Journal articles on the topic 'IED Scout'

Abstract Background The main issue to validating new molecules in the field of IBD is insufficient patient enrollment into clinical trials, resulting in premature trials termination and cost increase. CT-SCOUT™ platform is a web-based solution to help clinicians to pre-screen potential candidates and facilitating the coordination of the research team. Our aim was to compare the number of patients enrolled in IBD clinical trials in sites equipped or not with CT-SCOUT™. Methods We conducted a prospective, multicenter, open-label, observational study in sites participating to phase 3 trials evaluating the efficacy and safety of etrolizumab in ulcerative colitis (UC, Hickory) and in Crohn’s disease (CD, Bergamot). Recruitment figures were provided by the sponsor, and we considered the 21 French sites equipped with CTscout and 134 sites in other countries not equipped with CT-SCOUT™. The primary endpoint was the mean number of patients randomised per site in both trials. Secondary endpoints included a mean number of patients randomised in each study. Patients screened and those finally randomised were compared in sites equipped and non-equipped using one-way ANOVA followed by post-hoc Tukey test and Mann–Whitney test. Results During the observational period of 40 months (September 2015–December 2018), 644 and 289 patients were screened and randomised in Hickory and/or Gardenia, respectively. There were 307 and 149 patients in 78 sites for Hickory, and 337 and 140 patients for Bergamot in 102 sites. The mean numbers of screened and randomised patients in CT-SCOUT™ equipped sites vs. non-equipped are given in the table. The mean number of patients randomised in Hickory in CT-SCOUT™ sites increased by 4.0 folds as compared with non-equipped sites (p < 0.001). The mean number of patients randomised in Bergamot in CT-SCOUT™ equipped sites has been increased by 1.9-folds as compared with non-equipped sites (p = 0.009). Conclusion This multicentric study demonstrated a significant increase in patient recruitment in IBD clinical trials. Randomisation rates were twice to four times higher in equipped sites compared with non-equipped ones. CT-SCOUT™ appears to be a promising digital solution to the global issue of patient enrollment in clinical trials.

Abstract Background The main issue when validating new molecules in the field of IBD is insufficient patient recruitment into clinical trials, resulting in a considerable delay and cost increase. The selection of the best recruiting sites is a long and difficult process, especially since study sponsor has no visibility on the activity of the sites, and the sites have no penalties if the objectives are not achieved. The CT-SCOUT™ platform is a web-based solution to help clinicians to pre-screen potential candidate, facilitating the coordination of the research team and providing sponsor and principal investigator visibility into patient recruitment efforts and status on the site. We aimed to compare the recruitment rate in sites using the application according to Premium or Freemium modalities and in sites not equipped with CT-SCOUT™ for IBD clinical trials. Methods We conducted a prospective, multicentre, open-label, observational and comparative study in 25 sites participating in a selected phase 3 IBD clinical trials in France. All sites were proposed to be equipped with CT-SCOUT™, and the recruitment rate was compared according to 3 modalities: a) the Premium mode, giving access to all the functionalities of the application (including specific inclusion/exclusion criteria, possibility of sending notification to the team) in counterpart of which they undertook to use the application; b) the Freemium mode, a basic functionality that only gives the name of the study in the first selection phase; c) sites who were not interested to be equipped. The primary endpoint was the mean number of patients randomised per site per month. Patients screened and those finally randomised were compared in sites equipped (Premium or Freemium) and non-equipped using one-way ANOVA followed by post-hoc Tukey test. Results During the recruitment period from 4 to 36 months (mean 24.8 months), 221 and 130 patients were screened and randomised, respectively. The mean number of patients screened and randomised per site per month according to CT-SCOUT™ equipment is reported in the figure below. Conclusion This study shows that sites not equipped with CT-SCOUT™ recruit only a few patients. Among the equipped sites, those with Premium access have a significantly higher randomisation rate than those with limited functionality. Sites equipped with digital pre-screening support to facilitate patient recruitment and provide the sponsor visibility are the best candidates for trials.

Abstract Introduction Thrombosis is more common in inflammatory bowel disease (IBD) patients than the general population, but disease-specific correlates of thrombosis remain unclear. Methods We performed a retrospective analysis of discharge data from the National Inpatient Sample between 2009 and 2014, using International Disease Classification codes to identify IBD and non-IBD patients with or without thrombosis. We used NIS-provided discharge-level weights to reflect prevalence estimates. Categoric variables were analyzed by Rao-Scott Chi-square test, continuous variables by weighted simple linear regression, and covariates associated with thrombosis by weighted multivariable logistic regression. Results Thrombosis prevalence in IBD was significantly greater than in non-IBD, 7.52 versus 4.54%, p < 0.0001. IBD patients with thrombosis were older and more likely to be Caucasian than IBD without thrombosis, each p < 0.001. Thrombosis occurred most commonly in the mesenteric vein. Thrombotic risk factors in IBD include surgery, ports, malignancy, dehydration, malnutrition, and steroids at 53.7, 13.2, 13.1, 12.4, 8.9, and 8.2%, respectively. Those with thrombosis had greater severity of illness, 1.42 versus 0.96; length of stay, 7.7 versus 5.5 days; and mortality, 3.8 versus 1.5%; all p < 0.0001. Adjusting for age and comorbidity, odds ratios for predictors of thrombosis included ports, steroids, malnutrition, and malignancy at 1.73, 1.61, 1.34, and 1.13, respectively, while Asian race, 0.61, was protective, each p < 0.001. Conclusion Thrombosis prevalence is 1.7-fold greater in IBD than non-IBD patients. Adjusting for age and comorbidity, the odds ratio for thrombosis in IBD was 73% higher with ports, 61% higher with steroids, 34% with malnutrition, and 13% with malignancy. Whether long-term anticoagulation would benefit the latter is unknown.

Lumen-derived material gains access to the mucosa by permeating between adjacent epithelial cells (ie, paracellular pathway), by transcytosis across the apical and basolateral cell membranes (ie, transcellular pathway) or by exploiting breaks or erosions in the epithelium that may, for example, result from inflammation. Increased epithelial permeability (or decreased barrier function) has repeatedly been demonstrated in a variety of gut disturbances; notably, in inflammatory bowel disease (IBD). There has been an exponential increase in our knowledge of the structural elements that comprise the epithelial barrier, and of the intrinsic factors (eg, cytokines) and external stimuli (eg, bacterial toxins) that can either perturb or enhance epithelial permeability. Canadian researchers have been very active in the study of epithelial permeability and have been responsible for major advances in the field, documenting increased permeability in patients with ulcer disease and IBD and some of their first degree relatives (as well as before onset of overt inflammation), and elucidating mechanisms of stress-induced and cytokine-induced increases in permeability (1-8). A recent study from Scott et al (9) continues this impressive tradition.

1. Fraction B from a peptic-tryptic digest of gluten from Scout 66 wheat has already been shown to cause histological damage to the jejunal mucosa of coeliac patients. Peptide fractions, designated P1-P4, have been prepared from it by a combination of gel filtration (producing an intermediate fraction pseudo-B2: ψ B2) and reverse-phase high pressure liquid chromatography. 2. An enzyme-linked immunosorbent assay (ELISA) has been used to measure IgG antibodies to fraction B in sera from untreated coeliac patients, patients with inflammatory bowel disease (IBD) and healthy individuals. The coeliac group had significantly higher (P < 0.05) antibody levels to fraction B than either of the control groups [medians: coeliac disease (n = 21), 0.247; IBD (n = 17) 0.019; healthy controls (n = 13) 0.020]. Five coeliac sera which gave high absorbance values in the ELISA were chosen and pre-incubated with fraction B in a range of concentrations, before assay by ELISA: a dose-dependent inhibition of binding was found. 3. Two sera which gave high ELISA values were preincubated with fractions B2 and P1-P4. B2, P1, P2 and P4 gave a dose-dependent inhibition, with P1 being the most potent. Absolute values were different for the two sera but the same relative pattern of reactivity was observed for each. With the serum giving the higher ELISA value the concentration of fraction (μg/ml) giving a 50% inhibition of binding when 0.5 ml was added to 0.5 ml of a 1/500 dilution of the serum (IC50) was 2.6 for fraction B, 61 for P1, 155 for B2 and 285 and 295 for P4 and P2 respectively. Fraction P3 had negligible inhibitory effect at the doses tested. With the second serum, P1 was again the most active inhibitor. 4. It is concluded that different peptide fractions of wheat gluten have differing reactivity with antibodies to gluten fraction B present in the sera of two patients with untreated coeliac disease.

Abstract. Comic is one of the popular literary works that combining pictures and languages. It can be a work if it consist of story that using language as the medium. The aims of this study is to explain the formula of the comic by using theories of comic, escapism, and the narration’s structure of an adventure comics, The Life and Times Of Scrooge McDuck created by Don Rosa. To get relevant data, this study is employ one method, namely; library study. In this paper, the writer used theories of comic by Scott McCloud, escapism by Cawelty, and the narration’s structure of Vladimir Propp. The result indicates that in this comic, there is the reality of the idea that the existence of the main character is manifested by the presence of the villains. Comic is a complete books that can teaching the reader which is not only understand the stories, but also the world view inside, it is the good ideology of the existence from the bad side.Keywords: comic, escapism, narration, existence, and the villains.Abstrak. Komik adalah salah satu karya sastra populer yang menggabungkan gambar dan bahasa. Hal ini dapat bekerja jika itu terdiri dari cerita yang menggunakan bahasa sebagai media. Tujuan dari penelitian ini adalah untuk menjelaskan formula komik dengan menggunakan teori komik, melepaskan diri, dan narasi struktur komik petualangan, hidup dan Gober Bebek dibuat oleh Don Rosa. Untuk mendapatkan data yang relevan, studi ini menggunakan satu teknik, yaitu;\ studi perpustakaan. Dalam tulisan ini, penulis menggunakan teori Komik oleh Scott McCloud, eskapisme oleh Cawelty, dan struktur narasi Vladimir Propp. Hasilnya menunjukkan bahwa di komik ini, ada realitas gagasan bahwa keberadaan karakter utama diwujudkan oleh kehadiran penjahat. Komik sebuah bacaan yang berisi, mendidik, dan berbobot, karena melalui komik pembaca tidak hanya memahami ceritanya saja, tetapi realitas ide di baliknya, yakni ideologi baik dari keberadaan si pelaku kejahatan.Kata kunci: komik, eskapisme, narasi, keberadaan, dan para penjahat.

e16126 Background: Cancer Patients are at high risk of developing venous thromboembolism (VTE), pulmonary embolism (PE), and deep venous thrombosis (DVT). In this study, we aim to get an estimate of the incidence of VTE as a primary admission diagnosis among patients with genitourinary malignancies. Methods: We utilized ICD-9-CM and ICD-10-CM codes to identify patients with malignant neoplasms of the prostate, bladder, kidney, and testis who are older than 18 years and admitted with a primary diagnosis of DVT, PE within the NIS database during 2007-2016. Unadjusted incidence of DVT and PE was analyzed for each cancer site with the Rao-Scott chi-square test; multivariable logistic regression was employed to adjust for age, biological sex ( not for prostate/ testicular cancer), race, insurance, year of admission, and use of chemotherapy to further examine incidence. Results: We identified 3,339,985 admissions affiliated with genitourinary malignancies of whom 0.59% experienced DVT and 0.13% experienced PE with bladder cancer patients have the highest risk of hospitalization for VTE ( 79/1000). Within bladder cancer population; insurance ( p < 0.001) and hospital location and teaching status ( p < 0.001) were associated with DVT incidence; and biological sex ( p = 0.040) and race and ethnicity ( p = 0.026) with PE incidence. For all sites combined and after adjusting for all else, it was found that every year increase in age was associated with 1.2% increased odds of DVT or PE incidence (OR 95% CI: 1.01-1.02; p < 0.001). Further, rural vs. urban teaching hospitals had 41.2% increased odds (95% CI: 1.26-1.58; p < 0.001), and urban non teaching vs. urban teaching hospitals had 35.1% increased odds (95% CI: 1.26-1.45) of DVT or PE incidence. African Americans vs. whites had 46.8% increased odds of DVT or PE incidence (95% CI: 1.35-1.60; p < 0.001). Conclusions: Within the population of genitourinary malignancies who admitted with a primary diagnosis of VTE; the incidence was higher with older age, African Americans, uninsured population, in rural and urban non teaching facilities, bladder cancer population.

Abstract There are relatively few studies on brain metastases in the military population, despite increased risk factors for the development of some cancers. This data was compared to the results from previously published epidemiological data Surveillance, Epidemiology, and End Results (SEER; Cagney et al, 2017) from the general population. PURPOSE: The purpose of our research was to compare the frequency and etiology of metastatic brain cancer in the military and veteran population in our database relative to the general population. METHODS: Retrospective chart review of diagnoses retrieved from the Electronic Medical Record dated January 1, 2016 to July 1, 2019 capturing visits to the Baylor Scott & White Medical Center with specific ICD 10 brain cancer codes for nonhematologic malignancies originating outside of the CNS. RESULTS: Data from 63 individuals that met criteria for the study was analyzed. The military group was predominantly male (92.1%), white (66.7%) and non-Hispanic (90.5%). In our current sample (N=63) 74.6% had metastatic lung cancer with a histology subset of 24.5% having adenocarcinoma. Compared to the SEER general population our sample was more likely to have metastatic lung cancer with a similar frequency in the histologic subset adenocarcinoma. CONCLUSION: In this exploratory study using retrospective data, trends were found for lung cancer diagnosis with brain metastatic disease, appearing more common in the military sample from a single-center relative to previously published estimates in the general population. Rates were similar for adenocarcinoma. More research into the higher frequency of lung cancer in the military population compared to the general population should be further explored.

This article considers participation experiences of 14 year-old and upper secondary students in six European countries that were involved in the International Association for the Evaluation of Educational Achievement (IEA) Civic Education Study: the Czech Republic, Norway, Portugal, Slovenia, Sweden and Switzerland, countries that vary in their history of institution of democratic regimes. Participation has been considered as a crucial dimension of citizenship, and experiences within civil society are viewed as a relevant opportunity for developing personal and social resources essential for the survival and expansion of democracy. Additionally, participation experiences in adolescence seem to be a good predictor of political engagement during adult life. Results show that participation is most evident in organisations that provide enrichment activities (sports, music, computers), but both 14 year-old and upper secondary students are involved in voluntary activities, in some civic-related organisations (mainly Scouts, religious affiliated and environmental), and in experiences within the school (with student councils and school newspapers at the top). However, cross-national and cross-age variations are significant. Overall, there seems to be a positive impact of the frequency of students' involvement on civic concepts, attitudes and engagement, but results also reveal that more is not necessarily better. The most relevant implication for the development of citizenship education projects is that ‘action’ can be a powerful learning tool but only if it is intentionally designed and systematically supported: the quality of participation experiences, both in terms of meaningful involvement, of interaction with (different) others, and opportunities for personal integration, is therefore crucial if the goal is to promote the personal empowerment and social pluralism on which the essence of democracy relies.

Background: Epidemiological studies have utilized administrative discharge diagnosis codes to identify methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA and MSSA) infections and trends, despite debate regarding the accuracy of utilizing codes for this purpose. We assessed the sensitivity and positive predictive value (PPV) of MRSA- and MSSA-specific diagnosis codes, trends, characteristics, and outcomes of S. aureus hospitalizations by method of identification. Methods: Clinical micro biology results and discharge data from geographically diverse US hospitals participating in the Premier Healthcare Database from 2012–2017 were used to identify monthly rates of MRSA and MSSA. Positive MRSA or MSSA clinical cultures and/or a MRSA- or MSSA-specific International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification (ICD-9/10 CM) diagnosis codes from adult inpatients (aged ≥18 years) were included as S. aureus hospitalizations. Septicemia was defined as a positive blood culture or a MRSA or MSSA septicemia code. Sensitivity and PPV for codes were calculated for hospitalizations where admission status was not listed as transfer; true infection was considered a positive clinical culture. Negative binominal regression models measured trends in rates of MRSA and MSSA per 1,000 hospital discharges. Results: We identified 168,634 MRSA and 148,776 MSSA hospitalizations in 256 hospitals; 17% of MRSA and 21% of MSSA were septicemia. Less than half of all S. aureus hospitalizations (49% MRSA, 46% MSSA) and S. aureus septicemia hospitalizations (37% MRSA, 38% MSSA) had both a positive culture and diagnosis code (Fig. 1). Sensitivity of MRSA codes in identifying positive cultures was 61% overall and 56% for septicemia, PPV was 62% overall and 53% for septicemia. MSSA codes had a sensitivity of 49% in identifying MSSA cultures and 52% for MSSA septicemia; PPV was 69% overall and 62% for septicemia. Despite low sensitivity, MRSA trends are similar for cultures and codes, and MSSA trends are divergent (Fig. 2). For hospitalizations with septicemia, mortality was highest among those with a blood culture only (31.3%) compared to hospitalizations with both a septicemia code and blood culture (16.6%), and septicemia code only (14.7%). Conclusions: ICD diagnosis code sensitivity and PPV for identifying infections were consistently poor in recent years. Less than half of hospitalizations have concordant microbiology laboratory results and diagnosis codes. Rates and trend estimates for MSSA differ by method of identification. Using diagnosis codes to identify S. aureus infections may not be appropriate for descriptive epidemiology or assessing trends due to significant misclassification.Funding: NoneDisclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.

AbstractIntroductionThe Breathing Problems Chief Complaint (CC) protocol in the Medical Priority Dispatch System (MPDS) was the system's most frequently used protocol. While “severe breathing problems” is a significant predictor of cardiac arrest (CA), previous data have demonstrated that the DELTA-level determinant codes in this CC contain patients across a wide spectrum of acuity.HypothesisThe hypothesis in this study was that certain combinations of caller answers to the breathing problems protocol key questions (KQs) are correlated with different but specific patient acuities.MethodsThis was a retrospective study conducted at one International Academies of Emergency Dispatch (IAED) Accredited Center of Excellence. Key Question combinations were generated and analyzed from 11 months of dispatch data, and extracted from MPDS software and the computer assisted dispatch system. Descriptive statistics were used to evaluate measures between study groups.ResultsForty-two thousand cases were recorded; 52% of patients were female and the median age was 61 years. Overall, based on the original MPDS Protocol (before generating KQ combinations), patients withabnormal breathingandclammyconditions were the youngest. The MPDS DELTA-level constituted the highest percentage of cases (74.0%) and thedifficulty speaking between breaths(DSBB) condition was the most prevalent (50.3%).Ineffective breathingandnot alertconditions had the highest cardiac arrest quotient (CAQ). Based on the KQ combinations, the CA patients who also had thenot alertcondition were significantly older than other patients. The percentage of CA outcomes in asthmatic patients was significantly higher inDSBBplusnot alert; DSBBplusnot alertpluschanging color;andDSBBplusnot alertplusclammyconditions cases, compared to asthmaticabnormal breathingcases.ConclusionsThe study findings demonstrated that MPDS KQ answer combinations relate to patient acuity. Cardiac arrest patients are significantly less likely to be asthmatic than those without CA, and vice versa. Using a prioritization scheme that accounts for the presence of either single or multiple signs and/or symptom combinations for the Breathing Problems CC protocol would be a more accurate method of assigning DELTA-level cases in the MPDS.Clawson J, Barron T, Scott G, Siriwardena AN, Patterson B, Olola C. Medical Priority Dispatch System breathing problems protocol key question combinations are associated with patient acuity.Prehosp Disaster Med.2012;27(4):1-6.

Introduction: Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a potentially fatal complication that occurs after hematopoietic cell transplantation (HCT) and may also develop after high-dose chemotherapy alone. The reported incidence of VOD/SOS post-HCT has been estimated to be 14% (Coppell JA, et al. Biol Blood Marrow Transplant. 2010;16:157-168). In a study that defined severe VOD/SOS as the presence of multi-organ failure, the total medical costs per patient with severe VOD/SOS have been reported to be higher than those without severe disease (Zhang X, et al. Clin Ther. 2018;40:1711-1719). A previous retrospective study (Premier I), which evaluated patients from the Premier Healthcare Database (2009-2014) in the absence of formal diagnostic codes for VOD/SOS, reported an incidence of VOD/SOS of 5.3% and 6.3% in adult and pediatric patients, respectively (Cao Z, et al. J Med Econ. 2017;20:871-883). This study (Premier II) developed an algorithm to identify cases of VOD/SOS using ICD-10-CM diagnostic codes to evaluate health resource utilization, costs, and outcomes in patients with VOD/SOS post-HCT, with and without multi-organ dysfunction (MOD), compared to patients with no VOD/SOS. Methods: This retrospective, observational study used data from the Premier Healthcare Database and included patients with an inpatient hospitalization from October 2015 through January 2018 for HCT (identified by ICD-10-CM/PCS codes, CPT, HCPCS, or MS-DRG). VOD/SOS patients were identified by an algorithm based on clinical experience, which utilizes ICD-10-CM diagnostic code K76.5, other diagnosis codes for VOD/SOS-related clinical manifestations, or evidence of defibrotide use within 90 days following index hospitalization (ie, first hospitalization). VOD/SOS patients who also had diagnosis or procedure codes for MOD in the same hospitalization or visit comprised the VOD/SOS with MOD group. VOD/SOS patients without evidence of MOD comprised the VOD/SOS without MOD group. Patients with HCT but without evidence of VOD/SOS comprised the no VOD/SOS group. Patients aged ≥18 years were considered adults. Total hospital length of stay (LOS) and total costs were examined during index hospitalization and the 90 days following index discharge (ie, discharge from the index hospitalization stay). Bivariate analysis was performed to examine the difference in unadjusted outcomes between post-HCT patients with VOD/SOS and those without VOD/SOS. The Wilcoxon test was used for continuous variables, and the Chi-square test was used for categorical or dichotomous variables. An adjusted analysis based on multivariable regressions was used to control for patient and hospital characteristics. Results: The analysis included 4,642 patients with HCT and a qualifying discharge (no VOD/SOS: n = 4,352; VOD/SOS with MOD: n = 177; VOD/SOS without MOD: n = 113). Overall, VOD/SOS occurred in 6.2% of patients; 3.8% and 2.4% of patients had VOD/SOS with and without MOD, respectively. VOD/SOS was more common in pediatric (14.3%) than adult (5.7%) patients and in patients with allogeneic (11.4%) versus autologous HCT (3.5%). Regression-adjusted total hospital LOS in the 90-day follow-up period was longer both in patients with VOD/SOS with MOD and in patients with VOD/SOS without MOD, compared to patients with no VOD/SOS (Table). Compared to no VOD/SOS patients, adjusted total costs during follow-up were higher in patients with VOD/SOS with MOD (Table). Adjusted inpatient mortality in the 90-day follow-up period was higher for patients with VOD/SOS with MOD compared to patients with no VOD/SOS (Table). The difference in the rate of 90-day, all-cause readmission was not statistically significant across groups (Table). Conclusions: The results from this retrospective study using the Premier Healthcare Database are consistent with rates of VOD/SOS reported in the literature and in Premier I. This indicates that, although the incidence of VOD/SOS has declined over the years, the risk of VOD/SOS remains. The slightly higher rate of VOD/SOS reported here versus in Premier I was driven by a higher incidence in pediatric and allogeneic populations. The presence of VOD/SOS, especially VOD/SOS with MOD, in post-HCT patients was associated with increases in healthcare resource utilization, LOS, and costs compared to HCT patients without VOD/SOS. Disclosures Dvorak: Alexion Inc: Consultancy; Jazz Pharmaceuticals: Consultancy. Cao:Premier Inc.: Employment, Other: Premier received funding from Jazz Parmaceuticals to perform the study and analysis; Jazz Pharmaceuticals: Other: Zhun Cao is an employee of Premier Inc, which receives payments from Jazz Pharmaceuticals for this research project.. Price:Jazz Pharmaceuticals: Employment, Equity Ownership. Coaquira:Jazz Pharmaceuticals: Employment, Equity Ownership. Lipkin:Premier Inc.: Employment, Other: Premier received funding from Jazz Pharmaceuticals to perform the study and analysis. Robinson:Premier Inc.: Employment, Other: Premier received funding from Jazz Pharmaceuticals to perform the study and analysis; Jazz Pharmaceuticals: Other: Scott Robinson is an employee of Premier Inc, which receives payments from Jazz Pharmaceuticals for this research project.. Kebriaei:Jazz: Consultancy; Amgen: Research Funding; Pfizer: Honoraria; Kite: Honoraria.

Background: Hospitalists play a critical role in antimicrobial stewardship as the primary antibiotic prescriber for many inpatients. We sought to describe antibiotic prescribing variation among hospitalists within a healthcare system. Methods: We created a novel metric of hospitalist-specific antibiotic prescribing by linking hospitalist billing data to hospital medication administration records in 4 hospitals (two 500-bed academic (AMC1 and AMC2), one 400-bed community (CH1), and one 100-bed community (CH2)) from January 2016 to December 2018. We attributed dates that a hospitalist electronically billed for a given patient as billed patient days (bPD) and mapped an antibiotic day of therapy (DOT) to a bPD. Each DOT was classified according to National Healthcare Safety Network antibiotic categories: broad-spectrum hospital-onset (BS-HO), broad-spectrum community-onset (BS-CO), anti-MRSA, and highest risk for Clostridioides difficile infection (CDI). DOT and bPD were pooled to calculate hospitalist-specific DOT per 1,000 bPD. Best subsets regression was performed to assess model fit and generate hospital and antibiotic category-specific models adjusting for patient-level factors (eg, age ≥65, ICD-10 codes for comorbidities and infections). The models were used to calculate predicted hospitalist-specific DOT and observed-to-expected ratios (O:E) for each antibiotic category. Kruskal-Wallis tests and pairwise Wilcoxon rank-sum tests were used to determine significant differences between median DOT per 1,000 bPD and O:E between hospitals for each antibiotic category. Results: During the study period, 116 hospitalists across 4 hospitals contributed a total of 437,303 bPD. Median DOT per 1,000 bPD varied between hospitals (BS-HO range, 46.7–84.2; BS-CO range, 63.3–100; anti-MRSA range, 48.4–65.4; CDI range, 82.0–129.4). CH2 had a significantly higher median DOT per 1,000 bPD compared to the academic hospitals (all antibiotic categories P < .001) and CH1 (BS-HO, P = .01; anti-MRSA, P = .02) (Fig. 1A). The 4 antibiotic groups at 4 hospitals resulted in 16 models, with good model fit for CH2 (R2 > 0.55 for all models), modest model fit for AMC2 (R2 = 0.46–0.55), fair model fit for CH1 (R2 = 0.19–0.35), and poor model fit for AMC1 (R2 < 0.12 for all models). Variation in hospitalist-specific O:E was moderate (IQR, 0.9–1.1). AMC1 showed greater variation than other hospitals, but we detected no significant differences in median O:E between hospitals (all antibiotic categories P > .10) (Fig. 1B). Conclusions: Adjusting for patient-level factors significantly reduced much of the variation in hospitalist-specific DOT per 1,000 bPD in some but not all hospitals, suggesting that unmeasured factors may drive antibiotic prescribing. This metric may represent a target for stewardship intervention, such as hospitalist-specific feedback of antibiotic prescribing practices.Funding: NoneDisclosures: Scott Fridkin, consulting fee - vaccine industry (various) (spouse)

Background:Pediatric rheumatic diseases are chronic illnesses that impart a significant disease burden upon societies (1-3). Determination of the burden and clinical characteristics of these diseases is a critical first step to improving access to care and optimizing use of existing health systems for the well-being of these patients (4-6). A pediatric rheumatology registry is critical in defining the spectrum, clinical characteristics, outcomes and responses of various interventions for pediatric rheumatic diseases. Given that none exists in Kenya, the Kenya Pediatric Rheumatology Registry (KAPRI) registry offers a platform to generate this much needed data in sub-Sahara Africa.Objectives:Our objective was to determine the baseline patient characteristics, clinical features and outcomes of the Juvenile Idiopathic Arthritis (JIA) patients assessed at the Aga Khan University Medical College East Africa who were enrolled into the KAPRI registry from inception in March 2019 to December 2020.Methods:All patients with an ICD 10 M code diagnosis of Juvenile Arthritis were selected from the KAPRI registry database. Age, gender, laboratory and clinical features at diagnosis and treatment options offered were extracted from the database. A further detailed chart review was undertaken to determine the proportion of patients who achieved remission or minimally active diseases.Results:Among the 207 patients enrolled thus far, 16 (7.7%) were diagnosed to have JIA. Majority of the patients were females (75%; n=12) with a mean age of 7 years and 3 months (Range:1 year – 13 years 7 months).All patients had joint pain and swelling as the initial presenting complaints. Majority of the patients had polyarticular JIA (75%, n=12). The other 4 patients were oligoarticular (n=2) and systemic JIA (n=2). Among the polyarticular JIA patients (n=12), only 3 (25%) were rheumatoid factor (RF) positive and 1 was antinuclear antibody (ANA) positive. The oligoarticular and systemic JIA patients were all negative for antinuclear antibody, rheumatoid factor and cyclic citrullinated peptide antibodies (anti-ccp). Seven patients (43.8%) required biological therapies; tocilizumab (n=2: systemic JIA), adalimumab (n=2: polyarticular JIA), etanercept (n=2: polyarticular JIA) and tofacitnib (n=1: polyarticular JIA). One patient with systemic JIA on tocilizumab developed herpes simplex which was successfully managed with oral acyclovir. All the other patients did not develop any infections, allergic reactions or any other untoward events as adverse outcomes following the use of biological therapies. Five patients have attained remission as illustrated in the Table 1 below. Two patients have been lost to follow up.Conclusion:Seronegative polyarticular JIA was the predominant form of JIA observed with a predilection to affect more girls and boys. Over a period of 2 years, remission has been attained among 31.25% of the patients (5 of 16) with use of synthetic disease modifying anti-rheumatic drugs and biological therapies.References:[1]Moorthy LN, Peterson MG, Hassett AL, Lehman TJ. Burden of childhood onset arthritis. Pediatr Rheumatol Online J. 2010;8:20.[2]Minden K, Niewerth M, Listing J, et al. The economic burden of juvenile idiopathic arthritis-results from the German paediatric rheumatologic database. Clin Exp Rheumatol. 2009;27(5):863–9.[3]Bernatsky S, Duffy C, Malleson P, Feldman DE, St Pierre Y, Clarke AE. Economic impact of juvenile idiopathic arthritis. Arthritis Rheum. 2007;57(1):44–8.[4]Migowa A, Colmegna I, Hitchon C, Were E, Ng’ang’a E, Ngwiri T, et al. The spectrum of rheumatic in-patient diagnoses at a pediatric hospital in Kenya. Pediatric Rheumatology (2017)[5]Woolf AD. The bone and joint decade 2000–2010. Ann Rheum Dis. 2000; 59(2):81–2.[6]Scott C, Webb K. Pediatric rheumatology in sub-Saharan Africa. Rheumatology (Oxford). 2014;53(8):1357–8.Disclosure of Interests:None declared

Abstract INTRODUCTION This clinical investigation evaluates a novel conforming mesh device for single-level lumbar interbody fusion (IBF) treating degenerative disc disease. The device placed in the prepared disc space through a small portal and filled with bone graft in situ creates an endplate conforming large loadsharing footprint. Early/sustained improvements in pain and function are essential patient-centric metrics. These parameters combined with bone growth and safety must be demonstrated to warrant device use and future adoption. METHODS This prospective multicenter investigation of 102 subjects yielded 99 subjects with 12-mo data. Mean age/BMI are 57/30.6, respectively, with balanced gender. Primary measures include Visual Analog Scale (VAS) for low back pain (LBP), Oswestry Disability Index (ODI) for low back function, fusion assessed by CT scan, and safety. RESULTS Clinically relevant improvements are demonstrated in pain and function. At 12-mo postop, mean LBP VAS change from baseline is −50.3 mm (preop: 74.1, 12-mo: 23.6). This is improved over the 6-wk change from baseline of −45 mm. Similar trends are observed for lower extremity pain scores. Clinically relevant improvements in ODI also occur by 6-wk and continue to improve over time where the 6-wk mean ODI change from baseline is −16.9 compared 12-mo of −31.4 (pre-op: 53.6, 12 mo 21.8). Fusion rate of 96.9% (94/97). No investigation device-related serious adverse events occurred. High patient satisfaction rates reported early with 85.9% (85/99) rating satisfaction as Excellent/Good at 6-wk and maintained through 12-mo (89.7%, 87/97). CONCLUSION Observed early clinical improvements by 6-wk postop are maintained and/or continue to improve over time. Combined with high fusion rates, demonstrated device safety to date, and compelling levels of patient satisfaction, these results are highly positive and support use of this device for IBF. Sustained results at 2-yr postop are both anticipated and forthcoming.

Introduction: Moyamoya disease is a chronic steno-occlusive vasculopathy involving the circle of Willis and typically presents with ischemic or hemorrhagic stroke. Prior studies suggest that either direct or indirect extracranial-intracranial bypass (EC-IC) is an effective treatment for MMD. However, the burden of post-discharge neurological complications after the procedure is unknown. Our study aims to identify the 90 readmission rate (90-DRR) and neurological complications upon readmission in revascularization and untreated MMD patients. Method: We analyzed the data from the Nationwide Readmission Database (NRD) from 2010-2015. MMD was ascertained by ICD-9 discharge code 437.5 and revascularization (EC-IC) using 39.28. SAS 9.4 was used for data analysis with categorical and continuous variables tested using the Rao Scott Chi-square test and Student’s t-test respectively. Result: Among total 4,902 MMD index events, 1,840 had a revascularization procedure and 3,062 did not. The 90-DRR for the treatment group was 14.72% (readmitted N=271/Index cases N=1,840) vs. 34.75% (readmitted N=1,064/Index cases N=3,062) for the non-revascularization group (P <0.0001). Baseline characteristics of MMD with revascularization were mean age (Mean±SE) 41±0.6 vs. 40±0.5 (P=0.20), Charlson comorbidity index (CCI) 1.6±0.04 vs. 1.8±0.05 (P=0.0004), female: male 3:1. Cause-specific readmission rate in both groups was reported as per table. Conclusion: Our analysis shows that patients treated with revascularization had significantly fewer 90-day readmissions when compared to untreated patients. MMD and ischemic stroke were the top reasons for readmission within the 90 days of discharge for both groups. A seizure was reported higher in the treatment group.

This paper seeks to explore environmental, social and governance issues arising from investment in special economic zones (SEZs) in the mainland Southeast Asian region through a mixture of thick analytical description and multiple case study approach. All the states studied here have embraced the SEZ approach as it offers rapid economic development without any implications for the political settlement, which is considered beneficial by current administrations. Particular emphasis is placed on environmental, social and governance issues in the region covered and some complex issues that have emerged. It is shown that the situation is complex and continually evolving and that there are limited constraints on the actions of corporations. Consequently, there is an opportunity for investors to set precedents and protocols on a progressive basis. 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Ways of Seeing"Images … define our experiences more precisely in areas where words are inadequate." (Berger 33)"Different skins, you know, different ways of seeing the world." (Morrison)The research question animating this article is: 'How does an individual creative worker re-present themselves as a contemporary - and evolving - brand?' Berger notes that the "principal aim has been to start a process of questioning" (5), and the raw material energising this exploration is the life's work of Richard Morrison, the creative director and artist who is the key moving force behind The Morrison Studio collective of designers, film makers and visual effects artists, working globally but based in London. The challenge of maintaining currency in this visually creative marketplace includes seeing what is unique about your potential contribution to a larger project, and communicating it in such a way that this forms an integral part of an evolving brand - on trend, bleeding edge, but reliably professional. One of the classic outputs of Morrison's oeuvre, for example, is the title sequence for Terry Gilliam's Brazil.Passion cannot be seen yet Morrison conceives it as the central engine that harnesses skills, information and innovative ways of working to deliver the unexpected and the unforgettable. Morrison's perception is that the design itself can come after the creative artist has really seen and understood the client's perspective. As he says: "What some clients are interested in is 'How can we make money from what we're doing?'" Seeing the client, and the client's motivating needs, is central to Morrison's presentation of self as a brand: "the broader your outlook as a creative, the more chance you have of getting it right". Jones and Warren draw attention to one aspect of this dynamic: "Wealthy and private actors, both private and state, historically saw creative practice as something that money was spent on - commissioning a painting or a sculpture, giving salaries to composers to produce new works and so forth. Today, creativity has been reimagined as something that should directly or indirectly make money" (293). As Berger notes, "We never look at just one thing; we are always looking at the relation between things and ourselves…The world-as-it-is is more than pure objective fact, it includes consciousness" (9, 11). What is our consciousness around the creative image?Individuality is central to Berger's vision of the image in the "specific vision of the image-maker…the result of an increasing consciousness of individuality, accompanying an increasing awareness of history" (10). Yet, as Berger argues "although every image embodies a way of seeing, our perception or appreciation of an image depends also upon our own way of seeing" (10). Later, Berger links the meanings viewers attribute to images as indicating the "historical experience of our relation to the past…the experience of seeking to give meaning to our lives" (33). The seeing and the seeking go hand in hand, and constitute a key reason for Berger's assertion that "the entire art of the past has now become a political issue" (33). This partly reflects the ways in which it is seen, and in which it is presented for view, by whom, where and in which circumstances.The creation of stand-out images in the visually-saturated 21st century demands a nuanced understanding of ways in which an idea can be re-presented for consumption in a manner that makes it fresh and arresting. The focus on the individual also entails an understanding of the ways in which others are valuable, or vital, in completing a coherent package of skills to address the creative challenge to hand. It is self-evident that other people see things differently, and can thus enrich the broadened outlook identified as important for "getting it right". Morrison talks about "little core teams, there's four or five of you in a hub… [sometimes] spread all round the world, but because of the Internet and the way things work you can still all be connected". Team work and members' individual personalities are consequently combined, in Morrison's view, with the core requirement of passion. As Morrison argues, "personality will carry you a long way in the creative field".Morrison's key collaborator, senior designer and creative partner/art director Dean Wares lives in Valencia, Spain whereas Morrison is London-based and their clients are globally-dispersed. Although Morrison sees the Internet as a key technology for collaboratively visualising the ways in which to make a visual impact, Berger points to the role of the camera in relation to the quintessential pre-mechanical image: the painting. It is worth acknowledging here that Berger explicitly credits Walter Benjamin, including the use of his image (34), as the foundation for many of Berger's ideas, specifically referencing Benjamin's essay "The work of art in the age of mechanical reproduction". Noting that, prior to the invention of the camera, a painting could never be seen in more than one place at a time, Berger suggests that the camera foments a revolutionary transformation: "its meaning changes. Or, more exactly, its meaning multiplies and fragments into many meanings" (19). This disruption is further fractured once that camera-facilitated image is viewed on a screen, ubiquitous to Morrison's stock in trade, but in Berger's day (1972) particularly associated with the television:The painting enters each viewer's house. There it is surrounded by his wallpaper, his furniture, his mementoes. It enters the atmosphere of his family. It becomes their talking point. It lends its meaning to their meaning. At the same time it enters a million other houses and, in each of them, is seen in a different context. Because of the camera, the painting now travels to the spectator, rather than the spectator to the painting. In its travels, its meaning is diversified. (Berger, 19-20)Even so, that image, travelling through space and time is seen on the screen in a sequential and temporal context: "because a film unfolds in time and a painting does not. In a film the way one image follows another, their succession constructs an argument which becomes irreversible. In a painting all its elements are there to be seen simultaneously." Both these dynamics, the still and the sequence, are key to the work of a visual artist such as Morrison responsible for branding a film, television series or event. But the works also create an unfolding sequence which tells a different story to each recipient according to the perceptions of the viewer/reader. For example, instead of valorising Gilliam's Brazil, Morrison's studio could have been tagged with Annaud's Enemy at the Gates or, even, the contemporary Sky series, Niel Jordan's Riviera. Knowing this sequence, and that the back catalogue begins with The Who's Quadrophenia (1979), changes the way we see what the Morrison Studio is doing now.Ways of WorkingRichard Morrison harnesses an evolutionary metaphor to explain his continuing contribution to the industry: "I've adapted, and not been a dinosaur who's just sunk in the mud". He argues that there is a need to explore where "the next niche is and be prepared for change 'cause the only constant thing in life is change. So as a creative you need to have that known." Effectively, adaptation and embracing innovation has become a key part of the Morrison Studio's brand. It is trumpeted in the decision that Morrison and Ware made when they decided to continue their work together, even after Ware moved to Spain. This demonstrated, in an age of faxes and landlines, that the Morrison Studio could make cross country collaboration work: the multiple locations championed the fact that they were open for business "without boundaries".There was travel, too, and in those early pre-Internet days of remote location Morrison was a frequent visitor to the United States. "I'd be working in Los Angeles and he'd be wherever he was […] we'd use snail mail to actually get stuff across, literally post it by FedEx […]." The intercontinental (as opposed to inter-Europe) collaboration had the added value of offering interlocking working days: "I'd go to sleep, he wakes up […] We were actually doubling our capacity." If anything, these dynamics are more entrenched with better communications. Currah argues that Hollywood attempts to manage the disruptive potential of the internet by "seeking to create a 'closed' sphere of innovation on a global scale […] legitimated, enacted and performed within relational networks" (359). The Morrison Studio's own dispersed existence is one element of these relational networks.The specific challenge of technological vulnerability was always present, however, long before the Internet: "We'd have a case full of D1 tapes" - the professional standard video tape (1986-96) - "and we'd carefully make sure they'd go through the airport so they don't get rubbed […] what we were doing is we were fitting ourselves up for the new change". At the same time, although the communication technologies change, there are constants in the ways that people use them. Throughout Morrison's career, "when I'm working for Americans, which I'm doing a lot, they expect me to be on the telephone at midnight [because of time zones]. […] They think 'Oh I want to speak to Richard now. Oh it's midnight, so what?' They still phone up. That's constant, that never goes away." He argues that American clients are more complex to communicate with than his Scandinavian clients, giving the example that people assume a UK-US consistency because they share the English language. But "although you think they're talking in a tongue that's the same, their meaning and understanding can sometimes be quite a bit different." He uses the example of the A4 sheet of paper. It has different dimensions in the US than in the UK, illustrating those different ways of seeing.Morrison believes that there are four key constants in his company's continuing success: deadlines; the capacity to scope a job so that you know who and how many people to pull in to it to meet the deadline; librarian skills; and insecurity. The deadlines have always been imposed on creative organisations by their clients, but being able to deliver to deadlines involves networks and self-knowledge: "If you can't do it yourself find a friend, find somebody that's good at adding up, find somebody that's good at admin. You know, don't try and take on what you can't do. Put your hand up straight away, call in somebody that can help you". Chapain and Comunian's work on creative and cultural industries (CCIs) also highlights the importance of "a new centrality to the role of individuals and their social networks in understanding the practice of CCIs" (718).Franklin et al. suggest that this approach, adopted by The Morrison Studio, is a microcosm of the independent film sector as a whole. They argue that "the lifecycle of a film is segmented into sequential stages, moving through development, financing, production, sales, distribution and exhibition stages to final consumption. Different companies, each with specialized project tasks, take on responsibility and relative financial risk and reward at each stage" (323). The importance that Morrison places on social networks, however, highlights the importance of flexibility within relationships of trust - to the point where it might be as valid to engage someone on the basis of a history of working with that person as on the basis of that person's prior experience. As Cristopherson notes, "many creative workers are in vaguely defined and rapidly changing fields, seemingly making up their careers as they go along" (543).The skills underlying Morrison's approach to creative collaboration, however, include a clear understanding of one's own strength and weaknesses and a cool evaluation of others, "just quietly research people". This people-based research includes both the capabilities of potential colleagues, in order to deliver the required product in the specified time frame, along with research into creative people whose work is admired and who might provide a blueprint for how to arrive at an individual's dream role. Morrison gives the example of Quentin Tarantino's trajectory to directing: "he started in a video rental and all he did is watch lots and lots of films, particularly westerns and Japanese samurai films and decided 'I can do that'". One of his great pleasures now is to mentor young designers to help them find their way in the industry. That's a strategy that may pay dividends into the future, via Storper and Scott's "traded and untraded interdependencies" which are, according to Gornostaeva, "expressed as the multiple economic and social transactions that the participants ought to conduct if they wish to perpetuate their existence" (39).As for the library skills, he says that they are crucial but a bit comical:It's a bit like being a constant librarian in old-fashioned terms, you know, 'Where is that stuff stored?' Because it's not stored in a plan chest anymore where you open the drawer and there it is. It's now stored in, you know, big computers, in a cloud. 'Where did we put that file? Did we dump it down? Have we marked it up? […] Where's it gone? What did we do it on?'While juggling the demands of technology, people and product The Morrison brand involves both huge confidence and chronic insecurity. The confidence is evident in the low opinion Morrison has of the opportunities offered by professional disruptor sites such as 99designs: "I can't bear anything like that. I can see why it's happening but I think what you're doing is devaluing yourself even before you start […] it would destroy your self-belief in what you're doing". At the same time, Morrison says, his security is his own insecurity: "I'm always out hunting to see what could be next […] the job you finish could be your last job."Ways of BrandingChristopherson argues that there is "considerable variation in the occupational identities of new media workers among advanced economies. In some economies, new media work is evolving in a form that is closer to that of the professional [in contrast to economies where it is] an entrepreneurial activity in which new media workers sell skills and services in a market" (543). For The Morrison Studio, its breadth, history and experience supports their desire to be branded as professional, but their working patterns entirely resonate with, and are integrated within, the entrepreneurial. Seeing their activity in this way is a juxtaposition with the proposition advanced by Berger that:The existing social conditions make the individual feel powerless. He lives in the contradiction between what he is and what he would like to be. Either he then becomes fully conscious of the contradiction and its causes, and so joins the political struggle for a full democracy which entails, among other things, the overthrow of capitalism; or else he lives, continually subject to an envy which, compounded with his sense of powerlessness, dissolves into recurrent day-dreams (148).The role of the brand, and its publicity, is implicated by Berger in both the tension between what an individual is and what s/he would like to be; and in the creation of an envy that subjugates people. For Berger, the brand is about publicity and the commodifying of the future. Referring to publicity images, Berger argues that "they never speak of the present. Often they refer to the past and always they speak of the future". Brands are created and marketed by such publicity images that are often, these days, incorporated within social media and websites. At the same time, Berger argues that "Publicity is about social relationships, not objects [or experiences]. Its promise is not of pleasure, but of happiness: happiness as judged from the outside by others. The happiness of being envied is glamour." It is the dual pressure from the perception of the gap between the individual's actual and potential life, and the daydreaming and envy of that future, that helps construct Berger's powerless individual.Morrison's view, fashioned in part by his success at adapting, at not being a dinosaur that sinks into the mud, is that the authenticity lies in the congruence of the brand and the belief. "A personal brand can help you straight away but as long as you believe it […] You have to be true to what you're about and then it works. And then the thing becomes you [… you] just go for it and, you know, don't worry about failure. Failure will happen anyway".Berger's commentary on publicity is partially divergent from branding. Publicity is generally a managed message, on that is paid for and promoted by the person or entity concerned. A brand is a more holistic construction and is implicated in ways of seeing in that different people will have very different perceptions of the same brand. Morrison's view of his personal brand, and the brand of the Morrison Studio, is that it encompasses much more than design expertise and technical know-how. He lionises the role of passion and talks about the importance of ways of managing deadlines, interlocking skills sets, creative elements and the insecurity of uncertainty.For the producers who hire Morrison, and help build his brand, Berger's observation of the importance of history and the promise for the future remains key to their hiring decisions. Although carefully crafted, creative images are central to the Morrison Studio's work, it is not the surface presentation of those images that determines the way their work is perceived by people in the film industry, it is the labour and networks that underpin those images. While Morrison's outputs form part of the visual environment critiqued in Ways of Seeing, it is informed by the dynamics of international capitalism via global networks and mobility. Although one of myriad small businesses that help make the film industry the complex and productive creative sphere that it is, Morrison Studios does not so much seek to create a public brand as to be known and valued by the small group of industry players upon whom the Studio relies for its existence. Their continued future depends upon the ways in which they are seen.ReferencesBenjamin, Walter. Illuminations: Essays and Reflections. United States of America, 1969.Berger, John. Ways of Seeing. London: Penguin Books, 1972.Brazil. Dir. Terry Gilliam. Universal Pictures. 1985. Film. Chapain, Caroline, and Roberta Comunian. "Enabling and Inhibiting the Creative Economy: The Role of the Local and Regional Dimensions in England." Regional Studies 44.6 (2010): 717-734. Christopherson, Susan. "The Divergent Worlds of New Media: How Policy Shapes Work in the Creative Economy." Review of Policy Research 21.4 (2004): 543-558. Currah, Andrew. "Hollywood, the Internet and the World: A Geography of Disruptive Innovation." Industry and Innovation 14.4 (2007): 359-384. Enemies at the Gates. Dir. Jean-Jacques Annaud. Paramount. 2001. FilmFranklin, Michael, et al. "Innovation in the Application of Digital Tools for Managing Uncertainty: The Case of UK Independent Film." Creativity and Innovation Management 22.3 (2013): 320-333. Gornostaeva, Galina. "The Wolves and Lambs of the Creative City: The Sustainability of Film and Television Producers in London." Geographical Review (2009): 37-60. Jones, Phil, and Saskia Warren. "Time, Rhythm and the Creative Economy." Transactions of the Institute of British Geographers 41.3 (2016): 286-296. Morrison, Richard. Personal Interview. 13 Oct 2016.The Morrison Studio. The Morrison Studio, 2017. 16 June 2017 <https://themorrisonstudio.com/>.Quadrophenia. Dir. Franc Roddam. Brent Walker Film Distributing. 1979. Film.Riviera. Dir. Neil Jordan. Sky Atlantic HD. 2017. Film.Storper, Michael, and Scott, Allen. "The Geographical Foundations and Social Regulation of Flexible Production Complexes". The Power of Geography: How Territory Shapes Social Life. Eds. Jennifer Wolch and Michael Dear. New York: Routledge, 1989. 21-40.

Music from Another Time – One Perth Night in 2009The following extract is taken from fieldwork notes from research into the enduring Northern Soul dance scene in Perth, Western Australia.It’s 9.30 and I’m walking towards the Hyde Park Hotel on a warm May night. I stop to talk to Jenny, from London, who tells me about her 1970s trip to India and teenage visits to soul clubs in Soho. I enter a cavernous low-ceilinged hall, which used to be a jazz venue and will be a Dan Murphy’s bottle shop before the year ends. South West Soul organiser Tommy, wearing 34-inch baggy trousers, gives me a Northern Soul handshake, involving upturned thumbs. ‘Spread the Faith’, he says. Drinkers are lined up along the long bar to the right and I grab a glass of iced water. A few dancers are out on the wooden floor and a mirror ball rotates overhead. Pat Fisher, the main Perth scene organiser, is away working in Monaco, but the usual suspects are there: Carlisle Derek, Ivan from Cheltenham, Ron and Gracie from Derby. Danny is back from DJing in Tuscany, after a few days in Widnes with old friends. We chat briefly mouth to ear, as the swirling strings and echo-drenched vocals of the Seven Souls’ 45 record, ‘I still love you’ boom through the sound system. The drinkers at the bar hit the floor for Curtis Mayfield’s ‘Move on up’ and the crowd swells to about 80. When I move onto the floor, Barbara Acklin’s ‘Am I the Same Girl?’ plays, prompting reflection on being the same, older person dancing to a record from my teenage years. On the bridge of the piano and conga driven ‘’Cause you’re mine’, by the Vibrations, everybody claps in unison, some above their heads, some behind their backs, some with an expansive, open-armed gesture. The sound is like the crack of pistol. We are all living in the moment, lost in the music, moving forward and backward, gliding sideways, and some of us spinning, dervish-like, for a few seconds, if we can still maintain our balance.Having relocated their scene from England south to the Antipodes, most of the participants described on this night are now in their sixties. Part of the original scene myself, I was a participant observer, dancing and interviewing, and documenting and exploring scene practices over five years.The local Perth scene, which started in 1996, is still going strong, part of a wider Australian and New Zealand scene. The global scene goes back nearly 50 years to the late 1960s. Northern Soul has now also become southern. It has also become significantly present in the USA, its place of inspiration, and in such disparate places as Medellin, in Colombia, and Kobe, in Japan.The feeling of ‘living in the moment’ described is a common feature of dance-oriented subcultures. It enables escape from routines, stretches the present opportunity for leisure and postpones the return to other responsibilities. The music and familiar dance steps of a long-standing scene like Northern Soul also stimulate a nostalgic reverie, in which you can persuade yourself you are 18 again.Dance steps are forward, backward and sideways and on crowded dancefloors self-expression is necessarily attenuated. These movements are repeated and varied as each bar returns to the first beat and in subcultures like Northern Soul are sufficiently stylised as to show solidarity. This solidarity is enhanced by a unison handclap, triggered by cues in some records. Northern Soul is not line-dancing. Dancers develop their own moves.Place of Origin: Soul from the North?For those new to Northern Soul, the northern connection may seem a little puzzling. The North of England is often still imagined as a cold, rainy wasteland of desolate moors and smoky, industrial, mostly working-class cities, but such stereotyping obscures real understanding. Social histories have also tended to focus on such phenomena as the early twentieth century Salford gang members, the “Northern Scuttlers”, with “bell-bottomed trousers … and the thick iron-shod clogs” (Roberts 123).The 1977 Granada television documentary about the key Northern Soul club, Wigan Casino, This England, captured rare footage; but this was framed by hackneyed backdrops of mills and collieries. Yet, some elements of the northern stereotype are grounded in reality.Engels’s portrayal of the horrors of early nineteenth century Manchester in The Condition of the Working Class in England in 1844 was an influential exploration of the birth pains of this first industrial city, and many northern towns and cities have experienced similar traumas. Levels of social disadvantage in contemporary Britain, whilst palpable everywhere, are still particularly significant in the North, as researched by Buchan, Kontopantelis, Sperrin, Chandola and Doran in North-South Disparities in English Mortality 1965–2015: Longitudinal Population Study.By the end of the 1960s, the relative affluence of Harold Wilson’s England began to recede and there was increased political and counter-cultural activity. Into this social climate emerged both skinheads, as described by Fowler in Skins Rule and the Northern Soul scene.Northern Soul scene essentially developed as an extension of the 1960s ‘mod’ lifestyle, built around soul music and fashion. A mostly working-class response to urban life and routine, it also evidenced the ability of the more socially mobile young to get out and stay up late.Although more London mods moved into psychedelia and underground music, many soul fans sought out obscure, but still prototypical Motown-like records, often from the northern American cities Detroit and Chicago. In Manchester, surplus American records were transported up the Ship Canal to Trafford Park, the port zone (Ritson and Russell 1) and became cult club hits, as described in Rylatt and Scott’s Central 1179: The Story of Manchester's Twisted Wheel.In the early 1970s, the rare soul fans found a name for their scene. “The Dave Godin Column” in the fanzine Blues and Soul, published in London, referred for the first time to ‘Northern Soul’ in 1971, really defining ‘Northern’ directionally, as a relative location anywhere ‘north of Watford’, not a specific place.The scene gradually developed specific sites, clothes, dances and cultural practices, and was also popular in southern England, and actually less visible in cities such as Liverpool and Newcastle. As Nowell (199) argues, the idea that Northern Soul was regionally based is unfounded, a wider movement emerging as a result of the increased mobility made possible by railways and motorways (Ritson and Russell 14).Clubs like the Blackpool Mecca and Wigan Casino were very close to motorway slip roads and accessible to visitors from further south. The initial scene was not self-consciously northern and many early clubs, like the ‘Golden Torch’, in Tunstall were based in the Midlands, as recounted by Wall (441).The Time and Space of the DancefloorThe Northern Soul scene’s growth was initially covered in fanzines like Blues and Soul, and then by Frith and Cummings (23-32). Following Cosgrove (38-41) and Chambers (142), a number of insider accounts (Soul Survivors: The Wigan Casino Story by Winstanley and Nowell; Too Darn Soulful: The Story of Northern Soul by Nowell; The In-Crowd: The Story of the Northern & Rare Soul Scene by Ritson & Russell) were followed by academic studies (Milestone 134-149; Hollows and Milestone 83-103; Wall 431-445). The scene was first explored by an American academic in Browne’s Identity Scene and Material Culture: The Place of African American Rare Soul Music on the British Northern Soul Scene.Many clubs in earlier days were alcohol-free, though many club-goers substituted amphetamines (Wilson 1-5) as a result, but across the modern scene, drug-taking is not significant. On Northern Soul nights, dancing is the main activity and drinking is incidental. However, dance has received less subtle attention than it deserves as a key nexus between the culture of the scene and black America.Pruter (187) referred to the earlier, pre-disco “myopia” of many music writers on the subject of dance, though its connection to leisure, pleasure, the body and “serious self-realization” (Chambers 7) has been noted. Clearly Northern Soul dancers find “evasive” pleasure (Fiske 127) and “jouissance” (Barthes v) in the merging of self into record.Wall (440) has been more nuanced in his perceptions of the particular “physical geography” of the Northern Soul dance floor, seeing it as both responsive to the music, and a vehicle for navigating social and individual space. Dancers respond to each other, give others room to move and are also connected to those who stand and watch. Although friends often dance close, they are careful not to exclude others and dancing between couples is rare. At the end of popular records, there is often applause. Some dance all night, with a few breaks; others ‘pace’ themselves (Mercieca et al. 78).The gymnastics of Northern Soul have attracted attention, but the forward dives, back drops and spins are now less common. Two less noticed markers of the Northern Soul dancing style, the glide and the soul clap, were highlighted by Wall (432). Cosgrove (38) also noted the sideways glide characteristic of long-time insiders and particularly well deployed by female dancers.Significantly, friction-reducing talcum powder is almost sacramentally sprinkled on the floor, assisting dancers to glide more effectively. This fluid feature of the dancing makes the scene more attractive to those whose forms of expression are less overtly masculine.Sprung wooden floors are preferred and drink on the floor is frowned upon, as spillage compromises gliding. The soul clap is a communal clap, usually executed at key points in a record. Sometimes very loud, this perfectly timed unison clap is a remarkable, though mostly unselfconscious, display of group co-ordination, solidarity and resonance.Billy from Manchester, one of the Perth regulars, and notable for his downward clapping motion, explained simply that the claps go “where the breaks are” (Mercieca et al. 71). The Northern Soul clap demonstrates key attributes of what Wunderlich (384) described as “place-temporality in urban space”, emerging from the flow of music and movement in a heightened form of synchronisation and marked by the “vivid sense of time” (385) produced by emotional and social involvement.Crucially, as Morris noted, A Sense of Space is needed to have a sense of time and dancers may spin and return via the beat of the music to the same spot. For Northern Soul dancers, the movements forwards, backwards, sideways through objective, “geometric space” are paralleled by a traversing of existential, “conceived space”. The steps in microcosm symbolise the relentless wider movements we make through life. For Lefebvre, in The Production of Space, these “trialectics” create “lived space”.A Sense of Place and Evolving IdentitySpaces are plastic environments, charged with emerging meanings. For Augé, they can also remain spaces or be manipulated into “Non-Places”. When the sense of space is heightened there is the potential for lived spaces to become places. The space/place distinction is a matter of contention, but, broadly, space is universal and non-relational, and place is particular and relational.For Augé, a space can be social, but if it lacks implicit, shared cultural understandings and requires explicit signs and rules, as with an airport or supermarket, it is a non-place. It is not relational. It lacks history. Time cannot be stretched or temporarily suspended. As non-places proliferate, urban people spend more time alone in crowds, ”always, and never, at home” (109), though this anonymity can still provide the possibility of changing identity and widening experience.Northern Soul as a culture in the abstract, is a space, but one with distinct practices which tend towards the creation of places and identities. Perth’s Hyde Park Hotel is a place with a function space at the back. This empty hall, on the night described in the opening, temporarily became a Northern Soul Club. The dance floor was empty as the night began, but gradually became not just a space, but a place. To step onto a mostly empty dance floor early in the night, is to cross liminal space, and to take a risk that you will be conspicuous or lonely for a while, or both.This negotiation of space is what Northern Soul, like many other club cultures has always offered, the promise and risk of excitement outside the home. Even when the floor is busy, it is still possible to feel alone in a crowd, but at some stage in the night, there is also the possibility, via some moment of resonance, that a feeling of connection with others will develop. This is a familiar teenage theme, a need to escape bonds and make new ones, to be both mobile and stable. Northern Soul is one of the many third spaces/places (Soja 137) which can create opportunities to navigate time, space and place, and to find a new sense of direction and identity. Nicky from Cornwall, who arrived in Perth in the early 1970s, felt like “a fish out of water”, until involvement in the Northern Soul scene helped him to achieve a successful migration (Mercieca et al. 34-38). Figure 1: A Perth Northern Soul night in 2007. Note the talcum powder on the DJ table, for sprinkling on the dancefloor. The record playing is ‘Helpless’, by Kim Weston.McRobbie has argued in Dance and Social Fantasy that Northern Soul provides places for women to define and express themselves, and it has appealed to more to female and LGBTQIA participants than the more masculine dominated rock, funk and hip-hop scenes. The shared appreciation of records and the possibilities for expression and sociality in dance unite participants and blur gender lines.While the more athletic dancers have tended to be male, dancing is essentially non-contact, as in many other post-1960s ‘discotheque’ styles, yet there is little overt sexual display or flirtation involved. Male and female styles, based on foot rather than arm movements, are similar, almost ungendered, and the Soul scene has differed from more mainstream nightlife cultures focussed on finding partners, as noted in Soul Survivors: The Wigan Casino Story by Winstanley and Nowell. Whilst males, who are also involved in record buying, predominated in the early scene, women now often dominate the dance floor (Wall 441).The Perth scene is little different, yet the changed gender balance has not produced more partner-seeking for either the older participants, who are mostly in long-term relationships and the newer, younger members, who enjoy the relative gender-blindness, and focus on communality and cultural affinity. Figure 2: A younger scene member, ‘Nash’, DJing in Perth in 2016. He has since headed north to Denmark and is now part of the Nordic Northern Soul scene.In Perth, for Stan from Derby, Northern Soul linked the experiences of “poor white working class kids” with young black Americans (Mercieca et al. 97). Hollows and Milestone (87-94) mapped a cultural geographic relationship between Northern Soul and the Northern cities of the USA where the music originated. However, Wall (442) suggested that Northern Soul is drawn from the more bi-racial soul of the mid-1960s than the funky, Afro-centric 1970s and essentially deploys the content of the music to create an alternative British identity, rather than to align more closely with the American movement for self-determination. Essentially, Northern Soul shows how “the meanings of one culture can be transformed in the cultural practices of another time and place” (Wall 444).Many contemporary Australian youth cultures are more socially and ethnically mixed than the Northern Soul scene. However, over the years, the greater participation of women, and of younger and newer members, has made its practices less exclusive, and the notion of an “in-crowd” more relaxed (Wall 439). The ‘Northern’ connection is less meaningful, as members have a more adaptable sense of cultural identity, linked to a global scene made possible by the internet and migration. In Australia, attachment seems stronger to locality rather than nation or region, to place of birth in Britain and place of residence in Perth, two places which represent ‘home’. Northern Soul appears to work well for all members because it provides both continuity and change. As Mercieca et al. suggested of the scene (71) “there is potential for new meanings to continue to emerge”.ConclusionThe elements of expression and directional manoeuvres of Northern Soul dancing, symbolise the individual and social negotiation of direction, place, space, identity and time. The sense of time and space travelled can create a feeling of being pushed forward without control. It can also produce an emotional pull backwards, like an elastic band being stretched. For those growing older and moving far from places of birth, these dynamics can be particularly challenging. Membership of global subcultures can clearly help to create successful migrations, providing third spaces/places (Soja 137) between home and host culture identities, as evidenced by the ‘Southern’ Northern Soul scene in Australia. For these once teenagers, now grandparents in Australia, connections to time and space have been both transformed and transcended. They remain grounded in their youth, but have reduced the gravitational force of home connections, projecting themselves forward into the future by balancing aspects of both stability and mobility. Physical places and places and their connections with culture have been replaced by multiple and overlapping mappings, but it is important not to romanticise notions of agency, hybridity, third spaces and “deterritorialization” (Deleuze and Guattari in Anti-Oedipus: Capitalism and Schizophrenia). In a globalised world, most people are still located geographically and labelled ideologically. The Northern Soul repurposing of the culture indicates a transilience (Richmond 328) “differentially available to those in different locations in the field of power” (Gupta and Ferguson 20). However, the way in which Northern Soul has moved south over the decade via migration, has arguably now provided a stronger possible sense of resonance with the lives of black Americans whose lives in places like Chicago and Detroit in the 1960s, and their wonderful music, are grounded in the experience of family migrations in the opposite direction from the South to the North (Mercieca et al. 11). In such a celebration of “memory, loss, and nostalgia” (Gupta and Ferguson 13), it may still be possible to move beyond the exclusion that characterises defensive identities.ReferencesAugé, Marc. Non-Places: An Introduction to Supermodernity. Trans. John Howe. London: Verso, 2008.Barthes, Roland. The Pleasure of the Text. Trans. Richard Miller. New York: Hill and Wang, 1975Browne, Kimasi L. 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