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The experiments reported in this research paper aimed to investigate differences in the levels of chlorate (CHLO), perchlorate (PCHLO), trichloromethane (TCM) and iodine residues in bulk tank (BT) milk produced at different milk production periods, and to monitor those levels throughout a skim milk powder (SMP) production chain (BTs, collection tankers [CTs], whole milk silo [WMS] and skim milk silo [SMS]). Chlorate, PCHLO and iodine were measured in SMP, while TCM was measured in the milk cream. The CHLO, TCM and iodine levels in the mid-lactation milk stored in the WMS were lower than legislative and industrial specifications (0.0100 mg/kg, 0.0015 mg/kg and 150 µg/l, respectively). However, in late-lactation, these levels were numerically higher than the mid-lactation levels and specifications. Trichloromethane accumulated in the cream portion after separation. Perchlorate was not detected in any of the samples. Regarding iodine, the levels in mid-lactation reconstituted SMP were higher than that required by manufacturers (100 µg/l), indicating that the levels in milk should be lower than 142 µg/l. The higher residue levels observed in late-lactation could be related to the low milk volume produced during that period and changes in sanitation practices, while changes in feed management could have affected iodine levels. This study could assist in controlling and setting limits for CHLO, TCM and iodine levels in milk, ensuring premium quality dairy products.
The debate regarding euthanasia and physician-assisted suicide (E/PAS) raises key issues about the role of the doctor, and the professional, ethical, and clinical dimensions of the doctor-patient relationship. This review aimed to examine the published evidence regarding the response of doctors who have participated in E/PAS.
Original research papers were identified reporting either qualitative or qualitative data published in peer-reviewed literature between 1980 and March 2018, with a specific focus on the impact on, or response from, physicians to their participation in E/PAS. PRISMA and CASP guidelines were followed.
Nine relevant papers met selection criteria. Given the limited published data, a descriptive synthesis of quantitative and qualitative findings was performed. Quantitative surveys were limited in scope but identified a mixed set of responses. Where studies measured psychological impact, 30–50% of doctors described emotional burden or discomfort about participation, while findings also identified a comfort or satisfaction in believing the request of the patient was met. Significant, ongoing adverse personal impact was reported between 15% to 20%. A minority of doctors sought personal support, generally from family or friends, rather than colleagues. The themes identified from the qualitative studies were summarized as: 1) coping with a request; 2) understanding the patient; 3) the doctor's role and agency in the death of a patient; 4) the personal impact on the doctor; and 5) professional guidance and support.
Significance of results
Participation in E/PAS can have a significant emotional impact on participating clinicians. For some doctors, participation can contrast with perception of professional roles, responsibilities, and personal expectations. Despite the importance of this issue to medical practice, this is a largely neglected area of empirical research. The limited studies to date highlight the need to address the responses and impact on clinicians, and the support for clinicians as they navigate this challenging area.
The experiments reported in this research paper aimed to track the microbiological load of milk throughout a low-heat skim milk powder (SMP) manufacturing process, from farm bulk tanks to final powder, during mid- and late-lactation (spring and winter, respectively). In the milk powder processing plant studied, low-heat SMP was produced using only the milk supplied by the farms involved in this study. Samples of milk were collected from farm bulk tanks (mid-lactation: 67 farms; late-lactation: 150 farms), collection tankers (CTs), whole milk silo (WMS), skim milk silo (SMS), cream silo (CS) and final SMP. During mid-lactation, the raw milk produced on-farm and transported by the CTs had better microbiological quality than the late-lactation raw milk (e.g., total bacterial count (TBC): 3.60 ± 0.55 and 4.37 ± 0.62 log 10 cfu/ml, respectively). After pasteurisation, reductions in TBC, psychrotrophic (PBC) and proteolytic (PROT) bacterial counts were of lower magnitude in late-lactation than in mid-lactation milk, while thermoduric (LPC—laboratory pasteurisation count) and thermophilic (THERM) bacterial counts were not reduced in both periods. The microbiological quality of the SMP produced was better when using mid-lactation than late-lactation milk (e.g., TBC: 2.36 ± 0.09 and 3.55 ± 0.13 cfu/g, respectively), as mid-lactation raw milk had better quality than late-lactation milk. The bacterial counts of some CTs and of the WMS samples were higher than the upper confidence limit predicted using the bacterial counts measured in the farm milk samples, indicating that the transport conditions or cleaning protocols could have influenced the microbiological load. Therefore, during the different production seasons, appropriate cow management and hygiene practices (on-farm and within the factory) are necessary to control the numbers of different bacterial groups in milk, as those can influence the effectiveness of thermal treatments and consequently affect final product quality.
To compare risk of surgical site infection (SSI) following cesarean delivery between women covered by Medicaid and private health insurance.
Cesarean deliveries covered by Medicaid or private insurance and reported to the National Healthcare Safety Network (NHSN) and state inpatient discharge databases by hospitals in California (2011–2013).
Deliveries reported to NHSN and state inpatient discharge databases were linked to identify SSIs in the 30 days following cesarean delivery, primary payer, and patient and procedure characteristics. Additional hospital-level characteristics were obtained from public databases. Relative risk of SSI by primary payer primary payer was assessed using multivariable logistic regression adjusting for patient, procedure, and hospital characteristics, accounting for facility-level clustering.
Of 291,757 cesarean deliveries included, 48% were covered by Medicaid. SSIs were detected following 1,055 deliveries covered by Medicaid (0.75%) and 955 deliveries covered by private insurance (0.63%) (unadjusted odds ratio, 1.2; 95% confidence interval [CI], 1.1–1.3; P < .0001). The adjusted odds of SSI following cesarean deliveries covered by Medicaid was 1.4 (95% CI, 1.2–1.6; P < .0001) times the odds of those covered by private insurance.
In this, the largest and only multicenter study to investigate SSI risk following cesarean delivery by primary payer, Medicaid-insured women had a higher risk of infection than privately insured women. These findings suggest the need to evaluate and better characterize the quality of maternal healthcare for and needs of women covered by Medicaid to inform targeted infection prevention and policy.
Postmortem human brain studies provide the molecular, cellular, and circuitry levels of resolution essential for the development of mechanistically-novel interventions for cognitive deficits in schizophrenia. However, the absence of measures of premortem cognitive aptitude in postmortem subjects has presented a major challenge to interpreting the relationship between the severity of neural alterations and cognitive deficits within the same subjects.
To begin addressing this challenge, proxy measures of cognitive aptitude were evaluated in postmortem subjects (N = 507) meeting criteria for schizophrenia, major depressive or bipolar disorder, and unaffected comparison subjects. Specifically, highest levels of educational and occupational attainment of the decedent and their parents were obtained during postmortem psychological autopsies.
Consistent with prior findings in living subjects, subjects with schizophrenia had the lowest educational and occupational attainment relative to all other subject groups, and they also failed to show the generational improvement in attainment observed in all other subject groups.
Educational and occupational attainment data obtained during postmortem psychological autopsies can be used as proxy measures of premortem cognitive function to interrogate the neural substrate of cognitive dysfunction in schizophrenia.
Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.
To evaluate a 1-year programme to improve CRTs’ model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).
Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.
All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI −1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.
The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions.
Disability-related education is essential for disaster responders and critical care transporters to ensure positive patient outcomes. This pilot study evaluated the effect of an online educational intervention on disaster responders and critical care transporters’ knowledge of and feelings of self-efficacy about caring for individuals with developmental disabilities.
A 1-group, pretest-posttest, quasi-experimental design was used. A convenience sample of 33 disaster responders and critical care transporters participated.
Of the 33 participants, only 24% had received prior education on this topic, and 88% stated that such education would be beneficial to their care of patients. Nineteen participants completed both the pretest and posttest, and overall performance on knowledge items improved from 66% correct to 81% correct. Self-efficacy for caring for developmentally disabled individuals improved, with all 10 items showing a statistically significant improvement.
Online education is recommended to improve the knowledge and self-efficacy of disaster responders and critical care transporters who care for this vulnerable population after disasters and emergencies. (Disaster Med Public Health Preparedness. 2018;Page 1 of 5)
This study examined the effectiveness of a formal postdoctoral education program designed to teach skills in clinical and translational science, using scholar publication rates as a measure of research productivity.
Participants included 70 clinical fellows who were admitted to a master’s or certificate training program in clinical and translational science from 1999 to 2015 and 70 matched control peers. The primary outcomes were the number of publications 5 years post-fellowship matriculation and time to publishing 15 peer-reviewed manuscripts post-matriculation.
Clinical and translational science program graduates published significantly more peer-reviewed manuscripts at 5 years post-matriculation (median 8 vs 5, p=0.041) and had a faster time to publication of 15 peer-reviewed manuscripts (matched hazard ratio = 2.91, p=0.002). Additionally, program graduates’ publications yielded a significantly higher average H-index (11 vs. 7, p=0.013).
These findings support the effectiveness of formal training programs in clinical and translational science by increasing academic productivity.
Over the past half-century video games have become a significant part of our cultural environment, in part, by leading advances in both technology and artistic innovation. In recent years librarians and researchers have recognized these games as cultural objects that require collection and curation. Developing and maintaining collections of this fast moving and somewhat ephemeral media, however, poses challenges due to constantly advancing technology and a corresponding lack of consistent terminology. This article addresses the literature and critical issues surrounding collections of video games within libraries and presents a case study of the University of Michigan’s Computer and Video Game Archive (CVGA), one of the largest academic archives of its kind. Moreover, video games are situated in a humanistic approach to the field of game studies as the article draws on the relevance of methods from art history and film studies.
Bowel cancer risk is strongly influenced by lifestyle factors including diet and physical activity. Several studies have investigated the effects of adherence to the World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) cancer prevention recommendations on outcomes such as all-cause and cancer-specific mortality, but the relationships with molecular mechanisms that underlie the effects on bowel cancer risk are unknown. This study aimed to investigate the relationships between adherence to the WCRF/AICR cancer prevention recommendations and wingless/integrated (WNT)-pathway-related markers of bowel cancer risk, including the expression of WNT pathway genes and regulatory microRNA (miRNA), secreted frizzled-related protein 1 (SFRP1) methylation and colonic crypt proliferative state in colorectal mucosal biopsies. Dietary and lifestyle data from seventy-five healthy participants recruited as part of the DISC Study were used. A scoring system was devised including seven of the cancer prevention recommendations and smoking status. The effects of total adherence score and scores for individual recommendations on the measured outcomes were assessed using Spearman’s rank correlation analysis and unpaired t tests, respectively. Total adherence score correlated negatively with expression of Myc proto-oncogene (c-MYC) (P=0·039) and WNT11 (P=0·025), and high adherers had significantly reduced expression of cyclin D1 (CCND1) (P=0·042), WNT11 (P=0·012) and c-MYC (P=0·048). Expression of axis inhibition protein 2 (AXIN2), glycogen synthase kinase (GSK3β), catenin β1 (CTNNB1) and WNT11 and of the oncogenic miRNA miR-17 and colonic crypt kinetics correlated significantly with scores for individual recommendations, including body fatness, red meat intake, plant food intake and smoking status. The findings from this study provide evidence for positive effects of adherence to the WCRF/AICR cancer prevention recommendations on WNT-pathway-related markers of bowel cancer risk.
Ischemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied.
This study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED).
A retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers.
Barriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159).
Barriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ.
LiT, CushmanJT, ShahMN, KellyAG, RichDQ, JonesCMC. Barriers to Providing Prehospital Care to Ischemic Stroke Patients: Predictors and Impact on Care. Prehosp Disaster Med.2018;33(5):501–507.
In recent years, researchers have worked closely with parents, teachers, other school staff, and external stakeholders to increase knowledge on ways to effectively teach children and adolescents with disabilities in mainstream school settings. State, national, and global directives have encouraged the implementation of research-based practices and contributed to advocacy efforts for students with and without disabilities. In a longitudinal comparative case study, Grima-Farrell (2017) responded to these movements by striving to enhance teacher knowledge on how to effectively implement and sustain the use of validated teaching approaches to maximise the student engagement and success of all students. This paper specifically reports on the school-based efforts of 6 experienced teachers as they strive to implement research-based practices to respond to the diverse needs of their students. Results are presented using the research-to-practice model (Grima-Farrell, 2017) as a conceptual framework for guiding instructional decision-making through the implementation and sustained use of validated educational research approaches.
School leadership is critical to provide students with disabilities with opportunities to learn in inclusive schools. We summarise research about inclusive leadership, outlining factors that promoted and impeded inclusive schools in the United States. Next, we provide an example of a national collaboration between the Council of Chief State School Officers (CCSSO) and the Collaboration for Effective Educator Development, Accountability, and Reform (CEEDAR) Center that linked the Professional Standards for Educational Leaders (PSEL; National Policy Board for Educational Administration, 2015) to a supplemental guidance document, titled PSEL 2015 and Promoting Principal Leadership for the Success of Students With Disabilities. The latter illustrates what effective inclusive school leadership means for each of the 10 PSEL standards, and provides recommendations for improving leadership preparation and policy, including licensure. We also consider possible implications of this work for those in other countries, emphasising the need for widely understood and shared leadership practices and the need to link such practices to initial and ongoing leadership development.
The purpose of this research was to investigate leadership facilitating effective inclusive school practices. Data were collected from leaders at a complex multicultural school perceived by the system and local community as an inclusive school with a focus on quality education. A qualitative case study was used and data were collected over a 6-month period of immersion at the research site. Data included semistructured interviews with the head of special education and the school principal, observations of dialogical and behavioural data described within the lead researcher's reflective journal, and the documented operational structure of the school. The findings include insights into what the principal and head of special education believed inclusion to be, and how these leaders worked with staff to embed inclusive practices. The conclusion drawn from the study is that school leadership for inclusion involves making hard decisions. It is a complex and multifaceted act requiring consciously targeted effort, advocacy, and particular ways of leading. Inclusive practices need reinforcing by frequently articulated expectations, support, and acknowledgement that for all stakeholders inclusion is a constant journey toward a shared vision.