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Emergency department (ED) crowding is a significant problem in Canada and internationally and is associated with the potential for patient harm. Although pediatric patients represent a significant proportion of overall ED visits, there is limited research on pediatric ED crowding. The Canadian Association of Emergency Physicians defines department crowding as a mismatch between the required and available resources to provide timely emergency care. We propose that rather than crowding, it is better to think of ED patient populations as being more or less "complex" as defined by proxies of the human and physical resources needed for patient management. The study objectives are to explore the utility of a simple and easily available retrospective metric of ED complexity, and to assess the relationship this measure has on patient outcomes in a pediatric ED.Using administrative data from a tertiary care pediatric ED, we developed a departmental complexity score based on patient registration number, triage acuity, and departmental length of stay as a proxy for the resources necessary to provide ED care. We then explored the relationship between this departmental complexity score and clinical care indices.The score shows a strong relationship with the number of patients who left without being seen by a physician, as well as time to initial MD assessment, both measures which have been used to represent ED crowding in previous research. We found no association between our departmental complexity score and adverse impacts on patient care outcomes of hospital admission, pediatric ICU admission, or patients returning to the ED within 72 h of leaving.The departmental complexity score has promise as a retrospective measure of departmental resource requirement and may have a role in the ongoing assessment of patient flow.RéSUMé: OBJECTIF: L'encombrement des services d'urgence est un problème important au Canada et à l'échelle internationale et est associé à un risque de préjudice pour les patients. Bien que les patients pédiatriques représentent une proportion importante de l'ensemble des visites aux urgences, il existe peu de recherches sur l'encombrement des urgences pédiatriques. L'Association canadienne des médecins d'urgence définit l'encombrement des services comme une inadéquation entre les ressources nécessaires et les ressources disponibles pour fournir des soins d'urgence en en temps opportun. Nous proposons que, plutôt que de parler d'encombrement, il est préférable de considérer les populations de patients des urgences comme étant plus ou moins " complexes ", selon des approximations des ressources humaines et physiques nécessaires à la prise en charge des patients. Les objectifs de l'étude sont d'explorer l'utilité d'un indicateur rétrospectif simple et facilement accessible de la complexité des urgences, et d'évaluer la relation de cet indicateur sur les résultats des patients dans des urgences pédiatriques. MéTHODES: En utilisant les données administratives d'un service d'urgence pédiatrique de soins tertiaires, nous avons développé un score de complexité départementale basé sur le numéro d'enregistrement du patient, l'acuité du triage et la durée du séjour départemental comme un indicateur des ressources nécessaires pour fournir des soins d'urgence. Nous avons ensuite exploré la relation entre ce score de complexité départementale et les indices de soins cliniques. RéSULTATS: Le score présente une forte relation avec le nombre de patients qui sont partis sans être vus par un médecin, ainsi qu'avec le délai avant l'évaluation initiale du médecin, deux mesures qui ont été utilisées pour représenter l'encombrement des urgences dans des recherches antérieures. Nous n'avons trouvé aucune association entre notre score de complexité départementale et les effets négatifs sur les résultats des soins aux patients de l'admission à l'hôpital, de l'admission en unité de soins intensifs pédiatriques ou des patients qui reviennent aux urgences dans les 72 heures suivant leur départ. CONCLUSIONS: Le score de complexité départementale est prometteur en tant que mesure rétrospective des besoins en ressources départementales et peut jouer un rôle dans l'évaluation continue du flux de patients.

While cases of acquired Chiari I malformation following ventriculoperitoneal shunting for posthemorrhagic hydrocephalus have been reported, true disproportionate cerebellar growth is rare, with no previous cases requiring posterior fossa decompression reported. We present a premature neonate who underwent ventriculoperitoneal shunt placement for suspected posthemorrhagic hydrocephalus. He subsequently developed a symptomatic Chiari I malformation with volumetric measurements demonstrating disproportionate growth of the cerebellum. He did not demonstrate thickening of the supratentorial or posterior fossa cranium. The patient underwent an extradural posterior fossa decompression, with resolution of symptoms. We review the extant literature regarding the development of Chiari malformation type I as a manifestation of craniocerebral disproportion (CCD) following shunt placement for posthemorrhagic hydrocephalus of prematurity. Most previous reports reflect a mechanism that includes underdevelopment of the intracranial posterior fossa (or supratentorial) volume. The case presented in this report, as well as one additional case, indicates that there may exist a variant mechanism, characterized by rapid growth of the cerebellum itself, in the absence of one of the rare syndromes associated with primary macrocerebellum. While this case was effectively managed with extradural posterior fossa decompression, previous reports indicate that supratentorial cranial expansion procedures are preferable in some cases. As such, pediatric neurosurgeons should be able to distinguish the patterns of craniocerebral disproportion when considering treatment options for these patients. Further investigation regarding these uncommon patients may better describe the underlying mechanisms.

Update the evidence regarding how co-occurring personality disorders influence treatment outcomes for major depressive disorder and update the evidence regarding treatment options for personality disorders that are co-occurring with major depressive disorder. There is evidence that personality disorders can be effectively treated through a variety of psychotherapeutic modalities. Given the substantial evidence that co-occurring personality disorders impede the recovery from major depressive disorder, comprehensively addressing any co-occurring personality disorders is an essential part of an effective treatment plan for patients with major depressive disorder. Personality disorders such as borderline personality disorder, which is commonly co-occurring with major depressive disorder, have several validated treatment options. Since publication of past reviews on the topic, there have been multiple additional studies published to advance the discussion of the impact of personality disorders on treatment outcomes in major depression. There is now substantial evidence that personality disorders can negatively affect treatment outcomes in the setting of major depression, which is consistent with the clinical observation that co-occurring personality disorders need to be comprehensively addressed to achieve optimal outcomes for the individual. There also now exists substantial evidence that personality disorders can be effectively treated using several validated psychotherapeutic modalities. It is recommended that a comprehensive assessment, including assessment for co-occurring personality disorders, is implemented in all cases of major depressive disorder that have not been successfully treated. In those cases where a co-occurring personality disorder is identified, specific treatment for the personality disorder should be recommended.

Soil hydrological processes (SHP) support ecosystems, modulate the impact of climate change on terrestrial systems and control feedback mechanisms between water, energy and biogeochemical cycles. However, land-use changes and extreme events are increasingly impacting these processes. In this Review, we describe SHP across scales and examine their links with soil properties, ecosystem processes and climate. Soil structure influences SHP such as infiltration, soil water redistribution and root water uptake on small scales. On local scales, SHP are driven by root water uptake, vegetation and groundwater dynamics. Regionally, SHP are impacted by extreme events such as droughts, floods, heatwaves and land-use change; however, antecedent and current SHP partially determine the broader effects of extreme events. Emerging technologies such as wireless and automated sensing, soil moisture observation through novel synthetic aperture radars satellites, big data analysis and machine learning approaches offer unique opportunities to advance soil hydrology. These advances, in tandem with the inclusion of more key soil types and properties in models, will be pivotal in predicting the role of SHP during global change.

Biomaterial-based cell replacement approaches to regenerative medicine are emerging as promising treatments for a wide array of profound clinical problems. Here we report an interpenetrating polymer network (IPN) composed of gelatin-hydroxyphenyl propionic acid and hyaluronic acid tyramine that is able to enhance intravitreal retinal cell therapy. By tuning our bioinspired hydrogel to mimic the vitreous chemical composition and mechanical characteristics we were able to improve in vitro and in vivo viability of human retinal ganglion cells (hRGC) incorporated into the IPN. In vivo vitreal injections of cell-bearing IPN in rats showed extensive attachment to the inner limiting membrane of the retina, improving with hydrogels stiffness. Engrafted hRGC displayed signs of regenerating processes along the optic nerve. Of note was the decrease in the immune cell response to hRGC delivered in the gel. The findings compel further translation of the gelatin-hyaluronic acid IPN for intravitreal cell therapy.

Social movements carry out extensive character work, trying to define not only their own reputations but those of other major players in their strategic arenas. Victims, villains, and heroes form the essential triad of character work, suggesting not only likely plots but also the emotions that audiences are supposed to feel for various players. Characters have been overlooked in cultural analysis, possibly because they often take visual, non-narrative forms. By focusing on characters within movements, we illuminate some cultural dilemmas that both organizers and their opponents face as they try to influence players’ reputations.

We present a counterexample to a lower bound for the power domination number given in Liao (J Comb Optim 31:725–742, 2016). We also define the power propagation time, using the power domination propagation ideas in Liao and the (zero forcing) propagation time in Hogben et al. (Discrete Appl Math 160:1994–2005, 2012).

Background The 22q11.2 deletion syndrome is the most common microdeletion syndrome in livebirths, but data regarding its incidence in other populations is limited and also include ascertainment bias. This study was designed to determine the incidence of the 22q11.2 deletion in miscarriage samples sent for clinical molecular cytogenetic testing. Results Twenty-six thousand one hundred one fresh product of conception (POC) samples were sent to a CLIA- certified, CAP-accredited laboratory from April 2010–-May 2016 for molecular cytogenetic miscarriage testing using a single-nucleotide polymorphism (SNP)-based microarray platform. A retrospective review determined the incidence of the 22q11.2 deletion in this sample set. Fetal results were obtained in 22,451 (86%) cases, of which, 15 (0.07%) had a microdeletion in the 22q11.2 region (incidence, 1/1497). Of those, 12 (80%) cases were found in samples that were normal at the resolution of traditional karyotyping (i.e., had no chromosome abnormalities above 10 Mb in size) and three (20%) cases had additional findings (Trisomy 15, Trisomy 16, XXY). Ten (67%) cases with a 22q11.2 deletion had the common ~3 Mb deletion; the remaining 5 cases had deletions ranging in size from 0.65 to 1.5 Mb. A majority (12/15) of cases had a deletion on the maternally inherited chromosome. No significant relationship between maternal age and presence of a fetal 22q11.2 deletion was observed. Conclusions The observed incidence of 1/1497 for the 22q11.2 deletion in miscarriage samples is higher than the reported general population prevalence (1/4000–1/6000). Further research is needed to determine whether the 22q11.2 deletion is a causal factor for miscarriage.

We introduce and study a multivariate function that counts nowhere-zero flows on a graph G, in which each edge of G has an individual capacity. We prove that the associated counting function is a piecewise-defined polynomial in these capacities, which satisfies a combinatorial reciprocity law that incorporates totally cyclic orientations of G.

The relationship between religiosity and sexual behavior has been previously investigated, but researchers have not examined the relationship between the intellectual dimension of religiosity and sexual behavior. In this study, we developed an intellectual measure of religiosity, Hiding the Word (HTW), and examined whether it accounted for variation in the sexual behavior of college students, beyond that for which age and a generic measure of religiosity could account. Results showed, after accounting for age and generic religiosity, HTW made a significant contribution to distinguishing between students who had, and those who had not, engaged in various sexual behaviors. For females, this was the case in three of the five behaviors examined (all except receiving oral sex and participating in unprotected penile-vaginal intercourse at most recent sexual encounter), and for males, two of the four behaviors (sexual intercourse and anal intercourse). HTW was less of a factor in accounting for variation in the frequency of participation. For males, HTW was significant for the frequency of participation in penile-vaginal intercourse, receiving oral sex, and the number of sexual partners in the last month. For females, HTW was significant only for the number of sexual partners in the last month. Thus, religiosity, and specifically HTW, seems to play more of a role in determining whether or not a person has participated in behavior, rather than in the frequency of participation.

Several authors have suggested that the contract between the university and society formulated in the nineteenth century is breaking down, and a new relation between knowledge and society is being installed. This paper investigates what is at stake in this shift by re-visiting the roots of disciplinary knowledge, examining Durkheim’s social theory of knowledge to display the evolution of basic and professional disciplines in the nineteenth and early twentieth centuries. Two contemporary challenges to disciplinary knowledge are then examined and evaluated. The paper concludes that it is time to transcend the standoff between disciplinary knowledge and practice-based accounts of knowledge.

Objective To determine if olfactory analysis of toxin proxies aid in the identification of poisons when compared to case histories alone. Methods: A convenience sample of 42 emergency medicine residents participated in a prospective single-blind observational study using a sniffing bar designed with the technique described by Goldfrank et.al. Each subject received 12 written cases describing a patient with a chemical exposure. Ten chemicals with odors corresponding to a specific case history and 2 chemical case controls with no odor comprised the sniffing bar. Each subject was asked to identify the toxin first by reading the case history alone, then again after smelling the corresponding odor. All subjects were asked to record their level of confidence for each case before and after the addition of the sniffing bar using a 5-point Likert scale. Percentages correct before and after the sniffing bar intervention were calculated and two-tailed p-values and 95% confidence intervals were measured. Continuous comparative variables such as the means of the Likert scale confidence measurements were analyzed with the two-tailedt-test. Results: Median percentage of toxins correctly identified was 64.3% (range 9.5–97.6) when based on case description alone and 86.9% (range 9.5–95.2) with addition of the sniffing bar. The percentage of initially incorrect identification reversed after additional data provided by the sniffing bar was 11.5% (range 0–14). Of the 10 actual toxins, correct identification of 6 achieved statistical significance after introduction of the sniffing bar (p = 0.0017; 95% CI 4.6–11.4). There was no association between level of training and improved accuracy with use of the sniffing bar, and overall confidence did not improve significantly after addition of the sniffing bar. Conclusion: Diagnostic accuracy of poisons in case-based scenarios is improved with the use of a sniffing bar. The sniffing bar is a useful adjunct to a traditional case-based emergency medicine toxicology teaching curriculum.

Antigen receptor-mediated production of inositol-1,4,5-trisphosphate (Ins(1,4,5)P3) in lymphocytes triggers the release of Ca2+ from intracellular stores; this release of Ca2+ results in the opening of store-operated Ca2+ channels in the plasma membrane. Here we report that mice lacking Ins(1,4,5)P3 3-kinase B (Itpkb), which converts Ins(1,4,5)P3 to inositol-1,3,4,5-tetrakisphosphate (Ins(1,3,4,5)P4), had impaired B lymphocyte development and defective immunoglobulin G3 antibody responses to a T lymphocyte-independent antigen. Itpkb-deficient B lymphocytes had the phenotypic and functional features of tolerant B lymphocytes and showed enhanced activity of store-operated Ca2+ channels after B lymphocyte receptor stimulation, which was reversed by the provision of exogenous Ins(1,3,4,5)P4. Our data identify Itpkb and its product Ins(1,3,4,5)P4 as inhibitors of store-operated Ca2+ channels and crucial regulators of B cell selection and activation.

Adenosine deaminase-deficient severe combined immunodeficiency (ADA-SCID) is characterized by impaired T-, B- and NK-cell function. Affected children, in addition to early onset of infections, manifest non-immunologic symptoms including pulmonary dysfunction likely attributable to elevated systemic adenosine levels. Lung disease assessment has primarily employed repetitive radiography and effort-dependent functional studies. Through impulse oscillometry (IOS), which is effort-independent, we prospectively obtained objective measures of lung dysfunction in 10 children with ADA-SCID. These results support the use of IOS in the identification and monitoring of lung function abnormalities in children with primary immunodeficiencies. Electronic supplementary material The online version of this article (doi:10.1186/s13023-015-0365-z) contains supplementary material, which is available to authorized users.

The authoring of fictional stories is considered a creative process. The purpose of most story authoring is not to invent a new style or genre of story that will be accepted by the population but to invent a single narrative that is novel enough to be tellable. Computational story generation systems are more limited than human authors in the space of narratives that can be considered because it is often the case that story generation systems are constrained to operate within a fixed representation of the story world. These limitations can impact whether a story generation system is considered creative or not. In this paper, we describe a story planning system, Fabulist. Fabulist however is constrained by the world model input by the system user. We present two algorithms that enable story planning systems such as Fabulist to break outside the bounds of the initial world model in order to search a larger space of narratives.

From an ecological psychology perspective, afull analysis of any learning context mustacknowledge the complex nonlinear dynamics thatunfold as an intentionally-driven learnerinteracts with a technology-based purposefullydesigned learning environment. Further, a fullanalysis must avoid focusing only on theindividual within the learning context and notaccounting for the intentionality andconstraining influence of the designer and thebroader community. Finally, such an analysismust either pin down how learning anddevelopment can be driven by perception of theenvironment alone (detection of affordances),or alternatively from an ecologicalperspective, by a cyclical interaction ofperception and action. This paperpresents these parameters for any model ofcontext or situation in relationship to theissues raised by Akhras and Self's (this issue)presentation on intelligent learningenvironments. We propose that a full situationmodel would need to incorporate constraints notonly from the environment, but also from theindividual and most precisely from the specificinteraction at the moment of an occasion.

One-third of the population of Oman depends upon groundwater extracted from the alluvium of the Batinah Plain, on the coast of the Gulf of Oman. Deep geophysical exploration techniques were used to determine the depth and nature of the alluvium and the boundaries of the aquifer. The base and structural controls of the alluvial basin at its contact with Tertiary marine sediments and Cretaceous ophiolite were mapped with seismic reflection data, recorded originally for oil exploration. The base of the alluvium dips northward from the foothills of the Northern Oman Mountains, reaching a maximum depth of 2000 m at the coast. The varying facies of the alluvium are grossly characterised by different, overlapping ranges of electrical resistivity, depending largely on the clay content and degree of cementation. Resistivities near the coast are reduced by saline intrusion. These variations of resistivity were mapped with time-domain electromagnetic sounding along 400 km of profile, to distinguish among the three zones of the alluvial aquifer. The wedge of saline intrusion was also delineated, up to 10 km from the coast. The thickness of the saturated gravel aquifer ranges from 20–160 m in an area greater than 600 km2.

A questionnaire was sent to all the Deaf Schools in the U.S. including State Deaf Schools, Private Deaf Schools, and Public Schools that were listed as having a program specifically for students who are deaf. Ninety-two questionnaires were mailed and 76 were returned for a response rate of 83%. The questionnaire elicited information regarding current practices in sexuality education including materials used, mode of communication, media materials utilized, topics covered, and the instructor's perception of the quality of materials being used. Results indicate that teachers are spending more than 2 hours per week modifying materials for their sexuality curriculum. Most of the respondents expressed concerns about obtaining materials that are accessible and appropriate for students who are deaf, developing an overall curriculum, obtaining materials for students who have multiple disabilities, and obtaining materials that do not require modification before they are used with students who are deaf.

We begin with a discussion of contemporary approaches to assessment highlighting their reliance on a static, linear model of knowledgeable performance. Next we describe an ecological psychology approach to problem solving. Then, we propose the adoption of an agent-environment interaction as the unit of analysis. We continue by describing the problem-solving process from an ecological psychology perspective, to clarify the “intentional unit”. We close with a discussion of functional validity, the value added by access to assessment information during the problem-solving process.

The purposes of these studies were to investigate: a) the role of different intentions for constraining kiosk searches; b) whether selected variables related to reading comprehension (e.g., prior content knowledge) were also related to document search; and c) the potential of log files (timed-stamped records of students' navigational choices in the kiosk) as a non-intrusive tool for seamlessly capturing navigational performance. In Study 1, 64 college students were recruited and randomly assigned to one of two conditions. Both groups used an identical computer kiosk. However, one condition used the kiosk to address a specific problem, while the other condition used the kiosk based on their own interests-no specific task was provided. A discriminant function analysis was able to improve prediction about the group membership by 79% (adjusted with Cohen's Kappa) over and above chance. In Study 2, 54 participants were randomly assigned a simple or complex task. Participants were pretested on prior topic knowledge and solutions were rated based on a composite of navigational scores. Although prior content knowledge and the interaction were not significant, the type of task assigned was related to the quality of solution. These results provide further reason to distinguish between document search and reading comprehension. Further, they suggest new tools for assessment (log files) that have implications for many computerized applications, including hypertext, hypermedia, and the World Wide Web.

Based on a theory of situated learning, assessment must emphasize process as much as product. Assessment must move away from a linear additive model, accepting at the outset the complex, nonlinear, and possibly chaotic nature of real learning. Assessment must adapt to and take advantage of students working with technologies that extend their perceptual and problem-solving capacities beyond what they could do alone. To illustrate these points, several assessment examples are given, including a computer-based planning assistant for a videodisc mathematics and science video, suggestions for computer-based portfolio assessment, and speculations about embedded assessment of virtual situations. In all cases, the theory of situated learning emphasized perception over memory and the codetermined nature of learning and thinking.

The design of situated learning must be closely linked to the ecological psychology of “situated cognition,” as exemplified by problem solving in a complex situated context, the Jasper Series. The extreme view of situated learning contends thatall thinking must be viewed as situated, and is therefore better explained by concepts of perception and action than by the concepts of information processing psychology. In this article, ideas of ecological psychology provide the background for describing four broad tasks for the design of situated learning: selecting the situations, providing scaffolding, determining and supporting the role of the teacher, and assessing situated learning. Further, three metrics for evaluating situated learning are suggested: affording transfer, providing meaning, and providing an anchor for cross-curricular investigation.

We review the main components of autonomous scientific discovery, and how they lead to the concept of a Robot Scientist. This is a system which uses techniques from artificial intelligence to automate all aspects of the scientific discovery process: it generates hypotheses from a computer model of the domain, designs experiments to test these hypotheses, runs the physical experiments using robotic systems, analyses and interprets the resulting data, and repeats the cycle. We describe our two prototype Robot Scientists: Adam and Eve. Adam has recently proven the potential of such systems by identifying twelve genes responsible for catalysing specific reactions in the metabolic pathways of the yeast Saccharomyces cerevisiae. This work has been formally recorded in great detail using logic. We argue that the reporting of science needs to become fully formalised and that Robot Scientists can help achieve this. This will make scientific information more reproducible and reusable, and promote the integration of computers in scientific reasoning. We believe the greater automation of both the physical and intellectual aspects of scientific investigations to be essential to the future of science. Greater automation improves the accuracy and reliability of experiments, increases the pace of discovery and, in common with conventional laboratory automation, removes tedious and repetitive tasks from the human scientist.

Systematic study of social behaviour in terms of time may bring to light patterns worthy of investigation. For this, a terminology is needed, and some physical terms might usefully be applied to sociology.

A microplate rack has been designed for use with in vitro biological assays. The microplate rack can hold up to 15, 96-well microplates and easily fits into most incubator chambers. Placement and retrieval of large numbers of microplates is convenient and quick. Incubation conditions(e.g. temperature and gas diffusion) surrounding microplates arranged in the rack are more uniform than when microplates are stacked directly atop one another. Moreover, the incubator environment is disturbed less by virtue of the efficient quick entry and access afforded by the rack design.

An adjustable platform has been designed to facilitate the addition of biological assay components to a multiwell microplate. Nonmanifold additions of liquid components to microplate wells are made especially easy by using this device. The microplate platform can accommodate any of the common formats of disposable microplates. Moreover, it can be adjusted to varying angles allowing the investigator to view into all the wells as assay components are being added.