The potential use of artificial intelligence for venous thromboembolism prophylaxis and management: clinician and healthcare informatician perspectives.

Venous thromboembolism (VTE) is the leading cause of preventable death in hospitalized patients. Artificial intelligence (AI) and machine learning (ML) can support guidelines recommending an individualized approach to risk assessment and prophylaxis. We conducted electronic surveys asking clinician and healthcare informaticians about their perspectives on AI/ML for VTE prevention and management. Of 101 respondents to the informatician survey, most were 40 years or older, male, clinicians and data scientists, and had performed research on AI/ML. Of the 607 US-based respondents to the clinician survey, most were 40 years or younger, female, physicians, and had never used AI to inform clinical practice. Most informaticians agreed that AI/ML can be used to manage VTE (56.0%). Over one-third were concerned that clinicians would not use the technology (38.9%), but the majority of clinicians believed that AI/ML probably or definitely can help with VTE prevention (70.1%). The most common concern in both groups was a perceived lack of transparency (informaticians 54.4%; clinicians 25.4%). These two surveys revealed that key stakeholders are interested in AI/ML for VTE prevention and management, and identified potential barriers to address prior to implementation.

Neck stiffness and range of motion for young males and females.

Well characterised mechanical response of the normal head-neck complex during passive motion is important to inform and verify physical surrogate and computational models of the human neck, and to inform normal baseline for clinical assessments. For 10 male and 10 female participants aged 20 to 29, the range of motion (ROM) of the neck about three anatomical axes was evaluated in active-seated, passive-lying and active-lying configurations, and the neck stiffness was evaluated in passive-lying. Electromyographic signals from the agonist muscles, normalised to maximum voluntary contractions, were used to provide feedback during passive motions. The effect of sex and configuration on ROM, and the effect of sex on linear estimates of stiffness in three regions of the moment-angle curve, were assessed with linear mixed models and generalised linear models. There were no differences in male and female ROM across all motion directions and configurations. Flexion and axial rotation ROM were configuration dependent. The passive-lying moment-angle relationship was typically non-linear, with higher stiffness (slope) closer to end of ROM. When normalising the passive moment-angle curve to active lying ROM, passive stiffness was sex dependent only for lateral bending region 1 and 2. Aggregate moment-angle corridors were similar for males and females in flexion and extension, but exhibited a higher degree of variation in applied moment for males in lateral bending and axial rotation. These data provide the passive response of the neck to low rate bending and axial rotation angular displacement, which may be useful for computational and surrogate modelling of the human neck.

Evaluation of Apparatus and Protocols to Measure Human Passive Neck Stiffness and Range of Motion.

Understanding of human neck stiffness and range of motion (ROM) with minimal neck muscle activation ("passive") is important for clinical and bioengineering applications. The aim of this study was to develop, implement, and evaluate the reliability of methods for assessing passive-lying stiffness and ROM, in six head-neck rotation directions. Six participants completed two assessment sessions. To perform passive-lying tests, the participant's head and torso were strapped to a bending (flexion, extension, lateral bending) or a rotation (axial rotation) apparatus, and clinical bed, respectively. The head and neck were manually rotated by the researcher to the participant's maximum ROM, to assess passive-lying stiffness. Participant-initiated ("active") head ROM was also assessed in the apparatus, and seated. Various measures of apparatus functionality were assessed. ROM was similar for all assessment configurations in each motion direction except flexion. In each direction, passive stiffness generally increased throughout neck rotation. Within-session reliability for stiffness (ICC > 0.656) and ROM (ICC > 0.872) was acceptable, but between-session reliability was low for some motion directions, probably due to intrinsic participant factors, participant-apparatus interaction, and the relatively low participant number. Moment-angle corridors from both assessment sessions were similar, suggesting that with greater sample size, these methods may be suitable for estimating population-level corridors.

Geotemporal Fluorophore Biodistribution Mapping of Colorectal Cancer: Micro and Macroscopic Insights.

Fluorescence-guided oncology promises to improve both the detection and treatment of malignancy. We sought to investigate the temporal distribution of indocyanine green (ICG), an exogenous fluorophore in human colorectal cancer. This analysis aims to enhance our understanding of ICG's effectiveness in current tumour detection and inform potential future diagnostic and therapeutic enhancements. METHODS: Fifty consenting patients undergoing treatment for suspected/confirmed colorectal neoplasia provided near infrared (NIR) video and imagery of transanally recorded and ex vivo resected rectal lesions following intravenous ICG administration (0.25 mg/kg), with a subgroup providing tissue samples for microscopic (including near infrared) analysis. Computer vision techniques detailed macroscopic 'early' (<15 min post ICG administration) and 'late' (>2 h) tissue fluorescence appearances from surgical imagery with digital NIR scanning (Licor, Lincoln, NE, USA) and from microscopic analysis (Nikon, Tokyo, Japan) undertaken by a consultant pathologist detailing tissue-level fluorescence distribution over the same time. RESULTS: Significant intra-tumoural fluorescence heterogeneity was seen 'early' in malignant versus benign lesions. In all 'early' samples, fluorescence was predominantly within the tissue stroma, with uptake within plasma cells, blood vessels and lymphatics, but not within malignant or healthy glands. At 'late' stage observation, fluorescence was visualised non-uniformly within the intracellular cytoplasm of malignant tissue but not retained in benign glands. Fluorescence also accumulated within any present peritumoural inflammatory tissue. CONCLUSION: This study demonstrates the time course diffusion patterns of ICG through both benign and malignant tumours in vivo in human patients at both macroscopic and microscopic levels, demonstrating important cellular drivers and features of geolocalisation and how they differ longitudinally after exposure to ICG.

Iatrogenic necropolitics: forced anal examinations and state-sanctioned homophobia.

In 2016, Human Rights Watch, an international human rights organisation, published a report on the use of forced anal examinations to identify and prosecute putative 'homosexuals'. The report provided detailed descriptions and first-person accounts of these examinations in several countries in the Middle East and Africa. Drawing on theories of iatrogenesis and queer necropolitics, this paper uses these accounts and other reports of forced anal examinations to explore the role of medical providers in the 'diagnosis' and prosecution of homosexuality. The goal of these medical examinations is explicitly punitive rather than therapeutic, making them quintessential examples of iatrogenic clinical encounters which harm rather than heal. We argue that these examinations naturalise socioculturally derived beliefs about bodies and gender that construct homosexuality as 'readable' on the body through close medical inspection. These acts of inspection and 'diagnosis' reveal broader hegemonic state narratives of heteronormative gender and sexuality, both within countries as well as internationally as different state actors circulate and share these narratives. This article highlights the entanglement of medical and state actors, as well as contextualises the practice of forced anal examination within its colonial roots. Our analysis offers the potential for advocacy and holding medical professions and states accountable.

Artificial intelligence in the prediction of venous thromboembolism: A systematic review and pooled analysis.

BACKGROUND: Accurate diagnostic and prognostic predictions of venous thromboembolism (VTE) are crucial for VTE management. Artificial intelligence (AI) enables autonomous identification of the most predictive patterns from large complex data. Although evidence regarding its performance in VTE prediction is emerging, a comprehensive analysis of performance is lacking. AIMS: To systematically review the performance of AI in the diagnosis and prediction of VTE and compare it to clinical risk assessment models (RAMs) or logistic regression models. METHODS: A systematic literature search was performed using PubMed, MEDLINE, EMBASE, and Web of Science from inception to April 20, 2021. Search terms included "artificial intelligence" and "venous thromboembolism." Eligible criteria were original studies evaluating AI in the prediction of VTE in adults and reporting one of the following outcomes: sensitivity, specificity, positive predictive value, negative predictive value, or area under receiver operating curve (AUC). Risks of bias were assessed using the PROBAST tool. Unpaired t-test was performed to compare the mean AUC from AI versus conventional methods (RAMs or logistic regression models). RESULTS: A total of 20 studies were included. Number of participants ranged from 31 to 111 888. The AI-based models included artificial neural network (six studies), support vector machines (four studies), Bayesian methods (one study), super learner ensemble (one study), genetic programming (one study), unspecified machine learning models (two studies), and multiple machine learning models (five studies). Twelve studies (60%) had both training and testing cohorts. Among 14 studies (70%) where AUCs were reported, the mean AUC for AI versus conventional methods were 0.79 (95% CI: 0.74-0.85) versus 0.61 (95% CI: 0.54-0.68), respectively (p < .001). However, the good to excellent discriminative performance of AI methods is unlikely to be replicated when used in clinical practice, because most studies had high risk of bias due to missing data handling and outcome determination. CONCLUSION: The use of AI appears to improve the accuracy of diagnostic and prognostic prediction of VTE over conventional risk models; however, there was a high risk of bias observed across studies. Future studies should focus on transparent reporting, external validation, and clinical application of these models.

Venous thromboembolism prophylaxis for hospitalized adult patients: a survey of US health care providers on attitudes and practices.

Background: Venous thromboembolism (VTE) is a leading cause of preventable mortality among hospitalized patients, but appropriate risk assessment and thromboprophylaxis remain underutilized or misapplied. Objectives: We conducted an electronic survey of US health care providers to explore attitudes, practices, and barriers related to thromboprophylaxis in adult hospitalized patients and at discharge. Results: A total of 607 US respondents completed the survey: 63.1% reported working in an academic hospital, 70.7% identified as physicians, and hospital medicine was the most frequent specialty (52.1%). The majority of respondents agreed that VTE prophylaxis is important (98.8%; 95% CI: 97.6%-99.5%) and that current measures are safe (92.6%; 95% CI: 90.2%-94.5%) and effective (93.8%; 95% CI: 91.6%-95.6%), but only half (52.0%; 95% CI: 47.9%-56.0%) believed that hospitalized patients at their institution are on appropriate VTE prophylaxis almost all the time. One-third (35.4%) reported using a risk assessment model (RAM) to determine VTE prophylaxis need; 44.9% reported unfamiliarity with RAMs. The most common recommendation for improving rates of appropriate thromboprophylaxis was to leverage technology. A majority of respondents (84.5%) do not reassess a patient's need for VTE prophylaxis at discharge, and a minority educates patients about the risk (16.2%) or symptoms (18.9%) of VTE at discharge. Conclusion: Despite guideline recommendations to use RAMs, the majority of providers in our survey do not use them. A majority of respondents believed that technology could help improve VTE prophylaxis rates. A majority of respondents do not reassess the risk of VTE at discharge or educate patients about this risk of VTE at discharge.

An Early Evaluation of Remote Site Visits for ACGME Program Applications.

Background: Prior to the COVID-19 pandemic, accreditation site visit interviews occurred in-person. In response to the pandemic, the Accreditation Council for Graduate Medical Education (ACGME) developed a remote site visit protocol. Objective: To perform an early assessment of the remote accreditation site visits for programs applying for initial ACGME accreditation. Methods: A cohort of residency and fellowship programs that had remote site visits was evaluated from June to August 2020. Surveys were sent to program personnel, ACGME accreditation field representatives, and executive directors following the site visits. Comparison of accreditation decisions (Initial Accreditation or Accreditation Withheld) was completed for matched residency or fellowship programs having in-person site visits in 2019. Results: Surveys were sent to all program personnel from the 58 residency and fellowship programs that had remote site visits for new program applications, as well as the accreditation field representatives who performed the remote visits. The survey response rate was 58% (352 of 607). Ninety-one percent of all respondents were extremely or very confident that remote site visits provided a thorough assessment of proposed residency or fellowship programs. Fifty-four programs having remote site visits were matched by specialty to programs having had in-person program application site visits in 2019. Forty-six programs that had remote site visits received Initial Accreditation, and 52 programs that had in-person site visits in 2019 received Initial Accreditation (P=.093, 95% CI 0.91-22.38). Conclusions: Most program personnel and accreditation field representatives were confident that remote site visits conducted for program applications provided fair and thorough assessments of the program.

Deep Metric Learning for Scalable Gait-Based Person Re-Identification Using Force Platform Data.

Walking gait data acquired with force platforms may be used for person re-identification (re-ID) in various authentication, surveillance, and forensics applications. Current force platform-based re-ID systems classify a fixed set of identities (IDs), which presents a problem when IDs are added or removed from the database. We formulated force platform-based re-ID as a deep metric learning (DML) task, whereby a deep neural network learns a feature representation that can be compared between inputs using a distance metric. The force platform dataset used in this study is one of the largest and the most comprehensive of its kind, containing 193 IDs with significant variations in clothing, footwear, walking speed, and time between trials. Several DML model architectures were evaluated in a challenging setting where none of the IDs were seen during training (i.e., zero-shot re-ID) and there was only one prior sample per ID to compare with each query sample. The best architecture was 85% accurate in this setting, though an analysis of changes in walking speed and footwear between measurement instances revealed that accuracy was 28% higher on same-speed, same-footwear comparisons, compared to cross-speed, cross-footwear comparisons. These results demonstrate the potential of DML algorithms for zero-shot re-ID using force platform data, and highlight challenging cases.

Nitrogen and Phosphorus Treatment Can Be Sustainable During on-Site Wastewater Disposal.

Monitoring of a seasonal-use, on-site wastewater disposal system (septic system) in Canada, over a 33-year period from 1988 to 2021, showed that during recent sampling the groundwater plume had TIN (total inorganic nitrogen) averaging 12.2 mg/L that was not significantly different than early values, representing 80% removal, whereas SRP (soluble reactive phosphate), although higher than early values averaging 0.08 mg/L, was still 99% lower than the effluent concentration. Evidence suggests that the anammox reaction and possibly also denitrification contribute to TIN removal, whereas SRP removal is primarily the result of mineral precipitation. Most of the removal occurs in close proximity to the drainfield infiltration pipes (within about 1 m) demonstrating that reaction rates are relatively fast in the context of typical groundwater plume residence times. This long-term consistency demonstrates that sustainable nutrient treatment can be achieved with conventional on-site wastewater disposal systems that have low capital costs and require minimal energy input and maintenance.

Real-time administration of indocyanine green in combination with computer vision and artificial intelligence for the identification and delineation of colorectal liver metastases.

Introduction: Fluorescence guided surgery for the identification of colorectal liver metastases (CRLM) can be better with low specificity and antecedent dosing impracticalities limiting indocyanine green (ICG) usefulness currently. We investigated the application of artificial intelligence methods (AIM) to demonstrate and characterise CLRMs based on dynamic signalling immediately following intraoperative ICG administration. Methods: Twenty-five patients with liver surface lesions (24 CRLM and 1 benign cyst) undergoing open/laparoscopic/robotic procedures were studied. ICG (0.05 mg/kg) was administered with near-infrared recording of fluorescence perfusion. User-selected region-of-interest (ROI) perfusion profiles were generated, milestones relating to ICG inflow/outflow extracted and used to train a machine learning (ML) classifier. 2D heatmaps were constructed in a subset using AIM to depict whole screen imaging based on dynamic tissue-ICG interaction. Fluorescence appearances were also assessed microscopically (using H&E and fresh-frozen preparations) to provide tissue-level explainability of such methods. Results: The ML algorithm correctly classified 97.2 % of CRLM ROIs (n = 132) and all benign lesion ROIs (n = 6) within 90-s of ICG administration following initial mathematical curve analysis identifying ICG inflow/outflow differentials between healthy liver and CRLMs. Time-fluorescence plots extracted for each pixel in 10 lesions enabled creation of 2D characterising heatmaps using flow parameters and through unsupervised ML. Microscopy confirmed statistically less CLRM fluorescence vs adjacent liver (mean ± std deviation signal/area 2.46 ± 9.56 vs 507.43 ± 160.82 respectively p < 0.001) with H&E diminishing ICG signal (n = 4). Conclusion: ML accurately identifies CRLMs from surrounding liver tissue enabling representative 2D mapping of such lesions from their fluorescence perfusion patterns using AIM. This may assist in reducing positive margin rates at metastatectomy and in identifying unexpected/occult malignancies.

International Alliance of Urolithiasis (IAU) guidelines on the metabolic evaluation and medical management of urolithiasis.

The aim of this study was to construct the fourth in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis (IAU) that by providing a clinical framework for the metabolic evaluation, prevention, and follow-up of patients with urolithiasis based on the best available published literature. All recommendations were summarized following a systematic review and assessment of the literature in the PubMed database from January 1976 to June 2022. Each generated recommendation was graded using a modified GRADE methodology. Guideline recommendations were developed that addressed the following topics: initial evaluation, metabolic testing, dietary measures, medical management, and follow-up of recurrent stone formers. It was emphasized by the Panel that prevention of new stone formation is as important as the surgical removal of the stones. Although general preventive measures may be effective in reducing stone recurrence rates in some patients, specific medical and dietary management should be well considered and eventually applied in an individualized manner based on the outcomes of metabolic work-up, stone analysis and some certain patient related factors. A detailed follow-up of each case is essential depending on the metabolic activity of each individual patient.

Primitive Reflexes and Dementia in Adults With Down Syndrome.

Background and Objectives: To determine whether primitive reflexes serve as an indicator of dementia in adults with Down syndrome (DS), we collected neurologic examination data, cognitive and behavioral assessments, and clinical consensus diagnoses of dementia from 92 adults with DS. Methods: In a cross-sectional, observational study of a regional cohort, χ2 and Fisher exact tests examined individual reflexes across the diagnostic group (no, possible, or probable dementia). In 64 participants with all 8 reflexes assessed, the number of primitive reflexes was assessed as a predictor of diagnosis using age-controlled multinomial logistic regression and of performance on clinical assessments (Brief Praxis Test [BPT], Severe Impairment Battery [SIB], and the Dementia Questionnaire for People with Learning Disabilities [DLD]) using age-adjusted linear regression. Results: Primitive palmomental, grasp, snout, and suck reflexes were more frequent in individuals with probable dementia, but all participants showed at least 1 primitive reflex. Multiple primitive reflexes in combination served as a better indicator of dementia, with each additional abnormal reflex tripling probability of the probable dementia group membership controlling for age. Abnormal reflex count was not associated with direct assessment of cognition and praxis (SIB and BPT) but associated with informant ratings of cognitive and behavioral functioning (DLD). Discussion: The presence of multiple reflexes serves as an indicator of dementia status in DS as a supplement to direct assessment of cognition and praxis. The reflex examination may serve as a tool in the multimethod evaluation for dementia in DS, as it appears unaffected by intellectual disability and language mastery.

Prediction of Propulsion Kinematics and Performance in Wheelchair Rugby.

Prediction of propulsion kinematics and performance in wheelchair sports has the potential to improve capabilities of individual wheelchair prescription while minimizing testing requirements. While propulsion predictions have been developed for daily propulsion, these have not been extended for maximal effort in wheelchair sports. A two step-approach to predicting the effects of changing set-up in wheelchair rugby was developed, consisting of: (One) predicting propulsion kinematics during a 5 m sprint by adapting an existing linkage model; and (Two) applying partial least-squares regression to wheelchair set-up, propulsion kinematics, and performance. Eight elite wheelchair rugby players completed 5 m sprints in nine wheelchair set-ups while varying seat height, seat depth, seat angle, and tire pressure. Propulsion kinematics (contact and release angles) and performance (sprint time) were measured during each sprint and used for training and assessment for both models. Results were assessed through comparison of predicted and experimental propulsion kinematics (degree differences) for Step One and performance times (seconds differences) for Step Two. Kinematic measures, in particular contact angles, were identified with mean prediction errors less than 5 degrees for 43 of 48 predictions. Performance predictions were found to reflect on-court trends for some players, while others showed weaker prediction accuracy. More detailed modeling approaches that can account for individual athlete activity limitations would likely result in improved accuracy in propulsion and performance predictions across a range of wheelchair sports. Although this would come at an increased cost, developments would provide opportunities for more suitable set-ups earlier in an athlete's career, increasing performance and reducing injury risk.

COVID-19 and venous thromboembolism: A narrative review.

COVID-19 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) is associated with coagulopathy through numerous mechanisms. The reported incidence of venous thromboembolism (VTE) in hospitalized patients with COVID-19 has varied widely, and several meta-analyses have been performed to assess the overall prevalence of VTE. The novelty of this coronavirus strain along with its unique mechanisms for microvascular and macrovascular thrombosis has led to uncertainty as to how to diagnose, prevent, and treat thrombosis in patients affected by this virus. This review discusses the epidemiology and pathophysiology of thrombosis in the setting of SARS-CoV-2 infection along with an updated review on the preventative and treatment strategies for VTE associated with SARS-CoV-2 infection.

Wheelchair Rugby chair configurations: an individual, Robust design approach.

Prescription of wheelchair rugby chairs is difficult due to the range of athlete impairment types and severities in the sport, difficulty in adjusting wheelchair settings, and assessing on-court performance. Currently, elite players rely on experiential knowledge (personal, coaches, and support staff) to select an appropriate set-up. Technological advancements, such as with inertial measurement units and processing algorithms, and representative testing approaches, has improved the potential for assessing set-ups at an individual level. An orthogonal design approach was implemented using an adjustable wheelchair to investigate the effect of seat height, seat depth, seat angle, and tyre pressure on performance, mobility, and propulsion kinematics. Six elite wheelchair rugby players completed testing in nine individually tailored wheelchair set-ups while monitoring both quantitative and qualitative measures of performance. From this testing, a recommended set-up was compared with the current set-up for each individual. A single case-study approach shows how the assessment method identifies parameter settings that can potentially improve performance. Three of six players reported a blind preference for the recommended set-up over the current set-up, whilst remaining players often displayed similar performance between their current and recommended set-ups. This approach can improve upon the current prescription process for rugby wheelchairs.

Urinary metabolic profile and stone composition in kidney stone formers with and without heart disease.

OBJECTIVE: Kidney stone disease seems to be associated with an increased risk of incident cardiovascular outcomes; the aim of this study is to identify differences in 24-h urine excretory profiles and stone composition among stone formers with and without cardiovascular disease (CVD). METHODS: Data from patients attending the Department of Renal Medicine's metabolic stone clinic from 1995 to 2012 were reviewed. The sample was divided according to the presence or absence of CVD (myocardial infarction, angina, coronary revascularization, or surgery for calcified heart valves). Univariable and multivariable regression models, adjusted for age, sex, BMI, hypertension, diabetes, eGFR, plasma bicarbonate and potential renal acid load of foods were used to investigate differences across groups. RESULTS: 1826 patients had available data for 24-h urine analysis. Among these, 108 (5.9%) had a history of CVD. Those with CVD were older, have higher prevalence of hypertension and diabetes and lower eGFR. Univariable analysis showed that patients with CVD had significantly lower 24-h urinary excretions for citrate (2.4 vs 2.6 mmol/24 h, p = 0.04), magnesium (3.9 vs 4.2 mmol/24 h, p = 0.03) and urinary pH (6.1 vs 6.2, p = 0.02). After adjustment for confounders, differences in urinary citrate and magnesium excretions remained significant. No differences in the probability of stone formation or stone compositions were found. CONCLUSIONS: Stone formers with CVD have lower renal alkali excretion, possibly suggesting higher acid retention in stone formers with cardiovascular comorbidities. Randomized clinical trials including medications and a controlled diet design are needed to confirm the results presented here.

Malaria vector control tools in emergency settings: What do experts think? Results from a DELPHI survey.

BACKGROUND: The use and implementation of novel tools for malaria control such as long lasting impregnated bednets (LLINs) and Indoor Residual Spraying (IRS) over the last decade has contributed to a substantial reduction in malaria burden globally. However numerous challenges exist particularly in relation to vector control in emergency settings. This study seeks to explore expert opinion on the utility of existing tools within the emergency context setting and to better understand the attitude towards emerging and innovative tools (including Genetically Modified Mosquitoes) to augment current approaches. METHODS: 80 experts in the field of malaria and vector control were invited to participate in a two-round Delphi survey. They were selected through a combination of literature (academic and policy publications) review and snowball sampling reflecting a range of relevant backgrounds including vector control experts, malaria programme managers and emergency response specialists. The survey was conducted online through a questionnaire including the possibility for free text entry, and concentrated on the following topics: 1. Utility and sustainability of current vector control tools, both in and outside emergency settings 2. Feasibility, utility and challenges of emerging vector control tools, both in and outside emergency settings 3. Current and unmet research priorities in malaria vector control and in malaria control in general. RESULTS: 37 experts completed the first round and 31 completed the second round of the survey. There was a stronger consensus about the increased utility of LLIN compared to IRS in all settings, while insecticide-treated covers and blankets ranked very high only in emergency settings. When considering the combination of tools, the ones deemed most interesting always involved LLINs and IRS regardless of the setting, and the acceptability and the efficacy at reducing transmission are essential characteristics. Regarding perceptions of tools currently under development, consensus was towards improvement of existing tools rather than investing in novel approaches and the majority of respondents expressed distrust for genetic approaches. CONCLUSION: Malaria vector control experts expressed more confidence for tools whose efficacy is backed up by epidemiological evidence, hence a preference for the improvement rather than the combination of existing tools. Moreover, while several novel tools are under development, the majority of innovative approaches did not receive support, particularly in emergency settings. Stakeholders involved in the development of novel tools should involve earlier and raise awareness of the potential effectiveness amongst a wider range of experts within the malaria community to increase acceptability and improve early adoption once the evidence base is established.

Assessment of In-Use NOx Emissions from Heavy-Duty Diesel Vehicles Equipped with Selective Catalytic Reduction Systems.

This work evaluated the nitrogen oxide (NOx) emissions of 277 heavy-duty diesel vehicles (HDDVs) from three portable emission measurement system testing programs. HDDVs in these programs were properly maintained before emission testing, so the malfunction indicator lamp (MIL) was not illuminated. NOx emissions of some HDDVs were significantly higher than the certification standard even during hot operations where exhaust temperature was ideal for selective catalytic reduction to reduce NOx. For engines certified to the 0.20 g/bhp-hr NOx standard, hot operation NOx emissions increased with engine age at 0.081 ± 0.016 g/bhp-hr per year. The correlation between emissions and mileage was weak because six trucks showed extraordinarily high apparent emission increase rates reaching several multiples of the standard within the first 15,000 miles of operation. The overall annual increase in NOx emissions for the HDDVs in this study was two-thirds of what was observed in real-world emissions for HDDVs at the Caldecott Tunnel over the past decade. The vehicles at the Caldecott Tunnel would include those without proper maintenance, and the inclusion of these vehicles possibly explains the difference in the rate of emission increase. The results suggest that HDDVs need robust strategies to better control in-use NOx emissions.