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We designed two practical, user-friendly, low-cost, aesthetically pleasing resources, with the goal of introducing residents and observers to a new Competence by Design assessment system based on entrustable professional activities. They included a set of rotation- and stage-specific entrustable professional activities reference cards for bedside use by residents and observers and a curriculum board to organize the entrustable professional activities reference cards by stages of training based on our program's curriculum map. A survey of 14 emergency medicine residents evaluated the utilization and helpfulness of these resources. They had a positive impact on our program's transition to Competence by Design and could be successfully incorporated into other residency programs to support the introduction of entrustable professional activities-based Competence by Design assessment systems.
In recent years, the discovery of massive quasars at
has provided a striking challenge to our understanding of the origin and growth of supermassive black holes in the early Universe. Mounting observational and theoretical evidence indicates the viability of massive seeds, formed by the collapse of supermassive stars, as a progenitor model for such early, massive accreting black holes. Although considerable progress has been made in our theoretical understanding, many questions remain regarding how (and how often) such objects may form, how they live and die, and how next generation observatories may yield new insight into the origin of these primordial titans. This review focusses on our present understanding of this remarkable formation scenario, based on the discussions held at the Monash Prato Centre from November 20 to 24, 2017, during the workshop ‘Titans of the Early Universe: The Origin of the First Supermassive Black Holes’.
The COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) project is a large international collaborative effort to analyze individual-level phenotype data from twins in multiple cohorts from different environments. The main objective is to study factors that modify genetic and environmental variation of height, body mass index (BMI, kg/m2) and size at birth, and additionally to address other research questions such as long-term consequences of birth size. The project started in 2013 and is open to all twin projects in the world having height and weight measures on twins with information on zygosity. Thus far, 54 twin projects from 24 countries have provided individual-level data. The CODATwins database includes 489,981 twin individuals (228,635 complete twin pairs). Since many twin cohorts have collected longitudinal data, there is a total of 1,049,785 height and weight observations. For many cohorts, we also have information on birth weight and length, own smoking behavior and own or parental education. We found that the heritability estimates of height and BMI systematically changed from infancy to old age. Remarkably, only minor differences in the heritability estimates were found across cultural–geographic regions, measurement time and birth cohort for height and BMI. In addition to genetic epidemiological studies, we looked at associations of height and BMI with education, birth weight and smoking status. Within-family analyses examined differences within same-sex and opposite-sex dizygotic twins in birth size and later development. The CODATwins project demonstrates the feasibility and value of international collaboration to address gene-by-exposure interactions that require large sample sizes and address the effects of different exposures across time, geographical regions and socioeconomic status.
The first period of agrarian reforms with clear state control over the land (African socialisms) took place between 1945 and 1980, but then a second period started in which market agrarian reforms have prevailed. This work synthesizes agrarian structural reform policies (property systems and land tenure) between 1980 and 2016 in African countries, especially those that had or have bureaucratic bourgeoisie governments (one-party and/or African socialist). The two periods are complementary, rather then being opposed to each other, as state agrarian reforms smoothed the path to market agrarian reforms. Although there is not yet sufficient empirical research on the results of the agrarian reforms implemented during this period, our hypothesis is that they are helping to: increase the unequal structure of property; develop tenure systems and non-capitalist contractual labour relations in new ways, both non-associative (the grabbing of vast tracts of land) and associative (renewed control of customary lands by traditional authorities); and force peasant expropriation and the subsequent increase in the number of landless non-proletarianized peasants. Therefore, the problem of poor agrarian structures in Africa is still unresolved.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
Microstructural analysis and bulk dielectric property analysis (real and imaginary permittivity at 95 GHz) were performed at temperatures ranging from 25 to 550 °C for ceramic composites comprising a hot-pressed aluminum nitride matrix (containing yttria and trace carbon as sintering additives) with molybdenum powder as a millimeter-wave radiation-absorbing additive. Loading percentages in the range of 0.25 vol% to 4.0 vol% Mo were characterized. For the temperature regime evaluated, the temperature-related changes in real and imaginary components of permittivity were found to be relatively modest compared with those driven by Mo loading. Energy-dispersive X-ray spectroscopic analysis of Mo grains and surrounding regions showed the presence of a mixed-phase layer, containing Mo2C, at the AlN–Mo interface. The Mo2C-containing mixed-phase layer, typically a few micrometers thick, surrounded the Mo grains. Further characterization of this mixed-phase layer is required to determine its contribution to the dielectric properties of the composite.
The use of additives such as ractopamine (Rac) in pregnant sows during early-mid pregnancy is an alternative to increase foetal and progeny growth and development. However, Rac supplementation in finishing pigs can lead to behavioural and physiological changes similar to the typical stress responses. The objective of this study was to evaluate the effects of dietary supplementation with Rac in pregnant sows from day 25 to 50 of gestation (pre-hyperplastic stage) on piglet’s vitality, blood parameters, number, diameter and perimeter of muscle fibres in semitendinosus muscle and developmental characteristics of piglets at birth to weaning. Forty-one hybrid sows were divided into three dietary treatments: (1) control diet without Rac (control), (2) addition of 10 mg/kg of Rac (Rac10) and (3) addition of 20 mg/kg of Rac (Rac20). Higher numbers of low-vitality piglets (P<0.05) were observed in Rac-fed sows, regardless of dose, compared with the control group. Very low-density lipoprotein levels were lower in the Rac10 group when compared with the Rac20 group at day 21. Haematocrit was greater, and the mean corpuscular haemoglobin concentration was lower in piglets from Rac-fed sows. No significant statistical differences were detected regarding piglets body weight, average daily gain, blood gasometry, complete blood count and muscle fibre measurements in semitendinosus muscle. The use of Rac in pregnant sows reduced the vitality parameters of piglets but did not improve the performance from birth until weaning and did not negatively influence the haematological parameter and lipid metabolism.
Parasitological analysis of coprolites has allowed exploring ecological relationships in ancient times. Ancient DNA analysis contributes to the identification of coprolites and their parasites. Pleistocene mammalian carnivore coprolites were recovered from paleontological and archaeological site Peñas de las Trampas 1.1 in the southern Puna of Argentina. With the aim of exploring ancient ecological relationships, parasitological analysis was performed to one of them, dated to 16 573–17 002 calibrated years BP, with 95.4% probability. Parasite eggs attributed to Toxascaris sp. by morphological characters were isolated. DNA of coprolite and eggs was extracted to molecular identification. Ancient mitochondrial DNA analysis confirmed the zoological origin of the coprolite as Puma concolor and that of parasite eggs as Toxascaris leonina. This is the oldest molecular parasite record worldwide, and it supports the presence of this parasite since the Pleistocene in America. These findings have implications for the biogeographic history of parasites and for the natural history of the region.
It is generally accepted in industry and academia that trade-offs between functional design objectives are an inevitable factor in the development of mechanical systems. These trade-offs can have a large influence on the achievable robustness and performance of the final design, with many products only functioning in narrow sweet-spots between different objectives. As a result, the design process of multi- functional products can be prolonged when designers concurrently attempt to find sweet-spots between a number of potentially interdependent trade-offs. This paper will show that designers only have six different approaches available when attempting to manage a trade-off while trying to ensure robustness and a sufficient performance. These fall within one of three categories; accept, optimise, or redesign. Selecting the wrong approach, can result in consequences downstream which can be difficult to predict, amongst others a lack of robustness to geometric variation, constrained performance, and long development lead time. This points to a substantial potential in the synthesis of design methods that support the identification and management of trade-offs in early product development.
To sustainably improve cleaning of high-touch surfaces (HTSs) in acute-care hospitals using a multimodal approach to education, reduction of barriers to cleaning, and culture change for environmental services workers.
The study was conducted in 2 academic acute-care hospitals, 2 community hospitals, and an academic pediatric and women’s hospital.
Frontline environmental services workers.
A 5-module educational program, using principles of adult learning theory, was developed and presented to environmental services workers. Audience response system (ARS), videos, demonstrations, role playing, and graphics were used to illustrate concepts of and the rationale for infection prevention strategies. Topics included hand hygiene, isolation precautions, personal protective equipment (PPE), cleaning protocols, and strategies to overcome barriers. Program evaluation included ARS questions, written evaluations, and objective assessments of occupied patient room cleaning. Changes in hospital-onset C. difficile infection (CDI) and methicillin-resistant S. aureus (MRSA) bacteremia were evaluated.
On average, 357 environmental service workers participated in each module. Most (93%) rated the presentations as ‘excellent’ or ‘very good’ and agreed that they were useful (95%), reported that they were more comfortable donning/doffing PPE (91%) and performing hand hygiene (96%) and better understood the importance of disinfecting HTSs (96%) after the program. The frequency of cleaning individual HTSs in occupied rooms increased from 26% to 62% (P < .001) following the intervention. Improvement was sustained 1-year post intervention (P < .001). A significant decrease in CDI was associated with the program.
A novel program that addressed environmental services workers’ knowledge gaps, challenges, and barriers was well received and appeared to result in learning, behavior change, and sustained improvements in cleaning.
Diabetes mellitus is a global epidemic, characterised as a heterogeneous group of metabolic disorders associated with high risk of CVD. Green banana biomass, which is composed of resistant starches (RS) and cannot be hydrolysed by amylases, delays gastric emptying and modulates insulin sensitivity, thus contributing to improve metabolic disorders. The aim of the present study was to investigate the effects of consumption of RS from green banana biomass on body composition, fasting plasma glucose, glycated Hb (HbA1c) and homeostasis model assessment of insulin resistance in subjects with pre-diabetes or type 2 diabetes on top of treatment. Middle-aged subjects (n 113) of both sexes with pre-diabetes (HbA1c: 5·7–6·4 %) or diabetes (HbA1c ≥ 6·5 %) were randomised to receive nutritional support plus green banana biomass (40 g) (RS: approximately 4·5 g, G1, n 62) or diet alone (G2, n 51) for 24 weeks. Body composition, biochemical analyses and dietary intake were evaluated at the beginning and end of the study. In the experimental group (G1), consumption of RS was associated with reduction in HbA1c (P = 0·0001), fasting glucose (P = 0·021), diastolic blood pressure (P = 0·010), body weight (P = 0·002), BMI (P = 0·006), waist and hip circumferences (P < 0·01), fat mass percentage (P = 0·001) and increase in lean mass percentage (P = 0·011). In controls (G2), reductions were observed in waist and hip circumferences (P < 0·01), HbA1c (P = 0·002) and high-density lipoprotein-cholesterol (P = 0·020). In pre-diabetes or diabetes, non-significant differences were observed in the percentage reduction in HbA1c and fasting glucose in exploratory analyses. Our results indicate that the consumption of bioactive starches is a good dietary strategy to improve metabolic control and body composition.
Background: Previous post-hoc analysis of three 12-week, double-blind, placebo-controlled trials of adjunctive brivaracetam (BRV) in patients with focal seizures demonstrated similar efficacy over placebo regardless of previous carbamazepine (CBZ), lamotrigine (LTG), levetiracetam (LEV), or topiramate (TPM) failure. This analysis explored long-term retention of adjunctive BRV in patients with previous CBZ/LTG/LEV/TPM. Methods: Post-hoc analysis of double-blind, placebo-controlled trial (N01358 [NCT01261325]) and open-label extension (N01379 [NCT01339559]; cut-off 15-March-2017) of adjunctive BRV in patients (≥16 years) with focal seizures. Outcomes were assessed in patients randomized to BRV (100 or 200 mg/day) who had previous CBZ/LTG/LEV/TPM (stopped ≥90 days before BRV initiation). Results: 503 patients were analyzed. Baseline characteristics were generally similar in subgroups with previous CBZ/LTG/LEV/TPM (n=209/162/256/182). Overall, Kaplan-Meier-estimated BRV retention at 1-, 3-, and 5-years was 71.0%, 50.9%, and 32.4%. Across previous antiepileptic drug (AED) subgroups, Kaplan-Meier-estimated BRV retention (1-year: 64.8%–73.2%; 3-year: 41.9%–49.9%; 5-year: 31.5%–35.7%), BRV discontinuations (58.4%–63.0%), and most common reasons for discontinuation (lack of efficacy: 23.0%–25.3%; adverse event: 16.7%–22.2%) were generally similar. Conclusions: Post-hoc analysis demonstrated similar long-term retention rates and discontinuation reasons with adjunctive BRV in adults previously treated with CBZ/LTG/LEV/TPM. Adjunctive BRV provides long-term effectiveness in patients who failed common AED treatments, including LEV.
There is no suitable vaccine against human visceral leishmaniasis (VL) and available drugs are toxic and/or present high cost. In this context, diagnostic tools should be improved for clinical management and epidemiological evaluation of disease. However, the variable sensitivity and/or specificity of the used antigens are limitations, showing the necessity to identify new molecules to be tested in a more sensitive and specific serology. In the present study, an immunoproteomics approach was performed in Leishmania infantum promastigotes and amastigotes employing sera samples from VL patients. Aiming to avoid undesired cross-reactivity in the serological assays, sera from Chagas disease patients and healthy subjects living in the endemic region of disease were also used in immunoblottings. The most reactive spots for VL samples were selected, and 29 and 21 proteins were identified in the promastigote and amastigote extracts, respectively. Two of them, endonuclease III and GTP-binding protein, were cloned, expressed, purified and tested in ELISA experiments against a large serological panel, and results showed high sensitivity and specificity values for the diagnosis of disease. In conclusion, the identified proteins could be considered in future studies as candidate antigens for the serodiagnosis of human VL.
Temporary excavations during the construction of the Glendoe Hydro Scheme above Loch Ness in the Highlands of Scotland exposed a clay-rich fault gouge in Dalradian Supergroup psammite. The gouge coincides with the mapped trace of the subvertical Sronlairig Fault, a feature related in part to the Great Glen and Ericht–Laidon faults, which had been interpreted to result from brittle deformation during the Caledonian orogeny (c. 420–390 Ma). Exposure of this mica-rich gouge represented an exceptional opportunity to constrain the timing of the gouge-producing movement on the Sronlairig Fault using isotopic analysis to date the growth of authigenic (essentially synkinematic) clay mineralization. A series of fine-size separates was isolated prior to K–Ar analysis. Novel, capillary-encapsulated X-ray diffraction analysis was employed to ensure nearly perfect, random orientation and to facilitate the identification and quantification of mica polytypes. Coarser size fractions are composed of greater proportions of the 2M1 illite polytype. Finer size fractions show increasing proportions of the 1M illite polytype, with no evidence of 2M1 illite in the finest fractions. A series of Illite Age Analysis plots produced excellent R2 values with calculated mean ages of 296 ± 7 Ma (Late Carboniferous–Early Permian) for the oldest (2M1) illite and 145 ± 7 Ma (Late Jurassic–Early Cretaceous) for the youngest (1M) illite. The Late Carboniferous–Early Permian (Faulting event 1) age may represent resetting of earlier-formed micas or authigenesis during dextral displacement of the Great Glen Fault Zone (GGFZ). Contemporaneous WNW(NW)–ESE(SE) extension was important for basin development and hydrocarbon migration in the Pentland Firth and Moray Firth regions. The Late Jurassic–Early Cretaceous (Faulting event 2) age corresponds with Moray Firth Basin development and indicates that the GGFZ and related structures may have acted to partition the active extension in the Moray Firth region from relative inactivity in the Pentland Firth area at this time. These new age dates demonstrate the long-lived geological activity on the GGFZ, particularly so in post-Caledonian times where other isotopic evidence for younger tectonic overprints is lacking.
Trichomonas vaginalis is a protozoan parasite that causes trichomoniasis in humans, the most prevalent non-viral sexually transmitted disease (STD). Imidazole compounds are used for the treatment of trichomoniasis, and metronidazole is the most commonly prescribed. However, these compounds can lead to parasite resistance and unwanted side effects. Therefore, there is a need for an alternative treatment for this disease. Here, we explored the potential of clotrimazole (CTZ) and zinc compounds, as well as CTZ complexed with zinc salts ( acetate [Zn(CTZ)2(Ac)2] and  a chloride [Zn(CTZ)2Cl2] complexes) against T. vaginalis. We synthesized the zinc complexed CTZ compounds and determined their concentration values that inhibited parasite growth by 50% (IC50). We used scanning and transmission electron microscopy to visualize the ultrastructural alterations induced by CTZ and their zinc complexes. The incubation of the parasites with [Zn(CTZ)2(Ac)2] complex inhibited their growth, yielding an IC50 of 4.9 µm. Moreover, there were changes in the shape of treated parasites, including the formation of surface projections that subsequently detached from the cell, in addition to changes in the hydrogenosomes, endoplasmic reticulum and Golgi complex. We found [Zn(CTZ)2(Ac)2] to be a highly effective compound against T. vaginalis in vitro, suggesting its potential utility as an alternative chemotherapy for trichomoniasis.