bluuebunny/crossref_metadata_2025 huggingface dataset:
Estimation of the 2-DOF Time-Varying Impedance of the Human Ankle
Authors: Ficanha Evandro , Aramizo Ribeiro Guilherme , Knop Lauren , Rastgaar Aagaah Mohammad
Published: October 2017

The human ankle plays a major role in locomotion as it the first major joint to transfer the ground reaction torques to the rest of the body while providing power for locomotion and stability. One of the main causes of the ankle impedance modulation is muscle activation [1, 2], which can tune the ankle’s stiffness and damping during the stance phase of gait. The ankle’s time-varying impedance is also task dependent, meaning that different activities such as walking at different speeds, turning, and climbing/descending stairs would impose different profiles of time-varying impedance modulation.

The impedance control is commonly used in the control of powered ankle-foot prostheses; however, the information on time-varying impedance of the ankle during the stance phase is limited in the literature. The only previous study during the stance phase, to the best of the authors knowledge, reported the human ankle impedance at four points of the stance phase in dorsiflexion-plantarflexion (DP) [1] during walking. To expand previous work and estimate the impedance in inversion-eversion (IE), a vibrating platform was fabricated (Fig. 1) [3]. The platform allows the ankle impedance to be estimated at 250 Hz in both DP and IE, including combined rotations in both degrees of freedom (DOF) simultaneously. The results can be used in a 2-DOF powered ankle-foot prosthesis developed by the authors, which is capable of mimicking the ankle kinetics and kinematics in the frontal and sagittal planes [4]. The vibrating platform can also be used to tune the prosthesis to assure it properly mimics the human ankle dynamics. This paper describes the results of the preliminary experiments using the vibrating platform on 4 male subjects. For the first time, the time-varying impedance of the human ankle in both DP and IE during walking in a straight line are reported.
An Improved and Adjustable Vest System for the Support of Gravity-Counterbalancing Exoskeleton Arms
Authors: Andersen Bret , Angerhofer Nathan
Published: October 2017

Upper-limb motor impairment is caused by a wide variety of diseases, including Duchenne muscular dystrophy (DMD), stroke, and arthrogryposis multiplex congenita [1,2]. The resultant arm dysfunction can cause the patient to be incapable of many daily tasks, and therefore increasingly reliant on others for their care. Since many of the underlying diseases are either chronic or incurable, some current therapeutics take the form of orthotic devices that assist upper limb function, thereby improving patient quality of life [1]. One such example is the Wilmington Robotic Exoskeleton (WREX), consisting of a set of gravity-counterbalancing exoskeleton arms attached to either a full upper-body brace, or in previous models, a wheelchair [1]. This device and its successors have proven to be significant aids in allowing patients to perform everyday tasks such as eating and writing [1]. However, according to both patients and physicians, this device and others, while effective, are often underutilized due to factors including brace size and weight, low device comfort, unappealing brace aesthetics, low range of motion, and lack of brace adjustability. In order to increase patient utilization of exoskeleton arm systems, we thus propose the replacement of the current brace system with a novel vest device, designed specifically for increased patient comfort, device adjustability, aesthetics, and range of motion, while preserving the existing strength and durability of current solutions.
Hybrid Actuation Systems for Lightweight Transfemoral Prostheses
Authors: Lenzi Tommaso , Cempini Marco , Hargrove Levi , Kuiken Todd
Published: October 2017

Lower-limb amputation affects the ambulation ability and quality of life of about 600,000 individuals in the United States alone1. Individuals with transfemoral amputation typically walk slower, expend more energy, and have a higher risk of falls than able-bodied individuals2. Ambulation activities such as climbing ramps or stairs or standing up from a seated position are much more difficult than for able-bodied persons. Advances in prosthetic technologies are needed to improve the ambulation ability of above-knee amputees.

Passive knee prostheses are lightweight, robust, and quiet, but can only perform activities with dissipative dynamics. Powered prostheses3 overcome this limitation by motorizing the prosthetic joints throughout the entire day, thus enabling the achievement of more activities. However, the prosthesis actuator must then accommodate a wide range of speed and torque to support the various activities, plus provide power over the course of the entire day. Consequently, powered prostheses provide the ability to perform more tasks at the expense of substantial weight, noise, and battery life, which in turn affect their acceptability and clinical viability.

To address these shortcomings, we propose a hybrid actuation design for prosthetic knees. The proposed hybrid actuation system uses a motor, transmission, and control only for those activities requiring net-positive mechanical energy, such as climbing on stairs and ramps or performing sit-to-stand transfers. For non-positive mechanical energy tasks, such as standing and walking, the motor and transmission are mechanically disconnected, and passive knee components are used alone, thus achieving improved joint dynamics, and avoiding any electrical energy consumption.
Device for Safely Closing Trocar Sites in Minimally Invasive Abdominal Surgery
Authors: de la Torre Roger A. , Ghosh Jaya
Published: October 2017

Laparoscopic and robotic surgeries of the abdomen require a trocar to facilitate entry and removal of instrumentation. Some of these trocars are 5mm or less, but some trocars for these surgeries are larger, with 8mm to 15mm trocars commonly used. One of the well-known problems seen in minimally invasive surgery to the abdomen is the resulting defect left in the abdominal wall following removal of the trocars. Occasionally, especially after removal of larger trocars, a defect is left that is large enough to allow omentum or segments of small intestine to become entrapped within the resulting space in the abdominal wall. These trocar site hernias can cause pain, but they also may lead to small bowel obstruction and bowel ischemia or even infarction, perforation and death. The likelihood of a trocar site hernia is increased when the minimally invasive procedure requires removal of an organ or a mass. This often requires dilatation of the trocar site opening.1,2,3

Re-operation to reduce and repair trocar site hernias adds significant cost to the healthcare system. Two separate studies report that incidence of trocar site hernias are in the ranges of 0.65%–2.8%4 and 1.5%–1.8%5,6. Based on a 2016 report published by the American Society for Metabolic and Bariatric Surgery (ASMBS), 196,0007 bariatric procedures were performed in 2015. Assuming an average incidence rate of 1.7%, and based on the cost analysis provided by a 2008 case study8, in bariatric surgery alone, it is estimated that the treatment and hospitalization of such hernias adds an additional $86.2M to healthcare costs.

Several methods and devices exist to prevent the occurrence of trocar site hernias. However, closing superficial fascia externally is difficult, especially in obese patients, and often requires extending the skin incision significantly. Most instruments to close the potential hernia site involve introducing a hollow needle with a built-in, grasping device through tissue on one side of the defect and into the abdominal cavity. This puts internal structures at risk for potential injury. One end of suture is introduced with this needle and then using a separate instrument through a different trocar this suture is held while the needle is removed. The needle device is then re-introduced through tissue on the opposite side of the defect, and the suture is handed back to the needle device and pulled out completing a U-stitch to close the potential hernia site. If a surgeon inserts a finger into the abdomen along the trocar site to guide the needle, there is the potential for injury to the surgeon’s finger.

Therefore, we set about to design a device to close trocar site defects that would work efficiently, while being safe from injury to the patient or the surgeon, and preferably without the need for a separate instrument through a different trocar to assist.
Vortex Dynamics in Sidewall Aneurysms: Hemodynamic Transition During Growth and Clinical Implications
Authors: Le Trung Bao , Sotiropoulos Fotis
Published: October 2017

Recent works have suggested that aneurysm size and shape might not be the only indicators to predict aneurysm rupture. Rather, the long-term interaction between hemodynamics and aneurysmal wall via the loading condition (i.e shear stress and pressure) may also be important. In this work, we investigate the impact of flow pulsatility on the hemodynamic patterns on aneurysmal dome during its growth using numerical simulation.
Conceptual Design of Flex-DBS, a Mechanically Reconfigurable Deep Brain Stimulation Probe
Authors: Johnson Gregory , Lehto Lauri , Mangia Silvia , Gröhn Olli , Michaeli Shalom , Kodandaramaiah Suhasa
Published: October 2017

Deep Brain Stimulation (DBS) has demonstrated outstanding results for the treatment of medically intractable Parkinson’s disease (PD), essential tremor and other neurological and psychiatric disorders, such as Obsessive Compulsive Disorder (OCD) and major depression [1,2]. Despite widespread proliferation, efficacy of DBS treatment is limited primarily because of two key limitations as shown in Fig. 1: (a) non-specific activation of regions implicated in DBS side effects, and (b) inefficient neurostimulation due to complex anatomical structure and axonal orientations of target regions. Thus, there is a need to develop approaches to DBS that achieve more precise target selection and efficient activation of axonal pathways within the brain.

Recent efforts in target selection has focused on shaping the stimulation field by using multichannel electrodes for current steering [3]. These multichannel electrodes are limited to cylindrical lead configuration and can only correct for small spatial localization errors, and they do not utilize the direction of the electrical field’s gradients to stimulate neurons depending on their orientation (mainly orientation of axons). Thus, there is a critical need for new electrode architectures that enable both spatial steering and stimulation field orientation tuning capabilities. Here we present the Flex-DBS, a novel DBS electrode lead architecture that harnesses recent advances in flexible probe fabrication and precision guidance strategy to mechanically reconfigure electrodes in three dimensional orientations within anatomically complex brain tissue. Further, it incorporates dense arrays of electrodes with each lead that allow stimulation field orientation tuning.
Recognizing Sit-Stand and Stand-Sit Transitions for a Bionic Knee Exoskeleton
Authors: Liu Xiuhua , Zhou Zhihao , Wang Qining
Published: October 2017

Sit-to-stand and stand-to-sit transitions (STS), as one of the most demanding functional task in daily life, are affected by aging or stroke and other neurological injuries. Lower-limb exoskeletons can provide extra assistance for affected limbs to recover functional activities [1]. Several studies presented locomotion mode recognition of sitting, standing and STS, or only STS, or static modes [2–6]. They are based on fusing information of the mechanical sensors worn on the human body, e.g. inertial measurement unit (IMU) [2–4], plantar pressure force [5], barometric pressure[2], EMG [6]. However, most of them put sensors on the human body and did not show experiments integrated with exoskeletons. Since the physical interaction between the exoskeleton and human body, the recognition method might be different when wearing a real exoskeleton.

To deal with these problems, in this study we proposed a recognition method about STS based on the multi-sensor fusion information of interior sensors of a light-weight bionic knee exoskeleton (BioKEX). A simple classifier based on Support Vector Machine (SVM) was used considering the computational cost of the processing unit in exoskeleton.
The Paediatric Metered Dosage Inhaler (pMDI) Sleeve Attachment
Authors: Beukes Giancarlo L. , Levin Michael , Sivarasu Sudesh
Published: October 2017

Asthma is a chronic disease that causes fixed airflow obstruction, swelling and inflammation of the lung airways. This results in shortness of breath, wheezing and coughing [1]. 3.9 million People in South Africa are estimated to suffer from the disease and 1.5% of this total die as a result, annually [2]. The disease is the 3rd most common cause of child hospitalisation in South Africa.

In developing countries, the most common and affordable treatment option for asthma would be the standard metered dosage inhaler (MDI) [3, 4]. MDI’s provide a range of medications (including airway dilators and anti-inflammatories) contained within the aerosol canisters.

A large number of paediatric and geriatric patients suffering from asthma are unable to produce the necessary force required to activate the standard MDI. The study investigated fingertip pinch (action carried out when activating an MDI) strengths to determine the activation force deficit for paediatric patients [5]. In addition, patients using a standard MDI are unable to track the number of dosages remaining in the aerosol canisters [5]. The study presents a solution to the above mentioned patient limitations. A sleeve attachment was developed to reduce the required activation force of a standard MDI and track patient medication adherence. Additional features included height adjustability for varied MDI sizes (55mm to 90mm in length) and paediatric patient aesthetic appeal.
Tactile Feedback Wearable During a Surgical Simulation Task: Pilot Study Indicates No Distraction, Frustration or Performance Decrement for Users
Authors: Lowndes Bethany , Abdelrahman Amro , Yu Denny , Lachman Nirusha , Hallbeck Susan
Published: October 2017

With advancements in surgical techniques, patients have experienced improvements in health and recovery outcomes. However, about 87% of laparoscopic surgeons [1] and an increasing number of surveyed allied health professionals [2, 3] report musculoskeletal symptoms. Medical practitioners and human factors engineers have highlighted the “hostile” and “dangerous” operating room (OR) environment [1, 4, 5]. With increasing technology and surgical case complexity, physical demands for surgical team members will continue to increase due to circumstances such as technology restricting posture, taking up working space and more team members working around smaller surgical incisions [6]. There is widespread concern that these medical professionals’ work is unsustainable for safe and healthy patients and surgical team members.

Surgical team members can benefit from posture improvement during surgery; however, direct postural feedback may be difficult during their work due to the high visual and auditory stimuli during surgery. The tactile modality has been recently explored as a method to provide additional information without interfering with cognitive resources dedicated to visual and auditory pathways [7]. Tactile devices have successfully been implemented in high-stress environments, e.g., military, healthcare, and rehabilitation with a resulting improvement in performance [8–11]. Vibrotactile feedback has been specifically implemented in the healthcare field for improved performance by 31–75% anesthesiologists during simulated tasks [10]. Additionally, it has contributed to improved postural control in rehabilitation patients[11]. Despite success in other application areas, the potential of tactile devices for improving healthcare workers’ safety and performance remains unexplored. This study is a part of a larger project to design a wearable device that provides realtime vibrotactile feedback for preventing fatigue and musculoskeletal disorders for healthcare workers in the workplace.

This specific aim of this study is to measure distraction, frustration, and performance during a surgical simulation task performed with and without vibrotactile feedback. This is a test of initial feasibility of vibrotactile feedback for use in training proper ergonomics for surgical team members. The researchers hypothesize that there will be some distraction with the vibrotactile feedback wearable but no frustration or performance degradation during the basic simulation task.
A Socially Assistive Robot to Help With Getting Dressed
Authors: Woiceshyn Leo , Wang Yuchi , Nejat Goldie , Benhabib Beno
Published: October 2017

Getting dressed is a universally performed daily activity, and has a substantial impact on a person’s well-being. Choosing appropriate outfits to wear is important, as clothes protect a person from elements in the environment, and act as a barrier against harsh surfaces [1]. Studies have shown strong correlation between clothing choices and perceptions of sociability, emotional stability, and impression formation (e.g., [2]). This activity, however, can be difficult for some individuals, as they may lack the required reasoning and judgement required [3]. They include children with intellectual and learning disabilities [4] (e.g., Down syndrome [5], dyspraxia [6], autism spectrum disorder [7]), and older adults suffering from dementia including Alzheimer’s disease [8,9], or HIV-associated neurocognitive disorders [10].

In this paper, we present the development of a novel autonomous robotic clothing recommendation system to provide appropriate clothing options, which are personalized to a user’s wardrobe. This research expands on our previous work on socially assistive robots providing assistance with other daily activities, including meal eating [11] and playing Bingo games [12]. Currently, a few smartphone applications exist for providing outfit choices (e.g., [13,14]); however, unlike our proposed system, they are fashion-focused and not able to adapt online to a user’s preferences. Furthermore, by utilizing a socially assistive robot, we provide a more engaging interaction.

We utilize the small Nao social robot, Leia, to guide and interact with a user in order to obtain information regarding his/her preferences, the activity for which the clothing will be worn, as well as the environment in which the activity will take place in order to make outfit recommendations, Fig. 1.
Image-Based Modeling of Optic Nerve Head Mechanics Following Lumbar Puncture
Authors: Tong Junfei , Ghate Deepta , Kedar Sachin , Gu Linxia
Published: October 2017

Biomechanics of optic nerve head (ONH) has attracted increasing attention in recent years due to its association with ganglion cell damage and tissue remodeling resulted vision impairments [1, 2]. The ONH is exposed to both intraocular pressure (IOP) and intracranial pressure (ICP), separated by the lamina cribrosa (LC) which is regarded as the primary site of axonal injury in glaucoma[3]. The elevated IOP was widely acknowledged as a major risk factor for glaucoma. However, a large number of glaucoma patients never have an increase in IOP [4]. In studies that have looked at lumbar puncture (LP) data, patients with open-angle glaucoma were found to have lower ICPs than non-glaucomatous controls[5]. It suggests that higher translaminar pressure difference across the LC rather than IOP alone may have an important role in the pathogenesis of ONH damage. There were few computational models had been established to investigate the ICP’s role on ONH, such as Ethier et al. found elevated ICP could induce decreased strain within LC using finite element model[6]. However, less experimental data are available for delineating the role of ICP on the behaviors of LC. In this work, we present one dataset from LP patients and reconstruct its two-dimensional computational model of the ONH based on the patient’s images to delineate the role of ICP on ONH mechanics. The changes of LC depth, BMO width and papillary height were compared between the simulation and clinical dataset. The maximum principal strain of LC was calculated to reinforce its link with mechanosensitive cells in ONH.
Design of an Eye Speculum With Vibrational Anesthesia for Pain Management
Authors: Ruhala Laura , Malitz David , Elpers Brad , Megal Aaron , Perry Megan
Published: October 2017

An eye speculum is a device that holds the eyelids and lashes out of the way during ophthalmologic procedures. As described by Lam, et. al, ophthalmological surgical pain is usually controlled using eye drops [1]. However, in many cases the major source of pain or discomfort for the patients is not due to the surgery itself, but rather due to the eye speculum forcing the eye lids open [1]. Eyeball and eyelid physiological variation from patient to patient can cause variations in patient pain, and make it difficult for one speculum design to universally work for most patients [1]. Some eye specula include tubes for aspiration that is used to remove excess tear production on the eyeball surface. As aspirating speculum may aggravate dry eyes after surgery, the aspirating capabilities are ideally optional and at the discretion of the surgeon [2].

Fayers, et. al., found that vibration-assisted anesthesia during upper eyelid surgery had a beneficial pain reduction effect [3]. Additionally, vibrational anesthesia has been used in cosmetic and dental facial procedures [4, 5], but the inclusion of a vibrational anesthetic component to an eye speculum is novel.

A new eye speculum was design to minimize eye speculum patient pain, and be more universal with respect to patient eye shapes. It allows single-handed use by the surgeon, and optional eyeball aspiration. Most uniquely, it also incorporates an optional vibrational anesthesia component. The educational pedagogical aspects of this project were previously described by one of the authors. [6]
A Novel Two-Degree-of-Freedom Mechatronic Bed for Insomnia Treatment
Authors: Zavrel Erik A. , Ebben Matthew R.
Published: October 2017

The population prevalence of insomnia has been surveyed numerous times and is among the most common medical complaints. This common problem has wide ranging psychological and physiological health consequences.

Ample anecdotal evidence exists that motion promotes sleep: automobile and train passengers are routinely observed becoming drowsy and falling asleep [1]. The sleep-inducing effect of motion has long been appreciated in the scientific community as well. For example, rocking effectively produces sleep in infants [2]. Sleepiness is also a primary symptom of motion sickness and in some cases may be its sole manifestation [3]. To date, three studies have attempted to determine whether vestibular stimulation promotes sleepiness in adults. Two of these studies involved rocking beds. In one study, investigators found that regular, periodic motion achieved using a rocking bed reduced sleep onset latency (SOL) and increased REM in normal sleepers [4]. In another study, normal sleepers napped in a swinging bed of the same design. The study showed that rocking motion promotes sleep onset and transition to deeper, more restful stages of sleep [5]. In another study, investigators employed electrical stimulation of the inner ear in an attempt to decrease SOL, finding a significant reduction in a subset of participants whose SOL was elevated at baseline [6]. This illustrates that insomniacs may be particularly responsive to vestibular stimulation.

The non-pharmacological promotion of sleep is an active commercial pursuit with numerous related patents filed and commercial products introduced in recent years; however, existing devices suffer serious shortcomings. Previous experimental and current commercial designs intended for adults function(ed) as a pendulum, requiring a custom bed (and associated custom linens) along with a special overarching scaffolding installation to suspend the bed [7]. An advanced robotic infant seat [8], while elegantly designed, utilizes active load support, severely limiting the maximum weight capacity and excluding the possibility that a similar implementation could be used for adults. Phillips Respironics developed the SleepWave, a non-invasive (clip-on) device to electrically stimulate the vestibular nerve to generate the sensation of motion, which has undergone promising clinical trials but is not yet commercially available [9].

The motivation for a mechatronic bed as a treatment for insomnia is based on the demonstrated link between motion-induced vestibular stimulation and sleep induction. To date, no design has been proposed that is practical to implement or capable of being incorporated into existing beds: cost, necessary dedicated physical space, and convenience represent substantial barriers to acceptance.
Reconstruction of Brachytherapy Catheters and Needles Using EM Sensor-Based Navigation System
Authors: Liang Fan , Traughber Bryan , Musiz Raymond , Ellis Rodney , Podder Tarun K.
Published: October 2017

Brachytherapy is one the most effective treatment modalities for both gynecological (GYN) cancer and prostate cancer. The clinical outcome of brachytherapy, both high-dose-rate (HDR) and low-dose-rate (LDR), depends on the precision of the desired or planned dose distribution and delivery. In HDR procedure, the accuracy of reconstruction of catheters or needles (e.g. Syed catheter or Simon-Heyman capsule for GYN or needles for prostate) from CT images can significantly affect the accuracy of dose distribution in the treatment (dosimetric) plan, which can result in unwanted clinical outcome. In current practice, an authorized medical physicist manually reconstructs the catheters or needles for dosimetric plan, which determines the position and dwell time for the radiation source for delivering the prescription dose to the target volume sparing organs at risk (OARs) as much as possible. It is not only challenging but also time consuming for reconstructing all the catheters or needles (ranging 15–20) manually, slice-by-slice in CT images. As shown in Fig. 1, the needles on the right (HDR catheters) have created so much artifacts in CT images that it is almost impossible to reconstruct those applicators (catheters/ needles) manually. Additionally, the reconstruction can be operator dependent and can be inaccurate and inconsistent.

In this study, we have investigated the applicability of electromagnetic (EM) sensor-based navigation for fast and accurate reconstruction of HDR catheters and needles.
DNA topology in chromatin is defined by nucleosome spacing
Authors: Nikitina Tatiana , Norouzi Davood , Grigoryev Sergei A. , Zhurkin Victor B.
Published: October 2017

Nucleosome spacing variations cause topological polymorphism of chromatin that can affect DNA supercoiling and transcription.
Controlled growth and shape-directed self-assembly of gold nanoarrows
Authors: Wang Qian , Wang Zongpeng , Li Zhe , Xiao Junyan , Shan Hangyong , Fang Zheyu , Qi Limin
Published: October 2017

Shape-directed self-assembly of unique gold nanoarrows into supercrystals with unprecedented architectures is realized.
Topological liquid diode
Authors: Li Jiaqian , Zhou Xiaofeng , Li Jing , Che Lufeng , Yao Jun , McHale Glen , Chaudhury Manoj K. , Wang Zuankai
Published: October 2017

Janus gate: A unique topology blocks the flow of water in one direction but makes it run fast in the opposite direction.
Transformation of shock-compressed graphite to hexagonal diamond in nanoseconds
Authors: Turneaure Stefan J. , Sharma Surinder M. , Volz Travis J. , Winey J. M. , Gupta Yogendra M.
Published: October 2017

A rare hexagonal form of diamond, found at terrestrial impact sites, was observed in situ in shock compressed graphite.
Lysosome signaling controls the migration of dendritic cells
Authors: Bretou Marine , Sáez Pablo J. , Sanséau Doriane , Maurin Mathieu , Lankar Danielle , Chabaud Melanie , Spampanato Carmine , Malbec Odile , Barbier Lucie , Muallem Shmuel , Maiuri Paolo , Ballabio Andrea , Helft Julie , Piel Matthieu , Vargas Pablo , Lennon-Duménil Ana-Maria
Published: October 2017

Lysosomes control dendritic cell migration by linking macropinocytosis to cytoskeletal rearrangement via the TFEB-TRPML1 axis.
Fifteen-minute consultation: Diabulimia and disordered eating in childhood diabetes
Authors: Candler Toby , Murphy Rhian , Pigott Aisling , Gregory John W
Published: October 2017

Type 1 diabetes mellitus (T1DM) is a common chronic disease in children and young people. Living with diabetes can pose many challenges both medical and psychological. Disordered eating behaviours, intentional insulin omission and recognised eating disorders are common among young people with diabetes and are associated with increased risk of short-term and long-term complications and death. Recognition of these behaviours is important to ensure that relevant support is provided. Joint working between diabetes and mental health teams has challenges but is essential to ensure all needs are met during treatment and recovery.
Identifying risk for type 2 diabetes in different age cohorts: does one size fit all?
Authors: Alva Maria L , Hoerger Thomas J , Zhang Ping , Gregg Edward W
Published: October 2017

Objective

To estimate age-specific risk equations for type 2 diabetes onset in young, middle-aged, and older US adults, and to compare the performance of simple equations based on readily available demographic information alone, against enhanced equations that require both demographic and clinical information (fasting plasma glucose, high-density lipoprotein, and triglyceride levels).

Research design and methods

We estimated the probability of developing diabetes by age group using data from the Coronary Artery Risk Development in Young Adults (for ages 18–40 years), Atherosclerosis Risk in Communities (for ages 45–64 years), and the Cardiovascular Health Study (for ages 65 years and older). Simple and enhanced equations were estimated using logistic regression models, and performance was compared by age group. Thresholds based on these risk equations were evaluated using split-sample bootstraps and calibrating the constant of one age cohort to others.

Results

Simple risk equations had an area under the receiver-operating curve (AUROC) of 0.72, 0.79, 0.75, and 0.69 for age groups 18–30, 28–40, 45–64, and 65 and older, respectively. The corresponding AUROCs for enhanced equations were 0.75, 0.85, 0.85, and 0.81. Risk equations based on younger populations, when applied to older cohorts, underpredict diabetes incidence and risk. Conversely, risk equations based on older populations overpredict the likelihood of diabetes in younger cohorts.

Conclusions

In general, risk equations are more successful in middle-aged adults than in young and old populations. The results demonstrate the importance of applying age-specific risk equations to identify target populations for intervention. While the predictive capacity of equations that include biomarkers is better than of those based solely on self-reported variables, biomarkers are more important in older populations than in younger ones.
Achieving a ‘top-down’ change agenda by driving and supporting a collaborative ‘bottom-up’ process: case study of a large-scale enhanced recovery programme
Authors: Ogunlayi Fatai , Britton Philip
Published: October 2017

There is increasing recognition that organisations need to look beyond their boundaries for new innovations. However, the introduction and implementation of best practice that has been developed externally may need different processes of implementation if a successful change process is going to be achieved. Using an enhanced recovery programme as an example, we report a case study that combines the best of a top-down approach with the principles of bottom-up collaborative working to successfully embed a large-scale quality improvement programme that was commissioned to improve the adoption of enhanced recovery in elective surgery. We describe a large-scale change programme that was established, coordinated and driven from within a central ‘top’ organisation but delivered and owned locally by individual organisations working collaboratively across southeast region of England. We discuss why we believe our methodology of implementing this programme was successful, the important triggers for success and the lessons we learned from the programme.
Improving time efficiency gathering equipment in the treatment room
Authors: Karapinar Yesim , Habib Ali , Sawyerr Hannah
Published: October 2017

Each junior doctor spends on average 29 hours a year just accessing treatment rooms and approximately 4 working days per year collecting equipment. We identified areas where time efficiency could be improved: accessing treatment room door codes, standardising access to equipment in treatment rooms throughout the hospital, implementing the ‘procedure-specific’ tray (one tray per procedure which includes all needed equipment in one place) and indexing equipment. Our aim was to reduce the time taken to collect equipment, promote best practice and aid timely medical intervention. We collected data from 24 junior doctors with a Likert scale questionnaire, which confirmed the problem. We then designed an experiment where we timed healthcare professionals accessing treatment rooms with no prior knowledge of the codes and then with codes provided securely on our hospital-issued iPad. We project a time saving of 703 hours (88 working days) at Northampton General Hospital (NGH) over 1 year. We then implemented our prototype ‘procedure-specific trays’ for common procedures (cannulation, lumbar puncture, catheter). We calculated how much time was saved when collecting equipment using our indexed ‘procedure-specific’ tray method compared with current practice. Based on our piloted trays, we project to save a total of 802 hours (100 working days) at NGH over 1 year. To finalise our project, we trialled our custom design trays based on our prototype for cannulation and demonstrated a time saving of 97% relative improvement: from 225 s to 7 s. According to these results, once full roll of ‘procedure-specific tray’ is achieved, the trust will save projected £30 100 per year (based on average junior doctor salary of £20 per hour).
Improving handover between triage and locality wards in a large mental health trust
Authors: Debelle Alice , Dashwood Mark , Bird Louisa , Rao Ranga , Reilly Thomas
Published: October 2017

Background

South London and Maudsley NHS Foundation Trust is the largest mental health trust in the UK, serving four boroughs in South East London. In 2014, the ‘triage ward’ system was introduced in three boroughs. Similar to an acute medical admission unit, the triage ward would rapidly assess and treat all new admissions. The patients would either be discharged or admitted to a ‘locality ward’ for further treatment.

Problem

The unforeseen consequences of the ‘triage ward’ system were duplications and omissions of medical tasks on receiving wards, which affected efficiency and quality of care. This was due to a lack of formal medical handover. We aimed to improve efficiency and patient safety by formalising the junior doctor handover between triage and locality wards, ensuring every patient transferred had a documented handover in their electronic notes.

Method

We consulted our colleagues with a survey, ascertaining their views on the current system, the need for a more formalised system and what form that system should take. Using their feedback, we devised a handover template, to be completed for all patients transferred to locality wards. We then rolled the project out to the other two boroughs using the same methodology.

Results

A follow-up survey showed improvement in our baseline results and that the majority of transferred patients were formally handed over. Serious incident data showed a decrease in incident rates pre-intervention and post-intervention. The intervention was sustained a year later. The transfer of the intervention to other sites was problematic.

Discussion

The project showed the lack of handover was a concern shared by colleagues, and they considered our template a useful way of addressing this. The results suggested that the intervention was sustainable despite frequent rotations of staff. The difficulties in transferring an intervention to new sites are discussed.
Evaluation of simulation methods for teaching peripheral arterial examination to medical students
Authors: Naqi Syed Ali , Salih Abdel Monim , Hoban Anthony , Ayoub Firas , Quirke Michael , Hill Arnold D K , Condron Claire
Published: October 2017

Physical examination is a critical component of medical practice yet the focus on efficient patient turnover has impacted the availability of patients with clinical findings willing to be examined by students and skills' teaching is not consistent across clinical rotations. This work evaluates simulation methodologies for teaching of the peripheral arterial examination and evaluates whether skills learnt are transferable to clinical practice.

Second-year medical students were taught peripheral arterial examination on a SimMan 3G or with simulated patients (SPs). Both groups were assessed by Objective Structured Clinical Examination (OSCE) with outpatients who have been diagnosed with peripheral arterial disease.

There was no difference in the pass rate at OSCE between the two groups. SimMan better facilitated repeated practice, group learning, peer teaching and discussion, which were highly valued by the students. Students felt that the SImMan tutorial did not facilitate development of spatial cognition or pattern recognition. They also felt less well prepared to deal with real patients in terms of having practised appropriate language, issuing instructions and attempting to reassure patients.

Both methods of simulation teaching have distinct merits and the ideal approach maybe to use the SimMan in combination with SPs.
Biosimilars: considerations for clinical practice
Authors: Azevedo Valderilio , Dörner Thomas , Strohal Robert , Isaacs John , Castañeda-Hernández Gilberto , Gonçalves João , McInnes Iain
Published: October 2017

With the projected expansion of the biosimilars market, there will be an increased propensity for the substitution of reference biological products with cheaper biosimilars for economic reasons (ie, non-medical switching). This will lower the cost per patient and should provide the benefit of wider access to biological therapies. However, it is essential that patients and clinicians fully understand the rationale for non-medical switching and its potential implications in terms of efficacy, safety, and immunogenicity. To date, clinical experience supports the use of biosimilars and a growing body of evidence from clinical trials and real world observational studies specifically supports clinical decision making around non-medical switching. Equally, as non-medical switching becomes more common, it is essential that pharmacovigilance systems adapt to handle the increasing volumes of data needed to effectively monitor the use of biosimilars and detect new signals. This will require a reduced reliance on registries, as well as streamlining and integration of existing systems to allow a frequent cycle of online reporting of adverse events by healthcare professionals, analysis by national authorities, and feedback to treating clinicians. This article considers the current use and future uptake of biosimilars from a clinical perspective.
Student-inflicted injuries to staff in schools: comparing risk between educators and non-educators
Authors: Schofield Katherine E , Ryan Andrew D , Stroinski Craig
Published: October 2017

Objective

Student-inflicted injury to staff in the educational services sector is a growing concern. Studies on violence have focused on teachers as victims, but less is known about injuries to other employee groups, particularly educational assistants. Inequities may be present, as educational assistants and non-educators may not have the same wage, benefits, training and employment protections available to them as professional educators. We identified risk factors for student-related injury and their characteristics among employees in school districts.

Methods

Workers’ compensation data were used to identify incidence and severity of student-related injury. Rates were calculated using negative binomial regression; risk factors were identified using multivariate models to calculate rate ratios (RR) and 95% CIs.

Results

Over 26% of all injuries were student-related; 8% resulted in lost work time. Special and general education assistants experienced significantly increased risk of injury (RR=6.0, CI 5.05 to 7.15; RR=2.07, CI 1.40 to 3.07) as compared with educators. Risk differed by age, gender and school district type. Text analyses categorised student-related injury. It revealed injury from students acting out occurred most frequently (45.4%), whereas injuries involving play with students resulted in the highest percentage of lost-time injuries (17.7%) compared with all interaction categories.

Conclusion

Student-inflicted injury to staff occurs frequently and can be severe. Special education and general assistants bear the largest burden of injury compared with educators. A variety of prevention techniques to reduce injury risk and severity, including policy or environmental modifications, may be appropriate. Equal access to risk reduction methods for all staff should be prioritised.
Engaging, leading and improving at the Northern Ireland Faculty of Medical Leadership and Management (FMLM) conference
Authors: Curran Judy , Doherty Rachel , Donaghy Gráinne , Gardiner Keith
Published: October 2017

This article is a review of the Northern Ireland Faculty of Medical Leadership and Management (FMLM) conference, which took place on 9 March 2017 in Riddel Hall, Belfast. The conference programme included a number of inspiring and motivational keynote talks and workshops that embedded the theme of ‘Engaging, Leading and Improving’ throughout. This article summarises the main points from the keynote speakers and workshops. It also details the key learning points arising from the day as highlighted by delegate feedback.
Vulnerability, survival and shame in Nina Raine’sTiger Country
Authors: Bowman Deborah
Published: October 2017

Shame in healthcare remains relatively underexplored, yet it is commonplace and its impact is significant. This paper explores shame in healthcare using Nina Raine’s 2011 playTiger Country. Three manifestations of shame are explored, namely (1) shame in relation to professional identity and survival in the clinical workplace; (2) shame and illness as experienced by both patients and doctors; and (3) the systemic and organisational influences on shame within healthcare systems. I suggest that the theatre is particularly well-placed to elucidate shame, and thatTiger Countrydemonstrates the prevalence and impact of shame on clinical work. Shame has a fundamental and overlooked relationship with damaging and well-documented phenomena in healthcare, including moral distress, ethical erosion, compassion fatigue, burnout, stress and ill health. Attention to shame is essential for those interested in medicine and healthcare and must, I propose, include the experiences and perceptions of those who provide care, as well as attending to those who receive care.
Favorable revascularization therapy in patients with ASPECTS ≤ 5 on DWI in anterior circulation stroke
Authors: Mourand Isabelle , Abergel Eitan , Mantilla Daniel , Ayrignac Xavier , Sacagiu Tzvika , Eker Omer Faruk , Gascou Gregory , Dargazanli Cyril , Riquelme Carlos , Moynier Marinette , Bonafé Alain , Arquizan Caroline , Costalat Vincent
Published: October 2017

Background

A low baseline Alberta Stroke Programme Early CT Score (ASPECTS) is strongly associated with low rates of favorable outcome in patients with acute stroke.

Objective

To evaluate the efficacy and safety of revascularization therapy in patient with ASPECTS ≤5 in anterior circulation infarct.

Methods

We retrospectively analyzed 108 consecutive patients presenting low ASPECTS on diffusion-weighted imaging. Sixty patients were treated by mechanical thrombectomy, including 34 patients who received simultaneously intravenous thrombolysis. A control group of 48 patients not eligible for reperfusion therapy gave us a perspective on the natural history. Clinical outcome was evaluated at 90 days using the modified Rankin Scale (mRS) score. Hemicraniectomy after malignant infarction, mortality, and symptomatic intracranial haemorrhage (sICH) were also reported.

Results

Thrombolysis in Cerebral Infarction 2b–3 was assessed in 75% of treated patients. Reperfusion therapy led to significantly reduced disability (mRS score 0–2) at 90 days compared with the control group (30% vs 2.1%, p<0.001), hemicraniectomy (3.3% vs 22.9%, p=0.002), and death at 90 days (25% vs 47.9%, p=0.01). The sICH level was similar in treated patients and in the control group (p=0.78). Patients aged ≤70 years in the thrombectomy group had a significantly better clinical outcome than older patients (37.5% vs 10%, p=0.02), regardless of baseline characteristics or recanalization rate.

Conclusions

In patients with acute stroke in the anterior circulation and ASPECTS ≤5 revascularization therapy contributes to a favorable clinical outcome at 90 days, especially in patients younger than 70 years.
Environmental risk factors for bacteriological contamination in rural drinking water wells in Samson Cree Nation
Authors: Mah Fraser , Hnidan Travis , Davies Evan , Ulrich Ania
Published: October 2017

Bacteriological contamination of drinking water wells poses a challenge to many rural areas of First Nations communities in Alberta that rely on wells as the primary drinking water source for large proportions of their populations. Here we reviewed available historical data for the Samson Cree Nation near Maskwacis, Alberta (formerly Hobbema), to identify linkages between various environmental and historical factors and the risk of contamination by Escherichia coli and total coliform bacteria. Increased bacterial counts were found to be associated with a peak in total precipitation and surface water flow following a two to four month lag period. Wells installed by contractors operating at an earlier period in time were also found to be at greater risk than more recent installations. These findings can be used to better characterize the risk of contamination, which will assist in tailoring remedial actions to address chronic or recurring bacteriological presence in wells.
A bi-level model formulation for the distributed wood supply planning problem
Authors: Paradis Gregory , Bouchard Mathieu , LeBel Luc , D’Amours Sophie
Published: October 2017

The classic wood supply optimisation model maximises even-flow harvest levels and implicitly assumes infinite fibre demand. In many jurisdictions, this modelling assumption is a poor fit for actual fibre consumption, which is typically a subset of total fibre allocation. Failure of the model to anticipate this bias in industrial wood fibre consumption has been linked to increased risk of wood supply failure. In particular, we examine the distributed wood supply planning problem where the roles of forest owner and fibre consumer are played by independent agents. We use game theory to frame interactions between public forest land managers and industrial fibre consumers. We show that the distributed wood supply planning problem can be modelled more accurately using a bi-level formulation and present an extension of the classic wood supply optimisation model that explicitly anticipates industrial fibre consumption behaviour. We present a solution methodology that can solve a convex special case of the problem to global optimality and compare output and solution times of classic and bi-level model formulations using a computational experiment on a realistic dataset. Experimental results show that the bi-level formulation can mitigate risk of wood supply failure.