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Civil emergencies occurring with little warning can quickly produce mass casualties. To develop an Emergency Department’s surge capacity, medical student involvement in the disaster response has been advocated. Duke-NUS Medical School in Singapore is located in proximity to Singapore General Hospital (SGH) and represents an untapped manpower resource. With appropriate training, medical students can be leveraged upon as ready and reasonably qualified manpower.
This review provides a snapshot of the conceptualization and setting up of the Disaster Volunteer Corps (DVC) program. We discuss the overall strategy and benefits to stakeholders, emphasizing the close symbiotic relationship between academia and healthcare services.
Duke-NUS medical students will be recruited to receive training from SGH emergency physicians. The frequency of training will be four times yearly, with ad hoc participation in disaster simulation exercises. A call-tree will be employed for DVC activation. The DVC curriculum includes disaster response principles, HAZMAT, crowd control, marshaling, logistics, psychological support, and basic first aid. Teaching methods include didactic lectures, case discussions, involvement in event medical cover, and participation in disaster simulation exercises and response planning.
To date, there are 10 medical students and four emergency physician faculty volunteers involved in the program. Support is provided by adjunct instructors from nursing, nuclear medicine, social work, and security, for training in decontamination, radiological disasters, psychological first aid, and crowd control measures respectively. Assessment by faculty will be conducted to ensure the quality of training and competency of skills.
The DVC provides a unique way of teaching medical students disaster medicine principles in a hands-on experiential format, while simultaneously enhancing the operational readiness of the hospital in times of disaster. This model of close collaboration between university educational and healthcare services provides a feasible model of structured volunteerism that could be replicated in other similar settings.
Major depressive disorder (MDD) is a leading cause of disease burden worldwide, with lifetime prevalence in the United States of 17%. Here we present the results of the first prospective, large-scale, patient- and rater-blind, randomized controlled trial evaluating the clinical importance of achieving congruence between combinatorial pharmacogenomic (PGx) testing and medication selection for MDD.
1,167 outpatients diagnosed with MDD and an inadequate response to ≥1 psychotropic medications were enrolled and randomized 1:1 to a Treatment as Usual (TAU) arm or PGx-guided care arm. Combinatorial PGx testing categorized medications in three groups based on the level of gene-drug interactions: use as directed, use with caution, or use with increased caution and more frequent monitoring. Patient assessments were performed at weeks 0 (baseline), 4, 8, 12 and 24. Patients, site raters, and central raters were blinded in both arms until after week 8. In the guided-care arm, physicians had access to the combinatorial PGx test result to guide medication selection. Primary outcomes utilized the Hamilton Depression Rating Scale (HAM-D17) and included symptom improvement (percent change in HAM-D17 from baseline), response (50% decrease in HAM-D17 from baseline), and remission (HAM-D17<7) at the fully blinded week 8 time point. The durability of patient outcomes was assessed at week 24. Medications were considered congruent with PGx test results if they were in the ‘use as directed’ or ‘use with caution’ report categories while medications in the ‘use with increased caution and more frequent monitoring’ were considered incongruent. Patients who started on incongruent medications were analyzed separately according to whether they changed to congruent medications by week8.
At week 8, symptom improvement for individuals in the guided-care arm was not significantly different than TAU (27.2% versus 24.4%, p=0.11). However, individuals in the guided-care arm were more likely than those in TAU to achieve remission (15% versus 10%; p<0.01) and response (26% versus 20%; p=0.01). Remission rates, response rates, and symptom reductions continued to improve in the guided-treatment arm until the 24week time point. Congruent prescribing increased to 91% in the guided-care arm by week 8. Among patients who were taking one or more incongruent medication at baseline, those who changed to congruent medications by week 8 demonstrated significantly greater symptom improvement (p<0.01), response (p=0.04), and remission rates (p<0.01) compared to those who persisted on incongruent medications.
Combinatorial PGx testing improves short- and long-term response and remission rates for MDD compared to standard of care. In addition, prescribing congruency with PGx-guided medication recommendations is important for achieving symptom improvement, response, and remission for MDD patients.
Funding Acknowledgements: This study was supported by Assurex Health, Inc.
Polarization-dependent absorption spectra of two functionalized derivatives of fluorinated anthradithiophene, diF TES-ADT and diF TDMS-ADT, were studied in the crystal phase using a Holstein-like Hamiltonian. For both molecules, the primary contribution to the lowest energy absorption was found to be the S0-S1 excitonic transition perturbed by an intermolecular coupling of 15 meV for both TES and TDMS. A secondary contribution, consistent with that from charge-transfer states, was also found. Additionally, absorption spectra were analysed when crystals were placed inside of optical microcavities formed by two metal mirrors. Cavities exhibited a primary absorption peak determined to be an enhanced absorption from the lowest-energy S0-S1 transition.
Children with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.
Materials and methods
We sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.
A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.
The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.
Quality measures are increasingly reported by hospitals to the Centers for Medicare and Medicaid Services (CMS), yet there may be tradeoffs in performance between infection control (IC) and other quality measures. Hospitals that performed best on IC measures did not perform well on most CMS non–IC quality measures.
Integrated weed management (IWM) relies upon multiple chemical, physical, or biological weed management techniques to achieve an acceptable level of weed control. Agents that selectively suppress weeds but not crops and that can be manipulated in agriculture will be promising components for inclusion in IWM. We used a meta-analytic approach to investigate the potential of arbuscular mycorrhizal fungi (AMF) to contribute to IWM. We quantified the effect of crop and weed host status (strong and weak AMF hosts are divided in this study by a 10% root length colonization threshold), AMF diversity (single vs. mixed), and soil N and P fertility management on plant mycorrhizal growth responses (MGRs). Our results indicated that weak host weeds had consistently lower MGRs than strong host crops in both controlled and field conditions. Moreover, these differences in MGRs between weak host weeds and strong host crops were more pronounced under mixed AMF inoculum and low N and P nutrient availability. In contrast, MGR of strong host weeds was not different from strong host crops in general. However, we observed a wide range of MGRs among strong host weeds, some of which had much lower MGRs than strong host crops. In addition, in the presence of N and P fertilizers, strong host crops had a stronger positive response to AMF than strong host weeds. Thus, our meta-analysis indicates that AMF have potential to contribute to weed control by direct and indirect pathways: directly suppress weak host weeds, and indirectly suppress some strong host weeds mediating by competitive effects exerted by strong host crops. We suggest that management practices affecting AMF diversity and crop and weed mycorrhizal responses could be chosen to improve the contribution of AMF to IWM. Better understanding is needed of crop–weed–AMF interactions and management practices that enhance this form of weed management.
For wheeled mobile robots moving in rough terrains or uncertain environments, driving failure will be encountered when trafficability failure occurs. Continuous mobility of mobile robots with special ability for overcoming driving failure on rough terrain has rarely been considered. This study was conducted using a four-wheel-steering and four-wheel-driving mobile robot equipped with a binocular visual system. First, quasi-static force analysis is carried out to understand the effects of different driving-failure modes on the mobile robot while moving on rough terrain. Secondly, to make the best of the rest of the driving force, robot configuration transformation is employed to select the optimal configuration that can overcome the driving failure. Thirdly, sliding mode control based on back-stepping is adopted to enable the robot achieve continuous trajectory tracking with visual feedback. Finally, the efficacy of the presented approach is verified by simulations and experiments.
World-record solar-to-electricity energy conversion efficiency has been previously achieved by photovoltaic devices that maximize the use of the solar spectrum, such as multi-junction tandem solar cells. These cells are made of III-V materials whose high cost is a strong limitation on their widespread commercial application. One solution to suppress the cost of these types of devices is to grow III-V solar cells on low-cost carrier materials such as silicon. We will discuss the material, structure and analysis of GaAsP/SiGe-on-silicon multi-junction tandem solar cells. A low threading dislocation density is realized by effective lattice-matching of the top and bottom cells which demonstrate a device that achieves high open-circuit voltage in the top solar cell. The GaAsP/SiGe solar cells have reached a measured efficiency of 20.6% under one sun concentration. Analysis of these results based on the product of the best parameters shows efficiency potential of 26% under one sun, 30.8% at 20× and 35.1% at 400×.
Central-line–associated bloodstream infection (CLABSI) rate is an important quality measure, but it suffers from subjectivity and interrater variability, and decreasing national CLABSI rates may compromise its power to discriminate between hospitals. This study evaluates hospital-onset bacteremia (HOB, ie, any positive blood culture obtained 48 hours post admission) as a healthcare-associated infection–related outcome measure by assessing the association between HOB and CLABSI rates and comparing the power of each to discriminate quality among intensive care units (ICUs).
In this multicenter study, ICUs provided monthly CLABSI and HOB rates for 2012 and 2013. A Poisson regression model was used to assess the association between these 2 rates. We compared the power of each measure to discriminate between ICUs using standardized infection ratios (SIRs) with 95% confidence intervals (CIs). A measure was defined as having greater power to discriminate if more of the SIRs (with surrounding CIs) were different from 1.
In 80 ICUs from 16 hospitals in the United States and Canada, a total of 663 CLABSIs, 475,420 central line days, 11,280 HOBs, and 966,757 patient days were reported. An absolute change in HOB of 1 per 1,000 patient days was associated with a 2.5% change in CLABSI rate (P<.001). Among the 80 ICUs, 20 (25%) had a CLABSI SIR and 60 (75%) had an HOB SIR that was different from 1 (P<.001).
Change in HOB rate is strongly associated with change in CLABSI rate and has greater power to discriminate between ICU performances. Consideration should be given to using HOB to replace CLABSI as an outcome measure in infection prevention quality assessments.
Infect. Control Hosp. Epidemiol. 2016;37(2):143–148
Commission 8 has regularly published triennial reports in the past and the current OC therefore voted to adopt a traditional format also for this special Legacy issue of the IAU Transactions. The outgoing President is grateful for the support of many Commission members who contributed to this report. Our contribution consists of 3 parts: 1) this introduction, providing a general overview and highlights of recent research in astrometry, 2) a summary of the astrometry business & science meeting at the 2015 IAU General Assembly, and 3) the activity report of our Commisson covering the mid-2012 to mid-2015 period.
Background: A definitive diagnosis of multiple sclerosis (MS), as distinct from a clinically isolated syndrome, requires one of two conditions: a second clinical attack or particular magnetic resonance imaging (MRI) findings as defined by the McDonald criteria. MRI is also important after a diagnosis is made as a means of monitoring subclinical disease activity. While a standardized protocol for diagnostic and follow-up MRI has been developed by the Consortium of Multiple Sclerosis Centres, acceptance and implementation in Canada have been suboptimal. Methods: To improve diagnosis, monitoring, and management of a clinically isolated syndrome and MS, a Canadian expert panel created consensus recommendations about the appropriate application of the 2010 McDonald criteria in routine practice, strategies to improve adherence to the standardized Consortium of Multiple Sclerosis Centres MRI protocol, and methods for ensuring effective communication among health care practitioners, in particular referring physicians, neurologists, and radiologists. Results: This article presents eight consensus statements developed by the expert panel, along with the rationale underlying the recommendations and commentaries on how to prioritize resource use within the Canadian healthcare system. Conclusions: The expert panel calls on neurologists and radiologists in Canada to incorporate the McDonald criteria, the Consortium of Multiple Sclerosis Centres MRI protocol, and other guidance given in this consensus presentation into their practices. By improving communication and general awareness of best practices for MRI use in MS diagnosis and monitoring, we can improve patient care across Canada by providing timely diagnosis, informed management decisions, and better continuity of care.
No study systematically has investigated the supportive care needs of general head and neck cancer patients using validated measures. These needs include physical and daily living needs, health system and information needs, patient care and support needs, psychological needs, and sexuality needs. Identifying the unmet needs of head and neck cancer patients is a necessary first step to improving the care we provide to patients seen in our head and neck oncology clinics. It is recommended as the first step in intervention development in the Pan-Canadian Clinical Practice Guideline of the Canadian Partnership Against Cancer (see Howell, 2009). This study aimed to identify: (1) met and unmet supportive care needs of head and neck cancer patients, and (2) variability in needs according to demographics, disease variables, level of distress, and quality-of-life domains.
Participants were recruited from the otolaryngology–head and neck surgery clinics of two university teaching hospitals. Self-administered questionnaires included sociodemographic and medical questions, as well as validated measures such as the Supportive Care Needs Survey–Short Form (SCNS-SF34), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy–General (FACT-G) and Head and Neck Module (FACT-H&N) (quality of life measures).
One hundred and twenty-seven patients participated in the survey. 68% of them experienced unmet needs, and 25% revealed a clinically significant distress level on the HADS. The highest unmet needs were psychological (7 of top 10 needs). A multiple linear regression indicated a higher level of overall unmet needs when patients were divorced, had a high level of anxiety (HADS subscale), were in poor physical condition, or had a diminished emotional quality of life (FACT-G subscales).
Significance of results:
The results of this study highlight the overwhelming presence of unmet psychological needs in head and neck cancer patients and underline the importance of implementing interventions to address these areas perceived by patients as important. In line with hospital resource allocation and cost-effectiveness, one may also contemplate screening patients for high levels of anxiety, as well as target patients who are divorced and present low levels of physical well-being, as these patients may have more overall needs to be met.
The validity of the central line-associated bloodstream infection (CLABSI) measure is compromised by subjectivity. We observed significant decreases in both CLABSIs and total hospital-acquired bloodstream infections (BSIs) following a CLABSI prevention intervention in adult intensive care units. Total hospital-acquired BSIs could be explored as an adjunct, objective CLABSI measure.
We present the new characterization technique of multi-dimensional admittance measurements. In standard admittance measurements, a semiconductor device is probed in the transverse dimension, between flat plate contacts. We extend such measurements to distributed, possibly non-uniform solar cells where one of the two contacts has very small (point-like) dimensions. As a result, both the real and displacement currents spread into lateral directions while flowing between the electrodes. Correspondingly, the probing electric field may result in contact voltages that are laterally not equipotential. The spatial voltage distribution will depend on the probing DC bias and AC frequency. The resulting measurement will give information about the system’s lump parameters, such as open circuit voltage, sheet and shunt resistances, as well as the presence and location of shunts. Understanding of the measurement is developed through intuitive and analytic models. Numerical models, utilizing finite element circuits, are used to verify the analytic results, and also may be directly compared to or used to fit experimental data. While our focus is on introducing the physical theory, early experimental results demonstrating spatial scaling are shown.
An enduring question with regard to the voluntary sector is how it can nurture civic engagement and provide public goods. A World Heritage listing for Penang highlights this question by revealing a vibrant civil society network that has made heritage conservation an issue for public discourse and policy agenda. This paper discusses how the marginalized trajectory of Penang is related to the development of its civic realm, social cohesion and local identity, which are sources of Penang's voluntarism. It then examines the engagement pattern of the Penang Heritage Trust, a leading association, which has mounted resistance against the state's failure in heritage provision. This bottom-up approach has preserved Penang's cultural heritage and associated identity, and reveals the distinct nature and capacity of Penang's voluntary sector that goes against the general pattern in Malaysia.
In this paper, low-cost rectifier based on an organic diode for use in organic radio frequency identification (RFID) tags is proposed. Pentacene is the electroactive layer, with 7,7,8,8-tetracyanoquinodimethane (TCNQ) modified low-cost copper (Cu) and aluminum (Al) as the Ohmic and Schottky contacts, respectively. Hole injection barrier between Cu and pentacene can be decreased by forming the self-assembled layers of Cu-TCNQ. The diode shows a high rectification ratio of approximately 2×106 at 5V and the organic diode based rectifier circuit generated a dc output voltage of approximately 2V at 13.56MHz, using an input ac signal with zero-to-peak voltage amplitude of 5 V. The results indicate that chemical modification of the low-cost electrodes could be an efficient way toward low-cost high performance organic electronics devices.
Three techniques based on transmission electron microscope (TEM) have been successfully applied to measure strain/stress in the channel area of PMOS semiconductor devices with embedded SiGe in the source/drain areas: convergent beam electron diffraction (CBED), nano beam diffraction (NBD) and dark-filed holography (DFH). Consistent channel strain measurements from the three techniques on the same TEM sample (eSiGe PMOS with 17%Ge) were obtained. Reliable strain/stress measurement results in the channel area have been achieved with very good agreement with computer-aided design (TCAD) calculations.
Funding contingent upon evidence development (FED) has recently been the subject of some considerable debate in the literature but relatively little has been made of its economic impact. We argue that FED has the potential to shorten the lag between innovation and access but may also (i) crowd-out more valuable interventions in situations in which there is a fixed dedicated budget; or (ii) lead to a de facto increase in the funding threshold and increased expenditure growth in situations in which the programme budget is open-ended. Although FED would typically entail periodic review of provisional or interim listings, it may prove difficult to withdraw funding even at cost/QALY ratios well in excess of current listing thresholds. Further consideration of the design and implementation of FED processes is therefore required to ensure that its introduction yields net benefits over existing processes.
This paper reviews the status of hollow cathode sputtering as an evolving technology for production of thin-film transparent conducting oxides for PV applications. A large market segment for PV TCOs is represented by thin-film a-Si:H and tandem a-Si:H/nc-Si:H modules. For superstrate devices, textured SnO2:F produced on-line by APCVD is currently the market leader, although alternative off-line methods and materials are now emerging. In particular, zinc oxide can be produced by LPCVD, APCVD, magnetron sputtering, and hollow cathode sputtering (HCS). HCS is a stable process featuring low-cost metal targets and a soft deposition process. We discuss the deposition principles and the film results obtained using linear hollow cathodes 0.5 m and 1.0 m in length. We report the direct deposition of highly textured doped ZnO having an electron mobility in excess of 50 cm2/Vs. The production cost of textured ZnO is estimated for several competing techniques.