bluuebunny/crossref_metadata_2025 huggingface dataset:
25 Organ donation in emergency departments: an analysis of best practice
Authors: Empson Katja , Beale Sarah , Kerr Jacques , Gardiner Dale
Published: November 2017

Introduction

The 2015 RCEM End of Life Care best practice guideline highlighted the need for organ and tissue donation to be a usual part of end of life care in the Emergency Department (ED). NICE guideline states that all deaths meeting defined clinical triggers in the ED (in practice – mechanical ventilation, plan to withdraw life sustaining treatment, death expected) should prompt timely referral to organ donation services. Any family discussion in the ED regarding organ donation should be held collaboratively with a specialist nurse for organ donation (SNOD). What is the evidence in UK EDs that this is always the case?

Methodology

The NHS Blood and Transplant Potential Donor Audit, carried out by specialist nurses in organ donation, audits every death aged 80 years and under in UK Emergency Departments and Intensive Care Units. Data from the Potential Donor Audit was analysed and compared across the 12 Regional NHSBT teams.

Results

Almost all deceased donors in the UK are admitted to hospital via an Emergency Department (ED). The number of patients dying in UK EDs aged under 80 years of age and under (1 st April 2015 to 31 st March 2016) is variable across the country and not directly correlated with population. Patients dying in ED, who meet criteria for referral is equally variable across the UK (Range 1% Scotland – 3.9% Eastern).

PDA data (1 April 2016 – 31 March 2017) reveals that 284 patients died in ED meeting referral criteria but only 47% were referred (Range 22%–65% across the 12 regions). Longer 4 year analysis (1 st April 2012 – 31 st March 2016) demonstrated that up to 16% of these patients are on the Organ Donor Register. Of the 125 families approached in the ED (1 April 2016 – 31 March 2017) only 67% involved a SNOD (Range 0%–100% across the 12 regions).

Discussion

In 2017, with the endorsement of RCEM, NHS Blood and Transplant publishedOrgan Donation and the Emergency Department: A Strategy for Implementation of Best Practice.The strategy promotes identification and referral of potential organ donors in the emergency department and collaborative approach of their families when withdrawal of treatment is planned in the Emergency Department. Most importantly it is emphasised that organ donation should be firmly established as a usual part of end of life care irrespective of the location of the patient.

Figure 1

Audited deaths in ED by organ donation region 1st april 2015 to 31st march 2016

Figure 2

Died in emergency department meeting PDA referral criteria 1st April 2016 to 31st March 2017

Figure 3

Families approaches regarding organ donation in the ED 1st April 2016 to 31st March 2017
28 Are we measuring what we think we are measuring? Qualitative research exploring the role of the 0–10 pain score within the adult emergency department
Authors: Sampson Fiona , O’cathain Alicia , Goodacre Steve
Published: November 2017

Objectives and background

The assessment of pain in the emergency department (ED) is difficult but important for appropriate management of pain. Guidelines for the management of acute pain in the ED worldwide advocate using numeric rating scales such as the 0–10 pain score as tools to ensure consistency of documenting patient’s pain, and this is mandated at initial assessment in many EDs. Studies of interventions to improve pain management in the ED indicate that whilst the inclusion of mandatory pain scoring within interventions may improve documentation of pain, there was mixed evidence as to whether this resulted in improvements in provision of analgesia. As part of a wider study looking at barriers and enablers to pain management in the ED, we explored how pain scoring was used in the ED.

Methods

Qualitative data were collected within 3 case study EDs in the UK. Data comprised 143 hours of non-participant observation, 37 ED staff interviews and 19 patient interviews. Data were analysed using thematic analysis.

Results

Observation showed variation in how the pain score was documented between EDs. Some staff documented the score directly reported by the patient, whilst others documented a score they formulated using a combination of physiological signs, behavioural signs and presence of a ‘known’ painful condition. ED staff appeared to understand the score as an absolute measure used to guide analgesia requirements or triage categories rather than a relative measure used to document changes in pain levels. Even when documenting patient reported scores, they perceived patient reported scores to be inconsistent with their own assessment of the patients pain level, particularly where this could lead to patients being managed under a higher triage category or receiving stronger analgesia than ED staff considered appropriate. Staff documented pain scores that were appropriate for the treatment they planned to provide, rather than the scores reported by the patient, in particular when the pain score was used as a tool for auditing appropriate pain management.

Conclusions

The pain score appeared to have parallel but misaligned roles: to assess patient pain and ED staff practice. ED staff faced conflict between the need to record pain to ensure accountability of pain management, and recording pain to reflect the patient’s report. The role of the pain score needs to be reviewed in order for pain scoring to improve the patient experience of pain management in the ED.
29 Has the licensing ACT 2003 affected levels of violence in England and Wales? A systematic review of hospital and police studies
Authors: Callan Caitríona , Boyle Adrian
Published: November 2017

Background

Population-level legislation has been implemented in many countries to try and address alcohol misuse and related harms, including assault. Most violent incidents in the UK are alcohol-related, with alcohol misuse accounting for a substantial proportion of Accident and Emergency Department attendances. The Licensing Act 2003 aimed to reduce alcohol-related crime and disorder by abolishing set closing times and giving local authorities control over premises licensing in England and Wales. Concerns were raised, however, that greater availability of alcohol would lead to increased consumption and violence. This review examines primary research from hospital and police settings to evaluate whether the implementation of the Act in 2005 reduced or increased violence rates in England and Wales.

Methods

We performed an inclusive systematic review of the major biomedical databases. We included original research that evaluated changes in violence rates before and after the implementation of the Licensing Act, including hospital- and police- defined measures for this primary outcome. Our secondary outcome was whether there was change in temporal distribution of violent incidents after implementation of the Act.

Results

We identified 184 studies. 15 studies were included. The evidence was of overall poor quality, with the majority of included studies being uncontrolled before-after studies. 8 of these studies were conducted in the hospital setting, and 7 were from the police setting. Overall, 7 studies found reduced violence rates after implementation of the Licensing Act, 3 found increased rates, and 5 found no significant change. A subset of 9 papers analysed temporal distribution of violent incidents, 8 finding evidence of temporal displacement of assaults further into the early hours of the morning.

Conclusion

This is the most complete analysis to date of the effects of the Licensing Act on violence. There is no evidence for the Act having a significant or consistent effect on community violence rates, either in emergency departments or policing. There is consistent evidence from both hospital and police settings of a proportional increase in late-night violence since the implementation of the Act.
34 A systematic literature review of the pre-hospital lessons identified following mass casualty deliberate bombing incidents
Authors: Cooke Thomas , Chesters Adam , Grier Gareth
Published: November 2017

Background

Since the end of World War II, there has been an emergence of explosives used amongst civilian populations resulting in mass-casualty incidents. The development of pre-hospital medical systems, worldwide, has resulted in an increased response at these incidents. However, information about the pre-hospital medical response is sparse and not collated. This review aimed to collect and appraise the literature on the pre-hospital management of mass-casualty bombing incidents. The primary objective was to identify and discuss the common themes highlighted as problems in the pre-hospital medical response. The secondary objectives reviewed the injury patterns in victims and psychological impacts on pre-hospital responders.

Methods

A systematic literature search on the PubMed, SCOPUS and Web of Science databases took place. It included literature published from the 1 st of January 2000 to April 3rd 2017, with the last search performed on April 3rd 2017. Literature was included if it offered description, analysis, reflection or review of the bombing incidents.

Figure 1

The minimum number of recorded deaths and injuries from 11 deliberate mass casualty bombing incidents (note: two simultaneous marauding terrorist firearm attack and bombing incidents excluded)

Figure 2

Percentage of included literature identifying the following themes as problems in the pre-hospitals medical response

Results

1345 articles were found, with 54 included in analysis. 13 mass-casualty bombing incidents were described. Two of these included marauding terrorist firearm attacks (MTFA). In the 11 bombing-only incidents the death of 592–642 people and injury of 3,842–5229 more is described, with a further 301 deaths and 604 injuries from bombings with MTFA attacks. Quality appraisal showed a variation in reporting among incidents and a lack of uniform reporting.

Conclusions

Functioning and reliable communication, alongside regular training exercises with other emergency services, is important in the pre-hospital response. This is aided through accurate triage, in a safe area, to ensure even casualty distribution. A visible and established command and control enables scenes to be led effectively. Access to suitable and adequate supplies of equipment fosters improvement in patient outcomes. Awareness of secondary devices, as well as chemical, radiological and nuclear exposure, is vital in ensuring responder safety. A variety of injury patterns was found. Finally, psychological complications and support systems amongst pre-hospital responders varied.
36 Frailty flying squad: an emergency department focussed acute care of the elderly service DR genevieve robson, royal united hospital NHS foundation trust
Authors: Ballham Samantha , Buxton Scott , Camacho Rosa , Sinclair Adrianna , Dyer Chris , Jakeman Nicola
Published: November 2017

Introduction

The over 75 s make up 20% of our ED attendances. The greatest increase has been in the over 85 s. This very elderly cohort are more likely to be frail and are 10X more likely to require admission than 20–40 year olds and once in hospital have longer stays. There is evidence that multidisciplinary care and early Comprehensive Geriatric Assessment (CGA) improves outcomes for older patients, reducing readmissions, long term care, greater satisfaction and lower costs. The aim of this project was to improve the acute care provided to our older patients at the Front Door of the hospital.

Methodology

3 month pilot project underpinned by Big Room Quality Improvement methodology. The Frailty Big Room meets weekly and includes input from clinicians, QI experts and a data analyst. This project was driven by the following aims:

Frailty Flying Squad to see as many older±frail patients referred for admission as close to the front door as possible.

CGA at the front door with discharge planning from first review

MDT approach

Expedited discharge or transfer to other services from ED.

Review following day to make sure management plans being followed through or discharge without ward teams having to become involved.

Frailty Flying Squad Team:

2 Medical Nurse Practitioners

Physiotherapist

Consultant geriatrician

Key Performance Indicators:

Length of Stay

Readmission within 30 days of initial review

Results

355 patients were seen. 168 (47%) of patients were over 85 and the median Rockwood frailty score for the whole cohort was 6. 209 patients were ED referrals and 85 were GP referrals for admission. 237 (67%) patients were seen in ED, 49 in MAU and 7 in ED obs. During the pilot period, 97 patients who had been referred for admission were discharged direct from ED. 56 (16%) of patients had zero length of stay. A low number (9.4%) of patients were readmitted within 30 days.

Figure 1

LOS

Figure 2

Length of stay for the > 85s 2016 and 2017 compared

Conclusion

A multidisciplinary Acute Care of the Elderly Team predominantly based in the Emergency department can provide effective early Comprehensive Geriatric Assessment; facilitating discharge home from the Emergency Department, reducing length of stay for those admitted and reducing readmission rates within 30 days.
38 A comparison of two interventions in the treatment of severe ankle sprains and distal fibular avulsion fractures: a patient perspective
Authors: Powell Sarah
Published: November 2017

Stable ankle injuries are highly prevalent in Emergency Departments across the UK. Appropriate management to enable patients to experience a smooth recovery and prevent chronic ankle instability or reoccurrence is a priority. Current literature states that stable ankle fractures and severe ankle sprains can be successfully managed with the below knee plaster or the aircast brace and crutches. The functional brace has proved to be clinically effective in several reports. There has however, been no research to measure patient satisfaction levels between these two treatments.

An experimental, mixed method approach to the researching of this issue was performed in a busy, central London Emergency Department; a randomised controlled trial undertaken to compare the two devices and quantitative and qualitative data collection by means of a tailored questionnaire to determine patient satisfaction. Thirty nine patients were recruited during hospital attendance over 9 months. Patients were requested to complete the questionnaire 7 days into their treatment via post; stamped addressed envelopes were provided. Telephone interview was adopted as a secondary measure when postal responses failed. The primary outcome measured was patient satisfaction levels regarding comfort of the device, pain relief, daily activities, sleep, work, care of dependents and social life measured by use of a likert scale; ranging from very unsatisfactory to very satisfactory. The null hypothesis is that there is no significant difference in satisfaction levels between the two devices. Data was analysed using the unrelated t test.

31 responses were obtained; 16 participants with avulsion fractures to the distal fibular and 15 severe ankle sprains, 16 allocated to the ankle brace and 15 to the plaster. The findings demonstrate that there were statistically significant higher patient satisfaction levels in patients treated with an aircast brace than with the plaster cast. Using a probability level of 0.01, the critical value was 2.756, the t value 4.996; therefore the null hypothesis was rejected. The main indicators contributing to these findings were in the levels of comfort, daily activities, sleep work and social life. Overall it appears that patients preferred treatment with the aircast brace. Both forms of treatment were clinically equally effective in this study.

Evidence indicates that our current department guidelines may need to be re-evaluated. In addition, this a study focused on patient-centred care. The questionnaire developed, could potentially be used to measure patient satisfaction in other fields.
5 A study analysing the diagnostic performance of ECG interpretation for 30-day major cardiac events in the emergency department
Authors: Morris Niall , Body Rick
Published: November 2017

Study objective

This study evaluates the diagnostic accuracy of an Emergency Medicine (EM) clinician at identifying ischaemia on an ECG using 30-day major adverse cardiac events (MACE) as the primary outcome.

Methods

This is a secondary analysis of a prospective, multi-centre, observational cohort at 14 centres: the Bedside Evaluation of Sensitive Troponin study. All fourteen Emergency Departments were based in the United Kingdom. Emergency physicians’ assessments of the ECG were collected using a standardised form. Clinicians were asked to judge whether the ECG demonstrated ischaemia, the presence of ST depression (STD) and if there was abnormal T wave inversion (ATWI). Patients provided written informed consent and underwent serial high sensitivity troponin testing. 30 day follow-up was performed by research nurses using a standardised form via telephone. The primary outcome was 30-day major adverse cardiac events, defined as acute myocardial infarction, any cause of death and coronary revascularisation.

Results

In total, 756 patients were included in the analysis. Clinicians’ ECG diagnosis of ischaemia for 30-day MACE: ECG ischaemia produces a sensitivity (Sn) of 19.54% (95% CI:11.81% to 29.43%), specificity (Sp) of 93.27% (95% CI:91.10% to 95.05%), positive predictive value (PPV) of 27.42% (95% CI:18.47% to 38.65%) and negative predictive value (NPV) of 89.91% (95%CI 88.92% to 90.83%). ECG ST depression produces Sn of 16.09% (9.09% to 25.52%), Sp of 89.69% (87.13% to 91.89%), PPV 16.87 (10.68% to 25.62%), and NPV 89.15% (88.19% to 90.04%). ECG ATWI produces Sn of 4.60% (1.27% to 11.36%), Sp of 91.63% (89.27% to 93.62%), PPV of 6.67% (2.59% to 16.12%) and NPV of 88.07% (87.52% to 88.6).

Conclusion

This is the first prospective, multi-centre cohort study, that assess the diagnostic performance of EM clinician’s ECG interpretation, with 30-day MACE as the primary outcome. The findings are highly relevant to EM as they represent the ECG terms used by popular acute coronary syndrome clinical decision rules. In this study a clinician’s overall judgement of ischaemia has a better diagnostic performance compared to simple STD and ATWI. This may be due to an appreciation of morphology and the amount of deviation; future work should explore the effect of measuring deviation and analysing morphology.
50 How can informal support impact child PTSD symptoms following a psychological trauma?
Authors: Halligan Sarah
Published: November 2017

Background

An estimated 20% of children who present to hospital emergency departments following potentially traumatic events (e.g., serious injuries, road traffic accidents, assaults) will develop post-traumatic stress disorder as a consequence. The development of PTSD can have a substantial impact on a child’s developmental trajectory, including their emotional, social and educational wellbeing. Despite this, only a small proportion will access mental health services, with the majority relying on informal sources of support. Parents, in particular, are often the primary source of support. However, it remains unclear what types of parental responses may be effective, and parents themselves report experiencing uncertainty about the best approach. To address this gap in knowledge, we examined the capacity for specific aspects of parental responding in the aftermath of child trauma to facilitate or hinder children’s psychological recovery.

Method

We conducted a longitudinal study of 132 parent-child pairs, recruited following the child’s experience of trauma and subsequent attendance at one of four regional emergency departments. At an initial assessment, within 1 month post-trauma, we examined how parents appraised and responded to their child following the event, using both questionnaires and direct observations. Child-report questionnaires were used to assess PTSD symptom severity at 1 month, and at a follow up 6 months later. Children also reported on their own appraisals of the trauma and their coping behaviours, which were considered as potential mediators between parental support and later child symptoms.

Results

Controlling for relevant covariates and initial PTSD symptoms, parent negative appraisals of the trauma and encouragement of avoidant coping in children were associated with higher child-reported PTSD symptoms at 6 month follow-up. There was some evidence that children’s own trauma related appraisals and coping styles mediated these effects.

Conclusion

Findings indicate that children’s social support can influence their post-trauma psychological outcomes. That parenting was associated with 6 month PTSD, even after controlling for the child’s initial symptoms, suggests that parenting responses in the posttrauma period actively influence the child’s poorer longer-term adjustment, rather than simply being a response to the child’s initial distress. The results suggest that helping parents to provide fewer negative appraisals about the trauma/their child’s response, and to encourage more adaptive coping styles, could be effective in improving child psychological outcomes. As emergency departments provide primary care and support for families affected by trauma, they could play an important role in making this advice available to parents.
54 Paediatric traumatic cardiac arrest in England and Wales a 10 year epidemiological study
Authors: Vassallo James , Webster Melanie , Barnard Edward , Iniguez Marisol Fragoso , Lyttle Mark , Smith Jason
Published: November 2017

Introduction

Traumatic cardiac arrest (TCA) has traditionally been described as futile, with poor outcomes. Reported survival rates vary widely, with higher rates observed from mechanisms leading to a respiratory cause of traumatic cardiac arrest (e.g., drowning and hanging). Currently there is little evidence regarding outcomes following TCA in children. The primary aim of our study was to describe 30 day survival following TCA. Secondary aims were to provide an analysis of injury patterns (severe haemorrhage or traumatic brain injury), describe the functional outcome at discharge and to report the association between survival and interventions performed.

Methods

Using the Trauma Audit and Research Network (TARN) database, we conducted a population-based analysis of all paediatric (<18 years) trauma patients presenting to hospitals in England and Wales between 2006–2015. Patients with TCA in the pre-hospital setting and/or in the Emergency Department were included. Those without a GCS entry were excluded. Basic demographics are reported as number (%) and median (interquartile range), as appropriate. Survival odds ratios (95%CIs) and Chi Square tests were used during statistical analysis.

Results

During the study period, 21 710 paediatric patients were included in the database with 129 (0.6%) sustaining traumatic cardiac arrest and meeting study inclusion criteria (1.3%). The majority had a pre-hospital traumatic cardiac arrest (103 (79.8%)). Overall, 62.8% were male, aged 11.7 years (3.4–16.6), ISS 34 (25–45) and 110 (85.3%) had blunt injuries with road-traffic collision the most common mechanism (56.6%). 123 (95.3%) had severe haemorrhage and/or traumatic brain injury.

Table 1Table 2Table 3

Overall survival was 5.4% (95% CI:2.6 to 10.8) with 7 cases surviving to 30 days. ‘Pre-hospital only’ traumatic cardiac arrest (13.0%) had a significantly higher survival than ‘pre-hospital and Emergency Department’ traumatic cardiac arrest (1.8%), (p=0.04). Those with injuries to the thorax predominated the severe haemorrhage group (67.6%). There were no survivors from ‘Emergency Department only’ traumatic cardiac arrest. Treatment at a major trauma centre was associated with a statistically significant increase in survival (p=0.02). There was no difference in survival between different times of day of presentation. Of those with Glasgow Outcome Scale recorded at discharge (n=6), four (66.7%) had either a moderate disability or good functional outcome.

Conclusion

Although a rare event, this study has demonstrated that resuscitation of children in traumatic cardiac arrest is not futile with overall outcomes comparable to survival rates seen in adults. Survival from pre-hospital traumatic cardiac arrest is possible and the early identification and aggressive management of these patients is advocated.
55 ‘Mini Sim’ – innovative bite sized simulation teaching in a busy children’s emergency department
Authors: Sunley Rachel , Moloney Karen , Parker Jessica , Arrowsmith Christopher , Brown Kirsty , Wilson Alex
Published: November 2017

Emergency Medicine requires a highly skilled workforce who are passionate about delivering excellent patient care. Shift patterns linked with the ever increasing numbers of patients who attend Emergency Departments puts strain on educating the workforce and fostering team togetherness.

Our objective in devising and instigating the ‘Mini Sim’ programme was to embed regularin-situsimulation training to enhance the learning of all staff within our Emergency Department team, building a highly trained workforce to deliver excellent care within the remit of our busy department. The whole team is involved including junior nurses, senior nurses and all tiers of junior doctors including foundation, general practice and senior ED trainees (including Grid).

‘Mini Sim’ takes place on a weekly basis, every Tuesday morning from 0930–1000. This timing is to ensure maximum participation from all staff. The setup is a fifteen minute simulation (one nurse, one junior doctor, one senior doctor) followed by fifteen minutes of debrief. The format includes an assessment of the participants confidence prior to ‘Mini Sim’ in the subject being practiced. This is rated on a numerical scale from 1 (being not confident at all) to 5 (being completely confident). The topics chosen are based on feedback from trainees and nurses on clinical skills they feel under confident in, (e.g., pelvic binder application, rapid sequence induction, sickle cell crisis), clinical incidents which have occurred around the Trust (e.g., seizures and access to benzodiazepines), National Patient Safety Alerts (e.g., phenytoin toxicity), protocols (e.g., abducted child, rapid tranquilisation for the acutely disturbed adolescent) , governance issues (e.g., blocked tracheostomy, resuscitation room rebuild) and competencies linked to RCEM objectives. The ‘Mini Sim’ then takes placein situwithin the ED resus, ED main department or our short stay observation ward which is under the auspices of the Children’s Emergency Department using real equipment and drugs. After the simulation a debrief is held and any additional teaching is carried out to embed learning. Each medical participant is then offered the opportunity to complete a work place based assessment on the ‘Mini Sim’ for their e-portfolio.

Figure 1

Evaluation of impact of ‘mini sim’

The work flow of the department has been unaffected and we have received excellent written feedback from participants about the educational quality of the programme which has also shown improvements in staff confidence in dealing with a variety of emergency situations. We would suggest this model could be used in other departments for similar gain.

Figure 2
Cytokeratin-18 and Enhanced Liver Fibrosis Scores in Type 1 and Type 2 Diabetes and Effects of Two Different Insulins
Authors: Sanyal Arun , Cusi Kenneth , Hartman Mark L , Zhang Shuyu , Bastyr Edward J , Bue-Valleskey Juliana M , Chang Annette M , Haupt Axel , Jacober Scott J , Konrad Robert J , Zhang Qianyi , Hoogwerf Byron J
Published: November 2017

Data on cytokeratin-18 (K-18) and enhanced liver fibrosis (ELF) score in insulin-treated diabetes patients with non-alcoholic fatty liver disease (NAFLD) are limited. This study analyzed phase III data comparing basal insulin peglispro (BIL) and insulin glargine in type 1 (T1D), and type 2 diabetes (T2D) (insulin-naïve and insulin-treated). Alanine aminotransferase (ALT), K-18, ELF scores and liver fat content (LFC), measured by MRI, were obtained longitudinally. Baseline K-18 (U/L) was higher in T2D (range: 207-247) than T1D (range: 148-183), correlated with ALT in all populations (r (range) 0.264-0.637, p<0.05), but with LFC only in T2D (r (range) 0.474-0.586, p<0.05). K-18 increased significantly from baseline in BIL-treated, but not glargine-treated patients. Change from baseline (CFB) K-18 was significantly correlated with CFB in ALT in BIL-treated T2D populations. Baseline ELF scores were higher in T2D (range: 9.12-9.20) than T1D (range: 8.24-8.36), correlated with ALT in T1D only (0.209, p<0.05), and not correlated with LFC in any population. ELF scores increased significantly from baseline in BIL-treated but not glargine-treated patients. There were no correlations between CFB in LFC and ELF score at week 52 in any treatment group/population. In all BIL-treated populations, CFB in ALT and CFB in ELF score at week 52 were positively correlated. These data characterize associations of K-18 and ELF score with ALT and LFC in insulin-treated patients with T1D and T2D. Hepatopreferential insulins may be associated with increased K-18 and ELF scores but mechanisms and clinical significance are unknown. ClinicalTrials.gov identifiers are NCT01481779, NCT01435616, NCT01454284 and NCT01582451.
Food security, sweet potato production, and proximity to markets in northern Ghana
Authors: Glenna Leland , Borlu Yetkin , Gill Thomas , Larson Janelle , Ricciardi Vincent , Adam Rahma
Published: November 2017

Debates concerning how to achieve food security tend to fall into one of two camps. The first is that high-technology, market-oriented approaches promise to enhance agricultural productivity and improve food security. The counterargument is that low-technology approaches, when combined with building social and physical infrastructure, are more effective at meeting people’s food needs. Using a survey of 540 farm households in northern Ghana, we assess the level of food security for smallholders by analyzing the influence of a low-technology and low-external-input approach, such as sweet potatoes, and that of the production of an improved, commercially produced crop, such as rice. We also measure the influence of market access. Our results indicate that sweet potato producers are more likely to be food secure than commercial rice producers. However, the proximity to and interaction with markets is also associated with farmer food security, even when controlling for measures of prosperity. These findings suggest that low-technology approaches and high-technology, market-oriented approaches should not be treated as diametrically opposed to each other. Enhancing smallholder production of low-technology staple crops like sweet potatoes is likely to improve well-being. At the same time, interventions to build the physical and social infrastructure necessary to enable market participation would also be likely to enhance smallholder well-being.
Optimal Parallel Machine Allocation Problem in IC Packaging Using IC-PSO: An Empirical Study
Authors: Cuckler Robert , Chang Kuo-Hao , Hsieh Liam Y.
Published: November 2017

We model and apply a stochastic-simulation-based methodology to optimize the machine allocation of a flexible flow shop (FFS) dedicated to integrated circuit (IC) packaging. This contrasts with most previous research on non-deterministic FFS problems wherein stochastic simulation is mostly used to estimate throughput, cycle time, delay cost, or some other measure(s) in order to compare the performances of already-existing heuristic-based algorithms. The methodology applied in this research, called progressive simulation metamodeling for IC Packaging (IC-PSO), while rooted in the traditional metamodeling technique known as Response Surface Methodology (RSM), contrasts with RSM in that it is equipped with well-designed mechanisms to ensure an ever-increasing solution quality in an attempt to achieve the desirable optimality. The computational efficiency that IC-PSO affords IC packaging companies is demonstrated via a numerical study. Meanwhile, an empirical study based on real data was conducted to validate the viability of the proposed methodology in real settings.
An Unreliable Quorum Queueing System with Single and Multiple Vacations
Authors: Tadj Lotfi
Published: November 2017

This paper contributes to the literature of single server queueing models with a vacationing server. We have incorporated many features for a better control over the system. The server implements the N-policy, takes both single and multiple vacations, and is subject to breakdowns. The embedded Markov chain technique is used to obtain the pgf of the system size at a service completion epoch in the steady-state. The semi-regenerative technique is used to obtain the pgf of the system size at an arbitrary instant of time in the steady-state.
A Self-Adaptive Hybrid Optimization Algorithm for Solving Consecutive Reaction Problem
Authors: Zhou Di , Zhu Jiangning , Wang Yazi
Published: November 2017

The actual temperature control for consecutive reaction problem is a complex optimization problem. Genetic algorithms (GA) is a metaheuristic inspired by imitating the processes observed during natural evolution. It has a strong global search ability and less computation time, but it exists the premature convergence and poor stability. Ant colony optimization (ACO) is a metaheuristic inspired by imitating the behavior of real ants. It has the robustness and parallel computation, but it exists the slow convergence speed and stagnation phenomenon. In this paper, a new genetic and ant colony self-adaptive hybrid (NGASAH) algorithm based on the chaotic searching strategy, multi-populations and self-adaptive parameter control strategies is presented. In the proposed NGASAH algorithm, the chaotic searching strategy is used to avoid the optimal solution. The strategy of the multiple populations is used to avoid to converge to a local extreme point of all particles. The strategy of self-adaptive parameter control is used to dynamically balance the local search ability and the global ability, and improve the convergence speed. The actual temperature control of consecutive reaction problem is used to test the validity of the NGASAH algorithm. The experiment results show that the NGASAH algorithm can obtain the global search ability and the faster convergence speed in solving the complex optimization problems.
Estimation-Based Control of a Magnetic Endoscope without Device Localization
Authors: Edelmann Janis , Petruska Andrew J. , Nelson Bradley J.
Published: November 2017

Magnetically controlled catheters and endoscopes can improve minimally invasive procedures as a result of their increased maneuverability when combined with modern magnetic steering systems. However, such systems have two distinct shortcomings: they require continuous information about the location of the instrument inside the human body and they rely on models that accurately capture the device behavior, which are difficult to obtain in realistic settings. To address both of these issues, we propose a control algorithm that continuously estimates a magnetic endoscope’s response to changes in the actuating magnetic field. Experiments in a structured visual environment show that the control method is able to follow image-based trajectories under different initial conditions with an average control error that measures 1.8 % of the trajectory length. The usefulness for medical procedures is demonstrated with a bronchoscopic inspection task. In a proof-of-concept study, a custom 2[Formula: see text]mm diameter miniature camera endoscope is navigated through an anatomically correct lung phantom in a clinician-controlled manner. This represents the first demonstration of the controlled manipulation of a magnetic device without localization, which is critical for a wide range of medical procedures.
Ventricular Fibrillation following Varicella Zoster Myocarditis
Authors: Ioannou Adam , Tsappa Irene , Metaxa Sofia , Missouris Constantinos G.
Published: November 2017

Varicella-zoster virus (VZV) infection can rarely lead to serious cardiac complications and life-threatening arrhythmias. We present a case of a 46-year-old male patient who developed VZV myocarditis and presented with recurrent syncopal episodes followed by a cardiac arrest. He had a further collapse eight years later, and cardiac magnetic resonance imaging (MRI) demonstrated mild mid-wall basal and inferolateral wall fibrosis. He was treated with an implantable cardioverter defibrillator (ICD) and represented two years later with ICD shocks, and interrogation of the device revealed ventricular fibrillation episodes. This case demonstrates the life-threatening long-term sequelae of VZV myocarditis in adults. We suggest that VZV myocarditis should be considered in all patients who present with a syncopal event after VZV infection. In these patients, ICD implantation is a potentially life-saving procedure.
HLA Association with Drug-Induced Adverse Reactions
Authors: Fan Wen-Lang , Shiao Meng-Shin , Hui Rosaline Chung-Yee , Su Shih-Chi , Wang Chuang-Wei , Chang Ya-Ching , Chung Wen-Hung
Published: November 2017

Adverse drug reactions (ADRs) remain a common and major problem in healthcare. Severe cutaneous adverse drug reactions (SCARs), such as Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) with mortality rate ranges from 10% to more than 30%, can be life threatening. A number of recent studies demonstrated that ADRs possess strong genetic predisposition. ADRs induced by several drugs have been shown to have significant associations with specific alleles of human leukocyte antigen (HLA) genes. For example, hypersensitivity to abacavir, a drug used for treating of human immunodeficiency virus (HIV) infection, has been proposed to be associated with allele 57:01 ofHLA-Bgene (termsHLA-B∗57:01). The incidences of abacavir hypersensitivity are much higher in Caucasians compared to other populations due to various allele frequencies in different ethnic populations. The antithyroid drug- (ATDs- ) induced agranulocytosis are strongly associated with two alleles:HLA-B∗38:02andHLA-DRB1∗08:03. In addition,HLA-B∗15:02allele was reported to be related to carbamazepine-induced SJS/TEN, andHLA-B∗57:01in abacavir hypersensitivity and flucloxacillin induced drug-induced liver injury (DILI). In this review, we summarized the alleles of HLA genes which have been proposed to have association with ADRs caused by different drugs.
When Long Noncoding RNAs Meet Genome Editing in Pluripotent Stem Cells
Authors: Chen Fuquan , Ji Jiaojiao , Shen Jian , Lu Xinyi
Published: November 2017

Most of the human genome can be transcribed into RNAs, but only a minority of these regions produce protein-coding mRNAs whereas the remaining regions are transcribed into noncoding RNAs. Long noncoding RNAs (lncRNAs) were known for their influential regulatory roles in multiple biological processes such as imprinting, dosage compensation, transcriptional regulation, and splicing. The physiological functions of protein-coding genes have been extensively characterized through genome editing in pluripotent stem cells (PSCs) in the past 30 years; however, the study of lncRNAs with genome editing technologies only came into attentions in recent years. Here, we summarize recent advancements in dissecting the roles of lncRNAs with genome editing technologies in PSCs and highlight potential genome editing tools useful for examining the functions of lncRNAs in PSCs.
A Case of Segmental Arterial Mediolysis Presenting as Mucosal Gastric Hematoma
Authors: Sakuraba Shunsuke , Orita Hajime , Ueda Shuhei , Tokuda Satoshi , Ito Tomoaki , Kushida Tomoyuki , Sakurada Mutsumi , Maekawa Hiroshi , Wada Ryo , Sato Koichi
Published: November 2017

Background. Although segmental arterial mediolysis (SAM) has been increasingly recognized as arteriopathy and there are some case reports about SAM, it is still very rare. It is characterized clinically by aneurysm, dissection, stenosis, and occlusion within splanchnic arterial branches, causing intra-abdominal hemorrhage or bowel ischemia. Mortality is as high as 50% in acute events. Case Presentation. A 51-year-old man was referred to our hospital with hematemesis. Gastroscopy revealed a submucosal-like tumor on the posterior wall of gastric angle with ulceration. Computed tomography indicated a tumor measuring 65×50 mm in the stomach, which was suspected to have invaded into the pancreas. Significant hematemesis recurred; the patient developed shock and underwent emergency distal gastrectomy, distal pancreatectomy, and splenectomy. The pathology and the clinical course were compatible with SAM splenic artery rupture causing retroperitoneal hemorrhage that penetrated into the stomach. After that surgery, aneurysm of common hepatic artery ruptured and coil embolization was performed. Conclusion. SAM is an important cause of intra-abdominal or retroperitoneal hemorrhage in patients without underlying disease. SAM typically presents as intra-abdominal hemorrhage, but, in this case, the retroperitoneal hemorrhage penetrated into the stomach and it looked like a submucosal tumor.
Intraperitoneal Granulomas Unexpectedly Found during a Cesarean Delivery: A Late Complication of Dropped Gallstones
Authors: Suarez-Zamora David A. , Barrera-Herrera Luis E. , Caceres-Mileo Ricardo , Palau-Lazaro Mauricio A.
Published: November 2017

Laparoscopic cholecystectomy is the treatment of choice for patients with symptomatic cholelithiasis. Spillage of gallstones into the abdominal cavity during laparoscopic cholecystectomy occurs in approximately one-third of cases. Although retained gallstones remain asymptomatic, few cases may develop complications. We report the case of a 29-year-old nulliparous woman presenting with several hard nodules in the omentum, raising the possibility of a metastatic disease. Histological examination demonstrated a bile-stained material and a foreign body-type granulomatous response without neoplastic tissue. Our case demonstrates an example of a complication resulting two years after a laparoscopic cholecystectomy that was unexpectedly found during a cesarean delivery. Pathologists should be aware of this entity to avoid interpretation errors.
Seismic Collapse Analysis of RC Highway Bridges Based on a Simplified Multiscale FE Modeling Approach
Authors: Hu Menghan , Han Qiang , Du Xiuli , Liang Xiao
Published: November 2017

Multiscale finite element (FE) modeling offers a balance between computational efficiency and accuracy in numerical simulations, which is appropriate for analysis of seismic collapse of RC highway bridges. Some parts of structures that need detailed analysis can be modeled by solid elements, while some subordinate parts can be simulated by beam elements or shell elements to increase the computational efficiency. In the present study, rigid surface coupling method was developed to couple beam elements with solid elements using the LS-DYNA software. The effectiveness of this method was verified by performing simulation experiments of both a single-column pier and a two-span simply supported beam bridge. Using simplified multiscale FE modeling, analyses of collapse and local failure of a multispan simply supported beam bridge and a continuous rigid frame bridge were conducted to illustrate the approach in this paper. The results demonstrate that the simplified multiscale model reasonably simulates the collapse process and local damage of complex bridges under seismic loading.
Analysis of NEA-NSC PWR Uncontrolled Control Rod Withdrawal at Zero Power Benchmark Cases with NODAL3 Code
Authors: Sembiring Tagor Malem , Pinem Surian , Liem Peng Hong
Published: November 2017

The in-house coupled neutronic and thermal-hydraulic (N/T-H) code of BATAN (National Nuclear Energy Agency of Indonesia), NODAL3, based on the few-group neutron diffusion equation in 3-dimensional geometry using the polynomial nodal method, has been verified with static and transient PWR benchmark cases. This paper reports the verification of NODAL3 code in the NEA-NSC PWR uncontrolled control rods withdrawal at zero power benchmark. The objective of this paper is to determine the accuracy of NODAL3 code in solving the continuously slow and fast reactivity insertions due to single and group of control rod bank withdrawn while the power and temperature increment are limited by the Doppler coefficient. The benchmark is chosen since many organizations participated using various methods and approximations, so the calculation results of NODAL3 can be compared to other codes’ results. The calculated parameters are performed for the steady-state, transient core averaged, and transient hot pellet results. The influence of radial and axial nodes number was investigated for all cases. The results of NODAL3 code are in very good agreement with the reference solutions if the radial and axial nodes number is 2 × 2 and 2 × 18 (total axial layers), respectively.
RBP4: A Culprit for Insulin Resistance in End Stage Renal Disease That Can Be Cleared by Hemodiafiltration
Authors: Grosjean Fabrizio , Esposito Pasquale , Maccarrone Rosario , Libetta Carmelo , Dal Canton Antonio , Rampino Teresa
Published: November 2017

Introduction. Retinol Binding Protein 4 (RBP4) is mainly excreted by the kidney and plays a pivotal role in insulin resistance (IR). In our study, we evaluated the association between RBP4 and IR in hemodialysis subjects (HD). We also assessed how circulating RBP4 could be influenced by kidney transplant or different dialytic techniques.Methods. RBP4 serum levels were evaluated in HD (n=16) and matched healthy controls (C;n=16). RBP4 and glucose transporter type 4 (GLUT4) mRNA expressions were also determined in adipose tissue. Circulating RBP4 was evaluated after kidney transplant (n=7) and in hemodialysis patients (n=10) enrolled in a cross-over study treated with standard bicarbonate dialysis (BD) or hemodiafiltration (HDF).Results. HOMA index (P<0.05) and serum RBP4 (P<0.005) were higher in HD compared to C. RBP4 levels positively correlated with fasting serum glucose (P<0.05). RBP4 mRNA was lower in HD compared to C (P<0.05) and positively correlated with kidney function (P<0.05) and GLUT4 mRNA (P<0.001). Transplant or HDF reduced circulating RBP4 (P<0.01andP<0.05, resp.). Our results demonstrate that IR is associated with high circulating RBP4 and that suppressed RBP4 adipose tissue expression is accompanied by reduced GLUT4 expression in HD. Renal transplantation or HDF are effective in lowering serum RBP4 levels.
Recurrent Cesarean Scar Ectopic Pregnancy Treated with Systemic Methotrexate
Authors: Ndubizu Chima , McLaren Rodney A. , McCalla Sandra , Irani Mohamad
Published: November 2017

Cesarean scar pregnancy (CSP) is a rare event; however its incidence has been rising due to the increasing rates of cesarean deliveries. The majority of cases present with signs or symptoms requiring surgery, which often results in hysterectomy. The recurrence of CSP is even rarer with only few cases which have been reported. This is a report of recurrent cesarean scar ectopic pregnancy (RCSP) that was promptly diagnosed and managed with only systemic methotrexate. This was a 30-year-old woman, with a history of two prior cesarean deliveries followed by a CSP, who presented at 5 weeks and 3 days of gestation for her first prenatal visit. Transvaginal ultrasound revealed a RCSP. Her serum beta-human chorionic gonadotropin (β-hCG) level was 54,295 IU/L. The first CSP, which was diagnosed at a later stage, was treated with uterine artery embolization and systemic methotrexate leading to complete resolution within 10 weeks. The current ectopic was treated with two doses of systemic methotrexate; her serum β-hCG reached undetectable levels within 7 weeks. Thus, patients with a history of prior CSP should be carefully monitored with transvaginal ultrasound during subsequent pregnancies to allow early diagnosis of RCSP, which could then be treated conservatively.