is reliable and has potential to more accurately assess the severity of patients in alcohol withdrawal. We anticipate this resource will be easily disseminated and will impact and improve the care of patients with alcohol withdrawal.
Introduction: Resuscitation of a trauma patient requires a multidisciplinary team to perform in a dynamic, high-stakes environment. Error is ubiquitous in trauma care, often related to latent safety threats (LSTs) - previously unrecognized threats that can materialize at any time. In-situ simulation (ISS) allows a team to practice in their authentic environment while providing an opportunistic milieu to explore critical events and uncover LSTs that impact patient safety. Methods: At a Canadian Level 1 trauma centre, regular, unannounced trauma ISSs were conducted and video-recorded. A retrospective chart review of adverse events or unexpected deaths informed ISS scenario design. Each session began with a trauma team activation. The on-duty trauma team arrived in the trauma bay and provided care as they would for a real patient. Semi-structured debriefing with participant-driven LST identification and ethnographic observation occurred in real time. A framework analysis using video review was conducted by human factors experts to identify and evaluate LSTs. Feasibility was measured by the impact on ED workflow, interruptions of clinical care and participant feedback. Results: Six multidisciplinary, high-fidelity, ISS sessions were conducted and 70 multidisciplinary staff and trainees participated in at least one session. Using a framework analysis, LSTs were identified and categorized into seven themes that relate to clinical tasks, equipment, team communication, and participant workflow. LSTs were quantified and prioritized using a hazard scoring matrix. ISS was effectively implemented during both low and high patient volume situations. No critical interruptions in patient care were identified during ISS sessions and overall participant feedback was positive. Conclusion: This novel, multidisciplinary ISS trauma training program integrated risk-informed simulation cases with human factors analysis to identify LSTs. ISS offers an opportunity for an iterative review process of high-risk situations beyond the traditional morbidity and mortality rounds; rather than waiting for an actual case to generate discussion and review, we prophylactically examined critical situations and processes. Findings form a framework for recommendations about improvements in equipment, environment layout, workflow, system processes, effective team training, and ultimately patient safety.
During 1990 we surveyed the southern sky using a multi-beam receiver at frequencies of 4850 and 843 MHz. The half-power beamwidths were 4 and 25 arcmin respectively. The finished surveys cover the declination range between +10 and −90 degrees declination, essentially complete in right ascension, an area of 7.30 steradians. Preliminary analysis of the 4850 MHz data indicates that we will achieve a five sigma flux density limit of about 30 mJy. We estimate that we will find between 80 000 and 90 000 new sources above this limit. This is a revised version of the paper presented at the Regional Meeting by the first four authors; the surveys now have been completed.
The 2013 multistate outbreaks contributed to the largest annual number of reported US cases of cyclosporiasis since 1997. In this paper we focus on investigations in Texas. We defined an outbreak-associated case as laboratory-confirmed cyclosporiasis in a person with illness onset between 1 June and 31 August 2013, with no history of international travel in the previous 14 days. Epidemiological, environmental, and traceback investigations were conducted. Of the 631 cases reported in the multistate outbreaks, Texas reported the greatest number of cases, 270 (43%). More than 70 clusters were identified in Texas, four of which were further investigated. One restaurant-associated cluster of 25 case-patients was selected for a case-control study. Consumption of cilantro was most strongly associated with illness on meal date-matched analysis (matched odds ratio 19·8, 95% confidence interval 4·0–∞). All case-patients in the other three clusters investigated also ate cilantro. Traceback investigations converged on three suppliers in Puebla, Mexico. Cilantro was the vehicle of infection in the four clusters investigated; the temporal association of these clusters with the large overall increase in cyclosporiasis cases in Texas suggests cilantro was the vehicle of infection for many other cases. However, the paucity of epidemiological and traceback information does not allow for a conclusive determination; moreover, molecular epidemiological tools for cyclosporiasis that could provide more definitive linkage between case clusters are needed.