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Moral agency describes one’s comprehensive moral attitude developed through continuous evaluations of social and contextual information. However, in fixed-narrative games like The Last of Us (TLOU), player moral agency is compromised by excessive violence, restraints in player control, and moral dilemmas. Researchers suggest that video game players use moral disengagement and rationalization strategies to reduce emotional and moral distress arising from virtual participation in morally reprehensible activity. However, the realism of TLOU characters, the ubiquity of its violence, and the inability of its players to make in-game moral decisions may prove these coping mechanisms ineffectual, while suggesting the possibility of heretofore unexplored alternatives. In the present study, nine interview subjects explicate, through the evolution of the player-character relationship, the versatility of moral agency in games. The findings suggest that players expanded their moral agency and regained moral control through mentalizing or mind-reading character perspectives, thus reducing players' emotional distress, and increasing empathy and prosocial beliefs. This process was facilitated by TLOU's character realism and the simulation of social practice within player-character interactivity.

Introduction and hypothesis Standardized measures enable the comparison of outcomes across providers and treatments giving valuable information for improving care quality and efficacy. The aim of this project was to define a minimum standard set of outcome measures and case-mix factors for evaluating the care of patients with overactive bladder (OAB). Methods The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group (WG) of leading clinicians and patients to engage in a structured method for developing a core outcome set. Consensus was determined by a modified Delphi process, and discussions were supported by both literature review and patient input. Results The standard set measures outcomes of care for adults seeking treatment for OAB, excluding residents of long-term care facilities. The WG focused on treatment outcomes identified as most important key outcome domains to patients: symptom burden and bother, physical functioning, emotional health, impact of symptoms and treatment on quality of life, and success of treatment. Demographic information and case-mix factors that may affect these outcomes were also included. Conclusions The standardized outcome set for evaluating clinical care is appropriate for use by all health providers caring for patients with OAB, regardless of specialty or geographic location, and provides key data for quality improvement activities and research. Electronic supplementary material The online version of this article (10.1007/s00192-017-3481-6) contains supplementary material, which is available to authorized users.

Background and Purpose: Despite significant investment in EHR’s, most stroke centers continue to populate stroke registries, such as Get with the Guidelines - Stroke using manual abstraction. This is necessary because of a lack of EHR integration and persistence of non-discrete required data elements. Methods: American Heart Association (AHA) identified the need to offer a more interoperable version of Get with the Guidelines - Stroke (GWTG-S) as a strategic priority for 2016. AHA engaged a consultant to work with two pilot hospital locations to optimize stroke data collection in the EHR and allowing for automated data population into GWTG-S. The pilot work included: 1) Analysis of current documentation and abstraction methods to support reporting of performance data; 2) Design and implementation of improvement opportunities for a) Discrete capture of data elements for electronic reporting b) Improving clinical documentation and ordering c) Clinical decision support and d) Data structures and transmission. 3) Proof-of-concept data extract report; 4) ROI analysis for improvement opportunities and 5) Proposed implementation strategies and timelines for improvement opportunities. Results: The pilot sites implemented Epic tools including Orders, Notes, Narrators and Flowsheets to increase the percentage of discrete elements available for uploading into GWTG-S and to populate hospital quality reporting systems Conclusion: The optimization process improved stroke team ability to:1) Decrease manual abstraction, and allow the stroke team to conduct more concurrent review and handle additional patients without additional staff; 2) Quantify data collection; abstraction; and analysis processes for the emergency department team; neurology; interventional team; and stroke unit; 3) Leverage EHR tools for the clinical team to improve utilization; and 4) Demonstrated the critical collaboration between clinical operations and the information technology team.

Introduction Australia has one of the highest rates of malignant mesothelioma in the world, a legacy of the widespread use of asbestos for several decades until the 1980s. Methods In 2011, the Commonwealth Government commissioned a registry to provide on-going information on the incidence, mortality, case characteristics and exposure history of persons diagnosed with mesothelioma in Australia. Notifications come from state and territory cancer registries. Information on occupational and non-occupational asbestos exposure involves a self-completed questionnaire and a structured telephone interview using OccIDEAS, a computer-based exposure assessment system, and overseen by a research team at Monash University. The latest public data is current to 31 December 2014. Results In 2014, there were 641 new notifications (607 deaths) of persons diagnosed with mesothelioma – 81% male, 85% aged 65 years or older (47% 75 years or older), 93% pleural, age standardised rate = 2.8/100,000. Using historical data, the peak incidence appears to have occurred around 2003 (3.2/100,000), although the number of cases appears to have peaked in the last few years. Detailed exposure information was available for 449 people diagnosed from 1 July 2010. Key findings included possible or probable asbestos exposure above background levels in the following circumstances – occupational only (11%), non-occupational only (35%), both (49%), neither (5%). Occupational exposure was most common in construction workers, electricians and boilermakers/welders. The most common sources of non-occupational exposure were servicing cars in a non-occupational setting, home renovation and living with someone with an asbestos-exposed job. Discussion and conclusion Results confirm the high frequency and rate of mesothelioma in Australia and identify common sources of occupational and non-occupational asbestos exposure. Methodological and practical challenges to the running of the Registry include delays in notification and delays in providing consent for contact for exposure assessment (but participation is high once contact is made).

Small public water supplies that use surface water as a source for drinking water are frequently faced with elevated levels of color and natural organic matter (NOM) that are precursors for chlorinated disinfection byproduct (DBP) formation. Nanofiltration (NF) systems can prevent DBP formation by removing color and NOM before chlorination. Research studies were conducted on Fall Lake water in Minnesota and dechlorinated potable water spiked with NOM in Ohio by using nanofiltration (Fyne process). Several types of tubular membranes with various molecular weight cutoffs were studied. The effectiveness of the Fyne process in producing safe drinking water was gauged by measuring the removal efficiency of total organic carbon, color, 2–3 micron particles, Bacillus subtilis as a surrogate for bacteria removal and MS2 bacteriophage as a surrogate for virus removal. Results of tests conducted under controlled laboratory conditions and field conditions indicated that Fyne process NF membranes could be used by sma...

Case reports remain an invaluable resource in the literature, and they continue to serve an equally important role in scientific advancement. They record discoveries, report the unexpected, and spark further research. Preparation of a case report can be a great learning experience, especially for medical students, residents, and young physicians. It serves as an excellent introduction to academic writing, familiarizing them with all aspects of publishing, from a structured case presentation and literature review to submitting and revising a manuscript. It can also stimulate an interest in a specific topic and gradually lead to more involved and complex academic endeavors.

A study was conducted to characterize bubble formation behavior of pressurized microporous hollow fiber membranes with water flow normal to the fiber axis. The influence of operating conditions such as water velocity (0.07 to 0.6 m/s), gas pressure (275 to 380 kPa), and gas fluxes (0.001 to 0.02 m/s) on bubble formation behavior was examined. Within these operating conditions, bubbles with a diameter smaller than a 100 μm were formed at the membrane surface. Coalescence occurred close to the membrane, which resulted in bubble diameters of 100 to 500 μm above the fiber. Bubble diameters increased with increasing gas flow rate and decreasing water velocity. These effects are expected as they both lead to increased local bubble density and rates of coalescence. Bubble formation behavior of the membrane was predicted well by an empirical equation determined for a single orifice by Ito and Hirata.

Small community systems that use surface water as a source of drinking water are frequently faced with elevated levels of naturally-occurring organic matter (NOM) that are not removed by conventional filtration methods. These residual levels of NOM may combine with chlorine used for disinfection and create disinfection byproducts (DBPs) potentially in excess of the regulatory limit for various DBPs. Frequently, additional treatment for removal of these DBPs is necessary to avoid noncompliance with the requirements of the Safe Drinking Water Act (SDWA). The formation of DBPs can be prevented by removing NOM, which acts as a precursor to DBP formation. This paper presents the results of field tests conducted on lake water using a nanofilter membrane, incorporating a method for cleaning the membrane using a foam ball. The system uses a tubular membrane with the ends connected to effectively form a single, long, membrane. The lake water is fed into the inside of the membrane tube and the filtrate is forced out, through the membrane into the membrane housing outlet. Using a timer, a foam ball is periodically passed through the inside of the membrane by reversing the flow direction. This foam ball serves to remove accumulated organic matter capable of fouling the membrane surface. This organic matter is flushed to drain as the foam ball passes through the inside of the tube. The system can be operated with the membrane reject water recycled to the system inlet or in a dead-end mode where no membrane reject water is produced until the system is foam ball cleaned. Tests were conducted in both modes of operation. The system requires no pretreatment of the feed water other than a coarse (3mm) screen to prevent large solids from entering the system. The effectiveness of the system in producing drinking water was gauged by measuring the turbidity, color, and particle counts of the system inlet and outlet. Tests were also performed using the aerobic spore Bacillus subtilis (B. subtilis) as a surrogate for bacteria removal. Notice: Any opinions expressed in this article are those of the author(s) and do not, necessarily, reflect the official positions and policies of the EPA. Any mention of products or trade names does not constitute recommendation for use by EPA. This document has been reviewed in accordance with EPA's peer and administrative review policies and approved for publication. 2096 World Environmental and Water Resources Congress 2009: Great Rivers © 2009 ASCE

We describe eight patients who had terminal lung cancer causing severe dyspnea unrelieved by oxygen, nonnarcotic drugs, or intermittent bolus narcotics. We treated these patients with continuous intravenous infusion of morphine, beginning with bolus IV injections of 1 or 2 mg of morphine every 5 to 10 minutes until the patient reported relief. A continuous morphine infusion was then started, with the hourly dose equal to 50% of the cumulative bolus dose. Vital signs, degree of sedation, and blood gases were serially followed. Six patients achieved good dyspnea relief, one had moderate relief, and one had a poor response. Variable changes were noted in the PaO2, whereas PaCO2 steadily increased in five of seven patients, and pH decreased in six. There was little change in systolic blood pressure or pulse, and only one individual had less than 10 respirations per minute. The major side effect of treatment was sedation, treated by temporarily discontinuing morphine until the patients' mental status improved and then restarting the infusion at a 50% lower hourly morphine dose. Mean time of study was 30 hours (range 16 to 87 hours). Seven of the eight study patients died during treatment. Whether morphine therapy shortened survival is uncertain. We conclude that continuous morphine infusion is effective therapy for severe dyspnea. The treatment is ethically justified. Relief of suffering is the primary goal of therapy, and less risky treatments are unavailable.

The distribution of fluorescein between the anterior chamber and the anterior vitreous was measured in two groups of patients after oral administration: group I, extracapsular cataract extraction (ECCE) patients with intact capsule and posterior chamber intraocular lens (PC IOL) (n = 12); group II, intracapsular cataract extraction (ICCE) patients with anterior chamber IOL (AC IOL) (n =13). The fluorescein concentrations were measured by fluorophotometry and the penetration ratios were calculated. The penetration of fluorescein into the anterior vitreous was significantly less in the ECCE group (group I, penetration ratio=2.03 ± 1.00 × 10 −3 min −1 group II, penetration ratio=5.99 ± 4.89, × 10 −3 min −1 P

purpose: To determine the efficacy of vitamin E in the treatment of chemotherapy-induced mucositis in patients with malignancy. patients and methods: A randomized, double-blind, placebo-controlled study was performed to evaluate the efficacy of topical vitamin E in the treatment of oral mucositis in patients receiving chemotherapy for various types of malignancy. A total of 18 patients, 17 of whom had solid tumors and one with acute leukemia, were included in this study. Lesions were observed daily prior to and 5 days after topical application of either vitamin E or placebo oil. results: Six of nine patients receiving vitamin E had complete resolution of their oral lesions. In eight of nine patients who received placebo, complete resolution of their oral lesions was not observed. This difference is statistically significant ( p = 0.025 by Fisher's exact test). No toxicity was observed in this study. conclusion: These results suggest that vitamin E may be an effective therapy in patients with chemotherapy-induced mucositis.

Study objective To determine the effect of concurrent chest radiation therapy on response rate, recurrence, and treatment toxicity among patients with limited stage small cell lung cancer who are receiving combination chemotherapy. Design Randomized trial with a median follow-up of 57 months. Setting A single government institution--the National Cancer Institute. Patients Consecutive sample of 96 patients with histologically confirmed small cell lung cancer that was confined to the hemithorax of origin or mediastinal and supraclavicular nodes, and which could be encompassed within a tolerable radiation portal ("limited stage"). All patients were followed until death or the end of the study period. Interventions Chemotherapy: Cyclophosphamide, methotrexate, and lomustine in 6-week cycles alternating with vincristine, adriamycin, and procarbazine in 6-week cycles, for a total of 48 weeks. Radiation therapy: Chest irradiation to 40 Gy in 15 fractions over 3 weeks, given simultaneously with the first chemotherapy cycle. Measurements and main results The combined therapy led to a significantly higher response rate (complete responses, 81%, compared with partial responses, 43%; 95% Cl for the difference, 20% to 56%), significantly improved local control of the chest tumor (p less than 0.001), and significantly longer survival (p less than 0.035) (median, 15.0 months, compared with 11.6 for chemotherapy alone). The combined therapy produced significantly more myelosuppression, weight loss, esophagitis, and pulmonary dysfunction. There were more infections and deaths from toxicity in the combined treatment group, but the differences between groups were not statistically significant. Conclusion A regimen of combined chemotherapy and chest radiation therapy given concurrently is superior to chemotherapy given alone in inducing remission and prolonging survival in patients with limited stage small cell lung cancer, and the benefit of combined therapy is reduced by its greater toxicity.