Long-term Outcomes of Single and Dual En Bloc Kidney Transplants From Small Pediatric Donors: An ANZDATA Registry Study.

Kidney transplants from small pediatric donors are considered marginal and often transplanted as dual grafts. This study aimed to compare long-term outcomes between recipients of single kidney transplants (SKTs) and dual en bloc kidney transplants (EBKTs) from small pediatric donors. Methods: Data were obtained from the Australia and New Zealand Dialysis and Transplant Registry. All adult recipients of kidney transplants from donors aged ≤5 y were identified. The primary outcome of interest was death-censored graft survival by donor type. The secondary outcomes were early graft loss, delayed graft function, serum creatinine posttransplantation, acute rejection, and patient survival. Results: There were 183 adult recipients of kidney transplants from donors aged ≤5 y old. Of these, 60 patients had EBKT grafts, 79 patients had SKT grafts, and 44 patients had grafts of unknown type. Compared with SKT donors, EBKT donors had lower mean age (P < 0.001) and body weight (P < 0.001). There was no significant difference in death-censored graft survival between the groups, with median survival of 23.8 y (interquartile range 21.2-25) in the EBKT cohort and 21.8 y (11.6-26.8) in the SKT cohort (hazard ratio 1.3; 95% confidence interval, 0.59-2.64; P = 0.56). EBKT grafts had lower acute rejection rates than SKT grafts (P = 0.014). There was no significant difference observed between groups with respect to early graft loss, delayed graft function, posttransplantation serum creatinine posttransplantation, or patient survival. Conclusions: EBKT and SKTs from small pediatric donors are associated with excellent long-term graft survival rates.

Promoting passenger behaviour change with provision of occupancy information to help moderate train overcrowding: A cognitive work analysis approach.

Passengers' travel behaviour is one of the significant factors affecting train overcrowding. Train occupancy information has been introduced as a tool to stimulate passengers' behaviour change to ease in-vehicle crowding. However, there are limitations to this strategy as it often fails to consider other elements in the complex rail system that influence behaviour. This research provides insights to service providers to promote passenger behaviour change by revealing the behavioural constraints in the environment. Cognitive Work Analysis (CWA) was applied to systematically analyse passengers' behaviour and related constraints in the environment. Specifically, Work Domain Analysis (WDA) and Social Organisation and Cooperation Analysis (SOCA) were conducted and presented in the forms of Abstraction Hierarchy (AH) and Contextual Activity Template (CAT). Results showed that a wide range of informational, navigational and physical support alongside provision of occupancy information could better encourage passengers to select and use less busy carriages and trains. Behaviour change goals are likely to be achieved more effectively when the constraints of the system are better understood.

Atmospheric dispersion modeling for an accidental release from a SLOWPOKE-2 research reactor: a case study.

Atmospheric dispersion modeling was performed for a postulated design basis accident at a SLOWPOKE research reactor. The MCNP-5 computer code was used to estimate the neutron flux spectrum which was then used in the ORIGEN-S code to perform core depletion calculations and determine the radiological source term. The HotSpot health physics code was then used to model the atmospheric transport of the radioactive material released to estimate the resulting doses to the population downwind of the reactor. The highest total effective dose (TED) for a release from the reactor's exhaust stack in predominant meteorological conditions, stability class C, was 0.37 mSv, while a maximum TED of 4.29 mSv was estimated for a release at ground level. Ground deposition was estimated to be 3900 kBq/m2. It was shown that any hypothetical release of radioactive material resulting from such an accident would have no significant adverse effect on the municipal water reservoir close to the reactor.

Spontaneous Relaxation of Heteroepitaxial Thin Films by van der Waals-Like Bonding on Te-Terminated Sapphire Substrates.

Here the novel direct heteroepitaxial growth method of a 3D heteroepitaxial system is demonstrated on a 3D substrate, CdTe (111)/Al2 O3 (0001), which forms a spontaneous vdW-like bond at the interface, instead of the two 3D crystals being strongly bound. Despite a large lattice mismatch, the thin films are single crystals and maintain high quality due the compliance of the interface which accommodates strain. This weak bonding interface is accomplished by the self-assembly of a pseudomorphic chalcogenide layer on the sapphire surface during growth. Since the vdW-like interface forms spontaneously in situ during growth, it is easily scalable to large wafer sizes, without the need to layer transfer 2D materials onto the growth substrate for remote epitaxy. Further, the weak adhesion of the films on the substrates allow for epitaxial film transfer to a variety of other substrates, leaving the original growth substrate for future reuse. This type of 3D/3D vdW-like interface is exploitable as a compliant interlayer for additional epitaxy, and may even be observable directly in other material systems grown on complex oxides, allowing for the production of large area high quality freestanding and layer transferred epitaxial devices for material systems not currently possible by conventional processing techniques.

Temporal Change in Blood Group after Bone Marrow Transplant: A Case of Successful ABO-Incompatible Deceased Donor Transplant.

ABO-incompatible kidney transplantation has been successfully utilised in a deceased donor and living donor kidney transplantation to improve organ utilisation and decrease waiting times. We describe a case of a successful, unanticipated ABO-incompatible donation after cardiac death (DCD) kidney transplant in a patient who had a previous ABOi haematopoietic stem cell transplant (HSCT) and had reverted to his original blood group B, after matching as a blood group A recipient with a blood group A donor. The recipient was unsensitized with a cPRA which was 0% and no donor-specific antibodies and zero HLA mismatch. An urgent anti-A titre was 1 : 2. Given the low antibody titres, we proceeded to transplantation. The patient developed delayed graft function and required dialysis on postoperative day 1 and day 2. The creatinine fell spontaneously on day 5, with progressively increased urine output and stable graft function on discharge at day 6. Anti-A titres were 1 : 1 on serial postoperative measurements. There were no rejection episodes, and the patient has a functioning graft at 16 months posttransplant. We describe a rare case in which the blood group can change after stem cell transplant and should be checked. We also demonstrate that a DCD ABOi transplant in the context of low anti-A titres for a patient with previous ABOi stem cell transplant can be performed successfully with standard immunosuppression.

How do fatalistic beliefs affect the attitudes and pedestrian behaviours of road users in different countries? A cross-cultural study.

This paper reports on an exploratory investigation of the influence of five different fatalistic belief constructs (divine control, luck, helplessness, internality, and general fatalism) on three classes of self-reported pedestrian behaviours (memory and attention errors, rule violations, and aggressive behaviours) and on respondents' general attitudes to road safety, and how relationships between constructs differ across countries. A survey of over 3400 respondents across Bangladesh, China, Kenya, Thailand, the UK, and Vietnam revealed a similar pattern for most of the relationships assessed, in most countries; those who reported higher fatalistic beliefs or more external attributions of causality also reported performing riskier pedestrian behaviours and holding more dangerous attitudes to road safety. The strengths of relationships between constructs did, however, differ by country, behaviour type, and aspect of fatalism. One particularly notable country difference was that in Bangladesh and, to a lesser extent, in Kenya, a stronger belief in divine influence over one's life was associated with safer attitudes and behaviours, whereas where significant relationships existed in the other countries the opposite was true. In some cases, the effect of fatalistic beliefs on self-reported behaviours was mediated through attitudes, in other cases the effect was direct. Results are discussed in terms of the need to consider the effect of locus of control and attributions of causality on attitudes and behaviours, and the need to understand the differences between countries therein.

Vulnerable road users in low-, middle-, and high-income countries: Validation of a Pedestrian Behaviour Questionnaire.

The primary aim of this study was to validate the short version of a Pedestrian Behaviour Questionnaire across six culturally and economically distinct countries; Bangladesh, China, Kenya, Thailand, the UK, and Vietnam. The questionnaire comprised 20 items that asked respondents to rate the extent to which they perform certain types of pedestrian behaviours, with each behaviour belonging to one of five categories identified in previous literature; violations, errors, lapses, aggressive behaviours, and positive behaviours. The sample consisted of 3423 respondents across the six countries. Confirmatory factor analysis was used to assess the fit of the data to the five-factor structure, and a four-factor structure in which violations and errors were combined into one factor (seen elsewhere in the literature). For some items, factor loadings were unacceptably low, internal reliability was low for two of the sub-scales, and model fit indices were generally unacceptable for both models. As such, only the violations, lapses, and aggressions sub-scales were retained (those with acceptable reliability and factor loadings), and the three-factor model tested. Although results suggest that the violations sub-scale may need additional attention, the three-factor solution showed the best fit to the data. The resulting 12-item scale is discussed with regards to country differences, and with respect to its utility as a research tool in cross-cultural studies of road user behaviour.

Assessment of tumour-associated necrosis provides prognostic information additional to World Health Organization/International Society of Urological Pathology grading for clear cell renal cell carcinoma.

AIMS: The aims of this study were to evaluate the impact of tumour-associated necrosis (TAN) on metastasis-free survival for clear cell renal cell carcinoma (RCC), and to determine whether TAN provides survival information additional to World Health Organization (WHO)/International Society of Urological Pathology (ISUP) grading. METHODS AND RESULTS: The study consisted of 376 cases of clear cell RCC treated by nephrectomy, for which follow-up was available. WHO/ISUP grade was assigned, and sections were assessed for the presence of TAN. American Joint Committee on Cancer (AJCC) pT staging category and tumour size were also recorded. The development of metastatic disease was taken as the clinical endpoint, and survival analyses, utilising univariate and multivariate models, were performed. WHO/ISUP grades were: grade 1, 35 cases (9.3%); grade 2, 188 cases (50.0%); grade 3, 91 cases (24.2%); and grade 4, 62 cases (16.5%). Staging categories were pT1-pT2 [234 tumours (62.2%)] and pT3-pT4 [139 tumours (37.0%)]. TAN was seen in 128 cases (34.0%). Neither TAN nor metastases were seen in grade 1 tumours. Among grade 2-4 tumours, those with TAN had a significantly worse prognosis than those without TAN (P = 0.017, P = 0.04, and P = 0.006, respectively). Multivariate analysis (WHO/ISUP grade, pT staging category, and TAN) showed all three variables to be independently associated with outcome (P = 0.009, P = 0.005, and P = 0.001, respectively). For all tumour grades and pT staging categories, it was found that the presence of TAN was associated with a 2.91-fold greater risk of metastatic disease. CONCLUSION: Tumour-associated necrosis is an important prognostic factor for clear cell RCC, independently of WHO/ISUP grade. This supports the suggestion that TAN could be incorporated into tumour grading criteria.

Radiation and criticality safety analyses for the highly-enriched uranium core removal from a research reactor.

Analysis was performed to estimate radiation levels during removal and packaging of the highly-enriched uranium core of the JM-1 SLOWPOKE-2 research reactor. Due to severe limitations of space in and around the reactor pool, the core could not be removed in the conventional manner as was done for previous SLOWPOKE defuelling operations. A transfer shield, with a balance between shielding efficacy, volume and weight was designed. Fuel depletion, Monte Carlo shielding and criticality calculations were performed. Comparisons of measured and calculated dose rates as well as results of the criticality safety assessment are presented. The designed transfer shield reduced the calculated unshielded dose rate from 29Sv/h to 8mSv/h. The maximum calculated effective neutron multiplication factor of approximately 0.89 was below the 0.91 upper subricital limit.

Clear cell renal cell carcinoma: validation of World Health Organization/International Society of Urological Pathology grading.

AIMS: In 2012, the International Society of Urological Pathology (ISUP) introduced a novel grading system for clear cell renal cell carcinoma (ccRCC) and papillary renal cell carcinoma. This system is incorporated into the latest World Health Organization renal tumour classification, being designated WHO/ISUP grading. This study was undertaken to compare WHO/ISUP and Fuhrman grading and to validate WHO/ISUP grading as a prognostic parameter in a series of clear cell RCC. METHODS AND RESULTS: Analysis of 681 cases of ccRCC showed that 144 tumours could not be assigned a Fuhrman grade on the basis of ambiguous grading features. The application of WHO/ISUP grading resulted in a general down-grading of cases when compared with Fuhrman grading. In a sub-group of 374 cases, for which outcome data were available, 9.3% were WHO/ISUP grade 1, 50.3% were grade 2, 24.1% grade 3 and 16.3% grade 4, while the distribution of Fuhrman grades was 0.4% grade 1, 48.7% grade 2, 29.4% grade 3 and 21.5% grade 4. There were no recurrence/metastases amongst patients with WHO/ISUP grade 1 tumours and there was a significant difference in outcome for WHO/ISUP grades 2, 3 and 4. For Fuhrman grading the cancer-free survival was not significantly different for grade 2 and grade 3 tumours. On multivariate analysis WHO/ISUP grade and pT staging category were found to retain prognostic significance. CONCLUSIONS: The study demonstrates that FG cannot be applied in >20% of cases of ccRCC and the WHO/ISUP provides superior prognostic information.

New walking and cycling infrastructure and modal shift in the UK: A quasi-experimental panel study.

Heavy dependency on car use leads to traffic congestion, pollution, and physical inactivity, which impose high direct and indirect costs on society. Promoting walking and cycling has been recognised as one of the means of mitigating such negative effects. Various approaches have been taken to enhance walking and cycling levels and to reduce the use of automobiles. This paper examines the effectiveness of infrastructure interventions in promoting walking and cycling for transport. Two related sets of panel data, covering elapsed time periods of one and two years, were analysed to track changes in travel behaviour following provision of new walking and cycling infrastructure so that modal shift from private car use to walking and cycling can be investigated. Two types of exposure measures were tested: distance from the infrastructure (a measure of potential usage), and actual usage of the infrastructure. Only the latter measure was statistically significantly associated with modal shift. This in turn suggested that infrastructure provision was not a sufficient condition for modal shift, but may have been a necessary condition. Along with the use of new infrastructure, the loss of employment, higher education, being male and being part of the ethnic majority were consistently found to be significantly and positively associated with modal shift towards walking and cycling. The findings of this study support the construction of walking and cycling routes, but also suggest that such infrastructure alone may not be enough to promote active travel.

Pilot study: use of gallium-68 PSMA PET for detection of metastatic lesions in patients with renal tumour.

BACKGROUND: In this study, we prospectively evaluate the diagnostic potential of a gallium-68 (68Ga) prostate-specific membrane antigen (PSMA)-binding ligand and positron emission tomography (PET) in detecting metastatic lesions in patients with renal tumour. The secondary aim was to determine whether the findings would result in the alteration of patient management. RESULTS: Ten patients with renal lesion and potential metastatic disease on conventional imaging were recruited. Patients underwent PSMA PET in addition to standard imaging. Nine patients underwent nephrectomy and 4 patients underwent additional targeted biopsy to provide specimens for histopathological validation. There were 89 pathological lesions on CT, of which 32 were removed or biopsied for histopathological correlation. With PSMA PET, 86 PET avid lesions were identified with 36 samples being available for analysis. Thirty-five of 36 samples were positive for renal cell carcinoma deposits, whilst 1 sample was inconclusive for diagnosis on biopsy. For the histologically confirmed lesions, there were no false-negative PSMA PET lesions; however, CT was false negative in 11. In two patients, surgical strategies were changed based on PSMA PET findings. CONCLUSIONS: PSMA PET may potentially have a role in the preoperative staging of advanced renal cell carcinoma as PET detected multiple histologically proven metastatic lesions which were false negative on CT scanning, resulting in change in surgical strategies in some patients. We cautiously support a larger study to confirm these results and to assess the longitudinal impact on patient outcomes. TRIAL REGISTRATION: Australia and New Zealand Clinical Trial Registry (ANZCTR), ACTRN12615000854538 .

The rise of western rationalism: Paul Feyerabend's story.

I summarize certain aspects of Paul Feyerabend's account of the development of Western rationalism, show the ways in which that account is supposed to run up against an alternative, that of Karl Popper, and then try to give a preliminary comparison of the two. My interest is primarily in whether what Feyerabend called his 'story' constitutes a possible history of our epistemic concepts and their trajectory. I express some grave reservations about that story, and about Feyerabend's framework, finding Popper's views less problematic here. However, I also suggest that one important aspect of Feyerabend's material, his treatment of religious belief, can be given an interpretation which makes it tenable, and perhaps preferable to a Popperian approach.

Direct carbon dioxide emissions from civil aircraft.

Global airlines consume over 5 million barrels of oil per day, and the resulting carbon dioxide (CO2) emitted by aircraft engines is of concern. This article provides a contemporary review of the literature associated with the measures available to the civil aviation industry for mitigating CO2 emissions from aircraft. The measures are addressed under two categories - policy and legal-related measures, and technological and operational measures. Results of the review are used to develop several insights into the challenges faced. The analysis shows that forecasts for strong growth in air-traffic will result in civil aviation becoming an increasingly significant contributor to anthropogenic CO2 emissions. Some mitigation-measures can be left to market-forces as the key-driver for implementation because they directly reduce airlines' fuel consumption, and their impact on reducing fuel-costs will be welcomed by the industry. Other mitigation-measures cannot be left to market-forces. Speed of implementation and stringency of these measures will not be satisfactorily resolved unattended, and the current global regulatory-framework does not provide the necessary strength of stewardship. A global regulator with 'teeth' needs to be established, but investing such a body with the appropriate level of authority requires securing an international agreement which history would suggest is going to be very difficult. If all mitigation-measures are successfully implemented, it is still likely that traffic growth-rates will continue to out-pace emissions reduction-rates. Therefore, to achieve an overall reduction in CO2 emissions, behaviour change will be necessary to reduce demand for air-travel. However, reducing demand will be strongly resisted by all stakeholders in the industry; and the ticket price-increases necessary to induce the required reduction in traffic growth-rates place a monetary-value on CO2 emissions of approximately 7-100 times greater than other common valuations. It is clear that, whilst aviation must remain one piece of the transport-jigsaw, environmentally a global regulator with 'teeth' is urgently required.

Following the cognitive work analysis train of thought: exploring the constraints of modal shift to rail transport.

Environmental concerns show that transport is responsible for almost a quarter of all greenhouse gas emissions, and it is also the fastest growing sector. Modal shift towards public transport could help slow down, or even reverse, this trend. There appear to be a number of constraints that are preventing this from happening. This paper explores the constraints to modal shift to rail transport from the perspective of cognitive work analysis, specifically the abstraction hierarchy, the contextual activity template and social organisational and cooperation analyses. Whilst these analyses may not present any new barriers, they do show how the constraints are interlinked in an explicit manner. These interrelations are important for two reasons. First, in consideration of constraint removal, one must anticipate the likely effects on the remainder of the system. Second, by linking functions and situations, new concepts of travel may be identified and explored. PRACTITIONER SUMMARY: The purpose of this study was to use a semi-structured approach to identifying constraints to modal shift from a variety of perspectives. It is argued that cognitive work analysis offers a new way of thinking about the modal shift problem and helps to generate new insights into potential solutions.

Evaluating the travel, physical activity and carbon impacts of a 'natural experiment' in the provision of new walking and cycling infrastructure: methods for the core module of the iConnect study.

INTRODUCTION: Improving infrastructure to support walking and cycling is often regarded as fundamental to encouraging their widespread uptake. However, there is little evidence that specific provision of this kind has led to a significant increase in walking or cycling in practice, let alone wider impacts such as changes in overall physical activity or carbon emissions. Connect2 is a major new project that aims to promote walking and cycling in the UK by improving local pedestrian and cycle routes. It therefore provides a useful opportunity to contribute new evidence in this field by means of a natural experimental study. METHODS AND ANALYSIS: iConnect is an independent study that aims to integrate the perspectives of public health and transport research on the measurement and evaluation of the travel, physical activity and carbon impacts of the Connect2 programme. In this paper, the authors report the study design and methods for the iConnect core module. This comprised a cohort study of residents living within 5 km of three case study Connect2 projects in Cardiff, Kenilworth and Southampton, supported by a programme of qualitative interviews with key informants about the projects. Participants were asked to complete postal questionnaires, repeated before and after the opening of the new infrastructure, which collected data on demographic and socioeconomic characteristics, travel, car fuel purchasing and physical activity, and potential psychosocial and environmental correlates and mediators of those behaviours. In the absence of suitable no-intervention control groups, the study design drew on heterogeneity in exposure both within and between case study samples to provide for a counterfactual. ETHICS AND DISSEMINATION: The study was approved by the University of Southampton Research Ethics Committee. The findings will be disseminated through academic presentations, peer-reviewed publications and the study website (http://www.iconnect.ac.uk) and by means of a national seminar at the end of the study.

Effect of questionnaire length, personalisation and reminder type on response rate to a complex postal survey: randomised controlled trial.

BACKGROUND: Minimising participant non-response in postal surveys helps to maximise the generalisability of the inferences made from the data collected. The aim of this study was to examine the effect of questionnaire length, personalisation and reminder type on postal survey response rate and quality and to compare the cost-effectiveness of the alternative survey strategies. METHODS: In a pilot study for a population study of travel behaviour, physical activity and the environment, 1000 participants sampled from the UK edited electoral register were randomly allocated using a 2×2 factorial design to receive one of four survey packs: a personally addressed long (24 page) questionnaire pack, a personally addressed short (15 page) questionnaire pack, a non-personally addressed long questionnaire pack or a non-personally addressed short questionnaire pack. Those who did not return a questionnaire were stratified by initial randomisation group and further randomised to receive either a full reminder pack or a reminder postcard. The effects of the survey design factors on response were examined using multivariate logistic regression. RESULTS: An overall response rate of 17% was achieved. Participants who received the short version of the questionnaire were more likely to respond (OR=1.48, 95% CI 1.06 to 2.07). In those participants who received a reminder, personalisation of the survey pack and reminder also increased the odds of response (OR=1.44, 95% CI 1.01 to 1.95). Item non-response was relatively low, but was significantly higher in the long questionnaire than the short (9.8% vs 5.8%; p=.04). The cost per additional usable questionnaire returned of issuing the reminder packs was £23.1 compared with £11.3 for the reminder postcards. CONCLUSIONS: In contrast to some previous studies of shorter questionnaires, this trial found that shortening a relatively lengthy questionnaire significantly increased the response. Researchers should consider the trade off between the value of additional questions and a larger sample. If low response rates are expected, personalisation may be an important strategy to apply. Sending a full reminder pack to non-respondents appears a worthwhile, albeit more costly, strategy.

An applied ecological framework for evaluating infrastructure to promote walking and cycling: the iConnect study.

Improving infrastructure for walking and cycling is increasingly recommended as a means to promote physical activity, prevent obesity, and reduce traffic congestion and carbon emissions. However, limited evidence from intervention studies exists to support this approach. Drawing on classic epidemiological methods, psychological and ecological models of behavior change, and the principles of realistic evaluation, we have developed an applied ecological framework by which current theories about the behavioral effects of environmental change may be tested in heterogeneous and complex intervention settings. Our framework guides study design and analysis by specifying the most important data to be collected and relations to be tested to confirm or refute specific hypotheses and thereby refine the underlying theories.

Growing leaders in a professional membership organization.

AIMS: This study describes the background, development and delivery of an innovative approach to prepare elected state association leaders for their new leadership roles in their respective state organizations. BACKGROUND: State-based professional associations face unprecedented threats to scope of practice in the current volatile healthcare environment. In 2009 the American Association of Nurse Anesthetists (AANA) began offering a Leadership Development 'Boot Camp' for all nurse anesthetist state association presidents-elect designed with the intent of providing the participants with information, resources and tools they need in their new role. METHODS: An organizational assessment examined the philosophy of and need for leadership development across the entire organizational structure. RESULTS: Recommendations from the assessment included the need for intensive leadership development at the state level. A 3-day intensive workshop was designed and implemented. Adult learning theory was used for its development. CONCLUSIONS: The success of this programme has lead to its implementation as part of leadership development of the AANA. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers and elected volunteer leaders in state-based professional associations face similar challenges requiring sound leadership ability. Principles applied to the development of the AANA programme can be applied to leadership development for new nurse managers.