Abstract Economists and statisticians constructing the national income accounts usually overlook the many benefits derived by communities from natural forests and woodlands. This study attempted to impute a value for the ecosystem services of these resources in Swaziland employing an environmental accounting framework. The current measure of national income was found to underestimate GDP by 2% and under value national savings by 10% by not accounting for the flow and asset values of natural forests and woodlands. The study also revealed a very high dependence of the rural communities in Swaziland on natural forests and woodlands for their livelihoods as they derive more than 50% of the value of total household consumption expenditure from these resources. These results clearly indicate the significant contribution to and crucial role these resources play in the lives and wellbeing of the Swazi people and hence the importance of prudent management and utilisation of this resource sector.


An efficient and inexpensive laboratory approach for the generation and the purification of polyclonal antibodies to human antigen CD34 was developed. It was shown that cloned refolded and purified from Escherichia coli recombinant extracellular fragment of CD34 antigen retained immunogenic determinants of cell-surface expressed CD34. Immunization of mice with unglycosylated truncated recombinant protein elicit polyclonal antibodies specific for the native human antigen CD34. The antibodies generated are applicable for phenotyping of CD34+ cells using immunocytochemistry and flow cytometry assays.


Background:
 Swallowing is a complex process. Dysphagia, or impaired swallowing, may result in aspiration and can significantly contribute to morbidity and mortality. Approximately 25-70% of patients with stroke have dysphagia. Dysphagia and dependency for feeding/oral care are important risk factors in the development of aspiration pneumonia, which can delay patient functional recovery. Hospital acquired pneumonia (HAP) prevention studies have focused on critical care environments with intubated patients. Far fewer studies have investigated non-intubated patients, however the same physiologic principles apply.

 Purpose:
 The purpose of this program is to present an evidence-based practice initiative implemented utilizing ventilator-associated pneumonia (VAP) oral care techniques in the non-intubated, at risk stroke population.

 Methods:
 A multidisciplinary educational approach was utilized to implement a comprehensive oral care program recommended by the Centers for Disease Control and Prevention (CDC). Care practices include all patients, regardless of mental status, have their teeth brushed at least twice daily. Additionally, patients at risk who are eating, have their teeth brushed prior to meals and then mouth cleansed and moisturized after meals. Patients with altered mental status who are NPO receive oral care every 2-4 hours using swabs/cleanser and moisturizer.

 Results:
 Aspiration pneumonia rate of stroke patients on the neuro/stroke unit was tracked. Pre-implementation aspiration pneumonia rates were 4% (128 patients). Post implementation aspiration pneumonia rates were reduced to 1.4% (268 patients).

 Conclusion:
 Prevention of hospital acquired pneumonia is essential and has been shown to improve outcomes. A team approach is vital in providing oral care and preventing potential aspiration pneumonia. A nursing-led research study will be undertaken to further explore this topic.


Submittal of an algorithm for consideration for publication in Communications of the A C M implies unrestricted use of the algorithm within a computer is permissible. Copyright © 1973, Association for Computing Machinery, Inc. General permission to republish, but not for profit, all or part o f this material is granted provided that A C M ' s copyright notice is given and that reference is made to the publication, to its date of issue, and to the fact that reprinting privileges were granted by permission of the Association for Computing Machinery.


Anatomy education is undergoing significant transformation. It is unknown whether changes are in accordance with occupational therapy (OT) practice needs. The purpose of this pilot study was to survey OT clinicians to determine their perspectives on the value of anatomy in OT curricula, and anatomical knowledge required for practice. In addition to demographics, the survey asked questions on the value of a standalone anatomy course, integration of anatomical content in other coursework, practice areas requiring anatomy knowledge, course content, teaching media recommendations, and their opinions regarding whether graduates have adequate anatomy knowledge for competent practice. Surveys were distributed to OT practitioners in the state of Arizona (n = 107). Response rate was 51% on electronic surveys, 29% on mailed surveys. All respondents recommended an anatomy course in OT curricula; 97% as a standalone course with integration of course content throughout the curriculum. The most recommended teaching method was cadaver dissection. Content areas identified as important to cover included skeletal, muscular, and nervous systems. Regions recommended were the upper limb, thorax/trunk, head and neck, and lower limb. Practice areas requiring anatomy knowledge included joint range of motion and strengthening treatment interventions, goniometry, muscle strength testing, assessing muscle tone, wheelchair assessment/prescription, orthotics, physical agent modalities, and activity adaptation. Eighty‐one percent felt that entry‐level practitioners had adequate knowledge for competent practice. This study supports inclusion of a separate anatomy course in OT curricula, continued use of cadavers, and the importance of including input from practicing clinicians when determining anatomy course content. Anat Sci Educ 7: 97–106. © 2013 American Association of Anatomists


The purpose of this paper was to draw attention to particularly important aspects of pronouncing forensic psychiatric judgment regarding the accused or convicted individuals' competency to stand trial. The level of a person's mental capacity should be established using a structured psychiatric interview concerning a variety of aspects of a trial. Emphasis should be placed on evaluating the defendant's consciousness of the charges, knowledge of the potential punishment, ability to make significant decisions and be engaged in defense, knowledge about the role that particular people present in the courtroom play, understanding of the meaning of the evidence gathered in the case, the risk of aggression. The analysis should take into account the specificity of the mental disorder, the influence of proceedings on the course of disorder, as well as the presence of reactive disorders. Using testing tools by the expert can facilitate the process of evaluation to a certain degree. Forensic psychiatric evaluations can give rise to difficulties for the experts, what with the changing legal regulations and their interpretations. It would be justified to develop the standards of evaluation in this kind of cases, which would on the one hand apply to experts but which would also be respected by the judicial organ.


With the emergence of a variety of mobile data services with variable coverage, bandwidth, and handoff strategies, and the need for mobile terminals to roam among these networks, handoff in hybrid data networks has attracted tremendous attention. This article presents an overview of issues related to handoff with particular emphasis on hybrid mobile data networks. Issues are logically divided into architectural and handoff decision time algorithms. The handoff architectures in high-speed local coverage IEEE 802.11 wireless LANs, and low-speed wide area coverage CDPD and GPRS mobile data networks are described and compared. A survey of traditional algorithms and an example of an advanced algorithm using neural networks for PTO decision time in homogeneous networks are presented. The HO architectural issues related to hybrid networks are discussed through an example of a hybrid network that employs GPRS and IEEE 802.11. Five architectures for the example hybrid network, based on emulation of GPRS entities within the WLAN, mobile IP, a virtual access point, and a mobility gateway (proxy), are described and compared. The mobility gateway and mobile IP approaches are selected for more detailed discussion. The differences in applying a complex algorithm for HO decision time in a homogeneous and a hybrid network are shown through an example.


The detection of injury on the skin of fish has generally been limited to gross macro- scopic examination, which has numerous limitations, including researcher subjectivity and a lack of quantitative analytical capacity. The use of chemical enhancers, such as those used by forensic ana- lysts, can aid in the detection and quantification of skin injuries in fish, which can arise from fish interactions with humans and anthropogenic infrastructure (e.g. recreational and commercial fishing, research sampling, fishway passage or guidance, turbines). In this review, we examine several pre- sumptive tests for blood and evaluate their potential usefulness for detecting and quantifying injury in fish. Our evaluation was based on sensitivity, specificity, cost, carcinogenicity and ease of use. Fluorescein and Bluestar© offer the ability to perform whole body detection, but require low-light conditions and a digital camera to capture the emitted light. Several tests (i.e. Hemastix®, Hemi- dent™, phenolphthalein) yield rapid results and do not require large or expensive pieces of equip- ment, which makes them ideal for field use, although further research is needed to validate these tools for use on different fish species and in different contexts. Collectively, these tools show promise for a variety of fish research, conservation and management applications, including hydropower assessment, commercial fisheries bycatch evaluation, and analysis of the practices and gear regula- tions associated with recreational angling.


Recurrent parotitis in children is a well described but rare condition of unknown cause. The clinical features of 11 children with recurrent parotitis are described.


In this study we investigate Boots2Business (B2B), a new entrepreneurship program developed in 2012 by the US Small Business Administration in cooperation with several partners.  B2B is a program specifically tailored for military service members that are leaving active duty.  It is a part of the DOD's Transition Assistance Program (TAP).  The program offers veterans a chance to learn how to start a new business through a two-day workshop followed by an 8-week online course offered through Syracuse University, in cooperation with the SBA.   This study offers insights into the program based on first-hand observations, secondary information, and government reports, with an emphasis on the two-day workshop.  In addition, we compare and contrast it with three other SBA programs: SBDC, SCORE and SBI.  We conclude by discussing the implications of B2B for policy makers and suggesting directions for future research.


Oxalic acid is a complexing agent used in both chemical mechanical planarization (CMP) of copper and post-CMP cleaning. Aqueous solubility diagrams and potential-pH diagrams at different total dissolved copper and oxalic acid activities were derived to examine the electrochemistry of copper in aqueous oxalic acid solutions. The predictions of the diagrams are discussed in terms of the experimental data available in the electrochemistry and Cu CMP literature. Good correlations were found.


Bovine β-lactoglobulin (β-LG) was conjugated with chitosan (CHS) by means of a water-soluble carbodiimide to reduce the immunogenicity of β-LG. Each β-LG-CHS conjugate was purified by ion-exchange chromatography and hydrophobic chromatography. The conjugation between β-LG and CHS was confirmed by SDS–PAGE, the isoelectric point of the conjugate being higher than that of β-LG. Two types of the β-LG-CHS conjugate were obtained with molar ratios of β-LG to CHS of 1:1 (F1) and 1:2 (F2). Structural analyses by fluorescence measurement, ELISA with monoclonal antibodies and retinol-binding activity indicated that the conjugates had almost maintained the native structure of β-LG. The antigenicity of the β-LG-CHS conjugates was similar to that of β-LG in C3H/He mice. Reduction of the immunogemicity of β-LG was achieved by conjugation with CHS. In particular, F2 showed very low immunogenicity. B cell epitopes of β-LG and the conjugates recognized in C3H/He mice were determined with 15-mer multi-pin peptide; the linear epitope profiles of the conjugates were found to be similar to those of β-LG, while the antibody response to each epitope was dramatically reduced. Conjugation of β-LG with chitosan was effective for reducing the immunogenicity of β-LG.


Introduction
Multiple bone fractures in a newborn can be associated with osteogenesis imperfect (OI). OI is a rare genetic disorder that causes Type I collagen synthesis disturbance results in bone fragility.

Case Report
We present a female newborn which had numerous fractures of the humerus, bilateral clavicle, and bilateral femur. Her delivery was at 36 weeks gestation by spontaneous vaginal delivery. She had has not any pathological symptom at 2 weeks after birth, the patient had a fracture of the humerus, bilateral clavicle, and femur without any trauma. Genetic analysis of the patient was reported and OI diagnosed. The patient was followed up for 8 months with regularly and without any complication.

Conclusion
Multiple fractures with OI in an infant after birth may require an accurate orthopedic plan for diagnosing and treatment.


In this article, the differences in implementation of policies in relation to chronically ill employees are discussed in the context of organizational culture. It appears that an appropriate organizational culture is required to be able to take measures to retain chronically ill employees. Various stakeholders view organizational culture as a magic bullet to help introduce company policy to retain chronically ill workers. Within functionalist approach to organizational culture, the three perspectives (integration, fragmentation and differentiation) can be distinguished. According to these perspectives, we classify organizations in accordance to the decision-making and hierarchical structures. We shall explore how the three organizational culture perspectives can be used for understanding what may constitute 'best practice' or 'best strategy' in order to address the question of what the organizations can do to facilitate sustained employability for chronically ill workers. The main objective was to determine what type of organizational culture is more effective for policies and practices in case of optimal functioning of chronically ill employees. Preliminary research results are based on a number of case studies conducted with the managers and HRM of government and commercial organizations between March 2007 and October 2008. These case studies were based on open interviews and focus group sessions (for human resource departments) which were consequently analyzed using thematic analysis. For group sessions, we used concept mapping to collect information from two groups of HRM professionals and managers. Concept mapping is a structured methodology for eliciting, organizing and aggregating the ideas of groups of diverse stakeholders on a certain focus question. It uses qualitatively collected data from group members and results in quantitatively derived graphic maps (concept maps) displaying the interrelationships among ideas expressed by the group and its subgroups. i ii


Shock waves are indispensable tools for medical applications, and hence their interactions with human tissue become one of the most important basic research topics. In this paper, the determination of shock Hugoniot curves for liquids that can model human tissue, namely water, castor oil, and aqueous solutions of sodium chloride, sucrose and gelatin, at 10 and 20 weight percent are presented. Underwater shock waves were generated by ignition of 10 mg silver azide pellets and time variations of over-pressures were measured and simultaneously the shock speed was measured by the time of flight technique. Then shock Hugoniot curves were obtained, by assuming the Tait type equation of state, to relate the estimated density and measured pressure values. Results show in the cases of aqueous solutions that increasing amount of additives into water causes only a very minute decrease in the compressibility of the solution. This difference was more pronounced in the case of sodium chloride, less for gelatin, and almost none for sucrose aqueous solution.


A new species of reed snake, genus Calamaria, is described from the Banggai Islands off the east coast of Central Sulawesi, Indonesia. The new species, which is phenotypically similar to C. ceramensis from the central Moluccas, is characterised by the absence of preocular scales, five supralabials (third and fourth entering orbit), five infralabials (the first meet behind the mental), mental scale separated from the anterior chin shields, five scales surrounding the paraparietal, (most probably) seven modified maxillary teeth, a high number of ventral scales, a short, thick tail which is slightly tapering to a point, a single anal plate, as well as by a characteristic colour pattern of a pale brown dorsum dotted with darker spots, a pale collar behind the head, and a pale and dark lateral zigzag pattern along the body. Calamaria banggaiensis sp. nov. represents the fifty-eighth known species of Calamaria and the twelfth species of this genus recorded from the Sulawesi region. The new taxon is the only species of reed snake recorded from the Banggai Islands. It is known only from two adult specimens, a male and a female. For phenotypic comparison with the new species, both syntypes of C. ceramensis de Rooij, 1913, are depicted herein for the first time. An updated key to the Calamaria species of Sulawesi and its satellite islands is presented.


This paper presents three principles for alarm analysis to develop early warnings of failure. The concepts are illustrated with real data and experience drawn from Comverse voice mail systems installed by telecom service providers worldwide. The case study demonstrates practicality of the approach and insight to further advance this body of research.


Learn LabVIEW 2010 / 2011 Fast is written for users that have no experience with LabVIEW and only a limited understanding of automatic data acquisition. This primer will help you quickly become proficient using LabVIEW and confident in your ability to create applications in a wide variety of data acquisition topics. The goal of this primer is to introduce you to LabVIEW for hands-on use in automatic data acquisition and controls applications. This primer uses a number of practical real-life examples to provide both breadth and depth to the topic. The real-life examples used in this book demonstrate the value of LabVIEW, provide motivation for learning LabVIEW and make the examples fun to program. The first chapter of this book is designed to introduce you to the general concepts of LabVIEW through the development of a general program that acquires analog input data. The rest of the book introduces you to general concepts of data measurement and generation using LabVIEW s configuration approach for automatic data acquisition. This primer has a unique modular structure that does not require the chapters to be completed in succession. After you complete the first chapter you are free to complete whichever sections you would like, in the order you would like to complete them, allowing you to focus on the topics that are of most interest to you. Each section in the primer introduces you to a new data acquisition topic. After an introduction to the topic, a program is developed within this topic using step by step instructions. Each chapter concludes with several additional practical application problems, where the data acquisition program is given, but the detailed steps to create the program are left to you. Example problems are provided for all modes of data acquisition, including analog input and output, digital input and output, and counters. For example, the problems show many aspects of analog input, such as hardware and software timing, buffered and triggered acquisition, and examples with common sensors, such as thermocouples and strain gages. Examples from other acquisition modes show how to drive many common output devices, such as stepper motors, servo motors, and DC motors, as well as software control programs, such as the PID compensator and pulse width modulation. Table of Contents 1. LabVIEW for Data Acquisition 2. Analog Signal Measurement and Generation 3. Digital Signal Measurement and Generation 4. Counters Index


119 Published By: Blue Eyes Intelligence Engineering & Sciences Publication © Copyright: All rights reserved. Retrieval Number: J09900641020/2020©BEIESP DOI:10.35940/ijmh.J0990.0641020 Journal Website: www.ijmh.org Abstract: Through the development of technology and the increasing number of internet usage at this time, it is very interesting that many various business businesses to market their products through e-commerce, resulting in considerable business competition for participating companies. In e-commerce business competition, companies use various marketing strategies related to communication, one of which is advertising, because advertising attracts many consumers to see their products on the e-commerce site. In the use of advertising strategies, companies must have a variety of creative concepts in pairing their advertisements, one of which is by requiring ad stars who will present their products to consumers who can be said to be brand ambassadors. Companies must be smart in choosing brand ambassadors who will be used as weapons to market their products in these advertisements, in order to attract many consumers to view these products and buy them. So, the appeal of advertising and brand ambassadors is very important in making purchasing decisions. Because of the existence of attractive advertisements and brand ambassadors that can attract consumers to buy makes the company's best strategy to market its products. The research I did was to analyze the effect of ad appeal on Shopee's online purchasing decisions and also analyze the influence of brand ambassadors on Shopee's online purchasing decisions. The method used in this study is a survey method with a questionnaire as primary data. The results of research that uses the attractiveness of advertising and brand ambassadors find that the attractiveness of advertisements has a significant effect on purchasing decisions and brand ambassadors also show a significant influence on purchasing decisions. So it can be concluded that advertising and brand ambassadors have a very important role in the company's strategy in marketing its products.


The substantial reduction in ischemic events provided by the dual antiplatelet regimen with aspirin and clopidogrel is well documented in patients with acute coronary syndrome and patients undergoing percutaneous coronary intervention. Recently the variable response to the antiplatelet agents has received considerable attention after several "boxed warnings" on clopidogrel. This led to intense controversy on pharmacokinetic, pharmacodynamic, and pharmacogenomic issues of antiplatelet drugs, especially clopidogrel. Research use of platelet function testing has been successfully validated in identifying new antiplatelet drugs like prasugrel and ticagrelor. These platelet function assays are no longer regarded just as a laboratory phenomenon but rather as tools that have been shown to predict mortality in several clinical trials. It is believed that suboptimal response to an antiplatelet regimen (pharmacodynamic effect) may be associated with cardiovascular, cerebrovascular, and peripheral arterial events. There has been intense controversy about this variable response of antiplatelet drugs and the role of platelet function testing to guide antiplatelet therapy. While the importance of routine platelet function testing may be uncertain, it may be useful in high-risk patients such as those with diabetes mellitus, diffuse three vessels coronary artery disease, left main stenosis, diffuse atherosclerotic disease, and those with chronic renal failure undergoing percutaneous coronary intervention. It could also be useful in patients with suspected pharmacodynamic interaction with other drugs to assure the adequacy of platelet inhibition. While we wait for definitive trials, a predictive prognostic algorithm is necessary to individualize antiplatelet therapy with P2Y12 inhibitors based on platelet function assays and genetic testing.


As a result of the examination of fractured tracheids of Pinus insignis it is shown that an outer lamella (presumed to be the primary layer) of the tracheid wall is composed of cellulose chains which lie at an angle of some 11° to the transverse plane. This orientation is quite distinct from that in the secondary layer, where the cellulose chains lie in steep spirals and in which, as shown in the present paper by an optical method, the chain direction is more or less uniform throughout the whole thickness of the layer. There is no significant correlation between these two directions of orientation. This pseudo-transverse orientation in the primary wall necessitates re-examination of the connexion between secondary wall structure and tracheid length, established by the writer in 1934 and at that time ascribed to changes in primary wall structure which the present paper shows cannot occur. The opportunity is taken of examining some of the current ideas concerning the mechanism of orientation in primary walls, and it is pointed out that the mechanism may involve the cytoplasmic surface. In the cambial initial, as in growing cells investigated by other workers, elongation does not apparently involve any change in the orientation of the cellulose chains. The implications of this are briefly discussed, and it is shown that much needs to be known about the detailed organization of these walls before this maintenance of pseudo-transverse orientation can be completely understood.


A cross-sectional study on S6 females was conducted in the rural and urban areas of Lucknow district of Uttar Pradesh to assess the knowledge of females about exclusive breast-feeding. Knowledge from adolescent girls, married and lactating women was assessed by a pretested questionnaire for biosocial correlates (such as marital status,educational status, medium of education, working status, socio-economics status and family size), sources of information, time of initation of breast-feeding and the best method of feeding a baby <4 months of age. Only 9.8% in urban and 13.3% in rural areas had complete knowledge of Exclusive breast-feeding. Educated females had more knowledge in both urban and rural areas of initiating breast-feeding within 1 hr of delivery as compared to un-educated females. The study highlights the needs for continuing medical education and for including knowledge about Exclusive breast-feeding in school curriculum of adolescent girls.


This paper presents an FPGA implementation of Advance Encryption Standard (AES), using Minimal Instruction Set Computer (MISC) with Harvard Architecture. With simple logic components and a minimum set of fundamental instructions, the MISC using Harvard Architecture enables the AES encryption in severely constraint hardware environment, with lesser execution clock cycles. The MISC architecture was verified using the Handel-C hardware description language and implemented on a Xilinx Spartan3 FPGA. The implementation uses two separate block RAMs and occupied only 1% of the total available chip area.


Different proposals of SOLAP query languages exist in the literature; however, a taxonomy of SOLAP operators has not been formally defined to date. This paper presents a systematic method for classifying SOLAP operators which combines the elements that constitute a data cube with three application categories: multidimensional, spatial and temporal. Additionally, this paper proposes a set of SOLAP operators along with their syntax. A comparison between the set of operators derived from the proposed taxonomy and the operators from existing SOLAP query languages is carried out. Besides, some implementation results of the proposed operators are presented.


We measured the time course of saccadic suppression and tested whether suppression results entirely from retinal image motion or has an extraretinal source. We measured contrast thresholds for low-frequency gratings modulated either in luminance, at 17 cd/m2 and 0.17 cd/m2, or color at 17 cd/m2. Gratings were flashed on a uniform background before, during, or after voluntary 12° saccades and, additionally in the case of luminance modulated gratings, saccades simulated by mirror motion. A 10-fold decrease in contrast sensitivity was found for luminance-modulated gratings with saccades, but little suppression was found with simulated saccades. Adding high-contrast noise to the display increased the magnitude and the duration of the suppression during simulated saccades but had little effect on suppression produced by real saccades. Suppression anticipates saccades by 50 msec, is maximal at the moment of saccadic onset, and outlasts saccades by ∼50 msec. At lower luminance, suppression is reduced, and its course is shallower than at higher luminance. Simulated saccades produce shallower suppression over a longer time course at both luminances. No suppression was found for chromatically modulated gratings. Differences between real and simulated saccades in the magnitude and time course of sensitivity loss suggest that saccadic suppression has an extraretinal component. We model the effects of saccades by adding a signal to the visual input, so as to saturate the nonlinear stage of visual processing and make detection of a test stimulus more difficult.


Mass casualty incidents are a concern in many urban areas. A community ' s ability to cope with such events depends on the capacities and capabilities of its hospitals for handling a sudden surge in demand of patients with resource-intensive and specialized medical needs. This paper uses a whole-hospital simulation model to replicate medical staff, resources, and space for the purpose of investigating hospital responsiveness to mass casualty incidents. It provides details of probable demand patterns of different mass casualty incident types in terms of patient categories and arrival patterns, and accounts for related transient system behavior over the response period. Using the layout of a typical urban hospital, it investigates a hospital ' s capacity and capability to handle mass casualty incidents of various sizes with various characteristics, and assesses the effectiveness of designed demand management and capacity-expansion strategies. Average performance improvements gained through capacity-expansion strategies are quanti fi ed and best response actions are identi fi ed. Capacity-expansion strategies were found to have superadditive bene fi ts when combined. In fact, an acceptable service level could be achieved by implementing only 2 to 3 of the 9 studied enhancement strategies. ( Disaster Med Public Health Preparedness . 2018;12:778-790)


This paper addresses a problem often encountered when estimating control points used in visual speech synthesis. First, Hidden Markov Models (HMMs) are estimated for each viseme present in stored video data. Second, models are generated for each triseme (a viseme in context with the previous and following visemes) in the training set. Next, a decision tree is used to cluster and relate states in the HMMs that are similar in a contextual and statistical sense. The tree is also used to estimate HMMs for any trisemes that are not present in the stored video data when control points for such trisemes are required for synthesizing the lip motion for a sentence. Finally, the HMMs are used to generate sequences of visual speech control points for those trisemes not occurring in the stored data. Comparisons of mouth shapes generated from the artificially generated control points and the control points estimated from video not used to train the HMMs indicate that the process estimated accurate control points for the trisemes tested. This paper thus establishes a useful method for synthesizing realistic audio-synchronized video facial features.


The experiment for investigating the falling snow melting characteristics of warm water flowing along sheet channels spread on a roof was performed in Tookamachi city, Nigata prefecture from February 6 to February 7,1995. The sheet surface temperatures at 11 positions in 3 channels were measured. A physical model for a gas-water-snow system was constructed to compare the predicted results with the measured ones. A fully spread uniform water film in the sheet channel was observed in the experiments. The experimental results elucidated that it was feasible to use warm water flowing along sheet channels for melting falling snow on roofs. The temperature drop in the sheet channel mainly depended on the snowfall intensity, atmospheric temperature and wind speed. Under the influence of the roof edge, the temperature drop in the channel next to the side edge was much larger than that in middle channels. A water-snow two phase flow or a snow covered frozen water was experienced temporarily in the lower reaches of the water flowing channel. These suggest that a larger water flow rate is needed for the channel next to the roof edge, and a higher inlet temperature or a greater water flow rate is required for a severe weather condition. There was reasonably good agreement between the measured and predicted water temperatures.


BACKGROUND
Accurate estimated glomerular filtration rates (eGFR) is an important step in the diagnosis of chronic kidney disease (CKD). The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, based on creatinine alone (eGFRcr), was developed to improve on the Modification of Diet in Renal Disease equation, in particular by addressing the systematic underestimation of high GFR. Whether the CKD-EPI equation, based on cystatin C alone (eGFRcys), or the combined creatinine-cystatin C CKD-EPI equation (eGFRcr-cys C), actually perform better than the CKD-EPI equation based on creatinine (eGFRcr) remains unknown, especially in Asians including Chinese populations, where eGFR equations may overestimate true GFR.

METHODS
A standard dual plasma sampling method (DPSM) of estimating (99m)Tc-diethylene triamine penta-acetic acid clearance was used to determine the reference or measured GFR (mGFR). Linear regression analysis, Bland-Altman analysis, bias, absolute bias and accuracy (P30) were used to compare the performance of the combined creatinine-cystatin C equation (eGFRcr-cys) and equations based on each marker alone (eGFRcr and eGFRcys) in Chinese subjects, including both patients with CKD and healthy individuals.

RESULTS
We enrolled 617 Chinese participants (49.11% female, 47.11 ± 17.25 years old), with a mean mGFR of 73.80 ± 37.55 mL/min/1.73 m(2). The predictive abilities (r), the accuracy (P15, P30, P50), bias and absolute bias of the eGFRcr-cys equation were superior to eGFRcr equation and the eGFRcys equation in overall samples. Bland-Altman analysis also demonstrated a consistent result. When compared in subgroups, the accuracy (P30) of all three equations exceeded 90% at mGFR ≥90 mL/min/1.73m(2); the eGFRcr-cys equation had the highest accuracy (P30: 95.56%). At mGFR 60-89 mL/min/1.73 m(2), the accuracies (P30) of the eGFRcr-cys and eGFRcr equations exceeded the acceptable level (≥70%), and there was no significant difference between them (P = 0.58). At mGFR <60 mL/min/1.73 m(2), the accuracy (P30) of all three equations was below 70%, but the eGFRcr-cys equation had the greatest precision.

CONCLUSIONS
The performances of the eGFRcr-cys and eGFRcr equations were similar to superior to that of the eGFRcys equation at higher GFR levels in an Asian population, especially in normal and mild to moderate kidney disease. Further improvement is needed for these equations at GFR <60 mL/min per 1.73 m(2).


Gastric inhibitory polypeptide (GIP) release into the portal vein in response to duodenal instillation of glucose in doses of 0.695, 1.39, 2.78 and 5.56 mmol/kg body weight was studied in an acute condition in male Wistar rats. A rapid, dose-dependent, and significant rise in portal vein plasma GIP was found in response to increasing duodenal glucose loads, which could be described by Michaelis-Menten kinetics. It is suggested that the glucose-induced GIP release into the portal vein mainly is effected first after glucose has gained access inside the mucosal cells.


Climatic issues pervade early modern English drama, and three main reasons may be adduced for this. First, while in the first half of the 16th century Renaissance natural philosophers still felt compelled to acknowledge the accidental nature of weather‐related phenomena, in the second part of the century, new beliefs emerged and the dramatization of celestial events allowed for a more immediate access to the natural world. Second, then as now, Shakespeare's "sceptred isle" (Richard II) was often exposed to the wind, the rain and the freezing air, and such characteristics were believed to have a lasting impact on the habits of the English nation. Third, people then had to struggle against the adverse weather conditions characterized by what is now referred to as the "Little Ice Age." As actor and playwright, Shakespeare saw the sky as a theatrical element. While his so‐called festive comedies appear far less festive if we pay attention to their climatic specificities, his tragedies offer interesting insights into the way the playwright associates heavens and humors on the one hand, climate and the planets on the other. I thus argue that climate was for Shakespeare a framing device giving coherence to his playtexts and providing the audience with a natural, elemental, and cosmic background. His interest in the way weather conditions affect human behavior prompted him to modify traditional points of view and, as a result, to foreground Man's ominous capacity to trigger climatic disorders.


This paper analyses synchronization in business cycles across the European Union (EU) since 1989. We include both old and new European Union members and countries which are currently negotiating accession, as well as potential European Union members. Our methodological approach is based on the correlation matrix and the networks within, which allows us to summarize the individual interaction and co-movement, while also capturing the existing heterogeneity of connectivity within the European economic system. The results indicate that the synchronization of the old EU countries remained stable until the current financial crisis. Additionally, the synchronization of the new and potential members has approached to the old EU members although we observe the existence of different synchronization levels and dynamics in output growth in single countries as well as in groups of countries. Some countries have achieved an important degree of co-movement (such as the Baltic Republics, Hungary, Slovenia and Iceland), while others have experienced reduced synchronization, or even desynchronization (such as Romania, Bulgaria and even Greece and Ireland).


Purpose To quantify visual field (VF) variability as a function of threshold sensitivity and location, and to compare weighted pointwise linear regression (PLR) with unweighted PLR and pointwise exponential regression (PER) for data fit and prediction ability. Methods Two datasets were used for this retrospective study. The first was used to characterize and estimate VF variability, and included a total of 4,747 eyes of 3,095 glaucoma patients with six or more VFs and 3 years or more of follow-up. After performing PER for each series, standard deviation of residuals was quantified for each decibel of sensitivity as a measure of variability. A separate dataset was used to test and compare unweighted PLR, weighted PLR, and PER for data fit and prediction, and included 261 eyes of 176 primary open-angle glaucoma patients with 10 or more VFs and 6 years or more of follow-up. Results The degree of variability changed as a function of threshold sensitivity with a zenith and a nadir at 33 and 11 dB, respectively. Variability decreased with eccentricity and was higher in the central 10° (P < 0.001). Differences among the methods for data fit were negligible. PER was the best model to predict future sensitivity values in the mid term and long term. Conclusions VF variability increases with the severity of glaucoma damage and decreases with eccentricity. Weighted linear regression neither improves model fit nor prediction. PER exhibited the best prediction ability, which is likely related to the nonlinear nature of long-term glaucomatous perimetric decay. Translational Relevance This study suggests that taking into account heteroscedasticity has no advantage in VF modeling.


In recent decades, the demand for ready-to-eat (RTE) food items prepared by the food catering sector has increased together with the value of cook-serve, cook-chill, and cook-freeze food products. The technologies by which foods are cooked, chilled, refrigerated for storage, and reheated before serving are of prime importance to maintain safety. Packaging materials and food containers play an important role in influencing the cooling rate of RTE foods. Food items that are prepared using improper technologies and inappropriate packaging materials may be contaminated with foodborne pathogens. Numerous research studies have shown the impact of deficient cooling technologies on the survival and growth of foodborne pathogens, which may subsequently pose a threat to public health. The operating temperatures and cooling rates of the cooling techniques applied must be appropriate to inhibit the growth of pathogens. Food items must be stored outside the temperature danger zone, which is between 5 and 60 °C, in order to inhibit the growth of these pathogens. The cooling techniques used to prepare potentially hazardous foods, such as cooked meat, rice, and pasta, must be properly applied and controlled to ensure food safety. This paper critically reviews the effects of cooling and its relationship to food containers on the safety of RTE foods produced and sold through the food service industry.


Asymptotic fluctuation theorems are statements of a Gallavotti-Cohen symmetry in the rate function of either the time-averaged entropy production or heat dissipation of a process. Such theorems have been proved for various general classes of continuous-time deterministic and stochastic processes, but always under the assumption that the forces driving the system are time independent, and often relying on the existence of a limiting ergodic distribution. In this paper we extend the asymptotic fluctuation theorem for the first time to inhomogeneous continuous-time processes without a stationary distribution, considering specifically a finite state Markov chain driven by periodic transition rates. We find that for both entropy production and heat dissipation, the usual Gallavotti-Cohen symmetry of the rate function is generalized to an analogous relation between the rate functions of the original process and its corresponding backward process, in which the trajectory and the driving protocol have been time-reversed. The effect is that spontaneous positive fluctuations in the long time average of each quantity in the forward process are exponentially more likely than spontaneous negative fluctuations in the backward process, and vice-versa, revealing that the distributions of fluctuations in universes in which time moves forward and backward are related. As an additional result, the asymptotic time-averaged entropy production is obtained as the integral of a periodic entropy production rate that generalizes the constant rate pertaining to homogeneous dynamics.


IMPORTANCE
Schools are considered an attractive setting to promote healthy living behaviors in children, but previous school-based interventions aimed at preventing weight gain in children have yielded mixed results. Novel school-based approaches are needed to modify healthy living behaviors and attenuate weight gain in children.

OBJECTIVE
To assess the effectiveness of a peer-led healthy living program called Healthy Buddies on weight gain and its determinants when disseminated at the provincial level to elementary school students.

DESIGN, SETTING, AND PARTICIPANTS
Cluster-randomized effectiveness trial performed during the 2009-2010 school year. Baseline and follow-up measurements were made in October 2009 and May 2010, respectively. The study was performed in 19 elementary schools in Manitoba, Canada, and included 647 elementary school students aged 6 to 12 years (48% girls).

INTERVENTION
Schools were randomized to receive regular curriculum or Healthy Buddies lesson plans. Lesson plans were delivered by older (9- to 12-year-old) elementary school students to the younger (6- to 8-year-old) peers and targeted 3 components of health: physical activity, healthy eating, and self-esteem and body image.

MAIN OUTCOMES AND MEASURES
The primary outcome measures were the change in waist circumference and body mass index z score. Secondary outcomes included physical activity (steps per day), cardiorespiratory fitness, self-efficacy, healthy living knowledge, and self-reported dietary intake.

RESULTS
At baseline, 36% of children were overweight or obese and 11% achieved the recommended 13,500 steps per day. Intention-to-treat analyses showed that waist circumference declined significantly in the intervention group relative to controls: -1.42 cm (-2.68 to -0.17; P = .03). Reductions in waist circumference were particularly significant for children who were younger, overweight or obese, or attending First Nations schools. No difference in body mass index z score was observed between groups. Self-efficacy, healthy living knowledge, and dietary intake significantly improved in younger peers who received the intervention compared with students from control schools. No differences were observed in daily step counts or cardiorespiratory fitness between the groups.

CONCLUSIONS AND RELEVANCE
The implementation of Healthy Buddies lesson plans delivered by older peers within an elementary school setting is an effective method for attenuating increases in central adiposity and improving knowledge of healthy living behaviors among elementary school students. Improvements were achieved with parallel improvements in diet quality, self-efficacy, and knowledge of healthy living.

TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT01979978.


Medulloblastoma is the most common malignant pediatric central nervous system tumor. Despite the adequate therapy the tumor often recurs. The primary medulloblastoma expresses somatostatin receptor-2 (SSTR-2), but so far we had no experience about the receptor status in recurrent tumors. The presence of SSTR-2 may have an important role in the early detection and treatment of recurrent medulloblastomas. Our aim was to examine the state of SSTR-2 expression in recurrent childhood medulloblastomas. We examined SSTR-2 expression by immunohistochemistry in primary and recurrent medulloblastoma samples of ten children treated with recurrent medulloblastoma at Semmelweis University, Departments of Pediatrics, between 1998 and 2004. All primary and recurrent tumors have been operated at the National Institute of Neurosurgery. We examined the intensity and the percentage of SSTR-2-positive tumor cells in the primary and recurrent tumor samples. All primary tumors were receptor-positive and SSTR-2 was also expressed in all recurrent medulloblastomas. In our samples the percentage of SSTR-2-positive tumor cells was 30-90%. As a positive in vivo control Octreoscan images were available in two cases. In these cases the results of immunohistochemistry and Octreoscan imaging seemed to correlate. As a conclusion, SSTR-2-positive recurrent tumors can be detected early by Octreoscan imaging, and the presence of SSTR-2 establishes the opportunity of applying somatostatin analogues (octreotide) in the treatment of recurrent childhood medulloblastoma.


This paper reports the outcome of 60 pregnancies in 40 women, all of whom had concomitant Crohn's disease. Detailed analysis of pregnancy rates in Crohn's disease supports in outline the hypothesis that some patients with bowel symptoms may be rendered temporarily subfertile by the activity of their bowel complaints. In contrast there is little or no evidence of any adverse effect during pregnancy on mother or child. Most pregnancies went normally to term and, if anything, Crohn's disease tended to improve during the period of confinement. After delivery, however, over 40% of patients suffered a relapse of Crohn's disease. Such a situation might well constitute a logical indication for the administration of corticosteroid therapy.


Hydrogen energy, one of the energy sources of the future, represents a substantial issue which affects the industries and national technologies that will develop in the future. In order to utilize hydrogen energy, a hydrogen supply chain is required so that hydrogen can be processed and transported to vehicles. It is helpful for technology and policy development to analyze technologies necessary to charge the hydrogen energy generated into vehicles through the supply chain to discover technologies with high potential for future development. The purpose of this paper is to identify promising technologies required in storing, transporting, and charging vehicles generated by the hydrogen fuel supply chain. Afterward, the promising technologies identified are expected to help researchers set a direction in researching technologies and developing related policies. Therefore, we provide technology information that can be used promisingly in the future so that researchers in the related field can utilize it effectively. In this paper, data analysis is performed using related patents and research papers for technical analysis. Promising technologies that will be the core of the hydrogen fuel supply chain in the future were identified using the published patents and research paper database (DB) in Korea, the United States, Europe, China, and Japan. A text mining technique was applied to preprocess data, and then a generic topographic map (GTM) analysis discovered promising technologies. Then, a technology roadmap was identified by analyzing the promising technology derived from patents and research papers in parallel. In this study, through the analysis of patents and research papers related to the hydrogen supply chain, the development status of hydrogen storage/transport/charging technology was analyzed, and promising technologies with high potential for future development were found. The technology roadmap derived from the analysis can help researchers in the field of hydrogen research establish policies and research technologies.


Databases as software components may be used to serve a variety of smart applications. Currently, the Internet of Things (IoT), Artificial Intelligence (AI) and Cloud technologies are used in the course of projects such as the Horizon 2020 EU-Korea DECENTER project in order to implement four smart applications in the domains of Smart Homes, Smart Cities, Smart Construction and Robot Logistics. In these smart applications the Big Data pipeline starts from various sensor and video streams to which AI and feature extraction methods are applied. The resulting information is stored in database containers, which have to be placed on Edge, Fog or Cloud infrastructures. The placement decision depends on complex application requirements, including Quality of Service (QoS) requirements. Information that must be considered when making placement decisions includes the expected workload, the list of candidate infrastructures, geolocation, connectivity and similar. Software engineers currently perform such decisions manually, which usually leads to QoS threshold violations. This paper aims to automate the process of making such decisions. Therefore, the goals of this paper are to: (1) develop a decision making method for database container placement; (2) formally verify each placement decision and provide probability assurances to the software engineer for high QoS; and (3) design and implement a new architecture that automates the whole process. A new optimisation method is introduced, which is based on the theory and practice of stochastic Markov Decision Processes (MDP). It uses as input monitoring data from the container runtime, the expected workload and user-related metrics in order to automatically construct a probabilistic finite automaton. The generated automaton is used for both automated decision making and placement success verification. The method is implemented in Java. It also uses the PRISM model-checking tool. Kubernetes is used in order to automate the whole process when orchestrating database containers across Edge, Fog and Cloud infrastructures. Experiments are performed for NoSQL Cassandra database containers for three representative workloads of 50000 (workload 1), 200000 (workload 2) and 500000 (workload 3) CRUD database operations. Five computing infrastructures serve as candidates for database container placement. The new MDP-based method is compared with the widely used Analytic Hierarchy Process (AHP) method. The obtained results are used to analyse container placement decisions. When using the new MDP based method there were no QoS violations in any of the placement cases, while when using the AHP based method the placement results in some QoS threshold violations in all workload cases. Due to its properties, the new MDP method is particularly suitable for implementation. The paper also describes a multi-tier distributed computing system that uses multi-level (infrastructure, container, application) monitoring metrics and Kubernetes in order to orchestrate database containers across Edge, Fog and Cloud nodes. This architecture demonstrates fully automated decision making and high QoS container operation.


Field laboratories in realistic crop environments are needed In recent decades, the scientific, development, and farm communities have contributed to substantial gains in crop productivity, including in many less developed countries (LDCs) (1), yet current yield trends and agri-food systems are inadequate to match projected demand (2). Addressing transnational crop challenges will require refinement of research infrastructure and better leverage of global expertise and technologies. Drawing on lessons learned from international collaboration in wheat, we outline how such a model could evolve into a Global Crop Improvement Network (GCIN) encompassing most staple food crops, providing access to well-controlled "field laboratories," while harmonizing research practices and sharing data. Combined with socioeconomic and cropping systems research, a GCIN could revolutionize the ability to understand and model crop responses to environments globally and accelerate adoption of vital technologies.


This paper presents karyology aspects of the diploid and polyploid species frequency on the mountain pastures in the southwestern Gutai Mountains as well as the calculation of the diploid index. The phytocoenosis of the five plant associations identified on pasture were studied: Violo declinatae-Nardetum, Simon 1966, Agrostietum stoloniferae, (Ujvarosi 1941) Burduja et al . 1956, Scirpetum sylvatici, Ralski 1931, Maloch 1935 em. Schwick 1944, Calthetum laetae, Krajina 1933, Campanulo abientinae-Vaccinietum myrtilli , (Buia et al . 1962) Boscaiu 1971. Karyotypes were taken for all encountered vegetal species to achieve an accurate cytoaxonomic analysis. The frequency of polyploid species was found in the five vegetal associations that were identified and studied in karyology terms. The number of polyploids, comprised between 52.94-75%, is ahead of the diploids number comprised between 25-43,75%, in the vegetal associations phytocoenosis of the mountainous region. Diplo-polyploid plants and those with an unknown karyotype have lower participation. The calculated value of the diploid index decreases with the increasing of the altitude, with subunit values between 0.33 - 0.82. Diploid index (DI) indicates instable character of vegetal formations of above-mentioned area, reflecting completely station conditions of the grassland. The genetic structure of the phytocoenosis and vegetal associations studied seen from the perspective of karyotypes, indicates a drop in the dioloid index value with the increasing of the anthropo- zoogen factor (excessive grazing).


Background. Alcoholic hepatitis (AH) is largely a histopathologic diagnosis that is based upon the presence of significant inflammation, hepatocellular lipid accumulation, ballooned degeneration of hepatocytes, and Mallory-Denk bodies. Underlying biochemical and molecular abnormalities include increased oxidative and endoplasmic reticulum (ER) stress, mitochondrial dysfunction, insulin resistance, lipid dyshomeostasis, and cell death. Acute AH is often precipitated by binge drinking in the setting of chronic alcohol abuse, and is problematic due to its propensity to progress to chronic alcoholic liver disease with end-points of cirrhosis or liver failure. Improved understanding of AH pathogenesis could aid in the development of new treatments and preventive measures. Study Design. To mimic conditions leading to AH in humans, we generated a chronic-binge model of ethanol exposure in which Long Evans rats were fed with isocaloric liquid diets containing 0% or 37% ethanol (caloric content) for 5 weeks, and during the last 2 weeks, the ethanol diet fed rats were binged with 2 g/kg ethanol 3 times per week. Livers were used for histologic and electron microscopic studies. Results. Ethanol-exposed livers had severe panlobular steatohepatitis with disorganization of the chord-like architecture, foci of necrosis, apoptotic bodies, ballooned degeneration of hepatocytes, giant mitochondria, disrupted ER structure and relationship to mitochondria, and early fibrosis. These findings correspond well with those seen in human AH, except for the absence of Mallory-Denk bodies. Conclusion. The overall findings suggest that chronic-binge models of alcohol feeding produce pathologic lesions that correspond with AH in humans. This approach provides better tools for designing treatment and unraveling mechanisms by which AH progresses to chronic stages of liver disease.


Lung cancer is the most common malignant lesion and the principal cause of cancer-related death worldwide. This problem encourages researchers to build computer-aided solutions to help diagnose lung cancer. Content-based image retrieval (CBIR) systems are very promising in this context due to a large number of image generated everyday. However, semantic gaps have limited CBIR applicability. This work proposes a new approach to automatically adjust CBIR attribute weights to reflect users' semantic interpretation on retrieval process, minimizing the semantic gap problem and improving retrieval accuracy.


. Gravitational vector degrees of freedom typically arise in many examples of modified gravity models. We start to systematically explore their role in these scenarios, studying the effects of coupling gravitational vector and scalar degrees of freedom. We focus on set-ups that enjoy a Galilean symmetry in the scalar sector and an Abelian gauge symmetry in the vector sector. These symmetries, together with the requirement that the equations of motion contain at most two space-time derivatives, only allow for a small number of operators in the Lagrangian for the gravitational fields. We investigate the role of gravitational vector fields for two broad classes of phenomena that characterize modified gravity scenarios. The first is self-acceleration: we analyze in general terms the behavior of vector fluctuations around self-accelerating solutions, and show that vanishing kinetic terms of vector fluctuations lead to instabilities on cosmological backgrounds. The second phenomenon is the screening of long range fifth forces by means of Vainshtein mechanism. We show that if gravitational vector fields are appropriately coupled to a spherically symmetric source, they can play an important role for defining the features of the background solution and the scale of the Vainshtein radius. Our general results can be applied to any concrete model of modified gravity, whose low-energy vector and scalar degrees of freedom satisfy the symmetry requirements that we impose.


High soluble-sulfate (SO4) concentrations affect water quality,
soil chemistry, plant sulfur (S) levels, and possibly ruminant-animal health. The
objective of this greenhouse pot study was to determine the potential for
accumulating high levels of S by tansy mustard (Descurainia pinnata (Walt.)
Britton), kochia (Kochia scoparia L. Schrad.), yellow sweet clover (Melilotus
officinalis L.), slender wheatgrass (Elymus trachycaulus (Link) Gould ex
Shinners), and sunflower (Helianthus annuus L.). Plants were grown on both a
Brinegar (fine-loamy Ultic Argixeroll) and Portneuf (coarse silty Durixerollic
Calciorthid) soil. Each species received five-SO4 levels. The saturation extract
electrical conductivity (EC) of the cropped soils ranged from 6 to 16 dS/m, while
the soluble SO4 varied from 16 to 200 mmolc/kg soil. Soil solutions were
saturated or very nearly saturated with respect to gypsum at the conclusion of each
study. Plant dry matter yield, except of grass growing on the non-calcareous soil,
was not reduced by SO4 treatment nor by the sulfate-induced decrease in mole
fraction of calcium (Ca)/(sum cations) to values less than 0.10 for kochia and
grass. Sulfur concentration in the plants ranged from 2.5 mg/g in grass to 10 mg/g
in mustard and for each species was linearly related to the SO4 treatment and
soil-SO4 activity. Plant SO4-S values ranged from 70 µg/g in the grass to nearly
900 µg/g in mustard. Total nitrogen (N):organic S was 4.4, 7.5, 11.4, 16.5, and
5.8 for mustard, kochia, clover, grass, and sunflower, respectively. It was
concluded that these species could accumulate high levels of S in the above ground
tissue.


Adopting and implementing EU qualitz standards represent an important challenge for Romanian firms with a view of efficient integration into international market. Certified test and trial laboratories perform activities involving a severe rigor. It follows that it is necessarz to carry out and to make operational mathematival models in order to reduce uncertaintz of the results and to eliminate testing errors. This paper presents a flexible software able to give a solution to the quality control in a test and trial laboratory. This program can determine an optimal assignment of resources, i.e. an optimal assignment of staff per procedure and an optional assignment of procedures per apparatus. The criterion to be optimized is the minimization of every procedure cost. This way, it is possible to get a detailed analyze required by the quality management.


The lack of a strong evidence base to guide the management of adults with sickle cell disease (SCD) makes it difficult for patients to receive high quality care outside of specialty centers. As there is a dearth of providers with sickle cell expertise, the purpose of this article is to identify some of the key things every provider who manages the care of adults with SCD should know. Managing adults with SCD requires excellent clinical skills, as it can affect every organ and cause life-threatening complications but it also requires a willingness to manage patients who often have psychosocial issues that are complex and impact care and care delivery in very significant ways. We have chosen topics for which there is a limited evidence base but which have significant clinical consequences if left unrecognized or poorly managed. The topics that will be addressed include chronic pain, neurocognitive dysfunction, renal disease, venous thromboembolism, and avoiding the inappropriate use of red cell transfusions.


Aspect term extraction and opinion word extraction are two fundamental subtasks of aspect-based sentiment analysis. The internal relationship between aspect terms and opinion words is typically ignored, and information for the decision-making of buyers and sellers is insufficient. In this paper, we explore an aspect–opinion pair extraction (AOPE) task and propose a Question-Driven Span Labeling (QDSL) model to extract all the aspect–opinion pairs from user-generated reviews. Specifically, we divide the AOPE task into aspect term extraction (ATE) and aspect-specified opinion extraction (ASOE) subtasks; we first extract all the candidate aspect terms and then the corresponding opinion words given the aspect term. Unlike existing approaches that use the BIO-based tagging scheme for extraction, the QDSL model adopts a span-based tagging scheme and builds a question–answer-based machine-reading comprehension task for an effective aspect–opinion pair extraction. Extensive experiments conducted on three tasks (ATE, ASOE, and AOPE) on four benchmark datasets demonstrate that the proposed method significantly outperforms state-of-the-art approaches.


BirdQuestVR is a cross-platform asymmetric communication game between one player in Virtual Reality and another on a mobile device. The game explores asymmetric co-operative gaming in a shared physical space, taking the physical surroundings of the VR user into account in its design. Asymmetric games feature different rules, abilities, or objectives for different players, generating unique and nuanced game experiences. Multiplayer asymmetric games in particular have been shown to increase teamwork and a collaborative mindset even after a play session has ended. Asymmetric design is commonplace in both digital and analog games but has yet to see widespread adoption in the emerging Virtual Reality (VR) gaming space. BirdQuestVR seeks to leverage the affordances of current consumer-grade VR headsets to build asymmetric gameplay around communication, embodied performance, and physical humour.


Objective: Four laboratory studies and an online experiment explored psychophysical (mind-matter) interactions with quantum entangled photons. Method: Entanglement correlation strength measured in real-time was presented via a graph or dynamic images displayed on a computer monitor or web browser. Participants were tasked with mentally influencing that metric. Results: A statistically significant increase in entanglement strength was obtained in experimental conditions in the four lab studies (p < 0.02), with particularly strong results observed in three studies conducted at the Institute of Noetic Sciences (p < 0.0002). Modest results (p < 0.05) were observed in a high-quality subset of entanglement samples in an online experiment. Control experiments using the same equipment and protocols, but without observers present, showed results consistent with chance expectation in both the lab and online studies. Conclusion: These outcomes suggest that the fidelity of entangled states and the nonlocal resource they entail may be mutable in systems that include conscious awareness. This is potentially of interest for quantum information technologies such as quantum computation, encryption, key distribution, and teleportation. The results are also relevant for interpretations of quantum theory, especially if future studies show that entanglement strength can be mentally modulated above the Tsirelson Bound – the upper limit predicted by quantum theory. Such an outcome would suggest that quantum theory in its present form does not hold when physical systems interact with certain mental states. The results of these exploratory experiments justify continued investigation of entangled photons as targets of mind-matter interaction.


The pectoral limb of the African giant rat ( Cricetomys gambianus) was studied using 12 adult rats of both sexes. Characteristics of the bones were studied by gross observation after preparation. Measurements of manus and pectoral limb (articulated) were also taken. The bones of the pectoral limb were found to be generally similar in both structure and number to other rodent species. Variation came only in the size of the bones. The scapula presented a metacromion process in addition to the acromion process. Like in all burrowing mammals, the pectoral girdle presented a rodlike clavicle and coracoids process with tuberous end. The humerus midshaft presented a prominent deltoid tuberosity, while the distal extremity has both the supratrochlear and supracondylar fossae. The radio-ulna bones are fused except at two points (proximal and distal interosseous spaces). Both the radius and ulna ended with styloid processes distally. There are 9 carpal bones with four on the proximal and five on the distal rows, respectively. Each limb presented five digits with three phalanges on each with the exception of the first digit which has two phalanges. The number of bones on each of the pectoral limb was found to be 33 plus 16 sessamoid bones making the total number of 98 bones on the pectoral limb of this rat.


These sixteen illustrated essays present an important revision of surrealism by focusing on the works of women surrealists and their strategies to assert positions as creative subjects within a movement that regarded woman primarily as an object of masculine desire or fear.While the male surrealists attacked aspects of the bourgeois order, they reinforced the traditional patriarchal image of woman. Their emphasis on dreams, automatic writing, and the unconscious reveal some of the least inhibited masculine fantasies. The first resistance to the male surrealists' projection of the female figure arose in the writings and paintings of marginalized woman artists and writers associated with Surrealism. The essays in this collection explore the complexity of these women's works, which simultaneously employ and subvert the dominant discourse of male surrealists.Mary Ann Caws is Professor of French and Comparative Literature at the Graduate Center of the City University of New York. Rudolf Kuenzli is Professor of English and Comparative Literature and Director of the International Dada Archive at the University of Iowa. Gwen Raaberg is Director of the Center for Women's Resources and Research at Western Michigan University.The Essays : What Do Little Girls Dream Of: The Insurgent Writing of Gisi'1/2le Prassinos. Finding What You Are Not Looking For. From Di'1/2jeuner en fourrure to Caroline: Meret Oppenheim's Chronicle of Surrealism. Speaking with Forked Tongues: "Male" Discourse in "Female" Surrealism? Androgyny: Interview with Meret Oppenheim. The Body Subversive: Corporeal Imagery in Carrington, Prassinos, and Mansour. Identity Crises: Joyce Mansour's Narratives. Joyce Mansour and Egyptian Mythology. In the Interim: The Constructivist Surrealism of Kay Sage. The Flight from Passion in Leonora Carrington's Literary Work. Beauty and/Is the Beast: Animal Symbology in the Work of Leonora Carrington, Remedio Varo, and Leonor Fini. Valentine, Andri'1/2, Paul et les autres, or the Surrealization of Valentine Hugo. Refashioning the World to the Image of Female Desire: The Collages of Aube Elli'1/2oui'1/2t. Eileen Agar. Statement by Dorothea Tanning.


In the transmission of alchemical knowledge, alchemical practitioners have always been perplexed by the dilemma that they have the responsibility to transmit the Way but at the same time should not divulge the Way to unworthy recipients. In this paper, I show that Wu Wu 吳悮 (c. twelfth century), different from most of his contemporaries who stress the role of the teacher in the revelation of key points or secret instructions, puts more emphasis on the texts. For him, the teacher's function is to impart the right text. The Way of divine immortals can be achieved through the mastery of principles that can be grasped from the texts. Although ancient sages compiled the alchemical texts to make the Way known to everyone, only the virtuous can comprehend the principles of the Way underlying in the scriptures. Hence, there is no need to worry that the Way is divulged to unworthy people. Thus the transmission dilemma does not present a problem for Wu Wu.


A major metabolite of [3H]ecdysone injected into adults of the nematode Parascaris equorum maintained in vitro for 48 h was secreted into the culture medium. The compound could be hydrolysed with a crude hydrolase preparation from Helix pomatia, yielding ecdysone. Sufficient quantity of this material for identification was produced by administration of ecdysone to the parasites. The resulting compound was purified by h.p.l.c. and identified as ecdysone 25-O-beta-D-glucopyranoside by n.m.r. spectroscopy and by fast atom bombardment mass spectrometry of the conjugate and of the sugar released by enzymic hydrolysis. The significance of formation of the glucoside is uncertain.


We provide objective criteria for assessing the taxonomic status of genera, especially those that are monotypic, using the coccid genus Taiwansaissetia Tao, Wong & Chang. This genus contains only the type species, Lecanium formicarii Green [currently Taiwansaissetia formicarii (Green)], known from the Afrotropical and Oriental regions. Here, Taiwansaissetia is synonymised (syn.nov.) with Coccus Linnaeus (Hemiptera: Coccidae) on the basis of phylogenetic analyses of DNA sequence data and morphological examination. All analyses (maximum parsimony, neighbour‐joining and Bayesian inference) of four gene regions (18S, 28S, COI and EF‐1α), and a concatenation of these regions, placed the clade including T. formicarii and three unidentified Coccus specimens as sister to the type species of Coccus, C. hesperidum Linnaeus, with high support. Taiwansaissetia formicarii is more closely related to C. hesperidum than C. hesperidum is to C. viridis (Green), which is considered to be a 'typical' species of Coccus, and several other current members of Coccus [C. longulus (Douglas), C. penangensis Morrison and C. pseudomagnoliarum (Kuwana)]. Explicit criteria, including monophyly, diagnosability, sister taxa being of equal rank, and the level of genetic divergence between T. formicarii and C. hesperidum relative to within‐genus divergence of other scale insects, were used to assess the taxonomic status of Taiwansaissetia. The autapomorphic features of Taiwansaissetia that differentiate it from typical species of Coccus might be due to its myrmecophilous habit and adaptation to living inside ant nests – most other species of Coccus live externally on their host plants. Since its description in 1896, T. formicarii has been placed in four different genera: here we transfer it back to Coccus as C. formicarii (Green) stat.rev. We rediagnose the genus Coccus to accommodate the features of C. formicarii. This study also found that Coccus might not be monophyletic, warranting further study of the group.


The protective effect of 1,2 and 4 mg of nedocromil sodium against airway constriction induced by hyperventilation of cold, dry air was compared with 10 mg sodium cromoglycate and placebo in a double‐blind randomized trial. On 5 days, twelve asthmatic subjects received one of the trial medications from a metered dose inhaler. Twenty minutes, 2.5 and 5 hr later, airway responsiveness to hyperventilation of cold, dry air was measured. At 20 min, there was significant protection by all four active medications when compared to placebo, with a trend towards a nedocromil dose relationship but there was no statistical difference between the four active medications. All four showed a similar progressive decrease in protection over 5 hr. The results of this study suggest that nedocromil gives protection against hyperventilation‐stimulated airway constriction and that the magnitude and duration of effect for all three doses is similar to 10 mg of cromoglycate.


This paper uses a CGE mircosimulation approach to analyze the effects of tariff reduction on poverty and income inequality. The approach relaxes the representative household assumption in the traditional CGE modeling by replacing household groups with individual households. As such the approach allows one to model the link between trade reforms and individual households and their feedback to the general equilibrium of the economy. The present paper incorporates the whole 24,797 households of the 1994 Family Income and Expenditure Survey and simulates the tariff reduction from 1994 to 2000. Tariff reduction leads to higher imports and exports. Although domestic production for the local market declines, the overall production improves. These are due to substitution and scale effects of tariff reduction. Resource reallocation and factor movements favor the nonfood manufacturing sector. Agriculture wages, as well the rate of return to capital in agriculture, decline as a result of the drop in agriculture output and value added. Income of rural households in the different regions declines, while income of urban households in the various regions (including the NCR) improves. Tariff reduction results in poverty reduction in all areas not because of the improvement in household income, but because of the drop in consumer prices. Income inequality, however, worsens except in the NCR.


The effect of moisture conditioning on the mechanical and physical properties of ICI's 'Verton' range of long glass fibre reinforced Nylon 66 materials have been investigated using injection moulded test specimens. Natural and black grades, at glass loadings of 35%, 50% and 60% by weight have been examined together with a natural un-reinforcd Nylon 66 grade.The tensile strength of the matrix polymer reduced from 80 MPa at dry - "as moulded" to 30 MPa when fully moisture saturated. Dry - "as moulded" tensile strength values for the glass reinforced grades ranged between 198 MPa and 255 MPa for the natural grades and between 183 MPa and 251 MPa for the black. With moisture conditioning for 1000 hours (42 days) at 60oC these values were reduced from 92 MPa to 119 MPa for the natural grades and 87 MPa to 120 MPa for the black. The dry - "as moulded" flexural strength values ranged between 280 MPa to 365 MPa and 249 MPa to 369 MPa for the natural and black materials, respectively. As with tensile strength these values were also reduced with moisture uptake. For the same moisture conditions the values of strength measured in flexure were reduced more than in tension. For natural materials the values ranged between 80 MPa to 102 MPa and from 70 MPa to 92 MPa for the black. The dry impact strength of notched samples ranging from 22 kJ/m^2 to 42 kJ/m^2 was found to increase to approximately 63 kJ/m^2 for the natural glass/Nylon 66 materials when fully moisture conditioned. The impact strength of black materials ranged from 15 kJ/m^2 to 37 kJ/m^2 dry and increased to approximately 61 kJ/m^2 with moisture conditioning for 1000 hours at 60oC. All changes in mechanical and physical properties were interpreted in terms of the effects of Fickian moisture uptake on the likely properties of the 'skin' and 'core' regions of injection moulded samples.


Effects of steel slag powder on properties of cement and concrete are investigated. Results show that with the increase of steel slag power, water requirement of normal consistency is decreased, and the setting times are prolonged. The early mortar strength is lower, but late strength rate of increase is great. Steel slag powder is compatible with blast furnace slag. Moreover,concrete,which has harmonious development strength and excellent workability can be obtained by mineral additives two-element compounding.


On the basis of analysis of cDNA clones of alpha-tubulin RNAs expressed during spermiogenesis in chickens, we report the identification of a novel alpha-tubulin which is expressed exclusively in chicken testes. Comparison of its sequence with those previously determined not only demonstrates that the encoded polypeptide is significantly divergent from other alpha-tubulins but also supports the hypothesis that alpha-tubulin isotypes are distinguished by a carboxy-terminal variable region sequence and, to a lesser extent, by a domain near the amino terminus. Since essentially all previously known alpha-tubulins undergo a unique cycle of removal and posttranslational readdition of a tyrosine residue at the extreme carboxy terminus, the presence in this testes alpha-tubulin of a very divergent carboxy terminus that does not contain an encoded tyrosine raises the possibility that this polypeptide does not participate in the usual cycle of tyrosination/detyrosination.


Ecological and environmental problems become very complex due to regional differences, there are some differences in the concept and the calculation methods of ecological water demand. In this paper,the described method of ecological water demand which combined with GIS technology in the study area is proposed, based on the GIS technology to generate digital land use map, calculated the required extracted land use data. Finally, the application analysis instance of Shijiazhuang to verify this theoretical approach. the results can provide a scientific basis for the calculation of the regional eco-environmental water demand, water allocation and environmental protection.


We show analytically and numerically that a practically realizable first-order optical Hilbert transformer (OHT) can simultaneously function as a negative/positive first-order temporal optical differentiator (OD) in the stopband and a broadband ±90° phase shifter in the passbands. An integrated-optic OHT based on a four-tap finite impulse response filter is designed using the Remez iteration algorithm and is numerically verified.


Arthrography of the wrist joint is a possibility to show a disc lesion by demonstrating a communication between the radioulnar and -carpal space in cases of persistent wrist pain after an accident without any bone disorders in x-ray. For differentiation between a pre-existent disc variety with a central whole and a real traumatic tear or degenerative alterations arthroscopy is the method of choice. Furthermore other changes of the wrist as free bodies and chondropathy can be seen. The indication for an arthrotomy and a causal treatment are more exact and were proved by a follow-up of 10 patient between 1985-1987 at the orthopedic university clinic Berlin.


Since its maiden coup in 1978, which initiated both an era of recurrent coup activity and a regime type dubbed "Mauritania of the Colonels," the Mauritanian military, once an unassuming, apolitical institution, has been in power either directly or through a "civilianized" military regime. Since its creation in the early 1990s, the Battalion for Presidential Security (BASEP) has played a prominent role in the workings of Mauritania of the Colonels. Only during a 17-month interlude under a civilian democratically elected president, following a bungled transition marked by the underhanded interference of some military officers, did the military formally leave power—and then only formally.
 Whether they tried to meet them in earnest or not, the challenges of withdrawing the military from the political arena and democratizing the country have dogged all military heads of state. The challenges were complicated by Mauritania's intractable ethnocultural rivalries subsumed under the "national question" and the related "human rights deficit." After Colonel Ould Taya, whose lengthy and repressive regime had the deepest impact on the country and the national question in particular, the challenges were even harder for his successors to face.
 The latest transfer of power between one retired general and another, both of whom had conspired to overthrow Mauritania's only democratically elected civilian president, is evidence that, as major players, Mauritania's military leaders are well on their way to institutionalizing the Mauritania of the Colonels they assiduously fashioned for more than 40 years.


During the financial downturn of 2008, asset classes that investors traditionally found to have low correlation with U.S. stocks became more highly correlated at the most inopportune time. Post-downturn, investors increasingly looked for alternative assets that offer diversification benefits, one of which being farmland. One of the challenges of investing in farmland is that the asset is not a securitized, low-cost investment. The current research investigates the whether exposure to farmland via an index of agribusiness stocks provides significant diversification benefits. We estimated the dependence between daily returns of the S&P 500 and an index of agribusiness stocks from 1970 through 2008 using copulas. We find significant evidence that agribusiness stocks have strong lower tail dependence with large U.S. stocks and are actually less correlated in the upper tail of the distribution. Meaning, the agribusiness index moves in near lockstep with U.S. stocks in downturns and more independently in large upswings. This provides little evidence to support the investment strategy of purchasing agribusiness stocks broadly to gain exposure to farmland.


In the supply chain literature, little work has been done on modeling the propagation pattern of quality defects in supply chains. We quantitatively model a defect bullwhip effect in supply chains that can be addressed logistically by reducing time intervals between product deliveries. We explicitly consider the cause and effect of this defect bullwhip effect and demonstrate analytically that there is a strong incentive for practitioners to continuously reduce shipment size. We also consider production characteristics such as the frequency of supplier failure and stringency of the buyer's inspection process. Implications for managers are suggested.


In 1971 the editors of Oz magazine were prosecuted for obscenity in a London courtroom for their infamous 'School Kids Issue', almost the entire contents of which had been created by a team of young people. In today's Web 2.0 environment, similar kinds of content to that featured in the magazine is created by young people and made ubiquitous on fan websites. In particular 'manips' (manipulated images) of all kinds of pop culture heroes from boy band members to characters from Harry Potter are inserted into pornographic contexts. Whereas in the 1970s it was obscenity legislation that was used to restrict this form of cultural commentary, today child pornography legislation can be used to capture this content. I argue that changes to child pornography laws across the western world in the last two decades have resulted in the capture of even fictional images that are or may only 'appear to be' a person under the age of 18, rendering some aspects of online youth culture problematic. The 'juridicial discourse' that increasingly collapses a complex range of cultural representations into the category of child pornography is a cause for concern for all academics working on online youth cultures and for the young people involved.


1. Dose-response curves for the pressor activity of angiotensin II have been determined in unanaesthetized rats receiving diets containing 2-5% (w/w) or 0-007% (w/w) sodium and administered in various sequences. 2. Dose-response curves were shifted to the left in rats on a high-, compared with a low-, sodium intake. This response was maintained for 7 days on changing from high to low sodium. 3. There was no difference in the relation between the fall of cardiac output and the rise of blood pressure in any of the experimental groups. 4. Dose-response curves for peripheral resistance showed the same directional change as seen for the pressor response in rats on high- and low-sodium diets. Since depression of cardiac output was proportional to the pressure rise, the absolute change in peripheral resistance was greater than the blood pressure response. The proportional changes were similar. 5. It is concluded that alterations in the pressor response to angiotensin caused by changes in sodium loading are attributable to changes in peripheral resistance and not to changes in the cardiac output response to the acute rise in blood pressure.


Gender-biased harmful practices are prevalent across many parts of the world. Once these practices have become part of the cultural landscape, they are very difficult to alter without external stimuli. Whether those stimuli can be targeted toward individuals or they must be targeted toward the community as a whole is heavily debated. I study the effect of an individual-level intervention on the perceptions of an entrenched, gender-biased, cultural practice. Specifically, I study the effect of education on the perpetuation of female genital cutting (FGC) in Burkina Faso. Using a pseudo panel of 36,000 women born between 1949 and 1995, I find that educated women are 30 percent more likely to oppose the practice than uneducated women. Additionally, women who support the practice are more than twice as likely to have a daughter who has undergone FGC, and I find suggestive evidence that education raises a woman's bargaining power in the household. Together, my findings suggest that an individual-level intervention could reduce the prevalence of an entrenched cultural practice in the subsequent generations.


Santals are one of the many Adivasi (indigenous) communities in eastern India and are
particularly renowned for precision and craftsmanship in their domestic architecture. The
visually stunning dwellings and settlements fascinated me as an undergraduate architecture
student, and now, in this doctoral research project, I take this forward as a critical enquiry
into the production, use and transformation of Santal built environments. There are two
important concerns in the study. First, I examine Santal dwellings and settlements as both
sites and processes, i.e., I analyse built forms, everyday life, domestic art practices, and
people's perceptions of important aspects of their surroundings in order to understand
Santal senses of space and place. Second, I attempt to correlate architectural shifts to wider
changes in the Santal and other Adivasi communities and the Singhbhum region in order
that the architectural analysis may be brought to bear upon a wider understanding of
Adivasi pasts. In short, using architecture as a lens, I aim to understand Santal senses of
being-in-the-world and how these have transformed in the course of the past two centuries.
This study is an important departure from architectural discourses on traditional
environments since it examines processes of making and people's experiences together
with architectural forms. This approach allows a new kind of architectural history to
emerge: one that is no longer about buildings alone, but that offers insights into peoples'
sense of their collective lives, and in particular their phenomenological engagements with
the social, environmental and historical worlds that are in part defined by architecture. The
project is inherently interdisciplinary in that architectural analysis is combined with
ethnography and participatory visual methods in the effort to study senses of place. More
significantly, however, I aim to contribute to critical discourses on traditional built
environments and their historiography.


This paper is the first in a series from Educational Testing Service (ETS) concerning English language proficiency (ELP) assessments for K–12 English learners (ELs). The goal of this paper, and the series, is to present research-based ideas, principles, and recommendations for consideration by those who are conceptualizing, developing, and implementing ELP assessments for K–12 ELs and by all stakeholders in their education and assessment. We also hope to contribute to the active current discussion in the field on improving the instruction and assessment of EL students as well as contribute to bringing these ideas into practice. This paper articulates a high-level vision for a next-generation assessment system serving K–12 English learners with a brief overview of the current state of the art for K–12 ELP assessments and the context of current reforms. In addition, the paper discusses the role of digital technology in next-generation K-12 ELP assessment systems, noting the distinct conceptual and practical advantages that digital technology offers in assessing ELP as well as principles for evaluating the potential challenges of implementing a digitally based assessment system against these benefits. A proposed theory of action for K–12 ELP assessment systems is also discussed in this paper. The second paper in the series addressed accessibility issues in the context of ELP assessments for ELs and ELs with disabilities (Guzman-Orth, Laitusis, Thurlow, & Christensen, 2016), the third paper addressed issues related to summative ELP assessments that emerged from the presentations and discussions at the English Language Proficiency Assessment Research working meeting (Wolf, Guzman-Orth, & Hauck, 2016), and the fourth paper focused on a key concern within such systems—the initial identification and classification of ELs (Lopez, Pooler, & Linquanti, 2016).


The efficiency and distribution of water of an irrigation can be described by the measurement of as few as four independent quantities, provided three assumptions are made: (1)All water delivered to a field and not infiltrated or not collected as runoff for reuse is a loss, and the nature of that loss is not important; (2)the requirement at the time of irrigation is the water necessary to fill the root zone; and (3)a single lumped parameter is adequate to characterize the distribution. This result allows the performance of an infield distribution system to be determined with a minimum of effort. Furthermore, most of the commonly used efficiency terms can be calculated from the four measured quantities. If limits of acceptability for system performance are defined, then the four measured quantities can be used to make decisions for improved irrigation practices or to compare capabilities of different systems.


In the 1950s, Emanuel Friedman described the first comprehensive method of evaluating labour in clinical practice. In this landmark work, Friedman described the relationship between the duration of labour and cervical dilation as a sigmoid curve and outlined a tool for following labour progression and for identifying abnormal labour. His definitions of labour protraction and arrest continue to be applied in contemporary obstetric practice, although there have been considerable changes since in the clinical management of labour and delivery. This paper provides an overview of Friedman's work, addresses various methodological challenges in studying labour progression, and describes the utility of more advanced statistical methods for studying labour progression, such as survival analysis, compared with other approaches. Additional research that utilises and refines such methods will provide greater insight into labour progression and may assist in updating the diagnostic criteria for labour protraction and arrest disorders in contemporary obstetric practice. Moreover, such detailed information could have important clinical implications towards reducing the rate of primary caesarean delivery in the United States.


Background Methadone is a synthetic opioid used in refractory pain. There is increased awareness of methadone related adverse events including respiratory depression and QTc prolongation. In our region several methods exist for methadone initiation, falling into two categories: switching one opioid to methadone (stop and go — SAG) and adding methadone to another opioid (addition — ADD). Aims To characterise how methadone is being used locally. To quantify the nature and frequency of methadone induced side effects. Methods All patients prescribed methadone by the palliative care teams in Sheffield and Chesterfield over an eight month period were included. Data were prospectively collected on diagnoses, indication(s) for methadone, method of conversion, ECG recording, pain scores and side effects. Results 25 patients were prescribed methadone, all as inpatients. 20 patients had malignancy, the remainder chronic pain. Methadone was chosen in all cases due to persistent pain and/or medication side effects. A SAG method was used for 72% and ADD for 28%. The median daily oral morphine equivalent dose prior to initiation was 240 mg (range 50 mg – 1000 mg). 92% had an ECG prior to commencing methadone. Following titration, the median methadone dose was 10 mg BD (range 4 mg – 40 mg BD). Average pain scores reduced from 7/10 to 3/10 in both groups. 28% reported side effects of sedation, nausea, confusion or hallucinations. 2 patients required naloxone and 3 developed QTc prolongation, all in the SAG group. 72% were discharged home, 8% were transferred to another hospital and 20% died. None of the deaths were attributable to methadone. Conclusion Locally, methadone is prescribed for patients with chronic pain as well as those with malignancy. Methadone results in clinically meaningful pain relief regardless of method of initiation. A SAG method is used most frequently. All five clinically significant adverse events were reported in the SAG group.