bluuebunny/crossref_metadata_2025 huggingface dataset:
P128: The novel application of eye-tracking for the cognitive task analysis of expert physician decision-making while leading real-world traumatic resuscitations
Authors: White M. , Howes D. , Egan R. , Braund H. , Szulewski A.
Published: May 2017

Introduction: Resuscitation is a dynamic, complex and time-sensitive field which encompasses management of both critically-ill patients as well as large multidisciplinary teams. Expertise in this area has not been adequately defined, and to date, no research has directly examined the decision-making and cognitive processes involved. The evolving paradigm of competency-based medical education (CBME) makes better defining expertise in this field of critical importance to aid in the development of both educational and assessment methods. The technique of cognitive task analysis (CTA) has been used in a variety of fields to explicate the cognitive underpinnings of experts. Experts, however, often have limited insight and incomplete recall of their decision-making processes. We hypothesized that the use of eye-tracking, which provides the combination of first-person video as well as an overlying gaze indicator, could be used to enhance CTA to better understand the defining characteristics of experts in resuscitation. Methods: Over an 18-month period a sample of 11 traumatic resuscitations were obtained, each led by one of four pre-selected expert physicians outfitted with the Tobii Pro Eye-Tracking Glasses. After each resuscitation, the participant was debriefed using a cued-recall, think-aloud protocol while watching his or her corresponding eye-tracking video. A subsequent qualitative analysis of the resulting video and debrief transcript was performed using an ethnographic approach to establish emerging themes and behaviours of the expert physicians. Results: The expert participants demonstrated specific, common patterns in their cognitive processes. In particular, participants exhibited similar anticipatory and visual behaviours, dynamic communication strategies and the ability to distinguish between task-relevant and task-redundant information. All participants reported that this technique uncovered otherwise subconscious aspects of their cognition. Conclusion: The novel combination of eye-tracking technology to supplement the CTA of expert resuscitationists enriched our understanding of expertise in this field and yielded specific findings that can be applied to better develop and assess resuscitation skills.
P132: Development and implementation of an intubation registry within a Canadian tertiary-care hospital
Authors: Yoo J.H. , Trojanowski J. , Laberge M. , Griesdale D. , Brubacher J.R.
Published: May 2017

Introduction: Intubation is a high-risk procedure that is frequently performed within the ED. Few Canadian centres have a system in place to monitor intubation frequency, indications, methods used, operator characteristics, first-pass success, and adverse event rates. There are no published data on the frequency of success or complications of emergency airway management in Canada. An airway registry would be a valuable quality improvement (QI) tool for assessing the impact of practice changes such as pre-intubation checklists and for identifying patients with “difficult airways.” We describe the development and implementation of an airway registry in a Canadian tertiary-care centre. Methods: We created a collaborative working group with staff from EM, ICU, Respiratory Therapy (RT), and Privacy. An airway data form was created. Over a 3 month trial period, the form was completed by RTs following each non-OR intubation. At our centre, RTs are present at every intubation outside of the OR. If a patient was intubated outside of the hospital, forms were completed using verbal handover. RTs also provided constructive feedback and after 3 months the form was revised and finalized. Medical student volunteers entered data from the forms and from chart reviews into a secure online database created for this purpose. Results: We have enrolled 373 patients over the first 5 months with ongoing enrolment at the time of abstract submission. The airway form captures the seniority and discipline of the intubator, preparation, technique, and any airway manoeuvres that were used. The form also captures Cormack-Lehane airway grading, confirmation techniques, complications, and the option to identify the patient as a “Difficult Airway.” Privacy permission was granted to include patient identifiers in the airway registry so that additional information from chart reviews could be obtained at a later date. Preliminary results will be presented at the conference. Conclusion: Our airway registry tracks intubation performance and may identify factors associated with adverse patient outcomes, which could prompt system-wide changes. Comparison of intubation performance to other Canadian institutions may be possible if similar airway registries are implemented. The development and implementation of an airway registry requires multi-disciplinary collaboration, engagement, and user feedback.
LO01: Prevalence of pulmonary embolism among Canadian emergency department patients with syncope: a multicenter prospective cohort study
Authors: Thiruganasambandamoorthy V. , Sivilotti M. , McRae A. , Mukarram M.A. , Kim S. , Rowe B.H. , Huang L.
Published: May 2017

Introduction: A recent cross-sectional study reported a 17.3% prevalence of pulmonary embolism (PE) among patients with syncope. However, the study had several flaws including spectrum and work-up bias with over-diagnosis due to excessive investigations. We sought to evaluate the prevalence of PE among Canadian emergency department (ED) patients presenting with syncope. Methods: We enrolled adults with syncope at 5 EDs and collected demographics, proportion of patients evaluated for suspected PE, their Wells PE score values and results of investigations [d-dimer, computed angiography (CT) of chest or ventilation-perfusion (VQ) scan]. 30-day adjudicated outcome included diagnosis of PE requiring treatment. We used descriptive statistics to report the results. Results: 4,739 patients [mean age 54.3 years, 54.4% females, and 587 (12.4%) hospitalized] were enrolled. 323 patients (6.8%) had further evaluation and investigations performed for suspected PE: 255 patients had D-dimer performed, 140 had CT chest and 17 had VQ performed. Of the 323 patients, 300 patients were low risk (Wells score ≤4) and 23 were high-risk (score >4). A total of 16 patients (0.3%) in the study cohort were diagnosed with PE: 10 patients were diagnosed in the ED, 5 patients were diagnosed while hospitalized as inpatient, and 1 patient was diagnosed on a return ED visit. Overall the prevalence of PE was 0.3% among all ED patients with syncope; and a 0.9% among those hospitalized for syncope. Conclusion: Our study shows that the prevalence of PE is very low among all patients presenting to the ED with syncope. The prevalence is also very low among those hospitalized for syncope than previously reported. While PE should be suspected and further investigations performed among syncope patients if clinically appropriate, caution should also be taken against indiscriminate over-investigations for PE.
LO10: Quantity of opioid to prescribe for acute pain to limit misuse after emergency department discharge
Authors: Daoust R. , Paquet J. , Piette E. , Morris J. , Cournoyer A. , Émond M. , Gosselin S. , Lee J.S. , Lavigne G. , Chauny J.
Published: May 2017

Introduction: A 2008 survey found that 1.9% of the entire US population was using prescription pain medication non-medically and that 56% obtained them from a friend or relatives. Diversion of pain medication may occur when a portion of the prescription is unused for pain relief after an ED visit. We hypothesized that at least 10 pills (~40%) of an opioid prescription 2 weeks after an ED visit, will not be consumed and become available for potential misuse. Objective: Determine the quantity of unused opioids pills for common acute pain diagnoses, 2 weeks after an ED visit for acute pain. Methods: Prospective observational cohort study of consecutive ED patients from a tertiary academic urban hospital with 60,000 ED visits annually. Inclusion criteria: aged ≥18 years, acute pain conditions present ≤2 weeks, pain intensity at triage of ≥4 (on a 0-10 numeric rating scale; NRS), and discharged with a new opioid prescription. ED physicians identified (24/7) eligible patients. They recorded the pain complaint/location, the final diagnosis, the quantity and type of prescribed pain medication. Discharged patients completed paper or electronic 14-day diary (REDCap database) to document their pain medication consumption. As a mitigation strategy, they were also contacted by phone at 2 weeks for the same information. A paired t-test was used to test the difference between the amounts of opioids prescribed and consumed. Results: 350 patients were recruited. Mean age 50 (SD ±16) and 54.2% were men. Painful diagnosis: fracture (18.2%), acute back pain (15.3%), renal colic (15.3%), Sprain (excluding back/neck pain) (6.9%), Contusion (6.4%), acute neck pain (5.8%), abdominal pain (4.9%), and other (27.2%). Opioids prescribed: oxycodone (47%), morphine (37%) and hydromorphone (16%). Means quantity of opioid pills prescribed: 24 (IC95%: 23-26). Filled opioid prescription: 92%. Means quantity of opioid pills consumed: 8 (IC95%: 7-9). Means quantity of unused opioids pills: 16. Opioid pills available for misuse in our cohort: 5,600 pills. Conclusion: After an ED visit for acute pain a significant portion of opioids prescribed is unused and available for misuse. A large pragmatic study should be done to confirm that an opioid prescription strategy based on our results will limit unused opioid pills while maintaining pain relief.
LO16: Safety and efficiency of emergency physician supplementation in a provincially nurse-staffed telephone service for urgent caller advice
Authors: Grafstein E. , Abu-Laban R.B. , Wong B. , Stenstrom R. , Scheuermeyer F.X. , Root M. , Doan Q.
Published: May 2017

Introduction: In 2008 British Columbia created a nurse (RN) staffed telephone triage service, (TTS) to provide timely advice to non-911 callers (811). A perception exists that some callers are inappropriately directed to emergency departments (EDs) thereby worsening crowding. We sought to determine whether supplementary emergency physician (EP) triage would decrease ED visits while preserving caller safety and satisfaction. Methods: TTS RNs use computer algorithms and judgment to triage callers. Potentially sick callers are directed to “seek care now” (red calls). Often this is to an ED depending on acuity and time of day. In the Vancouver Health Region from April-September 2016 between 8:00-24:00 hours, a co-located EP also spoke with “red” callers to provide further guidance. Callers were followed up with 1 week and satisfaction was evaluated on a 5-point Likert scale. The TTS data was linked to the regional ED database to assess ED attendance within 7 days, and the provincial vital statistics database for 30-day mortality. Our primary outcome was the proportion of unique “red” callers who did not attend the ED compared with a historical cohort one year earlier without EP triage in place. Secondary outcomes were the proportion of “red” callers advised not to attend the ED but (a) attended, (b) admitted, or (c) died. Results: In the study period there were 5105 “red” calls of which 3440 were transferred to the EP (67.4%), 2958 of EP assessed callers (86.0%) had a family doctor, but only one-quarter of such patients could contact their family doctor. Overall, 2301/3440 “red” callers did not attend an ED (67.0%) compared to 2508/4770 in the control period (52.6%), for an absolute reduction of 14.4% (95% CI 12.2 to 16.4%, p<0.0001). In callers for those <17 years old there was a 20.3% (95% CI 16.5 to 24.1%) reduction in ED visits compared to the control group: 771/1520 (50.7%) vs 364/1067 (30.4%). 40% of callers attending an ED (458/1139) were advised to try non-ED follow up by the MD and 108 (9.5%) were admitted, with no difference in 30-day mortality between groups. Age and CTAS distribution were similar between the two groups and the non MD-transferred cohort. Mean caller satisfaction was excellent (4.7/5.0). Conclusion: EP supplementation of a RN advice service has the potential to reduce ED visits by almost 15% while providing excellent safety and satisfaction.
LO17: A comparative evaluation of ED crowding metrics and associations with patient mortality
Authors: McRae A. , Usman I. , Wang D. , Innes G. , Lang E. , Rowe B.H. , Schull M. , Rosychuk R.J.
Published: May 2017

Introduction: Over 700 different input, throughput and output metrics have been used to quantify ED crowding. Of these, only ED length-of-stay (ED LOS) has been shown to be associated with mortality. No comparative evaluation of ED crowding metrics has been performed to determine which ones have the strongest association with patient mortality. The objective of this study was to compare the strength of association of common ED input, throughput and output metrics to patient mortality. Methods: Administrative data from five years of ED visits (2011-2014) at three urban EDs were linked to develop a database of over 900,000 ED visits with patient demographics, electronic time stamps for care processes, dispositions and outcomes. The data were randomly divided into three partitions of equal size. Here we report the findings from one partition of 253,938 ED visits. The remaining two data partitions will be used to validate these findings. Commonly-used crowding metrics were quantified and aggregated by day or by shift (0800-1600, 1600-2400, 2400-0800), and the shift-specific metrics assigned to each patient. The primary outcome was 7-day all-cause mortality. Multilevel logistic regression models were developed for 7-day mortality, with selected ED crowding metrics and a common set of confounders as predictors. The strength of association between the crowding metrics and mortality was compared using Akaike’s Information Criterion (AIC) and the Bayesian Information Criterion (BIC): ED crowding metrics with lower AIC and BIC have stronger associations with 7-day mortality. Results: Of 909,000 ED encounters, 124,679 (16.5%) arrived by EMS, 149,233(19.7%) were admitted, and 3,808 patients (0.5%) died within 7 days of ED arrival. Of input metrics, the model with ED wait-time was better (i.e. had a smaller AIC and BIC) than models for daily census, ED occupancy or LWBS proportion for predicting 7-day mortality. Of throughput metrics, the model with mean ED LOS was better than the model for mean MD care time. Of output metrics, the model with daily inpatient hospital occupancy was better than the model with mean boarding time. Conclusion: Based on one data partition, regression models based on the average wait-time, ED LOS and inpatient occupancy best predicted 7-day mortality. These results will be validated in the two other data partitions to confirm the best-performing ED input, throughput and output metrics.
LO20: Student Run Simulation Team: A near-peer approach to simulation education
Authors: Bouwsema M. , Turner S. , Saleh D. , Rogers P. , Franke J. , Nicholas J.A. , Polsky Z. , Pfaff M. , Charania I. , Clark M.
Published: May 2017

Introduction/Innovation Concept: Student Run Simulation Team (SRST) is an extracurricular medical student group that provided peers with opportunities to learn and teach principles of acute care medicine in a simulated environment. Early exposure to simulation has been identified as a way for medical students to engage in self-directed education. SRST operated through a peer-led model. Senior medical students designed and delivered didactic sessions, simulation scenarios, and debriefed the scenarios to emphasise targeted objectives. Methods: Informal interviews conducted by the SRST as part of a needs analysis identified barriers to an effective transition from pre-clerkship to clerkship. Specifically, principles of team dynamics including effective communication and role clarification in emergency situations were identified as areas where students lacked confidence. The curriculum focused on leadership and an effective team approach to common acute presentations. SRST members acquired simulation skills under the guidance of a simulation team at the University of Calgary. In the inaugural year, 8 second year students developed and delivered the curriculum to 16 first year students. Quality improvement surveys and participant feedback contributed to ongoing program review and refinement. Curriculum, Tool, or Material: Didactic lectures and task-trainer based skills sessions were created to assist the medical students in developing a foundational approach to a patient presenting to the emergency department. Three distinct simulations of increasing complexity were designed for students to build on their skills. SRST members worked with simulation consultants during 4 custom designed training sessions to develop simulation skills (design and debriefing). The distinguishing aspect of SRST is an emphasis on the non-technical skills of teamwork, leadership, and communication, rather than knowledge acquisition alone. The structure also included a succession plan for continued peer-led education where the student participants will form the next year’s team and will receive similar simulation education. Conclusion: SRST is the first student-run simulation initiative to be established in a Canadian medical school. This near-peer team allowed for early practice of non-technical skills in emergency settings. SRST facilitated opportunities for simulation education for both the junior students as participants, and the senior medical students as educators. This is an ongoing initiative, with plans to continue program development in future years.
LO22: Implementation of an electronic clinical decision support tool to improve knowledge translation and imaging appropriateness for patients with mild traumatic brain injury and suspected pulmonary embolism
Authors: Andruchow J. , Grigat D. , McRae A. , Innes G. , Lang E.
Published: May 2017

Introduction/Innovation Concept: Utilization of CT imaging has increased dramatically over the past two decades, but has not necessarily improved patient outcomes. As healthcare spending grows unsustainably and evidence of harms from unnecessary testing accrues, there is pressure to improve imaging appropriateness. However, prior attempts to reduce unnecessary imaging using evidence-based guidelines have met with limited success, with common barriers cited including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. This project attempts to address these barriers through the development of an electronic clinical decision support (CDS) tool embedded in clinical practice. Methods: An interactive web-based point-of-care CDS tool was incorporated into computerized physician order entry software to provide real-time evidence-based guidance to emergency physicians for select clinical indications. For patients with mild traumatic brain injury (MTBI), decision support for the Canadian CT Head Rule pops up when a CT head is ordered. For patients with suspected pulmonary embolism (PE), the tool is triggered when a CT pulmonary angiogram is ordered and provides CDS for the Pulmonary Embolism Rule-out Criteria (PERC), Wells Score, age-adjusted D-dimer and CT imaging. To study the impact of the tool, all emergency physicians in the Calgary zone were randomized to receive voluntary decision support for either MTBI or PE. Curriculum, Tool, or Material: The tool uses a multifaceted approach to inform physician decision making, including visualization of risk and quantitative outcomes data and links to primary literature. The CDS tool simultaneously documents guideline compliance in the health record, generates printable patient education materials, and populates a REDCap™ database, enabling the creation of confidential physician report cards on CT utilization, appropriateness and diagnostic yield for both audit and feedback and research purposes. Preliminary data show that physicians are using the MTBI CDS approximately 30% of the time, and the PE CDS approximately 40% of the time. Evaluation of CDS impact on imaging utilization and appropriateness is ongoing. Conclusion: A voluntary web-based point-of-care decision support tool embedded in workflow has the potential to address many of the factors typically cited as barriers to use of evidence-based guidelines in practice. However, high rates of adherence to CDS will likely require physician incentives and appropriateness measures.
LO27: System outcomes associated with an emergency department clinical decision unit
Authors: Karacabeyli D. , Park D.K. , Meckler G. , Doan Q.
Published: May 2017

Introduction: A clinical decision unit (CDU) is an area within the emergency department (ED) that allows for protocol-driven treatment & observation of patients who may not require hospital admission, but are not ready for discharge after initial assessment & treatment. A CDU was established at BC Children’s Hospital in 2014 as a means to optimize hospital resource utilization. Preliminary administrative data review revealed a return to ED (RTED) rate of 15% following a CDU stay, 2-3 times the RTED rate reported in the literature. Whether this is the expected cost of reducing hospital admissions remains unclear. Research exploring the underlying reasons for RTED following a CDU stay is limited. Objectives: Following a CDU stay, to describe 1) disposition outcome distribution; 2) underlying reasons for RTED; and 3) the proportion of potentially preventable RTED. Methods: Retrospective cohort study of all ED visits with a CDU stay from Jan 1, 2015 to Dec 31, 2015. Health records data was extracted & entered into standardized online forms by trained research assistants, then blindly reviewed by two investigators to determine a) the most probable cause of each RTED & b) the number of RTED that were clinically unnecessary. Results: Of the 1696 index CDU visits, 1503 (89%) were discharged home. However, 139 (9%) had ≥1 associated RTED. Among these, 48 (35%) were deemed clinically unnecessary (89% agreement, Kappa=0.79) & therefore potentially preventable. The most common reason (88%) for unnecessary RTED was mismatch between expected natural progression of disease (not requiring further medical assessment or treatment) & families’ understanding of disease symptom range & duration. In 90% of these cases, anticipatory guidance regarding natural progression of disease was not communicated to parents upon discharge. Among the remaining 1364 (91%) that did not return, 750 had an initial visit total ED length of stay of >8 hours, thus were considered averted hospitalizations attributable to the CDU. Conclusion: The CDU has had a positive impact on patient & system outcomes through the prevention of several inpatient admissions. However, we observed a relatively large proportion of RTED, 35% of which were clinically unnecessary & 27% of which had inadequate discharge instructions. This highlights opportunities to further optimize the effectiveness of the CDU through quality improvement initiatives focusing on the ED discharge process.
PRACTICE OF CONSANGUINITY AND ATTITUDES TOWARDS RISK IN THE PASHTUN POPULATION OF KHYBER PAKHTUNKHWA, PAKISTAN
Authors: Pervaiz Ruqiya , Faisal Faisal , Serakinci Nedime
Published: May 2017

This study aimed to investigate the frequency of consanguineous marriages and level of understanding of consanguinity-associated genetic risks in the Pashtun population, Pakistan. Information was gathered using a detailed questionnaire completed by 1500 individuals of both sexes over the 11-month period between April 2015 and February 2016. The mean inbreeding coefficient of the respondents was calculated and a five-point response scale was used to assess their understanding of consanguinity risks. The frequency of consanguineous marriages in the Pashtun population was found to be 58.3%, with a mean inbreeding coefficient of 0.0259. Marriage between second cousins was found to be the dominant marriage type. Level of education was found to be negatively related to the incidence of consanguineous marriage (p<0.001), and higher consanguinity was reported among the rural than the urban population (p<0.001). Participants in the ≥25-year age group, those with a higher level of education and those residing in urban areas exhibited a significantly higher understanding of consanguinity risks. The overall prevalence of consanguinity in the Pashtun population is high, demonstrating the need for awareness of its risks in the target population. The timely dissemination of information on potential health-related risks and the introduction of genetic counselling in the region would benefit both the individuals concerned and the community in general.
Survival outcomes following salvage surgery for oropharyngeal squamous cell carcinoma: systematic review
Authors: Kao S S , Ooi E H
Published: May 2017

Background:

Recurrent oropharyngeal squamous cell carcinoma causes great morbidity and mortality. This systematic review analyses survival outcomes following salvage surgery for recurrent oropharyngeal squamous cell carcinoma.

Methods:

A comprehensive search of various electronic databases was conducted. Studies included patients with recurrent or residual oropharyngeal squamous cell carcinoma treated with salvage surgery. Primary outcomes were survival rates following salvage surgery. Secondary outcomes included time to recurrence, staging at time of recurrence, post-operative complications, and factors associated with mortality and recurrence. Methodological appraisal and data extraction were conducted as per Joanna Briggs Institute methodology.

Results:

Eighteen articles were included. The two- and five-year survival rates of the patients were 52 per cent and 30 per cent respectively.

Conclusion:

Improvements in treatment modalities for recurrent oropharyngeal squamous cell carcinoma were associated with improvements in two-year overall survival rates, with minimal change to five-year overall survival rates. Various factors were identified as being associated with long-term overall survival, thus assisting clinicians in patient counselling and selection for salvage surgery.
Modiolar ossification in paediatric patients with auditory neuropathy
Authors: Wang L , Wang Z , Gao F , Peng K A
Published: May 2017

Objective:

To describe our finding of increased ossification of the modiolus in paediatric patients with auditory neuropathy who met criteria for cochlear implantation.

Methods:

A retrospective case series with a comparison group at a tertiary referral centre is described. Seven paediatric patients with auditory neuropathy who met criteria for and underwent cochlear implantation were identified. Fifteen paediatric implantees with bilateral profound sensorineural hearing loss were included as the comparison group. All patients underwent pre-operative computed tomography. Attenuation at the modiolus was measured in all subjects by a neuroradiologist blinded to clinical information.

Results:

Attenuation values in the modiolus in the auditory neuropathy patients (mean ± standard deviation = 796.2 ± 53.0 HU) was statistically significantly higher than in the comparison sensorineural hearing loss patients (267.1 ± 45.6 HU;p< 0.05,t-test).

Conclusion:

Patients with auditory neuropathy who meet criteria for cochlear implantation demonstrate significantly higher modiolar attenuation on computed tomography imaging, consistent with increased ossification at the modiolus.
Non-canonical agreement in copular clauses
Authors: BÉJAR SUSANA , KAHNEMUYIPOUR ARSALAN
Published: May 2017

In this paper we investigate cross-linguistic variation in the morphosyntax of copular clauses, focusing on agreement patterns in binominal structures [NP1 BE NP2]. Our starting point is the alternation between NP1 and NP2 agreement, which arises both within and across languages. This alternation is typically taken to be confined to specificational (i.e. inverted) clauses, and previous analyses have strongly identified NP2 agreement with the syntax of inversion. However, we show that NP2 agreement is attested in a broader range of contexts, specifically in (assumed identity) equative structures, suggesting that it should not be correlated with specificational syntax. We present contrasting data from two languages – Persian and Eastern Armenian – for which the syntax of copular clauses is understudied. Whereas in Persian we see NP2 agreement in specificational structures but NP1 agreement in assumed identity equatives, in Eastern Armenian both types of structure yield NP2 agreement. We argue that the contrast between Persian and Eastern Armenian supports an approach that takes the NP1–NP2 alternation to arise as a phi-sensitivity in the probe–goal mechanics of Agree in a minimalist framework. Under this view, NP2 agreement is independent of syntactic inversion and is the result of the probe structure being articulated in such a way that certain NPs fail to Agree.
Within-host interference competition can prevent invasion of rare parasites
Authors: Quigley Benjamin J. Z. , Brown Sam P. , Leggett Helen C. , Scanlan Pauline D. , Buckling Angus
Published: May 2017

Competition between parasite species or genotypes can play an important role in the establishment of parasites in new host populations. Here, we investigate a mechanism by which a rare parasite is unable to establish itself in a host population if a common resident parasite is already present (a ‘priority effect’). We develop a simple epidemiological model and show that a rare parasite genotype is unable to invade if coinfecting parasite genotypes inhibit each other's transmission more than expected from simple resource partitioning. This is because a rare parasite is more likely to be in multiply-infected hosts than the common genotype, and hence more likely to pay the cost of reduced transmission. Experiments competing interfering clones of bacteriophage infecting a bacterium support the model prediction that the clones are unable to invade each other from rare. We briefly discuss the implications of these results for host-parasite ecology and (co)evolution.
Effect of high-Z dopant on the laser-driven ablative Richtmyer–Meshkov instability
Authors: Xu B. , Ma Y. , Yang X. , Tang W. , Wang S. , Ge Z. , Zhao Y. , Ke Y.
Published: May 2017

The effects of high-Z dopant on the laser-driven ablative Richtmyer–Meshkov instability (RMI) are investigated by theoretical analysis and radiation hydrodynamics simulations. It is found that the oscillation amplitude of ablative RMI depends on the ablation velocity, the blow-off plasma velocity and the post-shock sound speed. Owing to enhancing the radiation at the plasma corona and increasing the radiation temperature at the ablation front, the high-Z dopant in plastic target can significantly increase the ablation velocity and the blow-off plasma velocity, leading to an increase in oscillation frequency and a reduction in oscillation amplitude of the ablative RMI. The high-Z dopant in plastic target is beneficial to reduce the seed of ablative Rayleigh–Taylor instability. These results are helpful for the design of direct drive inertial confinement fusion capsules.
A NEW HEALTH TECHNOLOGY ASSESSMENT SYSTEM FOR DEVICES: THE FIRST FIVE YEARS
Authors: Campbell Bruce , Dobson Lee , Higgins Joanne , Dillon Bernice , Marlow Mirella , Pomfrett Chris
Published: May 2017

Objectives: The aim of this study was to review 5 years of activity from a new system devised by the National Institute for Health and Care Excellence (NICE), for assessing medical devices and diagnostics aimed at identifying and speeding adoption of technologies with clinical and cost advantages, compared with current practice in the United Kingdom healthcare system.

Methods: All eligible notified technologies were classified using the Food and Drug Administration and Global Medical Device Nomenclature nomenclatures. Decisions about selecting technologies for full assessment to produce NICE recommendations were reviewed, along with the reasons given to companies for not selecting products.

Results: Between 2009 and 2014, 186 technologies were notified (46 percent therapeutic and 54 percent diagnostic). Thirty-nine were judged ineligible (no regulatory approval), and 147 were considered by an independent committee. Of these, eighty (54 percent) were not selected for full assessment, most commonly because of insufficient evidence (86 percent): there were uncertainties specifically about benefits to the health service (54 percent), to patients (39 percent), and about cost (24 percent). The remaining 67 were selected and assessed for Medical Technology guidance (52 percent) (noninferior and/or lower cost consequences than current practice), for Diagnostics guidance (43 percent) or other NICE recommendations about adoption and use. Classifying technologies by two different systems showed no selection bias for any technology type or disease area.

Conclusions: Identifying new or under-used devices and diagnostics with potential benefits and promoting their adoption is important to health services in the United Kingdom and worldwide. This new system offers a means of fostering both uptake and further research. Lack of research data on new products is a major obstacle to evaluation.
The Educational Gradient in Health in China
Authors: Chen Qiulin , Eggleston Karen , Zhang Wei , Zhao Jiaying , Zhou Sen
Published: May 2017

It has been well established that better educated individuals enjoy better health and longevity. In theory, the educational gradients in health could be flattening if diminishing returns to improved average education levels and the influence of earlier population health interventions outweigh the gradient-steepening effects of new medical and health technologies. This paper documents how the gradients are evolving in China, a rapidly developing country, about which little is known on this topic. Based on recent mortality data and nationally representative health surveys, we find large and, in some cases, steepening educational gradients. We also find that the gradients vary by cohort, gender and region. Further, we find that the gradients can only partially be accounted for by economic factors. These patterns highlight the double disadvantage of those with low education, and suggest the importance of policy interventions that foster both aspects of human capital for them.
X-ray powder diffraction data for ertapenem side chain, C20H19N3O7S
Authors: Lin Xiang , Zhuo Wei Ling , Du Qiao Hong , Peng Xi Lin , Li Hui
Published: May 2017

X-ray powder diffraction data, unit-cell parameters, and space group for ertapenem side chain, C20H19N3O7S, are reported [a = 4.907(6) Å, b = 18.686(3) Å, c = 22.071(1) Å, α = γ = 90°, β = 90.759(5)°, unit-cell volume V = 2023.82 Å3, Z = 4, ρcal = 1.462 g cm−3, and space group P21/c]. All measured lines were indexed and are consistent with the P21/c space group. No detectable impurity was observed.
Study of the impact onSalmonellaof moving outdoor pigs to fresh land
Authors: SMITH R. P. , ANDRES V. , DORMER L. , GOSLING R. , OASTLER C. , DAVIES R. H.
Published: May 2017

Anecdotal evidence has suggested that outdoor-kept pigs show an improvement to health and productivity after being moved to a new site. This study explores whetherSalmonellaoccurrence reduced and was sustained after moving to a new site. Nine farms were followed for a year in which four sampling visits were completed. The highest detection ofSalmonellawas from pooled faecal dropping from pigs, run-off/ pooled water, rodents and wild birds. Descriptive summaries showed that the prevalence of both allSalmonellaand serovars of public health importance were lower at all visits after the move. Some variability was shown in results from individual farms, but a year after the move, six farms still maintained a lower prevalence. A risk factor model showed that the prevalence at visits 2 and 3 after the move was significantly lower than baseline, after accounting for a number of significant factors that were included in the model. These were sample type and seasonality (included asa priori), presence of coughing in the sampled group and Glasser's disease on the farm, and the use of tent or kennel accommodation. This finding provides important evidence that more frequent site moves may help reduceSalmonellaprevalence in outdoor herds.
ROSCOEA MEGALANTHA (ZINGIBERACEAE), A NEW SPECIES FROM EASTERN BHUTAN AND INDIA
Authors: Yoshida T. , Yangzom R. , Newman M. F.
Published: May 2017

A new species of Roscoea is described and illustrated. Roscoea megalantha Tosh.Yoshida & R.Yangzom occurs in the Eastern Zone of Bhutan and neighbouring Arunachal Pradesh in India. A distribution map and an IUCN conservation assessment are given. A key to the three species of Roscoea found in Bhutan is provided.
The ‘Baltimore Plan’: case-study from the prehistory of urban rehabilitation
Authors: LECLAIR-PAQUET BENJAMIN
Published: May 2017

Federally funded ‘urban rehabilitation’ began with the Housing Act of 1954 in the United States. Baltimore's Harlem Park was selected to pilot this experimental programme; a logical choice seeing how the pilot largely built on a programme dating from the prehistory of legislated urban rehabilitation that originated in Baltimore. This article lays bare the history of this programme, known as the ‘Baltimore Plan’, which offered empirical evidence that substantiated the potential of participatory urban planning. Beyond transferring upon minority communities a level of control over housing that black communities had seldom possessed before, the Baltimore Plan also constituted in an alternative to public housing.
DELAYED FUZZY CONTROL OF OFFSHORE STEEL JACKET PLATFORMS
Authors: ZHANG B.-L. , XU Y.-M.
Published: May 2017

We study a delayed fuzzy $H_{\infty }$ control problem for an offshore platform under external wave forces. First, by considering perturbations of the masses of the platform and an active mass damper, a Takagi–Sugeno fuzzy model is established. Then, by introducing time delays into the control channel, a delayed fuzzy state feedback $H_{\infty }$ controller is designed. Simulation results show that the delayed fuzzy state feedback $H_{\infty }$ controller can reduce vibration amplitudes of the offshore platform and can save control cost significantly.
COMPETITIVE ANALYSIS OF INTERRELATED PRICE ONLINE INVENTORY PROBLEMS WITH DEMANDS
Authors: HAN SHUGUANG , HU JUELIANG , ZHOU DIWEI
Published: May 2017

This paper investigates interrelated price online inventory problems, in which decisions as to when and how much of a product to replenish must be made in an online fashion to meet some demand even without a concrete knowledge of future prices. The objective of the decision maker is to minimize the total cost while meeting the demands. Two different types of demand are considered carefully, that is, demands which are linearly and exponentially related to price. In this paper, the prices are online, with only the price range variation known in advance, and are interrelated with the preceding price. Two models of price correlation are investigated, namely, an exponential model and a logarithmic model. The corresponding algorithms of the problems are developed, and the competitive ratios of the algorithms are derived as the solutions by use of linear programming.
Shared Parental Leave in the UK: can it advance gender equality by changing fathers into co-parents?
Authors: Atkinson Jamie
Published: May 2017

The paper aims to provide a critique of Shared Parental Leave (SPL) in the UK from a gender equality perspective, namely to assess whether SPL is capable of enabling more men to take leave in order to act as the main carer for their child. Leave policies in Nordic countries, where the rate of take-up by fathers is high, are also examined. It argues that SPL is open to legal challenge by fathers who do not meet the eligibility criteria, as the SPL scheme as currently drafted breaches the terms of the EU Parental Leave Directive and is also discriminatory on grounds of sex. The paper concludes that SPL is flawed as a policy. Whilst the UK government argues for a more equal division of childcare between father and mother, it seems unwilling to challenge the expectation that mothers provide the primary care for young children. Thus SPL will only be successful if the policy is reformed to include a higher rate of pay and a period of leave reserved for fathers.
Revolution and Revolutionary Movements in Latin America:A Special Teaching and Research Collection of The Americas
Authors: Toffoli Erica
Published: May 2017

This curated collection ofThe Americasexplores revolution and revolutionary movements in Latin American history from the colonial period to the present. This theme embraces events and processes contributing to the courses, outcomes, and reactions to both moments conventionally labeled “revolutions” in Latin American history, such as large-scale events like the Mexican Revolution, and more disparate efforts to secure—or resist—sociopolitical change.
Nerve growth factor from Chinese cobra venom stimulates chondrogenic differentiation of mesenchymal stem cells
Authors: Lu Zhenhui , Lei Danqing , Jiang Tongmeng , Yang Lihui , Zheng Li , Zhao Jinmin
Published: May 2017

Growth factors such as transforming growth factor beta1 (TGF-β1), have critical roles in the regulation of the chondrogenic differentiation of mesenchymal stem cells (MSCs), which promote cartilage repair. However, the clinical applications of the traditional growth factors are limited by their high cost, functional heterogeneity and unpredictable effects, such as cyst formation. It may be advantageous for cartilage regeneration to identify a low-cost substitute with greater chondral specificity and easy accessibility. As a neuropeptide, nerve growth factor (NGF) was involved in cartilage metabolism and NGF is hypothesized to mediate the chondrogenic differentiation of MSCs. We isolated NGF from Chinese cobra venom using a three-step procedure that we had improved upon from previous studies, and investigated the chondrogenic potential of NGF on bone marrow MSCs (BMSCs) bothin vitroandin vivo. The results showed that NGF greatly upregulated the expression of cartilage-specific markers. When applied to cartilage repair for 4, 8 and 12 weeks, NGF-treated BMSCs have greater therapeutic effect than untreated BMSCs. Although inferior to TGF-β1 regarding its chondrogenic potential, NGF showed considerably lower expression of collagen type I, which is a fibrocartilage marker, andRUNX2, which is critical for terminal chondrocyte differentiation than TGF-β1, indicating its chondral specificity. Interestingly, NGF rarely induced BMSCs to differentiate into a neuronal phenotype, which may be due to the presence of other chondrogenic supplements. Furthermore, the underlying mechanism revealed that NGF-mediated chondrogenesis may be associated with the activation of PI3K/AKT and MAPK/ERK signaling pathways via the specific receptor of NGF, TrkA. In addition, NGF is easily accessed because of the abundance and low price of cobra venom, as well as the simplified methods for separation and purification. This study was the first to demonstrate the chondrogenic potential of NGF, which may provide a reference for cartilage regeneration in the clinic.
Dehydration-driven stress transfer triggers intermediate-depth earthquakes
Authors: Ferrand Thomas P. , Hilairet Nadège , Incel Sarah , Deldicque Damien , Labrousse Loïc , Gasc Julien , Renner Joerg , Wang Yanbin , Green II Harry W. , Schubnel Alexandre
Published: May 2017

Intermediate-depth earthquakes (30–300 km) have been extensively documented within subducting oceanic slabs, but their mechanics remains enigmatic. Here we decipher the mechanism of these earthquakes by performing deformation experiments on dehydrating serpentinized peridotites (synthetic antigorite-olivine aggregates, minerals representative of subduction zones lithologies) at upper mantle conditions. At a pressure of 1.1 gigapascals, dehydration of deforming samples containing only 5 vol% of antigorite suffices to trigger acoustic emissions, a laboratory-scale analogue of earthquakes. At 3.5 gigapascals, acoustic emissions are recorded from samples with up to 50 vol% of antigorite. Experimentally produced faults, observed post-mortem, are sealed by fluid-bearing micro-pseudotachylytes. Microstructural observations demonstrate that antigorite dehydration triggered dynamic shear failure of the olivine load-bearing network. These laboratory analogues of intermediate-depth earthquakes demonstrate that little dehydration is required to trigger embrittlement. We propose an alternative model to dehydration-embrittlement in which dehydration-driven stress transfer, rather than fluid overpressure, causes embrittlement.
Low phosphate activates STOP1-ALMT1 to rapidly inhibit root cell elongation
Authors: Balzergue Coline , Dartevelle Thibault , Godon Christian , Laugier Edith , Meisrimler Claudia , Teulon Jean-Marie , Creff Audrey , Bissler Marie , Brouchoud Corinne , Hagège Agnès , Müller Jens , Chiarenza Serge , Javot Hélène , Becuwe-Linka Noëlle , David Pascale , Péret Benjamin , Delannoy Etienne , Thibaud Marie-Christine , Armengaud Jean , Abel Steffen , Pellequer Jean-Luc , Nussaume Laurent , Desnos Thierry
Published: May 2017

Environmental cues profoundly modulate cell proliferation and cell elongation to inform and direct plant growth and development. External phosphate (Pi) limitation inhibits primary root growth in many plant species. However, the underlying Pi sensory mechanisms are unknown. Here we genetically uncouple two Pi sensing pathways in the root apex of Arabidopsis thaliana. First, the rapid inhibition of cell elongation in the transition zone is controlled by transcription factor STOP1, by its direct target, ALMT1, encoding a malate channel, and by ferroxidase LPR1, which together mediate Fe and peroxidase-dependent cell wall stiffening. Second, during the subsequent slow inhibition of cell proliferation in the apical meristem, which is mediated by LPR1-dependent, but largely STOP1–ALMT1-independent, Fe and callose accumulate in the stem cell niche, leading to meristem reduction. Our work uncovers STOP1 and ALMT1 as a signalling pathway of low Pi availability and exuded malate as an unexpected apoplastic inhibitor of root cell wall expansion.
Probing nanofriction and Aubry-type signatures in a finite self-organized system
Authors: Kiethe J. , Nigmatullin R. , Kalincev D. , Schmirander T. , Mehlstäubler T. E.
Published: May 2017

Friction in ordered atomistic layers plays a central role in various nanoscale systems ranging from nanomachines to biological systems. It governs transport properties, wear and dissipation. Defects and incommensurate lattice constants markedly change these properties. Recently, experimental systems have become accessible to probe the dynamics of nanofriction. Here, we present a model system consisting of laser-cooled ions in which nanofriction and transport processes in self-organized systems with back action can be studied with atomic resolution. We show that in a system with local defects resulting in incommensurate layers, there is a transition from sticking to sliding with Aubry-type signatures. We demonstrate spectroscopic measurements of the soft vibrational mode driving this transition and a measurement of the order parameter. We show numerically that both exhibit critical scaling near the transition point. Our studies demonstrate a simple, well-controlled system in which friction in self-organized structures can be studied from classical- to quantum-regimes.