bluuebunny/crossref_metadata_2025 huggingface dataset:
Cyber Security Analysis for Advanced Train Control System (ATCS) in CTC Systems: Concepts and Methods
Authors: Wang Zezhou , Liu Xiang , Wang Yongxin , Yavvari Chaitanya , Jablonski Matthew , Wijesekera Duminda , Sykes Brian , Holt Keith
Published: July 2019

Advanced Train Control System (ATCS) is a proprietary network protocol that expands the functionality and efficiency of Centralized Traffic Control (CTC) systems, by using radio communications (radio code line) for message delivery. However, end-to-end cyber security issues were not considered during initial design of ATCS in the 1980s. Meanwhile, the landscape of cyber-physical threats and vulnerabilities has changed dramatically over the last three decades. Even though cutting-edge systems like Positive Train Control (PTC) have adopted security properties such as integrity check and encryption methods, major railroads in North America still deploy legacy ATCS standards to maintain their individual CTC system.

This paper first illustrated the background and general specifications of ATCS applications in North American railroads. The research team has noticed that few studies have systematically analyzed this topic since the emergence of ATCS, though its applications are still prevailing in the industry. Divided by both vital and non-vital operational scenarios, this paper presented case studies for ATCS-related vulnerabilities. We used a sender-receiver sequencing-based analysis and proposed a consequence-based simulation model to identify and further evaluate the cyber and physical risks under potential cyber-attacks. For the identified risk, the paper evaluated the likelihood based on the practical operational sequences, and recommended potential countermeasures for the industry to improve the security over the specific case. The research concluded that the fail-safe design in the ATCS systems would prevent the exploiting known security vulnerabilities which could result in unsafe train movements. However, the service disruptions under certain speculated attacks need further evaluation. At the end of this paper, we discussed our ongoing work for disruption evaluation in the wake of successful cyber attacks.
Use of Rail in Oil and Gas Regions of Texas to Reduce Truck Impacts
Authors: Warner Jeffery , Morgan Curtis , Rutter Allan , Lee Dahye
Published: July 2019

Burgeoning oil and gas production in Texas with the application of hydraulic fracturing (fracking) and horizontal drilling techniques has dramatically impacted the condition of rural roadway infrastructure. Many rural roadways are now inundated with trucks traveling to and from oil and gas well areas. Recent estimates indicate that each horizontal well requires over 2,000 truckloads for construction, drilling operations, maintenance, and crude oil transport over the life of the well. Rail has been an active partner in oil and gas exploration by shuttling fracking sand and drilling supplies to the oil and gas regions and transporting crude and petroleum products from the regions not served by pipelines. This partnership is restricted by limited rail service points and infrastructure close to the active wells; however, expanding existing rail services and network infrastructure could move rail operations closer to the active production areas. The cost and safety impacts of extreme reduction in pavement life may be offset substantially with increased use of rail transport closer to drilling locations.

This paper examines the potential options regarding expanded use of rail transportation to address the growing costs of roadway rehabilitation in energy production areas in order to reduce roadway network impacts. Rail service expansion can be through better use of the existing freight rail network, increasing the number of and better placement of transloading facilities along the rail network, and/or through improved rail capacity from double tracking or extending new rail lines. Both the private and public sectors potentially could play a role. A number of privately developed transloading facilities have sprung up along existing rail lines, attempting to deliver fracking sand, pipe, and other supplies. Additionally, public economic development corporations have been actively pursuing development. Expansion of the railroad network could come through the use of special districts such as Rural Rail Transportation Districts (RRTDs), Regional Mobility Authorities (RMAs), or through reactivation of abandoned rail lines. These trends are also examined.
Locomotive Crash Energy Management Coupling Tests Evaluation and Vehicle-to-Vehicle Test Preparation
Authors: Llana Patricia , Jacobsen Karina , Stringfellow Richard
Published: July 2019

Research to develop new technologies for increasing the safety of passengers and crew in rail equipment is being directed by the Federal Railroad Administration’s (FRA’s) Office of Research, Development, and Technology. Crash energy management (CEM) components which can be integrated into the end structure of a locomotive have been developed: a push-back coupler and a deformable anti-climber. These components are designed to inhibit override in the event of a collision. The results of vehicle-to-vehicle override, where the strong underframe of one vehicle, typically a locomotive, impacts the weaker superstructure of the other vehicle, can be devastating. These components are designed to improve crashworthiness for equipped locomotives in a wide range of potential collisions, including collisions with conventional locomotives, conventional cab cars, and freight equipment.

Concerns have been raised in discussions with industry that push-back couplers may trigger prematurely, and may require replacement due to unintentional activation as a result of loads experienced during service and coupling. Push-back couplers (PBCs) are designed with trigger loads meant to exceed the expected maximum service and coupling loads experienced by conventional couplers. Analytical models are typically used to determine these trigger loads. Two sets of coupling tests have been conducted that validate these models, one with a conventional locomotive equipped with conventional draft gear and coupler, and another with a conventional locomotive retrofit with a PBC. These tests allow a performance comparison of a conventional locomotive with a CEM-equipped locomotive during coupling, as well as confirmation that the PBC does not trigger at speeds below typical coupling speeds. In addition to the two sets of coupling tests, car-to-car compatibility tests of CEM-equipped locomotives, as well as a train-to-train test are also planned. This arrangement of tests allows for evaluation of the CEM-equipped locomotive performance, as well as comparison of measured with simulated locomotive performance in the car-to-car and train-to-train tests.

The conventional coupling tests and the CEM coupling tests have been conducted, the results of which compared favorably with their pre-test predictions. In the CEM coupling tests, the PBC triggered at a speed well above typical coupling speeds. This paper provides a comparison of the conventional coupling test results with the CEM coupling test results. The next test in the research program is a vehicle-to-vehicle impact test. This paper describes the test preparation, test requirements, and analysis predictions for the vehicle-to-vehicle test. The equipment to be tested, track conditions, test procedures, and measurements to be made are described. A model for predicting the behavior of the impacting vehicles and the CEM system has been developed, along with preliminary predictions for the vehicle-to-vehicle test.
A High Resolution Automated Prestressing Wire Indent Profiling System for Verification of Wire-Concrete Mix Compatibility
Authors: Beck B. Terry , Robertson Aaron A. , Peterman Robert J. , Savic Adrijana , Wu Chih-Hang John , Riding Kyle A. , Bloomfield John
Published: July 2019

It is well-known that the geometrical characteristics of the indents on prestressing wire used in the manufacture of prestressed concrete railroad ties affect the magnitude of the transfer length. In particular, it has been shown that such parameters as indent depth, indent volume and indent sidewall angle all affect transfer length, with indent volume being a major influence. Previous research has shown that the larger the indent volume, the shorter the transfer length.

For full load bearing capacity, it is important that the transfer length not exceed the distance to the rail seat. Consequently, transfer length has been identified as a key diagnostic parameter for evaluating the load bearing capability of prestressed concrete railroad crossties. Furthermore, it has been proposed for use as a valuable quality control parameter.

Ongoing research, as well as previously published research results, also indicates that the geometry of the prestressing wire indents plays a major role in the formation of cracking. This is particularly important in the manufacture of concrete ties intended for high speed rail applications. Cracking and debonding of prestressing wires associated with ties in service can result in severe splitting and complete tie failure. It is therefore not sufficient to guarantee a safe transfer length alone, without consideration of the cracking propensity. The wire specifications in standard ASTM A881 are intended to promote quality prestressed railroad tie behavior; however, the detailed causes of cracking and splitting, and the specific indent features that are responsible, are not well-known from a quantitative perspective.

Until recently, inspection of prestressing wire indent properties consisted of sampling a few indents from a small segment of wire, providing very limited statistical information on wire indent properties. To address this deficiency, a high-resolution automated non-contact optical wire indent scanning system has been developed for completely and rapidly characterizing all relevant indent geometrical parameters. The system is capable of measuring large segments of wire to yield statistically significant samples of all relevant indent parameters including indent depth, indent width, indent sidewall angle, indent pitch, and indent volume. The current state-of-the-art in this system development, along with some new insights based on recent indent scanning results, will be presented. This system represents a valuable tool to aid in identifying the key indent geometrical features related to cracking. The overall goal is to quickly assess critical indent parameters, so as to ensure high-quality bond and eliminate in-track tie splitting failures.
Evaluating the Effect of Natural Third Body Layers on Friction Using the Virginia Tech Roller Rig
Authors: Radmehr Ahmad , Kothari Karan , Ahmadian Mehdi
Published: July 2019

In this study, the effect of natural third body layers on the coefficient of friction and contact forces is evaluated using the Virginia Tech-Federal Railroad Administration (VT-FRA) roller rig facility. The test rig allows us to precisely control the contacting surfaces to study its effect on the wheel-rail interface forces and moments. Experiments have shown while running the tests, a slight amount of wear occurs at the running surfaces. The worn material deposits at the surface and behaves like a “natural” third-body layer at the contact, resulting in changes in traction coefficient and creep forces. The material wear and its accumulation on the running surfaces change with wheel longitudinal load and creepage.

A series of organized time-based experiments have been conducted with the running surfaces cleaned at the beginning of the test to study the effect of material wear accumulation on selected parameters including traction coefficient and creep forces over time. In order to highlight the effect of the natural third body layer on the wheel-rail contact forces, a series of experiments were conducted, in which the wheel and roller surfaces were cleaned in one case and left uncleaned in another. The results of the experiments are quite revealing. They indicate that when the running surfaces are cleaned after each test, the maximum creep force (or adhesion) is far lower than when the running surfaces are not cleaned, i.e., the natural third-body layer is allowed to accumulate at the surfaces. The results indicate that the wear debris act as a friction enhancer rather than a friction reducer.
Use of Alternative Crash Pulses for Interior Fixture Design Within CEM-Equipped Passenger Rail Cars
Authors: Spears Benjamin , Martinez Eloy
Published: July 2019

Over the past several years, Carbuilders have been developing car designs that utilize Crash Energy Management (CEM) as an alternative means to demonstrate compliance with carbody structural strength requirements. With the onset of CEM designs, the CFR has been amended to include requirements for alternative compliance to carbody structure requirements (see Docket No. FRA-2013-0060, Notice No. 3, [the Final Rule]) [14]. CEM designs often utilize crush zones with the overall goal of protecting occupant volume. These designs also change the structural behavior of the car during an accident, resulting in different acceleration responses than conventional car designs. This paper seeks to compare and contrast the interior fitting strength requirements between conventional car designs and a generic CEM design. The methodology utilizes simple mathematical simulations, modeling a conventional car design and a CEM design, with outputs of the simulation consisting of car response and behavior. Results indicate that alternative compliance requirements for all tiers of CEM-designed passenger equipment should be considered for interior fixtures.
The Creation of Cab Signaling
Authors: Hofbauer John
Published: July 2019

Cab signaling enforces the separation between trains as well as enforcing trains to reduce speed as the train approaches signals displaying STOP. Cab signaling allow for and provides a safe way to eliminate the number of wayside automatic signals while the number of controlled speeds can be increased. Light Rail Transit (LRT) systems today are built completely with cab signaling and only fixed wayside signals are placed at interlockings for routing information. Experimental cab signaling systems began in the United States in the 1920s, kicked off by the Interstate Commerce Commission (ICC) ruling that required some form of Automatic Train Control (ATC) be installed on one passenger division by 1925.

This paper will begin with examining the initial ATC designs (intermediate and continuous), the first experimental installations, the testing challenges and the overall enhancements that pioneered cab signaling systems in the US. The focus will include the teaming of the Pennsylvania Railroad with Union Switch and Signal (US&S) to develop, build and successfully test the continuous cab signaling system which later became the de facto standard. The early systems implemented used two (2) speeds, methods on adding a third speed and how the system became integrated with the existing automatic block signaling. How Pennsylvania Railroad (currently Amtrak) is still using the technology that started 100 years ago on the North East Corridor. It will also introduce how Light Rail systems operate on speed commands using cab codes.
Improve Safety at Highway Crossings Through Predictive Behavior and Innovative Technologies
Authors: Hofbauer John
Published: July 2019

The science and technology used in highway crossings in the United States and around the world have come a long way from a single flagman sitting in a booth, equipped with a red flag or lantern in his hand, to clear tracks and stop pedestrians, horses, and or a motor coaches for an approaching train to a fully automatic warning system requiring limited monthly testing. Today’s highway crossings are monitored by railways and municipalities such that, any changes in railway or roadway traffic conditions can be scrutinized. These changes, an increase in train or vehicle traffic, may trigger the need for additional protection devices to be implemented to make highway crossings safer for all; passing trains, motorists and pedestrians. But, are these requirements enough to eliminate accidents.

Historically speaking, these accidents range from; failures with the activation of the warning system; distracted motorists or motorists not willing to comply to the warning; pedestrians rushing to beat the train while underestimating the trains speed or; fully knowing and willing to not stop at the flashing lights and gates and willing to take the risk and go around flashing gates. This paper will investigate the current and future technologies that are being tested and implemented on highway crossings as well as look into the predictive behavior of motorists and pedestrians as they approach crossings and how changes can be implemented to maximize the effectiveness of a highway crossing. Key elements from various studies will be included that have been suggested through analyzing driver’s behavior at highway crossings, as well as the additional technologies that have and can be implemented to provide additional warnings to alert motorist of trains approaching.
Note on the history effect in fluid mechanics
Authors: Maris Humphrey J.
Published: July 2019

A freshman mechanics course often includes a theoretical discussion or demonstration of the motion of solid particles through fluids. The effect of viscosity is typically considered to provide a drag force on the particle which at each instant is proportional to the particle velocity. We present a brief discussion of the limitations of this approach and the importance of the so-called history effect first considered by Boussinesq and Basset in the late 19th century.
Data-driven decision making in an introductory physics lab
Authors: Walkup John R. , Key Roger A. , Talbot Patrick R. M. , Walkup Michael A.
Published: July 2019

A new lab activity for first-year introductory physics teaches students to use data to drive decision-making in science and engineering processes. Using the popular PDCA (plan-do-check-act) cycle, students manufacture a small sample of ball bearings out of modeling clay. By statistically analyzing their sample, they determine whether a larger shipment will meet tolerance levels specified by the lab TA. They then make decisions on ways to change their manufacturing process to improve results, employing another round of data analysis to confirm whether the change improved their process. Judging by student comments, such an activity reinforces the conceptual basis for numerous statistical properties, helps distinguish many commonly confused statistical concepts, and reinforces the use of data in process management. This activity can be incorporated into either algebra-based or calculus-based physics labs and, because it does not rely on background knowledge of physics concepts, should prove ideal for the early weeks of lab instruction.
Entropy and unavailable energy
Authors: Binder P.-M. , Tada Dallas K. , Howlett Cooper B.
Published: July 2019

We improve and clarify an explanation of how the entropy increase during a process is related to the energy that becomes unavailable to be transformed into work.
The delicate dance of orbital rendezvous
Authors: Carroll Bradley W.
Published: July 2019

The meeting of two spacecraft in orbit around a planet or moon involves a delicate dance that must carefully balance the gravitational, Coriolis, and centrifugal forces acting on the spacecraft. The intricacy of the relative motion between the two spacecraft caused problems for the Gemini missions in the mid-1960s. Although now mastered, the problem of how to bring two orbiting objects together continues to be misrepresented in popular movies and books. In this article, I will consider the case when the two spacecraft are in close proximity (compared with the radii of their orbits), and examine the counter-intuitive trajectories that are needed to bring them together. I will examine how a stranded astronaut might use an impulsive force to return to her ship in Earth orbit, how and when line-of-sight targeting may be used for a rendezvous, and how the Apollo 11 lunar module executed a Terminal Phase Initiation maneuver to rendezvous with the command/service module as they both circled the Moon.
Impact of low-pass filtering on masking release in understanding Mandarin sentences
Authors: Li Hua , Zhang Xinyu , Feng Yong , Chen Fei
Published: July 2019

The present work assesses the effect of low-pass filtering on masking release in Mandarin sentence recognition. Mandarin sentences were masked by steady-state noise and two-talker masker, processed by low-pass filtering, and presented to normal-hearing listeners to recognize. Negative release was observed at low-pass filtering cutoff frequencies ≤750 Hz, with listeners showing better performance under the steady-state noise condition than under the two-talker masker condition. The negative release was affected by the input signal-to-noise ratio. Language characteristics might partially account for the negative release observed with Mandarin speech.
Pinpoint brain stimulation probes perception
Authors: Servick Kelly
Published: July 2019

Triggering a handful of neurons in a mouse brain may conjure a visual experience.
Use of a scaffold peptide in the biosynthesis of amino acid–derived natural products
Authors: Ting Chi P. , Funk Michael A. , Halaby Steve L. , Zhang Zhengan , Gonen Tamir , van der Donk Wilfred A.
Published: July 2019

Growing independently

Bacteria produce natural products with a range of functions. A major family comprises ribosomally synthesized and posttranslationally modified peptides. Ting
et al.
identify a biosynthetic pathway in which a natural product is derived from an amino acid that is added to a ribosomally synthesized peptide independent of the ribosome. This biosynthetic paradigm is used in the synthesis of thiaglutamate and ammosamides, and the finding of related gene clusters suggests that the strategy may be used more widely.

Science
, this issue p.
280
New Jurassic mammaliaform sheds light on early evolution of mammal-like hyoid bones
Authors: Zhou Chang-Fu , Bhullar Bhart-Anjan S. , Neander April I. , Martin Thomas , Luo Zhe-Xi
Published: July 2019

Early suckler?

One trait that is unique to mammals is milk suckling. Suckling requires the presence of stability and motion in the throat, both of which require a complex hyoid apparatus. Zhou
et al.
describe a mammaliform docodontan fossil from the Jurassic that was preserved with a nearly intact hyoid (see the Perspective by Hoffmann and Krause). The structure is complex and saddle shaped, like that seen in modern mammals, suggesting that a muscularized throat was present before the development of mammals.

Science
, this issue p.
276
; see also p.
222
String patterns in the doped Hubbard model
Authors: Chiu Christie S. , Ji Geoffrey , Bohrdt Annabelle , Xu Muqing , Knap Michael , Demler Eugene , Grusdt Fabian , Greiner Markus , Greif Daniel
Published: July 2019

Looking for patterns in an optical lattice

One of the simplest models of interacting fermions on a two-dimensional (2D) lattice—the Hubbard model—becomes too tricky to simulate on classical computers as the density of empty lattice sites (holes) increases. Chiu
et al.
used a quantum microscope to take snapshots of thousands of realizations of the 2D Hubbard model in an optical lattice filled with fermionic lithium atoms at varying hole densities (see the Perspective by Schauss). The authors used pattern recognition algorithms to analyze the images, in which each lattice site was individually resolved. Comparing these patterns to the predictions of several theoretical models, they found the most consistency with the so-called geometric string model.

Science
, this issue p.
251
; see also p.
218
Reconfigurable ferromagnetic liquid droplets
Authors: Liu Xubo , Kent Noah , Ceballos Alejandro , Streubel Robert , Jiang Yufeng , Chai Yu , Kim Paul Y. , Forth Joe , Hellman Frances , Shi Shaowei , Wang Dong , Helms Brett A. , Ashby Paul D. , Fischer Peter , Russell Thomas P.
Published: July 2019

Liquid reconfigurable ferromagnetic materials

Ferromagnetic materials show a permanent magnetic dipole, whereas superparamagnetic ones only show magnetic properties under an applied field. Some materials, like ferrofluids, show liquid-like behavior but do not retain their magnetization in the absence of an applied field. Liu
et al.
show remnant magnetization of otherwise superparamagnetic magnetite nanoparticles at an oil-water interface of emulsion droplets (see the Perspective by Dreyfus). The permanent magnetization could be controlled by coupling and uncoupling the magnetization of individual nanoparticles, making it possible to “write and erase” shapes of the droplets or to elongate them into cylinders.

Science
, this issue p.
264
; see also p.
219
Stress signaling in pain control
Authors: Avril Tony , Chevet Eric
Published: July 2019

Endoplasmic reticulum stress can drive chronic pain, revealing a new target
How to make interlocked nanocarbons
Authors: Van Raden Jeff M. , Jasti Ramesh
Published: July 2019

Interlocked nanocarbon rings have promising properties for molecular machines
Membrane Protein of Human Coronavirus NL63 Is Responsible for Interaction with the Adhesion Receptor
Authors: Naskalska Antonina , Dabrowska Agnieszka , Szczepanski Artur , Milewska Aleksandra , Jasik Krzysztof Piotr , Pyrc Krzysztof
Published: July 2019

It is generally accepted that the coronaviral S protein is responsible for viral interaction with a cellular receptor. Here we show that the M protein is also an important player during early stages of HCoV-NL63 infection and that the concerted action of the two proteins (M and S) is a prerequisite for effective infection. We believe that this study broadens the understanding of HCoV-NL63 biology and may also alter the way in which we perceive the first steps of cell infection with the virus. The data presented here may also be important for future research into vaccine or drug development.
Waist circumference centiles for UK South Asian children
Authors: Shah Mahjabeen , Radia Dimple , McCarthy Huw David
Published: July 2019

Objectives

To develop waist circumference (WC) centile curves for UK South Asian children, to make comparisons with published centiles for British, indigenous Indian and Pakistani children, as well as to make anthropometric comparisons with their UK white peers.

Design

Cross-sectional study.

Setting

School-aged children from London boroughs (main measures: 2004–2007).

Participants

1562 (652 boys, 910 girls) UK South Asian and 1120 (588 boys, 532 girls) UK white children aged 4.0–13.9 years.

Interventions

WC, height, weight and body mass index (BMI).

Main outcome measures

The outcome measures were smoothed WC centile curves, constructed using the LMS (L = skewness, M = median, S = coefficient of variation) method. SD scores (SDS) were generated using UK90 and British (WC) growth references.

Results

WC increased with age for both sexes, rising more steeply at the upper centiles after the age of 6 years. Overall, UK South Asian children, similar to indigenous South Asian populations, had higher WC values than the British WC references. However, compared with their UK white peers, UK South Asian children had significantly (p<0.001) lower mean WC (UK white SDS=0.74 and SDS=0.64 vs UK South Asian SDS=0.32 and SDS=0.21 for boys and girls, respectively). Obesity prevalence was greater using WC than BMI for both ethnicities. At the 90th centile, for UK South Asian children, prevalence was 21.5% vs 24.4% for boys and 17% vs 24.5% for girls based on BMI and WC, respectively.

Conclusions

These curves represent the first WC centiles for UK South Asian children up to the age of 14 years. With a continued rise in childhood obesity, they provide a useful historical control for future comparisons.
Bleeding due to acquired dysfibrinogenemia as the initial presentation of multiple myeloma
Authors: Siddiq Namrah , Bergstrom Colin , Anderson Larry D , Nagalla Srikanth
Published: July 2019

Patients with multiple myeloma (MM) are at risk for acquired dysfibrinogenemia resulting in laboratory abnormalities and/or bleeding complications. We describe a 63-year-old man who presented with bleeding diathesis in the presence of a low fibrinogen activity level with a normal fibrinogen antigen level. Further studies revealed elevated levels of lambda free light chains, and he was diagnosed with MM. Despite initiating treatment with bortezomib/dexamethasone, he continued to have recurrent bleeds along with hypofibrinogenaemia, prompting a switch to carfilzomib/dexamethasone. The patient responded with improvement in bleeding symptoms, normalisation of fibrinogen activity and a decrease in serum free light chains.
Carotid-cochlear dehiscence: a dangerous mimicker of inner ear pathologies
Authors: Koochakzadeh Sina , Dornhoffer James R , Horton Joshua D , Meyer Ted A
Published: July 2019

A 67-year-old woman was referred to the otolaryngology service after presenting to the emergency department for dizziness and loss of balance. She reported several similar episodes over the past years. Physical examination was unremarkable. A temporal bone CT scan revealed dehiscence between the bony carotid canal and the cochlea resulting in the diagnosis of carotid-cochlear dehiscence (CCD). CCD is an extremely rare condition involving the thinning of the bony canal separating the internal carotid artery from the cochlea. CCD is best diagnosed with temporal bone CT scan. Treatment options include observation as well as chemical or surgical labyrenthectomy. Despite similar clinical and diagnostic characteristics of reported CCD cases, general trends and consensus on treatment options cannot be ascertained due to the extreme rarity of this condition. Regardless of these limitations, CCD is a critical diagnosis as it mimics other inner ear conditions and poses a potential, significant surgical risk for the otolaryngologist.
Seizures, renal failure and acute respiratory failure: not your typical case of Henoch-Schonlein purpura
Authors: Bose Subhasish , Pathireddy Samata , Baradhi Krishna M , Aeddula Narothama Reddy
Published: July 2019

A 30-year-old Caucasian woman with no prior medical history presented with pedal oedema, arthralgias and abdominal pain with diarrhoea, following a respiratory infection. She had mild abdominal tenderness along with a purpuric rash on the extremities and was anaemic. Following initial workup for anaemia and rash, her condition deteriorated with renal impairment, respiratory failure and seizures necessitating ventilatory support, dialysis and steroids. Serologies were negative, and skin biopsy showed leucocytoclastic vasculitis without vascular IgA deposition, and renal biopsy showed subendothelial, mesangial deposits of IgA with C3 indicative of Henoch-Schonlein purpura (HSP). She was treated with steroids, haemodialysis and on 6-month follow-up recovered renal function. We present the case to illustrate that HSP, though rare in adults, can present with multiorgan failure, with renal, pulmonary and central nervous system involvement, and the need for early diagnosis and prompt treatment for rapid clinical recovery.
Thymoma mimicking an aortic aneurysm: always expect the unexpected
Authors: Michaux Dario , Berzenji Lawek , Keulen Lotte , Rodrigus Inez
Published: July 2019

Thymic epithelial tumours (TETs) are rare lesions that represent less than 1% of all malignancies in adults. Presentation occurs in three ways: asymptomatic, with local thoracic symptoms or with paraneoplastic symptoms. Heterotopic ossifications are rare histological features in neoplasms and non-neoplastic lesions. Here, we present a 49-year-old male patient with a thymoma type B2 mimicking an aortic aneurysm. Alongside the thymoma, a cholesterol granuloma with unusual ossification features was found as well. This clinical presentation and pathological diagnosis are unusual findings.
Combined flexor carpi ulnaris and flexor carpi radialis transfer for restoring elbow function after brachial plexus injury
Authors: Atthakomol Pichitchai , Ozkan Sezai , Chen Neal , Lee Sang-Gil
Published: July 2019

The result of combined agonist and antagonist muscle innervation in traumatic brachial plexus injury through the intraplexal fascicle nerve transfers with the same donor function has not yet been reported. We describe a patient with a C5–C7 traumatic brachial plexus injury who had a combined transfer of the flexor carpi radialis (FCR) fascicle to the musculocutaneous nerve and the flexor carpi ulnaris (FCU) fascicle to the radial nerve of the triceps. The patient returned for his follow-up visit 2 years after his surgery. The muscle strengths of his triceps and biceps were Medical Research Council grade 2 and 0, respectively. Compared with his uninjured side, his grip strength was 9.8%, and his pinch strength was 14.2%. Our case report provides insights on result of combined agonist and antagonist muscle innervation through combining the motor fascicle of the FCR and FCU to restore the elbow flexor and extensor. The result may not be promising.
Clinical relevance of endoscopically identified extrinsic compression of the oesophagus and stomach
Authors: Kumar Kishore , Patel Harish , Mehershahi Shehriyar , Tariq Hassan , Glandt Mariela , Erfani Mohamad , Dev Anil , Zhang Aiyi , Makker Jasbir
Published: July 2019

Background

Various degree of extrinsic compression of the oesophagus and stomach are experienced during upper endoscopy. However, its utility in clinical practice has not been studied.

Methods

Electronic chart review of all upper gastrointestinal endoscopies done at our hospital between 2005 and 2016 was performed. A total of 79 patients with documented extrinsic compression on upper gastrointestinal procedure report who had a preceding or subsequent abdomen/chest CT imaging performed within 6 months were included.

Results

30 (38%) out of 79 patients had abnormal finding on CT scan. 14 (47%) out of 30 patients had an associated malignant lesion, whereas remaining had a benign lesion. Overall, patients with associated gastrointestinal symptoms (60% vs 22%, p=0.001) or history of weight loss (50% vs 16%, p=0.001) had increased odds of having an abnormal finding on CT scan compared with the patients who lacked such symptoms. Pancreatic cancer was the most commonly diagnosed malignancy. On subgroup analysis of patients with extrinsic compression and malignant lesion on imaging study, the likelihood of a malignancy was higher in blacks as compared with Hispanics (71%:29% vs 39%:61%, p=0.031), and with presence of gastrointestinal symptoms (64% vs 22%, p=0.003), presence of weight loss (64% vs 16%, p=0.0001) and hypoalbuminaemia (p=0.001).

Conclusion

Finding an extrinsic compression of the oesophagus and stomach on an upper endoscopy may suggest malignancy, and hence should prompt further work-up. Posterior wall gastric body compression may signal the presence of pancreatic cancer.
Relationship between employee engagement scores and service quality ratings: analysis of the National Health Service staff survey across 97 acute NHS Trusts in England and concurrent Care Quality Commission outcomes (2012–2016)
Authors: Wake Mark , Green William
Published: July 2019

Objective

This research explores measures of employee engagement in the National Health Service (NHS) acute Trusts in England and examines the association between organisation-level engagement scores and quality ratings by the Care Quality Commission (CQC).

Design

Cross-sectional.

Setting

97 acute NHS Trusts in England.

Participants

97 NHS acute Trusts in England (2012–2016). Data include provider details, staff survey results and CQC reports. Hybrid Trusts or organisations affected by recent mergers are excluded.

Outcome measures

Analysis uses organisation-level employee engagement and CQC quality ratings.

Results

Employee engagement is affected by organisational factors, including patient bed numbers (β=−0.46, p<0.05) and financial revenue (β=0.38, p<0.05). CQC ratings are predicted by overall employee engagement score (β=0.57, p<0.001) and financial deficit (β=−0.19, p<0.05). The most influential employee engagement dimension on provider ratings is ‘advocacy’ (λ=0.54, p<0.001). Analysis supports the notion that employee engagement can be predicted from advocacy scores alone (eigenvalue=4.03). Better still, combining advocacy scores from the previous year’s survey or adding in motivation scores is a highly reliable indication of overall employee engagement (95.4% of total variance).

Conclusions

NHS acute Trusts with high employee engagement scores tend to have better CQC ratings. Trusts with a high financial deficit tend to have lower ratings. Employee engagement subdimensions have different associations with CQC ratings, the most influential dimension being advocacy score. A two subdimension model of engagement efficiently predicts overall employee engagement in NHS acute Trusts in England. Healthcare leaders should pay close attention to the proportion of employees who would recommend their organisation as a place to work or receive treatment, because this is a proxy for the level of engagement, and it predicts CQC ratings.
Social support and depression among community dwelling older adults in Asia: a systematic review
Authors: Tengku Mohd Tengku Amatullah Madeehah , Yunus Raudah Mohd , Hairi Farizah , Hairi Noran N , Choo Wan Yuen
Published: July 2019

Objectives

This review aims to: (1) explore the social support measures in studies examining the association between social support and depression among community-dwelling older adults in Asia and (2) the evidence of association.

Design

A systematic review was conducted using electronic databases of CINAHL, PubMed, PsychINFO, Psychology and Behavioural Sciences Collection, SocINDEX and Web of Science for articles published until the 11th of January 2018.

Eligibility criteria

All observational studies investigating the association between social support and depression among community-dwelling older adults in Asia were included.

Participants

Older adults aged 60 years and more who are living in the community.

Exposure measures

Social support.

Outcome measures

Depression.

Results

We retrieved16 356 records and screened 66 full-text articles. Twenty-four observational studies were included in the review. They consisted of five cohort studies and 19 cross-sectional studies. Social support was found to be measured by multiple components, most commonly through a combination of structural and functional constructs. Perceived social support is more commonly measured compared with received social support. Good overall social support, having a spouse or partner, living with family, having a large social network, having more contact with family and friends, having emotional and instrumental support, good support from family and satisfaction with social support are associated with less depressive symptoms among community-dwelling older adults in Asia.

Conclusions

There were 20 different social support measures and we applied a framework to allow for better comparability. Our findings emphasised the association between good social support and decrease depression among older adults. Compared with western populations, family support has a greater influence on depression among community-dwelling older adults in Asia. This indicates that the family institution needs to be incorporated into designed programmes and interventions when addressing depression in the Asian context.

Trialregistration number

CRD42017074897.
Protocol for phase I study of pembrolizumab in combination with Bacillus Calmette-Guérin for patients with high-risk non-muscle invasive bladder cancer
Authors: Jamil Marcus L , Deebajah Mustafa , Sood Akshay , Robinson Kathy , Rao Krishna , Sana Sherjeel , Alanee Shaheen
Published: July 2019

Introduction

The initial treatment for high-risk non-muscle invasive bladder cancer (NMIBC) is endoscopic resection of the tumour followed by BCG therapy. In those who develop recurrence, the standard treatment is radical cystectomy. Despite the advancement in surgical technique and postoperative care, the degree of morbidity associated with radical cystectomy remains high, therefore less invasive treatment modalities are desirable. Therapies targeting the programmed death (PD) pathway have shown promise in urothelial carcinoma. We undertook the current study to determine the safety and efficacy of administering pembrolizumab (a monoclonal antibody targeting the interaction between PD-1 and its ligand) in combination with BCG in high-risk NMIBC.

Methods

This is a single-centre phase I safety and efficacy study of pembrolizumab used in combination with intravesicular BCG treatment for subjects with pathologically documented high-risk NMIBC despite having received two courses of induction therapy or BCG treatment followed by maintenance BCG. Fifteen subjects will be enrolled, patients will receive treatment with 200 mg of pembrolizumab every 21 days, starting 2 weeks from the initial endoscopic resection and continuing for 6 weeks after the final dose of BCG. The primary objective is to determine the safety of administering pembrolizumab at a fixed dose of 200 mg every 3 weeks in conjunction with intravesicular BCG treatment in patients with high-risk NMIBC who have failed previous treatment. Secondary objectives are to determine the 19 weeks and the 3, 12 and 24 months post-treatment completion complete response rate with combined pembrolizumab and intravesicular BCG therapy in the aforementioned patients.

Ethics and dissemination

The study has been approved by the Institutional Review Board of the Henry Ford Hospital. The results of this study will be published in a peer-reviewed journal and presented at a scientific conference.

Trial registration number

NCT02324582.
Protocol for a scoping review study to identify and map treatments for dysphagia following moderate to severe acquired brain injury
Authors: Eskildsen Signe Janum , Jakobsen Daniela , Riberholt Christian Gunge , Poulsen Ingrid , Curtis Derek John
Published: July 2019

Introduction

Dysphagia is highly prevalent in patients with acquired brain injury (ABI) and is associated with high morbidity and mortality. However, dysphagia management varies greatly between units and internationally, and there is currently no consensus, standard intervention or treatment. A review mapping the existing literature on dysphagia treatment is needed. In this paper, the protocol for a scoping review to identify and map dysphagia treatment following ABI is outlined.

Objective

The objective of the scoping review is to systematically map the existing research literature to answer the research question:Which non-surgical, non-pharmacological interventions are used in the treatment of dysphagia in patients with moderate and severe acquired brain injury in the acute and subacute phase?

Methods and analysis

The methodological framework for the study is based on methodology by Arksey and O’Malley and methodological advancement by Levacet al. We will search electronic databases in June 2019: MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library); EMBASE (Ovid); CINAHL (EBSCO); PsycINFO; Science Citation Index Expanded on Web of Science; OTseeker; Speechbite and PEDro. The search terms will be limited to patients with moderate to severe ABI and dysphagia. Four review authors will independently conduct an initial screening of title and abstract and subsequent full-text review of included studies. Data will be extracted and summarised in diagrammatic or tabular form (numerical summary), and a descriptive format (narrative summary). The strategy for data synthesis entails qualitative methods to categorise the interventions based on the treatment modality and subgroup diagnosis.

Ethics and dissemination

Scoping the existing literature will provide a foundation for further evaluating and developing our dysphagia treatment and inform future studies assessing the effectiveness of treatments. The review is part of an ongoing expansive research into dysphagia. The results will be disseminated through a peer-reviewed publication and conference presentations.
How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review
Authors: Moesker Marco J , de Groot Janke F , Damen Nikki L , Huisman Menno V , de Bruijne Martine C , Wagner Cordula
Published: July 2019

Objectives

Surgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied.

Design

A multicentre retrospective patient record review.

Setting and participants

Records from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed.

Primary and secondary outcome measures

Our primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level.

Results

Preoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%–100%), international normalised ratio testing (range 21%–94%) and postoperative bridging (range 20%–88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients’ weight.

Conclusions

Unsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.