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The use of transcatheter aortic valve implantation (TAVI) is evolving. Our Cardiovascular Evaluation Unit is implementing a comprehensive approach to inform decision-makers on optimal use of TAVI, including the development of quality standards. We are implementing a multifaceted evaluation framework in collaboration with clinical stakeholders.
Our unit has carried out a continuous field evaluation in collaboration with the clinical teams at all six TAVI centers in Québec for the past four years (1 April 2013–31 March 2017), with regular feedback to the teams and sharing of results with each individual center. Hospital documentation was reviewed according to established national quality indicator definitions. Field evaluation data were combined with the results of systematic literature review to establish provincial standards for practice, through a deliberation process by an interdisciplinary committee of clinical experts from each center. Systematic surveillance of the literature is ongoing.
In the period 2013–2017, use of TAVI in Québec was limited to very elderly patients with significant comorbidities at high risk of operative mortality. We observed improvements in both processes of care (e.g. documentation of risk scores) and clinical outcomes (e.g. 30-day and 1-year mortality) over time. Our consensus standards recognize the potential value of TAVI for patients at moderate operative risk, identify uncertainties and recommend best practices for patient evaluation and clinical decision-making about choice of treatment.
A comprehensive, long-term evaluation process of TAVI with feedback to centers is associated with improvements in processes of care and outcomes. In the present context of expanding clinical indications, we will continue to evaluate patient selection, processes and outcomes according to the newly-established provincial quality standards. This iterative approach facilitates continued evidence generation and decision-making for optimal use of an evolving intervention. We acknowledge the contribution of the members of the expert clinical committee.
One important objective at the Institut d'excellence en santé et en services sociaux (INESSS) is to guide the implementation of promising new technologies into Québec's healthcare system. A comprehensive evaluation framework was recently developed that takes into account the dynamic and iterative nature of the life cycle of such technologies. This framework is presently being used to inform the decision-making process concerning use of thrombectomy for ischemic stroke.
A field evaluation has been undertaken since April 2016 in all four of Québec's specialized tertiary stroke centers. This real-world evidence is communicated regularly to the clinical teams as well as decision-makers. A systematic literature surveillance is also ongoing, with results being shared amongst clinical experts on our interdisciplinary advisory committee. On the basis of the generated evidence from these sources, recommendations to optimize structures, processes of care and clinical outcomes will be developed, in collaboration with the interdisciplinary committee.
Thrombectomy has been shown to be safe and effective for treating ischemic stroke in the randomized trial setting in high-volume, expert centers. Real-world evidence from Québec indicates increasing use of this new technology but with wide variation across health regions. Observed times to treatment appear favorable for patients admitted directly to tertiary centers, but inter-hospital transfer is associated with important increases in delays from first door to thrombectomy. The documentation of 90-day outcomes is problematic, especially for patients transferred out of tertiary stroke centers prior to discharge. Uncertainties raised in the literature include patient selection criteria and optimal processes of care during prehospital and inter-hospital phases of the patient's trajectory.
The ongoing comprehensive evaluation of thrombectomy for ischemic stroke in Québec is a concrete example of how the use of an innovative, disruptive technology can be optimized. We acknowledge the contribution of the members of the clinical expert committee.
Decision-making about replacement or modification of an implantable cardioverter defibrillator (ICD) must be patient-centered and clinically appropriate. We engaged both patients and health care professionals in a multi-method approach in order to recommend structures and processes that facilitate informed and shared decision-making.
A systematic literature review (2000 to 2017) was performed focusing on the patient's perspective and the optimal organization of structures and processes for decision-making. A province-wide field evaluation based on medical chart review was carried out to provide ‘real world’ evidence in Québec's six ICD implanting centers (1 July to 31 December, 2016; N = 418). Patients and health care professionals reviewed the findings of the review and field evaluation, and deliberated recommendations in an anonymous manner by electronic mail. A joint meeting focused on proposed recommendations concerning shared decision-making.
The patients provided feedback on the literature review based on their ICD experience, and highlighted the need for better and more interactive decision aids, clinical information and time, and a private space for sensitive discussions. The field evaluation underlined the variability of treatment choices at the time of replacement and that more than one in ten patients had undergone ICD deactivation. Proposed recommendations focus on multi-disciplinary, integrated follow-up of patients and outline best practice for incorporating patient wishes and life objectives when discussing treatment options. The multi-round consultation process allowed both patients and professionals to co-construct recommendations with our evaluation team.
This multi-method approach enriched our interpretation of literature and ‘real world’ data and facilitated identification and prioritization of important themes. Partnership with both patients and clinicians added a new and energizing dynamic to our evaluation and recommendation processes. We acknowledge the contribution of the members of the patient committee and the clinical experts committee.
The deep subsurface of other planetary bodies is of special interest for robotic and human exploration. The subsurface provides access to planetary interior processes, thus yielding insights into planetary formation and evolution. On Mars, the subsurface might harbour the most habitable conditions. In the context of human exploration, the subsurface can provide refugia for habitation from extreme surface conditions. We describe the fifth Mine Analogue Research (MINAR 5) programme at 1 km depth in the Boulby Mine, UK in collaboration with Spaceward Bound NASA and the Kalam Centre, India, to test instruments and methods for the robotic and human exploration of deep environments on the Moon and Mars. The geological context in Permian evaporites provides an analogue to evaporitic materials on other planetary bodies such as Mars. A wide range of sample acquisition instruments (NASA drills, Small Planetary Impulse Tool (SPLIT) robotic hammer, universal sampling bags), analytical instruments (Raman spectroscopy, Close-Up Imager, Minion DNA sequencing technology, methane stable isotope analysis, biomolecule and metabolic life detection instruments) and environmental monitoring equipment (passive air particle sampler, particle detectors and environmental monitoring equipment) was deployed in an integrated campaign. Investigations included studying the geochemical signatures of chloride and sulphate evaporitic minerals, testing methods for life detection and planetary protection around human-tended operations, and investigations on the radiation environment of the deep subsurface. The MINAR analogue activity occurs in an active mine, showing how the development of space exploration technology can be used to contribute to addressing immediate Earth-based challenges. During the campaign, in collaboration with European Space Agency (ESA), MINAR was used for astronaut familiarization with future exploration tools and techniques. The campaign was used to develop primary and secondary school and primary to secondary transition curriculum materials on-site during the campaign which was focused on a classroom extra vehicular activity simulation.
Our cardiovascular evaluation unit is mandated to evaluate transcatheter aortic valve implantation (TAVI) in the province of Québec. In 2012, it was recommended that only patients at too high risk for surgery receive TAVI. In partnership with our six hospital TAVI programs, we have measured indicators of structure, process and outcomes since 2013. We are collaborating with multidisciplinary clinical experts to update recommendations for optimal use. Herein, we present the evolving portrait of TAVI in Québec and identify priority issues.
Clinical data were collected and analyzed for all TAVI performed from 1 April 2013 to 31 March 2016. Regular site feedback was provided. A systematic review of recent guidelines and randomized trials facilitated the interpretation of “real world” results and formulation of provincial quality standards.
Provincial TAVI volume increased from 294 in 2013–14 to 340 in 2014–15, and to 360 in 2015–16. Patient age and sex distribution remained relatively constant over time (median age 83 years; 47 percent female). However, the median predicted risk of operative mortality (STS score) decreased in the latest period [6 percent (Interquartile Range, IQR: 4–9) versus 7 percent (IQR: 4–9) versus 4 percent (IQR: 3–7)], suggesting TAVI is increasingly being performed in lower-risk patients. Clinical documentation and processes of care generally improved. Thirty-day mortality decreased (6.1 percent versus 4.1 percent versus 2.8 percent). The literature review identified two central issues: TAVI futility in patients who are too sick and apparent non-inferiority of TAVI compared with surgical valve replacement in medium-risk patients.
Our province-wide TAVI evaluation indicates improving processes and outcomes. Patient selection remains the key in our universal healthcare system, with the need to minimize futile and costly therapy and offer TAVI to those most likely to benefit. Continued monitoring of clinical practice and newly-established quality standards, in close collaboration with clinical teams, remains essential to promote optimal use of this evolving technology.
In the past decade numerous efforts have been made to enhance quality of care in the province of Québec for patients with ST-elevation myocardial infarction (STEMI). Despite two prior field evaluations and diffusion of a systematic review as well as recommendations, a third audit revealed persistent gaps in care, specifically excessive treatment delays. Our cardiovascular evaluation unit thus aimed to develop a more comprehensive quality improvement framework that further engaged healthcare professionals.
A literature update identified best practices and ways to reduce treatment delays and improve outcomes. This review, combined with the latest evaluation results, was used to establish structural and process quality standards adapted to the Québec context, via a consensus process with a panel of clinical experts. The standards identified quality-of-care targets and key elements of a governance structure to guide the improvement process. Quality indicators to monitor change were also developed. An implementation plan was then created, likewise based on literature and evaluation results.
For the first time, the unit publicly disseminated the results of the third evaluation according to region, in addition to standard individual hospital “report cards”. A summit conference was held during which the standards and indicators were presented to clinicians and other stakeholders, in collaboration with the health ministry and a panel of cardiovascular experts. Site visits are planned to facilitate change and establishment of local improvement plans and committees. A “tool kit” was developed containing a treatment algorithm, a drug protocol, five quality indicators each for processes and care networks, and measurement tools for indicators. A 75 percent minimal achievement target was set for treatment times.
A comprehensive framework aimed at improving quality of care for STEMI patients and monitoring change was created by combining evidence from the literature and “real world” data and mobilizing key stakeholders.
Recent results on low mass AGB stars are presented. Observed amounts of AGB mass loss imply that thermal pulses will only be encountered for stars of initial mass less than about 4M⊙ for Pop I and 3 M⊙ for Pop II. Mc – L, Me – τif, and Mc – Tb relations are summarized. Carbon dredge-up has been found in low mass stars of both Pop I and Pop II; the mixing length parameter α is crucial to dredge-up, and its value must be normalized according to each author's opacities and mixing length treatment (e.g., via the Sun's Te and L). The “carbon star mystery” is nearing a solution, but a new “s-process mystery” has appeared: only in a narrow range of mass and metallicity have theoretical models been found that encounter the semiconvective 13C s-process mechanism.
Early in this decade our theoretical work demonstrated that all AGB stars in the mass range ˜ 4 to ˜ 7 M⊙ pass through a stage when a tremendous amount of lithium [up to log ε(7Li) ˜ 4.5] is created and transported to the surface. These lithium-rich AGB stars are predicted to occupy a narrow luminosity range between Mbol = −6 and −7, in excellent agreement with the observations of Smith & Lambert (1989), and might be useful as approximate standard candles. Recently, we found that even low mass stars (˜ 1 to ˜ 2 M⊙) on the RGB could create a tremendous amount of surface lithium. In both the AGB and RGB cases, it is the Cameron-Fowler mechanism that is responsible for the lithium creation.
In the AGB stars, it is hot bottom burning (nuclear burning at the base of the convective envelope) that produces the lithium. In the RGB stars, it is “cool bottom processing” that can lead to either lithium production or destruction. Cool bottom processing results when extra mixing (presumably rotation-induced) transfers material from the cool convective envelope down to the outer wing of the hydrogen-burning shell (where nuclear reactions can take place) and back out to the envelope. If the extra mixing is slow, 7Li is destroyed; if it is fast enough, then 7Li is created - for sufficiently fast and deep extra mixing, log ε(7Li) ˜ 4 is possible.
Unlike 7Li, the 3He abundance is almost independent of the mixing speed, and is constrained by observations of 12C/13C or [C/Fe] on the RGB. Cool bottom processing causes low mass stars of sub-solar metallicity to be net destroyers of 3He, rather than net producers. This is in contrast to previous theoretical predictions, and has a far-reaching effect on our understanding of galactic chemical evolution of 3He.
The Commission formed a Sub-Commission on Zodiacal Light, presided over by Prof. Issei Yamamoto. The constitution of a sub-commission on the light of the night sky and kindred phenomena was proposed, but left in abeyance, pending the Stockholm Meeting. Dr Jean Dufay kindly consented to write, at the president’s request, a paper on the present state of the problem of the light of the night sky, which is printed with this Report.
The past few years have witnessed a great increase in the amount of work done on meteors and in the number of observers. At several observatories programmes of work have been undertaken in the hope of solving specific problems. Several countries now have flourishing meteor societies, or sections of larger astronomical societies, devoted to this field. To solve the problems that have arisen the help of other scientists, especially in physics, geology, and meteorology, has been enlisted to the mutual benefit of all. Historical research, particularly in Asia, has added much to our knowledge of meteor showers for the past thousand or more years.
A time-dependent “convective diffusion” algorithm for convective transport in the mixing-length framework has been coupled for the first time with a self-consistent full evolutionary computation, in order to investigate theoretically the creation of superrich lithium stars on the asymptotic giant branch. For intermediate mass stars in the mass range from 4 to 7 M⊙ with both Population I and II compositions, hot bottom burning in the convective envelope was found, with maximum temperatures Tce at the base of the convective envelope ranging from 20 to 100 million K, depending on stellar mass and mass loss rates. For Tce ≥ 40 million K, lithium-rich giants were produced (with log ε(7Li) ≳ 1, i.e., above the normal observed range in giants). For Tce ≥ 50 million K, superrich lithium giants were created, with log ε(7Li) ≳ 3 (i.e., larger than the present cosmic7Li abundance).
Computerized interpretation of the prehospital electrocardiogram (ECG) is increasingly being used in the basic life support (BLS) ambulance setting to reduce delays to treatment for patients suspected of ST segment elevation myocardial infarction (STEMI).
To estimate 1) predictive values of computerized prehospital 12-lead ECG interpretation for STEMI and 2) additional on-scene time for 12-lead ECG acquisition.
Over a 2-year period, 1,247 ECGs acquired by primary care paramedics for suspected STEMI were collected. ECGs were interpreted in real time by the GEMarquette 12SL ECG analysis program. Predictive values were estimated with a bayesian latent class model incorporating the computerized ECG interpretations, consensus ECG interpretations by study cardiologists, and hospital diagnosis. On-scene time was compared for ambulance-transported patients with (n 5 985) and without (n 5 5,056) prehospital ECGs who received prehospital aspirin and/or nitroglycerin.
The computer's positive and negative predictive values for STEMI were 74.0% (95% credible interval [CrI] 69.6–75.6) and 98.1% (95% CrI 97.8–98.4), respectively. The sensitivity and specificity were 69.2% (95% CrI 59.0–78.5) and 98.9% (95% CrI 98.1–99.4), respectively. Prehospital ECGs were associated with a mean increase in on-scene time of 5.9 minutes (95% confidence interval 5.5–6.3).
The predictive values of the computerized prehospital ECG interpretation appear to be adequate for diversion programs that direct patients with a positive result to hospitals with angioplasty facilities. The estimated 26.0% chance that a positive interpretation is false is likely too high for activation of a catheterization laboratory from the field. Acquiring prehospital ECGs does not substantially increase on-scene time in the BLS setting.
It could be argued that suffering is the sine qua non of all ethical subjects and of ethical subjectivity itself; the problem of suffering is the motivation of the ethical Subject and the subject matter to which all ethical concern must ultimately be referred. It is the provocation to which the Subject's becoming ethical is the response. Yet suffering is repugnant to the life of the Subject itself; suffering is precisely that from which life distances itself in order to live and to flourish. The relationship to suffering is thus profoundly ambiguous: in distancing itself from suffering, life remains fascinated by it; it provides the measure by which well-being comes to know itself as such and in terms of the absence of suffering and its distance from it. A relationship with suffering is thereby maintained across that distance opened up between the Subject and suffering, whilst suffering serves as a constant reminder to it of the fate that can befall it. That suffering persists and ‘demands’ alleviation across the distance between the suffering and the non-suffering Subject, suggests both a connection and a disjunction between the very existence of the Subject and the demand for alleviation from/of suffering to which it has already responded in its aversion to suffering.
There is never any pure censorship or pure lifting of censorship, which makes one doubt the rational purity of this concept.
CENSORSHIP AND THE PRESENT CONJUNCTURE
The year 2011 saw a unique centenary – the centenial disestablishment of the Swedish Board of Film Censorship (Statens Biografbyrå – hereafter SBB). The SBB was established around fifteen years after films had first begun to be screened in public in Sweden. Since the earliest film performances in the last years of the nineteenth century the police authorities had been responsible for the licensing of such screenings, and had granted or refused licences in the context of the prevailing popular concerns about detrimental effects of the new medium on audiences, and, as is the case today, in the context of film classification regimes, with a view to the supposed dangers film images posed to minors. In 1905 in a move which initiated the transition of control of film performances to the state, the Office of the Governor of Stockholm published a declaration that included the following:
Exhibitions of films shall not include any material that is offensive to public decency or disrespectful to the authorities or private individuals, nor pictures depicting the commission of murders, robberies or other serious crimes, and exhibitions that are open to children shall not include pictures depicting events or situations that are liable to arouse emotions of terror or horror in the audience or for other reasons be considered unsuitable for children to look at. Furthermore, pictures that are liable perversely to excite children's imagination or otherwise to have an adverse effect on their mental development or well-being shall not be passed for exhibition at performances to which children under the age of 15 are admitted.