bluuebunny/crossref_metadata_2025 huggingface dataset:
Design and identification of tilt-motor quadrotor control system
Authors: Shavin Mikhail
Published: October 2018

Unmanned aerial vehicle (UAV) with four tilt-motors is considered. The quadrotor includes four servomotors, which allow tilting the motors responsible for the thrust force. Additional control input signals enhance the UAVs maneuverability and forward flight speed in comparison with analogous classically designed UAVs. We develop a mathematical model of the tilt-motor quadrotor dynamics, which takes into account all principal forces and torques. On the basis of the mathematical model we design the control loop for a tiltmotor quadrotor. The implemented control algorithm not only allows to independently control position and attitude of the UAV, but also takes into account non-linear actuators constraints. Sensor signals, upon which the closed controlloop relies, are processed with the aid of Extended Kalman Filter. We demonstrate the performance of the model and the control-loop by simulating UAV’s passing an obstacle course. Our numerical experiments are also instrumental in identifying the key parameters of principal parts of the construction.
Measurement and analysis of truck vibrations during off-road transportation
Authors: Grzesica Dariusz
Published: October 2018

Measurement of vibration of the vehicle on the road surface is one of the key elements of cargo and vehicle security. This paper provides results from transporting military cargo study that analyzed the various vibrations of acceleration during transport on a stony pavement road. The data include vibrations from three directions: longitudinal, transverse and vertical. Based on collected data the quantitative analysis of vibrations was conducted. The peak acceleration as well as the acceleration level was identified. The growth rate acceleration affecting the smoothness of driving and the impact of the vehicle on the stony surface were calculated. The study shows that the greatest impact on transporting cargo have vertical vibrations. In addition, using the Fourier transform, amplitude spectrum for all directions of oscillation was assigned.
Analysis of classical flutter in steam turbine blades using reduced order aeroelastic model
Authors: Prasad Chandra Shekhar , Pešek Luděk
Published: October 2018

In the present paper classical flutter phenomena in LP steam turbine rotor is studied . A reduced order aeroelastic model (ROAM) with acceptable accuracy and fast execution is developed for this purpose. The aerodynamics damping (AD) is estimated using Traveling wave mode (TWM) method. Flow field is modeled using Panel method. For the structural part ROM non-linear beam element method (BEM) based FEM structural solver is used. Partitioned based ( loose) coupling approach is adopted to perform aeroelastic (flutter) cosimulation. Both 2D cascade flow and 3D cascade are modeled.The estimated stability parameters are compared with experimental data. Moreover, present ROAM shows significant reduction in computational time.
Palladium-Catalyzed Direct Acylation: One-Pot Relay Synthesis of Anthraquinones
Authors: Satyanarayana Gedu , Suchand Basuli
Published: October 2018

A bis-acylation strategy to access functionalized anthraquinones via one-pot relay process, is presented. The first acylation was feasible under [Pd]-catalyzed intermolecular direct acylation reaction, while, the second acylation was accomplished by using intramolecular Friedel–Crafts acylation. Notably, benchtop aldehydes have been utilized as non-toxic acylation agents in the key [Pd]-catalyzed acylation.
Guided by Evolution: Biology-Oriented Synthesis of Bioactive Compound Classes
Authors: Karageorgis George , Waldmann Herbert
Published: October 2018

Biology-oriented-synthesis (BIOS), is a chemocentric approach to identifying structurally novel molecules as tools for chemical biology and medicinal chemistry research. The vast chemical space cannot be exhaustively covered by synthetic chemistry. Thus, methods which reveal biologically relevant portions of chemical space are of high value. Guided by structural conservation in the evolution of both proteins and natural products, BIOS classifies bioactive compound classes in a hierarchical manner based on molecular architecture and bioactivity. Biologically relevant scaffolds inspire and guide the synthesis of BIOS libraries, which calls for the development of suitable synthetic methodologies. These compound collections have enriched biological relevance, leading to the discovery of bioactive small molecules. These potent and selective modulators allow the study of complex biological pathways and may serve as starting points for drug discovery programs. Thus, BIOS can also be regarded as a hypothesis-generating tool, guiding the design and preparation of novel, bioactive molecular scaffolds. This review elaborates the principles of BIOS and highlights selected examples of their application, which have in turn created future opportunities for the expansion of BIOS and its combination with fragment-based compound discovery for the identification of biologically relevant small molecules with unprecedented molecular scaffolds.

1 Introduction

2 Structural Classification of Natural Products

3 Implications and Opportunities for Biology-Oriented Synthesis

4 Applications of Biology-Oriented Synthesis

4.1 Chemical Structure and Bioactivity Guided Approaches

4.2 Natural-Product-Derived Fragment-Based Approaches

5 Conclusions and Outlook
Reliability and validity of a Turkish version of the Sexual Quality of Life – Male questionnaire: a methodological study
Authors: Kilic Ayse , Tastan Sevinc , Ayhan Hatice , Seven Memnun , Tastan Birhan
Published: October 2018

Background The aim of this methodological study was to assess the reliability and validity of the Sexual Quality of Life – Male (SQoL-M) questionnaire translated and adapted to measure the sexual quality of life of men in Turkey and Northern Cyprus. Methods: To assess the reliability and validity of the Turkish version of the SQoL-M questionnaire, in January and February 2017 we formed a sample of 128 men from Ankara, Turkey, and Girne, Northern Cyprus, to complete the questionnaire. Two weeks later, 65 of these men completed the questionnaire during a retest. Factor analysis was conducted to evaluate the questionnaire’s factor structure, internal consistency and test–retest reliability analyses were used to assess reliability and Pearson’s correlation coefficient was used to measure criterion-related validity. Results: Cronbach’s α for the Turkish version of the SQoL-M questionnaire was 0.91, with corrected item–total score correlations ranging from 0.432 to 0.819. The test–retest correlation, calculated to compare scale scores of both groups of participants, was 0.83 (P<0.001). We also observed a statistically significant relationship between the Turkish version of the SQoL-M questionnaire and the Arizona Sexual Experience scale. Conclusions: The Turkish version of the SQoL-M questionnaire is a valid, reliable instrument for evaluating the sexual quality of life of men in Turkey and Northern Cyprus.
Screening for risk of low energy availability in athletic and recreationally active females in Ireland
Authors: Logue Danielle M. , Madigan Sharon M. , Heinen Mirjam , McDonnell Sarah‐Jane , Delahunt Eamonn , Corish Clare A.
Published: October 2018

Introduction: Low energy availability (LEA) results in physiological adaptations, which can contribute to unfavourable health outcomes. Little information exists on risk of LEA in active individuals competing in different sports or levels of competition. The aims of this study were to (1) identify risk of LEA in females competing at different levels of competition and (2) investigate associations between risk of LEA, illness and dietary habits. Methods: The validated questionnaire, ‘Low Energy Availability in Females Questionnaire’ was distributed online (November 2016–February 2017) to assess risk of LEA. Twenty‐nine additional questions collected information on demographics, illness history and dietary habits. Participants were considered at risk of LEA if they attained a score of ≥ 8 and were grouped into: (i) international; (ii) provincial/inter‐county; (iii) competitive; and (iv) recreationally active. Chi‐square and logistic regression analyses were used to explore differences between those at risk or not at risk of LEA. Results: Risk of LEA was identified in 40% (n = 331) of 833 participants and was 1.7 and 1.8 times more likely in international and provincial/inter‐county athletes compared to those who were recreationally active (International: odds ratios (OR) 1.68, 95% confidence intervals (95%CI) 1.12–2.54; Provincial/inter‐county: OR 1.83, 95%CI 1.20–2.77). In participants at risk of LEA, missing >22 days of training during the previous year due to illness occurred 3 times more frequently (OR 3.01, 95%CI 1.81–5.02). Conclusion: Risk of LEA was widespread in this heterogeneous sample. Awareness of LEA and the development of appropriate energy management strategies to ensure athlete health across levels of competition are required.
Alterations in core temperature during World Rugby Sevens Series tournaments in temperate and warm environments†
Authors: Taylor Lee , Thornton Heidi R. , Lumley Nick , Stevens Christopher J.
Published: October 2018

Purpose: To characterize player core temperature (Tc) across two separate World Rugby Sevens Series (WRSS) tournaments in temperate and warm environments. Methods: Tc was collected in seventeen playing members of one men's team competing at the Singapore (n = 12) and London (n = 11) WRSS tournaments. Exertional heat illness (EHI) symptoms, cooling strategy use, playing minutes and wet blub globe temperature (WBGT) were also collected. Linear mixed models and magnitude‐based inferences assessed differences in Tc between all periods within‐and between tournaments and were also used to assess the effect of WBGT and playing minutes on Tc. Results: Several players experienced Tc in excess of 38°C during warm‐ups and 39°C during games. The highest mean Tc values were observed in the final game on all days and in Singapore Day Two, there were substantial game‐on‐game increases in mean Tc. These Tc responses were associated with playing minutes (effect size; ±90% CL = 0.38; ±0.20), although the effect of WBGT was trivial and unclear. Further, there were no differences in Tc between the two tournaments in the different environments. Despite high individual peak Tc values (Singapore 39.9°C; London 39.6°C); no signs/symptoms of EHI were reported, voluntary post‐game cooling usage was minimal, and pre‐ and mid‐cooling strategies were not implemented. Conclusions: During WRSS matches, peak Tc values approached thresholds associated with EHI (>40°C) and exceeded those demonstrated to reduce repeated sprint performance (>39°C). Practitioners may consider the use of compatible cooling and heat acclimation strategies to minimize Tc increase and maximize player preparedness and recovery.
Are professional young rugby league players eating enough? Energy intake, expenditure and balance during a pre‐season
Authors: Costello Nessan , Deighton Kevin , Preston Thomas , Matu Jamie , Rowe Joshua , Jones Ben
Published: October 2018

Due to the unique energetic demands of professional young collision sport athletes, accurate assessment of energy balance is required. Consequently, this is the first study to simultaneously investigate the energy intake, expenditure and balance of professional young rugby league players across a pre‐season period. The total energy expenditure of six professional young male rugby league players was measured via doubly labelled water over a fourteen‐day assessment period. Resting metabolic rate was measured and physical activity level calculated. Dietary intake was reported via Snap‐N‐Send over a non‐consecutive ten‐day assessment period, alongside changes in fasted body mass and hydration status. Accordingly, energy balance was inferred. The mean (standard deviation) difference between total energy intake (16.73 (1.32) MJ.day−1) and total energy expenditure (18.36 (3.05) MJ.day−1) measured over the non‐consecutive ten‐day period was unclear (−1.63 (1.73) MJ.day−1; ES = 0.91 ± 1.28; p = 0.221). This corresponded in a most likely trivial decrease in body mass (−0.65 (0.78) kg; ES = 0.04 ± 0.03; p = 0.097). Resting metabolic rate and physical activity level across the fourteen‐day pre‐season period was 11.20 (2.16) MJ.day−1 and 1.7 (0.2), respectively. For the first time, this study utilises gold standard assessment techniques to elucidate the distinctly large energy expenditures of professional young rugby league players across a pre‐season period, emphasising a requirement for equally large energy intakes to achieve targeted body mass and composition adaptations. Accordingly, it is imperative that practitioners regularly assess the energy balance of professional young collision‐sport athletes to ensure their unique energetic requirements are achieved.
Fabrication and Characterization of Pt-Co/C Catalyst for Fuel Cell Electrode
Authors: Rohendi Dedi , Rachmat Addy , Syarif Nirwan
Published: October 2018

One of the most important components in fuel cell is electrode which hold as center for electrochemical reaction on converting fuel and oxygen into electricity. Special attention hence must be given to this component in order to achieve high performance especially on its catalytic activity and durability. To obtain such performance, some aspect must be take into consideration i.e. the content and type of catalyst as well as preparation method. Impregnation-reduction and electrodeposition method were evaluated on fabrication of fuel cell electrode from Pt-Co/C catalyst using H2PtCl6.6H2O and CoCl2.6H2O in carbon Vulcan XC-72 substrate. Transition metal other than platinum as supporting catalyst was used not only to enhance catalytic activity but also to reduced cost and avoid poisoning which platinum suffers easily. Characterization of catalyst using Cyclic Voltammetry (CV) and Electrochemical Impedance Spectroscopy (EIS) confirmed that catalyst made from Pt-Co/C using ratio Pt : Co = 20:80 has good catalytic activity for fuel cell application. XRD diffractogram showed result of Pt reduction at 2-theta = 39.76° (111) and 46.23° (200) while the present of Co is not clear at 2-theta = 44.51° and 51.85°. Co was not detected due to it became an alloy with Pt and relatively small concentration (20%). Pt-Co/C catalyst prepared by impregnation-reduction and electrodeposition methods can be used as catalyst support in fuel cell electrode.
A resolution of singularities for Drinfeld’s compactification by stable maps
Authors: Campbell Justin
Published: October 2018

Drinfeld’s relative compactification plays a basic role in the theory of automorphic sheaves, and its singularities encode representation-theoretic information in the form of intersection cohomology. We introduce a resolution of singularities consisting of stable maps from nodal deformations of the curve into twisted flag varieties. As an application, we prove that the twisted intersection cohomology sheaf on Drinfeld’s compactification is universally locally acyclic over the moduli stack of

G
G

-bundles at points sufficiently antidominant relative to their defect.
Transient and Sustained Control Mechanisms Supporting Novel Instructed Behavior
Authors: Palenciano Ana F , González-García Carlos , Arco Juan E , Ruz María
Published: October 2018

The success of humans in novel environments is partially supported by our ability to implement new task procedures via instructions. This complex skill has been associated with the activity of control-related brain areas. Current models link fronto-parietal and cingulo-opercular networks with transient and sustained modes of cognitive control, based on observations during repetitive task settings or rest. The current study extends this dual model to novel instructed tasks. We employed a mixed design and an instruction-following task to extract phasic and tonic brain signals associated with the encoding and implementation of novel verbal rules. We also performed a representation similarity analysis to capture consistency in task-set encoding within trial epochs. Our findings show that both networks are involved while following novel instructions: transiently, during the implementation of the instruction, and in a sustained fashion, across novel trials blocks. Moreover, the multivariate results showed that task representations in the cingulo-opercular network were more stable than in the fronto-parietal one. Our data extend the dual model of cognitive control to novel demanding situations, highlighting the high flexibility of control-related regions in adopting different temporal profiles.
The Burden of Frailty Among U.S. Veterans and Its Association With Mortality, 2002–2012
Authors: Orkaby Ariela R , Nussbaum Lisa , Ho Yuk-Lam , Gagnon David , Quach Lien , Ward Rachel , Quaden Rachel , Yaksic Enzo , Harrington Kelly , Paik Julie M , Kim Dae H , Wilson Peter W , Gaziano J Michael , Djousse Luc , Cho Kelly , Driver Jane A
Published: October 2018

Background

Frailty is a key determinant of clinical outcomes. We sought to describe frailty among U.S. Veterans and its association with mortality.

Methods

Nationwide retrospective cohort study of regular Veterans Affairs (VA) users, aged at least 65 years in 2002–2012, followed through 2014, using national VA administrative and Medicare and Medicaid data. A frailty index (FI) for VA (VA-FI) was calculated using the cumulative deficit method. Thirty-one age-related deficits in health from diagnostic and procedure codes were included and were updated biennially. Survival analysis assessed associations between VA-FI and mortality.

Results

A VA-FI was calculated for 2,837,152 Veterans over 10 years. In 2002, 35.5% were non-frail (FI = 0–0.10), 32.6% were pre-frail (FI = 0.11–0.20), 18.9% were mildly frail (FI = 0.21–0.30), 8.7% were moderately frail (FI = 0.31–0.40), and 4.3% were severely frail (FI > 0.40). From 2002 to 2012, the prevalence of moderate frailty increased to 12.7%and severe frailty to 14.1%. Frailty was strongly associated with survival and was independent of age, sex, race, and smoking; the VA-FI better predicted mortality than age alone. Although prevalence of frailty rose over time, compared to non-frail Veterans, 2 years’ hazard ratios (95% confidence intervals) for mortality declined from a peak in 2004 of 2.01 (1.97–2.04), 3.49 (3.44–3.55), 5.88 (5.79–5.97), and 10.39 (10.23–10.56) for pre-frail, mildly, moderately, and severely frail, respectively, to 1.51 (1.49–1.53), 2.36 (2.33–2.39), 3.68 (3.63–3.73), 6.62 (6.53–6.71) in 2012. At every frailty level, risk of mortality was lower for women versus men and higher for blacks versus whites.

Conclusions

Frailty affects at least 3 of every 10 U.S. Veterans aged 65 years and older, and is strongly associated with mortality. The VA-FI could be used to more accurately estimate life expectancy and individualize care for Veterans.
Commutative regulation between endothelial NO synthase and insulin receptor substrate 2 by microRNAs
Authors: Sun Xiaoli , Lv Huizhen , Zhao Peng , He Jinlong , Cui Qinghua , Wei Minxin , Feng Shiqing , Zhu Yi
Published: October 2018

Endothelial NO synthase (eNOS) expression is regulated by a number of transcriptional and post-transcriptional mechanisms, but the effects of competing endogenous RNAs (ceRNAs) on eNOS mRNA and the underlying mechanisms are still unknown. Our bioinformatic analysis revealed three highly expressed eNOS-targeting miRNAs (miR-15b, miR-16, and miR-30b) in human endothelial cells (ECs). Among the 1103 mRNA targets of these three miRNAs, 15 mRNAs share a common disease association with eNOS. Gene expression and correlation analysis in patients with cardiovascular diseases identified insulin receptor substrate 2 (IRS2) as the most correlated eNOS-ceRNA. The expression levels of eNOS and IRS2 were coincidentally increased by application of laminar shear but reduced with eNOS or IRS2 siRNA transfection in human ECs, which was impeded by Dicer siRNA treatment. Moreover, luciferase reporter assay showed that these three miRNAs directly target the 3′UTR of eNOS and IRS2. Overexpression of these three miRNAs decreased, whereas inhibition of them increased, both mRNA and protein levels of eNOS and IRS2. Functionally, silencing eNOS suppressed the Akt signal pathway, while IRS2 knockdown reduced NO production in ECs. Thus, we identified eNOS and IRS2 as ceRNAs and revealed a novel mechanism explaining the coincidence of metabolic and cardiovascular diseases.
A User’s Guide to Hybrid Tools
Authors: Perl Caleb
Published: October 2018

Hybrid metaethical theories have significant promise; they would have important upshots if they were true. But they also face severe problems. The problems are severe enough to make many philosophers doubt that they could be true. My ambition is to show that the problems are just instances of a highly general problem: a problem about what are sometimes called ‘intensional anaphora'. I'll also show that any adequate explanation of intensional anaphora immediately solves all the problems for the hybrid theorist. We should regard hybrid tools as among the most legitimate tools in our toolkit—at least when we use them properly.
Prosumption
Authors: Ritzer George
Published: October 2018

While prosumption (the interrelated process of production and consumption) is a primal process and has always been ubiquitous, we have entered a revolutionary “new world” of prosumption in both the material, and especially the digital, world. Prosumption is conceived of as a continuum ranging from prosumption-as-production (usually thought of as “production”) to prosumption-as-consumption (usually seen as “consumption”). It is associated with a new stage of capitalism—prosumer capitalism—that has increasingly come to control the process and to exploit prosumers. Key to the new world of prosumer capitalism is a new, extreme, and more “magical” form of exploitation—“synergistically double exploitation.”
Physical activity and preventable premature deaths from non-communicable diseases in Brazil
Authors: Rezende Leandro Fórnias Machado de , Garcia Leandro Martin Totaro , Mielke Grégore Iven , Lee Dong Hoon , Giovannucci Edward , Eluf-Neto José
Published: October 2018

Background

Studies on the impact of counterfactual scenarios of physical activity on premature deaths from non-communicable diseases (NCDs) are sparse in the literature. We estimated preventable premature deaths from NCDs (diabetes, ischemic heart disease, stroke, and breast and colon cancers) in Brazil by increasing population-wide physical activity (i) to theoretical minimum risk exposure levels; (ii) reaching the physical activity recommendation; (iii) reducing insufficient physical activity by 10%; and (iv) eliminating the gender differences in physical activity.

Methods

Preventable fractions were estimated using data from a nationally representative survey, relative risks from a meta-analysis and number of premature deaths (30–69 years) from the Brazilian Mortality Information System.

Results

Physical activity could potentially avoid up to 16 700 premature deaths from NCDs in Brazil, corresponding to 5.75 and 3.23% of premature deaths from major NCDs and of all-causes, respectively. Other scenarios suggested the following impact on premature deaths: reaching physical activity recommendation (5000 or 1.74% of major NCDs); 10% reduction in insufficient physical activity (500 or 0.17% of major NCDs); eliminating gender differences in physical activity (1000 or 0.33% of major NCDs).

Conclusions

Physical activity may play an important role to reduce premature deaths from NCD in Brazil.
Quinine, Whisky, and Epsom Salts: Amateur Medical Treatment in the White Settler Communities of British East and South-Central Africa, 1890–1939
Authors: Wells Julia M
Published: October 2018

Between 1890 and 1939, many migrants settled in rural areas in Britain’s newly occupied territories in East and South-Central Africa. A number of these settlers produced memoirs about their lives in colonial Africa, many of which contain rich domestic detail, including about health and home medical treatment. This paper examines a selection of memoirs by women who lived in rural British East and South-Central Africa. First, it explores the literary presentation of disease, injury and home treatment in these memoirs, arguing that anecdotes about health played powerful and complex roles. Secondly, it illustrates that most authors regularly treated injuries and illnesses for themselves and their families, making home treatment an important part of their health care. Lastly, it highlights that these memoirs reveal a distinctive set of medicines and techniques used for amateur medical treatment. Overall, this paper positions amateur medical practice as an essential element of health care in the region.
Plain Language Drafting: A Study of the Laws of India (2009–17)
Authors: Bapna Niharika
Published: October 2018

The relation between the threat to rule of law in India and its poorly drafted legislation may not be obvious at first. And yet clear, intelligible laws have been the premise for the success of rule of law. There is little research done in the field of plain language legislative drafting in India. This article analyses three important elements of plain language drafting in nine Indian statutes passed in the last decade. They are as follows: arrangement of provisions, marginal notes, and sentence structure. Each of the selected nine statutes impacts the rights of vulnerable groups. Thus, the need to make these statutes comprehensible by drafting them in plain English is important. By suggesting ways to simplify the language of the nine statutes, this article asserts that these plain language drafting techniques must be adopted by Indian legislative drafters.
Prophage Diversity of ‘CandidatusLiberibacter asiaticus’ Strains in California
Authors: Dai Z. , Wu F. , Zheng Z. , Yokomi R. , Kumagai L. , Cai W. , Rascoe J. , Polek M. , Chen J. , Deng X.
Published: October 2018

Huanglongbing (HLB) is a highly destructive citrus disease and is associated with a nonculturable bacterium, ‘Candidatus Liberibacter asiaticus’. ‘Ca. L. asiaticus’ in the United States was first found in Florida in 2005 and is now endemic there. In California, ‘Ca. L. asiaticus’ was first detected in Hacienda Heights in Los Angeles County in 2012 and has now been detected in multiple urban locations in southern California. Knowledge of ‘Ca. L. asiaticus’ strain diversity in California is important for HLB management. In this study, genomic diversity among 10 ‘Ca. L. asiaticus’ strains from six California locations were analyzed using a next-generation sequencing (NGS) (Illumina MiSeq and HiSeq) approach. Draft genome sequences of ‘Ca. L. asiaticus’ strains were assembled. Sequences of the 16S ribosomal RNA gene and nrdB confirmed ‘Ca. L. asiaticus’ identity. Prophages were detected in all ‘Ca. L. asiaticus’ strains. The California ‘Ca. L. asiaticus’ strains formed four prophage typing groups (PTGs): PTG1, with type 1 prophage only (strains from Anaheim, San Gabriel, and Riverside); PTG2, with type 2 prophage only (strains from Hacienda Heights); PTG1-3, with both type 1 and 3 prophages (a strain from Cerritos); and PTG1-2, with both type 1 and type 2 prophages (a strain from La Habra). Analyses of the terL sequence showed that all California ‘Ca. L. asiaticus’ strains were not introduced from Florida but likely from locations in Asia. Miniature inverted-repeat transposable elements were found in all ‘Ca. L. asiaticus’ strains, yet, a jumping-out event was detected in the ‘Ca. L. asiaticus’ strain from Cerritos. Altogether, this study demonstrated that the NGS approach focusing on prophage variation was sensitive and effective in revealing diversity of ‘Ca. L. asiaticus’ strains in California.
Socially Accountable Academic Health Centers: Pursuing a Quadripartite Mission
Authors: Smitherman Herbert C. , Baker Richard S. , Wilson M. Roy
Published: October 2018

Academic health centers (AHCs) in the United States have had a leading role in educating the medical workforce, generating new biomedical knowledge, and providing tertiary and quaternary clinical care. Yet the health status of the U.S. population lags behind almost every other developed world economy. One reason is that the health care system is not organized optimally to address the major driver of health status, the social determinants of health (SDOH). The United States’ overall poor health status is a reflection of dramatic disparities in health that exist between communities and population groups, and these are associated with variations in the underlying SDOH. Improving health status in the United States thus requires a fundamental reengineering of the health delivery system to address SDOH more explicitly and systematically. AHCs’ tripartite mission, which has served so well in the past, is no longer sufficient to position AHCs to lead and resolve the intractable drivers of poor health status, such as unfair and unjust health disparities, health inequities, or differences in a population’s SDOH.

AHCs enjoy broad public support and have an opportunity—and an obligation—to lead in improving the nation’s health. This Perspective proposes a new framework for AHCs to expand on their traditional tripartite mission of education, research, and clinical care to include explicitly a fourth mission of social accountability. Through this fourth mission, comprehensive community engagement can be undertaken, addressing SDOH and measuring the health impact of interventions by using a deliberate structure and process, yielding defined outcomes.
Management of Anesthesia and Delivery in Women With Chiari I Malformations
Authors: Waters Janet F. R. , O'Neal M. Angela , Pilato Madison , Waters Samuel , Larkin Jacob C. , Waters Jonathan H.
Published: October 2018

OBJECTIVE:

To estimate whether vaginal delivery or neuraxial anesthesia poses a risk of neurologic deterioration in women with uncorrected Chiari I malformation.

METHODS:

To assemble this case series, electronic record databases were used to identify women with Chiari I malformation who delivered on two busy tertiary care obstetric services over a 5-year period from January 2010 through December 2015. Women who had undergone surgical decompression were not included in the study. The size of the Chiari malformation, neurologic symptoms before delivery, mode of delivery, anesthetic method used, and neurologic complications were recorded.

RESULTS:

Ninety-five deliveries in 63 patients were identified. The size of the Chiari malformation was 9.3±4.3 mm (mean±SD). In 58 pregnancies, women reported no headaches; in 36 they did. There was no association between the size of the Chiari malformation and the incidence of headache. Forty-four neonates were delivered by cesarean delivery and 51 were delivered vaginally. No neurologic deterioration occurred in either group. Neuraxial anesthesia was administered before 62 deliveries. No neurologic complications occurred. None of the women who delivered vaginally or received neuraxial anesthesia had signs of increased intracranial pressure. The upper limit of the 95% CI for the risk of neurologic complications from our study of 95 deliveries was 3.1%.

CONCLUSION:

This case series support that in patients with Chiari I malformation who have no signs of increased intracranial pressure, the mode of delivery should be based on obstetric rather than neurologic considerations. The absence of complications in patients who received epidural or spinal anesthesia suggests that these procedures should be made available to women with Chiari I malformation.
Don’t You Wish You Had Fused to the Pelvis the First Time
Authors: Nielsen Ena , Andras Lindsay M. , Bellaire Laura L. , Fletcher Nicholas D. , Minkara Anas , Vitale Michael G. , Troy Michael , Glotzbecker Michael , Skaggs David L.
Published: October 2018

Study Design.

A multicenter retrospective study.

Objective.

The aim of this study was to compare pelvic obliquity correction and reoperation rate in neuromuscular scoliosis patients who had their pelvis included in a posterior spinal fusion (pelvic fusion, PF) at their index procedure versus revision procedures.

Summary of Background Data.

There is limited information on outcomes specific to fusing to the pelvis for neuromuscular scoliosis in a revision operation versus index surgery.

Methods.

Charts and radiographs were reviewed of patients with PF for neuromuscular scoliosis from January 2003 to August 2015 at four high-volume pediatric spine centers with >2 year follow-up.

Results.

Two hundred eighty-five patients met inclusion criteria; 271 had PF done at index surgery and 14 had PF done during revision surgery. Before index procedure, there were no significant differences in Cobb angle (P = 0.13). Before PF, there was no difference in pelvic obliquity (P = 0.26). At the time of fusion to the pelvis, estimated blood loss (P = 0.23) and operative time (P = 0.43) did not differ between index and revision groups. Percent correction in pelvic obliquity was similar for both groups (P = 0.72). Overall, 69 patients had complications requiring return to the operating room. Excluding the revision surgery for inclusion of the pelvis for the revision group, there was still a lower reoperation rate with index PF (22.9%, n = 62/271) than revision PF (50.0%, n = 7/14) (P = 0.02). Implant failures were significantly higher in the revision group (index = 7.4%, 20/271; revision = 42.9%, 6/14; P < 0.001).

Conclusion.

PF at the index spinal fusion led to similar correction of pelvic obliquity with approximately half the reoperation rate compared with PF at a revision surgery. Operative time and blood loss were similar between index and revision spinal fusion.

Level of Evidence: 4
How Common Is Medial and Lateral Shoulder Discordance in Lenke 1 and 2 Curves?
Authors: Chung Weng Hong , Chiu Chee Kidd , Ng Sherwin Johan , Goh Saw Huan , Chan Chris Yin Wei , Kwan Mun Keong
Published: October 2018

Study Design.

Retrospective study of prospectively collected data.

Objective.

To analyze the incidence and the patterns of medial and lateral shoulder discordance among Lenke 1 and 2 patients.

Summary of Background Data.

Postoperative shoulder imbalance (PSI) is still common in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS). This could be due to presence of medial dan lateral shoulder discordance.

Methods.

One hundred fifty-one Lenke 1 and 2 AIS patients were recruited. Lenke 1 curves were subclassified into Lenke 1-ve (flexible) (proximal thoracic side bending [PTSB] Cobb angle <15°) and 1+ve curves (stiff) (PTSB Cobb angle between 15° and 24.9°). T1 tilt represented “medial shoulder balance” and radiological shoulder height (RSH) represented “lateral shoulder balance.” We categorized patients into three concordant shoulder pattern types (medial balanced/lateral balanced [MBLB], medial imbalanced+ve/lateral imbalanced+ve (MI+ve/LI+ve), medial imbalanced–ve/lateral Imbalanced–ve (MI–ve/LI–ve), and six discordant shoulder pattern types.

Results.

The mean age was 16.2 ± 5.7 years. Eighty-one patients (53.6%) had concordant pattern and 70 patients (46.4%) had discordant pattern. Lateral shoulder imbalance was noted in 35.1% of patients and medial shoulder imbalance in 43.7% of patients. In Lenke 1–ve curves, 35 patients (68.6%) had concordant shoulder imbalance with medial imbalanced–ve/lateral imbalanced–ve (MI–ve/LI–ve) being the commonest pattern (68.6%). In Lenke 1+ve curves, 33 patients (55.0%) had concordant shoulder pattern with medial balanced/lateral balanced (MB/LB) being the commonest type (57.6%). In Lenke 2 AIS, 27 patients (67.5%) had discordant pattern with medial imbalanced+ve/lateral balanced (MI+ve/LB) being the commonest pattern (44.4%) (P value = 0.002).

Conclusion.

46.4% Lenke 1 and 2 AIS patients had shoulder discordant pattern. This was more prevalent in Lenke 2 curves (67.5%). In Lenke 1-ve (flexible) curves, MI–ve/LI–ve pattern was the commonest pattern. In Lenke 1+ve curves (stiff), there were almost equal number of concordant and discordant shoulder pattern. In Lenke 2 patients, the most common pattern was MI+ve/LB.

Level of Evidence: 4
Skeletal Muscle Cell Oxidative Stress as a Possible Therapeutic Target in a Denervation-Induced Experimental Sarcopenic Model
Authors: Kinoshita Hideyuki , Orita Sumihisa , Inage Kazuhide , Yamauchi Kazuyo , Abe Koki , Inoue Masahiro , Norimoto Masaki , Umimura Tomotaka , Eguchi Yawara , Fujimoto Kazuki , Shiga Yasuhiro , Kanamoto Hirohito , Aoki Yasuchika , Furuya Takeo , Suzuki Miyako , Akazawa Tsutomu , Takahashi Kazuhisa , Ohtori Seiji
Published: October 2018

Study Design.

A basic study using a rodent model of sarcopenia.

Objective.

To elucidate the contribution of oxidative stress to muscle degeneration and the efficacy of antioxidant treatment for sarcopenia using an animal model of neurogenic sarcopenia.

Summary of Background Data.

Oxidative stress has been reported to be involved in a number of pathologies, including musculoskeletal disorders. Its relationship with sarcopenia, one of the potential origins of lower back pain, however, is not yet fully understood.

Methods.

Myoblast cell lines (C2C12) were treated with H2O2, an oxidative stress inducer, and N-acetyl-l-cysteine (NAC), an antioxidant. Apoptotic effects induced by oxidative stress and the antioxidant effects of NAC were assessed by western blotting, immunocytochemistry, and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays. An animal model of sarcopenia was produced via axotomy of the sciatic nerves to induce muscle atrophy. Twenty-four male Sprague-Dawley rats were divided into sham, sham+NAC, axotomy, and axotomy+NAC groups. Rats were provided water only or water containing NAC (1 g/L) for 4 weeks. The gastrocnemius muscle was isolated and stained with hematoxylin and eosin (H&E) 2 weeks after axotomy, from which muscle cells were harvested and protein extracted for evaluation.

Results.

Mitogen-activated protein kinases (MAPKs) were significantly activated by H2O2 treatment in C2C12 cells, which was ameliorated by NAC pretreatment. Furthermore, H2O2 induced apoptosis and death of C2C12 cells, which was prevented by NAC pretreatment. The weight of the gastrocnemius muscle was reduced in the axotomy group, which was prevented by NAC administration. Lastly, although muscle specimens from the axotomy group showed greater reductions in muscle fiber, the oral administration of NAC significantly inhibited amyotrophy via antioxidant effects.

Conclusion.

The current in vitro and in vivo study demonstrated the possible involvement of oxidative stress in sarcopenic pathology. NAC represents a potential anti-sarcopenic drug candidate, preventing amyotrophy and fatty degeneration.

Level of Evidence: 4
Closed Wound Subfascial Suction Drainage in Posterior Fusion Surgery for Adolescent Idiopathic Scoliosis
Authors: Ovadia Dror , Drexler Michael , Kramer Moti , Herman Amir , Lebel David Eduard
Published: October 2018

Study Design.

A prospective randomized control study.

Objective.

The aim of this study was to compare the complication rate in adolescent idiopathic scoliosis (AIS) posterior spinal fusion (PSF) surgery with and without drainage.

Summary of Background Data.

PSF is the mainstay of surgical treatment for AIS. Drains are commonly used despite contradictory findings in the literature for their having any clear advantage.

Methods.

A total of 100 AIS patients undergoing instrumented PSF were blindly randomized into two groups of either a deep drain or no drain. The collected data included wound follow-up findings, hemoglobin, hematocrit, vital signs and fever levels, and mean 20 months follow-up.

Results.

Fifty-two patients were randomly allocated to the “no drain” group and 48 to the “drain” group. There were no differences in patient characteristics, surgical data, and hemoglobin and hematocrit levels between the two groups. Only 4 units of packed cells were given in total. Fever during the first postoperative 1 to 3 days was equal, but increased in the no drain group on day 6 (P = 0.017). Length of hospitalization was equal (6 days) for all the patients. The mean follow-up period was 20 months [8.5–30.7 (SD 6.4)]. Complications included one case (1.9%) of pneumonia in the “no-drain” group, wound dehiscence in two cases (3.8%) in the “no-drain” group and in one case (2.1%) in the “drain” group, and two cases (3.8%) of superficial wound infection in the “no-drain” group. There was no case of deep infection in either group.

Conclusion.

The current results indicate that there is no advantage to deep drainage in AIS patients undergoing PSF. The number of wound healing complications was low and identical for both the drain and no-drain groups.

Level of Evidence: 2
Ease of use of electronic health records and relational coordination among primary care team members
Authors: Watterson Jessica L. , Rodriguez Hector P. , Aguilera Adrian , Shortell Stephen M.
Published: October 2018

Background:

Electronic health records (EHRs) have potential to improve quality, health outcomes, and efficiency, but little is known about the mechanisms through which these improvements occur.

Purpose:

One potential mechanism could be that EHRs improve care team communication and coordination, leading to better outcomes. To test this hypothesis, we examine whether ease of EHR use is associated with better relational coordination (RC), a measure of team communication and coordination, among primary care team members.

Methodology:

Surveys of adult primary care team members (n = 304) of 16 practices of two accountable care organizations in Chicago and Los Angeles were analyzed. The survey included a validated measure of RC and a measure of ease of EHR use from a national survey. Linear regression models estimated the association of ease of EHR use and RC, controlling for care site and patient demographics and accounting for cluster–robust standard errors. An interaction term tested a differential association of ease of EHR use and RC for primary care providers (PCPs) versus non-PCPs.

Results:

Ease of EHR use (mean = 3.5, SD = 0.6, range: 0–4) and RC were high (mean = 4.0, SD = 0.7, range: 0–5) but differed by occupation. In regression analyses, a 1-point increase in ease of EHR use was associated with a 0.36 point higher RC score (p = .001). The association of ease of EHR and RC use was stronger for non-PCPs than PCPs.

Conclusion:

Ease of EHR use is associated with better RC among primary care team members, and the benefits accrue more to non-PCPs than to PCPs.

Practice Implications:

Ensuring that clinicians and staff experience EHRs as easy to use for accessing and integrating data and for communication may produce gains in efficiency and outcomes through high RC. Future studies should examine whether interventions to improve EHR usability can lead to improved RC and patient outcomes.
Integration of cardiologists with hospitals: Effects on physician compensation and productivity
Authors: Chunn Vance M. , Sen Bisakha , O’Connor Stephen J. , Jessee William F. , Sasson Joseph , Landry Amy Yarbrough
Published: October 2018

Background

Hospital–physician vertical integration involving employment of physicians has increased considerably over the last decade. Cardiologists are one group of specialists being increasingly employed by hospitals. Although hospital–physician integration has the potential to produce economic and societal benefits, there is concern that this consolidation may reduce competition and concentrate bargaining power among providers. In addition, hospitals may be motivated to offer cardiologists higher compensation and reduced workloads as an incentive to integrate.

Purpose

The aim of the study was to determine if there are differences in compensation and clinical productivity, measured by work relative value units (RVUs), for cardiologists as they transition from being independent practitioners to being employed by hospitals.

Methodology/Approach

This study was a quantitative, retrospective, longitudinal analysis, comparing the compensation and work RVUs of integrated cardiologists to their compensation and work RVUs as independent cardiologists. Data from the MedAxiom Annual Survey from 2010 to 2014 were used. Participants included 4,830 unique cardiologists that provided 13,642 pooled physician-year observations, with ownership status, compensation, work (RVUs), and other characteristics as variables for analysis.

Results

Results from the multivariate regressions indicate that average compensation for cardiologists increases by $129,263.1 (p < .001) when they move from independent to integrated practice. At the same time, physician work RVUs decline by 398.04 (p = .01).

Conclusion

Our findings support the conjecture that hospitals may be offering higher pay and lower workloads to incentivize cardiologists to integrate.

Practice Implications

Although hospitals may have goals of quality improvement and lower costs, such goals may presently be secondary to service line growth and increased market power. There is reason to be cautious about some of the implications of hospital integration of cardiologists.
Working around hierarchy: Resident and medical assistant teaming
Authors: Brooks Joanna Veazey , Sheridan Bethany , Peters Antoinette S. , Chien Alyna T. , Singer Sara J.
Published: October 2018

Background

In health care, hierarchy can facilitate getting work done efficiently. It can also hinder performance by suppressing valuable contributions from lower-positioned individuals. Team-based care could mitigate negative effects by creating space for all team members to contribute their unique expertise.

Purpose

This article sought to understand how resident–medical assistant (MA) dyads interacted before and after primary care clinics transitioned to team-based care. We also studied how they negotiated changes in interpersonal dynamics given the challenge these changes presented to hierarchical norms.

Methodology

We conducted two qualitative interview studies, with 37 residents and 30 MAs at primary care clinics transitioning to team-based care. Interviews were transcribed, coded, and analyzed together using a thematic networks approach and focused coding.

Results

An intervention that promoted teamwork prompted resident–MA dyads to change their interactions to counter traditional hierarchy. Residents increasingly asked MAs questions about patient care, and MAs initiated interactions and volunteered ideas more frequently. We also found that MAs and residents expressed some discomfort with the hierarchical ambiguity that their new interactions produced and used alternate scripts to buffer this discomfort and to collaborate as teammates despite formal hierarchy.

Conclusion

Among resident–MA dyads, a team-based care intervention changed interpersonal dynamics by blurring hierarchical lines and shifting traditional boundaries in ways that were uncomfortable for both groups. They were able to work around discomfort by using new scripts that downplayed the threat to hierarchy.

Practice Implications

Organizational structures that encourage greater interprofessional collaboration may neutralize barriers that formal hierarchy in medicine can pose for effective teamwork, but this process can also bring social discomfort. Our findings suggest that health care professionals may use microlevel strategies, such as alternative scripts, to overcome formal hierarchies without openly engaging them. Together, new organizational structures and interaction techniques can help professionals work around hierarchy and improve team performance.