Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

A mixed-method approach to examining the experiences of allied health clinicians and managers of the performance, appraisal and development framework in a regional health care service

INTRODUCTION

Evaluating employee performance is important for organisational success however, limited research exists across the allied health workforce.

OBJECTIVE

This study investigated allied health clinician and manager experiences and perceptions of the appropriateness of the performance and development (PAD) framework.

DESIGN

A mixed methods design with purposive sampling was conducted in a medium size hospital and health service in regional Queensland to investigate the appropriateness of the PAD framework. A 29 item online survey collected likert scale and open ended responses. Identified respondents also completed a semi-structured interview. Aggregated satisfaction scores identifying PAD alignment, processes, education, resources and perceptions were analysed to identify organisational PAD appropriateness. Themes from interviews provided concurrent experiential data.

FINDINGS

Eighty-five respondents completed the online survey and 20 interviews were conducted. A Chi-Square Goodness of Fit test revealed a significant (p < 0.05) clinician (n = 75) response of moderate dissatisfaction (36%) for the PAD framework, while managers (n = 10) were neither dissatisfied nor satisfied (50%) or moderately satisfied (40%). Clinician aggregated agreement responses were significantly (p < 0.05) higher for PAD alignment (45%), processes (63%), education (49%) and lower for feedback (33%) and resources (28%). Manager aggregated agreement responses were high for PAD alignment (85%), processes (55%), education (57%), feedback (65%) and perceptions (50%). Interviews (n = 20) revealed three themes: uncertainty around PAD framework; expectations for experienced leadership and importance of discipline specific knowledge.

DISCUSSION

This study draws on both clinician and manager input to assess the overall PAD framework with responses favouring clinician dissatisfaction to the current process.

CONCLUSION

The PAD framework is valuable for staff development when there is positive rapport and discipline alignment between both clinician and manager. Successful staff appraisals require efficient and appropriate documentation that promotes individual development, clinical performance and organisational priorities.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

984 ADVANCE CARE PLANNING ON THE COMPLEX CARE WARDS AT ROYAL BOLTON HOSPITAL

Introduction

Advance care planning (ACP) is an important aspect of geriatric medicine, giving patients the opportunity to express their wishes and identify their preferred place of care and death whilst reducing unwanted hospital admissions. At Royal Bolton Hospital we reviewed the Complex Care department’s performance in engaging with ACP discussions with appropriate patients and considered how this could be improved.

Method

In October 2020, patients were identified from the current inpatients on the Complex Care wards using the following criteria: nursing home resident, clinical frailty score (CFS) 7 or above, or CFS 6 with 3 or more hospital admissions in the last 6 months. We reviewed the patient notes to ascertain whether any ACP had occurred and then followed the patients up at 6 and 12 months. At 6 and 12 months we identified the mortality and readmission rates to quantify whether the patients had been appropriate for ACP.

Results

35 patients identified as appropriate for ACP. ACP had been conducted in 10 patients. At 6 months, 13 patients had died and 17 had had hospital readmissions, totalling 196 readmission days. At 12 months, 8 patients had died, and 8 patients had been readmitted to hospital, totalling 85 readmission days. Combining the data for the 6- and 12-month results revealed 21 patients had died and 25 had been readmitted to hospital, totalling 281 readmission days. Only 4 of the 35 patients had neither died nor been readmitted to hospital.

Conclusion

Appropriate patients were accurately identified for ACP as confirmed by their subsequent mortality and readmission rates. However, there is scope for improving the quantity of ACP discussions by the Complex Care department in these patients. Further education for the medical staff, a patient leaflet and poster aimed at the ward juniors will be introduced with the aim of doing this.

The association between area-level residential instability and gray matter volume changes

Introduction

Area-level residential instability (ARI), an index of social fragmentation, has been shown to explain the association between urbanicity and psychosis. Urban upbringing has been shown to be associated with decreased gray matter volumes (GMV)s of brain regions corresponding to the right caudal middle frontal gyrus (CMFG) and rostral anterior cingulate cortex (rACC).

Objectives

We hypothesize that greater ARI will be associated with reduced right posterior CMFG and rACC GMVs.

Methods

Data were collected at baseline as part of the North American Prodrome Longitudinal Study. Counties where participants resided during childhood were geographically coded using the US Censuses to area-level factors. ARI was defined as the percentage of residents living in a different house five years ago. Generalized linear mixed models tested associations between ARI and GMVs.

Results

This study included 29 HC and 64 CHR-P individuals who were aged 12 to 24 years, had remained in their baseline residential area, and had magnetic resonance imaging scans. ARI was associated with reduced right CMFG (adjusted β = -0.258; 95% CI = -0.502 – -0.015) and right rACC volumes (adjusted β = -0.318; 95% CI = -0.612 – -0.023). The interaction terms (ARI X diagnostic group) in the prediction of both brain regions were not significant, indicating that the relationships between ARI and regional brain volumes held for both CHR-P and HCs.

Conclusions

Like urban upbringing, ARI may be an important social environmental characteristic that adversely impacts brain regions related to schizophrenia.

Disclosure

No significant relationships.

675 IMPROVING RECOGNITION OF DELIRIUM IN CRITICAL CARE PATIENTS

Introduction

Delirium is more prevalent in patients admitted to the critical care environment, those over 65 years old and living with frailty. By increasing the recognition of delirium we can improve management of patients and therefore reduce associated morbidity. Initial audit of this patient group highlighted that we are missing opportunities to screen for, diagnose and document the presence of delirium. This Quality Improvement project aimed to improve delirium screening, and therefore recognition, on the critical care unit at The Royal Bolton Hospital.

Method

A retrospective analysis of patients aged ≥65 years or with a CFS ≥5 admitted to critical care at The Royal Bolton Hospital over a 2-week period for each PDSA cycle. Three cycles were undertaken. The initial intervention was a local teaching session for medical and nursing staff on critical care. The second intervention was to display delirium information posters throughout critical care which encouraged recognition and screening of delirium.

Results

Prior to intervention 9% of this patient group were assessed for delirium on admission to critical care and 55% were re-assessed at some point during their admission. After the initial intervention these numbers significantly improved to 33% and 80% respectively. After the second intervention 8% were screened on admission and 69% were re-assessed. Missed opportunities to document delirium as a diagnosis remained similar throughout all cycles.

Conclusion

We can improve delirium screening via regular educational sessions for medical and nursing staff on critical care. Information posters do not appear to have as much impact. There is scope to improve documentation of delirium as a diagnosis which would further aid in management and outcomes. We suggest a further PDSA cycle with an intervention to address this.

228 Resilience, Mindset and Burnout of Healthcare Workers During the COVID-19 Pandemic

Introduction

We investigated the impact of the Biopsychosocial challenges associated with the COVID-19 Pandemic on the Healthcare Workforce, exploring the impact on and relationship between Healthcare Workers’ Mindset, Resilience and Burnout.

Method

An electronic survey was distributed to Healthcare Workers through Professional Associations' websites and social media. The survey contained demographic questions, a Burnout Inventory, a General Resilience scale, a scale to assess for Resilience during the Pandemic, as well as an Adapted Dweck Mindset instrument to measure Mindset as related to Workplace Environment and Resilience. Univariate and multivariate analysis was undertaken to examine the relationship between these factors.

Results

1,370 healthcare workers completed the questionnaire. 58.5%, 25.4%, 28.5% reported having Burnout, Low General Resilience and Low COVID Resilience, respectively. Burnout was significantly associated with Fixed Mindset, Low General Resilience and Low COVID Resilience. Resilience Training was found to be protective for Burnout.

Conclusions

The COVID-19 Pandemic has led to a higher proportion of HCWs experiencing Burnout than previously reported. Our findings demonstrate that HCWs with Low Resilience and Fixed Mindsets are more likely to experience Burnout, suggesting that, in combination with improved institutional support, there is a role for personalised Resilience and Mindset Training, in helping reduce the proportion of HCW Burnout.

Impact of intra-operative hypotension on mortality rates and post-operative complications in dogs undergoing cholecystectomy

OBJECTIVES

To report the mortality rate within a cohort of dogs undergoing cholecystectomy and investigate the impact of intra-operative hypotension on mortality.

MATERIALS AND METHODS

Clinical records at five UK referral centres were reviewed for dogs undergoing cholecystectomy. Data collected included presenting signs, pre-operative blood test results, intra-operative data including frequency and duration of hypotension and the incidence and type of post-operative complications.

RESULTS

Data from 119 dogs were included. Sixteen dogs (13%) died before discharge and by 28 days after surgery the total mortality was 19 dogs (17%). Hypotension lasting over 10 minutes during general anaesthesia occurred in 65 dogs (54.6%), with a mean ± sd duration of 36.1 ± 30.0 minutes. Intra-operative hypotension or the number of hypotensive episodes did not appear to be associated with in-hospital or 28-day mortality. American Society of Anaesthesiologists grade (of fitness for surgery) was significantly associated with both in-hospital and 28-day mortality on univariable analysis, as were post-operative hypoproteinaemia, ileus and pancreatitis. However on multivariable analysis, only ileus and pancreatitis were found to significantly impact mortality.

CLINICAL SIGNIFICANCE

Dogs presenting with a higher American Society of Anaesthesiologists grade appear to have a higher risk of mortality, although intra-operative hypotension did not appear to be part of this risk.

Long-term clinical outcomes following surgery for spontaneous pneumothorax caused by pulmonary blebs and bullae in dogs - a multicentre (AVSTS Research Cooperative) retrospective study

OBJECTIVES

To report the clinical characteristics and recurrence rate of spontaneous pneumothorax secondary to pulmonary blebs and bullae following surgical management in a large cohort of dogs. To explore potential risk factors for recurrence and describe outcome.

MATERIALS AND METHODS

Medical records were retrospectively reviewed for cases with spontaneous pneumothorax managed surgically between 2000 and 2017. Signalment, clinical presentation, diagnostic imaging, surgery, histopathology findings and patient outcomes were recorded. Follow-up was performed via patient records and telephone contact.

RESULTS

Records of 120 dogs with surgically treated pneumothorax were identified and reviewed, with 99 cases appropriate for exploratory statistical analysis. Median follow-up was 850 days (range: 9-5105 days). Two- and 5-year survival rates were 88.4% and 83.5%, respectively. There was recurrence in 14 of 99 dogs (14.1%) with adequate follow-up, with a median time to recurrence of 25 days (1-1719 days). Univariable Cox regression analysis suggested increased risk for recurrence in giant breeds (hazard ratio = 11.05, 95% confidence interval: 2.82-43.35) and with increasing bodyweight (HR = 1.04, 95% confidence interval: 1.00-1.09). Of 14 dogs with recurrence, six were euthanased, two died of causes related to pneumothorax and six underwent further treatment, of which five were resolved.

CLINICAL SIGNIFICANCE

Long-term survival for dogs with surgically managed spontaneous pneumothorax was good and associated with a low risk of recurrence. Giant breed dogs and increased bodyweight were the only variables identified as possible risk factors for recurrence. The outcome for dogs with recurrence undergoing a second intervention was also favourable.

Effect of age on the relationship between metabolizable energy and digestible energy for broiler chickens

A total of 960 male Ross 308 chicks (day-old) were used to investigate the effect of age on the relationship between metabolizable energy (ME) and digestible energy (DE) for broiler chickens. Bird growth variables, nitrogen retention (NR), nitrogen digestibility (ND), as well as the relative weight of liver, pancreas, and the gastrointestinal tract were determined. Practical diets that compared 2 cereals (corn and wheat) and exogenous xylanase (0 or 16,000 BXU/kg) were evaluated at 5 ages (7, 14, 21, 28, and 35 D) in a 2 × 2 × 5 factorial arrangement of treatments with 8 replicates per treatment and started with 30 birds per replicate. A randomized block ANOVA analysis of repeated measures was performed, and a 2 × 2 × 5 factorial structure was used to investigate the 2 dietary treatment factors (cereal type and the presence of xylanase) within the 5 bird ages (7, 14, 21, 28, and 35 D), and their interactions. Apparent metabolizable energy (AME) increased linearly from 7 until 28 D of age, but (P < 0.05) decreased at 35 D of age. Digestible energy was high at 7 D of age, then dropped and remained similar (P > 0.05) from 14 to 35 D of age. The AME: DE ratio was lowest (P < 0.05) at 7 D of age but there were no (P > 0.05) differences thereafter. Cereal type and xylanase supplementation did not (P > 0.05) change the ME: DE ratio. The results indicate that determining ME before 14 D of age may give absolute values that are lower than would be obtained with older birds. ME values that are determined on older broiler chickens may overestimate the energy availability of practical feeds used in broiler starter feeds.

Feeding dihydroquercetin to broiler chickens

1. A total of 80 male Ross 308 broilers were used in a study to investigate the effect of dietary dihydroquercetin (DHQ) on growth performance variables, gastrointestinal tract (GIT) and immune organ development, glutathione peroxidase (GPx) and haemoglobin in blood, hepatic vitamin E content, dietary N-corrected metabolisable energy (AMEn) and nutrient retention coefficients when fed to broiler chickens from 7 to 35 d of age.2. Two treatments were used in this study: control (C) and C + 0.5 g/kg extract of Siberian Larch (Larix sibirica) per kg feed, containing 85% DHQ. The diets were fed over 2 feeding phases, a grower phase from 7 to 28 d of age and a finisher phase from 28 to 35 d of age. The birds were reared under the breeder's recommended conditions.3. In general, there were no effects of DHQ on growth performance of broiler chickens. However, the results of this experiment showed that there can be changes in the redness colour of the breast meat when DQH is fed. No negative effects of feeding DHQ at 0.5 g/kg diet were observed in this study.4. Supplementation of poultry diets with DHQ under standard industry-rearing conditions did not improve the performance or any of the studied variables, except an increase of redness index of the breast fillets. Feeding DHQ at different doses and/or under more challenging conditions, e.g. heat stress, may, however, bring positive responses.

Surgical management of impalement injuries to the trunk of dogs: a multicentre retrospective study

OBJECTIVES

To review a large series of dogs referred for treatment of traumatic impalement injuries to the thorax and/or abdomen and to report aetiologies, injury characteristics, management and long-term outcomes.

MATERIALS AND METHODS

Previously collected data on dogs that were surgically treated for impalement injuries to the trunk at six veterinary specialist referral institutions in the UK over an 11-year period were reviewed. Data included patient signalment, physiological variables, injury-specific variables, diagnostic imaging reports, surgical procedures undertaken, duration of hospitalisation, antibiotic use, complications and outcomes. Data were reported with summary statistics.

RESULTS

Fifty-four dogs were included. Impalement occurred most frequently on wooden objects (n=34), and the thoracic cavity was most commonly penetrated (n=37). Computed tomography was sensitive and specific to identifying wooden material in 64% and 88% of cases (n=11), respectively. Thoracotomy was performed in 56%, coeliotomy in 20% and a foreign body or its fragments were retrieved during surgery in 37% of the cases. Complications occurred in 19 dogs (35%), and of these, 68% were minor and 32% major. The survival rate for thoracotomy cases was 93% (n=30). Overall long-term survival was 90%.

CLINICAL SIGNIFICANCE

Despite the often dramatic presentation of impalement injuries, the majority of patients treated in the specialist referral setting can achieve excellent outcomes. These injuries require thorough diagnostic imaging and interpretation before adequate surgical exploration and management, augmented by anaesthesia and critical care during the peri- and postoperative periods; therefore stable patients should be referred to centres able to provide this type of care.

Malnutrition screening in patients admitted to hospital with an exacerbation of chronic obstructive pulmonary disease and its association with patient outcomes

OBJECTIVES

There is a paucity of information on the prevalence and clinical implications of malnutrition in patients hospitalised for management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD). This study aimed to fill this gap in knowledge.

METHODS

We performed a retrospective observational cohort study of 100 hospitalised AECOPD patients. The Malnutrition Screening Tool (MST) was used to identify patients at risk of malnutrition (MST ≥2). Patient characteristics, length of stay, readmission rate, 12-month survival and overall survival were collected using a proforma.

RESULTS

MST scores were available in 90 patients, of whom 22% of patients had a MST score of ≥2. There were no significant differences in COPD severity, treatment received and biochemical parameters between the groups of patients 'at risk of malnutrition' and those 'not at risk of malnutrition'. Length of stay in hospital was longer in patients 'at risk of malnutrition' (median (IQR): 3.5 (2-7.5) vs. 3.0 (1-5), p = 0.048). Overall survival was significantly reduced in patients with 'at risk of malnutrition' compared to those patients 'not at risk of malnutrition' (337 ± 245 vs. 670 ± 292, p < 0.001).

CONCLUSIONS

Using the MST we found that one-fifths of our hospitalised AECOPD patients are at 'at risk of malnutrition'. Moreover, this cohort of patients had worse outcomes both during and extending beyond hospitalisation compared to patients 'not at risk of malnutrition'. Our study illustrates the need for routine malnutrition screening for hospitalised AECOPD patients because it has implications for potentially reducing morbidity and mortality in COPD.

5-HT(6) receptor agonists and antagonists enhance learning and memory in a conditioned emotion response paradigm by modulation of cholinergic and glutamatergic mechanisms

BACKGROUND AND PURPOSE

5-HT(6) receptors are abundant in the hippocampus, nucleus accumbens and striatum, supporting their role in learning and memory. Selective 5-HT(6) receptor antagonists produce pro-cognitive effects in several learning and memory paradigms while 5-HT(6) receptor agonists have been found to enhance and impair memory.

EXPERIMENTAL APPROACH

The conditioned emotion response (CER) paradigm was validated in rats. Then we examined the effect of the 5-HT(6) receptor antagonist, EMD 386088 (10 mg·kg(-1) , i.p.), and agonists, E-6801 (2.5 mg·kg(-1) , i.p.) and EMD 386088 (5 mg·kg(-1) , i.p.) on CER-induced behaviour either alone or after induction of memory impairment by the muscarinic receptor antagonist, scopolamine (0.3 mg·kg(-1) , i.p) or the NMDA receptor antagonist, MK-801 (0.1 mg·kg(-1) , i.p).

KEY RESULTS

Pairing unavoidable foot shocks with a light and tone cue during CER training induced a robust freezing response, providing a quantitative index of contextual memory when the rat was returned to the shock chamber 24 h later. Pretreatment (-20 min pre-training) with scopolamine or MK-801 reduced contextual freezing 24 h after CER training, showing production of memory impairment. Immediate post-training administration of 5-HT(6) receptor antagonist, SB-270146, and agonists, EMD 386088 and E-6801, had little effect on CER freezing when given alone, but all significantly reversed scopolamine- and MK-801-induced reduction in freezing. CONCLUSION AND IMPLICATIONS Both the 5-HT(6) receptor agonists and antagonist reversed cholinergic- and glutamatergic-induced deficits in associative learning. These findings support the therapeutic potential of 5-HT(6) receptor compounds in the treatment of cognitive dysfunction, such as seen in Alzheimer's disease and schizophrenia.

Stem cell stories: from bedside to bench

The stem cell story is not a simple story but a complex narrative: one that requires careful analysis in order to identify major themes and plots. This paper offers an analysis of the ethics of the clinical application of stem cells and argues that even quite risky therapies can be ethical. These arguments cannot be used to justify all aspects of contemporary stem cell science, including human embryonic stem cell science, which remains theoretical and speculative. It is argued that the homogenisation of stem cell science obscures the distinction between clinical application and experimental laboratory science in a morally problematic way.

Uncertainty of sweat chloride testing: does the right hand know what the left hand is doing?

Although analytical variation in sweat electrolyte testing can be easily estimated, there is limited data on total variation. This study aims to evaluate the total variation of the sweat test by measuring the difference between sweat electrolyte values in specimens obtained simultaneously from two sites. Chloride is recommended in published guidelines as the only discriminant for the diagnosis of cystic fibrosis, and sodium may be measured as a guide to the adequacy of collection and analysis. Both are reported here. Sweat was collected in patients by the Gibson Cooke method from two sites simultaneously. Coefficient of variation in this laboratory is 4.1 and 5% for chloride and sodium, respectively. 295 patients had sufficient sweat collected from both sites for analysis. The values for chloride and sodium were compared between the two sites. The total coefficient of variation (CVt) calculated for the whole group between the two sites was 20.2% for chloride and 16.9% for sodium, and the standard deviations 4.3 mmol/L and 4.8 mmol/L, respectively. In patients with intermediate chloride concentrations; in different age groups; and when those tests with a difference between sodium and chloride concentration of more than 15 were excluded, minimal differences in these figures were observed. Use of strictly defined cut-off points to discriminate between normal and intermediate electrolyte values, and between intermediate and raised electrolyte values, does not reflect the variation in sweat electrolyte content found within an individual patient. This has important implications for reporting.

Ethical and governance challenges in human fetal tissue research

Genetics holds the key to understanding normal human biology and possibly many of the major causes of human disease and impairment. Research into human developmental genetics seems, therefore, to be both necessary and justified. However, such research requires the use of embryonic and fetal tissue obtained from spontaneous abortions and elective termination of pregnancy. This paper examines the arguments in favour of using tissue from elective terminations and the evolution of regulatory frameworks for this research. The paper argues that the recent statutory and regulatory reforms in the UK have not properly addressed the issue of ethically obtaining postimplantation human embryos for research. It is argued that the recent reforms have left the Polkinghorne guidelines untouched but that these are now unequal to the task. A practical suggestion for reform of the approach to the informing and consent of potential donors is offered.