High-energy and high-intensity lasers are essential for pushing the boundaries of science. Their development has allowed leaps forward in basic research areas, including laser–plasma interaction, high-energy density science, metrology, biology and medical technology. The Helmholtz International Beamline for Extreme Fields user consortium contributes and operates two high-peak-power optical lasers using the high energy density instrument at the European X-ray free electron laser (EuXFEL) facility. These lasers will be used to generate transient extreme states of density and temperature to be probed by the X-ray beam. This paper introduces the ReLaX laser, a short-pulse high-intensity Ti:Sa laser system, and discusses its characteristics as available for user experiments. It will also present the first experimental commissioning results validating its successful integration into the EuXFEL infrastructure and viability as a relativistic-intensity laser driver.

Introduction: Acute heart failure (AHF) is a common emergency department (ED) presentation and may be associated with poor outcomes. Conversely, many patients rapidly improve with ED treatment and may not need hospital admission. Because there is little evidence to guide disposition decisions by ED and admitting physicians, we sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. Methods: We conducted prospective cohort studies at 9 tertiary care hospital EDs from 2007 to 2019, and enrolled adult patients who required treatment for AHF. Each patient was assessed for standardized real-time clinical and laboratory variables, as well as for SSO (defined as death within 30 days or intubation, non-invasive ventilation (NIV), myocardial infarction, coronary bypass surgery, or new hemodialysis after admission). The fully pre-specified, logistic regression model with 13 predictors (age, pCO2, and SaO2 were modeled using spline functions with 3 knots and heart rate and creatinine with 5 knots) was fitted to the 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions and estimated a sample size of 170 SSOs. Results: The 2,246 patients had mean age 77.4 years, male sex 54.5%, EMS arrival 41.1%, IV NTG 3.1%, ED NIV 5.2%, admission on initial visit 48.6%. Overall there were 174 (7.8%) SSOs including 70 deaths (3.1%). The final risk scale is comprised of five variables (points) and had c-statistic of 0.76 (95% CI: 0.73-0.80): 1.Valvular heart disease (1) 2.ED non-invasive ventilation (2) 3.Creatinine 150-300 (1) ≥300 (2) 4.Troponin 2x-4x URL (1) ≥5x URL (2) 5.Walk test failed (2) The probability of SSO ranged from 2.0% for a total score of 0 to 90.2% for a score of 10, showing good calibration. The model was stable over 1,000 bootstrap samples. Choosing a risk model total point admission threshold of >2 would yield a sensitivity of 80.5% (95% CI 73.9-86.1) for SSO with no change in admissions from current practice (48.6% vs 48.7%). Conclusion: Using a large prospectively collected dataset, we created a concise and sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of this risk scoring scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.

Introduction: Canada is in the midst of an opioid crisis. The number of apparent opioid-related deaths between January and March 2018 increased by 44% compared to the same period in 2016. The increasing use of prescription opioids and higher doses of opioids can lead to opioid addiction, toxicity and even death. Opioids are commonly prescribed for low back pain management in the ED, but the variability in opioid-prescribing patterns suggested an opportunity for improvement. Our centre implemented Clinician Performance Indicators (CPI) in 2015. CPIs were reported to each ED physician every 3 months and included the percentage of patients who were prescribed opioids. The intent was to raise awareness of opioid-prescribing patterns at our institution. Therefore, we evaluated opioid-prescribing patterns for patients with low back pain (LBP) before and after the CPI implementation. Methods: Data were obtained retrospectively for patients discharged from the ED from July 2015 to December 2018 with LBP-associated ICD 10 codes. We excluded admitted patients, those with specialist consultations, and patients who left without being seen. The primary outcome was opioid prescribing patterns for patients with LBP before and after CPI implementation. We performed a descriptive analysis of the data and compared the prescribing rates pre-implementation (July-Dec 2015) to post-implementation (July-Dec 2016) following a 6-month wash-out period. Moreover, we analyzed opioid-prescribing patterns over an extended period until December 2018. Results: After the exclusion criteria were applied, 8993 patients were included in the analysis. 53.5% were female and the mean (SD) age was 48.3 (19.78). During the three years of the study period, the percentage of LBP patients who received opioids showed a decreasing trend. Comparison of the pre and post CPI implementation periods showed a decrease in opioid prescriptions (42.0% vs 35.5%, 95%CI 2.9% to 10.2%). There was variation in opioids prescribed at our institution, the most common being hydromorphone (29.9%), followed by acetaminophen-oxycodone (24.2%) and acetaminophen-tramadol (20.0%). Conclusion: The implementation of CPIs positively impacted physicians' opioid-prescribing patterns for patients presenting with LBPs at our institution. Future studies are required to further improve the effectiveness of CPIs in influencing opioid-prescribing patterns.

Introduction: Depending on the time and day of initial Emergency Department (ED) presentation, some patients may require a return to the ED the following day for ultrasound examination. Return visits for ultrasound may be time and resource intensive for both patients and the ED. Qualitative experience suggests that a percentage of return ultrasounds could be performed at a non-ED facility. Our objective was to undertake a retrospective audit of return for ultrasound usage, patterns and outcomes at 2 academic EDs. Methods: A retrospective review of all adult patients returning to the ED for ultrasound at both LHSC ED sites in 2016 was undertaken. Each chart was independently reviewed by two emergency medicine consultants. Charts were assessed for day and time of initial presentation and return, type of ultrasound ordered, and length of ED stay on initial presentation and return visit. Opinion based questions were considered by reviewers, including urgency of diagnosis clarification required, if symptoms were still present on return, and if any medical or surgical treatment or follow up was arranged based on ultrasound results. Agreement between reviewers was assessed. Results: After eliminating charts for which the return visit was not for a scheduled ultrasound examination, 328 patient charts were reviewed. 63% of patients were female and median [IQR] age was 40 years [27-56]. Abdomen/pelvis represented 50% of the ultrasounds; renal 24%; venous Doppler 15.9%. Symptoms were still present and documented in 79% of cases. 22% of cases required a medical intervention and 9% an immediate surgical intervention. 11% of patients were admitted to hospital on their return visit. Outpatient follow-up based on US results was initiated in 29% of cases. Median [IQR] combined LOS was 479.5 minutes [358.5-621.75]. Agreement between reviewers for opinion based questions was poor (63%-96%). Conclusion: Ideally, formal ultrasound should be available on a 24 hour basis for ED patients in order to avoid return visits. A percentage of return for ultrasound examinations do not result in any significant change in treatment. Emergency departments should consider the development of pathways to avoid return visits for follow up ultrasound when possible. The low incidence of surgical treatment in those returning for US suggests that this population could be served in a non-hospital setting. Further research is required to support this conclusion.

Introduction: We previously derived (N = 559) and validated (N = 1,100) the 10-item Ottawa Heart Failure Risk Scale (OHFRS), to assist with disposition decisions for patients with acute heart failure (AHF) in the emergency department (ED). In the current study we sought to use a larger dataset to develop a more concise and more accurate risk scale. Methods: We analyzed data from the prior two studies and from a new cohort. For all 3 groups we conducted prospective cohort studies that enrolled patients who required treatment for AHF at 8 tertiary care hospital EDs. Patients were followed for 30 days. The primary outcome was short-term serious outcome (SSO), defined as death within 30 days, intubation or non-invasive ventilation (NIV) after admission, myocardial infarction, or relapse resulting in hospital admission within 14 days. The fully pre-specified logistic regression model with 13 predictors (where age, pCO2, and SaO2 were modeled using spline functions) was fitted to 10 multiple imputation datasets. Harrell's fast stepdown procedure reduced the number of variables. We calculated the potential impact on sensitivity (95% CI) for SSO and hospital admissions, and estimated a sample size of 2,000 patients. Results: The 1,986 patients had mean age 77.3 years, male 54.1%, EMS arrival 41.2%, IV NTG 3.3%, ED NIV 5.4%, admission on initial visit 49.5%. Overall there were 236 (11.9%) SSOs including 61 deaths (3.1%), meaning that current admission practice sensitivity for SSO was only 59.7%. The final HEARTRISK6 scale is comprised of 6 variables (points) (C-statistic 0.68): Valvular heart disease (2) Antiarrhythmic medication (2) ED non-invasive ventilation (3) Creatinine 80–150 (1); ≥150 (3) Troponin ≥3x URL (2) Walk test failed (1). The probability of SSO ranged from 4.8% for a total score of 0 to 62.4% for a score of 10, showing good calibration. Choosing a HEARTRISK6 total point admission threshold of ≥3 would yield sensitivity of 70.8% (95%CI 64.5-76.5) for SSO with a slight decrease in admissions to 47.9%. Choosing a threshold of ≥2 would yield a sensitivity of 84.3% (95%CI 79.0-88.7) but require 66.6% admissions. Conclusion: Using a large prospectively collected dataset, we created a more concise and more sensitive risk scale to assist with admission decisions for patients with AHF in the ED. Implementation of the HEARTRISK6 scale should lead to safer and more efficient disposition decisions, with more high-risk patients being admitted and more low-risk patients being discharged.

Background: Children with decompensated heart failure are at high risk for arrhythmias, and ventricular assist device placement is becoming a more common treatment strategy. The impact of ventricular assist devices on arrhythmias and how arrhythmias affect the clinical course of this population are not well described. Methods and results: A single-centre retrospective analysis of children receiving a ventricular assist device between 1998 and 2011 was performed. In all, 45 patients received 56 ventricular assist devices. The median age at initial placement was 13 years (interquartile range 6–15). The median duration of support was 10 days (range 2–260). The aetiology of heart failure included cardiomyopathy, transplant rejection, myocarditis, and congenital heart disease. In all, 32 patients (71%) had an arrhythmia; 19 patients (42%) had an arrhythmia before ventricular assist device and eight patients (18%) developed new arrhythmias on ventricular assist device. Ventricular tachycardia was most common (25/32, 78%). There was no correlation between arrhythmia and risk of death or transplantation (p=0.14). Of the 15 patients who weaned from ventricular assist device, post-ventricular assist device arrhythmias occurred in nine (60%), with five (33%) having their first arrhythmia after weaning. Patients with ventricular dysfunction after ventricular assist device were more likely to have arrhythmias (p<0.02). Conclusions: Arrhythmias, especially ventricular, are common in children requiring ventricular assist device. They frequently persist for those able to wean from ventricular assist device.

It is important to understand the electrolyte–electrode interactions for fabricating graphene oxide (GO)- and ionic liquid (IL)-based ultracapacitors. Therefore, we explored how the type and size of the cations in various ILs determine the nature of processed materials. In all cases, the ILs intercalate into the graphitic structure but marked differences are observed during exfoliation via thermal reduction. The combination of a long alkyl chain ammonium-based cation and a large-volume anion leads to strong interactions and defect formation, as evidenced by CO2 production during annealing. In contrast, using the same anions but different cations stabilize the GO functional groups below 400 °C.

We discuss the lithium storage process within a single-particle cathode of a lithium-ion battery. The single storage particle consists of a crystal lattice whose interstitial lattice sites may be empty or reversibly filled with lithium atoms. The resulting evolution equations describe diffusion with mechanical coupling and incorporate volume changes, phase transitions and surface tension. In order to simulate the dynamics, we assume spherical symmetry and fast bulk diffusion of the lithium atoms, which lead to a core shell model. We verify the common assumption of phase nucleation at the external boundary of the particle. This model is capable to predict voltage–capacity behaviour. For slow charging rates, we compare the results with experimental voltage–capacity plots exhibiting hysteretic behaviour. We observe that hysteresis cannot be described within the setting of a single-particle cathode. The origin of this fact is discussed in detail. The result is of enormous importance because single-particle models, in particular core shell models, up to now are very popular in the chemical literature.

The activation of inflammatory systems as a consequence of cardiopulmonary bypass represents one possible means by which inj ury to tissues and associated dysfunction of organs may occur in the postoperative cardiac patient, both pediatric and adult. Kirklin and colleagues demonstrated in the early 1980's that complement activation occurs as a consequence of blood exposure to the extracorporeal circuit. Subsequent studies demonstrated this to be true in systems using both bubble and membrane oxygenators. The anaphylatoxin C5a and its metabolite C5a des arg are produced during activation of the complement cascade. They are potent stimulants which may induce activation of neutrophils. This activation may be manifested as changes in shape, decreased cellular deformability, and changes in adhesive and secretory function. Activation of neutrophils by these fragments of complement could contribute to neutrophilmediated damage to tissues by promoting retention of neutrophils in vascular beds and secretion of cytotoxic substances. Recent studies demonstrating the release of neutrophil granular enzymes into the plasma following cardiopulmonary bypass are evidence that activation of neutrophils is taking place in this setting.

We describe the development and exacerbation of protein-losing enteropathy after relocating to an environment at an altitude of 3695 feet in El Paso, Texas, in a patient who had undergone a Fontan operation. This report should heighten awareness to the possibility of such patients developing protein-losing enteropathy at high-altitude, with hypoxemia-induced pulmonary vasoconstriction, and subsequent elevation of central venous pressure, the most likely underlying mechanism.

Multilayers consisting of two immiscible components (e.g. Fe/Ag Fe/Au or Ni/NiO) could by transformed by an annealing process into a nanostructured system of non statistically distributed nearly spherical particles in a surrounding matrix of the complementary component. The non statistical arrangement of the particles and the dynamics of the disintegration process strongly depend on the initial interface energy, i.e. the local interface curvature and the local interfacial stress. Detailed microstructure investigations of the different systems are used to interpret the measured transport properties.

Multilayers consisting of two immiscible components (e.g. Fe/Ag Fe/Au or Ni/NiO) could by transformed by an annealing process into a nanostructured system of non statistically distributed nearly spherical particles in a surrounding matrix of the complementary component. The non statistical arrangement of the particles and the dynamics of the disintegration process strongly depend on the initial interface energy, i.e. the local interface curvature and the local interfacial stress. Detailed microstructure investigations of the different systems are used to interpret the measured transport properties.

This research developed new forms of photocatalysts that could potentially move photocatalytic degradation of air contaminants into the main stream of industrially used remediation technologies. Tests of the photocatalytic activity of the TiO2 aerogel catalysts have been carried out using both acetone and methane as the air contaminant. For comparison, the same tests were carried out on a standard (non-aerogel) anatase powder. Despite having very low crystallinity, the aerogel decontaminates the air far more effectively than an equal volume of the anatase powder which indicates that a much larger fraction of the aerogel is activated by the UV light. Experimental data were used to determine adsorption equilibrium constants for acetone, and to determine reaction rate constants assuming a Langmuir-Hinshelwood type rate expression.

We find differential scanning calorimetry to be suitable for the characterization of the energetics and kinetics of interdiflusion in solder/metal diffusion couples. Differential scanning calorimetry studies of interdiffusion in Cu/Cu6Sn5 diffusion couples have shown that the driving force for interdiffusion is similar for thin film composites and for bulk diffusion couples. The heat of formation of Cu3Sn from Cu6Sn5 and Cu thin films was found to be ΔHr = −4.3 + 0.3 kJ/mol. Portions of our differential scanning calorimetry scans are identified with diffusion limited growth of Cu3Sn. From these calorimetry data we have estimated D(cm2 / s) = Do exp(−E / kbT), where kb is Boltzmann's constant, D0 = 3.2 × 10–2 cm2/s, and E=0.87 eV/atom.

We have investigated the effects of Cu and Si dopants on electromigration mass transport in Al interconnects for VLSI technology. Four Al alloys with different Cu and Si dopant concentrations (AI-1.5%Cu, AI-1.5%Cu-I.5%Si, AI-0.5%Cu-I.0%Si, and AI-I.O%Cu-I.0%Si) were sputter deposited onto Si substrates covered with 0.55 pRm of Si02 (tetraethylorthosilicate). All metal films were deposited using an MRC903 sputter deposition system to a thickness of 6800Å. Deposition parameters were held constant for each metallurgy, with a base pressure of 7x 10−2 torr, deposition pressure of 102 torr, forward power of 7 Kwatts, and substrate bias of 125 volts. Test structures designed according to National Institute of Standards design guidelines were fabricated in each metallurgy using conventional photolithography and reactive ion etching methods for line widths of 1.0, 1.8, 3.0, 5.0 and 10.0 μm. Accelerated test conditions of T=200°C and DC current density of 2x106 A/cm−2 were used. The results show that electromigration resistance increases with increasing Cu content and decreases as Si content increases. These results are explained in terms of precipitate, grain size distribution, orientation and stress by Transmission Electron Microscopy (TEM) and X-ray Diffraction (XRD). Our results provide a general guideline relating Cu and Si dopant concentrations, film microstructure and the intrinsic reliability of the metallization system.

A member of the Theology Department and of the Staff of Campus Ministry team taught at Marquette University a course in which the objective was to offer the opportunity for both the experience of prayer and for reflection upon that experience. In this article the two teachers describe that experiment and offer their reflections upon its potential for meeting the need for such cooperative ventures.