Unpacking a female language teacher's identity transformations: a perspective of multiple I-positions

The narrative inquiry investigates the construction and evolution of a female Chinese language teacher's identity across her pre-service and in-service phases. Utilising data from interviews, class observation and written reflections, the research examines how internal and external aspects shape her identity development. It specifically explores the role of third positions, meta positions, and promoter positions drawing on the dialogical self theory. The findings reaffirm that a teacher's identity is fluid and influenced by personal and professional factors. Over time, however, strong teaching beliefs and a growth mindset emerge as pivotal drivers for sustained and positive teacher development. The paper concludes by offering implications for pre-service teacher education and female teachers' continuing professional development.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Post-mortem computed tomography in the investigation of conflict and terrorist related deaths: UK military experience of developing a multidisciplinary service

This paper discusses the introduction, development and utility of post-mortem imaging relating specifically to conflict-related and terrorist-related deaths and considers the use of computed tomography (CT) in the investigations. We demonstrate how a multi-disciplinary approach involving direct communication between forensic pathologist and radiologist can maximise evidential yield, reduce the need for unnecessary dissection and further our understanding of such injuries. This summarises our shared experience of hundreds of cases, each having been individually discussed and reviewed, and has helped shape our understanding of conflict injury as well as contributing to the development of mitigation strategies and adaptations to protective equipment. A series of clinical cases are presented to demonstrate some of the strengths and weaknesses of the process.

A Randomized Trial of Autologous Chondrocyte Implantation Versus Alternative Forms of Surgical Cartilage Management in Patients With a Failed Primary Treatment for Chondral or Osteochondral Defects in the Knee

BACKGROUND

There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee.

PURPOSE

To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis.

RESULTS

Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation (P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI (P = .02).

CONCLUSION

Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI.

REGISTRATION

International Standard Randomised Controlled Trial Number: 48911177.

How to formulate hypotheses and IATAs to support grouping and read-across of nanoforms

Manufacturing and functionalizing materials at the nanoscale has led to the generation of a whole array of nanoforms (NFs) of substances varying in size, morphology, and surface characteristics. Due to financial, time, and ethical considerations, testing every unique NF for adverse effects is virtually impossible. Use of hypothesis-driven grouping and read-across approaches, as supported by the GRACIOUS Framework, represents a promising alternative to case-by-case testing that will make the risk assessment process more efficient. Through application of appropriate grouping hypotheses, the Framework facilitates the assessment of similarity between NFs, thereby supporting grouping and read-across of information, minimizing the need for new testing, and aligning with the 3R principles of replacement, reduction, and refinement of animals in toxicology studies. For each grouping hypothesis an integrated approach to testing and assessment (IATA) guides the user in data gathering and acquisition to test the hypothesis, following a structured format to facilitate efficient decision-making. Here we present the template used to generate the GRACIOUS grouping hypotheses encompassing information relevant to “Lifecycle, environmental release, and human exposure”, “What they are: physicochemical characteristics”, “Where they go: environmental fate, uptake, and toxicokinetics”, and “What they do: human and environmental toxicity”. A summary of the template-derived hypotheses focusing on human health is provided, along with an overview of the IATAs generated by the GRACIOUS project. We discuss the application and flexibility of the template, providing the opportunity to expand the application of grouping and read-across in a logical, evidence-based manner to a wider range of NFs and substances.

Exploring the influence of perceived classroom environment on learner autonomy in a Chinese EFL learning context

Developing learner autonomy has been a critical task in English teaching that requires a clear understanding of the feature of classroom environment. This study aims to examine how senior high school students perceive classroom environment and learner autonomy, and how classroom environment exerts its influence on learner autonomy in Chinese EFL learning context. Participants (N = 565) from 15 classes located in northeast of China were selected to fill in an adapted version of What is Happening in This Class (WIHIC) and English Autonomous Learning Ability scale. Interview was conducted to confirm and illustrate the quantitative findings. The results revealed that senior high students had favorable perceptions of English classroom environment and learner autonomy. Grade differences existed in their perceptions. Moreover, we found that 53.7% of the variance in learner autonomy was accounted for by students’ perceptions of English classroom environment, which indicated that English classroom environment had significantly positive effects on learner autonomy. Specifically, task orientation, student involvement, teacher support and finding references were strong predictors to learner autonomy. The possible reasons for the findings were discussed and recommendations for future research were given.

A Survey of Systematic Evidence Mapping Practice and the Case for Knowledge Graphs in Environmental Health and Toxicology

Systematic evidence mapping offers a robust and transparent methodology for facilitating evidence-based approaches to decision-making in chemicals policy and wider environmental health (EH). Interest in the methodology is growing; however, its application in EH is still novel. To facilitate the production of effective systematic evidence maps for EH use cases, we survey the successful application of evidence mapping in other fields where the methodology is more established. Focusing on issues of “data storage technology,” “data integrity,” “data accessibility,” and “transparency,” we characterize current evidence mapping practice and critically review its potential value for EH contexts. We note that rigid, flat data tables and schema-first approaches dominate current mapping methods and highlight how this practice is ill-suited to the highly connected, heterogeneous, and complex nature of EH data. We propose this challenge is overcome by storing and structuring data as “knowledge graphs.” Knowledge graphs offer a flexible, schemaless, and scalable model for systematically mapping the EH literature. Associated technologies, such as ontologies, are well-suited to the long-term goals of systematic mapping methodology in promoting resource-efficient access to the wider EH evidence base. Several graph storage implementations are readily available, with a variety of proven use cases in other fields. Thus, developing and adapting systematic evidence mapping for EH should utilize these graph-based resources to ensure the production of scalable, interoperable, and robust maps to aid decision-making processes in chemicals policy and wider EH.

Recommendations for the conduct of systematic reviews in toxicology and environmental health research (COSTER)

BACKGROUND

There are several standards that offer explicit guidance on good practice in systematic reviews (SRs) for the medical sciences; however, no similarly comprehensive set of recommendations has been published for SRs that focus on human health risks posed by exposure to environmental challenges, chemical or otherwise.

OBJECTIVES

To develop an expert, cross-sector consensus view on a key set of recommended practices for the planning and conduct of SRs in the environmental health sciences.

METHODS

A draft set of recommendations was derived from two existing standards for SRs in biomedicine and developed in a consensus process, which engaged international participation from government, industry, non-government organisations, and academia. The consensus process consisted of a workshop, follow-up webinars, email discussion and bilateral phone calls.

RESULTS

The Conduct of Systematic Reviews in Toxicology and Environmental Health Research (COSTER) recommendations cover 70 SR practices across eight performance domains. Detailed explanations for specific recommendations are made for those identified by the authors as either being novel to SR in general, specific to the environmental health SR context, or potentially controversial to environmental health SR stakeholders.

DISCUSSION

COSTER provides a set of recommendations that should facilitate the production of credible, high-value SRs of environmental health evidence, and advance discussion of a number of controversial aspects of conduct of EH SRs. Key recommendations include the management of conflicts of interest, handling of grey literature, and protocol registration and publication. A process for advancing from COSTER's recommendations to developing a formal standard for EH SRs is also indicated.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Medical records: Doctors' and patients' experiences of copying letters to patients

Aims and Method

We conducted a pilot study to determine patients' views on receiving a copy of the assessment letter sent to their general practitioner and to determine how psychiatrists' letter writing practice would be altered in the knowledge that patients would receive copies of such letters. Seventy-six consecutive new outpatients received copies of the initial assessment letter sent to general practitioners. Patients were asked to complete a short questionnaire on how the practice affected them. For each letter, psychiatrists were asked to provide details of anything of importance that had been omitted from the letter that in their normal practice they would have included.

Results

There was a broad range of responses on how patients felt about the letters. Only two patients found the letters unhelpful, and 83% expressed a positive desire to continue receiving letters, even though initially 18% found the letter distressing. For 56 out of 76 patients, psychiatrists stated that they composed and sent out the letter to the GP in accordance with their usual practice and copied the letter to the patient in an unaltered form. For 17 patients, the psychiatrist stated that some information he/she would usually have included in the GP letter was omitted in the copy the patient received. In a further 3 cases, the psychiatrist sent no letter to the patient.

Clinical Implications

Patients found it helpful to receive copies of their assessment letters. Psychiatrists might require training and reassurance about this policy before implementation.

An audit of drug management of acute behavioural disturbance

The management of acute behavioural disturbance in psychiatric patients is an area that continues to require investigation, as it is potentially dangerous for both patients and staff. We conducted an audit of the management of these episodes, looking particularly at the drugs given, the doses and any polypharmacy. We also examined whether the issue of guidelines led to any changes in prescribing patterns. We found that we were prescribing appropriately and that the guidelines did lead to some shift toward safer prescribing.

Incidence, Natural History and Risk Factors of Deep Vein Thrombosis in Elective Knee Arthroscopy

Aims: to determine the incidence, anatomical distribution and extent of deep vein thrombosis (DVT) in limbs undergoing elective unilateral knee arthroscopy without active prophylaxis, to evaluate its effect on venous function following early diagnosis, and to quantify the impact of risk factors on its incidence. Methods: 102 consecutive patients undergoing unilateral knee arthroscopy without prophylaxis were studied. A history was obtained with emphasis on the risk factors for thromboembolism, and physical examination and colour duplex were performed prior to and within a week after surgery. Patients who developed calf DVT were given aspirin (150 mg) and compression stockings; those with proximal DVT were admitted for anticoagulation (heparin followed by warfarin). Follow-up (mean 118 [range 84-168] days) entailed weekly physical and duplex examinations during the first month and monthly thereafter. Results: 8 patients developed calf DVT in the operated leg (incidence 7.84% [95% Cl: 2.7%-13.2%]); thrombosis was asymptomatic in 4 of those (50%), caused calf tenderness in 4 (50%) and a positive Homan’s sign in one (12.5%). DVT occurred in the following veins: peroneal 4 subjects (50%), soleal 4 (50%), gastrocnemial 2 (25%) and tibial 2 (25%). Propagation of a calf DVT to the popliteal vein was identified in 1 patient (12.5%). After a median period of 118 days, total clot lysis was found in 50% of DVTs, with partial thrombus resorption in the rest; reflux in the thrombosed veins was present in 75% of limbs with DVT. 43% of patients had 1 risk factor for DVT and 20% had ≥2. The incidence of DVT was higher amongst those with two or more risk factors for thromboembolism (p <.05) or those with previous thrombosis alone (p <.005). Symptoms or signs of pulmonary embolism were not documented. Conclusions: Elective unilateral knee arthroscopy performed without prophylaxis is complicated by ipsilateral calf DVT in 7.8% (95% CI: 2.7%-13.2%) of cases. The risk is higher in the presence of previous thrombosis (relative risk: 8.2) and two or more risk factors for DVT (relative risk: 2.94). Thrombosis may propagate to the proximal veins, despite early diagnosis. 50% of calf clots totally lyse in 4 months, yet reflux develops in at least 75% of limbs with DVT. Further studies to determine optimal prophylaxis are warranted.

Post-viraemic detection of bovine ephemeral fever virus by use of autogenous lymphoid tissue-derived bovine primary cell cultures

BACKGROUND

The potential tissue replication sites and specific cell types that support in vivo virus survival beyond the acute phase of bovine ephemeral fever virus (BEFV) infection have not been fully defined in cattle. To clarify the knowledge gap, tissue specimens were tested after collection from an adult steer necropsied 1 week after acute BEF.

CASE REPORT

Significant necropsy findings included fibrinoproliferative synovitis in the stifle joints and fibrin clot-laden fluid in serous body cavities. Moderate numbers of infiltrating neutrophils were demonstrated in sections of the prefemoral lymph nodes and haemal node, and lymphoid hyperplasia in the spleen, haemal node and prefemoral lymph nodes. Viral RNA was detected by qRT-PCR in fresh spleen, haemal node, prefemoral lymph node, synovial fluid and in several spleen-derived cell cultures. BEFV was isolated from autogenously derived splenic primary cell cultures 6 days after cessation of viraemia, and characteristic bullet-shaped virions were confirmed by electron microscopy of an ultrathin haemal node section. In sections of the spleen, haemal node and other tissues, immunohistochemistry demonstrated BEFV antigens that were intracellularly associated with probable histiocytic cells.

CONCLUSION

BEFV has preferential tropism for bovine lymphoid tissues and the spleen and haemal node may be potential sites for post-viraemic virus replication.

Patellar complications in single versus double tunnel medial patellofemoral ligament reconstruction

PURPOSE

Hamstring graft fixation on the patellar side during medial patellofemoral ligament (MPFL) reconstruction is usually with transosseous tunnels and can frequently lead to further problems. The aim of our study was to compare and analyse patellar complications in single patellar tunnel versus double tunnel hamstring graft fixation.

METHODS

Twenty-nine knees with MPFL reconstructions (group S) in which the hamstring tendon graft was transfixed using a suspensory fixation method in a single tunnel drilled across the patella were analysed in comparison with 29 knees (group D) with interference fixation of the graft through two tunnels drilled up to a predetermined depth in the patella. Primary outcome measured was any patellar complication like anterior knee pain and patella fracture. Secondary outcomes assessed were future functional instability and failure of reconstruction.

RESULTS

Anterior knee pain was noted in six patients in group S, of which three patients had removal of the irritating metalwork on the patella. In all, nine surgical interventions were needed in six patients in this group. Three patients in group D complained of knee pain, but no one in this group needed any further surgical interventions ( p value 0.02). Symptomatic instability requiring revision surgery or realignment surgery was required in two patients in the group S and none in group D. No patellar fractures were seen in either group.

CONCLUSION

Our study showed increasing problems with single tunnel patellar fixation, with more reoperation and failure rates compared to double tunnel fixation. The evidence supports the move towards anatomical double bundle MPFL reconstructions.

Frameworks and tools for risk assessment of manufactured nanomaterials

Commercialization of nanotechnologies entails a regulatory requirement for understanding their environmental, health and safety (EHS) risks. Today we face challenges to assess these risks, which emerge from uncertainties around the interactions of manufactured nanomaterials (MNs) with humans and the environment. In order to reduce these uncertainties, it is necessary to generate sound scientific data on hazard and exposure by means of relevant frameworks and tools. The development of such approaches to facilitate the risk assessment (RA) of MNs has become a dynamic area of research. The aim of this paper was to review and critically analyse these approaches against a set of relevant criteria. The analysis concluded that none of the reviewed frameworks were able to fulfill all evaluation criteria. Many of the existing modelling tools are designed to provide screening-level assessments rather than to support regulatory RA and risk management. Nevertheless, there is a tendency towards developing more quantitative, higher-tier models, capable of incorporating uncertainty into their analyses. There is also a trend towards developing validated experimental protocols for material identification and hazard testing, reproducible across laboratories. These tools could enable a shift from a costly case-by-case RA of MNs towards a targeted, flexible and efficient process, based on grouping and read-across strategies and compliant with the 3R (Replacement, Reduction, Refinement) principles. In order to facilitate this process, it is important to transform the current efforts on developing databases and computational models into creating an integrated data and tools infrastructure to support the risk assessment and management of MNs.

Viral neurotropism, peripheral neuropathy and other morphological abnormalities in bovine ephemeral fever virus-infected downer cattle

OBJECTIVE

This study assessed the neurotropism of bovine ephemeral fever (BEF) virus (BEFV) and described histomorphological abnormalities of the brain, spinal cord and peripheral nerves that may causally contribute to paresis or paralysis in BEF.

METHODS

Four paralysed and six asymptomatic but virus-infected cattle were monitored, and blood and serum samples screened by qRT-PCR, virus isolation and neutralisation tests. Fresh brain, spinal cord, peripheral nerve and other tissues were qRT-PCR-tested for viral RNA, while formalin-fixed specimens were processed routinely and immunohistochemically evaluated for histomorphological abnormalities and viral antigen distribution, respectively.

RESULTS

The neurotropism of BEFV was immunohistochemically confirmed in the brain and peripheral nerves and peripheral neuropathy was demonstrated in three paralysed but not the six aneurological but virus-infected animals. Wallerian degeneration (WD) was present in the ventral funicular white matter of the lumbar spinal cord of a paralysed steer and in cervical and thoracic spinal cord segments of three paralysed animals. Although no spinal cord lesions were seen in the steer euthanased within 7 days of illness, peripheral neuropathy was present and more severe in nerves of the brachial plexuses than in the gluteal or fibular nerves. The only steer with WD in the lumbar spinal cord also showed intrahistiocytic cell viral antigen that was spatially distributed within areas of moderate brain stem encephalitis.

CONCLUSION

The data confirmed neurotropism of BEFV in cattle and documented histomorphological abnormalities in peripheral nerves and brain which, together with spinal cord lesions, may contribute to chronic paralysis in BEFV-infected downer cattle.

Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

The Norwich Patellar Instability Score: Validity, internal consistency and responsiveness for people conservatively-managed following first-time patellar dislocation

BACKGROUND

This paper assessed the validity, internal consistency, responsiveness and floor-ceiling effects of the Norwich Patellar Instability (NPI) Score for a cohort of conservatively managed people following first-time patellar dislocation (FTPD).

METHODS

Fifty patients were recruited, providing 130 completed datasets over 12 months. The NPI Score, Lysholm Knee Score, Tegner Level of Activity Score and isometric knee extension strength were assessed at baseline, six weeks, six and 12 months post-injury.

RESULTS

There was high convergent validity with a statistically significant correlation between the NPI Score and the Lysholm Knee Score (p<0.001), Tegner Level of Activity Score (p<0.001) and isometric knee extension strength (p<0.002). Principal component analysis revealed that the NPI Score demonstrated good concurrent validity with four components account for 70.4% of the variability. Whilst the NPI Score demonstrated a flooring-effect for 13 of the 19 items, no ceiling effect was reported. There was high internal consistency with a Cronbach Alpha value of 0.93 (95% CI: 0.91 to 0.93). The NPI Score was responsive to change over the 12 months period with an effect size of 1.04 from baseline to 12 months post-injury.

CONCLUSIONS

The NPI Score is a valid tool to assess patellar instability symptoms in people conservatively managed following FTPD.

LEVEL OF EVIDENCE

Level II.

Kinetics of selected plasma cytokines during innate-adaptive immune response transition in adult cattle infected with the bovine ephemeral fever virus

While virus neutralizing antibodies are known to be variably protective against bovine ephemeral fever (BEF) virus (BEFV) infections, the cytokine events that mediate the nascent adaptive immune response have not been defined in cattle. This study determined the plasma kinetics of IL-2, IFN-γ, IL-6, and IL-10 during the period of innate-immune response transition and evaluated the relationship between the virus neutralizing antibody response and viraemia in BEFV-infected cattle. Plasma from four virus-infected and uninfected negative control animals was tested by cytokine-specific immunoenzymatic assays, viraemia monitored by qRT-PCR, and virus neutralizing antibody titres determined using a standard protocol. Unlike the negative controls, plasma IL-6 and IL-10 were increased in all the virus-infected animals starting several days prior to initiation of viraemia. In one animal, plasma IL-2 and IFN-γ were consistently higher than in the other three virus-infected animals and the negative control mean. The animal with the strongest IL-2 and IFN-γ responses had the shortest viraemia while the heifer with the lowest IL-2/IFN-γ indices demonstrated the longest viraemia. Evidently, increase in plasma IL-6 and IL-10 precedes seroconversion during BEFV infections in cattle suggesting the two cytokines may influence immunological events that pave way to B-cell activation and seroconversion. While there is remarkable variability in IL-2 and IFN-γ expression amongst BEFV-infected animals, increased plasma levels of the two cytokines appear to be associated with a shorter viraemia. Ongoing studies will help define the precise role of T cells in anti-BEFV adaptive immune responses.

The Netflix Recommender System

This article discusses the various algorithms that make up the Netflix recommender system, and describes its business purpose. We also describe the role of search and related algorithms, which for us turns into a recommendations problem as well. We explain the motivations behind and review the approach that we use to improve the recommendation algorithms, combining A/B testing focused on improving member retention and medium term engagement, as well as offline experimentation using historical member engagement data. We discuss some of the issues in designing and interpreting A/B tests. Finally, we describe some current areas of focused innovation, which include making our recommender system global and language aware.

The MARINA Risk Assessment Strategy: A Flexible Strategy for Efficient Information Collection and Risk Assessment of Nanomaterials

An engineered nanomaterial (ENM) may actually consist of a population of primary particles, aggregates and agglomerates of various sizes. Furthermore, their physico-chemical characteristics may change during the various life-cycle stages. It will probably not be feasible to test all varieties of all ENMs for possible health and environmental risks. There is therefore a need to further develop the approaches for risk assessment of ENMs. Within the EU FP7 project Managing Risks of Nanoparticles (MARINA) a two-phase risk assessment strategy has been developed. In Phase 1 (Problem framing) a base set of information is considered, relevant exposure scenarios (RESs) are identified and the scope for Phase 2 (Risk assessment) is established. The relevance of an RES is indicated by information on exposure, fate/kinetics and/or hazard; these three domains are included as separate pillars that contain specific tools. Phase 2 consists of an iterative process of risk characterization, identification of data needs and integrated collection and evaluation of data on the three domains, until sufficient information is obtained to conclude on possible risks in a RES. Only data are generated that are considered to be needed for the purpose of risk assessment. A fourth pillar, risk characterization, is defined and it contains risk assessment tools. This strategy describes a flexible and efficient approach for data collection and risk assessment which is essential to ensure safety of ENMs. Further developments are needed to provide guidance and make the MARINA Risk Assessment Strategy operational. Case studies will be needed to refine the strategy.

Died of wounds: a mortality review

OBJECTIVES

Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes.

METHODS

This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroner's reports.

RESULTS

There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths.

CONCLUSIONS

Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.

Kinetics of pro-inflammatory cytokines, interleukin-10, and virus neutralising antibodies during acute ephemeral fever virus infections in Brahman cattle

While fever and inflammation are hallmark features of bovine ephemeral fever (BEF), the cytokine networks that underlie the acute phase of the disease have not been empirically defined in cattle. This study characterised the plasma kinetics of proinflammatory cytokines (IL-1β, IL-6, TNF-α) and IL-10 during acute BEF and elucidated on the relationship between the onset of the virus neutralizing antibody response and resolution of viraemia in natural BEF virus (BEFV) infections in cattle. Plasma from three BEFV-infected and three uninfected cattle was tested for the study cytokines by a cELISA, viraemia monitored by qRT-PCR, and virus neutralizing antibody titres determined using a standard protocol. Unlike the negative controls, plasma concentrations of IL-1β, TNF-α, IL-6, and IL-10 were consistently increased in the three virus-infected animals. Two of the infected heifers were recumbent and pyrexic on the first day of monitoring and increased cytokine production was already in progress by the time viraemia was detected in all the three infected animals. In all the virus-infected heifers, IL-1β was the most strongly expressed cytokine, IL-6 and IL-10 manifested intermediate plasma concentrations while TNF-α was the least expressed and demonstrated bi-phasic peaks three and five days after the onset of pyrexia. In two of the BEFV-infected heifers, viraemia resolved on the day of seroconversion while in the other infected animal, viral RNA was detectable up to three days after seroconversion. The present data document variable increase in plasma IL-1β, IL-6, TNF-α, and IL-10 during natural BEFV infections and the fact that upregulation of all but TNF-α precedes seroconversion. In addition to virus neutralising antibodies, it is likely that cytokine-mediated cellular mechanisms may be required for resolution of viraemia in BEF. Considering the anti-inflammatory properties of IL-10, its upregulation may potentially antagonise the fever response in BEFV-infected cattle.

Isolated popliteus tendon injury does not lead to abnormal laxity in posterior-stabilised total knee arthroplasty

PURPOSE

The popliteus tendon is crucial to postero-lateral stability and prone to iatrogenic injury intra-operatively. Its role in the stability of the replaced knee remains contentious. The aim of this study was to use computer navigation to quantify the effect of popliteus sectioning on the 'envelope of laxity' (EoL) offered by a posterior-stabilised (PS) total knee arthroplasty (TKA) and compare with that of the native knee.

METHODS

Loaded cadaveric legs were mounted on a purpose built rig. EoL was measured in 3 degrees of freedom using computer navigation. Knees were subjectively stressed in varus/valgus, internal/external rotation and anterior draw. This was performed preoperatively, during TKA and after sectioning of the popliteus tendon. Real-time data were recorded at 0°, 30°, 60° and 90° of flexion as the operating surgeon stressed the knee in 3 degrees of freedom to its subjective endpoint. Mixed-effect modelling was used to quantify the effects of intervention on degree of laxity.

RESULTS

In all conditions, there was an increase in laxity with knee flexion. Insertion of a PS TKA resulted in increased constraint, particularly in rotation. Sectioning of the popliteus did not result in a significant increase in knee laxity to 90º of knee flexion. However, at deeper flexion angles, tendon sectioning overcame the constraints of the implant resulting in a significant increase in rotatory and varus/valgus laxity towards the native condition.

CONCLUSION

These findings support the view that certain current designs of PS knee replacement can constrain the knee in flexion in the absence of postero-lateral deficiency. For this implant, isolated sectioning of the popliteus tendon did not substantially generate abnormal knee laxity.

Initiation Stories: An Examination of the Narratives of People Who Assist With a First Injection

BACKGROUND

Research in the area of initiation to injection drug use that focuses on the perspective of initiators, or those who help with a first injection, is rare.

OBJECTIVE

To explore the process of initiation to injection drug use from the point of view of initiators.

METHODS

Semi-structured, in-depth qualitative interviews were conducted at a harm reduction program in Toronto, Canada. Twenty participants who had injected drugs in the last 30 days and who reported ever having initiated another person to injection drug use were recruited. A narrative analytic approach was used to explore the spectrum of narratives surrounding their experiences initiating others to injection drug use.

RESULTS

Initiation events arise in a complex interplay of individual circumstances and social contexts. People who inject may assist with a first injection for a variety of reasons, from conceding to social pressure, to wanting to help reduce a perceived risk of harm, to assisting because it provides a sense of pride at possessing a skill or of having helped someone achieve a desired state, to assisting to obtain drugs or to cope with withdrawal, or a mix of several of these reasons at once.

CONCLUSIONS/IMPORTANCE

Narratives reveal that preventing all instances of initiation is unrealistic. Combining elements from existing interventions that focus on enhancing reluctance to assist with initiation with safer injection training has the potential to reduce initiations and perhaps reduce injection related harm for novices if initiation occurs.

Experimental penetration of fragment simulating projectiles into porcine tissues compared with simulants

INTRODUCTION

Ballistic gelatin is well validated in its ability to simulate the retardation of bullets into homogenous muscle. However the relationship is less clear for fragmentation projectiles and non-homogenous tissues as would truly be found in a human.

METHOD

0.16 g, 1.10 g and 2.84 g NATO standardised cylindrical Fragment Simulating Projectiles (FSPs) were fired at a range of velocities (112-1652 m s(-1)) into four body areas (thigh, abdomen, thorax or neck) of six pig cadavers as well as 20% gelatin. Cadavers were imaged by Computed Tomography (CT) scanning and FSP Depth of Penetration (DoP) ascertained through radiology followed by dissection by a forensic pathologist.

RESULTS

106/149 (71%) FSPs were retained in tissues enabling DoP measurements and 43/149 (29%) exited the subjects. There was significantly less retardation of FSPs in the thorax and abdomen compared to gelatin but no difference in retardation in leg and neck tissue compared to gelatin. Although the gradient appeared identical for the 2.84 g FSP as well, there were insufficient FSPs retained in the neck and leg for meaningful analysis to be undertaken.

DISCUSSION

Porcine leg and neck muscle was demonstrated to be comparable to 20% ballistic gelatin in terms of retardation, validating the use of projectile penetration algorithms derived from this tissue simulant. The effect of pig skin was significant for the 0.16 g FSP, especially at lower velocities, and we would therefore suggest that specific algorithms for any future numerical injury models be based directly from animal data or validated skin simulants for this smaller sized FSP. Reproducing the retardation effects of FSPs in the thorax and abdomen using tissue simulants alone will be problematic due to the anatomical complexity as well as multiple tissue-air interfaces and we would recommend further research in this area.