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The US Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) program sponsors the development of systematic reviews to inform clinical policy and practice. The EPC program sought to better understand how health systems identify and use this evidence.
Representatives from eleven EPCs, the EPC Scientific Resource Center, and AHRQ developed a semi-structured interview script to query a diverse group of nine Key Informants (KIs) involved in health system quality, safety and process improvement about how they identify and use evidence. Interviews were transcribed and qualitatively summarized into key themes.
All KIs reported that their organizations have either centralized quality, safety, and process improvement functions within their system, or they have partnerships with other organizations to conduct this work. There was variation in how evidence was identified, with larger health systems having medical librarians and central bureaus to gather and disseminate information and smaller systems having local chief medical officers or individual clinicians do this work. KIs generally prefer guidelines, especially those with treatment algorithms, because they are actionable. They like systematic reviews because they efficiently condense study results and reconcile conflicting data. They prefer information from systematic reviews to be presented as short digestible summaries with the full report available on demand. KIs preferred systematic reviews from reputable entities and those without commercial bias. Some of the challenges KIs reported include how to resolve conflicting evidence, the generalizability of evidence to local needs, determining whether the evidence is up-to-date, and the length of time required to generate reviews. The topics of greatest interest included predictive analytics, high-value care, advance care planning, and care coordination. To increase awareness of AHRQ EPC reviews, KIs suggest alerting people at multiple levels in a health-system when new evidence reports are available and making reports easier to find in common search engines.
Systematic reviews are valued by health system leaders. To be most useful they should be easy to locate and available in different formats targeted to the needs of different audiences.
To evaluate the effectiveness of a computerized clinical decision support intervention aimed at reducing inappropriate Clostridium difficile testing
Retrospective cohort study
University of Pennsylvania Health System, comprised of 3 large tertiary-care hospitals
All adult patients admitted over a 2-year period
Providers were required to use an order set integrated into a commercial electronic health record to order C. difficile toxin testing. The order set identified patients who had received laxatives within the previous 36 hours and displayed a message asking providers to consider stopping laxatives and reassessing in 24 hours prior to ordering C. difficile testing. Providers had the option to continue or discontinue laxatives and to proceed with or forgo testing. The primary endpoint was the change in inappropriate C. difficile testing, as measured by the number of patients who had C. difficile testing ordered while receiving laxatives.
Compared to the 1-year baseline period, the intervention resulted in a decrease in the proportion of inappropriate C. difficile testing (29.6% vs 27.3%; P=.02). The intervention was associated with an increase in the number of patients who had laxatives discontinued and did not undergo C. difficile testing (5.8% vs 46.4%; P<.01) and who had their laxatives discontinued and underwent testing (5.4% vs 35.2%; P<.01). We observed a nonsignificant increase in the proportion of patients with C. difficile related complications (5.0% vs 8.9%; P=.11).
A C. difficile order set was successful in decreasing inappropriate C. difficile testing and improving the timely discontinuation of laxatives.
In spring 2014, an interdisciplinary media project titled “Troubled Waters: Tracing Waste in the Delaware River” was organized at Haverford College. This project brought together more than 50 students from four courses comprising introductory political science, chemistry, and documentary film students, as well as a community media artist and community partners. The aim was to explore the causes, impacts, and meanings of different types of waste that are polluting the Delaware River. Chemistry students collected samples to determine the presence of chemicals from various waste products, political science students traced the waste to globalized production processes, and documentary students explored diverse ways of representing the theme of waste on screen. This article describes the project and how it might serve as a pedagogical model for multicourse interdisciplinary collaboration and community engagement.
Objectives: Decrements in cognitive function may already be evident in young children with type 1 diabetes (T1D). Here we report prospectively acquired cognitive results over 18 months in a large cohort of young children with and without T1D. Methods: A total of 144 children with T1D (mean HbA1c: 7.9%) and 70 age-matched healthy controls (mean age both groups 8.5 years; median diabetes duration 3.9 years; mean age of onset 4.1 years) underwent neuropsychological testing at baseline and after 18-months of follow-up. We hypothesized that group differences observed at baseline would be more pronounced after 18 months, particularly in those T1D patients with greatest exposure to glycemic extremes. Results: Cognitive domain scores did not differ between groups at the 18 month testing session and did not change differently between groups over the follow-up period. However, within the T1D group, a history of diabetic ketoacidosis (DKA) was correlated with lower Verbal IQ and greater hyperglycemia exposure (HbA1c area under the curve) was inversely correlated to executive functions test performance. In addition, those with a history of both types of exposure performed most poorly on measures of executive function. Conclusions: The subtle cognitive differences between T1D children and nondiabetic controls observed at baseline were not observed 18 months later. Within the T1D group, as at baseline, relationships between cognition (Verbal IQ and executive functions) and glycemic variables (chronic hyperglycemia and DKA history) were evident. Continued longitudinal study of this T1D cohort and their carefully matched healthy comparison group is planned. (JINS, 2016, 21, 293–302)
A kinetic model of the Boltzmann equation for non-vibrating polyatomic gases is proposed, based on the Rykov model for diatomic gases. We adopt two velocity distribution functions (VDFs) to describe the system state; inelastic collisions are the same as in the Rykov model, but elastic collisions are modelled by the Boltzmann collision operator (BCO) for monatomic gases, so that the overall kinetic model equation reduces to the Boltzmann equation for monatomic gases in the limit of no translational–rotational energy exchange. The free parameters in the model are determined by comparing the transport coefficients, obtained by a Chapman–Enskog expansion, to values from experiment and kinetic theory. The kinetic model equations are solved numerically using the fast spectral method for elastic collision operators and the discrete velocity method for inelastic ones. The numerical results for normal shock waves and planar Fourier/Couette flows are in good agreement with both conventional direct simulation Monte Carlo (DSMC) results and experimental data. Poiseuille and thermal creep flows of polyatomic gases between two parallel plates are also investigated. Finally, we find that the spectra of both spontaneous and coherent Rayleigh–Brillouin scattering (RBS) compare well with DSMC results, and the computational speed of our model is approximately 300 times faster. Compared to the Rykov model, our model greatly improves prediction accuracy, and reveals the significant influence of molecular models. For coherent RBS, we find that the Rykov model could overpredict the bulk viscosity by a factor of two.
The aim of this study was to assess cognitive functioning in children with type 1 diabetes (T1D) and examine whether glycemic history influences cognitive function. Neuropsychological evaluation of 216 children (healthy controls, n = 72; T1D, n = 144) ages 4–10 years across five DirecNet sites. Cognitive domains included IQ, Executive Functions, Learning and Memory, and Processing Speed. Behavioral, mood, parental IQ data, and T1D glycemic history since diagnosis were collected. The cohorts did not differ in age, gender or parent IQ. Median T1D duration was 2.5 years and average onset age was 4 years. After covarying age, gender, and parental IQ, the IQ and the Executive Functions domain scores trended lower (both p = .02, not statistically significant adjusting for multiple comparisons) with T1D relative to controls. Children with T1D were rated by parents as having more depressive and somatic symptoms (p < .001). Learning and memory (p = .46) and processing speed (p = .25) were similar. Trends in the data supported that the degree of hyperglycemia was associated with Executive Functions, and to a lesser extent, Child IQ and Learning and Memory. Differences in cognition are subtle in young children with T1D within 2 years of onset. Longitudinal evaluations will help determine whether these findings change or become more pronounced with time. (JINS, 2014, 20, 238–247)
To examine the use of vitamin D supplements during infancy among the participants in an international infant feeding trial.
Information about vitamin D supplementation was collected through a validated FFQ at the age of 2 weeks and monthly between the ages of 1 month and 6 months.
Infants (n 2159) with a biological family member affected by type 1 diabetes and with increased human leucocyte antigen-conferred susceptibility to type 1 diabetes from twelve European countries, the USA, Canada and Australia.
Daily use of vitamin D supplements was common during the first 6 months of life in Northern and Central Europe (>80 % of the infants), with somewhat lower rates observed in Southern Europe (>60 %). In Canada, vitamin D supplementation was more common among exclusively breast-fed than other infants (e.g. 71 % v. 44 % at 6 months of age). Less than 2 % of infants in the USA and Australia received any vitamin D supplementation. Higher gestational age, older maternal age and longer maternal education were study-wide associated with greater use of vitamin D supplements.
Most of the infants received vitamin D supplements during the first 6 months of life in the European countries, whereas in Canada only half and in the USA and Australia very few were given supplementation.
Cognitive therapy (CT) has considerable utility for psychosomatic medicine (PM) in acute medical settings but, to date, no such cohesive adaptation has been developed. Part I delineated a CT model for acute medical settings focusing on assessment and formulation. In Part II, we review how CT can be applied to common PM clinical challenges. A pragmatic approach is helpful because this review targets PM trainees and educators.
Narrative review is used to discuss the application of CT strategies to common challenges in acute medical settings. Treatment complexities and limitations associated with the PM setting are detailed. Exemplary dialogues are used to model techniques.
We present CT approaches to eight common scenarios: (1) distressed or hopeless patients; (2) patients expressing pivotal distorted cognitions/images; (3) patients who catastrophize; (4) patients who benefit from distraction and activation strategies; (5) panic and anxiety; (6) suicidal patients; (7) patients who are stuck and helpless; (8) inhibited patients. Limitations are discussed.
Significance of results:
A CT informed PM assessment, formulation and early intervention with specific techniques offers a novel integrative framework for psychotherapy with the acutely medically ill. Future efforts should focus on dissemination, education of fellows and building research efficacy data.
Although cognitive therapy (CT) has established outpatient utility, there is no integrative framework for using CT in acute medical settings where most psychosomatic medicine (P-M) clinicians practice. Biopsychosocial complexity challenges P-M clinicians who want to use CT as the a priori psychotherapeutic modality. For example, how should clinicians modify the data gathering and formulation process to support CT in acute settings?
Narrative review methodology is used to describe the framework for a CT informed interview, formulation, and assessment in acute medical settings. Because this review is aimed largely at P-M trainees and educators, exemplary dialogues model the approach (specific CT strategies for common P-M scenarios appear in the companion article.)
Structured data gathering needs to be tailored by focusing on cognitive processes informed by the cognitive hypothesis. Agenda setting, Socratic questioning, and adaptations to the mental state examination are necessary. Specific attention is paid to the CT formulation, Folkman's Cognitive Coping Model, self-report measures, data-driven evaluations, and collaboration (e.g., sharing the formulation with the patient.) Integrative CT-psychopharmacological approaches and the importance of empathy are emphasized.
Significance of results:
The value of implementing psychotherapy in parallel with data gathering because of time urgency is advocated, but this is a significant departure from usual outpatient approaches in which psychotherapy follows evaluation. This conceptual approach offers a novel integrative framework for using CT in acute medical settings, but future challenges include demonstrating clinical outcomes and training P-M clinicians so as to demonstrate fidelity.
Using behavioral and blood oxygen level dependent (BOLD) response indices through functional magnetic resonance imaging (fMRI), the current study investigated whether youths with disruptive behavior disorders (conduct disorder and oppositional defiant disorder) plus psychopathic traits (DBD + PT) show aberrant sensitivity to eye gaze information generally and/or whether they show particular insensitivity to eye gaze information in the context of fearful expressions. The participants were 36 children and adolescents (ages 10–17 years); 17 had DBD + PT and 19 were healthy comparison subjects. Participants performed a spatial attention paradigm where spatial attention was cued by eye gaze in faces displaying fearful, angry, or neutral affect. Eye gaze sensitivity was indexed both behaviorally and as BOLD response. There were no group differences in behavioral response: both groups showed significantly faster responses if the target was in the congruent spatial direction indicated by eye gaze. Neither group showed a Congruence × Emotion interaction; neither group showed an advantage from the displayer's emotional expression behaviorally. However, the BOLD response revealed a significant Group × Congruence × Emotion interaction. The comparison youth showed increased activity within the dorsal endogenous orienting network (superior parietal lobule and inferior parietal sulcus) for fearful congruent relative to incongruent trials relative to the youth with DBD + PT. The results are discussed with reference to current models of DBD + PT and possible treatment innovations.
Permselective separation of aromatic from non-aromatic hydrocarbons in feed streams can be accomplished by using membrane systems in hyperfiltration mode. In petrochemical or refinery operations, feed streams containing aromatics such as benzene, toluene, or xylenes can be selectively enriched or depleted in aromatics content. The development program for the STARMEM™ series of membranes led to a commercial process for their large-scale manufacture. A range of membranes in terms of flux and selectivity has been made, and both 2-inch and commercial scale 8-inch diameter spiral wound elements manufactured from these membranes. Tests at 800 psi (55 bar) and 50 °C with a toluene recycle stream have shown stable operation of these modules in hot hydrocarbons. The high efficiencies of these modules allow for high stage cuts (50% and greater) from process streams of thousands of barrels per day. By combining existing refinery operations such as distillation with these new membrane units, cost savings through better purity, recovery, or through-put can be achieved. With these membranes acting as tight hyperfiltration devices, the permeation properties can be modeled through a solution-diffusion equation for molecular transport. Since these membranes also act as solvent resistant nanofiltration devices, unusual benefits can be found while practicing aromatics enrichment of refinery streams, including fractionation of different molecular weight species.
The science of extra-solar planets is one of the most rapidly changing areas of astrophysics and since 1995 the number of planets known has increased by almost two orders of magnitude. A combination of ground-based surveys and dedicated space missions has resulted in 560-plus planets being detected, and over 1200 that await confirmation. NASA's Kepler mission has opened up the possibility of discovering Earth-like planets in the habitable zone around some of the 100,000 stars it is surveying during its 3 to 4-year lifetime. The new ESA's Gaia mission is expected to discover thousands of new planets around stars within 200 parsecs of the Sun. The key challenge now is moving on from discovery, important though that remains, to characterisation: what are these planets actually like, and why are they as they are?
In the past ten years, we have learned how to obtain the first spectra of exoplanets using transit transmission and emission spectroscopy. With the high stability of Spitzer, Hubble, and large ground-based telescopes the spectra of bright close-in massive planets can be obtained and species like water vapour, methane, carbon monoxide and dioxide have been detected. With transit science came the first tangible remote sensing of these planetary bodies and so one can start to extrapolate from what has been learnt from Solar System probes to what one might plan to learn about their faraway siblings. As we learn more about the atmospheres, surfaces and near-surfaces of these remote bodies, we will begin to build up a clearer picture of their construction, history and suitability for life.
The Exoplanet Characterisation Observatory, EChO, will be the first dedicated mission to investigate the physics and chemistry of Exoplanetary Atmospheres. By characterising spectroscopically more bodies in different environments we will take detailed planetology out of the Solar System and into the Galaxy as a whole.
EChO has now been selected by the European Space Agency to be assessed as one of four M3 mission candidates.
In order to determine the impact of garlic on total cholesterol (TC), TAG levels, as well as LDL and HDL, and establish if any variables have an impact on the magnitude of this effect, a meta-analysis was conducted. A systematic literature search of MEDLINE, CINAHL and the Cochrane Database from the earliest possible date through to November 2007 was conducted to identify randomised, placebo-controlled trials of garlic that reported effects on TC, TAG concentrations, LDL or HDL. The weighted mean difference of the change from baseline (with 95 % CI) was calculated as the difference between the means in the garlic groups and the control groups using a random-effects model. Subgroup and sensitivity analyses were performed to determine the effects on type, brand and duration of garlic therapy as well as baseline TC and TAG levels, the use of dietary modification, and study quality on the meta-analysis's conclusions. Twenty-nine trials were included in the analysis. Upon meta-analysis garlic was found to significantly reduce TC ( − 0·19; 95 % CI − 0·33, − 0·06 mmol/l) and TAG ( − 0·11; 95 % CI − 0·19, − 0·06 mmol/l) but exhibited no significant effect on LDL or HDL. There was a moderate degree of statistical heterogeneity for the TC and TAG analyses. Garlic reduces TC to a modest extent, an effect driven mostly by the modest reductions in TAG, without appreciable LDL lowering or HDL elevation. Higher baseline line TC levels and the use of dietary modification may alter the effect of garlic on these parameters. Future studies should be conducted evaluating the impact of adjunctive garlic therapy with fibrates or statins on TAG concentrations.
Daniel M. White, Institute of Northern Engineering, PO Box 755910, University of Alaska Fairbanks, Fairbanks AK 99775–5910, USA,
D. Sarah Garland, Dept. of Civil and Environmental Engineering, University of Alaska Fairbanks, PO Box 755900, Fairbanks AK 99775, USA,
Craig R. Woolard, Anchorage Water and Wastewater Utility, 3000 Arctic Boulevard, Anchorage AK 99503–3898, USA
In order to demonstrate the effectiveness of a bioremediation project, one must have an accurate measure of the contaminants, both at the start of the project and throughout the treatment process. The measurement of the contaminants throughout the process is important to demonstrate that the treatment is successful and to identify advances or set-backs quickly and effectively.
Proving the disappearance of hydrocarbons is important to the success of a bioremediation project. An accurate measurement of hydrocarbons and their biodegradation products is needed to confirm that petroleum was actually consumed by bacteria (discussed in Chapter 7, Section 7.3). One method of confirming biodegradation of petroleum is the coupled measurement of biodegradation rates by proxy methods and the disappearance of the contaminant. Biodegradation rates do not, in and of themselves, prove the decomposition of contaminants. Measurement of biodegradation rates, however, can be an easy way to demonstrate that the potential exists for contaminant removal. While measures of biodegradation rates are often used to estimate time to closure for a site, or proof of technology, biodegradation rates can be unreliable. Common measures of aerobic biodegradation are loss of contaminants, oxygen (O2) consumption, and carbon dioxide (CO2) evolution. Unfortunately, the CO2 can result from non-biological sources (see Chapter 7, Section 22.214.171.124 for additional discussion). Particularly in low pH groundwater, pH adjustment made during bioremediation could result in CO2 off-gassing from groundwater. Oxygen depletion in the subsurface is also not proof of biodegradation.