Deconstructing the outsider puzzle: The legitimation journey of novelty

The proposition that outsiders often are crucial carriers of novelty into an established institutional field has received wide empirical support. But an equally compelling proposition points to the following puzzle: the very same conditions that enhance outsiders' ability to make novel contributions also hinder their ability to carry them out. We seek to address this puzzle by examining the contextual circumstances that affect the legitimation of novelty originating from a noncertified outsider that challenged the status quo in an established institutional field. Our research case material is John Harrison's introduction of a new mechanical method for measuring longitude at sea-the marine chronometer- which challenged the dominant astronomical approach.We find that whether an outsider's new offer gains or is denied legitimacy is influenced by (1) the outsider's agency to further a new offer, (2) the existence of multiple audiences with different dispositions toward this offer, and (3) the occurrence of an exogenous jolt that helps create a more receptive social space. We organize these insights into a multilevel conceptual framework that builds on previouswork but attributes a more decisive role to the interplay between endogenous and exogenous variables in shaping a field's shifting receptiveness to novelty. The framework exposes the interdependencies between the micro-, meso-, and macro-level processes that jointly affect an outsider's efforts to introduce novelty into an existing field

Voluntary stopping of eating and drinking in Switzerland from different points of view : protocol for a mixed-methods study

“To die with dignity” has reached the significance of a core value in democratic societies. Based on this unconditional value, people require autonomy and care. "Voluntary stopping of eating and drinking" (VSED) represents an alternative to assisted suicide because no one else is involved in the action of death fastening, even though from outside, it might be considered as an extreme form of passive euthanasia. However, there are no data available about the prevalence and frequency of either explicit VSED or the implicit reduction of food and liquid in Switzerland. The responsible and independent ethics committee of the Greater Region of Eastern Switzerland (EKOS 17/083) approved this study

Predicting Acute Kidney Injury at Hospital Re-entry Using High-dimensional Electronic Health Record Data

Acute Kidney Injury (AKI), a sudden decline in kidney function, is associated with increased mortality, morbidity, length of stay, and hospital cost. Since AKI is sometimes preventable, there is great interest in prediction. Most existing studies consider all patients and therefore restrict to features available in the first hours of hospitalization. Here, the focus is instead on rehospitalized patients, a cohort in which rich longitudinal features from prior hospitalizations can be analyzed. Our objective is to provide a risk score directly at hospital re-entry. Gradient boosting, penalized logistic regression (with and without stability selection), and a recurrent neural network are trained on two years of adult inpatient EHR data (3,387 attributes for 34,505 patients who generated 90,013 training samples with 5,618 cases and 84,395 controls). Predictions are internally evaluated with 50 iterations of 5-fold grouped cross-validation with special emphasis on calibration, an analysis of which is performed at the patient as well as hospitalization level. Error is assessed with respect to diagnosis, race, age, gender, AKI identification method, and hospital utilization. In an additional experiment, the regularization penalty is severely increased to induce parsimony and interpretability. Predictors identified for rehospitalized patients are also reported with a special analysis of medications that might be modifiable risk factors. Insights from this study might be used to construct a predictive tool for AKI in rehospitalized patients. An accurate estimate of AKI risk at hospital entry might serve as a prior for an admitting provider or another predictive algorithm.Comment: In revisio

Healthcare Utilization Among Youth with Chronic Illness Receiving Care at a Large Urban Academic Healthcare System

Background/objectiveWe sought to understand healthcare utilization and barriers to care among youth with chronic illness who interact frequently with the healthcare system.MethodsThis was a retrospective analysis of healthcare utilization for youth ≤25 years of age with chronic illness during one calendar year (1 January 2021-31 December 2021) in a single urban academic healthcare system. Inclusion criteria were (1) having at least one healthcare encounter in the calendar year of 2021 and (2) having at least six healthcare encounters over the preceding 3-year period or having a qualifying chronic illness. Demographic and clinical characteristics were collected along with self-reported and derived social determinants of health. Univariable and multivariable regression models were created to identify predictors of missed clinic visits, telehealth use, and activated patient portal accounts.ResultsThe cohort (N = 14,245) was demographically, clinically, and socioeconomically diverse. The youth had frequent clinic visits (median 9, IQR 4-18), multiple subspecialty care referrals (median 4, 1-8), were prescribed multiple medications (median 6, 3-10), and a high proportion received emergency department (18%) or inpatient treatment (15%). Race and public insurance were significant predictors of missed clinic visits and telehealth use. Primary language was a significant predictor of patient portal activation.ConclusionsYouth with chronic illness who are high users of the healthcare system face a high burden of clinic, emergency room, and hospital visits, referrals, and medications. Systematic efforts to lower the healthcare burden and improve care access should address existing racial and socioeconomic disparities affecting this patient population, who are likely to need frequent healthcare over their lifetime

Myosin inhibitors for treatment of hypertrophic cardiomyopathy

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:/ / Primary objective: To assess the effects of myosin inhibitors compared to usual care or placebo on exercise capacity, need for septal reduction therapy, and all-cause mortality in people with hypertrophic cardiomyopathy (HCM). / / Secondary objectives: To assess the effects of myosin inhibitors compared to usual care or placebo in people with HCM in the following population subgroups. By demographics, such as age and sex Obstructive HCM versus non-obstructive HCM Genotype-negative and genotype-positive disease People with and without pre-existing atrial fibrillation or other types of arrhythmias. /

Attitudes towards terminal sedation: an empirical survey among experts in the field of medical ethics

BACKGROUND: "Terminal sedation" regarded as the use of sedation in (pre-)terminal patients with treatment-refractory symptoms is controversially discussed not only within palliative medicine. While supporters consider terminal sedation as an indispensable palliative medical treatment option, opponents disapprove of it as "slow euthanasia". Against this background, we interviewed medical ethics experts by questionnaire on the term and the moral acceptance of terminal sedation in order to find out how they think about this topic. We were especially interested in whether experts with a professional medical and nursing background think differently about the topic than experts without this background. METHODS: The survey was carried out by questionnaire; beside the provided answering options free text comments were possible. As test persons we chose the 477 members of the German Academy for Ethics in Medicine, an interdisciplinary society for medical ethics. RESULTS: 281 completed questionnaires were returned (response rate = 59%). The majority of persons without medical background regarded "terminal sedation" as an intentional elimination of consciousness until the patient's death occurs; persons with a medical background generally had a broader understanding of the term, including light or intermittent forms of sedation. 98% of the respondents regarded terminal sedation in dying patients with treatment-refractory physical symptoms as acceptable. Situations in which the dying process has not yet started, in which untreatable mental symptoms are the indication for terminal sedation or in which life-sustaining measures are withdrawn during sedation were evaluated as morally difficult. CONCLUSION: The survey reveals a great need for research and discussion on the medical indication as well as on the moral evaluation of terminal sedation. Prerequisite for this is a more precise terminology which describes the circumstances of the sedation

11 C-Metomidate PET/CT is a useful adjunct for lateralization of primary aldosteronism in routine clinical practice.

OBJECTIVE: To describe clinical practice experience of 11 C-Metomidate PET/CT as an adjunct to adrenal vein sampling (AVS) in the lateralization of aldosterone-producing adenomas (APA) in primary aldosteronism (PA). CONTEXT: Accurate lateralization of APA in the setting of PA offers the potential for surgical cure and improved long-term cardiovascular outcomes. Challenges associated with AVS, the current gold standard lateralization modality, mean that only a small proportion of potentially eligible patients currently make it through to surgery. This has prompted consideration of alternative strategies for lateralization, including the application of novel molecular PET tracers such as 11 C-Metomidate. DESIGN: Clinical Service Evaluation/Retrospective audit. PATIENTS: Fifteen individuals with a confirmed diagnosis of PA, undergoing lateralization with 11 C-Metomidate PET/CT prior to final clinical decision on surgical vs medical management. MEASUREMENTS: All patients underwent screening aldosterone renin ratio (ARR), followed by confirmatory testing with the seated saline infusion test, according to Endocrine Society Clinical Practice Guidelines. Adrenal glands were imaged using dedicated adrenal CT. 11 C-Metomidate PET/CT was undertaken due to equivocal or failed AVS. Management outcomes were assessed by longitudinal measurement of blood pressure, ARR, number of hypertensive medications following adrenalectomy or institution of medical therapy. RESULTS: We describe the individual lateralization and clinical outcomes for 15 patients with PA. CONCLUSION: 11 C-Metomidate PET/CT in conjunction with adrenal CT and AVS provided useful information which aided clinical decision-making for PA within a multidisciplinary hypertension clinic

Review-Electrode Kinetics and Electrolyte Stability in Vanadium Flow Batteries

Two aspects of vanadium flow batteries are reviewed: electrochemical kinetics on carbon electrodes and positive electrolyte stability. There is poor agreement between reported values of kinetic parameters; however, most authors report that kinetic rates are faster for VIV/VV than for VII/VIII. Cycling the electrode potential increases the rates of both reactions initially due to roughening but when no further roughening is observed, the VII/VIII and VIV/VV reactions are affected oppositely by the pretreatment potential. Anodic pretreatment activates the electrode for the VII/VIII reaction, and deactivates it for VIV/VV. Three states of the carbon surface are suggested: reduced and oxidized states R and O, respectively, both with low electrocatalytic activity, and an intermediate state M with higher activity. The role of surface functional groups and the mechanisms of electron transfer for the VII/VIII and VIV/VV reactions are still not well understood. The induction time for precipitation of V2O5 from positive electrolytes decreases with temperature, showing an Arrhenius-type dependence with an activation energy of 1.79 eV in agreement with DFT calculations based on a VO(OH)3 intermediate. It also decreases exponentially with increasing VV concentration and increases exponentially with increasing sulphate concentration. Both arsenate and phosphate are effective additives for improving thermal stability

Modeling Wind Direction Distributions Using a Diagnostic Model in the Context of Probabilistic Fire Spread Prediction

With emerging research on the dynamics of extreme fire behavior, it is increasingly important for wind models, used in operational fire prediction, to accurately capture areas of complex flow across rugged terrain. Additionally, the emergence of ensemble and stochastic modeling frameworks has led to the discussion of uncertainty in fire prediction. To capture the uncertainty of modeled fire outputs, it is necessary to recast uncertain inputs in probabilistic terms. WindNinja is the diagnostic wind model currently being applied within a number of operational fire prediction frameworks across the world. For computational efficiency, allowing for real-time or faster than real-time prediction, the physical equations governing wind flow across a complex terrain are often simplified. The model has a number of well documented limitations, for instance, it is known to perform poorly on leeward slopes. First, this study is aimed at understanding these limitations in a probabilistic context, by comparing individual deterministic predictions to observed distributions of wind direction. Secondly, a novel application of the deterministic WindNinja model is presented in this study which is shown to enable prediction of wind direction distributions that capture some of the variability of complex wind flow. Recasting wind fields in terms of probability distributions enables a better understanding of variability across the landscape, and provides the probabilistic information required to capture uncertainty through ensemble or stochastic fire modeling. The comparisons detailed in this study indicate the potential for WindNinja to predict multi-modal wind direction distributions that represent complex wind behaviors, including re-circulation regions on leeward slopes. However, the limitations of using deterministic models within probabilistic frameworks are also highlighted. To enhance fire prediction and to better understand uncertainty, it is recommended that statistical approaches also be developed to complement existing physics-based deterministic wind models