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Background Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. Objectives We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. Methods As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. Results Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). Conclusions We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

The International Energy Agency Technology Collaboration Programme for Ocean Energy Systems (OES) initiated the OES Wave Energy Conversion Modelling Task, which focused on the verification and validation of numerical models for simulating wave energy converters (WECs). The long-term goal is to assess the accuracy of and establish confidence in the use of numerical models used in design as well as power performance assessment of WECs. To establish this confidence, the authors used different existing computational modelling tools to simulate given tasks to identify uncertainties related to simulation methodologies: (i) linear potential flow methods; (ii) weakly nonlinear Froude–Krylov methods; and (iii) fully nonlinear methods (fully nonlinear potential flow and Navier–Stokes models). This article summarizes the code-to-code task and code-to-experiment task that have been performed so far in this project, with a focus on investigating the impact of different levels of nonlinearities in the numerical models. Two different WECs were studied and simulated. The first was a heaving semi-submerged sphere, where free-decay tests and both regular and irregular wave cases were investigated in a code-to-code comparison. The second case was a heaving float corresponding to a physical model tested in a wave tank. We considered radiation, diffraction, and regular wave cases and compared quantities, such as the WEC motion, power output and hydrodynamic loading. The Danish partners acknowledge the support from the Danish Energy Agency through project 374 64017-05197. The Swedish partners were supported by the Swedish Energy Agency under Grants P44423-1 and 375 P44432-1. J.V.R. and G.G. acknowledge the support by Science Foundation Ireland under Grant 13/IA/1886. This research was made possible by support from U.S. the Department of Energy’s EERE Water Power Technologies Office. Sandia National Laboratories is a multi-mission laboratory managed and operated by National Technology and Engineering Solutions of Sandia, LLC., a wholly owned subsidiary of Honeywell International, Inc., for the U.S. Department of Energy’s National Nuclear Security Administration under contract DE-NA0003525. This work was authored (in part) by the National Renewable Energy Laboratory, operated by Alliance for Sustainable Energy, LLC, for the U.S. Department of Energy (DOE) under Contract No. DE-AC36-08GO28308. Funding was provided by the U.S. Department of Energy Office of Energy Efficiency and Renewable Energy Wind Energy Technologies Office. The views expressed in this article do not necessarily represent the views of the DOE or the U.S. Government. The U.S. Government retains and the publisher, by accepting the article for publication, acknowledge that the U.S. Government retains a non-exclusive, paid-up, irrevocable, worldwide license to publish or reproduce the published form of this work, or allow others to do so, for U.S. Government purposes.

OBJECTIVES To measure serial interleukin (IL)-6 levels in newly diagnosed patients with giant cell arteritis (GCA), treated in a randomized controlled trial of modified-release prednisone (MR) vs immediate-release prednisolone (IR) used in a tapering regimen conforming to British Society for Rheumatology GCA guidelines. METHODS Patients (n = 12) were randomized into 2 treatment arms (7 MR, 5 IR) and followed over 26 weeks. We measured IL-6 with additional markers. RESULTS A significantly higher overall mean IL-6 level (P

Study objective Online educational resources such as blogs are increasingly used for education by emergency medicine clinicians. The Social Media Index was developed to quantify their relative impact. The Medical Education Translational Resources: Indicators of Quality (METRIQ) study was conducted in part to determine the association between the Social Media Index score and quality as measured by gestalt and previously derived quality instruments. Methods Ten blogs were randomly selected from a list of emergency medicine and critical care Web sites. The 2 most recent clinically oriented blog posts published on these blogs were evaluated with gestalt, the Academic Life in Emergency Medicine Approved Instructional Resources (ALiEM AIR) score, and the METRIQ-8 score. Volunteer raters (including medical students, emergency medicine residents, and emergency medicine attending physicians) were identified with a multimodal recruitment methodology. The Social Media Index was calculated in February 2016, November 2016, April 2017, and December 2017. Pearson's correlations were calculated between the Social Media Index and the average rater gestalt, ALiEM AIR score, and METRIQ-8 score. Results A total of 309 of 330 raters completed all ratings (93.6%). The Social Media Index correlated moderately to strongly with the mean rater gestalt ratings (range 0.69 to 0.76) and moderately with the mean rater ALiEM AIR score (range 0.55 to 0.61) and METRIQ-8 score (range 0.53 to 0.57) during the month of the blog post's selection and for 2 years after. Conclusion The Social Media Index's correlation with multiple quality evaluation instruments over time supports the hypothesis that it is associated with overall Web site quality. It can play a role in guiding individuals to high-quality resources that can be reviewed with critical appraisal techniques.

Abstract Nineteenth-century German opera composer Richard Wagner was very knowledgeable about Buddhism and its teachings, at least for a European of that time, and he incorporated his knowledge of those teachings into his last five music dramas: The Ring of the Nibelung (a four-opera cycle) and his final opera, Parsifal. The Ring is traditionally performed separately from Parsifal, but this article explains how there is a basis to connect these five great works into one cycle, even to the extent where the performance of a five-opera cycle would one day become a reality. The basis for this connection includes Wagner’s own strong belief in reincarnation, as well as Buddhism’s general teaching and explanation of karma and rebirth.

Study objective Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. Methods We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. Results One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r=0.92) and residents (r=0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). Conclusion The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment.

The pharmaceutical industry, particularly the small molecule domain, faces unprecedented challenges of escalating costs, high attrition as well as increasing competitive pressure from other companies and from new treatment modes such as biological products. In other industries, process improvement approaches, such as Lean Sigma, have delivered benefits in speed, quality and cost of delivery. Examining the medicinal chemistry contributions to the iterative improvement process of design-make-test-analyse from a Lean Sigma perspective revealed that major improvements could be made. Thus, the cycle times of synthesis, as well as compound analysis and purification, were reduced dramatically. Improvements focused on team, rather than individual, performance. These new ways of working have consequences for staff engagement, goals, rewards and motivation, which are also discussed.

This paper is a continuation of our previous paper [1] (OMAE2014-23225) where we did a parametric study for wave-structure interaction of a hollow cylinder in regular sea waves without vessel motions. The effect of waves and current on the motion of the cylinder and the associated forces were evaluated using a state-of-the-art methodology [2] (OMAE2013-11569) for predicting the motions and loads of subsea equipment and structures during offshore operations. In this paper, we extend the solution to include wave – structure interaction in regular sea waves and vessel motions. The 5th order Stokes regular waves in CFD and vessel motions are included in the modeling. This methodology couples the transient CFD with a hydrodynamic motion analysis after diffraction analyses, instead of relying on the traditional approach which uses simplified equations or empirical formulae to estimate hydrodynamic coefficients [3], or using steady-state CFD simulation on stationary equipment and structures to predict drag and added masses on submerged structures. The time domain diffraction simulation is coupled with a multiphase CFD simulation of subsea equipment and structures in waves. A transient CFD model with rigid body motions for the equipment and structures calculates added masses, forces and moments on the equipment and structures for the diffraction analysis, while the diffraction analysis calculates linear and angular velocities for the CFD simulation. In this paper, simulations are performed to investigate effect of the vessel motions on the motion of a hollow cylinder in regular sea waves. The results are compared with that from the traditional approach. This coupled methodology has potential applications in analyses of the motions of subsea equipment and structures in waves during offshore operations. The results in this paper show wave-structure interaction of a hollow cylinder in regular sea waves, and the effect of vessel motions on the motion of the cylinder. The results provide better understanding of structure motion in regular waves with vessel motions using this coupled methodology. The coupled methodology eliminates the inaccuracy inherited from assumed or calculated hydrodynamic properties that are obtained by using simplified equations or empirical formulations, or by using steady-state CFD analyses in traditional decoupled approaches. The results show that the coupled physics of regular sea waves, vessel motions and cylinder motion is captured by using this methodology. The coupled physics is not captured by the traditional approach.Copyright © 2015 by ASME

Purpose: Gaucher disease is an exemplary orphan disorder. Enzyme replacement therapy with imiglucerase is effective, but very expensive. To improve the assessment of severity of disease and responses to this costly treatment, we have evaluated several enzymatic biomarkers and a newly-described chemokine. Subjects and methods: We studied 48 untreated adults with Type I Gaucher disease: 20 patients were studied after the introduction of enzyme replacement. Disease activity was monitored by serial measurement of platelet count, visceral volumes (spleen and liver) by magnetic resonance imaging, serum activities of total acid phosphatase, angiotensin-converting enzyme (ACE) and the lysosomal chitinase, chitotriosidase. Pulmonary and activation-regulated chemokine (PARC/CCL 18) was also determined in serurn by ELISA. Results: Serum PARC concentrations were elevated 10-40-fold in patients with Gaucher disease compared with 67 healthy controls, without overlap (P

The pharmacokinetic profile of cilomilast (Ariflo®), a selective phosphodiesterase 4 (PDE4) inhibitor, was investigated in three separate studies. Two of these studies explored the drug interaction potential of cilomilast with the nonselective PDE inhibitor, theophylline, and a third study compared the pharmacokinetic profile of cilomilast in smokers and nonsmokers. Repeated administration of cilomilast had no effect on the steady-state pharmacokinetics of theophylline in either a pilot dose-ranging or definitive therapeutic study. At therapeutic doses, the point estimate and 90% confidence interval for theophylline AUC 0 - 1 2 and C m a x were completely contained within the range (0.8, 1.25). Similarly, repeated administration of theophylline had little clinically relevant effect on the steady-state pharmacokinetics of cilomilast when compared to placebo, as only slight average increases in cilomilast AUC 0 - 1 2 and C m a x (6% and 3%, respectively) were observed. In addition, mean cilomilast exposure (AUC 0 - ∞ ) was found to be similar in both smokers and nonsmokers (8.47 ′ 2.20 μg.h/mL and 7.70 ′ 2.25 μg.h/mL, respectively). Throughout all three studies, cilomilast was well tolerated, and concomitant use of these selective and nonselective inhibitois, although unlikely in the clinic, is hypothetically feasible. Taken together, these studies clearly differentiate cilomilast from theophylline for drug-drug liability issues in a smoker and nonsmoker population, as well as highlight the potential to switch from one drug to another without undue clinical concern.

Study Objective. To determine the absolute bioavailability of cilomilast, and assess the effects of food, dosing time, and coadministration of antacid agents on its bioavailability and pharmacokinetics in healthy volunteers. Setting. Clinical pharmacology unit. Design. Five prospective pharmacokinetic studies: one single-blind, dose-escalating, placebo-controlled trial; four open-label, randomized studies. Subjects. Ninety-six healthy adult volunteers who were nonsmokers. Intervention. In the first study, four subjects received intravenous cilomilast 1, 2, and 4 mg. In the second study, 16 subjects received oral cilomilast 15 mg or intravenous cilomilast 4 mg. In the other three studies, a total of 76 subjects were given single oral 15-mg doses; one study compared its effects in fed versus fasted subjects, one looked for differences of morning versus evening dosing, and one examined coadministration with aluminum hydroxide-magnesium hydroxide. Measurements and Main Results. After intravenous administration of cilomilast, plasma concentrations increased in an approximately dose-proportional manner; the half-life, approximately 6.5 hours, was dose independent. Cilomilast clearance and volume of distribution were small. After oral dosing, the absolute bioavailability was consistently close to 100%. Absorption was slower in fed subjects than in fasted (median 2-hr delay in time to reach maximum plasma concentration, average 39% reduction in maximum plasma concentration), but the area under the concentration-time curve from time zero to infinity (systemic availability) was unaffected. Pharmacokinetic parameters were not influenced by time of dosing or coadministration of antacid. Conclusion. The absolute bioavailability of oral cilomilast was 100%; it was not adversely affected by time of dosing or coadministration with food or antacid.

We are in the midst of a multimedia revolution; standard textbooks are now simultaneously available in printed form and as CD-ROM; primary and secondary journals/magazines increasingly can be accessed via on-line services or on the World-Wide Web (WWW). Publishers are naturally enthusiastic about non-print formats because the production costs, after initial 'start-up', are reduced- no expensive paper. Many users can see advantages in the speedier publication, the possibility of updating the text, the ability to search large documents electronically and the possibility of downloading material directly into new manuscripts or teaching materials. It is against this background that the three

In a multicentre study, 824 patients with operable rectal cancer were randomized to receive surgery alone, surgery plus a single fraction of 500 rad (5 Gy) and surgery plus 2000 rad (20 Gy) in 10 equal daily, i.e. multiple, fractions. The ratio of abdominoperineal excision to anterior restorative operations was 3:1. There was no evidence of an increased morbidity or mortality following irradiation. The multiple fraction 2000 rad group had tumours which were significantly smaller than those of the other groups. There was also a reduction in the Dukes' C cases in the multiple fraction group. Neither the tumour size nor the lymph node status was altered in the single fraction group.

Until 1930 it was generally true that aspiring middle western painters, when they were really ambitious, moved on to the East. When the depression broke, however, the situation changed abruptly. On the one hand the procession to New York halted; on the other a number of other painters who had already jumped the gun, finding themselves now suddenly destitute, returned to their homes. Out of this reunion a new generation formed, and it is the question now to ascertain what, during the past seven years, it has done.Even so recently as a year ago it would have been easier to find an answer. For then the subject still seemed on the ascendant. The movement inspired originally (or at least immediately) by the Mexicans, and fostered by such homecomers as Grant Wood, to paint what was familiarly around one, was then still flowering into record after record of red barns and tall windmills and lush haystacks, which constituted almost exclusively the “American scene.” It was on to this bandwagon that young men like J...