bluuebunny/crossref_metadata_2025 huggingface dataset:
The Biology of Lakes and Ponds
Authors: Brönmark Christer , Hansson Lars-Anders
Published: December 2017

The Biology of Lakes and Ponds focuses on the interactions between the abiotic frame, such as turbulence, temperature, pH and nutrients, and the organisms, including interactions with and among organisms at the individual, population and community level. The book fills this niche between traditional limnology and evolutionary ecology by focusing on physiological, morphological and behavioural adaptations among organisms to abiotic and biotic factors and how interactions between biotic processes and abiotic constraints determine the structure and dynamics of lake and pond systems. In addition, the book describes and analyses the causes and consequences of human activities on freshwater organisms and ecosystems and covers longstanding environmental threats, such as eutrophication and acidification, as well as novel threats, such as biodiversity loss, use of everyday chemicals and global climate change. However, also signs of improvement and the possibilities to restore degraded ecosystems are discussed and provide hope for future generations.
Food Web Interactions in Freshwater Ecosystems
Authors: Brönmark Christer , Hansson Lars-Anders
Published: December 2017

This chapter on food web interactions connects the organisms and their interactions with the abiotic frame and provides a helicopter perspective on the function of freshwater ecosystems. Initially, the theoretical basis for an ecosystem approach is outlined, including food web theory, the bottom-up and top-down concepts and how these have evolved in concert with empirical advances. Specifically, the concepts of cascading trophic interactions and alternative stable states are discussed both from a theoretical and empirical viewpoint, as well as in both benthic and pelagic habitats. This chapter links all components, from microbes to vertebrates, to temporal and spatial changes in abiotic features leading to successional patterns in populations and communities.
Against Knowledge-First Epistemology
Authors: Gerken Mikkel
Published: December 2017

This chapter attacks, on several fronts, what is often cited as a theoretical advantage to regarding knowledge as a theoretical primitive—namely, that knowledge can be used to reductively analyse other epistemic phenomena. It suggests that proponents of such an approach commit a similar mistake to the one that they charge their opponents with—viz., the mistake of seeking to reductively analyse basic epistemic phenomena in terms of other allegedly more basic or fundamental phenomena. After leveling this charge against reductionist brands of knowledge-first epistemology, the chapter takes the knowledge norm of assertion as its critical focus and challenges non-reductionist brands of knowledge-first epistemology. It concludes by articulating an alternative to knowledge-first methodology: that is labeled ‘equilibristic epistemology’. According to equilibristic epistemology there isn’t a single epistemic phenomenon or concept that is ‘first’. Rather, there are a number of basic epistemic phenomena that are not reductively analysable although they may be co-elucidated in a non-reductive manner.
‘More Likely Than Not’Knowledge First and the Role of Bare Statistical Evidence in Courts of Law
Authors: Blome-Tillmann Michael
Published: December 2017

In this chapter, Michael Blome-Tillmann argues that embracing a knowledge-first approach can help to resolve important epistemological problems in legal philosophy. Blome-Tillmann takes, as a starting point, a puzzle arising from the evidential standard Preponderance of the Evidence and its application in civil procedure. The evidential standard captured by Preponderance of the Evidence is usually glossed as ‘greater than 0.5 given the admissible evidence’. But this characterization generates puzzles, where our intuitions about whether a defendant should be found liable diverge in case pairs where the evidential probability captured this way is the same. Blome-Tillmann argues that the tension generated by such puzzles can be resolved fairly straightforwardly within a knowledge-first framework.
Rescuing Religion from Faith
Authors: Sikka Sonia
Published: December 2017

This chapter argues for a broader and more inclusive approach to philosophy of religion. Philosophy of religion has traditionally derived its topics and its concept of religion from Christianity, with the result that this subfield is mainly an evaluation of the elements of Christian faith, and often dominated by Christian apologetics. A broader concept of religion, which takes into account Asian traditions as well as new religious movements, would not be confined to Christian theism. It would also not assume that the task of the philosophy of religion is exclusively to examine what “religion” holds by faith, as if faith, as a special mode of belief, necessarily defines the category of religion. Such a notion of the philosophy of religion, the chapter argues, is both descriptively and normatively inadequate. It is culturally parochial, and fails to offer much needed philosophical guidance in an age of religious questioning and uncertainty.
On Facing Up to the Question of Religion as Such
Authors: Bishop John
Published: December 2017

After noting the limitations of an ‘Epistemic’ and a ‘Content’ presupposition made in recent analytical philosophy of religion, this chapter argues that philosophy has a core normative interest in religion as making metaphysical posits that support hopeful and steadfast commitment to ethical ideals. The nub of religious faith is held to be practical commitment to the foundational propositions of such religious worldviews. Philosophy, therefore, needs to seek a theory of permissible faith-commitment to putatively revealed truths for use in assessing particular forms of religious commitment. While philosophy cannot construct an ideal religion, it can, this chapter contends, develop our understanding of the cognitive content that religions need to have in order to play the identified ethical role.
Continental Philosophy of Religion in a Kenotic Tone
Authors: Simmons J. Aaron
Published: December 2017

In this chapter, an account is offered of what renewal in continental philosophy of religion might involve. It is argued that a “kenotic tone” is needed. In particular, in order for continental philosophy to live, it must die to itself in the areas of confession, insularity, and arrogance. Such a kenotic tone should signal that continental philosophy of religion is not concerned about reinforcing its own significance, but instead is significant because it offers important resources for thinking philosophically—but also personally, hospitably, and humbly—about religion. This account of renewal in continental philosophy of religion, in turn, is likely to foster productive engagement both with analytic philosophers of religion and also with scholars in other fields working in the academic study of religion.
Novel Style
Authors: Masters Ben
Published: December 2017

Re-examining elaborate English stylists from the post-war period to the present day (including Anthony Burgess, Angela Carter, Martin Amis, Zadie Smith, Nicola Barker, and David Mitchell) through a fresh style of ethical criticism that does not over-rely on notions of character and interiority (the terrain of the ‘humanist revival’), and that returns the author to centre-stage (contra the approach of the ‘new ethics’, with its indebtedness to poststructuralism), Novel Style defends the stylistic excesses of writers who were conscious of both writing out of excessive times and of the need for new kinds of artistic response to contemporary ethical pressures. Through its methodology, Novel Style calls for a return to close reading and aesthetic evaluation and recovers its subjects from theoretical quagmires by repositioning them as stylists and ethicists, arguing that the two positions are inextricable. For example, it considers how forms of stylistic excess—ranging from puns and wordplay to long sentences, proliferating imagery, repetitions, idiosyncratic rhythms, multiple levels of narration, and variable points of view—might enact ethically-charged dynamics like curiosity, particularity, complexity, and empathy. As well as being an impassioned defence of literary excess, flamboyance, and close reading, Novel Style asks fundamental questions about how novels think, see, and feel, and how they might change us.
De Re Modality in the Late Twentieth Century
Authors: Divers John
Published: December 2017

Quine’s (in)famous sceptical critique of de re modality is expounded in the pair of 1953 classic papers ‘Reference and Modality’ and ‘Three Grades of Modal Involvement’. Here, I position the salient, and non-sceptical, treatments of de re modality in the later part of the twentieth century—those due to Kripke, Lewis, and Fine—in relation to that prior sceptical critique. My theses are: (a) that that Kripke, Lewis, and Fine all undertake non-sceptical defences of de re modal predication that conform to the Smullyan language-independence strategy; and (b) none does so in a way that falsifies Quine’s prediction of the commitments involved. I emphasize the insights on which Quine’s scepticism was based and commend these as sound and enduring.
Portraits from Life
Authors: Boyd Maunsell Jerome
Published: December 2017

Portraits from Life examines the ways in which a group of major Modernist writers—Joseph Conrad, Ford Madox Ford, Henry James, Wyndham Lewis, Gertrude Stein, H. G. Wells, and Edith Wharton—depicted themselves and each other in their memoirs and autobiographies, rather than in their fiction. In a series of reconstructions of biographical contexts, it reveals how each of these novelists approached the task of writing their own lives, and how they experimented with the form and style of autobiography. Memoirs and autobiographies, as this book argues, are often just as artful as novels. Showing how it is impossible to understand any author’s autobiography without an understanding of their life, this book offers a group portrait examining the temptations, difficulties, and benefits which the project of writing their lives brought these novelists. The act of writing autobiography is a central focus, and many recurring themes are analyzed: how autobiography is often a collaborative act; how the time of the writing of autobiography often has a major influence; how fact and fiction, biography and autobiography, interact; how autobiography is always mediated by memory. This book argues that autobiography is as much an act of group portraiture as of self-analysis. It shows how the keeping of biographical secrets acts to protect others rather than oneself; and it explores the ethical issues at stake in autobiography when dealing with real, rather than invented, people. It also opens up a rich network of Modernist encounters, examining how these seven writers’ memoirs interrelate.
Law, Commerce, and Finance in the Roman Empire
Authors: Sirks Boudewijn
Published: December 2017

This chapter considers the legal aspects of commercial transactions in the Roman Empire. While there was no specific body of Roman commercial law, a group of legal figures, accessible for and applicable against non-Romans, were concerned with issues important for commerce, such as sale, mandate, partnership, loans for consumption, and stipulation. There were also general applications, some of which proved very useful in commerce too (actiones adiecticiae qualitatis), while others were specifically designed for commerce, such as the action against shipmasters. Furthermore, the contract of deposit was ingeniously used to make banking and financing on a large and commercial scale possible, while the chirograph, originally a Hellenistic documentary debt paper, acquired the traits of a commercial paper that made transfer of debts very easy. The chapter considers both the effects of large-scale commerce on the development of Roman law, and the effects of the legal framework on the economy.
Market Regulation and Transaction Costs in the Roman Empire
Authors: Cascio Elio Lo
Published: December 2017

The unification of the Mediterranean world under Roman rule brought about the suppression of piracy and the resulting increased safety of seaborne commerce, better circulation of information, the spread of common metrological systems, the creation of a single monetary area, and the diffusion of common legal rules. All this certainly made the definition, protection, and exchange of property rights within the Empire much safer and therefore less expensive. This chapter shows, through the analysis of a series of interventions both at the central and at the local level, documented by juridical, epigraphic, and papyrological evidence, that this state of affairs was not merely the unintended and unexpected result of the political unification of the Mediterranean world, but the product of the role that the political organization of Rome purposely undertook in regulating market transactions, by guaranteeing the rights of all involved parties: producers, tradesmen, and consumers.
Novel Machines
Authors: Drury Joseph
Published: December 2017

Novel Machines argues that many of the most important formal innovations in eighteenth-century fiction were critical responses to the new prominence of machines in Britain’s Industrial Enlightenment. Although narratives and machines had been seen as sharing a basic affinity since Aristotle, their relationship acquired a new urgency in the eighteenth century as authors sought to organize their narratives according to the new ideas about nature, art, and the human subject that emerged out of the Scientific Revolution. Novel Machines tracks the consequences of this effort to transform the novel into an Enlightenment machine. On the one hand, the rationalization of the novel’s narrative machinery helped establish its legitimacy, such that by the end of the century it could be celebrated as a modern ‘invention’ that provided valuable philosophical knowledge about human nature. On the other hand, conceptualizing the novel as a machine opened up a new line of attack for the period’s moralists, whose polemics against the novel were often framed in the same terms used to reflect on the uses and effects of machines in other contexts. Eighteenth-century novelists responded by adapting the novel’s narrative machinery, devising in the process some of the period’s most characteristic and influential formal innovations. Novel Machines focuses on four of these innovations: the extended representation of the deliberating mind in Eliza Haywood’s amatory fiction; Henry Fielding’s performative, self-conscious narrator; Laurence Sterne’s slow, digressive, non-linear narration; and the atmospheric descriptions of acousmatic sound in Ann Radcliffe’s gothic romances.
Managing Science
Authors: Peach Ken
Published: December 2017

Managing science, which includes managing scientific research and, implicitly, managing scientists, has much in common with managing any enterprise, and most of these issues (e.g. annual budget planning and reporting) form the background. Equally, much scientific research is carried in universities ancient and modern, which have their own mores, ranging from professorial autocracy to democratic plurality, as well as national and international with their missions and styles. But science has issues that require a somewhat different approach if it is to prosper and succeed. Society now expects science, whether publicly or privately funded, to deliver benefits, yet the definition of science presumes no such benefit. Managing the expectations of the scientist with those of society is the challenge of the manager of science. The book addresses some issues around science and the organizations that do science. It then deals with leadership, management and communication, team building, recruitment, motivation, managing scientists, assessing performance, cooperation and competition. This is followed by a discussion of proposal writing and reviewing, committees and meetings, project management, risk and health and safety. Finally, there is a discussion on how to deal with disaster, how to cope with the stresses of management and how to deal with difficult problems.
Councils, Boards, Committees and Panels
Authors: Peach Ken
Published: December 2017

This chapter discusses the hierarchy, governance and role of the committee structure of universities and laboratories, along with the rights and responsibilities of the committee members. These days, nearly all scientific research, whether in universities or laboratories, is carried out in research teams which are embedded in some larger organization, and often derive most of their support through grants, awards or contracts from bodies established for that purpose. Many of these are public bodies, such as charities or research councils, and can have quite complex governance structures. Nowadays, many universities are structured more like businesses than the traditional ’community of scholars’ typical of the ancient seats of learning, with boards, panels and directors. It is important to understand these structures in order to understand the rights and responsibilities of individual research teams.
Powerbrokers and Patronage
Authors: Said Jonathan , Singini Khwima
Published: December 2017

This chapter investigates the patterns of growth in Malawi from 1954 to 2013. Using the deals and development framework, it highlights four growth regimes during this period. First, a period of growth stagnation under colonial rule. Second, a period of growth acceleration post-independence as a clientelist structure emerged in key sectors of the economy under president Banda. Third, from 1978 onwards the lack of sustainability of these structures led to a period of growth decline. In 1994 Malawi transitioned to multiparty elections, however the country failed to modernize and the systems of patronage were further entrenched. Fourth, from 2003 the country has seen weak growth acceleration. However, the country has failed to transform how the economy is organized, meaning that many of the structures remain in place. An overreliance on powerbrokers and rentiers within the economy has meant that the structural changes needed to improve living standards within the country remain elusive.
Dominance and Deals in Africa
Authors: Bukenya Badru , Hickey Sam
Published: December 2017

Uganda has experienced four growth episodes since the 1960s. In the most recent episode, 1988–2010, average growth rates have exceeded 3.5 per cent, with average growth rates of 7 per cent between 2001 and 2010. Yet this history of recent strong growth has failed to lead to structural transformation within the economy. This chapter highlights how each of the deals spaces remains closely embedded within, and informed by, the broader political settlement. This is due to the fact that Uganda is still reliant on a limited range of agricultural commodities, while recent discoveries of oil raise the spectre of Dutch Disease. It argues that greater support for agricultural processing, manufacturing, and increasing the state’s capacity, particularly through protecting the economic and regulatory technocracy for patronage politics, will help achieve this. A power shift to more market-based rents will help produce more productive dialogue between the state and business.
Evident Certainties
Authors: Pasnau Robert
Published: December 2017

What exactly is epistemology? As fundamental to philosophy as this subject has become, it is surprisingly unclear what it is centrally about. This lecture explains how our modern conception of epistemology grew out of the decline of scholasticism. Descartes is identified as the last great champion of the expectation of certainty, and Locke and other English authors are taken to be the vanguard of a new expectation, founded in mere moral certainty and the proportioning of belief to evidence. This development is traced back to John Buridan in the fourteenth century and then traced forward to the rise of epistemology in its current sense, with its focus on justification.
Deception and Hope
Authors: Pasnau Robert
Published: December 2017

Despite the tendency toward optimism that runs throughout the history of philosophy, the possibility of a deceiving deity looms over many traditions, calling into question just how secure our epistemic situation really is. Yet there is a surprising constraint on our vulnerability to deception, even at the hands of God. On the other hand, God himself faces a surprising vulnerability to deception, which makes even his case far less ideal than has always been supposed. With that in mind, we have reason to suspect that we are subject to epistemic defeat, meaning that, in the final analysis, we have no good evidence for the truth of any proposition. If this is so, then we might take refuge in faith, or we might take refuge in hope. Hope, I argue, is the better option.
Energy and Society
Authors: Rez Peter
Published: December 2017

The more ‘developed’ the country and the higher the ‘standard of living’, the greater the energy use per person. Energy use can be broken down into three main categories—maintaining a comfortable environment in buildings, transportation of people and things and manufacturing stuff. More energy per person is used in colder countries than in warmer ones. Also, countries where people drive large cars over longer distances every year (United States, Canada and Australia) use more oil per person than European countries. Carbon dioxide emission is related to how much oil is used per person, and how electricity is generated. If a lot of electricity is generated from coal power stations, this will result in higher carbon dioxide emissions. As France has shown, substitution of coal by nuclear power results in a significant reduction in carbon dioxide emissions.
Planning for climate change without climate projections?
Authors: Lawler Joshua J. , Michalak Julia
Published: December 2017

This chapter explores the relative uncertainty associated with popular approaches to conservation planning in the face of climate change. Concern about uncertainties inherent in climate-change projections and associated ecological impacts have led many in the conservation community to avoid climate modeling, and instead favor forecast-free approaches that involve increasing connectivity and protecting “nature’s stage” (geophysical settings) to produce climate-smart conservation plans. A comparison of each of these approaches reveals that the uncertainties associated with connectivity modeling and mapping geophysical settings can be as large, if not larger than, the uncertainties associated with climate-change projections. Whereas the uncertainties of climate forecasts are widely appreciated, the same cannot be said for the approaches that avoid climate forecasts. It is not the case that there is one best approach. The answer to uncertainty is to seek robust conservation plans that work regardless of which approach is taken.
Locke, Enlightenment, and Liberty in the Works of Catharine Macaulay and her Contemporaries
Authors: Green Karen
Published: December 2017

This chapter demonstrates how a number of women in eighteenth-century Europe exploited a contrast between ‘liberty’ and ‘licence’ in their political writings. The authors discussed include Catharine Macaulay (1731–91) and her contemporaries Catherine II of Russia, Octavie Belot, Louise Keralio, and Elise Reimarus. It is shown that, in their works, these women are strongly opposed to unfettered licence, the freedom to do as one wills in the absence of external impediments and constraints. They distinguish this kind of freedom from their own positive notion: the freedom to govern one’s self in accordance with the moral law of reason. In this respect, this chapter argues, these women adapt the earlier ideas of English philosopher John Locke. It is shown that in the writings of Macaulay, in particular, Locke’s sentiments about liberty and law are taken to a radical democratic conclusion: an ideal of fair and equal representation of the people.
Mary Astell on Liberty
Authors: Sowaal Alice
Published: December 2017

This chapter deals with a form of lack of liberty that Astell identifies as plaguing women, namely slavery to our passions and other internal features of our selves. It argues that Astell takes an unusual approach to such a lack of internal liberty; namely, rather than claiming that an external lack of liberty must be realized first before internal liberty is possible, Astell claims that we must first gain internal liberty and thereafter will we gain liberty from external constraints because they will become moot. This claim is substantiated by examining Astell’s understanding of the nature of the passions and of the human’s relation with God. The chapter concludes with reflections on Astell’s place in the history of feminism.
Trade Justice
Authors: Christensen James
Published: December 2017

The international trading system remains a locus of fierce social conflict. The protesters who besiege gatherings of its managers—most famously on the streets of Seattle at the turn of the millennium—regard it with suspicion and hostility, as a threat to their livelihoods, an enemy of global justice, and their grievances are exploited by populist statesmen peddling their own mercantilist agendas. If we are to support the trading system, we must first assure ourselves that it can withstand moral scrutiny. We must ensure that it works for and not against those whom it envelops; that it serves to emancipate, not ensnare. While there is an extensive literature addressing the economic and legal aspects of trade, the ethical questions its raises have escaped close inspection. This book contributes to resetting the balance. It grapples with moral quandaries relating to world politics, globalization, and international commerce, and recognizes that resolving these problems is essential if we are to move toward a world in which trade justice is a reality.
Multidimensional Poverty
Authors: Dutta Bhaskar
Published: December 2017

A rich literature on multidimensional poverty measurement has recently sprung up. In this multidimensional setting, an individual is identified as poor or deprived if he or she falls short of these poverty-line-like cut-offs along various dimensions. A key assumption is that these shortfalls are non-comparable—a shortfall in one dimension cannot be compensated by a gain in another. This chapter reviews some of these axiomatic treatments and questions some assumptions. It points out that there are other ways in which one can identify impoverished individuals even within the multidimensional framework.
In Our Own Image
Authors: Wildman Wesley J.
Published: December 2017

In Our Own Image is a work of comparative philosophical theology answering three questions. First, it is a study of the roles anthropomorphism and apophaticism play in the construction of conceptual models of ultimate reality. This answers the question: Do we create our ideas of God? Second, it is a comparative analysis of three major classes of ultimacy models, paying particular attention to the way those classes are impacted by anthropomorphism while tracing their relative strengths and weaknesses. This answers the question: Can there be better and worse in our constructed ultimacy models? Third, it is a constructive theological argument on behalf of an apophatic understanding of ultimate reality, showing how this understanding subsumes, challenges, and relates ultimacy models from the three classes being compared. This answers the question: Is there a best way to think about ultimate reality? The book describes and compares competing ultimacy models, fairly and sympathetically. The conclusion is that all models cognitively break on the shoals of ultimate reality, but that the ground-of-being class of models carries us further than the others in regard to the comparative criteria that matter most.
Intersecting shapes in music and in dance
Authors: Barnard Philip , deLahunta Scott
Published: December 2017

The concept of shape figures widely in discourse about both dance and music. This chapter discusses the shape using two analytic lenses explored over ten years of cumulative, interdisciplinary collaboration within R-Research, a team working alongside the contemporary dance company Wayne McGregor | Random Dance. These two lenses help locate issues, clarify problems and situate what we can learn from choreographic practice and empirical studies of dance. The first lens is a framework for describing what goes on in the making of an artwork or in design processes generally. The second lens is that of mental architecture, applied here to examine how the multiple components of the human mind work together in creative and performance contexts. Each of these can provide some insight into the multiple facets of choreomusical relationships and, in doing so, can offer some modest augmentations to choreographic practice.
Cross-cultural collaborations with the Kronos Quartet
Authors: Bayley Amanda
Published: December 2017

By examining the creative and interactive processes that take place between members of the Kronos Quartet and musicians from non-Western traditions, the research discussed in this chapter extends beyond the standard conventions of the classical string quartet repertoire to embrace unusual and unpredictable combinations of notation and improvisation. Examples of Kronos rehearsing with singers and instrumentalists from Central Asia, and with Ukrainian vocalist Mariana Sadovska, illustrate how conventional Western constructions of composer and performer become blurred when musicians work together across cultural boundaries. The chapter uses rehearsal and interview data to address questions regarding roles and responsibilities, the distribution of creativity in rehearsal, and the way composition, performance and improvisation are defined and re-defined in this context.
Video Colposcopy for Reducing Patient Anxiety During Colposcopy: A Randomized Controlled Trial
Authors: Hilal Ziad , Alici Ferizan , Tempfer Clemens B. , Seebacher Veronika , Rezniczek Günther A.
Published: December 2017

(Abstracted from Obstet Gynecol 2017;130:411–419)

Colposcopy—the standard diagnostic technique for women with suspected cervical dysplasia—causes anxiety and discomfort. Women undergoing this procedure may be especially anxious as a result of a potential cancer diagnosis.
Lifestyle in Progression From Hypertensive Disorders of Pregnancy to Chronic Hypertension in Nurses' Health Study II: Observational Cohort Study
Authors: Timpka Simon , Stuart Jennifer J. , Tanz Lauren J. , Rimm Eric B. , Franks Paul W. , Rich-Edwards Janet W.
Published: December 2017

(Abstracted from BMJ 2017;358:j3024)

Hypertensive disorders of pregnancy (HDPs: preeclampsia and gestational hypertension) are associated with earlier onset of chronic hypertension and a higher risk of ischemic heart disease and stroke and affect between 5% and 10% of parous women. There is little guidance for the prevention of chronic hypertension among women with a history of HDPs, and the role of lifestyle in the progression from HDPs to chronic hypertension is unclear, including whether established lifestyle interventions are as effective in women with a history of HDPs as in the general population.
The ASPIRE-to-Excellence Program: A Global Effort to Improve the Quality of Medical Education
Authors: Hunt Dan , Klamen Debra , Harden Ronald M. , Ali Farzand
Published: December 2017

Publications and organizations ranking medical schools rely heavily on schools’ research-oriented and grant-success data because those are the publicly available data. To address the vacuum of evidence for medical education quality, in 2012 the Association for Medical Education in Europe (AMEE) introduced an initiative entitled A Schools Programme for International Recognition of Excellence in Education (ASPIRE) awards. ASPIRE panels of international experts in specific areas of medical education have developed internationally peer-based criteria to benchmark excellence in social accountability, student engagement, student assessment, faculty development, and simulation; they plan to publish criteria on curriculum design and development in 2018. Schools are encouraged to use ASPIRE criteria to challenge themselves and, for a fee, may submit evidence that they have met the criteria for excellence in one or more of the five areas. The international panels then judge the evidence submitted by the school and determine whether an award of excellence is merited.

The authors share lessons learned from five years of program experience. Of the 88 schools submitting evidence, 38 have been recognized for their excellence in one of the ASPIRE topic areas. As the number of representatives from the schools that are awarded ASPIRE recognition continues to increase and those individuals find new ways to contribute, hopes are high for this program. Challenges remain in how to better define excellence in low-resources settings, what new areas to take on, and how to keep infrastructure costs down. However, as an example of continuing global interaction for quality improvement, optimism prevails.
The Current Use of United States Medical Licensing Examination Step 1 Scores: Holistic Admissions and Student Well-Being Are in the Balance
Authors: Moynahan Kevin F.
Published: December 2017

United States Medical Licensing Examination Step 1 scores increasingly are being used by graduate medical education programs to “screen out” applicants to invite for an interview; medical students with scores below a certain (usually unpublished) point are not considered for an interview. Conversely, many students are extended an interview invitation based solely on their Step 1 scores, prior to the release of their Medical Student Performance Evaluation. In this Invited Commentary, the author discusses why this practice has gained popularity as well as the unintended effects it has had in multiple domains—holistic undergraduate medical education admissions practices, student well-being, and medical school curricula. Possible solutions are considered, including a pass/fail reporting structure, a national basic science curriculum, and better alignment between undergraduate and graduate medical education admissions processes and values. Through collaborative work between the Association of American Medical Colleges, the National Board of Medical Examiners, the Accreditation Council for Graduate Medical Education, and medical educators, an alternative, more holistic standardized metric by which to compare students’ applications should be developed.
Looking Back to Move Forward: First-Year Medical Students’ Meta-Reflections on Their Narrative Portfolio Writings
Authors: Cunningham Hetty , Taylor Delphine , Desai Urmi A. , Quiah Samuel C. , Kaplan Benjamin , Fei Lorraine , Catallozzi Marina , Richards Boyd , Balmer Dorene F. , Charon Rita
Published: December 2017

The day-to-day rigors of medical education often preclude learners from gaining a longitudinal perspective on who they are becoming. Furthermore, the current focus on competencies, coupled with concerning rates of trainee burnout and a decline in empathy, have fueled the search for pedagogic tools to foster students’ reflective capacity. In response, many scholars have looked to the tradition of narrative medicine to foster “reflective spaces” wherein holistic professional identity construction can be supported. This article focuses on the rationale, content, and early analysis of the reflective space created by the narrative medicine-centered portfolio at the Columbia University Vagelos College of Physicians and Surgeons. In January 2015, the authors investigated learning outcomes derived from students’ “Signature Reflections,” end-of-semester meta-reflections on their previous portfolio work. The authors analyzed the Signature Reflections of 97 (of 132) first-year medical students using a constant comparative process. This iterative approach allowed researchers to identify themes within students’ writings and interpret the data. The authors identified two overarching interpretive themes—recognition and grappling—and six subthemes. Recognition included comments about self-awareness and empathy. Grappling encompassed the subthemes of internal change, dichotomies, wonder and questioning, and anxiety. Based on the authors’ analyses, the Signature Reflection seems to provide a structured framework that encourages students’ reflective capacity and the construction of holistic professional identity. Other medical educators may adopt meta-reflection, within the reflective space of a writing portfolio, to encourage students’ acquisition of a longitudinal perspective on who they are becoming and how they are constructing their professional identity.
Soft Factors, Smooth Transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care
Authors: Latzke Markus , Schiffinger Michael , Zellhofer Dominik , Steyrer Johannes
Published: December 2017

Background:

Intrahospital patient transports (IHTs) in intensive care involve an appreciable risk of adverse events (AEs). Research on determinants of AE occurrence during IHT has hitherto focused on patient, transport, and intensive care unit (ICU) characteristics. By contrast, the role of “soft” factors, although arguably relevant for IHTs and a topic of interest in general health care settings, has not yet been explored.

Purpose:

The study aims at examining the effect of safety climate and team processes on the occurrence of AE during IHT and whether team processes mediate the effect of safety climate.

Methodology/Approach:

Data stem from a noninterventional, observational multicenter study in 33 ICUs (from 12 European countries), with 858 transports overall recorded during 28 days. AEs include medication errors, dislodgments, equipment failures, and delays. Safety climate scales were taken from the “Patient Safety Climate in Healthcare Organizations” (short version), team processes scales from the “Leiden Operating Theatre and Intensive Care Safety” questionnaire. Patient condition was assessed with NEMS (Nine Equivalents of Nursing Manpower Use Score). All other variables could be directly observed. Hypothesis testing and assessment of effects rely on bivariate correlations and binomial logistic multilevel models (with ICU as random effect).

Findings:

Both safety climate and team processes are comparatively important determinants of AE occurrence, also when controlling for transport-, staff-, and ICU-related variables. Team processes partially mediate the effect of safety climate. Patient condition and transport duration are consistently related with AE occurrence, too.

Practice Implications:

Unlike most patient, transport, and ICU characteristics, safety climate and team processes are basically amenable to managerial interventions. Coupled with their considerable effect on AE occurrence, this makes pertinent endeavors a potentially promising approach for improving patient safety during IHT. Although literature suggests that safety climate is slow and hard to change (also compared to team processes), efforts to improve safety climate should not be forgone.
TREATMENT OF IDIOPATHIC RETINAL VASCULITIS, ANEURYSMS, AND NEURORETINITIS (IRVAN) WITH PHOTOCOAGULATION IN COMBINATION WITH SYSTEMIC IMMUNOSUPPRESSION
Authors: Ameratunga Rohan , Donaldson Mark
Published: December 2017

Background:

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome is a very rare primary retinal vasculitis. It seems to evolve in stages, where there is initially a florid vasculitis associated with aneurysm formation. Neuroretinitis and macula edema are common features. Subsequently, retinal ischemia ensues, leading to neovascularization. If untreated, further sight-threatening complications occur, including traction retinal detachment and secondary glaucoma.

Methods and Results:

Here, we describe a patient with early idiopathic retinal vasculitis, aneurysms, and neuroretinitis syndrome, who was treated with a combination of systemic immunosuppression and localized photocoagulation. There was substantial regression of the aneurysms and improvement of the macular edema. Treatment of the disorder should be based on the clinical stage and complications of the disorder.

Conclusions:

As shown here, a multidisciplinary approach can be very helpful in managing patients with this severe sight-threatening disorder.
Spinal Cord Injury Impairs Cardiovascular Capacity in Elite Wheelchair Rugby Athletes
Authors: Gee Cameron M. , Currie Katharine D. , Phillips Aaron A. , Squair Jordan W. , Krassioukov Andrei V.
Published: December 2017

Objective:

To examine differences in heart rate (HR) responses during international wheelchair rugby competition between athletes with and without a cervical spinal cord injury (SCI) and across standardized sport classifications.

Design:

Observational study.

Setting:

The 2015 Parapan American Games wheelchair rugby competition.

Participants:

Forty-three male athletes (31 ± 8 years) with a cervical SCI (n = 32) or tetraequivalent impairment (non-SCI, n = 11).

Main Outcome Measures:

Average and peak HR (HRavg and HRpeak, respectively). To characterize HR responses in accordance with an athletes' International Wheelchair Rugby Federation (IWRF) classification, we separated athletes into 3 groups: group I (IWRF classification 0.5-1.5, n = 15); group II (IWRF classification 2.0, n = 15); and group III (IWRF classification 2.5-3.5, n = 13).

Results:

Athletes with SCI had lower HRavg (111 ± 14 bpm vs 155 ± 13 bpm) and HRpeak (133 ± 12 bpm vs 178 ± 13 bpm) compared with non-SCI (both P < 0.001). Average HR was higher in group III than in I (136 ± 25 bpm vs 115 ± 20 bpm, P = 0.045); however, SCI athletes showed no difference in HRavg or HRpeak between groups. Within group III, SCI athletes had lower HRavg (115 ± 6 bpm vs 160 ± 8 bpm) and HRpeak (135 ± 11 bpm vs 183 ± 11 bpm) than non-SCI athletes (both P < 0.001).

Conclusions:

This study is the first to demonstrate attenuated HR responses during competition in SCI compared with non-SCI athletes, likely due to injury to spinal autonomic pathways. Among athletes with SCI, IWRF classification was not related to differences in HR. Specific assessment of autonomic function after SCI may be able to predict HR during competition and consideration of autonomic impairments may improve the classification process.
Neonatal Neuroprotection
Authors: Lockridge Terrie
Published: December 2017

Preterm birth interrupts the precise process of fetal maturation, forcing critical neurologic growth to continue within the Neonatal Intensive Care Unit (NICU). Concern for the impact of the NICU experience on the developing brain led to a unit-based Quality Improvement (QI) project to promote best outcomes for our graduates. The objective was to implement a standard of care for neonatal neuroprotection in a large urban tertiary center. A multidisciplinary committee researched and developed the Neonatal Neuroprotective Best Practice Guidelines to identify optimal interventions, as well as provide physiologic rationales to reinforce importance of these practices. An educational initiative accompanied release of this document to support consistency in clinical practice and to stress the critical role that every caregiver played in a child's outcome. As the Best Practice Guidelines encompassed virtually all aspects of caregiving in the NICU, it was impractical to measure the impact of such a broad range of interventions in a methodical manner. The full effect of these interventions will not likely be evident until NICU graduates have grown into childhood and adolescence. These constraints limited the scope of this QI project to the practicalities of identifying neuroprotective best practice and bringing it to the bedside. When combined with evidence-based medical and nursing care, neuroprotective care represents the best means of facilitating normal development and minimizing disability for our NICU graduates.
Facial Myokymia and Hemifacial Spasm in Multiple Sclerosis
Authors: Marin Collazo Iris V. , Tobin W. O.
Published: December 2017

Objective:

Facial Myokymia and hemifacial spasm have been associated with multiple sclerosis; however, their etiology and clinical outcome is uncertain. Here, we describe the clinical, radiologic features, and treatment outcomes of a cohort of patients with multiple sclerosis and history of facial myokymia or hemifacial spasm.

Methodology:

We reviewed the clinical features, radiologic features, and treatment outcomes of 35 patients with a diagnosis of multiple sclerosis and facial myokymia (28) or hemifacial spasm (7) seen at Mayo Clinic (Rochester, MN).

Results:

Facial myokymia was associated with a clinical or radiologic relapse in 11 of 28 patients. In 27 of 28 patients with facial myokymia, symptom resolution occurred within months regardless of treatment. An ipsilateral pontine lesion was found in 3 of 7 cases with hemifacial spasm. Hemifacial spasm was associated with a clinical or radiologic relapse in 3 of 7 cases. Hemifacial spasm resolved within 4 years in 5 of 7 cases, with the remaining cases persisting up to 9 years despite treatment.

Conclusions:

Facial myokymia and hemifacial spasm occurring in patients with multiple sclerosis is associated with an ipsilateral pontine MRI lesion in a minority of patients. Facial myokymia is a self-limited process while hemifacial spasm can be persistent in a minority of patients, despite treatment.
The Safety of Low-Molecular-Weight Heparin During and After Pregnancy
Authors: Lu Eric , Shatzel Joseph J. , Salati Jennifer , DeLoughery Thomas G.
Published: December 2017

Importance

In industrialized countries, venous thromboembolism remains a leading cause of mortality in pregnant women. Low-molecular-weight heparin (LMWH) is the most commonly recommended anticoagulant in pregnancy, having been proven effective and safe in multiple prospective clinical trials.

Objective

The aim of this article is to outline existing recommendations for proper use of LMWH in pregnancy and data on risks of LMWH.

Evidence Acquisition

We reviewed guidelines from a number of professional societies. We also examined the current literature behind the various risks associated with LMWH use.

Results and Conclusions

Our review outlines the current data that guide the use of LMWH in pregnancy. With prophylactic dosing, LMWH comes with a 0.5% risk of antepartum bleeding and a 1% risk of postpartum hemorrhage that is not different from clinical trial controls. With treatment dosing, there is a 1.5% risk of antepartum bleeding and a 2% risk of postpartum hemorrhage. Overall, current evidence behind these risks is limited, and this review suggests areas of further study moving forward.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to define the specific risk factors and preexisting conditions that would warrant LMWH use in pregnancy and postpartum; describe the different available doses of LMWH, when to use each dose, and when monitoring is appropriate; and discuss the risks of anticoagulation with LMWH during various stages of pregnancy and birth.
All-Cause Mortality After Fertility-Sparing Surgery for Stage I Epithelial Ovarian Cancer
Authors: Melamed Alexander , Rizzo Anthony E. , Nitecki Roni , Gockley Allison A. , Bregar Amy J. , Schorge John O. , del Carmen Marcela G. , Rauh-Hain J. Alejandro
Published: December 2017

(Abstracted from Obstet Gynecol 2017;130:71–79)

Most cases of epithelial ovarian cancer (EOC) In the United States are diagnosed in postmenopausal women. Only 7% of cases occur in women younger than 40 years.
Ventilation in Extremely Preterm Infants and Respiratory Function at 8 Years
Authors: Doyle Lex W. , Carse Elizabeth , Adams Anne-Marie , Ranganathan Sarath , Opie Gillian , Cheong Jeanie L. Y.
Published: December 2017

(Abstracted from N Engl J Med 2017;377:329–337)

It is common for extremely preterm infants (<28 weeks' gestation) to experience respiratory problems and to require assisted ventilation until they are able to breathe independently. Assisted ventilation is not without risk, however, as exposure to the airway pressure and higher concentrations of oxygen provided by the ventilators can injure the lungs and may result in arrested pulmonary development or bronchopulmonary dysplasia.