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Objective: The goal of this review was to assess the relationships among aims, designs, and outcomes of integrated inpatient medical and psychiatric care units (IMPUs) and gather the evidence base on the effectiveness of these units. Methods: Using online searches of Embase, Medline, Web of Science, PsycINFO, Scopus, CINAHL, Cochrane, and Google Scholar, the authors identified and reviewed literature describing the aims and outcomes of specific IMPU designs. Results: The search yielded 55 studies, in which the authors identified 39 IMPUs that focused on patients with mood, psychotic, somatic symptom, substance use, organic, and personality disorders and a broad array of medical diagnoses. Most units were psychiatric-medical units and had medium medical and psychiatric acuity capabilities. The studies reviewed provided little information on the cost-effectiveness of various IMPU designs. Although some comparative studies indicated reductions in hospital length of stay (LOS), these studies were generally of low quality and rarely reported other intended outcomes. Conclusions: IMPUs may help shorten LOS. IMPUs should focus care on patients with complex conditions and high acuity to maximize health system value. Implementing compulsory admission facilities; qualified psychiatric, medical, and nursing staff involvement; and cross-disciplinary training may improve IMPUs’ capacity to treat high-acuity patients. Future research should relate IMPU designs to intended outcomes.

Background: Active patient involvement in treatment decisions is seen as a feature of patient-centred care that will ultimately lead to better healthcare services and patient outcomes. Although many factors have been identified that influence patient involvement in treatment decisions, little is known about the different views that patients have on which factors are most important. Objective: This study explores the views of patients with a chronic condition on factors influencing their involvement in treatment decisions. Design: Q-methodology was used to study the views of patients. Respondents were asked to rank a set of 42 statements from the least important to the most important for active patient involvement in treatment decision-making. The set of 42 statements was developed based on a literature search and a pilot in which two external researchers, 15 patients and four healthcare professionals participated. A total of 136 patients with one of three major chronic conditions were included: diabetes types 1 and 2, respiratory disease (i.e., chronic obstructive pulmonary disease and asthma) and cancer (i.e., breast cancer and prostate cancer). Data were collected in a face-to-face interview setting in the Netherlands. Results: Four distinct views on the factors influencing active patient involvement were identified among patients with a chronic condition. (1) Enabled involvement: the extent to which patients are facilitated and empowered to participate will lead to patient involvement. (2) Relationship-driven involvement: the relationship between patients and healthcare professionals drives patient involvement. (3) Disease impact-driven involvement: the severity of disease drives patient involvement. (4) Cognition-driven involvement: knowledge and information drive patient involvement. Discussion and Conclusion: From the patients' perspective, this study shows that there is no one-size-fits-all approach to involving patients more actively in their healthcare journey. Strategies aiming to enhance active patient involvement among patients with a chronic condition should consider this diversity in perspectives among these patients. Patient Contribution: Patients are the respondents as this study researches their perspective on factors influencing patient involvement. In addition, patients were involved in pilot-testing the statement set.

This paper presents an optimisation model to assess the techno-economic feasibility of a hydrogen refuelling station, which purchases power from the electricity market, supplies the mobility sector with hydrogen, and participates in the ancillary service market. The problem is formed as a mixed-integer nonlinear programming model to investigate the optimal operational plans considering the nonlinear behaviour of an electrolyser and grid costs calculation model. Obtained results from various scenarios in 2020 and 2030 show that participation in the reserve market considering optimal sizing and dispatch of components increase revenues up to 16%, and as a result, decrease the hydrogen break-even price by up to 4.7% and 6.4% in 2020 and 2030, respectively. Exemption from tax and levies for connection to the grid reduces the hydrogen break-even price by up to 13%. Plant operators could benefit from the proposed approach to schedule components reliably while meeting the hydrogen demand and maximising the annual profits.

As the share of renewable energy sources increases, the grid frequency becomes more unstable. Therefore, grid balancing services will become more important in the future. Dedicated devices can be installed close to the point where off-shore wind farms are connected to the transmission grid on land. There, they can be used to attenuate power variations, reduce congestion and offer grid balancing. The provision of these ancillary services can create considerable additional economic revenue. In this study, the provision of the primary reserve by means of a large hydrogen electrolyser of 25 MW is investigated for the specific case of the Belgian transmission system. The revenue of the provision of the frequency containment reserve (FCR) is analysed on a techno-economic model, including capital costs, operational costs, the revenue of the generated hydrogen and oxygen products and the ancillary service income. The revenue depends strongly on the contracted power band. Therefore, it is optimised to yield maximum revenue. The results show that providing FCR creates considerable additional revenue. Therefore, a large electrolyser can be a good candidate to buffer excess renewable energy into green gas while simultaneously providing the grid support.

Background and study aims Delayed bleeding (DB) is the most frequent major adverse event after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs). Evidence-based guidelines for management of DB are lacking. We aimed to evaluate the clinical presentation, treatment and outcome of patients with DB and to determine factors associated with hemostatic therapy. Patients and methods Patients with DB were identified by analyzing all consecutive EMR procedures for LNPCPs (≥ 2 cm) from one academic center (2012–2017) and seven regional hospitals (2015–2017). DB was defined as any postprocedural bleeding necessitating emergency department presentation, hospitalization or reintervention. Outcome of DB was assessed for three clinical scenarios: continued bleeding (CB), spontaneous resolution without recurrent bleeding during 24 hours observation (SR), and recurrent bleeding (RB). Variables associated with hemostatic therapy were analyzed using logistic regression. Results DB occurred after 42/542 (7.7 %) EMR procedures and re-colonoscopy was performed in 30 patients (72 %). Re-colonoscopy and hemostatic therapy rates were 92 % and 75 % for CB (n = 24), 25 % and 8 % for SR (n = 12), and 83 % and 67 % for RB (n = 6), respectively. Frequent hematochezia (≥ hourly) was the only factor significantly associated with hemostatic therapy (RR 2.23, p = 0.01). Re-bleeding after endoscopic hemostatic therapy occurred in 3/22 (13.6 %) patients. Conclusion Ongoing or recurrent hematochezia is associated with a high rate of hemostatic therapy, warranting re-colonoscopy in these patients. A conservative approach is justified when bleeding spontaneously settles, and without recurrent hematochezia during 24 hours observation patients can be safely discharged without endoscopic re-examination.

Purpose of review The human upper respiratory tract is colonized with a variety of bacterial microorganisms including Haemophilus influenzae. The species H. influenzae consists of typeable and nontypeable H. influenzae (NTHi) variants. Typeable H. influenzae are subdivided into types a through f, based on the polysaccharide capsule, whereas the NTHi strains do not express a polysaccharide capsule. In this review, we highlight the current advances in the field of H. influenzae, with the focus on bacterial virulence mechanisms that facilitate bacterial colonization and disease, particularly for NTHi. Recent findings In the past decade, it has become apparent that NTHi has the ability to cause invasive infections. Recently, a number of adhesins have been shown to be crucial for bacterial colonization and invasion and these proteins were investigated as vaccine antigens. Although NTHi lacks a polysaccharide capsule, it expresses lipooligosaccharide that contribute to adhesion and evasion of complement-mediated killing, both contributing to bacterial virulence, which could potentially be targeted by novel antimicrobial drugs or vaccines. Summary The unraveling of H. influenzae virulence mechanisms resulted in the identification of promising targets for novel antimicrobials and vaccine antigens aiming to prevent or treat both typeable and nontypeable H. influenzae infections.

Complement C5 inhibitor eculizumab has a great impact on the treatment of patients with paroxysmal nocturnal hemoglobinuria (PNH). However, this treatment success has a major drawback: a substantially increased susceptibility for life-threatening Neisseria meningitidis infections. Therefore, N meningitidis vaccination is strongly advised before initiating complement C5–blocking therapy. In this study, we show that the multicomponent N meningitidis serogroup B (4CMenB) vaccination of PNH patients treated with eculizumab results in a significant increase in anti–N meningitidis serogroup B (MenB) plasma immunoglobulin G (IgG) levels. Anti-MenB IgG was able to bind to the bacterial surface and initiate complement activation; however, inhibition of the membrane attack complex formation completely blocked whole blood–mediated killing of MenB. This would suggest that, despite 4CMenB vaccination, PNH patients taking C5 inhibitors are not sufficiently protected against MenB infection, which is in line with the fact that vaccinated PNH patients still experience meningococcal infections.

Dutch policy stipulates that people with dementia should remain at home for as long as possible. If they need care, they must preferably appeal to family, friends and neighbours. Professional help and nursing homes are deemed last resorts. Therefore, case managers must coproduce their public services increasingly in healthcare triads with both people with dementia (PWDs) and their informal caregivers. Case managers are professionals who provide and coordinate care and support for PWDs and their informal caregivers during the entire trajectory from (suspected) diagnosis until institutionalisation. The literature on coproduction has focused on the bilateral interactions between service providers and users rather than the multilateral collaborative relationships through which many public services are currently delivered, as is the case in dementia care. Little is known about how frontline workers, case managers in this study, handle conflicts in these healthcare triads. Our study addresses this gap in the coproduction literature and explores the action strategies case managers use to handle conflicts. We interviewed 19 Dutch case managers and observed 10 of their home visits between January and May 2017. We focused on the end stage of dementia at home, just before admission to a nursing home, as we assumed that most conflicts occur in that phase. The findings reveal that the case managers use a variety of action strategies to resolve and intervene in these conflicts. Their initial strategies are in line with the ideals underlying coproduction; however, their successive strategies abandon those ideals and are more focused on production or result from their own lack of power. We also found that current reforms create new dilemmas for case managers. Future research should focus on the boundaries of coproducing public services in triadic relationships and the effects of current welfare reforms aimed at coproducing public services in healthcare triads.

Renewable Energy Sources (RES) have drawn significant attention in the past years to make the transition towards low carbon emissions. On the one hand, the intermittent nature of RES, resulting in variable power generation, hinders their high-level penetration in the power system. On the other hand, RES can aid not only to supply much more eco-friendly energy but also it allows the power system to enhance its stability by ancillary service provision. This article reviews the challenges related to the most intermittent RES utilised in Belgium, that is, wind energy and solar energy. Additionally, wind speed and solar irradiance variations, which are the cause of wind and solar intermittency, are studied. Then, recent techniques to forecast their changes, and approaches to accommodate or mitigate their impacts on the power system, are discussed. Finally, the latest statistics and future situation of RES in the Belgian power system are evaluated.

Wind energy is an important renewable source with a stochastic nature. To capture this energy, variable speed generators are installed in wind towers and different maximum power point (MPP) tracking (MPPT) strategies have been developed in literature to maximise the output power. However, in gusty weather, wind turbines fail to track the optimum operating point due to their relatively high inertia. This paper proposes an innovative MPPT strategy to capture the energy of wind gusts. The developed controller consists of a conventional TSR control together with a bidirectional controller, which takes over the control of the rectifier under varying wind condition. The simulation results show an overall efficiency improvement and more stability for the proposed strategy.

Currently, many policymakers try to encourage client involvement during the public service delivery process and make it a co‐production. Clients are encouraged to act as active agents and embrace an integrated approach to address their problems to empower them. However, different studies have raised questions regarding to what extent these ambitions are appropriate for clients with vulnerabilities, such as clients with multiple problems. Aiming to further explore this issue, we studied the expectations of clients with multiple problems concerning the co‐production of public services. We interviewed 46 clients with multiple problems at the start of their support trajectory. All 46 participants lived in five districts in Rotterdam, the Netherlands, and were recruited via community‐based primary care teams. Our study indicates that co‐production ambitions might not resonate with clients with multiple problems. The study shows that these clients’ expectations are driven by their feelings of being overwhelmed and stressed out by their situation, feelings of being a victim of circumstances, bad experiences with public services in the past, their evaluation of what counts as a problem and the envisioned solutions. These clients expect public service providers to take over, fix their main problem(s) and not interfere with other aspects of their lives (not an integrated approach). Although participants seek a ‘normal’ life with, e.g., a house, work, partner, children, holidays, a pet, and no stress (a white picket fence life) as ideal, they do not feel that this is attainable for them. More insight into the rationale behind these expectations could help to bridge the gap between policymakers’ ambitions and clients’ expectations.

Background New hemocytometric parameters can be used to differentiate causes of acute febrile illness (AFI). We evaluated a software algorithm–Infection Manager System (IMS)—which uses hemocytometric data generated by Sysmex hematology analyzers, for its accuracy to detect bacteremia in AFI patients with and without malaria in Burkina Faso. Secondary aims included comparing the accuracy of IMS with C-reactive protein (CRP) and procalcitonin (PCT). Methods In a prospective observational study, patients of ≥ three-month-old (range 3 months– 90 years) presenting with AFI were enrolled. IMS, blood culture and malaria diagnostics were done upon inclusion and additional diagnostics on clinical indication. CRP, PCT, viral multiplex PCR on nasopharyngeal swabs and bacterial- and malaria PCR were batch-tested retrospectively. Diagnostic classification was done retrospectively using all available data except IMS, CRP and PCT results. Findings A diagnosis was affirmed in 549/914 (60.1%) patients and included malaria (n = 191) bacteremia (n = 69), viral infections (n = 145), and malaria-bacteremia co-infections (n = 47). The overall sensitivity, specificity, and negative predictive value (NPV) of IMS for detection of bacteremia in patients of ≥ 5 years were 97.0% (95% CI: 89.8–99.6), 68.2% (95% CI: 55.6–79.1) and 95.7% (95% CI: 85.5–99.5) respectively, compared to 93.9% (95% CI: 85.2–98.3), 39.4% (95% CI: 27.6–52.2), and 86.7% (95% CI: 69.3–96.2) for CRP at ≥20mg/L. The sensitivity, specificity and NPV of PCT at 0.5 ng/ml were lower at respectively 72.7% (95% CI: 60.4–83.0), 50.0% (95% CI: 37.4–62.6) and 64.7% (95% CI: 50.1–77.6) The diagnostic accuracy of IMS was lower among malaria cases and patients, Author summary This study describes the diagnostic accuracy of the Infection Manager System (IMS), a novel diagnostic algorithm for febrile illnesses that is equipped on a routine hematology analyzer. The latest generation hematology analyzers allow better differentiation between leukocyte subsets and their phenotype. The IMS was created, using differences in immune cell subsets (their activation status for instance), to differentiate viral from bacterial etiologies of fever. Such a tool may guide clinicians in their decision the initiate or withhold antimicrobial therapy. The study was carried out among febrile patients aged 3 months and older in rural Burkina Faso, a sub-Saharan African setting where malaria is endemic. Standard microbiological techniques such as blood culture were used as a reference to assess the diagnostic accuracy of IMS. We then compared the diagnostic accuracy of the IMS with the marketed biomarkers C-reactive protein (CRP) and procalcitonin (PCT). Our study showed that the diagnostic performance of the IMS was similar to CRP and better than PCT to detect bacteremia in patients with and without malaria co-infection. Further studies are needed to see if the IMS can be safely used to guide initial antimicrobial treatment and help to reduce further spread of antimicrobial resistance.

Contains fulltext : 244720.pdf (Publisher’s version ) (Open Access) BACKGROUND: Current risk stratification models for early invasive (T1) colorectal cancer are not able to discriminate accurately between prognostic favourable and unfavourable tumours, resulting in over-treatment of a large (>80%) proportion of T1 colorectal cancer patients. The tumour-stroma ratio (TSR), which is a measure for the relative amount of desmoplastic tumour stroma, is reported to be a strong independent prognostic factor in advanced-stage colorectal cancer, with a high stromal content being associated with worse prognosis and survival. We aimed to investigate whether the TSR predicts clinical outcome in patients with non-pedunculated T1 colorectal cancer. METHODS: Haematoxylin and eosin (H&E)-stained tumour tissue slides from a retrospective multicentre case cohort of patients with nonpedunculated surgically treated T1 colorectal cancer were assessed for TSR by two independent observers who were blinded for clinical outcomes. The primary end point was adverse outcome, which was defined as the presence of lymph node metastasis in the resection specimen or colorectal cancer recurrence during follow-up. RESULTS: All 261 patients in the case cohort had H&E slides available for TSR scoring. Of these, 183 were scored as stroma-low, and 78 were scored as stroma-high. There was moderate inter-observer agreement κ = 0.42). In total, 41 patients had lymph node metastasis, 17 patients had recurrent cancer and five had both. Stroma-high tumours were not associated with an increased risk for an adverse outcome (adjusted hazard ratio = 0.66, 95% confidence interval 0.37-1.18; p = 0.163). CONCLUSIONS: Our study emphasises that existing prognosticators may not be simply extrapolated to T1 colorectal cancers, even though their prognostic value has been widely validated in more advanced-stage tumours.

Distributed generation (DG) allows the production of renewable energy where it is consumed, avoiding transport losses. It is envisioned that future DG units will become more intelligent, not just injecting power into the grid but also actively improving the power quality by means of active power filtering techniques. In this manner, voltage and current harmonics, voltage unbalance or over-voltages can be mitigated. To achieve such a smart DG unit, an appropriate multi-functional converter topology is required, with full control over the currents exchanged with the grid, including the neutral-wire current. For this purpose, this article studies the three-phase four-wire split-link converter. A known problem of the split-link converter is voltage unbalance of the bus capacitors. This mid-point can be balanced either by injecting additional zero-sequence currents into the grid, which return through the neutral wire, or by injecting a compensating current into the mid-point with an additional half-bridge chopper. For both methods, this article presents a discrete time domain model to allow controller design and implementation in digital control. Both techniques are validated and compared by means of simulation results and experiments on a test setup.

With the continuous evolution of the power system towards a more renewable energy based system, a natural and gradual transition will be to provide ancillary services by using renewable production units. Research has shown this to be feasible for wind farms by using efficient prediction and sophisticated control systems. In some parts of the world, strict grid codes are already being implemented that require wind farms to provide ancillary services. Moreover, the primary reserve market in Europe is moving towards shorter procurement periods, providing wind farms an opportunity to more efficiently optimise their resources based on short term forecasts. As a result of these developments, it is expected that more wind farms will provide ancillary services in the near future. The provision of Frequency Containment Reserve (FCR) requires a fast regulation of the turbine power based on the changes of the grid frequency. It is expected that this will have an impact on the wake behind the wind turbine. In wind parks with a high capacity density, such as the offshore wind parks in Belgium, it is important to investigate this impact as it can affect other neighbouring turbines. This paper investigates the dynamic behaviour of the wake generated by a wind turbine providing grid frequency support with FCR.

In light of the latest technological achievements in wind farm control, wind power producers (WPPs) are motivated to participate in the joint day-ahead energy and reserve market (JERM) so as to obtain additional revenue by offering ancillary services. However, their expected profit is potentially affected by fast fluctuations of the available wind power in real-time, which may prevent them to deliver the capacity offered at the day-ahead stage. In order to evaluate this impact, a stochastic framework aiming at maximizing the WPP’s profit in the day-ahead JERM, based on hourly mean wind power forecasts, is firstly developed. Once the optimal bids are obtained, an empirical ex-post analysis is performed to assess the impact of actual wind speed fluctuations on the WPP’s profit. Accordingly, the resulting revenue streams from the different market floors are separately compared to their related expected values, so as to determine the losses regarding the inability of both reserve capacity procurement and activation as well as deviations from the scheduled energy. The outcomes confirm that wind speed fluctuations have a significant impact on the WPP’s ability to deliver the scheduled reserve, thus negatively impacting its actual profit.

OBJECTIVES: Areas with declining malaria transmission in sub-Saharan Africa have recently witnessed important changes in the aetiology of childhood acute febrile illness (AFI). We describe the aetiology of AFI in a high malaria transmission area in rural Burkina Faso. METHODS: In a prospective hospital-based diagnostic study, children aged 3 months to 15 years with AFI were recruited and assessed using a systematic diagnostic protocol, including blood cultures, whole blood PCR on a selection of bacterial pathogens, malaria diagnostics and a multiplex PCR on nasopharyngeal swabs targeting 21 viral and 4 bacterial respiratory pathogens. RESULTS: A total of 589 children with AFI were enrolled from whom an infectious disease was considered in 575 cases. Acute respiratory tract infections, malaria and invasive bacterial infections (IBI) accounted for 179 (31.1%), 175 (30.4%) and 75 (13%) of AFI cases respectively; 16 (21.3%) of IBI cases also had malarial parasitaemia. A viral pathogen was demonstrated from the nasopharynx in 157 children (90.7%) with respiratory tract symptoms. Of all children with viral respiratory tract infections, 154 (92.4% received antibiotics, whereas no antibiotic was provided in 13 (17%) of IBI cases. CONCLUSIONS: Viral respiratory infections are a common cause of childhood AFI in high malaria transmission areas, next to malaria and IBI. These findings highlight the importance of interventions to improve targeted treatment with antimicrobials. Most patients with viral infections received antibiotics unnecessarily, while a considerable number with IBI did not receive antibiotics. ispartof: CLINICAL MICROBIOLOGY AND INFECTION vol:27 issue:4 pages:590-596 ispartof: location:England status: published

Contains fulltext : 241448.pdf (Publisher’s version ) (Closed access) Complement deficient patients are susceptible to rare meningococcal serogroups. A 6-year-old girl presented with serogroup Z meningitis. This led to identification of a C8 deficiency. The MenB-4C vaccine induced cross-reactive antibodies to serogroup Z and increased in vitro opsonophagocytic killing and may thus protect complement deficient patients.

With the increasing shares of intermittent renewable sources in the grid, it becomes increasingly essential to quantify the requirements of the power systems flexibility. In this article, an adjusted weight flexibility metric (AWFM) is developed to quantify the available flexibility within individual generators as well as within the overall system. The developed metric is useful for power system operators who require a fast, simple, and offline metric. This provides a more realistic and accurate quantification of the available technical flexibility without performing time-consuming multi-temporal simulations. Another interesting feature is that it can be used to facilitate scenario comparisons. This is achieved by developing a new framework to assure the consistency of the metric and by proposing a new adjusted weighting mechanism based on correlation analysis and analytic hierarchy process (AHP). A new ranking approach based on flexibility was also proposed to increase the share of the renewable energy sources (RESs). The proposed framework was tested on the IEEE RTS-96 test-system. The results demonstrate the consistency of the AWFM. Moreover, the results show that the proposed metric is adaptive as it automatically adjusts the flexibility index with the addition or removal of generators. The new ranking approach proved its ability to increase the wind share from 28% to 37.2% within the test system. The AWFM can be a valuable contribution to the field of flexibility for its ability to provide systematic formulation for the precise analysis and accurate assessment of inherent technical flexibility for a low carbon power system.

INTRODUCTION: China has made considerable progress with health system reforms in recent years. Rural China, however, has lagged behind as the diversity of needs of China's 3,000 rural counties were not always well addressed by national top-down reforms. China's Rural Health Reform Project Health XI (HXI) piloted a hybrid process of top down and bottom up implementation of health system reforms which were tailored to rural county level needs and covered a population of more than 21 million. Different studies provide evidence that HXI counties have achieved substantial benefits given the relatively limited investment. The Effectiveness of HXI subsequently raises the question how the hybrid approach may have resulted in effective implementation of interventions. We answer this question to advance understanding of hybrid approaches in general and in the rural Chinese context in particular, where the bottom-up elements might match poorly with the traditional organisational culture and learning style.MATERIALS & METHODS: We conducted an in-depth qualitative analysis in three 'best practice' counties, performing document-analyses, observations, semi-structured individual and group interviews. In alignment with the research question, this study is of an explorative nature and follows a sequence of deductive and inductive steps.RESULTS: HXI struggled initially as counties had difficulties to take initiative and autonomously select and adapt their own reforms. The initial reforms required multiple improvement iterations before achieving the planned results. The effectiveness of these bottom up reform processes has been aided by tight top down supervision and extensive domestic expert involvement. County level leadership is seen as essential to align the top down and bottom up structures and processes. Where successful, HXI has changed mind-sets and counties developed generic health improvement capabilities.CONCLUSION: Tailoring innovations to fit local needs formed a severe challenge for the three 'best practice' counties studied. A 'change of mindset' to actively take initiative and assume autonomy was needed to advance. Top down supervision and extensive support of experts was required to overcome the barriers. The studied counties finally achieved sustainable improvements and developed double loop learning capabilities beyond HXI objectives. Taken together, the above findings suggest that the continuum of healthcare reform implementation approaches in which hybrid approaches reside-from bottom up to top down-has two dimensions: a content dimension and a procedural dimension. Enabled by top down procedures, counties were able to bottom up tailor the content of best practice innovations to fit local needs.

Correction to: Nature Communications https://doi.org/10.1038/s41467-020-18279-x, published online 7 September 2020.The original version of this Article contained errors in Fig. 1. The label ‘a’ was omitted for the left panel and the label ‘b’ was omitted for the right panel. In Fig. 1b, the right parenthesis was incorrectly positioned indicating a 4-carbon linker, rather than the correct 6-carbon linker. These errors have been corrected in both the PDF and HTML versions of the Article.

Objective The aim of this study was to determine whether the extent of peritoneal metastases (PMs) on preoperative diffusion-weighted magnetic resonance imaging (DW-MRI) can be used as a biomarker of disease-free and overall survival in patients with colorectal cancer who are considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Methods For this retrospective cohort study, patients with PMs considered for CRS/HIPEC who underwent DW-MRI for preoperative staging in 2016-2017 were included. The DW-MRI protocol consisted of diffusion-weighted, T2-weighted, and pre- and post-gadolinium T1-weighted imaging of the chest, abdomen, and pelvis. DW-MRI images were evaluated by two independent readers to determine the extent of PMs represented by the Peritoneal Cancer Index (MRI-PCI), as well as extraperitoneal metastases. Cox regression and Kaplan-Meier analysis was performed to determine the prognostic value of DW-MRI for overall and disease-free survival. Results Seventy-eight patients were included. CRS/HIPEC was planned for 53 patients and completed in 50 patients (60.5%). Median follow-up after DW-MRI was 23 months (interquartile range 13-24). The MRI-PCI of both readers showed prognostic value for overall survival, independently of whether R1 resection was achieved (hazard ratio [HR] 1.06-1.08; p

This article investigates the impact of the pitch-to-stall and pitch-to-feather control concepts on horizontal axis wind turbines (HAWTs) with different blade designs. Pitch-to-feather control is widely used to limit the power output of wind turbines in high wind speed conditions. However, stall control has not been taken forward in the industry because of the low predictability of stalled rotor aerodynamics. Despite this drawback, this article investigates the possible advantages of this control concept when compared to pitch-to-feather control with an emphasis on the control performance and its impact on the pitch mechanism and structural loads. In this study, three HAWTs with different blade designs, i.e., untwisted, stall-regulated, and pitch-regulated blades, are investigated. The control system is validated in both uniform and turbulent wind speed. The results show that pitch-to-stall control enhances the constant power control for wind turbines with untwisted and stall-regulated blade designs. Stall control alleviates the fore-aft tower loading and the blades flapwise moment of the wind turbine with stall-regulated blades in uniform winds. However, in turbulent winds, the flapwise moment increases to a certain extent as compared to pitch-to-feather control. Moreover, pitch-to-stall control considerably reduces the summed blade pitch movement, despite that it increases the risk of surface damage in the rolling bearings due to oscillating movements with a small amplitude.

Background Neutrophil accumulation in the skin is a hallmark of psoriasis. Novel insights on neutrophil phenotypic and functional heterogeneity raise the question to what extent these cells contribute to the sustained inflammatory skin reaction. Objective We sought to examine the phenotype and functional properties of neutrophils in blood and skin of patients with psoriasis, and the effect of TNF-α and p40(IL-12/IL-23) antibody therapy on circulating neutrophils. Methods Thirty-two patients with psoriasis were enrolled in an observational study performed in 2 university hospitals. We evaluated neutrophil phenotype and function using in vitro (co)culture stimulation assays, flow cytometry, multiplex immunohistochemistry, and multispectral imaging of patient-derived blood and skin samples. Results Cluster of differentiation (CD)10pos and CD10neg neutrophils were increased in peripheral blood of patients with psoriasis. In CD10neg neutrophils, different maturation stages were observed, including a subset resembling aged neutrophils that was 3 times more abundant than in healthy individuals. These aged neutrophils displayed suboptimal canonical neutrophil functions and induced IL-17 and IFN-γ production by T cells in vitro, mediated by neutrophil extracellular trap formation. Also, mature and aged neutrophils were present in psoriatic skin and were found in the vicinity of T cells. Upon antibody therapy, numbers of these cells in circulation decreased. Conclusions Patients with psoriasis reveal a unique neutrophil profile in circulation, and 2 distinct neutrophil subsets are present in psoriatic skin. Targeted biological treatment may aid in the containment of sustained neutrophil-mediated inflammation.

In a decarbonised economy, hydrogen could be a promising energy carrier, mainly for the transportation sector. Using hydrogen-filled vehicles can decrease air pollution and greenhouse gas emission. One of the requirements for the implementation of hydrogen as a fuel for the transportation sector is a focus on the optimal design of hydrogen refuelling stations. In this work, a model was developed to study and optimise the performance of a hydrogen refuelling station located in Belgium. To maximise the total annual profits, the capacity of each subcomponent for a hydrogen refuelling station, including the electrolyser, compressor and storage, was optimised. The effect of participation in the reserve market on the economic feasibility of the hydrogen refuelling station was studied as well. The simulation was established by realistic data from the Belgian electricity market. The analysis showed that the price of both hydrogen and electricity notably affect the economic viability. Besides, results confirmed that the economic feasibility could be enhanced through participation in the reserve market.

Objective To examine the association between bacterial-viral co-occurrence in the nasopharynx and the risk of community acquired pneumonia (CAP) in young children living in resource-limited settings. Methods A case-control study was conducted between January and December 2017 in Moshi, Tanzania. Children 2–59 months with CAP and healthy controls were enrolled. RSV and Influenza A/B were detected with a standardized polymerase chain reaction (PCR) method, and a simplified real-time quantitative PCR method, without sample pre-processing, was developed to detect bacterial pathogens in nasopharyngeal samples. Results A total of 109 CAP patients and 324 healthy controls were enrolled. Co-detection of H. influenzae and S. pneumoniae in nasopharyngeal swabs was linked with higher odds of CAP (aOR=3.2, 95% CI=1.1–9.5). The majority of the H. influenzae isolated in cases and controls (95.8%) were non-typeable. Of the viruses examined, respiratory syncytial virus (RSV) was most common (n = 31, 7.2%) in cases and controls. Children with RSV had 8.4 times higher odds to develop pneumonia than healthy children (aOR=8.4, 95%CI= 3.2 – 22.1). Conclusions Co-occurence of H. influenzae and S. pneumoniae in the nasopharynx was strongly associated with CAP. The high prevalence of non-typeable H. influenzae might be a sign of replacement as a consequence of Haemophilus influenzae type b vaccination.

BackgroundA high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design.ObjectivesTo review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the “evidence base” levels of the research.MethodsSeven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.ResultsThree types of interventions were distinguished: (1)Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2)Toolscovers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3)Organizational (re)designis about (re)designing structures to stimulate team processes and team functioning.(4) Aprogrammeis a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.ConclusionOver the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

Background: Most interventions to improve patient safety (Patient Safety Practices (PSPs)), are introduced without engaging front-line professionals. Administrative staff, managers and sometimes a few professionals, representing only one or two disciplines, decide what to change and how. Consequently, PSPs are not fully adapted to the professionals' needs or to the local context and as a result, adoption is low. To support adoption, two theoretical concepts, Participatory Design and Experiential Learning were combined in a new model: Adaptive Design. The aim was to explore whether Adaptive Design supports adaptation and adoption of PSPs by engaging all professionals and creating time to (re) design, reflect and learn as a team. The Time Out Procedure (TOP) and Debriefing (plus) for improving patient safety in the operating theatre (OT) was used as PSP. Methods: Qualitative exploratory multi-site study using participatory action research as a research design. The implementation process consisted of four phases: 1) start-up: providing information by presentations and team meetings, 2) pilot: testing the prototype with 100 surgical procedures, 3) small scale implementation: with one or two surgical disciplines, 4) implementation hospital-wide: including all surgical disciplines. In iterations, teams (re) designed, tested, evaluated, and if necessary adapted TOPplus. Gradually all professionals were included. Adaptations in content, process and layout of TOPplus were measured following each iteration. Adoption was monitored until final implementation in every hospital's OT. Results: 10 Dutch hospitals participated. Adaptations varied per hospital, but all hospitals adapted both procedures. Adaptations concerned the content, process and layout of TOPplus. Both procedures were adopted in all OTs, but user participation and time to include all users varied between hospitals. Ultimately all users were actively involved and TOPplus was implemented in all OTs. Conclusions: Engaging all professionals in a structured bottom-up implementation approach with a focus on learning, improves adaptation and adoption of a PSP. As a result, all 10 participating hospitals implemented TOPplus with all surgical disciplines in all OTs. Adaptive Design gives professionals the opportunity to adapt the PSP to their own needs and their specific local context. All hospitals adapted TOPplus, but without compromising the essential features for its effectiveness.

Objectives Complement deficiencies are difficult to diagnose because of the variability of symptoms and the complexity of the diagnostic process. Here, we applied a novel ‘complementomics’ approach to study the impact of various complement deficiencies on circulating complement levels. Methods Using a quantitative multiplex mass spectrometry assay, we analysed 44 peptides to profile 34 complement proteins simultaneously in 40 healthy controls and 83 individuals with a diagnosed deficiency or a potential pathogenic variant in 14 different complement proteins. Results Apart from confirming near or total absence of the respective protein in plasma of complement‐deficient patients, this mass spectrometry‐based profiling method led to the identification of additional deficiencies. In many cases, partial depletion of the pathway up‐ and/or downstream of the absent protein was measured. This was especially found in patients deficient for complement inhibitors, such as angioedema patients with a C1‐inhibitor deficiency. The added value of complementomics was shown in three patients with poorly defined complement deficiencies. Conclusion Our study shows the potential clinical utility of profiling circulating complement proteins as a comprehensive read‐out of various complement deficiencies. Particularly, our approach provides insight into the intricate interplay between complement proteins due to functional coupling, which contributes to the better understanding of the various disease phenotypes and improvement of care for patients with complement‐mediated diseases., In this study, we measured the ‘complementome’ of 83 individuals with various complement deficiencies by means of a quantitative multiplex mass spectrometry‐based assay. We found distinct profiles that provided better insight in the intricate interplay between complement proteins. The potential clinical utility of this approach was shown for three patients with poorly defined complement deficiencies.

The global wind power capacity is on a constant rise. Many countries are moving towards renewable energy sources. Wind energy accounts for the biggest renewable energy resource in Europe. Despite all the benefits, wind energy tends to weaken the grid stability. One reason for this is the fact that most wind turbine generators are not directly coupled to the grid and do not provide ancillary services, such as primary frequency control, due to the lack of rotating inertia. This paper presents detailed models of a wind turbine with a permanent magnet synchronous generator (PMSG). This model is used to test the feasibility of providing ancillary services by performing the pre-qualification test for primary frequency control, as established by the Belgian Transmission System Operator (TSO). These tests are conducted under 4 different wind profiles, each having a different level of turbulence.

The objective of this paper is to investigate the performance pitch and active speed stall control, and their impact on the structural loads of small and medium wind turbines (SMWTs). Large wind turbines use blade pitching to limit the power at high wind speeds. For SMWTs, the cost and complexity of a blade pitching system are not justified, so that passive yaw, stall control, or a furling tail mechanism is used instead. However, the choice of a proper control concept is not straightforward for SMWTs. In this regard, it is important to take into account that the control strategy has a significant impact on the structural loads. Reducing the structural loads results in a longer lifespan and ensures the safe operation of the wind turbine in stormy wind gusts or fierce winds. In this study, a 10 kW wind turbine is operated with different control strategies to investigate the corresponding loads, both in uniform and turbulent winds. The simulation results show that controlling power around the rated value is feasible and stable for both control strategies. However, active speed stall control increases the bending moments at the blade root, while it lightens the tower base moments, in contrast to the pitch control.

Hypoxia and inflammation are closely intertwined phenomena. Critically ill patients often suffer from systemic inflammatory conditions and concurrently experience short-lived hypoxia. We evaluated the effects of short-term hypoxia on systemic inflammation, and show that it potently attenuates pro-inflammatory cytokine responses during murine endotoxemia. These effects are independent of hypoxia-inducible factors (HIFs), but involve augmented adenosine levels, in turn resulting in an adenosine 2B receptor-mediated post-transcriptional increase of interleukin (IL)-10 production. We translated our findings to humans using the experimental endotoxemia model, where short-term hypoxia resulted in enhanced plasma concentrations of adenosine, augmentation of endotoxin-induced circulating IL-10 levels, and concurrent attenuation of the pro-inflammatory cytokine response. Again, HIFs were shown not to be involved. Taken together, we demonstrate that short-term hypoxia dampens the systemic pro-inflammatory cytokine response through enhanced purinergic signaling in mice and men. These effects may contribute to outcome and provide leads for immunomodulatory treatment strategies for critically ill patients., Highlights • Short-term hypoxia attenuates the systemic pro-inflammatory cytokine response in vivo in both mice and men • The underlying mechanism involves adenosine 2B receptor-mediated enhanced production of anti-inflammatory interleukin-10 • These effects may contribute to outcome and provide leads for novel treatment strategies for critically ill patients Inflammation and short bouts of low oxygen levels are frequently encountered phenomena in severely ill patients admitted to the Intensive Care unit. This study investigated the effect of short-term low oxygen levels on the inflammatory response in both mice and humans. The results show that a short period of low levels of oxygen potently dampens inflammation, and identify the underlying mechanisms. These effects of low oxygen levels may contribute to the outcome of severely ill patients. Furthermore, the increased understanding of the underlying mechanisms provided by this study can be used to develop therapies to dampen inflammation in patients.

Antibody replacement therapy for patients with antibody deficiencies contains only IgG. As a result, concurrent IgM and IgA deficiency present in a large proportion of antibody deficient patients persists. Especially patients with IgM deficiency remain at risk for recurrent infections of the gastrointestinal and respiratory tract. The lack of IgM in the current IgG replacement therapy is likely to contribute to the persistence of these mucosal infections because this antibody class is especially important for complement activation on the mucosal surface. We evaluated whether supplementation with IgM increased serum bactericidal capacity in vitro. Serum was collected from a patient with agammaglobulinemia and supplemented with purified serum IgM to normal levels. Antibody and complement deposition on the bacterial surface was determined by multi-color flow cytometry. Bacterial survival in serum was determined by colony-forming unit counts. We present a patient previously diagnosed with agammaglobulinemia due to CD79A (Igα) deficiency revealing a novel pathogenic insertion variant in the CD79a gene (NM_001783.3:c.353_354insT). Despite IgG replacement therapy and antibiotic prophylaxis, this patient developed a Campylobacter jejuni spondylodiscitis of lumbar vertebrae L4–L5. We found that serum IgM significantly contributes to complement activation on the bacterial surface of C. jejuni. Furthermore, supplementation of serum IgM augmented serum bactericidal activity significantly. In conclusion, supplementation of intravenous IgG replacement therapy with IgM may potentially offer greater protection against bacterial infections, also in the context of increasing antibiotic resistance.

Wind turbines are one of the most rapid growing and promising technologies for renewable power generation today. However, the share of wind energy in the global energy mix is almost entirely attributed to large turbines. Despite their unique merits, small wind turbines remain a marginal phenomenon, as they lack the technological maturity of their large counterparts. They often have a disappointing energy yield, and consequently, poor economic viability. However, it was observed from test field data that turbines with a higher ratio of rotor size to drivetrain power perform better. This rises the question whether a different design methodology, tailored to the specifics of small turbines, would result in a performance improvement. Therefore, this article presents a techno-economic optimisation method specifically for small wind turbines. Parametrised technical and economic models are integrated within a co-design optimisation process, with maximum economic performance as primary goal. A cost model of the turbine was constructed by collecting price data from wind turbine manufacturers and manufacturers of their main components. The results of the optimisation process confirm that the economic performance can indeed be greatly increased by significantly increasing the ratio of rotor size to drivetrain power.

Permanent magnet synchronous machines (PMSMs) are popular due to their high efficiency and favorable dynamic properties. In practice, these machines often have a back-electromotive force (EMF) waveform, which deviates from a theoretically ideal sinusoid or trapezoid. In the past, current waveform shaping techniques were developed for these machines to calculate nonconventional current waveforms to reduce the torque ripple. However, in the light of global warming, energy efficiency has become more important than torque ripple in many applications. Therefore, current waveform shaping techniques can be used to focus on maximum efficiency. In this paper, a technique is presented that maximizes the efficiency of both the PMSM and the drive simultaneously. A time domain approach is used instead of the classical frequency domain approach, which allows us to include many machine aspects that had to be neglected previously, i.e., armature reaction, reluctance, zero-sequence components, and iron losses.

This study investigates the performance of ‘Group Method of Data Handling’ type neural network algorithm in short-term time series prediction of the renewable energy and grid-balancing variables, such as the Net Regulation Volume (NRV) and System Imbalance (SI). The proposed method is compared with a Multi-layer Perceptron (MLP) neural network which is known as a universal approximator. Empirical validation results show that the GMDH performance is more accurate in compression with the most recent forecast which is provided by ELIA (Belgian transmission system operator). This study aims to practice the applicability of the polynomial GMDH-type neural network algorithm in time series prediction under a wide range of complexity and uncertainty related to the environment and electricity market.

Summary Vaccination against meningococcal serogroup B is recommended for patients with a complement deficiency; however, although immunogenicity in this patient group has been shown, efficacy has not yet been established. In this study, we collected serum from children with a complement deficiency in the alternative pathway or in late terminal pathway before and after vaccination with multi‐component meningococcal serogroup B (MenB)‐4C. MenB‐4C is a multi‐component, protein‐based vaccine against MenB consisting of factor H‐binding protein, Neisserial heparin‐binding protein, Neisserial adhesion A and outer membrane vesicles containing Porin A. We assessed the vaccine immunogenicity and vaccine‐mediated protection by a whole cell enzyme‐linked immunosorbent assay with Neisseria meningitidis serogroup B strains H44/76, 5/99 and NZ98/254, which shows that vaccination induced antibody titers against meningococcus. We show that the classical serum bactericidal activity assay with exogenous serum indicates the presence of vaccine‐induced antibodies and capacity to activate complement‐mediated pathogen lysis. However, in children with a late terminal pathway deficiency, no complement‐mediated pathogen lysis was observed when autologous serum was applied in the serum bactericidal activity assay, demonstrating a lack of serum bactericidal activity in children with complement deficiencies. However, MenB‐4C vaccination still induced effective complement‐dependent opsonophagocytic killing against N. meningitidis serogroup B in reconstituted whole blood with autologous serum from children with an alternative pathway or late terminal pathway deficiency. These findings support the recommendation to vaccinate all complement‐deficient children against MenB., Patients with a complement deficiency are extensively vaccinated against Meningococcal infection, including with the 4C‐MenB vaccine against N. meningitidis serogroup B. We show that vaccination induces functional antibodies, but does not result in bacterial killing via the complement system in patients with a late terminal pathway deficiency. Despite the complement deficiency, killing can occur via opsonophagocytosis.

Summary With the introduction of market competition in health care, the Dutch government enabled health insurers to contract hospital care selectively. The assumption is that “selective contracting” will stimulate efficiency, effectiveness, and innovation and will diminish overcapacity. In 2010, the first Dutch health insurers started experimenting with “selective contracting” by setting a minimum treatment volume per year for complex treatments. In an explorative, multiple case study among 15 hospitals in five regions, we found that instead of competing, hospitals started to cooperate and strengthen their networks. The government intended to remove redundant hospital capacity and improve quality by stimulating specialization and concentration. Our study showed that specialization was indeed stimulated, which may have increased quality of care. However, facilitated by the absence of a countervailing power (government or insurer), hospitals in our cases negotiated to the effect of preserving hospital capacity. Within the current political debate between supporters of competition and advocates of a national health service, the importance and role of the (medical) networks should be taken into account. Otherwise, the outcomes of health care governance will be different than intended by either party.

SummaryBackground The Prevention and Reactivation Care Program (PReCaP) provides a novel approach targeting hospital-related functional decline among elderly patients. Despite the high expectations, the PReCaP was not effective in preventing functional decline (ADL and iADL) among older patients. Although elderly PReCaP patients demonstrated slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2–0.6]), lower depression (Geriatric Depression Scale 15; –0.9 [95% –1.1 to –0.6]), and higher perceived health (Short-form 20; 5.6 [95% CI 2.8–8.4]) 1 year after admission than control patients, the clinical relevance was limited. Therefore, this study aims to identify factors impacting on the effectiveness of the implementation of the PReCaPand geriatric care ‘as usual’. Methods We conducted semi-structured interviews with 34 professionals working with elderly patients in three hospitals, selected for their comparable patient case mix and different levels of geriatric care. Five non-participatory observations were undertaken during multidisciplinary meetings. Patient files (n = 42), hospital protocols, and care plans were screened for elements of geriatric care. Clinical process data were analysed for PReCaP components. Results The establishment of a geriatric unit and employment of geriatricians demonstrates commitment to geriatric care in hospital A. Although admission processes are comparable, early identification of frail elderly patients only takes place in hosptial A. Furthermore, nursing care in the hospital A geriatric unit excels with regard to maximizing patient independency, an important predictor for hospital-related functional decline. Transfer nurses play a key role in arranging post-discharge geriatric follow-up care. Geriatric consultations are performed by geriatricians, geriatric nurses, and PReCaP case managers in hospital A. Yet hospital B consultative psychiatric nurses provide similar consultation services. The combination of standardized procedures, formalized communication channels, and advanced computerization contributes significantly to geriatric care in hospital B. Nevertheless, a small size hospital (hospital C) provides informal opportunities for information sharing and decision making, which are essential in geriatric care, given its multidisciplinary nature. Conclusions Geriatric care for patients with multimorbidity requires a multidisciplinary approach in a geriatric unit. Geriatric care, which integrates medical and reactivation treatment, by means of early screening of risk factors for functional decline, promotion of physical activity, and adequate discharge planning, potentially reduces the incidence of functional decline in elderly patients. Yet low treatment fidelity played a major role in the ineffective implementation of the PReCaP. Treatment fidelity issues are caused by various factors, including the complexity of projects, limited attention for implementation, and inadequate interdisciplinary communication. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.

Distributed generation (DG) units usually do not participate in the grid voltage control and inject power regardless of the grid voltage. Only when the grid voltage level surpasses a certain threshold, these units shut down to avoid any damage. In this paper, a method is presented to control the grid voltage with both active and reactive power with a DG unit. The effect of active and reactive power exchange on the grid voltage depends on the grid impedance ratio R / X of the whole electrical power network the converter is connected to. Therefore, the presented grid voltage control method uses a grid impedance estimation method. In an online manner, a current harmonic is injected into the network and the harmonic response is analysed. This way, the DG unit provides improved grid voltage control, automatically adjusting to changes in the grid voltage and impedance. The end result is that the DG unit can still generate power under sub-optimal grid voltage conditions and more renewable energy is harvested. The presented method is generally applicable to DG units of any rated power. The effectiveness of the method is demonstrated by means of both simulations and experiments, showing the positive effect on the grid voltage.

In several countries, the wind power penetration increased tremendously in recent years. To ensure the proper functioning of the power system, some grid operators already require the capability to provide inertial response or primary control with wind turbines. This paper discusses the emulated inertial response with wind turbines by means of the synthetic inertia and the droop control strategy. The behavior of the synthetic inertia strategy is determined by the inertial and the droop constant, whereas droop control only has a droop constant. When these strategies are used, it is important to tune the control parameters depending on the power system to which the wind turbines are connected. Simulations show that it is possible to enhance but also to deteriorate the frequency response of the system, dependent on these parameters. For different power system compositions, the optimal inertial constant is always close to zero. This way, the synthetic inertia strategy reduces to a fast droop control strategy. This is an important outcome, as it means that no differentiation of the frequency is needed to obtain an optimal inertial response from the wind turbines, which is beneficial in terms of robustness. Consequently, droop control is a viable alternative for the synthetic inertia.

Streptococcus pneumoniae is a major cause of life-threatening infections. Complement activation plays a vital role in opsonophagocytic killing of pneumococci in blood. Initial complement activation via the classical and lectin pathways is amplified through the alternative pathway amplification loop. Alternative pathway activity is inhibited by complement factor H (FH). Our study demonstrates the functional consequences of the variability in human serum FH levels on host defense. Using an in vivo mouse model combined with human in vitro assays, we show that the level of serum FH correlates with the efficacy of opsonophagocytic killing of pneumococci. In summary, we found that FH levels determine a delicate balance of alternative pathway activity, thus affecting the resistance to invasive pneumococcal disease. Our results suggest that variation in FH expression levels, naturally occurring in the human population, plays a thus far unrecognized role in the resistance to invasive pneumococcal disease.

The energy yield of wind turbines is to a large extent determined by the performance of the Maximum Power Point Tracking (MPPT) algorithm. Conventionally, they are programmed to maximize the turbines power coefficient. However, due to losses in the generator and converter, the true optimal operating point of the system shifts. This effect is often overlooked, which results in a decreased energy yield. Therefore, in this paper, the wind turbine system is modeled including the dominant loss components to investigate this effect in detail. By simulations and experiments on a wind turbine emulator, it is shown that the location of the maximum power point is significantly affected for low wind speeds. For high wind speeds, the effect is less pronounced. The parameter of interest is the increase in yearly energy output with respect to the classical MPPT method, which is calculated in this paper by including a Rayleigh wind speed distribution. For typical average wind speeds, the energy yield can increase with 1–2%. There is no cost associated with operating the turbine in the overall MPP, making it worthwhile to include this effect. The findings are implemented in an MPPT algorithm to validate the increased performance in a dynamic situation.

Background Empirical evidence suggests that integrated palliative care (IPC) increases the quality of care for palliative patients and supports professional caregivers. Existing IPC initiatives in Europe vary in their design and are hardly comparable. InSuP-C, a European Union research project, aimed to build a taxonomy of IPC initiatives applicable across diseases, healthcare sectors and systems. Methods The taxonomy of IPC initiatives was developed in cooperation with an international and multidisciplinary focus group of 18 experts. Subsequently, a consensus meeting of 10 experts revised a preliminary taxonomy and adopted the final classification system. Results Consisting of eight categories, with two to four items each, the taxonomy covers the process and structure of IPC initiatives. If two items in at least one category apply to an initiative, a minimum level of integration is assumed to have been reached. Categories range from the type of initiative (items: pathway, model or guideline) to patients’ key contact (items: non-pc specialist, pc specialist, general practitioner). Experts recommended the inclusion of two new categories: level of care (items: primary, secondary or tertiary) indicating at which stage palliative care is integrated and primary focus of intervention describing IPC givers’ different roles (items: treating function, advising/consulting or training) in the care process. Conclusions Empirical studies are required to investigate how the taxonomy is used in practice and whether it covers the reality of patients in need of palliative care. The InSuP-C project will test this taxonomy empirically in selected initiatives using IPC. ispartof: BMJ Supportive & Palliative Care vol:6 issue:1 pages:14-20 ispartof: location:England status: published

The increased penetration of renewable energy sources in the electrical grid raises the need for more power system flexibility. One of the high potential groups to provide such flexibility is the industry. Incentives to do so are provided by variable pricing and remuneration of supplied ancillary services. The operational flexibility of a chlor-alkali electrolysis process shows opportunities in the current energy and ancillary services markets. A co-optimisation of operating the chlor-alkali process under an hourly variable priced electricity sourcing strategy and the delivery of Frequency Containment Reserve (FCR) is the core of this work. A short term price prediction for the Day-Ahead Market (DAM) and FCR market as input for a deterministic optimisation shows good results under standard DAM price patterns, but leaves room for improvement in case of price fluctuations, e.g., as caused by Renewable Energy Sources (RES). A two-stage stochastic optimisation is considered to cope with the uncertainties introduced by the exogenous parameters. An improvement of the stochastic solution over the deterministic Expected Value (EV) solution is shown.

Background Certain vaccines, such as Bacille Calmette-Guérin (BCG), have nonspecific effects, which modulate innate immune responses and lead to protection against mortality from unrelated infections (trained immunity). In contrast, in spite of the disease-specific effects, an enhanced overall mortality has been described after diphtheria-tetanus-pertussis (DTP) vaccination in females. This randomized trial aimed to investigate the nonspecific immunological effects of BCG and DTP-containing vaccines on the immune response to unrelated pathogens. Methods We randomized 75 healthy, female, adult volunteers to receive either BCG, followed by a booster dose of tetanus-diphtheria-pertussis inactivated polio vaccine (Tdap) 3 months later; BCG and Tdap combined; or Tdap followed by BCG 3 months later. Blood was collected before vaccination, as well as at 1 day, 4 days, 2 weeks, and 3 months after the first vaccination(s), plus 2 weeks after the second vaccination. Ex vivo leukocyte responses to unrelated stimuli and pathogens were assessed. Results Tdap vaccination led to short-term potentiation and long-term repression of monocyte-derived cytokine responses, and short-term as well as long-term repression of T-cell reactivity to unrelated pathogens. BCG led to short-term and long-term potentiation of monocyte-derived cytokine responses. When given together with Tdap or after Tdap, BCG abrogated the immunosuppressive effects of Tdap vaccination. Conclusions Tdap induces immunotolerance to unrelated antigens, which is partially restored by concurrent or subsequent BCG vaccination. These data indicate that the modulation of heterologous immune responses is induced by vaccination with Tdap and BCG, and more studies are warranted to investigate whether this is involved in the nonspecific effects of vaccines on mortality. Clinical Trials Registration NCT02771782.

OBJECTIVES: Delivering health care is emotionally demanding. Emotional competencies that enable caregivers to identify and handle emotions may be important to deliver safe care, as it improves resilience and enables caregivers to make better decisions. A relevant emotional competence could be psychological detachment, which refers to the ability to psychologically detach from work and patients in off-duty hours. The objective of this study was to examine the relationship between psychological detachment and patient safety. In addition, the ability of teams to create a safe environment to discuss errors and take personal risks, i.e., psychological safety, was explored as an underlying condition for psychological detachment.METHODS: A total of 1219 caregivers (response rate = 44%) from 229 teams in two long-term care organizations completed a survey on psychological safety and psychological detachment at T0. Team managers rated patient safety of those teams at two points in time (T0 and T1).RESULTS: Two-level regression analysis showed that both psychological safety (β = 0.72, P < 0.01) and psychological detachment (β = 0.54, P < 0.05) relate directly to patient safety. Psychological safety relates positively to psychological detachment (β = 0.48, P < 0.01) but was, however, not an underlying condition.CONCLUSIONS: Perceived patient safety is enhanced by emotional competencies, at individual level by psychological detachment and at team level by psychological safety. Caregivers should be aware of the important influence emotional competencies have on patient safety and be trained to develop these competencies. Future research should focus on exploring underlying conditions for emotional competencies.

Background & Aims: Most patients with pedunculated T1 colorectal tumors referred for surgery are not found to have lymph node metastases, and were therefore unnecessarily placed at risk for surgery-associated complications. We aimed to identify histologic factors associated with need for surgery in patients with pedunculated T1 colorectal tumors. Methods: We performed a cohort-nested matched case–control study of 708 patients diagnosed with pedunculated T1 colorectal tumors at 13 hospitals in The Netherlands, from January 1, 2000 through December 31, 2014, followed for a median of 44 months (interquartile range, 20–80 months). We identified 37 patients (5.2%) who required surgery (due to lymph node, intramural, or distant metastases). These patients were matched with patients with pedunculated T1 colorectal tumors without a need for surgery (no metastases, controls, n = 111). Blinded pathologists analyzed specimens from each tumor, stained with H&E. We evaluated associations between histologic factors and patient need for surgery using univariable conditional logistic regression analysis. We used multivariable least absolute shrinkage and selection operator (LASSO; an online version of the LASSO model is available at: http://t1crc.com/calculator/) regression to develop models for identification of patients with tumors requiring surgery, and tested the accuracy of our model by projecting our case–control data toward the entire cohort (708 patients). We compared our model with previously developed strategies to identify high-risk tumors: conventional model 1 (based on poor differentiation, lymphovascular invasion, or Haggitt level 4) and conventional model 2 (based on poor differentiation, lymphovascular invasion, Haggitt level 4, or tumor budding). Results: We identified 5 histologic factors that differentiated cases from controls: lymphovascular invasion, Haggitt level 4 invasion, muscularis mucosae type B (incompletely or completely disrupted), poorly differentiated clusters and tumor budding, which identified patients who required surgery with an area under the curve (AUC) value of 0.83 (95% confidence interval, 0.76–0.90). When we used a clinically plausible predicted probability threshold of ≥4.0%, 67.5% (478 of 708) of patients were predicted to not need surgery. This threshold identified patients who required surgery with 83.8% sensitivity (95% confidence interval, 68.0%–93.8%) and 70.3% specificity (95% confidence interval, 60.9%–78.6%). Conventional models 1 and 2 identified patients who required surgery with lower AUC values (AUC, 0.67; 95% CI, 0.60–0.74; P =.002 and AUC, 0.64; 95% CI, 0.58–0.70; P