Journal articles on the topic 'Harvard Medical Unit'

Formal course instruction in mineralogy and geology began in Harvard College in 1788 with Benjamin Waterhouse. He also assembled in the 1780's a reference and teaching collection of minerals, rocks, and ores—the first natural history collection at Harvard—that, following a gift by an English friend, J. C. Lettsom, became a cynosure of the College. Following Waterhouse's dismissal in 1812, the instruction was carried on by John Gorham until 1824. Waterhouse, his colleague Aaron Dexter, and Gorham all were professors in the Harvard Medical School, established 1782. The latter two men successively held an endowed chair therein, the Erving Professorship of Chemistry and Materia Medica. They produced some notable graduates: Parker Cleaveland in 1799, Lyman Spalding in 1797, Joseph Green Cogswell in 1806, John White Webster in 1811, John Fothergill Waterhouse in 1813, and Samuel Luther Dana and James Freeman Dana in 1813. Following years of futile effort by the Administration to establish a professorship of mineralogy and geology, with Cogswell as the selected candidate, the instruction in mineralogy and geology fell to John White Webster in 1824 in the Chemistry Department. The Erving Professorship also passed to him, with a change in title to Professor of Chemistry and Mineralogy. Webster's death in 1850, following his conviction for murder in a famous trial, terminated the first period of development of the geological sciences at Harvard. In this period, in spite of the early start by Waterhouse, Harvard lagged much behind the developments at Yale and other colleges in New England and beyond. The main period of development of the geological sciences at Harvard come in the latter 1800's. It was a consequence primarily of the founding of the the Lawrence Scientific School in 1848, with its emphasis on the applied aspects of the sciences, the appointments of Josiah Dwight Whitney and Raphael Pumpelly in 1865 and 1866, respectively to a School of Mines and Practical Geology endowed as a sub-unit therein, and the appointment of Josiah Parsons Cooke in 1850 as successor to Webster in the Chemistry Department.

This discussion was moderated by Karen A. Fagan, MD, Professor and Director, Division of Pulmonary Medicine, University of South Alabama College of Medicine, Mobile, Alabama. Panel members included Kamal K. Mubarak, MD, Assistant Professor of Medicine, Director, Pulmonary Hypertension Clinic, Wayne State University, Detroit, Michigan; Zeenat Safdar, MD, Assistant Professor of Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas; Aaron Waxman, MD, PhD, Associate Professor of Medicine, Harvard Medical School, Director, Pulmonary Vascular Disease Program and Pulmonary Critical Care Unit, Massachusetts General Hospital, Boston, Massachusetts; and Roham T. Zamanian, MD, Assistant Professor of Medicine, Director, Adult Pulmonary Hypertension Clinical Service, Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, Stanford, California.

Abstract Eduardo J. Villablanca 1, Jaime De Calisto 1, Patricia Torregrosa Paredes 1, 2, Barbara Cassani 1, Susanne Gabrielsson 2 & J. Rodrigo Mora 1 1 Gastrointestinal Unit, Massachusetts General Hospital & Harvard Medical School, Boston, MA; 2 Translational Immunology Unit, Karolinska Institutet, Stockholm, Sweden Intestinal mononuclear phagocytes, including dendritic cells (DC) and macrophages (MF), develop from at least two different bone marrow (BM) precursors. CD103- MF derive from lineage negative (Lin-) Ly6Chigh monocytes, whereas CD103+ DC, which metabolize vitamin A into all-trans retinoic acid (RA), derive from Lin-Ly6Clow BM precursors. However, how mononuclear phagocytes precursors are recruited to the intestinal mucosa remains unknown. Here, we show that BM Lin-Ly6Clow cells require β7 integrins to reconstitute intestinal mononuclear phagocytes and to give rise to RA-producing mesenteric lymph node DC. Interestingly, the BM contains a distinct population of α4β7+ Lin-Ly6Clow cells, which was markedly reduced in vitamin A-depleted mice. Importantly, mice lacking β7 integrins in the CD11c+ compartment showed decreased generation of antigen-specific regulatory T cells and were impaired in developing oral tolerance. Thus, BM progenitors require α4β7 to give rise to intestinal mononuclear phagocytes with tolerogenic potential.

This paper develops a mathematical model describing the potential buildup of high oxytocin concentrations in the maternal circulation during labor in terms of continuous Pitocin infusion rate, half-life, and maternal weight. Oxytocin override of the degradation of oxytocin by placental oxytocinase is introduced to model the potential transfer of oxytocin from the maternal circulation across the placenta into the fetal circulation and from there into the brain of the fetus. The desensitization unit D equal to 1.8E6 (pg·min)/ml is employed to establish a desensitization threshold and by extension, a downregulation threshold as a function of oxytocin override concentration and continuous Pitocin infusion time, that could be a factor in the subsequent development of autism among offspring. Epidemiological studies by Duke University [1], Yale University [2], and Harvard University [3] are discussed regarding Pitocin use and offspring autism development for an explanation of the weak correlations they identified. The findings of the Harvard epidemiological study are reinterpreted regarding Pitocin use and its conclusion questioned. Further evaluations of the findings of these three epidemiological studies are called for to incorporate medical information on quantity of Pitocin used, continuous Pitocin infusion rate, length of labor, and maternal weight to determine if a correlation can be established with offspring autism development above an empirically determined desensitization threshold for Pitocin use. Suggestions for research are discussed, including an alternative to continuous Pitocin infusion, pulsatile infusion of Pitocin during labor induction, which may mitigate possible offspring autism development.

This paper highlights the foundational research on multi-material 3-D bioprinting of human tissues, for which the Lewis Bioprinting team at Harvard University was awarded the 2017 Lush Science Prize. The team's bioprinting platform enables the rapid fabrication of 3-D human tissues that contain all of the essential components found in their in vivo counterparts: cells, vasculature (or other tubular features) and extracellular matrix. The printed 3-D tissues are housed within a customised perfusion system and are subjected to controlled microphysiological environments over long durations (days to months). As exemplars, the team created a thick, stem cell-laden vascularised tissue that was controllably differentiated toward an osteogenic lineage in situ, and a 3-D kidney tissue that recapitulated the proximal tubule, a sub-unit of the nephron responsible for solute reabsorption. This highly versatile platform for manufacturing 3D human tissue in vitro opens new avenues for replacing animal models used to develop next-generation therapies, test toxicity and study disease pathology.

Abstract Introduction:Patients undergoing cardiac surgery are among the most common recipients of allogenic red blood cell (RBC) transfusions. However, whether restrictive RBC transfusion strategies for cardiac surgery achieve a similar clinical outcome in comparison with liberal strategies remains unclear. Methods:We searched PubMed, Embase, the Cochrane Collaboration Central Register of Controlled Trials, and conference proceedings from inception to December 2017 for all randomized trials (RCTs). The primary outcome was mortality. Secondary outcomes were stroke, respiratory morbidity, renal morbidity, infections, myocardial infarction (MI), cardiac arrhythmia, gut morbidity, reoperation, intensive care unit (ICU) length of stay (hours), and hospital length of stay (days). We calculated the risk ratios (RR) and weighted mean difference (MD) for the clinical outcomes using a random-effects model. Results:We included 9 RCTs with a total of 9,005 patients. There was no significant difference in mortality between groups (RR 1.03; 95% CI 0.74-1.45; P=0.86). In addition, there were no significant differences between groups in the clinical outcomes of infections (RR 1.09; 95% CI 0.94-1.26; P=0.26), stroke (RR 0.98; 95% CI 0.72-1.35; P=0.91), respiratory morbidity (RR 1.05; 95% CI 0.89-1.24; P=0.58), renal morbidity (RR 1.02; 95% CI 0.94-1.09; P=0.68), myocardial infarction (RR 1.00; 95% CI 0.80-1.24; P=0.99), cardiac arrhythmia (RR 1.05; 95% CI 0.88-1.26; P=0.56), gastrointestinal morbidity (RR 1.93; 95% CI 0.81-4.63; P=0.14), or reoperation (RR 0.90; 95% CI 0.67-1.20; P=0.46). There was a significant difference in the intensive care unit length of stay (hours) (MD 4.29; 95% CI: 2.19-6.39, P<0.01) favoring the liberal group. However, there was no significant difference in the hospital length of stay (days) (MD 0.15; 95% CI -0.18-0.48; P=0.38). Conclusion:This meta-analysis showed that restrictive strategies for RBC transfusion are as safe as liberal strategies in patients undergoing cardiac surgery. Key points: Restrictive strategies for red blood cell transfusion are as safe as liberal approaches in patients undergoing cardiac surgery. Longer duration of stay in the intensive care unit is more common in patients managed with a restrictive transfusion approach. However, the overall hospital length of stay appeared to be similar between both groups. Further studies are needed to ascertain threshold triggers for RBC transfusion. Figure. Figure. Disclosures Hassan: abott: Other: grant. Bhatt:American Heart Association Quality Oversight Committee: Other: chair; Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSof: Membership on an entity's Board of Directors or advisory committees; Medscape Cardiology: Consultancy; Regado Biosciences: Consultancy; Elsevier Practice Update Cardiology: Consultancy, trustee; cardax: Consultancy; Abbott, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines: Research Funding; Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic, Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, Population: Other: Data monitoring committee; American College of Cardiology; Unfunded Research: FlowCo, Merck, PLx Pharma, Takeda.: Other: trustee; ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim), Belvoir Publications (Editor in Chief, Harvard Heart Letter),: Other: board member; American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org: Honoraria.

Objective Describe the incidence of delirium and associated outcomes among hospitalized, non-critically ill older people. Design Single-center, retrospective chart review. Setting A 217-bed academic teaching hospital in Cambridge, Massachusetts affiliated with Harvard Medical School. Patients People 65 years of age or older, admitted to a general medicine unit between January 1 and August 31, 2021, who were prescribed one or more deliriogenic medications prior to or during admission. Interventions Patient electronic medical records were reviewed for deliriogenic medications prescribed and administered during admission and associated clinical outcomes. Results The percentage of patients who developed delirium was 13% overall. The most implicated deliriogenic medications were benzodiazepines, antipsychotics, and histamine-2 receptor antagonists (H2RAs). Seventy-three percent of deliriogenic home medications were continued upon admission. Subgroup analyses of those with delirium had a mean length-of-stay of 20 days compared with 6 days in those who did not develop delirium. Those with delirium tended to have more deliriogenic medications used during admission. Conclusion This review describes the incidence of delirium for non-critically ill older people who were prescribed at least one deliriogenic medication. Of all the deliriogenic agents reviewed, moderate quality clinical evidence supports the association between use and development of delirium except for H2RAs, which have low-quality evidence. Pharmacist-driven efforts to deprescribe deliriogenic medications in at-risk patient populations may be better focused on agents with higher-quality evidence.

Walter B. Cannon (1871–1945), perhaps America’s preeminent physiologist, volunteered for service with the Army Expeditionary Force (AEF) during World War I. He initially served with Base Hospital No. 5, a unit made up of Harvard clinicians, before moving forward to the front lines to serve at a casualty clearing station run by the British. During his time there, he performed research on wounded soldiers to understand the nature and causes of traumatic shock. Subsequently, Cannon performed animal experimentation on the causes of traumatic shock in the London laboratory of Dr. William Bayliss before being assigned to the AEF Central Medical Laboratory in Dijon, France, where he continued his experimental studies. During this time, he also developed and taught a curriculum on resuscitation of wounded soldiers to medical providers. Although primarily a researcher and teacher, Cannon also performed clinical duties throughout the war, serving with distinction under fire. After the war, Cannon wrote a monograph entitled Traumatic Shock (New York: Appleton, 1923), which encapsulated the knowledge that had been gained during the war, both from direct observation of wounded soldiers, as well as laboratory experimentation on the causes and treatment of traumatic shock. In his monograph, Cannon elucidates a number of principles concerning hemorrhagic shock that were later forgotten, only to be “rediscovered” during the current conflicts in Iraq and Afghanistan. This paper summarizes Cannon’s wartime experiences and the knowledge gained concerning traumatic shock during World War I, with a comparison of current combat casualty care practices and knowledge to that which Cannon and his colleagues understood a century ago.

Ludwig Edinger (1855–1918) is often perceived as a functional neuroanatomist who primarily followed traditional lines of microscopic research. That he was a rather fascinating innovator in the history of neurology at the turn from the nineteenth to the twentieth century has, however, gone quite unnoticed. Edinger’s career and his pronounced hopes for future investigative progress in neurological work mark an important shift, one away from traditional research styles connected to department-based approaches towards a multi-perspective and quite advanced form of interdisciplinary scientific work. Being conceptually influenced by the Austrian neuroanatomist Heinrich Obersteiner (1847–1922) and his foundation of the Neurological Institute in Vienna in 1882, Edinger established a multi-faceted brain research program. It was linked to an institutional setting of laboratory analysis and clinical research that paved the way for a new type of interdisciplinarity. After completion of his medical training, which brought him in working relationships with illustrious clinicians such as Friedrich von Recklinghausen (1810–1879) and Adolf Kussmaul (1822–1902), Edinger settled in 1883 as one of the first clinically working neurologists in the German city of Frankfurt/Main. Here, he began to collaborate with the neuropathologist Carl Weigert (1845–1904), who worked at the independent research institute of the Senckenbergische Anatomie. Since 1902, Edinger came to organize the anatomical collections and equipment for a new brain research laboratory in the recently constructed Senckenbergische Pathologie. It was later renamed the “Neurological Institute”, and became an early interdisciplinary working place for the study of the human nervous system in its comparative, morphological, experimental, and clinical dimensions. Even after Edinger’s death and under the austere circumstances of the Weimar Period, altogether three serviceable divisions continued with fruitful research activities in close alignment: the unit of comparative neurology, the unit of neuropsychology and neuropathology (headed by holist neurologist Kurt Goldstein, 1865–1965), and an associated unit of paleoneurology (chaired by Ludwig Edinger’s daughter Tilly, 1897–1967, who later became a pioneering neuropaleontologist at Harvard University). It was especially the close vicinity of the clinic that attracted Edinger’s attention and led him to conceive a successful model of neurological research, joining together different scientific perspectives in a unique and visibly modern form.

This contribution describes the discovery and subsequent investigation of a cist in a rock-cut pit at Achavanich, Highland. Discovered and excavated in 1987, the cist was found to contain the tightly contracted skeletal remains of a young woman, accompanied by a Beaker, three flint artefacts and a cattle scapula. Initial post excavation work established a date for the skeleton together with details of her age and sex, and preliminary pollen analysis of sediments attaching to the Beaker was undertaken. The findings were never fully published and, upon the death of the excavator, Robert Gourlay, the documentary archive was left in the Highland Council Archaeology Unit. Fresh research in 2014–17, initiated and co-ordinated by the first-named author and funded by the Society of Antiquaries of Scotland with assistance from National Museums Scotland, the Natural History Museum and Harvard Medical School, has produced a significant amount of new information on the individual and on some of the items with which she was buried. This new information includes two further radiocarbon dates, a more detailed osteological report, isotopic information pertaining to the place where she had been raised and to her diet, histological information on the decomposition of her body, and genetic information that sheds light on her ancestry, her hair, eye and skin colour and her intolerance of lactose. (This is the first time that an ancient DNA report has been published in the Proceedings.) Moreover, a facial reconstruction adds virtual flesh to her bones. The significance of this discovery within the Chalcolithic to Early Bronze Age of this part of Scotland is discussed, along with the many and innovative ways in which information on this individual, dubbed ‘Ava’, has been disseminated around the world.

Abstract Introduction Umbilical cord blood (UCB) transplantation yields survival comparable to adult stem cell transplantation, but there is significant variability among UCB products, in large part because of differences in processing conditions from collection to cryopreservation at cord banks. While impact of processing conditions on the actual UCB product has been reported, there is a little information regarding impact on patient-level outcomes. We report a retrospective exploratory analysis of processing performed at cord banks prior to freezing of UCB units and the impact on clinical outcomes such as engraftment, cord dominance, transplant-related mortality (TRM) and overall survival (OS) in 133 UCB recipients. Methods All adult recipients of unmanipulated double UCB transplantation (dUCBT) for hematologic malignancy from 2003 to 2011 at the 3 Harvard Cancer Center sites (Dana-Farber Cancer Institute, Massachusetts General Hospital, and Beth Israel Deaconess Medical Center) were included. All UCB units were thawed and washed prior to infusion. Multivariate analyses controlled for prognostic factors including age, malignancy, conditioning intensity, degree of HLA matching, presence of anti-HLA antibodies, order of cord infusion, TNC/kg, and CD34+/kg infused. Time to engraftment and treatment-related mortality were analyzed in the competing risks regression setting and survival was analyzed using proportional hazards models. Results 98 recipients underwent reduced-intensity conditioning, primarily fludarabine, melphalan and anti-thymocyte globulin. 35 underwent myeloablative conditioning, primarily cyclophosphamide and total body irradiation. Of the 48 banks contributing cords to this study, 42% employed simple cryopreservation and 23% employed plasma/volume reduction only, at some point during operation. These 2 methods were considered “RBC replete”. Of the 34 banks sharing their current practices, simple cryopreservation is no longer practiced by any; 12% practice plasma/volume reduction alone. 88% of the banks now employ RBC depletion, of which 67% use hydroxyethyl starch for RBC sedimentation and 67% use automated processing systems. Engraftment – Neutrophil and platelet engraftment were not impacted by RBC depletion, sedimentation with hydroxyethyl starch, automated processing, HLA matching or CD34+/kg dose in multivariate analyses. An anti-HLA antibody against one or more cords (p<0.001), myeloablative conditioning (p=0.001) and lower TNC/kg doses (p=0.027) were associated with longer time to engraftment. Cord Dominance –Cord dominance was not significantly affected by RBC depletion, RBC sedimentation, use of an automated system, cord bank inventory or years in existence, time in storage, or viability less than 90% at infusion in a multivariate model. Transplant-related Mortality – None of the processing conditions had a significant effect on TRM at 100 days or 1 year. Overall Survival –Although recipient numbers were small, an interesting observation was the improved survival of the 17 recipients of 2 RBC replete units versus the 115 who received 1 or more RBC-depleted units. This was significant in univariate modeling (p=0.022, see Figure) and just significant in multivariate modeling (HR 3.20, p=0.049, 100day OS of 72% vs 100% and 1year OS of 47% vs 82%). Age over 50 and myeloablative conditioning were the only other cord or patient factors to correlate with increased TRM (p=0.033 and 0.001) and decreased overall survival (p=0.062 and 0.003). Conclusions 1) UCB bank practices have changed with time and currently employ primarily RBC depletion by sedimentation via automated systems prior to cryopreservation. 2) Neutrophil and platelet engraftment and TRM were not significantly affected by processing conditions at the cord bank in our models. 3) Receipt of 1 or more RBC-depleted units seemed to be associated with inferior survival at 100 days and 1 year vs receipt of 2 RBC-replete cords in multivariate modeling. A clear limitation to our interpretation is sample size, with only 17 recipients receiving 2 RBC-replete cords. While our observations require validation in a larger population, processing conditions at the collection banks and their potential impact on clinical outcomes merit further investigation to determine which aspects of processing should be considered in UCB unit selection. Disclosures: Koreth: Takeda Pharmaceuticals: Consultancy; Millennium pharmaceuticals: Research Funding.

Charlie van der Horst, an emeritus professor at the University of North Carolina and a friend of Pathogens and Immunity, disappeared from sight on Friday, June 14 during a marathon swim in the Hudson River. His death was confirmed. Few who knew him would call him Charles as formality was not his strong-suit. Charlie was born in Holland to a Dutch father and a Polish Holocaust survivor mother. His family moved to the Buffalo, New York area and sent Charlie to school at Andover. He attended Duke University where he captained the varsity swim team in 1973-74. He remained a powerful swimmer, competing often in national Masters’ competitions. He received his MD degree from Harvard in 1979 and trained in medicine at Montefiore Medical Center and Infectious Diseases at the University of North Carolina. He was an expert in the management of fungal diseases and when the AIDS epidemic began, he knew he had to commit his career to AIDS research and care. He led a highly successful AIDS Clinical Trials Unit at the University of North Carolina and was a respected leader in this national consortium who gained international recognition and respect for his work. More than most anyone else I know, Charlie was driven to fight for justice, anywhere, any time. At the 2000 IAS meeting in Durban, South Africa he recognized that the greater AIDS need was in the developing world and he redirected his entire career towards the development of research and care programs in Africa. When Ebola hit West Africa, Charlie rushed to Liberia to help. In the U.S., Charlie was on the front lines urging his state legislature to deal fairly with all North Carolinians, working hard to fight for equity in health care. He was beloved by so many, respected for his talents, admired for his decency. He was, as my grandmother would have said—a mentsch—and more. Our world is lucky to have had him and is diminished by his loss.

Objetivo: Analisar estudos baseados na aplicação do Design Thinking envolvendo dispositivos médicos para discutir a importância das necessidades dos usuários na resolução de problemas relacionados às tecnologias em saúde. Design⏐Metodologia⏐Abordagem: Neste artigo é apresentada uma revisão de forma sistemática da literatura, através do método Systematic Search Flow (SSF), por meio de uma pesquisa nas bases de dados Scopus, IEEE, Pubmed e Scielo. Foram encontradas 161 publicações segundo os critérios de busca e as palavras-chaves definidas. Por fim, foram selecionados seis artigos para a análise dos resultados. Resultados: Os resultados da revisão de forma sistemática mostraram diversas possibilidades de aplicação do Design Thinking no desenvolvimento de dispositivos médicos, desde em dispositivos de classe de risco mais elevado, até mesmo em equipamentos menos complexos, para uso domiciliar, e software para aporte clínico para melhorar a experiência de recém-nascidos, crianças, quanto também para auxiliar o envelhecimento saudável de idosos. Originalidade⏐Valor: O desenvolvimento de novas soluções tecnológicas centradas nos usuários e voltadas para a saúde permitem a aplicação do Design Thinking; especialmente aquelas que envolvem dispositivos médicos para melhorar a segurança e a qualidade das tecnologias de saúde para os usuários, proporcionando melhor usabilidade e compreensão do contexto atual dessas tecnologias na perspectiva dos usuários. Referências Abookire, S., Plover, C., Frasso, R., & Ku, B. (2020). Health Design Thinking: An Innovative Approach in Public Health to Defining Problems and Finding Solutions. Front Public Health, 8(459). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484480/ Altman, M., Huang, T. T., & Breland, J. Y. (2018). Design Thinking in Health Care. Prev Chronic Dis. Ayah, R., Ong'ech, J., Mbugua, E. M., Kosgei, R. C., Waller, K., & Gathara, D. (2020). Responding to maternal, neonatal and child health equipment needs in Kenya: a model for an innovation ecosystem leveraging on collaborations and partnerships. BMJ Innov, 6. https://doi.org/10.1136/bmjinnov-2019-000391 Brown, T. (2008). Design Thinking. Harvard Business Review. Brown, T. (2010). Design Thinking - Uma metodologia poderosa para decretar o fim das velhas ideias (Traduzida - 2017 ed.). Starlin Alta. Ferenhof, H. A., & Fernandes, R. F. (2016). Desmistificando a revisão de literatura como base para redação científica: método SFF. Revista ACB, 21(3). https://revista.acbsc.org.br/racb/article/view/1194 Flewwelling, C., Easty, A., Vicente, K., & Cafazzo, J. (2014). The use of fault reporting of medical equipment to identify latent design flaws. J Biomed Inform. Jiang, J., Liu, T., Zhang, Y., Song, Y., Zhou, M., Zheng, X., & Yan, Z. (2017). Design and development of an intelligent nursing bed - a pilot project of "joint assignment". Annu Int Conf IEEE Eng Med Biol Soc, 38–41. https://doi.org/10.1109/EMBC.2017.8036757 Marko-Holguin, M., Cordel, S. L., Voorhees, B., Fogel, J., Sykes, E., Fitzgibbon, M., & Glassgow, A. (2019). A Two-Way Interactive Text Messaging Application for Low-Income Patients with Chronic Medical Conditions: Design-Thinking Development Approach. JMIR Mhealth Uhealth, 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6658312/ Organização Mundial da Saúde. (2020). Dispositivo Médico - Definição Completa. Organização Mundial da Saúde. https://www.who.int/medical_devices/full_deffinition/en/ Poncette, A.-S., Spies, C., Mosch, L., Schieler, M., Weber-Carstens, S., Krampe, H., & Balzer, F. (2019). Clinical Requirements of Future Patient Monitoring in the Intensive Care Unit: Qualitative Study. JMIR Med Inform, 7. https://doi.org/10.2196/13064 Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2020). Medical Error Prevention. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK499956/ Shepherd, M. (2004). Clinical Engineering Handbook (1st ed.). Elsevier Academic. Sherman, J., Lee, H. C., Weiss, M. E., & Kristensen-Cabrera, A. (2018). Medical Device Design Education: Identifying Problems Through Observation and Hands-On Training. Des Technol Educ, 23, 154-174. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759072/ Tosi, F., & Rinaldi, A. (2017). Design and Usability of the Next Medical Devices for the Home Care. The Design Journal. https://doi.org/10.1080/14606925.2017.1352722 Van der Cammen, T. J., Albayrak, A., Voûte, E., & Molenbroek, J. F. (2016). New horizons in design for autonomous ageing. Oxford Academic, 46, 11-17. https://doi.org/10.1093/ageing/afw181

Abstract Inhibitory antibodies against factor VIII (fVIII) are the major complication of hemophilia A treatment, causing severe bleeding in spite of infused fVIII. Most antibodies are directed against the A2 or the C2 domain of fVIII and the degree of inhibition in clinical fVIII assays does not predict the severity of bleeding risk. We recently discovered that fVIII binds to a macromolecular complex including low molecular weight fibrin and the αIIbβ3integrin on membranes of thrombin-stimulated platelets rather than exposed phosphatidylserine (PS). Because clinical fVIII assays utilize PS-rich vesicles to support fVIII activity we asked whether the degree of inhibition of platelet-dependent activity by anti-C2 domain mAb's differs from inhibition on PS-rich phospholipid vesicles. Methods: Platelet dependent fVIII activity was measured in a defined activated platelet time (APT) assay containing fresh, density gradient-purified human platelets and fVIII deficient plasma supplemented with fVIII. Coagulation was triggered by simultaneous addition of calcium, thrombin receptor activation peptides for PAR-1 and PAR-4, and either factor XIa (intrinsic pathway) or factor fXa (extrinsic pathway) without standard exogenous activators or vesicles. aPTT assays were performed on the same plasma-preparations using a commercial preparation of activator and phospholipid vesicles. Assays were performed using BBL fibrometers, electromechanical devices. A panel of 12 defined, epitope-mapped mAb's against the fVIII-C2 domain was chosen in order to survey the relationship between inhibition and binding of anti-C2 antibodies. mAb's at 10 µg/ml were pre-incubated with fVIII for 60 min in the absence of VWF before mixing the fVIII-antibody mixture with plasma. Results: Platelets from nine donors supported a similar, near log-linear relationship between fVIII concentration and fibrin strand formation spanning at least 10,000-fold (0.0001 - 1 unit/ml). Time to fibrin strand formation was inversely related to platelet concentration over a range of at least 1 x 106 - 2 x 108/ml. Factor XIa and factor Xa concentrations of 20 pM and 0.01 pM, respectively were chosen emulating the intrinsic and extrinsic pathways. Four mAb's inhibited fVIII activity <10% in the aPTT assay, four others by 50-80%, with the final four in the 90-99% range. fVIII activity in the intrinsic APT had little correlation to inhibition in the aPTT assay with four mAb's causing less inhibition of the APT and the remaining 8 antibodies having 5-10 fold more inhibition. No mAb caused inhibition that was within 2-fold for the aPTT and APT assays. For the extrinsic APT, triggered by fXa, all antibodies produced greater than 99% inhibition of fVIII activity with 10 antibodies having 2-10 fold greater inhibition than with the intrinsic pathway. Conclusions: These results show that both platelet membranes and the pathway to fVIII activation determine the degree of inhibition by anti-C2 antibodies. The inhibition of platelet-dependent fVIII activity has little correlation to inhibition of the aPTT fVIII activity. Further, anti-C2 antibodies show greater inhibition of platelet-based activity when the fVIII activation pathway is via factor Xa vs. factor XIa. Additional studies will be needed to determine whether residual fVIII activity from the intrinsic APT or extrinsic APT better correlates to bleeding risk and whether the basis for activation pathway-dependent inhibition correlates to different proteolytic cleavage sites for factor VIII. Disclosures Meeks: Genentech: Membership on an entity's Board of Directors or advisory committees; Grifols: Membership on an entity's Board of Directors or advisory committees; CSL Behring: Membership on an entity's Board of Directors or advisory committees; Bayer Healthcare: Membership on an entity's Board of Directors or advisory committees; Biogen: Membership on an entity's Board of Directors or advisory committees; Shire: Membership on an entity's Board of Directors or advisory committees. Novakovic:Harvard Medical School: Patents & Royalties: Methods and Assays for Factor VIII Activity. Gilbert:Baxalta/Shire: Membership on an entity's Board of Directors or advisory committees, Research Funding; Harvard Medical School: Patents & Royalties: Methods and Assays for Factor VIII Activity; Grifols: Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Objectives World War I (WWI) left a devastating impact on Europe. Urologist George Gilbert (GG) Smith served with a Harvard-associated group of surgeons and nurses stationed at the western front from 1915-1916. First-hand accounts and medical observations from the front are rare, so Smith’s wartime diary is a valuable source to gain further insight into what was once termed the ‘War to End All Wars’. Our objective was to study Smith’s diaries from WWI to better understand the personal and professional experiences and sacrifices of those who fought and served Methods The GG Smith diaries were obtained courtesy of the Smith family. Archives were consulted from the American Urological Association (AUA) William P. Didusch library (Linthicum, MD), Center for the History of Medicine at Countway Library (Cambridge, MA), the British Red Cross, the American Hospital of Paris, and cited secondary sources. Results Smith graduated from Harvard medical school in 1908 after training at Massachusetts General Hospital (MGH). He joined the growing urology faculty at Harvard under the leadership of Hugh Cabot. Following the start of WWI and before the United States’ formal involvement in the war, the Harvard Surgical Unit (HSU) was one of a number of ‘neutral’ medical corps from America’s elite hospitals, composed of individual doctors and nurses who were deployed wherever they were needed for a 3-month tour of duty. As a member of the HSU, Smith was stationed by the warfront, braving air attacks and bombs to care for hundreds of wounded, combatting infections, trauma, and fractious personalities.. The skill in leadership he developed served him well as President of the AUA from 1935-1936, Chair of Urology at MGH from 1938-1945, and President of the Massachusetts Society of Social Hygiene from 1937-1945 Conclusions Smith’s war time diary is testimony to the great philanthropic efforts of America’s institutions during WWI, to the remarkable progress in medical and surgical care that was motivated by the devastation of that war, and to the diversity of people whose pragmatic heroism contributed to the Allied victory.

Dr Rebecca Lawn is a Postdoctoral Research Fellow at the Harvard T.H. Chan School of Public Health. She gained a first-class BSc (hons) in Psychology from Newcastle University and received her PhD from the University of Bristol, where she worked between the School of Psychological Science and the Medical Research Council (MRC) Integrative Epidemiology Unit. Dr Lawn’s PhD research applied Mendelian randomization to investigate causal relationships in evolutionary theories of development and behavior with a focus on life history theory (concentrating on age at menarche and age at first sexual intercourse) and the schizophrenia paradox. Her current research interests include the relation of trauma and post-traumatic stress disorder with health over the life course.

Abstract Thomas B. Fitzpatrick had a tremendous influence on the specialty of dermatology, including seminal scientific contributions, a legendary ability to teach and train, and remarkable innovations in clinical dermatology. Born in Wisconsin in 1919, he received his medical degree from Harvard, followed by a PhD in pathology. He served 2 years at an Army Chemical Centre, where his interest in skin pigmentation led to the discovery of human tyrosinase. Further innovation in basic sciences followed, with the discovery of the melanosome and epidermal melanin unit. He added to his academic accolades by completing a fellowship in chemistry at Oxford, then returned to the USA to pursue clinical dermatology training at Mayo Clinic. At the age of 32 years, following substantial success in his early career, he was appointed Professor and Chair of Dermatology at the University of Oregon. By 39 years of age, he was Chair of the Harvard Medical School Dermatology Department, Harvard’s youngest Professor and Chair, while serving as Chief of Dermatology at Massachusetts General Hospital. He was a master at motivating students and sharing his passion for dermatology. He often said ‘Practicing dermatologists are like the woodwind section of the orchestra—small in number, when they play they must play well’. In 1971, he wrote the first multiauthor medical textbook in the field entitled Fitzpatrick’s Dermatology in General Medicine, now in its eighth edition. Dr Fitzpatrick contributed heavily to the clinical advances in dermatology in the latter half of the 20th century. Alongside dermatopathologist Wallace Clark, he established the very first pigmented lesion clinic in 1966. From that clinic, studies enabled Dr Clark to devise the Clark level staging system for melanoma. Fitzpatrick described early diagnostic signs in melanoma, and the concept of sunlight as a factor in its aetiology. In 1975, he devised the Fitzpatrick scale of skin phototypes, which described a person’s skin type in terms of response to ultraviolet (UV) radiation exposure. To huge success, he experimented with psoralen and UVA to treat psoriasis, coining the term photochemotherapy, or PUVA. Fitzpatrick was a highly productive medical scholar, while having many other notable qualities and interests. He was an avid lover of music, a skilled pianist and a Johannes Brahms enthusiast. The Boston Globe called him a ‘dermatologist with an infectious enthusiasm for his specialty and philosopher’s love of a good quote’. For 20 years, he co-edited the Globe’s popular ‘Reflection for the Day’, alongside his loving wife Beatrice. Thomas Fitzpatrick was admired by many until his passing in 2003, leaving us with so much to remember him by.

Background: Readmission to the Intensive Care Unit (ICU) is associated with a high risk of in-hospital mortality and higher health care costs. Previously published tools to predict ICU readmission in surgical ICU patients have important limitations that restrict their clinical implementation. We sought to develop a clinically intuitive score that can be implemented to predict readmission to the ICU after surgery or trauma. We designed the score to emphasize modifiable predictors. Methods: In this retrospective cohort study, we included surgical patients requiring critical care between June 2015 and January 2019 at Beth Israel Deaconess Medical Center, Harvard Medical School, MA, USA. We used logistic regression to fit a prognostic model for ICU readmission from a priori defined, widely available candidate predictors. The score performance was compared with existing prediction instruments. Results: Of 7,126 patients, 168 (2.4%) were readmitted to the ICU during the same hospitalization. The final score included 8 variables addressing demographical factors, surgical factors, physiological parameters, ICU treatment and the acuity of illness. The maximum score achievable was 13 points. Potentially modifiable predictors included the inability to ambulate at ICU discharge, substantial positive fluid balance (>5 liters), severe anemia (hemoglobin <7 mg/dl), hyperglycemia (>180 mg/dl), and long ICU length of stay (>5 days). The score yielded an area under the receiver operating characteristic curve of 0.78 (95% CI 0.74-0.82) and significantly outperformed previously published scores. The performance of the underlying model was confirmed by leave-one-out cross-validation. Conclusion: The RISC-score is a clinically intuitive prediction instrument that helps identify surgical ICU patients at high risk for ICU readmission. The simplicity of the score facilitates its clinical implementation across surgical divisions.

Abstract Objective i2b2 offers the possibility to store biomedical data of different projects in subject oriented data marts of the data warehouse, which potentially requires data replication between different projects and also data synchronization in case of data changes. We present an approach that can save this effort and assess its query performance in a case study that reflects real-world scenarios. Material and Methods For data segregation, we used PostgreSQL’s row level security (RLS) feature, the unit test framework pgTAP for validation and testing as well as the i2b2 application. No change of the i2b2 code was required. Instead, to leverage orchestration and deployment, we additionally implemented a command line interface (CLI). We evaluated performance using 3 different queries generated by i2b2, which we performed on an enlarged Harvard demo dataset. Results We introduce the open source Python CLI i2b2rls, which orchestrates and manages security roles to implement data marts so that they do not need to be replicated and synchronized as different i2b2 projects. Our evaluation showed that our approach is on average 3.55 and on median 2.71 times slower compared to classic i2b2 data marts, but has more flexibility and easier setup. Conclusion The RLS-based approach is particularly useful in a scenario with many projects, where data is constantly updated, user and group requirements change frequently or complex user authorization requirements have to be defined. The approach applies to both the i2b2 interface and direct database access.

Introduction. The impact of traumatic experiences has always been a part of human life. According to Judith Herman, an American psychotherapist, and professor at Harvard Medical School, "traumatic events overload a person's usual strategies for adapting to life, his usual security systems that give a sense of control, connection, and meaning." Also, traumatic events, for the most part, contain close personal contact with violence and death and pose a threat to life or physical integrity. For almost one year of the war, Ukrainian society faced a large number of negative phenomena capable of causing severe psychological trauma: disruption of the usual lifestyle, loss of family friends, and property, lack of many vital needs for a person, forced migration, uncertainty, a constant threat for health and life, etc. The purpose of the study was to analysis of scientific and literary data reflecting the history of the formation of the concept of "post-traumatic stress disorder" as a nosological unit, as well as the peculiarities of its manifestation and prevalence, diagnostic criteria. Materials and methods: A systematic search was conducted in the main electronic medical databases, such as PubMed, Scopus, Web of Science, Google Scholar, and processed publications that studied the history of the formation of "post-traumatic stress disorder" as a nosological unit, the features of its manifestation and prevalence. diagnostic criteria. Eligible studies were identified using keywords: post-traumatic stress disorder, psychotraumatology, trauma, physioneurosis, history of medicine. All types of articles were reviewed, including original studies, systematic reviews, and meta-analyses. Review and discussion: For a long time, there was a stigmatization of combat-related disorders in society. The path to the development of PTSD as a psychiatric diagnosis is long and thorny. After the World War II, there was an urgent need to introduce a standard unified nomenclature that would enable doctors from all over the world to have a common language for discussing the psychopathology of this disorder, establishing a diagnosis and determining disability. Over 60 years, starting in 1952, when the American Psychiatric Association (APA) introduced the concept of "brutal stress reaction" in its first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) and up to 2013 (DSM-5) formation of post-traumatic stress disorder as a nosological unit was taking place. Conclusions: Despite the non-acceptance, stigmatization, indifference and other difficulties, PTSD finally achieved official status in the recognized list of diagnoses.

ABSTRACT Objective: Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments. Methods: a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks. Results: 18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4. Conclusion: populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

Introduction: Dexmedetomidine is a potent, highly selective α-2 adrenoceptor agonist with sedative, analgesic, anxiolytic, and opioid-sparing properties. A large number of dexmedetomidine-related publications have sprung out in the last 2 decades. However, no bibliometric analysis for clinical research on dexmedetomidine has been published to analyze hot spots, trends, and frontiers in this field.Methods: The clinical articles and reviews related to dexmedetomidine, published from 2002 to 2021 in the Web of Science Core Collection, were retrieved on 19 May 2022, using relevant search terms. VOSviewer and CiteSpace were used to conduct this bibliometric study.Results: The results showed that a total of 2,299 publications were retrieved from 656 academic journals with 48,549 co-cited references by 2,335 institutions from 65 countries/regions. The United States had the most publications among all the countries (n = 870, 37.8%) and the Harvard University contributed the most among all institutions (n = 57, 2.48%). The most productive academic journal on dexmedetomidine was Pediatric Anesthesia and the first co-cited journal was Anesthesiology. Mika Scheinin is the most productive author and Pratik P Pandharipande is the most co-cited author. Co-cited reference analysis and keyword analysis illustrated hot spots in the dexmedetomidine field including pharmacokinetics and pharmacodynamics, intensive care unit sedation and outcome, pain management and nerve block, and premedication and use in children. The effect of dexmedetomidine sedation on the outcomes of critically ill patients, the analgesic effect of dexmedetomidine, and its organ protective property are the frontiers in future research.Conclusion: This bibliometric analysis provided us with concise information about the development trend and provided an important reference for researchers to guide future research.

Abstract Background All health overuse implies an unnecessary risk of patients suffering adverse events (AEs). However, this hypothesis has not been corroborated by direct estimates for inappropriate hospital admission (IHA). The objectives of the study were the following: (1) to analyze the association between IHA and the development of subsequent AEs; (2) to explore the distinct clinical and economic implications of AEs subsequent IHA compared to appropriate admissions. Methods An observational cross-sectional study was conducted on hospitalized patients in May 2019 in a high-complexity hospital in Madrid, Spain. The Appropriateness Evaluation Protocol was used to measure IHA, and the methodologies of the Harvard Medical Practice Study and the European Point Prevalence Survey of Healthcare-associated Infections were used to detect and characterize AEs. The association between IHA and the subsequent. Results A total of 558 patients in the hospital ward were studied. IHA increased the risk of subsequent occurrence of AEs (OR [95% CI]: 3.54 [1.87 to 6.69], versus appropriate) and doubled the mean AEs per patient (coefficient [95% CI]: 0.19 [0.08 to 0.30] increase, versus appropriate) after adjusting for confounders. IHA was a predictive variable of subsequent AEs and the number of AEs per patient. AEs developed after IHA were associated with scheduled admissions (78.9% of AEs, versus 27.9% after appropriate admissions; p < 0.001). Compared with AEs developed after appropriate admissions, AEs after IHA added 2.4 additional days of stay in the intensive care unit and incurred an extra cost of €166,324.9 for the studied sample. Conclusions Patients with IHA have a higher risk of subsequent occurrence of AE. Due to the multifactorial nature of AEs, IHA is a possible contributing factor. AEs developed after IHA are associated with scheduled admissions, prolonged ICU stays, and resulted in significant cost overruns.

AbstractThe swift advancement of technology has led to the widespread utilization of artificial intelligence (AI) in the diagnosis of diseases and prediction of prognoses, particularly in the field of intensive care unit (ICU) and Anesthesia. Numerous evidential data have demonstrated the extensive potential of AI in monitoring and predicting patient outcomes in these fields. Using bibliometric analysis, this study provides an overview of the current state of knowledge regarding the application of AI in ICU and Anesthesia and investigates prospective avenues for future research. Web of Science Core Collection was queried on May 6, 2023, to select articles and reviews regarding AI in ICU and Anesthesia. Subsequently, various analytical tools including Microsoft Excel 2022, VOSviewer (version 1.6.16), Citespace (version 6.2.R2), and an online bibliometric platform were employed to examine the publication year, citations, authors, countries, institutions, journals, and keywords associated with this subject area. This study selected 2196 articles from the literature. focusing on AI-related research within the fields of ICU and Anesthesia, which has increased exponentially over the past decade. Among them, the USA ranked first with 634 publications and had close international cooperation. Harvard Medical School was the most productive institution. In terms of publications, Scientific Reports (impact factor (IF) 4.996) had the most, while Critical Care Medicine (IF 9.296) had the most citations. According to numerous references, researchers may focus on the following research hotspots: “Early Warning Scores”, “Covid-19″, “Sepsis” and “Neural Networks”. “Procalcitonin” and “Convolutional Neural Networks” were the hottest burst keywords. The potential applications of AI in the fields of ICU and Anesthesia have garnered significant attention from scholars, prompting an increase in research endeavors. In addition, it is imperative for various countries and institutions to enhance their collaborative efforts in this area. The research focus in the upcoming years will center on sepsis and coronavirus, as well as the development of predictive models utilizing neural network algorithms to improve well-being and quality of life in surviving patients. Graphical Abstract

At its first meeting, 23 Oct 1940, the Committee on Aviation Medicine (CAM) was tasked with making “…a survey of the present status of the medical and physiological problems pertaining to aviation…[and to] advise regarding the correlation and coordination of such research undertakings as are going forward in various government labs and flying fields, as well as in civilian labs and commercial aviation units. In addition the Committee should suggest the inauguration and development of new studies and investigative projects pertaining to the biological aspects of aviation and necessary to the national defense.” The CAM was comprised of Dr. E.F. DuBois, CAM Chairman (Cornell U) and members Drs. C.K. Drinker (Harvard U), J.F. Fulton (Yale U), W.R. Miles (Yale U) and E.M. Landis (U Va). The CAM and two USN liaison officers (Cdr. J.R. Poppen, Capt. L.E. Griffis) traveled by air from Washington D.C. to eight sites during 12 Nov – 1 Dec 1940: Langley Field; Norfolk Naval Air Base; Guantanamo Bay, Cuba and the Aircraft Carriers Wasp & Ranger; the Pensacola Naval Air Station and School of Aviation Medicine; San Diego Naval Air Base, and the Carrier Saratoga; Wright Field, Aero Medical Research Unit, Dayton; and the Banting Institute and Eglinton Labs, Toronto, Canada. The CAM's report to the National Research Council (NAS Archives: CAM Bulletin, pp. 52–96) made 20 recommendations to improve preparedness for a high‐altitude, high‐speed air war. They recognized that to date, aero medical research had lagged far behind development of aircraft. The limiting factor in flight operations was the pilot's physiology. Larger and better labs were needed at Wright Field, Randolph Field, Pensacola and Washington. Aero medical research should be expedited in civilian labs through immediate federal funding. Research projects the CAM deemed of urgent importance included: development of a suitable O2 breathing apparatus and pressurized aircraft cabins, with more studies in altitude chambers and planes at high‐altitude; mitigation strategies for relief from flyer's aeroembolism and black‐out from G‐forces during acceleration; effects of anoxemia on production of cerebral edema and increased cerebrospinal fluid pressure; effects of protracted breathing of 100% O2; psychological tests; fatigue; critical assessment of the Schneider test as a predictor of human efficiency; usefulness of the EEG in aviation medicine; studies of visual problems; problems of adequate clothing, particularly electrically‐heated clothing; and general studies of recreational and rest facilities at air stations. By 1942, the CAM had expanded into 7 subcommittees to oversee America's growing aero medical research program: Advisory Commission A (on the west coast near aircraft factories) to the CAM in Washington, Acceleration, Oxygen & Anoxia, Decompression Sickness, Visual Problems, Clothing, and Motion Sickness. Other general fields included adrenal physiology, the crash project, explosive decompression and pressure‐cabin aircraft, flying fatigue, injury to flying personnel by anti‐aircraft blasts, first aid aloft, rehabilitation program, and problem of securing information from operation squadrons.Support or Funding InformationUSF

Background:Vaccination is one of the most effective public health interventions. We investigate the impact of vaccination activities for Haemophilus influenzae type b, hepatitis B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serogroup A, rotavirus, rubella, Streptococcus pneumoniae, and yellow fever over the years 2000–2030 across 112 countries.Methods:Twenty-one mathematical models estimated disease burden using standardised demographic and immunisation data. Impact was attributed to the year of vaccination through vaccine-activity-stratified impact ratios.Results:We estimate 97 (95%CrI[80, 120]) million deaths would be averted due to vaccination activities over 2000–2030, with 50 (95%CrI[41, 62]) million deaths averted by activities between 2000 and 2019. For children under-5 born between 2000 and 2030, we estimate 52 (95%CrI[41, 69]) million more deaths would occur over their lifetimes without vaccination against these diseases.Conclusions:This study represents the largest assessment of vaccine impact before COVID-19-related disruptions and provides motivation for sustaining and improving global vaccination coverage in the future.Funding:VIMC is jointly funded by Gavi, the Vaccine Alliance, and the Bill and Melinda Gates Foundation (BMGF) (BMGF grant number: OPP1157270 / INV-009125). Funding from Gavi is channelled via VIMC to the Consortium’s modelling groups (VIMC-funded institutions represented in this paper: Imperial College London, London School of Hygiene and Tropical Medicine, Oxford University Clinical Research Unit, Public Health England, Johns Hopkins University, The Pennsylvania State University, Center for Disease Analysis Foundation, Kaiser Permanente Washington, University of Cambridge, University of Notre Dame, Harvard University, Conservatoire National des Arts et Métiers, Emory University, National University of Singapore). Funding from BMGF was used for salaries of the Consortium secretariat (authors represented here: TBH, MJ, XL, SE-L, JT, KW, NMF, KAMG); and channelled via VIMC for travel and subsistence costs of all Consortium members (all authors). We also acknowledge funding from the UK Medical Research Council and Department for International Development, which supported aspects of VIMC's work (MRC grant number: MR/R015600/1).JHH acknowledges funding from National Science Foundation Graduate Research Fellowship; Richard and Peggy Notebaert Premier Fellowship from the University of Notre Dame. BAL acknowledges funding from NIH/NIGMS (grant number R01 GM124280) and NIH/NIAID (grant number R01 AI112970). The Lives Saved Tool (LiST) receives funding support from the Bill and Melinda Gates Foundation.This paper was compiled by all coauthors, including two coauthors from Gavi. Other funders had no role in study design, data collection, data analysis, data interpretation, or writing of the report. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Background: The intensive care unit (ICU) is a fast-paced setting, in which physicians from different specialties work. The goal of this study is to understand whether characteristics of medical malpractice claims occurring in the ICU differ by physician specialty. Methods: A retrospective cohort study was performed using a national database called the Comparative Benchmarking System, which is operated by Harvard’s malpractice insurer. Claims were included if the harm events occurred in the ICU and closed between 2007-2016. Claims were analyzed according to physician specialty of the “primary responsible provider,” which was the physician most directly involved in the harm event. Patient-, provider- and claim-level characteristics were compared among the 6 most common physician specialties that were identified as “primary responsible provider.” Multivariable regression was performed to identify factors associated with claim payment. Results: Of 54,772 claims, 1,113 resulted from harm events in the ICU, of which 843 involved the following physician specialties: internal medicine (305), cardiology (163), pulmonary medicine (149), general surgery (98), neurology (97) and anesthesia (31). The minority of claims across physician specialties originated in academic medical centers (<30%). The most common severity of harm was death (Range 42-72%, P = 0.0001). The frequency with which claims involved procedures varied by physician specialty (Range 24-84%, P < 0.0001). The 3 most common contributing factors (patient assessment, selection/management of therapies and communication among providers) did not differ by physician specialty. In multivariable regression, claims that were procedure-related were statistically more likely to result in payment (Odds Ratio 2.29, 95% Confidence Interval 1.64-3.20), after adjusting for physician specialty. Conclusions: There were few unexpected differences in malpractice claims occurring in the ICU by physician specialty. Prevention efforts could focus on procedures, regardless of physician specialty, including: 1) maintaining procedural skills, 2) framing procedural risks well and 3) accurately describing procedural complications after they happen.

IntroductionThis article addresses the experience of designing and conducting life-writing workshops for a group of clients with severe mental illness; the aim of this pilot study was to begin to determine whether such writing about the self can aid in individual ‘recovery’, as that term is understood by contemporary health professionals. A considerable amount has been written about the potential of creative writing in mental health therapy; the authors of this article provide a brief summary of that literature, then of the concept of ‘recovery’ in a psychology and arts therapy context. There follows a first-hand account by one of the authors of being an arts therapy workshop facilitator in the role of a creative practitioner. This occurred in consultation with, and monitored by, experienced mental health professionals. Life-Writing as ‘Therapeutic’ Life-story or life-writing can be understood in this context as involving more than disclosure or oral expression of a subject’s ‘story’ as in psycho-therapy – life-story is understood as a written, structured narrative. In 2001, Wright and Chung published a review of the literature in which they claimed that writing therapy had been “restimulated by the development of narrative approaches” (278). Pennebaker argues that “catharsis or the venting of emotions” without “cognitive processing” has little therapeutic value and people need to “build a coherent narrative that explains some past experience” in order to benefit from writing” (Pennebaker, Telling Stories 10–11). It is claimed in the Clinical Psychology Review that life-writing has the therapeutic benefits of, for example, “striking physical health and behaviour change” (Esterling et al. 84). The reasons are still unclear, but it is possible that the cognitive and linguistic processing of problematic life-events through narrative writing may help the subject assimilate such problems (Alschuler 113–17). As Pennebaker and Seagal argue in the Journal of Clinical Psychology, the life-writing processallows one to organise and remember events in a coherent fashion while integrating thoughts and feelings ... This gives individuals a sense of predictability and control over their lives. Once an experience has structure and meaning, it would follow that the emotional effects of that experience are more manageable. (1243)It would seem reasonable to suggest that life-writing which constructs a positive recovery narrative can have a positive therapeutic effect, providing a sense of agency, connectedness and creativity, in a similar, integrating manner. Humans typically see their lives as stories. Paul Eakin stresses the link between narrative and identity in both this internal life-story and in outwardly constructed autobiography:narrative is not merely a literary form but a mode of phenomenological and cognitive self-experience, while self – the self of autobiographical discourse - does not necessarily precede its constitution in narrative. (Making Selves 100)So both a self-in-time and a socially viable identity may depend on such narrative. The term ‘dysnarrativia’ has been coined to describe the documented inability to construct self-narrative by those suffering amnesia, autism, severe child abuse or brain damage. The lack of ability to achieve narrative construction seems to be correlated with identity disorders (Eakin, Fictions in Autobiography 124). (For an overview of the current literature on creative and life-writing as therapy see Murphy & Neilsen). What is of particular relevance to university creative writing practitioners/teachers is that there is evidence, for example from Harvard psychiatrist Judith Herman and creative writing academic Vicki Linder, that life-narratives are more therapeutically effective if guided to be written according to fundamental ‘effective writing’ aesthetic conventions – such as having a regard to coherent structure in the narrative, the avoidance of cliché, practising the ‘demonstrate don’t state’ dictum, and writing in one’s own voice, for example. Defining ‘Recovery’There remains debate as to the meaning of recovery in the context of mental health service delivery, but there is agreement that recovery entails significantly more than symptom remission or functional improvement (Liberman & Kopelowicz). In a National Consensus Statement, the Substance Abuse and Mental Health Services Administration (SAMHSA) unit of the US Department of Health and Human Services in 2005 described recovery (in general terms) as being achieved by the enabling of a person with a mental illness to live meaningfully in a chosen community, while also attempting to realize individual potential. ‘Recovery’ as a central concept behind rehabilitation can be understood both as objective recovery – that is, in terms of noting a reduction in objective indicators of illness and disability (such as rates of hospital usage or unemployment) and a greater degree of social functioning – and also as subjective recovery. Subjective recovery can be ascertained by listening closely to what clients themselves have said about their own experiences. It has been pointed out (King, Lloyd & Meehan 2) that there is not always a correspondence between objective indicators of recovery and the subjective, lived experience of recovery. The experience of mental illness is not just one of symptoms and disability but equally importantly one of major challenge to sense of self. Equally, recovery from mental illness is experienced not just in terms of symptoms and disability but also as a recovery of sense of self … Recovery of sense of self and recovery with respect to symptoms and disability may not correspond. (King, Lloyd & Meehan; see also Davidson & Strauss)Symptoms of disability can persist, but a person can have a much stronger sense of self or empowerment – that is still recovery. Illness dislocates the sense of self as part of a community and of a self with skills and abilities. Restoring this sense of empowerment is an aim of arts therapy. To put it another way, recovery is a complex process by which a client with a mental illness develops a sense of identity and agency as a citizen, as distinct from identification with illness and disability and passivity as a ‘patient’. The creative arts have gone well beyond being seen as a diversion for the mentally ill. In a comprehensive UK study of creative arts projects for clients with mental illness, Helen Spandler et al. discovered strong evidence that participation in creative activity promoted a sense of purpose and meaning, and assisted in “rediscovering or rebuilding an identity within and beyond that of someone with mental health difficulties” (795). Recovery is aided by people being motivated to achieve self-confidence through mastery and competence; by learning and achieving goals. Clearly this is where arts therapy could be expected or hoped to be effective. The aim of the pilot study was not to measure ‘creativity’, but whether involvement in what is commonly understood as a creative process (life-writing) can have flow-on benefits in terms of the illness of the workshop participant. The psychologists involved, though more familiar with visual arts therapy (reasonably well-established in Australia – in 2006, the ANZAT began publishing the Australian and New Zealand Journal of Art Therapy), thought creative writing could also be valuable. Preparation for and Delivery of the Workshops I was acutely aware that I had no formal training in delivering a program to clients with mental health illness. I was counselled during several meetings with experienced psychologists and a social worker that the participants in the three workshops over two weeks would largely be people who had degrees of difficulty in living independently, and could well have perceptual problems, could misjudge signals from outside and inside the group, and be on medication that could affect their degree of engagement. Some clients could have impaired concentration and cognition, and a deficit in volition. Participants needed to be free to leave and rejoin the workshops during the afternoon sessions. Attendance might well fall as the workshops progressed. Full ethical clearance was attained though the University of Queensland medical faculty (after detailed description of the content and conduct of the proposed workshops) and consent forms prepared for participants. My original workshop ‘kit’ to be distributed to participants underwent some significant changes as I was counselled and prepared for the workshops. The major adjustment to my usual choice of material and approach was made in view of the advice that recounting traumatic events can have a negative effect on some patients – at least in the short term. For the sake of both the individuals and the group as a whole this was to be avoided. I changed my initial emphasis on encouraging participants to recount their traumatic experiences in a cathartic way (as suggested by the narrative psychology literature), to encouraging them to recount positive narratives from their lives – narratives of ‘recovery’ – as I explain in more detail below. I was also counselled that clients with mental health problems might dwell on retelling their story – their case history – rather than reflecting upon it or using their creative and imaginative ability to shape a life-story that was not a catalogue of their medical history. Some participants did demonstrate a desire to retell their medical history or narrative – including a recurring theme of the difficulty in gaining continuity with one trusted medical professional. I gently guided these participants back to fashioning a different and more creative narrative, with elements of scene creation, description and so on, by my first listening intently to and acknowledging their medical narrative for a few minutes and then suggesting we try to move beyond that. This simple strategy was largely successful; several participants commented explicitly that they were tired of having to retell their medical history to each new health professional they encountered in the hospital system, for example. My principal uncertainty was whether I should conduct the workshops at the same level of complexity that I had in the past with groups of university students or community groups. While in both of those cohorts there will often be some participants with mental health issues, for the most part this possibility does not affect the level or kind of content of material discussed in workshops. However, within this pilot group all had been diagnosed with moderate to severe mental illness, mostly schizophrenia, but also bipolar disorder and acute depression and anxiety disorders. The fact that my credentials were only as a published writer and teacher of creative writing, not as a health professional, was also a strong concern to me. But the clients readily accepted me as someone who knew the difficulty of writing well and getting published. I stressed to them that my primary aim was to teach effective creative writing as an end in itself. That it might be beneficial in health terms was secondary. It was a health professional who introduced me and briefly outlined the research aims of the workshop – including some attempt to measure qualitatively any possible benefits. It was my impression that the participants did not have a diminished sense of my usefulness because I was not a health professional. Their focus was on having the opportunity to practice creative writing and/or participate in a creative group activity. As mentioned above, I had prepared a workshop ‘kit’ for the participants of 15 pages. It contained the usual guidelines for effective writing – extracts from professional writers’ published work (including an extract from my own published work – a matter of equity, since they were allowing me to read their work), and a number of writing exercises (using description, concrete and abstract words, narrative point of view, writing in scenes, show don’t tell). The kit contained extracts from memoirs by Hugh Lunn and Bill Bryson, as well as a descriptive passage from Charles Dickens. An extract from Inga Clendinnen’s 2006 account in Agamemnon’s Kiss: selected essays of her positive interaction with fellow cancer patients (a narrative with the underlying theme of recovery) was also valuable for the participants. I stressed to the group that this material was very similar to that used with beginning writers among university students. I described the importance of life-writing as follows: Life-writing is simply telling a story from your life and perhaps musing or commenting on it at the same time. When you write a short account of something chosen from your life, you are making a pattern, using your memory, using your powers of description – you are being creative. You are being a story-teller. And story-telling is one very important thing that makes us humans different from all other animals – and it is a way in which we find a lot of meaning in our lives.My central advice in the kit was: “Just try to be as honest as you can – and to remember as well as you can … being honest and direct is both the best and the easiest way to write memoir”. The only major difference between my approach with these clients and that with a university class was in the selection of possible topics offered. In keeping with the advice of the psychologists who were experts in the theory of ‘recovery’, the topics were predominantly positive, though one or two topics gave the opportunity to recount and/or explore a negative experience if the participant wanted to do so: A time when I was able to help another personA time when I realised what really mattered in lifeA time when I overcame a major difficultyA time when I felt part of a group or teamA time when I knew what I wanted to do with my lifeA time when someone recognised a talent or quality of mineA time I did something that I was proud of A time when I learned something important to meA memorable time when I lived in a certain house or suburbA story that begins: “Looking back, I now understand that …”The group expressed satisfaction with these topics, though they had the usual writing students’ difficulty in choosing the one that best suited them. In the first two workshops we worked our way through the kit; in the third workshop, two weeks later, each participant read their own work to the group and received feedback from their peers and me. The feedback was encouraged to be positive and constructive, and the group spontaneously adopted a positive reinforcement approach, applauding each piece of writing. Workshop DynamicsThe venue for the workshops was a suburban house in the Logan area of Brisbane used as a drop-in centre for those with mental illness, and the majority of the participants would be familiar with it. It had a large, breezy deck on which a round-table configuration of seating was arranged. This veranda-type setting was sheltered enough to enable all to be heard easily and formal enough to emphasise a learning event was taking place; but it was also open enough to encourage a relaxed atmosphere. The week before the first workshop I visited the house to have lunch with a number of the participants. This gave me a sense of some of the participants’ personalities and degree of engagement, the way they related to each other, and in turn enabled them to begin to have some familiarity with me and ask questions. As a novice at working with this kind of client, I found this experience extremely valuable, especially as it suggested that a relatively high degree of communication and cognition would be possible, and it reduced the anxiety I had about pitching the workshops at an appropriate level. In the course of the first workshop, the most initially sceptical workshop participant ended up being the most engaged contributor. A highly intelligent woman, she felt it would be too upsetting to write about negative events, but ultimately wrote a very effective piece about the empowerment she gained from caring for a stray cat and locating the owner. Her narrative also expressed her realisation that the pet was partly a replacement for spending time with her son, who lived interstate. Another strong participant previously had written a book-length narrative of her years of misdiagnoses and trauma in the hospital system before coming under the care of her present health professionals. The participant who had the least literacy skills was accepted by the group as an equal and after a while contributed enthusiastically. Though he refused to sign the consent form at the outset, he asked to do so at the close of the first afternoon. The workshop was comprised of clients from two health provider organisations; at first the two groups tended to speak with those they already knew (as in any such situation in the broader community), but by the third workshop a sense of larger group identity was being manifested in their comments, as they spoke of what ‘the group’ would like in the future – such as their work being published in some form. It was clear that, as in a university setting, part of the beneficial effect of the workshops came from group and face to face interaction. It would be more difficult to have this dimension of benefit achieved via a web-based version of the workshops, though a chat room scenario would presumably go some way towards establishing a group feeling. Web-based delivery would certainly suit participants who lacked mobility or who lived in the regions. Clearly the Internet is a vital social networking tool, and an Internet-based version of the workshops could well be attempted in the future. My own previous experience of community digital storytelling workshops (Neilsen, Digital Storytelling as Life-writing) suggests that a high degree of technical proficiency can not be expected across such a cohort; but with adequate technical support, a program (the usual short, self-written script, recorded voice-over and still images scanned from the participants’ photo albums, etc) could make digital storytelling a further dimension of therapeutic life-writing for clients with mental illness. One of the most useful teaching techniques in a class room setting is the judicious use of humour – to create a sense of sharing a perspective, and simply to make material more entertaining. I tested the waters at the outset by referring to the mental health worker sitting in the background, and declaring (with some comic exaggeration) my concern that if I didn’t run the workshop well he would report adversely on me. There was general laughter and this expression of my vulnerability seemed to defuse anxiety on the part of some participants. As the workshop progressed I found I could use both humorous extracts of life-writing and ad hoc comic comments (never at the expense of a participant) as freely as in a university class. Participants made some droll comments in the overall context of encouraging one another in their contributions, both oral and written. Only one participant exhibited some temporary distress during one of the workshops. I was allowing another participant the freedom to digress from the main topic and the participant beside me displayed agitation and sharply demanded we get back to the point. I apologised and acknowledged I had not stayed as focused as I should and returned to the topic. I suspect I had a fortunate first experience of such arts therapy workshops – and that this was largely due to the voluntary nature of the study and that most of the participants brought a prior positive experience of the workshop scenario, and prior interest in creative writing, to the workshops. Outcomes A significantly positive outcome was that only one of the nine participants missed a session (through ill-health) and none left during workshops. The workshops tended to proceed longer than the three hours allotted on each occasion. Post-workshop interviews were conducted by a psychologist with the participants. Detailed data is not available yet – but there was a clear indication by almost all participants that they felt the workshops were beneficial and that they would like to participate in further workshops. All but one agreed to have their life-writing included in a newsletter produced by one of the sponsors of the workshops. The positive reception of the workshops by the participants has encouraged planning to be undertaken for a wide-ranging longitudinal study by means of a significant number of workshops in both life-writing and visual arts in more than one city, conducted by a team of health professionals and creative practitioners – this time with sophisticated measurement instruments to gauge the effectiveness of art therapy in aiding ‘recovery’. Small as the workshop group was, the pilot study seems to validate previous research in the UK and US as we have summarised above. The indications are that significant elements of recovery (in particular, feelings of enhanced agency and creativity), can be achieved by life-writing workshops that are guided by creative practitioners; and that it is the process of narrative construction within life-writing that engages with or enhances a sense of self and identity. NoteWe are indebted, in making the summary of the concept of ‘recovery’ in health science terms, to work in progress by the following research team: Robert King, Tom O'Brien and Claire Edwards (School of Medicine, University of Queensland), Margot Schofield and Patricia Fenner (School of Public Health, Latrobe University). We are also grateful for the generous assistance of both this group and Seiji Humphries from the Richmond Queensland Fellowship, in providing preparation for the workshops. ReferencesAlschuler, Mari. “Lifestories – Biography and Autobiography as Healing Tools for Adults with Mental Illness.” Journal of Poetry Therapy 11.2 (1997): 113–17.Davidson, Larry and John Strauss. “Sense of Self in Recovery from Severe Mental Illness.” British Journal of Medical Psychology 65 (1992): 31–45.Eakin, Paul. Fictions in Autobiography: Studies of the Art of Self-Invention. Princeton: Princeton UP, 1985.———. How Our Lives Become Stories: Making Selves. Ithaca: Cornell UP, 1999.Esterling, B.A., L. L’Abate., E.J. Murray, and J.W. Pennebaker. “Empirical Foundations for Writing in Prevention and Psychotherapy: Mental and Physical Health Outcomes.” Clinical Psychology Review 19.1 (1999): 79–96.Herman, Judith. Trauma and Recovery: The Aftermath of Violence - from Domestic Abuse to Political Terror. New York: Basic Books, 1992.King, Robert, Chris Lloyd, and Tom Meehan. Handbook of Psychosocial Rehabilitation. Oxford: Blackwell Publishing, 2007.Liberman, Robert, and Alex Kopelowicz. “Recovery from Schizophrenia: A Criterion-Based Definition.” In Ralph, R., and P. Corrigan (eds). Recovery in Mental Illness: Broadening Our Understanding of Wellness. Washington, DC: APA, 2005.Linder, Vicki. “The Tale of two Bethanies: Trauma in the Creative Writing Classroom.” New Writing: The International Journal for the Practice and Theory of Creative Writing 1.1 (2004): 6–14Murphy, Ffion, and Philip Neilsen. “Recuperating Writers – and Writing: The Potential of Writing Therapy.” TEXT 12.1 (Apr. 2008). ‹http://www.textjournal.com.au/april08/murphy_neilsen.htm›.Neilsen, Philip. “Digital Storytelling as Life-Writing: Self-Construction, Therapeutic Effect, Textual Analysis Leading to an Enabling ‘Aesthetic’ for the Community Voice.” ‹http://www.speculation2005.qut.edu.au/papers/Neilsen.pdf›.Pennebaker, James W., and Janel D. Seagal. “Forming a Story: The Health Benefits of Narrative.” Journal of Clinical Psychology, 55.10 (1999): 1243–54.Pennebaker, James W. “Telling Stories: The Health Benefits of Narrative.” Literature and Medicine 19.1 (2000): 3–18.Spandler, H., J. Secker, L. Kent, S. Hacking, and J. Shenton. “Catching Life: The Contribution of Arts Initiatives to ‘Recovery’ Approaches in Mental Health.” Journal of Psychiatric and Mental Health Nursing 14.8 (2007): 791–799.Wright, Jeannie, and Man Cheung Chung. “Mastery or Mystery? Therapeutic Writing: A Review of the Literature.” British Journal of Guidance and Counselling, 29.3 (2001): 277–91.

Introduction I have this somewhat diffuse concern that at some point, I am in an appointment procedure ... and people say: ‘He has to ... be on social media, [and] have followers ..., because otherwise he can’t say anything about the field of research, otherwise he won’t identify with it … and we need a direct connection to legitimise our discipline in the population!’ And this is where I think: ‘For God’s sake! No, I really don’t want that.’ (Postdoc) Social media such as Facebook or Twitter have become an integral part of many people’s everyday lives and have introduced severe changes to the ways we communicate with each other and about ourselves. Presenting ourselves on social media and creating different online personas has become a normal practice (Vorderer et al. 270). While social media such as Facebook were at first mostly used to communicate with friends and family, they were soon also used for work-related communication (Cardon and Marshall). Later, professional networks such as LinkedIn, which focus on working relations and career management and special interest networks, such as the academic social networking sites (ASNS) Academia.edu and ResearchGate, catering specifically to academic needs, emerged. Even though social media have been around for more than 15 years now, academics in general and German academics in particular are rather reluctant users of these tools in a work-related context (König and Nentwich 175; Lo 155; Pscheida et al. 1). This is surprising as studies indicate that the presence and positive self-portrayal of researchers in social media as well as the distribution of articles via social networks such as Academia.edu or ResearchGate have a positive effect on the visibility of academics as well as the likelihood of their articles being read and cited (Eysenbach; Lo 192; Terras). Gruzd, Staves, and Wilk even assume that the presence in online media could become a relevant criterion in the allocation of scientific jobs. Science is a field where competition for long-term positions is high. In 2017, only about 17% of all scientific personnel in Germany had permanent positions, and of these 10% were professors (Federal Statistical Office 32). Having a professorship is therefore the best shot at obtaining a permanent position in the scientific field. However, the average vocational age is 40 (Zimmer et al. 40), which leads to a long phase of career-related uncertainty. Directing attention to yourself by acquiring knowledge in the use of social media for professional self-representation might offer a career advantage when trying to obtain a professorship. At the same time, social media, which have been praised for giving a voice to the unheard, become a tool for the exclusion of scholars who might not want or be able to use these tools as part of their work and career-related communication, and might remain unseen and unheard. The author obtained current data on this topic while working on a project on Mediated Scholarly Communication in Post-Normal and Traditional Science under the project lead of Corinna Lüthje. The project was funded by the German Research Foundation (DFG). In the project, German-speaking scholars were interviewed about their work-related media usage in qualitative interviews. Among them were users and non-users of social media. For this article, 16 interviews with communication scholars (three PhD students, six postdocs, seven professors) were chosen for a closer analysis, because of all the interviewees they described the (dis)advantages of career-related social media use in the most detail, giving the deepest insights into whether social media contribute to a social exclusion of academics or not. How to Define Social Exclusion (in Academia)? The term social exclusion describes a separation of individuals or groups from mainstream society (Walsh et al.). Exclusion is a practice which implies agency. It can be the result of the actions of others, but individuals can also exclude themselves by choosing not to be part of something, for example of social media and the communication taking part there (Atkinson 14). Exclusion is an everyday social practice, because wherever there is an in-group there will always be an out-group. This is what Bourdieu calls distinction. Symbols and behaviours of distinction both function as signs of demarcation and belonging (Bourdieu, Distinction). Those are not always explicitly communicated, but part of people’s behaviour. They act on a social sense by telling them how to behave appropriately in a certain situation. According to Bourdieu, the practical sense is part of the habitus (Bourdieu, The Logic of Practice). The habitus generates patterns of action that come naturally and do not have to be reflected by the actor, due to an implicit knowledge that is acquired during the course of (group-specific) socialisation. For scholars, the process of socialisation in an area of research involves the acquisition of a so-called disciplinary self-image, which is crucial to building a disciplinary identity. In every discipline it contains a dominant disciplinary self-image which defines the scientific perspectives, practices, and even media that are typically used and therefore belong to the mainstream of a discipline (Huber 24). Yet, there is a societal mainstream outside of science which scholars are a part of. Furthermore, they have been socialised into other groups as well. Therefore, the disciplinary mainstream and the habitus of its members can be impacted upon by the societal mainstream and other fields of society. For example, societally mainstream social media, such as Twitter or Facebook, focussing on establishing and sustaining social connections, might be used for scholarly communication just as well as ASNS. The latter cater to the needs of scholars to not just network with colleagues, but to upload academic articles, share and track them, and consume scholarly information (Meishar-Tal and Pieterse 17). Both can become part of the disciplinary mainstream of media usage. In order to define whether and how social media contribute to forms of social exclusion among communication scholars, it is helpful to first identify in how far their usage is part of the disciplinary mainstream, and what their including features are. In contrast to this, forms of exclusion will be analysed and discussed on the basis of qualitative interviews with communication scholars. Including Features of Social Media for Communication Scholars The interviews for this essay were first conducted in 2016. At that time all of the 16 communication scholars interviewed used at least one social medium such as ResearchGate (8), Academia.edu (8), Twitter (10), or Facebook (11) as part of their scientific workflow. By 2019, all of them had a ResearchGate and 11 an Academia.edu account, 13 were on Twitter and 13 on Facebook. This supports the notion of one of the professors, who said that he registered with ResearchGate in 2016 because "everyone’s doing that now!” It also indicates that the work-related presence especially on ResearchGate, but also on other social media, is part of the disciplinary mainstream of communication science. The interviewees figured that the social media they used helped them to increase their visibility in their own community through promoting their work and networking. They also mentioned that they were helpful to keep up to date on the newest articles and on what was happening in communication science in general. The usage of ResearchGate and Academia.edu focussed on publications. Here the scholars could, as one professor put it, access articles that were not available via their university libraries, as well as “previously unpublished articles”. They also liked that they could see "what other scientists are working on" (professor) and were informed via e-mail "when someone publishes a new publication" (PhD student). The interviewees saw clear advantages to their registration with the ASNS, because they felt that they became "much more visible and present" (postdoc) in the scientific community. Seven of the communication scholars (two PhD students, three postdocs, two professors) shared their publications on ResearchGate and Academia.edu. Two described doing cross-network promotion, where they would write a post about their publications on Twitter or Facebook that linked to the full article on Academia.edu or ResearchGate. The usage of Twitter and especially Facebook focussed a lot more on accessing discipline-related information and social networking. The communication scholars mentioned that various sections and working groups of professional organisations in their research field had accounts on Facebook, where they would post news. A postdoc said that she was on Facebook "because I get a lot of information from certain scientists that I wouldn’t have gotten otherwise". Several interviewees pointed out that Twitter is "a place where you can find professional networks, become a part of them or create them yourself" (professor). On Twitter the interviewees explained that they were rather making new connections. Facebook was used to maintain and intensify existing professional relationships. They applied it to communicate with their local networks at their institute, just as well as for international communication. A postdoc and a professor both mentioned that they perceived that Scandinavian or US-American colleagues were easier to contact via Facebook than via any other medium. One professor described how he used Facebook at international conferences to arrange meetings with people he knew and wanted to meet. But to him Facebook also catered to accessing more personal information about his colleagues, thus creating a new "mixture of professional respect for the work of other scientists and personal relationships", which resulted in a "new kind of friendship". Excluding Features of Social Media for Communication Scholars While everyone may create an Academia.edu, Facebook, or Twitter account, ResearchGate is already an exclusive network in itself, as only people working in a scientific field are allowed to join. In 2016, eight of the interviewees and in 2019 all of them had signed up to ResearchGate. So at least among the communication scholars, this did not seem to be an excluding factor. More of an issue was for one of the postdocs that she did not have the copyright to upload her published articles on the ASNS and therefore refrained from uploading them. Interestingly enough, this did not seem to worry any of the other interviewees, and concerns were mostly voiced in relation to the societal mainstream social media. Although all of the interviewees had an account with at least one social medium, three of them described that they did not use or had withdrawn from using Facebook and Twitter. For one professor and one PhD student this had to do with the privacy and data security issues of these networks. The PhD student said that she did not want to be reminded of what she “tweeted maybe 10 years ago somewhere”, and also considered tweeting to be irrelevant in her community. To her, important scientific findings would rather be presented in front of a professional audience and not so much to the “general public”, which she felt was mostly addressed on social media. The professor mentioned that she had been on Facebook since she was a postdoc, but decided to stop using the service when it introduced new rules on data security. On one hand she saw the “benefits” of the network to “stay informed about what is happening in the community”, and especially “in regards to the promotion of young researchers, since some of the junior research groups are very active there”. On the other she found it problematic for her own time management and said that she received a lot of the posted information via e-mail as well. A postdoc mentioned that he had a Facebook account to stay in contact with young scholars he met at a networking event, but never used it. He would rather connect with his colleagues in person at conferences. He felt people would just use social media to “show off what they do and how awesome it is”, which he did not understand. He mentioned that if this “is how you do it now … I don't think this is for me.” Another professor described that Facebook "is the channel for German-speaking science to generate social traffic”, but that he did not like to use it, because “there is so much nonsense ... . It’s just not fun. Twitter is more fun, but the effect is much smaller", as bigger target groups could be reached via Facebook. The majority of the interviewees did not use mainstream social media because they were intrinsically motivated. They rather did it because they felt that it was expected of them to be there, and that it was important for their career to be visible there. Many were worried that they would miss out on opportunities to promote themselves, network, and receive information if they did not use Twitter or Facebook. One of the postdocs mentioned, for example, that she was not a fan of Twitter and would often not know what to write, but that the professor she worked for had told her she needed to tweet regularly. But she did see the benefits as she said that she had underestimated the effect of this at first: “I think, if you want to keep up, then you have to do that, because people don’t notice you.” This also indicates a disciplinary mainstream of social media usage. Conclusion The interviews indicate that the usage of ResearchGate in particular, but also of Academia.edu and of the societal mainstream social media platforms Twitter and Facebook has become part of the disciplinary mainstream of communication science and the habitus of many of its members. ResearchGate mainly targets people working in the scientific field, while excluding everyone else. Its focus on publication sharing makes the network very attractive among its main target group, and serves at the same time as a symbol of distinction from other groups (Bourdieu, Distinction). Yet it also raises copyright issues, which led at least one of the participants to refrain from using this option. The societal mainstream social media Twitter and Facebook, on the other hand, have a broader reach and were more often used by the interviewees for social networking purposes than the ASNS. The interviewees emphasised the benefits of Twitter and Facebook for exchanging information and connecting with others. Factors that led the communication scholars to refrain from using the networks, and thus were excluding factors, were data security and privacy concerns; disliking that the networks were used to “show off”; as well as considering Twitter and Facebook as unfit for addressing the scholarly target group properly. The last statement on the target group, which was made by a PhD student, does not seem to represent the mainstream of the communication scholars interviewed, however. Many of them were using Twitter and Facebook for scholarly communication and rather seemed to find them advantageous. Still, this perception of the disciplinary mainstream led to her not using them for work-related purposes, and excluding her from their advantages. Even though, as one professor described it, a lot of information shared via Facebook is often spread through other communication channels as well, some can only be received via the networks. Although social media are mostly just a substitute for face-to-face communication, by not using them scholars will miss out on the possibilities of creating the “new kind of friendship” another professor mentioned, where professional and personal relations mix. The results of this study show that social media use is advantageous for academics as they offer possibilities to access exclusive information, form new kinds of relations, as well as promote oneself and one’s publications. At the same time, those not using these social media are excluded and might experience career-related disadvantages. As described in the introduction, academia is a competitive environment where many people try to obtain a few permanent positions. By default, this leads to processes of exclusion rather than integration. Any means to stand out from competitors are welcome to emerging scholars, and a career-related advantage will be used. If the growth in the number of communication scholars in the sample signing up to social networks between 2016 to 2019 is any indication, it is likely that the networks have not yet reached their full potential as tools for career advancement among scientific communities, and will become more important in the future. Now one could argue that the communication scholars who were interviewed for this essay are a special case, because they might use social media more actively than other scholars due to their area of research. Though this might be true, studies of other scholarly fields show that social media are being applied just the same (though maybe less extensively), and that they are used to establish cooperations and increase the amount of people reading and citing their publications (Eysenbach; Lo 192; Terras). The question is whether researchers will be able to avoid using social media when striving for a career in science in the future, which can only be answered by further research on the topic. References Atkinson, A.B. “Social Exclusion, Poverty and Unemployment.” Exclusion, Employment and Opportunity. Eds. A.B. Atkinson and John Hills. London: London School of Economics and Political Science, 1998. 1–20. Bourdieu, Pierre. Distinction: A Social Critique of the Judgement of Taste. Cambridge, Massachusetts: Harvard UP, 1984. ———. The Logic of Practice. Stanford, California: Stanford UP, 1990. Cardon, Peter W., and Bryan Marshall. “The Hype and Reality of Social Media Use for Work Collaboration and Team Communication.” International Journal of Business Communication 52.3 (2015): 273–93. Eysenbach, Gunther. “Can Tweets Predict Citations? Metrics of Social Impact Based on Twitter and Correlation with Traditional Metrics of Scientific Impact.” Journal of Medical Internet Research 13.4 (2011): e123. Federal Statistical Office [Statistisches Bundesamt]. Hochschulen auf einen Blick: Ausgabe 2018: 2018. 27 Dec. 2019 <https://www.destatis.de/Migration/DE/Publikationen/Thematisch/BildungForschungKultur/Hochschulen/BroschuereHochschulenBlick.html>. Gruzd, Anatoliy, Kathleen Staves, and Amanda Wilk. “Tenure and Promotion in the Age of Online Social Media.” Proceedings of the American Society for Information Science and Technology 48.1 (2011): 1–9. Huber, Nathalie. Kommunikationswissenschaft als Beruf: Zum Selbstverständnis von Professoren des Faches im deutschsprachigen Raum. 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The Verdict: Is Blogging or Tweeting about Research Papers Worth It? LSE Impact Blog, 2012. 28 Dec. 2019 <https://blogs.lse.ac.uk/impactofsocialsciences/2012/04/19/blog-tweeting-papers-worth-it/>. Vorderer, Peter, et al. “Der mediatisierte Lebenswandel: Permanently Online, Permanently Connected.” Publizistik 60.3 (2015): 259–76. Walsh, Kieran, Thomas Scharf, and Norah Keating. “Social Exclusion of Older Persons: a Scoping Review and Conceptual Framework.” European Journal of Ageing 14.1 (2017): 81–98. Zimmer, Annette, Holger Krimmer, and Freia Stallmann. “Winners among Losers: Zur Feminisierung der deutschen Universitäten.” Beiträge zur Hochschulforschung 4.28 (2006): 30-57. 17 Mar. 2020 <https://www.uni-bremen.de/fileadmin/user_upload/sites/zentrale-frauenbeauftragte/Berichte/4-2006-zimmer-krimmer-stallmann.pdf>.