Heterogeneous coupling of the Sumatran megathrust constrained by geodetic and paleogeodetic measurements

Geodetic and paleogeodetic measurements of interseismic strain above the Sumatran portion of the Sunda subduction zone reveal a heterogeneous pattern of coupling. Annual banding in corals provides vertical rates of deformation spanning the last half of the 20th century, and repeated GPS surveys between 1991 and 2001 and continuous measurements at GPS stations operated since 2002 provide horizontal velocities. Near the equator, the megathrust is locked over a narrow width of only a few tens of kilometers. In contrast, the locked fault zone is up to about 175 km wide in areas where great interplate earthquakes have occurred in the past. Formal inversion of the data reveals that these strongly coupled patches are roughly coincident with asperities that ruptured during these events. The correlation is most spectacular for rupture of the M_w 8.7 Nias-Simeulue earthquake of 2005, which released half of the moment deficit that had accumulated since its previous rupture in 1861, suggesting that this earthquake was overdue. Beneath the Mentawai islands, strong coupling is observed within the overlapping rupture areas of the great earthquakes of 1797 and 1833. The accumulated slip deficit since these events is slowly reaching the amount of slip that occurred during the 1833 earthquake but already exceeds the slip that occurred during the 1797 earthquake. Thus, rerupture of part of the Mentawai patch in September 2007 was not a surprise. In contrast, coupling is low below the Batu islands near the equator and around Enggano island at about 5°S, where only moderate earthquakes (M_w < 8.0) have occurred in the past two centuries. The correlation of large seismic asperities with patches that are locked during the interseismic period suggests that they are persistent features. This interpretation is reinforced by the fact that the large locked patches and great ruptures occur beneath persistent geomorphologic features, the largest outer arc islands. Depth- and convergence-rate-dependent temperature might influence the pattern of coupling, through its effect on the rheology of the plate interface, but other influences are required to account for the observed along-strike heterogeneity of coupling. In particular, subduction of the Investigator Fracture Zone could be the cause for the low coupling near the equator

WHO guide to good prescribing is 25 years old:quo vadis?

Introduction: Twenty-five years ago, the World Health Organization (WHO) published the Guide to Good Prescribing (GGP), followed by the accompanying Teacher’s Guide to Good Prescribing (TGGP). The GGP is based on a normative 6-step model for therapeutic reasoning and prescribing, and provides a six-step guide for students to the process of rational prescribing. Method: We reviewed the need to update both WHO publications by evaluating their use and impact, including new (theoretical) insights and demands. Based on information from literature, Internet, and other (personal) sources, we draw the following conclusions. Results: 1. An update of the GGP and TGGP, both in terms of content and form, is necessary because of the current need for these tools (irrational medicine use and unavailability of medicines), the lack of similar documents, and the lack of connection with recent developments, such as Internet and modern education; 2. The basic (6-step) model of the GGP is effective in terms of rational prescribing in the undergraduate situation and is still consistent with current theories about (context) learning, clinical decision-making, and clinical practice; 3. The dissemination and introduction of the GGP and TGGP in education has been successful so far, but is still not optimal because of lack of support and cooperation. Conclusions: On the basis of the evaluation results, a plan for the revision of the GGP and TGGP is presented

The potential of training specialist oncology nurses in real-life reporting of adverse drug reactions

Specialist oncology nurses (SONs) have the potential to play a major role in monitoring and reporting adverse drug reactions (ADRs); and reduce the level of underreporting by current healthcare professionals. The aim of this study was to investigate the long term clinical and educational effects of real-life pharmacovigilance education intervention for SONs on ADR reporting. This prospective cohort study, with a 2-year follow-up, was carried out in the three postgraduate schools in the Netherlands. In one of the schools, the prescribing qualification course was expanded to include a lecture on pharmacovigilance, an ADR reporting assignment, and group discussion of self-reported ADRs (intervention). The clinical value of the intervention was assessed by analyzing the quantity and quality of ADR-reports sent to the Netherlands Pharmacovigilance Center Lareb, up to 2 years after the course and by evaluating the competences regarding pharmacovigilance of SONs annually. Eighty-eight SONs (78% of all SONs with a prescribing qualification in the Netherlands) were included. During the study, 82 ADRs were reported by the intervention group and 0 by the control group. This made the intervention group 105 times more likely to report an ADR after the course than an average nurse in the Netherlands. This is the first study to show a significant and relevant increase in the number of well-documented ADR reports after a single educational intervention. The real-life pharmacovigilance educational intervention also resulted in a long-term increase in pharmacovigilance competence. We recommend implementing real-life, context- and problem-based pharmacovigilance learning assignments in all healthcare curricula

Effect of heat treatment on microstructure and functional properties of additively manufactured NiTi shape memory alloys

Additive manufacturing of NiTi shape memory alloys has attracted attention in recent years, due to design flexibility and feasibility to achieve four-dimensional (4D) function response. To obtain customized 4D functional responses in NiTi structures, tailorable phase transformation temperatures and stress windows as well as one-way or two-way shape memory properties are required. To achieve this goal, various heat treatments, including direct aging, annealing and annealing followed by aging, were optimized for the Ti-rich NiTi (Ni49.6Ti (at. %)) fabricated by laser powder bed fusion (L-PBF). Microstructural evolution, phase transformation, precipitation and shape memory behaviour were systematically investigated by multiscale correlative microstructural, differential scanning calorimetry analysis and thermomechanical analysis. Based on optimized heat treatments, ∼25 K phase transformation temperature windows and ∼90 MPa stress windows were achieved for the one-way shape memory effect. Solutionized annealing was found to be the most effective way to improve one-way shape memory degradation resistance, due to the reduction of defects and solid solution strengthening. One of the main findings of this study is that the heterogonous microstructures between hard intergranular Ti2NiOx and soft NiTi matrix, induced by solutionized annealing with subsequent aging, result in strain partitioning and enclosing the internal stress state, which was found to promote a pronounced two-way shape memory effect response. The results of this work provide in-depth knowledge on tailoring and designing functional shape memory characteristics via heat treatments, which contributes to expanding L-PBF NiTi application fields, such as biomedical implants, aerospace components, and other advanced engineering applications.</p

Do medical students copy the drug treatment choices of their teachers or do they think for themselves?

PURPOSE: Although the importance of rational prescribing is generally accepted, the teaching of pharmacotherapy to undergraduate medical students is still unsatisfactory. Because clinical teachers are an important role model for medical students, it is of interest to know whether this extends to therapeutic decision-making. The aim of this study was to find out which factors contribute to the drug choices made by medical students and their teachers (general practitioners and clinical specialists). METHODS: Final-year medical students (n = 32), and general practitioners (n = 29), lung specialists (n = 26), orthopaedic surgeons (n = 24), and internists (n = 24) serving as medical teachers from all eight medical schools in the Netherlands participated in the study. They were asked to prescribe treatment (drug or otherwise) for uncomplicated (A) and complicated (B) written patient cases and to indicate which factors influenced their choice of treatment, using a list of factors reported in the literature to influence drug prescribing. RESULTS: Final-year medical students primarily based their drug choice on the factors 'effectiveness of the drugs' and 'examples from medical teachers'. In contrast, clinical teachers primarily based their drug choice on the factors 'clinical experience', 'effectiveness of the drugs', 'side effects of the drugs', 'standard treatment guidelines', and 'scientific literature'. CONCLUSIONS: Medical teachers would appear to base their drug choice mainly on clinical experience and drug-related factors, whereas final-year medical students base their drug choice mainly on examples provided by their medical teachers. It is essential that medical teachers clearly explain to their students how they arrive at a specific choice of medication since medical students tend to copy the therapeutic drug choices from their teachers, mainly because of a lack of experience. Presenting students with clinical therapeutic problems early during undergraduate training will not only give them a chance to gain experience in solving medical problems but will also give meaning to what they are studying as opposed to merely reproducing what they learn or copying what they are tol

Enhancing therapeutic reasoning: key insights and recommendations for education in prescribing

BackgroundDespite efforts to improve undergraduate clinical pharmacology &amp; therapeutics (CPT) education, prescribing errors are still made regularly. To improve CPT education and daily prescribing, it is crucial to understand how therapeutic reasoning works. Therefore, the aim of this study was to gain insight into the therapeutic reasoning process.MethodsA narrative literature review has been performed for literature on cognitive psychology and diagnostic and therapeutic reasoning.ResultsBased on these insights, The European Model of Therapeutic Reasoning has been developed, building upon earlier models and insights from cognitive psychology. In this model, it can be assumed that when a diagnosis is made, a primary, automatic response as to what to prescribe arises based on pattern recognition via therapy scripts (type 1 thinking). At some point, this response may be evaluated by the reflective mind (using metacognition). If it is found to be incorrect or incomplete, an alternative response must be formulated through a slower, more analytical and deliberative process, known as type 2 thinking. Metacognition monitors the reasoning process and helps a person to form new therapy scripts after they have chosen an effective therapy. Experienced physicians have more and richer therapy scripts, mostly based on experience and enabling conditions, instead of textbook knowledge, and therefore their type 1 response is more often correct.ConclusionBecause of the important role of metacognition in therapeutic reasoning, more attention should be paid to metacognition in CPT education. Both trainees and teachers should be aware of the possibility to monitor and influence these cognitive processes. Further research is required to investigate the applicability of these insights and the adaptability of educational approaches to therapeutic reasoning

Harmonizing and improving European education in prescribing: An overview of digital educational resources used in clinical pharmacology and therapeutics

Aim Improvement and harmonization of European clinical pharmacology and therapeutics (CPT) education is urgently required. Because digital educational resources can be easily shared, adapted to local situations and re-used widely across a variety of educational systems, they may be ideally suited for this purpose. Methods With a cross-sectional survey among principal CPT teachers in 279 out of 304 European medical schools, an overview and classification of digital resources was compiled. Results Teachers from 95 (34%) medical schools in 26 of 28 EU countries responded, 66 (70%) of whom used digital educational resources in their CPT curriculum. A total of 89 of such resources were described in detail, including e-learning (24%), simulators to teach pharmacokinetics and/or pharmacodynamics (10%), virtual patients (8%), and serious games (5%). Together, these resources covered 235 knowledge-based learning objectives, 88 skills, and 13 attitudes. Only one third (27) of the resources were in-part or totally free and only two were licensed open educational resources (free to use, distribute and adapt). A narrative overview of the largest, free and most novel resources is given. Conclusion Digital educational resources, ranging from e-learning to virtual patients and games, are widely used for CPT education in EU medical schools. Learning objectives are based largely on knowledge rather than skills or attitudes. This may be improved by including more real-life clinical case scenarios. Moreover, the majority of resources are neither free nor open. Therefore, with a view to harmonizing international CPT education, more needs to be learned about why CPT teachers are not currently sharing their educational materials.</div