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New farming systems and management options are needed in South Asia as the intensive rice–wheat production system is set to become increasingly unsustainable under climate change. In the current study, six cropping systems options/treatments varying in tillage, crop establishment method, residue management, crop sequence and fertilizer and water management were evaluated using a cropping systems model under current (1980–2009) and future (2030 and 2050) climate scenarios in the state of Bihar, India. The treatments were current farmers' practice (CP), best fertilizer and water management practices, zero tillage (ZT) with no crop residue retention, ZT with partial crop residue retention (ZTPR), future conservation agriculture-based rice–wheat intensive cropping system (FCS-1) and future conservation agriculture-based maize–wheat intensive cropping system (FCS-2). The results indicate that climate change is likely to reduce rice–wheat system productivity under CP by 4% across Bihar. All the crop management options studied increased yield, water productivity and net returns over that of the CP under the current and future climate scenarios. However, the ZTPR treatment gave significantly higher relative yield, lower annual yield variability and a higher benefit-cost-ratio than the other treatments across cropping system components and climate periods. Although all the new cropping system treatments had a positive yield implication under the current climate (compared to CP), they did not contribute to adaptation under the future climate except FCS-2 in wheat. It is concluded that adaptation to future climate must integrate both cropping system innovations, and genetic improvements in stress tolerance.
There is a need for clinical tools to identify cultural issues in diagnostic assessment.
To assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice.
Mixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored.
Mixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time.
The CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.
Silver nanowire-based contacts represent one of the major new directions in transparent contacts for opto-electronic devices with the added advantage that they can have Indium-Tin-Oxide-like properties at substantially reduced processing temperatures and without the use of vacuum-based processing. However, nanowires alone often do not adhere well to the substrate or other film interfaces; even after a relatively high-temperature anneal and unencapsulated nanowires show environmental degradation at high temperature and humidity. Here we report on the development of ZnO/Ag-nanowire composites that have sheet resistance below 10 Ω/sq and >90% transmittance from a solution-based process with process temperatures below 200 °C. These films have significant applications potential in photovoltaics and displays.
The primary extracardiac inferior cavopulmonary connection is an unusual novel palliation for single-ventricle physiology, which we first performed in the setting of unfavourable upper-body systemic venous anatomy for a standard bi-directional Glenn, and in lieu of leaving our patient with shunt-dependent physiology. After an initial 16-month satisfactory follow-up, increasing cyanosis led to the discovery of a veno-venous collateral that was coiled, but, more importantly, to impressive growth of a previously diminutive superior caval vein, which allowed us to perform completion Fontan with a good outcome. Performing the single-ventricle staging in a reverse manner, first from below with a primary inferior cavopulmonary connection, followed by Fontan completion from above with a standard superior caval vein bi-directional Glenn, is also possible when deemed necessary.
We compare the results of using a Random Forest Classifier with the results of using Nonparametric Discriminant Analysis to classify whether a filament channel (in the case of a filament eruption) or an active region (in the case of a flare) is about to produce an event. A large number of descriptors are considered in each case, but it is found that only a small number are needed in order to get most of the improvement in performance over always predicting the majority class. There is little difference in performance between the two classifiers, and neither results in substantial improvements over simply predicting the majority class.
We propose and analyse finite volume Godunov type methods based on discontinuous flux for a 2×2 system of non-linear partial differential equations proposed by Hadeler and Kuttler to model the dynamics of growing sandpiles generated by a vertical source on a flat bounded rectangular table. The problem considered here is the so-called partially open table problem where sand is blocked by a wall (of infinite height) on some part of the boundary of the table. The novelty here is the corresponding modification of boundary conditions for the standing and the rolling layers and generalization of the techniques of the well-balancedness proposed in . Presence of walls may lead to unbounded or discontinuous surface flow density at equilibrium resulting in solutions with singularities propagating from the extreme points of the walls. A scheme has been proposed to approximate efficiently the Hamiltonians with the coefficients which can be unbounded and discontinuous. Numerical experiments are presented to illustrate that the proposed schemes detect these singularities in the equilibrium solutions efficiently and comparisons are made with the previously studied finite difference and Semi-Lagrangian approaches by Finzi Vita et al.
To evaluate the success rate of dry and wet temporalis fascia grafts in type I underlay tympanoplasty.
A prospective, randomised study was conducted. One hundred adult patients (males and females) with chronic suppurative otitis media (mucosal type) were divided into 2 groups of 50 each: one group underwent dry graft tympanoplasty and the other underwent wet graft tympanoplasty. Fibroblast count was calculated in dry and wet grafts.
The dry graft and wet graft groups had overall surgical success rates of 82 and 90 per cent, respectively; this finding was not statistically significant. A statistically significant high fibroblast count was observed in wet grafts, but it did not correlate with surgical success.
A dry or wet temporalis fascia graft does not influence the outcome of tympanoplasty type I.
Introduction: ED patient comorbidity is difficult to ascertain for research. Traditional surrogates such as triage acuity, admission rate, and age have been used to approximate patient complexity. Differences between EDs for the management of similar conditions are nevertheless difficult to reconcile. The Charlson Comorbidity Index (CCI) contains 19 categories and is a validated predictor of the ten-year mortality for a patient who may have a range of comorbid conditions. CCI is based on the International Classification of Diseases (ICD) diagnosis codes found in administrative data such as the Discharge Abstract Database (DAD). The DAD collects this, and other inpatient information, for all Canadian hospitals. We sought to develop a linkage between the regional ED database and the regional inpatient DAD in order to derive a CCI score for each ED patient as a surrogate of comorbidity. Methods: We used regional data from Vancouver Coastal Health (VCH) over a 2.5 year period from April 2013 - September 2015. An algorithm was created to identify CCI conditions in the regional DAD. Whenever a patient visited the ED a query was made to the DAD going back for 5 years to acquire CCI relevant diagnoses and enter these diagnoses as well as the CCI weighting into the ED database. Patient DAD records from VCH were utilized no matter in which ED a patient presented. No information from admissions outside the region was available. Results: There were 931,596 regional ED visits made by 446,579 unique patients in a total of 11 EDs (6 urban and 5 rural). In total there were 127,233 patients with a CCI score (13.7% of total visits). The average CCI was 0.40 (SD 1.31) with a range of 0.12 at the urban urgent care centre to 0.52 at the urban tertiary care centre. More isolated rural EDs tended to have higher percentages of patients with CCI scores than community urban EDs. Higher acuity, age, and ambulance arrival, ED death, all correlated to higher CCI scores. The most common CCI conditions were “diabetes with complications” (10/11 EDs) and was present in 35,816 (3.8%) visits and “cancer” (10/11 EDs) present in 34,624 (3.7%) ahead of COPD (26,451 visits) and CHF (25,233 visits). Conclusion: Use of the CCI is a novel way to passively capture patient comorbidities without reliance on a data entry technician. Limitations include the inability to link to hospitalization data outside a specific health region.
With the increasing use of complex quantitative models in applications throughout the financial world, model risk has become a major concern. Such risk is generated by the potential inaccuracy and inappropriate use of models in business applications, which can lead to substantial financial losses and reputational damage. In this paper, we deal with the management and measurement of model risk. First, a model risk framework is developed, adapting concepts such as risk appetite, monitoring, and mitigation to the particular case of model risk. The usefulness of such a framework for preventing losses associated with model risk is demonstrated through case studies. Second, we investigate the ways in which different ways of using and perceiving models within an organisation both lead to different model risks. We identify four distinct model cultures and argue that in conditions of deep model uncertainty, each of those cultures makes a valuable contribution to model risk governance. Thus, the space of legitimate challenges to models is expanded, such that, in addition to a technical critique, operational and commercial concerns are also addressed. Third, we discuss through the examples of proxy modelling, longevity risk, and investment advice, common methods and challenges for quantifying model risk. Difficulties arise in mapping model errors to actual financial impact. In the case of irreducible model uncertainty, it is necessary to employ a variety of measurement approaches, based on statistical inference, fitting multiple models, and stress and scenario analysis.
Debilitating patient-related non-cardiac co-morbidity cumulatively increases risk for congenital heart surgery. At our emerging programme, flexible surgical strategies were used in high-risk neonates and infants generally considered in-operable, in an attempt to make them surgical candidates and achieve excellent outcomes.
Materials and methods
Between April, 2010 and November, 2013, all referred neonates (142) and infants (300) (average scores: RACHS 2.8 and STAT 3.0) underwent 442 primary cardiac operations: patients with bi-ventricular lesions underwent standard (n=294) or alternative (n=19) repair/staging strategies, such as pulmonary artery banding(s), ductal stenting, right outflow patching, etc. Patients with uni-ventricular hearts followed standard (n=96) or alternative hybrid (n=34) staging. The impact of major pre-operative risk factors (37%), standard or alternative surgical strategy, prematurity (50%), gestational age, low birth weight, genetic syndromes (23%), and major non-cardiac co-morbidity requiring same admission surgery (27%) was analysed on the need for extracorporeal membrane oxygenation, mortality, length of intubation, as well as ICU and hospital length of stays.
The need for extracorporeal membrane oxygenation (8%) and hospital survival (94%) varied significantly between surgical strategy groups (p=0.0083 and 0.028, respectively). In high-risk patients, alternative bi- and uni-ventricular strategies minimised mortality, but were associated with prolonged intubation and ICU stay. Major pre-operative risk factors and lower weight at surgery significantly correlated with prolonged intubation, hospital length of stay, and mortality.
In our emerging programme, flexible surgical strategies were offered to 53/442 high-risk neonates and infants with complex CHDs and significant non-cardiac co-morbidity, in order to buffer risk and achieve patient survival, although at the cost of increased resource utilisation.
The superior cavopulmonary anastomosis – bi-directional Glenn – is the standard palliation for single ventricle physiology. When upper body systemic venous anatomic concerns such as superior caval vein stenosis, hypoplasia, or inadequate collateral tributaries are present, a Glenn may be precluded or have a high risk of poor outcome. A primary inferior cavopulmonary connection with an extracardiac conduit is an alternative palliation that provides a generous pathway for pulmonary blood flow, with the additional benefit of including hepatic venous return. We report a case of primary extracardiac inferior cavopulmonary connection in a patient unsuitable for Glenn, with successful post-operative outcome and early follow-up.
Background: Anthracyclines are effective medications for childhood cancer. Their limitation is the risk of cardiomyopathy. Although diastolic dysfunction has been described in patients who received anthracyclines, cardiac monitoring has focused on systolic function, which is abnormal in up to 41% of the patients. We conducted a study to assess diastolic function utilising transmitral inflow Doppler velocities and tissue Doppler imaging in anthracycline-treated children 5 years post-therapy. Methods: This was a retrospective study on 63 anthracycline-treated patients. Echocardiographic parameters included peak early and late transmitral inflow Doppler velocities (E, A), E/A ratio, E deceleration time, and tissue Doppler imaging early and late diastolic mitral annulus velocities (E′, A′), E/E′ ratio, and E′/A′ ratio. Results: All indices of diastolic function that we measured were normal in the anthracycline-treated patients. Conclusion: We conclude that diastolic function assessed by transmitral inflow Doppler velocities and tissue Doppler imaging is normal in anthracycline-treated children 5 years after completion of treatment. Further longitudinal study is needed to determine whether diastolic function becomes abnormal with time in this patient population.
The emergence of invasive fungal wound infections (IFIs) in combat casualties led to development of a combat trauma-specific IFI case definition and classification. Prospective data were collected from 1133 US military personnel injured in Afghanistan (June 2009–August 2011). The IFI rates ranged from 0·2% to 11·7% among ward and intensive care unit admissions, respectively (6·8% overall). Seventy-seven IFI cases were classified as proven/probable (n = 54) and possible/unclassifiable (n = 23) and compared in a case-case analysis. There was no difference in clinical characteristics between the proven/probable and possible/unclassifiable cases. Possible IFI cases had shorter time to diagnosis (P = 0·02) and initiation of antifungal therapy (P = 0·05) and fewer operative visits (P = 0·002) compared to proven/probable cases, but clinical outcomes were similar between the groups. Although the trauma-related IFI classification scheme did not provide prognostic information, it is an effective tool for clinical and epidemiological surveillance and research.
Left atrial appendage aneurysm is an extremely rare anomaly and as such has been rarely imaged or seen intraoperatively with very little accumulated management experience. The available scant published literature stresses resection on cardiopulmonary bypass as the safest and by far the most commonly applied technique. We suggest a novel alternative imaging-guided management utilising an off-pump tourniquet snare technique under live transoesophageal echocardiography.
Basic emergency care at primary, secondary and tertiary health care level in India is in its infancy. Lack of training in emergency care is an important factor. We designed AIIMS basic emergency care course (AIIMS BECC) to address the issue.
To improve the knowledge, skill and attitude of healthcare workers and laypersons in basic emergency care and to identify and train instructors.
Prospective study conducted over a period of one and half years. The target groups were medical, police, fire fighter, paramilitary forces, teachers, school children of India. Provider AIIMS BECC is of one day duration. The contents of the course are cardio-pulmonary resuscitation, chocking and special scenarios like trauma, electrocution, drowning, hypothermia, pregnancy, etc. Course was disseminated via lectures, audio-visual and hands on training. The participants were evaluated by pre and post test questions. Subjects had to score 80% to be successful and those who scored more than 90% were eligible for instructor course. The confidence levels at baseline and at the end of the course were evaluated in policecourses were evaluated on course clarity, course delivery and trainers quality on a likert scale (1 = worst, 5 = excellent).
1614 subjects were trained. 99.81% became providers and 2.6% were trained as instructors. 83.1% were non-medical and16.9% were medical personals. 76.14% were police, paramilitary 0.8%, teachers 1.6%, students 2.1% and mixed groups were 2.6%. The average and modal increase in confidence level among police were 66.14% and 62.49%. Likert scale of ≥ 4 was observed in 90.7% in course clarity, 91.28% in course delivery and 95.26% in trainer quality.
Knowledge, skill and attitude of healthcare care and laypersons in providing basic emergency care improved by community emergency care initiative. Instructors were identified for further dissemination of the course. The confidence levels increased among police.
To assess the outcome of conservative management of vestibular schwannoma.
Tertiary referral centre.
Four hundred and thirty-six patients with vestibular schwannoma (490 tumours), including 327 sporadic tumours and 163 tumours in 109 patients with neurofibromatosis type two.
Main outcome measures:
The relationship of tumour growth to tumour size at presentation, and to certain demographic features.
The initial tumour size was significantly larger in the neurofibromatosis type two group (11 mm) than in the sporadic vestibular schwannoma group (5.1 mm). In both groups, 68 per cent of tumours did not grow during follow up (mean 3.6 years; range one to 14 years). The mean growth rate was 1.1 mm/year (range 0–15 mm/year) for sporadic tumours and 1.7 mm/year (range 0–18 mm/year) for neurofibromatosis type two tumours. The tumour growth rate correlated positively with tumour size in the sporadic tumour group, and correlated negatively with age in the neurofibromatosis type two group.
Two-thirds of vestibular schwannomas did not grow. Radiological surveillance is an acceptable approach in carefully selected patients. Once a sporadic vestibular schwannoma reaches 2 cm in intracranial diameter, it is likely to continue growing. We do not recommend conservative management for sporadic tumours with an intracranial diameter of 1.5 cm or more. Vestibular schwannoma management is more complex in patients with neurofibromatosis type two.
Oral submucous fibrosis is a chronic disease characterised by progressive inability to open the mouth. Various treatment modalities are available for its management, but these have largely been ineffective.
Materials and methods:
Nine cases of oral submucous fibrosis underwent a release procedure using a KTP-532 laser, from March 2005 to January 2006, within the ENT – head and neck surgery department of a tertiary centre.
Pre- and post-operative mouth-opening was compared using the Wilcoxon signed rank test, and a significant difference observed (Z = −2.690, p = 0.007). Follow up over an average period of 12 months showed encouraging results.
This preliminary study indicated that adequate release of oral submucous fibrosis can be achieved by using a KTP-532 laser release procedure, with minimal morbidity and satisfactory results. These promising results should encourage more widespread use of this technique in the management of this condition.
The first of several cases of meningococcal meningitis was reported in April 2005, in New Delhi, India. Subsequent to this the Government declared an outbreak, which persisted for two periods, from April–July 2005 and January–March 2006. The National Institute of Communicable Diseases (NICD) recommended using WHO criteria for diagnosis of disease. During the outbreak 380 clinically suspected cases were investigated. Of 55 cases diagnosed as confirmed/probable the mortality rate was 14·6%. Meningitis was reported in 60% of cases and meningococcaemia in 40%. Microscopy of petechial rash was positive in 87·5%, CSF Gram stain positive in 68·3%, and latex agglutination test of CSF positive in 64·9% of samples. Neisseria meningitidis (serogroup A) was isolated from 37·7% of cases, 57·7% from CSF. Blood culture was positive in 10·4% of cases. CrgA polymerase chain reaction for N. meningitidis confirmed the isolates. All isolates were susceptible to third-generation cephalosporins, azithromycin and rifampicin, with increasing resistance to ceftriaxone. Penicillin resistance was encountered in 15·4% of strains. Resistance to quinolones was very high at 100% for levofloxacin, 84·6% for ofloxacin and 65·4% for ciprofloxacin. All patients with penicillin-resistant organisms (4) or intermediate sensitivity (4) succumbed to the disease. These patients also had a higher minimum inhibitory concentration to ceftriaxone.
Fourteen strains of S. Typhi (n=13) and S. Paratyphi A (n=1) resistant to ciprofloxacin were compared with 30 ciprofloxacin decreased-susceptibility strains on the basis of qnr plasmid analysis, and nucleotide substitutions at gyrA, gyrB, parC and parE. In ciprofloxacin-resistant strains, five S. Typhi and a single S. Paratyphi A showed triple mutations in gyrA (Ser83→Phe, Asp87→Asn, Glu133→Gly) and a novel mutation outside the quinolone resistance determining region (QRDR) (Met52→Leu). Novel mutations were also discovered in an isolate (minimum inhibitory concentration 8 μg/ml) in gyrA gene Asp76→Asn and outside the QRDR Leu44→Ile. Out of 30 isolates with reduced susceptibility, single mutation was found in 12 strains only. Genes encoding qnr plasmid (qnr A, qnr B, AAC1-F) were not detected in ciprofloxacin-resistant or decreased-susceptibility strains. Antimicrobial surveillance coupled with molecular analysis of fluoroquinolone resistance is warranted for reconfirming novel and established molecular patterns of resistance, which is quintessential for reappraisal of enteric fever therapeutics.
Barium copper sulfur fluoride thin films with a face-centered cubic phase in the Fm3m space group were synthesized via RF magnetron sputtering. The results of a detailed optical and electronic characterization of the films are presented. As-deposited, they exhibit degenerate p-type conductivity at room temperature of approximately 260 S/cm – higher than that of any previously reported p-TC. Their conductivity after post-deposition processing increases to as high as 800 S/cm. The films exhibit bandgaps ranging from 1.45-1.75 eV. They are typically deposited with a substrate temperature between room temperature and 100°C, making them suitable for deposition on plastic as well as glass or crystalline substrates. It was found that a silica protective layer reduces degradation in film transparency that is caused by exposure to air.