Real world performance of the 21st Century Cures Act population-level application programming interface

OBJECTIVE

To evaluate the real-world performance of the SMART/HL7 Bulk Fast Health Interoperability Resources (FHIR) Access Application Programming Interface (API), developed to enable push button access to electronic health record data on large populations, and required under the 21st Century Cures Act Rule.

MATERIALS AND METHODS

We used an open-source Bulk FHIR Testing Suite at 5 healthcare sites from April to September 2023, including 4 hospitals using electronic health records (EHRs) certified for interoperability, and 1 Health Information Exchange (HIE) using a custom, standards-compliant API build. We measured export speeds, data sizes, and completeness across 6 types of FHIR.

RESULTS

Among the certified platforms, Oracle Cerner led in speed, managing 5-16 million resources at over 8000 resources/min. Three Epic sites exported a FHIR data subset, achieving 1-12 million resources at 1555-2500 resources/min. Notably, the HIE's custom API outperformed, generating over 141 million resources at 12 000 resources/min.

DISCUSSION

The HIE's custom API showcased superior performance, endorsing the effectiveness of SMART/HL7 Bulk FHIR in enabling large-scale data exchange while underlining the need for optimization in existing EHR platforms. Agility and scalability are essential for diverse health, research, and public health use cases.

CONCLUSION

To fully realize the interoperability goals of the 21st Century Cures Act, addressing the performance limitations of Bulk FHIR API is critical. It would be beneficial to include performance metrics in both certification and reporting processes.

Moving Biosurveillance Beyond Coded Data Using AI for Symptom Detection From Physician Notes: Retrospective Cohort Study

BACKGROUND

Real-time surveillance of emerging infectious diseases necessitates a dynamically evolving, computable case definition, which frequently incorporates symptom-related criteria. For symptom detection, both population health monitoring platforms and research initiatives primarily depend on structured data extracted from electronic health records.

OBJECTIVE

This study sought to validate and test an artificial intelligence (AI)-based natural language processing (NLP) pipeline for detecting COVID-19 symptoms from physician notes in pediatric patients. We specifically study patients presenting to the emergency department (ED) who can be sentinel cases in an outbreak.

METHODS

Subjects in this retrospective cohort study are patients who are 21 years of age and younger, who presented to a pediatric ED at a large academic children's hospital between March 1, 2020, and May 31, 2022. The ED notes for all patients were processed with an NLP pipeline tuned to detect the mention of 11 COVID-19 symptoms based on Centers for Disease Control and Prevention (CDC) criteria. For a gold standard, 3 subject matter experts labeled 226 ED notes and had strong agreement (F1-score=0.986; positive predictive value [PPV]=0.972; and sensitivity=1.0). F1-score, PPV, and sensitivity were used to compare the performance of both NLP and the International Classification of Diseases, 10th Revision (ICD-10) coding to the gold standard chart review. As a formative use case, variations in symptom patterns were measured across SARS-CoV-2 variant eras.

RESULTS

There were 85,678 ED encounters during the study period, including 4% (n=3420) with patients with COVID-19. NLP was more accurate at identifying encounters with patients that had any of the COVID-19 symptoms (F1-score=0.796) than ICD-10 codes (F1-score =0.451). NLP accuracy was higher for positive symptoms (sensitivity=0.930) than ICD-10 (sensitivity=0.300). However, ICD-10 accuracy was higher for negative symptoms (specificity=0.994) than NLP (specificity=0.917). Congestion or runny nose showed the highest accuracy difference (NLP: F1-score=0.828 and ICD-10: F1-score=0.042). For encounters with patients with COVID-19, prevalence estimates of each NLP symptom differed across variant eras. Patients with COVID-19 were more likely to have each NLP symptom detected than patients without this disease. Effect sizes (odds ratios) varied across pandemic eras.

CONCLUSIONS

This study establishes the value of AI-based NLP as a highly effective tool for real-time COVID-19 symptom detection in pediatric patients, outperforming traditional ICD-10 methods. It also reveals the evolving nature of symptom prevalence across different virus variants, underscoring the need for dynamic, technology-driven approaches in infectious disease surveillance.

Cumulus: A federated EHR-based learning system powered by FHIR and AI

Objective

To address challenges in large-scale electronic health record (EHR) data exchange, we sought to develop, deploy, and test an open source, cloud-hosted app 'listener' that accesses standardized data across the SMART/HL7 Bulk FHIR Access application programming interface (API).

Methods

We advance a model for scalable, federated, data sharing and learning. Cumulus software is designed to address key technology and policy desiderata including local utility, control, and administrative simplicity as well as privacy preservation during robust data sharing, and AI for processing unstructured text.

Results

Cumulus relies on containerized, cloud-hosted software, installed within a healthcare organization's security envelope. Cumulus accesses EHR data via the Bulk FHIR interface and streamlines automated processing and sharing. The modular design enables use of the latest AI and natural language processing tools and supports provider autonomy and administrative simplicity. In an initial test, Cumulus was deployed across five healthcare systems each partnered with public health. Cumulus output is patient counts which were aggregated into a table stratifying variables of interest to enable population health studies. All code is available open source. A policy stipulating that only aggregate data leave the institution greatly facilitated data sharing agreements.

Discussion and Conclusion

Cumulus addresses barriers to data sharing based on (1) federally required support for standard APIs (2), increasing use of cloud computing, and (3) advances in AI. There is potential for scalability to support learning across myriad network configurations and use cases.

Real World Performance of the 21st Century Cures Act Population Level Application Programming Interface

Objective

To evaluate the real-world performance in delivering patient data on populations, of the SMART/HL7 Bulk FHIR Access API, required in Electronic Health Records (EHRs) under the 21st Century Cures Act Rule.

Materials and Methods

We used an open-source Bulk FHIR Testing Suite at five healthcare sites from April to September 2023, including four hospitals using EHRs certified for interoperability, and one Health Information Exchange (HIE) using a custom, standards-compliant API build. We measured export speeds, data sizes, and completeness across six types of FHIR resources.

Results

Among the certified platforms, Oracle Cerner led in speed, managing 5-16 million resources at over 8,000 resources/min. Three Epic sites exported a FHIR data subset, achieving 1-12 million resources at 1,555-2,500 resources/min. Notably, the HIE's custom API outperformed, generating over 141 million resources at 12,000 resources/min.

Discussion

The HIE's custom API showcased superior performance, endorsing the effectiveness of SMART/HL7 Bulk FHIR in enabling large-scale data exchange while underlining the need for optimization in existing EHR platforms. Agility and scalability are essential for diverse health, research, and public health use cases.

Conclusion

To fully realize the interoperability goals of the 21st Century Cures Act, addressing the performance limitations of Bulk FHIR API is critical. It would be beneficial to include performance metrics in both certification and reporting processes.

Explaining vaccine hesitancy: A COVID-19 study of the United States

Using recent data on the unvaccinated population across US states, this paper focuses on the determinants of vaccine hesitancy related to the COVID-19 pandemic. Findings show that more prosperous states and states with more elderly residents and more physicians have lower vaccine hesitancy. There was some evidence of the significance of race, but internet access and history of other contagious diseases failed to make a difference. States with centralized health systems and those with mask mandates generally had a lower percentage of unvaccinated populations. Finally, the presence of Democrats in state legislatures tended to lower vaccination hesitancies, ceteris paribus.

Managing the risk of COVID-19 via vaccine passports: Modeling economic and policy implications

The increasing use of vaccine passports (VPs) to certify immunity from the prevailing coronavirus has created positive and negative aspects that have shaken the workings of markets. The VPs are, however, not universally used and not required by all businesses and governments at this point. Given the newness associated with VPs and the ongoing uncertainty of the pandemic, full implications of VPs have not been considered. This paper provides some formal insights into the implications of the use of VPs, borrowing from the established economic theory. Recommendations for public policy are provided.

Semantic Segmentation of Micro-CT Images to Analyze Bone Ingrowth into Biodegradable Scaffolds

The healing of bone fractures is a complex and well-orchestrated physiological process, but normal healing is compromised when the fracture is large. These large non-union fractures often require a template with surgical intervention for healing. The standard treatment, autografting, has drawbacks such as donor site pain and limited availability. Biodegradable scaffolds developed using biomaterials such as bioactive glass are a potential solution. Investigation of bone ingrowth into biodegradable scaffolds is an important aspect of their development. Micro-CT (μ-CT) imaging is widely used to evaluate and quantify tissue ingrowth into scaffolds in 3D. Existing segmentation techniques have low accuracy in differentiating bone and scaffold, and need improvements to accurately quantify the bone in-growth into the scaffold using μ-CT scans. This study proposes a novel 3-stage pipeline for better outcome. The first stage of the pipeline is based on a convolutional neural network for the segmentation of the scaffold, bone, and pores from μ-CT images to investigate bone ingrowth. A 3D rigid image registration procedure was employed in the next stage to extract the volume of interest (VOI) for the analysis. In the final stage, algorithms were developed to quantitatively analyze bone ingrowth and scaffold degradation. The best model for segmentation produced a dice similarity coefficient score of 90.1, intersection over union score of 83.9, and pixel accuracy of 93.1 for unseen test data.

Detection and Tracking Volumes of Interest in 3D Printed Tissue Engineering Scaffolds using 4D Imaging Modalities

Additive manufacturing (AM) platforms allow the production of patient tissue engineering scaffolds with desirable architectures. Although AM platforms offer exceptional control on architecture, post-processing methods such as sintering and freeze-drying often deform the printed scaffold structure. In-situ 4D imaging can be used to analyze changes that occur during post-processing. Visualization and analysis of changes in selected volumes of interests (VOIs) over time are essential to understand the underlining mechanisms of scaffold deformations. Yet, automated detection and tracking of VOIs in the 3D printed scaffold over time using 4D image data is currently an unsolved image processing task. This paper proposes a new image processing technique to segment, detect and track volumes of interest in 3D printed tissue engineering scaffolds. The method is validated using a 4D synchrotron sourced microCT image data captured during the sintering of bioactive glass scaffolds in-situ. The proposed method will contribute to the development of scaffolds with controllable designs and optimum properties for the development of patient-specific scaffolds.

Quality Improvement Tools in Total Joint Arthroplasty: A Systematic Review

Systems review and quality improvement (QI) is a significant need within orthopaedic surgery. The focus of this paper is to systematically review QI principles utilized in total joint arthroplasty to determine most successful QI tools. A systematic search on MEDLINE/Pubmed, Embase, Cochrane Library and other sources was conducted from September 1991 through October 2018. The three primary improved outcomes from each article were recorded along with the date, author and subspecialty. Thirty-four eligible studies related to joint arthroplasty were identified for inclusion in the systematic review. The most common outcomes that were improved in these publications were: length of stay (LOS), cost, medication management, and patient education. Lean, clinical care pathways (CCP), plan-do-check-act (PDCA), and shared decision-making improved those metrics. Four metrics were found that were consistently improved by certain quality improvement tools: LOS, cost, medication management, and patient education. Further research is warranted to continue to build a framework for quality improvement in orthopaedic surgery. (Journal of Surgical Orthopaedic Advances 30(3):125-130, 2021).

Do Geographic Region, Medicaid Status, and Academic Affiliation Affect Access to Care Among Medicaid and Privately Insured Total Hip Arthroplasty Patients?

BACKGROUND

Medicaid provides health coverage to those beneath the federal poverty line. The literature shows that patients with Medicaid experience barriers to scheduling initial and follow-up visits, although this has not been studied in patients undergoing total hip arthroplasty (THA). The purpose of this study is to assess whether insurance type, geographic location, Medicaid expansion, or academic affiliation affect access to evaluation for THA.

METHODS

The American Academy of Orthopedic Surgeons directory was used to call a total of 100 practices. Five random private and 5 random academic medical facilities were called from each of 5 Medicaid-expanded and 5 non-expanded states representing different US geographic regions. Calls were made by an investigator requesting the earliest available appointment for their fictitious parent to be evaluated for a THA. Half of the calls were made with the investigator reporting private insurance of Blue Cross Blue Shield (BCBS), and half reporting Medicaid. Appointment success rate and average time to appointment were compared. Further comparisons were drawn among Medicaid-expanded vs non-expanded states, geographic regions, and private vs academic affiliation.

RESULTS

Appointments were successful for 99 of 100 (99%) calls made with BCBS, and 72 of 100 (72%) with Medicaid (P < .001). Success rates were significantly higher for BCBS, regardless of academic vs private affiliation. In all geographic regions, appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ .01). Average time to appointment was also significantly longer for Medicaid (26 days) than private (13 days) insurance (P = .020). In the Medicaid group, appointment success rate was significantly greater for academically affiliated practices compared to private practices (84.0% vs 60.0%, respectively; P = .008).

CONCLUSION

Patients with Medicaid seeking consultation for THA experience limits in access to evaluation for THA when compared to patients with private insurance, regardless of geographic region or affiliation of the practice.

Multiscale analyses reveal native-like lamellar bone repair and near perfect bone-contact with porous strontium-loaded bioactive glass

The efficient healing of critical-sized bone defects using synthetic biomaterial-based strategies is promising but remains challenging as it requires the development of biomaterials that combine a 3D porous architecture and a robust biological activity. Bioactive glasses (BGs) are attractive candidates as they stimulate a biological response that favors osteogenesis and vascularization, but amorphous 3D porous BGs are difficult to produce because conventional compositions crystallize during processing. Here, we rationally designed a porous, strontium-releasing, bioactive glass-based scaffold (pSrBG) whose composition was tailored to deliver strontium and whose properties were optimized to retain an amorphous phase, induce tissue infiltration and encourage bone formation. The hypothesis was that it would allow the repair of a critical-sized defect in an ovine model with newly-formed bone exhibiting physiological matrix composition and structural architecture. Histological and histomorphometric analyses combined with indentation testing showed pSrBG encouraged near perfect bone-to-material contact and the formation of well-organized lamellar bone. Analysis of bone quality by a combination of Raman spectral imaging, small-angle X-ray scattering, X-ray fluorescence and focused ion beam-scanning electron microscopy demonstrated that the repaired tissue was akin to that of normal, healthy bone, and incorporated small amounts of strontium in the newly formed bone mineral. These data show the potential of pSrBG to induce an efficient repair of critical-sized bone defects and establish the importance of thorough multi-scale characterization in assessing biomaterial outcomes in large animal models.

Prediction of outcome in newly diagnosed myeloma: a meta-analysis of the molecular profiles of 1905 trial patients

Robust establishment of survival in multiple myeloma (MM) and its relationship to recurrent genetic aberrations is required as outcomes are variable despite apparent similar staging. We assayed copy number alterations (CNA) and translocations in 1036 patients from the NCRI Myeloma XI trial and linked these to overall survival (OS) and progression-free survival. Through a meta-anlysis of these data with data from MRC Myeloma IX trial, totalling 1905 newly diagnosed MM patients (NDMM), we confirm the association of t(4;14), t(14;16), t(14;20), del(17p) and gain(1q21) with poor prognosis with hazard ratios (HRs) for OS of 1.60 (P=4.77 × 10^-7), 1.74 (P=0.0005), 1.90 (P=0.0089), 2.10 (P=8.86 × 10^-14) and 1.68 (P=2.18 × 10^-14), respectively. Patients with 'double-hit' defined by co-occurrence of at least two adverse lesions have an especially poor prognosis with HRs for OS of 2.67 (P=8.13 × 10^-27) for all patients and 3.19 (P=1.23 × 10^-18) for intensively treated patients. Using comprehensive CNA and translocation profiling in Myeloma XI we also demonstrate a strong association between t(4;14) and BIRC2/BIRC3 deletion (P=8.7 × 10^-15), including homozygous deletion. Finally, we define distinct sub-groups of hyperdiploid MM, with either gain(1q21) and CCND2 overexpression (P<0.0001) or gain(11q25) and CCND1 overexpression (P<0.0001). Profiling multiple genetic lesions can identify MM patients likely to relapse early allowing stratification of treatment.

Second malignancies in the context of lenalidomide treatment: an analysis of 2732 myeloma patients enrolled to the Myeloma XI trial

We have carried out the largest randomised trial to date of newly diagnosed myeloma patients, in which lenalidomide has been used as an induction and maintenance treatment option and here report its impact on second primary malignancy (SPM) incidence and pathology. After review, 104 SPMs were confirmed in 96 of 2732 trial patients. The cumulative incidence of SPM was 0.7% (95% confidence interval (CI) 0.4–1.0%), 2.3% (95% CI 1.6–2.7%) and 3.8% (95% CI 2.9–4.6%) at 1, 2 and 3 years, respectively. Patients receiving maintenance lenalidomide had a significantly higher SPM incidence overall (P=0.011). Age is a risk factor with the highest SPM incidence observed in transplant non-eligible patients aged >74 years receiving lenalidomide maintenance. The 3-year cumulative incidence in this group was 17.3% (95% CI 8.2–26.4%), compared with 6.5% (95% CI 0.2–12.9%) in observation only patients (P=0.049). There was a low overall incidence of haematological SPM (0.5%). The higher SPM incidence in patients receiving lenalidomide maintenance therapy, especially in advanced age, warrants ongoing monitoring although the benefit on survival is likely to outweigh risk.

Race Effects on the Employee Engagement-Turnover Intention Relationship

In this paper we review extant research findings on employee engagement. We then outline and test potential differences in the relationship between engagement and intent to remain with the organization, based upon variations in the racial composition of the supervisor-employee dyad. Our analyses revealed an interaction whereby at low levels of engagement, members of different-race dyads report a lower tendency to remain with their organization for at least one year than members of same-race dyads; at high levels of engagement, intent to remain was greater for members of different-race dyads. We discuss implications of our findings for organizational practice and research.

Leadership Behaviors and Subordinate Resilience

Utilizing a sample of 150 part-time MBA students, this study evaluated the relationship between leader behaviors and subordinate resilience. We proposed that the transformational leadership dimensions of Attributed Charisma, Idealized Influence, Inspirational Motivation, Intellectual Stimulation, and Individualized Consideration, as well as the transactional leadership dimension of Contingent Reward would be positively associated with subordinate resilience. We also proposed that the transactional leadership dimensions of Management-by-Exception Active and Management-by-Exception Passive and the non-leadership dimension of Laissez-Faire leadership would not be positively associated with subordinate resilience. With the exception of Inspirational Motivation, all hypothesized relationships were supported. A post-hoc analysis of open-ended responses to the question "What helped you to deal with this situation? " indicated that participants who mentioned their leaders as a positive factor in dealing with the situation exhibited greater resilience than participants who did not. The implications of these results and suggestions for future research are discussed.

Twenty-Four Hour Social Isolation

A program was developed for reducing the aggressive behavior (i.e., attacks on others, self-injury, and property destruction) of an institutionalized, psychotic like, retarded adult male. All previous treatments, including drugs, prolonged custodial restraint, and various behavioral procedures, had been ineffective. The program consisted of excluding the resident from all social interactions for a 24-hour period, although he remained in the living area. Social and intellectual criteria for determining the resident's suitability for the program, an increased density of reinforcement, multiple timeout intervals, and a relaxation training procedure were all included in the program. The program reduced the percentage of days each month in which aggression occurred, from a baseline of about 90C% to 4% in the last month of the program. Comparisons of the resident's medical records before and during the program revealed that there were major reductions in: number of times sutures were required following self-injury (from twelve to four per year); daily Thorazine dosage (from 2000 to 800 mg.); and number of PRN Thorazine injections received (from an average of nine per month to one every other month). This stringent program appears to be an effective and enduring method of treating certain types of chronically aggressive individuals, provided that specific guidelines are followed.

A Remediation Program for Increasing the Spelling Achievement of Elementary and Junior High School Students

The present study evaluated four procedures designed to help poor spellers improve their achievement on weekly tests: (1) a pretest over the week's spelling words followed in two days by the regular weekly test; (2) a positive practice procedure in which students were required to correct any misspelled word on the weekly test by writing out its (a) correct spelling, (b) part of speech, (c) phonetic spelling, (d) complete definition, and (e) correct usage in five different sentences; (3) a pretest, positive practice of the pretest, and the weekly test; and (4) a pretest, positive practice of the pretest, weekly test, and positive practice of the weekly test. The pretest/positive practice/test/positive practice procedure was the most effective, producing a 14 percentage point increase in spelling achievement. The pretest/positive practice/test (11 percentage point increase) and positive practice (10 percentage point increase) procedures were of near equal effectiveness. The pretest procedure produced no increase.

A comparative study of oxygen diffusion in tissue engineering scaffolds

Tissue engineering scaffolds are designed to support tissue self-healing within physiological environments by promoting the attachment, growth and differentiation of relevant cells. Newly formed tissue must be supplied with sufficient levels of oxygen to prevent necrosis. Oxygen diffusion is the major transport mechanism before vascularization is completed and oxygen is predominantly supplied via blood vessels. The present study compares different designs for scaffolds in the context of their oxygen diffusion ability. In all cases, oxygen diffusion is confined to the scaffold pores that are assumed to be completely occupied by newly formed tissue. The solid phase of the scaffolds acts as diffusion barrier that locally inhibits oxygen diffusion, i.e. no oxygen passes through the scaffold material. As a result, the oxygen diffusivity is determined by the scaffold porosity and pore architecture. Lattice Monte Carlo simulations are performed to compare the normalized oxygen diffusivities in scaffolds obtained by the foam replication (FR) method, robocasting and sol-gel foaming. Scaffolds made by the FR method were found to have the highest oxygen diffusivity due to their high porosity and interconnected pores. These structures enable the best oxygen supply for newly formed tissue among the scaffold types considered according to the present numerical predictions.

A longitudinal field trial assesing the impact of feeding waste milk containing antibiotic residues on the prevalence of ESBL-producing Escherichia coli in calves

A longitudinal field trial was carried out on a farm known to harbour cefotaximase (CTX-M)-positive Escherichia coli, in order to assess the impact of feeding waste milk containing antibiotic residues (WM+AR) on the prevalence of these bacteria in the faeces of calves. Fifty calves were alternately assigned to one of two groups at birth and fed either milk replacer (control group) or WM+AR (treatment group). Faecal samples were collected from all calves daily for the first week after enrolment, twice weekly until weaning, then weekly for a further six weeks. Environmental samples from the calf housing were collected weekly. WM+AR and powdered milk samples were examined for antibiotic residues and CTX-M-positive E. coli. Total E. coli and CTX-M-positive E. coli in faecal samples were enumerated using selective media. Regression analyses were performed on the bacterial count data using a population-averaged approach based on generalised estimating equations (GEE) to account for repeated measurements on individual calves over time. Cefquinome, a fourth generation cephalosporin, was detected in 87% of WM+AR samples at a mean concentration of 0.746 mg/l. All environmental sampling locations yielded CTX-M-positive E. coli. Significantly more pen floor samples were positive in the treatment group. Calves in the treatment group shed greater numbers of CTX-M-positive E. coli than calves in the control group throughout the study, and shedding decreased at a slower rate in the treatment group. CTX-M-positive E. coli persisted in a larger number of calves fed WM+AR compared with calves fed milk replacer where the prevalence in the treatment group declined significantly slower over time. There was no difference between calves fed WM+AR or calves fed milk replacer in the proportion of E. coli isolates that were CTX-M-positive. These findings indicate that feeding WM+AR increased the amount of resistant bacteria shed in the faeces. Shedding of CTX-M-positive E. coli persisted for longer in calves fed WM+AR, and persisted after weaning.

Cotton-wool-like bioactive glasses for bone regeneration

Inorganic sol-gel solutions were electrospun to produce the first bioactive three-dimensional (3-D) scaffolds for bone tissue regeneration with a structure like cotton-wool (or cotton candy). This flexible 3-D fibrous structure is ideal for packing into complex defects. It also has large inter-fiber spaces to promote vascularization, penetration of cells and transport of nutrients throughout the scaffold. The 3-D fibrous structure was obtained by electrospinning, where the applied electric field and the instabilities exert tremendous force on the spinning jet, which is required to be viscoelastic to prevent jet break up. Previously, polymer binding agents were used with inorganic solutions to produce electrospun composite two-dimensional fibermats, requiring calcination to remove the polymer. This study presents novel reaction and processing conditions for producing a viscoelastic inorganic sol-gel solution that results in fibers by the entanglement of the intermolecularly overlapped nanosilica species in the solution, eliminating the need for a binder. Three-dimensional cotton-wool-like structures were only produced when solutions containing calcium nitrate were used, suggesting that the charge of the Ca(2+) ions had a significant effect. The resulting bioactive silica fibers had a narrow diameter range of 0.5-2μm and were nanoporous. A hydroxycarbonate apatite layer was formed on the fibers within the first 12h of soaking in simulated body fluid. MC3T3-E1 preosteoblast cells cultured on the fibers showed no adverse cytotoxic effect and they were observed to attach to and spread in the material.

Palaeoenvironmental modelling of δ(13) C and δ(15) N values in the North Atlantic Islands: understanding past marine resource use

RATIONALE

Carbon (δ(13) C) and nitrogen (δ(15) N) analysis has been extensively used to investigate the importance of marine foods in the diet of archaeological populations in the North Atlantic Islands; however, few faunal studies exist to aid the interpretation of results. Palaeoenvironmental modelling of δ(13) C and δ(15) N values is crucial in determining whether changes in the stable isotope values are a result of dietary change, rather than temporal or geographical fluctuations in carbon and nitrogen. Investigating faunal dietary behaviour can provide an insight into past foddering and land management strategies.

METHODS

Detailed sampling of wild and domestic species for bulk collagen analysis was undertaken in order to characterise geographical variations in δ(13) C and δ(15) N values in the Outer Hebrides and Orkney. Samples from the Neolithic to the Norse period were analysed to assess temporal and geographical variations in δ(13) C and δ(15) N values, in addition to determining the contribution of marine foods to the diet of local fauna.

RESULTS

A δ(15) N shift of 1‰ was observed between the Outer Hebrides and Orkney in the Neolithic and Iron Age. A geographical variation in δ(13) C values was observed in the Norse period between Orkney and the Outer Hebrides. Temporal fluctuations in δ(13) C and δ(15) N values demonstrate variations in foddering practices of sheep in the Outer Hebrides. Pig specimens from the Outer Hebrides demonstrated evidence of marine food consumption in the Iron Age.

CONCLUSIONS

Faunal dietary behaviour can act as a vital indicator of the importance of marine resources in the past. Characterisation of faunal δ(13) C and δ(15) N values geographically and temporally is crucial in our interpretation of human dietary behaviour.

Infrequent Manifestations of Kabuki Syndrome in a Patient with Novel MLL2 Mutation

We present a case of a 9-month-old Hispanic female with Kabuki syndrome with some infrequent manifestations including a single umbilical artery, butterfly vertebrae, a small larynx, a preauricular pit, microtia with internal ear abnormalities, abnormal calcium metabolism, premature thelarche, neonatal/persistent hypoglycemia and eventration of the diaphragm. She was found to have a previously unreported nonsense MLL2 mutation. This is the first case that includes all such findings occurring simultaneously that was genotyped.

A survey of antimicrobial usage on dairy farms and waste milk feeding practices in England and Wales

The cause for the high prevalence of cefotaximase-producing Escherichia coli reported in dairy calves is unknown but may be partly due to the selective pressure of antimicrobial residues in waste milk (milk unfit for human consumption) fed to the calves. Antimicrobial use and waste milk feeding practices were investigated in 557 dairy farms in 2010/2011 that responded to a randomised stratified postal survey. The mean number of cases of mastitis per herd in the previous year was 47, and 93 per cent of respondents used antibiotic intra-mammary tubes to treat mastitis. The most frequently used lactating cow antibiotic tubes contained dihydrostreptomycin, neomycin, novobiocin, and procaine penicillin (37 per cent), and cefquinome (29 per cent). Ninety-six per cent of respondents used antibiotic tubes at the cessation of lactation ('drying off'). The most frequently used dry cow antibiotic tube (43 per cent) contained cefalonium. Frequently used injectable antibiotics included tylosin (27 per cent), dihydrostreptomycin and procaine penicillin (20 per cent) and ceftiofur (13 per cent). Eighty-three per cent of respondents (413) fed waste milk to calves. Of these 413, 87 per cent fed waste milk from cows with mastitis, and only one-third discarded the first milk after antibiotic treatment. This survey has shown that on more than 90 per cent of the farms that feed waste milk to calves, waste milk can contain milk from cows undergoing antibiotic treatment. On some farms, this includes treatment with third- and fourth-generation cephalosporins. Further work is underway to investigate the presence of these antimicrobials in waste milk.

Characterizing the hierarchical structures of bioactive sol-gel silicate glass and hybrid scaffolds for bone regeneration

Bone is the second most widely transplanted tissue after blood. Synthetic alternatives are needed that can reduce the need for transplants and regenerate bone by acting as active temporary templates for bone growth. Bioactive glasses are one of the most promising bone replacement/regeneration materials because they bond to existing bone, are degradable and stimulate new bone growth by the action of their dissolution products on cells. Sol-gel-derived bioactive glasses can be foamed to produce interconnected macropores suitable for tissue ingrowth, particularly cell migration and vascularization and cell penetration. The scaffolds fulfil many of the criteria of an ideal synthetic bone graft, but are not suitable for all bone defect sites because they are brittle. One strategy for improving toughness of the scaffolds without losing their other beneficial properties is to synthesize inorganic/organic hybrids. These hybrids have polymers introduced into the sol-gel process so that the organic and inorganic components interact at the molecular level, providing control over mechanical properties and degradation rates. However, a full understanding of how each feature or property of the glass and hybrid scaffolds affects cellular response is needed to optimize the materials and ensure long-term success and clinical products. This review focuses on the techniques that have been developed for characterizing the hierarchical structures of sol-gel glasses and hybrids, from atomic-scale amorphous networks, through the covalent bonding between components in hybrids and nanoporosity, to quantifying open macroporous networks of the scaffolds. Methods for non-destructive in situ monitoring of degradation and bioactivity mechanisms of the materials are also included.

Clinical features of psoroptic mange in cattle in England and Wales

The clinical signs, treatments used and spread of psoroptic mange in cattle from October 2007 until March 2011 are described. The disease was first diagnosed in South West Wales, having not been reported in Great Britain since the 1980s. The likely source was identified as a farm that had imported two animals from mainland Europe in the summer of 2006. Since that time, disease has been diagnosed on a further 22 premises, the majority in South West Wales but also in South East and Mid Wales and on one farm in England. Bought in animals harbouring the Psoroptes species mite but not showing clinical signs were considered the greatest risk of introducing the infestation into a herd. This, together with the difficulties of treatment to eliminate the parasite, means that it is unlikely that this outbreak has been controlled. There is also a continuing threat of importing the disease from abroad. The disease is not notifiable in the UK.

Geographical association between the genotype of bovine tuberculosis in found dead badgers and in cattle herds

In a survey, 457 badgers that had been found dead in Wales were postmortem-examined, and samples were examined by histology and by extended culture (for up to 12 weeks). Mycobacterium bovis was cultured from 55 badgers (12.0 per cent), and the histology typical of M bovis infection was seen in a further six (1.3 per cent). The prevalence in badgers in each of 10 geographical areas varied between 0 and 26 per cent (P<0.001), and was associated with the incidence of confirmed M bovis infection in cattle herds in the same areas (P<0.01). In northern Wales, bTB was rare in both hosts. An infected badger was 12.3 times more likely to be within 5 km of a confirmed cattle bTB breakdown than an uninfected badger. The M bovis isolates from badgers belonged to one of four genotypes defined by spoligotype and variable number tandem repeat type. These genotypes were also found in 290 concurrent confirmed herd breakdowns, and tended to be similar to the genotypes in badgers in the same geographical areas. When badgers and cattle no more than 30 km apart were compared, the genotype diversity was greater in cattle than in badgers (P=0.016), suggesting that the movement of cattle plays a greater part in the spatial distribution of M bovis than the movement of badgers.

Three-dimensional bioactive glass implants fabricated by rapid prototyping based on CO(2) laser cladding

Three-dimensional bioactive glass implants were produced by rapid prototyping based on laser cladding without using moulds. CO(2) laser radiation was employed to melt 45S5 and S520 bioactive glass particles and to deposit the material layer by layer following a desired geometry. Controlled thermal input and cooling rate by fine tuning of the processing parameters allowed the production of crack-free fully dense implants. Microstructural characterization revealed chemical composition stability, but crystallization during processing was extensive when 45S5 bioactive glass was used. Improved results were obtained using the S520 bioactive glass, which showed limited surface crystallization due to an expanded sintering window (the difference between the glass transition temperature and crystallization onset temperature). Ion release from the S520 implants in Tris buffer was similar to that of amorphous 45S5 bioactive glass prepared by casting in graphite moulds. Laser processed S520 scaffolds were not cytotoxic in vitro when osteoblast-like MC3T3-E1 cells were cultured with the dissolution products of the glasses; and the MC3T3-E1 cells attached and spread well when cultured on the surface of the materials.

Germline mutation in BRAF codon 600 is compatible with human development: de novo p.V600G mutation identified in a patient with CFC syndrome

BRAF, the protein product of BRAF, is a serine/threonine protein kinase and one of the direct downstream effectors of Ras. Somatic mutations in BRAF occur in numerous human cancers, whereas germline BRAF mutations cause cardio-facio-cutaneous (CFC) syndrome. One recurrent somatic mutation, p.V600E, is frequently found in several tumor types, such as melanoma, papillary thyroid carcinoma, colon cancer, and ovarian cancer. However, a germline mutation affecting codon 600 has never been described. Here, we present a patient with CFC syndrome and a de novo germline mutation involving codon 600 of BRAF, thus providing the first evidence that a pathogenic germline mutation involving this critical codon is not only compatible with development but can also cause the CFC phenotype. In vitro functional analysis shows that this mutation, which replaces a valine with a glycine at codon 600 (p.V600G), leads to increased ERK and ELK phosphorylation compared to wild-type BRAF but is less strongly activating than the cancer-associated p.V600E mutation.

Hierarchically structured titanium foams for tissue scaffold applications

We present a novel route for producing a new class of titanium foams for use in biomedical implant applications. These foams are hierarchically porous, with both the traditional large (>300μm) highly interconnected pores and, uniquely, wall struts also containing micron scale (0.5-5μm) interconnected porosities. The fabrication method consists of first producing a porous oxide precursor via a gel casting method, followed by electrochemical reduction to produce a metallic foam. This method offers the unique ability to tailor the porosity at several scales independently, unlike traditional space-holder techniques. Reducing the pressure during foam setting increased the macro-pore size. The intra-strut pore size (and percentage) can be controlled independently of macro-pore size by altering the ceramic loading and sintering temperature during precursor production. Typical properties for an 80% porous Ti foam were a modulus of ∼1GPa, a yield strength of 8MPa and a permeability of 350 Darcies, all of which are in the range required for biomedical implant applications. We also demonstrate that the micron scale intra-strut porosities can be exploited to allow infiltration of bioactive materials using a novel bioactive silica-polymer composite, resulting in a metal-bioactive silica-polymer composite.

Bioactive glass scaffolds for bone regeneration and their hierarchical characterisation

Scaffolds are needed that can act as temporary templates for bone regeneration and actively stimulate vascularized bone growth so that bone grafting is no longer necessary. To achieve this, the scaffold must have a suitable interconnected pore network and be made of an osteogenic material. Bioactive glass is an ideal material because it rapidly bonds to bone and degrades over time, releasing soluble silica and calcium ions that are thought to stimulate osteoprogenitor cells. Melt-derived bioactive glasses, such as the original Bioglass® composition, are available commercially, but porous scaffolds have been difficult to produce because Bioglass and similar compositions crystallize on sintering. Sol-gel foam scaffolds have been developed that avoid this problem. They have a hierarchical pore structure comprising interconnected macropores, with interconnect diameters in excess of the 100 μm that is thought to be needed for vascularized bone ingrowth, and an inherent nanoporosity of interconnected mesopores (2–50 nm) which is beneficial for the attachment of osteoprogenitor cells. They also have a compressive strength in the range of cancellous bone. This paper describes the optimized sol-gel foaming process and illustrates the importance of optimizing the hierarchical structure from the atomic through nano, to the macro scale with respect to biological response.

Identification of multiple compartments present during the mastication of solid food

The particle size distributions (PSDs) of two portion sizes (2g and 4g) of five foods (cake, cereal bar, muesli bar, cooked pasta and peanuts) after human mastication were determined. The PSD of the expectorated bolus and residual 'debris' rinsed from the mouth were each determined by wet sieving. There were significant differences in the PSD between food types, between portion sizes in the debris fraction and between the bolus and debris fractions. The latter suggests the existence of a two compartment system where particles are comminuted in at least one compartment within the oral cavity.

In situ high-energy X-ray diffraction study of a bioactive calcium silicate foam immersed in simulated body fluid

The method of in situ time-resolved high-energy X-ray diffraction, using the intrinsically highly collimated X-ray beam generated by the European Synchrotron Radiation Facility, is demonstrated. A specially designed cell, which allows the addition of liquid components, has been used to study the reaction mechanisms of a foamed bioactive calcia-silica sol-gel glass immersed in simulated body fluid. Analysis of the X-ray diffraction data from this experiment provides atomic distances, via the pair correlation functions, at different stages of the dissolution of the glass and of the associated calcium phosphate, and ultimately hydroxyapatite, i.e. bone mineral, formation. Hence, changes in the atomic scale structure can be analysed as a function of reaction time, giving an insight into the evolution of the structure of both the glass matrix and the hydroxyapatite surface growth.

Diazinon toxicity in sheep and cattle arising from the misuse of unlicensed and out-of-date products

Two incidents involving the misuse of unlabelled or out-of-date diazinon products are described. In the first incident, 81 of a group of 210 five-month-old lambs died within 12 hours of being dipped with the contents of a partly used tin of 15-year-old sheep dip. Analysis showed that the diazinon had decomposed by hydrolysis into a range of breakdown products, including tetraethyldithiopyrophosphate (sulfotepp) and monothiono-tetraethylpyrophosphate (monothiono-TEPP), which are much more toxic to mammals than diazinon. In the second incident, four yearling bulls were affected within 48 hours of being treated with a liquid that the farmer believed to be a lice treatment but was actually old diazinon sheep dip. Three of the bulls recovered but one died four days after the treatment. Analysis of the dip confirmed the presence of diazinon but in this incident no breakdown products were detected.

Preparation of bioactive glass-polyvinyl alcohol hybrid foams by the sol-gel method

A new class of materials based on inorganic and organic species combined at a nanoscale level has received large attention recently. In this work the idea of producing hybrid materials with controllable properties is applied to obtain foams to be used as scaffolds for tissue engineering. Hybrids were synthesized by reacting poly(vinyl alcohol) in acidic solution with tetraethylorthosilicate. The inorganic phase was also modified by incorporating a calcium compound. Hydrated calcium chloride was used as precursor. A surfactant was added and a foam was produced by vigorous agitation, which was cast just before the gel point. Hydrofluoric acid solution was added in order to catalyze the gelation. The foamed hybrids were aged at 40 degrees C and vacuum dried at 40 degrees C. The hybrid foams were analyzed by Scanning Electron Microscopy, Mercury Porosimetry, Nitrogen Adsorption, X-ray Diffraction and Infra-red Spectroscopy. The mechanical behavior was evaluated by compression tests. The foams obtained had a high porosity varying from 60 to 90% and the macropore diameter ranged from 30 to 500 microm. The modal macropore diameter varied with the inorganic phase composition and with the polymer content in the hybrid. The surface area and mesopore volume decreased as polymer concentration increased in the hybrids. The strain at fracture of the hybrid foams was substantially greater than pure gel-glass foams.

In vitro release kinetics of proteins from bioactive foams

This study describes an approach to obtaining 3-D scaffolds for tissue engineering that allows the incorporation and release of biologically active proteins to stimulate cell function. Laminin was adsorbed on the textured surfaces of binary 70S30C (70 mol % SiO(2), 30 mol % CaO) and ternary 58S (60 mol % SiO(2), 36 mol % CaO, 4 mol % P(2)O(5)) foams. The covalent bonds between the binding sites of the proteins and the ligands on the scaffolds' surfaces did not denaturate the proteins. In vitro studies show that the foams modified with chemical groups and coated with laminin were bioactive, as demonstrated by the formation of a crystalline hydroxy carbonate apatite (HCA) layer formed on the surfaces of the foams upon exposure to simulated body fluid (SBF). The release of proteins from the foams also was investigated. Sustained and controlled release from the scaffolds over a 30-day period was achieved. Laminin release from the bioactive foams followed the dissolution rate of the material network. These results suggest that bioactive foams have the potential to act as scaffolds for soft-tissue engineering with a controlled release of proteins that can induce tissue formation or regeneration.

"Mending Fences on the Immigrant Frontier": A Call for Better Integration of Demographic Information in Human Resource Management Practice and Theory

The authors argue that human resource management practitioners and researchers do not adequately take national origin into account when devising policies and theories. It is further asserted that this failure puts companies at risk for both lesser achievement of organizational objectives and potential legal liability (e.g., disparate impact). The background of the legal concept of a "reasonable man " is discussed in order to provide a possible explanation for why insufficient attention is paid to demographic factors such as race and national origin, and implications for theory and practice.

Surface-modified 3D scaffolds for tissue engineering

The aim of this work was to use sol-gel processing to develop bioactive materials to serve as scaffolds for tissue engineering that will allow the incorporation and release of proteins to stimulate cell function and tissue growth. We obtained organofunctionalized silica with large content of amine and mercaptan groups (up to 25%). The developed method can allow the incorporation and delivery of proteins at a controlled rate. We also produced bioactive foams with binary SiO(2)-CaO and ternary SiO(2)-CaO-P(2)O(5) compositions. In order to enhance peptide-material surface properties, the bioactive foams were modified with amine and mercaptan groups. These materials exhibit a highly interconnected macroporous network and high surface area. These textural features together with the incorporation of organic functionally groups may enable them to be used as scaffolds for the engineering of soft tissue.

In vitro dissolution of melt-derived 45S5 and sol-gel derived 58S bioactive glasses

Effects of powder type, particle size (5-20 microm; 90-300 microm; 90-710 microm), and type of dissolution medium on the dissolution behavior of bioactive glasses were investigated in vitro using melt-derived 45S5 and sol-gel derived 58S bioactive glass powders. Dissolution studies were performed in simulated body fluid and in alpha-MEM based cell culture medium at 37 degrees C under dynamic conditions (1 Hz) for periods of 30 min, 1, 2, 4, 8, 17, and 22 h. The concentrations of elements dissolved from the glasses were evaluated using inductively coupled plasma analysis. The reacted powders were analyzed for bioactivity using Fourier transform infrared spectrometry to observe the formation of a calcium phosphate layer on the surface. The non-porous surfaces of melt-derived 45S5 glass powders exhibited lower dissolution rates and rate of surface layer formation than 58S gel-glass powders. The rates of dissolution for both types of powders were lower in culture medium, compared to simulated body fluid, and increased as the particle size decreased. Thus, particle size range, glass type, and powder volume fraction can be used as a means to control the release rate of active ions that stimulate the gene expression and cellular response for tissue proliferation and repair.

Dose-dependent behavior of bioactive glass dissolution

The effect of glass dosage (0.001 g ml(-1) to 0.015 g ml(-1)) on the in vitro dynamic dissolution behavior of melt-derived 45S5 and sol-gel-derived 58S bioactive glasses, in simulated body fluid (SBF) at 37 degrees C, was evaluated. These glasses differ significantly in texture, especially the specific surface area and porosity, as a result of differences in manufacturing route. The concentrations of elements (Si, Ca, P, and Na) leached from the glasses into the dissolution medium, from 1 to 22 h, were evaluated with the use of induced coupled plasma analysis (ICP). The reacted powders were analyzed with the use of FTIR to observe the formation of a hydroxycarbonate apatite layer on the surface. The results show that the rate of HCA formation on both gel- and melt-derived bioactive glass powders in vitro depends on the concentration of the powders in solution. This result must be taken into account when carrying out in vitro cell-culture studies to simulate conditions in vivo and in experiments using extracts of the bioactive glass powders.

Characterization of melt-derived 45S5 and sol-gel-derived 58S bioactive glasses

The ability of bioactive glasses to form a bond to living bone and also to stimulate bone-cell proliferation depends on the chemical composition and on the surface texture of the glasses. In this work, the differences in physical properties between the melt-derived 45S5 and sol-gel-derived 58S Bioglass powders of various particle-size ranges were studied. The powders were characterized for particle-size distribution by laser spectrometry, for specific surface area and porosity by nitrogen sorption analysis, and for morphological features by scanning electron microscopy. Melt-derived 45S5 powders exhibited a low-porosity texture with surface area in the range 0.15-2.7 m(2)/g. In contrast, the sol-gel-derived powders exhibited a highly mesoporous texture, with surface area in the range of 126.5-164.7 m(2)/g and a large fraction of 6-9 nm pore sizes. These differences in texture, as well as variations in chemical composition, account for significant changes in the resorption and in vivo responses.