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A novel system was developed to deploy settlement panels to monitor biofouling growth in situ and evaluate antifouling coatings at depths representative of operational conditions of full-scale marine renewable energy devices. Biofouling loading, species diversity, and succession were assessed at depths ranging from 25-40 m at four tests sites in Orkney (UK) featuring extreme wave and tidal current exposure to more sheltered conditions. Evaluations were carried out over a period of 8 months with intermediate retrieval of samples after 3 months. Early pioneer fouling communities, comprised of colonial hydroids, were succeeded by tube-forming amphipods across sites while solitary tunicates dominated in greater shelter. The highest biofouling loading was observed on high-density polyethylene (HDPE) panels (6.17 kg m-2) compared with coated steel (3.34 kg m-2) panels after 8 months. Distinct assemblages were present at exposed vs sheltered sites. Better understanding of fouling and antifouling strategies may provide guidance to more effectively manage biofouling impacts in this sector.

SummaryBackgroundThe world is at the cusp of experiencing local/regional hot-spots and spikes of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19 disease. We aimed to formulate an applicable epidemiological model to accurately predict and forecast the impact of local resurgence and outbreaks to guide the local healthcare demand and capacity, policy making, and public health decisions.MethodsThe model utilised the aggregated daily COVID-19 situation reports (including counts of daily admissions, discharges, and occupancy) from the local NHS hospitals and Covid-19 related weekly deaths in hospitals and other settings in Sussex (population 1-7M), Southeast England. These datasets corresponded to the first wave of COVID-19 infections from 24 March-15 June 2020. The counts of death registrations and regional population estimates were obtained from the Office of National Statistics. A novel epidemiological predictive and forecasting model was then derived based on the local/regional surveillance data. Through a rigorous inverse parameter inference approach, the model parameters were estimated by fitting the model to the data in an optimal sense and then subsequently validated to make predictions subject to 95% confidence.FindingsThe inferred parameters were physically reasonable and matched up to the widely used parameter values derived from the national datasets. Unlike other predictive models, which are restricted to a couple of days, our model can predict local hospital admissions, discharges (including deaths) and occupancy for the next 10, 20, and 30 days at the local level.InterpretationWe have demonstrated that by using local/regional data, our predictive and forecasting model can be utilised to guide the local healthcare demand and capacity, policy making, and public health decisions to mitigate the impact of COVID-19 on the local population. Understanding how future COVID-19 spikes/waves could possibly affect the regional populations empowers us to ensure the timely commissioning and organisation of services. Primary care and community services can be guided by the projected number of infectious and recovered patients and hospital admissions/discharges to project discharge pathways to bedded and community settings, thus allowing services to understand their likely load in future spikes/waves. The flexibility of timings in the model, in combination with other early warning systems, produces a timeframe for these services to prepare and isolate capacity for likely and potential demand within regional hospitals. The model also allows local authorities to plan potential mortuary capacity and understand the burden on crematoria and burial services. The model algorithms have been integrated into a web-based multi-institutional toolkit, which can be used by NHS hospitals, local authorities, and public health departments in other regions of the UK and elsewhere. The parameters, which are locally informed, form the basis of predicting and forecasting exercises accounting for different scenarios and impact of COVID-19 transmission.FundingThis study was supported by the Higher Education Innovation Fund through the University of Sussex (ECF, JVY, AMa). This work was partly supported by the Global Challenges Research Fund through the Engineering and Physical Sciences Research Council grant number EP/T00410X/1: UK-Africa Postgraduate Advanced Study Institute in Mathematical Sciences (AMa, ECF). ECF is supported by the Wellcome Trust grant number 204833/Z/16/Z.Research in contextEvidence before this studySince the beginning of the COVID-19 pandemic, healthcare managers and policy makers relied on epidemiological models based on national datasets to predict and mitigate the spread of the disease. The performance of these models has not always been validated against the available data, and they depend strongly on the values for the model parameters. Statistical models, e.g. those arising from time-series analysis, lack the temporal dynamics of the compartmentalised epidemiological model for the evolution of the disease and thus fail to capture the evolution far into the future with great accuracy. Compartmental models, on the other hand, capture the underlying dynamics of an infectious disease but typically use parameters estimated using datasets from other regions or countries, thus lacking the ability to capture local demographics and policy and therefore lack predicting local dynamics with accuracy.Added value of this studyAlthough our compartmental model follows standard SEIR-D model structure, the inference algorithm described and applied in this report is novel, along with the prediction technique used to validate the model. We checked bioRxiv, medRxiv, and arXiv up to the end of August 2020 using the terms “mathematical inference”, “COVID-19”, and “SIR” and found that there is a substantial use of Bayesian approaches to fit parameters but none that use the combination of statistical approaches with compartmental models, hence the originality of our work. We designed a compartmentalised epidemiological model that captures the basic dynamics of the COVID-19 pandemic and revolves around the data that are available at the local/regional level. We estimated all the parameters in the model using the local surveillance data, and in consequence, our parameters reflect the characteristics of the local population. Furthermore, we validated the predictive power of the model by using only a subset of the available data to fit the parameters. To the best of our knowledge, this is the first study which combines statistical approaches with a compartmental model and as such benefits greatly from the ability to predict and forecast much further into the future using the dynamical structure of the compartmental model with a relatively much higher accuracy than previously presented in the literature. This research sets the gold-standard benchmark by laying the framework for future adaptations to the model when more precise (and comprehensive) datasets are made available.Implications of all the available evidenceThe predictive power of our model outperforms previously available models for local forecasting of the impact of COVID-19. Using local models, rather than trying to use national models at a local scale, ensures that the model reflects the local demographics and provides reliable local-data-driven predictions to guide the local healthcare demand and capacity, policy making, and public health decisions to mitigate the impact of COVID-19 on the local population. Local authorities can use these results for the planning of local hospital demand as well as death management services by developing scenario-based analysis to which different values of the reproduction number R exiting a COVID-19 lockdown are assumed and results, such as maximum hospital occupancy, are compared to the first wave to establish a potential strain on resources. This can work as an early warning detection system to see what value of R that is currently followed, which in turn informs the relevant capacity and resources needed to mitigate the impact of COVID-19. The Web toolkit developed by us as a result of this study (https://alpha.halogen-health.org) demonstrates the predictive power of our model as well as its flexibility with the scenario-based analysis. Although our model is based on the data from Sussex, using similar variables/data from other regions in our model would derive respective COVID-19 model parameters, and thus enable similar scenario-based investigations to predict and forecast the impact of local resurgence to guide the local healthcare demand and capacity, policy making, and public health decisions.

Modernizing data systems to inform collaborative management is critical to adaptively managing fisheries in an era of climate change. In 2006, The Nature Conservancy of California purchased 13 federal groundfish permits in California with the objective of managing the fishing and reporting activities in a manner that protected sensitive habitats and species. At that time, collecting data for this fishery was done with paper logbooks. This made queries and visualization that could inform management decisions towards our objective impossible in a timely manner. To solve this problem, we built successive software prototypes that leveraged location-aware mobile devices, cloud-based computing, and visualization and query of geographic data over the web. The resulting software, eCatch, enabled avoidance of sensitive species and habitats and quantitative reporting on performance metrics related to those activities. What started as a technology solution to a problem of timely scientific monitoring revealed collateral benefits of collaboration with the fishing industry and markets that support sustainable activities.

Abdominal aortic aneurysm (AAA) is a focal dilation of the aorta associated with high mortality through rupture. Most of our understanding of the biology that drives AAA progression originates from surgical samples acquired in cases of elective open repair. These markers, which include macrophage infiltration and angiogenesis, have led to the exploration of novel radiopharmaceuticals to study AAA in preclinical models and human patients. Current clinical practice to detect AAA involves ultrasound-based screening and surveillance. Although ultrasound is cheap and without radiation risk, aortic diameter does not predict the heterogenous growth of AAA between patients. Positron emission tomography takes advantage of novel radiolabeled markers of disease to track biological changes. In human trials, the role of 2-[ 18 F]-flurordeoxyglucose in detecting aneurysm growth and outcome is still debated, whereas sodium [ 18 F]-fluoride has been shown to predict AAA growth and clinical outcome through highlighting microcalcification. Murine studies have been used to assess the suitability of radiotracers detecting inflammation, angiogenesis, and proliferation. However, in the absence of human data, the clinical suitability and applicability of these tracers remain speculative. This review examines how markers of AAA change over time and the ability of positron emission tomography to track these changes and discusses the radiopharmaceuticals that could have an application in stratifying AAA subjects.

Abdominal aortic aneurysm (AAA) disease is characterized by an asymptomatic, permanent, focal dilatation of the abdominal aorta progressing towards rupture, which confers significant mortality. Patient management and surgical decisions rely on aortic diameter measurements via abdominal ultrasound surveillance. However, AAA rupture can occur at small diameters or may never occur at large diameters, implying that anatomical size is not necessarily a sufficient indicator. Molecular imaging may help identify high-risk patients through AAA evaluation independent of aneurysm size, and there is the question of the potential role of positron emission tomography (PET) and emerging role of novel radiotracers for AAA. Therefore, this review summarizes PET studies conducted in the last 10 years and discusses the usefulness of PET radiotracers for AAA risk stratification. The most frequently reported radiotracer was [18F]fluorodeoxyglucose, indicating inflammatory activity and reflecting the biomechanical properties of AAA. Emerging radiotracers include [18F]-labeled sodium fluoride, a calcification marker, [64Cu]DOTA-ECL1i, an indicator of chemokine receptor type 2 expression, and [18F]fluorothymidine, a marker of cell proliferation. For novel radiotracers, preliminary trials in patients are warranted before their widespread clinical implementation. AAA rupture risk is challenging to evaluate; therefore, clinicians may benefit from PET-based risk assessment to guide patient management and surgical decisions.

Background Local policy change initiating new consent procedures was introduced during 2017–2018 for the human papillomavirus (HPV) vaccination programme year in two local authorities in the south–west of England. This study aims to assess impact on uptake and inequalities. Methods Publicly available aggregate and individual-level routine data were retrieved for the programme years 2015–2016 to 2018–2019. Statistical analyses were undertaken to show: (i) change in uptake in intervention local authorities in comparison to matched local authorities and (ii) change in uptake overall, and by local authority, school type, ethnicity and deprivation. Results Aggregate data showed uptake in Local Authority One increased from 76.3% to 82.5% in the post-intervention period (risk difference: 6.2% P = 0.17), with a difference-in-differences effect of 11.5% (P = 0.03). There was no evidence for a difference-in-differences effect in Local Authority Two (P = 0.76). Individual-level data showed overall uptake increased post-intervention (risk difference: +1.1%, P = 0.05), and for young women attending school in Local Authority One (risk difference: 2.3%, P Conclusion Implementation of new consent procedures can improve and overcome trends for decreasing uptake among matched local authorities. However, no evidence for reduction in inequalities was found. Implications and discussion The new consent procedures increased uptake in one of the intervention sites and appeared to overcome trends for decreasing uptake in matched sites. There are issues in relation to the quality of data which require addressing.

Duchenne muscular dystrophy (DMD) is the result of X-chromosome-linked mutations to the dystrophin protein gene that prevent the normal development and repair of muscles leading to muscle deterioration. The condition affects nearly 1 in 3,500 males worldwide. Current therapeutics have not been sufficient in providing a cure or resulting in a significant extension in life expectancy, but many therapeutic options are currently under investigation.This article provides an overview of the current and emerging therapies for DMD giving particular focus to synthetic therapeutic options. The authors further provide their expert opinion.Many discrepancies in primary outcomes of trials have led to questions of efficacy for medications, as well as difficulty in securing FDA approval. A standardization of primary outcome strategies, as well as better access to investigational medications, may alleviate some of the controversy and pressures that exist on medication approvals. Many trials have identified cohorts who responded more favorably to medications, despite a lack of significance in the overall intent-to-treat populations. This indicates that more medication screening and personalized treatment with patient-specific targeting might deliver more clinically significant results.

Objective To assess demographic, clinical, and biomarker features distinguishing patients with multisystem inflammatory syndrome in children (MIS-C); compare MIS-C sub-phenotypes; identify cytokine biosignatures; and characterize viral genome sequences. Study design We performed a prospective observational cohort study of 124 children hospitalized and treated under the institutional MIS-C Task Force protocol from March to September 2020 at Children's National, a quaternary freestanding children's hospital in Washington, DC. Of this cohort, 63 of the patients had the diagnosis of MIS-C (39 confirmed, 24 probable) and 61 were from the same cohort of admitted patients who subsequently had an alternative diagnosis (controls). Results Median age and sex were similar between MIS-C and controls. Black (46%) and Latino (35%) children were over-represented in the MIS-C cohort, with Black children at greatest risk (OR 4.62, 95% CI 1.151-14.10; P = .007). Cardiac complications were more frequent in critically ill patients with MIS-C (55% vs 28%; P = .04) including systolic myocardial dysfunction (39% vs 3%; P = .001) and valvular regurgitation (33% vs 7%; P = .01). Median cycle threshold was 31.8 (27.95-35.1 IQR) in MIS-C cases, significantly greater (indicating lower viral load) than in primary severe acute respiratory syndrome coronavirus 2 infection. Cytokines soluble interleukin 2 receptor, interleukin [IL]-10, and IL-6 were greater in patients with MIS-C compared with controls. Cytokine analysis revealed subphenotype differences between critically ill vs noncritically ill (IL-2, soluble interleukin 2 receptor, IL-10, IL-6); polymerase chain reaction positive vs negative (tumor necrosis factor-α, IL-10, IL-6); and presence vs absence of cardiac abnormalities (IL-17). Phylogenetic analysis of viral genome sequences revealed predominance of GH clade originating in Europe, with no differences comparing patients with MIS-C with patients with primary coronavirus disease 19. Treatment was well tolerated, and no children died. Conclusions This study establishes a well-characterized large cohort of MIS-C evaluated and treated following a standardized protocol and identifies key clinical, biomarker, cytokine, viral load, and sequencing features. Long-term follow-up will provide opportunity for future insights into MIS-C and its sequelae.

We describe a modelling project to estimate the potential effects of wave & tidal stream renewables on the marine environment. • Realistic generic devices to be used by those without access to the technical details available to developers are described. • Results show largely local sea bed effects at the level of the currently proposed renewables developments in our study area. • Large scale 3D modelling is critical to quantify the direct, indirect and cumulative effects of renewable energy extraction. • This is critical to comply with planning & environmental impact assessment regulations and achieve Good Environmental Status.

IMPORTANCE: PD-L1 (programmed cell death ligand 1) immunohistochemistry (IHC), tumor mutational burden (TMB), gene expression profiling (GEP), and multiplex immunohistochemistry/immunofluorescence (mIHC/IF) assays have been used to assess pretreatment tumor tissue to predict response to anti–PD-1/PD-L1 therapies. However, the relative diagnostic performance of these modalities has yet to be established. OBJECTIVE: To compare studies that assessed the diagnostic accuracy of PD-L1 IHC, TMB, GEP, and mIHC/IF in predicting response to anti–PD-1/PD-L1 therapy. EVIDENCE REVIEW: A search of PubMed (from inception to June 2018) and 2013 to 2018 annual meeting abstracts from the American Association for Cancer Research, American Society of Clinical Oncology, European Society for Medical Oncology, and Society for Immunotherapy of Cancer was conducted to identify studies that examined the use of PD-L1 IHC, TMB, GEP, and mIHC/IF assays to determine objective response to anti–PD-1/PD-L1 therapy. For PD-L1 IHC, only clinical trials that resulted in US Food and Drug Administration approval of indications for anti–PD-1/PD-L1 were included. Studies combining more than 1 modality were also included. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed. Two reviewers independently extracted the clinical outcomes and test results for each individual study. MAIN OUTCOMES AND MEASURES: Summary receiver operating characteristic (sROC) curves; their associated area under the curve (AUC); and pooled sensitivity, specificity, positive and negative predictive values (PPV, NPV), and positive and negative likelihood ratios (LR+ and LR−) for each assay modality. RESULTS: Tumor specimens representing over 10 different solid tumor types in 8135 patients were assayed, and the results were correlated with anti–PD-1/PD-L1 response. When each modality was evaluated with sROC curves, mIHC/IF had a significantly higher AUC (0.79) compared with PD-L1 IHC (AUC, 0.65, P

The 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa underscores the need for health care infection prevention and control (IPC) practices to be implemented properly and consistently to interrupt transmission of pathogens in health care settings to patients and health care workers. Training and assessing IPC practices in general health care facilities not designated as Ebola treatment units or centers became a priority for CDC as the number of Ebola virus transmissions among health care workers in West Africa began to affect the West African health care system and increasingly more persons became infected. CDC and partners developed policies, procedures, and training materials tailored to the affected countries. Safety training courses were also provided to U.S. health care workers intending to work with Ebola patients in West Africa. As the Ebola epidemic continued in West Africa, the possibility that patients with Ebola could be identified and treated in the United States became more realistic. In response, CDC, other federal components (e.g., Office of the Assistant Secretary for Preparedness and Response) and public health partners focused on health care worker training and preparedness for U.S. health care facilities. CDC used the input from these partners to develop guidelines on IPC for hospitalized patients with known or suspected Ebola, which was updated based on feedback from partners who provided care for Ebola patients in the United States. Strengthening and sustaining IPC helps health care systems be better prepared to prevent and respond to current and future infectious disease threats.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

We present a differential optical absorption spectroscopy (DOAS) instrument, called "miniDOAS", optimised for optical open-path field-measurements of ambient ammonia (NH3) alongside nitrogen oxide (NO) and sulfur dioxide (SO2). The instrument is a further development of the miniDOAS presented by Volten et al. (2012). We use a temperature-controlled spectrometer, a deuterium light source and a modified optical arrangement. The system was set up in a robust, field-deployable, temperature-regulated housing. For the evaluation of light spectra we use a new high-pass filter routine based upon robust baseline extraction with local regression. Multiple linear regression including terms of an autoregressive–moving-average model is used to determine concentrations. For NH3 the random uncertainty is about 1.4 % of the concentration, and not better than 0.2 µg m−3. Potential biases for the slope of the calibration are given by the precision of the differential absorption cross sections (±3 %) and for the offset by the precision of the estimation of concentration offsets (cref) introduced by the reference spectrum Iref. Comparisons of miniDOAS measurements to those by NH3 acid trap devices showed good agreement. The miniDOAS can be flexibly used for a wide range of field trials, such as micrometeorological NH3 flux measurements with approaches based upon horizontal or vertical concentration differences. Results from such applications covering concentration dynamics of less than one up to several hundreds of µg m−3 are presented.

Bolted connections used for connecting hollow structural steel (HSS) members are often made using bolts which have access to the HSS member from only one face. Hence, no nuts can be used in these connections. Such connections are often called as one-sided connection. Flow drilling and flow tapping techniques has the potential to make such one-sided bolted connections with relative ease. This paper presents outcomes of a study completed to determine the structural behavior of flow drilled connections made on HSS sections. The connections considered in this study were tested in tension and shear. A total of 150 tests of which 75 in tension and 75 in shear were completed. The effect of four different parameters namely HSS section geometry, screw hole drilling technique, tapping technique, and number of screw threads per unit length were considered. In all the connections considered in this study the diameter of the screw hole was kept unchanged at 19.05 mm (0.75 in). This study showed that the tension capacity of the one-sided connections can be increased to 95% by using flow drilled connections as it offers more number of threads for screw engagement. This study also showed that the flow drilling does not have significant influence on the shear behavior of the connections. Potential failure modes were identified. Analytical equations were developed to aid in the design of these connections.

This paper considers a number of long fictions from the modernist period to see how far their length serves specifically modernist concerns, especially temporality and history. Various extended narratives suit modernist aesthetic mythopoeia for which Nietzsche's essay on The Advantages and Disadvantages of History for Life provides a philosophical articulation. Joyce's Ulysses, Proust's A la recherche, and Mann's Joseph and his Brothers (along with Lawrence's The Rainbow and Women in Love) are the principal works compared and contrasted. But there are authors who stand apart from these encompassing, if not to say masterful, mythopoeic visions. Musil's unfinished Man without Qualities resists the modes of resolution which in several of the former instances have a strongly masculinist inflection. So too, to a significant extent, does Lawrence with his strongly feminine sensibility. Above all, Virginia Woolf and Dorothy Richardson, while engaging with similar concerns, constitute a critical outside to the mythopoeic grouping.

Purpose– A critical function of leadership formation is the leader’s deepening sensitivity, reflexivity, and self-reflection on one’s own, and others, practice. A particular tool that has potential to support such endeavour is the eportfolio (EP) (currently referred to as a personal learning space). The paper aims to discuss these issues.Design/methodology/approach– The paper presents a personal report from a collaborative self-study which focused on the usefulness and potential of EPs as a tool for leadership formation that might: first, support learning enquiries, second, enable contemplative thinking and reflection, and third, coordinate personal representations of “who” we are.Findings– Having engaged as academics in a collaborative quest to embrace the technology of EPs in the everyday professional lives, while also critiquing the influence and power of the tool, the authors present a personal position for the use of EPs in leadership programmes as well as some critical dimensions that appear to awaken and enable self-reflective practices.Originality/value– As a tool which can enable leadership formation, EPs can evoke individual and collective voice within a generative and shared space.

Acknowledgements This work received funding from the MASTS pooling initiative (The Marine Alliance for Science and Technology for Scotland) and their support is gratefully acknowledged. MASTS is funded by the Scottish Funding Council (Grant reference HR09011) and contributing institutions.

The Irish Sea represents a valuable resource to numerous industries, communities, and other stakeholders particularly in the areas of shellfisheries and aquaculture, energy development and ecosystem services. Climate change poses a substantial threat to marine environments in the region, with impacts exacerbated by struggles for ever limited space and resources, a pronounced need for conservation of important and vulnerable marine ecosystems, and lack of unified management. A concerted effort is required to: i) determine the impacts of climate change and potential risks to marine industry; ii) advise marine industries of future opportunities and areas of collaboration; and iii) develop coordinated marine management across the region to ensure the resource is exploited in an economically and environmentally sustainable manner. We propose that an Irish Sea Marine Research Forum be created that promotes a multi-disciplinary holistic research approach linking industry and research to identify and mitigate the socioeconomic and environmental impacts of climate change. Additionally, we propose that an integrated jurisdiction for the Irish Sea be formed to serve as a regulatory body on fisheries and marine policy for the entire region. Management and policy directives should consider both potential for economic development as well as protection of key environmental features and ecosystem services. Such concentrated efforts on the Irish Sea could then be used as a management model for other regional seas and resources.

Professionalism is one of the fundamental expectations and a core competency in residency education. Although programs use a variety of evaluative methods, little is known about residents' views of and preferences regarding various methods of assessment.The authors surveyed residents at seven psychiatry residency programs in the United States regarding their attitudes on professionalism, ethics preparation, and evaluation in psychiatry residency training. This report describes their views on methods of assessing professionalism.Residents strongly agreed that clinical supervision is an appropriate assessment method. Moreover, they rated clinical supervision more highly than oral examinations, short-answer questions, essays, and standardized patient interactions. Residents also strongly favored direct faculty observation of residents' interactions with actual patients and clinical team members.This study suggests that both direct faculty supervision and other clinically-based assessments are methods accepted by psychiatry residents. Future research on the validity and effectiveness of these modes of assessment is needed.

Those concentration camp officers who are said to have appreciated Mozart and Beethoven are often invoked as a knock-down argument against claims for the humanising function of high culture: claims which, in their modern form, stem from the European Enlightenment as, for example, in Friedrich Schiller. But what should be at stake here is not so much knowledge of high culture as the manner in which it is possessed. The contrasting conceptions of culture associated with Goethe and Lawrence, whi...

Women who become pregnant after recovery pose little risk for transmitting the virus to the baby or others., Many of the survivors of the 2014–2015 epidemic of Ebola virus disease (EVD) in West Africa were women of childbearing age. Limited clinical and laboratory data exist that describe these women’s pregnancies and outcomes. We report the case of an EVD survivor who became pregnant and delivered her child in the United States, and we discuss implications of this case for infection control practices in obstetric services. Hospitals in the United States must be prepared to care for EVD survivors.

Zika virus transmission was detected in the Region of the Americas (Americas) in Brazil in May 2015, and as of March 21, 2016, local mosquito-borne transmission of Zika virus had been reported in 32 countries and territories in the Americas, including Puerto Rico and the U.S. Virgin Islands.* Most persons infected with Zika virus have a mild illness or are asymptomatic. However, increasing evidence supports a link between Zika virus infection during pregnancy and adverse pregnancy and birth outcomes (1), and a possible association between recent Zika virus infection and Guillain-Barre syndrome has been reported (2). Although Zika virus is primarily transmitted through the bite of Aedes species of mosquitoes, sexual transmission also has been documented (3). Zika virus RNA has been detected in a number of body fluids, including blood, urine, saliva, and amniotic fluid (3-5), and whereas transmission associated with occupational exposure to these body fluids is theoretically possible, it has not been documented. Although there are no reports of transmission of Zika virus from infected patients to health care personnel or other patients, minimizing exposures to body fluids is important to reduce the possibility of such transmission. CDC recommends Standard Precautions in all health care settings to protect both health care personnel and patients from infection with Zika virus as well as from blood-borne pathogens (e.g., human immunodeficiency virus [HIV] and hepatitis C virus [HCV]) (6). Because of the potential for exposure to large volumes of body fluids during the labor and delivery process and the sometimes unpredictable and fast-paced nature of obstetrical care, the use of Standard Precautions in these settings is essential to prevent possible transmission of Zika virus from patients to health care personnel.

Lesotho’s population is concentrated in rural areas. Understanding the complexities of providing education to these areas is of paramount importance. Among the issues facing authorities charged with this task is preparing teachers to work in rural contexts. This chapter draws on the findings of a study of secondary teachers and their experiences of working in rural Lesotho. Findings indicate that inadequacies in teacher preparation programs may be undermining these teachers’ success and sustainability.

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. The guidelines contain detailed recommendations for the diagnosis of pulmonary hypertension. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the non-invasive diagnosis of pulmonary hypertension. This manuscript describes in detail the results and recommendations of the working group which were last updated in October 2011.

Background Left ventricular hypertrophy (LVH), a marker of cardiac end-organ damage, is frequently found in patients with arterial hypertension and is associated with cardiovascular and cerebrovascular morbidity and mortality. Therefore, LVH regression is an important treatment goal. For amlodipine plus valsartan (A/V) no specific study on LVH has been reported to date. Methods Prospective, open-label, randomized parallel-group study. Patients with essential hypertension and LVH were randomized to 52-week treatment with A/V 10/160 mg (n = 43) or the active comparator losartan/HCT 100/25 mg (L/H, n = 47). Add-on medication was allowed in case of inadequate blood pressure control. LV parameters were measured by cardiovascular magnetic resonance imaging (MRI), and adjudicated in a blinded manner. Study identifiers were NCT00446563 and EudraCT 2006-001977-17. Results In addition to the study treatment, 35% of patients in the A/V group and 49% in the L/H group received additional antihypertensive medication. Compared to baseline, both treatments reduced measures of LVH significantly after 52 weeks (e.g. LV mass index in the A/V group from 64.7 g/m2 by −3.5 g/m2, in the L/H group from 69.1 g/m2 by −4.4 g/m2, p

The modernist turn to myth is well known but little understood. Yeats, Joyce, Lawrence, and Thomas Mann reinvented in practice a model of mythopoeia mooted theoretically by both Friedrich Schlegel and Friedrich von Schelling in 1800. The modernists did not typically articulate their mythopoeia philosophically, although Nietzsche had done this for them and provided a link with German thought on myth and aesthetics. The aesthetic becomes the modern equivalent of myth: literature assumes the function of myth. But the self-conscious aesthetic bracketing in modernist mythopoeia was not widely understood. And so there is a tradition running through the reception of T. S. Eliot and the theory of Northrop Frye which assimilated literature to myth, presenting literature as the secular articulation of an offstage religious world-view. Although 'myth criticism' of that kind has now largely faded from the Anglophone academy, another version has appeared in common understandings of 'magical realism'. Myth is a 'repressed' which will always return if its essentially literary status is not recognized.

Purpose The purpose of this study was to evaluate the success of dental implants placed immediately into extraction sites in the presence of chronic periapical pathology. Materials and Methods The charts of 655 patients who had implants immediately placed into fresh extraction sites were reviewed for the presence or absence of periapical radiolucencies. A total of 922 implants were included. Of the 922 implants, 285 were immediately placed into sockets that had chronic periapical infections. The remaining 637 implants, without signs of periapical pathology, were used as the control group. Success of the implants was defined as successful osseointegration, successful restoration, and absence of evidence of bone loss or peri-implantitis. Other variables such as age, gender, smoking, diabetes, bisphosphonate use, lucencies of adjacent teeth, and implant stability at the time of placement were also evaluated. Results Of the 922 implants, 285 were placed into sockets with periapical radiolucencies. The success rate of implants placed in the study group was 97.5%, whereas the success rate of the control group was 98.7%. The difference was not found to be statistically significant. The mean follow-up was 19.75 months, with a maximum of 93 months and a minimum of 3 months. A statistically higher failure rate was found for implants placed adjacent to retained teeth with periapical pathology. Conclusions The placement of implants in sockets affected by chronic periapical pathology can be considered a safe and viable treatment option. There is a risk of implant failure when placing implants adjacent to teeth with periapical radiolucencies.

Many countries now recognise the need for mitigation of climate change induced by human activities and have incorporated renewable energy resources within their energy policy. There are extensive resources of renewable energy within the marine environment and increasing interest in extracting energy from locations with either large tidal range, rapid flow with and without wave interaction, or large wave resources. However, the ecological implications of altering the hydrodynamics of the marine environment are poorly understood. Ecological data for areas targeted for marine renewable developments are often limited, not least because of the considerable challenges to sampling in high energy environments. In order to predict the scale and nature of ecological implications there is a need for greater understanding of the distribution and extent of the renewable energy resource and in turn, of how marine renewable energy installations (MREIs) may alter energy in the environment. Regional ecological implications of a MREI need to be considered against the greater and global ecological threat of climate change. Finally, it is recommended that the identification of species and biotopes susceptible to the removal of hydrokinetic energy could be a suitable strategy for understanding how a MREI may alter flow conditions.

How strange that despite the thousands of times I must have read or written the name “Lawrence” I had never till now noticed that it contains, and indeed commences, with the capitalised word Law. The presence of law, at once asserted and unnoticed, has an ironically iconic value within a name which is itself iconic of a view of life, and of literature. For Lawrence, along with Blake and Nietzsche, is above all one of the great antinomians. But the invoking of all these names immediately sugge...

Background. Patients hospitalized in resource-poor health care settings are at increased risk for hospital-acquired respiratory infections due to inadequate infrastructure. Methods. From 1 April 2007 through 31 March 2008, we used a low-cost surveillance strategy to identify new onset of respiratory symptoms in patients hospitalized for >72 h and in health care workers in medicine and pediatric wards at 3 public tertiary care hospitals in Bangladesh. Results. During 46,273 patient-days of observation, we recorded 136 episodes of hospital-acquired respiratory disease, representing 1.7% of all patient hospital admissions; rates by ward ranged from 0.8 to 15.8 cases per 1000 patient-days at risk. We identified 22 clusters of respiratory disease, 3 of which included both patients and health care workers. Of 226 of heath care workers who worked on our surveillance wards, 61 (27%) experienced a respiratory illness during the study period. The cost of surveillance was US$43 per month per ward plus 30 min per day in data collection. Conclusions. Patients on these study wards frequently experienced hospital-acquired respiratory infections, including 1 in every 20 patients hospitalized for >72 h on 1 ward. The surveillance method was useful in calculating rates of hospital-acquired respiratory illness and could be used to enhance capacity to quickly detect outbreaks of respiratory disease in health care facilities where systems for outbreak detection are currently limited and to test interventions to reduce transmission of respiratory pathogens in resource-poor settings.

The Wide-Awake Approach to Dupuytren's contracture involves fasciectomy under local anesthetic with epinephrine and no tourniquet. The goal of this study is to show that the Wide-Awake Approach produces equivalent outcomes to fasciectomy under general anesthetic with a tourniquet, with fewer risks to the patient. A multicenter retrospective review was conducted on 111 patients with fasciectomies under local or general anesthetic between 2001 and 2007. Data on patient demographics, comorbidities, cost, as well as range of motion was collected and evaluated using Microsoft Excel and SAS. Of 148 fingers, 102 were treated under local and 46 under general anesthetic. The average postoperative Total Active Motion (TAM) for general anesthetic patients was 199.0 ± 29.6 (D5), 223.9 ± 29.3 (D4), 234.6 ± 14.6 (D3), and 246.7 ± 14.4 (D2). The average postoperative TAM for local anesthetic patients was 168.3 ± 62.2 (D5), 195.9 ± 67.5 (D4), 173.0 ± 72.6 (D3), and 177.5 ± 31.8 (D2). There were no significant differences between any of these individual groups (p = 0.09, 0.26, 0.12, and 0.20, respectively); however, when pooled, the overall TAM was significantly greater in the general anesthesia group (222.0 ± 29.7 vs. 186.0 ± 63.0, p = 0.002.). Complication rates and types were similar with both techniques. The Wide-Awake Approach to Dupuytren’s contracture avoids general anesthetic risks and has cost benefits to healthcare providers. Although it yields similar range of motion outcomes to fasciectomy performed under general anesthesia, total active motion may be better with fasciectomy done under general anesthesia.

Smoking during pregnancy has been shown to result in an increased risk of low birth weight. However, the mechanisms underlying this association are poorly understood. The insulin-like growth factor (IGF) system plays a critical role in the regulation of feto-placental growth and development, and abnormal processing of proIGF-II may alter its biological function. Our goal was to investigate the effects of exposure to nicotine on maternal, fetal, and neonatal IGF-II processing. Nulliparous female Wistar rats were randomly assigned to receive saline (vehicle) or nicotine bitartrate (1 mg x kg(-1) x d(- 1)). After mating, dams were euthanized at embryonic days 15, 18, and 21, and fetal body weight was recorded. Serum (fetal and maternal) was collected for determination of the IGF-II profile by Western blot analysis. Nicotine exposure prevented the decrease in maternal IGF-II processing seen in controls with advancing gestation. However, there was no influence of nicotine on fetal levels of IGF-II. Postnatally (postnatal day [PND] 21), pups exposed to nicotine in utero had decreased levels of big IGF-II. Our results show, for the first time, that nicotine exposure prevents the decrease of IGF-II processing in the maternal compartment. This may represent a compensatory mechanism allowing the mother to counteract the negative influence of nicotine on fetal growth and development. Our postnatal findings of suppressed IGF-II may help explain some of the long-term health complications seen in individuals exposed to smoking in utero.

Background Between August 1 and October 30, 1998 (outbreak period), an increased incidence of central venous catheter (CVC)-associated gram-negative bacterial bloodstream infection (GN-BSI) was detected in hematopoietic stem cell transplantation (HSCT) candidates and recipients in an outpatient HSCT unit. The objectives of the present study were to determine strategies for controlling the outbreak and identify risk factors for GN-BSI. Methods Two case-control studies, an assessment of infection control practices, microbiologic studies, and water quality analysis were conducted. A case was defined as any outpatient with a CVC and a primary GN-BSI during the outbreak period. Results All of the 31 case patients identified had needleless intravenous (IV) access devices. Independent risk factors for CVC-associated GN-BSI were self-administered IV infusion (odds ratio [OR] = 6.2; P = .02), lower frequency of needleless device changes (OR = 15.2; P = .03), and more frequent baths (OR = 1.4; P = .05). Interventions included increased frequency of needleless device change, recommending showers rather than baths, and use of CVC protection during showering/bathing. After these interventions, the CVC-associated GN-BSI rate declined to below the preoutbreak period rate (2.1/1000 vs 0.3/1000 CVC-days; P Conclusions This study demonstrated an increased risk of CVC-associated GN-BSIs related to self-IV infusion, bathing habits, and frequency of needleless device change. Infection control practices associated with the use of needleless devices may expose susceptible patients to increased risk for BSI.

Background In Bangladesh, 4 outbreaks of Nipah virus infection were identified during the period 2001-2004. Methods We characterized the clinical features of Nipah virus-infected individuals affected by these outbreaks. We classified patients as having confirmed cases of Nipah virus infection if they had antibodies reactive with Nipah virus antigen. Patients were considered to have probable cases of Nipah virus infection if they had symptoms consistent with Nipah virus infection during the same time and in the same community as patients with confirmed cases. Results We identified 92 patients with Nipah virus infection, 67 (73%) of whom died. Although all age groups were affected, 2 outbreaks principally affected young persons (median age, 12 years); 62% of the affected persons were male. Fever, altered mental status, headache, cough, respiratory difficulty, vomiting, and convulsions were the most common signs and symptoms; clinical and radiographic features of acute respiratory distress syndrome of Nipah illness were identified during the fourth outbreak. Among those who died, death occurred a median of 6 days (range, 2-36 days) after the onset of illness. Patients who died were more likely than survivors to have a temperature >37.8 degrees C, altered mental status, difficulty breathing, and abnormal plantar reflexes. Among patients with Nipah virus infection who had well-defined exposure to another patient infected with Nipah virus, the median incubation period was 9 days (range, 6-11 days). Conclusions Nipah virus infection produced rapidly progressive severe illness affecting the central nervous and respiratory systems. Clinical characteristics of Nipah virus infection in Bangladesh, including a severe respiratory component, appear distinct from clinical characteristics reported during earlier outbreaks in other countries.

A case of asystole (> 5 s) during electroconvulsive therapy (ECT) is reported in a patient who was subsequently diagnosed to have Brugada syndrome (BS). This hereditary sodium-channelopathy is characterized by typical, though intermittent, ECG abnormalities and carries a high risk of ventricular arrythmia and sudden cardiac death. The general occurence of BS is rare; however, it is more prevalent in men and in southeast Asian populations. As in the reported case, BS carriers may lack a telltale medical history and can present with normal ECG recordings. In these cases, BS can only be unmasked by repeated ECG recordings over time or by specialist cardiological examinations. To our knowledge, BS, which was first characterized in 1992, has not yet been in the focus of cardiac complications during ECT. However, as the presented case illustrates, this syndrome should be considered as a rare but potentially severe cardiac risk factor in the context of ECT.

Patients in Goalando were likely infected by direct contact with fruit bats or their secretions, rather than through contact with an intermediate host., Nipah virus (NiV) is a paramyxovirus that causes severe encephalitis in humans. During January 2004, twelve patients with NiV encephalitis (NiVE) were identified in west-central Bangladesh. A case–control study was conducted to identify factors associated with NiV infection. NiVE patients from the outbreak were enrolled in a matched case-control study. Exact odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by using a matched analysis. Climbing trees (83% of cases vs. 51% of controls, OR 8.2, 95% CI 1.25–∞) and contact with another NiVE patient (67% of cases vs. 9% of controls, OR 21.4, 95% CI 2.78–966.1) were associated with infection. We did not identify an increased risk for NiV infection among persons who had contact with a potential intermediate host. Although we cannot rule out person-to-person transmission, case-patients were likely infected from contact with fruit bats or their secretions.

Between the months of April and June 2004, an Ebola hemorrhagic fever (EHF) outbreak was reported in Yambio county, southern Sudan. Blood samples were collected from a total of 36 patients with suspected EHF and were tested by enzyme-linked immunosorbent assay (ELISA) for immunoglobulin G and M antibodies, antigen ELISA, and reverse-transcription polymerase chain reaction (PCR) of a segment of the Ebolavirus (EBOV) polymerase gene. A total of 13 patients were confirmed to be infected with EBOV. In addition, 4 fatal cases were classified as probable cases, because no samples were collected. Another 12 patients were confirmed to have acute measles infection during the same period that EBOV was circulating. Genetic analysis of PCR-positive samples indicated that the virus was similar to but distinct from Sudan EBOV Maleo 1979. In response, case management, social mobilization, and follow-up of contacts were set up as means of surveillance. The outbreak was declared to be over on 7 August 2004.

Epidemics of meningococcal meningitis in Africa have plagued the continent for over a century. These epidemics have a strong association with the environment and efforts are being made to develop models to predict both their location and their incidence. This review describes the predictive models based on climate/environmental information currently available, describes work in progress, and presents evidence that the distribution of the epidemics is changing in a pattern that is compatible with changes in the environment. Discussion of priorities for research in the context of the new conjugate vaccines in Africa is also provided.

Hantavirus pulmonary syndrome (HPS) is caused by an infection with viruses of the genus Hantavirus in the western hemisphere. Rodent hosts of hantaviruses are present throughout the United States. In July 2004, two HPS case-patients were identified in Randolph County, WV: a wildlife science graduate student working locally and a Randolph County resident. We interviewed family members and colleagues, reviewed medical records, and conducted environmental studies at likely exposure sites. Small mammals were trapped, and blood, urine, and tissue samples were submitted to the Centers for Disease Control and Prevention for laboratory analyses. These analyses confirmed that both patients were infected with Monongahela virus, a Sin Nombre hantavirus variant hosted by the Cloudland deer mouse, Peromyscus maniculatus nubiterrae. Other than one retrospectively diagnosed case in 1981, these are the first HPS cases reported in West Virginia. These cases emphasize the need to educate the public throughout the United States regarding risks and prevention measures for hantavirus infection.

The narrator of Borges's tale "Funes the Memorious" quotes in the opening paragraph a strange interpretation of Funes as a precursor to the Nietzschean Superman: "a vernacular and rustic Zarathustra." (1) Nothing could be further from the Superman, or from Zarathustra, than the paralytic Funes doomed to die young of congestion although the loose form in which Nietzschean ideas circulated in the early twentieth century makes it hard to judge the possibly intended significance behind such a reference. One possibility is that it is a piece of authorial coat-trailing through which Borges secretly both acknowledges and obfuscates the true source of the tale. For a quite different text, Nietzsche's early essay "On the Uses and Disadvantages of History for Life," makes use of a thought experiment which strikingly encompasses all the key elements of Borges's philosophical fantasy. Indeed, it is surely too close to the tale for comfort unless it is a Borgesian treble-bluff, a game in which the reader is to appreciate the directness of the steal: Imagine the extremest possible example of a man who did not possess the power of forgetting at all and who was thus condemned to see everywhere a state of becoming: such a man would no longer believe in his own being, would no longer believe in himself, would see everything flowing asunder in moving points and would lose himself in this stream of becoming: like a true pupil of Heraclitus, he would in the end hardly dare to raise a finger. Forgetting is essential to action of any kind, just as not only light but darkness too is essential for the life of everything organic. A man who wanted to feel historically through and through would be like one forcibly deprived of sleep, or an animal that had to live only by rumination and ever repeated rumination. Thus it is possible to live almost without memory, and to live happily moreover, as the animal demonstrates; but it is altogether impossible to live at all without forgetting. Or, to express my theme even more simply: there is a degree of sleeplessness, of rumination, of the historical sense, which is harmful and ultimately fatal to the living thing, whether this living thing be a man or a people or a culture. (Nietzsche's italics) (2) Borges's narrative redisposes the elements here: while Funes, for example, is ostensibly paralysed by his accident, the reader can readily see in this the symbol of his inner condition as spelt out by Nietzsche. The literally inconceivable weight of experiential specificity would be crushing, and it is difficult to see how Funes, with his incapacity for general ideas, could even speak. At a purely pragmatic level Funes's symbolically intrinsic paralysis has to appear with an apparent externality in order to allow the character to be mobilized within the narrative. The most crucial connection, however, lies in the linking of memory and insomnia. When in common parlance we defer a decision by saying that "we will sleep on it" the expression may be taken as merely a dead metaphor indicating a delay. But if psychic activity continues significantly during sleep, as may be obscurely evidenced by dreaming, then sleep may play a greater and more active part in the process of decision than the consciousness is able to recognize or control. In this connection it is noteworthy that Borges and his narrator build the story in stages which act as analytic layers spelling out the significance of his condition. Even before acquiring his extraordinary memory, he was locally famous as the "chronometrical" Funes, able to give the exact time at any moment. Already, he seems to lack a human sense of time, and in a way that is pregnantly suggestive for the function of the narrative in which he appears. For if one were to ask: "Can a clock tell the time?" the question would have two answers corresponding to the different meanings of "tell. …