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Objectives: Essential tremor (ET) is a movement disorder characterized by action tremor which impacts motor execution. Given the disrupted cerebellar-thalamo-cortical networks in ET, we hypothesized that ET could interfere with the control mechanisms involved in regulating motor performance. The ability to inhibit or stop actions is critical for navigating many daily life situations such as driving or social interactions. The current study investigated the speed of action initiation and two forms of action control, response stopping and proactive slowing in ET. Methods: Thirty-three ET patients and 25 healthy controls (HCs) completed a choice reaction task and a stop-signal task, and measures of going speed, proactive slowing and stop latencies were assessed. Results: Going speed was significantly slower in ET patients (649 ms) compared to HCs (526 ms; F(1,56) = 42.37; p <.001; η2 = .43), whereas proactive slowing did not differ between groups. ET patients exhibited slower stop signal reaction times (320 ms) compared to HCs (258 ms, F(1,56) = 15.3; p <.00; η2 = .22) and more severe motor symptoms of ET were associated with longer stopping latencies in a subset of patients (Spearman rho = .48; p <.05). Conclusions: In line with previous studies, ET patients showed slower action initiation. Additionally, inhibitory control was impaired whereas proactive slowing remained intact relative to HCs. More severe motor symptoms of ET were associated with slower stopping speed, and may reflect more progressive changes to the cerebellar-thalamo-cortical network. Future imaging studies should specify which structural and functional changes in ET can explain changes in inhibitory action control. (JINS, 2019, 25, 156–164)
Introduction: The field of Clinical Informatics (CI) and specifically the electronic health record, has been identified as a key facilitator to achieve a sustainable evidence-based healthcare system for the future. International graduate medical education programs have been challenged to ensure their trainees are provided with appropriate skills to deliver effective and efficient healthcare in an evolving environment. This study explored how international Emergency Medicine (EM) specialist training standards address training in relevant areas of CI. Methods: A list of categories of CI competencies relative to EM was developed following a thematic review of published references documenting CI curriculum and competencies. Publically available, published documents outlining core content, curriculum and competencies from international organizations responsible for specialty graduate medical education and/or credentialing in EM for the United States, Canada, Australasia, the United Kingdom and Europe. These EM training standards were reviewed to identify inclusion of topics related to the relevant categories of CI competencies. Results: A total of 23 EM curriculum documents were included in the thematic analysis. Curricula content related to critical appraisal/evidence based medicine, leadership, quality improvement and privacy/security were included in all EM curricula. The CI topics related to fundamental computer skills, computerized provider order entry and patient-centered informatics were only included in the EM curricula documents for the United States and were absent for each other organization. Conclusion: There is variation in the CI related content of the international EM specialty training standards which were reviewed. Given the increasing importance of CI in the future delivery of healthcare, organizations responsible for training and credentialing specialist emergency physicians must ensure their training standards incorporate relevant CI content, thus ensuring their trainees gain competence in essential aspects of CI.
There is a growing body of literature describing the characteristics of patients who plan for the end of life, but little research has examined how caregivers influence patients' advance care planning (ACP). The purpose of this study was to examine how patient and caregiver characteristics are associated with advance directive (AD) completion among patients diagnosed with a terminal illness. We defined AD completion as having completed a living will and/or identified a healthcare power of attorney.
A convenience sample of 206 caregiver–patient dyads was included in the study. All patients were diagnosed with an advanced life-limiting illness. Trained research nurses administered surveys to collect information on patient and caregiver demographics (i.e., age, sex, race, education, marital status, and individual annual income) and patients' diagnoses and completion of AD. Multivariate logistic regression was employed to model predictors for patients' AD completion.
Over half of our patient sample (59%) completed an AD. Patients who were older, diagnosed with amyotrophic lateral sclerosis, and with a caregiver who was Caucasian or declined to report an income level were more likely to have an AD in place.
Significance of results:
Our results suggest that both patient and caregiver characteristics may influence patients' decisions to complete an AD at the end of life. When possible, caregivers should be included in advance care planning for patients who are terminally ill.
We have conducted 1.1 mm ALMA observations of a contiguous 105” × 50” or 1.5 arcmin2 window in the SXDF-UDS-CANDELS. We achieved a 5σ sensitivity of 0.28 mJy, giving a flat sensus of dusty star-forming galaxies with LIR ~6×1011L⊙ (if Tdust=40K) up to z ~ 10 thanks to the negative K-correction at this wavelength. We detected 5 brightest sources (S/N>6) and 18 low-significant sources (5>S/N>4; they may contain spurious detections, though). One of the 5 brightest ALMA sources (S1.1mm = 0.84 ± 0.09 mJy) is extremely faint in the WFC3 and VLT/HAWK-I images, demonstrating that a contiguous ALMA imaging survey uncovers a faint dust-obscured population invisible in the deep optical/near-infrared surveys. We find a possible [CII]-line emitter at z=5.955 or a low-z CO emitting galaxy within the field, allowing us to constrain the [CII] and/or CO luminosity functions across the history of the universe.
The North Carolina Wetland Assessment Method (NC WAM) was developed from 2003 to 2007 by a team of federal and state agencies to rapidly assess the level of wetland function. NC WAM is a field method which is science-based, reproducible, rapid, and observational in nature used to determine the level of wetland function relative to reference for each of 16 North Carolina general wetland types. Three major functions (Hydrology, Water Quality, and Habitat) were recognized along with 10 sub-functions. Sub-functions and functions are evaluated using 22 field metrics on a field assessment form. Data are entered into a computer program to generate High, Medium, and Low ratings for each sub-function, function, and the overall assessment area based on an iterative Boolean logic process using 71 unique combinations. The method was field tested across the state at more than 280 sites of varying wetland quality. Examples are presented for the use of NC WAM for compensatory mitigation notably to calculate functional uplift from wetland enhancement. Calibration and verification analyses to date show that the results of the method are significantly correlated with long-term wetland monitoring data and NC WAM has been verified for one wetland type (headwater forest) using these data.
Films of GaN have been grown using a modified MBE method in which the active nitrogen is supplied from an RF activated plasma source. Wurtzite films grown on (0 0 1) oriented GaAs substrates show highly defective, ordered polycrystalline growth with a columnar structure; the (0 0 0 1) planes of the layers being parallel to the (0 0 1) planes of the GaAs substrate. Films grown using a coincident As flux, however, have a single crystal zinc-blende growth mode. They have better structural and optical properties. To improve the properties of the wurtzite films we have studied the growth of such films on (1 1 1)A and (1 1 1)B oriented GaAs substrates. The improved structural properties of such films, assessed using x-ray and TEM methods, correlate with better low temperature PL performance.
Transcranial magnetic stimulation (TMS) is an effective and safe therapy for major depressive disorder (MDD). This study assessed quality of life (QOL) and functional status outcomes for depressed patients after an acute course of TMS.
Forty-two, U.S.-based, clinical TMS practice sites treated 307 outpatients with a primary diagnosis of MDD and persistent symptoms despite prior adequate antidepressant pharmacotherapy. Treatment parameters were based on individual clinical considerations and followed the labeled procedures for use of the approved TMS device. Patient self-reported QOL outcomes included change in the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the EuroQol 5-Dimensions (EQ-5D) ratings from baseline to end of the acute treatment phase.
Statistically significant improvement in functional status on a broad range of mental health and physical health domains was observed on the SF-36 following acute TMS treatment. Similarly, statistically significant improvement in patient-reported QOL was observed on all domains of the EQ-5D and on the General Health Perception and Health Index scores. Improvement on these measures was observed across the entire range of baseline depression symptom severity.
These data confirm that TMS is effective in the acute treatment of MDD in routine clinical practice settings. This symptom benefit is accompanied by statistically and clinically meaningful improvements in patient-reported QOL and functional status outcomes.
TiAlTiAu and TiAlPdAu contacts to GaN/AlGaN, rapid thermal annealed at temperatures ranging from 650°C to 950°C, have been investigated using conventional and chemical TEM analysis. Ohmic behaviour was seen for TiAlTiAu contacts annealed at 750°C or higher, but was not observed in TiAlPdAu contacts annealed at up to 950°C. The effect of annealing temperature on the structural evolution of the contact is explained in terms of different extents of interfacial reaction. In particular, the formation of TiN after anneals at high temperatures is required to activate the contact. At anneals of 950°C, TiAlTiAu samples show a structure of TiN grains within an interfacial band, with TiN inclusions into the AlGaN preceded by an Al-Au diffusion front. Inclusion formation and the effect on the contact electrical performance is described.
AuTiAlTi, AuPdAlTi and AuAlTi ohmic contacts to AlGaN/GaN layers rapid thermal annealed at temperatures up to 950°C have been characterised using conventional and chemical transmission electron microscopy techniques. The relationship between the as-deposited metallic structure, annealing temperature, post-anneal interfacial microstructure and contact resistance is examined.
The presence of a TiN interfacial layer is found to correlate with the onset of ohmic behaviour. Ti and Pd barrier layers are found to be ineffective at stopping the diffusion of Au to the interface. Au is implicated in the development of the inclusions, which are associated with threading dislocations. Once activated, the presence of the inclusions has little influence on the ohmic behaviour of the sample.
Several studies have reported high levels of distress in family members who have made health care decisions for loved ones at the end of life. A method is needed to assess the readiness of family members to take on this important role. Therefore, the purpose of this study was to develop and validate a scale to measure family member confidence in making decisions with (conscious patient scenario) and for (unconscious patient scenario) a terminally ill loved one.
On the basis of a survey of family members of patients with amyotrophic lateral sclerosis (ALS) enriched by in-depth interviews guided by Self-Efficacy Theory, we developed six themes within family decision making self-efficacy. We then created items reflecting these themes that were refined by a panel of end-of-life research experts. With 30 family members of patients in an outpatient ALS and a pancreatic cancer clinic, we tested the tool for internal consistency using Cronbach's alpha and for consistency from one administration to another using the test–retest reliability assessment in a subset of 10 family members. Items with item to total scale score correlations of less than .40 were eliminated.
A 26-item scale with two 13-item scenarios resulted, measuring family self-efficacy in decision making for a conscious or unconscious patient with a Cronbach's alphas of .91 and .95, respectively. Test–retest reliability was r = .96, p = .002 in the conscious senario and r = .92, p = .009 in the unconscious scenario.
Significance of results:
The Family Decision-Making Self-Efficacy Scale is valid, reliable, and easily completed in the clinic setting. It may be used in research and clinical care to assess the confidence of family members in their ability to make decisions with or for a terminally ill loved one.
To investigate the marked increase noted over an 8-month period in the number of Legionella pneumophila isolates recovered from bronchoalveolar lavage fluid specimens obtained during bronchoscopy in our healthcare system.
Bronchoscopy suite that serves a 580-bed tertiary care center and a large, multisite, faculty practice plan with approximately 2 million outpatient visits per year.
Cultures of environmental specimens from the bronchoscopy suite were performed, including samples from the air and water filters, bronchoscopes, and the ice machine, with the aim of identifying Legionella species. Specimens were filtered and acid-treated and then inoculated on buffered charcoal yeast extract agar. Serogrouping was performed on all isolates recovered from patient and environmental samples.
AU L. pneumophila isolates recovered from patients were serogroup 8, a serogroup that is not usually recovered in our facility. An epidemiologic investigation of the bronchoscopy suite revealed the ice machine to be contaminated with L. pneumophila serogroup 8. Patients were exposed to the organism as a result of a recently adopted practice in the bronchoscopy suite that involved directly immersing uncapped syringes of sterile saline in contaminated ice baths during the procedures. At least 1 patient was ill as a result of the pseudo-outbreak. Molecular typing of isolates recovered from patient and environmental samples revealed that the isolates were indistinguishable.
Extensive cleaning of the ice machine and replacement of the machine's water filter ended the pseudo-outbreak. This episode emphasizes the importance of using aseptic technique when performing invasive procedures, such as bronchoscopies. It also demonstrates the importance of reviewing procedures in all patient areas to ensure compliance with facility policies for providing a safe patient environment.
We report our recent progress on extragalactic spectroscopic and continuum observations,
including HCN(J=1–0), HCO+(J=1–0), and CN(N=1–0) imaging surveys
of local Seyfert and starburst galaxies
using the Nobeyama Millimeter Array,
high-J CO observations (J=3–2 observations
using the Atacama Submillimeter Telescope Experiment (ASTE)
and J=2–1 observations with the Submillimeter Array) of galaxies,
and λ 1.1 mm continuum observations of high-z violent starburst galaxies
using the bolometer camera AzTEC mounted on ASTE.
Persons with ALS differ from those with other terminal illnesses in that they commonly retain capacity for decision making close to death. The role patients would opt to have their families play in decision making at the end of life may therefore be unique. This study compared the preferences of patients with ALS for involving family in health care decisions at the end of life with the actual involvement reported by the family after death.
A descriptive correlational design with 16 patient–family member dyads was used. Quantitative findings were enriched with in-depth interviews of a subset of five family members following the patient's death.
Eighty-seven percent of patients had issued an advance directive. Patients who would opt to make health care decisions independently (i.e., according to the patient's preferences alone) were most likely to have their families report that decisions were made in the style that the patient preferred. Those who preferred shared decision making with family or decision making that relied upon the family were more likely to have their families report that decisions were made in a style that was more independent than preferred. When interviewed in depth, some family members described shared decision making although they had reported on the survey that the patient made independent decisions.
Significance of results:
The structure of advance directives may suggest to families that independent decision making is the ideal, causing them to avoid or underreport shared decision making. Fear of family recriminations may also cause family members to avoid or underreport shared decision making. Findings from this study might be used to guide clinicians in their discussions of treatments and health care decision making with persons with ALS and their families.