Susceptibility of enamel to initial erosion in relation to tooth type, tooth surface and enamel depth

This study aimed at assessing the susceptibility of different tooth types (molar/premolar), surfaces (buccal/lingual) and enamel depths (100, 200, 400 and 600 μm) to initial erosion measured by surface microhardness loss (ΔSMH) and calcium (Ca) release. Twenty molars and 20 premolars were divided into experimental and control groups, cut into lingual/ buccal halves, and ground/polished, removing 100 μm of enamel. The initial surface microhardness (SMH 0 ) was measured on all halves. The experimental group was subjected to 3 consecutive erosive challenges (30 ml/tooth of 1% citric acid, pH 3.6, 25 ° C, 1 min). After each challenge, ΔSMH and Ca release were measured. The same teeth were consecutively ground to 200, 400 and 600 μm depths, and the experimental group underwent 3 erosive challenges at each depth. No difference was found in SMH 0 between experimental and control groups. Multivariate nonparametric ANOVA showed no significant differences between lingual and buccal surfaces in ΔSMH (p = 0.801) or Ca release (p = 0.370). ΔSMH was significantly greater in premolars than in molars (p < 0.05), but not different with respect to enamel depth. Ca release decreased significantly with increasing depth. Regression between Ca release and ΔSMH at 100 μm depth showed lower slope and r 2 value, associated with greater Ca release values. At 200-600 μm depths, moderately large r 2 values were observed (0.651-0.830). In conclusion, different teeth and enamel depths have different susceptibility to erosion, so when Ca release is used to measure erosion, the depth of the test facet in enamel should be standardized, whereas this is less important if ΔSMH is used.

Prognostic value of PCSK9 levels in patients with acute coronary syndromes.

AIMS Proprotein convertase subtilisin kexin 9 (PCSK9) is an emerging target for the treatment of hypercholesterolaemia, but the clinical utility of PCSK9 levels to guide treatment is unknown. We aimed to prospectively assess the prognostic value of plasma PCSK9 levels in patients with acute coronary syndromes (ACS). METHODS AND RESULTS Plasma PCSK9 levels were measured in 2030 ACS patients undergoing coronary angiography in a Swiss prospective cohort. At 1 year, the association between PCSK9 tertiles and all-cause death was assessed adjusting for the Global Registry of Acute Coronary Events (GRACE) variables, as well as the achievement of LDL cholesterol targets of <1.8 mmol/L. Patients with higher PCSK9 levels at angiography were more likely to have clinical familial hypercholesterolaemia (rate ratio, RR 1.21, 95% confidence interval, CI 1.09-1.53), be treated with lipid-lowering therapy (RR 1.46, 95% CI 1.30-1.63), present with longer time interval of chest pain (RR 1.29, 95% CI 1.09-1.53) and higher C-reactive protein levels (RR 1.22, 95% CI 1.16-1.30). PCSK9 increased 12-24 h after ACS (374 ± 149 vs. 323 ± 134 ng/mL, P < 0.001). At 1 year follow-up, HRs for upper vs. lower PCSK9-level tertiles were 1.13 (95% CI 0.69-1.85) for all-cause death and remained similar after adjustment for the GRACE score. Patients with higher PCSK9 levels were less likely to reach the recommended LDL cholesterol targets (RR 0.81, 95% CI 0.66-0.99). CONCLUSION In ACS patients, high initial PCSK9 plasma levels were associated with inflammation in the acute phase and hypercholesterolaemia, but did not predict mortality at 1 year.

Detection of haemorrhagic shock: Are vital signs obsolete? A commentary by Dr M. Luginbühl

The ATLS program by the American college of surgeons is probably the most important globally active training organization dedicated to improve trauma management. Detection of acute haemorrhagic shock belongs to the key issues in clinical practice and thus also in medical teaching. (In this issue of the journal William Schulz and Ian McConachrie critically review the ATLS shock classification Table 1), which has been criticized after several attempts of validation have failed [1]. The main problem is that distinct ranges of heart rate are related to ranges of uncompensated blood loss and that the heart rate decrease observed in severe haemorrhagic shock is ignored [2]. Table 1. Estimated blood loos based on patient's initial presentation (ATLS Students Course Manual, 9th Edition, American College of Surgeons 2012). Class I Class II Class III Class IV Blood loss ml Up to 750 750–1500 1500–2000 >2000 Blood loss (% blood volume) Up to 15% 15–30% 30–40% >40% Pulse rate (BPM) <100 100–120 120–140 >140 Systolic blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or ↑ Decreased Decreased Decreased Respiratory rate 14–20 20–30 30–40 >35 Urine output (ml/h) >30 20–30 5–15 negligible CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Initial fluid replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood Table options In a retrospective evaluation of the Trauma Audit and Research Network (TARN) database blood loss was estimated according to the injuries in nearly 165,000 adult trauma patients and each patient was allocated to one of the four ATLS shock classes [3]. Although heart rate increased and systolic blood pressure decreased from class I to class IV, respiratory rate and GCS were similar. The median heart rate in class IV patients was substantially lower than the value of 140 min−1 postulated by ATLS. Moreover deterioration of the different parameters does not necessarily go parallel as suggested in the ATLS shock classification [4] and [5]. In all these studies injury severity score (ISS) and mortality increased with in increasing shock class [3] and with increasing heart rate and decreasing blood pressure [4] and [5]. This supports the general concept that the higher heart rate and the lower blood pressure, the sicker is the patient. A prospective study attempted to validate a shock classification derived from the ATLS shock classes [6]. The authors used a combination of heart rate, blood pressure, clinically estimated blood loss and response to fluid resuscitation to classify trauma patients (Table 2) [6]. In their initial assessment of 715 predominantly blunt trauma patients 78% were classified as normal (Class 0), 14% as Class I, 6% as Class II and only 1% as Class III and Class IV respectively. This corresponds to the results from the previous retrospective studies [4] and [5]. The main endpoint used in the prospective study was therefore presence or absence of significant haemorrhage, defined as chest tube drainage >500 ml, evidence of >500 ml of blood loss in peritoneum, retroperitoneum or pelvic cavity on CT scan or requirement of any blood transfusion >2000 ml of crystalloid. Because of the low prevalence of class II or higher grades statistical evaluation was limited to a comparison between Class 0 and Class I–IV combined. As in the retrospective studies, Lawton did not find a statistical difference of heart rate and blood pressure among the five groups either, although there was a tendency to a higher heart rate in Class II patients. Apparently classification during primary survey did not rely on vital signs but considered the rather soft criterion of “clinical estimation of blood loss” and requirement of fluid substitution. This suggests that allocation of an individual patient to a shock classification was probably more an intuitive decision than an objective calculation the shock classification. Nevertheless it was a significant predictor of ISS [6]. Table 2. Shock grade categories in prospective validation study (Lawton, 2014) [6]. Normal No haemorrhage Class I Mild Class II Moderate Class III Severe Class IV Moribund Vitals Normal Normal HR > 100 with SBP >90 mmHg SBP < 90 mmHg SBP < 90 mmHg or imminent arrest Response to fluid bolus (1000 ml) NA Yes, no further fluid required Yes, no further fluid required Requires repeated fluid boluses Declining SBP despite fluid boluses Estimated blood loss (ml) None Up to 750 750–1500 1500–2000 >2000 Table options What does this mean for clinical practice and medical teaching? All these studies illustrate the difficulty to validate a useful and accepted physiologic general concept of the response of the organism to fluid loss: Decrease of cardiac output, increase of heart rate, decrease of pulse pressure occurring first and hypotension and bradycardia occurring only later. Increasing heart rate, increasing diastolic blood pressure or decreasing systolic blood pressure should make any clinician consider hypovolaemia first, because it is treatable and deterioration of the patient is preventable. This is true for the patient on the ward, the sedated patient in the intensive care unit or the anesthetized patients in the OR. We will therefore continue to teach this typical pattern but will continue to mention the exceptions and pitfalls on a second stage. The shock classification of ATLS is primarily used to illustrate the typical pattern of acute haemorrhagic shock (tachycardia and hypotension) as opposed to the Cushing reflex (bradycardia and hypertension) in severe head injury and intracranial hypertension or to the neurogenic shock in acute tetraplegia or high paraplegia (relative bradycardia and hypotension). Schulz and McConachrie nicely summarize the various confounders and exceptions from the general pattern and explain why in clinical reality patients often do not present with the “typical” pictures of our textbooks [1]. ATLS refers to the pitfalls in the signs of acute haemorrhage as well: Advanced age, athletes, pregnancy, medications and pace makers and explicitly state that individual subjects may not follow the general pattern. Obviously the ATLS shock classification which is the basis for a number of questions in the written test of the ATLS students course and which has been used for decades probably needs modification and cannot be literally applied in clinical practice. The European Trauma Course, another important Trauma training program uses the same parameters to estimate blood loss together with clinical exam and laboratory findings (e.g. base deficit and lactate) but does not use a shock classification related to absolute values. In conclusion the typical physiologic response to haemorrhage as illustrated by the ATLS shock classes remains an important issue in clinical practice and in teaching. The estimation of the severity haemorrhage in the initial assessment trauma patients is (and was never) solely based on vital signs only but includes the pattern of injuries, the requirement of fluid substitution and potential confounders. Vital signs are not obsolete especially in the course of treatment but must be interpreted in view of the clinical context. Conflict of interest None declared. Member of Swiss national ATLS core faculty.

Measuring value in cancer-related health care: A case study in head and neck cancer

In the current climate of escalating health care costs, defining value and accurately measuring it are two critical issues affecting not only the future of cancer care in particular but also the future of health care in general. Specifically, measuring and improving value in cancer-related health care are critical for continued advancements in research, management, and overall delivery of care. However, in oncology, most of this research has focused on value as it relates to insurance industry and payment reform, with little attention paid to value as the output of clinical interventions that encompass integrated clinical teams focusing on the entire cycle of care and measuring objective outcomes that are most relevant to patients. ^ In this study, patient-centered value was defined as health outcomes achieved per dollar spent, and calculated using objective functional outcomes and total care costs. The analytic sample comprised patients diagnosed with three common head and neck cancers—cancer of the larynx, oral cavity, and oropharynx—who were treated in an integrated tertiary care center over an approximately 10-year period. The results of this study provide initial empirical data that can be used to assess and ultimately to help improve the quality and value of head and neck cancer care, and more importantly they can be used by patients and clinicians to make better-informed decisions about care, particularly what therapeutic services and outcomes matter the most to patients.^

Effects of RoHs and REACH regulations on firm-level production and export, and the role of global value chains : the cases of Malaysia and Vietnam

This paper uses firm-level data to examine the impact of foreign chemical safety regulations such as RoHS and REACH on the production costs and export performance of firms in Malaysia and Vietnam. This paper also investigates the role of global value chains in enhancing the likelihood that a firm complies with RoHS and REACH. We find that in addition to the initial setup costs for compliance, EU RoHS (REACH) implementation imposes on firms additional variable production costs by requiring additional labor and capital expenditures of around 57% (73%) of variable costs. We also find that compliance with RoHS and REACH significantly increases the probability of export and that compliance with EU RoHS and REACH helps firms enter a greater variety of countries. Furthermore, firms participating in global value chains have higher compliance with RoHS and REACH regulations, regardless of whether the firm is directly exporting, when the firm operates in upstream or downstream industries of the countries' supply chain.

The value of cultural assets. Maintenance Costs and economic sustainability at heritage

Under the 12th International Conference on Building Materials and Components is inserted this communication related to the field of management of those assets that constitute the Spanish Cultural Heritage and maintenance. This work is related to the field of management of those assets that constitute the Spanish Cultural Heritage which share an artistic or historical background. The conservation and maintenance become a social demand necessary for the preservation of public values, requiring the investment of necessary resources. The legal protection involves a number of obligations and rights to ensure the conservation and heritage protection. The duty of maintenance and upkeep exceeds the useful life the property that must endure more for their cultural value for its usability. The establishment of the necessary conditions to prevent deterioration and precise in order to fulfill its social function, seeking to prolong the life of the asset, preserving their physical integrity and its ability to convey the values protected. This obligation implies a substantial financial effort to the holder of the property, either public or private entity, addressing a problem of economic sustainability. Economic exploitation, with the aim of contributing to their well-maintained, is sometimes the best way to get resources. The work will include different lines of research with the following objectives. - Establishment of processes for assessing total costs over the building life cycle (LCC), during the planning stages or maintenance budgets to determine the most advantageous operating system. - Relationship between the value of property and maintenance costs, and establishing a sensitivity analysis.

Problem-based learning supported by semantic techniques

Problem-based learning has been applied over the last three decades to a diverse range of learning environments. In this educational approach, different problems are posed to the learners so that they can develop different solutions while learning about the problem domain. When applied to conceptual modelling, and particularly to Qualitative Reasoning, the solutions to problems are models that represent the behaviour of a dynamic system. The learner?s task then is to bridge the gap between their initial model, as their first attempt to represent the system, and the target models that provide solutions to that problem. We propose the use of semantic technologies and resources to help in bridging that gap by providing links to terminology and formal definitions, and matching techniques to allow learners to benefit from existing models.

Lateral orbitofrontal cortex involvement in initial negative aesthetic impression formation

It is well established that aesthetic appreciation is related with activity in several different brain regions. The identification of the neural correlates of beauty or liking ratings has been the focus of most prior studies. Not much attention has been directed towards the fact that humans are surrounded by objects that lead them to experience aesthetic indifference or leave them with a negative aesthetic impression. Here we explore the neural substrate of such experiences. Given the neuroimaging techniques that have been used, little is known about the temporal features of such brain activity. By means of magnetoencephalography we registered the moment at which brain activity differed while participants viewed images they considered to be beautiful or not. Results show that the first differential activity appears between 300 and 400 ms after stimulus onset. During this period activity in right lateral orbitofrontal cortex (lOFC) was greater while participants rated visual stimuli as not beautiful than when they rated them as beautiful. We argue that this activity is associated with an initial negative aesthetic impression formation, driven by the relative hedonic value of stimuli regarded as not beautiful. Additionally, our results contribute to the understanding of the nature of the functional roles of the lOFC.

Phase transition in the countdown problem

We present a combinatorial decision problem, inspired by the celebrated quiz show called Countdown, that involves the computation of a given target number T from a set of k randomly chosen integers along with a set of arithmetic operations. We find that the probability of winning the game evidences a threshold phenomenon that can be understood in the terms of an algorithmic phase transition as a function of the set size k. Numerical simulations show that such probability sharply transitions from zero to one at some critical value of the control parameter, hence separating the algorithm's parameter space in different phases. We also find that the system is maximally efficient close to the critical point. We derive analytical expressions that match the numerical results for finite size and permit us to extrapolate the behavior in the thermodynamic limit.

Valuation: Developer support for by-references to by-value type conversion.

Modern object oriented languages like C# and JAVA enable developers to build complex application in less time. These languages are based on selecting heap allocated pass-by-reference objects for user defined data structures. This simplifies programming by automatically managing memory allocation and deallocation in conjunction with automated garbage collection. This simplification of programming comes at the cost of performance. Using pass-by-reference objects instead of lighter weight pass-by value structs can have memory impact in some cases. These costs can be critical when these application runs on limited resource environments such as mobile devices and cloud computing systems. We explore the problem by using the simple and uniform memory model to improve the performance. In this work we address this problem by providing an automated and sounds static conversion analysis which identifies if a by reference type can be safely converted to a by value type where the conversion may result in performance improvements. This works focus on C# programs. Our approach is based on a combination of syntactic and semantic checks to identify classes that are safe to convert. We evaluate the effectiveness of our work in identifying convertible types and impact of this transformation. The result shows that the transformation of reference type to value type can have substantial performance impact in practice. In our case studies we optimize the performance in Barnes-Hut program which shows total memory allocation decreased by 93% and execution time also reduced by 15%.

Unbalanced value chain in perishable agricultural products.

Value chain in agriculture is a current issue affecting from farmers to consumers. It questions important issues as profitability, and even though continuity of certain sectors. Although there has been an evolution along time in the structure and concentration of intermediate and final levels of the value chain between distribution and retail sector, a similar evolution seems not to arrive at the initial level of the chain, the production sector. This produces large imbalances in power and leverage between levels of the value chain that could imply several problems for rural actors. Relatively little attention has been paid to possible market distortions caused by the high level of concentration distribution side of the agrifood system.

Discussion of “Initial Pore Pressure from Vertical Surface Loads” by Jacobo Bielak (September, 1982)

The author presents a very interesting application of the ideas developed by Scott to determine the initial pore pressure in excess of the hydrostatic pore pressure in linear, elastic, homogeneous and isotropic soil-skeleton. Scott demonstrates that under vertical surface loads the problem is governed by Laplace's equation. Nevertheless the writers' think that it could be interesting to state clearly the conditions under which this analogy can be applied.

Discontinuous solutions and boundary value problems for non-linearly elastic fibre-reinforced materials

En este trabajo se han analizado varios problemas en el contexto de la elasticidad no lineal basándose en modelos constitutivos representativos. En particular, se han analizado problemas relacionados con el fenómeno de perdida de estabilidad asociada con condiciones de contorno en el caso de material reforzados con fibras. Cada problema se ha formulado y se ha analizado por separado en diferentes capítulos. En primer lugar se ha mostrado el análisis del gradiente de deformación discontinuo para un material transversalmente isótropo, en particular, el modelo del material considerado consiste de una base neo-Hookeana isótropa incrustada con fibras de refuerzo direccional caracterizadas con un solo parámetro. La solución de este problema se vincula con instabilidades que dan lugar al mecanismo de fallo conocido como banda de cortante. La perdida de elipticidad de las ecuaciones diferenciales de equilibrio es una condición necesaria para que aparezca este tipo de soluciones y por tanto las inestabilidades asociadas. En segundo lugar se ha analizado una deformación combinada de extensión, inación y torsión de un tubo cilíndrico grueso donde se ha encontrado que la deformación citada anteriormente puede ser controlada solo para determinadas direcciones de las fibras refuerzo. Para entender el comportamiento elástico del tubo considerado se ha ilustrado numéricamente los resultados obtenidos para las direcciones admisibles de las fibras de refuerzo bajo la deformación considerada. En tercer lugar se ha estudiado el caso de un tubo cilíndrico grueso reforzado con dos familias de fibras sometido a cortante en la dirección azimutal para un modelo de refuerzo especial. En este problema se ha encontrado que las inestabilidades que aparecen en el material considerado están asociadas con lo que se llama soluciones múltiples de la ecuación diferencial de equilibrio. Se ha encontrado que el fenómeno de instabilidad ocurre en un estado de deformación previo al estado de deformación donde se pierde la elipticidad de la ecuación diferencial de equilibrio. También se ha demostrado que la condición de perdida de elipticidad y ^W=2 = 0 (la segunda derivada de la función de energía con respecto a la deformación) son dos condiciones necesarias para la existencia de soluciones múltiples. Finalmente, se ha analizado detalladamente en el contexto de elipticidad un problema de un tubo cilíndrico grueso sometido a una deformación combinada en las direcciones helicoidal, axial y radial para distintas geotermias de las fibras de refuerzo . In the present work four main problems have been addressed within the framework of non-linear elasticity based on representative constitutive models. Namely, problems related to the loss of stability phenomena associated with boundary value problems for fibre-reinforced materials. Each of the considered problems is formulated and analysed separately in different chapters. We first start with the analysis of discontinuous deformation gradients for a transversely isotropic material under plane deformation. In particular, the material model is an augmented neo-Hookean base with a simple unidirectional reinforcement characterised by a single parameter. The solution of this problem is related to material instabilities and it is associated with a shear band-type failure mode. The loss of ellipticity of the governing differential equations is a necessary condition for the existence of these material instabilities. The second problem involves a detailed analysis of the combined non-linear extension, inflation and torsion of a thick-walled circular cylindrical tube where it has been found that the aforementioned deformation is controllable only for certain preferred directions of transverse isotropy. Numerical results have been illustrated to understand the elastic behaviour of the tube for the admissible preferred directions under the considered deformation. The third problem deals with the analysis of a doubly fibre-reinforced thickwalled circular cylindrical tube undergoing pure azimuthal shear for a special class of the reinforcing model where multiple non-smooth solutions emerge. The associated instability phenomena are found to occur prior to the point where the nominal stress tensor changes monotonicity in a particular direction. It has been also shown that the loss of ellipticity condition that arises from the equilibrium equation and ^W=2 = 0 (the second derivative of the strain-energy function with respect to the deformation) are equivalent necessary conditions for the emergence of multiple solutions for the considered material. Finally, a detailed analysis in the basis of the loss of ellipticity of the governing differential equations for a combined helical, axial and radial elastic deformations of a fibre-reinforced circular cylindrical tube is carried out.