Concept design overview: a question of choices and compromise.

The Spherical Tokamak for Energy Production (STEP) programme hypothesizes that a compact machine offers a route to reduced capital cost that directly tackles the barrier to entry of this potentially transformative technology. History has shown that with an unsolved, complex and highly interdependent design challenge, there is a need to balance exploration of the problem with progress. Almost all complex systems arise from the evolutionary improvement of simpler systems which is an approach the programme has adopted by working through a virtual natural selection of design families towards a single concept consistent with the initiating hypothesis.

Surveillance of bacterial disease in wartime Ukraine.

This analysis considers circulation of bacterial disease in wartime Ukraine. Anthrax, brucellosis, botulism and tularaemia are all naturally occurring in the country. The causative agents of these diseases also formed components of the biological weapons programme the Russian Federation inherited from the Soviet Union at the end of the Cold War.

Mental Health Nurses' Experiences of Working in the Emergency Department of Two Rural Australian Settings.

Providing effective mental health care in Emergency Departments (ED) is a fundamental expectation, as EDs increasingly become the first point of contact with health services for people in mental distress. As part of a larger multi-site translational research project this study explored the experiences, perspectives and recommendations of mental health liaison nurses (MHLN) employed in the EDs of two rural hospitals in New South Wales, Australia. Participants identified numerous benefits associated with embedding the MHLNs within the ED team.

Low light intensities increase avoidance behaviour of diurnal fish species: implications for use of road culverts by fish.

Inadequately designed culverts can be physical barriers to fish passage if they increase the velocity of water flow in the environment, alter natural turbulence patterns or fail to provide adequate water depth. They may also act as behavioural barriers to fish passage if they affect the willingness of fish species to enter or pass through the structure due to altered ambient light conditions. To understand how reduced light intensity might affect fish behaviour in culverts, the authors performed a behavioural choice experiment quantifying the amount of time individual fish spent in dark and illuminated areas of a controlled experimental channel.

Factors associated with older people's emergency department attendance towards the end of life: a systematic review.

Background: Emergency department (ED) attendance for older people towards the end of life is common and increasing, despite most preferring home-based care. We aimed to review the factors associated with older people's ED attendance towards the end of life.

Methods: Systematic review using Medline, Embase, PsychINFO, CINAHL and Web of Science from inception to March 2017.

Clinical audit does not work, is quality improvement any better?

This article reviews the history of clinical audit and appraises its effectiveness. It discusses why audit can be ineffective in improving care and makes proposals to remove these barriers. The article describes how quality improvement and improvement science may offer a better alternative to traditional audit.

Comparative Analysis of Women With Notable Subjective Health Indicators Compared With Participants in the Australian Longitudinal Study on Women's Health: Cross-Sectional Survey.

Background: At least six communities with unusually good health and longevity have been identified, but their lifestyles aren't adopted widely. Informal evidence suggests that women associated with Universal Medicine (UM), a complementary medicine health care organization in Eastern Australia and the United Kingdom with normal lifestyles, also have several unusual health indicators.

Objective: Our objective was to determine how UM participants compared with women in the Australian population at large on a variety of health indicators.

A Group of 500 Women Whose Health May Depart Notably From the Norm: Protocol for a Cross-Sectional Survey.

Background: Longitudinal studies of women's health often seek to identify predictors of good health. Research has shown that following simple guidelines can halve women's mortality. The ongoing Australian Longitudinal Study of Women's Health (ALSWH) shows that Australian women are getting better at reducing their smoking and alcohol use, and are generally diligent about attending recommended health screenings, but are becoming less successful at dealing with obesity.

National early warning score at Emergency Department triage may allow earlier identification of patients with severe sepsis and septic shock: a retrospective observational study.

Introduction: Severe sepsis and septic shock (SS) are time-critical medical emergencies that affect millions of people in the world. Earlier administration of antibiotics has been shown to reduce mortality from SS; however, the initiation of early resuscitation requires recognition that a patient may have sepsis. Early warning scores (EWS) are broadly used to detect patient deterioration, but to date have not been evaluated to detect patients at risk for SS.

Analysis of cerebrospinal fluid for xanthochromia versus modern computed tomography scanners in the diagnosis of subarachnoid haemorrhage: experience at a tertiary trauma referral centre.

Background: Diagnosis of subarachnoid haemorrhage, a neurosurgical emergency in patients with headache remains a logistical challenge. The rationale of the traditional pathway of cerebrospinal fluid xanthochromia analysis following negative computed tomography head scans to exclude subarachnoid haemorrhage has been challenged by the increasing accuracy of modern computed tomography scanners.

Aim: We set out to establish whether our xanthochromia service was adding value to the diagnostic pathway for subarachnoid haemorrhage or whether it was acting merely as a supportive test.

A cross-sectional study of knife injuries at a London major trauma centre.

Introduction: No national recording systems for knife injuries exist in the UK. Understanding the true size and nature of the problem of knife injuries is the first stage in reducing the burden of this injury. The aim of this study was to survey every knife injury seen in a single inner city emergency department (ED) over a one-year period.

Influence of age on thrombolysis outcome in wake-up stroke.

Background And Purpose: Thrombolysis in patients >80 years remains controversial; we hypothesized that >80-year-old patients with wake-up ischemic stroke (WUIS) will benefit from thrombolysis despite risks because of poor outcomes with no treatment.

Methods: The study included 68 thrombolysed patients with WUIS (33 [48%] >80 years), 54 nonthrombolysed patients with WUIS (21 [39%] >80 years), and 117 patients (>80 years old) thrombolysed within 4.5 hours of symptom onset (reference group).

A case-controlled comparison of thrombolysis outcomes between wake-up and known time of onset ischemic stroke patients.

Background And Purpose: Wake-up ischemic stroke (WUIS) patients are not thrombolysed even if they meet other criteria for treatment. We hypothesized that patients with WUIS showing no or early ischemic changes on brain imaging will have thrombolysis outcomes comparable with those with known time of symptom onset.

Methods: Consecutive sampling of a prospective registry of patients with stroke between January 2009 and December 2010 identified 394 thrombolysed patients meeting predefined inclusion criteria, 326 presenting within 0 to 4.

An observational study of thrombolysis outcomes in wake-up ischemic stroke patients.

Background And Purpose: Wake-up ischemic stroke (WUIS) patients are not eligible for thrombolysis; the a priori hypothesis was that thrombolysis of selected WUIS patients who meet clinical and imaging criteria for treatment is associated with better outcomes.

Methods: The sample consisted of consecutive WUIS patients who fulfilled predefined criteria: (1) were last seen normal >4.5 hours and <12 hours before presentation; (2) National Institute of Health Stroke Scale score ≥ 5; (3) No or early ischemic changes <1/3 middle cerebral artery territory on computed tomography imaging; (4) No absolute contraindications to thrombolysis.

Paracetamol toxicity: What would be the implications of a change in UK treatment guidelines?

Background: Treatment of single-time-point ingestion acute paracetamol (acetaminophen) poisoning with N-acetylcysteine (NAC) is guided by plotting a timed plasma paracetamol concentration on established nomograms. Guidelines in the UK differ from those in the U.S.

Safety and clinical outcome of thrombolysis in ischaemic stroke using a perfusion CT mismatch between 3 and 6 hours.

Objective: It may be possible to thrombolyse ischaemic stroke (IS) patients up to 6 h by using penumbral imaging. We investigated whether a perfusion CT (CTP) mismatch can help to select patients for thrombolysis up to 6 h.

Methods: A cohort of 254 thrombolysed IS patients was studied.

How common are palliative care needs among older people who die in the emergency department?

Objective: To determine the prevalence and nature of palliative care needs in people aged 65 years or more (65+) who die in emergency departments (EDs).

Methods: This was a retrospective analysis of routine hospital data from two EDs in South London. Patients aged 65+ living in the hospitals' catchment area who died in the ED during a 1 year period (2006-2007) were included.

How common are palliative care needs among older people who die in the emergency department?

Objective: To determine the prevalence and nature of palliative care needs in people aged 65 years or more (65+) who die in emergency departments (EDs).

Methods: This was a retrospective analysis of routine hospital data from two EDs in South London. Patients aged 65+ living in the hospitals' catchment area who died in the ED during a 1 year period (2006-2007) were included.

An unusual case of stroke in a young patient.

The patent foramen ovale (PFO) has been increasingly implicated in the aetiology of stroke, particularly in young patients with no other identifiable cause (cryptogenic stroke). A case of Parinaud's syndrome secondary to thromboembolism from a PFO is reported here.