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Recurring chest pain and other cardiac symptoms that cannot be adequately explained by organic pathology are common and can be associated with substantial disability, distress and high healthcare costs. Common mental disorders such as depression and anxiety frequently co-occur with these symptoms and, in some cases, account for their presentation, although they are not universally present. Due to the frequency of functional cardiac presentations and risks of iatrogenic harm, physicians should be familiar with strategies to identify, assess and communicate with patients about these symptoms. A systematic and multidisciplinary approach to diagnosis and management is often needed. Health beliefs, concerns and any associated behaviours should be elicited and addressed throughout. Psychiatric comorbidities should be concurrently identified and treated. For those with persistent symptoms, psychosocial outcomes can be poor, highlighting the need for further research and investment in diagnostic and therapeutic approaches and multidisciplinary service models.

A new series of MW-class, RF loads were developed that can dissipate power levels exceeding 1.5 MW at frequencies from 28 GHz to 180 GHz. The new loads are designed to reflect less than 0.25% of the input power and operate continuously (CW). Stainless-steel and anodized aluminum versions were developed. The stainless steel version is designed to meet requirements for nuclear facilities, such as ITER, while the aluminum version is capable of power levels exceeding 2 MW CW. The aluminum version is also lighter and less expensive. This paper describes the design and capabilities of the loads.

The Nightingale Hospital London (NHL) was the first of seven new UK National Health Service (NHS) hospitals designed to address the potential shortfall in critical care capacity caused by the rapidly escalating first wave of the SARS-CoV-2 pandemic. When scenes of hospitals at risk of saturation were being broadcast internationally, the initial NHL mandate was to deliver a large-scale intensive care unit (ICU) for up to 4000 ventilated patients to increase the capacity of London’s existing hospitals. Before this, ICU bed capacity in London and England was 839 and 3766, respectively.1 Healthcare projects of this pace, scale or complexity are usually overseen by experienced teams over many years, and within specifically designed environments and timetables.2 However, the NHL was constructed in an events centre, and started accepting patients within weeks of conception. The newly formed NHL leadership team was redeployed from different hospitals across London at a time of unprecedented national uncertainty, before disease-modifying COVID-19 therapies were approved and when staff in existing hospitals were preparing ICU expansions of their own.3 This unique mandate resulted in the NHL being exposed to a level of potential risk and vulnerability to human error that healthcare services have worked to reduce in recent years.4 5 Fortunately, due to lockdown restrictions and ICU expansion in existing hospitals, only 54 patients were admitted to the NHL. Therefore, in comparison to forecasts, existing hospitals and its potential capacity, the overall contribution of the NHL to the ICU COVID-19 response in London was relatively small. Importantly, however, clinical outcomes were comparable to existing hospitals. NHL patient mortality was 48.1% compared with 47.7% nationally, and the requirements for, and duration of, organ support were also similar.6 Although its true potential was fortunately never reached, the NHL did fulfil its role in urgently providing …

The ongoing coronavirus disease-2019 (COVID-19) pandemic is testing the resilience of societies, services, families, and individuals across the world. Even though this virus causes a respiratory illness, cardiology patients and doctors will continue to be affected both directly and indirectly by the

Bone fractures often result in complications that require surgical intervention to promote fracture healing. Tissue engineering seeks to alleviate the need for autologous bone grafting by utilizing scaffolds that can promote bone fracture healing. Plant-derived materials are desirable biomaterials because of their biodegradability, availability, and low immunogenicity. Among various plant-derived proteins, zein, which is a corn protein, has shown promise for bone repair. However, when processed, zein is often blended with synthetic materials to improve mechanical properties and overall hydrolytic stability. In this study, pure zein was electrospun to create fibrous scaffolds and cross-linked with trimethylolpropane triglycidyl ether to improve hydrolytic stability. Scaffolds were characterized and evaluated in vitro for promoting the osteogenic differentiation of MC3T3-E1 cells, which are bone progenitor cells. Cross-linked zein scaffolds retained their uniform fiber morphologies after hydration. MC3T3-E1 cells grew and differentiated on the zein scaffolds even in the absence of induction factors, as demonstrated by increased alkaline phosphatase activity, mineralization, and early upregulation of Runx2 gene expression, a transcription factor associated with osteoblast differentiation. These studies demonstrate that stable, zein fibrous scaffolds could have potential for use in bone repair applications.

Calabazas Creek Research, Inc. (CCR), in collaboration with Fermilab and Communications and Power Industries, LLC (CPI), developed a 100-kW peak, 10-kW average, 1300-MHz, magnetron-based, RF system with amplitude and phase control for driving accelerators. Phase locking was achieved using an approach originated at Fermilab that uses phase modulation of the locking signal to control the amplitude and phase into a superconducting cavity on a fast time scale. Experimental results, including demonstration of phase locking and amplitude control, are reported.

High power gyrotrons typically produce RF power in a ${HE}_{11}$ waveguide inside the vacuum. The direct coupler was Gaussian free-space mode. An internal converter transforms the integrated into the 110 GHz, 1 MW, short pulse gyrotron at MIT, whispering gallery mode from the cavity to a Gaussian beam using a shown in Fig. 1. Tests indicated that the gyrotron produced the quasi-optical launcher and a series of mirrors. Transmission of this same output power and efficiency as the conventional Gaussian power typically requires transformation into an ${HE}_{11}$ mode in corrugated waveguide. This conversion is achieved using a Mirror Optical Unit, which uses a second series of mirrors. The transformation of the whispering gallery mode to a Gaussian beam and then to an ${HE}_{11}$ mode requires a complexity of RF structures, increasing cost and RF losses. This program is developing a coupler that transforms the whispering gallery mode directly into an ${HE}_{11}$ mode inside the gyrotron. This results in significant reduction in gyrotron cost and RF losses and eliminates the Mirror Optical Unit.

Calabazas Creek Research, Inc., in collaboration with the SLAC National Accelerator Laboratory, is developing a high efficiency, 1.3 GHz, 100 kW klystron for driving accelerators. The goal for the efficiency is at least 85%. Designs for the RF circuit, electron gun and collector are presented.

We read with interest the recent publication by Rauche et al. and congratulate them on highlighting the potentially significant role VWF may play in the progression and prognosis of COVID19. Since SARS-Cov2 first presented there has been an increasing recognition that the disease may trigger a widespread endotheliopathy. This fact could help to explain the highly varied presentation of patients with COVID19 from bowel ischaemia to large vessel occlusion causing strokes in addition to the more common presentation of respiratory symptoms.

BACKGROUND: COVID-19 infection is characterised, among other features, by a prothrombotic state with high rate of venous thromboembolism (VTE), D-dimer, and fibrinogen levels. Clinical observations have also highlighted that these patients have elevated von Willebrand factor (vWF) and factor VIIIc. METHODS: 24 consecutive COVID-19 positive patients were selected from the intensive care unit (ICU) or the high acuity ward of Brighton and Sussex University Hospitals NHS Trust. RESULTS: The rate of VTE was 25% and mortality rate was 16.7%. Fibrinogen and D-Dimers were elevated, 7.9 (1.6) g/L and 2.4 (2.02) ug/ml respectively. Factor VIIIc and von vWF antigen levels were both extremely elevated at 279 (148) u/dL and 350 (131) % respectively, which are comparable to levels seen in ICU patients with severe sepsis. vWF levels were significantly higher in patients that died (p=0.017) and showed a positive correlation with age. There was a statistically significant association between COVID-19 disease and non-O blood group (p=0.02); 80% (4/5) of COVID-19 patients with VTE were blood group A. CONCLUSION: Very high levels of vWF and factor VIIIc are common in COVID-19 patients, comparable to levels in severely septic non-COVID ICU patients. This could contribute to the hypercoagulable state and increased VTE rate in COVID-19. Further studies are needed to evaluate the use of vWF for stratifying thrombotic risk in COVID-19 and to determine if elevated vWF is contributing to disease pathogenesis.

High power, high efficiency RF sources are required at frequencies below 700 MHz for ion and proton accelerators. These sources are also used for high energy accelerators, such as the Advanced Photon Source, which is seeking 350 MHz RF sources producing more than 200 kW of continuous power. The program is developing multiple beam triodes capable of providing this RF power at efficiencies exceeding 80%. The sources would be extremely compact and low cost. Both the triodes and the associated RF cavities are being developed.

ObjectivesTo understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19.MethodsWe systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomesResultsThere was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62–118) min in 2020 vs 75 (57–95) min in 2019, pConclusionThese findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.

Biomaterial-based scaffolds used in nerve conduits including channels for confining regenerating axons and 3-dimensional (3D) gels as substrates for growth have made improvements in models of nerve repair. Many biomaterial strategies, however, continue to fall short of autologous nerve grafts, which remain the current gold standard in repairing severe nerve lesions (

The British Society of Echocardiography (BSE) highlights the importance of patient questionnaires as part of the quality improvement process, To this end, we implemented a novel system whereby paired surveys were completed by patients and physiologists for transthoracic echocardiography scans, allowing for parallel comparison of the experiences of service providers and end users. Anonymised questionnaires were completed for each scan by the patient and physiologist for outpatient echocardiographic scans in a teaching hospital. In 26% of the responses, patient found the scans at least slightly painful, and in 24% of scans physiologists were in discomfort. The most common reason given by physiologists for technically difficult or inadequate scans was patient discomfort. In 38% of the scans at least one person (the patient or the physiologist) was in at least some discomfort. Comparative data showed that the scans reported as most painful by patients were also reported by the physiologists as difficult and uncomfortable. In summary, these results demonstrate the feasibility of implementing paired surveys. Patient information leaflets by the BSE and National Health Service (NHS) describe echocardiography as painless but the results here indicate this is not always the case.

RF sources are used in many applications, including high-power radar, communications, cancer therapy and diagnosis, electronic countermeasures, and high-energy accelerators. Many of these sources are located in well controlled environments where high-quality coolant fluids are readily available. Others, however, are located on platforms where harsh environmental conditions exist, and high-quality coolants are not easily provided. This includes ships at sea and remote transmitters in the second-world and third-world countries. Corrosive ethylene glycol mixtures may be required where extreme temperatures are encountered. Essentially, all high-power RF sources are fabricated from brazed copper structures, which are particularly susceptible to corrosion from corrosive coolants. This paper demonstrates using atomic layer deposition (ALD) to deposit nanometer-scale ceramic coatings inside coolant passages to separate the coolant from the underlying metal surface. This effectively reduces or eliminates corrosion and erosion, thereby increasing lifetime and reliability of RF sources. We describe ALD equipment and process specifically focused on RF sources and related components. The results of numerous experiments are reported, confirming the efficacy of the technology.

Articular cartilage has a limited capacity to heal after damage from injury or degenerative disease. Tissue engineering constructs that more closely mimic the native cartilage microenvironment can be utilized to promote repair. Glycosaminoglycans (GAGs), a major component of the cartilage extracellular matrix, have the ability to sequester growth factors due to their level and spatial distribution of sulfate groups. This study evaluated the use of a GAG mimetic, cellulose sulfate, as a scaffolding material for cartilage tissue engineering. Cellulose sulfate can be synthesized to have a similar level and spatial distribution of sulfates as chondroitin sulfate C (CSC), the naturally occurring GAG. This partially sulfated cellulose (pSC) was incorporated into a fibrous gelatin construct by the electrospinning process. Scaffolds were characterized for fiber morphology and overall stability over time in an aqueous environment, growth factor interaction, and for supporting mesenchymal stem cell (MSC) chondrogen...

Cloud providers seek to maximize their market share. Traditionally, they deploy datacenters with sufficient capacity to accommodate their entire computing demand while maintaining geographical affinity to its customers. Achieving these goals by a single cloud provider is increasingly unrealistic from a cost of ownership perspective. Moreover, the carbon emissions from underutilized datacenters place an increasing demand on electricity and is a growing factor in the cost of cloud provider datacenters. Cloud-based systems may be classified into two categories: serving systems and analytical systems. We studied two primary workload types, on-demand video streaming as a serving system and MapReduce jobs as an analytical systems and suggested two unique energy mix usage for processing that workloads. The recognition that on-demand video streaming now constitutes the bulk portion of traffic to Internet consumers provides a path to mitigate rising energy demand. On-demand video is usually served through Content Delivery Networks (CDN), often scheduled in backend and edge datacenters. This publication describes a CDN deployment solution that utilizes green energy to supply on-demand streaming workload. A cross-cloud provider collaboration will allow cloud providers to both operate near their customers and reduce operational costs, primarily by lowering the datacenter deployments per provider ratio. Our approach optimizes cross-datacenters deployment. Specifically, we model an optimized CDN-edge instance allocation system that maximizes, under a set of realistic constraints, green energy utilization. The architecture of this cross-cloud coordinator service is based on Ubernetes, an open source container cluster manager that is a federation of Kubernetes clusters. It is shown how, under reasonable constraints, it can reduce the projected datacenter’s carbon emissions growth by 22% from the currently reported consumption. We also suggest operating datacenters using energy mix sources as a VoltDB-based fast data system to process offline workloads such as MapReduce jobs. We show how cross-cloud coordinator service can reduce the projected data- centers carbon emissions growth by 21% from the currently expected trajectory when processing offline MapReduce jobs.

Cloud computing is one of the largest emerging utility services that is expected to grow enormously over the next decade. Many organizations are moving into hybrid cloud/hosted computing models. Single cloud service provider introduces cost and environmental challenges. Also, multi-cloud solution implemented by the Cloud tenant is suboptimal as it requires expensive adaptation costs. Cloud Federation is a useful structure for aggregating cloud based services under a single umbrella to share resources and responsibilities for the benefit of the member cloud service providers. An efficient security model is crucial for successful cloud business. However, with the advent of large scale and multi-tenant environments, the traditional perimeter boundaries along with traditional security practices are changing. Defining and securing asset and enclave boundaries is more challenging, and system perimeter boundaries are more susceptible to breach. This paper to describe security best practices for Cloud Federation. The paper also describes a tool and technique for detecting anomalous behavior in resource usage across the federation participants. This is a particularly serious issue because of the possibility of an attacker potentially gaining access to more than one CSP federation member. Specifically, this technique is developed for Cloud Federations since they have to deal with heterogeneous multi-platform environments with a diverse mixture of data and security log schema, and it has to do this in real time. A Semantic-less Breach detection system that implements a self-learning system was prototyped and resulted in up to 87% True-Positive rate with 93% True-Negative.

A federated cloud-based multi-platform Power System is presented to meet the growing challenges confronting power system operators. It uses a federated architecture to provide a group sourced increase in cyber security, in reducing the need for computing resource overcapacity, for sharing computing and power resources during emergencies, for minimizing energy costs, and for sharing information on threats and incident responses. In the face of nation-state and organized crime complex, multi-technology, coordinated attacks, a single organization stands an ever reducing chance of remaining safe. The proposed federated cloud preserves the economic efficiency advantages of marketplace of non-monopolistic organizations innovating to obtain competitive advantage with shared preparation, resources, information, and resiliency enabled by individual Power System cloud-based computing creating a federated System. The paper applies earlier advances. This paper combines the results previously published in different publications and applies them to a single paradigmatic example of a power system consisting of a number of individual asset owners. It includes the architecture, model of energy, and resource sharing as well as a novel, self-learning, semantic-less breach detection system for detecting anomalous behavior in resource usage across the power system participants. The paper extends previous work published about federated cloud. The simulations results provided to demonstrate the usefulness of the proposed system.

Spinal cord injury can lead to severe dysfunction as a result of limited nerve regeneration that is due to an inhibitory environment created at the site of injury. Neural tissue engineering using materials that closely mimic the extracellular matrix (ECM) during neural development could enhance neural regeneration. Glycosaminoglycans (GAGs), which are sulfated polysaccharides, have been shown to modulate axonal outgrowth in neural tissue depending upon the position and degree of sulfation. Cellulose sulfate (CelS), which is a GAG mimetic, was evaluated for its use in promoting neurite extension. Aligned fibrous scaffolds containing gelatin blended with 0.25% partially sulfated cellulose sulfate (pCelS), having sulfate predominantly at the 6-carbon position of the glucose monomer unit, and fully sulfated cellulose sulfate (fCelS), which is sulfated at the 2-, 3-, and 6-carbon positions of the glucose monomer unit, were fabricated using the electrospinning method. Comparisons were made with scaffolds containing native GAGs, chondroitin sulfate-A (CS-A) and chondroitin sulfate-C (CS-C), which were obtained from commercial sources. CS-A and CS-C are present in neural tissue ECM. The degree of sulfation and position of sulfate groups was determined using elemental analysis, Fourier-transform infrared spectroscopy (FTIR), Raman microspectroscopy, and 13C nuclear magnetic resonance (NMR). In vitro studies examined both nerve growth factor (NGF) binding on scaffolds and neurite extension by dorsal root ganglion (DRG) neurons. NGF binding was highest on scaffolds containing pCelS and fCelS. Neurite extension was greatest for scaffolds containing fCelS followed by pCelS, with the lowest outgrowth on the CS-A containing scaffolds, suggesting that the degree and position of sulfation of CelS was permissible for neurite outgrowth. This study demonstrated that cellulose sulfate, as a GAG mimetic, could be used for future neural tissue regeneration application. STATEMENT OF SIGNFICANCE: Scaffolds that closely mimic the native extracellular matrix (ECM) during development may be a promising approach to enhance neural regeneration. Here, we reported a glycosaminoglycan (GAG) mimetic derived from cellulose that promotes neurite extension over native GAGs, chondroitin sulfate-A (CS-A) and chondroitin sulfate-C (CS-C), which are present in neural ECM. Depending upon the degree and position of sulfation, the GAG mimetic can impact nerve growth factor binding and permissive neurite outgrowth.

This chapter explores resuscitation, including early warning scores, intensive care, peri-arrest, in-hospital resuscitation, Advanced Life Support (ALS), arrest equipment and tests, Advanced Trauma Life Support (ATLS), Paediatric Basic Life Support, Newborn Life Support (NLS), and obstetric arrest.

This chapter explores psychiatry, including aggressive behaviour emergency, the Mental Health Act, alcoholism, aggression and violence, acute confusion, dementia, mood disturbance/psychosis, and anxiety disorders/neuroses.

This chapter discusses neurology, including coma and reduced GCS and coma and reduced GCS emergency, adult seizures emergency, paediatric seizures emergency, seizures, neurodegenerative disorders, stroke and stroke/CVA/TIA emergency, focal neurology, back pain, headache, and dizziness.

The Oxford Handbook for the Foundation Programme provides a unique resource for medical students and junior doctors as a definitive guide to the Foundation Programme. It is divided into 18 chapters, each covering a core area of the curriculum, including being a doctor, life on the wards, history and examination, prescribing, drugs, resuscitation, cardiovascular, respiratory, gastroenterology, endocrinology, neurology, psychiatry, fluids and renal, haematology, skin and eyes, emergency department, procedures, and interpreting results. It presents evidence-based clinical guidance in a clear way that makes it easy to revise, remember, and implement on the ward. It gives reliable advice on what to do, and when and how to do it, with clinical diagrams that bring theory to life. It helps junior doctors navigate all aspects of their working life, from career development to workplace relations, paperwork to pay and pensions.

This chapter discusses fluids and renal, including acute kidney injury, chronic kidney disease, haematuria, proteinuria, glomerular disease, urological disorders, low urine output, IV fluids, potassium emergencies, and electrolyte imbalance.

This chapter discusses history and examination, including basic history and examination, recording your clerking, cardiovascular medicine, respiratory medicine, gastrointestinal medicine, neurological medicine, endocrine medicine, skin, oncological/haematological medicine, breast surgery, eye surgery, head and neck surgery, musculoskeletal surgery, urological surgery, the female reproductive system, obstetric medicine, psychiatric medicine, neonatal examination, and paediatrics.

This chapter discusses cardiovascular medicine, including chest pain and chest pain emergency, tachyarrhythmia and tachyarrhythmia emergency, bradyarrhythmia and bradyarrhythmia emergency, hypertension and hypertension emergency, and heart failure.

This chapter explores the emergency department, including trauma, head injury, neck injury, falls and collapse, acutely painful limb emergency, acute limb pain, chronic limb pain, limb swelling, joint pain, neck lumps, ENT, groin lumps, burns and burns emergency, anaphylaxis in adults, hypotension emergency, hypotension, shock, pyrexia, overdose emergency, overdose and deliberate self-harm, vaginal bleeding, gynaecological causes of pain, contraception, early pregnancy (1st trimester), later pregnancy (2nd/3rd trimester), delivery, and after delivery (post-partum).

This chapter explores endocrinology, including hypoglycaemia and hypoglycaemia emergency, hyperglycaemia, sliding scales, diabetes mellitus, pituitary axis, adrenal disease, and thyroid disease.

This chapter explores haematology, including anaemia, transfusion of blood products, clotting emergencies, bleeding, and anticoagulation.

This chapter discusses disorders of the skin and eyes, including rash and rash emergency, bacterial infections causing a rash, viral infections causing a rash, fungal infections causing a rash, infestations causing a rash, chronic inflammatory rashes, other causes of rash, skin lumps, skin cancers, breast lumps, leg ulcers, acute red eye emergency, sudden visual loss, gradual visual loss, and other visual disturbances.

This chapter explores what is involved in being a doctor. It includes details of the Foundation Programme and how to apply, the curriculum and assessment, healthcare in the UK, starting life as an F1, what to do before you start, your first day, occupational health, what to carry, organization and efficiency, patient-centred care, communication and conduct, breaking bad news, cross-cultural communication, outside agencies, quality and ethics, clinical governance/quality, medical ethics, patient confidentiality, capacity, consent, what to do when things go wrong, medical errors, complaints, incident reporting, colleagues and problems, hating your job, relaxation, causes of stress, pay and contracts, making more money, debt, NHS entitlements, career, specialty training applications, options, and competition, career structure, choosing a job, specialties in medicine, your curriculum vitae, post-Foundation Programme CV, interviews, membership exams, continuing your education, audit, presentations and teaching, teaching medical students, and research and academia.