Journal articles on the topic 'Air-pilot guides'

On 3 March 2009, the Council of the International Civil Aviation Organization (ICAO) approved international standards, which stipulate that regulations on flight and duty time limitations must be based on 'scientific principles and knowledge'. These standards became effective on 19 November 2009 and remain applicable. On 13 June 2011, the Council adopted international standards for Fatigue Risk Management Systems (FRMS) with a view to better addressing crew fatigue, which is considered a key contributor to aircraft accidents. The new standards, which would amend current standards of ICAO Annex 6 to the Convention on International Civil Aviation - Operation of Aircraft Part I - International Operations - Aeroplanes came into effect on 30 October 2011 and become applicable on 15 December 2011. Global standards on limitations applicable to crew duty hours have gradually become obsolete and inapplicable in the face of varying operational contexts that require globally harmonized management systems containing standards and guidance material. In July 2011, ICAO, the International Air Transport Association (IATA) and the International Federation of Air Line Pilots' Associations (IFALPA) issued guidance for operators that provide air operators with information for implementing an FRMS that is consistent with applicable standards and recommended practices (SARPs) of ICAO. Also in existence, hand in hand with this guidance, is the Regulator's Manual that guides regulators through the FRMS process. Both these documents are accessible through the ICAO website. On 30 and 31 August 2011, ICAO held an FRMS Symposium where a unique gathering of more than 500 representatives from government, the air transport industry and the scientific community held important discussions that resulted in several conclusions. Both the regulatory regime and the discussions in the Symposium bring to bear important issues of air crew integrity and their responsibility to disclose vital information in terms of their fitness to pilot a flight as well as their continuing health. This article, written from the perspective of the crew with focus on the technical crew, discusses their liability for non-disclosure of critical information of a pre-existing medical condition and concludes by asking compelling questions to ensure safety of flight.

In developing Sultan Hasanuddin Airport Makassar, one of the efforts is by installing Approach Light System, a navigation tool installed at both runway edges used to improve flight security and safety. By installing Approach Light System at both runway edges, it can guarantee safety flight in order to develop air traffic system in the movement area that is safe, fast and smooth.The objective of Approach Light System is to provide clear guides to pilots when performing landing on the runways. The tool is also useful for making accurate landing of the aircraft.By using descriptive qualitative technical approach method in the analysis of this study, it can be concluded that by completely installing the Approach Light System at both runway edges in Sultan Hasanuddin Airport, it has met the regulation number SKEP/114/VI/2002 on the Airport Installation System Standard Blueprint (Airfield Lighting System) issued by the General Directorate of Air Transport so that safe and secure flight can be conducted optimally and aircraft movement can be increased as well.Approach Light System merupakan peralatan navigasi pada kedua ambang landasan untuk meningkatkan keamanan dan keselamatan penerbangan. Tujuan dan manfaat dari Approach Light system adalah untuk memberikan tuntutan kepada pilot/penerbang saat melakukan pendaratan menuju landasan dan manfaatnya untuk ketepatan pendaratan pesawat udara.Melalui metode pendekatan teknis deskriptif kualitatif dalam melakukan analisis pembahasan dapat disimpulkan bahwa dengan terpenuhinya kebutuhan Approach Light system pada kedua ambang landasan bandara Sultan Hasanudin Makassar, maka sudah sesuai dengan ketentuan yang berlaku yaitu SKEP/114/VI/2002 yang diterbitkan oleh Direktorat Jenderal Perhubungan Udara tentang Standar Gambar Instalasi Sistem Bandar Udara (Airfield Lighting System) sehingga dapat terselenggara keamanan dan keselamatan penerbangan secara optimal dan dapat meningkatkan pergerakan pesawat udara.

INTRODUCTION: There is a current belief in aviation suggesting that aerobic training may reduce G-tolerance due to potential negative impacts on arterial pressure response. Studies indicate that increasing maximal aerobic capacity (<mml:math id="ie1" display="inline"><mml:mrow><mml:mover><mml:mtext>V</mml:mtext><mml:mo>˙</mml:mo></mml:mover></mml:mrow></mml:math>o2 max) through aerobic training does not hinder G-tolerance. Moreover, sustained centrifuge training programs revealed no instances where excessive aerobic exercise compromised a trainee’s ability to complete target profiles. The purpose of this review article is to examine the current research in the hope of establishing the need for routine <mml:math id="ie2" display="inline"><mml:mrow><mml:mover><mml:mtext>V</mml:mtext><mml:mo>˙</mml:mo></mml:mover></mml:mrow></mml:math>o2-max testing in air force pilot protocols.METHODS: A systematic search of electronic databases including Google Scholar, PubMed, the Aerospace Medical Association, and Military Medicine was conducted. Keywords related to “human performance,” “Air Force fighter pilots,” “aerobic function,” and “maximal aerobic capacity” were used in various combinations. Articles addressing exercise physiology, G-tolerance, physical training, and fighter pilot maneuvers related to human performance were considered. No primary data collection involving human subjects was conducted; therefore, ethical approval was not required.RESULTS: The <mml:math id="ie3" display="inline"><mml:mrow><mml:mover><mml:mtext>V</mml:mtext><mml:mo>˙</mml:mo></mml:mover></mml:mrow></mml:math>o2-max test provides essential information regarding a pilot’s ability to handle increased Gz-load. It assists in predicting G-induced loss of consciousness by assessing anti-G straining maneuver performance and heart rate variables during increased G-load.DISCUSSION: <mml:math id="ie4" display="inline"><mml:mrow><mml:mover><mml:mtext>V</mml:mtext><mml:mo>˙</mml:mo></mml:mover></mml:mrow></mml:math>o2-max testing guides tailored exercise plans, optimizes cardiovascular health, and disproves the notion that aerobic training hampers G-tolerance. Its inclusion in air force protocols could boost readiness, reduce health risks, and refine training for fighter pilots’ safety and performance. This evidence-backed approach supports integrating <mml:math id="ie5" display="inline"><mml:mrow><mml:mover><mml:mtext>V</mml:mtext><mml:mo>˙</mml:mo></mml:mover></mml:mrow></mml:math>o2-max testing for insights into fitness, risks, and tailored exercise.Zeigler Z, Acevedo AM. Re-evaluating the need for routine maximal aerobic capacity testing within fighter pilots. Aerosp Med Hum Perform. 2024; 95(5):273–277.

Despite the popularity of Rapid Rhino packs, there are no clear guidelines regarding the volume of air to be inflated when used in the management of epistaxis. The manufacturers suggest that subjective assessment by pilot cuff palpation is used to guide inflation. However, studies have clearly demonstrated that clinicians are poor at judging balloon pressure by pilot cuff palpation when used in other settings. Our objective was to investigate the relationship between the volume of air inflated and the resultant intra-nasal pressure generated by nasal balloon packing. Twelve healthy subjects were packed with 5.5 cm Rapid Rhino packs, which were connected to a manometer and 20 ml syringe via a 3-way tap in a closed circuit. Increments of 2.5 mls of air were inflated and the resultant intra-nasal pack pressure was measured. There appeared to be a linear relationship between increasing volume and pack pressure. However, between individuals, there was a large variation in the intra-nasal pack pressure produced for a given fixed volume of air inflated. This is presumably due to variations in nasal anatomy. It may be that a manometer-measured, pressure guided nasal pack inflation technique would represent best practice, especially for less experienced staff.

Abstract The working pressure of the start-up compressed air pilot solenoid valve is 40bar when it starts, it is an important part of the emergency diesel air start system of nuclear power plants. Since the operation of the nuclear power plant, it has been found that the start-up compressed air pilot solenoid valve has more frequent failures, the failure modes are air leaks and jams. The start-up compressed air pilot solenoid valve are all solenoid valves of the same type, the manufacturer is MABO, the model is MV320V DN20 G34 NC. Once the start-up compressed air pilot solenoid valve fails, it will affect the reliability and availability of the diesel engine’s start-up air system, directly cause the diesel engine to fail to start. Through a series of tests, the jamming and air leakage failures in the use of the start-up compressed air pilot solenoid valve are tested and analyzed. The reasons for the frequent air leakage and jamming of the starting compressed air pilot solenoid valve are determined, effective improvement plans are proposed, such as changing to another type of grease, adding the solenoid spool guide ring and return spring, improving the spool structure, increasing the diameter of the pilot valve and coil power, etc.. After analysis and demonstration, it is further clarified that the reasons for the leakage and jamming of the pilot solenoid valve are clear, the improvement plan is effective. The results show that the improved program obtained through research has laid a foundation for solving the problem of frequent leakage and jamming of the pilot solenoid valve.

In the process of air combat implementation, the real-time command and guidance of air pilot is the key element of air combat irreplaceable. In this paper, a multi-aircraft air combat command and guidance target allocation model is established based on the actual air combat situation. The unbalanced target allocation problem of multi-aircraft air combat command and guidance is studied by combining Hungarian algorithm and evolutionary Hungarian algorithm. Finally, two cases of increasing aircraft number and decreasing aircraft number are simulated and studied. Simulation results show that the method can shorten the computation time and ensure the overall command and guidance advantages of the target allocation scheme effectively.

Este trabalho teve como objetivo determinar a altura total, de 30 árvores em um plantio de Pinus taeda, com apoio de tecnologias de geoprocessamento. Obteve-se a alturas por meio de aerolevantamento e também com o método convencional (com hipsômetro), avaliando estatisticamente os resultados. Foram adquiridas imagens com Aeronave Remotamente Pilotada (ARP), utilizando pontos de controle, que serviram para a relação das coordenadas da imagem com as do terreno. A geração do Modelo Digital do Terreno (MDT), foi realizada por meio de topografia convencional, fornecendo dados para a planialtimetria local, ao longo do alinhamento do plantio. Para obtenção das alturas, aplicou-se a subtração entre as altitudes do MDS e do MDT, sendo consideradas como tratamento 1. Com hipsômetro, foram mensuradas as alturas das mesmas árvores, sendo consideradas como tratamento 2 e posteriormente foi aplicado teste t, para a comparação entre as médias, usando significância estatística de 5% de probabilidade. Foi observada a diferença média de 4,05%, entre tratamentos, fato que orienta a viabilidade da metodologia através do uso de imagens obtidas por ARP, havendo diferença estatística significativa entre diferentes formas de obtenção dos dados. Porém, verificou-se a maior precisão e menor dispersão, naqueles dados coletados com metodologia apoiada por imagem, sendo necessário destacar que o hipsômetro, é um método indireto de medição, que apresentar sub ou superestimado das alturas.Palavras-chave: aerolevantamento; mensuração florestal; modelo digital de terreno; modelo digital de superfície. DETERMINATION OF HEIGHT In Pinus taeda L. USING UNCONSCIOUS AIR VEHICLE ABSTRACT: The objective of this work was to determine the total height of 30 trees in a plantation of Pinus taeda, with the support of geoprocessing technologies. Height was obtained by means of aerial survey and also with the conventional method (with hypsometer), statistically evaluating the results. Images were obtained with Remotely Pilot Aircraft (ARP), using control points, which served to relate the coordinates of the image with those of the terrain. The generation of the Digital Terrain Model (TDM) was performed by means of conventional topography, providing data for local planialtimetry along the alignment of the plantation. In order to obtain the heights, the subtraction was applied between the MDS and MDT altitudes, being considered as treatment 1. With a hypsometer, the heights of the same trees were measured, being considered as treatment 2 and later t-test was applied for the comparison between means, using statistical significance of 5% probability. The mean difference of 4.05% between treatments was observed. This fact guides the viability of the methodology through the use of ARP images, and there is a statistically significant difference between different ways of obtaining the data. However, it was verified the greater precision and less dispersion, in those data collected with methodology supported by image, being necessary to emphasize that the hypsometer, is an indirect method of measurement, that presents sub or overestimated of the heights.Keywords: aerial survey; forest mensuration; digital terrain model; digital surface model.

Abstract: The Effect Of Linguistic Intelligence, Learning Motivation, And Self-Trust On Communication Performance Taruna Air Traffic Guide In The Tower Lab The Air Traffic Control Program at the Medan Aviation Polytechnic aims to produce students who are able to become professional Air Traffic Controller (ATC) personnel at airports that provide air traffic control services. In doing their duties, the air traffic controller communicates with the pilot to guide the aircraft in accordance with aviation safety rules. In conducting flight communication, there are several aspects that need to be considered such as self-confidence, learning motivation and language intelligence. The research conducted at the Medan Aviation Polytechnic involved 103 cadets as the research sample. Retrieval of data using measuring instruments from each aspect that had previously been tested for validity and reliability. The result of the study indicates that there is a positive and significant influence between language intelligence, self-confidence, learning motivation on communication performance. Keywords: Communication Performance; Linguistic Intelligent; Motivation; Self-Confidence Abstrak: Pengaruh Kecerdasan Linguistik, Motivasi Belajar, dan Kepercayaan Diri Terhadap Communication Performance Taruna Pemanduan Lalu Lintas Udara di Lab Tower. Program Pemanduan Lalu Lintas Udara di Politeknik Penerbangan Medan bertujuan menghasilkan peserta didik yang mampu menjadi tenaga professional Air Traffic Controller (ATC) di bandara udara yang memberikan layanan pengaturan lalu lintas udara. Dalam tugasnya pemandu lalu lintas udara berkomunikasi dengan pilot untuk memandu pesawat sesuai dengan aturan keselamatan penerbangan. Dalam melakukan komunikasi penerbangan terdapat beberapa aspek yang perlu diperhatikan seperti kepercayaan diri, motovasi belajar dan kecerdasan bahasa. Penelitian yang dilakukan di Politeknik Penerbangan Medan melibatkan 103 orang taruna sebagai sampel penelitian. Pengambilan data menggunakan alat ukur dari masing-masing aspek yang sebelumnya telah diuji validitas dan reliabilitasnya. Adapun hasil penelitian menunjukkan bahwa terdapat pengaruh yang positif dan signifikan antara kecerdasan bahasa, kepercayaan diri, motivasi belajar terhadap communication performance. Kata Kunci: Communication Performance, Kecerdasan Bahasa, Kepercayaan Diri, Motivasi Belajar

A methodology for identifying ergonomics risk factors and control strategies in office environments has been developed and pilot tested. Developed as part of an overall ergonomics program being implemented by the United States Air Force, the employees impacted include both civilian and military personnel performing a wide range of administrative tasks typically performed in offices. The research design included: a focused literature review; strategic site visits; and review of criteria established by the Air Force; an iterative developmental process of a Screening Survey and an Ergonomics Assessment Methodology Guide; and testing. The results indicate that the process can be used as an effective means for identifying and controlling ergonomics hazards in administrative work areas.

DVOR (Doppler VHF Omnidirectional Range) equipment is used by pilots as a navigation aid when the plane is about to land at the destination airport. DVOR is an air navigation equipment to guide aircraft in order to land perfectly at the destination airport, where the equipment functions to provide information in the form of azimuth, bearing in the frequency range of 108 MHz - 118 MHz using the Doppler effect. If the DVOR equipment in the form of a remote control system unit (RSCU) is damaged, it will prevent the aircraft from landing because there is no guide that can be used by the pilot. In this study, we succeeded in analyzing the damage to the remote control system unit on DVOR equipment by resetting the radio link on the antenna and on the laptop so that it can function as expected.

This theoretical paper advocates for research to assess whether tests of mental imagery may be used as reliable and valid predictors to inform the design of human-computer interactions suited to individual differences, and industrial-organizational psychology applications including personnel selection and customized training regimens. Mental imagery includes multisensory, non-sensory spatial, and motor rehearsal forms, and has been correlated with emotional reactivity and performance on laboratory tasks such as memory recognition and recall. We focus on air traffic control and aircraft pilot roles, as cognitive testing has been pioneered in these high-consequence professions, with resulting cultural and institutional support for the use of testing to guide personnel development decisions. Mental imagery testing may also offer benefits in the lifelong career pipeline for STEM, creative, and problem-solving work roles more broadly.

An air traffic controller (ATC) is one of the jobs with the highest job demands. The safety of the soul is a mental burden that must be borne by each air traffic controller officer. Sultan Muhammad Salahuddin Bima Airport is in charge of providing air traffic guidance services. Guide the pilot from the aircraft's start in the apron, taxi, takeoff, and landing. This study aims to find out if there is work Stresss felt by air traffic controller officers and to gauge the level of flight safety at Sultan Muhammad Salahuddin Bima Airport.
 This research uses qualitative methods with descriptive qualitative research types. Data collection for this study was conducted at Perum LPPNPI AirNav Indonesia Bima Auxiliary Branch. The study used data from documentation, live observations, and interviews conducted with senior air traffic controllers and junior air traffic controllers. Data analysis techniques use data organizing, data management, data verification and interpretation, and inference.
 The results of this study showed that there was work stress felt by the air traffic controller officer of Bima Auxiliary Branch. The distance between the Stresss felt in doing the work by the air traffic controller officer is very clearly visible. This is in view of the surrounding environmental conditions that are directly adjacent to the livelihood area of the surrounding population (pond). In addition, Sultan Salahuddin Bima Airport is undergoing reconstruction so that many shocks are felt while inside the tower due to heavy equipment and passing trucks. The results of this study also showed that the level of flight safety at Sultan Muhammad Salahuddin Bima Airport is relatively safe, considering the rare occurrence of accidents and serious incidents.
 Keywords : air traffic controller, work Stress, flight safety, Sultan Muhammad Salahuddin Bima Airport.
 Air Traffic Controller (ATC) merupakan salah satu pekerjaan yang memiliki tuntutan kerja tinggi. Tanggung jawab terhadap keselamatan jiwa merupakan beban mental tersendiri yang harus dipikul oleh tiap-tiap petugas Air Traffic Controller. Air Traffic Controller Bandar Udara Sultan Muhammad Salahuddin Bima bertugas memberikan pelayanan pemanduan lalu lintas udara. Memandu pilot mulai dari pesawat start di apron, taxi, take off sampai landing. Penelitian ini bertujuan untuk mengetahui apakah terdapat stress kerja yang dirasakan oleh petugas Air Traffic Controller dan untuk mengetahui tinggkat keselamatan penerbangan di Bandar Udara Sultan Muhammad Salahuddin Bima.
 Penelitian ini menggunakan metode kualitatif dengan jenis penelitian kualitatif deskriptif. Pengumpulan data pada penelitian ini dilakukan di Perum LPPNPI AirNav Indonesia Cabang Pembantu Bima. Penelitian ini mengambil data dari dokumentasi, observasi secara langsung, dan wawancara yang dilakukan bersama Senior Air Traffic Controller dan Junior Air traffic Controller. Teknik analisis data menggunakan pengorganisasian data, pengelolaan data, verifikasi dan penafsiran data, dan pengambian kesimpulan.
 Hasil dari penelitian ini menunjukkan bahwa terdapat stress kerja yang dirasakan oleh petugas Air Traffic Controller Cabang Pembantu Bima. Stress keja yang dirasakan dalam melakukan pekerjaan oleh petugas Air Traffic Controller sangat terlihat jelas. Hal ini ditinjau dari kondisi lingkungan sekitar yang berbatasan langsung dengan kawasan mata pencaharian penduduk sekitar (tambak) selain itu juga Bandara Sultan Salahuddin Bima sedang melakukan rekonstruksi sehingga banyak guncangan-guncangan yang dirasakan saat berada di dalam tower karena alat berat maupun truk yang lewat. Hasil penelitian ini juga menunjukkan bahwa tingkat keselamatan penerbangan di Bandar Udara Sultan Muhammad Salahuddin Bima tergolong aman, mengingat jarang terjadinya accident dan serious insident.
 Kata Kunci : Air Traffic Controller, Stress kerja, keselamatan penerbangan, dan Bandar Udara Sultan Muhammad Salahuddin Bima.

Abstract A 37-year-old active duty male Air Force instructor pilot, with no prior medical history, was found unresponsive at his home after awakening with symptoms of altered mental status when the Emergency Medical Service (EMS) was called. The patient was found to be hypoglycemic with a glucose of 37 mg/dL. The patient recovered after administration of a dextrose bolus. Further investigation revealed that over the last several years, the patient exhibited symptoms of lightheadedness and tremors if fasted greater than 3 hours. Further clinical workup strongly suggested the presence of a neuroendocrine tumor. Initial imaging studies to include a multiphasic dedicated pancreatic computed tomography (CT) scan did not demonstrate a pancreatic lesion. However, the utilization of an innovative new nuclear medicine imaging modality, a 68Ga-Dotatate PET/CT, clearly demonstrated a 19 × 16 mm lesion of the distal pancreatic tail, which guided surgical resection. He underwent a robotic-assisted laparoscopic distal pancreatectomy, pathologically characterized as an insulinoma. The patient’s symptoms immediately resolved with no recurrence over the next 6 months. The pilot was granted a waiver, returning him to his flying duties. The 68Ga-Dotatate PET/CT enabled the identification of an otherwise occult pancreatic neuroendocrine tumor ultimately leading to this patient’s definitive cure and the salvage of this military asset’s aviation career.

We aim to evaluate a novel bioresorbable fiducial for marking tumor bed margins in head and neck cancers (HNCs) to improve upon current use of nonresorbable materials. A feasibility test was done placing the marker (L-lactide and ε-caprolactone) in an orange for computed tomography (CT) and applesauce for T1-, T2-, and PD-weighted magnetic resonance imaging (MRI) image acquisition, using routine clinical parameters. The resulting CT and MRI images showed excellent delineation of the marker with all of its margins well seen without adjacent artifact. The marker appeared similar to air on CT and MRI, surrounded by fluid-like appearance of the medium. Surgical bed appearance when radiotherapy is planned should not produce any artifact near the marker, and there should be no inherent marker-related artifact. These pilot CT and MR images show clinical utility for intraoperative marking of positive margins in the skull base or neck to guide future treatment and monitoring.

There is a limited understanding of householders’ cultural differences and their impact on spatial organisation and energy behaviour in dwellings. Indoor air quality directly impacts the health and well-being of occupants. The airborne COVID-19 epidemic has highlighted shortcomings of controlled ventilation systems in recent reports (PHE, Dec 2020). While efficiency interventions can make homes more affordable to heat, they can exacerbate conditions such as asthma, due to reduced indoor air quality and ventilation. Preliminary research conducted in Plymouth by the applicant indicates that British Asians use their homes differently compared to native British in terms of spatial organisation, cooking habits (on average, they spend five times more time cooking the daily meal) and ventilation strategies, all of which have an impact on indoor air quality. This project sets out to establish the impact of culturally informed choices on indoor air quality and the extent to which the norms that guide the design of energy-efficient homes ignore potentially significant cultural and behavioural differences. It will achieve this by focusing on the impact of energy behaviour and choices related to cooking on the indoor air quality of British-Asian households. The project aims to quantify temperature, humidity and air quality by data collected by a pilot study in Plymouth, UK. We will engage the community in a participatory methodology using correlational research and survey questionnaires and IAQ Data Loggers to evidence anomalies from the design norms currently used in the UK. In addition to traditional data analysis, our methodology includes artistic research, utilising observational and sensory ethnographic filmmaking techniques, to support, document, and evidence the impact of cooking in the home. We aim to explore how the intersection between these two methods can reveal and communicate new perspectives. The main outcome is to evaluate the impact of cultural behaviour on the air quality of super-insulated British-Asian homes through an interdisciplinary methodology. This project lays foundations for larger-scale research working with diverse ethnic minority communities to promote engagement in a low-carbon society.

This research work examined the environmental impacts of automotive air conditioning system maintenance practices embraced by service technician in Niger State, Nigeria. The study sought out the problem associated with automotive air conditioning maintenance practices and the way of improving automotive air conditioning system maintenance practices by automotive air conditioning services technicians in Niger State. Two research questions and two hypotheses guided the study. A descriptive survey research designed was adopted for the study. A total population of 155 respondents comprises of 97 highly experienced registered air conditioning service technicians and 58 moderately experienced registered air conditioning service technicians in Niger State. The respondents were selected according to the year of service, which was 1-14 years for moderately experienced and 15 above for highly experienced service technicians. Due to manageable sizes of the respondents, the entire population was used i.e no sampling techniques was utilized for the study. A structured questionnaire title “Automotive Air Conditioning System Maintenance Practices Questionnaire” was faced validated by three experts (one lecturer from Department of Industrial and Technology Education, Federal University of Technology Minna, one expert from Ministry of Environment Niger State and one expert from Ministry of Health Niger State). The questionnaire was pilot tested using 30 automotive air conditioning service technicians from Abuja. The data collected were analyzed using Cronbach Alpha Statistics and its yielded to 0.71 reliability coefficient. Mean and standard deviation were used to analyze the research questions and hypotheses were tested at 0.05 level of significance using z-test statistics. The numerical values obtained from the responses of the respondents were tabulated and analyzed using statistical package for social science (SPSS) version 23. The findings among other revealed that inhalation of concentration refrigerant vapour is dangerous and can be fatal, exposure to level of fluorocarbons above recommended exposure levels can results in loss of concentration and drowsiness, inhaling refrigerants adds to the effect of chronic illness. It is recommended amongst other that hazardous automotive air conditioning waste generated by automotive service technicians’ shops should always be removed by licensed personnel under the supervision of environmental agencies. Manufacturer instructions on refrigerants should be followed by technicians.

IntroductionIncreasing use of cleaner fuels, such as liquefied petroleum gas (LPG), and abandonment of solid fuels is key to reducing household air pollution and realising potential health improvements in low-income countries. However, achieving exclusive LPG use in households unaccustomed to this type of fuel, used in combination with a new stove technology, requires substantial behaviour change. We conducted theory-grounded formative research to identify contextual factors influencing cooking fuel choice to guide the development of behavioural strategies for the Household Air Pollution Intervention Network (HAPIN) trial. The HAPIN trial will assess the impact of exclusive LPG use on air pollution exposure and health of pregnant women, older adult women, and infants under 1 year of age in Guatemala, India, Peru, and Rwanda.MethodsUsing the Capability, Opportunity, Motivation–Behaviour (COM–B) framework and Behaviour Change Wheel (BCW) to guide formative research, we conducted in-depth interviews, focus group discussions, observations, key informant interviews and pilot studies to identify key influencers of cooking behaviours in the four countries. We used these findings to develop behavioural strategies likely to achieve exclusive LPG use in the HAPIN trial.ResultsWe identified nine potential influencers of exclusive LPG use, including perceived disadvantages of solid fuels, family preferences, cookware, traditional foods, non-food-related cooking, heating needs, LPG awareness, safety and cost and availability of fuel. Mapping formative findings onto the theoretical frameworks, behavioural strategies for achieving exclusive LPG use in each research site included free fuel deliveries, locally acceptable stoves and equipment, hands-on training and printed materials and videos emphasising relevant messages. In the HAPIN trial, we will monitor and reinforce exclusive LPG use through temperature data loggers, LPG fuel delivery tracking, in-home observations and behavioural reinforcement visits.ConclusionOur formative research and behavioural strategies can inform the development, implementation, monitoring and evaluation of theory-informed strategies to promote exclusive LPG use in future stove programmes and research studies.Trial registration numberNCT02944682, Pre-results.

BACKGROUND: Collaborative self-management is a core recommendation of national asthma guidelines; the written action plan is the knowledge tool that supports this objective. Mobile health technologies have the potential to enhance the effectiveness of the action plan as a knowledge translation tool.OBJECTIVE: To design, develop and pilot a mobile health system to support asthma self-management.METHODS: The present study was a prospective, single-centre, nonrandomized, pilot preintervention-postintervention analysis. System design and development were guided by an expert steering committee. The network included an agnostic web browser-based asthma action plan smart-phone application (SPA). Subjects securely transmitted symptoms and peak flow data daily, and received automated control assessment, treatment advice and environmental alerts.RESULTS: Twenty-two adult subjects (mean age 47 years, 82% women) completed the study. Biophysical data were received on 84% of subject days (subject day = 1 subject × 1 day). Subjects viewed their action plan current zone of control on 54% and current air quality on 61% of subject days, 86% followed self-management advice and 50% acted to reduce exposure risks. A large majority affirmed ease of use, clarity and timeliness, and 95% desired SPA use after the study. At baseline, 91% had at least one symptom criterion for uncontrolled asthma and 64% had ≥2, compared with 45% (P=0.006) and 27% (P=0.022) at study close. Mean Asthma Quality of Life Questionnaire score improved from 4.3 to 4.8 (P=0.047).CONCLUSIONS: A dynamic, real-time, interactive, mobile health system with an integrated asthma action plan SPA can support knowledge translation at the patient and provider levels.

The human factors analysis and classification system (HFACS) was developed as an analytical framework for the investigation of the role of human error in aviation accidents. A total of 523 accidents in the Republic of China (ROC) Air Force between 1978 and 2002 were analysed using this framework. The results showed that in a great many cases, poor pilot decision making was implicated. Following a survey of flight instructors’ opinions, two of most promising mnemonic-based methods currently available to guide the decision making of pilots were identified (SHOR and DESIDE). These methods were developed into a short (four hour) aeronautical decision making training course. A total of 41 pilots from the Republic of China Tactical Training Wing then participated in a study to evaluate the effectiveness of this training course. Half of the participants received the short ADM training programme and half did not. Their decision making skill was evaluated in a series of emergency situations presented in a full-flight simulator. Furthermore, their decision making processes were examined in a series of pencil-and-paper based tests. The results clearly showed significant improvements in the quality of pilots’ situation assessment and risk management (underpinning processes in pilot decision making) although this was usually at the expense of speed of response. Pilots used the quicker to apply SHOR mnemonic in situations that which required a fast decision and the more comprehensive but slower to perform DESIDE method when there were fewer time pressures. The results do strongly suggest that ADM is trainable and the short programme devised was effective.

Hue city was chosen for a pilot application of indicators on environmentally sustainable city, which were developed by Vietnam Ministry of Natural Resources and Environment. The indicator set is composed of four key categories (water, air, solid waste and climate change response), which are broken down into 16 underlying performance indicators. In reality, there has not been any assessment process in place to guide cities in Vietnam in doing their own assessment. In this research, an assessment process including 5 steps was built up; and a barometer with 5 classification bands ranging from 0 to 100 was recommended to use for both category and overall assessment. The weighting of 4 urban environmental categories was undertaken based upon a Delphi method with informed inputs from an expert panel. The 5 - step analysis process showed that Hue city was ranked “medium” with the score between 41 - 60 for water and solid waste, “fairly good” in terms of air (score of 85) and “poor” as to climate change response (score of 40). The sum of all category scores of Hue city, which is also rebased to 100, is valued at 60. Thus, the city was ranked “fairly good” in the overall. Such assessment results are much expected to provide assistance in decision-making at various levels of local authority and help them set forth some appropriate improvement measures on urban environmental sustainability issues. As such, the city would soon meet some concerned requirements to become a leading city of Vietnam in urban environmental sustainability.

This article discusses the problems of creating an integrated system for monitoring the technical condition of highly responsible helicopter units, and analyzed options for its creation. Fiber-optical technology is considered as a technology, on the basis of which it is possible to build an integrated system, since this technology makes it possible to measure various physical parameters such as vibration, deformation, temperature, acoustic emission and other parameters, and due to the miniature dimensions of the fiber-optic light guide. It can be built into the PCM design, which is a relevant factor due to the growth use of PCM in the design and manufacture of helicopters. The results of bench and flight tests of helicopter pilot and rotor blades with fasteners using fiber optic deformation sensors based on a Bragg fiber grille demonstrate the fundamental possibility of creating a system for monitoring the technical condition of helicopter rotors using fiber optic sensors .Also, there are examples of creating other elements of an integrated monitoring system based on the use of fiber-optic technology, such as a system for signaling the breakdown of air flow and flutter on the helicopter rotor blades, a system for measuring the weight and alignment of helicopter cargo and a system for monitoring the technical condition of the airframe.

Lean operation of Spark-Ignition engines can provide higher thermal efficiency compared to standard stoichiometric operation. However, for a homogeneous lean mixture, the associated reduction of flame speeds becomes an important issue from the perspective of robust ignition and fast flame spread throughout the charge. This study is focused on the use of a lean partial fuel stratification strategy that can stabilize the deflagration, while sufficiently fast combustion is ensured via the use of end-gas autoignition. The engine has a spray-guided Direct-Injection Spark-Ignition combustion system and was fueled with either a high-octane certification gasoline or E85. Partial fuel stratification was achieved using several fuel injections during the intake stroke in combination with a small pilot-injection concurrent with the Spark-Ignition. The results reveal that partial fuel stratification enables very stable combustion, offering higher thermal efficiency for parts of the load range in comparison to well-mixed lean and stoichiometric combustion. The heat release and flame imaging demonstrate that the combustion often has three distinct stages. The combustion of the pilot-injected fuel, ignited by the normal spark, acts as a “super igniter,” ensuring a very repeatable initiation of combustion, and flame incandescence reveals locally rich conditions. The second stage is mainly composed of blue flame propagation in a well-mixed lean mixture. The third stage is the compression autoignition of a well-mixed and typically very lean end-gas. The end-gas autoignition is critical for achieving high combustion efficiency, high thermal efficiency, and stable combustion. Partial fuel stratification enables very effective combustion-phasing control, which is critical for controlling the occurrence and intensity of end-gas autoignition. Comparing the gasoline and E85 fuels, it is noted that achieving end-gas autoignition for the higher octane E85 requires a more aggressive compression of the end-gas via the use of a more advanced combustion phasing or higher intake-air temperature.

Рассматривается повышение эффективности боевого применения управляемой авиационной ракеты класса «воздух – поверхность» по полученным целеуказаниям с беспилотного летательного аппарата, позволяющее на больших расстояниях автоматически решать задачи поиска, обнаружения и распознавания целей в условиях реального масштаба времени при сложной фоноцелевой обстановке в зоне боевых действий, тем самым уменьшая риск попадания самолета-носителя в зону действия ПВО противника. Разработана оптимизированная архитектура сверточной нейронной сети для сегментации изображений и распознавания наземных целей в оптико-электронной системе беспилотного летательного аппарата, а также разработанный алгоритм автоматического распознавания наземной цели искусственной нейронной сетью в телевизионной головке самонаведения управляемых авиационных средств поражения класса «воздух – поверхность». Проведено аналитическое сравнительное исследование по вероятности поражения наземной цели типа танка между разработанными алгоритмами автоматического распознавания наземной цели и использованием визуального (оптического) обнаружения и распознавания наземной цели летчиком (штурманом) при разных значениях средней интенсивности потока огневого воздействия ракет противовоздушной обороны противника. Осуществлена программная реализация алгоритмов автоматического распознавания наземной цели и обучения оптимизированной нейронной сети с использованием объектно ориентированного языка программирования Matlab. This article discusses the increase in the effectiveness of the combat use of an air-to-surface guided missile based on the received target designations from an unmanned aerial vehicle, which makes it possible to automatically solve the tasks of searching, detecting and recognizing targets in real time conditions at large distances in a complex background-target situation in the combat zone actions, thereby reducing the risk of the carrier aircraft falling into the enemy air defense coverage area. An optimized architecture of a convolutional neural network has been developed for image segmentation and ground target recognition in the optoelectronic system of an unmanned aerial vehicle, as well as an algorithm for automatic recognition of a ground target by an artificial neural network in a television homing head of controlled air-to-surface weapons. An analytical comparative study was carried out on the probability of hitting a ground target such as a tank between the developed algorithms for automatic recognition of a ground target and the use of visual (optical) detection and recognition of a ground target by a pilot (navigator) at different values of the average intensity of the flow of fire from enemy air defense missiles. The software implementation of algorithms for automatic recognition of a ground target and training of an optimized neural network using the object-oriented programming language Matlab has been implemented.

The introduction of highly sophisticated, glass cockpit aircraft has profoundly affected the flightdeck environment, and has changed the nature of crew resource management (CRM). CRM and decision making in advanced aircraft are qualitatively different from the same processes in older fleets. Automation also alters the nature of interaction among crewmembers, and between crewmembers and Air Traffic Control (ATC) These differences would seem to necessitate special training and procedures for CRM in glass cockpits. Moreover, training for managing automation cannot be merely an added module in current CRM programs. The effects of automation pervade throughout all aspects of resource management. Coincidentally, advances in the air traffic control system are altering the modern airspace environment. In the not-too-distant future, it will be possible for ATC computers to generate or amend clearances, which the Air Traffic Manager will send to the aircraft via datalink. The aircraft FMS (flight management system) will determine whether or not the clearance may be accepted, and its effects on fuel consumption, arrival time, etc. The role of the pilot will be to accept or reject the suggested clearance. The effects of automation on operator and team processes in both of these domains, as well as on the interaction between the domains, has only begun to be defined. Some of the issues already raised in the flightdeck realm, such as diffusion of responsibility among crewmembers, the breakdown of traditional roles and responsibilities as a result of familiarity with automation, or the possibility that crewmembers will “communicate” more with the automation than with each other, may only be exacerbated by increased automation in the air-ground communication link. The goal of this panel is to present an overview of some of the issues and questions to be resolved if resource management is to be a vital construct in the highly automated airspace system. To open discussion, the first panel member will present an overview of the general issues involved in the confluence of CRM and automation. Following, an industry representative will discuss one airline's specialized program to introduce crewmembers to the glass cockpit, and guide them in the appropriate use of automation. The measurement of CRM components specifically related to crew interaction with automation will be the focus of the third panelist. The analysis of CRM issues associated with equipment design, and, in particular, with the introduction of datalink communication systems, will be the next panel topic. Lastly, possible implications for human operators of the increasing sophistication and decision-making capabilities of automated systems in the air and on the ground will be introduced. The panel chair will summarize the major points and propose questions for discussion.

This article presents an interdisciplinary teaching–learning sequence (TLS) about air quality for pre-service primary teachers using an organic learning garden. The design involved a curricular integration of concepts and competences about sustainability, mathematics, and science disciplines following constructivist and active learning strategies, such as problem-based learning and place-based education. In this TLS, both the topic and the learning context act as facilitators of education for sustainable development (ESD). The contents address the overarching STEM and sustainability concepts related to air pollutants, weather, and climate. Our results show that students learned about a STEM topic within a space and context that enables ESD. Several misconceptions related to air quality, weather, and statistics were identified through the evaluation of students’ initial ideas. Furthermore, students’ attitudes towards the topic of study and self-efficacy and perceived relevance of ESD improved after the implementation. These results will guide further improvements of the designed TLS, which connects STEM education and ESD as a transformative educational experience for pre-service teachers. In this sense, we conclude that such initiatives can improve pre-service primary teachers’ self-efficacy as agents of change towards sustainable development goals.

Objectives: To develop and implement a pilot online data collection tool to help local health departments with their COVID-19 pandemic response efforts and inform health department actions. Design: The COVID-19 Outbreak Public Evaluation (COPE) was an online survey and was distributed by participating sites to individuals who recently tested positive for SARS-CoV-2. Surveys recorded participant demographics and assessed recent infection risk behaviors (eg, mask use, air travel), vaccination status, sleep and exercise habits, social behaviors and beliefs, and physical and mental health. Setting: Seven health departments participated in the initiative, which took place during May 1 to September 30, 2022. Identical items were administered to demographically representative samples of adults nationally in the United States within a similar timeframe. Participants: A total of 38 555 participants completed surveys. Responses from participants with recent SARS-CoV-2 infections were compared with respondents from the national surveys who did not have evidence or awareness of prior SARS-CoV-2 infections. Main outcome measure: To implement of a process that allows health departments to receive data from local cases and compare this information to national controls during the COVID-19 pandemic. Results: Fifty-four biweekly reports were provided to public health departments between May and September 2022. Information and comparisons within the reports were updated in response to evolving public health priorities for the pandemic response. The initiative helped to guide public health response efforts during the COVID-19 pandemic. Moreover, the receptiveness by local health departments and participants provides evidence to support this data collection and reporting model as a component of the public health response to future emergencies. Conclusion: This project demonstrates the feasibility of a centralized, rapid, and adaptive data collection system for local health departments and provides evidence to advocate for data collection methods to help guide local health departments to respond in a timely and effective manner to future public health emergencies.

Purpose The purpose of this work is to develop an in-flight icing risk assessment methodology by quantification of changing flight dynamic characteristics under icing conditions. Design/methodology/approach This paper develops an approach for the quantitative assessment of flight risk under icing conditions. Using the six degree-of-freedom simulation model, the icing effects model is used to obtain the extreme values of the key parameters relevant to fight safety, allowing calculation of accident probability based on extreme value theory. The risk portion of the flight risk index is designed to account for different levels of flight risk and to provide criteria to allow pilots’ decision-making. Numerical examples are carried out by a series of simulated elevator overshoots of various levels and different distributions of ice accretion to compare the risk index under different icing conditions. Findings Case results show that the proposed methodology is able to analyze conditions of different severity and distribution of icing and assess quantitatively how these different parameters affect flight safety. Practical implications The quantification of flight risk in icing conditions demonstrated here can be applied to provide an objective and intuitive instrument to facilitate decisions by the aircrew or air traffic controller, especially prior to the aircraft entering into areas with adverse meteorological conditions. Originality/value Existing flight risk assessments under icing conditions are typically guided by aerodynamic changes, ice accumulation process or the subjective feeling of the pilot. Here, it is proposed to use the probability of flight risk event to measure different icing intensity levels in a quantitative way. This quantitative metric combines the alteration of aerodynamic characteristics, flight dynamic characteristics and limitation of critical parameters, providing a new and comprehensive viewpoint to measure in-flight icing risk. This may be a promising and more reasonable way to assess the risk.

Abstract Introduction Deployment-limiting medical conditions are the primary reason why service members are not medically ready. Service-specific standards guide clinicians in what conditions are restrictive for duty, fitness, and/or deployment requirements. The Air Force (AF) codifies most standards in the Medical Standards Directory (MSD). Providers manually search this document, among others, to determine if any standards are violated, a tedious and error-prone process. Digitized, standards-based decision-support tools for providers would ease this workflow. This study digitized and mapped all AF occupations to MSD occupational classes and all MSD standards to diagnosis codes and created and validated a readiness decision support system (RDSS) around this mapping. Materials and Methods A medical coder mapped all standards within the May 2018 v2 MSD to 2018 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. For the publication of new MSDs, we devised an automated update process using Amazon Web Service’s Comprehend Medical and the Unified Medical Language System’s Metathesaurus. We mapped Air Force Specialty Codes to occupational classes using the MSD and AF classification directories. We uploaded this mapping to a cloud-based MySQL (v5.7.23) database and built a web application to interface with it using R (v3.5+). For validation, we compared the RDSS to the record review of two subject-matter experts (SMEs) for 200 outpatient encounters in calendar year 2018. We performed four separate analyses: (1) SME vs. RDSS for any restriction; (2) SME interrater reliability for any restriction; (3) SME vs. RDSS for specific restriction(s); and (4) SME interrater reliability for categorical restriction(s). This study was approved as “Not Human Subjects Research” by the Air Force Research Laboratory (FWR20190100N) and Boston Children’s Hospital (IRB-P00031397) review boards. Results Of the 709 current medical standards in the September 2019 MSD, 631 (89.0%) were mapped to ICD-10-CM codes. These 631 standards mapped to 42,810 unique ICD codes (59.5% of all active 2019 codes) and covered 72.3% (7,823/10,821) of the diagnoses listed on AF profiles and 92.8% of profile days (90.7/97.8 million) between February 1, 2007 and January 31, 2017. The RDSS identified diagnoses warranting any restrictions with 90.8% and 90.0% sensitivity compared to SME A and B. For specific restrictions, the sensitivity was 85.0% and 44.8%. The specificity was poor for any restrictions (20.5%–43.4%) and near perfect for specific restrictions (99.5+%). The interrater reliability between SMEs for all comparisons ranged from minimal to moderate (κ = 0.33–0.61). Conclusion This study demonstrated key pilot steps to digitizing and mapping AF readiness standards to existing terminologies. The RDSS showed one potential application. The sensitivity between the SMEs and RDSS demonstrated its viability as a screening tool with further refinement and study. However, its performance was not evenly distributed by special duty status or for the indication of specific restrictions. With machine consumable medical standards integrated within existing digital infrastructure and clinical workflows, RDSSs would remove a significant administrative burden from providers and likely improve the accuracy of readiness metrics.

IntroductionOver a third of the world’s population relies on solid fuels as their primary energy source. These fuels have damaging effects on health, air quality and forest resources. Interventions to promote access to cleaner solid fuel cookstoves and clean fuels have existed for decades. However, the adoption by local communities has largely failed, which led to a waste of resources and suboptimal outcomes. Therefore, the objective of this umbrella review is to identify factors that determine implementation success for cleaner cooking interventions in low-resource settings and weigh their level of confidence in the evidence.Methods and analysisWe identified systematic and narrative reviews examining factors that influence the acquisition, initial adoption or sustained use of cleaner solid fuel cookstoves and clean fuels at any scale by a literature search in PubMed, Embase, Global Health Database, Cochrane, PsycINFO, Emcare, Web of Science and CINAHL, without date or language restrictions. The search was conducted on 23 October 2017 and updated on 10 July 2019. Reviews based on qualitative, quantitative or mixed-methods studies were included and will be appraised using the Meta Quality Appraisal Tool combined with the Assessment of Multiple Systematic Reviews. Data will be extracted and factors affecting implementation will be coded using the Consolidated Framework for Implementation Research. The Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative Research tool will be used to determine the level of confidence in the coded factors. Two researchers will independently conduct these steps.Ethics and disseminationThis umbrella review does not require the approval of an ethical review board. Study results will be published in an international peer-reviewed journal. The outcomes will be converted into two practical tools: one for cleaner solid fuel cookstoves and one for clean fuels. These tools can guide the development of evidence-based implementation strategies for cleaner cooking interventions in low-income and middle-income countries to improve implementation success. These tools should be pilot-tested and promoted among regional and global initiatives.PROSPERO registration numberCRD42018088687.

Abstract Abstract 1515 Poster Board I-538 BACKGROUND Acute chest syndrome (ACS) is a common cause of morbidity and mortality for individuals with sickle cell disease (SCD). The treatment of ACS is mainly supportive. Prior studies have shown that intravenous pulse-dose corticosteroids, such as dexamethasone, can decrease the duration and morbidity of ACS. However, such treatment may also precipitate ‘rebound‘ episodes of vaso-occlusive pain in some individuals that might negate the overall benefit of corticosteroids. Tapered corticosteroid therapy might decrease the rebound effect while maintaining therapeutic benefit. Therefore, we designed a prospective study to begin to test this hypothesis and to assess biomarkers that might clarify the therapeutic and toxic mechanisms of corticosteroids in SCD, predict outcome, and guide therapy. METHODS We conducted a multi-center, placebo-controlled pilot study to test the feasibility and safety of high-dose oral dexamethasone followed by a taper for ACS. Children and adults with SCD and ACS of any severity were randomized to dexamethasone (0.3 mg/kg q12h x 2, 0.3 mg/kg q24h x 2, 0.2 mg/kg q24h x 2, 0.1 mg/kg q24h x2, then stop) or placebo to start within 24 hours of diagnosis. All subjects received standard, protocol-directed supportive care for ACS. We defined the duration of ACS using a novel, objective tool that assessed rate and effort of breathing, oxygen saturation in room air, thoracic pain, and use of supplemental oxygen and ventilatory support. The primary outcomes were the duration of ACS and the duration of hospitalization for ACS. We also measured a panel of biomarkers before, during and after therapy. Inflammatory biomarkers included high sensitivity C-reactive protein and secretory phospholipase A2 (sPLA2). White cell and endothelial activation markers included sVCAM-1, sICAM-1, vWF:Ag and vWF:RCoF, sE-selectin, sP-selectin, sL-selectin, nitric oxide metabolites (NO), and whole blood tissue factor. We used generalized linear mixed models controlling for age to test for differences between treatment groups. RESULTS We enrolled 12 subjects (9 children, 3 adults; mean age 17.3 years, range 5 - 45) with homozygous sickle cell anemia at 4 centers and randomized 11 (1 drop-out) to either dexamethasone (N=5) or placebo (N=6). The objective ACS assessment tool was completed on all subjects without difficulty. In this pilot study, dexamethasone reduced the duration of hospitalization (41.5 vs 62.3 hrs; P=0.024), but not the duration of ACS (log of duration 2.4 vs 3.5 hrs; P=0.127), supplemental oxygen (17.5 vs 41.2 hrs; P=0.876), hypoxemia (13.8 vs 34.3 hrs; P=0.770), or total opioid usage in morphine equivalents (54.4 vs 68.8 mg; P=0.885). There were no statistically significant differences in adverse events between arms. However, 3 patients treated with dexamethasone had a painful event in the 2 weeks after hospital discharge (1 required re-hospitalization), compared to 1 patient in the placebo group (0 re-hospitalizations). No marked leukocytosis occurred in either treatment group, but the leukocyte count at 1-week follow-up had decreased less from baseline in the dexamethasone group compared to placebo (-17.7 vs -37.6%; P=0.028). The baseline sPLA2 concentration was 3 100 ng/mL in 4/5 and 4/6 patients in the dexamethasone and placebo arms. The white cell activation marker, sL-selectin was significantly decreased at 1-week follow-up in the dexamethasone group compared to placebo (573.8 ng/mL vs 742.8; change from baseline -121.2 vs 57.2; P<0.001). Patients who had rebound pain (N=4) had a significantly higher sL-selectin concentration after 24 hours of study drug (746.0 ng/mL vs 568.7, P=0.042). NO metabolites were significantly decreased after 24 and 48 hours of dexamethasone group compared to placebo (6.5 nMol/mL vs 9.1; change from baseline -2.7 vs 4.4; P=0.041). CONCLUSIONS A multi-center, randomized trial of tapered oral dexamethasone is feasible. Our novel ACS assessment tool is also feasible and useful for objective clinical ratings of ACS. Dexamethasone shortened the duration of hospitalization for ACS in this pilot study. Rebound vaso-occlusive pain occurred in both treatment groups. The WBC activation marker sL-selectin appears to be a promising biomarker of ACS therapy and rebound vaso-occlusion. Our results justify a definitive study of tapered oral dexamethasone for ACS that incorporates objective assessment tools and biomarkers. Disclosures Off Label Use: Dexamethasone is a corticosteroid agent. We test its use for acute chest syndrome in this study.

Change is inherent in contemporary organizations and its management is not only critical to organizational performance and survival but is also at the centre of organization development. Since the performance of organizations is dependent on the fit between them and their environment, any change in environment require firms to adapt to the environment. The purpose of this study was to examine the effect of strategic change management on performance of the National Hospital Insurance Fund in Kenya. The specific objectives of this study were; to establish the effect of technology change management on performance of the National Hospital Insurance Fund, Kenya, to determine the effect of leadership change management on performance of the National Hospital Insurance Fund in Kenya, to assess the effect of culture change management on performance of the National Hospital Insurance Fund in Kenya and to establish the effect of environmental change management on performance of the National Hospital Insurance Fund in Kenya. This study was informed by resource based view theory, theory of reasoned action and change theory. The study adopted descriptive research design. The target population of the study was made up of 200 employees at NHIF headquarter in Nairobi. Census approach was used to study all the 200 employees made up both management employees and junior employees. Before data collection, both validity and reliability testing was conducted to test for the suitability of the research tools. The primary data was collected using structured questionnaires. Pilot study was done involving 13 respondents. Content validity was used to test for validity. Cronbach Alpha coefficient was used in testing reliability. The collected data was analyzed using both descriptive statistics and inferential statistics. Descriptive statistics such as mean and standard deviation was adopted. The relationship between the dependent variable and the independent variables was tested using linear regression model and correlation analysis. The results were then presented in form of figures, tables and chats. The study established that technology change management, leadership change management, culture change management and environmental change management had a positive and significant influence on performance. The study concluded that technology assists organizations with managing changes to operations. Implementing change leadership can make many positive impacts on organizations and aids the management in reaching the organizational goals through problem solving, executing changes such as developing new marketing strategies can build a business's brand and help a business fulfill their mission. Organization culture grows around shared beliefs and attitudes, it is an authentic, and therefore effective, tool in organizations. Environmental change management is a common part of business growth. Regardless of the reason for the change, understanding why companies implement change strategies can help the management navigate fluctuating circumstances in their organization. The study recommended that a technology change management team requires a special combination of skills and personalities. The organization should ensure that their leaders have the right tools to guide them. The organization culture should encompass existing qualities that have been recognized across all levels of the company and then tightly defined, rather than plucked out of thin air and enforced upon the business. The study also recommended that the organization should establish a sense of urgency - inspire people to move, make objectives real and relevant.

AbstractHurricanes and sea level rise pose significant threats to infrastructure and critical services (e.g., air and sea travel, water treatment), and can hinder sustainable development of major economic sectors (e.g., tourism, agriculture, and international commerce). Planning for a disaster-resilient future requires high-resolution, standardized data. However, few standardized approaches exist for identifying, inventorying, and quantifying infrastructure lands at risk from natural hazards. This research presents a cost effective, standardized and replicable method to geospatially inventory critical coastal infrastructure land use and components, for use in risk assessments or other regional analyses. While traditional approaches to geospatial inventorying rely on remote sensing or techniques, such as object-based image analysis (OBIA) to estimate land use, the current approach utilizes widely available satellite imagery and a “standard operating procedure” that guides individual mappers through the process, ensuring replicability and confidence. As a pilot study to develop an approach that can be replicated for other regions, this manuscript focuses on the Caribbean. Small islands rely heavily on a small number of critical coastal infrastructure (airports, seaports, power plants, water and wastewater treatment facilities) and climate related hazards threaten sustainable development and economic growth. The Caribbean is a large and diverse area, and gaps exist between countries in the resources required for planning but much of the region lacks a comprehensive inventory of the land, infrastructure, and assets at risk. Identifying and prioritizing infrastructure at risk is the first step towards preserving the region’s economy and planning for a disaster resilient future. This manuscript uses high resolution satellite imagery to identify and geo-spatially classify critical infrastructure land area and assets, such as structures, equipment, and impervious surfaces. We identified 386 critical coastal infrastructure facilities across 28 Caribbean nations/territories, with over 19,000 ha of coastal land dedicated to critical infrastructure. The approach establishes a new standard for the creation of geospatial data to assess land use change, risk, and other research questions suitable for the regional scale, but with sufficient resolution such that individual facilities can utilize the data for local-scale analysis.

Losses of separation (LoS) are breaches of regulations that specify the minimum distance between aircraft in controlled airspace. Erroneous communications between air traffic controllers (ATCs) and pilots are leading contributors to LoS that result in elevated risk of fatal accidents. An air traffic control system that could identify communication errors promptly would, therefore, be advantageous. Establishing such a system requires a systematic characterization of communication errors to reveal how various communication arrangements and errors influence the development of LoS. Such know-how could guide the ATCs and pilots in identifying the parts of their communication processes and content that most influence the occurrence of LoS. Existing studies of LoS focus on simulation of aircraft operation processes with little quantitative analysis about how communication issues arise and result in elevated risks of LoS. This paper presents a method for supporting automatic communication error detection through integrated use of speech recognition, text analysis, and formal modeling of airport operational processes. The proposed method focuses on: identifying communication features to guide the detection of vulnerable communications; characterizing communication errors; and Bayesian Network modeling for predicting communication errors and LoS using the features derived from ATC–pilot communications. Major findings show that incorrect read-backs by pilots are highly correlated with a majority of LoS. Results indicate the proposed method could form a basis for automating communication error detection and preventing LoS. The integrated Automatic Speech Recognition and Natural Language Processing functions may be incorporated into existing aviation applications for real-time ATC–pilot communication monitoring and preventive LoS control.

Abstract Delivery of enteral nutrition in critical infants post-paediatric cardiac surgery is sometimes hampered, necessitating direct feeding into the small intestine. This study is highlighting the role of ultrasound-guided post-pyloric feeding tube insertion performed by the paediatric cardiac ICU intensivist in critically ill infants. Methods: We carried out a prospective pilot observational experimental study in peri-operative cardiac infants with feeding intolerance between 2019 and 2021. Feeding tube insertion depends on a combination of ultrasound and gastric insufflation with air-saline mixture. Insertion was confirmed by bedside abdominal X-ray. Results: Out of 500 peri-operative cardiac infants, 15 needed post-pyloric feeding tube insertion in median 15 postoperative day. All were under 6 months of age with average weight of 3 ± 0.2 kg. Median Risk Adjustment for Congenital Heart Surgery Categories was 4. Median insertion time was 15 minutes. No complications have been reported. First pass success rate was 87%, while a second successful insertion attempt was needed in 2 cases (13%). Target daily calorie intake was achieved within average of 3.5 ± 0.4 days. Mean post-pyloric feeding tube stay was 20 ± 3 days. Out of 15 infants, 3 patients died, 1 patient needed gastrostomy tube, and 11 patients were discharged home on oral feeds. Conclusions: Ultrasound-guided post-pyloric feeding tube insertion using gastric insufflation with air-saline mixture in peri-operative cardiac infants with feeding intolerance is a useful and practical bedside tool, and it can be performed by a trained paediatric cardiac ICU intensivist. It may have potential positive effects on morbidity and outcome.

Rising greenhouse gas levels heat the earth’s surface and alter climate patterns, posing unprecedented threats to planetary ecology and human health. At the same time, obesity, diabetes, and cardiovascular disease have reached epidemic proportions across the globe, caused in part by decreases in physical activity and by over-consumption of carbon-intensive foods. Thus, interventions that support active transportation (walking or cycling rather than driving) and healthier food choices (eating plant-based rather than meat-based diets) would yield health and sustainability “co-benefits.” Emerging research suggests that mindfulness-based practices might be effective means toward these ends. At the University of Wisconsin-Madison, we have developed a mindfulness-based group program, Mindful Eco-Wellness: Steps Toward Healthier Living. Loosely based on the Mindfulness-Based Stress Reduction course, our curriculum teaches mindfulness practices in tandem with sustainability principles, following weekly themes of Air, Water, Food, Energy, Transportation, Consumption, Nature Experience, and Ethics. For example, the “Air” class offers participants practice in guided breath meditations while they learn about the benefits of clean air. The theme of “Food” is presented through mindful eating, accompanied by educational videos highlighting the consequences of food production and consumption. “Transportation” includes walking/movement meditations and highlights the health benefits of physical activity and detriments of fossil-fueled transportation. Pedagogical lessons on energy, ecological sustainability, and the ethics of planetary health are intertwined with mindful nature experience and metta (loving-kindness) meditation. Curricular materials, including teaching videos, are freely available online. Pilot testing in community settings (n = 30) and in group medical visits (n = 34) has demonstrated feasibility; pilot data suggests potential effectiveness. Rigorous evaluation and testing are needed.

Gaseous fuels for heavy-duty internal combustion engines provide inherent advantages for reducing CO2, particulate matter (PM), and NOX emissions. Pilot-ignited direct-injected NG (PIDING) combustion uses a small pilot injection of diesel to ignite a late-cycle main direct injection of NG, resulting in significant reduction of unburned CH4 emissions relative to port-injected NG. Previous works have identified NG premixing as a critical parameter establishing indicated efficiency and emissions performance. To this end, a recent experimental investigation using a metal engine identified six general regimes of PIDING heat release and emissions behavior arising from variation of NG stratification through control of relative injection timing (RIT) of the NG with respect to the pilot diesel. The objective of the current work is to provide comprehensive description of in-cylinder fuel mixing of direct injected gaseous fuel and its impacts on combustion and pollutant formation processes for stratified PIDING combustion. In-cylinder imaging of OH*-chemiluminescence (OH*-CL) and PM (700 nm), and measurement of local concentration of fuel is considered for 11 different [Formula: see text], representing 5 regimes of stratified PIDING combustion (performed with [Formula: see text] MPa and [Formula: see text]). The magnitude and cyclic variability of premixed fuel concentration near the bowl wall provides direct experimental validation of thermodynamic metrics ([Formula: see text], [Formula: see text], [Formula: see text]) that describe the fuel-air mixture state of all 5 regimes of PIDING combustion. The local fuel concentration develops non-monotonically and is a function of RIT. High indicated efficiency and low CH4 emissions previously observed for stratified-premixed PIDING combustion in previous (non-optical) investigations are due to: (i) very rapid reaction zone growth ([Formula: see text] m/s) and (ii) more distributed early reaction zones when overlapping pilot and NG injections cause partial pilot quenching. These results connect and extend the findings of previous investigations and guide the future strategic implementation of NG stratification for improved combustion and emissions performance.

Objectives This phantom and animal pilot study aimed to compare image quality and radiation exposure between detector-dose–driven exposure control (DEC) and contrast-to-noise ratio (CNR)–driven exposure control (CEC) as functions of source-to-image receptor distance (SID) and collimation. Materials and Methods First, an iron foil simulated a guide wire in a stack of polymethyl methacrylate and aluminum plates representing patient thicknesses of 15, 25, and 35 cm. Fluoroscopic images were acquired using 5 SIDs ranging from 100 to 130 cm and 2 collimations (full field of view, collimated field of view: 6 × 6 cm). The iron foil CNRs were calculated, and radiation doses in terms of air kerma rate were obtained and assessed using a multivariate regression. Second, 5 angiographic scenarios were created in 2 anesthetized pigs. Fluoroscopic images were acquired at 2 SIDs (110 and 130 cm) and both collimations. Two blinded experienced readers compared image quality to the reference image using full field of view at an SID of 110 cm. Air kerma rate was obtained and compared using t tests. Results Using DEC, both CNR and air kerma rate increased significantly at longer SID and collimation below the air kerma rate limit. When using CEC, CNR was significantly less dependent of SID, collimation, and patient thickness. Air kerma rate decreased at longer SID and tighter collimation. After reaching the air kerma rate limit, CEC behaved similarly to DEC. In the animal study using DEC, image quality and air kerma rate increased with longer SID and collimation (P < 0.005). Using CEC, image quality was not significantly different than using longer SID or tighter collimation. Air kerma rate was not significantly different at longer SID but lower using collimation (P = 0.012). Conclusions CEC maintains the image quality with varying SID and collimation stricter than DEC, does not increase the air kerma rate at longer SID and reduces it with tighter collimation. After reaching the air kerma rate limit, CEC and DEC perform similarly.

Abstract Objective: The oral cavity contains numerous microorganisms, including antimicrobial-resistant bacteria. These microorganisms can be transmitted via respiratory particles from patients to healthcare providers and vice versa during dental care. We evaluated the spread of Staphylococcus aureus during standardized dental procedures using different scaling devices and rinsing solutions. Methods: During systematic therapy for dental biofilm removal (guided biofilm therapy), using an airflow or ultrasound device to a model simulation head. Staphylococcus aureus suspension was injected into the mouth of the model to mimic saliva. Different suction devices (conventional saliva ejector or a prototype) and rising solutions (water or chlorhexidine) were used. To assess contamination with S. aureus, an air-sampling device was placed near the oral cavity and samples of surface areas were collected. Results: S. aureus was only detected by air sampling when the conventional saliva ejector with airflow was used. No growth was observed during treatments with the ultrasonic piezo instrument or the prototype suction device. Notably, a rinsing solution of chlorhexidine digluconate decreased the bacterial load compared to water. Surface contamination was rarely detected (1 of 120 samples). Conclusions: Although our findings indicate potential airborne bacterial transmission during routine prophylactic procedures, specific treatment options during biofilm removal appear to reduce air contamination. These options include ultrasonic piezo devices or the prototype suction device. The use of chlorhexidine reduced the CFU counts of S. aureus detected by air sampling. Surface contamination during dental procedures was a rare occurrence.

IntroductionRenal calculi are the predominant urological ailment in air force pilots. Flexible ureteroscopy (FURS) constitutes a valuable approach for renal calculi treatment. This study presents a decade-long exploration of using FURS for renal calculi treatment in air force pilots. Additionally, it investigates the safety and feasibility of granting waiver flights to pilots with renal parenchyma calcification.MethodsFrom December 2009 to December 2019, a retrospective review was conducted on Chinese air force pilots undergoing treatment for renal calculi. Among the pilots assessed, a total of 71 individuals underwent FURS. Endoscopic methodology involved the insertion of a flexible ureteroscope into the ureter and renal pelvis, guided by a safety wire. Stone fragmentation was achieved using a holmium laser fibre, followed by extraction using a soft stone basket. Postoperative non-enhanced CT (NECT) scans was used to confirm stone clearance. Furthermore, clinical diagnoses were classified based on endoscopic findings and postoperative NECT results. All data were presented as mean (SD) or median (minimum-maximum) for continuous variables and frequency counts and percentages for categorical variables.ResultsFURS identified free kidney stones in 60 cases among all patients. The remaining 11 cases, without free stones detected during ureteroscopy, exhibited persistent high-density spots on postoperative NECT. Of the 60 cases with stones, renal calculi were successfully cleared in 30 pilots, while the remaining 30 exhibited persistent high-density spots on NECT postsurgery. Pilots with completely cleared free stones were deemed fit for flight. Pilots with diagnosed renal parenchyma calcification were granted permission to fly under waivers following a meticulous evaluation.ConclusionsFURS could not only effectively eliminate renal calculi but also accurately diagnose renal parenchyma calcification, facilitating a prompt return to flight for pilots. A protocol for managing pilot renal calculi, informed by FURS and our experience, is proposed.

BackgroundDespite the growing research on environment-physical activity (PA) relationships, field experimental studies are limited. Such studies offer opportunities to focus on real-world environmental exposure and related PA and health outcomes, allowing researchers to better isolate the causal effect of exposures/interventions. Focusing on the street/pedestrian environment as a routine setting for people's daily activities, this research aims to develop and test a field experiment protocol that integrates instantaneous assessments of the environment, PA, and health outcomes. The protocol involves the use of state-of-the-art environmental monitoring and biosensing techniques and focuses on physically active road users (pedestrians and bicyclists) who are more directly exposed to their surrounding environment than others such as drivers.Methods/DesignAn interdisciplinary research team first identified the target measurement domains for the health outcomes (e.g., stress, thermal comfort, PA) and the street-level environmental exposures (e.g., land use, greenery, infrastructure conditions, air quality, weather) guided by the previous literature which was primarily observational. Portable or wearable measurement instruments (e.g., GPS, accelerometer, biosensor, mini camera, smartphone app, weather station, air quality sensor) were identified, pilot tested, and selected for the identified measures. We ensured that these measures are readily linkable using the time stamp and include eye-level exposures as they impact the users' experiences more directly yet missing in most prior studies relying on secondary, aerial-level measures. A 50-min experimental route was then determined to include typical everyday environments in park and mixed-use settings and to engage participants in three common modes of transportation (walking, bicycling, and driving). Finally, a detailed staff protocol was developed, pilot-tested, and used in a 36-participant within-subject field experiment in College Station, TX. The experiment was successfully executed, showing its potential to support future field experiments that can provide more accurate real-time, real-environment, and multi-dimensional information.DiscussionOur study demonstrates the feasibility of capturing the multifold health benefits/harms related to walking and bicycling in varying urban environments by combining field experiments with environmental, behavioral, and physiological sensing. Our study protocol and reflections can be helpful for a broad spectrum of research addressing the complex and multi-level pathways between the environment, behavior, and health outcomes.

Abstract Background Exposure to air pollution can exacerbate asthma with immediate and long-term health consequences. Behaviour changes can reduce exposure to air pollution, yet its ‘invisible’ nature often leaves individuals unaware of their exposure, complicating the identification of appropriate behaviour modifications. Moreover, making health behaviour changes can be challenging, necessitating additional support from healthcare professionals. Objective This pilot study used personal exposure monitoring, data feedback, and co-developed behaviour change interventions with individuals with asthma, with the goal of reducing personal exposure to PM2.5 and subsequently improving asthma-related health. Methods Twenty-eight participants conducted baseline exposure monitoring for one-week, simultaneously keeping asthma symptom and medication diaries (previously published in McCarron et al., 2023). Participants were then randomised into control (n = 8) or intervention (n = 9) groups. Intervention participants received PM2.5 exposure feedback and worked with researchers to co-develop behaviour change interventions based on a health behaviour change programme which they implemented during the follow-up monitoring week. Control group participants received no feedback or intervention during the study. Results All interventions focused on the home environment. Intervention group participants reduced their at-home exposure by an average of 5.7 µg/m³ over the monitoring week (−23.0 to +3.2 µg/m³), whereas the control group had a reduction of 4.7 µg/m³ (−15.6 to +0.4 µg/m³). Furthermore, intervention group participants experienced a 4.6% decrease in participant-hours with reported asthma symptoms, while the control group saw a 0.5% increase. Similarly, the intervention group’s asthma-related quality of life improved compared to the control group. Impact statement This pilot study investigated a novel behaviour change intervention, utilising personal exposure monitoring, data feedback, and co-developed interventions guided by a health behaviour change programme. The study aimed to reduce personal exposure to fine particulate matter (PM2.5) and improve self-reported asthma-related health. Conducting a randomised controlled trial with 28 participants, co-developed intervention successfully targeted exposure peaks within participants’ home microenvironments, resulting in a reduction in at-home personal exposure to PM2.5 and improving self-reported asthma-related health. The study contributes valuable insights into the environmental exposure-health relationship and highlights the potential of the intervention for individual-level decision-making to protect human health.

Purpose Indoor environmental quality (IEQ) in buildings has an impact on people’s health, productivity and comfort. Maintaining the highest possible IEQ level in complex buildings, such as health care, is difficult due to economic and organizational constraints. This study aims to categorize the vicinities in a typical health-care facility in terms of importance and criticality in relation to the various IEQ factors, as well as to develop an IEQ assessment procedure. Design/methodology/approach A comprehensive literature review, established standards and structured interviews with industrial hygiene professionals in health-care settings were used in this study. To test the applicability of the developed IEQ assessment procedure, a pilot study was conducted in an existing health-care facility. Findings This study categorized health-care facilities into various vicinities and discovered three respondents group had varying IEQ perceptions (facility managers, environmental health specialists and nurses). According to the findings, indoor air quality is the most important and dominant factor influencing overall IEQ in health-care facilities. The trial application of the framework shows that much work is needed to improve the level of response and readiness of facility management and occupants to allow for the effective use of the developed procedure. Originality/value Previous research did not include a detailed categorization of vicinities in health-care buildings based on IEQ requirements. The findings of this study will help to close this knowledge gap and guide facility managers and operators in recognizing the relative importance of different IEQ factors, maintaining functional requirements and identifying priorities when developing maintenance and operational procedures and allocating resources.

Background: Talking about personal olfactory experiences is challenging because subjective, often latent reactions to odor are difficult to perceive and express. In qualitative empirical research on the effects of Aromatherapy (AT), this issue needs to be considered in data collection. Therefore, we developed a new data-collection method to support participants in perceiving and articulating their own olfactory experiences. The method development was embedded in the background study arth4WOMEN about AT for women with gynecological cancers. Method: The data-collection method was developed in five steps inspired by A rts-informed R esearch (AIR) and Creative Writing (CW). A workshop on scent and writing was conceptualized for an existing CW course ( n = 8) (step 1). The findings were condensed (step 2) into the new data-collection method called the Olfactory Journey (OLFJ), then pilot tested, discussed with qualitative research experts and adapted (step 3). The final version of the OLFJ was carried out with 15 participants of the background study arth4WOMEN as one part of a qualitative interview concept (step 4), then analyzed via qualitative content analysis (step 5). Results: The analysis of the workshop showed that pictures can be a useful tool to focus on olfactory experiences and find words to express them. Thus, in the OLFJ inner visuals were stimulated by an olfactory trigger and brought into focus through a guided instruction. The inner visuals were used as a tool to talk about the olfactory experiences. The resulting descriptions were characterized by many pictorial associations and marked by contrasts and comparisons. Discussion: The OLFJ as a data-collection method has potential to support participants in their verbal expressions of their olfactory experiences. The inclusion of creative art forms in the development process of the OLFJ was helpful and should be encouraged in future research. Further research is needed to test OLFJ validity and reliability.

ABSTRACT Introduction Twelve percent of reproductive aged females in the United States have utilized fertility services, and it is estimated that 25% of infertility patients have ovulatory dysfunction. Clomiphene and letrozole are currently first-line treatment options for ovulatory dysfunction. These are both disqualifying medications in the U.S. Navy and Air Force for duties that involve flying. These medication restrictions could reduce the likelihood of female aviators seeking infertility treatment. This pilot study seeks to evaluate the severity of common side effects in order to provide recommendations to the current aeromedical guidelines. Materials and Methods An anonymous survey was provided to all active duty and dependent patients who presented to the infertility clinic at a single military medical center for a mid-cycle scan from February 2021 to February 2022. The survey included demographic, treatment cycle, medication type, medication dose, and the presence and severity of common adverse reactions. The provider additionally recorded the number of dominant follicles that were noted at the time of ultrasound. The Kruskal–Wallis test was used to analyze the severity of adverse effects, and chi-square analysis was used to compare the difference in symptoms from previous cycles. Results A total of 569 surveys were collected. Of the participants, 45.4% were military members and 3.5% worked in the field of aviation. Letrozole was prescribed to 88.7% of the patients. Less than 3% reported severe or debilitating side effects. There was no difference in presence or severity when comparing the cycle number. Conclusions The majority of side effects for oral ovulation induction medications were described as slight or mild. Therefore, this study provides evidence-based data of severity side effects that could be used to guide the waiver process and improve readiness for female aviators in the military.

Globally, the urban environment faces many threats, of which polythene waste is also among key ones. This research project aimed at assessing the effects of polythene waste on the urban environment. The study was carried out in Bungoma town, Kenya. Bungoma town is located in Bungoma county, also serving as the headquarter of the county and Bungoma south sub-county. The purpose of the study was to assess effects of polythene waste on the urban environment in Bungoma town Kenya with the view of eliminating or reducing its negative effects. This research project was guided by the following objectives: to establish the sources of polythene waste on the urban environment in Bungoma town, to evaluate the effects of polythene waste to the urban environment in Bungoma town and to identify optional management approaches of polythene waste other than the EMCA, (2017) ban on the urban environment in Bungoma town. The study applied descriptive survey research design. The target population was 17,274 with a sample size of 375 people. Stratified sampling technique was employed whereby business people, residents, officers from NEMA, public health and environment, water and natural resources were be placed in different strata. Random sampling was used to select individuals. Snow ball sampling was also used to sample individual home owners. Data was collected using questionnaires and interview schedules and data was analyzed using measures of central tendency and SPSS. The analyzed data was then presented through tables, Pie Charts and graphs. Validity of instruments was taken care by supervisors and other experts in the field of Geography, while reliability of the instruments was tested through a pilot study and test pre-test of the instruments. The study results will be significant to town planners, policy makers like NEMA and town residents on waste management mechanisms, especially polythene. The study will also be a basis for further research in the field of Geography, Health, Environmental studies among others. Ethical issues of concern were privacy and confidentiality, informed consent, anonymity and researcher’s responsibility. Findings from the study established that sources of polythene waste come from household or domestic waste from residential areas, industries, commercial institutions like supermarkets, wholesale and retail shops, institutions like schools, both private and public and finally other open air businesses. The study also established that negative effects of polythene waste are blockage of drainage channels, production of harmful gas when burned, a hazard to children, reduction of soil fertility, fatal to animals, they are non-biodegradable, are breeding grounds of vectors like mosquitoes, unending in the environment and cause cancer. For management of polythene waste, the study established use of biodegradable papers, involving of the local community, re-use and recycling, proper education, burning by use of incinerators, and enforcement of laws and legislations. This study recommends that NEMA and the ministry of environment are required to intensify their efforts to increase awareness of the public through formal and informal education about the importance of caring about the environment and the dangers of polythene waste, manufacturers, supermarkets, wholesale and retail shop owners should be held responsible for their behavior with respect to the distribution and disposal of polythene waste, in line with the polluter pays principle. Bungoma town waste management strategy should contain waste separation at source to make sure that actors within the recycling chain are guaranteed of less contaminated waste. Manufacturers and commercial institutions, which handle bigger quantities of polythene waste should be facilitated to form associations so as to consolidate their waste for recycling.

The thesis ‘COOLFACADE – Architectural integration of solar cooling strategies in the building envelope’ aims to shed light on the possibilities and constraints for architectural integration of solar cooling systems in façades, in order to support the design of climate responsive architectural products for office buildings as self-sufficient alternatives to conventional air-conditioning systems. Increasing cooling needs in the built environment present an important and complex challenge for the design of sustainable buildings and cities. Even though the first course of action should always aim to reduce energy consumption through saving measures and passive design, this is often not enough to avoid mechanical equipment altogether, particularly in the case of office buildings in warm climate contexts. Solar cooling technologies have been increasingly explored, as an environmentally friendly alternative to harmful refrigerants used within vapour compression systems; while also being driven by solar, thus, renewable energy. The principles behind some of these technologies have been researched for over a century, reaching mature solutions and components, and being recognised as promising alternatives to common air-conditioning units. Nonetheless, building application remains mostly limited to demonstration projects and pilot experiences. Recently, façade integrated concepts have been explored, as a way to promote widespread application throughout the development of multifunctional building components. However, while these are regarded as relevant and promising standalone concepts, further research is still needed to assess the integration potential of diverse solar cooling technologies, and identify barriers to overcome, in order to promote the widespread application of solar cooling components in the built environment. The aim of this research project is to explore the possibilities and constraints for architectural integration of solar cooling strategies in façades, in order to support the design of climate responsive architectural products for office buildings, without compromising the thermal comfort of users. The underlying hypothesis then is that self-sufficient solar cooling integrated facades may be a promising alternative to conventional centralised air-conditioning systems widely used in office buildings in warm climates. Most research efforts on solar cooling currently deal with the optimisation of the systems in terms of their performance, testing new materials and simplifying their operation to increase reported efficiencies. However, there is a lack of knowledge on the requirements and current limits for widespread façade application. In order to achieve the research goal and comprehensively assess the façade integration potential of solar technologies and discuss current barriers, different aspects must be acknowledged. These distinct aspects are addressed through several research questions, which in turn define the different chapters of the dissertation. Introduction and conclusions aside, the research body is structured on three sequential parts, with 2-3 chapters each. The first part deals with the state-of-the-art in the field and the theoretical framework, laying the groundwork for the following sections. The second part explores different aspects required as input for façade integration; while the third part comprises the evaluation of solar cooling technologies in terms of current possibilities and constraints for the development of integrated façades, based on the inputs identified in the second part. Furthermore, all chapters were published or submitted for publication as scientific articles in peer review academic journals. The first part considers two chapters that lay the foundations for the research project, The first chapter after the introduction expands the background of the dissertation by identifying knowledge gaps and research trends while contributing to the generation of a reference database of research experiences, throughout a systematic literature review of cooling research in office buildings during the last 25 years. On the other hand, the following chapter delves specifically in the main themes addressed within the dissertation, proposing a framework for the understanding of solar cooling integrated façades. This considers the theoretical discussion of the concept of architectural façade integration; and the identification of the main working principles and technical components from most common solar cooling technologies, based on a state-of-the-art review. The second part explores different required inputs for façade integration. Design and construction requirements for façade integration are explored; while the response from façade design parameters to various climate conditions is assessed in parallel. The exploration of design and construction requirements is conducted through the identification of the main perceived problems for the façade integration of building services and solar technologies, by means of a survey addressed to façade professionals. On the other hand, a separate chapter explores the relation between climate conditions and cooling requirements in office buildings, evaluating the potential impact of several passive cooling strategies in various warm climates, as a first step before considering further technologies. This was conducted through the statistical analysis of reported research experiences, and dynamic energy simulations of a base scenario using specialised software. The third part of the dissertation consists of two chapters that incorporate previous outcomes for the evaluation of selected solar cooling technologies in terms of current possibilities and constraints for the development of integrated façades. The first of these chapters showcases a qualitative evaluation of the façade integration potential of several solar cooling technologies, based on a comprehensive review of key aspects of each technology and their prospects to overcome the identified barriers for façade integration. This is complemented by a feasibility assessment of integrated concepts in several climates, throughout numerical calculations based on climate data and building scenarios simulated with specialised software; showcased in the following and final chapter. The driving force of the research project is the intention to test the limits of solar cooling integration in façades, showcasing current possibilities while identifying technical constrains and barriers to overcome for the widespread application of integrated façade concepts. Although interesting prospects were identified in this dissertation, important technical constraints need to be solved to conceive a façade component fail-tested for application in buildings. Furthermore, several barriers related to the façade design and development process would need to be tackled in order to introduce architectural products such as these into the building market. The identification and discussion of these barriers, along with the definition of technology driven development paths and recommendations for the generation of distinct architectural products, are regarded as the main outcomes of this dissertation, serving as a compass to guide further explorations in the topic, under an overall environmentally conscious design approach.

IntroductionFor both consumers and creators, Web series have been viewed for some time as an appealing alternative to television series. As Alice explains, creating content for the Web was once seen as “a last resort” for projects that were unable to secure funding for television production (59). However, the Web has, in recent years, become a “legitimized” space, allowing Web series to be considered a media platform capable of presenting narratives of various genres (Alice 59). Moreover, due to the lack of restrictions and overheads placed on Web producers, it is argued that there is more capacity to take risks in Web series and thus depict “a broader array of stories” (Christian, “The Web” 352). Nevertheless, television still remains the traditional mode of storytelling, and for many producers, it is still an “object of desire” (Christian, “The Web” 352). Emerging producers still see television as the ultimate “end goal”, leaving the Web as a sufficient platform that will allow them to create something. Alternatively, for many established creators, the Web is understood to be a stage upon which they can tell stories television would perhaps never consider. Regardless of why creators are attracted to the Web, the platform has indeed cemented its place as an alternative in the television media landscape. For Abbi Jacobson and Ilana Glazer, the Web, or more specifically, YouTube, provided an unbridled space for their creativity when nowhere else would. The two comediennes co-wrote and starred in their Web series, Broad City, back in 2009, and it has since been picked up by Comedy Central and successfully turned into a television series. The fourth season is set to air in August 2017. Both versions of the series follow two twenty-something women, Abbi Abrams and Ilana Wexler (played by Jacobson and Glazer respectively), as they explore themselves, and New York City. Broad City is one of the few Web series to be picked up as a television series and maintain its success; an impressive accomplishment, no matter how legitimate Web series have become. However, the unwavering devotion maintained by the television series to continue depicting millennial women in the same fashion as the Web series is, arguably, more impressive. With a focus on Broad City’s depiction of its two eccentric protagonists, this article explores how the transitions from Web to television are negotiated. In the case of Broad City, I contend that its unconventional start as a web series is what allows the television series to continue depicting contemporary womanhood honestly. Taking the Alternate Path: YouTubeDefined as “scripted, episodic and experimental videos made for the internet”, Web episodes (or Webisodes) hold many advantages to the traditional television medium (Kornblum; Peirce 317). Aware of these advantages and struggling to be noticed naturally for their work in the sketch comedy group, Upright Citizens Brigade (UCB), Glazer and Jacobson took to the Internet to write and create their own series, Broad City. This trend arose in 2007 during the difficult phase American television when the Writers Guild of America began its fifteen-month strike (De Moraes). During this time, Peirce states that producing a new program for television proved “almost impossible” (315). There was a level of uncertainty plaguing the future of prime-time television, and with budgets being refashioned, reality programs were filling television line-ups more than any other genre of show (Peirce 315). Within this climate, it is unsurprising that the Google-owned video-sharing website, YouTube, quickly became the frontrunner in online video (Christian, “The Web” 351). YouTube is argued to be responsible for opening the doors to the next wave of entertainment media, after pledging to give users their own personal video network. Suddenly, amateurs, independents and corporations alike were, for the first time, able to compete against each other in shaping this post-network era of television (Christian, “The Web” 351). Moreover, the premise of “anyone can upload” meant that this era allowed for a new variety of television, in a range of genres and storytelling modes that were once considered untouchable to television networks (Christian, “The Web” 351). Evidently, such freedom is appealing to all kinds of online content creators, no matter their status. Established actor, comedian, and writer Louis C.K. most recently joined the Web series movement with his creation Horace and Pete (2016-). The dark comedy is written, directed, and produced entirely by C.K. and he plays the main protagonist, Horace. However, the appeal was not so much the control he would potentially have over the product, but more how the viewers could access it. Upon the release of the pilot episode, C.K. released a statement clarifying why he made a series outside of the television studio system. He explains that he was intrigued by the idea of providing viewers with the newly made show “directly and immediately”, with each episode being posted onto his Website as soon as it is shot. Additionally, C.K. also sought to create a show “without the usual promotion” that, he states, tells the viewer “what the show feels and looks like before you get to see it yourself” (C.K.). It is clear that the unique nature of the modern medium provides benefits to creators at all levels. For the Broad City duo, who unlike C.K., had yet to be noticed, YouTube was appealing because it provided them with an outlet through which they could control the product themselves. Jacobson states, “After a while, we thought, ‘why are we trying to be on something that someone else controls?’” (Paumgarten). The Web series commenced in late 2009 and ran until 2011, with each episode ranging anywhere between one and eight minutes. In the thirty-three episodes created, Abbi and Ilana consistently find themselves in awkward and comedic situations while they try to navigate their lives in New York City. These awkward situations vary in their complexity. One episode simply looks at the two protagonists trying to survive riding the subway, while another looks at the issue of being catcalled and objectified by strangers. There is no narrative arc in either season, the storylines are simply extracted from the lives of the creators. Glazer and Jacobson have discussed this in various interviews, explaining that these characters are essentially exaggerations of themselves and the show is a “heightened version” of their dynamic (Amy Poehler’s Smart Girls, 2014; Justin; Matthews). As such, Broad City contributes to a well-established trend of comedians impersonating younger, lazier, and poorer versions of themselves. However, since the Web series’ thematic relies so heavily on the experiences and personality traits of the writers, Glazer and Jacobson are more like the characters they portray than the likes of Tina Fey’s Liz Lemon (30 Rock, 2007-2013) or Lena Dunham’s Hannah Horvath (Girls, 2012-), for example. A result is that the Web series does not seek to provide its viewers with neat conclusions, or have the protagonists grow and evolve over the span of a season. This freedom is only designated to the Web series format, as television viewers – despite not always getting it – yearn for a heartier resolution (DeFino 99). Another attribute of video-sharing sites like YouTube is that they allow anyone to share anything they create, regardless of the budget. The two seasons of Broad City, the Web series, are written, created, and produced by Glazer and Jacobson primarily. As they were still undiscovered, both women were working on the series with very limited funds, and were therefore only able to have friends or family assist them in the production. This results in a series which feels authentically home-made in its aesthetic; features which eventually become characteristics essential to the transferral from Web to television. Glazer and Jacobson resolved to make the Web series from a more professional standpoint by the second season by following a production schedule and choosing to treat the vignettes as if they were real television shorts. As Glazer states, the pair “just had a new attitude”, and suddenly the aim shifted from producing webisodes as a creative outlet, to pitching the show in Los Angeles (Kameir). By the time the final episode was set to go into production, the two creators believed that the chances of having the series picked up by a network would increase if the episode featured a guest star. Because of their involvement in the UCB, Glazer and Jacobson approached one of the founders of the sketch group, Amy Poehler, to make a brief cameo. The Web series as a whole had garnered half a million hits, but the finale in which Poehler plays herself, received almost seventy-five thousand (Paumgarten). Poehler agreed to work with the Broad City duo following her appearance in the finale, and signed on to be Executive Producer should the show ever be made into a television series. The star power held by Poehler is undoubtedly a lead contributor to the success in Broad City’s transfer between the media. Poehler states that she felt a kinship towards the project because of her work in translating UCB sketches to television. In a roundtable interview, she says “Feeling very protective about the material, but wanting to bring it to a bigger audience…I related to that and understood it” (The Paley Centre for Media). On the difficult business of bringing Web series to television, Poehler compares it to that of an organ transplant, explaining “You have to move fast. You have to keep it on ice and be careful not to harm it in any way. A lot of things can go wrong. Sometimes the best way to get a heart or a kidney to a recipient is to get people to move out of the way” (Paumgarten). With Poehler’s assistance, the concept of Broad City as a television series was introduced to various networks before being successfully picked up by Comedy Central. From January of 2014, the network aired Broad City’s first season, comprised of ten, twenty-two-minute-long episodes. Averaging 1.2 million viewers per episode, season one of Broad City became one of Comedy Central’s highest rated shows since 2012 (Ng). From Web to TV: Alternative Ideas of Millennial Women in Broad CityThe factors behind why certain texts effectively transfer from Web to television and others fail continues to be debated within academic and popular culture circles. Series such as Quarterlife (2007), The CollegeHumor Show (2009), and the more recent Haters Back Off (2016-) - all texts which were originally made for online consumption only - were each met with criticism when translated for television (Peirce 317; Lowry; Christian, “How” ). This does not necessarily mean that a Web series is undeserving of a place in commercial or network television. Obviously, it comes down to multiple factors, but often it is because the television series comes across as out of touch, compared to its online version. As Alice points out, with the speed of online release, and the “virality” that accompanies this kind of media, writers have the ability to be “guided by and to capitalise on what and how the viewer public feels” (60). Television series are often seen commenting on outside criticism within episodes, but there is extensive lagging due to the time it takes to produce a season. Broad City was set to have an easier time on television, what with its impressive following, and “Celebrity Shepherd”, Amy Poehler - Poehler presented as a necessity when making the jump from Web to TV, according to Christian (“The Web”). But there appears to be a fine line when shifting between the platforms: in staying too close to the original, a series could come off as unoriginal and therefore unnecessary. Or, alternatively, a series could add too many other storylines in order to fill the time slot, and ruin the simplicity of the premise. Adaptation theorist, Linda Hutcheon, contends that a successful translation occurs when a text remains loyal to the original, but brings creativity to the reimagining (21). If investigating the transferral within the realm of adaptation theory, Broad City’s success as a television series is arguably due to it following this formula. Hutcheon writes that to adapt is not to slavishly copy, but rather, is the process of reclaiming the adapted material. “What one does with the text” is where the novelty is found (21). In looking at what Broad City, the television series, has done with Broad City, the Web series, there is clear loyalty shown to the original. This is seen most significantly in the treatment of the same two protagonists, and the dynamic of their friendship. In both versions of Broad City, Abbi is the older of the two and the more responsible one, to a degree. While she still enjoys smoking marijuana with Ilana, Abbi is also constantly striving to reach traditional goals in her life such as having a career she enjoys, or maintaining a healthy relationship. Ilana, on the other hand, is a proud marijuana enthusiast who occasionally shows up for her job, but cares more for smoking weed, enjoying casual sex, and being with her friends (primarily Abbi). Neither the Web series nor the television series explicitly states how the two characters met, but it is implied that they have built a strong, sister-like relationship with one another. Often Ilana comments on her sexual attraction to Abbi, but it is always seen as comedic rather than as a hint towards a possible coupling in future episodes. In the Web series’ second season, the episode Valentine’s Day, introduces this satirical take on female friendships for the first time. The three-minute episode shows brief cuts of Abbi and Ilana doing various activities in the city, all of which are stereotypically featured in films of the romantic comedy genre. As they play in the snow, ride a ferry, and watch couples ice-skate at the Rockefeller Centre, the clarinet music playing over the sequence builds momentum. However, the scene is suddenly halted as Ilana goes in to kiss Abbi and, unlike in said romantic film montages, Abbi quickly jolts back and cries “Ilana, what the fuck? How many times do I have to fucking tell you?” This is the first line of audible dialogue in the scene thus far, to which a frustrated Ilana responds, “I’m trying to seal the night with a kiss.” Following this is a heated debate regarding how each character viewed the intention of the day, with Ilana thinking it was a really “romantic day”, despite knowing that Abbi is decidedly heterosexual. This kind of satirical angle taken towards the trope of female friendship is carried over to the television series and made just as prominent, with almost every single episode making a joke at Ilana’s romantic desire for Abbi. Alongside the sexual attraction, the closeness of the two female leads remains unchanged between the two media. In the television series, for example, jokes about Ilana’s love for Abbi are scattered throughout, and as in the original series, they remain brief and inconsequential. In the television pilot, What a Wonderful World, the episode opens to a typical scene of the two characters having a V-chat (a nod to a favoured motif in the Web series). While chatting to Abbi, it initially appears as though Ilana is bopping up and down to the music of Lil Wayne. However, it is quickly revealed when Ilana shifts her laptop screen down, that she is actually having sex with her casual partner, Lincoln (Hannibal Buress). The sequence cuts to Abbi looking outraged at her laptop, asking “Oh my god, is that Lincoln?”. Lincoln then replies, “Yep”, just before the camera cuts to him lying on the bed, with Ilana’s laptop on his stomach. When Abbi asks if they are having sex, Ilana casually replies “I’m just keeping it warm”, forcing Abbi to once again have a discussion about boundaries. Once they close the V-chat, the scene stays on a low angle shot of Ilana as she says to Lincoln, “That was like a threesome”, reassuring the audience that she has learned nothing. This is a strong opening scene as it reinforces the understanding that the relationship between the two characters is unchanged. Furthermore, it proves to audiences that although Broad City has moved into a television landscape, it will not be tamed. The result of refusing to be tamed in its new environment is that Broad City can continue representing female friendship in more honest ways, as well as offer new ideas of what it is to be a millennial woman today.Conclusion In an interview, Glazer explains how television has a history of never being honest in its representation of women, arguing, “Nothing’s real on TV” (Miller). Jacobson follows on from this, stating “When we write for these characters… I think the thing we talk about the most is like, well, what would we really do? It’s just real” (Miller). In abiding by this sentiment throughout the web series and the television series, Broad City effectively offers the idea that depicting diversity is possible on both platforms. With various Web series still unable to successfully make the jump to television today, it becomes more obvious that Broad City’s decision to continue showcasing bold female narratives is what allows it to maintain its popularity. Starting in such an uninhibited environment has proven a burden for other texts when it comes to transferring creativity to the more traditional medium of television. For Broad City, however, the alternative storytelling platform allowed the show to create its strong foundation and dedicated fan base. One that has willingly followed Broad City across the platforms, but will only stay tuned if it stays true to representing millennial women honestly, regardless of whether mainstream television is ready.ReferencesAlice, Jessica. “Clicking with Audiences: Web Series and Diverse Representations.” Metro Magazine: Media and Education 187 (2016): 58-63.Angelo, Megan. “The Sneak Attack Feminism of Broad City.” Wall Street Journal, 2011. 17 Dec. 2016 <http://blogs.wsj.com/speakeasy/2011/02/14/the-sneak-attack-feminism-of-broad-city/>. Blay, Zeba, “How Feminist TV Became the New Normal.” Huffington Post, 2015. 15 Dec. 2016. <http://www.huffingtonpost.com.au/entry/how-feminist-tv-became-the-new-normal_n_7567898>. Broad City. Comedy Central. New York City. 22 Jan. 2014. Television.“Broad City: Smart Girls w/ Amy Poehler.” YouTube. Uploaded by Amy Poehler’s Smart Girls, 17 May 2013. 15 Dec. 2016 <https://www.youtube.com/watch?v=gd0Lovd4Xv0>.Christian, Aymar Jean. “How Does a Web Series Jump to TV?” IndieWire 2014. 2 Dec. 2016. 15 Dec. 2016 <http://www.indiewire.com/2014/02/how-does-a-web-series-jump-to-tv-29618/>. ———. “The Web as Television Reimagined? Online Networks and the Pursuit of Legacy Media.” Journal of Communication Enquiry 36.4 (2012): 340-356.C.K., Louis. “On Horace and Pete.” LouisCK 2016. 2 Jan. 2017 <https://louisck.net/news/about-horace-and-pete>. DeFino, D.J. The HBO Effect. Sydney: Bloomsbury Academic, 2014. De Moraes, L. "Score One for Old Media." Washington Post, 27 Feb. 2008. 28 Dec. 2016 <www.washingtonpost.com/wp-dyn/content/article/2008/02/27/AR2008022703374.html>. Girls. HBO Time Warner. New York City. 15 Apr. 2012. Television. Haters Back Off. Netflix. Scotts Valley. 14 Oct. 2016. Television. Hutcheon, L. A Theory of Adaptation. 2nd ed. New York: Routledge, 2013. Kameir, R. “7 Tips for Making a Hit TV Show, According to the Creators of Broad City.” Fader 22 May 2015. 1 Aug. 2016 <http://www.thefader.com/2015/05/22/7-tips-for-making-a-hit-tv-show-according-to-the-creators-of-broad-city>. Kornblum, Janet, “Check Out These Episodes of Webisodes.” USA Today 12 Dec. 2007. 16 Dec. 2016 <http://www.usatoday.com/life/2007-11-12-webisodes-side_N.htm>.Lowry, Brian, “’Haters Back Off’ Doesn’t Earn Much Love on Netflix.” CNN 12 Oct. 2016. 2 Dec. 2016 <http://edition.cnn.com/2016/10/12/entertainment/haters-back-off-review/>.Miller, B. “Broad City Talks Friendship, Feminism, and F*ck/Marry/Kill.” Bust Magazine 2015. 17 Nov. 2016 <http://bust.com/tv/13755-broad-city-talks-friendship-feminism-and-f-ck-marry-kill.html>.Ng, P. “Comedy Central Renews ‘Broad City’ for Second Season.” Hollywood Reporter 2014. 1 Aug. 2016 <http://www.hollywoodreporter.com/live-feed/broad-city-renewed-season-2-683083>.Paley Center for Media. “Broad City – Ilana Glazer, Abbi Jacobson, Amy Poehler, and Seth Rogen.” YouTube. Uploaded by The Paley Center for Media, 16 Dec. 2014. 15 Dec. 2016 <https://www.youtube.com/watch?v=4Ab9AmSk8Yg>.Pierce, Meghan L. “Remediation Theory: Analyzing What Made Quarterlife Successful as an Online Series and Not a Television Series.” Television & New Media 12.4 (2011): 314-325. Quarterlife. NBC. Los Angeles. 26 Feb. 2008. Television.The CollegeHumor Show. MTV. New York City. 8 Feb. 2009. Television. 30 Rock. NBC. Los Angeles. 3 Dec. 2007. Television. “Valentine’s Day.” YouTube. Uploaded by Broad City, 12 Feb. 2011. 15 Dec. 2016 <https://www.youtube.com/watch?v=JcoJW2BOs6g&index=1&list=PLA51423997CDEA1DA>. “What a Wonderful World.” Broad City. Comedy Central, 22 Jan. 2014. Television.

Introduction: Serial Space“It feels …like the edge of the world; far more remote than it actually is, perhaps because it looks at such immensity” (Godden “Black,” 38). This is the priest’s warning to Sister Clodagh in Rumer Godden’s 1939 novel Black Narcissus. The young, inexperienced Clodagh leads a group of British nuns through the Indian Himalayas and onto a remote mountain top above Mopu. Michael Powell and Emeric Pressburger adapted Godden’s novel into the celebrated feature film, Black Narcissus (1947). Following the novel, the film narrates the nuns’ mission to establish a convent, school, and hospital for the local population. Yet, immensity moves in mysterious ways. Sister Clodagh (Deborah Kerr) loses her managerial grip. Sister Philippa (Flora Robson) cultivates wild flowers instead of vegetables. Sister Ruth (Kathleen Byron) sheds nun’s attire for red lipstick and a Parisian dress. The young Indian woman Kanchi (Jean Simmons) becomes a force of libidinous disturbance. At the twilight of the British Empire, white, western nuns experience the psychical effects of colonialism at the precipice. Taking such cues from Pressburger and Powell’s film, Michelle Williams Gamaker, an artist, filmmaker, and scholar, responds to Black Narcissus, both film and novel. She does so through a radical interpretation of her own. Gamaker William’s 24-minute film, The Fruit Is There to Be Eaten (forthcoming, London 2018) is a longer “short,” which breaks the mould of what scholar Linda Hutcheon would term an “adaptation” (2006). For Hutcheon, there is a double “mode of engagement” between an original work and its adapted form (22). On the one hand, there is a “transcoding” (22). This involves “transporting” characters from a precedent work to its adapted form (11). On the other, there is an act of “creative interpretation” (22). The Fruit Is There to Be Eaten transports yet recreates the Indian “beggar girl” Kanchi, played by a “blacked up” white Hollywood actor Jean Simmons (Black Narcissus), into Williams Gamaker’s contemporary Kanchi, played by Krishna Istha. In this 2018 instalment, Kanchi is an Asian and transgender protagonist of political articulacy. Hence, Williams Gamaker’s film engages a double tactic of both transporting yet transforming Kanchi, as well as Sisters Clodagh and Philippa, from the feature film into The Fruit Is There to Be Eaten. To analyse Williams Gamaker’s film, I will make a theoretical jump off the precipice, stepping from Hutcheon’s malleable concept of adaptation into a space of “trans-serial” narrative.In what follows, I shall read The Fruit Is There to Be Eaten as an “episode” in a serial. The prior episodes, Williams Gamaker’s House of Women (London 2017, Berlin 2018) is a short, fictional, and surreal documentary about casting the role of Kanchi. It can be read as the next episode in Kanchi’s many incarnations. The relationship between Sister Clodagh (Kelly Hunter as voiceover) and Kanchi in House of Women develops from one of confrontation to a transgender kiss in the climatic beat of The Fruit Is There to Be Eaten. Williams Gamaker’s film can be read as one of a series which is itself inflected with the elements of a “trans-serial.” Henry Jenkins argues that “transmedia storytelling represents a process where integral elements of a fiction get dispersed systematically across multiple delivery channels” (emphasis in original, “Transmedia”). I use the word “trans” to define the gap between novelistic texts and film. Throughout Williams Gamaker’s series, she uses many textual citations from Godden’s novel, and dialogue from Pressburger and Powell’s film. In other words, verbal elements as well as filmic images are adapted in Hutcheon’s sense and transmediated in Jenkins’s sense. To build the “serial” concept for my analysis requires re-working concepts from television studies. Jason Mittell introduces “narrative complexity” as the “redefinition of episodic forms under serial narration” (“Narrative,” 32). In serial TV, characters and narratives develop over a sequence of episodes and seasons. In serial TV, missing one episode can thwart the viewer’s reception of later ones. Mittell’s examples reveal the plasticity of the narrative complexity concept. He mentions TV series that play games with the audience’s expectations. As Mittell points out, Seinfeld has reflexive qualities (“Narrative,” 35) and Twin Peaks mixes genres (“Narrative,” 33). I would add that Lynch’s creative liberties offered characters who could appear and disappear while leaving their arcs hanging intriguingly unresolved. The creative possibilities of reflexivity via seriality, of characters who appear and disappear or return in different guises, are strategies that underpin William’s Gamaker’s short film serial. The third in her trilogy, The Eternal Return (in post-production 2018) fictionalises the life of Sabu, the actor who played the General’s son in Black Narcissus. Once again, the protagonist, this time male, is played by Krishna Istha, a non-binary transgender actor who, by taking all the lead roles in William’s Gamaker’s trilogy, grows over the serial as a malleable ethnic and transgender subject. Importantly, The Eternal Return carries residues of the characters from The Fruit Is There to Be Eaten by casting the same team of actors again (Charlotte Gallagher and myself Catherine Lord), and switching their genders. Istha played Kanchi in the previous two episodes. The General’s son, played by Sabu, courted Kanchi in Black Narcissus. In The Eternal Return, Istha crosses the character and gender boundary by playing Sabu. Such casting tactics subvert the gender and colonial hegemonies inherent in Pressburger and Powell’s film.The reflexive and experimental approach of Williams Gamaker’s filmmaking deploys serial narrative tactics for its political goals. Yet, the use of “serial” needs to be nuanced. Glen Creeber sets out three terms: “episodic,” “series” and “serial.” For Creeber, a series provides continuous storylines in which the connection between episodes is strong. In the serial format, the connection between the episodes is less foregrounded. While it is not possible to enjoy stand-alone episodes in a serial, at the same time, serials produce inviting gaps between episodes. Final resolutions are discouraged so that there are greater narrative possibilities for later seasons and the audience’s own game of speculative storytelling (11).The emerging “serial” gaps between Williams Gamaker’s episodes offer opportunities for political interpretation. From House of Women and The Fruit Is There to Be Eaten, Kanchi develops an even stronger political voice. Kanchi’s character arc moves from the wordless obedience of Pressburger and Powell’s feature to the transgender voice of post-colonial discourse in House of Women. In the next episode, The Fruit Is There to Be Eaten, Kanchi becomes Clodagh’s guide both politically, spiritually, and erotically.I will read The Fruit Is There to Be Eaten as both my primary case-study and as the third episode in what I shall theorise to be a four-part serial. The first is the feature film Black Narcissus. After this is Williams Gamaker’s House of Women, which is then followed by The Fruit Is There to Be Eaten, my central case study here. There may be immediate objections to my argument that Williams Gamaker’s series can be read by treating Pressburger and Powell’s feature as the first in the series. After all, Godden’s novel could be theorised as the camouflaged pilot. Yet, a series or serial is defined as such when it is in the same medium. Game of Thrones (2011-) is a TV series that adapts George R.R. Martin’s novel cycle, but the novels are not episodes. In this regard, I follow Hutcheon’s emphasis on theorising adapted works as forged between different media, most commonly novels to films. The adaptive “deliveries” scatter through The Fruit Is There to Be Eaten with an ecological precision.Eco SeriesEcological descriptions from Godden’s novel and Pressburger and Powell’s mise-en-scene are performed in The Fruit Is There to Be Eaten through Kelly Hunter’s velvety voiceover as it enjoys a painterly language: butterflies daub the ferns with “spots of ochre, scarlet, and lemon sherbet.” Hutcheon’s term transcoding usefully describes the channelling of particles from the novelist’s text into an intensified, ecological language and cinematic mise-en-scene. The intensification involves an ingestion of Godden’s descriptive prose, which both mimics and adds an adjectival and alliterative density. The opening descriptions of the nuns’ arrival in Mopu is a case in point. In the novel, the grooms joke about the nuns’ habits appearing as “snows, tall and white” (Godden “Black,” 1). One man remarks that they look like “a row of teeth” (Godden “Black,” 2). Williams Gamaker resists shots of nuns as Godden described them, namely on Bhotiya ponies. Rather, projected onto a white screen is an image of white and red flowers slowly coming into focus. Kelly Hunter’s voiceover describes the white habits as a set of “pearly whites” which are “hungry for knowledge” and “eat into the landscape.” White, western nuns in white habits are metaphorically implied to be like a consuming mouth, eating into Indian territories and Indian people.This metaphor of colonial consumption finds its corollary in Godden’s memoirs where she describes the Pressburger, Powell, and Simons representation of Kanchi as “a basket of fruit, piled high and luscious and ready to eat” (“A House,” 24-5; 52). The nun’s quest colonially consumes Mopu’s natural environment. Presumably, nuns who colonially eat consume the colonised Other like fruit. The Kanchi of the feature film Black Narcissus is a supporting character, performed by Simmons as mute, feral and objectified. If Kanchi is to release herself from the “fruity” projections of sexism and racism, it will be through the filmmaker’s aesthetic and feminist tactic of ensuring that planets, trees, fruits and flowers become members of the film cast. If in episode 1 (Black Narcissus), plants and Asian subalterns are colonised, in episode 2, House of Women, these fruits and flowers turn up as smart, young Asian women actors with degrees in law and photography, ready to hold their own in the face of a faceless interviewer. In episode 3, The Fruit Is There to Be Eaten, it is important that Krishna Istha’s Kanchi, turning up like a magical character from another time and space (transformed from episode 1), commands the film set amidst an excess of flowers, plants and fruits. The visual overflow correlates with Kanchi’s assertiveness. Flowers and Kanchi know how to “answer back.”Like Black Narcissus the feature, The Fruit Is There to Be Eaten relies heavily on a mise-en-scene of horticultural and mountain ecology. Just as Michael Powell filmed at Pinewood and Leonardslee Gardens in East Sussex, Williams Gamaker used Rotherhithe’s Brunel Museum roof Gardens and Sands Film Studios. The lusciousness of Leonardslee is film-intertextually echoed in the floral exuberance of the 2018 shots of Rotherhithe. After the crew have set up the classroom, interwoven with Kelly Hunter’s voiceover, there is a hard cut to a full, cinematic shot of the Leonardslee garden (fig. 1).Then cutting back to the classroom, we see Kanchi calmly surveying the set, of which she is the protagonist, with a projection of an encyclopaedic display of the flowers behind her. The soundtrack plays the voices of young women students intoning the names of flowers from delphinium to lupens.These meta-filmic moments are supported by the film’s sharp juxtaposition between classroom and outdoor scenes. In Pressburger and Powell’s school scenes, Sister Ruth attempts to teach the young General how to conjugate the French verb “recevoir.” But the lesson is not successfully received. The young General becomes aphasic, Kanchi is predictably mute and the children remain demure. Will colonialism let the Other speak? One way to answer back in episode 3 is through that transgressive discourse, the language of flowers.In The Fruit Is There to Be Eaten, the young women study under Sister Clodagh and Sister Philippa (myself, Catherine Lord). The nuns teach botanical lists and their ecological contexts through rote learning. The young women learn unenthusiastically. What is highlighted is the ludicrous activity of repetition and abstractions. When knowledge becomes so objectified, so do natural environments, territories and people. Clodagh aligns floral species to British locations. The young women are relatively more engaged in the garden with Sister Philippa. They study their environment through sketching and painting a diverse range of flowers that could grow in non-British territory. Philippa is the now the one who becomes feral and silent, stroking stalks and petals, eschewing for the time being, the game of naming (fig. 2).However, lessons with colonial lexicons will be back. The young women look at screen projections of flowers. Sister Philippa takes the class through an alphabet: “D is for Dogbright … L is for Ladies’ Fingers.” Clodagh whirls through a list of long, Latin names for wild flowers in British Woodlands. Kanchi halts Clodagh’s act of associating the flowers with the British location, which colonizes them. Kanchi asks: “How many of us will actually travel, and which immigration border will test our botanical knowledge?” Kanchi then presents a radically different alphabet, including “Anne is African … Ian is Intersex … Lucy loves Lucy.” These are British names attributed to Africans, Arabs, and Asians, many of their identities revealed to be LGBQT-POC, non-binary, transgender, and on the move. Clodagh’s riposte is “How do you know you are not travelling already?” The flowers cannot be pinned down to one location. They cannot be owned by one nation.Like characters who travel between episodes, the travelling flowers represent a collision of spaces that undermine the hegemonies of race, gender and sexuality. In episode 1, Black Narcissus the feature film, the western nuns face the immensities of mountain atmosphere, ecology and an unfamiliar ethnic group. In episode 2, House of Women, the subalterns have transformed their role, achieving educational and career status. Such political and dramatic stakes are raised in episode 3, The Fruit Is There to Be Eaten. There is a strong focus on the overlapping oppressions of racial, colonial and ecological exploitation. Just as Kanchi has a character arc and serial development, so do plants, fauna, fruits, flowers and trees. ‘Post’-Space and Its AtmosphereThe British Empire colonised India’s ecological space. “Remember you and your God aren't on British Territory anymore” declares the auditioning Krishna Istha in House of Women. Kanchi’s calm, civil disobedience continues its migration into The Fruit is There to be Eaten between two simultaneously existing spaces, Mopu and Rotherhithe, London. According to literature scholar Brian McHale, postmodern worlds raise ontological questions about the dramatic space into which we are drawn. “Which” worlds are we in? Postmodern worlds can overlap between separate spaces and different temporalities (McHale 34-35). As McHale notes, “If entities can migrate across the semipermeable membrane that divides a fictional world from the real, they can also migrate between two different fictional worlds” (35).In The Fruit Is There to Be Eaten, the semipermeable membrane between it and Black Narcissus folds together the temporalities of 1947 and 2018, and the terrains of India and London. Sister Philippa tells a Kanchi seeking Mopu, that “My dear, you are already here.” This would seem odd as Sister Philippa describes the death of a young man close to Saint Mary’s Church, London. The British capital and woodlands and the Himalayas co-exist as intensified, inter-crossing universes that disrupt the membranes between both colonial and ecological space-time, or what I term “post-space.”Williams Gamaker’s post-spaces further develop Pressburger and Powell’s latent critique of post-colonialism. As film scholar Sarah Street has observed, Black Narcissus the film performs a “post-colonial” exploration of the waning British Empire: “Out of the persistence of the colonial past the present is inflected with a haunting resonance, creating gaps and fissures” (31). This occurs in Powell’s film in the initial Calcutta scenes. The designer Alfred Junge made “God shots” of the nuns at dinner, creating from them the iconic shape of a cross. This image produces a sense of over-exactness. Once in the mountains, it is the spirit of exactitude that deteriorates. In contrast, Williams Gamaker prefers to reveal the relative chaos of setting up her world. We watch as the crew dress the school room. Un-ceremoniously, Kanchi arrives in shorts before she picks up a floral dress bearing the label “Kanchi.” There is then a shot in which Kanchi purveys the organised set, as though she is its organiser (fig. 3).Post-spaces are rich in atmosphere. The British agent Dean tells Clodagh in Black Narcissus the film that the mountain “is no place to put a nunnery” due its “atmosphere.” In the climactic scene of The Fruit Is There to Be Eaten, Kanchi and Clodagh face two screens revealing the atmospheric projection of the high mountains, the black cut between them visible, like some shadowy membrane. Such aesthetic strategies continue Powell’s use of technical artifice. Street details the extensive labour of technical and craft work involved in creating the artificial world of Black Narcissus, its mountains, artificial colours, and hence atmosphere, all constructed at Pinewood studios. There was a vast amount of matte painting and painting on glass for special effects (19).William Gamaker’s screens (projection work by Sophie Bramley and Nick Jaffe) reflexively emphasise atmosphere as artifices. The atmosphere intensifies with the soundscape of mountain air and Wayne Urquhart’s original and haunting music. In Powell and Pressburger’s feature, Brian Easdale’s music also invokes a sense of mystery and vastness. Just as TV series and serials maintain musical and mise-scene-scene signatures from one episode to another, so too does Williams Gamaker reframe her precursor’s cinematic aesthetics with that of her own episode. Thus, serial as stylistic consistency is maintained between episodes and their post-spaces.At the edge of such spaces, Kanchi will scare Clodagh by miming a tight-rope walk across the mountain: it is both real and pretend, dramatic, but reflexively so. Kanchi walks a membrane between colliding worlds, between colonialism and its transgression. In this episode of extreme spirituality and eroticism, Kanchi reaches greater heights than in previous episodes, discoursing on the poetics of atmosphere: “… in the midst of such peaks, one can draw near what is truly placeless … the really divine.” Here, the membrane between the political and cultural regions and the mountains that eschew even the human, is about to be breached. Kanchi relates the legend of those who go naked in the snow. These “Abominable Men” are creatures who become phantoms when they merge with the mountain. If the fractures between locations are too spacious, as Kanchi warns, one can go mad. In this episode 3, Kanchi and Clodagh may have completed their journeys. In Powell and Pressburger’s interpretation, Sister Ruth discards nun’s attire for a Parisian, seductive dress and red lipstick. Yet, she does so for a man, Dean. However, the Sister Clodagh of 2018 is filmed in a very long take as she puts on an elegant dress and does her make-up. In a scene of philosophical intimacy with Kanchi, the newly dressed Clodagh confesses her experience of “immensity.” As they break through the erotic membrane separating their identities, both immersed in their full, queer, transgender kiss, all racial hierarchies melt into atmosphere (fig. 4).Conclusion: For a Pitch By making a film as one episode in a series, Williams Gamaker’s accomplishment is to enhance the meeting of narrative and political aims. As an arthouse film serial, The Fruit Is There to Be Eaten has enabled definitions of “serial” to migrate from the field of television studies. Between Hutcheon’s “adaptation” and Mittell and Creeber’s articulations of “narrative complexity,” a malleable concept for arthouse seriality has emerged. It has stretched the theoretical limits of what can be meant by a serial in an arthouse context. By allowing the notion of works “adapted” to occur between different media, Henry Jenkins’ broader term of “transmedia storytelling” (Convergence) can describe how particles of Godden’s work transmigrate through episodes 1, 2, and 3, where the citational richness emerges most in episodes 3, The Fruit Is There to Be Eaten.Because one novel informs all the episodes while each has entirely different narratives and genres, The Fruit Is There to Be Eaten is not a serial adaptation, as is Game of Thrones. It is an experimental serial inflected with trans-serial properties. Kanchi evolves into a postcolonial, transgender, ecological protagonist who can traverse postmodern worlds. Perhaps the witty producer in a pitch meeting might say that in its serial context, The Fruit Is There to Be Eaten is like a cross between two fantasy TV serials, still to be written: Transgender Peaks meets Kanchi Is the New Black. The “new black” is multifaceted and occupies multi-worlds in a post-space environment. ReferencesCreeber, Glen. Serial Television: Big Drama on the Small Screen. London: BFI, 2004.Godden, Rumer. 1939. Black Narcissus: A Virago Modern Classic. London: Hatchette Digital, 2013.———. A House with Four Rooms. New York: William Morrow, 1989. Hutcheon, Linda. A Theory of Adaptation. 2nd ed. New York: New York University Press, 2012.Jenkins, Henry. Convergence Culture: Where Old and New Media Collide. New York: New York University Press, 2006.———. “Transmedia, 202: Further Reflections.” Confessions of an Aca-Fan 1 Aug. 2011. 1 May 2012 <http://henryjenkins.org/blog/2011/08/defining_transmedia_further_re.html>.McHale, Brian. Postmodernist Fiction. London: Routledge, 1987.Powell, Michael. A Life in Movies: An Autobiography. London: Heinemann, 1986.Mittell, Jason. “Narrative Complexity in Contemporary American Television.” The Velvet Light Trap 58 (Fall 2006): 29-40. Street, Sarah. Black Narcissus. London: I.B. Tauris, 2005.FilmographyBlack Narcissus. Dirs. Michael Powell and Emeric Pressburger. Pinewood Studios, 1947.House of Women. Dir. Michelle Williams Gamaker. Cinema Suitcase, 2017.The Fruit Is There to Be Eaten. Dir. Michelle Williams Gamaker. Cinema Suitcase, 2018.The Eternal Return. Dir. Michelle Williams Gamaker. Cinema Suitcase, 2018-2019.

Apocacidal Tendencies: Three Excerpts from the Heaven's Gate Website 1995 (A term which blends apocalypse with suicide, apocacides could be best described as those groups or individuals who understand salvation from an imagined approaching armageddon to involve, indeed depend upon, the voluntary sacrifice of one's own life on earth.) 1. '95 Statement by An E.T. Presently Incarnate: "... We brought to Earth with us a crew of students whom we had worked with (nurtured) on Earth in previous missions. They were in varying stages of metamorphic transition from membership in the human kingdom to membership in the physical Evolutionary Level Above Human (what your history refers to as the Kingdom of God or Kingdom of Heaven). It seems that we arrived in Earth's atmosphere between Earth's 1940s and early 1990s. We suspect that many of us arrived in staged spacecraft (UFO) crashes and many of our discarded bodies (genderless, not belonging to the human species), were retrieved by human authorities (government and military). Other crews from the Level Above Human preceded our arrival and 'tagged' -- placed a despite 'chip' -- in each of the vehicles (bodies) that we would individually incarnate into, when that instruction would be given. These 'chips' set aside those bodies for us ... In any given civilisation on a fertile planet such as Earth (and Earth has had many periodic/cyclical civilisations), the Level Above Human plants all the new life forms (including humans) for that civilisation in a neutral condition so that they have a chance to choose the direction of their growth. The Level Above Human -- or Next Level -- directly (hands on) relates significantly to the civilisation at its beginning stage, and subsequently (with few exceptions) at approximately 2000-year intervals (48-hour intervals from a Next Level perspective) until that civilisation's final 'Age.' ..." 2. Our Position Against Suicide: " ... We know that it is only while we are in these physical vehicles (bodies) that we can learn the lessons needed to complete our own individual transition, as well as to complete our task of offering the Kingdom of Heaven to this civilisation one last time. We take good care of our vehicles so they can function well for us in this task, and we try to protect them from any harm. We fully desire, expect, and look forward to boarding a spacecraft from the Next Level very soon (in our physical bodies). There is no doubt in our mind that our being 'picked up' is inevitable in the very near future. But what happens between now and then is the big question. We are keenly aware of several possibilities ... The true meaning of 'suicide' is to turn against the Next Level when it is being offered. In these last days, we are focused on ... entering the Kingdom of Heaven ..." 3. Last Chance to Evacuate Earth Before It's Recycled (Sept 29, 1996): "... I'm in a vehicle that is already falling apart on me, and I'm desperate to try to help you have a last chance to go ... I don't mean to make fun of this. I am desperate -- for your sakes. Within the past twenty-four hours I have been clearly informed by my Older Member of how short the remaining time is; how clearly we cannot concentrate on anything except the perspective that says: the end of this civilisation is very close. The end of a civilisation is accompanied by spading under, refurbishing the planet in preparation for another civilisation. And the only ones who can survive that experience have to be those who are taken into the keeping of the Evolutionary Level Above Human ..." Heaven's Gate -- http://www.trancenet.org/heavensgate/index.html Magnificat Meal Movement [Toowoomba, Australia] -- http://homepages.iol.ie/~magnific/ Apocaholic Cocktails: Mixing Visions of the End Armageddon Anonymous: Hidden Faces Plotting the End on Television The 1996 book release X-Files Confidential describes its subject matter as "'social-science fiction' ... fuelled by the realities -- and internal anxieties -- of [our] time: the era of diminished expectations", a television show which "concerns itself with the dark side of technology, competition, politics, ambition, and selfishness", warning against the "risks of abandoning an interior life or one's community" and reinforcing the notion that "our attempts to combat evil are usually an exercise in futility" though that "effort alone is significant". Unlike the participants within the apocaholic communities who intimate that the 'truth is with us', the X-Files, as an entertainment product of the secular industry, proclaims that the 'truth is out there'. This conceptual and narrative framework within the X-Files works on several levels: Frustrates resolution through contrived revelation; Frustrates revelation through contrived resolution; Identifies and resists externally imposed futures; Gives a narrative voice to marginalised hierarchies of genres, values and futures mythology, eg., those involving ufology, genetic mutations and the like; De-emphasises mainstream hierarchies of authority, genres, values and futures mythology; Suggests a regime of hidden truth, embedded within what initially appears as disconnected and unrelated phenomena; Implicates the mainstream future as conspiricist (i.e., the governments which control our futures do not have our interests at heart); Identifies the ritualistic reassurance set by the mainstream discursive strategy (e.g., "apology is policy"); Cultivates its own in-language, or futurespeak, where special terms refer to a future-oriented conspiracy of mammoth proportions. And, finally, it gives meaning to the millennium beyond a mere change in dates. All in all, the X-Files is popular and successful because it explores the possibilities of resolvable and unresolvable endings. It blurs the boundaries between the theological and the secular imaginings of the end. It borrows elements common to contemporary evangelicalism, endtime signs such as the mark of the beast, and gives them a plausible secular narrative. For example, whereas it might be difficult to suspend disbelief for a story that has a charismatic antichrist controlling the world through marking its population with 666, X-Files modernises the setting by creating a mysterious consortium of 12 elders who are in allegiance with some alien plan to initiate a scheduled holocaust. Such an organised drive towards armageddon involves genetic tagging of the populations through smallpox injections, little biochips which switch on and switch-off cancers, transportation of plague through bee stings and heavenly lights that harbour creatures with sinister purposes. In the X-Files, mainstream society is the cult whose future has been pre-organised by its real architects and whose adherents, the general populace, move through society blinded by ideas and doctrines of thought that Mulder sees as lies. His ultimate quest is find the truth, to reveal the future being secretly planned for the world. His quest involves reading the signs of the times in his encounters with the X-Files. Scully, whose initial introduction was to provide a sceptic balance to his quest, in fact provides a scientific rationale for Mulder's seemingly odd flights of fancy. In explaining Mulder's theories away in pseudo-scientific terms, Scully makes the unthinkable seem more plausible, and her character development from sceptic to believer provides the narrative added credibility for long-term viewers. If Scully can be convinced, then there must really be a hidden sinister future embedded beyond the mainstream outlook. Mainstream programmes such as these can in themselves throw wine of the proverbial armageddon fire. Both Star Trek and the X-Files were favourite pastimes for the Heaven's Gate Cult. Star Trek epitomised the ultimate open-ended humanist future, exploration of the unknown, while the X-Files epitomised the nature of this level, a conspiricist and closed future in which the world's only hope lay in the revealing of the sinister unknown before the great destructive end. Needless to say, X-Files-styled sites proliferate the Webscape in late 1999: Apocalypse Soon -- http://www.apocalypsesoon.org/english.html UFOs & Antichrist Millennium Bug Connection New World Order -- http://www.mt.net/~watcher/nwoy2k.html UFOs, Aliens & Antichrist: The Angelic Conspiracy & End Times Deception -- http://www.mt.net/~watcher/ "The Bible says that the b'nai Elohim, angels, sons of God, were ministers of creation, from before the worlds, Job 38:7. Contrary to popular secular theories, the b'nai Elohim are created beings distinct from ELOHIM the God of Israel. God created the b'nai Elohim to reflect His glory, and reflect His word which spoke all things into being. Before a third of the heavenly host rebelled, they were stewards of creation, building civilizations on the terrestrial planets of our solar system designed to glorify the Word of God. The Cydonia "face" is a monument constructed by these Sons of God, revealing their knowledge of the message in the stars. Both the Cydonia face and the Sphinx are cherubim, combining figures in the constellations Virgo and Leo, symbolic representations of the first and second advent of Christ on Earth." Satan's Plan to Escape Judgement -- http://www.mt.net/~watcher/hate.html "Previous pages explained how Satan was created to lead the angelic hierarchy, ruling over physical civilizations of angels on planets, such as the one still in evidence on Mars. After Satan rebelled, the center of his angelic civilization was destroyed "from among the stones of fire", yet the Bible tells us Satan is still waiting for the time of God's judgment. Satan is not in hell, he is still allowed audience before God, where he accuses the faithful (Rev.), and he still roams above and within the earth (Job). Since Satan is the most beautiful and powerful cherub, Prince of the Powers of the Air, intelligence behind UFO phenomena, the authority over all the aerial regions outward from earth..." The Millennium Group -- http://www.millenngroup.com/ Australia's Fair Dinkum Magazine -- http://unforgiven.iweb.net.au/~dinkum/ Eyes on the World -- http://eotw.orac.net.au/articles/index.html Antichrist / False Prophet -- http://members.tripod.com/jonastheprophet1/antipope.html "Antichrist will arise out of the British Monarchy within the context of the European Union/False prophet will arise out of the Vatican-Whore Church/Both will work together to build Satan's end time kingdom in these last and final days." 666 Sketch: The Mark of the Beast -- http://www.greaterthings.com/Essays/666mark.htm Conspiracy Books -- http://parascope.com/parastore/booksconspiracy.htm Corrupt Government, Conspiracy, New World Order, A Future? -- http://www.pushhamburger.com/ Dark Conspiracy -- http://www.blazing-trails.com/DarkConspiracies/welcome.html "Things have gotten really seriously convoluted. To try to follow some of the conspiracies requires a substantial amount of dedication. Any one thread can lead to so many other threads, eventually, maybe they will come together into a complete tapestry that could scare the bejabbers out of you." New World Order Conspiracy -- http://www.ufomind.com/para/conspire/nwo/ Silver Screen Endings: Blockbuster Profits in Apocalypse Gripped in a delirium of apocaholicism, contemporary secular society is exploring the conditions and consequence of endings. Mainstream presentations such as Independence Day, Event Horizon, Armageddon, End of Days, The Matrix and Deep Impact depict the notion of endings in elaborate and extravagant modes. Independence Day is a lesson in Orwellian doublethink -- it begins by destroying the very values it eschews at its closure. The statue of liberty, the White House, and the Empire State Building, all contemporary icons of western democratic and consumerist values, are brutally and spectacularly disintegrated. Yet the very core of the western meta-narrative, the maintenance of independence, which brought about the empowerment of these icons, is upheld throughout the film, leaving a critical viewer with the sense that what we are watching in this film is not the destruction of the world by some alien force -- certainly no other nation is depicted as so grossly devastated nor are any icons of other significantly known cultures destroyed -- but the annihilation of contemporary western icons: essentially, the death of icons. The values are constant, as emoted by the President of the United States towards the fiery conclusion of the movie, but the icons are unstable, susceptible to external disruption, unlike the proverbial humanist spirit. Hence, most audiences reacted gleefully to seeing famous landmarks blasted to smithereens -- this goes hand in hand I suspect with the prevailing social atmosphere cultivating change: do away with the current icons, they are no longer valid nor do they faithfully represent the social world around us, we require new ones to image our emerging spirit. Event Horizon is very different in content and style. It blends conventional theology with science fiction to create an incredible narrative about a starship so fast that it punches a hole through to hell and back. The concern throughout the film as the blood thickens is not with the collective end to society but rather with the very personal and private closure to individual life and the post-death experience. Other films, like Deep Impact and Armageddon, draw on the "worst bits" in the bible, to quote one trailer, and depict disturbing destructive images of the western metropolitan society, with dramatic wrangling over who will survive and how in order to establish a brave new world. What links these varying cinematic depictions of the end? Is it perhaps the imagined triumph of humanist spiritism, usually legitimised through the sacrificial offering of a main character in a film's final showdown? (Bruce Willis dies in Armageddon, Tea Leoni waits with her estranged father for the tidal wave in Deep Impact, and a half-drunk kamikaze pilot in an old biplane destroys the mothership at the close of Independence Day.) Being excessively popular, one needs to ask what role these films play within the collective social narrative of endism: do these films serve to quiet anxieties about the end by visualising human solutions to impossible destructive odds? Or do apocalyptic blockbusters market towards existing endtimes tension, reflecting the growing apocaholic nature of our societies as we near the close of the twentieth century and thereby, in true western capitalist fashion, profit from this cultural dysfunction? Or do films of this nature answer a more base, unacknowledged desire within our societies to see the end and survive? Event Horizon -- http://www.eventhorizonmovie.com/ End of Days -- http://www.end-of-days.com/ The Matrix -- http://www.whatisthematrix.com/ Deep Impact -- http://www.deepimpact.com/ Timeout: Clocking the Endtimes Christian End-Time Expectations -- Millennia Monitor -- http://www.fas.org/2000/endtime1.htm This resource provides links to a wide variety of Christian sources with a primary focus on millennial, apocalyptic, or other End Time expectations. Countdown 2000: Your Guide to the Millennium -- http://www.countdown2000.com/index.htm "As we approach the millennium, the world seems to be getting weirder. Countdown 2000 is packed with the latest news, hype, and hysteria. Where will the blow-out parties be? Will Y2K cause global havoc? How can I get involved in improving the world? Whatever the millennium and year 2000 mean to you, Countdown 2000 can help you learn what you want to know. Countdown 2000 is packed with over 150 pages, and 2500 links." Amazing Prophecy -- http://bibleprophecy.com/ Topics covered: Bible prophecy, rapture, tribulation, millennium, last days, end times, end of time, second coming, covenants, revelation, advent, antichrist, 666, parousia (appearing of Christ), preterist (fulfilled prophecy), eschatology (the study of last things), and many more. 888 Christ Come: Your Bible Prophecy Website -- http://www.888c.com/ Apocalists: The Tribulation Inbox Interesting things happen on discussion lists. Perhaps a more significant example of apocalyptic dissemination, capable of real-time feedback and iteration on endtime signs within every corner of the Web, millions on the bible highway speak of the premillennial tension that characterises contemporary cultural life and thousands more direct these lunges into apocalyptic extrapolation via discussion lists. Nowhere has the apocalyptic urge to image the end, to identify the sign of its approach, been more revitalised than on this electronic frontier: indeed, Apocalypse has an impressive online presence. Today, anyone can receive daily updates sent to their email inbox on the progress or nearness of the great endtimes tribulation, press releases of the latest armageddon publication list, prophecy ezines, the latest incarnation of the mark of the beast 666, new candidates for antichrist identification and revelation reports, to name but a few: Bible Prophecy Discussion List -- http://www.geocities.com/~dawn-/index.html Bible Prophecy-L was created as an open, moderated forum to discuss and share information related to end times Bible prophecy. Some of the topics you may find discussed are: Eschatology; Global Government; Global Religion and the New Age Movement; Rapture; Antichrist; Environmental Changes (earthquakes, tornados, volcanoes, freak storms, flooding etc.); Israel and the Middle East; Signs in the Heavens (UFOs, Comets, etc.); Pestilence (infectious diseases); Wars and Rumors of Wars; Prophecy Conference Updates ... etc. Bible Prophecy Report -- http://philologos.org/bpr Bible Codes News Update -- http://thebiblecodes.com/news/bcnu.htm Tribulation News -- http://www.tribnews.net/mir Conspiracy Journal -- http://www.members.tripod.com/uforeview/welcome.html Citation reference for this article MLA style: Jason Ensor. "Apocacide, Apocaholics and Apocalists: A Selective Webography of Endism." M/C: A Journal of Media and Culture 2.8 (1999). [your date of access] <http://www.uq.edu.au/mc/9912/apocacide.php>. Chicago style: Jason Ensor, "Apocacide, Apocaholics and Apocalists: A Selective Webography of Endism," M/C: A Journal of Media and Culture 2, no. 8 (1999), <http://www.uq.edu.au/mc/9912/apocacide.php> ([your date of access]). APA style: Jason Ensor. (1999) Apocacide, Apocaholics and Apocalists: A Selective Webography of Endism. M/C: A Journal of Media and Culture 2(8). <http://www.uq.edu.au/mc/9912/apocacide.php> ([your date of access]).

Cognitive biases, or systematic errors in cognition, are important contributors to diagnostic error in medicine. In our review, we explore the psychological underpinnings of cognitive bias and highlight several common biases using clinical cases. We conclude by reviewing strategies to improve diagnostic accuracy and by discussing controversies and future research directions.RésuméLes préjugés cognitifs, ou les erreurs systématiques dans la cognition, sont des contributeurs importants à l'erreur diagnostique dans la médecine. Dans notre examen, nous explorons les fondements psychologiques du biais cognitif et soulignons plusieurs préjugés communs en utilisant des cas cliniques. Nous concluons en examinant les stratégies visant à améliorer la précision diagnostique et en discutant des controverses et des futures orientations de recherche.Research in the field of behavioural psychology and its application to medicine has been ongoing for several decades in an effort to better understand clinical decision making.1 Cognitive biases (systematic errors in cognition) are increasingly recognized in behavioural economics2 and more recently have been shown to affect medical decision making.3 Over 100 such cognitive biases have been identified and several dozen are postulated to play a major role in diagnostic error.4 Cognitive errors can take many forms and in one study contributed to as many as 74% of diagnostic errors by internists. 5 Most of these errors were due to “faulty synthesis” of information, including premature diagnostic closure and failed use of heuristics.5 Inadequate medical knowledge, on the other hand, was rare and mostly identified in cases concerning rare conditions. 5 Professional organizations such as the Royal College of Physicians and Surgeons of Canada and the Canadian Medical Protective Association have since been working to raise awareness of cognitive bias in clinical practice.6In our review, we explore the role of cognitive bias in diagnostic error through the use of clinical cases. We also review the literature on de-biasing strategies and comment on limitations and future directions of research.The Dual Process TheoryA prevailing theory to explain the existence of cognitive bias is the dual process theory, which asserts that two cognitive systems are used in decision making, herein called System 1 and System 2 (Table 1). 2,7System 1 can be thought of as our intuitive mode of thinking. It generates hypotheses rapidly, operates beneath our perceptible consciousness and makes judgments that are highly dependent on contextual clues. System 1 is characterized by heuristics (short cuts, or “rules of thumb”) and is an important component of clinical judgment or expertise. In contrast, System 2 is slow, deliberate, analytical and more demanding on cognition. It applies rules that are acquired through learning and it can play a “monitoring role” over System 1, and thus overrides heuristics when their use is inappropriate. The dual process theory implies that errors result when inappropriate judgments generated by System 1 fail to be recognized and corrected by System 2. Maintaining constant vigilance over System 1 would be both impractical and time consuming for routine decisions and would diminish the value of intuition. It follows that a more practical way of improving reasoning is to identify the most common biases of System 1 and to recognize situations when mistakes are most likely to occur.2Alternative Theories of CognitionVariations of dual process theory have further refined our understanding of medical decision making. Fuzzy trace theory, for example, proposes that individuals process information through parallel gist and verbatim representations.8 The “gist” is analogous to System 1 and represents the bottom-line “meaning” of information. This representation is subject to an individual’s worldview, emotions and experiences. In contrast, verbatim representations are precise, literal and analogous to System 2. Fuzzy trace theory is particularly useful in explaining how patients might interpret health information. Proponents of this theory contend that in order for information to lead to meaningful behavioural change, physicians must appeal to both gist and verbatim representations when communicating with patients.8 Other models, such as dynamic graded continuum theory, do away with the dichotomy of System 1 and System 2 and instead represent implicit, automatic and explicit cognitive processes on a continuous scale.9 These single system models are useful to compare against dual process theory but have not replaced it as a well-established framework for understanding and mitigating cognitive bias in clinical decision making.7Case 1: A 55-Year-Old Male with Retrosternal Chest PainA 55year-old non-smoking male was assessed in a busy Emergency Department (ED) for retrosternal chest pain. Past medical history is significant for osteoarthritis for which he takes naproxen. On review of his history, the patient has had multiple visits for retrosternal chest pain in the previous two months. At each encounter, he was discharged home after a negative cardiac workup.Vital signs in the ED were within normal limits except for sinus tachycardia at 112 beats per minute. On exam, the patient was visibly distressed. Cardiac and respiratory exams were normal. There was mild tenderness in the epigastrium. Basic blood-work revealed leukocytosis (16.0 × 109/L), a mildly elevated high sensitivity cardiac troponin, and no other abnormalities. An ECG revealed T wave flattening in leads V3-V4.The patient was referred to the internal medicine service with a diagnosis of non-ST-elevation myocardial infarction and treated with aspirin, clopidogrel, and fondaparinux. Several hours later, the patient became more agitated and complained of worsening retrosternal and epigastric pain. On re-examination, heart rate had increased to 139 beats per minute, blood pressure dropped to 77/60 and he had a rigid abdomen. Abdominal radiography revealed free air under the right hemi-diaphragm and the patient was rushed to the operating room where a perforated gastric ulcer was detected and repaired. The case above illustrates numerous cognitive biases, including:1. Premature diagnostic closure: the tendency to accept a diagnosis before it is fully verified.42. Anchoring: the tendency to over-emphasize features in the patient’s initial presentation and failing to adjust the clinical impression after learning new information.43. Confirmation bias: the tendency to look for confirming evidence to support a diagnosis, rather than to look for (or explain) evidence which puts the diagnosis in question.4In this case, the physician based the diagnosis of myocardial infarction primarily on symptoms of chest pain and an elevated cardiac troponin. However, several other objective findings were present and when taken together, suggested a diagnosis other than myocardial infarction. These included a tender epigastrium, leukocytosis, and resting sinus tachycardia. These symptoms/signs were not explicitly explained or investigated before a treatment decision was made. Premature diagnostic closure is one of the most common cognitive biases underlying medical errors5 and it affects clinicians at all levels of training.10 It is multifactorial in origin5 and is especially common in the face of other cognitive biases such as anchoring and confirmation bias.The physician in this case “anchored” to a diagnosis of cardiac chest pain given the patient’s previous ED visit history and his/her best intentions of ruling out a “worst case scenario.” Anchoring can be especially powerful in the face of abnormal screening investigations that have been reviewed even before the physician has acquired a history or performed a physical examination. If the physician had reviewed the screening investigations before seeing the patient, he/she might have narrowed the differential diagnosis prematurely, failed to gather all the relevant information and failed to adjust the clinical impression based on new information.The physician demonstrated confirmation bias by failing to explain the abnormalities that put the diagnosis of myocardial infarction in question (e.g. tender epigastrium, leukocytosis). Confirmation bias arises from an attempt to avoid cognitive dissonance, a distressing psychological conflict which occurs when inconsistent beliefs or theories are held simultaneously.11 In one study evaluating clinical decision making amongst 75 psychiatrists and 75 medical students,12 13% of psychiatrists and 25% of medical students demonstrated confirmation bias when searching for information after having made a preliminary diagnosis. In this study, confirmation bias resulted in more frequent diagnostic errors and predictably impacted subsequent treatment decisions.An appropriate consideration of all diagnostic possibilities is the first step in avoiding diagnostic error. While acquiring information, physicians should step back and consolidate new data with the working diagnosis, as failure to do so can result in confirmation bias.13 All abnormal findings and tests, especially if considered clinically relevant should be explained by the most probable diagnosis. An alternate diagnosis or the possibility of more than one diagnosis should be considered when an abnormal finding or test cannot reasonably be explained by the working diagnosis.Tschen et al observed a team of physicians working through a simulated scenario which had diagnostic ambiguity.14 Two approaches were found to be effective in reducing the effect of confirmation bias: explicit reasoning and talking to the room. Explicit reasoning involves making causal inferences when interpreting and communicating information. Talking to the room is a process whereby diagnostic reasoning is explained in an unstructured way to a team member or colleague in the room. This allows the clinician the opportunity to elaborate on their thoughts and observers to point out errors or suggest alternate diagnoses in a shared mental model.Case 2: A 30-Yearold Male with Confusion and SeizuresA 30-year-old homeless male is found confused on the street by paramedics and brought to the ED for assessment. Empty bottles of alcohol were noted at the scene. The CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol is initiated and he is given several doses of lorazepam to minimal effect. Several hours after the patient is admitted, a resident on-call is paged for elevated CIWA scores on the basis of diaphoresis and agitation. Several additional doses of lorazepam are ordered which fail to completely resolve the symptoms. Gradually, the patient becomes more obtunded. The on-call resident orders a capillary blood glucose and it measures 1.1 mmol/L. Intravenous D50W is promptly administered, the blood glucose normalizes and the patient’s level of consciousness improves.The case above illustrates the following biases:1. Availability bias: the tendency to weigh a diagnosis as being more likely if it comes to mind more readily.42. Diagnostic momentum: the tendency for labels to “stick” to patients and become more definite with time.4Although the symptoms of diaphoresis and agitation are not specific to alcohol withdrawal, this diagnosis was deemed most likely based on how readily it came to mind, the empty alcohol bottles at the scene, and potentially on the patient’s demographics. The unproven diagnosis of alcohol withdrawal “stuck” with the patient despite minimal improvement after a therapeutic trial of benzodiazepines.Availability bias has been shown to affect internal medicine residents. In one single-centre study,15 18 first-year and 18 second-year residents were exposed to case descriptions with associated diagnoses as part of an exercise. They were then asked to diagnose a series of new cases, some of which appeared similar to those they had previously encountered but with pertinent differences that made an alternate diagnosis more likely. Second year residents had lower diagnostic accuracy on these similar-appearing cases; a result consistent with availability bias. First year residents were less prone to this bias because of their limited clinical experience. Most importantly, subsequent reflective diagnostic reasoning countered the bias and improved accuracy.General Strategies to Avoid Cognitive BiasInterventions aimed at mitigating diagnostic error due to cognitive bias take several approaches.1. Improving clinical reasoning2. Reducing cognitive burden3. Improving knowledge and experienceDespite a large number of proposed interventions, there is a lack of empirical evidence supporting the efficacy of many de-biasing strategies. 16 What follows is a brief review of the current evidence.Improving Clinical ReasoningSeveral “de-biasing” strategies have been proposed to improve clinical reasoning. De-biasing strategies assume that System 1 processes are more prone to bias due to their heavy reliance on heuristics and therefore the solution is to activate System 2 at critical points in decision making. De-biasing occurs in several stages: at first an individual is educated about the presence of a cognitive bias, they then employ strategies to eliminate that bias and finally they maintain those strategies in the long term.17Metacognition, or “thinking about thinking,” involves reflecting on one’s own diagnostic reasoning. Internal reflection along with awareness of potential biases should allow the clinician to identify faulty reasoning. However, the evidence underlying reflective practice is mixed.16 Several studies have tried to encourage reflective practice and System 2 processes by instructing participants to proceed slowly through their reasoning18 or by giving participants the opportunity to review their diagnoses.19 These studies have found minimal or no impact on reducing the rate of diagnostic error. On the other hand, some studies have shown improved diagnostic accuracy when physicians are asked to explicitly state their differential diagnoses along with features that are consistent or inconsistent with each diagnosis.20 These results suggest that if reflective practice is to be effective, it must involve a thorough review of the differential diagnosis as opposed to simply taking additional time.Reducing Cognitive BurdenTools that reduce the cognitive burden placed on physicians may reduce the frequency of diagnostic errors. One suggestion has been to incorporate the use of checklists in the diagnostic process. These checklists would be matched to common presenting symptoms and include a list of possible diagnoses. One randomized controlled trial failed to show a statistically significant reduction in the diagnostic error rate with the use of checklists, except in a small subgroup of patients treated in the ED. 21 These findings challenge the results of two other studies that found checklists to be effective in improving scrutiny22 and diagnostic accuracy23 when interpreting electrocardiograms. More advanced forms of clinician decision support systems have also been studied.24 Software programs such as DXplain generate a list of potential diagnoses based on a patient’s chief complaint. In one study, when the software provided physicians a list of possible diagnoses before evaluating patients, diagnoses were 1.31 times more likely to be correct. 25 The use of diagnostic support tools may grow in the future as they are integrated into electronic medical record systems.Improving Knowledge and ExperienceA combination of experience, knowledge and feedback are integral in developing a clinician’s intuition to produce the best hypotheses. Experience without feedback can lead to overconfidence, which itself is a cognitive bias. The evidence supporting feedback is strong. Fridriksson et al showed a significant reduction in diagnostic error when referring doctors were provided feedback on the identification of subarachnoid hemorrhage.26 A systematic review of 118 randomized trials concluded that feedback was effective in improving professional practice.27 The specific characteristics of the best feedback were elusive. In general, however, feedback was thought to be most effective when it was explicit and delivered close to the time of decision making. ConclusionsIn our review, we explore clinical decision making through the lens of dual-process theory. However, multiple different dual-processing models are still being explored and fundamental questions are still under debate. For example, some experts believe that instead of focusing on de-biasing strategies, the key to improving intuitive (System 1) processes is simply to acquire more formal and experiential knowledge.19 Other unanswered questions include: the impact and magnitude of cognitive bias in actual clinical practice, which biases are most prevalent in each medical specialty and which strategies are the most effective in mitigating bias. Further study is also needed to assess the impact of novel educational methods, such as case-based and simulation-based learning, which are promising venues where trainees may identify and correct cognitive biases in a directly observed setting. References 1. Norman G. Research in clinical reasoning: past history and current trends. Med Educ 2005;39:418–27.2. Kahneman D. Thinking, fast and slow. Farrar, Straus and Giroux; 2011.3. Croskerry P. From mindless to mindful practice — cognitive bias and clinical decision making. N Engl J Med 2013;368:2445–8.4. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine 2003;78:775–80.5. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493–9.6. Parush A, Campbell C, Hunter A, et al. Situational awareness and patient safety - a short primer. Ottawa ON: The Royal College of Physicians and Surgeons of Canada; 2011.7. Pelaccia T, Tardif J, Triby E, Charlin B. An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med Educ Online 2011;16.8. Reyna VF. A theory of medical decision making and health: fuzzy trace theory. Med Decis 2008;28:850–65.9. Osman M. An evaluation of dual-process theories of reasoning. Psychonom Bull review 2004;11:988–1010.10. Dubeau CE, Voytovich AE, Rippey RM. Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect. Med Dec Mak 1986;6:169–73.11. Nickerson RS. Confirmation bias: A ubiquitous phenomenon in many guises. Rev Gen Psychol 1998;2:175.12. Mendel R, Traut-Mattausch E, Jonas E, et al. Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses. Psychol Med 2011;41:2651–9.13. Pines JM. Profiles in patient safety: confirmation bias in emergency medicine. Acad Emerg Med 2006;13:90–4.14. Tschan F, Semmer NK, Gurtner A, et al. Explicit reasoning, confirmation bias, and illusory transactive memory: a simulation study of group medical decision making. Small Group Res 2009;40:271–300.15. Mamede S, van Gog T, van den Berge K, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA 2010;304:1198–203.16. Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Safe 2012;21:535–57.17. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013.18. Norman G, Sherbino J, Dore K, et al. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med 2014;89:277–84.19. Monteiro SD, Sherbino J, Patel A, Mazzetti I, Norman GR, Howey E. Reflecting on diagnostic errors: taking a second look is not enough. J Gen Intern Med 2015;30:1270–4.20. Bass A, Geddes C, Wright B, Coderre S, Rikers R, McLaughlin K. Experienced physicians benefit from analyzing initial diagnostic hypotheses. Can Med Educ J 2013;4:e7–e15.21. Ely JW, Graber MA. Checklists to prevent diagnostic errors: a pilot randomized controlled trial. Diagnosis 2015;2.22. Sibbald M, de Bruin ABH, Yu E, van Merrienboer JJG. Why verifying diagnostic decisions with a checklist can help: insights from eye tracking. Adv Health Sci Educ Theory Pract 2015;20:1053–60.23. Sibbald M, de Bruin ABH, van Merrienboer JJG. Checklists improve experts' diagnostic decisions. Med Educ 2013;47:301–8.24. Garg AX, Adhikari NKJ, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293:1223–38.25. Kostopoulou O, Rosen A, Round T, et al. Early diagnostic suggestions improve accuracy of GPs: a randomised controlled trial using computer-simulated patients. Br J Gen Pract 2015;65:e49–54.26. Fridriksson S, Hillman J, Landtblom AM, Boive J. Education of referring doctors about sudden onset headache in subarachnoid hemorrhage. A prospective study. Acta Neurol Scand 2001;103:238–42.27. Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Qual Saf Health Care 2006;15:433–6.