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Background: Massive hemorrhage protocols (MHPs) streamline the complex logistics required for prompt care of the bleeding patient, but their uptake has been variable and few regions have a system to measure outcomes from these events. Aim Statement: We aim to implement a standardized MHP with uniform quality improvement (QI) metrics to increase uptake of evidence-based MHPs across 150-hospitals in Ontario between 2017 and 2021. Measures & Design: We performed ongoing PDSA cycles; 1) stakeholder analysis by surveying the Ontario Regional Blood Coordinating Network (ORBCoN), 2) problem characterization and Ishikawa analysis for key QI metrics based on areas of MHP variability in 150 Ontario hospitals using a web-based survey, 3) creation of a consensus MHP via a modified Delphi process, 4) problem characterization at ORBCoN for the design of a freely available toolkit for provincial implementation by expert working groups, 5) design of 8 key QI metrics by a modified Delphi process, and 6) identification of process measures for QI data collection by implementation metrics. Evaluation/Results: PDSA1-2; 150-hospitals were surveyed. 33% of hospitals lacked MHPs, mostly in smaller sites. Major areas for QI were related to activation criteria, hemostatic agents, protocolized hypothermia management, variable MHP naming, QI metrics and serial blood work requirements. PDSA3; 3 Delphi rounds were held to reach 100% expert consensus for 42 statements and 8 CQI metrics. Major areas for modification were protocol name, laboratory resuscitation targets, cooler configurations, and role of factor VIIa. PDSA4; adaptable toolkit is under development by the steering committee and expert working groups. Implementation is scheduled for Spring 2020. PDSA5; the 8 CQI metrics are: TXA administration < 1 h, RBC transfusion < 15 min, call to transfer for definitive care < 60 min, temp >35°C at end of protocol, Hgb kept between 60-110g/L, transition to group-specific RBC by 90 min, appropriate activation defined by ≥6 units RBC in the first 24 hours, and any blood component wastage. Discussion/Impact: MHP uptake, content, and tracking is variable. A standardized MHP that is adaptable to diverse settings decreases complexity, improves use of evidence-based practices, and provides a platform for continuous QI. PDSA6 will occur after implementation; we will complete an implementation survey, and design a pilot and feasibility study for prospective tracking of patient outcomes using existing prospectively collected inter-hospital and provincial databases.

This handbook offers an important and timely contribution to the interdisciplinary field of Olympic studies. For the first time a close look into specific issues of the Paralympics is co-hosted in the same volume with the Olympics. It brings together a complete analysis of current and future economic, commercial, socio-political, cultural and governance challenges facing both the Olympic and Paralympic Games, their athletes and institutions. The book presents new research and broad surveys exploring pressing debates, challenges and possible solutions surrounding the modern Olympic and Paralympic Games, across diverse socioeconomic and political contexts. Featuring chapters written by leading scholars, athletes and administrators from a range of disciplines and backgrounds, the handbook is divided into four main areas: athletes, business, governance, socio-cultural and political issues within the Olympic and Paralympic Games. Examining key themes, theories and new emerging issues within the field, the book offers expert insights into every major topic related to the Olympic and Paralympic Games, including doping, integrity, athletes’ rights, culture, nationality, sponsorship, branding, governance, sports policy and law, marketing, social media, technology, e-sports, politics, ethics, international relations, legacy and impact. The only up-to-date handbook to reflect the true breadth and depth of this international field of research, the Routledge Handbook of the Olympic and Paralympic Games is a landmark publication for all students and scholars of sport studies, as well as those working in sport business, media, event management and administration, economics, marketing, management, politics, Olympic studies and cultural studies. It is also an important resource for sport management practitioners and sports officials.

Streptococcus pneumoniae is an opportunistic Gram-positive pathogen that can cause invasive disease. Recent studies have shown that S. pneumoniae is able to invade the myocardium and kill cardiomyocytes, with one-in-five adults hospitalized for pneumococcal pneumonia having a pneumonia-associated adverse cardiac event. Furthermore, clinical reports have shown up to a 10-year increased risk of adverse cardiac events in patients formerly hospitalized for pneumococcal bacteremia. In this study, we investigated the ability of nine S. pneumoniae clinical isolates, representing eight unique serotypes, to cause cardiac damage in a mouse model of invasive disease. Following intraperitoneal challenge of C57BL/6 mice, four of these strains (D39, WU2, TIGR4, and 6A-10) caused high-grade bacteremia, while CDC7F:2617-97 and AMQ16 caused mid- and low-grade bacteremia, respectively. Three strains did not cause any discernible disease. Of note, only the strains capable of high-grade bacteremia caused cardiac damage, as inferred by serum levels of cardiac troponin-I. This link between bacteremia and heart damage was further corroborated by Hematoxylin & Eosin and Trichrome staining which showed cardiac cytotoxicity only in D39, WU2, TIGR4, and 6A-10 infected mice. Finally, hearts infected with these strains showed varying histopathological characteristics, such as differential lesion formation and myocytolysis, suggesting that the mechanism of heart damage varied between strains.

Abstract Free play is essential for children’s development and for their physical, mental, and social health. Opportunities to engage in outdoor free play—and risky play in particular—have declined significantly in recent years, in part because safety measures have sought to prevent all play-related injuries rather than focusing on serious and fatal injuries. Risky play is defined by thrilling and exciting forms of free play that involve uncertainty of outcome and a possibility of physical injury. Proponents of risky play differentiate “risk” from “hazard” and seek to reframe perceived risk as an opportunity for situational evaluation and personal development. This statement weighs the burden of play-related injuries alongside the evidence in favour of risky play, including its benefits, risks, and nuances, which can vary depending on a child’s developmental stage, ability, and social and medical context. Approaches are offered to promote open, constructive discussions with families and organizations. Paediatricians are encouraged to think of outdoor risky play as one way to help prevent and manage common health problems such as obesity, anxiety, and behavioural issues.

GSK3532795 (formerly BMS955176) is a second-generation maturation inhibitor (MI) that progressed through a Phase 2b study for treatment of HIV-1 infection. Resistance development to GSK3532795 was evaluated through in vitro methods and was correlated with information obtained in a Phase 2a proof-of-concept study in HIV-1 infected participants. Both low and high concentrations of GSK3532795 were used for selections in vitro, and reduced susceptibility to GSK3532795 mapped specifically to amino acids near the capsid/ spacer peptide 1 (SP1) junction, the cleavage of which is blocked by MIs. Two key substitutions, A364V or V362I, were selected, the latter requiring secondary substitutions to reduce susceptibility to GSK3532795. Three main types of secondary substitutions were observed, none of which reduced GSK3532795 susceptibility in isolation. The first type was in the capsid C-terminal domain and downstream SP1 region (including (Gag numbering) R286K, A326T, T332S/N, I333V and V370A/M). The second, was an R41G substitution in viral protease that occurred with V362I. The third was seen in the capsid N-terminal domain, within the cyclophilin A binding domain (V218A/M, H219Q and G221E). H219Q increased viral replication capacity and reduced susceptibility of poorly growing viruses. In the Phase 2a study, a subset of these substitutions was also observed at baseline and some were selected following GSK35323795 treatment in HIV-1-infected participants.

Paddy parboiling in rice industries is an energy-intensive process that requires huge attention for energy conservation, fuel economy, and sustainability. Thus, several research initiatives have been undertaken to adopt a suitable energy conversion system in such industries to improve thermal efficiency and reduce environmental impact. In this study, exergy performance and exergy-based sustainability indicators have been investigated on a reversible bed paddy dryer coupled with a rice husk-fuelled downdraft gasifier. The experiment was conducted at the optimum operating conditions such as an equivalence ratio of 0.2 in the gasifier and a drying air temperature of 80℃ in the dryer. The exergy efficiency of the reversible bed dryer and the gasifier were 65.53% and 70.92% respectively. The lowest exergy efficiency of 35.29% was seen in the combustion chamber since a huge exergy destruction of 2.75 kW occurred. Therefore, the combustion chamber has a high potential improvement of about 1.66 kW. Due to less exergy destruction, the gas cooler and air duct showed high exergy efficiency of 62.36% and 76.2% respectively and the lowest values in exergy-based sustainability indicators. The assessment of environmental and sustainability factors on each component showed that the combustion chamber has a high waste exergy ratio of 0.688, environment effect factor of 1.95, exergy destruction coefficient of 0.69, and exergy sustainability index of 0.51.

Coordinating robotic teams across multiple concurrent search tasks is a critical challenge in search and rescue operations. This work presents a new multi-agent framework designed to manage and optimize search efforts when several missing-person reports occur in parallel. The method extends iso-probability curve-based trajectory planning to the multi-target case and introduces a dynamic task allocation scheme that distributes search agents (e.g., UAVs) across tasks according to evolving probabilities of success. Overlapping search regions are explicitly resolved to eliminate duplicate coverage and to ensure balanced effort among tasks. The framework also extends the behavior-based motion prediction model for missing persons and the non-parametric estimator for iso-probability curves to capture more realistic search conditions. Extensive simulated experiments, with multiple concurrent tasks, demonstrate that the proposed method tangibly improves mean detection times compared with equal-allocation and individual static assignment strategies.

Energy is the important criterion for a decentralized network. By the cooperative physical layer network coding scheme, the requirement of energy transmission can be reduced. This could be implemented using two routing algorithms namely CCSPR and COSPNCR. An algorithm is constructed for reducing power consumption and rate control. In contradiction of the conventional power aware algorithms, an efficient power aware routing (EPAR) method is proposed which distinguishes the capability of nodes by its residual battery power, and through the expected energy that spent in reliably data packets forwarding on a specific link. To evaluate this, the data routing is performed with high mobility in dynamic environment. By using this algorithm, less cost path can be chosen and data rate can also be controlled. Thus energy consumption can be decreased and hence lifetime of a node can be improved. This approach first identifies the path having high lifetime and through that path, the communication will take place. This work consumes a lesser amount of energy for the routing, thus makes power efficient routing. Hence the throughput is increased and the power consumption is reduced. The conventional shortest path routing method on regular line and the grid line networks attains the gain of energy savings up to 45–75% correspondingly. By using EPAR algorithm, the energy consumption rate is minimized, so the network life time and the performance are improved. The energy consumption rate can be decreased to 80% by using EPAR approach in Mobile Ad hoc Networks.