bluuebunny/crossref_metadata_2025 huggingface dataset:
Lowermost mantle thermal conductivity constrained from experimental data and tomographic models
Authors: Deschamps Frédéric , Hsieh Wen-Pin
Published: May 2019

Heat transfer through Earth's mantle is sensitive to mantle thermal conductivity and its variations. Thermal conductivities of lower mantle minerals, bridgmanite (Bm) and ferropericlase (Fp), depend on pressure, temperature, and composition. Because temperature and composition are expected to strongly vary in the deep mantle, thermal conductivity may also vary laterally. Here, we compile self-consistent data on lattice thermal conductivities of Bm and Fp at high pressure to model lower mantle thermal conductivity and map its possible lateral variations. Importantly, our data set allows us to quantify the influence of iron content on mantle conductivity. At the bottom of the mantle, the thermal conductivity for a pyrolitic mantle calculated along an adiabat with potential temperature 2000 K is equal 8.6 W m–1 K–1. Using 3-D thermochemical models from probabilistic tomography, which include variations in temperature, iron content, and bridgmanite fraction, we then calculate possible maps of conductivity anomalies at the bottom of the mantle. In regions known as low shear-wave velocity provinces, thermal conductivity is reduced by up to 26 per cent compared to average mantle, which may impact mantle dynamics in these regions. A simple analysis of threshold and saturation effects related to the iron content shows that our estimates of thermal conductivity may be considered as upper bounds. Quantifying these effects more precisely however requires additional mineral physics measurements. Finally, we estimate variations in core–mantle boundary heat flux, and find that that these variations are dominated by lateral temperature anomalies and are only partly affected by changes in thermal conductivity.
Emotions, Social Practices and the Changing Composition of Class, Race and Gender in the National Health Service, 1970–79: ‘Lively Discussion Ensued’
Authors: Saunders Jack
Published: May 2019

During the 1970s, Britain’s trade unions expanded into new areas of the economy, making considerable progress among the low-paid workers of the expanding welfare state. The Confederation of Health Service Employees (COHSE) and the National Union of Public Employees (NUPE) both made huge strides recruiting women and particularly women of colour in the National Health Service, as the laundry, cleaning, catering and portering services of Britain’s hospitals became union strongholds. This article questions why the increased weight of feminized service work is so marginal in our idea of 1970s workplace activism and why it features so rarely in histories of British trade unionism, despite being one of the movement’s most significant growth areas. Drawing on NUPE’s photographic archive, I argue that by looking at the changing character of worker-activist visual culture in this period we can reinsert women and women of colour back into those histories. This is followed by a close reading of trade-union branch minutes which explores how women re-ordered the gendered hierarchy of both their male-dominated union and their hospital between 1970 and 1979, exercising new-found agency within the highly paternalist setting of the NHS.
Economic Injury Level for Bermudagrass Stem Maggot (Diptera: Muscidae) in Bermudagrass Forage Production in Texas
Authors: Knutson Allen E , Mitchell Forrest
Published: May 2019

The bermudagrass stem maggot, Atherigona reversura Villeneuve (Diptera: Muscidae), was first reported damaging bermudagrass Cynodon dactylon (L.) Pers grown for forage in 2010 in the southeastern United States. Injury results from individual larvae feeding internally on the vascular tissue just above the terminal node of the grass stem. Injury slows plant growth and reduces forage accumulation. To address the need for economic guidelines to manage this new pest, the relationship between the percent of stems damaged by bermudagrass stem maggot and forage yield was measured in commercial bermudagrass hay fields in northcentral Texas. Yield loss was estimated to be 9.97 kg/ha (8.90 lbs /acre) for each percentage of stems with bermudagrass stem maggot damage. This relationship was used to calculate economic injury levels for a range of hay market values and control costs. The impact of stem damage on protein content, energy, and digestibility of bermudagrass hay was also investigated. Although there was a significant trend for declining forage quality with increasing stem damage, stem damage explained very little of the model’s variability.
Understanding the Profile of Cancer-Related Cognitive Impairments: A Critique of Meta-Analyses
Authors: Horowitz Todd S , Treviño Melissa , Gooch Ingrid M , Duffy Korrina A
Published: May 2019

A large body of evidence indicates that cancer survivors who have undergone chemotherapy have cognitive impairments. Substantial disagreement exists regarding which cognitive domains are impaired in this population. We suggest that is in part due to inconsistency in how neuropsychological tests are assigned to cognitive domains. The purpose of this paper is to critically analyze the meta-analytic literature on cancer-related cognitive impairments (CRCI) to quantify this inconsistency. We identified all neuropsychological tests reported in seven meta-analyses of the CRCI literature. Although effect sizes were generally negative (indicating impairment), every domain was declared to be impaired in at least one meta-analysis and unimpaired in at least one other meta-analysis. We plotted summary effect sizes from all the meta-analyses and quantified disagreement by computing the observed and ideal distributions of the one-way χ2 statistic. The actual χ2 distributions were noticeably more peaked and shifted to the left than the ideal distributions, indicating substantial disagreement among the meta-analyses in how neuropsychological tests were categorized to domains. A better understanding of the profile of impairments in CRCI is essential for developing effective remediation methods. To accomplish this goal, the research field needs to promote better agreement on how to measure specific cognitive functions.
A Network Meta-Analysis of Surgical Treatment in Patients With Early Breast Cancer
Authors: Gui Yu , Liu Xunzhou , Chen Xianchun , Yang Xi , Li Shichao , Pan Qingwen , Luo Xiangdong , Chen Li
Published: May 2019

Background

In early breast cancer treatment, the preferred surgical regimen remains a topic of controversy, and conventional pairwise meta-analysis cannot provide a hierarchy based on clinical trial evidence. Therefore, a network meta-analysis was performed both for direct and indirect comparisons and to assess the survival outcomes of surgical regimens.

Methods

Randomized clinical trials comparing different surgical regimens for the treatment of early breast cancer were identified. Overall survival (OS) and disease-free-survival (DFS) were analyzed using random-effects network meta-analysis on the hazard ratio (HR) scale and calculated as combined HRs and 95% confidence intervals (CIs). All statistical tests were two-sided.

Results

The network meta-analysis compared 11 different surgical regimens that consisted of 13 and 17 direct comparisons between strategies for OS (34 trials; n = 23 587 patients) and DFS (32 trials; n = 22 552 patients), respectively. The values of surface under the cumulative ranking for OS and DFS after mastectomy (M)+radiotherapy (RT) were observed to be the largest. Breast-conserving surgery (BCS)+axillary node sampling+RT almost achieved the threshold for inferiority compared with the other surgical treatment arms and was statistically significantly associated with worse OS (HR = 0.51, 95% CI = 0.24 to 0.94; HR = 0.48, 95% CI = 0.22 to 0.92; HR = 0.51, 95% CI = 0.23 to 0.96). No statistically significant difference between BCS+sentinel lymph node biopsy (SLNB)+RT vs BCS+SLNB+intraoperative RT was observed in carrying out network meta-analysis (HR = 0.95, 95% CI = 0.64 to 1.36).

Conclusions

M+RT is safer than other surgical regimens for the treatment of early breast cancer patients because of the favorable balance between the survival outcomes. Early breast cancer patients who receive BCS should be given SLNB and not axillary node sampling. Intraoperative RT is no better than postoperative RT in patients who receive SLNB.
Article 3—Answer and Counterclaim
Authors: Gusy Martin F , Hosking James M
Published: May 2019

This chapter focuses on Article 3 of the ICDR Rules, which addresses the Respondent’s Answer to the Claimant’s Notice of Arbitration. In filing the Answer, the Respondent may introduce counterclaims and set-offs. The Respondent is not required to provide a full defense in the Answer but may do so if it so wishes. In practice, as a responsive pleading, the contents of the Answer will depend on the facts and arguments presented by the Claimant in the Notice of Arbitration. The Respondent is required to ‘respond to the Notice of Arbitration’ and must submit its statement to the Claimant and any other parties, as well as to the Administrator. In a typical case, the Respondent will request that the claims be dismissed or the relief denied, and that the Claimant be ordered to bear the costs of arbitration, including the Respondent’s legal costs.
Article 12—Appointment of Arbitrators
Authors: Gusy Martin F , Hosking James M
Published: May 2019

This chapter addresses Article 12 of the ICDR Rules, which sets out the default procedures for selecting the arbitrator(s). It is a hallmark of arbitration that the parties can agree on the process of selection and, in many cases, choose the specific arbitrators best suited to resolving the dispute. This differs from national courts systems, within which existing judges—permanently installed—hear randomly assigned cases. In arbitration, the parties compose the tribunal according to their agreement, the particular arbitration rules chosen, and the applicable law. The parties’ agreement on the procedure to constitute the tribunal is often contained in the arbitration agreement. If not contained therein, the ICDR Rules stipulate important procedural safeguards and substantive mechanisms for the appointment of their arbitrators in the event that the parties cannot agree on the process.
Article 16—Party Representation
Authors: Gusy Martin F , Hosking James M
Published: May 2019

This chapter examines Article 16 of the ICDR Rules. Although some jurisdictions have traditionally placed restrictions on who can appear on behalf of the parties in an arbitration proceeding conducted on its territory, there is a clear trend in international arbitration towards allowing the parties freely to choose a representative as they deem appropriate, whether that be a local lawyer or foreign counsel, or someone not qualified as a lawyer at all. Article 16 does not provide express guidance as to who may or may not represent a party in arbitration. However, it does provide that each party has the right to representation and, given the liberal approach underlying modern doctrine and the ICDR Rules, this provision should be interpreted to provide each party with the freedom to select a representative of its choosing, whether that is a lawyer or a non-lawyer.
Article 21— Exchange of Information
Authors: Gusy Martin F , Hosking James M
Published: May 2019

This chapter addresses Article 21, which effectively incorporates into the ICDR Rules the principles outlined in the ICDR Guidelines for Arbitrators Concerning Exchanges of Information (ICDR Guidelines). Article 21 establishes guiding principles for a tribunal to carry out its mandate to manage the exchange of information in a cost-effective and economic manner; but this mandate should take into account wide-ranging differences in international practice and balancing the goals of efficiency and cost-effectiveness against the need for parties to be able to properly present their case and to be heard. It is a welcomed addition to the ICDR Rules, considering that tribunals and counsel often may have divergent views of disclosure that are typically informed by their respective home jurisdictions. Indeed, Article 21 provide a great deal of discretion for tribunals to shape the procedure to the needs of a particular matter.
Article 25—Tribunal-Appointed Expert
Authors: Gusy Martin F , Hosking James M
Published: May 2019

This chapter examines Article 25 of the ICDR Rules, which addresses tribunal-appointed—as opposed to party-appointed—experts. Although tribunal-appointed experts are more common in the civil law tradition, the practice is not infrequently seen in general international arbitration. Article 25 of the ICDR Rules was only lightly amended in the 2014 revisions. While it provides the framework for empowering the tribunal to appoint such experts and some basic rules, Article 25 leaves to the tribunal’s discretion other practical issues, such as the method of selecting the expert, qualifications required of the expert, arrangements for payment of the expert’s fees and expenses, and negotiation of the expert’s terms of engagement. In this respect, a tribunal may well turn to internationally accepted procedural guidelines on using tribunal-appointed experts.
Article 26—Default
Authors: Gusy Martin F , Hosking James M
Published: May 2019

This chapter focuses on Article 26 of the ICDR Rules. Article 26 addresses the situation in which one party to a proceeding ‘defaults’, whether by failing to file a timely Answer, appear at a hearing, produce evidence, or otherwise contravene an order of the tribunal. Unsurprisingly, such a default occurs only where the errant party has been duly notified of the steps required and, in some cases, where the party fails to show sufficient cause to excuse its failure. In such circumstances, the tribunal may choose to proceed with the arbitration regardless of such failure. In contrast to litigation in many jurisdictions, this approach is preferred to issuing any sort of ‘summary judgment’ or ‘default judgment’. In other words, the claimant must still make out his or her case and the arbitrators must still review the legal and evidential record before making a final determination.
Article 33—Interpretation and Correction of the Award
Authors: Gusy Martin F , Hosking James M
Published: May 2019

This chapter examines Article 33 of the ICDR Rules. As with most other arbitral rules, the ICDR Rules provide a limited opportunity for interpretation or correction of an award and for an additional award to be made on claims presented, but not included within the award. Article 33 provides a strict deadline for any such interpretations, corrections, or additional awards. The rationale behind such a limited review and on such a strict timeline is the concern not to interfere with the parties’ agreement for a fast and final resolution of their dispute. For this reason, arbitrators, courts, and commentators are quick to emphasize the very limited scope of an application under Article 33 or its analogous provisions in other rules. Given the likelihood, however, of at least one party feeling aggrieved by the tribunal’s decision, Article 33 can also be subject to creative attempts to reargue a particular legal, evidential, or procedural point.
Article 37—Confidentiality
Authors: Gusy Martin F , Hosking James M
Published: May 2019

This chapter addresses Article 37 of the ICDR Rules. The extent to which arbitral proceedings are, or should be, confidential is a topic of recurring debate within the international arbitration community. Article 37—with its focus on imposing a duty of confidentiality on the arbitrators and the institution—represents an innovation by the ICDR that has since been partially adopted by some other institutions. The 2014 revisions to the ICDR Rules added a new provision to this rule that makes clear that issues of confidentiality are otherwise left to the agreement of the parties and any procedural order entered by the tribunal. The revision serves as a reminder to counsel and the tribunal that confidentiality concerns may best be addressed by way of a carefully tailored order within the proceeding itself.
Article E-10—The Award Under the Expedited Procedures
Authors: Gusy Martin F , Hosking James M
Published: May 2019

This concluding chapter discusses Article E-10 of the ICDR Rules, which provides some basic requirements for an award made under the Expedited Procedures. Unlike its analogous counterpart in Article 30 of the main ICDR Rules, Article E-10’s direction is more limited. While Article 30 also provides instruction on the form, content, and confidentiality of the award, Article E-10 only provides specific direction that the award should be in writing, that it is final and binding on the parties, and that it must be rendered within a 30-day time period. Consequently, as with other provisions of the Expedited Procedures and as is provided for in Article E-1, arbitrators and the parties should refer to the provisions of the main ICDR Rules to supplement Article E-10.
A logic of efficient and optimal designs
Authors: Primiero Giuseppe
Published: May 2019

Logics of design have been formulated until recently to offer systematic treatments of the way systems express the relation between resources, processes and their outputs. We present a logic of systems design which explicitly formalizes this relation as a decidable checking problem on resource access and define computable efficiency and optimality properties.
RNA polymerase II-independent recruitment of SPT6L at transcription start sites in Arabidopsis
Authors: Chen Chen , Shu Jie , Li Chenlong , Thapa Raj K , Nguyen Vi , Yu Kangfu , Yuan Ze-Chun , Kohalmi Susanne E , Liu Jun , Marsolais Frédéric , Huang Shangzhi , Cui Yuhai
Published: May 2019

SPT6 is a conserved elongation factor that is associated with phosphorylated RNA polymerase II (RNAPII) during transcription. Recent transcriptome analysis in yeast mutants revealed its potential role in the control of transcription initiation at genic promoters. However, the mechanism by which this is achieved and how this is linked to elongation remains to be elucidated. Here, we present the genome-wide occupancy of Arabidopsis SPT6-like (SPT6L) and demonstrate its conserved role in facilitating RNAPII occupancy across transcribed genes. We also further demonstrate that SPT6L enrichment is unexpectedly shifted, from gene body to transcription start site (TSS), when its association with RNAPII is disrupted. Protein domains, required for proper function and enrichment of SPT6L on chromatin, are subsequently identified. Finally, our results suggest that recruitment of SPT6L at TSS is indispensable for its spreading along the gene body during transcription. These findings provide new insights into the mechanisms underlying SPT6L recruitment in transcription and shed light on the coordination between transcription initiation and elongation.
Restriction of AID activity and somatic hypermutation by PARP-1
Authors: Tepper Sandra , Mortusewicz Oliver , Członka Ewelina , Bello Amanda , Schmidt Angelika , Jeschke Julia , Fischbach Arthur , Pfeil Ines , Petersen-Mahrt Svend K , Mangerich Aswin , Helleday Thomas , Leonhardt Heinrich , Jungnickel Berit
Published: May 2019

Affinity maturation of the humoral immune response depends on somatic hypermutation (SHM) of immunoglobulin (Ig) genes, which is initiated by targeted lesion introduction by activation-induced deaminase (AID), followed by error-prone DNA repair. Stringent regulation of this process is essential to prevent genetic instability, but no negative feedback control has been identified to date. Here we show that poly(ADP-ribose) polymerase-1 (PARP-1) is a key factor restricting AID activity during somatic hypermutation. Poly(ADP-ribose) (PAR) chains formed at DNA breaks trigger AID-PAR association, thus preventing excessive DNA damage induction at sites of AID action. Accordingly, AID activity and somatic hypermutation at the Ig variable region is decreased by PARP-1 activity. In addition, PARP-1 regulates DNA lesion processing by affecting strand biased A:T mutagenesis. Our study establishes a novel function of the ancestral genome maintenance factor PARP-1 as a critical local feedback regulator of both AID activity and DNA repair during Ig gene diversification.
Treatment Options for Hydrocephalus Following Foramen Magnum Decompression for Chiari I Malformation: A Multicenter Study
Authors: Bartoli Andrea , Soleman Jehuda , Berger Assaf , Wisoff Jeffrey H , Hidalgo Eveline Teresa , Mangano Francesco T , Keating Robert F , Thomale Ulrich W , Boop Frederick , Roth Jonathan , Constantini Shlomi
Published: May 2019

BACKGROUND

New-onset hydrocephalus following foramen magnum decompression (FMD) for Chiari I malformation (CM-I) is rare; its natural history and pathophysiology are poorly understood.

OBJECTIVE

To describe a series of patients who developed hydrocephalus following FMD for CM-I, provide possible explanations of this phenomenon, and outline treatment options.

METHODS

Out of patients undergoing FMD for CM-I from 6 different tertiary centers, we evaluated patients presenting with new-onset hydrocephalus following FMD. The retrospectively collected data included demographics, clinical, and radiological findings of the CM-I and hydrocephalus patients. Time from FMD and hydrocephalus onset, treatment, and surgical techniques were assessed.

RESULTS

Of 549 patients who underwent FMD for CM-I, 28 (5.1%) subsequently developed hydrocephalus (18 females, 10 males), with a mean age of 11.7 ± 11.9 yr (range 6 mo to 52 yr). Hydrocephalus occurred on average 2.2 ± 2.6 mo after FMD (range 1 wk to 8 mo). Four patients did not have a violation of the arachnoid during the FMD surgery. Main presenting symptoms of hydrocephalus were headaches (17, 41%), vomiting (10, 24.4%), and cerebrospinal fluid (CSF) leak or pseudomeningocele (7, 17%).

Overall, 23 patients (82.1%) underwent CSF shunting, 1 patient (3.5%) had an endoscopic third ventriculostomy, 3 patients (10.7%) temporary CSF diversion only, and 1 patient (3.5%) was treated with acetazolamide.

CONCLUSION

Hydrocephalus following FMD for CM-I is uncommon, but important. Based on our series and literature review, its incidence is about 5% to 7% and most likely will require further surgery. Shunting appears to be the favored treatment option.
The effects of fiscal stimulus: firm-level evidence from selective temporary consumption tax cuts
Authors: Misch Florian , Seymen Atılım
Published: May 2019

The paper investigates the effects of temporary consumption tax cuts for selected durables in Turkey in 2009 using firm-level data. Our empirical strategy exploits variation in firm exposure to the tax cuts and at the same time controls for unobserved industry- and region-specific shocks to address potential endogeneity. Using data on the change of sales of firms that benefited from this measure and of those that did not over different periods, we find positive and robust effects of consumption tax cuts on the change of firm sales. In line with theoretical predictions, we also find a reversal of these effects following the expiration of the tax cuts.
A Truth-Seeking Justification for Press Freedom?†
Authors: Stephenson Randall
Published: May 2019

The relationship between press freedom and representative democracy has captured the interest of philosophers and constitutional law scholars for centuries. John Charney’s The Illusion of the Free Press argues that the truth-seeking justification for expressive freedoms can alone explain the continuing importance of a free press to contemporary democracies. This review essay examines two rebuttals to this argument. First, adopting a more modern ‘process-relational’ philosophy reveals that Charney’s epistemological ‘illusion’ is itself based on misconceptions. Secondly, the author’s incomplete use of democratic theory precludes a more convincing explanation based on marginalised notions of horizontal accountability and the checking function of the press.
Surgical Resection of Cervical Meningioma: 3-Dimensional Operative Video
Authors: Sorenson Thomas J , Lanzino Giuseppe , Rangel Castilla Leonardo
Published: May 2019

Spinal cord meningiomas are rare, benign lesions typically found at the cervical or thoracic spinal region. They can cause symptoms through compression of the spinal cord and nerve roots. These tumors often have a challenging surgical course due to their location in relation to spinal cord and nerve rootlets. We present a 33-yr-old female who presented with cervical radicular and myelopathy symptoms. MRI of the cervical spinal demonstrated an anterolateral, 3 cm intradural, extrameduallary tumor causing significant cord compression at C6-7 level. The patient was taken to surgery for cervical laminoplasty and microsurgical tumor removal. The current 3-dimensional video demonstrates the steps involved during the microsurgical resection of the tumor. In order to facilitate spinal cord rotation without compromising blood supply the dentate ligaments at 3 levels (C5-C7) were identified and transected, the anterolateral-situated tumor was separated from the exiting right C6 and C7 nerve rootlet followed by circumferential dissection, and subsequent en bloc resection. No complications were encountered during the procedure; somatosensory and motor evoked potential registration remained intact. The patient recovered well from the procedure and was discharged on postoperative day three with improvement in her presenting symptoms.
Communicating with Slurs
Authors: Rappaport Jesse
Published: May 2019

An adequate linguistic theory of slurs must address three major aspects of their meaning: descriptive, evaluative and expressive. Slurs denote specific groups, they are used to convey speakers’ evaluative attitudes, and some have a very strong emotional impact. In this paper, I argue that a variety of mechanisms are required to account for this range of properties. Semantically, slurs simply denote the groups that they target. Pragmatically, speakers use slurs to show, in the Relevance-Theoretic sense, that they share a negative attitude towards the targeted group. However, this does not yet explain the capacity of certain ‘toxic’ slurs to express strong emotions of the speaker and to elicit a strong emotional reaction in hearers. In order to account for this psychological impact, I posit that, like curse words, slurs undergo distinct neurolinguistic processing that links them directly to emotional centers in the brain.
Strengthening HPV vaccination delivery: findings from a qualitative service evaluation of the adolescent girls’ HPV vaccination programme in England
Authors: Paterson P , Mounier-Jack S , Saliba V , Yarwood J , White J , Ramsay M , Chantler T
Published: May 2019

Background

In 2014, the number of HPV vaccine doses given to adolescent girls as part of the English school-based immunization programme was reduced from three to two. This was based on evidence that a two-dose schedule provides long-lasting protection against HPV infection. In 2015/16 a small decline in HPV vaccination coverage in adolescent girls was noted; from 86.7% for the three-dose schedule in 2013/14 to 85.1% for the two-dose schedule. This evaluation examined whether service-related factors contributed to this decline.

Methods

In May–August 2017, we conducted semi-structured qualitative interviews with 39 participants responsible for commissioning or delivering immunization programmes in six local authorities in the South West, North Central Midlands and South Central Midlands, England.

Results

Effective planning and data management were key for successful service provision of HPV vaccination, as well as close collaboration between commissioners, service providers and data system managers, a team skill mix with experienced staff, pro-active engagement with schools and service providers equipped to respond to parental concerns.

Conclusions

To maintain and improve the high HPV adolescent girls’ vaccine coverage rates achieved in England, in the context of an expanding school-based immunization programme, it is essential to strengthen the organizational capacity of the delivery system.
Policy Change and Partisan Politics: Understanding Family Policy Differentiation in Two Similar Countries
Authors: León Margarita , Pavolini Emmanuele , Miró Joan , Sorrenti Antonino
Published: May 2019

This article looks at how different electoral competition dynamics can result in differentiated party positioning on childcare and family policy. Italy and Spain are compared using a most similar case design. The presence of women in politics, the socioeconomic profiles of the voters of the two main left-wing and right-wing Italian and Spanish parties, and opinions on traditional norms of motherhood explain different policy trajectories and higher incentives for the conservative party in Spain to converge toward the social democratic party in more progressive views of family policy.
Identifying factors associated with successful implementation and uptake of an evidence-based voluntary medical male circumcision program in Zambia: the Spear and Shield 2 Program
Authors: Rodriguez Violeta J , Chahine Antonio , de la Rosa Aileen , Lee Tae Kyoung , Cristofari Nicholas V , Jones Deborah L , Zulu Robert , Chitalu Ndashi , Weiss Stephen M
Published: May 2019

Voluntary medical male circumcision has been shown to provide a 50%–70% reduction in the risk of HIV infection without contributing to behavioral disinhibition of safer sexual practices. This study examined the interim implementation and dissemination data of Spear and Shield 2, an HIV risk-reduction program in Zambia. The purpose of this interim review was to identify contextual challenges to implementation and implement midcourse corrections associated with sustainability of program delivery. Using a mixed-methods design, quantitative evaluations of organizational functioning, barriers to implementation, burnout, and organizational readiness, as well as qualitative data utilizing the Consolidated Framework for Implementation Research (CFIR), were examined to evaluate program implementation. Participants were 184 health care providers from 46 clinics in Zambia. Successful implementation was associated with better community and leader support, and employee readiness and motivation. Quantitative assessments were not related to implementation and provided a limited picture of implementation outcomes. Results suggest that the qualitative data underlying the CFIR constructs provided a nuanced, contextual assessment of implementation, and dissemination outcomes. The CFIR may be valuable in informing the implementation of evidence-based interventions in other parts of Zambia.
Healthcare coverage in the US and Japan
Authors: Ruggles Bernadette Martin , Xiong Amy , Kyle Brittany
Published: May 2019

Understanding different models of healthcare worldwide and examining the benefits and challenges of those systems can inform potential improvements in the US. This article compares healthcare coverage in the US and Japan with respect to legislation, healthcare system models, eligibility of coverage, financial expenditures, health resources, and quality of care.
Maternity Leave in Residency: A Multicenter Study of Determinants and Wellness Outcomes
Authors: Stack Shobha W. , Jagsi Reshma , Biermann J. Sybil , Lundberg Gina P. , Law Karen L. , Milne Caroline K. , Williams Sigrid G. , Burton Tracy C. , Larison Cindy L. , Best Jennifer A.
Published: May 2019

Purpose

To characterize determinants of resident maternity leave and the effect of length of leave on maternal well-being.

Method

In 2017, the authors sent a voluntary, anonymous survey to female residents at 78 programs, in 25 unique specialties, at 6 institutions. Survey items included personal, partner, and child demographics, and logistics of leave, including whether leave was paid or vacation or sick leave was used. Outcomes were maternity leave length; duration of breastfeeding; burnout and postpartum depression screens; perceptions of support; and satisfaction with length of leave, breastfeeding, and childbearing during residency.

Results

Fifty-two percent (804/1,537) of residents responded. Among 16% (126) of respondents who were mothers, 50% (63) had their first child during residency. Seventy-seven maternity leaves were reported (range, 2–40 weeks), with most taking 6 weeks (32% of leaves; 25) and including vacation (81%; 62) or sick leave (64%; 49). Length of leave was associated with institution, use of sick leave or vacation, and amount of paid leave. The most frequently self-reported determinant of leave was the desire not to extend residency training (27%; 59). Training was not extended for 53% (41) of mothers; 9% (7) were unsure. Longer breastfeeding duration and perceptions of logistical support from program administration were associated with longer maternity leaves. Burnout affected approximately 50% (38) of mothers regardless of leave length.

Conclusions

This study illustrates variability in administration of resident maternity leaves. Targets for intervention include policy clarification, improving program support, and consideration of parent wellness upon return to work.
Jump-Starting Faculty Development in Quality Improvement and Patient Safety Education: A Team-Based Approach
Authors: van Schaik Sandrijn M. , Chang Anna , Fogh Shannon , Haehn Melissa , Lyndon Audrey , O’Brien Bridget , O’Sullivan Patricia , Ranji Sumant , Rosenbluth Glenn , Sehgal Niraj , Tabas Jeffrey , Baron Robert B.
Published: May 2019

Problem

Quality improvement (QI) and patient safety (PS) are cornerstones of health care delivery. Accreditation organizations increasingly require that learners engage in QIPS. For many faculty, these are new domains. Additional faculty development is needed for them to teach and mentor trainees. Existing programs, such as the Association of American Medical Colleges Teaching for Quality (Te4Q) program, target individual faculty and thus accommodate only limited participants at a time, which is problematic for institutions that need to train many faculty to support their learners.

Approach

The authors invited diverse stakeholders from across the University of California, San Francisco (UCSF) School of Medicine and related health systems to participate in a team-based adaptation of the Te4Q program. The teams completed 5 projects based on previously identified priority areas to increase local capacity for QIPS teaching: (1) online modules for faculty new to QIPS, (2) a tool kit for graduate medical education programs, (3) a module for medical school clerkship directors, (4) guidelines for faculty to integrate early learners into QI projects, and (5) a “Teach-for-UCSF” certificate program in teaching QIPS.

Outcomes

Thirty-five faculty members participated in the initial Te4Q workshop in January 2015, and by fall 2016, all projects were implemented. These projects led to additional faculty development initiatives and a rapidly expanding number of faculty across campus with expertise in teaching QIPS.

Next Steps

Further collaborations between faculty focused on QIPS in care delivery and those focused on QIPS education to promote QIPS teaching have resulted from these initial projects.
Conceptualizing Medical Humanities Programs in Low-Resource Settings in Africa
Authors: Eichbaum Quentin , Reid Steve , Coly Ayo , Naidu Thirusha , Omaswa Francis
Published: May 2019

The role of the humanities in medical education remains a topic of dynamic debate in medical schools of high-income countries. However, in most low- and middle-income countries, the medical humanities are less topical and rarely even have a place in the curriculum. Reasons for this dearth include inadequate resources to support such programs coupled with misapprehension of the role and significance of the humanities in medical education.

In this article, the authors argue that the humanities have a vital role to play in the low-resource settings of African medical education. They discuss the complexities of the continent’s sociohistorical legacies, in particular the impact of colonization, to provide contexts for conceptualizing humanities programs in African schools. They outline the challenges to developing and implementing such programs in the continent’s underresourced medical schools and present these as four specific conundrums to be addressed. As a general guide, the authors then suggest four nonprescriptive content domains that African medical schools might consider in establishing medical humanities programs.

The goal is to jump-start a crucial and timely discussion that will open the way for the feasible implementation of contextually congruent humanities programs in the continent’s medical schools, leading to the enhanced education, training, and professional development of its graduating physicians.
S-PACK: A Modular and Modifiable, Comprehensive Predeparture Preparation Curriculum for Global Health Experiences
Authors: St Clair Nicole E. , Butteris Sabrina M. , Cobb Carmen , Connolly Emilia , Groothuis Elizabeth , Jones Andrea , Lauden Stephanie , Miller Kathleen , Winter Jameel , Pitt Michael B.
Published: May 2019

Problem

Approximately 25% of trainees participate in a global health elective during their undergraduate or graduate medical education. Increasingly, educators in the United States and international partners are calling for improved predeparture preparation training for global health experiences. Yet, freely available, easily modifiable curricula are rare.

Approach

Educators who created the Simulation Use for Global Away Rotations (SUGAR) curriculum formed a workgroup in September 2017 to develop the SUGAR Pre-Departure Activities Curricular Kit (S-PACK). Using Kern’s 6-step approach to curriculum development, they identified 10 essential domains for global health preparation, developed learning objectives, created interactive activities pertinent to those domains using different education strategies, piloted and refined the curriculum, packaged it for online facilitator training, and disseminated it in March 2018.

Outcomes

The S-PACK curriculum includes 6 interactive, modifiable modules that use a variety of educational strategies to enable educators to comprehensively prepare trainees for global health electives. Modules incorporate simulations, procedural training, small-group case-based discussions, and reflection exercises on topics ranging from providing treatment when resources are limited to mitigating culture shock to considering wellness while away. Each module includes a facilitator training packet, curricular resources, and introduction videos. All are freely available at sugarprep.org.

Next Steps

Since an initial in-person workshop at a national conference, the S-PACK curriculum has been available online. Further evaluation is underway, including developing assessments for educators to measure trainee readiness for global health electives. Piloting the feasibility of regional S-PACK preparation bootcamps to support training programs with limited global health resources is planned.
Remifentanil for Procedural Sedation and Analgesia in Central Venous Catheter Insertion
Authors: Vardon Bounes Fanny , Pichon Xavier , Ducos Guillaume , Ruiz Jean , Samier Caroline , Silva Stein , Sommet Agnès , Fourcade Olivier , Conil Jean-Marie , Minville Vincent
Published: May 2019

Objective:

Central venous catheter (CVC) insertion is a common practice for anesthetists, but this invasive procedure generates anxiety and pain in patients that are often underestimated. We compared target-controlled infusion of remifentanil and local lidocaine infiltration with placebo and local lidocaine infiltration to decrease pain scores during CVC placement.

Materials and Methods:

We included conscious, adult patients without contraindication to remifentanil or lidocaine. We excluded pregnant women, emergency situations, and opioid abuse. Patients requiring CVC were randomly assigned, using computer-generated allocation numbers stored in sealed envelopes, to receive target-controlled infusion of remifentanil or placebo—all patients received local anesthesia with lidocaine. All patients were hospitalized in a recovery room or intensive care unit, monitored, and received 4 L/min of oxygen.

The primary outcome was global pain (Verbal Numeric Rating Pain Scale) during the procedure. Secondary outcomes were pain perceived at every stage of the procedure, anxiety, patient satisfaction, operational ease, and side effects.

Results:

In this double-blind study, we included 90 patients (split into 2 groups of 45 patients). Global pain was significantly reduced in the remifentanil group: 20 of 100 (95% confidence interval, 16-40) versus 50 of 100 (95% confidence interval, 40-60) in the placebo group; P=0.0009. No major adverse events were observed during this study, and there were no significant differences between both groups regarding side effects.

Discussion:

Target-controlled infusion of remifentanil is an effective drug to reduce pain during CVC insertion in association with lidocaine-based local anesthesia, in conscious patients.
Changing practice patterns: flexed versus semi-extended positioning for tibial nailing
Authors: Goodnough L. Henry , Campbell Sean T. , Githens Michael F. , Gardner Michael J. , Bishop Julius A.
Published: May 2019

Background:

Recent studies have demonstrated several benefits to semi-extended leg position for intramedullary nailing (IMN) without increased complications. The purpose of this study was to evaluate how surgeon preference for flexed versus semi-extended positioning has changed over time.

Methods:

We distributed an anonymous online survey to orthopaedic surgeons via the Orthopaedic Trauma Association (OTA) website. We compared surgeon demographics and preferred leg positioning for tibial nailing.

Results:

Twenty-seven percent of surgeons reported substantial experience (>50% of cases) with semi-extended positioning during training, while 49% of surgeons preferred semi-extended nailing in current practice (P<0.001). Surgeons who practiced in the U.S. (P<0.001) or who completed a trauma fellowship (P<0.05) were more likely to have had exposure to the semi-extended positioning during training. Surgeons who practiced in the U.S. (P<0.001), supervised residents (P<0.05) or had completed a trauma fellowship (P<0.01) were significantly more likely to currently prefer the semi-extended positioning. Surgeons in the U.S. (P<0.01), or who supervised residents (P<0.05) were more likely to have changed from the hyper-flexed to semi-extended position. Facilitating reduction in proximal fractures was the most cited reason for switching to the semi-extended position (28%).

Conclusions:

Semi-extended has become the preferred position during intramedullary nailing of tibial fractures among U.S. surgeons, those supervising residents, or those completing a trauma fellowship. Flexed nailing remains the preferred technique for international surgeons. Further investigation of extended nailing techniques is necessary. However, given its preference for the conventional flexed nailing, the international community may benefit from further educational interventions, demonstrating the benefits of extended nailing.
Hip fractures: current review of treatment and management
Authors: Kim Daniel C. , Honeycutt Michael W. , Riehl John T.
Published: May 2019

Hip fractures are one of the most common major orthopaedic injuries in the United States, with an incidence that is growing with the aging population. These fractures vary significantly in anatomy, pathogenesis, and treatment. Orthopaedists must be able to carefully distinguish between femoral neck, intertrochanteric, and subtrochanteric femoral fractures because diagnosis is essential in guiding treatment. The extent of complex decision-making and management is often underappreciated in this diverse group of fractures. In this review, the relevant background, anatomy, and current treatment considerations essential to optimize management of these common and significant injuries are discussed.
Lisfranc open reduction and internal fixation in an athletic population: screw versus suture button fixation
Authors: Gee Shawn , Harris Mitchell C. , Anderson Claude , Groth Adam , Ryan Paul
Published: May 2019

Background:

Primarily ligamentous Lisfranc injuries occur in athletic populations. Unstable Lisfranc injuries are treated with internal fixation or arthrodesis. Internal fixation has been described with both screws and suture button devices, but there currently are only case reports in the medical literature describing the use of suture buttons. This study assessed the return to duty rate, time to full activity, hardware removal rate, and complications after open reduction and internal fixation (ORIF) of primarily ligamentous Lisfranc injuries in an active duty military population, comparing screw fixation with suture button fixation.

Methods:

A retrospective review was performed of ORIF of Lisfranc injuries performed at our institution from 2009-2012. Inclusion criteria were active duty at the time of surgery, primarily ligamentous Lisfranc injuries undergoing ORIF, and minimum 6-month follow-up. Twelve patients were identified who met the inclusion criteria.

Results:

Six patients underwent screw fixation (five men and one woman with a mean age of 25.7 yr). Six underwent suture button fixation (five men and one woman, with a mean age of 29.7 yr). Only half of the patients in the screw fixation group returned to full activity, whereas all patients in the suture button fixation group returned to full activity. Average time to return to full activity was 358 days in the screw fixation group and 181 days in the suture button group. The hardware removal rate was 83% in the screw fixation group, with no hardware removals in the suture button group.

Conclusions:

Our results demonstrate that suture button fixation serves as a viable alternative to screw fixation in an athletic population.
Risk Factors for Tibial Plafond Nonunion: Medial Column Fixation May Reduce Nonunion Rates
Authors: Haller Justin M. , Githens Michael , Rothberg David , Higgins Thomas , Nork Sean , Barei David
Published: May 2019

Objectives:

To identify the incidence and risk factors for development of tibial plafond nonunion.

Design:

Retrospective comparative study.

Setting:

Two Level 1 academic trauma centers.

Patients/Participants:

Seven hundred forty tibial plafond fractures (OTA/AO 43B3 and 43C) treated January 2006 to December 2015.

Intervention:

Open reduction and internal fixation.

Main Outcome Measurement:

Nonunion.

Results:

Five hundred eighteen patients with a mean age of 43 years (range, 18–81 years) and mean follow-up of 27 months (range, 12–115 months) were involved. Seventy-two patients (72/518, 14%) were identified as having a nonunion. Surgical approach was not associated with nonunion in univariate analysis. Multiple regression model 1 identified OTA/AO 43C [odds ratio (OR) = 4.43; 95% confidence interval (CI), 1.01–19.41; P = 0.048], tobacco use (OR = 2.02; 95% CI, 1.10–3.71; P = 0.024), both minimal and substantial bone loss (P = 0.006 and P < 0.001, respectively), and open fracture (OR = 1.96; 95% CI, 1.10–3.48; P = 0.022) as risk factors for tibial plafond nonunion. Model 2 identified locking plate (OR = 1.97; 95% CI, 1.13–3.40; P = 0.016) and failure to treat the medial column (vs. screw P = 0.047, or plate P = 0.038) as risk factors.

Conclusions:

The tibial plafond nonunion rate was 14%. Bone loss, open fracture, failure to treat the medial column, locking plates, and tobacco use were all significant risk factors for developing tibial plafond nonunion. Equally important, surgical approach was not significantly associated with plafond nonunion.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.