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Documentation of code status and advance directives for end-of-life (EOL) care improves care and quality of life, decreases cost of care, and increases the likelihood of an experience desired by the patient and his/her family. However, the use of advance directives and code status remains low and only a few organizations maintain code status in electronic form. Members of the American Medical Informatics Association’s Ethics Committee identified a need for a patient’s EOL care wishes to be documented correctly and communicated easily through the electronic health record (EHR) using a minimum data set for the storage and exchange of code status information. After conducting an environmental scan that produced multiple resources, Ethics Committee members used multiple conference calls and a shared document to arrive at consensus on the proposed minimum data set. Ethics Committee members developed a minimum required data set with links to the HL7 C_CDA Advance Directives Module. Data categories include information on the organization obtaining the code status information, the patient, any supporting documentation, and finally the desired code status information including mandatory, optional, and conditional elements. The “minimum set of attributes” to exchange advance directive / code status data described in this manuscript enables communication of patient wishes across multiple providers and health care settings. The data elements described serve as a starting point for a dialog among informatics professionals, physicians experienced in EOL care, and EHR vendors, with the goal of developing standards for incorporating this functionality into the EHR systems.
Movement disorders associated with exposure to antipsychotic drugs are common and stigmatising but underdiagnosed.
To develop and evaluate a new clinical procedure, the ScanMove instrument, for the screening of antipsychotic-associated movement disorders for use by mental health nurses.
Item selection and content validity assessment for the ScanMove instrument were conducted by a panel of neurologists, psychiatrists and a mental health nurse, who operationalised a 31-item screening procedure. Interrater reliability was measured on ratings for 30 patients with psychosis from ten mental health nurses evaluating video recordings of the procedure. Criterion and concurrent validity were tested comparing the ScanMove instrument-based rating of 13 mental health nurses for 635 community patients from mental health services with diagnostic judgement of a movement disorder neurologist based on the ScanMove instrument and a reference procedure comprising a selection of commonly used rating scales.
Interreliability analysis showed no systematic difference between raters in their prediction of any antipsychotic-associated movement disorders category. On criterion validity testing, the ScanMove instrument showed good sensitivity for parkinsonism (90%) and hyperkinesia (89%), but not for akathisia (38%), whereas specificity was low for parkinsonism and hyperkinesia, and moderate for akathisia.
The ScanMove instrument demonstrated good feasibility and interrater reliability, and acceptable sensitivity as a mental health nurse-administered screening tool for parkinsonism and hyperkinesia.
To quantitatively test the hypothesis that older patients have increased thyroarytenoid muscle atrophy by comparing thyroarytenoid muscle volumes across different age groups.
A retrospective chart review was conducted. The study included 111 patients with no history of laryngeal pathology. Two investigators reviewed magnetic resonance imaging studies of these patients and manually traced the thyroarytenoid muscles on multiple slices bilaterally. Thyroarytenoid muscle volumes were then computed using imaging analysis software. Patients were stratified into three age groups (18–50 years, 51–64 years, and 65 years or older) for comparison.
Intra- and inter-rater reliabilities were excellent for all measurements (intraclass correlation co-efficient > 0.90). There was no statistically significant difference in the mean volumes of left and right thyroarytenoid muscles in all age and gender groups.
Given the lack of statistically significant difference in thyroarytenoid muscle volume between age groups on magnetic resonance imaging, the prevailing assumption that age-related thyroarytenoid muscle atrophy contributes to presbyphonia should be re-examined.
The hedging practices survey took place towards the end of 2015 in the final few months prior to Solvency II regulations coming into force. At the point of completing the survey we would expect that companies would have largely transitioned their hedging approaches to work in a Solvency II environment. There may be some cases where further changes were planned but not implemented at the point of completing the survey. Further, as familiarity with working under the new regulations increases, approaches are expected to continue to develop over time. The working party hopes that this report is useful in summarising industry attitudes at this point in time and as a comparator in future years. Before launching the survey we did have several conjectures of what we may expect to see in the results. Some proved true, for some it was difficult to glean any strong conclusion from the data, and there were one or two where results countered what we expected to see.
Background: ETV/CPC has become an increasingly common technique for the treatment of infant hydrocephalus. Both flexible and rigid neuroendoscopy can be used, with little empirical evidence directly comparing the two. We, therefore, used a propensity-matched cohort and survival analysis to assess the comparative efficacy of flexible and rigid neuroendoscopy. Methods: Individual data were collected through retrospective review of infants < 2 years of age, treated at one of 2 hospitals: 1) Boston Children’s Hospital, exclusively utilizing flexible neuroendoscopy, and 2) Nicklaus Children’s Hospital, exclusively utilizing rigid neuroendoscopy. Patient characteristics and post-operative outcome were assessed. A propensity score (PS) model was developed to balance patient characteristics in the case mix. Results: A PS model was developed with 5 independent variables: chronological age, sex, hydrocephalus etiology, prior CSF diversion, and prepontine scarring. PS analysis revealed that compared to flexible neuroendoscopy, rigid neuroendoscopy had an ETV/CPC failure OR of 1.43 and 1.31 respectively, compared to unadjusted OR of 2.40. Furthermore, in a Cox regression analysis controlled by propensity score, rigid neuroendoscopy had a HR of 1.10, compared to unadjusted HR of 1.61. Conclusions: Much of the difference in ETV/CPC outcome between endoscopy types is attributed to the case mix. An observational study or randomized controlled trial is required to provide evidence-based guidelines.
We apply gravitational lensing statistics to: (1) place a limit on the cosmological constant (ΩΛ); (2) place a limit on the average red-shift (< z >) of gamma-ray bursters (GRBs); (3) investigate models of galaxy evolution to see how compatible these models are with lensing statistics. We also point out the sources of uncertainty in lensing statistics, leading to uncertainty in the results.
The SAS 2 and COS B observations have established the existence of diffuse γ-rays in our Galaxy in various energy ranges. The diffuse radiation is attributed to the interaction of cosmic ray nuclei and electrons with the particles of interstellar atomic and molecular gas (via the decay of pions and bremsstrahlung, respectively). Inverse Compton scattering of interstellar photons by the high energy electrons of cosmic rays may also be contributing to this background. In addition some contribution may come from discrete sources of γ-rays.
Introduction: Despite strong evidence that antithrombotic drugs in atrial fibrillation/flutter (AF) patients reduce stroke risk, previous emergency department (ED) pre-novel anticoagulant (NOAC) studies have shown that most discharged patients are not optimally treated. This study sought to determine baseline antithrombotic management in AF patients, and appropriate antithrombotic prescription upon ED discharge since the introduction of NOACs. Methods: Consecutive AF patients discharged by the ED physician from three academic EDs in Toronto, Canada were retrospectively identified using ECG data. Primary AF was defined as AF in patients ≥18 years without congenital heart disease or other acute medical conditions. All management and disposition decisions were left to the discretion of the emergency doctor. Results: From July 2012 to October 2014, 691 patients with primary AF were identified. Of these, 34.4% (n=238) had new onset AF and 66.4% (n=459) were discharged home directly from the ED. Of those with previously known AF (n= 453), 44.2% (n=200) were on anticoagulation at ED arrival (warfarin 59.5%, dabigatran 23.0%, rivaroxaban 11.5%); 25.6% (n=116) on antiplatelets, and 29 (6.4%) on both. Based on 2012 Canadian AF guidelines, 60.1% of those who should have received anticoagulation were receiving it. In discharged patients meeting de novo criteria for anticoagulation (n=130), 20.0% (n=26) were started on anticoagulation and 23.1% (n=30) on antiplatelets. In patients with CHADS2 score ≥ 2 (n=61), 26.2% (n=16) were started on anticoagulation. Warfarin (73.1%) was most commonly prescribed followed by dabigatran (15.4%) and rivaroxaban (11.5%). Age was the only inverse independent predictor for appropriate anticoagulation (OR 0.92 per 5 year of age 95% CI 0.89-0.95, p <0.0001) i.e. older patients were less likely to be anticoagulated. The CHADS2 score was not an independent predictor of appropriate anticoagulation. Conclusion: Our study shows a persistent gap in the antithrombotic treatment of ED AF patients irrespective of their risk.
Soybean is a leading oilseed crop in India, which contains about 40% of protein and 20% of oil. Core collection will accelerate the management and utilization of soybean genetic resources in breeding programmes. In the present study, eight agromorphological traits of 3443 soybean germplasm were analysed for the development of core collection using the principal component score (PCS) strategy and the power core method. The PCS strategy yielded core collection (CC1) of 576 accessions, which accounted for 16.72% of the entire collection (EC). The analysis based on the power core programme resulted in CC2 of 402 accessions, which accounted for 11.67% of the EC. Statistical analysis showed similar trends for the mean and range estimated in both core collections and EC. In addition, the variance, standard deviation and coefficient of variance were in general higher in core collections than in the EC. The correlations observed in the EC in general were preserved in core collections. A total of 311 and 137 unique accessions were found in CC1 and CC2 in addition to 265 accessions that were found to be common in both core collections. These 265 common accessions were the most diverse core sets, which accounted for 7.64% of the EC. We proposed to constitute an integrated core collection (ICC) by integrating both common and unique accessions. The ICC comprised 713 accessions, which accounted for about 20.62% of the EC. Statistical analysis indicated that the ICC captured maximum variation than CC1 and CC2. Therefore, the ICC can be extensively evaluated for a large number of economically important traits for the identification of desirable genotypes and for the development of mini core collection in soybean.
Given the discrepancy between men and women’s equal rates of medical school matriculation and their rates of academic promotion and leadership role acquisition, the need to provide mentorship and education to women in academic medicine is becoming increasingly recognized. Numerous large-scale programs have been developed to provide support and resources for women’s enrichment and retention in academic medicine. Analyses of contributory factors to the aforementioned discrepancy commonly cite insufficient mentoring and role modeling as well as challenges with organizational navigation. Since residency training has been shown to be a critical juncture for making the decision to pursue an academic career, there is a need for innovative and tailored educational and mentorship programs targeting residents. Acknowledging residents’ competing demands, we designed a program to provide easily accessible mentorship and contact with role models for our trainees at the departmental and institutional levels. We believe that this is an important step towards encouraging women’s pursuit of academic careers. Our model may be useful to other emergency medicine residencies looking to provide such opportunities for their women residents.
A field experiment was carried out at the farm of Indian Agricultural Research Institute, New Delhi to quantify the effect of elevated carbon dioxide (CO2) and different levels of N fertiliser application on nitrous oxide (N2O) and carbon dioxide (CO2) emissions from soil under maize. The experiment included five treatments: 60 kg N ha−1 under ambient CO2 (385 ppm) in open plots, 120 kg N ha−1 under ambient CO2 (385 ppm) in open plots, 160 kg N ha−1 under ambient CO2 (385 ppm) in open plots, 120 kg N ha−1 under ambient CO2 (385 ppm) in open top chambers (OTC) and 120 kg N ha−1 under elevated CO2 (500 ± 50 ppm) in the OTC. Peaks of N2O flux were observed after every dose of N application. Cumulative N2O emission was 13% lower under ambient CO2 as compared to the elevated CO2 concentrations. There was an increase in CO2 emissions with application of N from 60 kg ha−1 to 160 kg ha−1. Higher yield and root biomass was observed under higher N treatment (160 kg N ha−1). There was no significant increase in maize yield under elevated CO2 as compared to ambient CO2. The carbon emitted was more than the carbon fixed under elevated CO2 as compared to ambient CO2 levels. The carbon efficiency ratio (C fixed/C emitted) was highest in ambient CO2 treatment in the OTC.
The findings of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study and the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS) called previous trials of antipsychotics into question, including pre-licensing trials. Concerns regarding methodological robustness and quality of reporting increased. This systematic review aimed to examine the quality of reporting of phase II and III trials for new antipsychotics in the aftermath of the CATIE and CUtLASS studies.
Electronic searches were conducted in EMBASE, Medline and Cochrane databases and also ClinicalTrials.gov for antipsychotic trials (published between January 2006 and February 2012). Phase II and III randomized controlled trials (RCTs) for iloperidone, asenapine, paliperidone, olanzapine, lurasidone and pomaglumetad methionil were selected for schizophrenia and schizoaffective disorder. The reporting of the methodology was evaluated in accordance with Consolidated Standards of Reporting Trials (CONSORT) guidelines.
Thirty-one articles regarding 32 studies were included. There was insufficient reporting of design in 47% of studies and only 13% explicitly stated a primary hypothesis. Exclusion criteria were poorly reported for diagnosis in 22% of studies. Detail regarding comparators, particularly placebos, was suboptimal for 56% of studies, and permitted concomitant medication was often not reported (19%). Randomization methods were poorly described in 56% of studies and reporting on blinding was insufficient in 84% of studies. Sample size calculations were insufficiently reported in 59% of studies.
The quality of reporting of phase II and III trials for new antipsychotics does not reach the standards outlined in the CONSORT guidelines. Authors often fail to adequately report design and methodological processes, potentially impeding the progress of research on antipsychotic efficacy. Both policymakers and clinicians require high quality reporting before decisions are made regarding licensing and prescribing of new antipsychotics.
For over three decades, bone conduction hearing aids have been changing the lives of patients with impaired hearing. The size, appearance and fitting discomfort of early generations of bone conduction hearing aids made them unpopular. The advent of bone-anchored hearing aids in the 1970s offered patients improved sound quality and fitting comfort, due to the application of osseointegration. However, the issue of post-operative peri-abutment pin tract wound infection persisted. The Bonebridge system incorporates the first active bone conduction device, and aims to resolve peri-abutment issues. Implantation of this system in an Asian patient is presented.
Few residency curricular interventions have focused on improving well-being and promoting humanism. We describe the implementation of a novel curriculum based on small-group reflection rounds—the Emergency Medicine Reflection Rounds (EMRR)—at a 4-year US emergency medicine (EM) residency. During the inaugural year (2010–2011), nine residents volunteered to take part in 1-hour monthly sessions with faculty facilitators. Residents were provided with a confidential environment to discuss difficult ethical and interpersonal encounters from their clinical experiences. Ongoing feedback from participants was solicited, culminating with a four-question survey in which all respondents remarked that the EMRR contributed to improving their own well-being and agreed that it provided an important forum for residents to discuss difficult issues in a safe environment. In this article, we describe our innovation as an example of a wellness initiative that has promoted reflective practice and fostered cooperative learning around the communication, professional, and ethical challenges inherent in EM practice. Our EMRR model may be useful to other EM residences looking to supplement their wellness curriculum.
We describe our strategies and results in the preparation of supramolecularly ordered ultrathin films of DNA assemblies using the layer-by-layer (LbL) alternate polyelectrolyte adsorption technique. The properties of DNA are intimately associated with their polyelectrolyte behavior in solution. Deposition at interfaces is governed by conformation, orientation, and charge density of these biomolecules in relation to the physisorption phenomena in oppositely charged surfaces. Thus, controlling the nature of surfaces (polymer charge density, ionic strength, other non-covalent interactions, etc.) is important in modifying the adsorption phenomena. In this work, differences in adsorption and incorporation of DNA with dyes, linear polymers and dendrimers are highlighted. A number of surface sensitive spectroscopic and microscopic techniques were used to probe the adsorption and multilayer assembly phenomena, e.g. surface plasmon resonance spectroscopy (SPS), AFM, quartz crystal microbalance (QCM) and ellipsometry. These studies are important for future applications such as the use of polycations as non-viral gene transfection vectors for drug-delivery and DNA adsorption on microarray surfaces. By combining with the alternate assembly of azobenzene and phthalocyanine dyes, we have been able to prepare optobiolelectronic substrates where the phenomena of irradiation and electrochemistry can be used to probe the ordering and response of these films.