General practitioners generate many clinical questions during consultations. However, when they seek answers to these queries they tend to rely on colleagues and "desk top" references rather than searching the literature themselves. [1][2][3] ATTRACT was created in 1997 to provide rapid, evidence based summaries to clinical queries. All general practitioners in Gwent were invited to send their clinical queries to ATTRACT. For each query an information manager (JB) undertook a rapid search of the literature. The information found was appraised, summarised onto one side of A4 paper, and faxed to the requestor within six hours (see appendix on the BMJ's website for more details on the search, appraisal, and summary process). Examples of the questions received include "Do decongestants help in people with eustachian tube dysfunction?" and "What are the risks of flying while pregnant?" (see BMJ's website for list of most popular questions). We report here an initial evaluation of this service. Participants, methods, and resultsWe developed a brief anonymised questionnaire to seek doctors' views on the usefulness of ATTRACT. We sent this to the first 15 general practitioners to use the service and, one year after the initial survey, to the general practitioners who had asked the 35 most recent questions. In addition, we analysed the clinical queries received during that period (1 January 1997 to 31 January 1998).Forty two (84%) of the 50 general practitioners replied. Of these, 29 (69%) rated the service "very useful" and 13 (31%) rated it "useful." All the respondents rated the service as "very quick" or "quick," and all reported that they would use it again. For the 40 doctors who replied to the question about the effect of the supplied information, nine clinicians were already practising in line with the evidence supplied, 24 changed their practice as a result of the information, six did not change practice because of the weakness of the presented evidence, and the remaining one asked a question about prognosis so that change in practice was not relevant.Of the 193 questions received by ATTRACT in 13 months, 124 (64%) related to therapeutic issues and 23 (12%) related to harm, the next most prevalent category (figure). CommentOur study shows that Gwent general practitioners use and value the ATTRACT service. Although our assessment is based on a small number of users, it merits reporting because of the strength of the opinions expressed and our clear impression that fast answers to clinical questions actually change practice. This study is the first to evaluate a fast, evidence based query answering service for doctors in the NHS, and our results support McColl et al's conclusion that doctors want summaries of evidence rather than the skills to produce them themselves. 4 Our results also confirm Smith's and Ely et al's reports that most clinical queries relate to therapeutic issues. The reported changes in practice are encouraging. This is probably because, instead of "pushing" information towards clinicians in th...

Background and Purpose: Conditions associated with frailty are common in people experiencing stroke and may explain differences in outcomes. We assessed associations between a published, generic frailty risk score, derived from administrative data, and patient outcomes following stroke/transient ischemic attack; and its accuracy for stroke in predicting mortality compared with other measures of clinical status using coded data. Methods: Patient-level data from the Australian Stroke Clinical Registry (2009–2013) were linked with hospital admissions data. We used International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes with a 5-year look-back period to calculate the Hospital Frailty Risk Score (termed Frailty Score hereafter) and summarized results into 4 groups: no-risk (0), low-risk (1–5), intermediate-risk (5–15), and high-risk (>15). Multilevel models, accounting for hospital clustering, were used to assess associations between the Frailty Score and outcomes, including mortality (Cox regression) and readmissions up to 90 days, prolonged acute length of stay (>20 days; logistic regression), and health-related quality of life at 90 to 180 days (quantile regression). The performance of the Frailty Score was then compared with the Charlson and Elixhauser Indices using multiple tests (eg, C statistics) for predicting 30-day mortality. Models were adjusted for covariates including sociodemographics and stroke-related factors. Results: Among 15 468 adult patients, 15% died ≤90 days. The frailty scores were 9% no risk; 23% low, 45% intermediate, and 22% high. A 1-point increase in frailty (continuous variable) was associated with greater length of stay (OR adjusted , 1.05 [95% CI, 1.04 to 1.06), 90-day mortality (HR adjusted , 1.04 [95% CI, 1.03 to 1.05]), readmissions (OR adjusted , 1.02 [95% CI, 1.02 to 1.03]; and worse health-related quality of life (median difference, −0.010 [95% CI −0.012 to −0.010]). Adjusting for the Frailty Score provided a slightly better explanation of 30-day mortality (eg, larger C statistics) compared with other indices. Conclusions: Greater frailty was associated with worse outcomes following stroke/transient ischemic attack. The Frailty Score provides equivalent precision compared with the Charlson and Elixhauser indices for assessing risk-adjusted outcomes following stroke/transient ischemic attack.

Background Frequent practice of functional movements after stroke may optimise motor recovery; however, it is challenging for patients to remember to integrate an impaired limb into daily activities. We report the activity responses of stroke patients receiving a vibrating alert delivered by a tri-axial accelerometer wristband to prompt movement of the impaired arm if hourly activity levels fell. Methods Adults with upper limb impairment ≤28 days post-stroke wore the device for four weeks. Therapists and patients reviewed movement activity data twice weekly to agree ongoing rehabilitation activities and programme the wristband with a personalised prompt threshold (median baseline activity + 5%, 25% or 50%). Results: S even patients completed the programme (five males; mean ± standard deviation (age) 64 ± 5 years; days post-stroke 13 ± 7; baseline/four-week Action Research Arm Test median (Interquartile range (IQR)) 39 (8, 44)/56 (11, 57)). Wristbands were worn for 89% of programme duration. A total of 1,288 prompts were delivered, with a median of four (IQR 3,7) prompts per patient per day. Mean activity increases following a prompt ranged from 11% to 29%. Conclusions Feedback delivered by a programmable accelerometer increased impaired arm activity. Improvements are required in device reliability before conducting a pragmatic clinical trial to examine the impact upon recovery.

Flash-boiling of sprays may occur when a superheated liquid is discharged into an ambient environment with lower pressure than its saturation pressure. Such conditions normally exist in direct-injection spark-ignition engines operating at low incylinder pressures and/or high fuel temperatures. The addition of novel high volatile additives/fuels may also promote flashboiling. Fuel flashing plays a significant role in mixture formation by promoting faster breakup and higher fuel evaporation rates compared to non-flashing conditions. Therefore, fundamental understanding of the characteristics of flashing sprays is necessary for the development of more efficient mixture formation. The present computational work focuses on modelling flash-boiling of n-Pentane and isoOctane sprays using a Lagrangian particle tracking technique. First an evaporation model for superheated droplets is implemented within the computational framework of STAR-CD, along with a full set of temperature dependent fuel properties. Then the computational tool is used to model the injection of flashing sprays through a six-hole asymmetric injector. The computational results are validated against optical experimental data obtained previously with the same injector by high-speed imaging techniques. The effects of ambient pressure (0.5 and 1.0 bar) and fuel temperature (20-180° C) on the non-flashing and flashing characteristics are examined. Effects of initial droplet size and break-up submodels are also investigated. The computational methodology is able to reproduce important physical characteristics of flashboiling sprays like the onset and extent of spray collapse. Based on the current observations, further improvements to the mathematical methodology used for the flash-boiling model are proposed.

Aims -Paramedics play a crucial role in identifying patients with suspected stroke and transporting them to appropriate acute care. Between 25% and 50% of suspected stroke patients are later diagnosed with a condition other than stroke known as a 'stroke mimic'. If stroke mimics could be identified in the pre-hospital setting, unnecessary admissions to stroke units could potentially be avoided. This survey describes UK paramedics' stroke training and practice, their knowledge about stroke mimic conditions and their thoughts about pre-hospital identification of these patients.Methods -An online survey invitation was circulated to members within the UK College of Paramedics and promoted through social media (8 September 2016 and 23 October 2016). Topics included: stroke training; assessment of patients with suspected stroke; local practice; and knowledge about and identification of stroke mimics.