The aim of this study was to investigate the effects of clinical information on the accuracy, timeliness, reporting confidence and clinical relevance of the radiology report.A systematic review of studies that investigated a link between primary communication of clinical information to the radiologist and the resultant report was conducted. Relevant studies were identified by a comprehensive search of electronic databases . Studies were screened using pre‐defined criteria. Methodological quality was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi‐Experimental Studies. Synthesis of findings was narrative. Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines.There were 21 studies which met the inclusion criteria, of which 20 were included in our review following quality assessment. Sixteen studies investigated the effect of clinical information on reporting accuracy, three studies investigated the effect of clinical information on reporting confidence, three studies explored the impact of clinical information on clinical relevance, and two studies investigated the impact of clinical information on reporting timeliness. Some studies explored multiple outcomes. Studies concluded that clinical information improved interpretation accuracy, clinical relevance and reporting confidence; however, reporting time was not substantially affected by the addition of clinical information.The findings of this review suggest clinical information has a positive impact on the radiology report. It is in the best interests of radiologists to communicate the importance of clinical information to reporting via the creation of criteria standards to guide the requesting practices of medical imaging referrers. Further work is recommended to establish these criteria standards. The aim of this review was to investigate the effects of clinical information on the radiology report. We conducted a systematic review of studies that investigated a link between primary communication of clinical information to the reporting radiologist and the resultant report. The findings of this review suggest that clinical information is beneficial to radiology reporting. It is in the best interests of radiologists to communicate the importance of clinical information on reporting via the creation of criteria standards to guide the requesting practices of medical imaging referrers. Further work is recommended to establish these criteria standards. It is common practice for radiologists to interpret imaging examinations and formulate a report using clinical information communicated to assist with this process. Clinical information refers to all information detailing the patient's clinical situation and can include the current problem, co‐existing and past medical history, current medications, allergies, fasting status, suspected diagnosis and clinical question to be answered.For all medical imaging examinations in Australia to be performed, a request must be completed by a referrer.When the patient presents to the referrer, they are medically assessed and a request for imaging is completed, using information about the patient's medical history and current presentation. This request can take one of two paths from the referrer to the radiologist, via the radiographer, who completes the imaging before sending it along with the request to the radiologist; or the request is transmitted directly to the radiologist who then reviews the clinical information and selects the imaging protocol to be performed, before transferring it to the radiographer. The radiologist is also able to review clinical information in the request when interpreting imaging and formulating their report.Loy & Irwig'sThis review followed the methods described in a published protocol in the PROSPERO register CRD42019138509).9138509.1Studies were included if they were as follows: (1) primary studies, published in peer‐reviewed journals, (2) related to diagnostic imaging for any population of human patients and (3) investigated a relationship between primary communication of clinical information to the radiologist and the resultant radiology report. This review defined primary communication as any method of communication given directly to the radiologist, such as clinical information accompanying imaging , clinical information received in patient charts or verbal communication between referrer and radiologist. Studies published in languages other than English were excluded. Conference proceedings, reviews, case reports, study protocols, commentary and letters to the editor were also excluded.After duplicates were removed, titles and abstracts of studies were screened by two reviewers (CC and TS) to determine eligibility for inclusion. Screening of full text of publications was performed if the abstract provided insufficient information to judge eligibility. Disagreement or uncertainty of study eligibility was resolved by consensus discussion. The reference lists of all included studies were interrogated and subjected to the same screening process.The full text of included studies was read by two reviewers (CC and LC). Data were extracted on study characteristics , interobserver agreement, outcome measures and results summary related to the research question. Data extraction was performed by one reviewer (CC), with validation by a second reviewer (LC). Disagreements were resolved through discussion.The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi‐Experimental StudiesWhilst some included studies shared commonalities in design, heterogeneity of methodologies, interventions and statistical analysis rendered them difficult to compare statistically. Therefore, a narrative synthesis was conducted to contextualise findings relevant to the review question, these being reporting accuracy, confidence, timeliness and clinical relevance.The data extraction process allowed us to categorise study characteristics into consistent fields across included studies. The data extraction and categorisation facilitated narrative synthesis by allowing us to examine the context of each study. All authors met regularly during the process and using the extracted data, discussed and subsequently refined the narrative. Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines.We identified 21 studies that met our inclusion criteria, and after quality assessment, 20 studies were included in our review. The excluded studySixteen studiesX‐ray examinations were the diagnostic test in 12 (57%) of included studies.The size of data sets and the number and consistency of reviewers varied throughout studies. Data set sizes ranged from sevenA total of 16 of 20 studies used a similar method involving a sample set of images, assessed twice by a group of reviewers.Additional information available to readers varied significantly between studies. Whilst many included all clinical information available to referrers at the time of reporting in the second read, others tried to demonstrate effect of an intervention to evaluate any change to reporting. These interventions included patient questionnaires,The JBI quality score ranged from 2 to 7 out of a possible 9 points with a median score of 4  curves to quantify the average difference in improvement in accuracy. Results ranged from minimal improvementThree studies described an impact on overall accuracy of reporting.Three studies described accuracy in terms of influencing change to the original radiologist report. Two studiesThree studies investigated the effect of clinical information on the confidence of reporting, each in a different way.The importance of the inclusion of a specific clinical question in the imaging request was investigated in three of the included studies. Aubin et alThe impact of clinical information on radiologist reporting time was investigated in two studies.The majority of included studies support the notion that clinical information has a positive effect on the reporting process. Studies demonstrated improved interpretation accuracy, clinical relevance and reporting confidence. The addition of clinical information was found not to substantially affect reporting time. These findings were based on studies of moderate quality, with a median quality and risk of bias assessment score of 4 out of 9.These results are in keeping with Loy & Irwig'sOne of the studies investigated the impact of the timing of when clinical information is introduced. Berbaum et alOther studies, which were outside the scope of this review, have investigated the effect of prevalence expectation on diagnostic performance of radiologists. Littlefair et al'sAnother study by Littlefair et alOur study was limited by the number of eligible studies specific to the research question. Whilst 21 articles were deemed eligible for inclusion, not all of these studies solely focused on the effect of clinical information on the radiology report. Similarly, the broad range of publication dates of included studies may be perceived as a limitation. We found this difficult to restrict as there was no existing review on the effects of clinical information on all aspects of reporting. However, the broad range of publication dates may demonstrate the issue of inadequate clinical information communicated to radiologists has persisted over several decades.The rationale of three of the most recently published included studiesWhilst many of the included studies shared similar elements of design, it was clear there was no gold standard or standardisation of requirements for clinical information. This made results difficult to compare, as many studies relied on the expert opinion of radiologists to determine whether clinical information was deemed important or useful when reporting. This measurement of usefulness of clinical information varied across studies, as radiologists taking part in studies would have had different training, skills and specialisations.In contrast, both Cooperstein et alGiven the findings of this review regarding clinical information and its effect on the accuracy, confidence, clinical relevance and timeliness of reporting, Qureishi et al'sIt is clear the lack of clinical information in requests is an issue affecting reporting quality. One of the possible causes for this may be a lack of awareness or education of referring clinicians on what constitutes relevant clinical information. It may be in the best interests of radiologists to seek to educate referrers on the effect of clinical information on diagnostic performance, including the rationale behind providing high‐quality clinical information.The findings of this review indicate that clinical information communicated to the radiologist has a positive impact on the radiology report. These results are relevant to the main consumers of medical imaging, those being referrers and by extension their patients. These results are also relevant to radiologists, as they demonstrate the potential improvement that the communication of clinical information can have on the quality of reporting. It is in the best interests of radiologists to communicate the importance of clinical information for reporting via the creation of criteria standards to guide the requesting practices of medical imaging referrers.


The COVID-19 pandemic has altered the course of events globally. Enforcement of lock down orders to curtail the spread of the pandemic had untoward consequences on the economy and health of the citizenry. In Nigeria, access to renal care was reduced by restriction of movement; inability to afford care due to economic downturn; suspension of transplant programs; uncertainties about dialysis guidelines; anxiety and reduced motivation of health care workers (HCWs) due to lack of government’s commitment to their welfare and increasing rate of COVID-19 infection among HCWs. Formulation and implementation of policies to improve HCWs welfare and ease the burden of CKD patients should be prioritized in order to ensure optimal care of renal patients during the present pandemic. The coronavirus disease-19 (COVID-19) pandemic has altered the course of events globally since its outbreak in late 2019. Globally, over 8,184,867 cases and 443,872 deaths have been recorded across the world as at 18th June, 2020 . The ongChronic kidney disease patients are at higher risk of having severe COVID-19 and succumbing to the disease due to higher prevalence of cardiovascular risks such as diabetes, hypertension, hypoalbuminaemia and anaemia compared to the general population . Also, rMajority of renal transplant programmes were suspended therefore denying renal patients who could afford transplant, better quality of life. The suspension was due to uncertainties such as fear of shortage of personnel to monitor patients especially in the early postoperative period; increased susceptibility to COVID-19 due to high dose of immunosuppressants during the induction period of transplant; issues with methodology and sensitivity of COVID-19 testing that may lead to inadvertent transplant of donor kidneys infected with SARS-CoV-2 ,8. The tThe rate of infection of health care workers (HCWs) with COVID-19 across the world and particularly, the increasing rate of infection of HCWs in the African region is of concern. Number of infected HCWs has consistently increased in Nigeria which has recorded the highest number of infected HCWs in the African region in the last few weeks. HCWs in renal centers are thus concerned about risk of transmission of COVID-19 to them by renal patients during treatment especially with limited supplies of personal protective equipment (PPE). The morale of HCWs in Nigeria to fight the COVID-19 pandemic is dampened because the government had not shown enough commitment to their welfare. Presently, the monthly hazard allowance of HCWs is less than 15USD and majority are not under life insurance cover by the government. The payment of the newly approved hazard allowance that was occasioned by the COVID-19 pandemic is still yet to be implemented.There were also uncertainties about guidelines that suit renal units in order to protect other kidney disease patients and HCWs while attending to patients with COVID-19 requiring dialysis. The recently published guidelines for the prevention, detection and management of the renal complications of COVID-19 by the African Association of Nephrologists has been able to clarify gray areas and douse anxiety among renal health care workers . This waIt is evident and highly imperative that both Nigerian government and corporate organizations need to show greater and genuine commitment to the welfare of the HCWs especially those on the frontline in this present pandemic. Policy formulation and implementation that will ease the burden of CKD patients should be prioritized in order to ensure optimal care delivery to renal patients during this present pandemic.


Stem cells from adipose tissue (ADSCs) and platelet-rich plasma (PRP) are innovative modalities that arise due to their regenerative potential.  The aim of this study was to characterize possible histological changes induced by PRP and ADSC therapies in photoaged skin.  A prospective randomized study involving 20 healthy individuals, showing skin aging. They underwent two therapeutic protocols . Biopsies were obtained before and after treatment (4 months).  PRP protocol showed unwanted changes in the reticular dermis, mainly due to the deposition of a horizontal layer of collagen (fibrosis) and elastic fibers tightly linked. Structural analyses revealed infiltration of mononuclear cells and depot of fibrotic material in the reticular dermis. The ADSC protocol leads to neoelastogenesis with increase of tropoelastin and fibrillin. There was an improvement of solar elastosis inducing an increment of macrophage polarization and matrix proteinases. These last effects are probably related to the increase of elastinolysis and the remodeling of the dermis.  The PRP promoted an inflammatory process with an increase of reticular dermis thickness with a fibrotic aspect. On the other hand, ADSC therapy is a promising modality with an important antiaging effect on photoaged human skin. The aging skin is a complex biological phenomenon that is composed of intrinsic and extrinsic processes. Facial aging is a degenerative process that affects the skin and deep structures resulting from the action of the intrinsic factor (age) associated with an extrinsic factor related to exposure to ultraviolet radiation –5. The cIn recent years, there is an increasing interest in the use of the regenerative properties of adipose tissue , 8. In tex vivo expansion, with the ability to differentiate into several cell lineages  regeneration of loss of oxytalanic and elaunin fiber networks in the papillary dermis and [2] replacement of pathological deposits of actinic elastin with a normal fibrillary structure, elastic fibers in the deep dermis. This remodeling action of the ECM at the elastic system level was demonstrated by the increased fiber density of the smaller diameter elastic system at the expense of new fibers in zone 1 (under DEJ). The density increase of this zone probably occurred due to the emergence of new oxytalanic/elaunin fibers shown in In ADSC-treated skin, inflammatory cells may be implicated in the resolution of the ECM repair and reorganization process by polarizing the macrophage population to M2 . These fRegarding the aspect of biosafety in tissue and cell transfer, despite the short time interval of the present study (4 months), between the application of ADSCs and their effects on tissue samples submitted to the action of ADSCs, no dysplastic or oncogenic changes in the skin of the population studied were observed as found in the literature . The mesThe limitations of this study were the difficulty of accurately quantifying skin photoaging, morphofunctional analysis of all elements involved in the regenerative process after treatment with PRP and ADSCs, and knowledge of all involved biological events and their mechanisms.The advantages of using isolated stem cells as antiaging skin therapy over PRP, fat grafting, and/or ADSC-matching therapies are as follows: there is no risk of cyst formation and fibrosis, use of small injection volumes with high regenerative potential, precise application, possibility of reapplication after reexpansion of stored stem cells, and/or cryopreserved cell reuse.The future of this research line is aimed at creating new possibilities in regenerative therapy not only in skin diseases but in other clinical applications in the case of organs and tissues with reduction and/or alteration in the elastic system , with a better understanding of the mechanisms involved and the control of these processes.It was concluded that the action of PRP when injected on aged human skin induces an inflammatory process, contributing to the increase of collagen fiber deposits and the increase of reticular dermis thickness with a fibrotic aspect, not bringing any significant tissue regenerative role. On the other hand, expanded ADSC therapy in photoaged skin is related to ECM remodeling, increased production of new elastic fibers, and degradation of elastotic material deposited in the dermis (elastosis), inducing an important regenerative effect that could be considered a promising skin rejuvenation therapy.


The current understanding of radical hysterectomy is more centered on the uterus and little is discussed regarding the resection of the vaginal cuff and the paracolpium as an essential part of this procedure. The anatomic dissections of two fresh and 17 formalin-fixed female pelvis cadavers were utilized to understand and decipher the anatomy of the pelvic autonomic nerve system (PANS) and its connections to the surrounding anatomical structures, especially the paracolpium. The study mandates the recognition of the three-dimensional (3D) anatomic template of the parametrium and paracolpium and provides herewith an enhanced scope during a nerve-sparing radical hysterectomy procedure by precise description of the paracolpium and its close anatomical relationships to the components of the PANS. This enables the medical fraternity to distinguish between direct infiltration of the paracolpium, where the nerve sparing technique is no longer possible, and the affected lymph node in the paracolpium, where nerve sparing is still an option. This study gives rise to a tailored surgical option that allows for abandoning the resection of the paracolpium by FIGO stage IB1, where less than 2 cm vaginal vault resection is demanded. While the radical hysterectomy, first described by Ernst Wertheim , has beeA cadaver study was undertaken in addition to our long experience with nerve-sparing radical hysterectomy  to arrivThe current understanding of radical hysterectomy is more centered on the uterus, especially the uterine cervix, and little or nothing is discussed on the significance of the resection of the vaginal cuff  and the paracolpium as an essential part of a radical hysterectomy ,9,13. SiFurther, the ventral and lateral parametrium (and of course the paracolpium) have extensive vascularization for the blood supply of the uterus , populated with the numerous local lymph nodes and lymphatic supply. It is worth mentioning the contribution of Girardi  and BeneThe cadaver studies and their interpretation in surgical steps primarily mandate the recognition of the three-dimensional (3D) anatomic template proposed as early as 2011  for paraA precise dissection of the area reveals that whilst there is no clear border between the stated structures, the dorsal paracolpium is denser, connects the vaginal part beneath the cervix to the lateral mesorectum and is located in the same level in between the rectal fascia and the pelvic nerve-vessel guiding plate laterally . TherefThe lateral paracolpium is where the vaginal vascular supply originates from (artery) and discharges into (vein) the internal iliac artery and vein beneath the ureter.In this way, it is possible to label the ureter as an anatomical marker that splits the lateral parametrium  into the lateral parametrium above the ureter, containing the uterine artery and vein, and the lateral paracolpium beneath the ureter, containing the vaginal artery and vein . These tHowever, it is imperative to mention that the vaginal artery goes undetected laterally in about 14/33 hemi-pelvises in a cadaver study (42.4%) and in 37/84 hemi-pelvises in a clinical study (44%). This is due to the fact that this artery in such instances is construed to come in as a branch of the uterine artery, crossing directly into the ventral parametrium above the ureter and travelling caudally to the anterolateral side of the vagina. Both of these variations could be noticed in the same patient in 23/42 patients from a clinical study (55%)  and in 1Hence, the ventral paracolpium is nothing but the deep layer of the vesicouterine ligament  and theThe pelvic splanchnic nerves have been found to run directly from the sacral roots in front of the common trunk of the internal pudendal and inferior gluteal vessels at the dorsal edge of the lesser sciatic foramen, and then medial from the inferior vesical vein cranially to merge in the inferior hypogastric plexus.The inferior hypogastric plexus lies on the endopelvic fascia at the lateral vaginal and rectal sidewall. The bladder branches of the inferior hypogastric plexus leave the plexus medial from the medial vesicovaginal vein ca. 2 cm beneath the vaginal vault .This study also shows that most of the injuries to the inferior hypogastric plexus or the components of the autonomic nerve system in the radical hysterectomy procedure occur during the resection of the vaginal vault. This element has been reported and substantiated by published literature, which conclude that the more extensive the vaginal and surrounding tissue ablation, the greater the resultant bladder denervation . This suTherefore, it is essential to emphasize the accurate identification of all the components of the autonomic nerve system, especially while attempting a nerve-sparing radical hysterectomy procedure, complying with only the resection of the uterine branches and the dissection of the endopelvic fascia directly at the level of the first bladder branch of the inferior hypogastic plexus ,12,14 F.During a radical hysterectomy, the resection of vaginal length that is deemed appropriate for the disease stage has to be calibrated according to the tumor size and infiltration into the vagina. Furthermore, cutting the vaginal cuff without highlighting and isolating the endopelvic fascia (at the pelvic nerve-vessel guiding plate) would lead to injuries of the inferior hypogastric plexus from its medial facets . The endLateral and cranial from this endopelvic fascia is the vascular supply of the vagina and cervix, consisting of the lateral and ventral paracolpium and parametrium. The vaginal vessels cross over the inferior hypogastric plexus to run lateral to the vaginal sidewall; therefore, the last step of a radical hysterectomy will be the resection of the descending vaginal vessels at the lateral side of the vagina. The inferior vesical artery arises from the common trunk of the internal pudendal artery and the inferior gluteal artery  and the inferior vesical vein discharges into the internal iliac vein. The inferior vesical vessels are chiefly engaged in supplying the lower wall of the retrovesical ureter ,26.The implications of this comprehensive anatomy identification of the parametrium and paracolpium have a fundamental relevance not only in the nerve-sparing radical hysterectomy procedure, but more so with the empowerment of the surgeon to modify the radical hysterectomy according to the tumor size and infiltration. The study outcomes provide an enhanced scope during a nerve-sparing radical hysterectomy procedure by precise identification, isolation and sparing of the inferior vesical vessels to avoid ureteral ischemia at the distal part of the ureter, which usually is prevalent in 6.4% of cases after a radical hysterectomy procedure .Since the ventral and lateral paracolpium are closely connected to the pelvic autonomic nerve system and the vaginal vessels pretty close to the pelvic splanchnic nerves running above the pelvic nerve-vessel guiding plate medially along the lateral vaginal sidewall , the preThe study also gives rise to a tailored surgical option that allows for abandoning the resection of the paracolpium  if the tumor is restricted to the cervix, and less than 2 cm in size .This will allow for revising the classification of radical hysterectomy ,9 to redThe type C radical hysterectomy will then be the radical hysterectomy with parametrium and paracolpium resection for stage IB1 (the old FIGO classification ) with deThe anatomic dissections of 2 fresh and 17 formalin-fixed female pelvis cadavers were utilized to study, understand and decipher the hitherto ambiguously annotated anatomy of the pelvic autonomic nerve system and its connections to the surrounding anatomical structures, especially the paracolpium, with reference to radical hysterectomy. Since medical students had previously dissected the formalin-fixed cadavers, we excluded five hemi-pelvises where the pelvic sidewall was grossly over-dissected.The new anatomical knowledge from a cadaver study used to enhance and develop the Muallem technique for nerve-sparing radical hysterectomy was described in a previous study . All datAt the end of this study, PubMed and PMC  were searched for studies pertaining to radical hysterectomy, radical hysterectomy and anatomic complications, anatomy of the pelvic autonomic nerve system and its connections to surrounding anatomical structures, especially the paracolpium and parametrium, and surgical challenges in radical hysterectomy for a complete literature search for comparison and reference.The comprehensive anatomy of the parametrium, paracolpium and pelvic autonomic nerve system as presented in this study is a contradictory concise paradigm for radical hysterectomy, which provides a precise concept of the nerve-sparing radical hysterectomy that shall enable surgeons to perform such a complex procedure without the ensuing common ureter related complications. The key steps are to distinguish between direct (continuous) and lymphatic infiltration of the paracolpium, rethink the needed radicality and devise tailored surgical procedures to suit individual cases.


Aggressive behaviour is a major problem in clinical practice of mental health care and can result in the use of coercive measures.Coercive measures are dangerous for psychiatric patients and international mental healthcare works on the elimination of these interventions.There is no previous review that summarizes the attitude of nursing staff towards coercive measures and the influence of nursing staff characteristics on attitude towards and the use of coercive measures.The attitude of nurses shifted from a therapeutic paradigm (coercive measures have positive effects on patients) to a safety paradigm .Nurses express the need for less coercive interventions to prevent seclusion and restraint, but their perception of intrusiveness is influenced by how often they use specific coercive measures.The knowledge from scientific literature on the influence of nursing staff on coercive measures is highly inconclusive, although the feeling of safety of nurses might prove to be promising for further research.There is need for increased attention specifically for the feeling of safety of nurses, to better equip nurses for their difficult work on acute mental health wards.The use of coercive measures generally has negative effects on patients. To help prevent its use, professionals need insight into what nurses believe about coercion and which staff determinants may influence its application. There is need for an integrated review on both attitude and influence of nurses on the use of coercion.To summarize literature concerning attitude of nurses towards coercive measures and the influence of staff characteristics on the use of coercive measures.Systematic review.The attitude of nurses changed during the last two decades from a therapeutic to a safety paradigm. Nurses currently view coercive measures as undesirable, but necessary to deal with aggression. Nurses express the need for less intrusive interventions, although familiarity probably influences its perceived intrusiveness. Literature on the relation between staff characteristics and coercive measures is inconclusive.Nurses perceive coercive measures as unwanted but still necessary to maintain safety on psychiatric wards. Focussing on the determinants of perception of safety might be a promising direction for future research.Mental health care could improve the focus on the constructs of perceived safety and familiarity with alternative interventions to protect patients from unnecessary use of coercive interventions. We describe the full search strategy in Data 3.3We performed the first selection based on title and abstract. We subsequently retrieved the full text of the included studies for the final assessment of eligibility. Two reviewers (PD and JV) performed the selection independently and settled disagreements through discussion. In case of disagreement, the reviewers consulted a third reviewer (CL).We selected studies based on inclusion and exclusion criteria. Inclusion criteria concerning study design were cohort studies, case–control studies, case series, cross‐sectional studies, surveys and qualitative studies on the attitude of nursing staff towards coercive measures and/or the influence of nursing staff characteristics on the use of one or more coercive measures . We included studies performed in acute mental health inpatient services or psychiatric facilities in general or academic hospitals that cared for psychiatric patients with primary diagnosis of axis I or II of the DSM‐IV‐TR  tool  performed the data extraction with a standardized form. Studies that described the attitude of nurses were mostly qualitative or survey studies, and the results were not suitable for statistical pooling. We carefully read the studies and extracted important themes from these studies independently. Thereafter, we discussed the interpretation of the qualitative findings. Subsequently, we extracted descriptive themes from the analysis of the qualitative studies based on consensus between the reviewers and combined these with the results from the surveys. We observed that literature on nursing staff characteristics had high levels of heterogeneity, which made it unlikely that performing a meta‐analysis would be appropriate. We summarized the most important results of the included studies. We extracted data on the research question, design, sample size, population, setting and outcome measures from the included studies.44.1The initial search resulted in 7,517 references. After the selection process, we included 84 publications Figure . A crossn = 13 nurses . The av4.2In our study of the included literature on the attitudes of nurses towards coercive measures, we observed two major themes: (a) the discrepancy between treatment paradigm and safety paradigm; and (b) the need for less intrusive alternative interventions.4.2.1We observed a paradigm shift in the attitude towards coercive measures from a treatment paradigm to a safety paradigm. The belief that patients experience therapeutic benefits from the use of coercive measures characterizes the treatment paradigm. Distinctive for the safety paradigm is the belief that the patient undergoing coercive measures experiences negative consequences, but coercive measures are necessary to maintain safety for patients and staff members.Tooke and Brown  were theAfter 2010, reports that supported the therapeutic paradigm became scarce, although it seems clear that a minority of nurses still view coercive measures as calming for specific types of patients  on the use of and attitude towards coercive measures.4.3.1Gender of the nurse is the most reported nursing staff characteristic associated with use of and attitude towards coercive measures, although findings are inconsistent. Several studies reported that the presence of male nurses was associated with more use of coercive measures, such as seclusion  and an increase in the use of coercive measures  showed less use of coercive measures compared to the clusters with lowest scores (n = 56).A higher score on the subscale programme clarity of the Ward Atmosphere Scale Moos, , indicatOther authors found no association between ward atmosphere and frequency of use of coercive measures : “undesOur second aim was the influence of nursing staff factors on the use of coercive measures and on the attitude of nurses towards coercive measures. The results in literature were remarkably inconclusive. For example, we found twelve studies that investigated the association of gender of the nurse and the use of coercion. Five of them concluded that male nurses were more prone to use coercion (Bowers et al., When combining the findings of the perceived necessity of coercive measures for safety reasons and the inconsistency in the influence of nursing staff characteristics, we want to stipulate the possible importance of the feeling of safety of nurses. Despite the troubles of measuring this trait, some authors suggest that the feeling of safety of nurses may be associated with less use of coercive measures (Goulet & Larue, This current systematic review is, to the best of our knowledge, the first to explicitly combine a review on the attitude of nurses and the influence of nursing staff characteristics. The strengths are that we performed an extensive literature search in several databases and to several forms of coercive measures, instead of focussing on seclusion and restraint. There are also some limitations. Summarizing qualitative studies inevitably entails de‐contextualisation of qualitative findings, because of the dependency of qualitative research findings on the particular context, time and group of participants (Thomas & Harden, 6The attitude of nurses towards coercive measures has changed over the years from a therapeutic paradigm to a safety paradigm. The current attitude towards use of coercive measures is not to treat patients, but to protect patients and staff from violence. Nurses consider coercive measures as necessary interventions and express the need for less intrusive alternatives. Although nurses recognize the negative consequences for patients, the frequent use of a specific coercive measure may decrease the value that nurses give to the negative consequences associated with that measure. The research on the influence of nursing staff characteristics is highly inconclusive. However, the feeling of safety of nurses may be a key concept in the prevention of coercive measures.7We propose that mental health care could improve the focus on the constructs of safety and danger to protect patients from unnecessary use of coercive interventions. Lack of attention to the feeling of safety of nurses working at psychiatric wards can threaten further reduction in the use of coercive measures. Using coercive measures has been common practice in mental health care for centuries, as well as the debate on reducing them (Yellowlees, 8The use of coercion is associated with adverse events. Nurses have influence on the decision to use coercive measures. Attitude of nurses towards coercion and nursing staff characteristics influence these decisions. This review summarizes the literature on the influence of attitude of nurses and nursing characteristics on the use of coercive measures. Our findings indicate, based on the attitude towards coercive measures and some evidence on perception of safety, the importance of the feeling of safety of nurses by clinicians, researchers and policymakers. This might be a more relevant road towards better quality of care than focus on nursing characteristics.The authors declare no conflicts of interest.All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. All authors agree with the manuscript. Click here for additional data file. Click here for additional data file.


Numerous studies exist that define polypharmacy and its impact on health. Additionally, the literature is rich in studies documenting the benefits of care provided by nurse practitioners. A gap in research exists at the intersection of the value of nurse practitioners in caring for older adults and their management of polypharmacy. Coinciding with a growth of America’s older adult population and the need for adequate care, the purpose of this study was to explore the experiences of nurse practitioners caring for older adults experiencing polypharmacy. A qualitative descriptive study was conducted using a purposive sampling of nurse practitioners who care for older adults. Interviews were conducted and data was analyzed for themes. Four themes emerged: defining polypharmacy, communicating and collaborating, clinical judgement of nurse practitioners in relation to polypharmacy, and medication issues of older adults. Major themes emerged that depict the complexity of medication management in older adults as well as the important role of NPs in providing care to older adults. The significance of the study findings to future practice includes improving communication and collaboration of prescribing health care providers, better identification and management of polypharmacy, and improving the health care delivered to older adults. Safe and effective prescribing for older adults requires NPs consider the unique needs of each older adult while utilizing technology to support collaboration and decision making.


Current and future NAGE policy-related activities will be the focus of this presentation. The Geriatric Academic Career Awards (GACAs), which support the career development of junior faculty clinician educators in geriatrics, were reinstituted by HRSA in 2019 after a 13-year absence. We will discuss the role of this award in the broader context of geriatrics education and GWEPs, how GACA awardees have been integrated into NAGE, and the need for expansion of the GACA program to support both the GWEP and geriatric education pipelines. Areas for future NAGE engagement will be focused on advocacy efforts to support: permanent GWEP reauthorization by Congress; expanding current level of $40.737 million to $51 million to enable HRSA to increase the number of GWEPS to further extend their reach; increasing funding for GACA awardees; and strengthening the synergies between the GACA and GWEP programs to support development of future GWEP leadership.


Meloidogyne incognita induced galls is the reorganization of the vascular tissues. During the interaction of the model tree species Populus and M. incognita, a pronounced xylem proliferation was previously described in mature galls. To better characterise changes in expression of genes possibly involved in the induction and the formation of the de novo developed vascular tissues occurring in poplar galls, a comparative transcript profiling of 21-day-old galls versus uninfected root of poplar was performed. Genes coding for transcription factors associated with procambium maintenance and vascular differentiation were shown to be differentially regulated, together with genes partaking in phytohormones biosynthesis and signalling. Specific signatures of transcripts associated to primary cell wall biosynthesis and remodelling, as well as secondary cell wall formation  were revealed in the galls. Ultimately, we show that molecules derived from the monolignol and salicylic acid pathways and related to secondary cell wall deposition accumulate in mature galls.One of the most striking features occurring in the root-knot nematode  Meloidogyne spp.) are obligate sedentary parasites that enter the root of the plant host at the second juvenile stage. The larvae penetrate the root elongation zone, migrating intercellularly to the root tip and entering the vascular cylinder where they induce the trans-differentiation of parenchyma cells into multinucleate feeding cells . Alongside, neighbouring cells divide contributing to the development of root swellings, named galls. An extensive network of xylem cells enfolding GCs is a typical anatomical feature in galls induced by RKN .Uninfected roots and 21 dai galls  model was computed with the lm function in which weighing was necessary due to the loss of one root sample.Galls in poplar result from the proliferation of xylem and phloem tissues to support the feeding of the nematode through the GCs. These biological processes rely on the preferential expression of several TFs and downstream biosynthetic genes, notably those involved in SCW formation. Nematode is therefore able to manipulate plant transcriptional regulation to mimic a developmental differentiation process favouring its own life cycle, at the expense of plant metabolism. However, the identification of the nematode molecular signals steering this programme will require further investigations. It seems that phytohormones such as cytokinins, GA and SA shape the development of galls. The targeted analysis of metabolites related to monolignols and salicylated products confirmed the reaction of the plant after nematode infection, which consists in the biosynthesis of monolignol intermediates and phenolic glycosides as lignin building blocks for xylem SCW.


To assess the perception and attitude of HCPs and health-related science colleges’ students regarding the clinical pharmacists’ roles and responsibilities in providing better pharmaceutical care to patients in Taif, Saudi Arabia and to detect its impact on management of cancer. This study was conducted in four randomly selected hospitals in Taif and three health-related science colleges in Taif University. A questionnaire was distributed to HCPs and another questionnaire to students of health-related science colleges. Three quarters of students perceived that the clinical pharmacist is an important part of the healthcare team. Two-thirds of HCPs expressed confidence in the ability of clinical pharmacists to minimize medication errors. Although two-thirds of HCPs reported that they did not have clinical pharmacists in their institutions, there was substantial willingness among HCPs to cooperate with the clinical pharmacists. Most HCPs expressed the view that the clinical pharmacist is an important integral part of the healthcare team and has a positive impact on cancer management. HCPs and students of health-related science colleges valued the role of clinical pharmacists in healthcare delivery and management of cancer. However, new developments in clinical pharmacy services in Taif hospitals are recommended to improve perception and attitudes towards the clinical pharmacy services. Also, well-organized programs should be conducted to students of health-related science colleges to improve their perceptions and attitudes towards the clinical pharmacy services which may have a positive impact on cancer management. Cancer is a group of diseases characterized by unregulated cell growth and differentiation. Management of cancer necessitates effective cooperation between various healthcare services and healthcare providers including the physicians, nurses and the clinical pharmacists . Clinical pharmacy is a health science whereby pharmacists provide patient care that optimizes medication therapy and promotes health, wellness and disease prevention . This field of pharmacy practice focuses on patient-oriented rather than drug product-oriented service . This science emerged as a result of dissatisfaction with old practice norms and the pressing need for a competent health professional with a comprehensive knowledge in the therapeutic use of drugs. Clinical pharmacists are a primary source of scientifically valid information and advice regarding the safe, appropriate, and cost–effective use of medications . Already, the level of interaction between the physicians and pharmacists in the developed world is high, resulting in safer, more effective and less costly drug therapy .In 1959, the first college of pharmacy in Saudi Arabia was established and baccalaureate degrees in pharmacy were granted. In mid-1970s, clinical pharmacy practice was introduced in the country . After thirteen years, the first pharmacy department in King Khalid University Hospital (KKUH) implemented clinical pharmacy program outside the United States of America (USA) . About 15 clinical pharmacists after the initial trial were employed, and then the service was expanded to cover all hospitals. In Saudi Arabia, clinical pharmacy is relatively well developed . Whereas the number of academic centers are currently 28 academic centers that grant pharmacy degrees, some centers offer a Bachelor in Pharmacy (B-Pharm) and others offer the Master-level (MSc) or Doctor of Pharmacy (PharmD) degrees. Most universities are headings for clinical pharmacy, which hints will eventually be phased out from B-Pharm degree. In some universities, students start in the B-Pharm program. If they meet specific criteria during their studies, they will progress into the PharmD program . The aim of this study was to assess the perception and attitude of HCPs and health-related science colleges’ students regarding the clinical pharmacists’ roles and responsibilities in providing better pharmaceutical care to patients in Taif, Saudi Arabia and to detect its impact on the management of cancer. Subjects and methodsA cross-sectional study was conducted in four randomly selected hospitals  and three health-related science colleges in Taif University  and college of nursing). This study was conducted according to the National Research Council Guidelines and was approved by the ethics committee of Taif University, Saudi Arabia (Code 40-35-0181). The participants were randomly selected from lists provided by their facility administrators. A written consent was obtained from the participants before being included in this study. Inclusion criteria1. Male and female students of health-related science colleges in Taif University .2. Male and female HCPs including physicians, nurses and technicians working in physiotherapy, laboratory and radiology departments in King Faisal Hospital, King Abdul-Aziz Hospital, Pediatrics Hospital and Prince Mansour Military Hospital in Taif, Kingdom of Saudi Arabia (KSA).Exclusion criteria1. Male and female students of other colleges in Taif University.2. Male and female HCPs in departments other than the above-mentioned.MethodologyThe questionnaires were distributed to HCPs and students of health-related science colleges. The participants were approached directly to arrange a 15 minutes interview with the researchers at a convenient time. The questionnaires were completed by the participants under the supervision of the researchers in order to improve clarity and limit response bias. The questionnaire consists of a series of questions prepared by the researchers with one version targeted at HCPs and the other at students. To ensure face validity, the questionnaire was sent to three academics and three physicians with a wide range of professional experience. Their views and comments were considered and then incorporated, where appropriate, into the final version of the questionnaire. To assess test-retest reliability, the questionnaire was administered on two occasions to 12 randomly selected HCPs. The second testing took place two weeks later. Test-retest reliability was calculated using Spearman’s correlation coefficient (r). The rho-value was 0.82, which implies acceptable test-retest reliability .  Respondents were asked to answer a question using the options “yes” or “no”, or to rate their response using the options “agree”, “neutral”, or “disagree”. The study was carried out over a period of three months (October to December 2018).Statistical analysisThe statistical analysis of the results was carried out using Minitab 16 . Descriptive analysis was used to calculate the proportion of each group of respondents who agreed/disagreed with each statement in the questionnaire. Chi-square test was used to identify any significant difference among the participants’ responses regarding certain statements in the questionnaire. P-values less than 0.05 were considered statistically significant.Demographic data of the studentsStudents’ perception and attitude Interestingly, Healthcare providers’ demographic dataHealthcare providers’ perception and attitudeInterestingly, In the last years, significant changes took place in the practice of pharmacy which necessitate changes in procedures and training of pharmacists . Moreover, these changes require more imaginative use of pharmacy skills and involvement of the clinical pharmacists at the healthcare process at all stages . However, there is still a wide gap between the clinical pharmacists and other HCPs which may deprive the society from getting the benefits of clinical pharmacy in the healthcare process . In the present study, there was a strong belief among students of health-related science colleges that clinical pharmacists represent an important integral part of the clinical team and are able to minimize medication errors in the hospital settings. The present study found that only about half of the students heard about the clinical pharmacy in their institutions during their study period. This may be due to absence of patient-oriented PharmD programs . Also, a large proportion of the students agreed that HCPs will accept the pharmacists to provide additional services within the framework of clinical pharmacy. This may be attributed to the presence of pharmacists or physicians in the families of these students who gave them this concept .In the present study, about 40% of the students reported that there is increased interest in clinical pharmacy as a profession in KSA. This may attract the attention of the healthcare authorities to the strong need to apply and expand the role of the clinical pharmacists in the healthcare team to provide the patients with better pharmaceutical care . This may be in the same line with a previous study in KSA which reported that there is shortage of clinical pharmacists services in most ministry of health hospitals, which necessitates the presence of clinically-oriented training programs for pharmacists and pharmacy students to overcome this shortage and to improve the pharmacists’ role in providing the patients with healthcare in the hospital settings .In the present study, the college of the respondents significantly affected the responses of the participants to the statement that the clinical pharmacist is an important and integral part of the medical team. Also, it significantly affected the responses of the students to the statements that the clinical pharmacist can acquire training in certain medical areas enabling them to perform patient counseling and that doctors and other healthcare staff will accept the involvement of the clinical pharmacists in patient management and providing extra services within the framework of clinical pharmacy. This may reflect that the students of the college of medicine have more perception and attitude towards the participation of the clinical pharmacy services in the patient’s healthcare than the students of the other health-related science colleges. This may be attributed to the content of the curricula of the subjects given to these students during the college years which may give them a positive attitude towards the participation of the clinical pharmacists in the healthcare team .In the present study, HCPs in Taif hospitals showed a high perception of the role of the clinical pharmacists in improving the therapeutic outcomes of the patients. Also, HCPs in the present study expected that clinical pharmacists can play an important role in direct patient care, particularly in patient counseling and education. Moreover, nearly about three-quarters of HCPs in the present study stated that clinical pharmacists can be of great help to improve the quality of patient care in the hospital settings. This was in agreement with the results of a previous study which indicated that clinical pharmacists working in hospitals managed by international institutions had the ability to provide more efficient clinical pharmacy services because they are involved in review of patient medications and practice an active role in therapy management .In the present study, HCPs particularly physicians and nurses supported the participation of the clinical pharmacists in the clinical ward team work. They expected that in the near future, they will have the ability to regularly seek advice with regard to patient medications from the clinical pharmacists in their institutions. These findings reinforce the importance of implication of the role of the clinical pharmacists in various aspects of healthcare and prove that the expected resistance of HCPs to implication of the role of the clinical pharmacists should not stand as an obstacle to instituting clinical pharmacy services in the hospital settings .In the present study, Less than 30% of HCPs believed that the clinical pharmacist has fulfilled his/her role in KSA. This may be due to lack of the clinical pharmacists in the hospitals  which was supported by the findings of the present study where only 31.4% of the participants reported that they have a clinical pharmacist in their institutions. This lack is not limited to the hospitals of the ministry of health but also extends to the private hospitals. Private hospitals should improve the patient’s care services provided by them by incorporating the clinical pharmacists to become a part of their clinical ward teams . Also, findings from the present study supported the hypothesis that the clinical pharmacists should perform specific duties that may have a great impact on the healthcare services such as education of the patients and minimizing medication errors .In the present study, the profession of the HCPs significantly affected their response to the statement that HCPs are willing to cooperate with the clinical pharmacist. Also, it significantly affected the responses of HCPs to the statements that the clinical pharmacist can improve the quality of patient care in the hospital settings and the clinical pharmacist can acquire training in certain medical areas to perform patient counseling. This was in agreement with Bondesson et al., (2012) and Sabry and Farid (2014) who reported there is a high level of acceptance by the physicians more than other HCPs to the involvement of the clinical pharmacists in the healthcare team. However, Sabry and Farid (2014) suggested that greater efforts are needed in the Arab countries to increase the physicians’ awareness and knowledge of the importance of the clinical pharmacists in the hospital settings and to promote the benefits from the clinical pharmacy services.In the present study, about three quarters of the students and 60% of HCPs agreed to the statement that implication of the clinical pharmacy services will have a positive impact on management of cancer. This was in the same line with Delpeuch et al., (2015) and Yokoyama et al., (2018) who reported that patients who received medical care from a collaborative team that included a clinical pharmacist showed significant improvement in the most important key indicators of cancer management. On the other side, some studies reported resistance of HCPs especially the physicians to implication of the role of the clinical pharmacists in the hospital settings . This resistance may be attributed to the lack of direct contact between the physicians’ and the clinical pharmacists participating in the clinical activities . Also, lack of knowledge with the importance of the clinical pharmacists in healthcare and deficiency of well-trained and efficient clinical pharmacists in the hospitals may be contributing factors . In order to overcome this resistance, continuous improvement and incorporation of courses related to inter-professional relationships between HCPs and the clinical pharmacists in the curricula of the medical, pharmaceutical and nursing education should be applied to encourage the collaboration between the clinical pharmacists and other HCPs in provision of patient care .In conclusion, HCPs and the students of health-related science colleges in this study valued the role of the clinical pharmacists in healthcare delivery and management of cancer. However, new developments in clinical pharmacy services in Taif hospitals are recommended to improve the perceptions and attitudes towards the services of clinical pharmacy and improve the healthcare provided to the patients. Also, well-organized programs should be included in the curricula of the subjects given to the students of health-related science colleges to improve their perception and attitude towards the clinical pharmacy services. Further studies are needed to investigate the impact of improving the clinical pharmacy services on the outcomes of cancer management.


The webbed penis represents a common genital abnormality consisting of penoscrotal transposition of various degrees, the presence of a skin fold tethering the ventral penile shaft to the scrotum promoting the absence of a penoscrotal angle and an abnormally short ventral shaft. Besides, a stenotic ring of distal prepuce (phimosis or paraphimosis) is frequently found. We want in this video to illustrate the steps of this common procedure associated with an excellent cosmetic result and improvement of self-esteem.Surgery consists of treating penoscrotal transposition when present by two inverted scrotal V-shaped skin flaps to be brought down to its natural position. The ventral penile shaft is detached from the scrotum, excising or dividing the fibrotic and fatty tissue. We dissect the skin and deglove the penis proximally almost reaching the pelvic floor, producing a release of the penile shaft and increase in size. After that, we suture the ventral penile skin at the lowest level of dissection by two 3.0 vycril sutures anchoring them to the Buck's fascia one at each side of the urethra. Subsequently, the circumcision is performed and the scrotum reconstructed with removal of redundant skin when necessary.Surgery produced improvement of ventral surface of the penis and better cosmetic appearance without any local complicationThe webbed penis is a frequently under-recognized abnormality by pediatricians, but a major cause of anxiety for parents. This technique can be regarded as an alternative to most webbed penis patients.


Development of low-cost robots to assist older adults requires the input of end users: older adults, paid caregivers and clinicians. This study builds on prior work focused on the task investigation and deployment of mobile robots in a Program of All-inclusive Care for the Elderly. We identified hydration, walking and reaching as tasks appropriate for the robot and helpful to the older adults. In this study we investigated the design specifications for a socially assistive robot to perform the above tasks. Through focus groups of clinicians, older adults and paid caregivers we sought preferences on the design specifications. Using conventional content analysis, the following four themes emerged: the robot must be polite and personable; science fiction or alien like; depends on the need of the older adult; and multifaceted to meet the needs of older adults. These themes were used in the design and deployment of the Quori robot.


An adaptive dynamic sliding mode control via a backstepping approach for a microelectro mechanical system (MEMS) vibratory z-axis gyroscope is presented in this paper. The time derivative of the control input of the dynamic sliding mode controller (DSMC) is treated as a new control variable for the augmented system which is composed of the original system and the integrator. This DSMC can transfer discontinuous terms to the first-order derivative of the control input, and effectively reduce the chattering. An adaptive dynamic sliding mode controller with the method of backstepping is derived to real-time estimate the angular velocity and the damping and stiffness coefficients and asymptotical stability of the designed systems can be guaranteed. Simulation examples are investigated to demonstrate the satisfactory performance of the proposed adaptive backstepping sliding mode control.  Microelectro mechanical system (MEMS) gyroscopes can measure the sensor angular velocity of inertial navigation and guidance systems, widely used in aviation, aerospace, marine and positioning fields. However, parameter uncertainties and external disturbances, the manufacturing errors, and the influence of the ambient temperature decrease the accuracy and sensitivity of the micro gyroscope. The manufacturing errors and the influence of the external conditions as main factors affecting the decrease in the accuracy and sensitivity of the gyro system, the nonlinear effects in the model applied is also of great importance. The problem concerning the impact of the nonlinearity is discussed ,2,3. TheDynamic sliding mode control (DSMC) schemes ,17,18,19However, an adaptive backstepping scheme combined with dynamic sliding mode controller has not been applied to a MEMS gyroscope yet. The backstepping method is a powerful design tool for dynamic systems with pure or strict feedback forms. The gyroscope equations can be transformed into an analogically cascade system that is easily implemented by the backstepping method. This work is an extended version of the 2013 work  and the In this paper, an adaptive dynamic sliding mode controller based on backstepping control is designed to realize position tracking and effectively decrease the chattering problem. The advantages of the proposed controller can be summarized as follows:(1) Adaptive control, DSMC and backstepping control are combined and applied to a MEMS gyroscope. DSMC using the derivative of the switching function is utilized to eliminate the chattering and attenuate the model uncertainties and external disturbances and adaptive control is derived to estimate the dynamics of the micro gyroscope. Hence, dynamic sliding mode control not only removes some of the fundamental limitations of the traditional approach but also provides improved tracking accuracy under sliding mode.(2) The proposed DSMC adds additional compensators to achieve system stability, thereby obtaining the desired system property. An integrator is added in the front end to transform the original system into an augmented system, with the derivative of the original control input as the system input. Therefore, the proposed integrator can filter out high frequency noise.(3) The advantages of the backstepping design are that it is able to relax the matching condition and avoid cancelation of useful nonlinearities. The procedure of backstepping design is to develop a controller recursively by regarding some of the state variables as “virtual controls” and deriving control laws to improve the robustness.The paper is organized as follows. In The typical MEMS vibratory gyroscope depicted in z axis.We assume that the table where the proof mass is mounted is moving with a constant velocity; the gyroscope is rotating at a constant angular velocity Referring to , with thFabrication imperfections result in the asymmetric spring and damping terms, Define non-dimensional time On both sides of the Equation (1) divide by the mass Equation (3) is a mathematical model of the MEMS gyroscope under ideal conditions. Considering the presence of model uncertainties and external disturbances of a MEMS gyroscope under the actual conditions, ignoring the superstar for the convenience of notation, then rewriting non-dimensional model (3) in matrix form yieldsSuppose an ideal oscillator generates a reference trajectory and the control objective is to make the trajectory of the MEMS gyroscope follow that of the reference model. The reference model is defined asThe tracking error is defined asThe virtual controller is defined asIn the backstepping control, the introduction of virtual control is essentially a static compensation idea. The front subsystem must achieve stabilization purposes through the virtual control of the back subsystem.In this section, an adaptive DSMC method based on backstepping design is developed for the trajectory tracking and system identification of a MEMS gyroscope as shown in We select the first Lyapunov function as follows:The time derivative of the When Define the second Lyapunov function as followsThinking about Equations (4) and (6), the sliding surface is defined asSubstituting Equation (8) into Equation (12) yieldsReferring to Equations (4) and (13), we can obtainThe derivative of the sliding surface isThe time derivative of the To make Substituting Equation (17) into Equation (16) yieldsTo make Substituting Equation (19) into Equation (18) yieldsIt is assumed that With the choice of In this section, based on the backstepping design, an adaptive DSMC strategy is designed for the trajectory tracking and system identification of the MEMS gyroscope. The parameters of the micro gyroscope sensor are described as:The reference trajectory is chosen to be The tracking trajectory and tracking error are shown in The parameters of the MEMS gyroscope are in In this study, an adaptive DSMC strategy with a backstepping approach was successfully applied to a MEMS gyroscope for the trajectory tracking. The derivative of the switching function is employed to differentiate classical sliding surface and transfer discontinuous terms to the first-order derivative of the control input, and effectively decrase the chattering. The asymptotical stability of the closed loop system can be guaranteed with the proposed DSMC strategy. Moreover, the proposed adaptive dynamic sliding mode control can estimate the system parameters online. Simulation studies are conducted to demonstrate the good performance of the proposed dynamic sliding mode control methods.


Hydrocephalus is the most common cause of pediatric surgical intervention . We are aware only of the single aforementioned study by Waybright et al. for proteomic analysis of the CSF of hydrocephalic infants.Clearly, none of the previous studies affords comparison with the comparative proteomics we undertook  were detected in the CSF of hydrocephalic patients  are produced in the CNS, including the choroid plexus (Tseng et al., Two of the overabundant proteins are the serpins angiotensinogen and PEDF . AngioteFew previous studies had analyzed the diagnostic potential of the CSF. Developmental defects originating from attenuated cycling of germinal matrix cells in the brains of hydrocephalus-harboring rats had been attributed to alteration in the composition of the CSF relative to healthy subjects, but the putative difference between the CSF of healthy and hydrocephalic rats had not been identified (Owen-Lynch et al., The interpretation of the overabundance of ECM proteins, complement factors, and apolipoproteins present in the subgroup of 18 proteins reported by Yang et al. as biomarkers of brain injuries is supported by previous studies (Mcallister, The combined overabundance of all the five cytokine-binding proteins present in the above subgroup suggests that IGF signaling is a major autoregulatory pathway employed by the brain, possibly to counteract the neuronal injury caused by ventriculomegaly (Johnston et al., AH initiated the proteomics data analysis. All authors contributed to the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Five (5) years old male patient came to outpatient department with complain of multiple swelling over chest region with upper extremities. The clinical examination revealed that there is chest multiple mass growth of about 3-4 cm bilaterally each over chest, upper extremities and forehead. The development of multiple benign osteocartilaginous masses (exostoses) begins with the relation with the ends of long bones of the lower limbs such as the femurs and tibias and of the upper limbs such as the humerus and forearm bones with chest region. The patient also had complains of difficulty in eating, finger grips, as well as loss of functional independence. On clinical examination the patient was diagnosed with a rare case of hereditary multiple osteochondromas (HMO).


Seismicity pattern changes that are associated with strong earthquakes are an interesting topic with potential applications for natural hazard mitigation. As a retrospective case study of the Ms7.3 Yutian earthquake, which was an inland normal faulting event that occurred on 21 March 2008, the Region-Time-Length (RTL) method is applied to the seismological data of the China Earthquake Administration (CEA) to analyze the features of the seismicity pattern changes before the Yutian earthquake. The temporal variations of the RTL parameters of the earthquake epicenter showed that a quiescence anomaly of seismicity appeared in 2005. The Yutian main shock did not occur immediately after the local seismicity recovered to the background level, but with a time delay of about two years. The spatial variations of seismic quiescence indicated that an anomalous zone of seismic quiescence appeared near the Yutian epicentral region in 2005. This result is consistent with that obtained from the temporal changes of seismicity. The above spatio-temporal seismicity changes prior to the inland normal faulting Yutian earthquake showed similar features to those reported for some past strong earthquakes with inland strike faulting or thrust faulting. This study may provide useful information for understanding the seismogenic evolution of strong earthquakes. The Q parameter defined by Equation (3) can describe quantitatively the spatial map of quiescence anomaly of seismicity in the time window  with respect to the background seismicity from the start time of a complete earthquake catalog to the ending time tB. Some case studies indicated that the Q parameter is effective in quantifying the spatial map of quiescence anomaly of seismicity  was chosen as six months in this study, i.e., tB − tA = 6 months. Although the selection of this interval was somehow empirical ) with respect to the background seismicity from the start time of the adopted complete earthquake catalog  to the ending time tB. The temporal changes of the Q-map can be obtained by sliding the calculated ending time of the earthquake catalog . The temporal change of seismicity in Yutian area showed that the most significant quiescence appeared at around late 2005  indicated that an anomalous zone of seismic quiescence appeared in 2005 near the Yutian epicentral area, consistent with the features revealed by the temporal variation of the RTL parameters. The size of the anomalous quiescence zone is about 200 km, several times of the rupture length of the main shock. The retrospective case study on the Yutian earthquake showed a combination of a temporal change and a spatial map of seismicity would provide useful information for seismic risk assessments.


The most pronounced effects of a given inflammatory stimulus on both systems are the induction of fever and the manifestation of inflammatory pain, which is an increased sensitivity of the nociceptive system due to the inflammatory response. Traditionally, the distinct functional components of the afferent somatosensory system have been investigated in vivo in conscious or anesthetized experimental animals. Most frequently, an inflammatory stimulation of the thermoregulatory system to evoke fever was achieved by administration of bacterial lipopolysaccharide (LPS) and continuous recording of body core temperature . InflammIn this issue of Pflügers Archiv – European Journal of Physiology, Leisengang et al.  introduc


Background: In order to tackle the public health threat of antimicrobial resistance, improvement in antibiotic prescribing in primary care was included as one of the priorities of the Quality Premium (QP) financial incentive scheme for Clinical Commissioning Groups (CCGs) in England. This paper briefly reports the outcome of a workshop exploring the experiences of antimicrobial stewardship (AMS) leads within CCGs in selecting and adopting strategies to help achieve the QP antibiotic targets. Methods: We conducted a thematic analysis of the notes on discussions and observations from the workshop to identify key themes. Results: Practice visits, needs assessment, peer feedback and audits were identified as strategies integrated in increasing engagement with practices towards the QP antibiotic targets. The conceptual model developed by AMS leads demonstrated possible pathways for the impact of the QP on antibiotic prescribing. Participants raised a concern that the constant targeting of high prescribing practices for AMS interventions might lead to disengagement by these practices. Most of the participants suggested that the effect of the QP might be less about the financial incentive and more about having national targets and guidelines that promote antibiotic prudency. Conclusions: Our results suggest that national targets, rather than financial incentives are key for engaging stakeholders in quality improvement in antibiotic prescribing. Clinical Commissioning Groups (CCGs) were established in the English National Health Service (NHS) in April 2013 as the statutory bodies responsible for the planning and commissioning of health care services for their local area ,5,6,7, tThis paper briefly reports the key findings from a workshop with antimicrobial stewardship (AMS) leads, which aimed to explore the experiences of selecting and adopting strategies within CCGs to help achieve the QP targets on improving antibiotic prescribing. We have also reported a concept mapping activity by the CCGs to develop a conceptual framework for modelling the mechanism of QP effect on antibiotic prescribing.Participants were sent an invitation letter via email with details of the study. We invited 80% of the AMS leads for the 191 CCGs in England (as of May 2019) [Participants were assigned to one of three small groups, and each group had a researcher to observe and record discussions. In assigning participants to small working groups, we aimed to have diverse perspectives and experiences in each group in relation to regions and prescribing behaviour of the CCGs represented by the participants. This was important to facilitate comparison of experiences and drive creativity and inclusiveness in the development of the conceptual framework. Discussions within each small group started with participants identifying and summarising the interventions and strategies adopted in their CCGs towards achieving the QP antibiotic prescribing targets. The second part of the workshop was an interactive activity to build a conceptual model to demonstrate the pathways from the QP to antibiotic prescribing through the identified AMS interventions/strategies , and associations between the identified potential mediators, if any.The modelling activity was followed by a whole-group discussion on key observations about how the QP had been implemented, building on earlier contributions by the participants in the three small groups. This discussion was useful for comparing and summarising the models, looking at triangulation of the data and exploring how the discussed experiences compared between groups and individuals .Detailed notes on discussions and observations within the small and whole groups were taken by PA, AB, CC and other researchers involved in the workshop. The notes were combined and analysed by PA and CC. We conducted a thematic analysis to identify themes across the dataset. The notes were descriptively coded to summarise the key concepts of statements and observations from the group discussions. We reviewed the codes for patterns. Codes that relate to specific fundamental concepts on the experiences of the participants were linked to form themes ,12. To iWe recruited 10 AMS leads, three GPs, and one Nurse Prescriber from a diverse range of CCGs and practices in relation to antibiotic prescribing rates and geographical location. Four of the participants who expressed interest did not attend the workshop.The findings were organised into three main themes, which constituted constructs linking the various aspects of participants’ experiences (discussed below). Increased CCG engagement with practices on prudent antibiotic prescribing: Practice visits, needs assessments, peer feedback and audits were identified as a set of strategies integrated towards increasing the level of engagement between CCGs and practices, and within practices. Some CCGs used practice visits as an avenue to assess what prescribers need to help them reduce their antibiotic prescribing. Audits to assess antibiotic prescribing in practices against national guidelines were commonly adopted by CCGs alongside feedback to practices to motivate change in prescribing to help meet the QP antibiotic targets. Heavy workload in CCGs and practices was identified as the main barrier to regular antibiotic audit in practices. Participants also reported benchmarking local prescribing data against the national and regional averages as a social norm strategy.Local financial incentive schemes: The use of other local financial incentives by CCGs to encourage practices to reduce their antibiotic prescribing was widely discussed with most participants recognising the existence of local incentive schemes even before the QP. Some of the local incentives were integrated with the QP targets from 2015.Other strategies: Other strategies described to help with QP antibiotic targets included the use of AMS training resources—in particular those available on the Treat Antibiotics Responsibly, Guidance, Education, Tools (TARGET) toolkit-, and C-reactive Protein point-of-care testing (CRP POCT).The participants stressed that the identified strategies were not adopted in isolation. For instance, some of the participants described the integration of audit, feedback, practice visits, and a CCG-level incentive scheme. A practice visit by CCG AMS leads (or Prescribing Advisors) was recognised as a strategy used to conduct an antibiotic audit and offer feedback to practices. Additionally, local financial incentives were sometimes set up to encourage practices to conduct self-audit.Increased availability of prescribing data for CCGs and practices: Increased surveillance, availability and feedback of prescribing data following the introduction of QP were perceived to be associated with increased engagement with the QP scheme. This was also reported to be related to increased adoption of strategies like antibiotic audit and benchmarking.National guideline on antibiotic prescribing: Participants also reported that having a national guideline helps in developing local strategies towards the QP antibiotic targets by providing a framework to underpin their AMS activities. In discussing the available guidelines on antibiotic prescribing, most of the participants indicated a preference for guidelines that were less frequently updated given the limited time allocated to AMS duties. In addition, most of the participants shared the view that the effect of the QP might be less about the financial incentive and more about having national targets and guidelines that promote antibiotic prudency. Even when their CCGs expected not to receive the QP financial payments , some participants reported that they still worked towards the QP antibiotic targets.One of the challenges to meeting the QP antibiotic targets reported by the participants was balancing the goal of AMS whilst ensuring access to antibiotics for those patients who needed them .Another reported challenge was engaging high antibiotic prescribers. AMS interventions such as practice visits, audits and feedback were often targeted by the CCGs specifically to high prescribing practices. Participants raised a concern about the possibility of disengagement by high prescribers due to continuously labelling and targeting them for most AMS interventions.Our paper summarises the strategies and activities reported by a selection of CCGs in England to facilitate antibiotic stewardship in primary care practices towards achieving the QP antibiotic targets. Evidence on the mechanism of impact of financial incentive schemes to improve the quality of care in primary care is insufficient given the limited number of rigorous studies on this . We demoOur findings are important to healthcare policymakers and quality improvement agencies in the planning and systemised implementation of programs towards antimicrobial stewardship. The participants reported some of the ways in which AMS strategies such as national guidelines, audits and feedbacks can be integrated to optimise their individual effects. The co-developed conceptual framework can inform a user-led investigation of the mechanism of the impact of financial incentive schemes on antibiotic prescribing in primary care practices. Given that the Quality Premium is one of the first national financial incentive schemes towards improvement in antibiotic prescribing in England, the developed framework depicting pathways for maximising the potentials of such a scheme can be useful in the development of future AMS financial incentive interventions.The adoption of some of the AMS strategies identified in our workshop was also reported by a survey of CCGs in England . PreviouWe recognise the limitation posed by the small sample size with regards to the representativeness of our findings. However, the diversity of the workshop participants  was important in capturing different perspectives and experiences, contributing to the credibility of our findings.