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Sustainability defined as development meeting needs of the present without compromising on the ability of future generations to meet their own needs, has become a wide area of study in Civil Engineering. It has particularly become important in the transportation sector as a result of non-renewable fuel depletion, energy insecurity, traffic congestion, air pollution, global climate change and so many other negative issues. Sustainable transportation aims to tackle all these issues while providing other advantages. Furthermore sustainability is steadily gaining more footholds in the construction industry and is now one of the main expected competencies in a Civil Engineer. This paper focuses on the economical implications of sustainable transport measures. Furthermore it focuses on user rating and acceptance of these measures and how that affects their economical repercussions. In this research, A questionnaire was come up with aim to monitor user acceptance and rating of sustainable transport measures in the city of Lahore. It was found that public transportation has a very high rating and user acceptance whereas car sharing has low user acceptance in Lahore region. The research uses the data on user acceptance and rating to evaluate the economical impacts of sustainable transport measures. From the user acceptance and rating, it can be concluded that congestion charging would have a positive economical impact if it was employed in the area. However it has to be reiterated that the survey only reflected the views and opinions of only a small percentage of the population. Sustainable transport measures have both positive and negative impacts, which are social, economical and environmental. However the positive impacts, as seen in this research outweighs the negative ones especially in terms of economical impacts. [ABSTRACT FROM AUTHOR]

Deficient or deteriorating reinforced-concrete columns in many existing structures have to be strengthened using economical, efficient, and fast methods. In the present study, different strengthening techniques to improve the load-carrying capacity of reinforced concrete (RC) columns have been compared. Five groups of fifteen square reinforced concrete columns (150 mm × 150 mm × 600 mm) and one group of three circular columns ( φ 170 mm) that have cross-sectional areas equivalent to those of the square columns were cast from normal-strength concrete. The test program was designed to examine the behavior of columns strengthened by carbon fiber-reinforced polymer (CFRP), steel jacketing, ferro cement, steel fibers, and silica fumes under cyclic axial compression. The efficiency of each strengthening method in increasing the column’s axial capacity, energy absorption, and ductility was studied using the experimental data. The test results showed that strengthening the columns could significantly enhance their load-carrying capacity and failure strains.

Background: About 25% of palliative medication incidents involve continuous subcutaneous infusions. Complex structural and human factor issues make these risk-prone interventions. Detailed analysis of how this safety-critical care can be improved has not been undertaken. Understanding context, contributory factors and events leading to incidents is essential., Aims: (1) Understand continuous subcutaneous infusion safety incidents and their impact on patients and families; (2) Identify targets for system improvements by learning from recurrent events and contributory factors., Design: Following systematic identification and stratification by degree of harm, a mixed methods analysis of palliative medication incidents involving continuous subcutaneous infusions comprising quantitative descriptive analysis using the P at I ent SA fety (PISA) classification system and qualitative narrative analysis of free-text reports., Setting/participants: Palliative medication incidents ( n  = 7506) reported to the National Reporting and Learning System, England and Wales (2016-2021)., Results: About 1317/7506 incidents involved continuous subcutaneous infusions with 943 (72%) detailing harms. Primary incidents (most proximal to patient outcomes) leading to inappropriate medication use (including not using medication when it was needed) were underpinned by breakdowns in three major medication processes: monitoring and supply (405, 31%), administration (383, 29%) and prescribing (268, 20%). Recurring contributory factors included discontinuity of care within and between settings, inadequate time, inadequate staffing and unfamiliarity with protocols. Psychological harms for patients and families were identified., Conclusions: System infrastructure is needed to enable timely supply of medication and equipment, effective coordinated use of continuous subcutaneous infusions, communication and continuity of care. Training is needed to improve incident descriptions so these pinpoint precise targets for safer care., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Central and North West London NHS Foundation Trust Starter Grant Scheme. ACS’s and SH’s contribution to the study was funded by PRIME Centre Wales. BB is supported by Wellcome Trust [225577/Z/22/Z]. Cardiff University is the sponsor of this study.

Background: COVID-19 spurred rapid adoption and expansion of telemedicine. We investigated the factors driving visit modality (telemedicine vs. in-person) for outpatient visits at a large cardiovascular center., Methods: We used electronic health record data from March 2020 to February 2021 from four cardiology subspecialties (general cardiology, electrophysiology, heart failure, and interventional cardiology) at a large academic health system in Northern California. There were 21,912 new and return visits with 69% delivered by telemedicine. We used hierarchical logistic regression and cross-validation methods to estimate the variation in visit modality explained by patient, clinician, and visit factors as measured by the mean area under the curve., Results: Across all subspecialties, the clinician seen was the strongest predictor of telemedicine usage, while primary visit diagnosis was the next most predictive. In general cardiology, the model based on clinician seen had a mean area under the curve of 0.83, the model based on the primary diagnosis had a mean area under the curve of 0.69, and the model based on all patient characteristics combined had a mean area under the curve of 0.56. There was significant variation in telemedicine use across clinicians within each subspecialty, even for visits with the same primary visit diagnosis., Conclusion: Individual clinician practice patterns had the largest influence on visit modality across subspecialties in a large cardiovascular medicine practice, while primary diagnosis was less predictive, and patient characteristics even less so. Cardiovascular clinics should reduce variability in visit modality selection through standardized processes that integrate clinical factors and patient preference., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: NK reports consulting fees from Ultromics and equity in Gordy Health outside the submitted work. FR reports consulting fees from Novartis, NovoNordisk, and HealthPals outside the submitted work. RD reports research funding from Bayer AG and consulting fees from HealthPals outside the submitted work. The remaining authors have nothing to disclose.

ANKRD11 (ankyrin repeat domain 11) is a chromatin regulator and the only gene associated with KBG syndrome, a rare neurodevelopmental disorder. We have previously shown that Ankrd11 regulates murine embryonic cortical neurogenesis. Here, we show a novel olfactory bulb phenotype in a KBG syndrome mouse model and two diagnosed patients. Conditional knockout of Ankrd11 in murine embryonic neural stem cells leads to aberrant postnatal olfactory bulb development and reduced size due to reduction of the olfactory bulb granule cell layer. We further show that the rostral migratory stream has incomplete migration of neuroblasts, reduced cell proliferation as well as aberrant differentiation of neurons. This leads to reduced neuroblasts and neurons in the olfactory bulb granule cell layer. In vitro, Ankrd11-deficient neural stem cells from the postnatal subventricular zone display reduced migration, proliferation, and neurogenesis. Finally, we describe two clinically and molecularly confirmed KBG syndrome patients with anosmia and olfactory bulb and groove hypo-dysgenesis/agenesis. Our report provides evidence that Ankrd11 is a novel regulator of olfactory bulb development and neuroblast migration. Moreover, our study highlights a novel clinical sign of KBG syndrome linked to ANKRD11 perturbations in mice and humans., (© 2024. The Author(s).)

Early in the COVID-19 pandemic, cardiology clinics rapidly implemented telemedicine to maintain access to care. Little is known about subsequent trends in telemedicine use and visit volumes across cardiology subspecialties. We conducted a retrospective cohort study including all patients with ambulatory visits at a multispecialty cardiovascular center in Northern California from March 2019 to February 2020 (pre-COVID) and March 2020 to February 2021 (COVID). Telemedicine use increased from 3.5% of visits (1200/33,976) during the pre-COVID period to 63.0% (21,251/33,706) during the COVID period. Visit volumes were below pre-COVID levels from March to May 2020 but exceeded pre-COVID levels after June 2020, including when local COVID-19 cases peaked. Telemedicine use was above 75% of visits in all cardiology subspecialties in April 2020 and stabilized at rates ranging from over 95% in electrophysiology to under 25% in heart transplant and vascular medicine. From June 2020 to February 2021, subspecialties delivering a greater percentage of visits through telemedicine experienced larger increases in new patient visits (r = 0.81, p  = 0.029). Telemedicine can be used to deliver a significant proportion of outpatient cardiovascular care though utilization varies across subspecialties. Higher rates of telemedicine adoption may increase access to care in cardiology clinics., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: FR reports consulting fees from Novartis, Janssen, NovoNordisk, and HealthPals outside the submitted work. RD reports research funding from Bayer AG and consulting fees from HealthPals outside the submitted work.

Background: COVID-19 disrupted healthcare routines and prompted rapid telemedicine implementation. We investigated the drivers of visit modality selection (telemedicine versus in-person) in primary care clinics at an academic medical centre., Methods: We used electronic medical record data from March 2020 to May 2022 from 13 primary care clinics ( N  = 21,031 new, N  = 207,292 return visits), with 55% overall telemedicine use. Hierarchical logistic regression and cross-validation methods were used to estimate the variation in visit modality explained by the patient, clinician and visit factors as measured by the mean-test area under the curve (AUC)., Results: There was significant variation in telemedicine use across clinicians (ranging from 0-100%) for the same visit diagnosis. The strongest predictors of telemedicine were the clinician seen for new visits (mean AUC of 0.79) and the primary visit diagnosis for return visits (0.77). Models based on all patient characteristics combined accounted for relatively little variation in modality selection, 0.54 for new and 0.58 for return visits, respectively. Amongst patient characteristics, males, patients over 65 years, Asians and patient's with non-English language preferences used less telemedicine; however, those using interpreter services used significantly more telemedicine., Conclusion: Clinician seen and primary visit diagnoses were the best predictors of visit modality. The distinction between new and return visits and the minimal impact of patient characteristics on visit modality highlights the complexity of clinical care and warrants research approaches that go beyond linear models to uncover the emergent causal effects of specific technology features mediated by tasks, people and organisations., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: The efficacy and safety of Folfirinox (FFX) or gemcitabine + nab-paclitaxel (GnP) to be used as the first-line drugs for pancreatic cancer (PC) is yet to be established. We conducted an analysis of retrospective studies to assess the efficacy and safety of these two regimens by comparing their survival and safety outcomes in patients with PC., Methods: We conducted an extensive review of two electronic databases from inception till February 2023 to include all the relevant studies that compared FFX with GnP published and unpublished work. Retrospective studies were only included. Overall survival (OS) and progression-free survival (PFS) were pooled using hazard ratios (HRs), while objective response rate (ORR) and safety outcomes were pooled using odds ratios (ORs) with 95% confidence interval (CI) using the random effects model., Results: A total of 7,030 patients were identified in a total of 21 articles that were shortlisted. Pooled results concluded that neither FFX nor GnP was associated to increase the OS time (HR: 0.93, 95% CI: 0.83 - 1.04; P = 0.0001); however, FFX was more likely associated with increased PFS when compared to GnP (HR: 0.88, 95% CI: 0.81 - 0.97; P < 0.0001). ORR proved to be non-significant between the two regimens (OR: 0.90, 95% CI: 0.64 - 1.27; P = 0.15). Safety outcomes included neutropenia, anemia, thrombocytopenia and diarrhea. GnP was more associated with diarrhea (OR: 1.96, 95% CI: 1.22 - 3.15; P = 0.001), while FFX was seen to cause anemia (OR: 0.70, 95% CI: 0.51 - 0.98; P = 0.10) in PC patients. Neutropenia and thrombocytopenia were in-significant in the two drug regimens (OR: 1.10, 95% CI: 0.92 - 1.31; P = 0.33 and OR: 0.83, 95% CI: 0.60 - 1.13; P = 0.23, respectively)., Conclusion: FFX and GnP showed a significant difference in increasing the PFS, while no difference was observed while measuring OS. Safety outcomes showed that FFX and GnP shared similar safety profiles as FFX was associated with hematological outcomes, while GnP was more associated with non-hematological outcomes., Competing Interests: The authors declare that they have no conflict of interest., (Copyright 2023, Merza et al.)

Background: The COVID-19 pandemic accelerated adoption of telemedicine in cardiology clinics. Early in the pandemic, there were sociodemographic disparities in telemedicine use. It is unknown if these disparities persisted and whether they were associated with changes in the population of patients accessing care., Methods: We examined all adult cardiology visits at an academic and an affiliated community practice in Northern California from March 2019 to February 2020 (pre-COVID) and March 2020 to February 2021 (COVID). We compared patient sociodemographic characteristics between these periods. We used logistic regression to assess the association of patient/visit characteristics with visit modality (in-person vs telemedicine and video- vs phone-based telemedicine) during the COVID period., Results: There were 54,948 pre-COVID and 58,940 COVID visits. Telemedicine use increased from <1% to 70.7% of visits (49.7% video, 21.0% phone) during the COVID period. Patient sociodemographic characteristics were similar during both periods. In adjusted analyses, visits for patients from some sociodemographic groups were less likely to be delivered by telemedicine, and when delivered by telemedicine, were less likely to be delivered by video versus phone. The observed disparities in the use of video-based telemedicine were greatest for patients aged ≥80 years (vs age <60, OR 0.24, 95% CI 0.21, 0.28), Black patients (vs non-Hispanic White, OR 0.64, 95% CI 0.56, 0.74), patients with limited English proficiency (vs English proficient, OR 0.52, 95% CI 0.46-0.59), and those on Medicaid (vs privately insured, OR 0.47, 95% CI 0.41-0.54)., Conclusions: During the first year of the pandemic, the sociodemographic characteristics of patients receiving cardiovascular care remained stable, but the modality of care diverged across groups. There were differences in the use of telemedicine vs in-person care and most notably in the use of video- vs phone-based telemedicine. Future studies should examine barriers and outcomes in digital healthcare access across diverse patient groups., Competing Interests: Disclosures NK reports stock options from Gordy Health outside the submitted work. FR reports consulting fees from Novartis, Janssen, NovoNordisk, and HealthPals outside the submitted work. RD reports research funding from Bayer AG and consulting fees from HealthPals outside the submitted work. The remaining authors have nothing to disclose., (Published by Elsevier Inc.)

Concern over climate change is growing in the healthcare space, and telemedicine has been rapidly expanding since the start of the COVID19 pandemic. Understanding the various sources of environmental emissions from clinic visits-both virtual and in-person-will help create a more sustainable healthcare system. This study uses a Life Cycle Assessment with retrospective clinical data from Stanford Health Care (SHC) in 2019-2021 to determine the environmental emissions associated with in-person and virtual clinic visits. SHC saw 13% increase in clinic visits, but due to the rise in telemedicine services, the Greenhouse Gas emissions (GHGs) from these visits decreased 36% between 2019 and 2021. Telemedicine (phone and video appointments) helped SHC avoid approximately 17,000 metric tons of GHGs in 2021. Some departments, such as psychiatry and cancer achieved greater GHG reductions, as they were able to perform more virtual visits. Telemedicine is an important component for the reduction of GHGs in healthcare systems; however, telemedicine cannot replace every clinic visit and proper triaging and tracking systems should be in place to avoid duplicative care., (© 2023. The Author(s).)

Objectives: Palliative care research suffers from underfunding and a workforce spread across multiple settings leading to a lack of large-scale studies. To facilitate multisite research and audit we set up the UK Palliative trainees Research Collaborative (UKPRC), the first national trainee-led audit and research collaborative in palliative care. Here, we critically review the progress and potential of the UKPRC since its inception in 2016, identifying key challenges and facilitators. Members of the UKPRC steering committee collaborated to write this reflection, reviewing existing evidence regarding trainee-led research collaboratives., Findings: The UKPRC has representation from 16/19 UK training regions. Projects are run by a core team; local collaborators collect data at each site. The collaborative is supported by academic leads and newly qualified consultants to develop a culture of continuous improvement in practice. We have conducted four national projects to date, including an audit covering 119 sites. Facilitators for our work include a focus on inclusivity and national representation; support from recently qualified consultants to ensure continuity; and taking a pragmatic approach, focusing initially on straightforward projects to build momentum. Challenges include the step from national audit to multisite, patient-facing research and maintaining continuity in a membership with high turnover., Conclusions: There is potential to change practice through large scale data collection via the trainee-led collaborative model. Collaboration is especially important in a small specialty with limited resources. The UKPRC has demonstrated 'proof of concept' and has the potential to support and sustain a culture where research can flourish within palliative care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We sought to determine whether a prospective audit and feedback intervention decreased antibiotic utilization in a pediatric cardiac ICU and to describe the characteristics of prospective audit and feedback audits and recommendations., Design: Before-after study., Setting: Pediatric cardiac ICU of a freestanding children's hospital., Patients: All patients admitted to the cardiac ICU., Interventions: A prospective audit and feedback program was established in our hospital's pediatric cardiac ICU on December 7, 2015. The antimicrobial stewardship program audited IV antibiotics, communicated prospective audit and feedback recommendations to the cardiac ICU, and regularly reviewed recommendation adherence. Mean monthly antibiotic utilization 18 months before ("preprospective audit and feedback"; from June 1, 2014 to November 30, 2015) and 24 months after ("prospective audit and feedback"; from January 1, 2016 to December 31, 2017) prospective audit and feedback implementation was compared. Antibiotic audit data during the prospective audit and feedback period were reviewed to capture the characteristics of prospective audit and feedback audits, recommendations, and adherence., Measurements and Main Results: Mean cardiac ICU IV antibiotic use decreased 20% (701 vs 880 days of therapy per 1,000 patient days, p = 0.001) during the prospective audit and feedback period compared with the preprospective audit and feedback period. There was no difference in mean cardiac ICU length of stay (p = 0.573), mean hospital length of stay (p = 0.722), or the rate of discharge due to death (p = 0.541). There were 988 antibiotic audits and 370 prospective audit and feedback recommendations (37% recommendation rate) during the study period. The most commonly audited antibiotic category was broad-spectrum gram-negative agents and the most common indication for use was sepsis. Broad-spectrum gram-positive agents were more likely to be associated with a recommendation., Conclusions: There was a significant reduction in antibiotic use following implementation of a prospective audit and feedback program in our pediatric cardiac ICU. Over one-third of antibiotics audited in our cardiac ICU were associated with a prospective audit and feedback recommendation, revealing important targets for future antimicrobial stewardship efforts in this population., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Portland cement concrete is fragile in tension and it has numerous negative impacts on the environment. To deal with these issues, both fiber reinforcement and recycled materials can be utilized to manufacture sustainable and ductile concrete. In this study, the synergistic effects of high-performance mineral admixture silica fume and glass fiber reinforcement were investigated on the hardened properties of RC. For this purpose, two concrete mix families, namely, NC and RC were prepared. To understand the benefits of synergistic utilization of glass fiber and silica fume, in both NC and RC, 0.5% glass fiber was incorporated with three different levels of silica fume. i.e., 0%, 5%, and 10%. Both strength and permeability-related durability properties were investigated. Results revealed that combined incorporation of 0.5% fiber and 10% silica fume can help in the production of RC having better mechanical and durability performance compared to reference "NC". Simultaneous incorporation of silica fume and glass fiber produces a combined effect greater than their individual effects on both mechanical and permeability properties of concrete. Silica fume plays a very dominant and positive role in the development of CS, WA, and CIPR of RC, whereas glass fiber plays a vital role in upgrading STS and FS of RC and whereas, with the addition of 0.5% glass fiber, RC can yield 8-9 times higher flexural toughness than that of the plain NC.

Background: Little research has explored the detail of practice when using sedative medications at the end of life. One work package of the I-CAN-CARE research programme investigates this in UK palliative care., Aims: To investigate current practices when using sedative medication at the end of life in London, UK, by (1) qualitatively exploring the understandings of palliative care clinicians, (2) examining documented sedative use in patient records and (3) comparing findings from both investigations., Design: We conducted focus groups with experienced palliative care physicians and nurses, and simultaneously reviewed deceased patient records., Setting/participants: In total, 10 physicians and 17 senior nurses in London hospice or hospital/community palliative care took part in eight focus groups. Simultaneously, 50 patient records for people who received continuous sedation at end of life in the hospice and hospital were retrieved and reviewed., Results: Focus group participants all said that they used sedative medication chiefly for managing agitation or distress; selecting drugs and dosages as appropriate for patients' individual needs; and aiming to use the lowest possible dosages for patients to be 'comfortable', 'calm' or 'relaxed'. None used structured observational tools to assess sedative effects, strongly preferring clinical observation and judgement. The patient records' review corroborated these qualitative findings, with the median continuous dose of midazolam administered being 10 mg/24 h (range: 0.4-69.5 mg/24 h)., Conclusion: Clinical practice in these London settings broadly aligns with the European Association for Palliative Care framework for using sedation at the end of life, but lacks any objective monitoring of depth of sedation. Our follow-on study explores the utility and feasibility of objectively monitoring sedation in practice.