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Introduction: The addition of computerized physician order entry (CPOE) to Emergency Departments in recent years has led to speculation over potential benefits and pitfalls. Recent studies have shown benefits to CPOE, though there lacks sufficient evidence on how it could change physician behaviour. Physician practices are known to be difficult to change, with getting evidence into daily practice being the main challenge of knowledge translation. Our study aims were to determine if well-designed electronic order sets for CPOE improved MD practices. Methods: The Calgary Zone Pain Management in the Emergency Department Working Group relied on a GRADE-based literature review for identifying best practices for analgesia and antiemetics, resulting in soft changes to the dedicated analgesia and antiemetic electronic order set noting working group preference, and emphasizing hydromorphone over morphine, as well as 4 mg ondansetron over 8 mg. The new electronic order set was started in the only Calgary Region order entry system on December 11th, 2014. Data was collected from July 2014 - May 2015. A Yates chi-squared analysis was completed on all orders in a category, as well as the subgroups of ED staff and residents, and orders placed using the new order set. Results: A total of 100460 orders were analyzed. The use of hydromorphone increased significantly across all 4 EDs. IV hydromorphone use increased (5.82% of all opioid orders up to 26.93%, P<0.0001) with a reciprocal decline in IV morphine (67.81% of all opioid orders down to 46.56%, P<0.0001). Similar effects were observed with ondansetron 4 mg IV orders increasing (1.37% of all ondansetron orders to 18.64%, P<0.0001) with a decrease in 8 mg dosing (15.75% of all ondansetron orders to 7.23%, P<0.0001). These results were replicated to a lesser degree in the non-ED staff and non-order set subgroups. Implementation of the new order set resulted in an increase of its use (37.64% of all opioid orders up to 49.29%, P<0.0001). Finally, a cost-savings analysis was completed showing a projected annual savings of $185,676.52 on medications alone. Conclusion: This data supports the manipulation of electronic order sets to help shape physician behaviour towards best practices. This provides another strong argument towards the benefits of CPOE, and can help maintain best practices in Emergency Medicine.
We examined the utility of a brief values inventory as a discussion aid to elicit patients' values and goals for end-of-life (EoL) care during audiotaped outpatient physician–patient encounters.
Participants were seriously ill male outpatients (n = 120) at a large urban Veterans Affairs medical center. We conducted a pilot randomized controlled trial, randomizing 60 patients to either the intervention (with the values inventory) or usual care. We used descriptive statistics and qualitative methods to analyze the data. We coded any EoL discussions and recorded the length of such discussions.
A total of 8 patients (13%) in the control group and 13 (23%) in the intervention group had EoL discussions with a physician (p = 0.77). All EoL discussions in the control group were initiated by the physician, compared with only five (38%) in the intervention group. Because most EoL discussions took place toward the end of the encounter, discussions were usually brief.
Significance of results:
The outpatient setting has been promoted as a better place for discussing EoL care than a hospital during an acute hospitalization for a chronic serious illness. However, the low effectiveness of our intervention calls into question the feasibility of discussing EoL care during a single outpatient visit. Allowing extra time or an extra visit for EoL discussions might increase the efficacy of advance care planning.
The first four sections of this note discuss loan plans and bonus funding generally, and some simple examples are shown. Section V and the appendix describe a more powerful method of solution using linear programming techniques, and the final section draws some practical conclusions.
No attempt has been made to describe the basic theories of linear programming. I am indebted for the slight knowledge of the subject I possess to the text-book mentioned in Section V; the object of this note is to demonstrate that linear programming methods can be applied in a somewhat unusual context to solve loan plan and bonus funding problems. Any errors in the technical content of this note are due to my misapplication of the text-book methods rather than to the methods themselves.
A survey of the Milky Way disk and the Magellanic System at the wavelengths of the 21-cm atomic hydrogen (H i) line and three 18-cm lines of the OH molecule will be carried out with the Australian Square Kilometre Array Pathfinder telescope. The survey will study the distribution of H i emission and absorption with unprecedented angular and velocity resolution, as well as molecular line thermal emission, absorption, and maser lines. The area to be covered includes the Galactic plane (|b| < 10°) at all declinations south of δ = +40°, spanning longitudes 167° through 360°to 79° at b = 0°, plus the entire area of the Magellanic Stream and Clouds, a total of 13 020 deg2. The brightness temperature sensitivity will be very good, typically σT≃ 1 K at resolution 30 arcsec and 1 km s−1. The survey has a wide spectrum of scientific goals, from studies of galaxy evolution to star formation, with particular contributions to understanding stellar wind kinematics, the thermal phases of the interstellar medium, the interaction between gas in the disk and halo, and the dynamical and thermal states of gas at various positions along the Magellanic Stream.
Under- and over-nutrition during gestation may influence fetal hypothalamic development resulting in individuals predisposed to adverse health effects. This study examined fetuses from obese and control ewes to determine whether dam obesity alters hypothalamic expression of fetal appetite regulatory genes. A second objective was to contrast the expression of appetite regulatory genes in ewes that become the most obese to those that remained in moderate body condition on the same energy-rich diet. Multiparous, western white-faced ewes were weighed and individually fed 100% (control) or 150% (obese) of National Research Council requirements from day 60 before mating until day 75 of gestation. At day 75 of gestation, fetuses were collected and weighed. Hypothalamic tissue from fetal lambs and dams was collected and frozen for mRNA extraction. Dam obesity (P ⩾ 0.16), fetal sex (P ⩾ 0.44) or their interaction (P ⩾ 0.42) did not affect the relative expression of fetal hypothalamic regulators of appetite, including neuropeptide Y, agouti-related protein, pro-opiomelanocortin, cocaine- and amphetamine-regulated transcript and receptors for leptin. Maternal obesity at day 75 of gestation in ewes did not affect developmental mechanisms responsible for the expression of fetal appetite regulatory genes and would not be expected to predispose offspring to adult-onset obesity through disrupted appetite regulation at this developmental time point. In the ewe, appetite regulatory genes did not differ (P > 0.20) with ewe adiposity; however, expression of estrogen receptor α, but not β (P = 0.37), in the medial basal hypothalamus was greater (P = 0.04) in obese than in control ewes.
Thin, polycrystalline silicon solar cells have the potential for the realization of a 15%, lowcost photovoltaic product. As a photovoltaic material, polycrystalline material is abundant, benign, and electrically stable. The thin-film polycrystalline silicon solar cell design achieves high efficiency by incorporating techniques to enhance optical absorption, ensure electrical confinement, and minimize bulk recombination currents. AstroPower's approach to a thin-film polycrystalline silicon solar cell technology is based on the Silicon-Film™ process, a continuous sheet manufacturing process for the growth of thin films of polycrystalline silicon on low-cost substrates. A new barrier layer and substrate have been developed for advanced solar cell designs. External gettering with phosphorus has been employed to effect significant improvements leading to effective minority carrier diffusion lengths greater than 250 micrometers in the active silicon layer. Light trapping has been observed in 60-micrometer thick films of silicon grown on the new barrier-coated substrate. An efficiency of 12.2% in a 0.659 cm2 solar cell has been achieved with the advanced structure.
Patients with schizophrenia (SZ) characteristically exhibit supranormal levels of cortical activity to self-induced sensory stimuli, ostensibly because of abnormalities in the neural signals (corollary discharges, CDs) normatively involved in suppressing the sensory consequences of self-generated actions. The nature of these abnormalities is unknown. This study investigated whether SZ patients experience CDs that are abnormally delayed in their arrival at the sensory cortex.
Twenty-one patients with SZ and 25 matched control participants underwent electroencephalography (EEG). Participants' level of cortical suppression was calculated as the amplitude of the N1 component evoked by a button press-elicited auditory stimulus, subtracted from the N1 amplitude evoked by the same stimulus presented passively. In the three experimental conditions, the auditory stimulus was delivered 0, 50 or 100 ms subsequent to the button-press. Fifteen SZ patients and 17 healthy controls (HCs) also underwent diffusion tensor imaging (DTI), and the fractional anisotropy (FA) of participants' arcuate fasciculus was used to predict their level of cortical suppression in the three conditions.
While the SZ patients exhibited subnormal N1 suppression to undelayed, self-generated auditory stimuli, these deficits were eliminated by imposing a 50-ms, but not a 100-ms, delay between the button-press and the evoked stimulus. Furthermore, the extent to which the 50-ms delay normalized a patient's level of N1 suppression was linearly related to the FA of their arcuate fasciculus.
These data suggest that SZ patients experience temporally delayed CDs to self-generated auditory stimuli, putatively because of structural damage to the white-matter (WM) fasciculus connecting the sites of discharge initiation and destination.
This timely meeting (appropriately held in Toruń, the “city of
Copernicus”) provided an excellent venue for researchers to review
the theoretical and observational progress in the intervening years,
share recent results, and make preparations for progress in
the quests to learn whether our Solar System is typical and to
understand how our own Solar System relates to the rest of the
Universe. It had been nearly six years since the last major
scientific meeting focusing soley on multiple planet systems and
planets in multiple star systems in Saas Fee, Switzerland during
September of 2002 (Udry et al. 2006). Here I review some of the
observational and theoretical progress in understanding multi-body
systems reported in Toruń.
We investigate biases in the measurement of exoplanet orbital
parameters – especially eccentricity – from radial velocity (RV)
observations. In this contribution we consider single-planet
systems. We create a mock catalog of RV data, choosing planet masses
and orbital periods, and observing patterns to mimic those of actual RV
surveys. Using Markov chain Monte Carlo (MCMC) simulations, we
generate a posterior sample for each mock data set, calculate best-fit
orbital parameters for each data set, and compare these to the true
values. We find that the precision of our derived eccentricities is
most closely related to the effective signal-to-noise ratio,
K√N/σ, where K is the velocity amplitude, σ is
the effective single-measurement precision, and N is the number of
observations. We also find that eccentricities of planets on nearly
circular (e<0.05) orbits are preferentially overestimated. While the
Butler et al. (2006) catalog reports e<0.05 for just 20% of its
planets, we estimate that the true fraction of e<0.05 orbits is
about 50%. We investigate the accuracy, precision, and bias of
alternative sets of summary statistics and find that the median values
of h = esinω and k = ecosω (where ω is the
longitude of periapse) of the posterior sample typically provide more
accurate, more precise, and less biased estimates of eccentricity than
We ask if Earth-like planets (terrestrial mass and habitable-zone orbit) can be detected in multi-planet systems, using astrometric and radial velocity observations. We report here the preliminary results of double-blind calculations designed to answer this question.
The planetary system of HD 69830 is uniquely constrained by observations of (i)
an infrared excess indicative of a debris disk with warm dust and (ii) radial
velocity variations indicative of three planets. This presents a valuable
opportunity to test planet formation models by integrating dynamical models of
planetary formation and migration with those for the sculpting of a
dust-producing planetesimal disk. We perform n-body
simulations and investigate the excitation of both planet and planetesimal
eccentricities, the accretion of planetesimals onto the planets, and the
clearing of a planetesimal disk by the planets as they grow in mass and migrate
through the disk. In simulations tuned to closely follow previous semi-analytic
models for the growth and migration of the planets, we find that the inner
planet accretes significantly more planetesimals than previously estimated. We
find that eccentricity excitation due to mutual planetary perturbations during
and after the migration do not naturally produce the observed eccentricities.
Our simulations suggest that this discrepancy may be reduced or possibly
reconciled if the planets are significantly more massive
than expected (possible if the planetary system's angular
momentum were nearly parallel to our line of sight). Even if the planets are
significantly more massive than previously assumed, we find that the migrating
planets are inefficient at clearing the outer planetesimal disk and that a
significant fraction of the planetesimal population beyond 1 AU remains bound on
moderately eccentric and inclined orbits. While much of the remaining
planetesimal belt would have eroded via a collisional cascade and radiation
pressure, we explore whether some of the highly excited planetesimals may be
able to persist over the age of the central star,
producing the dust observed in the HD 69830 system.
Direct imaging searches have begun to detect planetary
and brown dwarf companions and to place constraints
on the presence of giant planets at large separations
from their host star. This work helps to motivate
such planet searches by predicting a population of
young giant planets that could be detectable by
direct imaging campaigns. Both the
classical core accretion and the gravitational
instability model for planet formation are
hard-pressed to form such planets in
situ. Therefore, direct imaging searches have
traditionally appealed to the possibility of
in situ planet formation via a large
scale gravitational instability. Here, we show
that dynamical instabilities among
planetary systems that originally formed
multiple giant planets much closer to the
host star could produce a population of giant
planets at large separations. The number and
distribution of such planets is a strong
function of time, complicating the statistical
analysis of direct imaging surveys. The
number and radial distribution of such planets
is related to the number of giant planets
formed per host star and the timescale for the
disk evolution. Thus, direct imaging programs
with sufficient sensitivity and survey
size could place interesting constraints on
planet formation models.
The use of the methylene blue test for the examination of cows milk was investigated in an inter-laboratory survey. A poor relationship was found between results of these tests and total viable counts. Coliforms were detected in a large number of pasteurized milks, indicating frequent post-pasteurization contamination. No relationship was found between the results of the methylene blue test and the presence of coliforms.
Results from this survey highlight the need for reappraisal of the methylene blue test as a statutory method for the examination of milk. A total viable count and coliform test are suggested for providing information regarding dairy hygiene and the quality of the product at the point of retail sale.