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Deep learning using convolutional neural networks represents a form of artificial intelligence where computers recognise patterns and make predictions based upon provided datasets. This study aimed to determine if a convolutional neural network could be trained to differentiate the location of the anterior ethmoidal artery as either adhered to the skull base or within a bone ‘mesentery’ on sinus computed tomography scans.
Coronal sinus computed tomography scans were reviewed by two otolaryngology residents for anterior ethmoidal artery location and used as data for the Google Inception-V3 convolutional neural network base. The classification layer of Inception-V3 was retrained in Python (programming language software) using a transfer learning method to interpret the computed tomography images.
A total of 675 images from 388 patients were used to train the convolutional neural network. A further 197 unique images were used to test the algorithm; this yielded a total accuracy of 82.7 per cent (95 per cent confidence interval = 77.7–87.8), kappa statistic of 0.62 and area under the curve of 0.86.
Convolutional neural networks demonstrate promise in identifying clinically important structures in functional endoscopic sinus surgery, such as anterior ethmoidal artery location on pre-operative sinus computed tomography.
In this chapter, we shall study the role of institutions in clean energy transitions in developing countries. Renewable energy (RE) for electricity generation has been proposed as a way to bridge the gap between affordable and clean-energy infrastructure. We shall examine the drivers of past and planned solar photovoltaic (PV) electricity-capacity expansion in eight African countries during a period of rapidly falling technology costs. The countries in our sample that experienced RE expansion do not have liberalized market-oriented electricity sectors, and many provide only limited policy support. Careful cross-case comparisons point to a set of financing, political/regulatory, value capture and technical capabilities that may help to explain RE outcomes. Although these findings are specific to the group of African countries we studied, they may hold lessons for other settings in the ‘second wave’ of RE development.
We explored identity formation among nine gay men who were born between 1946 and 1964. This group of nine was the largest homogeneous sub-group within a larger sample (N = 18). Although participants share similar demographic characteristics, their individual social, personal and narrative identities diverge to represent distinctive embodied selves. Guided by queer and feminist theories, the qualitative analysis identified dominant and counter-narratives that demonstrate the complexity of sexual identity as it evolves over time. All nine men recall being aware of their gay identity as children; however, like many socially constructed labels, their outward identity was more complex and difficult to understand. The findings demonstrate how participants negotiated their sexual identities through decades of social change. As illustrated within each subset of identity (i.e. social, personal and narrative), some participants found themselves breaking ground for a broader gay rights social movement, while others described their experience of being relegated to silence and invisibility for most of their lives. This research contributes to an ongoing discussion concerning the individuality found among lesbian, gay, bisexual and transgender (LGBT) individuals in later life. As the LGBT population becomes more visible, there will be a growing need to understand the individualism that exists within this coalition and affirm their diversifying sexual and gender identities.
To determine the impact of a passive, prescriber-directed, electronic best-practice advisory coupled with prescriber education on the rate of antibiotic prescribing for acute, uncomplicated bronchitis in ambulatory adults across a large health system.
This study was a quasi-experiment examining antibiotic prescribing for ambulatory adults with acute bronchitis from January 1, 2016 through December 31, 2018. The intervention was implemented in December 2016 for emergency departments and urgent care clinics followed by ambulatory clinics in September 2017.
Outpatient settings across a health system, including 15 emergency departments, >30 urgent care clinics, and >150 ambulatory clinics.
All adults with a primary diagnosis of acute bronchitis who were seen and discharged from a study site were included.
A passive, prescriber-directed, best-practice advisory for treatment of acute bronchitis in the electronic health record and an optional, online education module regarding acute bronchitis.
The study included 81,975 ambulatory adults with a primary diagnosis of acute bronchitis during the preintervention period (19.8% >65 years of age; 61.9% female) and 89,571 ambulatory adults during the postintervention period (16.5% >65 years of age; 61.1% female). Antibiotic prescribing rates decreased from 60.8% (49,877 of 81,975 patients) preintervention to 51.4% (46,018 of 89,571 patients) postintervention (absolute difference, 9.4%; P < .001). The largest reduction occurred in the emergency departments.
An electronic best practice advisory combined with prescriber education was associated with a statistically significant reduction in antibiotic prescribing for adults with acute bronchitis. Future studies should incorporate patient education and address prescriber-reported barriers to appropriate antibiotic prescribing.
Sheath blight caused by soil borne necrotrophic fungus Rhizoctonia solani [teleomorph-Thanatephorus cucumeris (Frank) Donk.] is a major disease of rice. The disease is increasing over the year in India and cause up to 69% yield loss under favourable conditions. A total of 67 accessions of Oryza nivara were screened to identify resistance against sheath blight during 2015. Out of these, 16 accessions were found moderately resistant (MR) which were further evaluated during the year 2016 and 2017. After three years of screening, 12 of them were found to have a consistent moderate resistant reaction whereas four of the O. nivara accessions namely, IRGC81941, IRGC102463C, CR100097 and CR100110A have shown moderately susceptible to susceptible reaction against sheath blight. A correlation study revealed that different disease variables measured were significantly (P < 0.05) correlated. All the genotypes and genotype × environment interaction had a significant (P < 0.001) effect on all the disease variables. Cluster analysis showed that all the accessions were clustered into four groups which showed resistant, MR, moderately susceptible and susceptible reactions. Among all the O. nivara accessions IRGC81941A showed the maximum potential against sheath blight due to a least relative lesion height of 22.80%. None of the accession had complete resistance to the disease. The identified promising accessions such as IRGC81835, IRGC81941A, CR100008 and CR100111B can be utilized in a sheath blight resistance breeding program.
This paper describes and analyzes a new technique used in Q-slot antenna to generate circular polarization (CP). The CP characteristics were investigated carefully by studying the surface current distribution, the phase difference between the left hand circular polarization (LHCP) and right hand circular polarization (RHCP) at some resonant frequencies, and the measured values of the axial ratio bandwidth (ARBW). Normal arms (E1 and E2) were cut in the upper elliptical feeding strip line to form an open-mouth structure. The arms E1 and E2 were made equal in length and set perpendicular to each other to have normal electric fields, leading to the generation of CP radiation. A formula was modified for the dual resonant frequencies f1, f2 of the modes TM010 and TM001. The measured values of the ARBW indicated that the antenna has a wide ARBW of 4.8–5.93 GHz, which is approximately 52% of the 3rd operating band of 4.7–6.8 GHz. The wide ARBW in a small size indicated that the design of the Q-slot antenna overcame the limits of designing antennas with wide ARBW in small size and low profile. A formula for normalized field was driven according to the complementary of the Q-slot antenna.
Biochar has received attention due to its potential for mitigating climate change through carbon sequestration in soil and improving soil quality and crop productivity. This study evaluated the effects of rice straw biochar (RSB) and rice husk ash (RHA) each applied at 5 Mg ha−1 and four N levels (0, 40, 80, and 120 kg ha−1) on soil fertility, growth, and yield of rice and wheat for three consecutive rice–wheat rotations. RSB significantly increased electrical conductivity, dehydrogenase activity, and P and K contents when compared to control (no amendment) up to 7.5 cm soil depth. Both RSB and RHA did not influence shoot N concentration in wheat plant but significantly increased P and K concentrations at 60 days after sowing. Grain yields of both rice and wheat were significantly higher in RSB as compared to control (no amendment) and RHA treatments. While the highest grain yields of rice and wheat were observed at 120 kg N ha−1 in RHA and no biochar-treated plots, a significant increase in grain yields was observed at 80 kg N ha−1 in RSB treatment, thereby saving 40 kg N ha−1 in each crop. Both agronomic and recovery N efficiencies in rice and wheat were significantly higher in RSB-amended soil compared to control. Significant positive correlations were observed between soil N, P, and K concentrations and total N, P, and K concentrations in aboveground biomass of wheat at 60 days after sowing. This study showed the potential benefits of applying RSB for improving soil fertility and yields of rice and wheat in a rice–wheat system.
Describe the epidemiological and molecular characteristics of an outbreak of Klebsiella pneumoniae carbapenemase (KPC)–producing organisms and the novel use of a cohorting unit for its control.
A 566-room academic teaching facility in Milwaukee, Wisconsin.
Solid-organ transplant recipients.
Infection control bundles were used throughout the time of observation. All KPC cases were intermittently housed in a cohorting unit with dedicated nurses and nursing aids. The rooms used in the cohorting unit had anterooms where clean supplies and linens were placed. Spread of KPC-producing organisms was determined using rectal surveillance cultures on admission and weekly thereafter among all consecutive patients admitted to the involved units. KPC-positive strains underwent pulsed-field gel electrophoresis and whole-genome sequencing.
A total of 8 KPC cases (5 identified by surveillance) were identified from April 2016 to April 2017. After the index patient, 3 patients acquired KPC-producing organisms despite implementation of an infection control bundle. This prompted the use of a cohorting unit, which immediately halted transmission, and the single remaining KPC case was transferred out of the cohorting unit. However, additional KPC cases were identified within 2 months. Once the cohorting unit was reopened, no additional KPC cases occurred. The KPC-positive species identified during this outbreak included Klebsiella pneumoniae, Enterobacter cloacae complex, and Escherichia coli. blaKPC was identified on at least 2 plasmid backbones.
A complex KPC outbreak involving both clonal and plasmid-mediated dissemination was controlled using weekly surveillances and a cohorting unit.
Cardiopulmonary exercise testing has been used to measure functional capacity in children who have undergone a heart transplant. Cardiopulmonary exercise testing results have not been compared between children transplanted for a primary diagnosis of CHD and those with a primary diagnosis of cardiomyopathy despite differences in outcomes. This study is aimed to compare cardiopulmonary exercise testing performance between these two groups.
Patients who underwent heart transplant with subsequent cardiopulmonary exercise testing at least 6 months after transplant at our institution were identified. They were then divided into two groups based on primary cardiac diagnosis: CHD or cardiomyopathy. Patient characteristics, echocardiograms, cardiac catheterisations, outcomes, and cardiopulmonary exercise test results were compared between the two groups.
From the total of 35 patients, 15 (43%) had CHD and 20 (57%) had cardiomyopathy. Age at transplant, kidney disease, lung disease, previous rejection, coronary vasculopathy, catheterisation, and echocardiographic data were similar between the groups. Mean time from transplant to cardiopulmonary exercise testing, exercise duration, and maximum oxygen consumption were similar in both groups. There was a difference in heart rate response with CHD heart rate response of 63 beats per minute compared to cardiomyopathy group of 78 (p = 0.028). Patients with CHD had more chronotropic incompetence than those with cardiomyopathy (p = 0.036).
Primary diagnosis of CHD is associated with abnormal heart rate response and more chronotropic incompetence compared to those transplanted for cardiomyopathy.
Chronic maxillary atelectasis is a rare and underdiagnosed condition in which there is a persistent and progressive decrease in maxillary sinus volume secondary to inward bowing of the antral walls. Chronic maxillary atelectasis is typically unilateral. Simultaneous bilateral chronic maxillary atelectasis is extremely uncommon.
A retrospective review was performed of patient data collected by the senior clinician over a three-year period (2015–2018). A comprehensive literature search was conducted to locate all documented cases of chronic maxillary atelectasis in English-language literature. Abstracts and full-text articles were reviewed.
Three patients presented with sinonasal symptoms. Imaging findings were consistent with bilateral chronic maxillary atelectasis. The literature review revealed at least nine other cases of bilateral chronic maxillary atelectasis. Management is typically via endoscopic middle meatus antrostomy.
Chronic maxillary atelectasis was initially defined as a unilateral disorder, but this description has been challenged by reports of bilateral cases. Further investigation is required to determine the aetiology and pathophysiology of the disease.
Grewia tenax locally known as ‘Gangerun’, is an important multipurpose underutilized shrub and potentially threaten species of the Thar Desert of India. Owing to its importance, naturally available germplasm was collected and evaluated for its sustainable utilization in future. Data on individual mother plant, seed characters and soil profile were investigated. Habitat occurrence of G. tenax was found in patches with dominant association of Euphorbia caducifolia across the four districts of western Rajasthan. Individual plant on unprotected area portrayed far lower average height (0.95 m) and canopy area (1.75 m2) than protected area (2.63 m and 13.89 m2) signifying level of browsing pressure on this species in Jaisalmer. Soil samples belonging to Pali region have high organic carbon and low electrical conductivity content than Jaisalmer and Jodhpur. The statistical analysis of seed characters revealed the presence of high coefficient of variation (%) in 100-seed weight (HSW; 27.36) followed by seed length (SL; 8.06) and least in seed breadth (SB; 5.85). The range and mean values of HSW, SL, SB and length:breadth ratio (LBR) were (2.02–7.00 and 3.34 g), (4.36–6.15 and 5.36 mm), (3.73–4.68 and 4.25 mm) and (1.11–1.44 and 1.27), respectively. Significantly positive correlation was observed between SL and LBR (0.73) followed by HSW and SL (0.66). Along with these findings, its economic importance, utilization and conservation are detailed in this paper as to hasten further research on its various aspects for its successful conservation and utilization.
It has been nearly 70 years since the discovery that strict adherence to a diet low in phenylalanine prevents severe neurological sequelae in patients with phenylalanine hydroxylase deficiency (phenylketonuria; PKU). Today, dietary treatment with restricted phenylalanine intake supplemented with non-phenylalanine amino acids to support growth and maintain a healthy body composition remains the mainstay of therapy. However, a better understanding is needed of the factors that influence N balance in the context of amino acid supplementation. The aim of the present paper is to summarise considerations for improving N balance in patients with PKU, with a focus on gaining greater understanding of amino acid absorption, disposition and utilisation. In addition, the impact of phenylalanine-free amino acids on 24 h blood phenylalanine/tyrosine circadian rhythm is evaluated. We compare the effects of administering intact protein v. free amino acid on protein metabolism and discuss the possibility of improving outcomes by administering amino acid mixtures so that their absorption profile mimics that of intact protein. Protein substitutes with the ability to delay absorption of phenylalanine and tyrosine, mimicking physiological absorption kinetics, are expected to improve the rate of assimilation into protein and minimise fluctuations in quantitative plasma amino acid levels. They may also help maintain normal glycaemia and satiety sensation. This is likely to play an important role in improving the management of patients with PKU.
The term ‘mood stabiliser’ is ill-defined and lacks clinical utility. We propose a framework to evaluate medications and effectively communicate their mood stabilising properties – their acute and prophylactic efficacy across the domains of mania and depression. The standardised framework provides a common definition to facilitate research and clinical practice.
Declaration of interest
The Treatment Algorithm Group (TAG) was supported logistically by Servier who provided financial assistance with travel and accommodation for those TAG members travelling interstate or overseas to attend the meeting in Sydney (held on 18 November 2017). None of the committee were paid to participate in this project and Servier have not had any input into the content, format or outputs from this project.
Let K be a field of characteristic zero and let R = K[X1, . . .,Xn], with standard grading. Let
= (X1, . . ., Xn) and let E be the *injective hull of R/
. Let An(K) be the nth Weyl algebra over K. Let I, J be homogeneous ideals in R. Fix i, j ≥ 0 and set M = HiI(R) and N = HjJ(R) considered as left An(K)-modules. We show the following two results for which no analogous result is known in charactersitc p > 0.
(TorRν(M, N)) ≅ E(n)al,ν for some al,ν ≥ 0.
(ii)For all ν ≥ 0; the finite dimensional vector space TorAn(K)ν(M♯, N) is concentrated in degree -n (here M♯ is the standard right An(K)-module associated to M).
We also conjecture that for all i ≥ 0 the finite dimensional vector space ExtiAn(K)(M, N) is concentrated in degree zero. We give a few examples which support this conjecture.
Background: Children diagnosed with medulloblastoma (MB) that are refractory to upfront therapy or experience recurrence have very poor prognoses. Reports of phase I and II studies for these children exist, but bear significant treatment related morbidity and mortality. Methods: A retrospective review of children diagnosed with a pediatric MB from 2002-2015 from the McMaster Pediatric Brain Tumour Study Group (PBTSG) captured a number of pediatric recurrent MB. Results: Over the 13-year period, 31 children with a histological diagnosis of MB were treated. At two years, 21 (67.7%) of 31 patients were free of recurrence and 25 (80.6%) survived. Thirteen children had recurrent or treatment refractory MB. mean time to recurrence was 14.6 months. The mean follow-up for survivors of recurrent MB was 4.0 years. In 3 recurrent MB, the disease had significantly progressed and the patients palliated. For the remaining children, therapy offered included surgery, radiation, and chemotherapy agents either in isolation or in varying combinations. Conclusions: Recurrent MB in our cohort carried a poor prognosis despite administration of salvage therapy. Though there is standardization of the upfront treatment exists, we observed great heterogeneity in the treatment of our 13 patients experiencing recurrence. A greater understanding of the biology of recurrent MB has the potential to guide salvage therapy.