Haptics in medicine and clinical skill acquisition

THE clinical skills of medical professionals rely strongly on the sense of touch, combined with anatomical and diagnostic knowledge. Haptic exploratory procedures allow the expert to detect anomalies via gross and fine palpation, squeezing, and contour following. Haptic feedback is also key to medical interventions, for example when an anaesthetist inserts an epidural needle, a surgeon makes an incision, a dental surgeon drills into a carious lesion, or a veterinarian sutures a wound. Yet, current trends in medical technology and training methods involve less haptic feedback to clinicians and trainees. For example, minimally invasive surgery removes the direct contact between the patient and clinician that gives rise to natural haptic feedback, and furthermore introduces scaling and rotational transforms that confuse the relationship between movements of the hand and the surgical site. Similarly, it is thought that computer-based medical simulation and training systems require high-resolution and realistic haptic feedback to the trainee for significant training transfer to occur. The science and technology of haptics thus has great potential to affect the performance of medical procedures and learning of clinical skills. This special section is about understanding

Influence of the Tibetan Plateau uplift on the Asian monsoon-arid environment evolution

As one of the most important geological events in Cenozoic era, the uplift of the Tibetan Plateau (TP) has had profound influences on the Asian and global climate and environment evolution. During the past four decades, many scholars from China and abroad have studied climatic and environmental effects of the TP uplift by using a variety of geological records and paleoclimate numerical simulations. The existing research results enrich our understanding of the mechanisms of Asian monsoon changes and interior aridification, but so far there are still a lot of issues that need to be thought deeply and investigated further. This paper attempts to review the research on the influence of the TP uplift on the Asian monsoon-arid environment, summarize three types of numerical simulations including bulk-plateau uplift, phased uplift and sub-regional uplift, and especially to analyze regional differences in responses of climate and environment to different forms of tectonic uplifts. From previous modeling results, the land-sea distribution and the Himalayan uplift may have a large effect in the establishment and development of the South Asian monsoon. However, the formation and evolution of the monsoon in northern East Asia, the intensified dryness north of the TP and enhanced Asian dust cycle may be more closely related to the uplift of the main body, especially the northern part of the TP. In this review, we also discuss relative roles of the TP uplift and other impact factors, origins of the South Asian monsoon and East Asian monsoon, feedback effects and nonlinear responses of climatic and environmental changes to the plateau uplift. Finally, we make comparisons between numerical simulations and geological records, discuss their uncertainties, and highlight some problems worthy of further studying.

Modern pollen samples from alpine vegetation on the Tibetan Plateau.

1  A set of 316 modern surface pollen samples, sampling all the alpine vegetation types that occur on the Tibetan Plateau, has been compiled and analysed. Between 82 and 92% of the pollen present in these samples is derived from only 28 major taxa. These 28 taxa include examples of both tree (AP) and herb (NAP) pollen types. 2  Most of the modern surface pollen samples accurately reflect the composition of the modern vegetation in the sampling region. However, airborne dust-trap pollen samples do not provide a reliable assessment of the modern vegetation. Dust-trap samples contain much higher percentages of tree pollen than non-dust-trap samples, and many of the taxa present are exotic. In the extremely windy environments of the Tibetan Plateau, contamination of dust-trap samples by long-distance transport of exotic pollen is a serious problem. 3  The most characteristic vegetation types present on the Tibetan Plateau are alpine meadows, steppe and desert. Non-arboreal pollen (NAP) therefore dominates the pollen samples in most regions. Percentages of arboreal pollen (AP) are high in samples from the southern and eastern Tibetan Plateau, where alpine forests are an important component of the vegetation. The relative importance of forest and non-forest vegetation across the Plateau clearly follows climatic gradients: forests occur on the southern and eastern margins of the Plateau, supported by the penetration of moisture-bearing airmasses associated with the Indian and Pacific summer monsoons; open, treeless vegetation is dominant in the interior and northern margins of the Plateau, far from these moisture sources. 4  The different types of non-forest vegetation are characterized by different modern pollen assemblages. Thus, alpine deserts are characterized by high percentages of Chenopodiaceae and Artemisia, with Ephedra and Nitraria. Alpine meadows are characterized by high percentages of Cyperaceae and Artemisia, with Ranunculaceae and Polygonaceae. Alpine steppe is characterized by high abundances of Artemisia, with Compositae, Cruciferae and Chenopodiaceae. Although Artemisia is a common component of all non-forest vegetation types on the Tibetan Plateau, the presence of other taxa makes it possible to discriminate between the different vegetation types. 5  The good agreement between modern vegetation and modern surface pollen samples across the Tibetan Plateau provides a measure of the reliability of using pollen data to reconstruct past vegetation patterns in non-forested areas.

Massive Open Online Courses on health and medicine: review

Background: Massive Open Online Courses (MOOCs) have become immensely popular in a short span of time. However, there is very little research exploring MOOCs in the discipline of Health and Medicine. This paper is aimed to fill this void by providing a review of Health and Medicine related MOOCs. Objective: Provide a review of Health and Medicine related MOOCs offered by various MOOC platforms within the year 2013. Analyze and compare the various offerings, their target audience, typical length of a course and credentials offered. Discuss opportunities and challenges presented by MOOCs in the discipline of Health and Medicine. Methods: Health and Medicine related MOOCs were gathered using several methods to ensure the richness and completeness of data. Identified MOOC platform websites were used to gather the lists of offerings. In parallel, these MOOC platforms were contacted to access official data on their offerings. Two MOOC aggregator sites (Class Central and MOOC List) were also consulted to gather data on MOOC offerings. Eligibility criteria were defined to concentrate on the courses that were offered in 2013 and primarily on the subject ‘Health and Medicine’. All language translations in this paper were achieved using Google Translate. Results: The search identified 225 courses out of which 98 were eligible for the review (n = 98). 58% (57) of the MOOCs considered were offered on the Coursera platform and 94% (92) of all the MOOCs were offered in English. 90 MOOCs were offered by universities and the John Hopkins University offered the largest number of MOOCs (12). Only three MOOCs were offered by developing countries (China, West Indies, and Saudi Arabia). The duration of MOOCs varied from three weeks to 20 weeks with an average length of 6.7 weeks. On average MOOCs expected a participant to work on the material for 4.2 hours a week. Verified Certificates were offered by 14 MOOCs while three others offered other professional recognition. Conclusions: The review presents evidence to suggest that MOOCs can be used as a way to provide continuous medical education. It also shows the potential of MOOCs as a means of increasing health literacy among the public.

Traditional medicine use by cancer patients in Thailand

Ethnobotanical relevance Cancer patients commonly use traditional medicines (TM) and in Thailand these are popular for both self-medication and as prescribed by TM practitioners, and are rarely monitored. A study was conducted at Wat Khampramong, a Thai Buddhist temple herbal medicine hospice, to document some of these practices as well as the hospice regime. Materials and methods Cancer patients (n=286) were surveyed shortly after admission as to which TMs they had previously taken and perceptions of effects experienced. They were also asked to describe their current symptoms. Treatment at the hospice is built upon an 11-herb anti-cancer formula, yod-ya-mareng, prescribed for all patients, and ideally, its effects would have been evaluated. However other herbal medicines and holistic practices are integral to the regime, so instead we attempted to assess the value of the patients׳ stay at the hospice by measuring any change in symptom burden, as they perceived it. Surviving patients (n=270) were therefore asked to describe their symptoms again just before leaving. Results 42% of patients (120/286; 95% CI 36.4%, 47.8%) had used herbal medicines before their arrival, with 31.7% (38/120; 95% CI 24%, 40.4%) using several at once. Mixed effects were reported for these products. After taking the herbal regime at Khampramong, 77% (208/270 95% CI; 71.7%, 81.7%) reported benefit, and a comparison of the incidence of the most common (pain, dyspepsia, abdominal or visceral pain, insomnia, fatigue) showed statistical significance (χ2 57.1, df 7, p<0.001). Conclusions A wide range of TMs is taken by cancer patients in Thailand and considered to provide more benefit than harm, and this perception extends to the temple regime. Patients reported a significant reduction in symptoms after staying at Khampramong, indicating an improvement in quality of life, the aim of hospices everywhere. Based on this evidence, it is not possible to justify the use of TM for cancer in general, but this study suggests that further research is warranted. The uncontrolled use of TMs, many of which are uncharacterised, raises concerns, and this work also highlights the fact that validated, robust methods of assessing holistic medical regimes are urgently needed.

Impacts of uplift of northern Tibetan Plateau and formation of Asian inland deserts on regional climate and environment

Based on the geological evidence that the northern Tibetan Plateau (NTP) had an uplift of a finite magnitude since the Miocene and the major Asian inland deserts formed in the early Pliocene, a regional climate model (RegCM4.1) with a horizontal resolution of 50 km was used to explore the effects of the NTP uplift and the related aridification of inland Asia on regional climate. We designed three numerical experiments including the control experiment representing the present-day condition, the high-mountain experiment representing the early Pliocene condition with uplifted NTP but absence of the Asian inland deserts, and the low-mountain experiment representing the mid-Miocene condition with reduced topography in the NTP (by as much as 2400 m) and also absence of the deserts. Our simulation results indicated that the NTP uplift caused significant reductions in annual precipitation in a broad region of inland Asia north of the Tibetan Plateau (TP) mainly due to the enhanced rain shadow effect of the mountains and changes in the regional circulations. However, four mountainous regions located in the uplift showed significant increases in precipitation, stretching from the Pamir Plateau in the west to the Qilian Mountains in the east. These mountainous areas also experienced different changes in the rainfall seasonality with the greatest increases occurring during the respective rainy seasons, predominantly resulted from the enhanced orographically forced upwind ascents. The appearance of the major deserts in the inland Asia further reduced precipitation in the region and led to increased dust emission and deposition fluxes, while the spatial patterns of dust deposition were also changed, not only in the regions of uplift-impacted topography, but also in the downwind regions. One major contribution from this study is the comparison of the simulation results with 11 existing geological records representing the moisture conditions from Miocene to Pliocene. The comparisons revealed good matches between the simulation results and the published geological records. Therefore, we conclude that the NTP uplift and the related formation of the major deserts played a controlling role in the evolution of regional climatic conditions in a broad region in inland Asia since the Miocene.

Factors affecting dairy farmers' attitudes towards antimicrobial medicine usage in cattle in England and Wales

There has been growing concern about bacterial resistance to antimicrobials in the farmed livestock sector. Attention has turned to sub-optimal use of antimicrobials as a driver of resistance. Recent reviews have identified a lack of data on the pattern of antimicrobial use as an impediment to the design of measures to tackle this growing problem. This paper reports on a study that explored use of antibiotics by dairy farmers and factors influencing their decision-making around this usage. We found that respondents had either recently reduced their use of antibiotics, or planned to do so. Advice from their veterinarian was instrumental in this. Over 70% thought reducing antibiotic usage would be a good thing to do. The most influential source of information used was their own veterinarian. Some 50% were unaware of the available guidelines on use in cattle production. However, 97% thought it important to keep treatment records. The Theory of Planned Behaviour was used to identify dairy farmers’ drivers and barriers to reduce use of antibiotics. Intention to reduce usage was weakly correlated with current and past practice of antibiotic use, whilst the strongest driver was respondents’ belief that their social and advisory network would approve of them doing this. The higher the proportion of income from milk production and the greater the chance of remaining in milk production, the significantly higher the likelihood of farmers exhibiting positive intention to reduce antibiotic usage. Such farmers may be more commercially minded than others and thus more cost-conscious or, perhaps, more aware of possible future restrictions. Strong correlation was found between farmers’ perception of their social referents’ beliefs and farmers’ intent to reduce antibiotic use. Policy makers should target these social referents, especially veterinarians, with information on the benefits from, and the means to, achieving reductions in antibiotic usage. Information on sub-optimal use of antibiotics as a driver of resistance in dairy herds and in humans along with advice on best farm practice to minimise risk of disease and ensure animal welfare, complemented with data on potential cost savings from reduced antibiotic use would help improve poor practice.

Evaluation of the realism of climate reconstruction using the Coexistence Approach with modern pollen samples from the Tibetan Plateau

We apply the Coexistence Approach (CoA) to reconstruct mean annual precipitation (MAP), mean annual temperature (MAT), mean temperature of thewarmestmonth (MTWA) and mean temperature of the coldest month (MTCO) at 44 pollen sites on the Qinghai–Tibetan Plateau. The modern climate ranges of the taxa are obtained (1) from county-level presence/absence data and (2) from data on the optimum and range of each taxon from Lu et al. (2011). The CoA based on the optimumand range data yields better predictions of observed climate parameters at the pollen sites than that based on the county-level data. The presence of arboreal pollen, most of which is derived fromoutside the region, distorts the reconstructions. More reliable reconstructions are obtained using only the non-arboreal component of the pollen assemblages. The root mean-squared error (RMSE) of the MAP reconstructions are smaller than the RMSE of MAT, MTWA and MTCO, suggesting that precipitation gradients are the most important control of vegetation distribution on the Qinghai–Tibetan Plateau. Our results show that CoA could be used to reconstruct past climates in this region, although in areas characterized by open vegetation the most reliable estimates will be obtained by excluding possible arboreal contaminants.

Where were the monsoon regions and arid zones in Asia prior to the Tibetan Plateau uplift?

The impact of the Tibetan Plateau uplift on the Asian monsoons and inland arid climates is an important but also controversial question in studies of paleoenvironmental change during the Cenozoic. In order to achieve a good understanding of the background for the formation of the Asian monsoons and arid environments, it is necessary to know the characteristics of the distribution of monsoon regions and arid zones in Asia before the plateau uplift. In this study, we discuss in detail the patterns of distribution of the Asian monsoon and arid regions before the plateau uplift on the basis of modeling results without topography from a global coupled atmosphere–ocean general circulation model, compare our results with previous simulation studies and available biogeological data, and review the uncertainties in the current knowledge. Based on what we know at the moment, tropical monsoon climates existed south of 20°N in South and Southeast Asia before the plateau uplift, while the East Asian monsoon was entirely absent in the extratropics. These tropical monsoons mainly resulted from the seasonal shifts of the Inter-Tropical Convergence Zone. There may have been a quasi-monsoon region in central-southern Siberia. Most of the arid regions in the Asian continent were limited to the latitudes of 20–40°N, corresponding to the range of the subtropical high pressure year-around. In the meantime, the present-day arid regions located in the relatively high latitudes in Central Asia were most likely absent before the plateau uplift. The main results from the above modeling analyses are qualitatively consistent with the available biogeological data. These results highlight the importance of the uplift of the Tibetan Plateau in the Cenozoic evolution of the Asian climate pattern of dry–wet conditions. Future studies should be focused on effects of the changes in land–sea distribution and atmospheric CO2 concentrations before and after the plateau uplift, and also on cross-comparisons between numerical simulations and geological evidence, so that a comprehensive understanding of the evolution of the Cenozoic paleoenvironments in Asia can be achieved.