Neural inference at the frontier of energy, space, and time.

Computing, since its inception, has been processor-centric, with memory separated from compute. Inspired by the organic brain and optimized for inorganic silicon, NorthPole is a neural inference architecture that blurs this boundary by eliminating off-chip memory, intertwining compute with memory on-chip, and appearing externally as an active memory chip. NorthPole is a low-precision, massively parallel, densely interconnected, energy-efficient, and spatial computing architecture with a co-optimized, high-utilization programming model. On the ResNet50 benchmark image classification network, relative to a graphics processing unit (GPU) that uses a comparable 12-nanometer technology process, NorthPole achieves a 25 times higher energy metric of frames per second (FPS) per watt, a 5 times higher space metric of FPS per transistor, and a 22 times lower time metric of latency. Similar results are reported for the Yolo-v4 detection network. NorthPole outperforms all prevalent architectures, even those that use more-advanced technology processes.

Symptom appraisal and help seeking in males with symptoms of possible prostate cancer: a qualitative study with an ethnically diverse sample in London.

BACKGROUND: Prostate cancer mortality in Black males is disproportionately high. This problem may be overcome by reducing delays in the pathway to diagnosis, particularly those occurring before initial medical help seeking. A greater understanding of symptom appraisal and help seeking could support the development of targeted interventions for improving early presentation among Black males. AIM: To provide an in-depth understanding of males' pre-consultation experiences following the onset of symptoms of possible prostate cancer, identifying both general trends as well as potential differences that may exist between Black and White males. DESIGN AND SETTING: Qualitative study of 18 males (nine Black, nine White) in London, UK, who had recently seen their GP with urinary symptoms, erectile dysfunction, or haematuria. METHOD: Semi-structured interviews from a previous multi-methods study of primary care use by males with symptoms of possible prostate cancer were analysed using thematic framework analysis. RESULTS: Symptoms were often interpreted by patients as unimportant. Most delays occurred due to the absence of reasons to seek help, which, in Black males, often stemmed from poor awareness of prostate cancer. This lack of awareness could have been a consequence of their reluctance to seek health information and discuss health issues with others in their social network. Friends and relatives played an important role in symptom appraisal and help seeking. CONCLUSION: Cognitive biases, cultural stigmas, and everyday interpersonal interactions should be important areas at which to target strategies seeking to reduce delays and improve early presentation in males with possible prostate cancer, particularly Black males.

Frontier Lapita interaction with resident Papuan populations set the stage for initial peopling of the Pacific.

The initial peopling of the remote Pacific islands was one of the greatest migrations in human history, beginning three millennia ago by Lapita cultural groups. The spread of Lapita out of an ancestral Asian homeland is a dominant narrative in the origins of Pacific peoples, and although Island New Guinea has long been recognized as a springboard for the peopling of Oceania, the role of Indigenous populations in this remarkable phase of exploration remains largely untested. Here, we report the earliest evidence for Lapita-introduced animals, turtle bone technology and repeated obsidian import in southern New Guinea 3,480-3,060 years ago, synchronous with the establishment of the earliest known Lapita settlements 700 km away. Our findings precede sustained Lapita migrations and pottery introductions by several centuries, occur alongside Indigenous technologies and suggest continued multicultural influences on population diversity despite language replacement. Our work shows that initial Lapita expansion throughout Island New Guinea was more expansive than previously considered, with Indigenous contact influencing migration pathways and island-hopping strategies that culminated in rapid and purposeful Pacific-wide settlement. Later Lapita dispersals through New Guinea were facilitated by earlier contact with Indigenous populations and profoundly influenced the region as a global centre of cultural and linguistic diversity.

Emergence of a Neolithic in highland New Guinea by 5000 to 4000 years ago.

The emergence of agriculture was one of the most notable behavioral transformations in human history, driving innovations in technologies and settlement globally, referred to as the Neolithic. Wetland agriculture originated in the New Guinea highlands during the mid-Holocene (8000 to 4000 years ago), yet it is unclear if there was associated behavioral change. Here, we report the earliest figurative stone carving and formally manufactured pestles in Oceania, dating to 5050 to 4200 years ago. These discoveries, at the highland site of Waim, occur with the earliest planilateral axe-adzes in New Guinea, the first evidence for fibercraft, and interisland obsidian transfer. The combination of symbolic social systems, complex technologies, and highland agricultural intensification supports an independent emergence of a Neolithic ~1000 years before the arrival of Neolithic migrants (Lapita) from Southeast Asia.

A Network Approach to Neonatal Palliative Care Education: Impact on Knowledge, Efficacy, and Clinical Practice.

More than 80 000 babies are admitted to specialist neonatal units in the United Kingdom every year, with approximately 2109 neonatal deaths a year; 98% in hospital. A common element in guidance and pathways to facilitate the provision of palliative care to infants and their families is the importance of good education and training to develop high-quality staff and services. This article presents a mixed-methods, sequential, explanatory design evaluation of 1 day palliative care education workshops delivered using a network-wide approach to multidisciplinary professionals. Workshops were delivered by healthcare professionals and bereaved parents and evaluated using questionnaires, adapted for neonatal staff from standardized measures, and follow-up interviews. The workshop content and shared learning approach resulted in significant improvements in participant's knowledge, attitude, self-beliefs and confidence in neonatal palliative care, enhanced awareness of services, and improved links between professionals. Participants cascaded their learning to their teams and provided examples of changes in their clinical practice following the workshop. Parent stories were identified as a very powerful component of the training, with lasting impact on participants. Formal, integrated palliative care education programs for perinatal and neonatal staff and longitudinal research into the impact on practice and the experience received by families are needed.

Heated Humidified High-Flow Nasal Cannula for Preterm Infants: An Updated Systematic Review and Meta-analysis.

BACKGROUND: Heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity as a mode of respiratory support. We updated a systematic review and meta-analyses examining the efficacy and safety of HHHFNC compared with standard treatments for preterm infants. The primary outcome was the need for reintubation for preterm infants following mechanical ventilation (post-extubation analysis) or need for intubation for preterm infants not previously intubated (analysis of primary respiratory support). METHODS: We searched PubMed, MEDLINE, Embase, and the Cochrane Library for randomized controlled trials (RCTs) of HHHFNC versus standard treatments. Meta-analysis was conducted using Review Manager 5.3. RESULTS: The post-extubation analysis included ten RCTs (n = 1,201), and the analysis of primary respiratory support included ten RCTs (n = 1,676). There were no statistically significant differences for outcomes measuring efficacy, including the primary outcome. There were statistically significant differences favoring HHHFNC versus nasal cannula positive airway pressure (NCPAP) for air leak (post-extubation, risk ratio [RR] 0.29, 95 percent confidence interval [CI] 0.11 to 0.76, I2 = 0) and nasal trauma (post-extubation: 0.35, 95 percent CI 0.27 to 0.46, I2 = 5 percent; primary respiratory support: RR 0.52, 95 percent CI 0.37 to 0.74; I2 = 27 percent). Studies, particularly those of primary respiratory support, included very few preterm infants with gestational age (GA) <28 weeks. CONCLUSIONS: HHHFNC may offer an efficacious and safe alternative to NCPAP for some infants but evidence is lacking for preterm infants with GA ≤28 weeks.

A wolf in sheep's clothing? Patients' and healthcare professionals' perceptions of oxygen therapy: An interpretative phenomenological analysis.

BACKGROUND: Despite emerging evidence and guidelines, poor prescribing and administration of oxygen therapy persists. This study aimed to explore healthcare professionals' (HCPs) and patients' perceptions of oxygen. DESIGN: Semi-structured interviews with 28 patients and 34 HCPs. FINDINGS: Three master themes uncovered: oxygen as a panacea, the burden of oxygen and antecedents to beliefs. Patients used oxygen for breathlessness and as an enabler; they were grateful to oxygen and accepted it as part of the disease. HCPs used oxygen because it helps patients; it works; and it makes HCPs feel better. But oxygen is not benign and a burden is evident with potential antecedents to beliefs revealed. SUMMARY: The findings suggest that a set of fixed beliefs regarding oxygen exist, influenced by several impacting factors. The perception that oxygen is a universal remedy presides, but is, at times, contradictory. These findings will raise awareness of entrenched cultures, influence future educational and research strategies, and inform policy.

An analysis of whether a working-age ward-based liaison psychiatry service requires the input of a liaison psychiatrist.

Aims and method This article presents a 12-month case series to determine the fraction of ward referrals of adults of working age who needed a liaison psychiatrist in a busy tertiary referral teaching hospital. Results The service received 344 referrals resulting in 1259 face-to-face contacts. Depression accounted for the most face-to-face contacts. We deemed the involvement of a liaison psychiatrist necessary in 241 (70.1%) referrals, with medication management as the most common reason. Clinical implications A substantial amount of liaison ward work involves the treatment and management of severe and complex mental health problems. Our analysis suggests that in the majority of cases the input of a liaison psychiatrist is required.

Opening the 'black box': liaison psychiatry services and what they actually do.

Aims and method To develop a simple, pragmatic typology to characterise the nature of liaison interventions delivered by a liaison service in a National Health Service setting. We carried out a retrospective electronic case-note review of referrals to a ward-based liaison psychiatry service. Results Three hundred and forty-four patients were referred to the service over a 12-month period. Ten different types of liaison interventions were identified, with the most common interventions being diagnosis (112 patients, 32.6%), medication management (57 patients, 16.6%), risk assessment and treatment (56 patients, 16.3% each). Mental Health Act work accounted for the greatest number of contacts per patient (median 7). Clinical implications There are inherent limitations in any single-site observational study, as site-specific results cannot be generalised to other liaison services. The intervention categories we developed, however, are easy to use and will provide a way of comparing and benchmarking the range of interventions delivered by different liaison psychiatry services.

The clinical effectiveness and cost-effectiveness of heated humidified high-flow nasal cannula compared with usual care for preterm infants: systematic review and economic evaluation.

BACKGROUND: Respiratory problems are one of the most common causes of morbidity in preterm infants and may be treated with several modalities for respiratory support such as nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive-pressure ventilation. The heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity in clinical practice. OBJECTIVES: To address the clinical effectiveness of HHHFNC compared with usual care for preterm infants we systematically reviewed the evidence of HHHFNC with usual care following ventilation (the primary analysis) and with no prior ventilation (the secondary analysis). The primary outcome was treatment failure defined as the need for reintubation (primary analysis) or intubation (secondary analysis). We also aimed to assess the cost-effectiveness of HHHFNC compared with usual care if evidence permitted. DATA SOURCES: The following databases were searched: MEDLINE (2000 to 12 January 2015), EMBASE (2000 to 12 January 2015), The Cochrane Library (issue 1, 2015), ISI Web of Science (2000 to 12 January 2015), PubMed (1 March 2014 to 12 January 2015) and seven trial and research registers. Bibliographies of retrieved citations were also examined. REVIEW METHODS: Two reviewers independently screened all titles and abstracts to identify potentially relevant studies for inclusion in the review. Full-text copies were assessed independently. Data were extracted and assessed for risk of bias. Summary statistics were extracted for each outcome and, when possible, data were pooled. A meta-analysis was only conducted for the primary analysis, using fixed-effects models. An economic evaluation was planned. RESULTS: Clinical evidence was derived from seven randomised controlled trials (RCTs): four RCTs for the primary analysis and three RCTs for the secondary analysis. Meta-analysis found that only for nasal trauma leading to a change of treatment was there a statistically significant difference, favouring HHHFNC over NCPAP [risk ratio (RR) 0.21, 95% confidence interval (CI) 0.10 to 0.42]. For the following outcomes, there were no statistically significant differences between arms: treatment failure (reintubation < 7 days; RR 0.76, 95% CI 0.54 to 1.09), bronchopulmonary dysplasia (RR 0.92, 95% CI 0.72 to 1.17), death (RR 0.56, 95% CI 0.22 to 1.44), pneumothorax (RR 0.33, 95% CI 0.03 to 3.12), intraventricular haemorrhage (grade ≥ 3; RR 0.41, 95% CI 0.15 to 1.15), necrotising enterocolitis (RR 0.41, 95% CI 0.15 to 1.14), apnoea (RR 1.08, 95% CI 0.74 to 1.57) and acidosis (RR 1.16, 95% CI 0.38 to 3.58). With no evidence to support the superiority of HHHFNC over NCPAP, a cost-minimisation analysis was undertaken, the results suggesting HHHFNC to be less costly than NCPAP. However, this finding is sensitive to the lifespan of equipment and the cost differential of consumables. LIMITATIONS: There is a lack of published RCTs of relatively large-sized populations comparing HHHFNC with usual care; this is particularly true for preterm infants who had received no prior ventilation. CONCLUSIONS: There is a lack of convincing evidence suggesting that HHHFNC is superior or inferior to usual care, in particular NCPAP. There is also uncertainty regarding whether or not HHHFNC can be considered cost-effective. Further evidence comparing HHHFNC with usual care is required. STUDY REGISTRATION: This review is registered as PROSPERO CRD42015015978. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

How stressful is the Newborn Life Support airway test? An observational study.

Objectives: To determine whether there is a significant stress response to the Newborn Life Support airway test (NLSAT) among healthcare professionals in the UK. Design: Quantitative study measuring both stress and anxiety of candidates on Newborn Life Support (NLS) courses measuring salivary cortisol levels along with validated anxiety questionnaires (State Trait Anxiety Inventory). Setting: UK NLS course centres. Participants: 80 healthcare professionals (nurses, doctors and midwives) on NLS courses. Interventions: Stress levels measured (cortisol swabs and State-Trait Anxiety Inventory (STAI)) at baseline, immediately before and 20 min after starting the NLSAT. Results: Cortisol measurements failed to detect any significant rise in stress levels as a result of the NLSAT. Significant anxiety was induced by the NLSAT based on STAI scores. STAI scores rose significantly in all professionals from baseline to post-NLSAT, with the greatest change detected for midwives (+11.82 (SD 7.64, p<0.001)) compared with nurses (+8.86 (SD 12.1, p<0.001)) and doctors (+7.96 (SD 2.9.69, p<0.001)). Experience had no impact on stress levels. Conclusions: Anxiety levels induced by the NLSAT are significant and should be considered when instructing and developing the NLS course.

Markedly raised levels of C-reactive protein are associated with culture-proven sepsis or necrotising enterocolitis in extremely preterm neonates.

AIM: A serious inflammatory process is suspected when C-reactive protein (CRP) is very high, and we established the causes and outcomes when CRP was >100 mg/L in neonates. METHODS: We retrospectively reviewed all 277 episodes where CRP exceeded 100 mg/L between January 2007 and December 2011 at a tertiary neonatal unit. RESULTS: Of the 6025 neonates admitted during the study period, 258 had CRP >100 mg/L at least once. The overall mortality rate was 44/258 (17%); 36 died within 7 days of CRP >100 mg/L, and 34 were extremely preterm infants. CRP exceeded 100 mg/L in 106 infants within the first 3 days of life - 74 term, 25 preterm and seven extremely preterm - with no infection identified in 81%. In contrast, infections were found in 87% of the 171 episodes from day four of life - 129 extremely preterm, 23 preterm and 19 term - predominantly coagulase-negative staphylococcus sepsis and necrotising enterocolitis. CONCLUSION: Markedly elevated CRP in the first 3 days of life was most likely to affect term neonates (74/106) with no infectious cause (81%). However, CRP >100 mg/L from the fourth day of life was most likely to affect extremely preterm neonates (129/171) and have an infectious cause (87%).

Amnioinfusion in preterm premature rupture of membranes (AMIPROM): a randomised controlled trial of amnioinfusion versus expectant management in very early preterm premature rupture of membranes--a pilot study.

BACKGROUND: Fetal survival is severely compromised when the amniotic membrane ruptures between 16 and 24 weeks of pregnancy. Reduced amniotic fluid levels are associated with poor lung development, whereas adequate levels lead to better perinatal outcomes. Restoring amniotic fluid by means of ultrasound-guided amnioinfusion (AI) may be of benefit in improving perinatal and long-term outcomes in children of pregnancies with this condition. OBJECTIVE: The AI in preterm premature rupture of membranes (AMIPROM) pilot study was conducted to assess the feasibility of recruitment, the methods for conduct and the retention through to long-term follow-up of participants with very early rupture of amniotic membranes (between 16 and 24 weeks of pregnancy). It was also performed to assess outcomes and collect data to inform a larger, more definitive, clinical trial. DESIGN: A prospective, non-blinded randomised controlled trial. A computer-generated random sequence using a 1 : 1 ratio was used. Randomisation was stratified for pregnancies in which the amniotic membrane ruptured between 16(+0) and 19(+6) weeks' gestation and 20(+0) and 24(+0) weeks' gestation. The randomisation sequence was generated in blocks of four. Telephone randomisation and intention-to-treat analysis were used. SETTING: Four UK hospital-based fetal medicine units - Liverpool Women's NHS Trust, St. Mary's Hospital, Manchester, Birmingham Women's NHS Foundation Trust and Wirral University Hospitals Trust. PARTICIPANTS: Women with confirmed preterm prelabour rupture of membranes between 16(+0) and 24(+0) weeks' gestation. Women with multiple pregnancies, resultant fetal abnormalities or obstetric indication for immediate delivery were excluded. INTERVENTIONS: Participants were randomly allocated to either serial weekly transabdominal AI or expectant management (Exp) until 37 weeks of pregnancy, if the deepest pool of amniotic fluid was < 2 cm. MAIN OUTCOME MEASURE: Short-term maternal, pregnancy and neonatal outcomes and long-term outcomes for the child were studied. Long-term respiratory morbidity was assessed using validated respiratory questionnaires at 6, 12 and 18 months of age and infant lung function was assessed at approximately 12 months of age. Neurodevelopment was assessed using Bayley's Scale of Infant Development II at a corrected age of 2 years. RESULTS: Fifty-eight women were randomised and two were excluded from the analysis owing to termination of pregnancy for lethal anomaly, leaving 56 participants (28 serial AI, 28 Exp) recruited between 2002 and 2009, with annual recruitment rates varying between 2 and 14. Recruitment to the study improved significantly from 2007 with National Institute for Health Research (NIHR) funding. There was no significant difference in perinatal mortality [19/28 vs. 19/28; relative risk (RR) 1.0; 95% confidence interval (CI) 0.70 to 1.43], maternal morbidity or neonatal morbidity. The overall chance of surviving without long-term respiratory or neurodevelopmental disability is 4/56 (7.1%): 4/28 (14.3%) in the AI arm and 0/28 in the expectant arm (0%) (RR 9.0; 95% CI 0.51 to 159.70). CONCLUSIONS: This pilot study found no major differences in maternal, perinatal or pregnancy outcomes. The study was not designed to show a difference between the arms and the number of survivors was too small to draw any conclusions about long-term outcomes. It does signal, however, that a larger, definitive, study to evaluate AI for improvement in healthy survival is indicated. The results suggest that, with appropriate funding, such a study is feasible. A larger, definitive, study with full health economic analysis and patient perspective assessment is required to show whether AI can improve the healthy survivor rate.

An investigation of factors affecting the outcome of the clinical skills assessment (CSA) in general practice specialty training.

Identifying general practice trainees at risk of failing the CSA early in their training is important so that supportive measures can be put in place to ensure training progression. The aim of this study was to determine aspects of the trainee's learning portfolio activity which might predict performance in the CSA. From the Mersey School of General Practice records, details were obtained for trainees who had completed their ST3 year between 1 August and 31 December 2012 with respect to the numbers of entries for the Mini Clinical Evaluation Exercise (Mini-CEX), case-based discussions (CBDs), directly observed procedures (DOPS), learning logs and personal development plans (PDPs) that they had carried out in each of their ST1 and ST2 years. Gender, university of qualification and years since qualification were also recorded. Records were obtained for 116 trainees (94 had passed their CSA). ST1 number of CBD and ST1 number of DOPS, university of qualification, gender, and shorter time since qualification were significantly associated with CSA pass. A multivariate model indicated that graduation from a European university and being female were both associated with an increased chance of passing. Longer time since qualification, non-European university graduation and male gender are the strongest predictors of failing the CSA. Portfolio activity is not a predictor of CSA outcome.

The first New Zealanders: patterns of diet and mobility revealed through isotope analysis.

Direct evidence of the environmental impact of human colonization and subsequent human adaptational responses to new environments is extremely rare anywhere in the world. New Zealand was the last Polynesian island group to be settled by humans, who arrived around the end of the 13th century AD. Little is known about the nature of human adaptation and mobility during the initial phase of colonization. We report the results of the isotopic analysis (carbon, nitrogen and strontium) of the oldest prehistoric skeletons discovered in New Zealand to assess diet and migration patterns. The isotope data show that the culturally distinctive burials, Group 1, had similar diets and childhood origins, supporting the assertion that this group was distinct from Group 2/3 and may have been part of the initial colonizing population at the site. The Group 2/3 individuals displayed highly variable diets and likely lived in different regions of the country before their burial at Wairau Bar, supporting the archaeological evidence that people were highly mobile in New Zealand since the initial phase of human settlement.

A longitudinal cohort study to investigate the retention of knowledge and skills following attendance on the Newborn Life support course.

AIM: To investigate whether airway management and non-invasive ventilatory skills are retained after the Neonatal Life support (NLS) course. METHODS: Candidates who attended and passed the NLS course were retested by two registered instructors using the NLS 'airway testing sheet' unannounced at 3-5 and 12-14 months after their NLS course. Prior to the test, they were also asked to complete a proforma, indicating their own assessment of their competence in being able to effectively carry out all the items used in the NLS airway test. RESULTS: Sixty-seven candidates were tested at 3-5 months, 26 (39%) passed first time, 34 (51%) on retest and 7 (10%) failed. At 12-14 months, 43 were tested, 19 (44%) passed on first attempt, 22 (51%) on retest and 2 (5%) failed. At 12-14 months, more candidates exposed to more than five resuscitations per month passed first time compared to those who were exposed to less than one resuscitation per month (p=0.029). More candidates who were offered resuscitation training at 6 monthly intervals compared to at yearly intervals passed the test on their first attempt at 3-5 months (p=0.022). Self-assessment of competence was not different between candidates who passed and those who failed. CONCLUSIONS: This study suggests that skills when tested in a simulated scenario are highly likely to have deteriorated within a few months of attending the NLS course. There is a need for research to determine whether deteriorations in skills after the NLS, as assessed by simulation, correlate with deterioration of skills in clinical practice.

Randomised controlled trial of the use of an educational board game in neonatology.

BACKGROUND: Games have been used in healthcare education to encourage active learning. AIM: To investigate whether an educational board game which had been developed in the speciality of neonatology could influence the learning experience of medical students during their neonatal attachment. METHOD: A randomised controlled trial of using the game was conducted amongst 67 student participants. RESULTS: The average final assessment score was 4.15 points higher in the group of students that played the game compared to the control group (95% CI-0.88-9.17; p = 0.09). The game was well received by the students. CONCLUSION: Although we cannot conclude firmly that the game produces an effect on learning, this study suggests that educational games should be investigated further in the delivery of undergraduate learning in specialities where exposure is brief.

What is the impact of structured resuscitation training on healthcare practitioners, their clients and the wider service? A BEME systematic review: BEME Guide No. 20.

A large number of resuscitation training courses (structured resuscitation training programmes (SRT)) take place in many countries in the world on a regular basis. This review aimed to determine whether after attending SRT programmes, the participants have a sustained retention of resuscitation knowledge and skills after their initial acquisition and whether there is an improvement in outcome for patients and/or their healthcare organisation after the institution of an SRT programme. All research designs were included, and the reported resuscitation training had to have been delivered in a predefined structured manner over a finite period of time. Data was extracted from the 105 eligible articles and research outcomes were assimilated in tabular form with qualitative synthesis of the findings to produce a narrative summary. Findings of the review were: SRTs result in an improvement in knowledge and skills in those who attend them, deterioration in skills and, to a lesser extent, knowledge is highly likely as early as three months following SRTs, booster or refresher sessions may improve an individual's ability to retain resuscitation skills after initial training and the instigation of resuscitation training in a healthcare institution significantly improves clinical management of resuscitations and patient outcome (including survival) after resuscitation attempts.