Beyond Cost Per Use: Exploring Multivariable E-Resource Assessment

The converging pressures of dwindling budgets, increasing subscription costs, and shifting user expectations has intensified the impact of collection management decision making. Assessing e-resource subscriptions is an integral part of any library’s collection management process, though it is especially important in academic environments. While cost per use (CPU) can be a straightforward and informative measure to consider, that lone data point might not reveal the true value of an e-resource. This paper outlines a multifaceted assessment strategy that considers the various merits of an e-resource, such as supporting accreditation, providing access to material not easily obtained through resource-sharing channels, discoverability, platform ease of use, and the quality of vendor support or responsiveness. Incorporating CPU data into a more holistic rubric might require additional time and energy, but the resulting decisions to renew or discontinue subscriptions will be more nuanced and compatible with a library’s underlying commitment to curating distinctive and accessible e-resource collections. While the proposed rubric is not a panacea, it is an inherently flexible tool that can be customized at the local level to help libraries define and articulate their priorities, analyze value as a multifaceted concept, and strategically invest their collection budgets into resources that resonate with long-term goals and needs

Comparison and Review of 17 E-Book Platforms

The University of Michigan Press, with support from the Mellon Foundation, asked John Lavender, of Lavender Consulting, to conduct a review of the American Council of Learned Societies (ACLS) Humanities E-Book collection (HEB) following its launch on Michigan’s new Fulcrum platform. ACLS-HEB is an online collection of over 5,400 high-quality humanities books from over 100 publishers. Now that the market for e-books has matured, part of the review was a comparative study of e-book platforms run by publishers, university presses and e-book vendors; 17 platforms were selected. The review looked at the key features offered by each platform, how they handled searching, content delivery, displaying results, ability to view and download and other key features, there was no attempt to judge the value of the content. Following this review, Michigan Press felt that it would be beneficial to share the results with the wider community. As well as being of interest to publishers, the review will also be relevant for librarians making purchasing decisions and vendors selling e-book services. In addition to synthesizing the results of the e-book platform review, this paper presents a librarian’s perspectives on e-book assessment criteria. Courtney McAllister, Electronic Resources Librarian at Yale University’s Law Library, describes the importance of attributes such as accessibility compliance, library branding, and metadata. Library collections are shaped by a plethora of concerns and criteria. This paper seeks to outline some key elements to consider as part of e-book platform decision-making

Wrangling Weirdness: Lessons Learned from Academic Law Library Collections

Academic law libraries face some challenges that are consistent with larger trends in higher education. However, there are unique aspects that shape the way collections are selected, evaluated, managed, and promoted. Most electronic resources designed for legal research do not generate COUNTER compliant usage data. Many subscription resources and services that libraries provide access to are primarily geared towards non-academic customers, such as law firms and corporations. Patrons increasingly need and request research products that rely on data collection, personalization, and non-IP access controls, which complicates law librarians’ professional commitment to things like preserving patron privacy and providing walk-in access. Law library technical services departments are perpetually negotiating these and other challenges to ensure the needs of law faculty and students are met as seamlessly as possible. Some of these methods and strategies might be applicable to other types of libraries navigating unfamiliar issues

Slow Breathing Reduces Markers of Stress in Response to a Virtual-Reality Active Shooter Training Drill

Law enforcement officers are expected to respond to potential life-threatening scenarios in high stress environments. Acute participation in virtual reality (VR) active shooter scenarios has been shown to increase markers of stress. Tactical occupations (i.e., military, law enforcement personnel) are trained to use slow breathing methods to aid in stress reduction, but there is no known evidence supporting the effectiveness of slow breathing in relation to a VR-active shooter training drill (VR-ASD). PURPOSE: To determine the effects of slow breathing on markers of stress in response to a VR-ASD. METHODS: A parallel between subjects design was used, during which, eighty-one (n=81) subjects performed five minutes of either slow breathing method 1 (SB1), slow breathing method 2 (SB2), or no modified breathing [normal breathing (NB)] immediately pre and post VR-ASD. SB1 (i.e., box breathing) involved a four second inhalation, two second pause, four second exhalation, and a two second pause. SB2 involved a four second inhalation, followed by a two second exhalation. The VR-ASD (~1 minute) included a single gunman and simulated victims. Subjects were fitted with a VR headset and equipped with a Glock 17 training pistol. Salivary samples and heart rate (HR) were collected thirty minutes pre, five minutes pre, five minutes post, and thirty minutes post VR-ASD. Saliva was analyzed for stress markers: α-amylase (AA) and secretory immunoglobulin-A (Sig-A). AA and SIgA were analyzed via 3x4 (treatment x timepoint) factorial ANOVAs. HR was analyzed via 2x4 factorial ANOVA. RESULTS: Both methods of slow breathing (SB1 and SB2) resulted in significantly lower AA concentrations at five (p \u3c 0.001), and thirty-minutes post VR-ASD (SB1: p= 0.008; SB2: p \u3c 0.001) compared to NB. In the NB condition, AA concentrations were significantly elevated five minutes post VR-ASD (p \u3c 0.001) compared to all other timepoints but did not change across time in SB1 or SB2 (p \u3e .05). A significant increase in SIgA concentrations was noted five minutes post VR-ASD compared to all the other time points (p \u3c 0.001), and significantly higher SIgA concentrations were found in the NB compared to SB1 and SB2 (p\u3c0.001). Finally, slow breathing resulted in a significant decrease in HR from pre to post VR-ASD (p \u3c 0.05). CONCLUSION: The VR-ASD resulted in a significant increase in stress markers AA and SIgA. Slow breathing (both SB1 and SB2) prevented a significant increase in AA concentrations and resulted in lower concentrations post VR-ASD. Future studies should investigate the effects of longitudinal participation in slow breathing methods on markers of stress in response to a VR-ASD

Management of early pregnancy loss with mifepristone and misoprostol: clinical predictors of treatment success from a randomized trial.

BackgroundEarly pregnancy loss is a common event in the first trimester, occurring in 15%-20% of confirmed pregnancies. A common evidence-based medical regimen for early pregnancy loss uses misoprostol, a prostaglandin E1 analog, with a dosage of 800 μg, self-administered vaginally. The clinical utility of this regimen is limited by suboptimal effectiveness in patients with a closed cervical os, with 29% of patients experiencing early pregnancy loss requiring a second dose after 3 days and 16% of patients eventually requiring a uterine aspiration procedure.ObjectiveThis study aimed to evaluate clinical predictors associated with treatment success in patients receiving medical management with mifepristone-misoprostol or misoprostol alone for early pregnancy loss.Study designWe performed a planned secondary analysis of a randomized trial comparing mifepristone-misoprostol with misoprostol alone for management of early pregnancy loss. The published prediction model for treatment success of single-dose misoprostol administered vaginally included the following variables: active bleeding, type of early pregnancy loss (anembryonic pregnancy or embryonic and/or fetal demise), parity, gestational age, and treatment site; previous significant predictors were vaginal bleeding within the past 24 hours and parity of 0 or 1 vs >1. To determine if these characteristics predicted differential proportions of patients with treatment success or failure, we performed bivariate analyses; given the small proportion of treatment failures in the combined treatment arm, both arms were combined for analysis. Thereafter, we performed a logistic regression analysis to assess the effect of these predictors collectively in each of the 2 treatment groups separately as well as in the full cohort as a proxy for the combined treatment arm. Finally, by using receiver operating characteristic curves, we tested the ability of these predictors in association with misoprostol treatment success to discriminate between treatment success and treatment failure. To quantify the ability of the score to discriminate between treatment success and treatment failure in each treatment arm as well as in the entire cohort, we calculated the area under the curve. Using multivariable logistic regression, we then assessed our study population for other predictors of treatment success in both treatment groups, with and without mifepristone pretreatment.ResultsOverall, 297 evaluable participants were included in the primary study, with 148 in the mifepristone-misoprostol combined treatment group and 149 in the misoprostol-alone treatment group. Among patients who had vaginal bleeding at the time of treatment, 15 of 17 (88%) in the mifepristone-misoprostol combined treatment group and 12 of 17 (71%) in the misoprostol-alone treatment group experienced expulsion of pregnancy tissue. Among patients with a parity of 0 or 1, 94 of 108 (87%) in the mifepristone-misoprostol treatment group and 66 of 95 (69%) in the misoprostol-alone treatment group experienced expulsion of pregnancy tissue. These clinical characteristics did not predict treatment success in the combined cohort alone (area under the curve=0.56; 95% confidence interval, 0.48-0.64). No other baseline clinical factors predicted treatment success in the misoprostol-alone treatment arm or mifepristone pretreatment arm. In the full cohort, the significant predictors of treatment success were pretreatment with mifepristone (adjusted odds ratio=2.51; 95% confidence interval, 1.43-4.43) and smoking (adjusted odds ratio=2.15; 95% confidence interval, 1.03-4.49).ConclusionNo baseline clinical factors predicted treatment success in women receiving medical management with misoprostol for early pregnancy loss. Adding mifepristone to the medical management regimen of early pregnancy loss improved treatment success; thus, mifepristone treatment should be considered for management of early pregnancy loss regardless of baseline clinical factors

Six-month Expulsion of Postplacental Copper Intrauterine Devices Placed After Vaginal Delivery

Background Immediate placement of an intrauterine device after vaginal delivery is safe and convenient, but longitudinal data describing clinical outcomes have been limited. Objective We sought to determine the proportion of TCu380A (copper) intrauterine devices expelled, partially expelled, malpositioned, and retained, as well as contraceptive use by 6 months postpartum, and determine risk factors for expulsion and partial expulsion. Study Design In this prospective, observational study, women who received a postplacental TCu380A intrauterine device at vaginal delivery were enrolled postpartum. Participants returned for clinical follow-up at 6 weeks, and for a research visit with a pelvic exam and ultrasound at 6 months. We recorded intrauterine device outcomes and 6-month contraceptive use. Partial expulsion was defined as an intrauterine device protruding from the external cervical os, or a transvaginal ultrasound showing the distal end of the intrauterine device below the internal os of the cervix. Multinomial logistic regression models identified risk factors associated with expulsion and partial expulsion by 6 months. The area under the receiver operating characteristics curve was used to assess the ability of a string check to predict the correct placement of a postplacental intrauterine device. The primary outcome was the proportion of intrauterine devices expelled at 6 months. Results We enrolled 200 women. Of 162 participants with follow-up data at 6 months, 13 (8.0%; 95% confidence interval, 4.7–13.4%) experienced complete expulsion and 26 (16.0%; 95% confidence interval, 11.1–22.6%) partial expulsion. Of 25 malpositioned intrauterine devices (15.4%; 95% confidence interval, 10.2–21.9%), 14 were not at the fundus (8.6%; 95% confidence interval, 5.2–14.1%) and 11 were rotated within the uterus (6.8%; 95% confidence interval, 3.8–11.9%). Multinomial logistic regression modeling indicated that higher parity (odds ratio, 2.05; 95% confidence interval, 1.21–3.50; P = .008) was associated with expulsion. Provider specialty (obstetrics vs family medicine; odds ratio, 5.31; 95% confidence interval, 1.20–23.59; P = .03) and gestational weight gain (normal vs excess; odds ratio, 9.12; 95% confidence interval, 1.90–43.82; P = .004) were associated with partial expulsion. Long-acting reversible contraceptive method use at 6 months was 80.9% (95% confidence interval, 74.0–86.6%). At 6 weeks postpartum, 35 of 149 (23.5%; 95% confidence interval, 16.9–31.1%) participants had no intrauterine device strings visible. Sensitivity of a string check to detect an incorrectly positioned intrauterine device was 36.2%, and specificity of the string check to predict a correctly positioned intrauterine device was 84.5%. This corresponds to an area under the receiver operating characteristics curve of 0.5. Conclusion This prospective assessment of postplacental TCu380A intrauterine device placement, with ultrasound to confirm device position, finds a complete intrauterine device expulsion proportion of 8.0% at 6 months. The association of increasing parity with expulsion is consistent with prior research. The clinical significance of covariates associated with partial expulsion (provider specialty and gestational weight gain) is unclear. Due to the observational study design, any associations cannot imply causality. The proportion of partially expelled and malpositioned intrauterine devices was high, and the area under the receiver operating characteristics curve of 0.5 indicates that a string check is a poor test for assessing device position. Women considering a postplacental intrauterine device should be counseled about the risk of position abnormalities, as well as the possibility of nonvisible strings, which may complicate clinical follow-up. The clinical significance of intrauterine device position abnormalities is unknown; future research should evaluate the influence of malposition and partial expulsion on contraceptive effectiveness and side effects

A comparison of tumour and host prognostic factors in screen-detected versus non screen-detected colorectal cancer: a contemporaneous study

Aim: In addition to TNM stage, there are adverse tumour and host factors, such as venous invasion and the presence of an elevated systemic inflammatory response (SIR) that influence the outcome in colorectal cancer. The present study aimed to examine how these factors varied in screen detected (SD) and non-screen detected tumours (NSD). Method: Prospectively maintained databases of the prevalence round of a biennial population FOBt screening programme and a regional cancer audit database were analysed. Interval cancers (INT) were defined as cancers identified within two years of a negative screening test. Results: Of the 395 097 invited, 204 535 (52%) responded, 6159 (3%) tested positive, and 421 (9%) had cancer detected. From this cohort, a further 708 (63%) NSD patients were identified (468 (65%) non-responders, 182 (25%) INT cancers and 58 (10%) did not attend or did not have cancer diagnosed at colonoscopy). Comparing SD and NSD patients, SD patients were more likely to be male, and have a tumour with a lower Dukes stage (both p<0.05). On stage-by-stage analysis, SD patients had less evidence of an elevated SIR (p<0.05). Both the presence of venous invasion (p=0.761) and an elevated SIR (p=0.059) were similar between those with INT cancers and in those that arose in non-responders. Conclusion: Independent of TNM stage, SD tumours have more favourable host prognostic factors than NSD tumours. There is no evidence that INT cancers are biologically more aggressive than those that develop in the rest of the population and hence are likely to be due to limitations of screening in its current format

Physiological Stress Responses to a Live-Fire Training Evolution in Career Firefighters

Firefighters have a physically demanding job that exposes them to many specific and unique stressors, which contribute to cardiovascular disease (CVD) risk (i.e., cardiovascular strain, inflammation, and oxidative stress) or even mortality. At present, the literature lacks data evaluating these physiological stress responses amongst firefighters in any realistic or simulated scenarios, such as a live-fire training evolution (LFTE). Given the elevated risk of premature mortality, there is a critical need to better understand the physiological stress responses to an LFTE. This information could aid in developing nutritional, training, and other various interventions to mitigate stress load and reduce the incidence of CVD among this population. PURPOSE: To assess the physiological stress response to an LFTE among firefighters. METHODS: Seventy-six (n = 76) career firefighters completed an LFTE. Salivary samples were collected pre, immediately post, and 30-min post the LFTE, and analyzed the following stress markers: α-amylase (AA), secretory immunoglobulin-A (SIgA), and cortisol. One-way repeated measures analysis of variance was used to assess changes over time. Fisher’s LSD and Cohen’s d effect size calculations were used for Post hoc analysis. RESULTS: Significant main effects for time were found for AA, SIgA, and cortisol (p\u3c0.001). Fisher’s LSD post hoc analysis found AA, SIgA, and cortisol concentrations were all significantly elevated immediately post LFTE compared to pre (p\u3c0.0001) and 30-min post (p\u3c0.0001). Medium to large effect sizes were noted for AA, SIgA, and cortisol with respect to changes pre to immediately post-LFTE (d = 0.84, 0.61, and 0.78, respectively). CONCLUSION: While many studies have shown increased inflammation and oxidative stress, as well as adverse cardiovascular and metabolic responses to firefighting activities, these data provide insight into the physiological stress placed upon a firefighter engaging in fire-suppressive evolutions

Pharyngeal Oxygen Delivery Device Sustains Manikin Lung Oxygenation Longer Than High-Flow Nasal Cannula

PURPOSE: Hypoxemia during a failed airway scenario is life threatening. A dual-lumen pharyngeal oxygen delivery device (PODD) was developed to fit inside a traditional oropharyngeal airway for undisrupted supraglottic oxygenation and gas analysis during laryngoscopy and intubation. We hypothesized that the PODD would provide oxygen as effectively as high-flow nasal cannula (HFNC) while using lower oxygen flow rates. METHODS: We compared oxygen delivery of the PODD to HFNC in a preoxygenated, apneic manikin lung that approximated an adult functional residual capacity. Four arms were studied: HFNC at 20 and 60 liters per minute (LPM) oxygen, PODD at 10 LPM oxygen, and a control arm with no oxygen flow after initial preoxygenation. Five randomized 20-minute trials were performed for each arm (20 trials total). Descriptive statistics and analysis of variance were used with statistical significance of RESULTS: Mean oxygen concentrations were statistically different and decreased from 97% as follows: 41 ± 0% for the control, 90 ± 1% for HFNC at 20 LPM, 88 ± 2% for HFNC at 60 LPM, and 97 ± 1% (no change) for the PODD at 10 LPM. CONCLUSION: Oxygen delivery with the PODD maintained oxygen concentration longer than HFNC in this manikin model at lower flow rates than HFNC

Age at First Concussion Influences Number of Subsequent Concussions

Background: Individuals that sustain their first concussion during childhood may be at greater risk for sustaining multiple concussions throughout their lifetime, due to a longer window of vulnerability. Purpose: To estimate the association between age at first concussion with number of subsequent concussions. Methods: A total of 23,582 collegiate athletes from 26 universities and military cadets from three military academies completed a concussion history questionnaire (65% males, age: 19.9±1.4years). Participants self-reported concussions and age at time of each injury. Participants with a history of concussion (n=3,647, 15.5%) were categorized as having sustained their first concussion during childhood (<10 years old - yo) or adolescence (≥10yo & ≤18yo). Poisson regression was used to model age group (childhood, adolescence) predicting number of subsequent concussions (0, 1, 2+). A second Poisson regression was developed to determine whether age at first concussion predicted number of subsequent concussions. Results: Participants self-reporting their first concussion during childhood had an increased risk of sustaining subsequent concussions (RR=2.19, 95% CI: 1.82, 2.64) compared to participants self-reporting their first concussion during adolescence. For every one-year increase in age at first concussion, we observed a 16% reduction in the risk of subsequent concussion (RR=0.84, 95% CI:0.82,0.86). Conclusion(s): Individuals self-reporting a concussion at a young age sustained a higher number of concussions prior to the age of 18. Concussion prevention, recognition, and reporting strategies are of particular need at the youth level