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Background The Quantra QPlus System is a cartridge-based device with a unique ultrasound technology that can measure the viscoelastic properties of whole blood during coagulation. These viscoelastic properties correlate directly with hemostatic function. The primary objective of this study was to assess blood product utilization in cardiac surgery patients before and after the implementation of the Quantra QPlus System. Methods Yavapai Regional Medical Center implemented the Quantra QPlus System to aid in their efforts to reduce the transfusion of allogenic blood products and improve outcomes in patients undergoing cardiac surgery. A total of 64 patients were enrolled prior to the utilization of the Quantra (pre-Quantra cohort), and 64 patients were enrolled after (post-Quantra cohort). The pre-Quantra cohort had been managed via standard laboratory assays along with physician discretion for transfusion decisions. The utilization of blood products and frequency of transfusions were compared and analyzed between the two cohorts. (using the Student’s t-test) Results The implementation of the Quantra resulted in a change in the pattern of blood product utilization leading to a demonstrated decrease in the amount of blood products transfused and the associated costs. The amount of FFP transfused was significantly decreased by 97% (P = 0.0004), whereas cryoprecipitate decreased by 67% (P = 0.3134), platelets decreased by 26% (P = 0.4879), and packed red blood cells decreased by 10% (P = 0.8027) however these trends did not reach statistical significance. The acquisition cost of blood products decreased by 41% for total savings of roughly $40,682. Conclusions Use of the Quantra QPlus System has the potential to improve patient blood management and decrease costs. Study registered at ClinicalTrials.gov NCT05501730

Contains fulltext : 243959.pdf (Publisher’s version ) (Closed access) PURPOSE: The ClinGen Variant Curation Expert Panels (VCEPs) provide disease-specific rules for accurate variant interpretation. Using the hearing loss-specific American College of Medical Genetics and Genomics/Association for Molecular Pathology (ACMG/AMP) guidelines, the Hearing Loss VCEP (HL VCEP) illustrates the utility of expert specifications in variant interpretation. METHODS: A total of 157 variants across nine HL genes, previously submitted to ClinVar, were curated by the HL VCEP. The curation process involved collecting published and unpublished data for each variant by biocurators, followed by bimonthly meetings of an expert curation subgroup that reviewed all evidence and applied the HL-specific ACMG/AMP guidelines to reach a final classification. RESULTS: Before expert curation, 75% (117/157) of variants had single or multiple variants of uncertain significance (VUS) submissions (17/157) or had conflicting interpretations in ClinVar (100/157). After applying the HL-specific ACMG/AMP guidelines, 24% (4/17) of VUS and 69% (69/100) of discordant variants were resolved into benign (B), likely benign (LB), likely pathogenic (LP), or pathogenic (P). Overall, 70% (109/157) variants had unambiguous classifications (B, LB, LP, P). We quantify the contribution of the HL-specified ACMG/AMP codes to variant classification. CONCLUSION: Expert specification and application of the HL-specific ACMG/AMP guidelines effectively resolved discordant interpretations in ClinVar. This study highlights the utility of ClinGen VCEPs in supporting more consistent clinical variant interpretation.

Background Adolescents with chronic kidney disease (CKD) are a unique population with a high prevalence of hypertension. Management of hypertension during the transition from adolescence to adulthood can be challenging given differences in normative blood pressure values in adolescents compared with adults. Methods In this retrospective analysis of the Chronic Kidney Disease in Children Cohort Study, we compared pediatric versus adult definitions of ambulatory- and clinic-diagnosed hypertension in their ability to discriminate risk for left ventricular hypertrophy (LVH) and kidney failure using logistic and Cox models, respectively. Results Overall, among 363 adolescents included for study, the prevalence of systolic hypertension was 27%, 44%, 12%, and 9% based on pediatric ambulatory, adult ambulatory, pediatric clinic, and adult clinic definitions, respectively. All definitions of hypertension were statistically significantly associated with LVH except for the adult ambulatory definition. Presence of ambulatory hypertension was associated with 2.6 times higher odds of LVH using pediatric definitions (95% CI 1.4–5.1) compared to 1.4 times higher odds using adult definitions (95% CI 0.8–3.0). The c-statistics for discrimination of LVH was statistically significantly higher for the pediatric definition of ambulatory hypertension (c=0.61) compared to the adult ambulatory definition (c=0.54), and the Akaike Information Criterion was lower for the pediatric definition. All definitions were associated with progression to kidney failure. Conclusion Overall, there was not a substantial difference in pediatric versus adult definitions of hypertension in predicting kidney outcomes, but there was slightly better risk discrimination of the risk of LVH with the pediatric definition of ambulatory hypertension. Graphical abstract

The forest has always been a potent subject for ecocriticism, with the complex and often contradictory cultural representations these landscapes inspire being a microcosm of broader human/nature re...

OBJECTIVE Cannabis Hyperemesis Syndrome (CHS) is characterized by recurrent episodes of intractable emesis associated with heavy use of cannabis. Recognition of CHS can be problematic due to the lack of specific biomarkers, which can point the clinician to the diagnosis. We present, retrospectively, a series of adolescent/young adult patients who presented to a pediatric gastroenterology (GI) service with acute on chronic nausea and vomiting, subsequently found to have CHS with associated elevated urinary cannabis metabolite concentrations. METHODS We describe 15 patients referred to our pediatric GI division for intractable emesis with spot urinary cannabis metabolite carboxy-THC (THC-COOH) concentrations from January 1, 2018 through April 20, 2019. Urinary testing was performed using gas chromatography mass-spectrometry (GC-MS) in a manner consistent with Clinical Laboratory Improvement Amendments (CLIA) requirements at Mayo Clinic laboratory (Rochester, MN). The laboratory cutoffs were 3.0 ng/mL. Data was extracted via chart review and analyzed via online statistical application. RESULTS Fifteen patients (seven females, eight males) were studied with an average age of 17.7 years. All patients reported frequent cannabis use for at least 1 month and exhibited intractable, non-bilious emesis for at least 2 weeks. Twelve patients also reported weight loss. Two patients had underlying gastrointestinal disease (one with Crohn disease and one with irritable bowel syndrome). All patients had essentially normal GI workup including laboratory tests, imaging studies and endoscopies.Fourteen of 15 patients had urinary THC-COOH concentrations >100 ng/mL, with seven individuals exhibiting levels >500 ng/mL. One patient had a urinary TCH-COOH concentration level under 100 ng/mL had not used cannabis for 2 weeks. Most other patients had used cannabis within 2 days of providing a urine sample. The Binomial test for CHS patients with urinary THC-COOH levels over 100 ng/mL was significant with a P-value of

Introduction MDMA (3,4-methylenedioxymethamphetamine) is a popular drug of abuse associated with a variety of clinical manifestations. There are a number of life-threatening sequelae, including, but not limited to, agitated delirium, cardiac dysrhythmias, and hyperthermia. Similar to other substances that cause sympathomimetic toxidromes, MDMA also induces a syndrome of inappropriate antidiuretic hormone secretion-like state resulting in hyponatremia. The management of hyperthermia is of particular importance, as time to correction, particularly at temperatures greater than 106 °F, is directly associated with increased risk of morbidity and mortality. Methods We created a simulation-based intervention to address and improve clinical skills relating to the management of MDMA intoxication. The scenario used a simulated patient to teach emergency medicine residents how to properly diagnose sympathomimetic toxicity and manage resultant hyperthermia and hyponatremia with cooling measures and appropriate fluid administration. Learners participated in a debrief session and were given an anonymous survey to assess their perceived knowledge. The case was performed as part of monthly emergency medicine resident didactics. Results Eighteen learners took part in the case, with a 100% response rate. All participants agreed that the scenario increased their knowledge of cooling methods in severe hyperthermia, particularly whole-body packing. Eighty-nine percent (n = 16) reported that the scenario changed their practice patterns. Discussion This simulated scenario requires minimal resources and can be instituted with emergency medicine residents from all levels of training. The scenario achieved its primary goal of improving residents' perceived knowledge of cooling measures in severe hyperthermia.

A common assumption for argumentation-based dialogues is that any argument exchanged is complete, in the sense that its premises entail its claim. However, in real world dialogues, agents commonly exchange enthymemes—arguments with incomplete logical structure. This paper formalises the dialogical exchange of enthymemes that are missing some constituent elements, such that it is not possible to directly entail the claim of the intended argument from the premises of the enthymeme exchanged. This can lead to misunderstandings between agents; we provide a rich set of locutions for identifying and resolving such misunderstandings, and a protocol that governs the use of these. We show that, under certain conditions, the status of moves made during a dialogue conforming to our system corresponds with the status of arguments in the Dung argument framework instantiated by the contents of the moves made at that stage in the dialogue. This is significant since it ensures that the use of enthyememes does not prevent the agents from reaching the appropriate decision according to the information they have shared.

Supplemental Digital Content is available in the text., Background. Living donor kidney transplants have declined among adults with end-stage renal disease (ESRD), with increases in racial/ethnic disparities over time. Secular trends in racial/ethnic disparities in living donor kidney transplantation have not been well studied in children. Methods. Using multivariable Cox modeling, we examined changes in living donor kidney transplant rates over time and probability of receiving living donor kidney transplantation within 2 years of incident ESRD by race/ethnicity among 19 772 children in the US Renal Data System, 1995–2015. We also examined racial/ethnic concordance between donors and recipients. Results. Overall, living donor kidney transplant rates declined by 3% annually since 1995 for all racial/ethnic groups except Asians for whom living donor kidney transplant rates remained stable; however, disparities persist. Compared with non-Hispanic white children, Hispanics were 42% less likely (adjusted hazard ratio: 0.58; 95% confidence interval: 0.49-0.67), Asians 39% less likely (0.61; 0.47-0.79), and blacks 66% less likely (0.34; 0.28-0.42) to receive living kidney donor transplantation within 2 years, even when accounting for deceased donor transplantation as a competing risk. Additionally, while 95% of non-Hispanic white children had non-Hispanic white donors, only 56% of Asian recipients had Asian donors (P < 0.001). Asian recipients were more likely to have nonrelated donors (P < 0.001). Conclusions. There are ongoing declines in living donation for children with ESRD for uncertain reasons, and minority populations experience significantly reduced access to timely living donor transplant, even when accounting for changes in deceased donation and donor-recipient relationships.

Maternal low-protein and postnatal high-fat (HF) diets program offspring obesity and type 2 diabetes mellitus (T2DM) risk by epigenetically reducing beige adipocytes (BAs) via increased G9a protein expression (Histone3 Lysine9 dimethyl transferase), an inhibitor of the BA marker fibroblast growth factor 21 (FGF21). Conversely, offspring exercise reduces fat mass and white adipocytes, but the mechanisms are not yet understood. This work investigated whether exercise reduces offspring obesity and T2DM risk caused by a maternal HF diet via regulation of G9a and FGF21 expression that would convert white to BA. Two-month-old female C57Bl/6J mice (F0) were fed a 16% (normal fat; NF) or a 45% HF diet for 3 months prior to breeding, and subsequent gestation and lactation. Male offspring (F1) were fed the same NF and HF diets and further divided into either sedentary (S) or voluntary wheel running (Ex) groups for an additional 3 months yielding eight groups: NF (maternal treatment condition)-NF-S (postweaning treatment conditions), NF-HF-S, NF-NF-Ex, NF-HF-Ex, HF-NF-S, HF-HF-S, HF-NF-Ex, and HF-HF-Ex. Subcutaneous adipose tissue was collected for protein and mRNA analysis of FGF21, peroxisome proliferator-activated receptor-gamma coactivator (PGC-1 alpha, inducer of FGF21), G9a, E4BP4 (G9a coactivator), and protein expression of H3K9 demethylases (KDM4C). Postnatal HF diet decreased FGF21 positive BA numbers regardless of maternal diets and postnatal exercise. Under sedentary conditions, postnatal HF diet increased protein expression of FGF21 transcription inhibitors G9a and E4BP4 compared to NF diet resulting in decreased FGF21 expression. In contrast, postnatal HF diet and exercise decreased G9a and E4BP4 protein expression while decreasing FGF21 expression compared to NF diet. Under exercised condition, postnatal HF diet-induced KDM4C protein expression while no changes in KDM4C protein expression were induced by postnatal HF diet under sedentary conditions. These findings suggest that the postnatal diet exerts a greater impact on offspring adiposity and BA numbers than maternal diets. These data also suggest that offspring exercise induces KDM4C to counter the increase in G9a that was triggered by maternal and postnatal HF diets. Future studies need to determine whether KDM4C induces methylation status of G9a to alter thermogenic function of BA.

Whilst the majority of First–World War poetry is associated with trench warfare and the human cost of conflict, Edward Thomas’s war poetry is notable for its lack of explicit commentary on the war or the experience of fighting. Instead, Thomas’s work centres on the environmental impact of the conflict on the British countryside and the ways in which it disrupts rural communities. This article argues that this alternative perspective on the Great War results in the creation of a new, ecocentric form of war poetry that emphasises the deep interconnections between the human and non-human world by linking the effects of violence abroad to its impact on the environment and ways of life at home. It also suggests that Thomas’s earth-centred war poetry proves the ability of nature writing to go beyond the small scale or local to confront global issues in a way that continues to speak to current anxieties in the age of the Anthropocene.

Background This study employed a structural equation model to examine the relationships between poor physical health, suicide, depression, psychosocial stress, interpersonal conflict, and panic. Methods The sample consisted of a large, archived set of mental health treatment-seeking adults who completed a behavioral outcome questionnaire prior to beginning treatment. Results Results supported the extant literature indicating that poor physical health, depression, psychosocial stress, interpersonal conflict, and panic impose increased risk for suicidal ideation, with depression demonstrating the highest risk for increased suicidal ideation. The results also supported the hypotheses that depression, psychosocial stress, interpersonal conflict, and panic would mediate the association between poor physical health and suicidal ideation. Although no a priori hypotheses were made regarding relationships among the 15 physical illnesses examined, results indicated that HIV/AIDS had the strongest correlation with depression and the weakest correlation with interpersonal conflict. Limitations Firstly, the study sample was primarily Caucasian, limiting its generalizability. Secondly, causal inferences should be interpreted with caution, due to the quasi-experimental design. Thirdly, these data were self-reported, which create response biases since suicidal ideation is stigmatized. Conclusions These findings highlight the importance of considering interpersonal factors as potential mediators in the relationship between poor physical health, mental illness, and suicide. Clinically, the impact of an active major depressive episode on an individual who is struggling with a serious physical illness may be strongly predictive of suicidal ideation.

This paper describes a study which assesses a software prototype designed as part of the POSTURE project. POSTURE (Pressure Offloading Support Technologies for Ulcer REduction) comprises the design and development of a prototype system to help patients suffering from Diabetic Foot Ulcer (DFU) self-manage their treatment. The system is designed to take input from commercial wellness sensors and other sensors specially crafted for tracking aspects of foot ulcer progress. The sensor data is fed into a data-backed decision support tool which interacts with users via an intelligent agent, using a chatbot style interface, underpinned by computational argumentation-based dialogue. A recent Patient and Public Involvement (PPI) study was conducted in which DFU patients were presented with the prototype system design and offered opinions about the utility of the system from their unique perspectives. The preliminary results of this study are presented here.

OBJECTIVES: We have shown that a maternal low protein and postnatal high fat (HF) diet increases offspring obesity and type 2 diabetes mellitus (T2DM) risk by epigenetically reducing beige adipocyte (BA) numbers via increased protein expression of G9a (Histone3 Lysine9 dimethyl transferase), an inhibitor of the BA marker FGF21. It is not yet known whether offspring exercise reverses the offspring obesity and T2DM risk caused by the maternal HF diet. METHODS: Two month old female C57Bl/6 J mice (F0) were fed a normal fat (NF) 16% diet or a 45% HF diet for 3 months prior to breeding, and subsequent gestation and lactation. Male offspring (F1) were fed the same NF and HF diets and further divided into either cage active (CA) or voluntary wheel running (Ex) groups for an additional 3 months yielding eight groups: NF (maternal treatment condition)-Ex-NF (post weaning treatment conditions), NF-Ex-HF, NF-CA-NF, NF-CA-HF, HF-Ex-NF, HF-Ex-HF, HF-CA-NF, and HF-CA-HF. Subcutaneous adipose tissue samples were collected for protein and mRNA analysis of FGF21, G9a, E4BP4 (G9a coactivator), and H3K9 methylation regulators that are induced by exercise including Activating Transcription Factor 4 (ATF4) and H3K9 demethylases (KDM4C). RESULTS: Postnatal HF diet decreased FGF21 positive BA numbers regardless of the maternal diet. A postnatal HF diet plus limited postnatal activity (CA) increased G9a and E4BP4 expression to suppress FGF21, while a postnatal HF diet plus exercise condition increased KDM4C expression. Although BA were detectable, the morphology of BA under CA conditions were compromised or scarred. CONCLUSIONS: These findings suggest that a postnatal HF diet has a greater impact on offspring adiposity and BA number than a maternal HF diet. These data also suggest that offspring exercise induces KDM4C to counter the increase in G9a triggered by a postnatal HF diet. Whether KDM4C induces reduction in H3K9-me2 to regulate adipose tissue FGF21 needs investigation. Futures studies should determine whether H3K9 epigenetic modifications in BA have any functional differences that contribute to the observed phenotypic abnormalities. FUNDING SOURCES: USDA Agricultural Research Service Project #3062-51000-052-00D.

In most proposals for logic-based models of argumentation dialogues between agents, the arguments exchanged are logical arguments of the form where Φ is a set of formulae (called the support) and α is a formula (called the claim) such that Φ is consistent and Φ entails α. However, arguments presented by real-world agents do not normally fit the mould of being logical arguments. They are normally enthymemes, and so they only explicitly represent some of the premises for entailing their claim and/or they do not explicitly state their claim. For example, for a claim that ‘you need an umbrella today’, a husband may give his wife the premise ‘the weather report predicts rain’. Clearly, the premise does not entail the claim, but it is easy for the wife to identify the assumed knowledge used by the husband in order to reconstruct the intended argument correctly (i.e. ‘if the weather report predicts rain, then you need an umbrella’). Whilst humans are constantly handling examples like this, proposals for logic-based formalizations of the process remain underdeveloped. In this article, we present a logic-based framework for handling enthymemes, some design features of which are influenced by aspects of relevance theory (proposed by Sperber and Wilson). In particular, we use the ideas of maximizing cognitive effect and minimizing cognitive effort in order to enable a proponent of an intended logical argument to construct an enthymeme appropriate for the intended recipient, and for the intended recipient to deconstruct the intended logical argument from the enthymeme. We relate our framework back to Sperber andWilson's relevance theory via some formal properties.

The majority of existing work on agent dialogues considers negotiation, persuasion or deliberation dialogues; we focus on inquiry dialogues, which allow agents to collaborate in order to find new knowledge. We present a general framework for representing dialogues and give the details necessary to generate two subtypes of inquiry dialogue that we define: argument inquiry dialogues allow two agents to share knowledge to jointly construct arguments; warrant inquiry dialogues allow two agents to share knowledge to jointly construct dialectical trees (essentially a tree with an argument at each node in which a child node is a counter argument to its parent). Existing inquiry dialogue systems only model dialogues, meaning they provide a protocol which dictates what the possible legal next moves are but not which of these moves to make. Our system not only includes a dialogue-game style protocol for each subtype of inquiry dialogue that we present, but also a strategy that selects exactly one of the legal moves to make. We propose a benchmark against which we compare our dialogues, being the arguments that can be constructed from the union of the agents' beliefs, and use this to define soundness and completeness properties that we show hold for all inquiry dialogues generated by our system.

Background: Gaps in the knowledge of general practitioners (GPs) in medical genetics prevent the effective utilization of genetic services and increase the risk of liability. Educators recommend that genetics should be integrated into existing teaching programs but the effectiveness of these types of programs is unknown. Aim: The objective of this study was to provide a 2-year educational program for GPs untrained in genetics and to document its impact on genetic knowledge and referrals to a genetic counselor (GC). Methods: Eight genetic lectures series were given at quarterly intervals. Family practice residents received additional training in a genetics clinic, and participated in monthly seminars and bi-annual journal clubs. A pretest–post-test study design (n ¼ 143) was used to evaluate the genetic knowledge of GPs. Post-test scores [mean (%) � SD; 76.1 � 16.8] showed significant improvement compared to pretest scores (61.9 � 19.1). The majority of participants (81%) indicated that the program would have an impact on their clinical practice. The number of referrals to a GC from GPs untrained in genetics did not change over the 2-year period of the program. Conclusion: The results suggest that an integrated educational program in genetics can enhance physicians’ knowledge but may not alter referral patterns to a GC.

Different sources of data on past oil spill incidents contain different kinds of information about each incident and different degrees of accuracy. The appropriate data can be used to develop spill statistics and spill rate relationships. This paper examines data on reported oil spills that have occurred in the United States. Characteristics studied include the number of spills, spill sizes, spill sources, and the types of oil spilled. Studying characteristics of past spills can help government and industry to determine the scope of oil spill prevention policies and response planning methods. The main data sources used for this paper include the Oil Spill Intelligence Report's International Oil Spill Statistics annual summaries and the National Response Center online database. This report provides a discussion of the accuracy of information from sources of oil spill data, to help support the development of spill statistics and spill rate relationships.

Dialogical argumentation allows agents to interact by constructing and evaluating arguments through a dialogue. Numerous proposals have been made for protocols for dialogical argumentation, and recently there is interest in developing better strategies for agents to improve their own outcomes from the interaction by using an opponent model to guide their strategic choices. However, there is a lack of clear formal reasons for why or how such a model might be useful, or how it can be maintained. In this paper, we consider a simple type of persuasion dialogue, investigate options for using and updating an opponent model, and identify conditions under which such use of a model is beneficial.

This paper deals with an approach to opponent-modelling in argumentation-based persuasion dialogues. It assumes that dialogue participants (agents) have models of their opponents’ knowledge, which can be augmented based on previous dialogues. Specifically, previous dialogues indicate relationships of support, which refer both to arguments as abstract entities and to their logical constituents. The augmentation of an opponent model relies on these relationships. An argument external to an opponent model can augment that model with its logical constituents, if that argument shares support relationships with other arguments that can be constructed from that model. The likelihood that the constituents of supporting arguments will in fact be known to an opponent, varies according to support types. We therefore provide corresponding quantifications for each support type.

In order for an agent or a group of agents such as a team to achieve a goal, a sequence of actions have to be performed. These actions bring about state transitions that constitute a plan. Multiple ways of achieving the goal may exist. In some situations, one may want to prevent or delay an agent or group of agents from achieving a goal. We argue that plans can be disrupted by preventing particular state transitions from happening. We propose four algorithms to identify which state transitions should be thwarted such that the achievement of the goal is prevented total disruption or delayed partial disruption. In order to evaluate the performance of our algorithms we define disruption partial and total and also provide metrics for its measurement. We do acknowledge that the disruptor may not always have an accurate representation of the disruptee's plans. Thus, we perform an experimental analysis to examine the performance of the algorithms when some of the state transitions available to the disruptee are unknown to the disruptor.

Argument-based deliberation dialogues are an important mechanism in the study of agent coordination, allowing agents to exchange formal arguments to reach an agreement for action. Agents participating in a deliberation dialogue may begin the dialogue with very similar sets of arguments to one another, or they may start the dialogue with disjoint sets of arguments, or some middle ground. In this paper, we empirically investigate whether the similarity of agents’ arguments affects the dialogue outcome. Our results show that agents that have similar sets of initially known arguments are less likely to reach an agreement through dialogue than those that have dissimilar sets of initially known arguments.

Information and its cognate concepts are frequently used in increasingly varied areas of scientific and scholarly investigations, from computing and engineering to philosophy and the social sciences. As a consequence, a great deal of interesting and exciting research is taking place in a wide range of fields, which do not always communicate with each other. So the second workshop1 of the IEG (the interdepartmental research group in philosophy of information at the University of Oxford2), took the shape of a series of seminars, hosted in Oxford by the Department of Engineering Science, during the academic year 2008–2009. The project aimed to bring together leading experts in the broadly construed area of information research, with the goal of offering a stimulating series of talks and discussions on “the nature and scope of information”.

The death of Princess Diana set in train a series of official and popular responses which are broadly consistent with Durkheimian ideas of civic ritual. Mass media accounts of Princess Diana's purportedly extraordinary appeal are speculative, lack methodological foundation, and fail to give adequate consideration to potential variability in responses to her life and death. In order to explore popular understandings of Diana, focus groups were conducted in Australia with Anglo-Celtic women of different ages within three weeks of her death and funeral. The women professed a diversity of orientations and experiences towards Diana. Significant barriers to identification with Diana included a wealth gap between her and the participants in the study, the routine nature of charity work and suffering for many ordinary people, the irresponsible circumstances of her death and reflexivity about the media as a source of information. Sources of identification included her physical and character attributes, the mothering role and the universal tragedy of death. There was no support in the transcripts for the view that women identified with Diana as a feminist heroine. Caution is expressed about both the generalisability of the results of the study to other groups of women and also the comparability of the study with data collected at other points in time.

Nursing practice is being redefined. Today's graduating nurse is practicing in a tomorrow full of unknowns. The relevancy of traditional nursing education is being questioned in today's health care climate of crisis. In an attempt to prepare the graduating RN-BSN student to cope with these changes, nurse educators developed a process of empowerment. The framework for this effort was derived from the curriculum revolution, adult learning theory and empowerment research. The faculty defined empowerment as both an interpersonal process and an outcome. A graphic model has been created consisting of the four elements of empowerment: collegiality, communication, autonomy and accountability. Learning experiences are selected based upon these four elements. Teaching strategies axe identified. Positive changes in student behavior have been reported anecdotally. The faculty are beginning the next phase: designing a research project to investigate behavior changes related to this empowerment model.

In this paper, we present an implemented system that enables autonomous agents to engage in dialogues that involve inquiries embedded within a process of practical reasoning. The implementation builds upon an existing formal model of value-based argumentation, which has itself been extended to permit a wider range of arguments to be expressed. We present extensions to the formal underlying theory used for the dialogue system, as well as the implementation itself. We demonstrate the use of the system through a particular case study. We discuss a number of interesting issues that have arisen from the implementation and the experimental avenues that this test-bed will enable us to pursue.

We present an empirical simulation-based study of the use of value-based argumentation in two-party deliberation dialogues, investigating the impact that argumentation can have on the quality of the outcome reached. Our simulation allows us to vary the number of values, actions and arguments that appear in the system; we investigate how the behaviour of the system changes as these parameters vary. This parameter sensitivity analysis tells us whether a value-based deliberation dialogue system may be useful for a particular real-world application. We measure the quality of the dialogue outcome (i.e. the action that the agents agree to) against a global view of whether that action would be agreeable to each agent if all of the agents' knowledge were taken into account. We compare the deliberation outcome with a simple consensus forming procedure (where no arguments are exchanged). Our results show that the deliberation dialogue system we present outperforms consensus forming.

When deliberating about what to do, an autonomous agent must generate and consider the relative pros and cons of the different options. The situation becomes even more complicated when an agent is involved in a joint deliberation, as each agent will have its own preferred outcome which may change as new information is received from the other agents involved in the deliberation. We present an argumentation-based dialogue system that allows agents to come to an agreement on how to act in order to achieve a joint goal. The dialogue strategy that we define ensures that any agreement reached is acceptable to each agent, but does not necessarily demand that the agents resolve or share their differing preferences. We give properties of our system and discuss possible extensions. ACM Category: I.2.11 Multiagent systems. General terms: Theory.

Background: Body image distortions are a core feature of anorexia nervosa (AN). We, and others, previously reported abnormalities in adipose tissue distribution after acute weight restoration in adult women with AN compared with body mass index–matched healthy control women. Whether these abnormalities persist over time remains unknown. Objectives: We aimed to 1) replicate previous findings that showed preferential central accumulation of adipose tissue in recently weight-restored AN women compared with control subjects, 2) describe the change within patients with longer-term (1-y) weight maintenance, and 3) compare adipose tissue distribution after 1-y maintenance with that of control subjects. Design: Body composition and adipose tissue distribution were assessed by whole-body magnetic resonance imaging in women with AN shortly after weight normalization (n = 30) and again 1 y after hospital discharge (n = 16) and in 8 female control subjects at 2 time points. Results: With acute weight restoration, AN patients had significantly greater visceral and intermuscular adipose tissue compared with control women [visceral: 0.75 ± 0.26 compared with 0.51 ± 0.26 kg in AN patients and controls, respectively (P = 0.02); intermuscular: 0.46 ± 0.17 compared with 0.29 ± 0.13 kg in AN patients and controls, respectively (P = 0.01)]. With maintenance of normal weight for ≈1 y, visceral adipose tissue distribution in AN patients was not different from that in healthy control subjects. Conclusions: In adult women with AN, normalization of weight in the short term is associated with a distribution of adipose tissue that is consistent with a central adiposity phenotype. This abnormal distribution appears to normalize within a 1-y period of weight maintenance. This research was registered at clinicaltrials.gov as {"type":"clinical-trial","attrs":{"text":"NCT 00271921","term_id":"NCT00271921"}}NCT 00271921 and {"type":"clinical-trial","attrs":{"text":"NCT 00368667","term_id":"NCT00368667"}}NCT 00368667.

The need for clinical guidelines to be implemented at different sites, to adapt to rapidly changing environments, and to be carried out by distributed clinical teams, implies a degree of flexibility beyond that of current guideline languages. We propose an extension to the PROforma language allowing hierarchical goal-based plans. Sub-plans to achieve goals are proposed at runtime so that changing circumstances may be flexibly accommodated without redefining the workflow.

Logic-based argumentation offers an approach to querying and revising multiple ontologies that are inconsistent or incoherent. A common assumption for logic-based argumentation is that an argument is a pair ****** ,*** *** where *** is a minimal subset of the knowledgebase such that *** is consistent and *** entails the claim *** . Using dialogue games, agents (each with its own ontology) can exchange arguments and counterarguments concerning formulae of interest. In this paper, we present a novel framework for logic-based argumentation with ontological knowledge. As far as we know, this is the first proposal for argumentation with multiple ontologies via dialogues. It allows two agents to discuss the answer to queries concerning their knowledge (even if it is inconsistent) without one agent having to copy all of their ontology to the other, and without the other agent having to expend time and effort merging that ontology with theirs. Furthermore, it offers the potential for the agents to incrementally improve their knowledge based on the dialogue by checking how it differs from the other agent's.

Research on computer interpretable clinical guidelines has largely focused on individual points of care rather than processes of care. Whether we consider simple aids like clinical alerts and reminders or more sophisticated data interpretation and decision-making, guideline developers tend to focus on specific tasks rather than processes like care plans and pathways which are extended in time. In contrast, research on business process modelling has demonstrated notations and tools which deal directly with process modelling, but has not been concerned with problems like data interpretation and decision making. In this chapter we describe these two traditions, and compare some of their strengths and weaknesses. We also briefly discuss the distinct theoretical frameworks which have grown up around them, notably Petri nets for workflow modelling and mathematical logics for guidelines. We conclude that these offer complementary views of clinical processes and that a key research challenge is find a way of unifying them.