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The National Institute for Health and Care Excellence referral guidelines prompting urgent two-week referrals were updated in 2015. Additional symptoms with a lower threshold of 3 per cent positive predictive values were integrated. This study aimed to examine whether current pan-London urgent referral guidelines for suspected head and neck cancer lead to efficient and accurate referrals by assessing frequency of presenting symptoms and risk factors, and examining their correlation with positive cancer diagnoses.
The risk factors and symptoms of 984 consecutive patients (over a six-month period in 2016) were collected retrospectively from urgent referral letters to University College London Hospital for suspected head and neck cancer.
Only 37 referrals (3.76 per cent) resulted in a head and neck cancer diagnosis. Four of the 23 recommended symptoms demonstrated statistically significant results. Nine of the 23 symptoms had a positive predictive value of over 3 per cent.
The findings indicate that the current referral guidelines are not effective at detecting patients with cancer. Detection rates have decreased from 10–15 per cent to 3.76 per cent. A review of the current head and neck cancer referral guidelines is recommended, along with further data collection for comparison.
The diurnal feeding patterns of dairy cows affects the 24 h robot utilisation of pasture-based automatic milking systems (AMS). A decline in robot utilisation between 2400 and 0600 h currently occurs in pasture-based AMS, as cow feeding activity is greatly reduced during this time. Here, we investigate the effect of a temporal variation in feed quality and quantity on cow feeding behaviour between 2400 and 0600 h as a potential tool to increase voluntary cow trafficking in an AMS at night. The day was allocated into four equal feeding periods (0600 to 1200, 1200 to 1800, 1800 to 2400 and 2400 to 0600 h). Lucerne hay cubes (CP = 19.1%, water soluble carbohydrate = 3.8%) and oat, ryegrass and clover hay cubes with 20% molasses (CP = 11.8%, water soluble carbohydrate = 10.7%) were offered as the ‘standard’ and ‘preferred’ (preference determined previously) feed types, respectively. The four treatments were (1) standard feed offered ad libitum (AL) throughout 24 h; (2) as per AL, with preferred feed replacing standard feed between 2400 and 0600 h (AL + P); (3) standard feed offered at a restricted rate, with quantity varying between each feeding period (20:10:30:60%, respectively) as a proportion of the (previously) measured daily ad libitum intake (VA); (4) as per VA, with preferred feed replacing standard feed between 2400 and 0600 h (VA + P). Eight non-lactating dairy cows were used in a 4 × 4 Latin square design. During each experimental period, treatment cows were fed for 7 days, including 3 days habituation and 4 days data collection. Total daily intake was approximately 8% greater (P < 0.001) for the AL and AL + P treatments (23.1 and 22.9 kg DM/cow) as compared with the VA and VA + P treatments (21.6 and 20.9 kg DM/cow). The AL + P and VA treatments had 21% and 90% greater (P < 0.001) dry matter intake (DMI) between 2400 and 0600 h, respectively, compared with the AL treatment. In contrast, the VA + P treatment had similar DMI to the VA treatment. Our experiment shows ability to increase cow feeding activity at night by varying feed type and quantity, though it is possible that a penalty to total DMI may occur using VA. Further research is required to determine if the implementation of variable feed allocation on pasture-based AMS farms is likely to improve milking robot utilisation by increasing cow feeding activity at night.
This chapter examines the Shareholder Primacy Norm (SPN) as a widely acknowledged impediment to corporate social responsibility (CSR), including how this relates to Stakeholder Theory. We start by explaining the SPN and then review its status under US and UK law and show that it is not a legal requirement, at least under the guise of shareholder value maximization. This is in contrast to the common assertion that managers are legally constrained from addressing CSR issues if doing so would be inconsistent with the economic interests of shareholders. Nonetheless, while the SPN might be muted as a legal norm, we show that it is certainly evident as a powerful social norm among managers and in business schools— reflective, in part, of the sole voting rights of shareholders on corporate boards and of the dominance of Shareholder Theory. We argue that this view of CSR is misguided, not least when associated with claims of a purported legally enforceable requirement to maximize shareholder value. We propose two ways by which the influence of the SPN among managers might be attenuated: extending voting rights to non-shareholder stakeholders or extending fiduciary duties of executives to non-shareholder stakeholders.
In the decades since R. Edward Freeman first introduced stakeholder theory, which views firms in terms of their relationships to a broad set of partners, the stakeholder approach has drawn increasing attention as a model for ethical business. Edited by Freeman, alongside other leading scholars in stakeholder theory and strategic management, this handbook provides a comprehensive foundation for study in the field, with eighteen chapters covering some of the most important topics in stakeholder theory written by respected and highly cited experts. The chapters contain an overview of the topic, an examination of the most important research on the topic to date, an evaluation of that research, and suggestions for future directions. Given the pace of new scholarship in the field, this handbook will provide an essential reference on both foundational topics as well as new applications of stakeholder theory to entrepreneurship, sustainable business, corporate responsibility, and beyond.
Introduction: Endotracheal intubation (ETI) is a lifesaving procedure commonly performed by emergency department (ED) physicians that may lead to patient discomfort or adverse events (e.g., unintended extubation) if sedation is inadequate. No ED-based sedation guidelines currently exist, so individual practice varies widely. This study's objective was to describe the self-reported post-ETI sedation practice of Canadian adult ED physicians. Methods: An anonymous, cross-sectional, web-based survey featuring 7 common ED scenarios requiring ETI was distributed to adult ED physician members of the Canadian Association of Emergency Physicians (CAEP). Scenarios included post-cardiac arrest, hypercapnic and hypoxic respiratory failure, status epilepticus, polytrauma, traumatic brain injury, and toxicology. Participants indicated first and second choice of sedative medication following ETI, as well as bolus vs. infusion administration in each scenario. Data was presented by descriptive statistics. Results: 207 (response rate 16.8%) ED physicians responded to the survey. Emergency medicine training of respondents included CCFP-EM (47.0%), FRCPC (35.8%), and CCFP (13.9%). 51.0% of respondents work primarily in academic/teaching hospitals and 40.4% work in community teaching hospitals. On average, responding physicians report providing care for 4.9 ± 6.8 (mean ± SD) intubated adult patients per month for varying durations (39.2% for 1–2 hours, 27.8% for 2–4 hours, and 22.7% for ≤1 hour). Combining all clinical scenarios, propofol was the most frequently used medication for post-ETI sedation (38.0% of all responses) and was the most frequently used agent except for the post-cardiac arrest, polytrauma, and hypercapnic respiratory failure scenarios. Ketamine was used second most frequently (28.2%), with midazolam being third most common (14.5%). Post-ETI sedation was provided by > 98% of physicians in all situations except the post-cardiac arrest (26.1% indicating no sedation) and toxicology (15.5% indicating no sedation) scenarios. Sedation was provided by infusion in 74.6% of cases and bolus in 25.4%. Conclusion: Significant practice variability with respect to post-ETI sedation exists amongst Canadian emergency physicians. Future quality improvement studies should examine sedation provided in real clinical scenarios with a goal of establishing best sedation practices to improve patient safety and quality of care.
The cognitive process of worry, which keeps negative thoughts in mind and elaborates the content, contributes to the occurrence of many mental health disorders. Our principal aim was to develop a straightforward measure of general problematic worry suitable for research and clinical treatment. Our secondary aim was to develop a measure of problematic worry specifically concerning paranoid fears.
An item pool concerning worry in the past month was evaluated in 250 non-clinical individuals and 50 patients with psychosis in a worry treatment trial. Exploratory factor analysis and item response theory (IRT) informed the selection of scale items. IRT analyses were repeated with the scales administered to 273 non-clinical individuals, 79 patients with psychosis and 93 patients with social anxiety disorder. Other clinical measures were administered to assess concurrent validity. Test-retest reliability was assessed with 75 participants. Sensitivity to change was assessed with 43 patients with psychosis.
A 10-item general worry scale (Dunn Worry Questionnaire; DWQ) and a five-item paranoia worry scale (Paranoia Worries Questionnaire; PWQ) were developed. All items were highly discriminative (DWQ a = 1.98–5.03; PWQ a = 4.10–10.7), indicating small increases in latent worry lead to a high probability of item endorsement. The DWQ was highly informative across a wide range of the worry distribution, whilst the PWQ had greatest precision at clinical levels of paranoia worry. The scales demonstrated excellent internal reliability, test-retest reliability, concurrent validity and sensitivity to change.
The new measures of general problematic worry and worry about paranoid fears have excellent psychometric properties.
The goal of this study was to determine physician performance in diagnosis and management of postpartum depression (PPD) and to provide needed education in the consequence free environment of a virtual patient simulation (VPS).
∙ A continuing medical education activity was delivered via an online VPS learning platform that offers a lifelike clinical care experience with complete freedom of choice in clinical decision-making and expert personalized feedback to address learner’s practice gaps
∙ Physicians including psychiatrists, primary care physicians (PCPs), and obstetricians/gynecologists (ob/gyns) were presented with two cases of PPD designed to model the experience of actual practice by including use of electronic health records
∙ Following virtual interactions with patients, physicians were asked to make decisions regarding assessments, diagnoses, and pharmacologic therapies. The clinical decisions were analyzed using a sophisticated decision engine, and clinical guidance (CG) based on current evidence-based recommendations was provided in response to learners’ clinical decisions
∙ Impact of the education was measured by comparing participant decisions pre- and post-CG using a 2-tailed, paired t-test; P <.05 was considered statistically significant
∙ The activity launched on Medscape Education on April 26, 2018, and data were collected through to June 17,2018.
∙ From pre- to post-CG in the simulation, physicians were more likely to make evidence-based clinical decisions related to:
∙ Ordering appropriate baseline tests including tools/scales to screen for PPD: in case 1, psychiatrists (n=624) improved from 34% to 42% on average (P<.05); PCPs (n=197) improved from 38% to 48% on average (P<.05); and, ob/gyns (n=216) improved from 30% to 38% on average (P<.05)
∙ Diagnosing moderate-to-severe PPD: in case 2, psychiatrists (n=531) improved from 46% to 62% (P<.05); PCPs (n=154) improved from 43% to 55% (P<.05); and, ob/gyns (n=137) improved from 55% to 73% (P<.05)
∙ Ordering appropriate treatments for moderate-to-severe PPD such as selective serotonin-reuptake inhibitors: in case 2, psychiatrists (n=531) improved from 47% CG to 75% (P<.05); PCPs (n=154) improved from 55% to 74% (P<.05); and, ob/gyns (n=137) improved from 51% to 78% (P<.05)
∙ Interestingly, a small percentage of physicians (average of 5%) chose investigational agents for PPD which were in clinical trials pre-CG, and this increased to an average of 9% post-CG
Physicians who participated in VPS-based education significantly improved their clinical decision-making in PPD, particularly in selection of validated screening tools/scales, diagnosis, and pharmacologic treatments based on severity. Given that VPS immerses physicians in an authentic, practical learning experience matching the scope of clinical practice, this type of intervention can be used to determine clinical practice gaps and translate knowledge into practice.
Funding Acknowledgements: The educational activity and outcomes measurement were funded through an independent educational grant from Sage Therapeutics, Inc.
Sprays are a class of multiphase flows which exhibit a wide range of drop size and velocity scales spanning several orders of magnitude. The objective of the current work is to experimentally investigate the prospect of dynamical similarity in these flows. We are also motivated to identify a choice of length and time scales which could lead towards a universal description of the drop size and velocity spectra. Towards this end, we have fabricated a cohort of geometrically similar pressure swirl atomizers using micro-electromechanical systems (MEMS) as well as additive manufacturing technology. We have characterized the dynamical characteristics of the sprays as well as the drop size and velocity spectra (in terms of probability density functions, p.d.f.s) over a wide range of Reynolds (
) and Weber numbers (
) using high-speed imaging and phase Doppler interferometry, respectively. We show that the dimensionless Sauter mean diameter (
) scaled to the boundary layer thickness in the liquid sheet at the nozzle exit (
) exhibits self-similarity in the core region of the spray, but not in the outer zone. In addition, we show that global drop size spectra in the sprays show two distinct characteristics. The spectra from varying
collapse onto a universal p.d.f. for drops of size
, a residual effect of
persists in the size spectra. We explain this characteristic by the fact that the physical mechanisms that cause large drops is different from that which is responsible for the small drops. Similarly, with the liquid sheet velocity at the nozzle exit (
) as the choice of velocity scale, we show that drops moving with a velocity
collapse onto a universal p.d.f., while drops with
exhibit a residual effect of
. From these observations, we suggest that physically accurate models for drop size and velocity spectra should rely on piecewise descriptions of the p.d.f. rather than invoking a single mathematical form for the entire distribution. Finally, we show from a dynamical modal analysis that the conical liquid sheet flapping characteristics exhibit a sharp transition in Strouhal number (
) at a critical
Achieving a consistent level of robot utilisation throughout 24 h maximises automatic milking system (AMS) utilisation. However, levels of robot utilisation in the early morning hours are typically low, caused by the diurnal feeding behaviour of cows, limiting the inherent capacity and total production of pasture-based AMS. Our objective was to determine robot utilisation throughout 24 h by dairy cows, based on milking frequency (MF; milking events per animal per day) in a pasture-based AMS. Milking data were collected from January and February 2013 across 56 days, from a single herd of 186 animals (Bos taurus) utilising three Lely A3 robotic milking units, located in Tasmania, Australia. The dairy herd was categorised into three equal sized groups (n=62 per group) according to the cow’s mean daily MF over the duration of the study. Robot utilisation was characterised by an interaction (P< 0.001) between the three MF groups and time of day, with peak milking time for high MF cows within one h of a fresh pasture allocation becoming available, followed by the medium MF and low MF cows 2 and 4 h later, respectively. Cows in the high MF group also presented for milking between 2400 and 0600 h more frequently (77% of nights), compared to the medium MF group (57%) and low MF group (50%). This study has shown the formation of three distinct groups of cows within a herd, based on their MF levels. Further work is required to determine if this finding is replicated across other pasture-based AMS farms.
Current scholarship on Anne Askew has tended to disparage the editorial tactics of John Bale, her first editor, as intrusive and distorting. In contrast, the reprinting of her text by John Foxe, in his “Book of Martyrs, “ has been commended for its lack of editorial intervention. Yet afresh consideration of Foxes work with Askew's narrative suggests that Foxe's shaping force in the text was as strong as Bale's, if more subtle. Furthermore, attempts to locate Askew's authorial agency within one text or the other impose modern ideas about authorship on a period in which such ideas were still being formed.
The stakeholder perspective is an alternative way of understanding how companies and people create value and trade with each other. Freeman, Harrison and Zyglidopoulos discuss the foundation concepts and implementation of stakeholder management as well as the advantages this approach provides to firms and their managers. They present a number of tools that managers can use to implement stakeholder thinking, better understand stakeholders and create value with and for them. The Element concludes by discussing how managers can create stakeholder oriented control systems and by examining some of the important stakeholder-related issues that are worthy of future scholarly and managerial attention.
We present observations of 50 deg2 of the Mopra carbon monoxide (CO) survey of the Southern Galactic Plane, covering Galactic longitudes l = 300–350° and latitudes |b| ⩽ 0.5°. These data have been taken at 0.6 arcmin spatial resolution and 0.1 km s−1spectral resolution, providing an unprecedented view of the molecular clouds and gas of the Southern Galactic Plane in the 109–115 GHz J = 1–0 transitions of 12CO, 13CO, C18O, and C17O.
We present a series of velocity-integrated maps, spectra, and position-velocity plots that illustrate Galactic arm structures and trace masses on the order of ~106 M⊙ deg−2, and include a preliminary catalogue of C18O clumps located between l = 330–340°. Together with the information about the noise statistics of the survey, these data can be retrieved from the Mopra CO website and the PASA data store.