Flag System Research Articles

A Red Flag for the Licensing Regime (A Postscript to ‘A Red Flag for Hong Kong Credit Ratings’)

In July 2011 Moody's Investors Service Hong Kong issued a report that used a system of red flags to highlight corporate governance and accounting risks in a specified population of listed companies. Although the report is not itself a credit rating, it remains unclear whether Moody’s publication of it should be subject to the disciplinary powers of the Securities and Futures Commission (“SFC”). At issue is the construction of section 193(1)(d) of the Securities and Futures Ordinance (“SFO”), which provides that an act or omission relating to the carrying on of a regulated activity is liable to be regarded as misconduct subject to the disciplinary powers of the SFC under section 194 SFO. The earlier determination of the Securities and Futures Appeals Tribunal and the judgment of the Court of Appeal both supported a broad, purposive interpretation of relation to find that the SFC’s disciplinary oversight applied. Moody’s appeal to the Court of Final Appeal is likely to have ramifications that go well beyond the credit rating industry. As the case concerns the interpretation of a disciplinary provision that all regulated persons are subject to, the Court’s ruling will have significant implications on the ambit of the SFC’s disciplinary powers over all companies engaging in regulated activities that require a license from or registration with the SFC. This article examines the approach taken by the Tribunal and the Court of Appeal and suggests it is flawed and ill suited to the complexities of the business environment surrounding the undertaking of regulated activities. In the absence of an acceptable degree of legal and commercial certainty, there is a risk that regulatory oversight of a wide range of activities other than statutorily defined regulated activities may be introduced via a backdoor opened by the prospect of the SFC’s discipline. An alternative view of relation is proposed that may assist develop a test of relation that better serves statutory purposes, as well as regulatory and commercial needs. It is hoped the Court of Final Appeal will take the opportunity to clarify the law in this area in order to facilitate greater certainty as to the extent of the regulatory obligations of licensed corporations as well as the ambit of the SFC’s disciplinary powers.

Coupled motion of two side-by-side inverted flags

The interaction and coupling between two inverted flags that are placed side-by-side in a uniform flow is investigated in an effort to determine the behavior of systems that are formed by arrays of cantilevered plates. Inverted flags are elastic plates that are free to move at their leading edge and clamped at their trailing edge. We show that placing two inverted flags of equal dimensions side-by-side will cause their motion to couple. In-phase, anti-phase, staggered, alternating and decoupled flapping modes are present, with the anti-phase mode being predominant at small flag distances and low wind speeds. Increases both in amplitude and frequency of flapping are observed in the two flag system with respect to a single flag. Two side-by-side inverted flags of different lengths are found to interact for small length differences, with the longer flag being able to induce a motion on the shorter flag even when the latter is outside of its flapping wind speed range.

High sensitivity of the Hematoflow™ solution for chronic myelomonocytic leukemia screening.

Accumulation of classical monocytes CD14++ CD16- (also called MO1) ≥ 94% can accurately distinguish chronic myelomonocytic leukemia (CMML) from reactive monocytosis. The HematoFlow™ solution, able to quantify CD16 negative monocytes, could be a useful tool to manage monocytosis which remains a common issue in routine laboratories. Classical monocytes were quantified from 153 whole blood samples collected on EDTA using both flow cytometry methods, either MO1 percentage determination by the multiparameter assay previously published and regarded here as the reference method, or CD16 negative monocyte percentage determination by the means of HematoFlow™. Both methods of classical monocyte percentage determination were highly and significantly correlated (r = 0.87, P < 0.0001). The HematoFlow™ solution leant toward an overestimation of the genuine classical monocyte percentages obtained by the reference method. Percentages of CD16 negative monocytes provided by HematoFlow were higher than 94% for all the 73 patients displaying classical monocytes MO1 found ≥94% by the reference method, indicating a sensitivity of 100%. Furthermore, the calculation of CD16 negative monocyte percentage can be easily computerized and integrated to the middleware. We propose a new application of the Hematoflow™ solution that can be used as a flag system for monocytosis management and CMML detection. © 2017 International Clinical Cytometry Society.

Weekend surgical handover enhances early management of acute clinical changes using a red flag system.

Recent implementation of the European Working Time Directive in Ireland has resulted in a change from thetraditional model of patient care to a system characterised by shift work among clinicians. Effective handover ofpatient information is essential for transfer of responsibility between clinicians and maintaining continuity of care. The weekend has been identified as a particularly vulnerable transition of patient care. Our study aims to determine if implementing a formal face-to-face handover accompanied by an electronictemplate in our surgical department can improve the number of adverse events reported back to the primary teamafter a weekend on call. Data was collected over 12 weekends between February and May 2016. A list of adverseevents was established, and during an initial observation period of 6 weeks, we documented the number of adverseevents that were informally handed over. A 6-week intervention was then performed, involving a formal face-to-facehandover on Monday morning supported by an electronic patient census using a red-flag system to highlightpatients who experienced an adverse event over the weekend. Our results showed the mean number of adverse events recorded pre-intervention was 3.17±0.6 over the 6-week period. Following the introduction of weekend face-to-face handover, there was 147% increase in the number of adverse events recorded with a mean of 7.83±1.2. The introduction of a formal face-to-face weekend handover with a red-flag system resulted in increased reporting of patient adverse events, allowing earlier recognition and management.

A Red Flag for Hong Kong Credit Ratings

In July 2011 Moody’s Investors Service Hong Kong issued a report that used a system of red flags to highlight corporate governance and accounting risks in a specified population of listed companies. Although Moody’s did not consider the report a credit rating, the Securities and Futures Commission, and the Securities and Futures Appeals Tribunal in its March 2016 determination, regarded the issuance of it as part of Moody’s regulated activity as a provider of credit rating services. As such, Moody’s was held subject to regulatory codes of conduct it was said to have breached, and was consequently disciplined. Moody’s has since appealed that determination, which will bring the case before the Court of Appeal.This paper undertakes a detailed legal analysis of the Tribunal’s determination. It suggests the Tribunal’s purposive approach to legislative interpretation is flawed, and its determination impaired by the way the Tribunal has framed the syntax of its reasoning and has conflated important distinctions between credit risk, creditworthiness, credit ratings and the methodology used to produce a rating opinion. Other legislative provisions relevant to the publication of information are reviewed and it is noted there is no lacuna in Hong Kong’s law that would necessitate the approach taken by the Tribunal to address the perceived wrongdoing. Whether the Tribunal’s interpretation of the law is necessary or consistent with the policy intent of the Legislature is queried. The ramifications of a Court of law upholding the Tribunal’s determination are considered. Locally this includes blurring the perimeter around regulated and unregulated activities and the possible creation of an uneven playing field. Of particular significance for Hong Kong’s credit rating industry, it may create uncertainties as to whether Hong Kong would remain an equivalent jurisdiction for the purposes of recognition under European Union regulations. The paper concludes with a brief consideration of the regulatory approach to managing the introduction of a new regulatory regime.

Evaluation and optimization of the extended information process unit (E-IPU) validation module integrating the sysmex flag systems and the recommendations of the French-speaking cellular hematology group (GFHC)

The French-Speaking Cellular Haematology Group (GFHC) recently published criteria for microscopic analysis of a blood smears when a hemogram is requested. In order to evaluate and improve these recommendations using an XN (Sysmex) analyzer, we assessed 31,836 samples categorized into two sub-groups of patients either receiving or not receiving care in the clinical hematology/oncology departments of two university hospitals. By combining the manufacturer’s recommendations and the GFHC recommendations, 21.3% of samples had a positive review flag in phase 1 of our study (17,991 samples). In phase 2 (13,845 samples), increasing the immature granulocytes (IG) percentage from 5–10% as a review trigger threshold, and ignoring slides with isolated flags ‘PLT HIGH’ (thrombocytosis) or ‘MCV LOW’ (microcytosis) or ‘Blast/Abn Lymph and Atypical Lymph’ (blast cells/abnormal lymphocytes and atypical lymphocytes) (in the absence of abnormal cells on a previous blood smear within 72 h), enabled us to significantly reduce the number of slides reviewed from 21.3–15.0% (p < 0.0001), without loss of clinical value. This decrease occurred in both sub-groups (hematology 48.7–38.0%, non-hematology 18.3–11.7%, p < 0.0001). In conclusion, the application of the GFHC criteria adapted to XN analyzers has enabled us to optimize the hematology laboratory processes, and thus reduce the production costs and the turnaround time of hemogram results.

An audit of the quality of inpatient care for adults with learning disability in the UK

ObjectivesTo audit patient hospital records to evaluate the performance of acute general and mental health services in delivering inpatient care to people with learning disability and explore the influence of...

English

This paper is a continuation of Part I where the general setup was developed. Here we discuss the general equivalence problem for geometric structures and provide criteria for the equivalence, local and global, of transitive structures. Cartan's Flag Systems illustrate the theory as a major example and, finally, some attention though little is given to non-transitive structures with regular orbits i.e., intransitivity classes.

Issue highlights--November 2015 (88:B6).

Issue highlights--November 2015 (88:B6).

The routine leukocyte differential flow cytometry HematoFlow™ method: A new flagging system for automatic validation.

The complete blood cell count and white blood cell differential are the first step in the biological diagnosis of hematological diseases. Both are currently performed by automated instruments which control data and produce alerts. If such flags are activated, the automated differential cannot be validated and the operator must activate a visual blood smear review. Microscopic examination is still today the reference method despite its lack of sensitivity and reproducibility. The HematoFlow™ (Beckman Coulter) system is the first flow cytometry commercialized method designed for the routine differential. Using six markers in five colors and an automated gating strategy, it provides differentials proven to be reliable for 17 leukocyte subpopulations detection. Relying first on a retrospective analysis of 6,462 blood samples processed by HematoFlow™, thresholds were determined to detect the presence of immature granulocytes and/or blast cells. All possible gating strategy misclassifications of leukocyte subpopulations were then summarized in a systematic nomenclature leading to the development of an original flag system based on the detection of aberrant localization of cell events in specific new bivariate histograms. Ultimately, more than 50% of the results could be automatically validated using the HematoFlow™ system, without any false negative, thereby dramatically contributing to an important decrease of technicians' workload. Moreover a noticeable help was given for smear review interpretation and new immunological flags led to the confirmation of blood disease after classical immunophenotyping. These results were confirmed in a second prospective study including 15,335 cases, where more than 50% of the results were automatically validated by this new flag system. MFC stands as being more and more essential for analyzing differentials in routine and this new flag system could greatly improve its implementation.

Tracking and managing high risk offenders: A Canadian initiative.

The purpose of the current study was to evaluate the utility of a national initiative (the National Flagging System [NFS]) in correctly identifying high risk violent and sexual offenders and facilitating the appropriate application of preventative detention in Canada. A sample of 516 flagged offenders (FOs) was compared with 58 dangerous offenders (DOs) and 129 long-term offenders (LTOs) on demographic variables and risk assessment measures. Recidivism was also examined for a sample of FOs and LTOs. Results found many similarities among the 3 groups but FOs, on average, scored lower on structured risk assessment measures. Despite this latter finding, a significant proportion of FOs were rated as high or very high risk to reoffend according to the risk categories of the risk assessment instruments used in this study and based on percentile rankings. Violent (including sexual) reconviction rates for FOs were also significantly higher when compared to both LTOs and a sample of federal offenders. The base rate for preventative detention designations among FOs was substantially higher than the expected base rate among violent and sexual recidivists, thereby confirming the utility of the NFS. Although the NFS identifies high risk offenders, NFS coordinators would benefit from utilizing structured risk assessments when making flagging decisions.

Public Understanding and Knowledge of Rip Currents and Beach Safety in the UK

Rip currents present a severe hazard for water users on beaches and account for the greatest cause of lifeguard rescues worldwide. The physical dynamics of rip currents are well studied, and more recently, the social and behavioural science research surrounding human interaction of rip currents has been expanding, providing a social perspective and feeding into public education strategies. The aim of this study was to assess levels of public understanding of rip currents and beach safety on UK beaches. A questionnaire was undertaken (N = 407) during the summer of 2012 on four beaches. Beach users had a poor knowledge of rip currents (n = 263), but those who have been caught in a rip have a higher level of knowledge. Conversely, beach users had a good understanding of what the beach safety flags indicated (n = 314), and most people complied with this flag system (n = 339). In addition, people previously educated on rip currents had a higher knowledge, and lifeguards proved to be the most effective form of education. The study presents an insight into UK beach users’ knowledge of rip currents and provides more evidence with which to pilot a rip current education scheme within the UK.

Public Understanding and Knowledge of Rip Currents and Beach Safety in the UK

Rip currents present a severe hazard for water users on beaches and account for the greatest cause of lifeguard rescues worldwide. The physical dynamics of rip currents are well studied, and more recently, the social and behavioural science research surrounding human interaction of rip currents has been expanding, providing a social perspective and feeding into public education strategies. The aim of this study was to assess levels of public understanding of rip currents and beach safety on UK beaches. A questionnaire was undertaken (N = 407) during the summer of 2012 on four beaches. Beach users had a poor knowledge of rip currents (n = 263), but those who have been caught in a rip before have a higher level of knowledge. Conversely, beach users had a good understanding of what the beach safety flags indicated (n = 314), and most people complied with this flag system (n = 339). In addition, those previously educated on rip currents had a higher knowledge, and lifeguards proved to be the most effective form of education. The study presents an insight into UK beach users’ knowledge of rip currents and provides more evidence with which to pilot a rip current education scheme within the UK.

A green flag for the Flag System? Towards a child protection policy in Flemish sport

Over the past decade, the international agenda on the prevention of child sexual harassment and abuse in sport has been strengthened by a number of general policy recommendations. Despite a growing body of literature and research about sexual harassment and abuse in sport, there is hardly any evidence-based policy and prevention research to guide the policy implementation process. By using the Flemish sport system as its empirical focus, this article investigates the feasibility of the so-called Flag System to translate policy into practice. The Flag System is a didactic tool created to assist sport stakeholders in the assessment of sexual behaviour involving children. It is in the process of being implemented in Flanders, and preliminary findings suggest a high level of feasibility at all levels of organized sports. Demonstrating that a number of inhibiting forces have effectively been reduced in Flanders, the current analysis of the process of planned change suggests that the Flag System has potential in bridging the gap between policy and practice and may also be suitable for implementation in other Western countries.

Implementation of the Hepatitis C Screening in the Medicine Clinic: A Quality Improvement Project

Introduction: Chronic Hepatitis C (CHC) is a treatable viral infection that affects approximately 3.2 million people in the United States. Individuals, who were born between 1945-1965, the baby boomers, comprised 75% of the patients with this infection in this country. In January of 2014, hepatitis C screening for this group of subjects became a law in New York (NY) state; accordingly, we implemented a process to improve screening for CHC in the medicine clinic of our hospital. Methods: In March 2014, CHC screening was established as part of the routine health maintenance for patients who attend the clinic. Patients who were born between 1945-1965 were identified by a protected confidential form that served as a flag system to the physicians. Hepatitis C antibody (HCV Ab) followed by hepatitis C RNA (HCV RNA) to confirm chronic infection in patients who tested positive were requested in patients who had not been tested. In addition, weekly lectures were given to the clinic physicians on screening of the target population. We did a retrospective review of the electronic medical records of subjects who have had at least 1 medical encounter. Two periods were included: A.) September 2012, 1 month after the CDC published the screening guidelines, to August 2013 (period I), and B.) January of 2014, the month that the NY state law was enacted to April 2014 (period II). The proportion of patients screened from both periods was calculated. Results: Five thousand, two hundred thirty-three charts were reviewed from period I. 1444 /5233 (28%) had been screened for CHC and 3789/5233 (72%) had not. In this group, 1240/5233 (24%) had a negative HCV Ab and 204/5233 (4%) had a positive test. Among the patients with positive HCV Ab, 136 (66.6 %) had serum HCV RNA detected, consistent with chronic hepatitis C infection, and 38 (18.6 %) did not. Five hundred-eleven charts from period II were reviewed. 21/511 (4 %) patients were tested for CHC from January to February 2014; 429/511 (84 %) were screened from March to April 2014. Ten patients had positive HCV Ab, 3 of whom were positive for HCV RNA. Conclusion: There was an improvement in the rates of hepatitis C screening since the establishment of the NY state law with further increase noted in March to April 2014. Education of physicians and modification of identification process of a target population with the use of a flag system were fundamental in the inclusion of CHC screening under regular health care maintenance.

Reducing image interpretation errors – Do communication strategies undermine this?

IntroductionErrors in the interpretation of diagnostic images in the emergency department are a persistent problem internationally. To address this issue, a number of risk reduction strategies have been suggested but only radiographer abnormality detection schemes (RADS) have been widely implemented in the UK. This study considers the variation in RADS operation and communication in light of technological advances and changes in service operation. MethodsA postal survey of all NHS hospitals operating either an Emergency Department or Minor Injury Unit and a diagnostic imaging (radiology) department (n = 510) was undertaken between July and August 2011. The questionnaire was designed to elicit information on emergency service provision and details of RADS. Results325 questionnaires were returned (n = 325/510; 63.7%). The majority of sites (n = 288/325; 88.6%) operated a RADS with the majority (n = 227/288; 78.8%) employing a visual ‘flagging’ system as the only method of communication although symbols used were inconsistent and contradictory across sites. 61 sites communicated radiographer findings through a written proforma (paper or electronic) but this was run in conjunction with a flagging system at 50 sites. The majority of sites did not have guidance on the scope or operation of the ‘flagging’ or written communication system in use. ConclusionsRADS is an established clinical intervention to reduce errors in diagnostic image interpretation within the emergency setting. The lack of standardisation in communication processes and practices alongside the rapid adoption of technology has increased the potential for error and miscommunication.

An automatic dose verification system for adaptive radiotherapy for helical tomotherapy

Purpose: During a typical 5-7 week treatment of external beam radiotherapy, there are potential differences between planned patient's anatomy and positioning, such as patient weight loss, or treatment setup. The discrepancies between planned and delivered doses resulting from these differences could be significant, especially in IMRT where dose distributions tightly conforms to target volumes while avoiding organs-at-risk. We developed an automatic system to monitor delivered dose using daily imaging. Methods: For each treatment, a merged image is generated by registering the daily pre-treatment setup image and planning CT using treatment position information extracted from the Tomotherapy archive. The treatment dose is then computed on this merged image using our in-house convolution-superposition based dose calculator implemented on GPU. The deformation field between merged and planning CT is computed using the Morphon algorithm. The planning structures and treatment doses are subsequently warped for analysis and dose accumulation. All results are saved in DICOM format with private tags and organized in a database. Due to the overwhelming amount of information generated, a customizable tolerance system is used to flag potential treatment errors or significant anatomical changes. A web-based system and a DICOM-RT viewer were developed for reporting and reviewing the results. Results: More than 30 patients were analysed retrospectively. Our in-house dose calculator passed 97% gamma test evaluated with 2% dose difference and 2mm distance-to-agreement compared with Tomotherapy calculated dose, which is considered sufficient for adaptive radiotherapy purposes. Evaluation of the deformable registration through visual inspection showed acceptable and consistent results, except for cases with large or unrealistic deformation. Our automatic flagging system was able to catch significant patient setup errors or anatomical changes. Conclusions: We developed an automatic dose verification system that quantifies treatment doses, and provides necessary information for adaptive planning without impeding clinical workflows.

Evaluation of the Mindray BC-6800 Complete Blood Counts Analyzer

This article is available from http://www.labmedonline.org 2013, Laboratory Medicine Online This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Background: The BC-6800 (Mindray, China) is a recently developed hematology analyzer that utilizes ‘SF Cube Technology’ to improve the reliability of complete blood counts (CBC), white blood cell (WBC) differentials, and erythroblast counts. In this study, we evaluated the performance of the BC-6800 for CBC, WBC differentials, reticulocyte counts, and erythroblast counts and analyzed the efficiency of its flag system. Methods: Specimens from 100 healthy controls and 95 patients were used. We performed precision and correlation studies of CBC, WBC differentials, reticulocyte counts, and erythroblast counts. We also analyzed the efficiency of the flag system in detecting abnormal blood cells. Results: The coefficients of variation (CVs) of precision were 0.9800 for CBC except erythrocyte indices, and >0.9500 for WBC differentials except monocyte and basophil. The WBC differentials and erythroblast counts obtained using the BC-6800 were well correlated with those of manual counts. The efficiencies of the flag system were 77.9% for Blasts, 82.1% for Immature Gran, 86.3% for Atypical Lymph, and 92.6% for NRBC present. Conclusions: The BC-6800 showed good precision and correlation with pre-existing hematology analyzers. The flag systems were quite efficient for detecting abnormal blood cells. Our study demonstrated that the BC-6800 hematology analyzer exhibits suitable performance and is helpful in routine laboratories.

Analysis of Bias and ART Enrollment for a Point-of-Care CD4/CD4% Analyzer

Point-of-care technologies are a cornerstone for effective HIV care of patients in resource poor settings. They greatly reduce loss to follow up as the patients receive their results immediately and obtain appropriate treatment and other care. There are 593,000 people in urgent need of antiretroviral therapy in Zimbabwe for whom point-of-care technology may be a benefit. The PointCare NOW device was evaluated in order to assess systematic errors between it and conventional flow cytometry and haematology devices, such as the Becton Dickinson FACS Calibur Single Platform and the Sysmex XT-1800i. There being no calibration method for CD4 count on any platform, large systematic errors could affect therapy enrollment decisions. Specimens were collected from 104 patients from the Harare Central Hospital Opportunistic Infection clinic by venipuncture using EDTA tubes. Three samples were automatically excluded as unsuitable for analysis by the PointCare NOW internal control software flag system; for a rejection rate of 2.9%. No other samples were excluded. Each device performed within manufacturer’s replicate precision specifications for all parameters. There was a small but statistically insignificant difference in mean absolute CD4 cell count (+8.6 cells/ μl), mean CD4% (+0.76%) and mean total lymphocyte count (+0.054×103 cells/μl) between the PointCare NOW and the central laboratory systems. There was a small but statistically significant difference in mean total white cell count (+0.28×103 cells/μl) and mean total haemoglobin (-0.74g/dl) measurements and Sysmex XT1800i. We compare two methods for qualifying patients for therapy and show that there was no statistically significant difference between PointCare NOW and FACSCalibur qualifications for either method. One method uses a conventional sharp cut-off and the other uses a newer idea based on patient variability. Our results indicate that the systematic errors determined in our study would not produce disparity in therapy enrollment action taken for a patient receiving results from a PointCare NOW and a FACSCalibur. Our study was completed in 2011 and when compared to other studies carried out in 2009, it suggests that there have been improvements in the PointCare NOW systematic error performance.

Diagnostic and therapeutic problems of back pain syndromes and their distribution according to a colour coding system of flags

Back pain poses a serious clinical problem in some cases, because under the clinical symptoms of back pain might be other hidden diseases. The aim of this study was to present difficulties in diagnosis and treatment of various diseases of the spine and 2. description to the flagship division, based on the traffic lights. The clinical material is based on a group of 20 patients with diagnostic and therapeutic difficulties, among 1825 patients treated due to low back pain. Diagnosis was based on clinical examination and various imaging techniques. In the case of cancer biopsy was performed, and in specific and nonspecific infections of the spine treated surgically toward the microscopic examination of tuberculous granulation tissue or inflammatory. The diagnosis of osteoporotic fractures was based on the digital 3D CT. The studied group of 20 patients were divided according to color flag system. Among the analyzed patients 14 received red flag, 5 yellow and 1 black. The red flag has received seven patients with spinal infection, 3 patients with cancer and two with osteoporotic fracture, and 2 patients with low back pain due to an aortic aneurysm. Yellow flag received 5 patients with compensation claims. 1. In patients with back pain, diagnostic examinations should be administered according to a particular order. Clinical and radiographic examinations are basic tools which should be supplemented by the modern techniques of MRI and CT. 2. Histopathological evaluation of tissue preparations facilitates the diagnosis of an infection or tumour. 3. Classification according to colored flags are useful in clinical practice. It describes the degree of risk of serious illness and difficulties in therapy.