In Brazil, alcohol consumption is estimated to range from 7 to 40% in pregnant women. This research investigated the motivation for alcohol consumption or abstinence during pregnancy in a purposive sample of Brazilian women.Clinical-qualitative research was conducted, in which 14 women participated, identified as risk-drinkers during pregnancy by the T-ACE screening tool. Data were collected through semi-structured individual interviews. Reports were recorded, transcribed and investigated by a thematic content analysis approach. The results were discussed based on a comprehensive and interpretive framework.Sixteen themes were extracted and these were then classified into three thematic categories: (a) general motives for alcohol use, (b) specific motives for drinking during pregnancy, and (c) reasons for partly or fully abstaining from drinking during pregnancy. Social motives were the most relevant, particularly due to deeply rooted cultural values. Enhancement motives were widely mentioned and associated with a hedonic posture. Consumption also aimed to deal with negative emotions, characterizing two types of coping specifically to pregnancy: first, perceiving pregnancy as a period of less opportunity for social interaction and, therefore, drinking alcohol at home to compensate; secondly, perceiving pregnancy as a period of greater irritability, and hence experiencing difficulties to abstain. On the other hand, concern about fetal health, disapproval of consumption by relatives and health professionals, as well as the social construction of mothering were reported as reasons to abstain.Some specificities influence the decision to continue or discontinue alcohol consumption during pregnancy. To reduce consumption, we suggest educational actions based on a collective health perspective, articulated with individualized measures that allow identification and proper intervention for women at risk. At present, alcohol is the most common teratogenic agent in the world . ResearcThe current state of evidence and medical recommendations are to avoid any prenatal alcohol consumption , 11–13. The literature has sought to identify factors that comprise a complex set of cognitions and behaviors that culminate in alcohol consumption . In a geOne of the main theoretical models concerning the motivations to use alcohol was hypothesized by Cooper 1994)  based on94  basedWhile motives for alcohol consumption play a prominent role in the cognitive models that explain the decision to drink , 23, theAlthough there is a vast body of literature on prevalence, associated factors and potential harm from to pregnant women by alcohol consumption, studies of how women themselves interpret alcohol use during pregnancy are scarce. Qualitative research in this sense began in the last decade and is believed to be important in issues such as prevention and distribution of information, as well as the approach of these women and health professionals by whom they are oriented , 31. ResWe did not identify explanatory or interpretive models for alcohol use during pregnancy contextualized for the Brazilian scenario in the literature. The characterization of the motivation for alcohol consumption and the reasons for abstinence can be useful for clinical interventions, as well as for planning public health education policies. This justifies the relevance of this subject from a scientific and social point of view, which prompted the development of the present study.Sistema Único de Saúde), which is universal and free for everyone  is silly until we get pregnant, and then find out it’s true. One day when I was pregnant, I craved beer. I said, ‘I need to have a beer, my mouth is watering.’” (Participant 8)Some women expressed their motivation to drink as a way of coping with social prohibitions (from family members or partners), apparently aiming at reaffirming their independence.“I’m pretty stubborn. If I hear someone saying, ‘Going to drink, are you?!’, then I’ll do it just out of stubbornness. Just to make it clear that no one bosses me around.” (Participant 9)This theme was also understood as a coping strategy towards the social judgment of drinking during pregnancy, by showing indifference towards criticism.“I would even drink something, and me pregnant, some people would look, others wouldn’t. So, I said, ‘I don’t care. I didn’t really care about what people were thinking.’” (Participant 9)One of the participants also mentioned that the recommendation to abstain/ban consumption during pregnancy made abstinence more difficult, increasing the desire for alcohol and becoming a specific drinking motive.“You know, just one sip while cooking lunch, even on my own. So, then I downloaded a pregnancy app on my phone and it said ‘You must not consume alcoholic beverages.’ God, it seemed I was in the Sahara Desert. I strangely craved for beer. You crave it three times more.” (Participant 14)Although most women consider pregnancy as a period marked by psychological conflicts between consumption and abstinence, some participants reported partial or even total abstinence after recognizing pregnancy. Among the motives, concerns about the fetus and newborn growth and development were frequently cited.“I feared that she would be born with some body part missing. Besides being retarded. Because we know how the world is nowadays. People reject others, they don’t really care, ain’t that right? So, I thought, ‘how is that girl going to grow up with some body part missing?’ Arriving at kindergarten and being laughed at by her friends.” (Participant 4)“I kept imagining if I drink, he would too. People say, ‘the baby eats everything we eat.’ So, I thought what if he wiggles around, and rolls himself up in the [umbilical] cord.” (Participant 12)Although generally substantiated in empirical popular basis (a kind of spontaneous epidemiology), some beliefs were remotely connected with scientific knowledge, while others exclusively had a religious background . Commonly the damage to the baby was referred to as proportional to the amount of alcohol intake in each drinking episode . From this point of view, there seems to be a spontaneous posture of damage control: one participant, for example, conveyed her “moderation” saying she would only drink beer, not liquor, only during the weekends and only at home (Participant 6). Another woman justified abstinence because of the specific fear of abortion, due to a personal history of losses. The perception of “everything or nothing” was also presented: abortion would happen, or pregnancy would follow without any other negative outcomes. Fear of other negative outcomes apart from abortion, such as malformation and intellectual disability, as well as the feeling of guilt, were also recurrent. Sometimes, having previous knowledge or experiencing negative outcomes in another women’s pregnancy was relevant.“I was pregnant when I heard about the negative outcome. Because she [a friend] said her nose was all flat, and the doctor said it was because of all the alcohol her mom consumed. So, I saw the whole thing, and I said wow, so this is no lie, right? So, I cut back a little.” (Participant 11)“I would even try it, but I was scared something would happen to the baby.” (Participant 13)“I drank up to 5 months. Then I found out about the pregnancy, and I stopped. And, you see, I even felt like it, but I said, ‘I can’t, because of my daughter.’ Because I thought about her health.” (Participant 4)“You don’t know if it’s gonna be really bad for the baby. So, you end up cutting back a bit.” (Participant 10)Consumption disapproval by family, friends or healthcare professionals was also referred to as a reason to abstain. Reassurance, from healthcare givers, about the risks associated with alcohol consumption during pregnancy would have, in some women’s opinion, a positive impact on stopping drinking. On the other hand, it was supposed that, sometimes, healthcare professionals were only aiming to intimidate or frighten women, not being a reliable source. The lack of consistent information was perceived as a reason for keeping the pattern.“Sometimes it seems they [healthcare professionals] are only saying it to scare you.” (Participant 6)“I won’t drink because of them, not even secretly. Because if she [mother] finds out, oh God!” (Participant 7)“If she [the doctor] came to me and said ‘You must not drink anything,’ I wouldn’t. I wouldn’t risk my child’s life because of a beer, I wouldn’t drink. But when she [doctor] said it was ok, I sort of got laid-back.” (Participant 14)“We just hear it’s not good, but what can it cause? I don’t know. So, I’d like to have more information. And that’s also a medical mistake. I think the doctor should inform us, mainly mothers who are having their first baby. I think if I’d had this information since the beginning, I would definitely have done it differently. But since I had the information that a glass of wine per day was fine, I said ‘Why not?’ The doctor knows what he is talking about.” (Participant 11)Some gender issues were mentioned by the participants: abstaining to not expose their behavior to their children ; and the perception of the drinking habit as something “ugly” for the woman, but not for the man.“When my daughter is around, I avoid it. Her dad drinks more. I’m the mum, so I always have to be sober.” (Participant 4)“Drinking is already disgusting for a man, imagine for a woman.” (Participant 2)“It’s the mum’s child, not the dad’s. It’s the mum’s responsibility. That’s why the mum can’t drink. Imagine a drunk mum, the child keeps waking up all night long and she can’t manage to get up.” (Participant 14)To the best of our knowledge, this is the first study to make a qualitative interpretation of drinking during pregnancy through the “four-factor model” , 21. As In agreement with previous studies , 44, 45,Coping motives were also widely cited by our subjects, corroborating with another qualitative study in which Crawford-Williams et al.  observedOne of the participants reported that the recommendation to abstain during pregnancy made abstinence more difficult, increasing alcohol desire. Drinking as a way of confronting social sanctions (from family or partners) and of reassuring independence was also expressed. Transgression of tradition and pre-established order are considered attitudes towards obtaining autonomy and individuality, and alcohol is commonly used in this context, for example, by teenagers . This reOur study also showed that, in general, the emphatic abstinence recommendation during pregnancy was not accompanied by consistent information about the potential harm of consumption to the fetus. There seems to have been, in fact, a clash between an excessive amount of divergent, unspecific recommendations, coming from different sources, and a lack of dependable information available through reliable sources, such as healthcare professionals. This is also consistent with international data, in which women reported that the information that their healthcare practitioners provided regarding alcohol use and pregnancy were limited and superficial . In anotAlthough drinking motives have a prominent role in cognitive models for explaining alcohol consumption, the complementary construct of abstaining motives has been largely neglected , 31. OurA variety of complaints was expressed by the subjects about healthcare professionals’ clinical approach and the Brazilian healthcare system. In spite of this, the finding that an emphatic orientation from the healthcare professionals about risks associated with alcohol consumption would have, for some subjects, a positive impact on habit cessation, reinforces the importance of a clear, didactic and broad approach to risks in prenatal settings. Healthcare professionals must be updated on the subject and realize their potential to manage pregnant women’s concerns . BraziliThe importance of addressing the subject during prenatal care was highlighted by Jones et al. , who conThe participants in our research also emphasized the idea of abstinence associated with maternal responsibility, as opposed to the paternal responsibility, which does not imply in abstinence. These results corroborate with a study carried out by Jones and Telenta , in whicDespite the research constraints in terms of the external validity, since the sample of participants was formed by convenience, we consider that internal validity of the results was significant, as the employed data collection technique provided ample opportunities for free expression to participants, thus enabling an initial approach of the subject in the Brazilian context.A key limitation of the study is that the T-ACE survey is unable to distinguish between alcohol occasional use, moderate use, and heavy use. Even though the current medical recommendation is to avoid any prenatal alcohol consumption, the general population are unaware of the effects of moderate and occasional prenatal use of alcohol. Motives to drink or abstain should be based on these norms and, thus, one would expect motives for heavy drinking to differ from those for moderate drinking. Additionally, motivations to decrease or to stop prenatal alcohol use were analyzed together. A further limitation of our study includes the fact that the interviews were conducted within two years of the pregnancy and this can be a long time for an accurate retrospective recall of drinking motives.The results enable us to propose some issues to be considered by health authorities in Brazil. Current Brazilian ministerial recommendations for primary healthcare should be revised in agreement with international recommendations, and therefore the subject of alcohol consumption should be systematically approached during prenatal care. This could be done by screening pregnant women using validated instruments, such as the T-ACE questionnaire, as well as by more emphatic recommendations about alcohol abstinence during pregnancy by health professionals.We reinforce the importance of public campaigns on the harmful effects of alcohol use in pregnancy aimed not only to women but also to their social context. We also consider the need to inform people about the risk of alcohol use in pregnancy, in any quantity and at any time, on alcoholic beverage packaging.This qualitative study provides in-depth information to better understand the motivations for alcohol consumption or abstinence during pregnancy in a purposive sample of Brazilian women. Some specificities influence the decision to continue or discontinue alcohol consumption during pregnancy. To reduce alcohol consumption, we suggest instigating educational actions based on public health perspectives, as well as a systematic approach of alcohol intake during prenatal care, articulated with individualized actions, which enables proper and early identification and intervention for women, if necessary.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(DOCX)Click here for additional data file.


Smaller groups of victims of violence, abuse, neglect or exploitation – such as male victims of intimate partner violence (IPV), victims of elder abuse, victims of abuse by carers, victims of parent abuse, victims of human trafficking, girls and boys below 18 years engaging in sex work, victims of sexual exploitation by gangs or groups and victims of honour based violence  – are often in contact with the health care system without being identified as such and frequently do not receive appropriate treatment. To address this problem, two things need to happen: 1) that ALL groups of victims of violence, abuse, neglect or exploitation are explicitly listed in policies and protocols, and 2) that both the similarities as well as the differences between the groups with regard to identification, support and referral – described in this article – are explained, so that health providers are appropriately supported in this important function.The online version of this article (10.1186/s12914-018-0178-y) contains supplementary material, which is available to authorized users. A positive development in global public health and social policy in the past few decades has been the recognition of the importance of adequate responses to victims of violence, abuse, neglect or exploitation . This has led to much improved policies and practices supporting female victims of intimate partner violence (IPV) and victims of child abuse. However, other specific groups of victims of VANE are often neglected in current policies and service delivery. As a result, health providers lack knowledge of these lesser-known groups, often meaning victims are in contact with the health system without being identified as such , 2 and fresearching and documenting signs of VANE (including asking about VANE in the first place – that’s ‘step 0’ in this model);consulting peers and experts;deciding if it is appropriate to interview the patient (and/or others involved) and if yes, doing so;conferring with other professionals who know the patient ; andA)the situation needs to be ‘reported’, meaning that the health provider chooses to discuss the situation with an organization with a legal mandate to 1) provide advice on domestic violence or child abuse and 2) arrange referral when needed  there is (risk of) acute or structural unsafety, or ii) when the health provider is not able to provide or organise help/care him−/herself. This ensures that VANE professionals are involved in decision-making processes when needed);B)care/help can be provided by the health provider him−/herself or whether the patient needs to be referred.To be able to make these two decisions, two questions need to be answered about the situation: 1) Is there a suspicion of VANE? and 2) is there acute or structural unsafety? –8.reaching decisions about whether:It is key that health providers recognize both the similarities and differences between these groups. Similar steps may be taken to a) identify, b) support and c) refer victims (if needed) Fig. :researchRecognizing that these general steps are the same for all types of VANE makes it easier for providers to respond appropriately to lesser-known types, as they can follow the same protocol.assessing safety, e.g., with human trafficking criminal networks may be involved leading to different safety assessments;breaking confidentiality, e.g., considerations around breaking confidentiality to ‘report’ VANE are different for VANE against adults than for child abuse ;urgency, e.g., victims of some types of VANE, such as parent abuse and honour-based violence, typically present very late, necessitating swift action;communication, e.g., with some types of VANE, such as honour-based violence or cross-border human trafficking, if patients do not speak your language, it is important to speak to them via an independent translator when they are accompanied by someone .At the same time, there are differences between the various groups of victims that providers need to take note of  identifying, b) supporting and c) referring victims (if needed). Unfortunately, these protocols are often limited in the types of VANE that they cover . Expliciany type of VANE if health providers  are able to a) identify, b) support and, if needed, c) refer them appropriately. To address some of these problems, the Netherlands have opted to use the term ‘Violence in power-imbalanced relationships’, [Violence, abuse, neglect or exploitation in power-imbalanced relationships’.This may be aided by using a more inclusive umbrella term to describe these groups. Currently, umbrella terms that are used frequently are ‘domestic violence’ (this is limited to violence by family members or other persons in a domestic setting) and ‘IPV’ (this is limited to violence between partners), excluding victims of violence by people outside the home  or by non-partners respectively. Also, the term ‘violence’ is often interpreted quite narrowly, e.g., as meaning only physical violence ; therefore, it is better to speak about ‘violence, abuse, neglect or exploitation’. These exclusions are missed opportunities, because clearly it is beneficial for victims of nships’,  which inSustainable Development Goals (SDGs) 5 and 16 ask that we aim to end ALL forms of violence, neglect, abuse and exploitation. To this end, we recommend health ministries and professional health provider organizations ensure two things happen: 1) that all groups of victims of VANE are explicitly listed in policies and protocols, and 2) that both the similarities  in terms of identification, support and referral: an overview for health providers and social workers. (DOCX 36 kb)Additional file 2:Sources used in the development of Table


Nowadays, ‘personalized medicine’—often used interchangeably with ‘precision medicine’—is a trendy topic in popular and medical media. The term suggests a significant new development in clinical medicine; authors often claim a paradigm shift in healthcare. University hospitals proudly announce the founding or planning of initiatives dedicated to research in ‘precision medicine’ and politicians are eager to provide the funds for these important medical developments [lopments .With our emphasis on tailored care for the individual patient, evidence being one ingredient for decision-making but personal preferences and circumstances of the patient playing a major role as well, one might wonder whether general practitioners (GPs) have not always been practicing ‘personalized’ medicine.‘Precision medicine, sometimes called personalized medicine, is an approach for protecting health and treating disease that takes into account a person’s genes, behaviours, and environment. Interventions are tailored to individuals or groups, rather than using a one-size-fits-all approach in which everyone receives the same care’ [Let us first have a look at some definitions. The Centre for Disease Control explains: me care’ . The Natme care’ . The medThese definitions and explanations should immediately remind us about a similar term, describing one of the core competencies of our discipline: the ‘person-centred approach.’ As the Wonca definition reads: ‘The general practitioner/family doctor develops a person-centred approach, orientated to the individual, his/her family, and their community. Family medicine deals with people and their problems in the context of their life circumstances, not with impersonal pathology or “cases”. It is as important to understand how the patients cope with and view their illness as dealing with the disease process itself. The common denominator is the person with his or her beliefs, fears, expectations and needs’ .From comparing these various definitions, it becomes clear that the terms ‘personalized medicine/precision medicine’ and ‘person-centred medicine’ are in fact all referring to the most important focus of high-quality care: the person in front of the doctor asking for advice or help. To provide optimal medical care, the experienced GP always had to take into account the detailed history of individual patients and their families (‘genetics’), their individual background in terms of social and occupational circumstances (‘environment’) and their individual approach to health and disease such as adherence to therapy, coping mechanism and lifestyle (‘behaviour’). Each experienced GP also knows the challenge of treating patients with the same condition but with a different response to identical treatments, e.g., for pain, hypercholesterolaemia, hypertension or diabetes. As a result, in general practice, treatment of individual patients routinely is ‘personalized’ or ‘individualized.’Obviously, the traditional approach of GPs to individual peoplès health problems is quite similar to the meaning of ‘personalized or precision medicine’ and is, therefore, nothing new. Just remember the famous quotes by William Osler from the nineteenth century: ‘It is more important to know what sort of person has a disease than to know what sort of disease a person has.’ His advice to students was ‘Care more particularly for the individual patient than for the special features of the disease’ . Only thDespite the similarities between the ‘person-centred approach’ in general practice and ‘personalized or precision medicine’ in some specialities, there is, in fact, a major paradigm shift in medicine and in healthcare in general. For the management of patients in terms of diagnostic and therapeutic procedures, GPs and specialists alike have become accustomed in the past to consider disease-specific guidelines with the aim of standardizing the care for all patients with a given condition. Healthcare administrators and policy-makers saw standardization in healthcare as a way to improve patient care and at the same time keep healthcare affordable. On the other hand, practitioners are critical about the concept of using practice guidelines as ‘cookbook medicine’ or as the only ‘correct recipe’ for patient care. As Wonca World’s former president Richard Roberts once said: ‘Guidelines are for standard patients … but I have never met a standard patient!’ . Therefore, the scientific developments in genetics and in genetic testing to identify subtypes of various diseases or subtypes of responses to drug treatment have now paved the way to the broader recognition of tailoring medical treatment to the specific characteristics of individual patients with a disease. This shift away from thoughtlessly using a ‘one-size-fits-all’ approach to medical care can be considered as progress and relief. Moreover, is such an approach not evidence-based medicine at a state-of-the-art level?Since the achievements of the Human Genome Project, genetic tests are increasingly available and their high costs will eventually get lower over time. At the higher levels of healthcare and at the direct consumer level their use for individual patients likely will increase. For primary care, it will undoubtedly take more time until relevant genetic tests for point-of-care use will be accessible. If affordable for public healthcare systems, such a development would certainly help to inform decisions of the family doctor. However, collecting comprehensive information about the individual family history of patients (‘primary care genetics’) and using this knowledge for their management will certainly remain to be a pillar of high-quality general practice at low cost for the healthcare system .In conclusion, the concepts of ‘personalized medicine’ and ‘precision medicine’ as well as ‘person-centred medicine’ refer to the ability to use hereditary information to ‘personalize’ treatment. This approach has existed in medicine since time immemorial, in particular in the field of general practice. However, recent technical advances in genetic testing allow assessing this information of individual patients more accurately.Department of General Practice, Centre for Public Health, Medical University of Vienna, Vienna, Austriamanfred.maier@meduniwien.ac.atManfred Maier


As the ideas and technologies behind the Internet of Things (IoT) take root, a vast array of new possibilities and applications is emerging with the significantly increased number of devices connected to the Internet. Moreover, we are also witnessing the fast emergence of location-based services with an abundant number of localization technologies and solutions with varying capabilities and limitations. We believe that, at this moment in time, the successful integration of these two diverse technologies is mutually beneficial and even essential for both fields. IoT is one of the major fields that can benefit from localization services, and so, the integration of localization systems in the IoT ecosystem would enable numerous new IoT applications. Further, the use of standardized IoT architectures, interaction and information models will permit multiple localization systems to communicate and interoperate with each other in order to obtain better context information and resolve positioning errors or conflicts. Therefore, in this work, we investigate the semantic interoperation and integration of positioning systems in order to obtain the full potential of the localization ecosystem in the context of IoT. Additionally, we also validate the proposed design by means of an industrial case study, which targets fully-automated warehouses utilizing location-aware and interconnected IoT products and systems. Over the past few years, we have been experiencing a fast emergence of the Internet of Things (IoT), where things and objects become smart and connected . By provBesides IoT, indoor localization is another growing trend in our hyper-connected society with a large amount of research and industrial focus . MoreoveIn this sense, we see several standardization initiatives and research efforts targeting interoperability and Machine-to-Machine (M2M) understandability in the IoT domain. These efforts aim to create more loosely-coupled systems, better interoperable and connective devices via common interfaces and data models. For instance, oneM2M , the OpeIn this work, we study the first design for the interoperation and integration of positioning systems by means of IoT application protocols and data models, more specifically, the ones defined by OMA Lightweight Machine-to-Machine (LwM2M)  and IPSOWe believe that such an integration will enable a seamless and spontaneous interoperation of localization technologies independent of their specific characteristics, hardware and software components. This will also enable IoT applications to simultaneously use a multitude of diverse positioning solutions in order to face various application needs or improve overall localization performance.The remainder of this paper is organized as follows. Localization is the process of determining the position of equipment, people or any other object . In the past decade, it has become an active research area. Up to now, a large variety of localization technologies have been proposed, but no one-size-fits-all solution has emerged . TherefoFirst of all, there is a wide variety of technologies on which localization systems can be based, such as WiFi, BLE, RFID, UWB, LoRa, GPS, ultrasound and vision . Some ofOn the other side, different applications may also ask for different localization requirements in terms of various quality metrics, such as accuracy, precision, scalability, update frequency, etc. . This diRegarding the interoperation of localization systems, we recently have started to see a number of research efforts that are investigating semantic location models, mathematical methods, ontologies and structures for location-based applications with no resource constraints, especially related to location navigation and browsing ,12,13,14LwM2M, specified by the OMA Alliance, is a secure, efficient and deployable client-server protocol with several functionalities for managing resource-constrained devices on a variety of networks. Besides fundamental management functionalities such as bootstrapping, client registration and firmware updates, LwM2M also defines efficient interactions for remote application management and the transfer of service and application data . For thiX,Y,Z).According to LwM2M, a client consists of one or more instances of objects, which are typed containers that define the semantic type of instances. Each object is a collection of mandatory and optional resources, which are atomic pieces of information that can be read, written or executed. These objects, instances and resources are mapped into the URI path hierarchy with integer identifiers and can be accessed via simple URIs in the form of sourceID . For inssourceID . Among tNext to OMA, the IPSO alliance performs a similar and adherent effort in order to provide a common design pattern and an object model based on the OMA LwM2M specification . By usinThanks to the use of open IoT standards, unified information and interaction models and powerful management functions, LwM2M is a very promising candidate to achieve global interoperability within the IoT Ecosystem, especially when constrained devices are involved. Therefore, within the IoT ecosystem, there are ongoing efforts defining mechanisms and protocols in order to realize semantic and structural interoperability. However, there is no effort available that extensively targets the interoperability of localization technologies by considering their specific characteristics or constraints. Therefore, in this work, we tried to leverage the LwM2M protocol to target interoperability and integration of localization systems in IoT.The successful integration of IoT and localization technologies is mutually beneficial and even essential for both fields. Such an advancement would enable numerous new IoT applications and products with location awareness and location-based reasoning. On the other side, multiple localization systems would communicate and interoperate with each other in order to obtain better context information, improve localization accuracy, resolve positioning errors or conflicts and activate/inactivate each other in order to save resources in various conditions. Ultimately, all these new applications and features will result in a broader and smarter ecosystem, as illustrated in However, despite the plethora of technologies and the remarkable progress made in these domains, their integration, interoperation and harmonization is still an open issue. Considering the diversity of localization technologies, as described in In this context, we defined the following functionalities as vital enablers for the realization of full structural, syntactical and semantic interoperability between localization systems and also IoT applications, as illustrated in First of all, the concerns about the security and privacy of localization data must be sufficiently addressed, so only authenticated and authorized parties can reach location data and perform trustworthy operations in a security domain. Especially, considering large-scale IoT scenarios, a vast number of localization devices and systems needs to be authenticated and authorized along with a wide range of smart objects.Secondly, the vision of the seamless interconnection of localization technologies necessitates mechanisms for automatic discovery of devices, resources, their properties and capabilities, as well as the means to access them. Therefore, any application or device can discover these devices  with positioning capabilities, along with their types and settings. Furthermore, such discovery mechanisms also depend on other services like configuration management, registration and un-registration of self-descriptive devices, systems and resources.Moreover, considering that the majority of IoT devices are expected to be severely constrained in terms of memory, CPU and power capacities, the interoperability solution must embody a light, compact, efficient and scalable nature. Therefore, it can easily adapt to constrained environments and large-scale deployments (support for tracking of thousands of devices).Next, there has to be a common dictionary (uniform data models) describing formally-relevant concepts, resources, attributes and relations without ambiguity in order to achieve semantic interoperability and global understandability. This will enable systems to perform machine computable logic, knowledge discovery, data federation and semantic-based reasoning. In addition, along with essential location data, further additional information  has to be reachable for other applications and devices, so interested parties can correlate positions from different localization technologies and map them to other coordinate systems.Finally, in pursuit of the interoperation of the large variety of localization systems, the interoperability solution needs to consider all aspects and variations of the localization technologies  and provide support for all localization architectures .For this purpose, we study a design for the interoperation and integration of positioning systems by means of IoT application protocols and data models defined by OMA LwM2M and IPSO. We show that, with extensions of uniform and well-defined data and interaction models targeting localization systems, these IoT protocols and specifications, by design, offer the necessary mechanisms and features in order to obtain syntactic and semantic interoperability between positioning systems and also IoT applications.In this section, we first present the mechanisms in the LwM2M protocol that constitute the fundamentals (defined in the previous section) of the full integration and interoperation of the localization technologies, including bootstrapping, resource registration, operations and common system architectures. Then, we describe the designed uniform object models, based on LwM2M/IPSO specifications, that can be used to inclusively represent the location-related data from various and diverse localization technologies. Finally, for each aspect of the architecture, we describe the overall flow of the interoperation process based on the proposed solution.Bootstrapping is an LwM2M functionality that is used for server configuration, security and credential management, as well as provisioning of access control lists . For cliDevice registration is another LwM2M feature that allows a LwM2M client device to inform an LwM2M server about its existence and register its capabilities and resources . This waThis not only allows device registration, but also enables a discovery of the application/device to understand what kind of location-related objects a device holds and which resources are exposed by the particular object. Further, by identifying object IDs and/or reading the descriptive resources , additional and detailed information can be retrieved. Next, it can start reading the location data, retrieving the information it is interested in and also performing all the operations defined in the following section. In X, Y and Z coordinates of a localized object with a single FETCH request, upon which it will only receive the related data aggregated in a single packet. Although the current LwM2M specification does not support CoAP PATCH/FETCH functionality, the preview of the next version of the LwM2M specification declares that these methods will be included in the near future [Since LwM2M relies on the CoAP application protocol, the CoAP methods constitute the fundamentals of the LwM2M interactions and operations. A minimal CoAP request consists of the method to be applied to the resource, the identifier of the resource, a payload and metadata about the request . CoAP sur future .The LwM2M protocol also defines an information reporting interface (based on the CoAP observe mechanism), which can be used to achieve object tracking by means of the repeating retrieval of the location data . Using tAs we mentioned in the previous sections, LwM2M relies on uniform object models, which are collections of mandatory and optional resources representing atomic pieces of information. Therefore, we create powerful location-related objects and resources that can be used to represent spatial and non-spatial location data in various technologies.In Therefore, we define three new object models, namely position object, localization relay object and localization server object. The position object (3360) provides the necessary resources to represent coordinate-based localization data, whereas an instance of the localization relay object (3361) will expose all necessary resources to associate and link the tag with a localization server, which can provide its location data. Finally, the localization server object (3362) can be used to expose the localization server itself as an LwM2M device. The last two object models can be used for infrastructure-based localization systems. The details of these models are provided in For each resource, the ‘Operations’ field indicates the supported operations by this specific LwM2M resource. As can be seen in X value’ and ‘Y value’ are mandatory resources and have to be defined in any position object. The ‘Z value’ is optional due to the existence of 2D localization systems. The optional minimum and maximum values for the X, Y and Z coordinates can be used to define the measurement area in which localization is performed. ‘Sensor unit’ defines the unit in which the coordinate measurements are expressed. The ‘uncertainty’ can be used to deliver the accuracy of the latest localization measurement, so third parties can evaluate the location data accordingly. ‘Timestamp’ exposes crucial information regarding the age of the location data. As the tracked objects are mobile, location data are valid for a certain amount of time. The timestamp is also useful when someone tries to combine or match location data from two or more different resources in order to improve location accuracy.As is presented in The position object also offers the ‘latitude’, ‘longitude’, ‘altitude’, ‘compass direction’ and ‘elevation direction’ resources, which can be used in order to specify the actual position of the reference point and the relative orientation of the measurement area with respect to this reference point. By mapping reference points of the localization systems, any location data can be translated between two systems, which enables the interoperation of multiple localization systems.‘Server URI’ can be used to link the position object with the corresponding localization server, if existing. Then, the client application can retrieve detailed information about the localization technology and system setup, such as the number of anchors, the number of tracked objects and any supported feature . The ‘target ID’ resource can be used to read the unique ID exposed by the tag or assigned by the localization server, while the ‘update flag’ is used to notify that the position data have been last updated by a localization server. Finally, ‘application type’ defines a string resource where system developers can embed any kind of information regarding the localization system. For instance, “cm-level UWB localization technology” would show that this application is exposing really accurate location data for tracked objects.The localization relay object (3361) is an object we created in order to expose the necessary resources to associate and link the target tag with a localization server. This object is necessary for the localization systems where the location is calculated by a backend server. This way, the tag can relay any request to the corresponding backend server by means of created ‘server URI’ and/or ‘tag ID’ resources. The ‘server URI’ resource can provide an URI (in string format) that identifies the backend server itself or any instance or resource available on the server. Any client first needs to retrieve the server URI and/or the tag ID, and then, it can start retrieving the location data directly from the localization server.The localization server object (3362) is another proposed object model used to represent a single localization server, which tracks several objects, but only exposes proprietary API. Apart from the ‘application type’, this object exposes only a ‘location server’ resource, which can be used to describe a proprietary API via a string written in JSON format. This server object could also encompass technology-related resources  in order to expose more information about the localization system.As is mentioned in the Background section, the architecture of localization systems is one of the features that the localization technologies divert. There are technologies that use a self-positioning architecture, in which objects calculate their positions by themselves. Besides GPS, which is the best-known self-positioning technology, there are also several indoor localization technologies where the tag positions itself by interacting with fixed anchor devices that have known positions, such as the Pozyx UWB Accurate Positioning System . On the 3360/0, 3360/1, 3360/2, etc.), and it can also read the ‘application type’ or ‘server URI’ resources to find out the corresponding localization system. In order to track target objects, the application server can send an observe request to the target tag and receive notifications whenever the tag calculates a new position. Besides the data delivery and monitoring, the LwM2M device management interfaces can also be used to configure the tags with the necessary information  in order to calculate their own positions. Again, with uniform data models, such an interface can offer a generic solution for the tag configuration; however, this is not in the scope of this paper.In this interaction model, the target device is calculating its own position, and it can directly expose any measured data via the proposed position object model (3360) in case the technology is not GPS. Any device interested in this information can directly interact with the tag device and read any relevant location information after the resource discovery. If the device exposes multiple location data with different technologies, then the application can reach the data via different position instances  can write to the particular position object resources exposed by the tag and set the ‘update flag’. Our position object model enables this operation by exposing all resources as both writable and readable. At the same time, a third party application can read or observe these resources on the tag whenever the server updates the location data.For infrastructure-backend localization systems, there can be four approaches for using our LwM2M object and resource model in order to expose location data.Using the first approach, the infrastructure server exposes position data for every tag that is being localized via a dedicated instance of a position object. The link between this object and the tag is created by including the ‘target ID’ resource in this position object instance, with the ID being unique for each tag. At the other side, each tag exposes a localization relay object that contains the ‘server URI’ resource, which constitutes a one-to-one link to the position object instance at the server side. During the bootstrapping process, the infrastructure server needs to create and assign position object instances for the new target tags and inform each tag about the address and URI of the specific position object instance. Whenever an application server would like to read the location of a certain tag, it first has to send a request to the tag in order to retrieve the ‘server URI’ in the localization relay object and learn the address of the relevant location resources at the backend server. After that, it can start retrieving or observing the position-related resources available at this server. The interaction model for this architecture is provided in The second approach is based on a localization server that is exposing a single position object instance, which will be used for all of the tags; whereas, on the tag side, the location relay object with both the ‘server URI’ and ‘tag ID’ resources is used. The server URI holds a link to the position object instance in the localization server. Therefore, this model creates a an N-to-one link between tags and the localization server. Any client or application that reads the server URI and tag ID can interact with the localization server and retrieves the position data of the tag. In the case of a request on the position instance, the localization server will return the latest position update of whichever the positioned tag is. This enables very efficient operations when an application would like to track all of the tags. In this case, the tag ID can be used in order to match position information with the corresponding tag.Using the third approach, the support for several localization servers is considered. In this case, the backend server exposes several (k) position object instances, while each target only needs to expose a location relay object containing the ‘tag ID’ resource. This approach creates a loosely-coupled architecture, where the ‘tag ID’ resource available at the tag is the only information available in order to match the tag and the position data obtained from different servers. With this approach, an application that is interested in tag locations can discover all tracked tags and find out their ‘tag ID’, as well as additional information exposed via other LwM2M resources. In a similar way, it can also discover all localization servers, as these behave as LwM2M devices, as well. Next, it can start retrieving notifications for a tag from several localization servers. Then, by combining the discovered tag information with the location update data, the application has all required information for further processing and taking actions.Lastly, if one would like to make a localization server or localized tags, with a proprietary API, discoverable for interested third parties, then localization relay and localization server object (3362) can be used. The localized tags will expose a localization relay object instance, which is linked to a localization server object instance at the backend server. Within this localization server object instance, the exposed localization server resource will be used to describe the proprietary server API in JSON format. Any client application can discover these localization servers and tags, learn the used API and start retrieving the position data with a certain level of integration cost.Although these four approaches use the same object, the relay object, at the tag, they differ in the sense of the resources they expose. Therefore, a client that discovers the resources at the tag can understand which model is used. If the tag exposes a server URI resource, linked to a position instance, but not tag ID, then it is based on the one-to-one approach. In case it exposes tag ID, but not server URI, then the loosely-coupled approach is followed. Thirdly, if it exposes both resources, this means the N-to-one approach is implemented by the localization system. Finally, if the tag exposes server URI linked to a localization server instance, then it is based on a proprietary API. Optionally, the first three approaches can also expose the localization object instance in order to advertise their existence or more information about the localization system by means of technology-related resources . The objects and necessary resources used for each approach are presented in In the HyCoWareproject , we targHybrid tag: The first target system encompasses the design of a hybrid tag, which will be used to improve the visibility of industrial trolleys. During warehouse operations, the transport trolleys, with tags attached, will be monitored  by a control unit, which is closely interconnected with other systems. For this purpose, the tag needs to be equipped with wireless communication and indoor/outdoor localization technologies.  Connected operator: Another target product is the connected operator, which consists of an operator interface and navigation system to enable an operator to dynamically monitor and interact with other connected products. The location of the operators will be also tracked in order to navigate and direct them to the most relevant operations. Ideally, commercially-available PDAs or smart glasses are used as operator devices. Therefore, the operator needs to be located using technologies that are already part of these products, such as GPS, WiFi or BLE.  Connected conveyor: The last system is the chain conveyor system, which enables a finer tracking of pallets, carts and roll containers within the warehouse, as well as active involvement of the connected operators in the material flow. For this purpose, the transported pallets and carts have to be tracked by a localization system in addition to already existing RFID technology.Generally, warehouses consist of various zones or areas with different purposes, features or characteristics that mandate different requirements, such as location accuracy, update rate and many others . For insTaking the application requirements and the characteristics of warehouses as the input, we came up with the system design and architecture, with various localization technologies, given in Thanks to powerful LwM2M management functionalities, LwM2M-compliant applications will be able to access not only position data, but also other device-  and application-  related resources exposed on the same interface. However, due to the focus of this paper, we only provide the utilized location-related LwM2M models for the target devices described in the previous section, in As is presented in this table, the connected operator devices expose a single instance of the position object for WiFi-based localization, an IPSO GPS location object for GPS data and finally a location relay object for BLE-based localization technology in order to expose a web link to the localization server, which holds a position object for the operator. While hybrid tags have three instances of the localization relay object for all localization technologies , it holds. Finally, the connected conveyors expose a position object instance and a localization relay object instance for UWB and RFID technologies, respectively.On the other side, as the location is calculated by a backend server for LoRa, BLE- and RFID-based localization technologies, the backend server of each technology exposes necessary location object instances. For LoRa- and RFID-based technologies, we applied the infrastructure backend loosely-coupled interaction model; therefore, they expose several instances of the position object; while for BLE, the localization server uses the one-to-one interaction model and again exposes multiple position object instances for tracked devices.In order to demonstrate the targeted interoperability functionalities and realize the integrated ecosystem defined in the case study, we prepared a demonstration and validation setup along with the prototypes of the target products with localization capabilities. The resulting system architecture and design are provided in For the implementation of the LwM2M client, we used an open source standard-compliant implementation, Anjay , that imInitially, the Warehouse Management System (WMS) and Device Management System (DMS)  constitRegarding other members of this ecosystem, we used a newly-developed hybrid tag prototype, illustrated in The designed interconnected system and products are installed in a real flower auction warehouse, namely Euroveiling Flower Auction Center in Brussels, Belgium, and we demonstrated the interoperation functionalities with real warehouse scenarios, which include various zones and areas with different purposes, features or characteristics that mandate different localization requirements. The demonstration area is provided in In order to validate the interoperation of localization technologies in the context of IoT, we present three use cases from the HycoWaRe project where we illustrate how the targeted functionalities can be achieved via the LwM2M interoperability model that we have defined.In this use case, we face a scenario where mobile trolleys must be tracked inside the warehouse by means of attached hybrid tags and monitored by a control and monitoring application. As is described in the previous section, the hybrid tag supports three different localization technologies with different localization capabilities. Initially, RFID readers are used to detect the arrival or departure of the trolleys for a certain zone in the warehouse. LoRa-based localization is used for non-critical areas, which require relatively low localization accuracy and update rate. Finally, the BLE-based localization technology is only deployed inside the buffer zone, where sub-meter accuracy is required and achieved by means of angle-of-arrival BLE localization.We use the interaction and data models provided in the previous section for the hybrid tag. After commissioning a hybrid tag, the control application initially discovers the localization relay objects for each localization technology and the localization servers that expose the location data. After this discovery process, the application sends an observe request for the corresponding location resources and starts receiving position updates for all of the tags attached to the trolleys.We considered a scenario where a trolley is entering the warehouse and moves across the auction room, buffer zone and finally the distribution zone, with the resulting trajectory shown in Algorithm 1 Localization calculation for a device with multiple localization technology. 1:For every position update, do: 2: 3: 4: 5:ifthen                    ▹ First position measurement 6:  7:  8:return  9:end if10:ifthen  ▹ No other measurements for post-processing11: 12: 13:else14: 15: 16:end if17:returnAnother useful feature in this scenario is that different localization technologies can activate or deactivate each other in order to save resources. For instance, an RFID reader at the gate of the buffer zone or the LoRa-based low power localization technology detects an object that starts moving in the buffer zone, subsequently enabling a more accurate localization system (BLE in our scenario) for more precise tracking.The second use case is targeting the position translation and coordinate mapping across multiple technologies. For this use case, we consider a scenario where a connected operator would like to monitor the location of other operators, connected conveyor carts and trolleys in the warehouse. However, as is described above, all of these devices use a variety of indoor and outdoor localization technologies, which probably have different coordinate systems. Therefore, in order to realize the target scenario, there is a need for a mapping and translation process not only between non-spatial and spatial data, but also between different coordinate systems. For instance, In this sense, we can define a reference coordinate system  and translate all of the non-spatial or spatial location data into this coordinate system by using the provided resources in position object  in order to specify the actual position of the reference point and the relative orientation of the measurement area with respect to this reference point. The pseudo algorithm for the coordinate translation between the two coordinate systems is provided in Algorithm 2. In this algorithm, initially, the great-circle distance based on the Haversine formula  and the Algorithm 2 Location mapping/translation. 1: 2:For every position update, do: 3: 4:ifthen                        ▹ First position update for the technology 5:  6:  7:  8:  9: 10: 11: 12: 13: 14: 15: 16:end if17:18:19:20:returnThe last use case is about the easy combination of position data with other application- and device-related semantic data. As mentioned before, the usage of LwM2M enables our applications and devices to access not only position data, but also other device-  and application-  related resources exposed on the same interface. For instance, if a control application would like to know all of the operators in a certain zone, it can retrieve the device information and position information via LwM2M and filter only the operator devices within the target zone; or a monitoring unit can monitor the position, temperature and humidity of a transport trolley at the same time without any need for an extra interface. A sample preview of the interconnected data plane is provided in As mentioned, the objective of this case study is to enable fully-automated and smart warehouses by means of the interconnection of these and any other heterogeneous systems of multiple vendors. For that purpose, we make use of open IoT technologies to ease the deployment of and interconnection between different solutions and multiple localization technologies, which are able to track thousands of objects and also interoperate seamlessly and spontaneously. The outcome of the case study shows that such an integration and interoperation will enable location-aware applications (in the context of IoT) to improve location accuracy, overcome temporary failures or omit incorrect location data, to translate several pieces of location information into a reference coordinate system and finally combine LwM2M semantic capabilities with location information without any extra effort.Despite their significant potential in IoT applications, the amount of research targeting the integration of indoor localization technologies in real-life IoT applications is limited. In this work, we investigated the semantic interoperation and integration of different positioning systems in the context of IoT and validated our approach based on a real IoT case study.In order to overcome the seamless and spontaneous interoperation of localization systems and their interconnection with minimized integration cost, we focused on open IoT technologies and defined interfaces for these products based on LwM2M/IPSO specifications. Our design is clean and able to support all interaction models we have encountered in today’s localization systems. In addition, it is able to handle a wide variety of connected actors, as illustrated by our use case, as well as localization technologies, despite any kind of variation in their nature. Therefore, we can conclude that IoT protocols already offer powerful and efficient mechanisms in order to realize all of these functionalities. We believe this work can provide a baseline, for the localization system developers, about how to use IoT protocols and platforms in order to integrate their products in IoT applications. It can also help IoT system providers to understand the characteristics and needs of different localization technologies in order to realize their semantic and structural interoperability in the context of IoT.


A 38-year-old female presented to the emergency department (ED) with acute-onset right lower quadrant abdominal pain following two days of nausea and vomiting. Physical examination revealed right lower quadrant tenderness to palpation, rebound tenderness, and guarding. Point-of-care ultrasound (POCUS) of the right lower abdomen was performed and interpreted as probable appendicitis. However, upon laparoscopic examination of the abdomen, a benign-appearing appendix was visualized. Further investigation revealed the source of the patient’s pain to be a torsed Meckel’s diverticulum. Although rare, a torsed and inflamed Meckel’s diverticulum can be visualized by POCUS in the ED without the need for further imaging or delay. Acute abdominal pain is a common presentation in the emergency department (ED). Pain localized to the right lower quadrant (RLQ) warrants a workup for appendicitis, a diagnosis commonly made in the ED and a prevalent cause of urgent abdominal surgery.33/microliter, a normal hepatic and pancreatic function panel, a normal basic metabolic panel, and a negative pregnancy test.A 38-year-old white female with no significant past medical history presented to the ED with acute onset RLQ abdominal pain that began earlier that day. The pain was described as being sharp, stabbing, radiating to the right flank, and greatly exacerbated by movement. She reported decreased appetite, nausea, and vomiting two days prior to presentation with only nausea on the day of admission. On physical examination, the RLQ of her abdomen was tender to palpation with guarding and rebound tenderness. Other examination findings included a blood pressure of 90/60 millimeters of mercury, a heart rate of 97 beats per minute, and a temperature of 36.8 degrees Celsius. Pertinent laboratory findings included leukocytosis, with a white blood cell count of 17.6 *10Based on the patient’s presenting symptoms and workup, a point-of-care ultrasound (POCUS) of the abdomen focused on the RLQ was performed to assess for suspected appendicitis. A linear probe was used on the RLQ to first obtain a short-axis view, and then rotated 90° to obtain a long-axis view. The bedside US interpreted by the emergency physician showed a tubular, non-peristalsing structure superficial to the iliac vessels 0.9 centimeters in diameter with edematous walls consistent with appendicitis Image, . FurtherSurgery was promptly consulted for acute abdomen with a preoperative diagnosis of appendicitis. The patient was consented for a laparoscopic appendectomy and taken into the operating room. Upon initial laparoscopic examination of the lower abdomen, the patient’s appendix appeared normal, with no signs of appendiceal inflammation, induration, or injection. The appendix was removed despite its normal appearance, and the lower abdomen was again examined for another source of the patient’s pain. An area of torsed, dark tissue was identified on the antimesenteric portion of the small bowel and subsequently detorsed, revealing an ischemic Meckel’s diverticulum that appeared to be the cause of the patient’s symptoms. The transected tissue was sent to pathology, which confirmed both a normal appendix and a Meckel’s diverticulum. The patient recovered and was discharged two days later with weight restrictions and home rest for two weeks.Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract, with a prevalence of 2–4%.6What do we already know about this clinical entity?Meckel’s diverticulum is the most common congenital gastrointestinal anomaly. When torsed or inflamed, it can clinically and radiologically mimic acute appendicitis.What makes this presentation of disease reportable?A rare, torsed Meckel’s diverticulum was thought to be appendicitis but properly treated after visualization via point-of-care ultrasound.What is the major learning point?Visualization of the pathological process is more crucial to patient care than distinguishing an inflamed Meckel’s diverticulum from appendicitis.How might this improve emergency medicine practice?Point-of-care sonography can save time and resources as well as reduce radiation exposure without negatively affecting outcomes in right lower quadrant pain.Many factors contribute to the difficulty in correctly distinguishing between a torsed or inflamed Meckel’s and an inflamed appendix. Both can present with a similar history of acute onset right lower abdominal pain with variable abdominal distention, nausea and vomiting, especially in the case of bowel obstruction with Meckel’s diverticulum.Regarding imaging findings, torsion of a Meckel’s diverticulum is an extremely rare complication and thus there are limited studies of optimal imaging modalities.10US can also visualize a torsed Meckel’s diverticulum, as shown in this case; however, it is often misdiagnosed as acute appendicitis due to similar location, features, and anatomy. Anatomically, Meckel’s diverticulum is classically found within 100 centimeters of the ileocecal valve, placing it in the RLQ or near the midline, analogous to the appendix. US findings are also similar between the two diagnoses. Both are true diverticula meaning they contain all gut wall layers, resulting in the classic gut signature or “target” appearance on ultrasonography, and both show non-compressible, blind-ending, tubular, non-peristaltic structures with edematous walls .While it is possible to correctly identify a Meckel’s diverticulum on ultrasonography by its lack of association with the cecum, this case shows that from an ED perspective, the visualization of a pathological process that is likely the source of the patient’s pain is much more crucial and meaningful than accurately diagnosing a Meckel’s diverticulum at the bedside. The aforementioned sonographic findings coupled with the patient’s presenting symptoms would warrant surgical consultation in either case. Whether the findings are indicative of appendicitis or a torsed Meckel’s diverticulum can be demonstrated intraoperatively, as both of these etiologies would require surgery.Here, we see that US is a valuable study for RLQ pain even in the setting of bowel ischemia secondary to axial torsion of a Meckel’s diverticulum. In this particular case, a torsed Meckel’s diverticulum was mistakenly identified as appendicitis, but the patient’s treatment course and outcome were not affected. On the contrary, the patient was quickly consented for laparoscopic surgery without the need for further imaging, interpretation by a radiologist, or exposure to unnecessary radiation.Few studies have investigated the utility of ultrasonography in the setting of an axially torsed Meckel’s diverticulum. Here, we have shown that POCUS in the ED is a capable and appropriate tool for investigating acute RLQ abdominal pain even in the setting of a Meckel’s diverticulum. Although US is relatively operator-dependent, in the right hands it is a readily available and quickly interpreted imaging modality, making it an important skill for emergency physicians.Video.A linear probe is being used on the right lower quadrant of the abdomen in this video clip. An edematous, fluid-filled, non-compressible structure is seen just below the abdominal wall musculature in short-axis view and is circled in yellow. The structure displays a “targetoid” gut signature and is shown adjacent to normal loops of small bowel, making it suspicious for acute appendicitis. It was later found to be an inflamed Meckel’s diverticulum.


John Harris,How to be good: The possibility of moral enhancement, Oxford University Press, Oxford, 2016, 195 pp, ISBN 978-0198707592Yuval Noah Harari,Homo Deus: A brief history of tomorrow. Harvill Secker, London, 2016, 440 pp, ISBN 978-1910701874Willem H. Vanderburg,Our battle for the human spirit: scientific knowing, technical doing, and daily living.University of Toronto Press, Toronto, 2016, 440 pp, ISBN 978-1487520359Homo sapiens. Species members may find themselves encased in a type of existence they deem to be wanting in comparison with their present form, even if the promised form was assured to be better. Plausibly, the concern is not merely fear of change or of the unknown, but rather it arises out of individuals’ general identification with what they are and what their friends and family are. In altering that identity beyond a point, they lose it and thus lose themselves in a kind of living death. The films about endemic zombieism seem to reflect such concerns about living death. Much of the recent literature on this issue of increasingly dissonant human/technology relations has largely come from medical ethics: from philosophers and physicians. Are we, as some contend, ethically obliged to incorporate these devices and methods into our being; or does such intervention violate some kind of tacit natural law? Already, as I have implied, the discussion reaches much further into the psychology of one’s identity, which has seen sparse examination in terms of this concern.One of the most salient contemporary concerns in academic debates and pop culture alike is the extent to which new technologies may re-cast The three volumes reviewed in this essay offer widely differing perspectives on the relations between humans and new technology. The first by John Harris comes from an established tradition in medical ethics , providiI start with Harris. A professional moralist, Harris has for many decades promoted the project most neutrally characterized as composite redesign of humanity’s nature (CROHN). This project is often narrowly deemed human enhancement (and some versions of it transhumanism); however, it is clearer to designate the project with less normatively loaded terminology. Harris has written so extensively promoting CROHN that this new volume’s bibliography lists only works that he himself has authored. I mention this fact because it plays into the book’s approach and method, as described below. In his work, Harris largely concentrates on CROHN projects—such as human cloning, genetic engineering, cognitive enhancement, and chimeras—and downplays the so-called ‘yuck’ factor in response to bioengineered beings, this factor being veritably immoral because it purportedly delimits the possibility for types of potential beings. While promoting a preponderance of CROHN techniques, he has also long debated other CROHN-favoring commentators regarding the use of projected pharmaceutical “moral bioenhancement” (MB). This new volume seems to be primarily focused on the ethics of various routes to moral improvement, as he finds the pharmaceutical method a threat to society and to the CROHN programs themselves.I say this “seems” to be his focus because one of the central drawbacks to the volume is its sketchy, ununified structure. While only three of the twelve chapters are previously published essays, and while such reprinting is common and can support effective book-length arguments, justification for the volume’s lack of cohesion is not evident. Much of the book presents large passages from or summaries of the author’s earlier scholarship, and many of the footnoted citations are attributed to him. To read a book so pervaded by specters of the author’s previous work is, at best, an insignificant nuisance; at worst, it amounts to an elliptical experience for the reader. One would need to have at-hand access to the bibliography’s exclusive list of the author’s prior works, as well as unique insight into both what the author intends the reader to distill from each work and how to interpret this kernel within the context of the present volume. The result of this method, as reflected in the peculiar bibliography, reads like a patchy collage of the author’s oeuvre. As such, it is difficult to ascertain the precise theses of each chapter, much less that of the entire volume.Despite this drawback in method and form, some content peeps through. As mentioned, the volume seems to unfold by differentiating MB from non-pharmacological moral enhancement  and arguing against the former. In this respect, Chapters 4 and 5 are crucial—the latter critically describing MB and the former calling on the need for NONME, especially in the context of emerging technologies that may alter our species. The NONME that Harris holds is that “our chief hope of finding solutions to the most threatening sources of probable mass destruction and … our only proven forms of moral enhancement” are “science, innovation, and knowledge production, particularly education” , p. 74. When the reader gets to this point in Chapter 5, one can sense an overall theme materializing—one that, in retrospect, helps to contextualize Chapters 2 and 3. Buried in the last section of Chapter 2, which is astonishingly saltatory among a miscellany of topics, is the notion that moral enhancement must involve more than moral emotions, states of mind, intentions, or brain states; rather, it must consist in a “realistic calculation of consequence” , p. 37. Although clear progress toward an overall argument remains obscure, in these chapters the reader is still able to interpolate—given lack of road signs—some kind of coherent endeavor. However, come the final section of Chapter 5, this hope for structure is frustrated by an inscrutable detour. After criticizing MB as intractable, Harris abruptly tosses in five pages about how humanity would best make moral progress by getting rid of males, the species’ single greatest moral burden. Certainly, he advocates doing so without murder—just select out male zygotes or y-sperm at the conception stage. With females’ better oxytocin capacity, a female-only world would be much more moral than the one we have today. Yet, notably, the author does not reconcile this authoritarian, paternalistic proposal for society with his vehemently argued position for freedom of choice as essential for moral action. Furthermore, the proposal for increasing levels of the neuroactive substance oxytocin in the population as a way to enhance morality does not mesh well with his criticism of MB, which also calls for raising levels of neuroactive substances in the population to enhance morality. At this juncture, with such patent contradiction, the book loses so much credibility as to threaten the validity of the remaining chapters. Indeed, the chapters that follow maintain the book’s saltatory structure. The thought experiment of an omniscient God Machine beaming into everyone’s brain would only stifle liberty; the notion that normal, non-pharmacological ethics is for ‘bad guys’ because ‘good guys’ know how to act does not contradict the MB position that cognition is not necessary for ethical behavior. Harris distances his arguments from Patricia Churchland’s views about molecular morality , then deSapiens, offers a skillfully concise telling of our species from our forager ancestors to early cultivators and thence industrial societies [Harris’s new volume stands somewhere in the regions of traditional bioethical concerns for CROHN and exemplifies the range of such debates, even among CROHN-project supporters. Another new work, by the historian Yuval Harari , recogniocieties . His preYet—and it takes reaching the end of the long (67-page) first chapter to realize—the volume does become serious and more inviting, erasing fears of its potential cuteness. The author articulates his most basic and far-reaching assumption: “The following chapters discuss how humanism—the worship of humankind—has conquered the world. Yet the rise of humanism also contains the seeds of its downfall” [The major issue, contrasted with the main antagonist (humanism) in this attempted tale, is emerging technologies, especially those that do not exist but that many an engineer, a businessperson, and a philosophical cohort believe beyond a doubt will exist: the usual suspects—super intelligence, mind uploading, thoroughly virtual worlds, humanlike automata, and nanotech correction of any and all malady. These may appear, in some glistening eyes, to be something new on the planet. But for this volume, they are merely manifestations of the same old multi-century social-political phenomenon: humanism.H. sapiens at the center of the universe (pace Copernicus) and promoting the species’ self-worship, humanism has led the Earth to the Anthropocene, wherein the species is the most powerful force shaping the globe and life upon it. Supposedly, nature is nearly conquered; the species has almost entirely alienated itself from other lifeforms in the process, and now it can allegedly have as complete control of itself and the technical environment as the Greek gods had over their world. Yet “while the attempt to upgrade humans into gods takes humanism to its logical conclusion, it simultaneously exposes humanism’s inherent flaws” [Humanism in this book is a “religion” , p. 66, t flaws”  p. 66. It flaws” , p. 67. humanitas, in a drive to reform education so as to inculcate values of civic virtue. Certainly, movements like Niethammer’s and later humanisms had existed for millennia, both in the West and in the East. But the perplexity for historians is the diachronic diversity of such movements. Why should they all be subsumed under the term “humanism”?The book’s intention, then, is clear and inviting. The problem lies not in its succoring hope, but in the fact that there is no singular creed of humanism. Rather, there seem to be multiple humanisms. Harari avers that, by the advent of the Twentieth Century, humanism had undergone a schism into three groups: orthodox liberal, socialist, and evolutionary. Yet there is still a nagging complication in speaking of humanism as the result of a schism as opposed to a multiplicity of ideologies or doctrines that have developed over millennia. To treat humanism as one monolithic movement, although certainly not unique among commentators, may be too much of a stretch. A historian of Harari’s expertise must understand the term “humanism” did not enter occidental vocabulary until Niethammer coined it in 1808, invoking Cicero’s Pièce et main d’oeuvre), maintains that it is anti-human to try to climb out of what their opponents deem to be an unworthy, faulty body and soul and to remake these in their own image of perfection.These movements seem to share with one another little more than the idea that members of the species should treat others well. Some humanists, such as Niethammer and even Cicero, would still allow a place for the Divine in human civic life; others would emphasize moral values derived purely from human interests. Some humanisms underscore the importance of understanding humanity’s position within nature and among other life forms; others encourage the notion that it is human destiny is to conquer nature. In a contemporary example, some commentators may indeed maintain, much in line with Harari’s assessment, that human-based values of exploration, discovery, and improvement dictate the species’ evolution toward a new type of species, harnessed by the drive to overwhelm or enslave nature. By contrast, at least one countermovement  humanistic CROHN plan—a route he does not endorse—or buck humanism, sending a warning about the trend toward CROHN. It is simply not clear that attempts to fulfill humanism  are what have led the species to the brink of likely self-destruction via techniques designed to guarantee consumers “immortality, bliss and divinity” , p. 278.Since humanism has long sanctified the life, the emotions and the desires of human beings, it’s hardly surprising that a humanist civilisation will want to maximise human lifespans, human happiness and human power. , p. 279In this quote and the rest of the paragraph, the book subtly reverts from the schism-fraught humanism to the monolithic humanism. Thus, at least in terms of this volume’s presentation, it remains unconvincing that the CROHN movement and its successes so far—by duping billions of consumers into buying high-technology products and thereby indirectly funding the movement—arise simply from the faulty philosophy of humanism.The link to humanism seems to be thus: while liberal humanism enabled the scientific revolution and the technological wonders inspired by it, liberal free-market policies produced hyper-activated consumerism. Further, biological research increasingly shows that humans, like any organisms, are just mechanisms wholly determined and without free agency—thus undermining the very liberal humanism that gave rise to this scientific inquiry in the first place. Chapter 9’s great decoupling of liberal-humanism individuality from the results of liberal-humanism’s sciences makes the former obsolete and renders a crisis: (1) humans lose their economic and military status, rendering them useless and worthless; (2) for a while at least, the species as a whole will retain some value, while the individual loses all value; (3) for a while at least, the very few elite individuals upon whom the mechanized system depends will retain some value, making their extermination unlikely.This prospective decoupling, which mirrors and intensifies Hannah Arendt’s concerns about automation, is indeed unsettling. The thesis merits the book’s convincing dissection and constitutes a large part of its warning. However, by the book’s end , it is not apparent that either the extensive routing through a scapegoated humanism or the casting of CROHN as a demented humanism is necessary in order to make this warning sufficiently loud. In fact, because the humanisms are many, faulting humanism may detract even from efforts to help fence-sitters climb down and join the effort to defuse CROHN.What exactly should be done in the face of CROHN scenarios that, as Harari implies, are totalitarian and very possibly genocidal remains unclear. Harari, for all his excellent insights (the humanism red herring aside), leaves readers with only three questions to think about as they go about their day: (1) Are we just algorithms? (2) Is consciousness not as important as intelligence? And (3) do we want our lives to be dominated by mechanisms that know more about each of us than we know ourselves? These are great concerns but are not emphasized in the book’s structure. Part of the author’s strategy may be to make the full implementation of CROHN so vivid and threatening as to disturb readers as much as any possible set of instructions can do.Harris’ book reveals yet another anguishing angle here: though it represents only one of the few available explicitly philosophical works in support of CROHN, it is nonetheless poorly organized, lacks clear argumentation, and remains fraught with logical and critical-analytic pitfalls. In exemplifying what little substantial philosophical work has come out supporting CROHN, the Harris volume shows just how steeped the CROHN movement is in irrationality and in scant critical analysis.Our Battle for the Human Spirit [A third recent volume, Vanderburg’s n Spirit —though nAnother main contributor to the current deadened fact-driven industrial society is desymbolization—whereby activities and products render no integrated symbolic meaning to our idiosyncratic human identities. Little does one relate to anything else one does or what the rest of the universe means in terms of its relation to these actions. This is the challenge of secularization: “If technique destroys our being a symbolic species, it will likely disappear with us” , p. 85. A solution may come from the process of resymbolization and extension beyond the discipline-based approach. Vanderburg offers the examples of Brazil’s Semco and Sweden’s Volvo Uddevala plant, which instigated worker-driven product assembly, wherein workers assembled entire automobiles in small teams. Such practice may seem to compromise efficiency, but in the end it proved sufficiently meaningful for the workers that efficiency was not significantly compromised. Yet, to return, symbolization would require a deliberate overhaul on the part of citizens, as well as on the parts of businesses and political leaders. Education would be a primary venue for restructuring discipline-based approaches as more culturally integrative, in the interest of resymbolization and restoring meaning to work, and in the interest of returning to real-life needs and the needs of the community and biosphere.The author admits to having made inroads towards such goals in his work with the Canadian educational administration. Although many of those inroads have since been eroded, he maintains hope that change for the betterment of the human spirit is at least feasible—if only leaders would concur and act.Vanderburg’s work may hold the most potential value of the three books discussed in this essay. He suggests how we as individuals, as citizens, and as members of a species can optimally respond to the ongoing barrage of new techniques. Vanderburg does not explicitly take on CROHN projects, although he mentions some CROHN techniques in passing. Yet these projects implicitly fall within the scope of his concern about how techniques and designs in the current cultural context are hampering the human spirit.Unfortunately, despite the urgency of Vanderburg’s message, this book  has stylistic shortfalls that can impede the promulgation of its message. The book’s style is at the same time thick and exceedingly repetitious, as though it were written spontaneously with little editing. The paragraphs are long and rambling, and it is hard to follow how the author’s thoughts connect. Certain phrases, while key, are reiterated to the point of irritation, such as the—albeit emphatically important—phrasing of concern for “human life, society, and the biosphere” .Nonetheless, the book’s message is sufficiently urgent and original that it is well worth a read by people on the many different sides of the CROHN debate. Unfortunately, few authors, such as Harari, have written non-antitechnology criticisms of CROHN, which has an enormous worldwide support system. As the three works reviewed here together make clear, a whole, fully coherent, definitive work on CROHN still has yet to materialize.


P. K. Newby’s treatment of this perennial topic is somewhat daunting in its scope. As she says in her preface:no individual book could ever do justice to this vast subject, covering in depth the myriad ways food shapes and impacts our health, environment, economy and society. I try, even so, to provide what everyone needs to know,…large bodies of literature across scientific disciplines like nutrition, agriculture, biology, and anthropology—to better understand how and why what we eat matters, from farm to fork. (p. xv)She reiterates this at the start of the first section as well: “it is not possible for one book alone to provide ‘everything you need to know’” (p. 8), which then raises the question for using such a title.This book is marketed to appeal to the casual lay reader, with an almost overwhelming focus on factual data. Given the chicanery present in much of nutrition and diet publishing, that is refreshing.The book is divided into five parts: 1. “Why What We Eat Matters: From Farm to Fork”; 2. “Dining Throughout Human History: Science, Technology, Eater, Environment”; 3. “Essential Food and Nutrition: Separating Science from Junk Science”; 4. “Food, Glorious Food”; and 5. “Diets for Optimal Health, Longevity, Sustainability: Today and Tomorrow.”Any one of these topics could be a book in itself. It is a vast scope for 293 pages. Because Newby wants to cover so much ground, her approach must be broad. In her quest to span both global and individual food issues, some things, such as the federal government bodies and policies that affect so much of the business of food, are overlooked. The lack of treatment of such federal programs as MyPlate or Dietary Reference Intakes (DRIs) is inexplicable for a book designed for lay people, especially since statistics from the US Department of Agriculture (USDA), Food and Drug Administration (FDA), National Institutes of Health (NIH), and Environmental Protection Agency (EPA) are heavily quoted. The entire industry of commercial marketing of food and food choices to people is not explored.Each of the above-named sections contains approximately twenty-five questions that are posed and answered. Sample questions are “Is sugar addictive?;” “What’s in a nut?”; and “What is a concentrated animal feeding operation (CAFO) and why does it matter?” The topics are interesting, but again, each is worthy of in-depth treatment but does not receive it. For example, CAFOs are defined by the EPA (p. 170), but the USDA program that encourages CAFO managers to practice environmentally responsible nutrition management is not mentioned. Another example is the consumption of fish caught locally. Newby advises against eating this more than once per week due to possible (unnamed) contaminants in these fish (p. 191); specific species or differences in freshwater or saltwater fish are not delineated. The reader is left scrolling through Chapter 13’s citations in the portable document format (PDF) file, wondering which references apply to this edict.Newby’s website via a submenu. She quotes many studies on world nutrition, foodborne illness, and global agribusiness practices from medical journals, newspapers, government reports, and the Encyclopaedia Britannica. Her sources are varied, current, and within accepted medical literature conventions but are not tethered to her actual writings regarding the 134 questions. Why this severing of information from original sources? At the back of the book, there is a short list of selected references for each chapter, unannotated. There is also a footnoted “Notes” section on each chapter, as well as an index, so why not the complete bibliography? The “over 1200 references” are available at www.pknewby.com, something easily overlooked by any reader who does not bother with reading prefaces or introductions.I reviewed the separate PDF of citations that are available only on Eat, Drink and Be Healthy: The Harvard Medical School Guide to Healthy Eating (2017), a Harvard Medical School book codeveloped with the Harvard T.H. Chan School of Public Health (published by Free Press), seems a reasonable choice. It has a slightly different focus: it concerns itself with the pitfalls of dietary choices and the need to better understand nutrition labels; the USDA’s DRIs, the RDAs of old; and MyPlate. It is not as comprehensive a book as Newby’s, but it shares the same basic philosophy as hers and it covers the politics of food as well. It is more academic in that its bibliography is included in the book, but it is also not for clinical use.Given the broad scope of this work, it is a challenge to find a book with which to compare it. Walter Willet’s I laud Professor Newby for her effort in producing a nutrition book that is accessible for a casual reader, but I cannot condone the severing of sources of information; it undermines the credibility of the writing. If this is a new industry custom, I hope it is short-lived. What happens to this book if her website ceases to exist? This structuring of the work does Newby a grave disservice, but the true harm is to reliable, authoritative, responsible secondary research such as hers. I cannot recommend this book to a medical or hospital library. A public library may want to have it on their shelves but will need to add a prominent sticker or notice to patrons that the references are separate from this book and to provide the website’s uniform resource locator (URL) for those who want citations.