Search

We shall not cease from explorationAnd the end of all our exploringWill be to arrive where we startedAnd to know the place for the first time T.S. Eliot (Little Gidding, Four Quartets)Don’t Be Sa...

Pattern formation in plasma–solid interaction represents a great research challenge in many applications from plasma etching to surface treatment, whereby plasma attachments on electrodes (arc roots) are constricted to self-organized spots. Gliding arc discharge in a Jacob’s Ladder, exhibiting hopping dynamics, provides a unique window to probe the nature of pattern formation in plasma–surface interactions. In this work, we find that the existence of negative differential resistance (NDR) across the sheath is responsible for the observed hopping pattern. Due to NDR, the current density and potential drop behave as activator and inhibitor, the dynamic interactions of which govern the surface current density re-distribution and the formation of structured spots. In gliding arc discharges, new arc roots can form separately in front of the existing root(s), which happens periodically to constitute the stepwise hopping. From the instability phase-diagram analysis, the phenomenon that arc attachments tend to constrict itself spontaneously in the NDR regime is well explained. Furthermore, we demonstrate via a comprehensive magnetohydrodynamics (MHD) computation that the existence of a sheath NDR can successfully reproduce the arc hopping as observed in experiments. Therefore, this work uncovers the essential role of sheath NDR in the plasma–solid surface pattern formation and opens up a hitherto unexplored area of research for manipulating the plasma–solid interactions.

This paper explores the imprint of slavery and its ensuing intergenerational transmission of trauma. It further explores a biracial man’s shame over the disavowed paternity of his white father. His...

Children who are tracheostomy dependent require comprehensive caregiver preparation for safe hospital-to-home transition. Although a structured discharge education program successfully trained caregivers to provide routine daily tracheostomy care, emergency response training was limited, lacking realistic experiences. Initiation of simulated emergency training for caregivers indicated performance confusion related to tracheostomy cardiopulmonary resuscitation (CPR). This study evaluated the effectiveness of an evidence-based tracheostomy CPR education intervention via caregiver participation in a high-fidelity simulation of a home-based emergency scenario on the performance of essential behaviors, comfort, and satisfaction.The study utilized a prospective descriptive pre- and post interventional design; 44 caregivers of children who were tracheostomy dependent participated. All caregiver participants completed: video- and instructor-assisted specialized tracheostomy CPR class, high-fidelity simulation performance of a home-based emergency (respiratory failure with cardiac arrest), postsimulation video debriefing, performance assessment with an objective scoring rubric, and pre- and post simulation surveys on levels of comfort and satisfaction.On the performance of essential emergency management behaviors, 86.4% of caregivers performed all four behaviors, but only 36.4% performed these essential behaviors in order. Post simulation caregiver comfort with emergency management significantly increased from pre simulation (p = .001). All caregivers were satisfied with this training and would recommend simulation of home-based emergencies for all caregivers. Qualitative feedback from caregivers revealed themes of gratitude and the importance of hands-on practice with guided debriefing/feedback. Study power was 0.98.Objective evaluation of caregiver performance demonstrated specialized tracheostomy CPR education prepared caregivers to respond in a home emergency. Caregivers viewed simulation as an opportunity to gain hands-on experience and improve emergency responses. It may be beneficial for other similar programs to include specialized tracheostomy CPR and emergency scenario simulation in their discharge education protocols and subsequently compare this program to other similar programs to establish best practice guidelines.

AIMS In patients with palliative end-stage heart failure, interventions that could provide symptomatic relief and prevent hospital admissions are important. Ambulatory continuous intravenous inotropes have been advocated by guidelines for such a purpose. We sought to determine the effect of intravenous dobutamine on symptomatic status, hospital stay, mortality, and cost expenditure. METHODS AND RESULTS All consecutive end-stage heart failure patients not amenable for advanced therapies and discharged with continuous intravenous home dobutamine from a single tertiary centre between April 2011 and January 2017 were retrospectively analysed. Dobutamine (fixed dose) was infused through a single-lumen central venous catheter with a small pump that was refilled by a nurse on a daily basis. Symptomatic status was longitudinally assessed as the change in New York Heart Association class and patient global assessment scale. Antecedent and incident heart failure hospitalizations were determined in a paired fashion, and cost impact was assessed. A total of 21 patients (age 77 ± 9 years) were followed up for 869 ± 647 days. At first follow-up (6 ± 1 weeks) after the initiation of dobutamine, patients had a significant improvement in New York Heart Association class (-1.29 ± 0.64; P

Replies to Dr. Kaplan and Dr. Nahum (this issue) focus on the complexly layered aspects of both attachment dimensions and clinical engagement. Attachment is looked at in the context of multiple self states. Thus, despite the predominant annihilation anxiety that accompanies disorganized attachment, there may also be self experiences of shame and humiliation generated by dependency needs. In response to the Boston Change Process Study Group, the paper proposes the idea that there is “something more” than implicit relational knowledge— something that is not subsumed under that theoretical paradigm. In keeping with the theme of multiple self states, “dissociation” and “enactment” are believed to be useful concepts in providing a path for transformative relational experience.

This paper looks at and counters the notion that the analyst’s reluctance to know, to comprehend and interpret, the fuller meaning of a patient’s behavior is a countertransference avoidance. Drawing on attachment theory and infant research that has not yet been fully integrated into the clinical literature, the author believes that the movement from enactment to the expression of dissociated feeling is a process that leads to the creation of previously unknown meaning within an analytic impasse. The infant research literature and the literature on disorganized attachment is referenced to elucidate aspects of the clinical process. The clinical material presented involves the analyst’s failure to engage a patient’s chronic lateness, a failure that represented a mutual avoidance. The meaning of this enactment was locked in the patient’s traumatic past and could not be transmuted into new relational experience until the analyst had emerged from her own dissociative state. The therapeutic space created by thei...

Nano-coatings, which are generally composed of inorganic nanofillers and polymer binders, have attracted increasing interest in electrical industry, because of their unique advantages for improving the dielectric and electrical properties of the electric devices, accompanied by the versatile manufacturing process. Here, a uniform coating layer of aluminum hydroxide (ATH), bound by polymethyl methacrylate (PMMA), was successfully manufactured by dip/spray coating process. It can be found the filler contents show an apparent influence on the DC breakdown strength of the coating materials. Furthermore, to deal with the brittleness of the coating layer, Polyvinyl Butyral (PVB) was adopted as the third component, and, as a result, the DC breakdown strength is also significantly enhanced with an optimized content of PVB. This work shows a feasible route, i.e., compositional tailoring, to modify the electrical properties of the nano-coating materials, which provide opportunities for their wide applications, especially under harsh and extreme working conditions.

Plasma–solid interaction represents a major concern in many applications such as power-interruption and plasma–metal processing. Characterized by high-current density and voltage drop, the arc roots dissipate intensive heat to electrode vaporization, which participates in the ionization and, thereby, significantly alters the plasma properties and gas dynamics. Most of the arc root models feature approaches based on surface temperature or (temperature dependent) current density. Due to the complexity of conjugated heat transfer across arc roots involving three-phase interactions of plasma with liquid spots and solid electrodes, accurately determining the surface temperature distribution is extremely computationally demanding. Hence, models hitherto fail to quantitatively estimate neither the molten spot size nor the total amount of vaporization. In this work, we propose an arc root model featuring a hemispherical structure that correlates the molten spot size with the heat partition between conduction and vaporization to estimate the energy dissipation at arc roots and, thus, to trace the vaporization rate. Following local partial pressure adjusted Langmuir vaporization, we deduce an analytical solution of molten spot size for quasi-steady-state, which compares favorably with experiments. Specifically, the vaporization dominates over conduction for large molten spots as in the case of high-current arcs. However, for low-current arcs, the vaporization heat is trivial compared with conduction. Furthermore, we integrate this arc root model into a study case of arc plasma based on the magnetohydrodynamics method. The simulated arc voltage and arc displacement match with the experiment. This model is expected to find broad applications in power interruption and plasma etching.

Low-voltage circuit breakers provide essential protection for industrial and residential power distribution, by taking advantage of cathode drop to force current zero. This is accomplished by using the magnetic force and pressure on the arc as the contacts open to push the arc towards a stack of steel plates which break the arc into sub-arcs and thereby multiply the number of cathode drops. As the fault current can be high, substantial energy can be dissipated, which results in interactions among the arc and solid materials: ablation of wall materials. Comprehensive CFD/MHD studies have been conducted for arc running and splitting, although an important mechanism in arc breaking computation, the effect of Stefan flow induced by species generation, has not been considered. In this work, we report out a simulation approach for taking into account the effect of Stefan flow, particularly for the breakers with highly gasified wall materials. This approach accounts for the initial velocity of added-in species from the surface of the polymer wall and electrodes' surface, which will largely influence the flow field and the property of plasma mixture. The ability of conducting computation with considering Stefan flow effect will further enhances the accuracy of arc simulation in low-voltage circuit breakers.

Nano-Iaminate coatings with highly ordered and oriented nanostructures based on Organically Modified Montmorillonite (o-MMT) were formed via co-assembling with polymer binders and applied by using various coating methods including spray coating, dip coating and blade cast coating for making films/coatings with enhanced dielectric and electrical discharge resistance. Dielectric properties of the nanoclay coatings along with their nanostructure characterization were studied for the coating processing optimization. The DC breakdown strength test and small-angle x-ray diffraction results consistently indicated that dip coated samples led to the most highly oriented nano-Iaminated structure with the highest breakdown strength. Corona endurance test was also performed on dip coated MMT nano-composite materials in comparison with other commercial available discharge resistant film. A remarkable enhancement was observed for nano-Iaminate coating, which indicated that this new nano-composite material has potential to be a processable and cost-effective dielectric material for many applications where discharge resistance device/structure/materials are needed.

Testicular cancer survivors are at increased risk of cardiovascular disease after cisplatin-based chemotherapy. Among 787 testicular cancer survivors, the Framingham Risk Score for cardiovascular disease was elevated among less educated and less vigorously active patients, but did not differ by chemotherapy regimen (4 cycles of EP [etoposide and cisplatin] or 3–4 cycles of BEP [bleomycin, etoposide, and cisplatin]). Follow-up and counseling in high-risk subgroups is recommended. BACKGROUND: Testicular cancer survivors (TCSs) are at increased risk of cardiovascular disease (CVD) after cisplatin-based chemotherapy (CBCT). Identifying at-risk survivors would allow early intervention, but risk prediction tools such as the Framingham Risk Score (FRS) have not been applied to TCSs given modern chemotherapy. METHODS: TCSs > 1 year post-CBCT were evaluated. Associations between FRS and clinical, socioeconomic, and lifestyle measures and treatment regimen (4 cycles, etoposide and cisplatin [EP × 4]); 3 or 4 cycles, bleomycin plus EP (BEP × 3, BEP × 4) were analyzed with general linear multivariable models. Controls from the National Health and Nutrition Examination Survey were matched 1:1 to TCSs by age, race, and education with differences in mean FRS evaluated with 2-sided t tests. RESULTS: Of 787 TCSs (median age, 37.3 years; median follow-up, 4.2 years), 284, 342, and 161 received EP × 4, BEP × 3, or BEP × 4, respectively. TCSs had higher median systolic blood pressure (126 vs. 119 mm Hg; P < .001), but fewer were smokers (8.4% vs. 28.2%; P < .001) than controls. In multivariable analysis, no significant differences in FRS between EP × 4, BEP × 3, and BEP × 4 were observed, but less than college education (P < .001) and lack of vigorous exercise (P = .006) were associated with higher FRS. Mean FRS did not differ between TCSs and controls (6.8% vs. 7.3%; P = .67). CONCLUSION: This is the first study to apply the office-based FRS to TCSs. Chemotherapy regimen (BEP × 3 vs. EP × 4) was not associated with FRS, but less educated and less vigorously active patients had higher FRS, and present a high-risk subgroup for intense follow-up and counseling.

The author discusses the binary posited by Laurel Silber between child and adult therapies. However, this paper shifts the focus to the binary between classical and relational models. Classical child therapists fail to conceptualize the child’s experience as embedded in attachments and real relationships. In contrast, the relational turn in psychoanalytic theory has repudiated the idea of the “isolated mind.” Rather, relational child therapists see child and adult treatment on a continuum and maintain a view of the mind as dyadically created and shared. These seminal shifts, based on attachment theory and infant research, have created a new paradigm which rests on greater collaboration between therapist and parent. Thus, relational, intersubjectively organized child therapists have turned to an increasing degree, to working with parents in consultative relationships. The growing body of research that supports work with parents is seen as more compatible with the relational turn and more consistent with cu...

AIMS: To assess the influence of device-registered episodes of atrial tachyarrhythmia (AT) on the response to cardiac resynchronization therapy (CRT). METHODS AND RESULTS: Consecutive CRT patients without history of atrial fibrillation (AF; n = 118) were followed prospectively. AT was defined as a device-registered episode of atrial rate >190 b.p.m. for ≥30 s. Episodes of electrocardiographically documented AF, accompanied by symptoms, or need for cardioversion, were classified as clinical AF. During mean follow-up of 26 ± 9 months, 39 patients (33%) had ≥1 episode of asymptomatic device-registered AT. Twenty-one patients (18%) developed clinical AF of whom seven had previously experienced episodes of asymptomatic device-registered AT. Patients with asymptomatic AT or AF had a higher body mass index, but otherwise similar baseline characteristics, compared with the subjects without AT. Reverse remodelling after CRT was similar among the groups. While clinical AF was significantly associated with the composite endpoint of all-cause mortality or unplanned hospital admission (hazard ratio = 2.43, 95% confidence interval: 1.40-4.24), this correlation was not observed in patients with asymptomatic device-registered AT (P value = 0.540). CONCLUSION: Episodes of asymptomatic device-registered AT are frequent in CRT patients, but are not associated with impaired reverse remodelling. In contrast to clinical AF, such episodes are not associated with worse clinical outcome.

Low-voltage circuit breakers provide essential protection for industrial and residential power installations, by taking advantage of the voltage drop at the electrode–plasma interface to force current zero. This is accomplished by using the magnetic force and unbalanced pressure on the arc as the contacts open to push the arc toward a stack of steel plates that break the arc into subarcs and thereby multiply the number of voltage drops. As the fault current can be high, substantial energy can be dissipated, which results in interactions among the arc and solid counterparts in terms of wall ablation and metal evaporation. In this study, ablation experiments are conducted to demonstrate its great influence on the arc voltage and on the pressure field. Significant progress has been accomplished in the computation of arc dynamics through the coupling of fluid motion with electromagnetics, although an important mechanism in arc breaking simulation, the effect of Stefan flow caused by species generation, has not been considered. We report out a numerical approach for taking into account the effect of Stefan flow, particularly for the breakers with high gasifying wall materials. This approach accounts for the diffusion induced convection due to added-in species from the evaporation surfaces, which will largely influence the flow field and the properties of the plasma mixture. Apart from the voltage drop, this mechanism plays an important role in simulating arc interruption. The ability of conducting Stefan flow computation further enhances the understanding of arc behaviors and improves the design of practically oriented low-voltage circuit breakers.

Aims Cardiac resynchronization therapy (CRT) leads to reverse ventricular remodelling, improved functional capacity, and better clinical outcome in patients with advanced chronic heart failure, reduced ejection fraction, and evidence of ventricular conduction delay, who are under optimal medical therapy. This study investigated whether these benefits can be extrapolated to older patients, typically not included in randomized clinical trials. Methods and results Consecutive patients who received a CRT device between October 2008 and June 2011, including optimization afterwards in a dedicated clinic, were stratified into 3 pre-specified groups, according to age

Background The influence of comorbid conditions on ventricular remodeling, functional status, and clinical outcome after cardiac resynchronization therapy (CRT) is insufficiently elucidated. Methods and Results The influence of different comorbid conditions on left ventricular remodeling, improvement in New York Heart Association (NYHA) functional class, hospitalizations for heart failure, and all-cause mortality after CRT implantation was analyzed in 172 consecutive patients (mean age 71 ± 9 y), implanted from October 2008 to April 2011 in a single tertiary care hospital. During mean follow-up of 18 ± 9 months, 21 patients died and 57 were admitted for heart failure. Left ventricular remodeling and improvement in NYHA functional class were independent from comorbidity burden. However, diabetes mellitus (hazard ratio [HR] 3.45, 95% confidence interval [CI] 1.24–9.65) and chronic kidney disease (HR 3.11, 95% CI 1.10–8.81) were predictors of all-cause mortality, and the presence of chronic obstructive pulmonary disease (HR 1.89, 95% CI 1.02–3.53) was independently associated with heart failure admissions. Importantly, those 3 comorbid conditions had an additive negative impact on survival and heart failure admissions, even in patients with reverse left ventricular remodeling. Conclusions Reverse ventricular remodeling and improvement in functional status after CRT implantation are independent from comorbidity burden. However, comorbid conditions remain important predictors of all-cause mortality and heart failure admissions.

The author presents a perspective on school psychological services, beginning with the assessment process, that focuses on parent and teacher consultation. The paper outlines a focal shift from the individual child to the parental and systemic life in which the child is embedded. The role of the school psychologist is conceived as, primarily, consultative and collaborative in nature. Collaborating with parents and teachers in the assessment process involves mutual exploration and information gathering and reflects a paradigmatic shift from individual analysis to the analysis of dyadic and systemic parent-child and family-school relationships. Understanding parents' and teachers' perspectives and needs, providing a supportive, collaborative environment, and serving as a conduit between the family and the school is seen as vital to the role of the school psychologist.

The author uses the lens of myth and fairy tales to examine the narratives generated by the analytic experience. Fairy tales are understood as representing fundamental developmental conflicts, accounting for their enduring power over time. The analytic encounter is seen as an analogue of the fairy tale in which the hidden self, damaged by loss and abandonment, reemerges only through the redemptive power of [an] other's love. Clinical material is presented in which hidden parts of the patient's self are projected into the analyst for safekeeping; these hidden parts resonate with the analyst's own lost, unrealized potential and form an intersubjective experience which the author believes is transformative. The patient's dormant powers emerge in a newly experienced atmosphere of recognition, and in this way, the analytic encounter resembles the fairy tale in providing an identificatory bond and a protective space for the patient's hidden vitality.

The author explores the influence of the analyst's subjectivity as a lens to understanding the implicit ways in which our inner worlds affect our analytic decisions. She further asserts that it is the coalescence of the analyst's and patient's subjective experiences that underlies the direction the analysis takes and informs what is mutative for the patient. Drawing on her own sense of familial loss and abandonment, both real and imagined, she decides to break the frame and holds a session in the patients home. This event dynamically moves the analysis forward in ways that highlight the use of the analyst's personal sensibility and vulnerabilities that form a necessary resonance with those of the patient.