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Dermatology is a field of medicine where urgent cases occur commonly. However, access to specialized emergency dermatology services is very limited. Following the declaration of the COVID-19 pandemic, the cessation of all elective dermatology visits was widely urged. Accordingly, in Italy, a country severely affected by the pandemic, various measures were applied and the care at university clinics was limited to urgent cases. Here we retrospectively analyzed data of patients who presented at an Italian academic outpatient clinic reserved only for emergency cases. In total, 252 patients (109 males and 143 females) with a mean age of 55.25±20.99 years were cared for at our clinic during a three-month period. We classified 10 patients (4%) as real emergency cases. Pityriasis rosea was diagnosed in three patients. Many patients sought care for skin cancer screening. In 131 patients (52%) dermoscopic skin examinations were performed. In 39 patients (15%), actinic keratosis or non-melanoma skin cancer was detected, while melanoma was diagnosed in three patients, two of which were proven later as in situ melanoma. 111 patients (44%) visited our clinic for other, non-urgent skin diseases. Our results imply that many patients felt that their skin problems required immediate attention, even if this could not be justified. Melanoma care may be considered an emergency care for its highly malignant potential and the possibility of rapid spreading. Adequately taken photos with a dermoscope may be readily read without the presence of specialist in the emergency room to prevent unnecessary delay in diagnosing oncologic skin diseases. This article is protected by copyright. All rights reserved.

SARS‐COV‐2 is a highly virulent positive‐sense single stranded RNA virus that spreads rapidly via respiratory droplets, causing severe acute respiratory syndromes with significant mortality and morbidity. Currently 210 countries and territories are affected around the world with a reported 2.6 million confirmed cases.1 The COVID 19 pandemic has changed the way patients attend their specialist appointments and receive medical care. Whilst some specialist clinics have closed we have implemented strategies and restructured our academic practice in Australia to minimize the spread of disease whilst treating patients who need urgent care. We hope to share these strategies in the hope they may be useful to the dermatology community. This article is protected by copyright. All rights reserved.

Background The decision to use patient portals can be influenced by multiple factors, including individuals’ perceptions of the tool, which are based on both their personal skills and experiences. Prior experience with one type of portal may make individuals more comfortable with using newer portal technologies. Experienced outpatient portal users in particular may have confidence in their ability to use inpatient portals that have similar functionality. In practice, the use of both outpatient and inpatient portal technologies can provide patients with continuity of access to their health information across care settings, but the influence of one type of portal use on the use of other portals has not been studied. Objective This study aims to understand how patients’ use of an inpatient portal is influenced by outpatient portal use. Methods This study included patients from an academic medical center who were provided access to an inpatient portal during their hospital stays between 2016 and 2018 (N=1571). We analyzed inpatient portal log files to investigate how inpatient portal use varied by using 3 categories of outpatient portal users: prior users, new users, and nonusers. Results Compared with prior users (695/1571, 44.24%) of an outpatient portal, new users (214/1571, 13.62%) had higher use of a select set of inpatient portal functions (messaging function: incidence rate ratio [IRR] 1.33, 95% CI 1.06-1.67; function that provides access to the outpatient portal through the inpatient portal: IRR 1.34, 95% CI 1.13-1.58). Nonusers (662/1571, 42.14%), compared with prior users, had lower overall inpatient portal use (all active functions: IRR 0.68, 95% CI 0.60-0.78) and lower use of specific functions, which included the function to review vitals and laboratory results (IRR 0.51, 95% CI 0.36-0.73) and the function to access the outpatient portal (IRR 0.53, 95% CI 0.45-0.62). In comparison with prior users, nonusers also had lower odds of being comprehensive users (defined as using 8 or more unique portal functions; odds ratio [OR] 0.57, 95% CI 0.45-0.73) or composite users (defined as comprehensive users who initiated a 75th or greater percentile of portal sessions) of the inpatient portal (OR 0.42, 95% CI 0.29-0.60). Conclusions Patients’ use of an inpatient portal during their hospital stay appeared to be influenced by a combination of factors, including prior outpatient portal use. For new users, hospitalization itself, a major event that can motivate behavioral changes, may have influenced portal use. In contrast, nonusers might have lower self-efficacy in their ability to use technology to manage their health, contributing to their lower portal use. Understanding the relationship between the use of outpatient and inpatient portals can help direct targeted implementation strategies that encourage individuals to use these tools to better manage their health across care settings.

Background Documentation burden is a common problem with modern electronic health record (EHR) systems. To reduce this burden, various recording methods (eg, voice recorders or motion sensors) have been proposed. However, these solutions are in an early prototype phase and are unlikely to transition into practice in the near future. A more pragmatic alternative is to directly modify the implementation of the existing functionalities of an EHR system. Objective This study aims to assess the nature of free-text comments entered into EHR flowsheets that supplement quantitative vital sign values and examine opportunities to simplify functionality and reduce documentation burden. Methods We evaluated 209,055 vital sign comments in flowsheets that were generated in the Epic EHR system at the Vanderbilt University Medical Center in 2018. We applied topic modeling, as well as the natural language processing Clinical Language Annotation, Modeling, and Processing software system, to extract generally discussed topics and detailed medical terms (expressed as probability distribution) to investigate the stories communicated in these comments. Results Our analysis showed that 63.33% (6053/9557) of the users who entered vital signs made at least one free-text comment in vital sign flowsheet entries. The user roles that were most likely to compose comments were registered nurse, technician, and licensed nurse. The most frequently identified topics were the notification of a result to health care providers (0.347), the context of a measurement (0.307), and an inability to obtain a vital sign (0.224). There were 4187 unique medical terms that were extracted from 46,029 (0.220) comments, including many symptom-related terms such as “pain,” “upset,” “dizziness,” “coughing,” “anxiety,” “distress,” and “fever” and drug-related terms such as “tylenol,” “anesthesia,” “cannula,” “oxygen,” “motrin,” “rituxan,” and “labetalol.” Conclusions Considering that flowsheet comments are generally not displayed or automatically pulled into any clinical notes, our findings suggest that the flowsheet comment functionality can be simplified (eg, via structured response fields instead of a text input dialog) to reduce health care provider effort. Moreover, rich and clinically important medical terms such as medications and symptoms should be explicitly recorded in clinical notes for better visibility.

Background The battle against COVID-19 remains ongoing, and social media has played an important role during the crisis for both communication and health promotion, particularly for health care organizations. Taiwan’s success during the COVID-19 outbreak is well known and the use of social media is one of the key contributing factors to that success. Objective This nationwide observational study in Taiwan aimed to explore the use of Facebook by academic medical centers during the COVID-19 pandemic. Methods We conducted a nationwide observational study of all Facebook fan page posts culled from the official accounts of all medical centers in Taiwan from December 2019 to April 2020. All Facebook posts were categorized into either COVID-19–related posts or non–COVID-19–related posts. COVID-19–related posts were split into 4 categories: policy of Taiwan’s Center for Disease Control (TCDC), gratitude notes, news and regulations from hospitals, and education. Data from each post was also recorded as follows: date of post, headline, number of “likes,” number of messages left, number of shares, video or non-video post, and date of search. Results The Facebook fan pages of 13 academic medical centers, with a total of 1816 posts, were analyzed. From January 2020, the percentage of COVID-19 posts increased rapidly, from 21% (January 2020) to 56.3% (April 2020). The trends of cumulative COVID-19 posts and reported confirmed cases were significantly related (Pearson correlation coefficient=0.93, P Conclusions Social media has been a useful tool for communication during the COVID-19 pandemic. This nationwide observational study has helped demonstrate the value of Facebook for academic medical centers in Taiwan, along with its engagement efficacy. We believe that the experience of Taiwan and the knowledge it can share will be helpful to health care organizations worldwide during our global battle against COVID-19.

Background The coronavirus disease (COVID-19) pandemic has led to rapid acceleration in the deployment of new digital technologies to improve both accessibility to and quality of care, and to protect staff. Mixed-reality (MR) technology is the latest iteration of telemedicine innovation; it is a logical next step in the move toward the provision of digitally supported clinical care and medical education. This technology has the potential to revolutionize care both during and after the COVID-19 pandemic. Objective This pilot project sought to deploy the HoloLens2 MR device to support the delivery of remote care in COVID-19 hospital environments. Methods A prospective, observational, nested cohort evaluation of the HoloLens2 was undertaken across three distinct clinical clusters in a teaching hospital in the United Kingdom. Data pertaining to staff exposure to high-risk COVID-19 environments and personal protective equipment (PPE) use by clinical staff (N=28) were collected, and assessments of acceptability and feasibility were conducted. Results The deployment of the HoloLens2 led to a 51.5% reduction in time exposed to harm for staff looking after COVID-19 patients (3.32 vs 1.63 hours/day/staff member; P=.002), and an 83.1% reduction in the amount of PPE used (178 vs 30 items/round/day; P=.02). This represents 222.98 hours of reduced staff exposure to COVID-19, and 3100 fewer PPE items used each week across the three clusters evaluated. The majority of staff using the device agreed it was easy to set up and comfortable to wear, improved the quality of care and decision making, and led to better teamwork and communication. In total, 89.3% (25/28) of users felt that their clinical team was safer when using the HoloLens2. Conclusions New technologies have a role in minimizing exposure to nosocomial infection, optimizing the use of PPE, and enhancing aspects of care. Deploying such technologies at pace requires context-specific information security, infection control, user experience, and workflow integration to be addressed at the outset and led by clinical end-users. The deployment of new telemedicine technology must be supported with objective evidence for its safety and effectiveness to ensure maximum impact.

The authors aimed at analyzing the costs of inpatient care of schizophrenia in Kiel (Germany). The study was also to present treatment regimens used at the German Academic Center. Moreover, the study is a continuation and complement of the previous study conducted in Polish and Ukrainian Academic Center. Therefore, it helps increase the awareness and knowledge of residents concerning the cost of inpatient care of schizophrenia. The analysis was based on 105 hospital records of patients treated between January 2012 and June 2013. According to inclusion criteria, 50 adult patients (27 women and 23 men) were included in the study. The study was approved by the Ethics Committee of the Medicine Faculty of CAU in Kiel. The cost of schizophrenia treatment of 50 patients in Kiel was EUR 604,280.90 (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\bar{x}$$\end{document}x¯ = EUR 12,085.62). The duration of hospital stay was on average \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\bar{x}$$\end{document}x¯ = 51.02 days. The patients were treated with neuroleptics of all generations. The most popular atypical neuroleptic was amisulpride and the most popular typical neuroleptic was haloperidol. Patients from Kiel were provided a comprehensive non-pharmacological treatment. Treatment regiments and evaluations of costs of schizophrenia vary between countries. The costs of inpatient care of schizophrenia are high in Kiel. Treatment of schizophrenia seems to be comprehensive in Kiel and wide range of treatment opportunities contribute to a more effective treatment confirmed by less frequent relapses of schizophrenia than in Lviv (Ukraine), for example. Comprehensive treatment should be available everywhere, because it is a right of every patient.

This paper describes how a large, academic health sciences library built capacity for supporting global health at its university and discusses related outcomes. Lean budgets require prioritization and organizational strategy. A committee, with leadership responsibilities assigned to one librarian, guided strategic planning and the pursuit of collaborative, global health outreach activities. A website features case studies and videos of user stories to promote how library partnerships successfully contributed to global health projects. Collaborative partnerships were formed through outreach activities and from follow-up to reference questions. The committee and a librarian's dedicated time established the library's commitment to help the university carry out its ambitious global agenda.

Objective: To identify possible predictors of missed opportunities for human papillomavirus (HPV) counseling and vaccination prior to presentation at an academic colposcopy clinic. Materials and Methods: We examined the characteristics of 638 vaccinated and 1,024 unvaccinated age-eligible patients using data from a patient registry of women presenting for colposcopic evaluation between 2/26/2007 and 3/10/2014 who were aged 26 or less at presentation. Demographics, smoking history, pregnancy history, sexually transmitted infections (STIs), sexual history, contraception use, immunosuppression, and medical problems were compared between HPV vaccinated and unvaccinated women. Multivariable logistic regression models included age, race, language, marital status, insurance type, lifetime number of sexual partners, other medical illnesses, number of pregnancies, contraception use, history of STIs, and smoking history to determine predictors of HPV vaccination. Results: In multivariable analysis, race, marital status, and language were not significantly associated with HPV vaccination. Women with fewer pregnancies were more likely to be vaccinated (p-trend

BackgroundPatient satisfaction has not been widely studied with respect to implementation of the electronic medical record (EMR). There are few reports of the impact of the EMR in pediatrics. ObjectiveThe objective of this study was to assess the impact of implementation of an electronic medical record system on families in an academic pediatric rheumatology practice. MethodsFamilies were surveyed 1 month pre-EMR implementation and 3 months post-EMR implementation. ResultsOverall, EMR was well received by families. Compared with the paper chart, parents agreed the EMR improved the quality of doctor care (55% or 59/107 vs 26% or 26/99, P < .001). More parents indicated they would prefer their pediatric physicians to use an EMR (68% or 73/107 vs 51% or 50/99, P = .01). ConclusionsTransitioning an academic pediatric rheumatology practice to an EMR can increase family satisfaction with the office visit.

The problem of Alzheimer's disease (AD) exemplifies the challenges of dealing with a broad range of aging-related chronic disorders that require long-term, labor-intensive, and expensive care. As the baby boom generation ages and brain diseases become more prevalent, the need to confront the pending health care crisis is more urgent than ever before. Indeed, there is now a critical need to expand significantly the national effort to solve the problem of AD, with special focus on prevention. The Campaign to Prevent Alzheimer's Disease by 2020 (PAD2020) aims to create a new paradigm for planning and supporting the organization of worldwide cooperative research networks to develop new technologies for early detection and treatments of aging-related memory and motor impairments. PAD 2020 is developing an implementation plan to justify (1) increasing the federal budget for research, (2) developing novel national resources to discover new interventions for memory and motor disorders, and (3) creating innovative and streamlined decision-making processes for selecting and supporting new ideas. Since 1978 the National Institute on Aging or National Institute of Health (NIH) established an extensive national network of AD research facilities at academic institutions including AD Centers (ADCs), Consortium to Establish a Registry for AD, AD Cooperative Study (ADCS), AD Drug Discovery Program, National Alzheimer's Coordinating Center, National Cell Repository for AD, and AD Neuroimaging Initiative. However, despite the success of these programs and their critical contributions, they are no longer adequate to meet the challenges presented by AD. PAD 2020 is designed to address these changes by improving the efficiency and effectiveness of these programs. For example, the ADCs (P30s and P50s) can be enhanced by converting some into Comprehensive Alzheimer's Disease Centers (CADCs) to support not only research, but also by being demonstration projects on care/treatment, clinical trials, and education as well as by seamlessly integrating multisite collaborative studies (ADCS, AD Neuroimaging Initiative, Patient Registries, Clinical Data Banks, etc) into a cohesive structure that further enhances the original mission of the National Institute on Aging ADCs. Regional CADCs offer greater efficiency and cost savings while serving as coordinating hubs of existing ADCs, thereby offering greater economies of scale and programmatic integration. The CADCs also broaden the scope of ADC activities to include research on interventions, diagnosis, imaging, prevention trials, and other longitudinal studies that require long-term support. Thus, CADCs can address the urgent need to identify subjects at high risk of AD for prevention trials and very early in the course of AD for clinical trials of disease modification. The enhanced CADCs will allow more flexibility among ADCs by supporting collaborative linkages with other institutions and drawing on a wider expertise from different locations. This perspective article describes the University of Pennsylvania (Penn) CADC Model as an illustrative example of how an existing ADC can be converted into a CADC by better utilization of Penn academic resources to address the wide range of problems concerning AD. The intent of this position paper is to stimulate thinking and foster the development of other or alternative models for a systematic approach to the study of dementia and movement disorders.

Objective To compare factors considered by parents to those considered by adolescents making decisions about chronic disease treatments. Methods We conducted individual interviews with 15 parent–adolescent dyads in which the adolescent had either juvenile idiopathic arthritis or Crohn's disease. Questions focused on treatment decisions, with an emphasis on the factors that influenced each individual's preferences related to biologic therapies. A multidisciplinary team developed a coding structure. All interviews were coded by two people with disagreements resolved through discussion. We used content analysis and coding matrices to examine decision factors within and between parent–adolescent dyads. Results Parents and adolescents both participated in decisions about treatment with biologic therapies but considered decision factors differently. In only half of cases did parents and adolescents agree on the factor that most influenced their decision. Although their decision factors often fell into similar categories (e.g. treatment risks, quality of life), in many cases the specifics varied between adolescents and their parents. Adolescents were more likely to focus on immediate treatment effects and quality of life while parents took a longer term view of the decision. Agreement within dyads was most consistent when a special circumstance influenced the treatment decision. Conclusions Differences regarding influential decision factors exist within parent–adolescent dyads. Continued research is needed to determine the extent to which such differences are due to individual preferences or to variations in the information available to each person. Future decision support interventions will need to address parents’ and adolescents’ potentially disparate views and information needs.

Background: The emergency department (ED) is an environment fraught with increasing patient volumes, competing priorities, fluctuating information, and ad hoc interprofessional clinical teams. Limited time is available to reflect on and discuss clinical experiences, policies, or research with others on the involved team. Online resources, such as webcasts and blogs, offer an accessible platform for emergency shift workers to engage in interprofessional discussion and education. Objective: Our objective was to explore the current opportunities for shared learning and discussion and to discover the potential of online resources to foster and facilitate interprofessional education within an academic tertiary emergency department community. Methods: A qualitative study using semistructured interviews was conducted to solicit participants’ views of the current culture of IPE in the ED, the potential value of introducing new online resources and technology in support of IPE, and possible barriers to uptake. Participation was voluntary and participants provided verbal informed consent. Results: Online resources discussed included webcasts, interactive discussion forums, websites, and dashboard with links to central repositories. Identified barriers to uptake of new online resources were an unwillingness to “work” off-shift, a dislike of static one-directional communication, concerns with confidentiality, and the suggestion that new resources would be used by only a select few. Conclusions: Owing to the sensitive dynamics of emergency medicine—and the preference among its professional staff to foster interprofessional discussion and education through personal engagement, in an unhurried, non-stressful environment—introducing and investing in online resources should be undertaken with caution. [J Med Internet Res 2014;16(6):e162]

To review all admissions (age13) to three surgical patient care centers at a single academic medical center between January 1, 1995, and December 6, 1999, for significant surgical adverse events.Little data exist on the interrelationships between surgical adverse events, risk management, malpractice claims, and resulting indemnity payments to plaintiffs. The authors hypothesized that examination of this process would identify performance improvement opportunities overlooked by standard medical peer review; the risk of litigation would be constant across the three homogeneous patient care centers; and the risk management process would exceed the performance improvement process.Data collected included patient demographics (age, gender, and employment status), hospital financials (hospital charges, costs, and financial class), and outcome. Outcome categories were medical (disability:1 month, 1-6 months, permanent/death), legal (no legal action, settlement, summary judgment), financial (indemnity payments, legal fees, write-offs), and cause and effect analysis. Cause and effect analysis attempts to identify system failures contributing to adverse outcomes. This was determined by two independent analysts using the 17 Harvard criteria and subdividing these into subsystem causative factors.The study group consisted of 130 patients with surgical adverse events resulting in total liabilities of $8.2 million US dollars. The incidence of adverse events per 1,000 admissions across the three patient care centers was similar, but indemnity payments per 1,000 admissions varied (cardiothoracic = $30 US dollars, women's health = $90 US dollars, trauma = $520 US dollars). Patient demographics were not predictive of high-risk subgroups for adverse events or litigation. In terms of medical outcome, 51 patients had permanent disability or death, accounting for 98% of the indemnity payments. In terms of legal outcome, 103 patients received no indemnity payments, 15 patients received indemnity payments, four suits remain open, and in eight cases charges were written off ($0.121 million US dollars). To date, no cases have been adjudicated in court. Cause and effect analysis identified 390 system failures contributing to the adverse events (mean 3.0 failures per adverse event); there were 4.7 failures per adverse event in the 15 indemnity cases. Five categories of causes accounted for 75% of the failures (patient management, n = 104; communication, n = 89; administration, n = 33; documentation, n = 32; behavior, n = 23). The current medical review process would have identified 104 of 390 systems failures (37%).This study demonstrates no rational link between the tort system and the reduction of adverse events. Sixty-three percent of contributing causes to adverse events were undetected by current medical review processes. Adverse events occur at the interface between different systems or disciplines and result from multiple failures. Indemnity costs per hospital day vary dramatically by patient care center (range $3.60-97.60 US dollars a day). The regionalization of healthcare is in jeopardy from the burden of high indemnity payments.

BACKGROUND: Use of information technology in information acquisition, especially MEDLINE on CD-ROM and online, has been evaluated in several localities and regions, especially in the advanced countries. Use of MEDLINE on CD-ROM is still very poor among the medical students of the University of Lagos, Lagos, Nigeria, due to lack of awareness, insufficient personal computers, nonperiodic training, and the high cost of using the facility. Due to financial constraints, MEDLINE online and sufficiently-networked computer systems are not available. OBJECTIVE: To report on the situation in Nigeria, a developing country, so as to compare the current awareness of searching MEDLINE on CD-ROM among the medical students at the University of Lagos with the awareness of their overseas' counterparts. This is the first step toward setting up an online PubMed search as well as expanding the computer systems and network. METHODS: Essentially based on cross-sectional proportional sampling using structured questionnaires, in-depth interviews, and focus-group discussions among the medical students and library staff. The study involved the medical students in their second year to sixth (final) year of study. RESULTS: Of the 250 students interviewed, 130 (52%) were aware of MEDLINE on CD-ROM searches as a means of information retrieval. Only 60 (24%) had used MEDLINE on CD-ROM — 2% had used MEDLINE on CD-ROM more than 9 times; 4%, 7 to 9 times; 8%, 4 to 6 times; and 10%, 1 to 3 times. Of the students who used MEDLINE on CD-ROM search, 22% used it in preparing for examinations, 24% in research, 6% in patient care, and 26% in preparation of assignments and clinical cases. Lack of awareness (52%) and cost of undertaking MEDLINE on CD-ROM search (46%) were identified as important factors that discouraged the use of MEDLINE on CD-ROM. CONCLUSIONS: Though the above factors were recognized as important, it was concluded that the reasons for the poor use of MEDLINE on CD-ROM are multifactorial. Poor use of MEDLINE on CD-ROM could be attributed to these critical underlying factors: nonavailability of networked personal computers, which should be connected to a central server; lack of mandatory assignments to the medical students that would specifically require use of MEDLINE on CD-ROM; financial constraints on the university management; and infrequent periodic orientation on use of MEDLINE on CD-ROM. It was therefore suggested that the number of personal computers should be increased and that the library staff should periodically train the preclinical and clinical medical students in searching MEDLINE on CD-ROM. These steps would enable the medical students to benefit from online PubMed searching when it becomes fully operational in the future. [J Med Internet Res 2003;5(1):e7]

Early career academic cardiologists currently face unprecedented challenges that threaten a highly valued career path. A team consisting of early career professionals and senior leadership members of American College of Cardiology completed this white paper to inform the cardiovascular medicine profession regarding the plight of early career cardiologists and to suggest possible solutions. This paper includes: 1) definition of categories of early career academic cardiologists; 2) general challenges to all categories and specific challenges to each category; 3) obstacles as identified by a survey of current early career members of the American College of Cardiology; 4) major reasons for the failure of physician-scientists to receive funding from National Institute of Health/National Heart Lung and Blood Institute career development grants; 5) potential solutions; and 6) a call to action with specific recommendations.

Right ventricular function (RVF) is often selectively declined after coronary artery bypass graft surgery. In adult patients with congenital heart disease (CHD) the incidence and persistence of declined RVF after cardiac surgery is unknown. The current study aimed to describe RVF after cardiac surgery in these patients. Adult CHD patients operated between January 2008 and December 2009 in the Academic Medical Centre in Amsterdam were studied. Clinical characteristics, laboratory tests, surgical data and intensive care unit outcome were obtained from medical records. RVF was measured by trans-thoracic echocardiography (TTE) and expressed by tricuspid annular plane systolic excursion (TAPSE), tissue Doppler imaging (RV S') and myocardial performance index (MPI) pre-operatively and direct, at intermediate and late follow up. Of a total of 185 operated, 86 patients (mean age 39 +/- A 13 years, 54% male) had echo data available. There was a significant fall in RVF after cardiac surgery. TAPSE and RV S' were significantly higher and MPI was significantly lower pre-operatively compared to direct post-operative values (TAPSE 22 +/- A 5 versus 13 +/- A 3 mm (P

Background The results of recent surveys indicate that more than 50% of the German population has experience with complementary and alternative medicine (CAM) or uses CAM regularly. This study investigated the CAM usage and CAM-related needs of hospitalized patients at university medical centres in the state of Baden-Württemberg, Germany. Methods A multi-centre, paper-based, pseudonymous survey was carried out by the members of the Academic Centre for Complementary and Integrative Medicine. Patients of all ages, regardless of sex, diagnosis and treatment, who were hospitalized in the Department of Cardiology, Gastroenterology, Oncology, Gynaecology or Surgery at the university medical centres in Freiburg, Heidelberg, Tübingen and Ulm were eligible for inclusion. Results Of the 1275 eligible patients, 67% (n = 854) consented to participate in the survey. Forty-eight percent of the study participants stated that they were currently using CAM. The most frequently used therapies were exercise (63%), herbal medicine (54%) and dietary supplements (53%). Only 16% of the patients discussed CAM usage with their attending physician. Half of the patients (48%) were interested in CAM consultations. More than 80% of the patients desired reliable CAM information and stated that physicians should be better informed about CAM. Conclusions The frequency of CAM usage and the need for CAM counselling among hospitalized patients at university medical centres in Baden-Württemberg are high. To better meet patients’ needs, CAM research and physician education should be intensified. Trial registration German Clinical Trial register (DRKS00015445).

Objective: To assess physician–patient communication patterns associated with use of an electronic medical record (EMR) system in an outpatient setting and provide an empirical foundation for larger studies. Design: An exploratory, observational study involving analysis of videotaped physician–patient encounters, questionnaires, and medical-record reviews. Setting: General internal medicine practice at an academic medical center. Participants: Three physicians who used an EMR system (EMR physicians) and three who used solely a paper record (control physicians). A total of 204 patient visits were included in the analysis (mean, 34 for each physician). Main Outcome Measures: Content analysis of whether physicians accomplished communication tasks during encounters; qualitative analysis of how EMR physicians used the EMR and how control physicians used the paper chart. Results: Compared with the control physicians, EMR physicians adopted a more active role in clarifying information, encouraging questions, and ensuring completeness at the end of a visit. A trend suggested that EMR physicians might be less active than control physicians in three somewhat more patient-centered areas (outlining the patient's agenda, exploring psychosocial/ emotional issues, discussing how health problems affect a patient's life). Physicians in both groups tended to direct their attention to the patient record during the initial portion of the encounter. The relatively fixed position of the computer limited the extent to which EMR physicians could physically orient themselves toward the patient. Although there was no statistically significant difference between the EMR and control physicians in terms of mean time across all visits, a difference did emerge for initial visits: Initial visits with EMR physicians took an average of 37.5 percent longer than those with control physicians. Summary: An EMR system may enhance the ability of physicians to complete informationintensive tasks but can make it more difficult to focus attention on other aspects of patient communication. Further study involving a controlled, pre-/post-intervention design is justified.

Over the last 50 years, the nation's academic health centers (AHCs)--defined here as the 125 institutions that include at least a medical school and its closely affiliated clinical facilities and faculty practice plans--have come to serve a unique set of functions in the nation's health care system and in their communities. The AHCs produce a variety of health-related goods and services that have social value, but tend to be undervalued and undersupplied in competitive markets. These goods and services include basic and clinical research, the training of health professionals, certain highly specialized clinical services, and continuous innovation in health care services. In the balance of this paper, we refer to these functions as the "social missions" of AHCs. (Though some AHCs, especially the publicly owned centers, also consider care for the indigent a vital social mission, not all AHCs are disproportionate providers of indigent care. Therefore, this paper does not deal specifically with the indigent care mission of AHCs.) A number of commentators 1-3 have suggested that the evolution of the US health care system into a more market-competiti ve system could have dramatic consequences for the ability of AHCs to discharge their social missions. Providing these goods and services requires resources. Until recently, AHCs and other teaching institutions financed a significant proportion of these costs through

Analysis of frequency and structure of paternity exclusions in the material collected by the Department of Forensic Medicine, Medical University of Bialystok in 2008-2017.The paper is based on paternity test reports involving alleged father-child-mother trios. In a total of reviewed 958 cases, 187 exclusions were identified. The analysis was carried out on the basis of the results of DNA tests. DNA extraction was performed using QIAamp DNA Mini Kit (Qiagen) and DNA quantitation using Quantifiler Human DNA Quantification Kit and 7500 Real-Time PCR System (Applied Biosystems). AmpFLSTR Identifiler PCR Amplification Kit and a PCR System 9700 thermal cycler (Applied Biosystems) were used for DNA amplification.Over the analyzed period, the number of paternity tests was nearly halved, whereas the percentage of exclusions in individual years varied significantly (33.9-13.3%), with the average of 26.3%. The highest efficiency of exclusions was observed for D18S51 (0.7166) and FGA (0.7059), and the least effective system was TPOX (0.3048).The applied set of markers has been demonstrated to be an efficient tool in genetic paternity tests in the context of the recommended rules of exclusion.Celem pracy była analiza częstości i struktury wykluczeń ojcostwa na podstawie materiału zgromadzonego w Zakładzie Medycyny Sądowej Uniwersytetu Medycznego w Białymstoku w latach 2008–2017.Dokonano analizy dokumentacji obejmującej wyniki testów ojcostwa w trójkach: domniemany ojciec–dziecko–matka. Ocenie poddano 958 spraw, wśród których 187 stanowiły wykluczenia. Analiza opierała się na wynikach badań, w czasie których dokonano ekstrakcji DNA przy użyciu zestawów QIAamp DNA Mini Kit (Qiagen) i oznaczenia ilościowego DNA za pomocą zestawu Quantifiler Human DNA Quantification Kit w aparacie 7500 Real-Time PCR System (Applied Biosystems). Próbki DNA amplifikowano w zakresie markerów zestawu AmpFLSTR Identifiler PCR Amplification Kit w termocyklerze PCR System 9700 (Applied Biosystems).W analizowanym okresie zanotowano blisko dwukrotny spadek liczby testów ojcostwa, natomiast odsetek wykluczeń w poszczególnych latach ulegał znacznym fluktuacjom (33,9–13,3%), osiągając średnią 26,3%. Najwyższą obserwowaną skuteczność wykluczania wykazały układy D18S51 (0,7166) i FGA (0,7059), najniższą – TPOX (0,3048).Zastosowany zestaw markerów okazał się skutecznym narzędziem w genetycznych testach ojcostwa w kontekście przyjętych reguł wykluczania.

BACKGROUND: The number needed to treat or excise (NNT) is commonly used to measure the number of skin biopsies performed to detect one melanoma. The NNT for melanoma varies widely between clinical settings. OBJECTIVE: To provide a formal statistical comparison of the efficacy of melanoma detection between different clinical settings. METHODS: A systematic review and meta-analysis of all relevant observational studies on NNT in relation to melanoma was performed on MEDLINE. We performed a random effects model meta-analysis and reported NNTs with 95% confidence intervals (CIs). The subgroup analysis was related to clinical setting. RESULTS: In all, 29 papers including a total of 398,549 biopsies/excisions were analyzed. The overall NNT was 9.71 (95% CI, 7.72-12.29): 22.62 (95% CI, 12.95-40.10) for primary care, 9.60 (95% CI, 6.97-13.41) for dermatologist, and 5.85 (95% CI, 4.24-8.27) for pigmented lesion specialists. LIMITATIONS: There is heterogeneity in data reporting and possibility of missing studies. In addition, the incidence of melanoma varies among clinical settings and could affect NNT calculations. CONCLUSION: Specialists have the lowest NNT, followed by dermatologists, suggesting involving specialists in the diagnosis and treatment of pigmented skin lesions can likely improve patient outcomes.

AimThis study is aimed at developing a Rural Primary Health Care (PHC) Model for delivering comprehensive PHC for dementia in rural settings and addressing the gap in knowledge about disseminating and implementing evidence-based dementia care in a rural PHC context.BackgroundLimited access to specialists and services in rural areas leads to increased responsibility for dementia diagnosis and management in PHC, yet a gap exists in evidence-based best practices for rural dementia care.MethodsElements of the Rural PHC Model for Dementia were based on seven principles of effective PHC for dementia identified from published research and organized into three domains: team-based care, decision support, and specialist-to-provider support. Since 2013 the researchers have collaborated with a rural PHC team in a community of 1000 people in the Canadian province of Saskatchewan to operationalize these elements in ways that were feasible in the local context. The five-step approach included: building relationships; conducting a problem analysis/needs assessment; identifying core and adaptable elements of a decision support tool embedded in the model and resolving applicability issues; implementing and adapting the intervention with local stakeholders; and sustaining the model while incrementally scaling up.ResultsDeveloping and sustaining relationships at regional and PHC team levels was critical. A comprehensive needs assessment identified challenges related to all domains of the Rural PHC Model. An existing decision support tool for dementia diagnosis and management was adapted and embedded in the team’s electronic medical record. Strategies for operationalizing other model elements included integrating team-based care co-ordination into the decision support tool and family-centered case conferences. Research team specialists provided educational sessions on topics identified by the PHC team. This paper provides an example of a community-based process for adapting evidence-based practice principles to a real-world setting.

St George's Hospital hyperacute neurology service (HANS) is a comprehensive, consultant-delivered service set in a teaching hospital regional neuroscience centre. The service addresses deficiencies in acute neurological care previously highlighted by the Royal College of Physicians and the Association of British Neurologists. HANS adopts a disease-agnostic approach to acute neurology, prioritising the emergency department (ED) management of both stroke and stroke mimics alike alongside proactive daily support to the acute medical unit and acute medical take. Rapid access clinics provide a means to assess ambulatory patients, providing an outlet to reduce the burden of referral from primary care to acute medicine. This paper reports the results from the first year of the service. Admission was avoided in 25% of the cases reviewed in the ED. Compared to historic data, there was a significant improvement in the length of stay for non-stroke disorders while the occupancy of stroke beds by non-stroke cases reduced by 50%. The configuration of this service is replicable in other neuroscience centres and provides a framework to reduce the barriers facing patients who present with acute neurological symptoms.

Palliative care for Parkinson's disease (PD) is an emerging area of interest for clinicians, patients and families. Identifying the palliative care needs of caregivers is central to developing and implementing palliative services for families affected by PD. The objective of this paper was to elicit PD caregiver needs, salient concerns, and preferences for care using a palliative care framework.11 PD caregivers and one non-overlapping focus group (n = 4) recruited from an academic medical center and community support groups participated in qualitative semi-structured interviews. Interviews and focus group discussion were digitally recorded, transcribed and entered into ATLAS.ti for coding and analysis. We used inductive qualitative data analysis techniques to interpret responses.Caregivers desired access to emotional support and education regarding the course of PD, how to handle emergent situations (e.g. falls and psychosis) and medications. Participants discussed the immediate impact of motor and non-motor symptoms as well as concerns about the future, including: finances, living situation, and caretaking challenges in advanced disease. Caregivers commented on the impact of PD on their social life and communication issues between themselves and patient. All participants expressed interest and openness to multidisciplinary approaches for addressing these needs.Caregivers of PD patients have considerable needs that may be met through a palliative care approach. Caregivers were receptive to the idea of multidisciplinary care in order to meet these needs. Future research efforts are needed to develop and test the clinical and cost effectiveness of palliative services for PD caregivers.

Since 2007 our department could establish a very fruitful and important connection with the SOBRADPEC by the first author of this paper, thanking especially to Professor Saul Goldenberg and to Professor Edna F.S. Montero. By these connections and when attending the unforgettable congresses in Cuiaba (2007), Ribeirao Preto (2011) and in Belem (2012), we could exchange scientific and organizational concerns

Background Around the world, the last two decades have been characterised by an increase in the numbers of mergers between healthcare providers, including some of the most prestigious university hospitals and academic health centres. However, many mergers fail to bring the anticipated benefits, and successful post-merger integration in university hospitals and academic health centres is even harder to achieve. An increasing body of literature suggests that organisational culture affects the success of post-merger integration and academic-clinical collaboration. Methods This paper reports findings from a mixed-methods single-site study to examine 1) the perceptions of organisational culture in academic and clinical enterprises at one National Health Service (NHS) trust, and 2) the major cultural issues for its post-merger integration with another NHS trust and strategic partnership with a university. From the entire population of 72 clinician-scientists at one of the legacy NHS trusts, 38 (53%) completed a quantitative Competing Values Framework survey and 24 (33%) also provided qualitative responses. The survey was followed up by semi-structured interviews with six clinician-scientists and a group discussion including five senior managers. Results The cultures of two legacy NHS trusts differed and were primarily distinct from the culture of the academic enterprise. Major cultural issues were related to the relative size, influence, and history of the legacy NHS trusts, and the implications of these for respective identities, clinical services, and finances. Strategic partnership with a university served as an important ameliorating consideration in reaching trust merger. However, some aspects of university entrepreneurial culture are difficult to reconcile with the NHS service delivery model and may create tension. Conclusions There are challenges in preserving a more desirable culture at one of the legacy NHS trusts, enhancing cultures in both legacy NHS trusts during their post-merger integration, and in aligning academic and clinical cultures following strategic partnership with a university. The seeds of success may be found in current best practice, good will, and a near identical ideal of the future preferred culture. Strong, fair leadership will be required both nationally and locally for the success of mergers and post-merger integration in university hospitals and academic health centres. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0673-3) contains supplementary material, which is available to authorized users.

PURPOSE Patient participation in clinical decision making improves outcomes, including quality of life (QOL), but the typical problem-oriented approach may impede consideration of functional goals. We wondered if patients could encourage primary care physicians to pay attention to their QOL goals by writing them on pre-encounter forms. METHODS We conducted a randomized controlled trial comparing the impact of 2 different pre-visit questionnaires on the content of patient-physician encounters in a family medicine practice at an academic medical center. Using investigator-blinded block randomization, we arranged for 8 faculty and 8 resident physicians to participate in 2 intervention and 2 control videotaped encounters each for a total of 64 encounters. The intervention questionnaire included questions about QOL goals and concerns, while the control questionnaire asked about symptoms. Videotapes were reviewed to determine whether the patients’ QOL goals were mentioned and whether they were used in decision making. We also scored encounters using Modified Flanders Interaction Analysis, which assesses and codifies patient and physician communication, and the Modified Carkhuff-Truax Scale, which measures empathy, attending, congruence, and positive regard. RESULTS Patients were able to record QOL goals and concerns, but QOL issues were mentioned in only 2 of the 64 encounters, once by a patient and once by a physician. In neither case was this information used in decision making. More empathy was expressed by physicians during control encounters (P = .03). CONCLUSIONS Patients were able to articulate their QOL goals on paper, but that did not prime them or their physicians to alter the process or content of the clinical encounters. In fact, providing QOL information was associated with reduced physician empathy.

Venous thromboembolism (VTE) affects 0.1–0.3% people each year. The risk of VTE following gynecological surgery and invasive procedures is well established and presents one of the major challenges in gynecological practice. Moreover, commonly use assisted reproductive techniques (ART) are reported to increase the risk of VTE. Despite continued efforts to reduce its incidence, postoperative VTE remains the second most common perioperative complication and the third most common cause of mortality. Several practice guidelines have been developed regarding prophylaxis and treatment of VTE. However, there is a large inconsistency between the recommendations and the medical practice in various centers. Moreover, prophylaxis in gynecological patients and women undergoing ART should be chosen individually for the patient, taking into account the possible risk factors for VTE and perioperative bleeding complications. Until recently, the percentage of women, who have not received anticoagulant prophylaxis or administrated it inadequately may reach 50%. This paper presents the current recommendations regarding thromboprophylaxis in women undergoing gynecological surgery or assisted reproductive techniques and addresses challenging practical issues in this field.

T his retrospective, interrupted time-series analysis by Gonzalo et al. evaluated the effect of an overnight academic hospitalist (OAH) program on patient-level outcomes at a large university-based acute care hospital. The intervention consisted of a year-round overnight academic hospitalist program staffed by one hospitalist physician and coincided with the hours of the night float housestaff. The study showed no significant change in their patientlevel outcomes including the average length of stay, inhospital mortality rate, 30-day readmission rate, and upgrades in care to intensive care unit. The outcomes as described above were important to evaluate in this study. However, there are likely better components for measuring whether residents and supervising hospitalists were in fact impacting the health of patients. Patient-reported outcome measures (PROMs) are a helpful component of assessing whether clinicians are improving the health of patients. Unlike process measures, which capture provider productivity and adherence to the standards of recommended care, or patient experience measures, which focus on aspects of care delivery, PROMs seek to understand whether the services provided actually improved patients health and sense of well-being. For example, through the implementation of an OAH program, patients might be asked to assess their general health and satisfaction in care overnight. Moreover, it would seem that not only the patient-reported outcome measures but also a learner-reported outcome measure would show promising results. In the paper by Haber et al., increased overnight supervision enhanced the clinical value of the night float rotation, increased rates of attending contact during critical clinical decision-making, and improved perception of patient care. Nighttime supervision is a key concept in medical education and is critical in ensuring safe and effective patient care. As noted by Hanson et al., nighttime education should be transformed in a way that maintains clinical productivity for both attending and resident physicians, integrates high-quality teaching and curricula, and achieves a balance between patient safety and resident autonomy. The results of the study are promising and helpful for programs as they aim to implement systems to ensure appropriate nighttime supervision. Further study is needed to assess the impact on broader patient outcomes.

AIM: To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established. METHODS: Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians’ knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators. RESULTS: An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient’s visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett’s esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer. CONCLUSION: Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.

Knowledge about what motivates patients to visit the emergency department (ED) of a hospital for minor complaints, instead of visiting their general practitioner (GP), can help to reduce unnecessary utilization of expensive services. This paper reports on a study designed to investigate the reasons why patients visit the ED and to determine the influence of patient characteristics on specific motives. A multidimensional measurement instrument was designed to identify the motives of patients who bypass their GP and visit the ED. The instrument assessed 21 motives, all measured by means of three questions in Likert format. During a period of 1 week, all patients who visited the ED of two hospitals in Amsterdam were asked to complete a questionnaire when they were 'self-referred' with minor complaints. A total of 403 questionnaires were analysed, and the results show that motives relating to the GP play a minor role in the decision of patients to visit the ED. Profiles of two major patient groups could be identified. One group comprised patients with a high socio-economic status living in suburbs, whose motives for visiting the ED are mainly of a financial nature. Patients in the second group mainly lived in the inner-city, and preferred the expertise and facilities provided by the ED.

Two distinct but interrelated phenomena are currently impacting the practice of medicine: the shift in gender balance and the changing expectations of the present generation regarding the importance of work and family life. Although many more women are studying medicine, certain disciplines have been slow to reflect this change, perhaps owing to the culture of the specific area of practice. While the percentage of women choosing a surgical career is increasing, the numbers remain low, particularly in academic surgery.1–3 Over the last 2 decades, there has been a growing interest in the challenges faced by female surgeons.1,2,4–8 Studies have examined the deterrents to choosing a surgical career as well as the barriers, such as a lack of mentors, child-bearing and child care, workload and lifestyle issues, to women pursuing an academic position in surgery.1,2,6–9 Furthermore, female surgeons consistently report the challenges they encounter in balancing the demands of their personal and professional responsibilities.1,5,10,11 The era that defines one’s generation is associated with specific behaviours, attitudes and expectations. Generation X, which includes individuals born between 1965 and 1981, represents many of the young physicians who are commencing their medical practice. Characteristics often attributed to Generation X include an expectation to work hard but not at the expense of family, friends or personal growth; a desire for autonomy; and loyalty to themselves versus an organization or institution. They also seek flexibility and portability in their career paths and are up to date with the latest technology.12–19 While editorials comment on the potential impact of the current generation of young physicians on the practice of medicine and surgery specifically, empirical research on this issue is scant.12–15 In a mixed methods study examining generational differences among internal medicine physicians, the qualitative findings revealed that Generation X physicians were less committed, whereas the quantitative survey data found few differences between the attitudes of Baby Boomers and the Generation X physicians toward patient care and work–life balance. The notable difference was that the younger physicians worked significantly longer hours than their senior colleagues.16 In contrast, recent policy decisions have regulated resident duty hours; hence the decrease in hours likely reflects both the attitudes of this current generation and the externally imposed guidelines.17,18 The literature also suggests that as Generation X physicians assume academic positions in medical schools, a shift in priorities may influence the culture of the institution.19 The issues of the gender balance in medicine and Generation X are not unique to the discipline of surgery. However, this specialty has historically been male-dominated and has been described as an environment that is “macho” in nature and in which long hours, at the expense of family time, have been the norm.3,19 The initial impetus of the present study was recognition of a substantial increase in the number of female academic surgeons recently recruited to the Department of Surgery at the Schulich School of Medicine and Dentistry, Western University. Departmental leadership had paid specific attention to increasing the number of qualified women candidates in the recruitment pool. In 2002, the department had 55 full-time clinical faculty. In the subsequent 7 years, 24 full-time faculty were hired with an equal distribution of men and women, bringing the total number of women in the department from 2 to 14. In a prior publication,20 we reported the complexity of making choices as experienced by these new recruits as they tried to establish a balance between their personal and professional lives. The present paper focuses on how the new recruits perceived the change in the gender balance and how the different priorities of their generation influenced their attitudes and behaviours.

Prostate cancer (PrCA) is the most commonly diagnosed non-skin cancer among men. PrCA mortality in African-American (AA) men in South Carolina is ~50% higher than for AAs in the U.S as a whole. AA men also have low rates of participation in cancer research. This paper describes partnership development and recruitment efforts of a Community-Academic-Clinical research team for a PrCA education intervention with AA men and women that was designed to address the discordance between high rates of PrCA mortality and limited participation in cancer research. Guided by Vesey's framework on recruitment and retention of minority groups in research, recruitment strategies were selected and implemented following multiple brainstorming sessions with partners having established community relationships. Based on findings from these sessions culturally appropriate strategies are recommended for recruiting AA men and women for PrCA education research. Community-based research recruitment challenges and lessons learned are presented.

Objectives Although candidaemia is a well-known complication of hospital stay and has a crude mortality of ∼40%, few data are available for episodes diagnosed within 10 days after hospital admission. In this paper, we compared the risk factors for mortality according to the onset of candidaemia. Methods This was a retrospective study of hospitalized patients with early-onset candidaemia (EOC; ≤10 days) or late-onset candidaemia (LOC; >10 days) to identify any distinct clinical characteristics and risk factors for 30 day mortality in two Italian academic centres. Results A total of 779 patients were included in the study: 183 EOC and 596 LOC. Mortality was significantly lower in EOC (71/183, 38.8% versus 283/596, 47.5%, P = 0.03). In EOC, multivariate analysis showed that inadequate initial antifungal therapy (IIAT) (P = 0.005, OR 3.02, 95% CI 1.40–6.51), Candida albicans aetiology (P = 0.02, OR 2.17, 95% CI 1.11–4.26) and older age (P

Evidence suggests selenium concentrations outside the nutritional range may worsen cardiovascular health. This paper examines the relationship between selenium and maternal blood pressure among 270 deliveries using umbilical cord serum as a proxy for maternal exposure levels. Multivariable models used linear splines for selenium and controlled for gestational age, maternal age, race, median household income, parity, smoking, and prepregnancy body mass index. Nonparametric analysis of this dataset was used to select spline knots for selenium at 70 and 90 μg/L. When selenium was 90 μg/L. Other studies indicate that the maternal/cord selenium ratio is 1.46 (95% CI: 1.28, 1.65). This u-shaped relationship between selenium and blood pressure is consistent with a dual role of selenium as an essential micronutrient that is nonetheless a toxicant at higher concentrations; however this needs to be studied further.

Arterial blood pressure (BP) measurement at least every 5 minutes is part of the American Society of Anesthesiologists' monitoring standard, but prolonged BP gaps in electronic anesthesia records have been noted. We undertook multicenter studies to determine the frequency of cases with at least 1 interval ≥10 minutes between successive BP measurements and then to ascertain whether educational feedback via an electronic, near real-time notification system alerting providers to the presence of such gaps would reduce their incidence.We evaluated 212,706 electronic anesthesia records from 3 large academic centers. We determined the fraction of cases with ≥10-minute BP monitoring gaps at baseline and did a root cause analysis to determine common causes for these lapses. We then designed and implemented automated systems at 2 of the hospitals to notify point-of-care providers immediately after such 10-minute gaps occurred and determined the subsequent impact of this feedback on BP gap incidence, compared with baseline.At Hospital A, the notification system reduced the incidence of cases with at least 1 BP gap (1.48%± 0.19% SD vs 0.79% ± 0.36% SD, P0.0001). At Hospital B, the gap incidence was not significantly altered when notification was provided after a 10-minute gap had already occurred (2.72% ± 0.60% SD vs 2.45% ± 0.48% SD, P = 0.27), but the incidence was reduced when such notification was provided after 6 minutes without a BP reading (2.72% ± 0.60% SD vs 1.54% ± 0.19% SD, P0.0001). At Hospital C, where notification was not implemented, the baseline rate of BP gaps was consistent across the preintervention and follow-up periods (7.03% ± 1.27% SD vs 7.13% ± 0.11% SD, P = 0.74). Although monitors disconnected during position change was the most common identifiable cause of BP gaps, reasons for the missing BP measurements were often not documented. During a week when the electronic charting system was temporarily inoperable, no BP gaps were noted on a convenience sample of 500 paper records from Hospital A (99% upper confidence limit = 0.83%).BP gaps of ≥10 minutes were common in electronic anesthesia records, and their incidence was reduced but not eliminated by near real-time feedback to providers. The American Society of Anesthesiologists' standard for BP documentation every 5 minutes might not be achievable with current practices and technology. Anesthesia information management systems users need to be cognizant of the potential for gaps in BP measurement, take steps to minimize their occurrence, and document an explanation when such failures occur.

Background Employees in health care service are at high risk for developing mental health complaints. The effects of mental health complaints on work can have serious consequences for the quality of care provided by these workers. To help health service workers remain healthy and productive, preventive actions are necessary. A Workers' Health Surveillance (WHS) mental module may be an effective strategy to monitor and promote good (mental) health and work performance. The objective of this paper is to describe the design of a three arm cluster randomized controlled trial on the effectiveness of a WHS mental module for nurses and allied health professionals. Two strategies for this WHS mental module will be compared along with data from a control group. Additionally, the cost effectiveness of the approaches will be evaluated from a societal perspective. Methods The study is designed as a cluster randomized controlled trial consisting of three arms (two intervention groups, 1 control group) with randomization at ward level. The study population consists of 86 departments in one Dutch academic medical center with a total of 1731 nurses and allied health professionals. At baseline, after three months and after six months of follow-up, outcomes will be assessed by online questionnaires. In both intervention arms, participants will complete a screening to detect problems in mental health and work functioning and receive feedback on their screening results. In cases of impairments in mental health or work functioning in the first intervention arm, a consultation with an occupational physician will be offered. The second intervention arm offers a choice of self-help e-mental health interventions, which will be tailored based on each individual's mental health state and work functioning. The primary outcomes will be help-seeking behavior and work functioning. Secondary outcomes will be mental health and wellbeing. Furthermore, cost-effectiveness in both intervention arms will be assessed, and a process evaluation will be performed. Discussion When it is proven effective compared to a control group, a WHS mental module for nurses and allied health professionals could be implemented and used on a regular basis by occupational health services in hospitals to improve employees' mental health and work functioning. Trial Registration NTR2786

BCM faculty members spearheaded development of a first generation Personal Genome Profile (Baylor PGP) assay to assist physicians in diagnosing and managing patients in this new era of medicine. The principles that are guiding the design and implementation of the Baylor PGP are high quality, robustness, low expense, flexibility, practical clinical utility and the ability to facilitate broad areas of clinical research. The single most distinctive feature of the approach taken is an emphasis on extensive screening for rare disease causing mutations rather than common risk-increasing polymorphisms. Because these variants have very large direct effects, the ability to inexpensively screen for them could have major immediate clinical impact in disease diagnosis, carrier detection, pre-symptomatic detection of late onset disease and even prenatal diagnosis. In addition to creating a counseling tool for individual ‘consumers’ this system will fit into the established medical record and be used by physicians involved in direct patient care. This paper describes an overall framework for clinical diagnostic array genotyping, and the available technologies as well as highlights the opportunities and challenges for implementation.

Background The evaluation of academic research performance is nowadays a priority issue. Bibliometric indicators such as the number of publications, total citation counts and h-index are an indispensable tool in this task but their inherent association with the size of the research output may result in rewarding high production when evaluating institutions of disparate sizes. The aim of this study is to propose an indicator that may facilitate the comparison of institutions of disparate sizes. Methods The Modified Impact Index (MII) was defined as the ratio of the observed h-index (h) of an institution over the h-index anticipated for that institution on average, given the number of publications (N) it produces i.e. (α and β denote the intercept and the slope, respectively, of the line describing the dependence of the h-index on the number of publications in log10 scale). MII values higher than 1 indicate that an institution performs better than the average, in terms of its h-index. Data on scientific papers published during 2002–2006 and within 36 medical fields for 219 Academic Medical Institutions from 16 European countries were used to estimate α and β and to calculate the MII of their total and field-specific production. Results From our biomedical research data, the slope β governing the dependence of h-index on the number of publications in biomedical research was found to be similar to that estimated in other disciplines (≈0.4). The MII was positively associated with the average number of citations/publication (r = 0.653, p < 0.001), the h-index (r = 0.213, p = 0.002), the number of publications with ≥ 100 citations (r = 0.211, p = 0.004) but not with the number of publications (r = -0.020, p = 0.765). It was the most highly associated indicator with the share of country-specific government budget appropriations or outlays for research and development as % of GDP in 2004 (r = 0.229) followed by the average number of citations/publication (r = 0.153) whereas the corresponding correlation coefficient for the h-index was close to 0 (r = 0.029). MII was calculated for first 10 top-ranked European universities in life sciences and biomedicine, as provided by Times Higher Education ranking system, and their total and field-specific performance was compared. Conclusion The MII should complement the use of h-index when comparing the research output of institutions of disparate sizes. It has a conceptual interpretation and, with the data provided here, can be computed for the total research output as well as for field-specific publication sets of institutions in biomedicine.

Perseverance is central to a successful career in aca-demic surgery [2] . The acquisition of patient data and subsequent analysis can be extremely tedious and frus-trating. Moreover, only rarely do manuscripts or grant submissions meet with immediate success. In many cas-es, acceptance is contingent upon major revisions, or even more likely, the article will simply be rejected out of hand. It is essential that the aspiring academic surgeon remains undiscouraged by these setbacks and continues resolutely in his or her course of action. The authors, themselves, experienced having a manuscript rejected multiple times by high-quality journals before it was fi-nally published. It would have been easy to abandon this manuscript in profound frustration after the third or fourth rejection, but the authors were convinced that the article had real merit and should be offered to the surgi-cal community. In another instance, one of the authors submitted an article to a high-impact factor, peer-reviewed surgical journal, which was summarily rejected. Persistence, how-ever, paid off: when the author carefully read the review-ers’ remarks, he found that some of the comments that had prompted the rejection of the paper were, in his esti-A c areer in academic surgery can be a challenging un-dertaking, with many potentially daunting hurdles to overcome. What does it take to succeed in the field of academic surgery? Which aspects are needed to excel as an academic surgeon?T he objective of the following short article [1] i s to pro-vide a guide for the surgical resident who has the desire and enthusiasm to become an academic surgeon.

My title is adapted from that used by Professor Sir Stanley Peart in a personal paper published in 1970.1 His argument was that general internal medicine had differentiated sufficiently for there to be no place for a general physician in an academic department. There would be physicians specialising in the various body systems, relying on general practitioners (GPs) to choose the most suitable for their patients. Similar developments are taking place in UK paediatrics but I will argue that (a) there will remain an important place for the general paediatrician and (b) the specialty of general paediatrics should be recognised as one alongside others such as paediatric gastroenterology and carrying comparable esteem. Developments in medical knowledge and consumer preference mean that the traditional authority of doctors to determine the content and style of their practice is being challenged.2 3 Other physicians and professionals may claim that they could do a general paediatrician’s job more effectively or cheaply. Paediatrics is not the only specialty where stock might be taken of its content and purpose.4-6 However the establishment of the Royal College of Paediatrics and Child Health, closer integration with Europe, and changes in primary and tertiary care in paediatrics all justify questioning the future of the generalist paediatrician. What is general paediatrics? In the UK it is secondary care paediatrics practised by up to half a dozen specialist consultants serving a population of approximately 250 000. The position is different in most of the rest of the world. Here the general paediatrician may be a primary care physician providing services to a population similar to a UK primary care GP but seeing only children and having greater paediatric expertise. In some parts of the world the traditional primary care paediatrician is under threat, particularly from the development of family …

Background Although regulatory compliance in academic research is enforced by law to ensure high quality and safety to participants, its implementation is frequently hindered by cost and logistical barriers. In order to decrease these barriers, we have developed a Web-based application, Duke Surgery Research Central (DSRC), to monitor and streamline the regulatory research process. Results The main objective of DSRC is to streamline regulatory research processes. The application was built using a combination of paper prototyping for system requirements and Java as the primary language for the application, in conjunction with the Model-View-Controller design model. The researcher interface was designed for simplicity so that it could be used by individuals with different computer literacy levels. Analogously, the administrator interface was designed with functionality as its primary goal. DSRC facilitates the exchange of regulatory documents between researchers and research administrators, allowing for tasks to be tracked and documents to be stored in a Web environment accessible from an Intranet. Usability was evaluated using formal usability tests and field observations. Formal usability results demonstrated that DSRC presented good speed, was easy to learn and use, had a functionality that was easily understandable, and a navigation that was intuitive. Additional features implemented upon request by initial users included: extensive variable categorization (in contrast with data capture using free text), searching capabilities to improve how research administrators could search an extensive number of researcher names, warning messages before critical tasks were performed (such as deleting a task), and confirmatory e-mails for critical tasks (such as completing a regulatory task). Conclusion The current version of DSRC was shown to have excellent overall usability properties in handling research regulatory issues. It is hoped that its release as an open-source application will promote improved and streamlined regulatory processes for individual academic centers as well as larger research networks.

The World Health Organization's goal of Health for All by the Year 2000 (HFA) has become a major force in national and international health policies. This paper deals with some of the historical roots of HFA and describes ways in which the major components of the health sector--health services, manpower, and universities--have evolved and should evolve in the future if they are to support the idea of HFA. One conclusion is that the changes called for in relation to HFA are not simply incremental extensions of previous values, structures, and functions. Rather a radical break with the past is often required. To expect otherwise is to misunderstand how fundamentally the concepts of HFA differ from values that have governed the health sector in the past. A second conclusion is that recent decades have seen a remarkable progression of new ideas and changes in the health sector, so much so that the changes called for by HFA are not so improbable as one might otherwise think.