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BackgroundThe large volume of patients, rapid staff turnover and high work pressure mean that the usability of all systems within the ED is important. The transition to electronic health records (EHRs) has brought many benefits to emergency care but imposes a significant burden on staff to enter data. Poor usability has a direct consequence and opportunity cost in staff time and resources that could otherwise be employed in patient care. This research measures the usability of EHR systems in UK EDs using a validated assessment tool.MethodsThis was a survey completed by members and fellows of the Royal College of Emergency Medicine conducted during summer 2019. The primary outcome was the System Usability Scale Score, which ranges from 0 (worst) to 100 (best). Scores were compared with an internationally recognised measure of acceptable usability of 68. Results were analysed by EHR system, country, healthcare organisation and physician grade. Only EHR systems with at least 20 responses were analysed.ResultsThere were 1663 responses from a total population of 8794 (19%) representing 192 healthcare organisations (mainly UK NHS), and 25 EHR systems. Fifteen EHR systems had at least 20 responses and were included in the analysis. No EHR system achieved a median usability score that met the industry standard of acceptable usability.The median usability score was 53 (IQR 35–68). Individual EHR systems’ scores ranged from 35 (IQR 26–53) to 65 (IQR 44–80).ConclusionIn this survey, no UK ED EHR system met the internationally validated standard of acceptable usability for information technology.

Participants attempted to center a cursor on a video display of a winding roadway with a rate control system. Fourier analysis of their steering movements in response to sinusoidal perturbations of the roadway revealed how much attention they allocated to different roadway preview locations. We compared a full 1.0 s of preview with preview restricted to a narrow slit around 0.3 s or 0.6 s. Participants were able to flexibly shift their attention to either slit. However, they performed better in terms of root-mean-squared error, velocity error, and acceleration error with the fuller view. They concentrated their attention over a range from 0.1 s to 0.3 s of preview in a manner qualitatively consistent with Miller's optimal control model.

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality worldwide.1 In survivors, disability may persist for years after the initial injury. Even mild TBI can result in cognitive deficits, somatic symptoms (eg, headaches), mental health problems (eg, depression) and an increased risk of dementia.2 3 Accurate estimates of the incidence and prevalence of TBI are needed to inform polices on prevention, resource allocation and to meet the needs of those who have sustained a TBI. A recent Lancet Neurology Commission recommended that defining and recording accurate measurements of incidence, mortality and rates of access hospital care in patients with TBI is essential.1 A recent analysis of the effect of the Scottish Intercollegiate Guidelines Network head injury guideline, National Institute for Health and Care Excellence (NICE) Guideline 176 (Head injury: assessment and early management), a National Institute for Health Research (NIHR) evidence summary, and numerous peer-reviewed articles and web pages all cite an oft-used statistic that ‘1.4 million people attend emergency departments in England and Wales with a recent head injury each year’.4–6 This number has been reported in the medical literature for more than a quarter of a century and forms the basis of our understanding of the public health burden from TBI. > Numerous peer-reviewed articles cite the oft-used statistic that 1.4 million people attend emergency departments in England and Wales each year. The original source of this statistic is elusive. The source of …

Dear Editor, We were interested to read the letter by Kakleas and colleagues.1 They report three findings. The first is that of 89 children referred to an allergy clinic, diagnoses made in the Emergency Department (ED) clinical notes matched the Emergency Care Data Set (ECDS) diagnosis in 60% of cases (43 children with ‘other allergic reaction’ and 10 children with ‘anaphylaxis’). The second is that in the ED clinical notes, clinicians made two allergy diagnoses that are not available in ECDS (cow’s milk protein allergy and non-IgE allergy, occurring in 10 and 2 cases respectively). Their final finding is that diagnoses made in an allergy clinic were, in descending order of frequency: food allergy, urticaria, cow’s milk protein allergy and food/skin allergy. They note that the diagnosis of urticaria made in the allergy clinic is not usually a diagnosis associated with allergy. ‘Urticaria’ is in fact available in ECDS, in the ‘Skin and soft tissues’ subgroup, not the ‘Allergy’ subgroup. This implies that in those cases at least, …

Introduction: Mechanical ventilation is a commonly performed procedure in the emergency department (ED). Approximately 240,000 patients per year receive mechanical ventilation in the ED representing 0.23% of ED visits. An ED-based trial published in 2017 showed that a bundle of interventions in mechanically ventilated patients, including low tidal volume ventilation, reduced the development of acute respiratory distress syndrome by nearly 50%. Prior literature has shown that as many as 40% of ED patients do not receive lung protective ventilation. Our goal was to determine whether differences exist between the percent of males vs females who are ventilated at ≥ 8 milliliters per kilogram (mL/kg) of predicted body weight. Methods: We conducted this study at Temple University Hospital, a tertiary care center located in Philadelphia, Pennsylvania. This was a planned subgroup analysis of study looking at interventions to improve adherence to recommended tidal volume settings. We used a convenience sample of mechanically ventilated patients in our ED between September 1, 2017, and September 30, 2018. All adult patient > 18 years old were eligible for inclusion in the study. Our primary outcome measure was the number of patients who had initial tidal volumes set at > 8 mL/kg of predicted body weight. Our secondary outcome was the number of patients who had tidal volumes set at ≥ 8 mL/kg at 60 minutes after initiation of mechanical ventilation. Results: A total of 130 patients were included in the final analysis. We found that significantly more females were initially ventilated with tidal volumes ≥ 8 mL/kg compared to men: 56% of females vs 9% of males (p=

We present a fully operational ultra-stable-laser system for cooling, trapping and manipulating Rydberg states in optical tweezer arrays of neutral Sr-atoms. Some CW-lasers are phase-coherently disciplined by an ultra-low-noise comb referenced to a sub-Hz ultra-stable-laser.

Objective: To determine the short-term cognitive and symptomatic outcome following mild traumatic brain injury. Methods: Setting: Emergency Departments of two UK tertiary referral hospitals. Participants: Adult patients presenting to the Emergency Departments of the Royal London Hospital and Salford Royal Hospital with suspected traumatic brain injury within 24 hours and Glasgow Coma Score > 8. A non-TBI comparison group included adult patients with no head or neck injury. Design: Prospective multi-centre cohort study. Main measures: The Standardized Assessment of Concussion (SAC), the Concussion Symptom Inventory (CSI) and total number of symptoms, measured at baseline and 72 hours. Results: This study enrolled 189 patients with and 51 patients without TBI. Patients with TBI had marked cognitive impairment which persisted at 72 hours (SAC score at baseline = 25 [23–27] vs 72 hours = 25 [22–27]; p = 0.1). Patients with TBI had persistent high symptom severity, although this had decreased at 72 hours (CSI score at baseline = 9 [4–22] vs 72 hours = 5 [1–19], p = 0.002). A similar pattern was observed with the total number of symptoms (baseline = 4 [2–8] vs 72 hours = 0 [0–4]; p < 0.001). Patients with TBI had worse neurocognitive function, higher overall symptom severity and higher total number of symptoms compared with patients without TBI. Patients without TBI’ neurocognitive function and symptom severity remained constant, but the number of symptoms reduced between baseline and 72 hours. Conclusion: There is a cognitive deficit and symptom burden in patients with mild TBI presenting to the Emergency Department which persists at 72 hours.

BackgroundWe previously conducted a pilot study that reported the safety of isosorbide dinitrate boluses for elderly emergency patients with acute heart failure syndrome.AimsTo assess the temporal trend in the rate of elderly patients treated with isosorbide dinitrate, and to evaluate subsequent outcome differences.MethodsThis was a single-centre study. We compared patients aged > 75 years who attended the emergency department with a primary diagnosis of acute pulmonary oedema in the years 2007 and 2014. The primary endpoint was the rate of patients who received isosorbide dinitrate boluses in the emergency department. Secondary endpoints included in-hospital mortality, need for intensive care and length of stay.ResultsWe analysed 368 charts, 232 from patients included in 2014 (63%) and 136 in 2007 (37%). The mean age was 85 ± 6 years in both groups. There was a significant rise in the rate of patients treated with isosorbide dinitrate between 2007 and 2014: 97 patients (42%) in 2014 vs. 24 patients (18%) in 2007 (P < 0.01). Comparing the two periods, we report similar in-hospital mortality rates (8% vs. 11%; P = 0.5), rates of admission to the intensive care unit (13% vs. 17%; P = 0.3) and lengths of stay (10 days in both groups).ConclusionWe observed a significant rise in the rate of elderly patients treated with isosorbide dinitrate boluses for acute heart failure. However, we did not observe any significant improvement in outcomes., ContexteNous avons publié précédemment une étude rapportant la sécurité d’utilisation du dinitrate d’isosorbide (ISDN) chez les patients de plus de 75 ans aux urgences.ObjectifsÉvaluer l’évolution temporelle du taux de patients âgés traités par ISDN aux urgences pour œdème aigu pulmonaire (OAP), et l’impact en terme de pronostic.MéthodesÉtude monocentrique rétrospective. Nous avons comparé les patients de plus de 75 ans admis aux urgences pour OAP sur les années 2007 et 2014. Le critère de jugement principal était le traitement par bolus intraveineux d’ISDN. Les critères secondaires incluaient la mortalité hospitalière, l’admission en soins intensifs, et la durée d’hospitalisation.RésultatsNous avons analysé 368 dossiers – 232 en 2014 (63 %) et 136 en 2007 (37 %). L’âge moyen était de 85 ans (écart-type 6) dans les deux groupes. Il y avait une augmentation significative du taux de patients traités par ISDN en 2014 : 97 patients (42 %) vs 24 (18 %) en 2007. La mortalité hospitalière, l’admission en soins intensifs et la durée d’hospitalisation étaient inchangées entre les deux périodes.ConclusionLe taux de patients traités par ISDN a bien augmenté avec le temps, sans que nous n’ayons pu en montrer un impact pronostique.

Objective To determine the reliability of Internet-based information on community-based weight-loss programs and grade their degree of concordance with 2013 American Heart Association, American College of Cardiology, and The Obesity Society weight-management guidelines. Methods An online search was conducted for weight-loss programs in the Maryland-Washington, DC-Virginia corridor. Content analysis was performed to abstract program components from their websites, and then 80 programs were randomly selected for a telephone survey to verify this information. Reliability of Internet information was determined in comparison with telephone interview responses. Results Of the 191 programs, 1% were graded as high, 8% as moderate, and 91% as low with respect to guideline concordance based on website content. Fifty-two programs participated in the telephone survey (65% response rate). Program intensity, diet, physical activity, and use of behavioral strategies were underreported on websites as compared to description of these activities during the phone interview. Within the subsample, 6% of programs were graded as high based on website information, whereas 19% were graded as high after the telephone interview. Conclusions Most weight-loss programs in an urban, mid-Atlantic region do not currently offer guideline-concordant practices and fail to disclose key information online, which may make clinician referrals challenging.

We present the first atomic clock based on quantum degenerate matter, overcoming atomic collisions, reaching a record spectroscopic quality factor of Q = 5.2 ⨉ 1015, and measuring a frequency difference to 3 ⨉ 10-19 in 2 hours.

Objective: To investigate factors associated with unscheduled admission following presentation to emergency departments (EDs) at three hospitals in England. Design and setting: Cross-sectional analysis of attendance data for patients from three urban EDs in England: a large teaching hospital and major trauma centre (site 1) and two district general hospitals (sites 2 and 3). Variables included patient age, gender, ethnicity, deprivation score, arrival date and time, arrival by ambulance or otherwise, a variety of ED workload measures, inpatient bed occupancy rates and admission outcome. Coding inconsistencies in routine ED data used for this study meant that diagnosis could not be included. Outcome measure: The primary outcome for the study was unscheduled admission. Participants: All adults aged 16 and older attending the three inner London EDs in December 2013. Data on 19 734 unique patient attendances were gathered. Results: Outcome data were available for 19 721 attendances (>99%), of whom 6263 (32%) were admitted to hospital. Site 1 was set as the baseline site for analysis of admission risk. Risk of admission was significantly greater at sites 2 and 3 (adjusted OR (AOR) relative to site 1 for site 2 was 1.89, 95% CI 1.74 to 2.05, p

We describe and implement a family of entangling gates activated by radio-frequency flux modulation applied to a tunable transmon that is statically coupled to a neighboring transmon. The effect of this modulation is the resonant exchange of photons directly between levels of the two-transmon system, obviating the need for mediating qubits or resonator modes and allowing for the full utilization of all qubits in a scalable architecture. The resonance condition is selective in both the frequency and amplitude of modulation and thus alleviates frequency crowding. We demonstrate the use of three such resonances to produce entangling gates that enable universal quantum computation: one iSWAP gate and two distinct controlled Z gates. We report interleaved randomized benchmarking results indicating gate error rates of 6% for the iSWAP (duration 135ns) and 9% for the controlled Z gates (durations 175 ns and 270 ns), limited largely by qubit coherence., Comment: As submitted. 7 pages, 6 figures

Strontium optical lattice clocks have the potential to simultaneously interrogate millions of atoms with a high spectroscopic quality factor of $4 \times 10^{-17}$. Previously, atomic interactions have forced a compromise between clock stability, which benefits from a large atom number, and accuracy, which suffers from density-dependent frequency shifts. Here, we demonstrate a scalable solution which takes advantage of the high, correlated density of a degenerate Fermi gas in a three-dimensional optical lattice to guard against on-site interaction shifts. We show that contact interactions are resolved so that their contribution to clock shifts is orders of magnitude lower than in previous experiments. A synchronous clock comparison between two regions of the 3D lattice yields a $5 \times 10^{-19}$ measurement precision in 1 hour of averaging time., Comment: 19 pages, 4 figures; Supplementary Materials

Harnessing techniques from analog signal processing, we establish a new path for large-scale quantum computation., We show that parametric coupling techniques can be used to generate selective entangling interactions for multi-qubit processors. By inducing coherent population exchange between adjacent qubits under frequency modulation, we implement a universal gate set for a linear array of four superconducting qubits. An average process fidelity of ℱ = 93% is estimated for three two-qubit gates via quantum process tomography. We establish the suitability of these techniques for computation by preparing a four-qubit maximally entangled state and comparing the estimated state fidelity with the expected performance of the individual entangling gates. In addition, we prepare an eight-qubit register in all possible bitstring permutations and monitor the fidelity of a two-qubit gate across one pair of these qubits. Across all these permutations, an average fidelity of ℱ = 91.6 ± 2.6% is observed. These results thus offer a path to a scalable architecture with high selectivity and low cross-talk.

The aim of this study is to provide a systematic review of the literature reporting agreement between arterial and venous pH, partial pressure of carbon dioxide (PCO2), bicarbonate (HCO3⁻), base excess and lactate; and to perform a meta-analysis of the differences. Medline and Embase searches using Eduserv Athens from 1950 to present were conducted using the terms 'VBG', 'ABG', 'arterial', 'venous', 'blood', 'gas', 'lactate', 'emergency' and 'department'. References of the published papers were hand searched and full-text versions of those deemed helpful to the question were obtained. Mean difference (MD) and 95% limits of agreement (LOA) were either reported or calculated from the published data. Pooled MDs with 95% confidence intervals (CIs) were calculated for differences between arterial and venous pH, PCO2, bicarbonate and lactate. Thirteen articles relevant to pH, 12 relevant to PCO2, 10 relevant to bicarbonate and three relevant to lactate were found. The pooled MD (venous-arterial) for pH was -0.033 pH units (95% CI -0.039 to 0.027) with narrow 95% LOA, the pooled MD for PCO2 was 4.41 mmHg (95% CI 2.55-6.27) with 95% LOA ranging from -20.4 to 25.8 mmHg, the pooled MD for bicarbonate was 1.03 mmol/l (95% CI 0.56-1.50) with 95% LOA ranging from -7.1 to 10.0 mmol/l and the pooled MD for lactate was 0.25 mmol/l (95% CI 0.15-0.35) with 95% LOA ranging from -2.0 to 2.3 mmol/l. Venous and arterial pH and bicarbonate agree reasonably at all values, but the agreement is highest at normal values. Arteriovenous agreement for PCO2 is poor and PvCO2 cannot be relied upon as an absolute representation of PaCO2. However, normal peripheral PvCO2 has a good negative predictive value for normal arterial PCO2, and a normal PvCO2 can be used as a screen to exclude hypercapnic respiratory disease. There may be a poor agreement between arterial and venous lactate at abnormal values; however, if the venous lactate is normal, it is likely the arterial values of this parameter will also be normal.

ObjectiveTo investigate factors predictive of short hospital admissions and appropriate placement to inpatient versus clinical decision units (CDUs).MethodThis is a retrospective analysis of attendance and discharge data from an inner-city ED in England for December 2013. The primary outcome was admission for less than 48 hours either to an inpatient unit or CDU. Variables included: age, gender, ethnicity, deprivation score, arrival date and time, arrival method, admission outcome and discharge diagnosis. Analysis was performed by cross-tabulation followed by binary logistic regression in three models using the outcome measures above and seeking to identify factors associated with short-stay admission.ResultsThere were 2119 (24%) admissions during the study period and 458 were admitted for less than 24 hours. Those who were admitted in the middle of the week or with ambulatory care sensitive conditions (ACSCs) were significantly more likely to experience short-stays. Older patients and those who arrived by ambulance were significantly more likely to have a longer hospital stay. There was no association of length of inpatient stay with being admitted in the last 10 min of a 4 hours ED stay.ConclusionOnly a few factors were independently predictive of short stays. Patients with ACSCs were more likely to have short stays, regardless of whether they were admitted to CDU or an inpatient ward. This may be a group of patients that could be targeted for dedicated outpatient management pathways or CDU if they need admission.

International audience; Objective: Simulation-based teaching offers promising and diverse teaching possibilities. We aim to assess whether the death of the manikin increased anxiety amongst learner compared to similar simulation-based course where the manikin stays alive. Methods: We conducted a cluster randomized study amongst multidisciplinary teams of emergency workers. Teams of physicians, nurses, and healthcare assistants were randomly assigned to participate in a simulation-based course where the simulated patient died (death group) or not (life group). We assessed anxiety at 1 month after the teaching using Spielberger STAI-state anxiety questionnaire. We compared reduction of anxiety when facing a life-threatening situation in both groups. Results: We included 25 teams for a total of 129 participants. We analysed 63 participants in the death group and 57 in the life group. Baseline characteristics were similar in both groups, including baseline anxiety (STAI-state score 39.6 (7.8) in the death group vs 38.6 (7.1) in the life group). We report a significant reduction in both groups 1 month after the training: 6.6 (7.8) vs 6 (8.0), mean difference 0.5 (−2.4; 3.4). At 3 months, we report a significant greater reduction of anxiety in the death group (mean difference 4 [0.1; 7.9]). Conclusion: We observed in our sample that unexpected simulated patient death did not increase anxiety amongst multidisciplinary emergency workers.

This paper is a comment to the paper "Classification of Traumatic Brain Injury Severity Using Informed Data Reduction in a Series of Binary Classifier Algorithms" by Bloom et al. The authors inform the editors that they have conducted a similar study on behalf of, and funded BrainScope Company, Inc. and that the method used to acquire the QEEG data suffer from a technical fault. Same methods seem to have been used by Bloom et. al. It is noted that the authors do not refer to this technical fault even though it arose months before the publication of the papers.

Introduction We aimed to determine the rate of preventable death in patients who died early and unexpectedly following hospital admission from the emergency department (ED). Methods We conducted a retrospective multicenter study in four centers from the Paris metropolitan area. Inclusion criteria were medical patients who died in hospital within 72 hours of ED attendance and were not admitted to the intensive care unit (unexpected death). Exclusion criteria were limitations of care determined by treating physicians. The existence of a limitation of care decision was adjudicated by two independent chart abstractors. Preventable death was defined as death occurring as a result of medical error. For each selected patient with unexpected death, charts were examined for medical errors and rated on a 1 to 5 preventability scale (from very unlikely to very likely) for the preventability of the death. The primary endpoint was the likely preventable death, rated as 4 or 5 on the preventability scale. Results We retrieved 555 charts; 47 unexpected deaths were analysed; 24 (51%) were considered as preventable. There was a median number of medical errors of two. The most common process breakdowns were incorrect choice of treatment (47% of patients) and failure to order appropriate diagnostic tests (38% of patients). The most common medical error was a severe delay or absence of recommended treatment for severe sepsis, which occurred in 10 (42%) patients. Conclusions In our sample, more than half of unexpected deaths are related to a medical error, and could have been prevented.

the BISTRO Investigators; International audience; ObjectiveTo evaluate the performance of S100-B protein and copeptin, in addition to clinical variables, in predicting outcomes of patients attending the emergency department (ED) following a seizure.MethodsWe prospectively included adult patients presented with an acute seizure, in four EDs in France and the United Kingdom. Participants were followed up for 28 days. The primary endpoint was a composite of seizure recurrence, all-cause mortality, hospitalization or rehospitalisation, or return visit in the ED within seven days.ResultsAmong the 389 participants included in the analysis, 156 (40%) experienced the primary endpoint within seven days and 195 (54%) at 28 days. Mean levels of both S100-B (0.11 μg/l [95% CI 0.07–0.20] vs 0.09 μg/l [0.07–0.14]) and copeptin (23 pmol/l [9–104] vs 17 pmol/l [8–43]) were higher in participants meeting the primary endpoint. However, both biomarkers were poorly predictive of the primary outcome with a respective area under the receiving operator characteristic curve of 0.57 [0.51–0.64] and 0.59 [0.54–0.64]. Multivariable logistic regression analysis identified higher age (odds ratio [OR] 1.3 per decade [1.1–1.5]), provoked seizure (OR 4.93 [2.5–9.8]), complex partial seizure (OR 4.09 [1.8–9.1]) and first seizure (OR 1.83 [1.1–3.0]) as independent predictors of the primary outcome. A second regression analysis including the biomarkers showed no additional predictive benefit (S100-B OR 3.89 [0.80–18.9] copeptin OR 1 [1.00–1.00]).ConclusionThe plasma biomarkers S100-B and copeptin did not improve prediction of poor outcome following seizure. Higher age, a first seizure, a provoked seizure and a partial complex seizure are independently associated with adverse outcomes.

The pursuit of better atomic clocks has advanced many research areas, providing better quantum state control, new insights in quantum science, tighter limits on fundamental constant variation and improved tests of relativity. The record for the best stability and accuracy is currently held by optical lattice clocks. Here we take an important step towards realizing the full potential of a many-particle clock with a state-of-the-art stable laser. Our 87Sr optical lattice clock now achieves fractional stability of 2.2 × 10−16 at 1 s. With this improved stability, we perform a new accuracy evaluation of our clock, reducing many systematic uncertainties that limited our previous measurements, such as those in the lattice ac Stark shift, the atoms' thermal environment and the atomic response to room-temperature blackbody radiation. Our combined measurements have reduced the total uncertainty of the JILA Sr clock to 2.1 × 10−18 in fractional frequency units., Atomic clocks are increasingly important for many applications in scientific research and technology. Here, Nicholson et al. present a series of developments allowing them to achieve a new record in atomic clock performance, with a systematic uncertainty of just 2.1 × 10−18 for their 87Sr atomic clock.

Optical Feshbach resonances (OFRs) have generated significant experimental interest in recent years. These resonances are promising for many-body physics experiments, yet the practical application of OFRs has been limited. The theory of OFRs has been based on an approximate model that fails in important detuning regimes, and the incomplete theoretical understanding of this effect has hindered OFR experiments. We present the most complete theoretical treatment of OFRs to date, demonstrating important characteristics that must be considered in OFR experiments and comparing OFRs to the well-studied case of magnetic Feshbach resonances. We also present a comprehensive treatment of the approximate OFR model, including a study of the range of validity for this model. Finally, we derive experimentally useful expressions that can be applied to real experimental data to extract important information about the resonance structure of colliding atoms.

Blood gas analysers provide electrolyte and metabolic data. In the author's institution, these values were not used clinically because of the risk of inaccuracy. To discover whether this approach was warranted, we compared values from our Radiometer point-of-care (POC) analyser and the laboratory. A total of 207 patients from an urban Emergency Department received venepuncture for sodium, potassium, creatinine and haemoglobin. Two samples were drawn; one analysed in the laboratory, the other on the POC machine. The results were: sodium: n=182, mean difference (MD) (lab-POC) 3.36, 95% limits of agreement (LOA) 0.18-6.54; potassium: n=171, MD 0.46, 95% LOA -0.12 to 1.03; creatinine: n=183, MD 1.6, 95% LOA -16.2 to 18.7; haemoglobin: n=191, MD -0.29, 95% LOA -1.71 to 1.12. Thus, sodium and potassium showed negative bias on the Radiometer compared with the laboratory. Creatinine and haemoglobin agreed well. We advocate the clinical use of POC values when taken in clinical context.

Study objective We seek to evaluate whether age greater than 75 years is an independent predictor of prolonged waiting time in the emergency department (ED). Methods We retrospectively analyzed all adult attendances to 9 EDs within the Paris area during 2011. The primary endpoint was target waiting time exceeded, defined as a waiting time for medical assessment longer than the maximal recommended waiting time according to triage level. To assess our primary objective, we performed logistic regression using patient- and ED-related variables to determine whether age greater than 75 years was independently associated with higher rate of target waiting time exceeded. Results A total of 317,793 patients were included, of whom 173,629 (55%) had an exceeded target waiting time. Mean age was 45.8 years and 12.7% were older than 75 years. Target waiting time was exceeded for 55% of patients: 53% for patients younger than 75 years (95% confidence interval [CI] 53% to 54%) versus 64% for older patients (95% CI 63% to 65%), relative risk 1.20. In the multivariate analysis, age greater than 75 years was independently associated with an exceeded target waiting time (odds ratio [OR] 1.30; 95% CI 1.27 to 1.33). Other variables associated with exceeded target waiting time were triage level (OR 5.45 [95% CI 5.32 to 5.60] for triage level 2 versus triage level 4), high daily occupancy (OR 3.78 [95% CI 3.53 to 4.03]), day of the week (OR 1.12 [95% CI 1.09 to 1.14] for Monday), and time of the visit (OR 1.79 [95% CI 1.76 to 1.82] from 6 pm to 8 am). Conclusion Patients older than 75 years are less likely to be seen within the target waiting time.

Many-particle optical lattice clocks have the potential for unprecedented measurement precision and stability due to their low quantum projection noise. However, this potential has so far never been realized because clock stability has been limited by frequency noise of optical local oscillators. By synchronously probing two ^{87}Sr lattice systems using a laser with a thermal noise floor of 1×10(-15), we remove classically correlated laser noise from the intercomparison, but this does not demonstrate independent clock performance. With an improved optical oscillator that has a 1×10(-16) thermal noise floor, we demonstrate an order of magnitude improvement over the best reported stability of any independent clock, achieving a fractional instability of 1×10(-17) in 1000 s of averaging time for synchronous or asynchronous comparisons. This result is within a factor of 2 of the combined quantum projection noise limit for a 160 ms probe time with ~10(3) atoms in each clock. We further demonstrate that even at this high precision, the overall systematic uncertainty of our clock is not limited by atomic interactions. For the second Sr clock, which has a cavity-enhanced lattice, the atomic-density-dependent frequency shift is evaluated to be -3.11×10(-17) with an uncertainty of 8.2×10(-19).

We describe recent experimental progress with the JILA Sr optical frequency standard, which has a systematic uncertainty at the 10−16 fractional frequency level, currently limited by frequency shifts due to atomic interactions and room temperature blackbody radiation (BBR). We will discuss systematic measurements of collisional shifts and provide a complete theory to understand these interaction effects at the 10−17 level. We will also discuss plans to interrogate atoms inside a cryogenic shield region to eliminate BBR shifts. We will present our recent successful efforts in improving the laser stability with the aim for the JILA Sr standard to reach the standard quantum measurement limit and achieve record levels of stability. Finally, a second Sr optical lattice clock has been constructed at JILA, and we will discuss the results of intercomparison experiments between the two standards.

Parkinson’s disease, an age-related neurodegenerative disorder, is characterized by the loss of dopamine neurons in the substantia nigra, the accumulation of α-synuclein in Lewy bodies and neurites, and neuroinflammation. While the exact etiology of sporadic Parkinson’s disease remains elusive, a growing body of evidence suggests that misfolded α-synuclein promotes inflammation and oxidative stress resulting in neurodegeneration. α-Synuclein has been directly linked to microglial activation in vitro and increased numbers of activated microglia have been reported in an α-synuclein overexpressing mouse model prior to neuronal loss. However, the mechanism by which α-synuclein incites microglial activation has not been fully described. Microglial activation is governed in part, by pattern recognition receptors that detect foreign material and additionally recognize changes in homeostatic cellular conditions. Upon proinflammatory pathway initiation, activated microglia contribute to oxidative stress through release of cytokines, nitric oxide, and other reactive oxygen species, which may adversely impact adjacent neurons. Here we show that microglia are directly activated by α-synuclein in a classical activation pathway that includes alterations in the expression of Toll-like receptors. These data suggest that α-synuclein can act as a danger-associated molecular pattern.

Using a narrow intercombination line in alkaline earth atoms to mitigate large inelastic losses, we explore the optical Feshbach resonance effect in an ultracold gas of bosonic $^{88}\mathrm{Sr}$. A systematic measurement of three resonances allows precise determinations of the optical Feshbach resonance strength and scaling law, in agreement with coupled-channel theory. Resonant enhancement of the complex scattering length leads to thermalization mediated by elastic and inelastic collisions in an otherwise ideal gas. Optical Feshbach resonance could be used to control atomic interactions with high spatial and temporal resolution.

We demonstrate a heralded quantum memory where a photon announces the mapping of a light polarization state onto a single collective-spin excitation (magnon) shared between two atomic ensembles. The magnon can be converted at a later time into a single polarized photon with polarization fidelity over 90(2)% for all fiducial input states, well above the classical limit of $\frac{2}{3}$. The process can be viewed as a nondestructive quantum probe where a photon is detected, stored, and regenerated without touching its---potentially undetermined---polarization.

Adaptive optics (AO) is used to correct ocular aberrations primarily in the cornea, lens, and tear film of every eye. Among other applications, AO allows high lateral resolution images to be acquired with scanning laser ophthalmoscopy (SLO) and optical coherence tomography (OCT). Spectral domain optical coherence tomography (SDOCT) is a high-speed imaging technique that can acquire cross-sectional scans with micron-scale axial resolution at tens to hundreds of kHz line rates. We present a compact clinical AO-SDOCT system that achieves micron-scale axial and lateral resolution of retinal structures. The system includes a line scanning laser ophthalmscope (LSLO) for simultaneous wide-field retinal viewing and selection of regions-of-interest. OCT and LSLO imaging and AO correction performance are characterized. We present a case study of a single subject with hyper-reflective lesions associated with stable, resolved central serous retinopathy to compare and contrast AO as applied to scanning laser ophthalmoscopy and optical coherence tomography. The two imaging modes are found to be complementary in terms of information on structure morphology. Both provide additional information lacking in the other. This preliminary finding points to the power of combining SLO and SDOCT in a single research instrument for exploration of disease mechanisms, retinal cellular architecture, and visual psychophysics.

Spectral domain optical coherence tomography (SDOCT) is a relatively new imaging technique that allows high-speed cross-sectional scanning of retinal structures with little motion artifact. However, instrumentation for these systems is not yet fast enough to collect high-density three-dimensional retinal maps free of the adverse effects of lateral eye movements. Low coherence interferometry instruments must also contend with axial motion primarily from head movements that shift the target tissue out of the coherence detection range. Traditional SDOCT instruments suffer from inherent deficiencies that exacerbate the effect of depth motion, including limited range, depth-dependent signal attenuation, and complex conjugate overlap. We present initial results on extension of our transverse retinal tracking system to three-dimensions especially for SDOCT imagers. The design and principle of operation of two depth tracking techniques, adaptive ranging (AR) and Doppler velocity (DV) tracking, are presented. We have integrated the threedimensional tracking hardware into a hybrid line scanning laser ophthalmoscope (LSLO)/SDOCT imaging system. Imaging and tracking performance was characterized by tests involving a limited number of human subjects. The hybrid imager could switch between wide-field en-face confocal LSLO images, high-resolution cross-sectional OCT images, and an interleaved mode of sequential LSLO and OCT images. With 3-D tracking, the RMS error for axial motion decreased to

We report the case of a man who underwent urgent surgery to relieve compression of the cauda equina caused by a large L4/5 disc protrusion. A post-operative but not pre-operative MRI scan showed appearances suggestive of intradural migration of a disc fragment, confirmed at re-operation. We believe that this event happened during the first operation and not before it.

We describe the mapping of quantum states between single photons and an atomic ensemble. In particular, we demonstrate a heralded quantum memory based on the mapping of a photon polarization state onto a single collective-spin excitation (magnon) shared between two atomic ensembles. The polarization fidelity above 90(2)% for any input polarization far exceeds the classical limit of . The process also constitutes a quantum non-destructive probe that detects and regenerates a photon without measuring its polarization.

We have developed a compact, multimodal instrument for simultaneous acquisition of en face quasi-confocal fundus images and adaptive-optics (AO) spectral-domain optical coherence tomography (SDOCT) cross-sectional images. The optical system including all AO and SDOCT components occupies a 60x60 cm breadboard that can be readily transported for clinical applications. The AO component combines a Hartmann-Shack wavefront sensor and a microelectromechanical systems-based deformable mirror to sense and correct ocular aberrations at 15 Hz with a maximum stroke of 4 microm. A broadband superluminescent diode source provides 4 mum depth resolution for SDOCT imaging. In human volunteer testing, we observed up to an 8 dB increase in OCT signal and a corresponding lateral resolution of10 microm as a result of AO correction.

International audience; Background : Chronic granulomatous disease (CGD) is a rare primary immunodeficiency caused by inborn errors of the phagocyte nicotinamide adenine dinucleotide phosphate oxidase complex. From the first year of life onward, most affected patients display multiple, severe, and recurrent infections caused by bacteria and fungi. Mycobacterial infections have also been reported in some patients.Objective : Our objective was to assess the effect of mycobacterial disease in patients with CGD.Methods : We analyzed retrospectively the clinical features of mycobacterial disease in 71 patients with CGD. Tuberculosis and BCG disease were diagnosed on the basis of microbiological, pathological, and/or clinical criteria.Results : Thirty-one (44%) patients had tuberculosis, and 53 (75%) presented with adverse effects of BCG vaccination; 13 (18%) had both tuberculosis and BCG infections. None of these patients displayed clinical disease caused by environmental mycobacteria, Mycobacterium leprae, or Mycobacterium ulcerans. Most patients (76%) also had other pyogenic and fungal infections, but 24% presented solely with mycobacterial disease. Most patients presented a single localized episode of mycobacterial disease (37%), but recurrence (18%), disseminated disease (27%), and even death (18%) were also observed. One common feature in these patients was an early age at presentation for BCG disease. Mycobacterial disease was the first clinical manifestation of CGD in 60% of these patients.Conclusion : Mycobacterial disease is relatively common in patients with CGD living in countries in which tuberculosis is endemic, BCG vaccine is mandatory, or both. Adverse reactions to BCG and severe forms of tuberculosis should lead to a suspicion of CGD. BCG vaccine is contraindicated in patients with CGD.

Dengue is a major international public health concern and one of the most important arthropod-borne diseases [1]. Approximately 2.5 billion people—40% of the world's population, in over 100 countries—are at risk of dengue virus (DENV) infection [2]. In recent years the average annual incidence of dengue-related serious disease in many tropical counties has been rising dramatically, with the infection becoming endemic in areas where its occurrence was once sporadic [3]. The exponential increase over the last decade has been connected to societal changes, such as population growth and increasing urbanization [4]. In addition, it has been suggested that rising temperatures and global climate change may lead to the expansion of the range of major mosquito vectors into new areas, extension of the transmission season in current endemic areas, and increase in the mosquito species vectorial capacity [5]–[7]. Human migration (likely including infected hosts) and international travel are constantly introducing new vectors and pathogens into novel geographic areas [8]. For example, chikungunya virus was introduced into northeastern Italy in 2007, causing an outbreak with local transmission due to the presence of Aedes albopictus, a vector also capable of transmitting dengue virus [9]. In 2010, three authochthonous cases of dengue were reported in Europe, thereby highlighting the potential for global spread of this disease [10], [11]. The island of Madeira, where the mosquito vector Aedes aegypti is present, experienced a major dengue outbreak in the fall of 2012 [12], highlighting that the introduction of dengue to non-endemic areas is a real threat. Dengue has been neglected for many years. Major research gaps for dengue exist in the areas of epidemiology under changing climate conditions, clinical management, pathogenesis, vector control, surveillance and response, vaccines, drugs, and health policy research [13]. The European Commission (EC) launched a call under the Seventh Framework Programme with the title of “Comprehensive control of Dengue fever under changing climatic conditions” (http://ec.europa.eu/research/participants/portal/page/cooperation?callIdentifier=FP7-HEALTH-2011-single-stage). The focus of this call is summarized in Box 1. Within this framework, in 2011, the EC awarded a total of approximately €18 million to three consortia. The hosting institutions are Heidelberg University Hospital (Germany), the Institute Pasteur (Paris, France), and Umea University (Sweden). Each consortium has partners from countries with endemic and epidemic dengue. In total, the consortia comprise 38 partners from 21 countries, of which 11 are from Asia and Latin America, the current hotspots of dengue endemicity, and one from Africa (Figure 1). Figure 1 The world map of the three EU-funded dengue consortia. Box 1. European Commission Seventh Framework Programme FP7 Cooperation - Health HEALTH.2011.2.3.3-2: Comprehensive control of Dengue fever under changing climatic conditions. FP7-HEALTH-2011-single-stage Research should develop innovative tools for one or more of the following aspects: better diagnosis, surveillance, development of treatment, prevention and vaccination strategies, prevention, and/or prediction and prevention of the spread of dengue fever to previously uninfected regions (including Europe), in the context of climate change. Research may also include studies on the underlying pathogenesis with respect to viral and host factors that can predict disease severity and prepare for further development of new vaccines, antiviral compounds, and more targeted treatment schemes. Funding Scheme Specific International Cooperation Action (SICA) Collaborative Project (small- or medium-scale focused research project) target regions: Latin America and/or Asia. SICA aims to bring about the balanced participation of third countries in collaboration with European partners. Expected Impact Better tools, and the use thereof, for improved comprehensive control of dengue fever at a global level. Participation from both SICA target regions and Small and Medium Enterprises SMEs in the projects should help ensure innovation and exploitation of the results in this area/topic. The degree of such participation will be considered during the evaluation. Source: http://ec.europa.eu/research/health/infectious-diseases/emerging-epidemics/call-for-proposals_en.html The funding of such a large and complex research programme focusing on a single disease highlights the emphasis that the European Commission has put on dengue and its potential threat to Europe. In this paper, we present these three consortia and outline their scientific strategies and potential role within the international dengue research community.

EULAR/PRINTO/PRES Objectives To validate the previously proposed classification criteria for Henoch-Schonlein purpura (HSP), childhood polyarteritis nodosa (c-PAN), c-Wegener granulomatosis (c-WG) and c-Takayasu arteritis (c-TA).Methods Step 1: retrospective/prospective webdata collection for children with HSP, c-PAN, c-WG and c-TA with age at diagnosis