As countries approach their scale-up targets for the voluntary medical male circumcision program for HIV prevention, they are strategizing and planning for the sustainability phase to follow. Global guidance recommends circumcising adolescent (below 14 years) and/or early infant boys (aged 0–60 days), and countries need to consider several factors before prioritizing a cohort for their sustainability phase. We provide community and healthcare provider-side insights on attitudes and decision-making process as a key input for this strategic decision in Zambia and Zimbabwe. We studied expectant parents, parents of infant boys (aged 0–60 days), family members and neo-natal and ante-natal healthcare providers in Zambia and Zimbabwe. Our integrated methodology consisted of in-depth qualitative and quantitative one-on-one interviews, and a simulated-decision-making game, to uncover attitudes towards, and the decision-making process for, early adolescent or early infant medical circumcision (EAMC or EIMC). In both countries, parents viewed early infancy and early adolescence as equally ideal ages for circumcision . If offered for free, about half of Zambian parents and almost 2 in 5 Zimbabwean parents indicated they would likely circumcise their infant boy; however, half of parents in each country perceived that the community would not accept EIMC. Nurses believed their facilities currently could not absorb EIMC services and that they would have limited ability to influence fathers, who were seen as having the primary decision-making authority. Our analysis suggests that EAMC is more accepted by the community than EIMC and is the path of least resistance for the sustainability phase of VMMC. However, parents or community members do not reject EIMC. Should countries choose to prioritize this cohort for their sustainability phase, a number of barriers around information, decision-making by parents, and supply side will need to be addressed. Sustaining the impact of scaled health interventions is a key challenge for the development sector. Few programs take into account sustainability considerations at the early stages of scale-up . VoluntaAs countries focus their efforts to achieve their VMMC scale-up targets, early planning for the sustainability phase will ensure a smooth and efficient transition and sustained impact . A key cIn priority countries 35%-74% of the males being circumcised as part of the “catch-up” phase are adolescents (10–14 years of age), while they represent only 34–55% of the target population to be circumcised, suggesting a high degree of acceptability by circumcising adolescents . ServiceThe aim of the present study was to use an integrated methodology to explore the comparative preference and decision-making path for EIMC versus EAMC by parents, caregivers and healthcare providers. In particular, we sought to understand the difference in decision-making processes of parents when choosing whether to circumcise their baby boy compared with their adolescent boy. The study was conducted in Zambia and Zimbabwe to inform their national sustainability strategies and implementation plans regarding demand-side preferences and beliefs, as they also consider other important factors such as the feasibility, scale-up and cost-effectiveness of each. , 17.Prior to conducting the study, it was reviewed and approved by the Medical Research Council of Zimbabwe institutional review board in Zimbabwe, the Research Council of Zimbabwe and the ERES Converge institutional review board in Zambia. Primary data was collected in three phases through semi-structured qualitative interviews and structured quantitative surveys. Each phase informed the design of the subsequent phase in order to give a holistic analysis framework and provide robust evidence. Phases 1 and 2 were analyzed in full prior to the creation of phase 3 study materials.For each phase of the research, written consent was obtained from respondents. For illiterate respondents, agreement to participate in the study as illustrated by an inked thumb print were treated as written consent. Interviewers used a consent form that they read and explained to potential study participants. Participants were informed that they could terminate the interview at any point in time without any consequences. A document summarizing respondents’ rights was provided, including the telephone number and contact information for the principal investigator (PI). This one page document was translated into local languages. The IRBs in each country approved this consent procedure and the relevant forms and documents in English and local languages.Phase 1 consisted of qualitative in-depth interviews conducted with new and expectant fathers, mothers, paternal grandfathers and paternal grandmothers of baby boys younger than 2 months, given their crucial role as influencers of family decisions . The intPhase 2 consisted of a qualitative behavioral economics assessment (Ethnolab) to understand context, mental models, and emotions that influence parents’ decision-making in relation to circumcising their infant boys (younger than 2 months). Ethnolab is a game-based research technique designed to minimize the impact of biases in decision-making. In research settings, biases such as fear of value judgment, social desirability, and expectation of higher self-control in future make respondents claim behaviors that may not play out in real life, i.e., “Say–Do” gaps.In Ethnolab, 10 participants play the game at a time. The profile of all participants is similar in terms of their income, age, and gender. Participants are exposed to unique situations–a narrative with audio-visual aid or through a live narration. The narrative ends with a decision conundrum, exposing a set of 3–4 different scenarios among which the participants must choose. Participants make their choice based on what they believe the majority in the group will select as the most likely outcome among the options. If the response of the participant matches that of the majority response in the group of 10 people playing the game, the participant stands to win cash . The game generates responses which are representative of the participants’ emotions, mental models, and biases, rather than their deliberative and rational analyses regarding why they ‘think’ they behave. This approach addresses both individual and social biases, such as fear of value judgment and social desirability. Participants are asked to play the game over 12 rounds. Following the game, participants are engaged in a short conversation regarding their experience, decisions, and preferences in the game.Hypotheses on behavioral outcomes to be tested were developed based on our review of the available literature and the findings from Phase 1 qualitative research see . These hIn total, 48 expectant or new mothers (6 groups of 8 respondents each) and 48 expectant or new fathers  of newborn baby boys younger than 2 months participated in the Ethnolab in each country. Districts (provinces) where the study was conducted were Kitwe (Copperbelt), Katete (Eastern), and Lusaka (Lusaka) in Zambia, and Harare (Harare) Bulawayo (Bulawayo) and Kwekwe (Midlands) in Zimbabwe.Phase 3 of the research was a quantitative survey that used a structured questionnaire, designed to test with a larger, nationally representative sample the insights and hypotheses generated from the qualitative phases. This phase was focused on EIMC, given that there are fewer data on infant circumcision and less experience with it. The Phase 3 research explored general attitudes towards health outcomes of infant boys, knowledge of HIV, general knowledge of male circumcision, knowledge of EIMC, attitudes towards EIMC, preferred location for EIMC services and willingness to pay for services. New and expectant mothers (n = 500 per country) and fathers (n = 500 per country) were interviewed face-to-face. Sample sizes of 500 expectant mothers and fathers each were determined based on the expectation to test nested cross-tabulations for significant differences with a minimum sample of n = 30 to 50 in the smallest respondent filter to be tested. In collaboration with the ministries, 8 (from 10) provinces, deemed representative of the country’s non-circumcising community, were selected in Zambia, and all 10 provinces in Zimbabwe. Within each province, interviews were conducted in urban, peri-urban and rural areas. The sample in each province mirrored the VMMC target per region (80% coverage at district level) set by the national VMMC program in each country. Households were randomly sampled in the selected provinces and a mothers or fathers were identified and approached in each household for the interview. If more than one eligible respondent lived in the household, selection among them was made by random selection using a table of random numbers. If a father lived in the household but were not currently present, the interviewer arranged to return to the household to interview that father at a later time. Interviews were conducted in private settings identified within or close to the home. All responses were directly entered into the survey, programmed on a mobile device, by the interviewer.Qualitative interviews in phase 1 were transcribed in English. Responses to questions were grouped together by content to pick out dominant themes as well as differences in opinions to test during the Ethnolab (Phase 2) and quantitative survey (Phase 3). Transcripts from fathers, mothers, grandfathers, grandmothers, and healthcare workers were all analyzed as separate groups. Findings were synthesized by group and compared with those from other groups.Quantitative data from Phase 3 were analyzed using the SPSS statistical package (version 6.0.1). Data for mothers and fathers were analyzed separately, and statistical significance comparisons were made at the question level, including across provinces, between HIV status (positive or negative), between spontaneous awareness of VMMC or not, and between circumcision status of the father (circumcised or not).The Phase 3 quantitative survey provided insights into knowledge of EIMC and sources of this knowledge. Among the respondents from Zambia, 34% had heard about infant circumcision, compared with 67% in Zimbabwe. The most common source of information on EIMC in both countries was from healthcare providers (41% in Zambia and 58% in Zimbabwe), with this being a more likely source for expectant mothers than for expectant fathers . The secIn the Phase 3 quantitative survey we asked mothers and fathers, each, the most common age at which males in their community tend to get circumcised, medically or traditionally, if they do at all, and what they thought is the ideal age for a boy or man to be medically circumcised Figs  and 2. CBeliefs about the ability of the circumcision wound to heal faster , the boy’s likelihood not to suffer as much pain , and other personal benefits  were cited as the most common reasons for choosing 0–2 months as the ideal age to circumcise . In ZimbIn the Phase 3 interviews, almost half of the parents interviewed perceived that the community would not accept EIMC  . Among tWhen respondents were asked whether they would circumcise their baby boys if the procedure was offered for free, 54% vs. 42% in Zambia, and 36% vs. 52% in Zimbabwe, said they definitely would or probably would vs. definitely or probably would not . In bothParents who demonstrated willingness to circumcise their baby boy would prefer to do so in the general hospital (83% of the respondents in Zambia and 90% in Zimbabwe) . Data frWe asked parents who indicated that they were likely to circumcise their baby boy  how likely they would be to follow through if they had to pay a fee for the service . In ZambQualitative interviews with ANC and PNC healthcare providers included one working in a clinic in Zambia that also provided EIMC, but none providing EIMC services in Zimbabwe. These interviews highlighted that providers were well informed about male circumcision and saw significant benefits to circumcising males in infancy . Nurses felt that their facilities would need equipment, space, and trained staff to be able to perform EIMC services . Almost none of the nurses felt that they could currently absorb EIMC services. They felt that there was currently limited opportunity to sensitize parents on EIMC and that the mother’s knowledge of health interventions did not necessarily transfer into the household, where a lot of the decisions were made jointly with, or exclusively by, other family members.While the Phase 1 qualitative and Phase 3 quantitative surveys uncovered stated attitudes towards EIMC and EAMC, we used the Ethnolab to uncover underlying drivers of decision-making by parents of infant boys. When presented with competing scenario choices for EIMC vs. EAMC, both mothers and fathers preferred circumcising their boys at adolescence. The reason for this was the desire among parents to ‘abdicate responsibility’ for the choice. The choice would be entirely with the parents for EIMC, whereas with EAMC the boy himself brings the idea of circumcision to the family home from school.The anticipated regret for an action which goes wrong, such as an adverse event in a circumcision procedure, was greater than regret for not taking an action. The uncertainty parents had about the procedure with infants led to exaggerated claims about dangers and the vulnerability of the infant. Familiarity with what EIMC procedure involves was quite low for both countries, and relatively lower in Zambia.The sense of vulnerability of the child and anticipation of regret was higher for EIMC than for EAMC. The fear of pain for the child was also higher for EIMC. Both of these findings were confirmed by Phase 3 survey results. Fathers believed that adolescents could tolerate the pain. The emotions of shame and pain felt by adolescents are much better managed in EAMC than in adult MC, thanks to the group dynamics of sending boys to be circumcised with their friends or classmates. Here-and-now benefits scored high, which explains the preference for EAMC. Benefits of EIMC seemed too distant in the future for it to appear relevant.Close to 70% of the parents in both countries stated that the father was the most important decision-maker for circumcising an infant, compared with 27% who believed it to be the mother. This was also confirmed in the Ethnolab, where it was clearly the father’s decision from the perspective of all participants. Fathers who were circumcised themselves were more likely to circumcise their sons. In the Ethnolab, we also found that women had better awareness than men, but that mothers lacked confidence in making the decision and abdicated it to their husbands. In Zimbabwe, parents placed greater weight on themselves, compared with their partners, in influencing decision-making. Healthcare providers played a minor role . When asked who else would influence decision-making, if the father was not mentioned as the primary decision-maker, mothers were prominent (58% in Zambia and 70% in Zimbabwe), followed by the baby’s father , the paternal grandfather  the paternal grandmother  and then the maternal grandfather or grandmother . The Ethnolab uncovered that grandparents had a small influence and their influence seemed to be diminishing, especially since there was a strong belief that circumcision will become the norm by the time the boys grow up.Our analysis uncovered the complex network of direct and indirect influences on EIMC in the community . Both paThis study provides community and healthcare provider-side insights to help policy-makers in Zambia and Zimbabwe strategize and design programs to sustain the impact of the current VMMC services (as part of the “catch-up” phase), especially relating to the choice of the appropriate age cohort to prioritize. Our findings are in line with much of what has been uncovered on EIMC acceptability by previous research studies, but also provide new insights . To the It should be stated here, that while our study sought to compare attitudes regarding EIMC versus EAMC among parents and providers, a key limitation of the study was that our research was conducted only with expectant or recent parents of infants and providers of antenatal and post-natal care services. The results are thus representative of the views of decision-makers and providers for infant boys, and do not reflect the same for adolescent boys. Since the consent decisions by parents to circumcise at infancy versus at adolescence are essentially two separate sequential decisions–yes at infancy or delay decision to later, then yes or no at adolescence–the results of our study should be viewed as reflecting understanding of the first decision (at infancy) and not of the decision-making parents make when their boys are adolescents.Our results suggest differences in attitudes towards EAMC vs. for EIMC among parents of infant boys, and in the decision-making that parents undergo for these two procedures. EAMC is more accepted and is the path of least resistance compared with EIMC, possibly because it already occurs as part of the “catch-up” phase. Close to 50% of the circumcisions in both countries today take place among early adolescent males, illustrating parents’ willingness to consent to their boys being circumcised at this age. Furthermore, the decision-making burden for EAMC is perceived as shared with the boy and his parents. There is large degree of uncertainty regarding the EIMC procedure, likely not in part due to the general lack of service provision for EIMC in each country. When asked to hypothetically consider EIMC for their infant boys, some parents feel that the baby is ‘too small’ and they cannot visualize how much skin will be removed. Sexual hygiene and the protection against HIV and sexually transmitted infections that programs prioritize today to young adolescents are perceived as closer to near-term benefits for these boys, as compared with for infants, which makes them more relatable to parents for EAMC decisions.Despite the relative success of EAMC to date, and the propensity of parents to favor EAMC, EIMC still can offer a compelling solution. Benefits that parents see with circumcising infants include faster healing, less pain experienced, and that the child will not remember the pain. However, EIMC faces strong competition from EAMC, and several community and healthcare-side challenges would need to be overcome for EIMC to be a scalable intervention for the sustainability phase. Almost half of the parents interviewed perceive that their community would not accept EIMC. Between 40–50% of the parents said they would not circumcise their infants even if services were offered for free. At the community level, the challenges include conveying information about the benefits and process of EIMC to fathers, managing the uncertainties associated with the procedure, and addressing the emotional impact on parents in their decision-making process. Parents feel quite isolated when making the decision to circumcise their baby boy as compared with their adolescent son. For EAMC, parents feel some of the burden of responsibility is shared with the boy himself, removing potential blame. The benefits of circumcising before sexual debut are also well understood and salient.Whilst antenatal nurses believe that EIMC is an effective circumcision solution, there are supply-side factors to address, such as training, space, time, and protocol. Furthermore, parents feel that the general hospital is the ideal setting to circumcise their baby boy. Should something go wrong, they trust that the hospital is the most appropriate place for rapid expert attention.There are a few strategies that countries can prioritize, should they wish to scale up EIMC services. Males who are circumcised during the current ‘catch-up’ phase could be sensitized on EIMC to help create a culture of normalcy. Programs could also consider charging a small fee for the services, as parent are willing to pay and this would relieve the cost-side burden of scaling an indefinite national health program. Healthcare providers are one of the most trusted sources of health information; however, they lack many opportunities to sensitize new parents and have a weak link to the father, who is the main decision-maker. Because of their bias towards the present, parents tend to excessively discount long-term benefits, so the here-and-now benefits of EIMC should be highlighted. This is further necessitated by parents’ perception that although HIV risk is real, the probability of their son contracting the infection is uncertain. This uncertainty barrier would need to be addressed. Uncertainty leads parents to indecision–a state where they believe in the benefits but do not understand the risks and therefore exaggerate them to the point of not being able to decide. Knowledge barriers around the process should be relatively simple to correct, and this would be effective in reducing the over-exaggeration of potential risks of EIMC. Novel approaches are needed to either sensitize couples together, prior to or early on in their pregnancy, to give them enough time to decide, and to directly reach the fathers. Fathers seem to be especially influenced by their parents. Therefore, programs should explore creating direct channels of communication between healthcare providers, the father, and his parents. Broader community-level sensitization is also needed, given that cultural norms and religious factors do play a role in decision-making. Scalable approaches can include media campaigns and direct advocacy with community leaders and gatekeepers.S1 Table(DOCX)Click here for additional data file.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(PDF)Click here for additional data file.S4 File(PDF)Click here for additional data file.S5 File(PDF)Click here for additional data file.S6 File(PDF)Click here for additional data file.


Supplemental Digital Content is available in the text. Ward rounds permeate health care delivery worldwide and form an important daily activity within all hospitals. In this study, the daily morning ward round in plastic surgery was examined from a teleological and systems point of view.Data were gathered from the following sources to inform the systems analysis: patient interviews, staff interviews, direct observations of the ward round on multiple occasions, and through process mapping.To better understand the ward and its layout, a schematic of it was developed. Following observations of the ward round and the way in which decisions are made on it, an IDEF0 map was developed. Three patients were invited to take part in the study. Three members of staff were interviewed. The overarching themes from the interviews related to aspects of communication which this paper details.This small-scale study demonstrates how the ward round as a process can be assessed, including product quality, process quality, the measurement and management of capacity, the role of standardization, the role and significance of bottlenecks, the key information flows, including the role of feedback, and the motivation and incentives of system participants and ideas for improvement generated. New joint guidance from the Royal Colleges of Physicians and Royal Colleges of Nursing cites “considerable variability in the way ward rounds are conducted” and that they need to become multidisciplinary to be effectiveThe ward round is of vital importance in the specialty of plastic surgery. UK-based Consultant Plastic Surgeon Jeremy RawlinsKnow the teamTake chargeSay somethingUse everybodyListenBring people inBe alert to psychosocial needsTeach them a thing or twoBe systematic but be flexibleBe diplomaticHave a planSummarizeReflectIn this study, the daily morning ward round in plastic surgery was examined from a teleological and systems point of view. This paper has been reported in line with the standards for reporting qualitative research: a synthesis of recommendations (SRQR) reporting guidelinesData were gathered to inform the systems analysis from a number of sources including: patient interviews, staff interviews, direct observations of the ward round on multiple occasions, and through process mapping.Fig.1).Stoke Mandeville Hospital (SMH) is part of Buckinghamshire Healthcare NHS Trust along with Wickham and Amersham hospitals. The hospital is located on the edge of the market town of Aylesbury in Buckinghamshire. The hospital has 479 beds and treats over 48,000 inpatients and 219,000 outpatients a yearPlastic surgery at SMH provides an on-call and elective service for hand surgery, burns, breast surgery, congenital deformities (including hypospadias), skin cancer, and wound management. Patients are admitted to ward 16 where they share 23 beds (including 3 side rooms) with gynecology and general surgical patients. Pediatric patients are admitted to ward 3 and adult burn patients to the dedicated burns unit. For the purposes of this study, only the daily morning ward round on ward 16 was studied, where the majority of patients are.For 6 days within a 2-week period in November 2012, the daily morning ward round was observed by the author. The ward round typically starts at 8:30 to 8:45 after the morning trauma meeting. As problems arose notes were made on a patient list being carried by the observer. The ward round was timed and the number of patients seen noted. A problem was defined as anything which:“Burns energy off from the organization or its staff” or leads to their frustration.the amount of energy in an organisation that is consumed in unproductive work. It is a measure of the conflict, friction and frustration that exists within an organizationLeads to increased “cultural entropy” in the systemIn November 2012, over 3 consecutive days, patients were offered a chance to participate in the study. Patients were selected if they had been seen on at least 2 ward rounds. Day case admissions and 23-hour stay patients were excluded. Patients with dementia who would be unable to comprehend the consent form or the questions were excluded.Patients and staff were interviewed using a grounded theory approach as espoused by Glaser and StraussWhat are your thoughts and feelings about the daily morning ward round.The interview would begin each time with the same open question and then subsequent questions would follow dynamically based on the answer to the first and the issues raised. The opening question was:Following discussion with the Stoke Mandeville Hospital Research and Development department and the Clinical Audit department as well as consultation of relevant National Research Ethics Service (NRES) guidancehttp://links.lww.com/IJSO/A2) based on the World Health Organisation Research Ethics Review Committee template consent form for qualitative studiesAll patients who participated in the study through face-to-face interviews, did so through an informed consent process. A consent form was developed .To better understand the ward and its layout, a schematic of it was developed .Some photographs of the ward are shown .One to 3 Senior House Officers or SHOs (junior doctors with 2 to 4 years of postgraduate experience).A House Officer .One nurse.One or 2 physiotherapists/occupational therapists.Table1.The results of the observations are shown in On all 6 days, all plastic surgical patients on ward 16 were seen with no omissions. All requested tests from the ward round were ordered by the house officer after the ward round had finished, there was no delay for this during the ward round itself for this activity. A patient list was not ready in time for the start of the ward round on any of these days. It was provided at the end of the ward round after the house officer had gone to another ward to print it.Three patients were invited to take part in the study. All 3 consented to take part and to have the interview audio recorded. Six patients on the ward were excluded for being days cases or not having been seen on 2 or more occasions during the study period. One patient was excluded due to dementia. Three members of staff were interviewed (1 band 5 and 1 band 6 nurse and 1 house officer), 1 was audio recorded and the other 2 were written down.The main themes emerging from the interviews are listed below, mostly they are centered on aspects of communication:Ward round is too quick and impersonal.Lack of privacy, feels intimidating.Too many people on the ward round.Don’t feel they can ask questions, feel “stupid.”Not sure who the members of the ward round are, do they belong to their consultant’s team?Not clear on the treatment plan.Use of technical jargon.Talking as if the patient is not there.Hearing different or conflicting information from different registrars.Doctors don’t know me well enough and may make a wrong decision.Miscommunication meant patient was fed and missed their operation slot.Would appreciate someone double checking that the patient is clear on the plan before they leave.http://links.lww.com/IJSO/A2):Portions of interviews are shown below , house officer, physio/OT. Should not split up this can lead to chaos. A Consultant should be on the ward round when there is bed pressure as otherwise there is a four hour gap waiting for a Consultant who may or may not be in the hospital.I found that some patients actually find it overwhelming because all doctors are stood around looking at them specially ladies breast surgery and it’s quite a personal thing to them to then have sort of eight or nine doctors all looking at them. They don’t like it. Also I find that sometimes two doctors look after that patient then two would go there and the nurse in charge trying to find where these three different break of doctors are all trying to say at the same time.Not enough computers. Can’t update the list. Ward is too small and you can’t fit the trolley and doctors into a bay. Patients are close together, no privacy. Amount of direction you get depends on the Registrar. You have to call the Registrar back to get discharge details like antibiotics and follow-up. One registrar in particular tells patients their fingers will fall off. This never goes down well and he upsets a lot of patients.Figs.2, 9).Following observations of the ward round and the way in which decisions are made on it, an IDEF0 map was developed Planning dischargeMultiprofessional training and educationAs a result one can state that product and process quality encompass numerous elements as highlighted below.High Quality Care for AllThe quality of the ward round as a product has a number of dimensions but as a starting point, reference was made to Lord Darzi’s report Good clinical decision making—encompassing patient safety and clinical effectiveness.Patient experience—patient satisfaction with the experience of the ward round, questions answered, etc.Timely decision making.All patients are seen.Clear plans are articulated to the patient and other members of the ward round  and documented in the medical notes.All patient’s seen.Minimize missing information, duplication, wasted movements.Timely decision making.Figs.10, 11).Availability of tools for the job, for example, medium-size gloves and alcohol foam dispenser .A high degree of variability was also shown for the number of staff on the ward round and the number of person-minutes wasted  and patients are admitted on an ongoing basis to an available bed in a same-sex bay. It is also not clear when walking around the ward if the patient is a Plastic Surgery, Gynecology, or General Surgery patient. A clear printed card above the patient’s bed would make this far easier, or some sort of color coding. At present, the only way the people on the ward round know is to look at the list (was never printed for the start of the ward round) and rely on the house officer’s memory. This system is vulnerable if the house officer was to become sick, as they are the only doctor with that “panoramic” understanding of the patient’s on the ward. In addition, the list is also not typically structured in bay order, so the sequence of stops is not clear and again means reliance on house officer’s memory.The consultation itself could be more standardized. Patients stated how they did not know who people were on the ward round, how they were not clear about plans and would have appreciated being given the opportunity to ask questions and check their understanding against that of the team’s.So like if we have questions, I don’t feel, I don’t feel comfortable being able to ask in front of everybody what I want to know because I feel stupid.At the end of the ward round, a mini-checklist with the house officer would be useful. Do they have any questions? Are they clear about what jobs need to be done? What is the priority of the tasks? Are there potential problems that could be mitigated at this juncture? This can be run through with the list in hand. The same could be done with the nurses. For instance stating estimated discharge dates  so social care assessments and packages can be put in place in a timely manner.A number of bottlenecks were identified. Some of the most significant and those that wasted the most person-minutes were:Not having a nurse available for the ward round.Needing to go and get gloves for each wound examination.Patients dressings not down in time for the ward round.AM when clinics start, to complete the ward round giving them about 35 to 40 minutes to complete it. The overrun to 50 minutes on an average means they are often late starting the morning clinic in outpatients . Hence the 3 nurses need to provide approximately 50 minutes of resource. But when plastic surgery, gynecology, and general surgery ward rounds come simultaneously, this resource is utilized 100% and there is no spare capacity for nursing patients, doing observations, taking patients to the toilet, rolling them, washing, feeding, dressing, changing bed sheets, answering phone calls from relatives, etc.The ward round takes about 50 minutes on average. With 3 nurses on the ward handling 23 patients  they are pushed for time. Nurses do not have a set “protected” amount of time set aside for the ward round since any spare time is taken up with nursing patients and the running of the ward. Doctors, however, do have till 9 Table1 further emphasizes the need for slack in the process. As the patient does not know exactly when the ward round is going to happen, they may often be in the toilet when the ward round comes (as occurred in ward round 3), meaning it has to double back or wait.The demand on the nurses is then further increased when the Plastic Surgery ward splits into 2 or 3 to increase speed. This often means there is a delay in starting the ward round as the nurse has to finish the activity she/he had already started. The high variation shown in Fig.12).Another source of frustration identified by the nurses is the current paradigm for some of the decision making on the ward round .The registrar will see a patient on the ward round and then have to go and speak to a consultant to determine the best course of action. This leads to the nursing staff and patient waiting for the registrar to come back later in the day with the plan. A better idea may be to have more consultant-led ward rounds, this may improve the training in decision making then as well , sometimes, people cannot physically fit around the bed or hear what is going on. Hence, their input may be limited.Verbal information spoken by the patient and registrar needs to be translated into the notes as the formal record. However, the jobs that need to be done as a result of the consultation can be forgotten if they do not get written on a patient list, for example, ordering tests, etc. This may or may not be written down by the house officer or SHO. The registrar does not typically check in a systematic way that the house officer has acknowledged the jobs that need to be done and does not inspect the list where the jobs may be written. Ideally the SHO would do this since the house officer is often writing in the notes. The house officer’s understanding of the jobs that need to be done should be checked at the end of the ward round by an SHO who wrote down the jobs as they went along .The patient list itself, does lack a checklist, which ensures that certain information is captured. This could be amenable to modification. Feedback relates to the mechanisms that regulate the system and how it responds to change. These are poor. The main control is time, so ultimately the doctors need to move on and get through the ward round as a process. Hence, there is some urgency about the ward round. If a nurse is not available for the start of the round, the team will wait a short while  but will ultimately start and brief the nurse later. This prevents nursing input onto the round when its needed. Also, if a job created on the ward round was not done, members of the team will not be notified, it may be picked up later in the day by another member of the team, for example, another Registrar who did not lead the morning ward round. So there is little tracking of progress and information flow downstream.The interviews and observations demonstrate that the house officers are motivated to impress their senior colleagues  and want the ward round and the ward generally to run smoothly since they work solely in that environment all day . House officers want clear plans so they can execute them efficiently.Amount of direction you get depends on the Registrar. You have to call the Registrar back to get discharge details like antibiotics and follow-up.http://links.lww.com/IJSO/A2 and Appendix III, Supplemental Digital Content 1, http://links.lww.com/IJSO/A2).The Registrars want to make the right clinical decisions for the patients as a leader of the ward round and as a more senior responsible figure. The nursing staff would like the doctors to provide clear plans so their day can run more smoothly. They need to be clear since we know from the patient interviews how the nursing staff will provide much additional information and explanation to the patients after the doctors have gone , that the pens sitting at the bottom of the white board actually work and spares are available and people know where to get them from, that the operation note can be found as its been filed in the correct place, etc. When medium-sized gloves run out or alcohol hand foam is not available, there is no one to report the fault to there and then, no system to put in place a chain of events that rectifies this problem. Another adaptation could be to give the doctors their own belt-lipped alcohol dispenser to act as a backup.The ward clerk is a key individual in making sure that administrative things are done and that excess stock is stored away neatly .muda (Japanese for waste), and a focus on incentivizing the staff to do a job well and take pride in it as has been accomplished for example at the Shouldice clinic in Ontario, CanadaSeveral quality improvement principles could be applied to the system, including use of lean and the Toyota Production systemThe substantive system could be improved from a staff and patient perspective by:The ward round could potentially be standardized with a single registrar doing the ward round for the whole week. This would avoid multiple looks at dressings by different registrars, which disrupts and annoys the nurses. The same registrar would also be able to provide better continuity of care and get to the know patients and their clinical histories. This would require an adjustment of the rota but would not result in greater cost. Indeed, such a system exists at other hospitals but require careful planning.Limit the number of people on the ward round to essential staff, making it more mobile, more private and intimate, less disruptive, and less intimidating for the patient.A named nurse for the ward round who has been assigned that role for the day—their name will go onto the board and they should ensure they are available in time for the ward round . This will prevent the bottleneck of waiting for a nurse and will respect Little’s Law (work in progress=output rate×throughout time)There is no substitute for good communication and compassionate patient-centered care on the ward round. Examples include: getting down to eye level of the patient if practically possible, ensuring privacy (perhaps asking excess people to politely leave or not enter), checking patient understanding of the plan, giving them the opportunity to ask questions and encouraging their participation. Shared decision making is now a central theme of the Department of Health’s Liberating the NHSGreater teaching, education, and understanding of the problems and potential solutions highlighted by this type of work should be fed back to staff in a multiprofessional setting through seminars, emails and posters, and reminders during handover (a guaranteed activity the staff will attend).This work has given an insight into the Johari windowPrioritizing the ward round as an important activity in the day that needs to be done well and in a more structured and systematic manner—like a nursing drug round or handover. It should be made part of professional development activities at the trust for the staff involved.Improving the layout and design of the patient list. So important aspects related to quality of care are incorporated in a checklist like manner. Patients should be listed in bay order, not in the random manner they currently are. All of this is possible within the existing computer software, using existing functions, and the house officer investing more time in the updating of the list (5 min more per day).muda board at the nurses desk . Every day the muda board will be reviewed by nursing staff during handover, the ward clerk, and by doctors at the end of the ward round to see what faults and frustrations have been reported. The muda board would give visibility to problems, log them, and would also help generate ideas of how to deal with them through a proposed action column so people can see what has been suggested by others.If people see a problem in the system or with a meta-process, they can write it down on a muda board may need to be collated and ultimately presented at an audit half day so people can understand and take action collectively against consistently reported problems. A multidisciplinary, voluntary group of people from across administration, doctors, nurses, managers, pharmacists, etc., could take the lead in delivering practical solutions. This group could be called the Kaizen or improvement Committee, which would be backed by senior management and work locally on the ward but learn from other such groups around the hospital.The findings of the Kaizen Committee can have a nominated quality improvement budget that would be set monthly by management after a trial and scoping exercise to determine the initial costs of this sort of activity.None of the above will cost in material terms, and extra time spent with the patient will free up house officer and nursing time later as the patient will not need them to explain what is going on. The There are some material costs, however:Buying a printer for the ward to ensure the list can be printed and the house officer does not have to go elsewhere  and then rectified quickly and efficiently either in situ or through the Kaizen development committee. The additional money could fund extra hours of work or even a part time assistant.The costs of adjusting the ward clerk role would be an extra £4 an hour in salary (subject to negotiation). Hence, the approximate cost would be £4×8 hours per day×5 days a week×52 weeks a year=£8320. This would not include weekends when the ward clerk does not work, but ward rounds on the weekends are much smaller and lighter and there are less staff. The ward clerk being consistently onsite, could also be the person to whom failures could be reported to  for the 6 or so members=£10/day saved=£10×5 days×52 weeks=£2600 saved.Net investment would thus be: £10,176−£2,600=£7576.One cannot put a price on increased patient satisfaction with the ward round but this is something to have in the equation. The Care Quality Commission’s NHS Inpatient survey revealed how important communication is to patients; specifically answering questions, talking as if they are not there, appearance of teamwork, availability of staff, and involvement in their own decision makingProgress would be tracked through Deming’s PDCA cycles and statistical process control charts for key target areasThe limitations of this work include how different professionals and patients may have their own biased viewpoint and the small sample sizes are not representative in a statistical way. The ward on which the work was done had only been in use for a short while since it opened in early November and hence there may be an element of bedding down.This work will be extended further by examining additional data sources such as incident reports and patient complaints. Potentially other patient groups like children and their parents as well as burn patients could be involved to determine the special needs of these patient subgroups. The results of this study will be fed back to the department of Plastic Surgery and the Clinical Audit department and will be presented to staff at an audit half-day meeting. The patients who participated in this work will also be informed of its progress through periodic updates from the author.This small-scale study demonstrates how the ward round as a process can be assessed, including product quality, process quality, the measurement and management of capacity, the role of standardization, the role and significance of bottlenecks, the key information flows, including the role of feedback, and the motivation and incentives of system participants and ideas for improvement generated.www.IJSOncology.com.Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,


Our results showed that mean SOC content decreased from 9.30 g kg−1 near the surface to 2.36 g kg−1 in 80–100 cm whereas mean SIC content increased from 10.48 to 12.72 g kg−1. On average, SOC and SIC stocks over 0–100 cm were 5.73 kg C m−2 and 16.89 kg C m−2, respectively. There was a significantly positive correlation  between SOC and SIC in the cropland. We also found that SIC had a significantly positive correlation with both soluble Ca2+  and Mg2+ . Our study suggested that increasing SOC might lead to an increase in SIC stocks in the cropland of North China Plain. This study highlights the importance of SIC in the carbon cycle of China’s semi-arid region.Soil inorganic carbon (SIC) and organic carbon (SOC) are important carbon reservoirs in terrestrial ecosystems. However, little attention was paid to SIC dynamics in cropland. We conducted a survey in the upper Yellow River Delta of North China Plain. We collected 155 soil samples from 31 profiles, and measured SOC, SIC and soluble Ca An increase in soil pH  would drive the reaction (1) to the right, resulting in production of HCO3−. When there is no limitation of soluble Ca2+/Mg2+, precipitation of calcium carbonate would occur in soil. On the other hand, an increase in soil CO2 or a decrease in soil pH would drive the reaction (2) to the left. Therefore, acidic conditions could lead to dissolution of carbonate, causing a decrease in SIC stock, whereas alkaline environment would benefit the formation of carbonate2+/Mg2+ with SIC stockThe formation of calcium carbonate is affected by soil carbon dioxide  and Mg2+ (21–102 g m−2) stocks over 0–100 cm. Overall, soluble Ca2+ stock was apparently higher in the sites near the Yellow River than other sites far away from the Yellow River. Higher values of soluble Ca2+ stock were found in the southern part than in the northern part of the sampling area. Interestingly, soluble Mg2+ revealed a different spatial pattern, showing random high values.The spatial distributions of soluble Ca−1), but a large variation in SIC (7.71–21.21 g kg–1) of subsoil. As shown in –1 in the 20–40, 40–60, 60–80 and 80–100 cm, respectively, whereas mean SIC content increased from 10.5 ± 2.6 in the 0–20 cm to ~11.7 ± 3.1 and 12.7 ± 3.8 g kg–1 in the 20–60 and 60–100 cm, respectively. The magnitudes and vertical distributions of SOC and SIC were similar to those in the loess profiles of northwest China−2, respectively. It appeared that both SOC and SIC stocks were higher near the Yellow River than those far away from the Yellow River. Overall, SOC stock was higher in the south side of the Yellow River although there was a large variation in SOC in the southwest part of the study area. In general, SIC stock was higher in the south side of the Yellow River than in the north side, except three sites showing low value of SIC stock. Interestingly, the highest SIC values were found at the sites that showed relatively high SOC stock. On average, SIC stock (16.89 kg C m−2) was nearly three times of SOC stock (5.73 kg C m−2) over 0–100 cm in the cropland of the upper Yellow River Delta, indicating that SIC stock accounted for approximately 75% of the total carbon stock.2+ and Mg2+ stocks, especially soluble Ca2+ , but a stronger positive relationship with soluble Ca2+   .−2 in the cropland of Zibo–Binzhou area, which was close to the values of 6.6 and 6.0 kg C m−2 in the cropland of Zhengzhou and Lanzhou areas, respectively  was 5.73 kg C mectively . Liu et −2 over 0–100 cm in the Zibo–Binzhou area, which was significantly higher than the reported value for the semi-arid cropland at Zhengzhou (8.14 kg C m−2), where soils were developed on the same parent material . The SIC stock in this study was also higher than the semi-arid cropland at Yangling (9.00 kg C m−2), where soil was developed on the deposited loess. A range of 12–15 kg C m−2 was found in the Zibo–Binzhou region for irrigated fields using the data from the Second National Soil Survey−2 in the loess soil of Lanzhou−2 in the brown desert soil of Yanqi12The SIC stock was 16.89 kg C met al.Carbonate (and bicarbonate) and calcium (and magnesium) are the essential elements for carbonate precipitation. Previous study has demonstrated that organic amendments in cropland of north China can significantly enhance carbonate accumulation, in particular in the subsoil−1 SOC in the 0–20 cm, which was similar to that used in the Lanzhou area by Zhang, et al.−1 to 14.91 g kg–1in the high fertility soils, and from 10.07 g kg−1 to 12.33 g kg−1 in the low fertility soils (−2) than in the low fertility soils (16.24 kg C m−2).To explore the impacts of soil fertility on SIC stock in the cropland of upper Yellow River Delta, we divided our data into two groups (low fertility and high fertility) using a criterion of 9.0 g kgty soils . The SIC2+ and with soluble Mg2+. Given that higher soluble Ca2+ and Mg2+ were found near the Yellow River, we postulate that the sources of Ca2+ and/or Mg2+ in this area may come from the ground water and/or river water . Earlier studies showed that Ca2+ and Mg2+ contents in the main channel of the lower Yellow River were 45–51 mg L−1 and 22–26 mg L−1, respectively, which were significantly higher than those (30–40 mg L−1 for Ca2+ and 6.3–14 mg L−1 for Mg2+) in the main channel of the Yangtze River272+ and Mg2+ and therefore benefit the formation of SIC. In addition, there might be other sources of Ca2+/Mg2+, such as dust, fertilization, and weathering of Ca/Mg silicate minerals52+/Mg2+sources and to explore the mechanisms regulating SIC formation.Our analyses showed that the SIC stock was positively correlated with soluble Ca2 production is high due to root respiration and decomposition of SOC, which creates acidic conditions, thus leads to dissolution of soil carbonate; the positive relationship may be more common in high pH soils and without Ca/Mg limitationThere have been inconsistent finding on the relationship between SIC and SOC. On the one hand, there was evidence that the negative relationship between SIC and SOC was found in the surface soil of North China Plainet al. also found that the slope reached 1.9 (over 0–100 cm) in Yanqi Basin’s cropland that had access to groundwater (containing high level of Ca2+/Mg2+)Our data showed a significantly positive correlation between the SIC and SOC stocks  in the cropland of upper Yellow River Delta . The slo32−/HCO3− and Ca2+/Mg2+ ionsAs revealed in Our study area, in the Zibo and Binzhou City, is located in the upper Yellow River Delta . The are2+ and Mg2+. Soil pH and EC were measured using a soil:water (1:2.5) mixture. Soluble Ca2+ and Mg2+ were determined using a soil:water (1:5) mixture by an Atomic Absorption Spectrophotometeret al.3PO4) for 12 h to remove carbonate. The pretreated sample was combusted at 1020 °C with a constant helium flow carrying pure oxygen to ensure completed oxidation of organic materials. Production of CO2 was determined by a thermal conductivity detector. Soil inorganic carbon was calculated as the difference between total soil carbon and SOC. The analyses of total soil carbon and SOC were performed at the State Key Laboratory of Lake Science and Environment, Nanjing Institute of Geography and Limnology, Chinese Academy of Sciences.In order to assess the Yellow River’s influence on the distributions of SOC and SIC stocks, we sampled along five lines, in which three lines were parallel with the Yellow River and two lines across to the Yellow River. We sampled 31 soil sites in the cropland during August 2015, with sampling sites distributed as evenly as possible (about 10 km in distance between the two sites) . We rand−2) were calculated from carbon content (g C kg−1), BD  and thickness :For each soil site, SOC and SIC stocks  and Arcgis (version 10.1).We used Fisher’s protected least significant difference (LSD) to compare SOC, SIC and soil parameters  between depths. We applied Student’s How to cite this article: Guo, Y. et al. Dynamics of soil organic and inorganic carbon in the cropland of upper Yellow River Delta, China. Sci. Rep.6, 36105; doi: 10.1038/srep36105 (2016).Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


N = 135). The results suggest that betting advertising aligns drinking alcohol with sports culture and significantly associates emotionally charged sporting situations such as watching live games or celebrating goals with alcohol. Additionally, alcohol drinking is more frequent in betting adverts with a higher number of characters, linking friendship bonding and alcohol drinking  in the context of sports gambling.The prevalence of sports betting advertising has become a major concern for gambling regulators, particularly since the legalization of online gambling in many European jurisdictions. Although the composition of gambling advertisement narratives has received some limited attention, nothing is known regarding how betting advertisements  might be associating gambling with other potentially risky behaviors. The present paper examines the representation of alcohol drinking and low nutritional value food eating in sports betting advertising. By means of a mixed-methods approach to content analysis, a sample of British and Spanish soccer betting adverts was analyzed ( Problem gambling is a risky behavior that when engaged in with problem drinking and eating disorders can potentially multiply its detrimental effects on individuals. The associations between the three behaviors remain unclear, although some studies, predominantly among university students, have theorized possible commonalties. For instance, a study conducted with a sample of 246 psychology students found that urgency (no specification whether negative or positive) is the impulsivity-related construct that best predicts alcohol drinking, gambling, and binge eating behavior  eating . The study complements the paradigm of individually motivated risky behavior by focusing on the effects that media representation of behavior—by means of repeated patterns of characters, situations, and/or actions in adverts—might have on the imitation and normalization of gambling behavior. Here, the underlying assumption is that sports betting advertising depicts specific gambling behaviors, sometimes in conjunction with LNVF eating and alcohol drinking, creating a symbolic understanding of what gambling on sports means  were proposed in the present paper to understand how sports betting advertising represents bettors’ behavior. RQ1: How is eating LNVF and drinking alcohol in sports betting adverts represented in sport culture. In particular, this question seeks to explore whether sports betting adverts present gambling, eating LNVQ, and drinking alcohol in association with emotionally charged situations, such as watching live sport. RQ2: How is drinking alcohol and eating LNVF portrayed in sports betting adverts in relation to friendship building.N = 135) were sampled from a larger cross-sectional study. Advertisements with an upload date from June 2014 to November 2016 were downloaded from the official YouTube channels of 29 different betting brands. These brands were primarily selected based on their presence as sponsors, official partners, or regular advertisers in sport events. All adverts met the following inclusion criteria: (i) only those advertising soccer were included, thus excluding horse and dog racing as well as other sports whose popularity is more country-specific; (ii) only advertisements from Spain and the UK were selected because these were the two languages that the authors could understand as native speakers, and the representativeness of La Liga and Premier League competitions in European soccer ; (iii) the advertisements belonged to companies with a legal license to operate in one or both of the countries analyzed; (iv) the adverts had to have a televisual and temporal format (between 20 and 60 s duration). This latter inclusion criterion excluded made-for-internet promotions that typically allow informal shooting or discussion-like videos including tipsters sponsoring a brand. Also, longer advertisements were excluded because they were unlikely to have been shown on television; and (v) for the purpose of assessing new behavioral patterns attached to new products, the advertisements had to focus on online sports betting, excluding those addressing offline betting. Further details of the adverts analyzed can be obtained from the first author on demand.Sports betting television adverts  was recorded from May to June 2016. The results confirmed that every television advertisement was made accessible, sometimes with a few weeks’ delay, via the operator’s YouTube profile. Also, the electronic banners around the soccer field were analyzed to make sure no betting brand being promoted was excluded from the study sample.To check if the The initial analysis was conducted by three coders. Coder 1 rated the whole sample of advertisements. For reliability purposes, a sub-sample composed 23 adverts (17.03%) was randomly generated and coded independently by coders 2 and 3. Interrater reliability was calculated using ReCal3 software, which is especially designed for situations with three or more coders analyzing nominal data wherein Cronbach’s alpha is not useful. In the present study, a solid interrater reliability was found. Krippendorff’s alpha coefficients ranged from 0.78 to 1, with all except one variable punctuating below the 0.80 cut-off point generally recommended for acceptable reliability, but enough for exploratory analysis , sugary drinks, pizza, hamburgers, and French fries.To assess the association between alcohol and LNVF with sports culture (RQ1), characters in the adverts consuming alcohol or LNVF were hypothesized to be associated with (1) having a sentimental bond with sport ; (2) being depicted as in an emotional state; (3) appearing celebrating a goal; (4) betting while viewing sport ; (5) being offered by the advert free bets, money back, or similar promotions; and (6) showing satisfaction from the outcome of a bet or a game. To explore RQ2, namely the association between unhealthy food and alcohol with friendship building, variables 1 to 6 were hypothesized to vary depending on the number of characters in adverts portrayed drinking alcohol; and similarly on the number of characters in adverts portrayed eating LNVF. Additionally, adverts were analyzed in terms of (7) the type of drink consumed, under the assumption that drinking beer  will be more likely to occur in group settings in contrast to drinking wine or spirits.p value lower than 0.05 was accepted as statistically significant without controlling for multiple comparisons error.Chi-square tests were performed between the variables outlined above using IBM SPSS 23 for Mac. Fisher’s exact test (one-sided) was used when the distribution expected cell counts were below 5. Considering the exploratory purpose of the study, and given the scarcity of scientific literature in the field and the mixed-methods approach, a threshold χ2 = 6.401, p < .041); and (ii) the number of characters in the advert eating LNVF was associated with showing satisfaction to what could be implied as a satisfactory game or bet outcome .Initial analysis of the 135 adverts identified 36 betting adverts depicting LNVF consumption (26.7%), and 30 betting adverts depicting alcohol consumption (22.2%). The incidence of simultaneous alcohol drinking and LNVF eating was relatively low, comprising only 11 adverts (8.14%). LNVF eating behavior showed little association with any of the variables analyzed. Sentimental identification with the team, emotionally charged scenes, in-play betting situations, and free bet promotions, had no statistically significant association with LNVF eating behavior. Only two variables were suggestive of an association. More specifically, (i) LNVF eating was associated with the characters in the advert celebrating a goal ; (ii) the characters in the advert watching live sport while betting  ; (iii) any of the characters celebrating a goal  ; and (iv) the character showing satisfaction for what appears to be the outcome of a bet or a game . The provision of free bets (or other similar promotions) and how emotionally charged the main character appeared to be did not yield any statistically significant relationship with alcohol drinking behavior.In contrast, alcohol drinking showed several associations with sports betting behavior. The presence of alcohol in the advert co-occurred with (i) the appearance of characters with a sentimental bond ; (ii) the characters celebrating a goal ; (iii) the characters watching live sport while betting ; and (iv) the advert offering free bets ; and (5) drinking beer . The number of characters drinking was not statistically associated with the (i) appearance of characters with a sentimental bond, or (ii) showing of satisfaction due to bet or game outcome.Further analysis showed that a higher number of characters in the adverts that depicted alcohol drinking was associated with (i) the main character being more emotionally involved ; (ii) free money offers ; and (iii) characters celebrating a goal . Contrary to what was hypothesized, in-play betting, emotional involvement of the main character, and sentimental identification were not statistically associated with beer drinking. However, among the 11 adverts showing both alcohol and LNVF consumption, drinking beer was not only associated with eating LNVF , but also with a higher number of characters eating LNVF in the advert . Among the 11 adverts showing wine/spirits drinking, only one (9.09%) also depicted LNVF consumption, whereas among the 19 adverts with characters drinking beer, 10 also consumed LNVF (52.63%).Alcohol type was further analyzed, binary coding whether the adverts portrayed beer drinking  as opposed to wine/spirits drinking. Those adverts with characters drinking beer were associated with (i) a higher number of overall characters in the advert  and LNVF (26.7%) consumption. However, when combined, 55 out of 135 adverts (40.7%) depicted at least one of the two behaviors. Gambling, like consuming LNVF and alcohol, is largely considered a risky product whose marketing and advertising must be limited  more frequently sentimental bonds between characters and sport; (ii) more frequent betting while watching a live game; (iii) more goal celebrations; and (iv) in general, characters demonstrating greater satisfaction for the outcome of the games or bets. These activities were examined in order to explore the representation of bettors’ behavior in emotionally charged situations. Sport is far from being an emotionally neutral content, and often entails identity and belonging aspects  more characters in their narratives than those adverts with no alcohol drinking. Solitary gambling, similar to solitary alcohol drinking, exposes individuals to greater risks of developing problems  should be cognizant and react to the symbolic linkage of independent risky behaviors, particularly in contexts of enhanced emotions and impulses, such as popular sports, and considering the appeal of such content to children.


In the vehicular networks, the real-time video reporting service is used to send the recorded videos in the vehicle to the cloud. However, when facilitating the real-time video reporting service in the vehicular networks, the usage of the fourth generation (4G) long term evolution (LTE) was proved to suffer from latency while the IEEE 802.11p standard does not offer sufficient scalability for a such congested environment. To overcome those drawbacks, the fifth-generation (5G)-enabled vehicular network is considered as a promising technology for empowering the real-time video reporting service. In this paper, we note that security and privacy related issues should also be carefully addressed to boost the early adoption of 5G-enabled vehicular networks. There exist a few research works for secure video reporting service in 5G-enabled vehicular networks. However, their usage is limited because of public key certificates and expensive pairing operations. Thus, we propose a secure and lightweight protocol for cloud-assisted video reporting service in 5G-enabled vehicular networks. Compared to the conventional public key certificates, the proposed protocol achieves entities’ authorization through anonymous credential. Also, by using lightweight security primitives instead of expensive bilinear pairing operations, the proposed protocol minimizes the computational overhead. From the evaluation results, we show that the proposed protocol takes the smaller computation and communication time for the cryptographic primitives than that of the well-known Eiza-Ni-Shi protocol. Forear 2017 . Let us ear 2017 ,9,10. Alear 2017 ,12,13. TBefore the full deployment of the 5G cellular network in the year 2020 , securitThe Eiza-Ni-Shi protocol relies on convectional public key certificates that should be renewed in the vehicle periodically, e.g., every year. However, such periodic renewal is proved to be burdensome over the vehicular networks ,21,22.The Eiza-Ni-Shi protocol is built on expensive pairing operations. Thus, the overall efficiency of the Eiza-Ni-Shi protocol can be decreased despite the merits of 5G cellular networks.The Eiza-Ni-Shi protocol is designed by using an attribute-based encryption. When attribute-based encryption is used to achieve access control, the video sender should know the public key of the receiver. This preliminary makes the Eiza-Ni-Shi protocol to be only applicable in limited services.To send the videos recorded by the vehicle’s cameras into the cloud server, we propose a secure and lightweight cloud-assisted video reporting protocol for 5G-enabled vehicular networks. Recently, Eiza et al.  and Yoo non-repudiation property, the conditional traceability of all the vehicles should be achieved.Also, we note that the cloud-assisted video reporting protocol should be designed to fulfill security requirements such as privacy, authorization and fine-grained access control over the vehicles. For example, the sender’s personal data should not be revealed to unauthorized entities or even the reporting vehicles should not be traced by any malicious users. Even under the huge computation capabilities of 5G-enabled vehicular network, the cloud entities should not waste much time and computation capabilities before they discard bogus, unauthenticated and unauthorized videos. In addition, for the proposed protocol to attain the We define an application model for a secure and lightweight cloud-assisted video reporting protocol over 5G-Enabled vehicular networks. The model highlights the security objectives that the protocol should satisfy within the 5G-Enabled vehicular networks architecture.authorization through anonymous credential. Since the reported videos are broadcasted by the fixed entities, the designated vehicles can recover the reported videos without making any time-consuming communication. Also, by using lightweight security primitives, the proposed protocol minimizes the computation overhead and meets the performance requirement for the real-time ITS-based services in 5G-Enabled vehicular networks.We develop a secure and lightweight cloud-assisted video reporting protocol for 5G-enabled vehicular networks. Without using the conventional public key certificates, the proposed protocol supports entities’ We evaluate the performance of the proposed protocol in terms of security objectives, computation cost and communication overhead.To fulfill the above-mentioned goals of 5G-enabled cloud-assisted video reporting protocol and to overcome the drawbacks of the Eiza-Ni-Shi protocol, we propose a new secure and lightweight video reporting protocol for 5G-enabled vehicular networks. We summarize the contributions of this work as follows:The rest of this paper consists of as follows. After we describe the related work in In this section, we overview the evolution of vehicle communication architectures for supporting the video reporting service in 5G-enabled vehicular networks.VANETs using Cloud [VANETs using Cloud is defined as vehicular networks equipped with smart devices which communicate with the cloud in the same way as our mobile phones connect to different servers located in the cloud. VANETs using Cloud was introduced in [VANETs using Cloud. In [VANETs using Cloud compared to convectional VANETs. Also, the feasibility of VANETs using Cloud was approved by several researchers [Vehicular Cloud refers to the full utilization of vehicle devices as computers to form mobile servers. In this architecture, one could use the vehicle’s OBU to make his/her personal cloud. As a combination of Vehicular cloud and VANETs using Cloud, Hybrid vehicle cloud was proposed. The proposed protocol is built on VANETs using Cloud framework, i.e., cloud-assisted vehicular networks. In the following sections, vehicular networks and cloud-assisted vehicular networks are used interchangeably.As an extension of mobile ad-hoc networks (MANETs) , the maing Cloud . VANETs duced in  by Olariloud. In , Hussainearchers ,30,31,32Security and privacy related topics in 5G cellular networks have mostly being dedicated to security threats of each of the distinct technology (SDN or NFV) ,34. AmonFor vehicular environment, several researches have addressed potential security and privacy issues in VANETs ,39,40,41We overview the preliminary security properties such as attribute-based encryption (ABE) and certificateless signature scheme.The ABE scheme in  is desigq and P is a generator of On input of a random For each Set Returns For the universe of attributes m, m, On input of Compute For Output the ciphertext For a message ABE.KGN for all children z which are attached to the node u.D, z) D, u) output ⊥. We use N to denote NodeKey in the next paragraph for paper formatting.Suppose that Else, let To proceed with a non-leaf node K = NodeKey  consists−G be an additive group with a prime order q and Let −Choose −Let −Output the public parameters −Output CertS.Setup computes a master key along with a public system parameters as follows:−Choose −Return CertS.Secret.Compute −Output CertS.PartialK = 1, where Select a random −q).Generates −Output the signature CertS.Sign: It is in charge of the registration of all entities  inside our system and issues cryptographic materials during the system initialization.Department of Motor Vehicles (DMV): All the vehicles are assumed to register with the DMV periodically. Beside the conventional techniques for vehicle’s identification including the Electronic License Plate (ELP) or the Electronic Chassis Number (ECN), each vehicle is registered with a 5G identifier (5GID) with the same functionalities as the subscriber identification module (SIM) chip.Road Side cloud (RSC): RSCs are servers located along the roads and accessible by the vehicles. RSCs stores the videos files (VFs) sent by the vehicles. In that case, the designated vehicles (DV) such as police or ambulance can download the files through the RSCs using mmWare communications. Due to the advancements of technology, we assume that RSCs are connected to an electricity power generator with enough computational capability.Designated Vehicles: The designated vehicles can be public or private vehicles registered by the government through the DMV that offers public services.Vehicles: Vehicles are equipped with OBUs which allow them to communicate with RSCs in order to send the recorded video files.We describe the communication entities in the proposed protocol: TA, DV, DMV, RSC and vehicles that communicate through the on board unit (OBU) as shown in The proposed protocol is designed to satisfy the following security requirements.Authentication and Authorization: Any vehicle has to be authenticated before it can send (report) a video recorded by its camera.Identity privacy preservation: The real identity of every vehicle should be protected from being known by other vehicles, RSC, DVs and DMV.Fine-grained access control: ABE should guarantee a fine-grained access control by which a designated vehicle should strictly be capable to recover a video fitting to its possessed access structure.Non-repudiation: A given vehicle should not deny its participation in video reporting.Traceability: TA should be capable of disclosing the real identity of all the entities in the system.The overall operation of the proposed protocol consists of system setup, periodic credential generation, on-duty token generation and accident Reporting procedures.System setup: TA sets up its master secret key and its corresponding public key. Each vehicle provides its real identity and TA generates the corresponding pseudo identity from which a partial private key is computed. DMVs and RSCs also provide their real identities and TA computes their partial private keys. Each vehicle registers with the TA through the DMV, the designated vehicles such as the police or ambulance also register with the TA through the DMV.Periodic credential generation: Periodically, a vehicle request for credential in order report the recorded videos. DMV generates the periodic credential to vehicles along with the set of attributes corresponding to the type of request. We assume that based on some criteria such as accident record or reckless driving, DMV can decide to give different set of attributes to participating vehicles.On-duty token generation: The designated vehicles also received on-duty tokens. These tokens will be used by the designated to retrieve reported videos from the RSCs.Accident Reporting: Periodically, a vehicle registers for road reporting services. During the registration, the vehicle specifies the types of services to be reported such as accident or abnormal scene (we assume that the camera of a vehicle is not limited to report road’s accidents only). An incentive technique based on point accumulation could be considered in order to motivate the vehicle users to participate in video reporting. Whenever an accident or abnormal scene occurs the camera records the scene and upload the files to the RSC using mmWare technology or D2D communication. The designated vehicles would later on acquire the report from the RSCs as long as they possess enough access structure to recover the secret.In this section, we describe the secure and lightweight cloud assisted video reporting protocol over 5G-enabled vehicular networks in details. In q with TA selects an elliptic curve group In order to get the master secret In order to keep a record of each vehicle TA provides Each Likewise, every In setup phase, TA generates global system parameters and all the entities register to the TA as follows:K is a secret key to be used later.Upon receiving the message Periodically (on a daily basis), the vehicles request a road reporting credential  with a processing speed of 65 MB/s. We also consider the size of the video ranging from 2 to 8 Gigabytes. We use SHA-512 hash function with a processing speed of 231 MB/s. The connection speed for the 5G-enabled vehicular network is set to 1.2 Gb/s and vehicle’s velocity to 100 km/h . We alsopublic key encryption with key search [To recover the video file, tocol in  requiresy search ; (d+1)TmIn this paper, we noted that although there exist a few research works for secure video reporting service in 5G-enabled vehicular networks, their usage is limited because of public key certificates and expensive pairing operations are required. To overcome the limitation, we proposed a new secure and lightweight protocol for cloud-assisted video reporting service in 5G-enabled vehicular networks. Based on a fined-grained access control, the proposed protocol allowed the designated vehicles to recover the recorded video files without any prior communication. By providing security and privacy for the participating entities, the proposed protocol prevents malicious users from tracking, revealing or impersonating the system entities. Also, by using a new certificateless signature scheme, the proposed protocol assured the authentication of legitimate vehicles. With anonymous credentials instead of public key certificates, the proposed protocol guaranteed the authorization of participating entities. From the security and performance analysis results, we showed that the proposed protocol took a lightweight overhead compared to the state-of-the-art works. From these analysis results, we believe that the proposed protocol will help to realize timely and secure cloud-assisted video reporting service over 5G-enabled vehicular networks.


Nude mice subsequently produced mouse CD3 Here we show that slices of human thymus tissue that have been frozen and thawed can induce and support T‐cell development when transplanted into nude mice.Infants born without a thymus require urgent treatment to reconstitute T‐cell immunity We therefore decided to use a nude mouse model of human thymus transplantation + and CD8+ T‐cells were observed 12 weeks after transplantation (Fig. + and CD8+ cells in the transplanted animals stained positive for CD3, confirming they were T‐cells (Fig. +CD3+ cells or between CD4+CD25− and CD4+CD25+ cells in lymph nodes between mice transplanted with fresh thymus slices and slices that had been frozen and thawed (Fig. +CD3+ and γδ+CD3+ cells (Fig. Thawed slices were cultured for 24 h before transplantation into athymic nude mice, as described previously wed Fig. . All thrIn conclusion, these animal experiments show that slices of human thymus can still induce and support T‐cell development after cryopreservation. The tissue that has been frozen behaves in a comparable manner to fresh human thymus slices in our animal model S.R., M.C., C.I.L., N.S., and E.G.D. carried out experimental work; M.B., T.C., and E.G.D. obtained funding; P.K., B.F., and G.J.M. provided expertise in cryopreservation; S.R. and T.C. wrote manuscript.The authors declare no financial or commercial conflict of interest.Nu‐C‐Tpnude mouse cryopreserved human thymus transplantNu‐F‐Tpnude mouse fresh thymus transplantWTwild typeSupporting InformationClick here for additional data file.Peer review correspondenceClick here for additional data file.


Lifestyle behaviour may play a role in refractive error among children, but the association between near work habits and refractive anisometropia remains unclear.We estimated the prevalence of refractive anisometropia and examined its association with near work activities among 23,114 children in the Myopia Investigation Study in Taipei who were grade 2 elementary school students at baseline in 2013 and 2014. Baseline data on demographics, medical history, parental history and near work habits were collected by parent-administered questionnaire survey. Refractive status was determined by cycloplegic autorefraction. Refractive anisometropia was defined as the spherical equivalent difference ≥ 1.0 diopter between eyes.The prevalence of refractive anisometropia was 5.3% . The prevalence and severity of refractive anisometropia increased with both myopic and hyperopic refractive error. Multivariate logistic regression analysis revealed that refractive anisometropia was significantly associated with myopia , hyperopia , degree of astigmatism , amblyopia , male gender  and senior high school level of maternal education . Though anisometropic children were more likely to spend more time on near work  and to have less eye-to-object distance in doing near work , these associations became insignificant after additional adjustment for ocular, demographic and parental factors.The present study provides large-scale, population-based evidence showing no independent association between refractive anisometropia and near work habits, though myopia is associated with refractive anisometropia. Refractive anisometropia, a between-eye difference in ocular refraction, is of great clinical interest because it is a well-known amblyogenic factor in children. Early detection of refractive anisometropia in children with timely intervention could prevent permanent impairment in binocular vision and stereopsis. Refractive anisometropia represents a unique condition in that the fellow eyes of an individual with presumably similar sociodemographic, environmental, and genetic influences can have asymmetric ocular growth. Thus, investigation of refractive anisometropia among schoolchildren is helpful to understand the development of refractive error.The structural basis of refractive anisometropia is attributed to the interocular difference in axial length . It has Despite a number of studies describing the ocular structure, demographic and refractive status of subjects with anisometropia –20, epidThe MIT, a citywide, population-based cohort study, is designed to investigate the refractive status in schoolchildren for 3 consecutive years. The study design, methods and rationale have been previously described elsewhere . In brieThe eye examination for the MIT participants include slit lamp examination and the measurement of visual acuity (unaided and best-corrected) and refractive status (before and after cycloplegia). Three kinds of cycloplegic eye drops were approved for use in the MIT, including Cyclogyl (1% cyclopentolate), Mydriacyl (1% tropicamide), and Mydrin-P (0.5% phenylephrine hydrochloride/0.5% tropicamide). Among these three drugs, each hospital or clinic could use only one kind of cycloplegic eye drop to perform cycloplegia for the MIT participants. Two drops of the cycloplegic drug were administered 10 minutes apart. Thirty minutes after the second drop of the cycloplegic drug, a penlight was used to check the pupil light reflex. If the pupil still responded to penlight, an additional 10-minunte wait was required before cycloplegic refraction. Refractive status was determined by the average of three consecutive autorefraction measurements. The spherical equivalent (SE) of the refractive error was calculated as: the spherical power plus half the magnitude of the cylinder power. Only the eye with less SE (less positive or more negative refractive error) in each child was used for defining the baseline SE and the degree of astigmatism.Similar to previous epidemiological studies , we defiWe hypothesized that the potential risk factor for anisometropia may include ocular, demographic, and parental factors and near work habits. The data of these potential risk factors were obtained from parent-administered questionnaire surveys covering demographics, medical history, parental history, time spent on near work and outdoor activities, reading habits, and eye-care seeking behavior. The MIT parent questionnaire was composed of closed-ended questions with two option (yes/no) responses or a list of ordered choices. Respondents were asked to check the choice they felt was the most proper. Questions regarding near work habits and analyzed in the present study included age of near work initiation, eye-to-object distance, use of computer or mobile devices, average daily quantity of near work activities, including reading, writing, painting, playing instruments, watching television, and playing computer/video games, the presence of adequate rest, as well as attending an after-school tutorial program.2 and Akaike information criterion (AIC) of each model were also calculated. The pseudo-R2 value in the logistic regression model is helpful to understand how much of the variance is accounted for by the independent variables. The AIC value is used for model selection. The model with a lower AIC value is a better fit for the data and loses less information. Furthermore, to check the possible association of near work habits with severe refractive anisometropia, multivariate logistic regression analysis was also conducted with the presence of severe refractive anisometropia as the dependent variable for the sensitivity analysis. It has been reported that more time spent on near work activities is a risk factor for childhood myopia[The data of participants enrolled in 2013 or 2014 who had completed the cycloplegic autorefraction measurements and responded to the survey were analysed. All data were expressed as mean± SD or percentage. The differences between groups in terms of refractive status, sociodemographic characteristics, parental myopia status, and near work activities were compared with Chi-square tests or independent t-tests as appropriate. To examine the potential association between ocular, demographic and parental factors, near work activities, and refractive anisometropia, multivariate logistic regression analyses were conducted with the presence of refractive anisometropia as the dependent variable. To estimate how, and to what extent, these factors influenced refractive anisometropia, a hierarchical logistic regression was performed. Ocular, demographic, and parental factors and near work activities were entered block-wise into models. The estimated risk of refractive anisometropia was separately assessed using three models with different arrays of independent variables. Model 1 consisted of ocular factors , and Model 2 combined ocular factors in Model 1 with demographic and parental factors . In the final model (Model 3), all factors in Model 1 and Model 2 as well as near work habits  were included. The values of adjusted pseudo-Rod myopia. Hence, A total of 23,114 subject  were finally recruited into the statistical analysis. 2, 0.1012) to Model 3 , whereas the increment between Model 2 and Model 3 (Δpseudo-R2 = 0.0019) was smaller than that between Model 1 and Model 2 (Δpseudo-R2 = 0.0028). Among all 3 models, Model 2 had the lowest AIC value (8738.672).From the baseline data of this large-scale, population-based study, we observed that the prevalence of refractive anisometropia was 5.3% among 23,114 predominantly 8-year-old schoolchildren in a metropolitan city in East Asia and refractive anisometropia was associated with baseline refractive status, astigmatism, presence of amblyopia, gender and maternal education level. None of the factors regarding near work activities was found to be a risk factor for refractive anisometropia. To our knowledge, the present study provides the first population-based data on the epidemiology of refractive anisometropia among schoolchildren in Taiwan.The main results of epidemiological studies on prevalence of refractive anisometropia among children and adolescents are summarized in Near work activities have been found to be associated with childhood myopia in previous epidemiological studies –30. Howe2 between Model 2 (0.1040) and Model 3 (0.1059) indicated a poor explanatory power attributable to the near work-related variables added in Model 3. Furthermore, Model 2, including ocular, demographic and parental factors as independent variables, had the lowest AIC value and was the best fit among all 3 models. Subgroup analysis also showed no association between near work habits and refractive anisometropia among both myopic and hyperopic schoolchildren. In the questionnaire survey of our study, time spent on near work activities was defined as the average daily quantity of all kinds of near work, including reading, writing, painting, playing instruments and playing computer/video games over the past year [Recently, Hu et al. reported that more time spent indoors reading or writing was significantly associated with higher prevalence of refractive anisometropia  and higher amount of refractive anisometropia and anisomyopia  in the multivariate models . In the ast year . By contConsistent with previous literature ,25, the The present study has some strengths. Due to the well-executed compulsory education system in Taiwan, the MIT study, for the purpose of identifying every undiagnosed myope in early childhood, invited all grade 2 schoolchildren in Taipei City to participate with the help of school authorities. This design makes it as one of the largest epidemiological studies of anisometropia among schoolchildren and minimizes potential selection bias occurring in the sampling procedure. In addition, the high number of participants from the population gives the study greater power to detect differences.Several limitations of the present study should be noted. First, similar to a cross-sectional study design, only baseline data of the MIT cohorts was analyzed in the present study and it is hard to differentiate cause and effect from simple association. Second, near work activities of schoolchildren were assessed based on parent-completed questionnaire surveys rather than direct measurement. Therefore, our analysis is subject to recall bias. The questionnaire, while practical, may not be the most accurate tool to evaluate the quantity of near work activities. Parents whose children have had myopia may be more likely than parents of non-myopic children to remember details of myopiogenic behaviors. However, no independent association between near work activities and refractive anisometropia was found in both myopic and hyperopic groups in our study. Third, ocular biometric measurements were not carried out in the MIT study. Therefore, the data regarding axial length was not available. Finally, generalizability of anisometropia data in MIT to other ethnic populations is a concern.The present study provides large-scale, population-based evidence regarding the estimation of prevalence and risk factors for refractive anisometropia among young schoolchildren in Taipei City. Though anisometropic children were more likely to spend more time on near work and to have less eye-to-object distance in doing near work, these associations became insignificant after additional adjustment for ocular, demographic and parental factors. The impact of near work habits on the development of refractive anisometropia still warrants further large-scale cohort studies among schoolchildren.S1 Table(DOC)Click here for additional data file.