bluuebunny/crossref_metadata_2025 huggingface dataset:
The Objective and Coverage of this Book; Doctrinal and Social Propositions; Social and Critical Morality; Terminology; and the Tenor of the Footnote Apparatus
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 1 states the objective of this book: to develop contract law as it should be. Attention is also given to describing contract law as it is, because what contract law should be cannot be developed in a vacuum. Chapter 1 also describes some of the terms used in this book: doctrinal propositions is used in this book to mean propositions that purport to state legal rules and are found in or can be derived from sources that are generally regarded as authoritative by the legal profession. Social propositions is used to mean policies, which characterize states of affairs as good or bad, depending on whether they are conducive or adverse to the general welfare; moral norms, which characterize conduct as right or wrong; and experiential propositions, which describe the way in which the world works and mediate between moral and policy propositions, on the one hand, and doctrinal propositions on the other. All doctrinal propositions should be based on social propositions.
Theories of Contract Law
Authors: Eisenberg Melvin A.
Published: October 2018

Theories of contract law fall into three basic categories: formalist, interpretive, and normative. Formalist theories proceed by first purporting to identify a core set of rules that are justified on the ground that they are self-evident axioms, and then purporting to derive the remaining rules by logical deduction from the axioms. Interpretive theories proceed by describing areas of contract law and then determining the social propositions that are to be found in the most fundamental doctrines in the area or that meet some standard of fit with and best justify or rationalize doctrine in the area. Under normative theories the content of contract law depends on the rules that are generated by properly weighted and reconciled policy, moral, and empirical propositions. Unlike the objectives of formalist and interpretive theories, the objective of normative theories is to formulate the best possible rules of contract law.
The Transformation of Contract Law from Classical to Modern
Authors: Eisenberg Melvin A.
Published: October 2018

From the middle of the nineteenth century until the first part of the twentieth century contract law was dominated by a school of thought now known as classical contract law. Over the last seventy or eighty years contract law has been transformed from classical to modern. One area of transformation concerns the nature of contract-law reasoning. Reasoning in classical contract law was formal: social propositions played little or no role. In contrast, the objective of modern contract law is to craft rules that are justified by social propositions or, to put it differently, are normatively desirable. The transformation from classical to modern contract law can also be observed through examination of four spectra along which contract-law doctrines can be ranged: from objectivity to subjectivity, from standardization to individualization, from the static to the dynamic, and from binary to multifaceted rules.
The Building Blocks of Formulas to Measure Expectation Damages; the Indifference Principle
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 13 concerns the building blocks of formulas to measure expectation damages: replacement cost, market price, resale price, diminished value, and lost profits. Replacement-cost damages are based on the difference between the contract price and the actual or imputed cost of a replacement transaction. Resale-price damages are based on the difference between the contract price payable by a breaching buyer and the price the seller received on resale to a third party. Diminished-value damages are based on the difference between the value of the performance that a breaching seller rendered and the value of the performance that she promised to render. Lost-profit damages are based on the difference between the price a breaching buyer agreed to pay and the seller’s variable costs.
Formulas for Measuring Expectation Damages for Breach of a Contract to Provide Services
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 15 concerns formulas for measuring expectation damages for contracts to provide services, including breaches by both service-purchasers and service-providers. In case of breach by service-purchasers one formula is based on the service-provider’s lost profit. Under an alternative formula the service-provider is entitled to the contract price minus the out-of-pocket costs remaining to be incurred by the service-provider at the time of breach. Although these two expressions look very different they are algebraically equivalent and yield the same amount of damages. In case of breach by the service-provider the core formulas for measuring damage to the service-purchaser involve either cost-of-completion or diminished-value damages.
The Principle of Hadley v. Baxendale
Authors: Eisenberg Melvin A.
Published: October 2018

This chapter concerns the principle of Hadley v. Baxendale. Under this principle a promisee injured by a breach of contract can recover only those damages that either should “reasonably be considered . . . as arising naturally, i.e., according to the usual course of things” from the breach, or might “reasonably be supposed to have been in the contemplation of both parties, at the time they made the contract, as the probable result of the breach of it.” On the basis of Hadley v. Baxendale contract law has conventionally distinguished between general and consequential damages. General damages are damages that flow from a given type of breach without regard to the buyer’s particular circumstances. Consequential damages are damages that flow from the buyer’s particular circumstance. They can be recovered only if at the time the contract was made it was reasonably foreseeable that the damages would probably result from the breach. A better alternative to Hadley v. Baxendale, which is more in keeping with general law, has three elements: contractual allocation of losses resulting from the breach, the principle of proximate cause, and limits on disproportionate damages.
Other Limitations on Expectation Damages
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 20 concerns limitations on expectation damages other than the principle of Hadley v. Baxendale and the certainty principle. The most significant limitation is that generally speaking, under the common law each party to a dispute pays its own litigation costs—attorney’s fees, expert fees, and so forth—win or lose. Oher limitations include the time value of forgone gains—especially since even if prejudgment interest is granted, it will generally be at a lower rate than the actual market rate for interest—and the risk of the promisor’s insolvency. Accordingly, a promisee will never be indifferent between performance and damages.
Critiques of the Expectation Measure, and Alternative Damage Regimes
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 22 considers critiques of the expectation measure of damages and alternative damages regime that have been proposed. Most or all of these critiques argue that a given alternative damages regime would significantly further a worthwhile goal. The validity of the arguments that these alternative regimes would significantly further a worthwhile goal that is not promoted by expectation damages is questionable. In some cases the alternative regime would add only a miniscule incentive to the incentives contracting actors already have. In other cases the desired goal is already incentivized by expectation damages, and in all or almost all cases the alternative regime would be unadministrable.
The Specific-Performance Principle
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 24 considers the most prominent alternative to expectation damages—specific performance. Specific performance is a judicial decree that orders a promisor to render the performance she agreed to render, on pain of a penalty for contempt of court if she does not. The principle that should govern specific-performance—the Specific-Performance Principle—is as follows: actual specific performance should be awarded unless a special moral, policy, or experiential reason suggests otherwise in a given class of cases or the promisee can achieve virtual specific performance by acquiring goods or services in the market that are equivalent to the contracted-for goods or services. Under this principle specific performance should be liberally but not routinely granted.
The General Principles of Contract Interpretation
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 28 considers theories of contract interpretation, which generally fall into two schools. Theories in one school, contextualism, hold that a contract cannot be sensibly interpreted without regard to the context in which the contract was made. Theories in the other school, literalism, hold that if a contract is embodied in a relatively comprehensive writing it should be interpreted solely on the basis of the writing. The most prominent form of textualism is the plain-meaning rule. Under that rule if there exists a more or less complete writing that reflects the existence of a contract and the court determines, by looking only at the writing, that the writing is unambiguous, the parties are not allowed to introduce evidence outside the writing concerning the meaning of the writing. The plain-meaning rule is fatally defective because a writing cannot be sensibly interpreted without regard to the context in which it was written, and disputed contract language is almost never unambiguous.
Prizes and Rewards
Authors: Eisenberg Melvin A.
Published: October 2018

Prizes and rewards may be either freely bestowed for achievement, like the Nobel, or awarded as due, like prizes in contests or rewards for the return of lost property. Prizes and rewards that are freely bestowed for achievement normally do not raise issues of contract law because they do not involve promises. Prizes and rewards that are awarded as due constitute offers for unilateral contracts. These prizes and rewards raise two difficult damages issues: (1) What measure of damages should be utilized if the reward or prize is not forthcoming when due? (2) What should be the remedy for the wrongful denial of a contestant’s chance to win a prize?
Implied-in-Law and Implied-in-Fact Contracts
Authors: Eisenberg Melvin A.
Published: October 2018

This chapter concerns implied-in-fact and implied-in-law contracts. Most contracts are explicitly agreed upon. However, some contracts are implied in fact rather than explicit. An implied-in-fact contract is a true contract. It differs from a run-of-the-mill contract only in that the parties’ assent, although real, is not explicit. Another category of legal obligation is an implied-in-law contract, sometimes referred to a quasi-contract. Implied-in-law contracts are not contracts; rather, they are obligations that are based on unjust enrichment. They are referred to as contracts for purely historical reasons.
Incomplete Contracts
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 36 considers issues that result from the incompleteness of a contract. In economic theory a complete contract is a contract that specifies the parties’ rights, duties, and remedies under every possible state of the world. Under this conception every contract is incomplete, because it would be prohibitively expensive to delineate the effect of all possible future states and the consequences of each state. In contract law the term incomplete contract means a contract that is gappy or indefinite in important respects. The law on incomplete contracts concerns when a contract has too many gaps or is too indefinite to enforce, when and how a court should fill gaps in a contract, what is the effect of a provision in an agreement that contemplates the later execution of a final contract, and when is there a duty to negotiate in good faith to make an incomplete contract sufficiently complete or to reach a contemplated final contract.
Mechanical Errors (“Unilateral Mistakes”)
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 41 concerns unilateral mistakes. A unilateral mistake is a transient mental blunder that results from an error in the mechanics of an actor’s mental machinery, such as incorrectly adding a column of figures. Mistakes of these kinds are referred to in this book as mechanical errors. Mechanical errors differ from evaluative mistakes in several critical respects. For one thing, unlike evaluative mistakes the prospect that a counterparty will make a mechanical error normally is not a risk that is bargained for. And unlike evaluative mistakes, relief for mechanical errors would not undermine the very idea of promise: A promisor who seeks relief on the ground of a mechanical error does not assert that all things considered she doesn’t wish to perform. Rather, she asserts that she has a morally acceptable excuse that is well within the systemics of promise.
Disclosure in Contract Law
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 44 concerns the following issue: suppose A and B propose to make a contract for the purchase and sale of a commodity. A knows a material fact, F, concerning the commodity, and also knows or has reason to know that B does not know F. Is it permissible for A not to disclose fact F to B, or is disclosure required? The principle that should govern this type of case (the Disclosure Principle) is as follows: In a contractual context, disclosure of material facts that one party knows and knows or has reason to know the other party does not know should be required except in those classes of cases in which a requirement of disclosure would entail significant efficiency costs. This principle puts a thumb on the scale—in effect, creates a presumption—in favor of disclosure because of the moral and efficiency reasons that support disclosure. To overcome this presumption it is not enough that in a given class of cases a requirement of disclosure would entail some efficiency costs. Instead, the presumption is overcome only if disclosure would entail significant efficiency costs.
The Effects of Unexpected Circumstances—Impossibility, Impracticability, and Frustration
Authors: Eisenberg Melvin A.
Published: October 2018

In unexpected circumstances cases relief normally should be granted to the adversely affected party if the parties shared a tacit incorrect assumption that the nonoccurrence of some circumstance during the life of the contract was certain rather than problematic, and the incorrectness of that assumption would have provided a basis for judicial relief if the assumption had been explicit rather than tacit. Relief should also normally be granted to the adversely affected party if as a result of a dramatic and unexpected general rise in prices, and therefore costs, performance would result in an unbargained-for loss to a promisor. Where judicial relief is based on a shared tacit assumption the promisor should not be liable for expectation damages. Where relief is based on an unbargained-for risk the promisor should be liable for a modified form of expectation damages.
The Order of Performance; Constructive Conditions
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 47 concerns the order in which each party to a contract must render or tender his or her performance. The significance of this issue is that if party A must render or tender performance before or simultaneously with party B, then unless A has performed or tendered B, is not obliged to perform and will not be in breach for not performing.. Where neither the contract nor the circumstances provide an answer to the order-of-performance issue the answer is supplied by implication of law. Generally speaking the law favors the implication of simultaneous performance, if that can be achieved. If it cannot reasonably be implied that the parties’ performances are to be simultaneous, the usual implication is that if one party’s performance takes time and the other party’s performance does not, the performance that takes time must be rendered first.
Augmented Sanctions: Material Breach, Total Breach, and Opportunistic Breach; Cure; Suspension and Termination
Authors: Eisenberg Melvin A.
Published: October 2018

Every breach of contract gives the promisee the right to recover expectation damages. Under certain circumstances a promisee may also have the right to invoke augmented sanctions, including damages measured on the basis that the promisor totally failed to perform the contract (as opposed to damages measured only by the harm from breach of a particular term), and suspension and termination of the contract. If a promisor commits a breach that was neither material nor opportunistic and the breach is curable—that is, if the effect of the breach is reversible—she should be able to avoid the imposition of an augmented sanction by curing the breach promptly after the promisee gives her notice that she is in breach and that unless she promptly cures the breach he will terminate the contract.
The Principle of Substantial Performance
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 51 concerns the principle of substantial performance. Suppose a promisor has committed a breach but has substantially performed the contract. Under the principle of substantial performance the promisor can recover expectation damages, subject to an offset for damages resulting from the breach. There are good reasons for this rule. If the parties had addressed the issue when the contract was made, it is unlikely they would have agreed that any imperfection in performance, no matter how immaterial, would bar a suit for expectation damages. Indeed, in the case of complex performances it is often virtually impossible to render a performance that is completely defect-free, and minor defects can ordinarily be cured either by the promisor or by a third party at the promisor’s expense. The principle of substantial performance is the law, apart from a limited exception concerning contracts for the sale of goods.
Third-Party Beneficiaries
Authors: Eisenberg Melvin A.
Published: October 2018

Chapter 55 concerns third-party beneficiaries. A third-party beneficiary is a person who is not a party to a contract but would benefit by its performance. The principle that should determine whether any given third-party beneficiary should have power to enforce a contract as follows: A third-party beneficiary should have the right to enforce a contract if but only if: (I) allowing the beneficiary to enforce the contract is a necessary or important means of effectuating the contracting parties’ objectives as manifested in the contract read in the light of surrounding circumstances; or (II) allowing the beneficiary to enforce the contract is supported by reasons of policy or morality independent of contract law and would not conflict with the contracting parties’ performance objectives.
Introduction
Authors: Egorova Yulia
Published: October 2018

The chapter outlines the research questions to be explored in the book and reflects on the main bodies of academic literature that the discussion subsequently draws on. It suggests that the book uses the South Asian context to pursue two separate but co-dependent strands of analysis, as it both focuses on the conceptual relationship between notions of Jewishness and meanings assigned to being Muslim on the subcontinent, and explores the diverse incarnations of interactions that could be broadly described under the rubric of Jewish-Muslim relations, putting the growing literature on this topic in dialogue with academic interventions interrogating anti-Semitism, Islamophobia, and their overlapping histories.
The Tropes of Jewish/Muslim Difference
Authors: Egorova Yulia
Published: October 2018

The chapter explores how notions of Jewish and Muslim difference play out in the history of communal violence in independent India. In doing so it will first interrogate the way in which trajectories of anti-Muslim ideologies intersect in India with Nazi rhetoric that harks back to Hitler’s Germany, and the (lack of) the memory of the Holocaust on the subcontinent. It will then discuss how the experiences of contemporary Indian Jewish communities both mirror and contrast those of Indian Muslims and how Indian Jews and the alleged absence of anti-Semitism in India have become a reference point in the discourse of the Hindu right deployed to mask anti-Muslim and other forms of intolerance.
Un/settled Relations
Authors: Egorova Yulia
Published: October 2018

The chapter reflects on the trope of Jewish-Muslim relations by exploring the daily interactions between members of the two communities in India and Pakistan and the mutual attitudes and perceptions that they demonstrate. The discussion highlights the processual and context-dependent nature of the multiple and varied interactions that one might describe under the rubric of Jewish-Muslim relations and argues that the latter can be seen as denoting two overlapping sets of meanings, serving both as an umbrella term for the multiple and diverse (rather than in any way systematic) encounters between Jews and Muslims and, as a Western trope conveying a projection of the non-Western other.
Below 100 Hz
Authors: Fink Robert
Published: October 2018

This chapter explores cultural theories of sub-bass production and reception in electronic dance music (EDM), reggae, and other bass-heavy popular musics. After a brief review of the musicology surrounding sub-bass (particularly the work of Steve Goodman and Julian Henriques), the discussion moves on to a cultural history of the sub-bass signal chain, including the subject of subwoofer design and other aspects of audio engineering for the reproduction of musical sounds below 100 Hz. The chapter details the perceptual responses to low frequencies and the physics of sub-bass sound propagation in order to critique the mystification of recent theorists of “bass culture.”
Auto-Tune, Labor, and the Pop-Music Voice
Authors: Provenzano Catherine
Published: October 2018

Long used in popular music to smooth vocal imperfections, Auto-Tune has become a much-discussed production tool since the early 2000s through artists including Cher, Daft Punk, and Kanye West. This chapter examines the relationship among artist skill, Auto-Tune, and reception. Artist T-Pain overtly used Auto-Tune to give his voice a synthetic, often robotic quality. Through T-Pain, overt use of Auto-Tune became associated with black music and was often reviled by the general public. T-Pain’s acoustic performance on NPR’s Tiny Desk Concert series redeemed him in the eyes of many listeners whose disdain for Auto-Tune arises from a belief that the technology erodes authenticity by making skillful singing irrelevant. In contrast, Taylor Swift’s producers also use Auto-Tune as well, but rather than treating it as a special effect, they use it to correct intonation and amplify desirable vocal timbre. This use is also controversial, as Swift’s recordings are often considered disingenuous.
Synthesizers As Social Protest in Early-1970s Funk
Authors: Woodworth Griffin
Published: October 2018

The advent of the synthesizer brought a new timbral palette for artists to explore. Early synthesizers sought to imitate acoustic instruments, but over time they developed their own unique timbral qualities used in 1970s funk and progressive rock. Occupying the Freudian uncanny, synthesized sounds are just distinguishable enough from those of acoustic instruments to inspire discomfort or create an otherworldly, science-fiction sound. This chapter argues that African-American funk musicians of the 1970s used synthesizers in the spirit of black social empowerment movements, which advocated for the reclamation of technology to be used in the defense of black communities. Artists such as Stevie Wonder and Parliament-Funkadelic’s Bernie Worrell utilized the synthesizer to articulate social protest against the plight of inner-city black Americans. To explore these issues, the chapter analyzes “Chocolate City” and “Living for the City” from lyrical, structural, and timbral perspectives.
The Spectromorphology of Recorded Popular Music
Authors: Zagorski-Thomas Simon
Published: October 2018

This chapter explores the cognitive processes involved in listening to electronically mediated music. Drawing on theories of embodied cognition, the chapter argues that the record-production process can result in “sonic cartoons,” with certain aspects of a performance accentuated and others attenuated. This can lead to paradoxical listening experiences, such as an acoustic sound rendered antinaturalistically or an electronic sound imitating the behavior of a real sound-producing event. The chapter illustrates these perceptual ambiguities with examples of spectrographic analyses of acoustic works by Shania Twain and Terence Blanchard, in addition to electronic works by Aphex Twin and William Orbit.
Afterword
Authors: Frith Simon
Published: October 2018

The afterword comments on the central concepts of the book. It begins with a critique of traditional musicology and of sociological studies of music, the former examining musical content with insufficient focus on social content and the latter doing the reverse. In reviewing the book’s chapters, the afterword points to the complex networks of commerce and art that are present in all pieces of music. The study of musical instruments is also crucial in this volume, as the authors examine the interaction between instrument and instrumentalist and how the concept of “musical instrument” has expanded to include electronic media. The afterword also points to the book’s focus on the social context of both instrument and genre. It concludes by pointing out the synthesis of musical pleasure and serious academic study achieved by the volume.
A brief review of recent discoveries in human anatomy
Authors: Kumar A , Ghosh S K , Faiq M A , Deshmukh V R , Kumari C , Pareek V
Published: October 2018

In the last few years, a cluster of anatomical discoveries has been reported which overturned the long existing dogmas about the structure and function of human body. First to come was the discovery that established the existence of a lymphatic system pertaining to the central nervous system (CNS). CNS was believed to be anatomically immune privileged owing to the absence of any lymphatics and presence of the blood-brain barrier around it, but latest research has established beyond any reasonable doubt that true lymphatic channels carry immune cells in meninges thus challenging the existing theory. Studies also supported the presence of a ‘Glymphatic system’ (created by the perivascular spaces lined with the leptomeninges and a sheath of glial cells) in the CNS draining interstitial metabolic waste from CNS. The second discovery unraveled the previously unknown parts of the human mesentery in adult and established that it is a continuous entity all along the intra-abdominal gut tube against the previous notion that it is fragmented in the adult humans. A very recently reported third discovery demonstrated a previously unknown tissue component—‘interstitium’—a networked collagen bound fluid-filled space existent in a number of human organs. All these structures bear considerable applied importance towards the pathogenesis, prognostic and diagnostic investigations and management of human diseases. This article attempts to present a brief review of all three remarkable discoveries and emphasizes their applied importance within the realm of medical sciences.
Analysis of Symptom Development in Relation to Quantity of Rice stripe virus in Rice (Oryza sativa) to Simplify Evaluation of Resistance
Authors: Okuda Mitsuru , Shiba Takuya , Hirae Masahiro , Masunaka Akira , Takeshita Minoru
Published: October 2018

Rice stripe virus (RSV) is one of the most devastating pathogens of rice (Oryza sativa) in rice-growing regions of East Asia. We analyzed the increase in RSV accumulation in infected rice plants over time and evaluated the association between disease severity and RSV accumulation with the aim of establishing an experimental system for accurate and efficient evaluation of RSV resistance in rice. As an index of RSV accumulation in plants, relative concentration of RNA corresponding to the coat protein gene region was measured using reverse-transcription quantitative polymerase chain reaction. Actin and elongation factor 1a were used as the host reference genes. RSV concentrations tended to increase with time from 7 to 28 days after inoculation, and a strong positive correlation was observed between the log RSV concentrations in the midsections of the uppermost leaves and in the stems at the first leaf sheath position. We analyzed RSV concentrations at these two locations 21 days after inoculation with RSV and assessed severity of disease symptoms based on a commonly used scale (Washio’s six-grade scale) rated as A (most severe), B, Bt, C, Cr, or D (mild symptoms). RSV concentrations at both locations were high in plants graded A, B, or Bt, with no significant difference in concentration of RSV among the three grades, but concentrations were significantly higher in the three grades compared with that in the plants in grade D. RSV concentrations were highly variable among plants in grades C and Cr. On the basis of these data, we propose a new formula to estimate the range of disease severities with greater ease and practical value. The values calculated by the new formula corresponded well to those based on Washio’s six-grade scale.
Characterization and Molecular Mapping of Two Novel Genes Resistant to Pythium Stalk Rot in Maize
Authors: Duan Canxing , Song Fengjing , Sun Suli , Guo Cheng , Zhu Zhendong , Wang Xiaoming
Published: October 2018

Pythium stalk rot caused by Pythium inflatum is becoming a more and more serious disease in maize, and it has caused severe yield loss in China in recent years. Deployment of resistant maize varieties is the most effective way to control this disease. Searching for the resistant maize germplasm and identifying the resistance genes are the vital processes in the breeding program. The maize inbred line X178 previously showed high resistance to Pythium stalk rot. Thus, this study aimed to reveal the gene(s) resistance to Pythium stalk rot in X178 by resistance inheritance analysis using the derived F2 and F2:3 genetic populations. The results showed that two independently inherited dominant genes, designated RpiX178-1 and RpiX178-2, carried by X178 are responsible for its resistance relative to the susceptible parent Ye107; they are located on regions of maize chromosome (chr.) 1 bin 1.09 and chr. 4 bin 4.08, respectively, and flanked by markers umc2047 and bnlg1671 as well as bnlg1444 and umc1313, respectively, by linkage analysis. Subsequently, RpiX178-1 was finely mapped between markers SSRZ8 and IDP2347, with genetic distances of 0.6 and 1.1 cM, respectively, and the physical distance of the target region was about 700 kb. RpiX178-2 was also further located between markers bnlg1444 and umc2041, with a genetic distance of 2.4 cM. Moreover, we confirmed that the two genes RpiX178-1 and RpiX178-2 were newly identified and different from those genes known on chrs. 1 and 4 according to results of allelism testing. Herein, we newly identified two genes resistant to P. inflatum, which provided important genetic information for resistance to Pythium stalk rot in maize.
The Power of Subjectivity in the Assessment of Medical Trainees
Authors: ten Cate Olle , Regehr Glenn
Published: October 2018

Objectivity in the assessment of students and trainees has been a hallmark of quality since the introduction of multiple-choice items in the 1960s. In medical education, this has extended to the structured examination of clinical skills and workplace-based assessment. Competency-based medical education, a pervasive movement that started roughly around the turn of the century, similarly calls for rigorous, objective assessment to ensure that all medical trainees meet standards to assure quality of health care. At the same time, measures of objectivity, such as reliability, have consistently shown disappointing results. This raises questions about the extent to which objectivity in such assessments can be ensured.

In fact, the legitimacy of “objective” assessment of individual trainees, particularly in the clinical workplace, may be questioned. Workplaces are highly dynamic and ratings by observers are inherently subjective, as they are based on expert judgment, and experts do not always agree—for good, idiosyncratic, reasons. Thus, efforts to “objectify” these assessments may be problematically distorting the assessment process itself. In addition, “competence” must meet standards, but it is also context dependent.

Educators are now arriving at the insight that subjective expert judgments by medical professionals are not only unavoidable but actually should be embraced as the core of assessment of medical trainees. This paper elaborates on the case for subjectivity in assessment.
Transforming Resident Assessment: An Analysis Using Deming’s System of Profound Knowledge
Authors: Warm Eric J. , Kinnear Benjamin , Kelleher Matthew , Sall Dana , Holmboe Eric
Published: October 2018

W. Edwards Deming, in his System of Profound Knowledge, asserts that leaders who wish to transform a system should understand four essential elements: appreciation for a system, theory of knowledge, knowledge about variation, and psychology. The Accreditation Council for Graduate Medical Education (ACGME) introduced the milestones program as a part of the Next Accreditation System to create developmental language for the six core competencies and facilitate programmatic assessment within graduate medical education systems. Viewed through Deming’s lens, the ACGME can be seen as the steward of a large system, with everyone who provides assessment data as workers in that system. The authors use Deming’s framework to illustrate the working components of the assessment system of the University of Cincinnati College of Medicine’s internal medicine residency program and draw parallels to the macrocosm of graduate medical education. Successes and failures in transforming resident assessment can be understood and predicted by identifying the system and its aims, turning information into knowledge, developing an understanding of variation, and appreciating the psychology of motivation of participants. The authors offer insights from their experience for educational leaders who wish to apply Deming’s elements to their own assessment systems, with questions to explore, pitfalls to avoid, and practical approaches in doing this type of work.
Intraoperative Hypothermia Is Associated with Reduced Acute Kidney Injury After Spine Surgery Under General Anesthesia: A Retrospective Observational Study
Authors: Oh Tak Kyu , Ryu Jung-Hee , Sohn Hye-Min , Jeon Young-Tae
Published: October 2018

Background:

Although hypothermia is known to have protective effects against ischemic injuries, the effects of hypothermia on kidney injury have not yet been elucidated. Therefore, this study aimed to identify the association between intraoperative hypothermia and postoperative acute kidney injury (AKI) in patients who underwent spine surgery under general anesthesia.

Methods:

In this retrospective observational study, we analyzed the medical records of adult patients who underwent elective spine surgery between January 2010 and March 2018. Patients were classified into the normothermia group (36.5 to 37.5°C), mild hypothermia group (35 to 36.5°C), and hypothermia group (<35°C) based on the mean intraoperative temperature, measured using an esophageal stethoscope. The association between mean intraoperative temperature and the incidence of postoperative AKI was analyzed using logistic regression analysis after inverse probability of treatment weighting (IPTW) adjustment.

Results:

The analysis included 6520 patients, of whom 248 (3.8%) were diagnosed with AKI within POD 3. After applying IPTW adjustment, the incidence of postoperative AKI was 32% lower in the hypothermia group than in the normothermia group (odds ratio, 0.68; 95% confidence interval, 0.53-0.87; P=0.002), whereas the incidence of postoperative AKI in the mild hypothermia group was not significantly different from that in the normothermia (P=0.139) and hypothermia groups (P=0.075).

Conclusions:

This study showed that intraoperative hypothermia is associated with a reduction in the incidence of AKI following spine surgery under general anesthesia. Further, this association was evident in the group with hypothermia <35°C.
Perioperative Effects Associated With the Surgical Treatment of Degenerative Spondylolisthesis
Authors: Colman Matthew W. , Baronne Lon M. , Brodke Darrel S. , Woodbury Ashley M. , Annis Prokopis , Lawrence Brandon D.
Published: October 2018

Study Design:

This is a retrospective analysis.

Objective:

The purpose of this study was to compare the clinical, radiographic, and perioperative complication profiles of performing an interbody and posterior arthrodesis (CAGE) versus posterolateral lumbar fusion (PLF) alone in patients undergoing surgery for degenerative spondylolisthesis (DS).

Summary of Background Data:

DS is a common disorder that, failing nonoperative treatment, may be managed with surgical decompression and concomitant posterior arthrodesis. At present, the risk/benefit ratio of including an additional interbody arthrodesis has not been clearly delineated in the literature.

Materials and Methods:

We reviewed 174 consecutive patients (118 female and 56 male) diagnosed with single-level DS that met the inclusion/exclusion criteria, from January 1, 2000 to August 1, 2011. Clinical outcomes, fusion rates, radiographic outcomes, and complication profiles were recorded.

Results:

We identified 174 patients who received a single-level lumbar interbody fusion with posterolateral fusion (CAGE, n=89) or posterolateral fusion alone (PLF, n=85). No difference in patient-reported outcomes or fusion rate was detected between the 2 groups. We did identify better segmental lordosis increase (4.9±3.2 vs. 0.9±1.9 degrees; P=0.001) and interdiscal height change (2.1±2.4 vs. 0.6±1.6 mm) in the CAGE group. Operative time, 199.8±36.6 versus 142.6±28.5 minutes (P<0.001); blood loss, 355±216.4 versus 269±28.5 mL (P<0.001); and postoperative radiculitis, 28.9% versus 7.0% (P=0.003) were worse in the CAGE group compared with the PLF group.

Conclusions:

The ideal surgical approach when treating patients with DS remains in question. This study suggests, when comparing PLF with or without additional interbody fusion, that the lack of clinical or fusion-related benefit may not justify the higher risk profile including longer surgery, higher blood loss, and increased risk of postoperative radiculitis. Long-term prospective studies are required to further clarify these findings.

Level of Evidence:

Level III.
Ambient Particulate Matter and Paramedic Assessments of Acute Diabetic, Cardiovascular, and Respiratory Conditions
Authors: Johnston Fay H. , Salimi Farhad , Williamson Grant J. , Henderson Sarah B. , Yao Jiayun , Dennekamp Martine , Smith Karen , Abramson Michael J. , Morgan Geoffrey G.
Published: October 2018

Background:

Ambulance data provide a useful source of population-based and spatiotemporally resolved information for assessing health impacts of air pollution in nonhospital settings. We used the clinical records of paramedics to quantify associations between particulate matter (PM2.5) and diabetic, cardiovascular, and respiratory conditions commonly managed by those responding to calls for emergency ambulance services.

Methods:

We evaluated 394,217 paramedic assessments from three states in Southeastern Australia (population 13.2 million) and daily PM2.5 concentrations modeled at 5 km resolution from 2009 to 2014. We used a time-stratified, case-crossover analysis adjusted for daily meteorology to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for each clinical outcome per 10 µg/m3 increase in daily PM2.5 at lags from 0 to 2 days.

Results:

Increased PM2.5 was associated with increased odds of paramedic assessments of hypoglycemia (OR = 1.07; 95% CI = 1.02, 1.12, lag 0), arrhythmia (OR = 1.05; 95% CI = 1.02, 1.09, lag 0), heart failure (OR = 1.07; 95% CI = 1.02, 1.12, lag 1), faint (OR = 1.09; 95% CI = 1.04–1.13, lag 0), asthma (OR = 1.06; 95% CI = 1.01, 1.11, lag 1), chronic obstructive pulmonary disease (OR = 1.07; 95% CI = 1.01, 1.13, lag 1), and croup (OR = 1.09; 95% CI = 1.02, 1.17). We did not identify associations with cerebrovascular outcomes.

Conclusions:

Ambulance data enable the evaluation of important clinical syndromes that are often initially managed in nonhospital settings. Daily PM2.5 was associated with hypoglycemia, faint, and croup in addition to the respiratory and cardiovascular outcomes that are better established.
Management of the Lateral Breast
Authors: Khincha Priyatma P. , Pikturnaite Jurga , Mahajan Ajay L.
Published: October 2018

Breast asymmetry is a common finding in developing adolescents. In select cases, there is maldevelopment of 1 or both breasts, which persists into adulthood and causes significant negative impact on life. Various surgical techniques (eg, breast augmentation/reduction) and nonsurgical techniques (eg, bras/gel inserts) are currently in practice to achieve breast symmetry. We describe a unique case of a young lady with Poland’s syndrome, who presented with a lateralized right breast. We have used a V-Y advancement flap, along with a breast implant, to medialize the breast and achieve symmetry in contour and volume, followed by medialization of the nipple areolar complex. Using this technique produced an excellent result on our patient. We, therefore, feel that using the V-Y advancement flap is a novel and good option for dealing with difficult cases of lateralized breast.
New Approach to Oncoplastic Breast Conservation: Combining Autologous Volume Replacement and the Wise-pattern Mammaplasty
Authors: Schwartz Jean-Claude D.
Published: October 2018

Background:

Oncoplastic breast-conserving surgery describes a set of techniques that allow for generous oncological resection with immediate tumor-specific reconstruction. These techniques are classically divided into either volume displacement (local breast flaps and or reduction mammaplasty/mastopexy strategies) versus volume replacement strategies (transfer of autologous nonbreast tissue from a local or distant site and, less commonly, implant placement). There have been few descriptions of merging these 2 classical approaches to facilitate breast-conserving surgery. The purpose of this report was to evaluate the efficacy of combining the most common oncoplastic volume displacement strategy (Wise pattern mammaplasty) with simultaneous autologous volume replacement from the lateral intercostal artery perforator (LICAP) flap to reconstruct the extensive partial mastectomy defect in patients with ptosis.

Methods:

A retrospective analysis of 25 consecutive patients with multifocal or multicentric breast cancers who underwent simultaneous volume replacement from the LICAP flap and volume displacement (Wise pattern mammaplasty) to achieve breast conservation was performed between January 2016 and January 2018. Clinical outcomes and postoperative complications were examined.

Results:

Twenty-five consecutive patients with a mean age of 56 years (range, 37–74 years) and mean body mass index of 28 kg/m2 (range, 22–37 kg/m2) all successfully underwent breast conservation by simultaneously employing the LICAP flap and Wise pattern mammaplasty to reconstruct the partial mastectomy defect. The average resection specimen weight was 220 g (range, 130–310 g) and average size of the malignancy resected was 6.5 cm (range, 3.7–9.2 cm). Three patients (12%) required re-excision for close or positive margins but were ultimately cleared. There were no complications related to the donor site. There were 4 patients (16%) with delayed wound healing related to the Wise pattern closure but no instances of LICAP necrosis or failure.

Conclusions:

The merger of Wise pattern volume displacement and autologous volume replacement techniques represents a novel strategy that is useful in the most challenging breast conservation patients with some degree of ptosis.
UVEAL METASTASIS BASED ON PATIENT AGE IN 1,111 PATIENTS
Authors: Shields Carol L. , Acaba-Berrocal Luis A. , Selzer Evan B. , Mayro Eileen L. , Newman Jennifer H. , Malik Kunal , Welch R. Joel , Shields Jerry A.
Published: October 2018

Purpose:

To evaluate clinical features and survival outcomes of uveal metastasis based on patient age.

Methods:

Retrospective analysis of all patients with uveal metastasis evaluated on the Ocular Oncology Service, Wills Eye Hospital, Philadelphia, PA, USA between February 1, 1974 and June 1, 2017. The features and outcomes were analyzed based on patient age classified as children (0–20 years), young adults (21–40 years), middle [aged] adults (41–60 years), older adults (61–80 years) and senior adults (81–100 years).

Results:

There were 1111 consecutive patients, including children (n = 3, <1%), young adults (n = 77, 7%), middle adults (n = 472, 42%), older adults (n = 509, 46%), and senior adults (n = 50, 4%). At uveal metastasis diagnosis, demographics included mean patient age of 60 years, Caucasian race (88%), and female gender (64%). Compared to the largest cohort (older adults), there were significant differences (age group versus [vs.] older adults) in Caucasian race (senior adult 98% vs. 89%, p = 0.042), male sex (young adults: 22% vs. 43%, p < 0.001) (middle adults: 29% vs. 43%, p < 0.001), unilateral tumor (young adult: 70% vs. 86%, p < 0.001) (middle adult: 79% vs. 86%, p = 0.003) (senior adults: 96% vs. 86%, p = 0.045), and cancer origin in breast (young adults: 51% vs. 32%, p = 0.002) (middle adults: 44% vs 32%, p < 0.001), lung (young adults: 14% vs. 30%, p = 0.004), kidney (young adults: 0% vs. 5%, p = 0.043), prostate (middle adults: 1% vs. 4%, p = 0.001), gastrointestinal tract (senior adults: 8% vs. 2%, p = 0.028), and others (children: 100% vs. 4%, p < 0.001) (young adults: 10% vs. 4%, p = 0.044). Kaplan-Meier survival (children, young, middle, older, and senior adults) at 1 year was 33%, 48%, 60%, 62%, and 76% and at 5 years was 0%, 22%, 29%, 25%, and 40%, respectively, with no difference per age category. The mean overall survival was 17.2 months and children demonstrated hazard ratio (HR) for death at 1 year of 2.1 relative to older adults.

Conclusion:

Uveal metastasis is found in all age groups. Compared to older adults, primary cancer site was more often breast and less likely lung in young and middle adults. Other rare sites were more often seen in children. Survival outcomes at 1 and 5 years were most favorable for senior adults and least favorable for children.