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© European Stroke Organisation 2021, Purpose: Many daily-life clinical decisions in patients with cerebrovascular disease and cognitive impairment are complex. Evidence-based information sustaining these decisions is frequently lacking. The aim of this paper is to propose a practical clinical approach to cognitive impairments in patients with known cerebrovascular disease. Methods: The document was produced by the Dementia Committee of the European Stroke Organisation (ESO), based on evidence from the literature where available and on the clinical experience of the Committee members. This paper was endorsed by the ESO. Findings: Many patients with stroke or other cerebrovascular disease have cognitive impairment, but this is often not recognized. With improvement in acute stroke care, and with the ageing of populations, it is expected that more stroke survivors and more patients with cerebrovascular disease will need adequate management of cognitive impairment of vascular etiology. This document was conceived for the use of strokologists and for those clinicians involved in cerebrovascular disease, with specific and practical hints concerning diagnostic tools, cognitive impairment management and decision on some therapeutic options. Discussion and conclusions: It is essential to consider a possible cognitive deterioration in every patient who experiences a stroke. Neuropsychological evaluation should be adapted to the clinical status. Brain imaging is the most informative biomarker concerning prognosis. Treatment should always include adequate secondary prevention.

Background Harmful Alcohol use is frequent among opioid dependents patients undergoing agonist maintenance treatment. The objective assessment of harmful alcohol use can be done using laboratory measures of serum biomarkers. For community-based patients, there is often a requirement of an alternative method due to lack of onsite laboratory services. The aim of the study was to examine filter paper as a matrix to measure serum biomarkers of harmful alcohol use. Methods The initial phase involved standardization of the filter-paper-based assay. Conditions were optimised for extraction and estimation of alcohol biomarkers (Aspartate Aminotransferase; AST, Alanine Aminotransferase; ALT, Gamma Glutamyl transferase; GGT and Carbohydrate Deficient Transferrin; CDT) from the filter paper. For clinical validation, serum samples were collected from community clinics. Biomarker levels obtained from both the methods were correlated using linear regression analysis. Limits of agreement between the two methods was estimated using the Intraclass Correlation Coefficient (ICC). Results The extraction of enzymes (AST, ALT and GGT) from filter paper was carried out using the substrate buffer available with the reagent kit (Randox, UK). CDT was readily extracted from filter paper using deionised water. Serum biomarker levels measured from samples collected from community clinics correlated well with filter paper extracted levels (ICC 0.97-0.99). More than 90% of alcohol biomarker levels were recovered from the filter paper matrix using this method. Conclusion Filter paper has the potential to be used as a matrix to objectively measure alcohol biomarkers among opioid-dependent patients from community settings lacking onsite laboratory facilities.

Gender disparity exists in leadership roles within healthcare. While the majority of the healthcare workforce is comprised of women, significantly fewer women occupy leadership positions, particularly at executive and board levels. As the field of oncology pharmacy continues to rapidly expand and evolve, an assessment of the current state of women in oncology pharmacy leadership roles is vital to the growth and development of the profession. In the fall of 2017, the Hematology/Oncology Pharmacy Association (HOPA) hosted a summit to explore leadership issues facing women in oncology pharmacy which have the potential to affect our membership and our profession. This meeting included invited participants from across the fields of oncology and pharmacy and was part of HOPA’s strategic leadership initiative developed through the work of the HOPA Leadership Development Committee in 2016. This promotes a primary goal of HOPA, which is to support oncology pharmacists as they assume leadership roles within their practices and within healthcare to assure oncology pharmacy is integrated into cancer care. The purpose of this white paper is to (1) summarize key issues that were identified through a membership survey; (2) review ongoing efforts to address the needs of female oncology pharmacists in leadership development; (3) serve as a call to action for individuals and professional organizations to assist with and disseminate these efforts and highlight available resources, and (4) to provide practical steps to meet the needs of individuals, training programs, and institutions/employers.

The clinical, educational, and research facets of lung transplantation have advanced significantly since the first lung transplant in 1963. The formation of the International Society for Heart and Lung Transplantation (ISHLT) and subsequent Registry has forged a precedent of collaborative teamwork that has significantly affected current lung transplantation outcomes. The Society for the Advancement of Anesthesia (SATA) is dedicated to developing educational platforms for all facets of transplant anesthesia. Additionally, we believe that the anesthetic training for lung transplantation has not kept pace with other advances in the field. As such, SATA presents for consideration these educational milestones and competencies for anesthetic fellowship training in the field of lung transplantation. The proposed milestones were designed on the framework of 6 core competencies created by the Accreditation Council on Graduate Medical Education. The milestones were identified by combining the expert opinion of our Thoracic Transplant Committee, our experience as educators, and literature review. We offer this White Paper to the anesthesiology and transplant communities as a starting point for the discussion and evolution of perioperative anesthetic care in the field of lung transplantation.

Background Missed nursing care is a complex healthcare problem. Extant literature in this area identifies several interventions that can be used in acute hospital settings to minimise the impact of missed nursing care. However, controversy still exists as to the effectiveness of these interventions on reducing the occurrence of missed nursing care. Aim This theoretical paper aimed to provide a conceptual understanding of missed nursing care using complexity theory. Methods The method utilised for this paper is based on a literature review on missed care and complexity theory in healthcare. Results We found that the key virtues of complexity theory relevant to the missed nursing care phenomenon were adaptation and self-organisation, non-linear interactions and history. It is suggested that the complex adaptive systems approach may be more useful for nurse managers to inform and prepare nurses to meet uncertain encounters in their everyday clinical practice and therefore reduce instances of missed care. Conclusions This paper envisions that it is time that methods used to explore missed care changed. Strategies proposed in this paper may have an important impact on the ability of nursing staff to provide quality and innovative healthcare in the modern healthcare system.

Artificial intelligence (AI) is rapidly moving from an experimental phase to an implementation phase in many fields, including medicine. The combination of improved availability of large datasets, increasing computing power, and advances in learning algorithms has created major performance breakthroughs in the development of AI applications. In the last 5 years, AI techniques known as deep learning have delivered rapidly improving performance in image recognition, caption generation, and speech recognition. Radiology, in particular, is a prime candidate for early adoption of these techniques. It is anticipated that the implementation of AI in radiology over the next decade will significantly improve the quality, value, and depth of radiology's contribution to patient care and population health, and will revolutionize radiologists' workflows. The Canadian Association of Radiologists (CAR) is the national voice of radiology committed to promoting the highest standards in patient-centered imaging, lifelong learning, and research. The CAR has created an AI working group with the mandate to discuss and deliberate on practice, policy, and patient care issues related to the introduction and implementation of AI in imaging. This white paper provides recommendations for the CAR derived from deliberations between members of the AI working group. This white paper on AI in radiology will inform CAR members and policymakers on key terminology, educational needs of members, research and development, partnerships, potential clinical applications, implementation, structure and governance, role of radiologists, and potential impact of AI on radiology in Canada.

In September 1847, David John Thomas read a paper on etherisation at a monthly meeting of the Port Phillip Medical Association. Thomas’ paper is the earliest known presentation of a paper on etherisation in the Australian colonies. Almost half of Thomas’ 27-page manuscript was published in October 1847 in the Australian Medical Journal. The original manuscript was acquired at an unknown date by the Medical Society of Victoria. Although a full transcript of the manuscript was published in 1933, the original manuscript of Dr Thomas remained unknown to anaesthesia historians and is now held by the Medical History Museum, University of Melbourne.

Cancer & the Kidney International Network was created in 2014. The aim was to improve the management of cancer patients by developing clinical and scientific knowledge on the main topic of cancer and the kidney. Therefore, the Cancer & the Kidney International Network created a special working group: the Thrombosis, Kidney Disease, and Cancer working Group. The first step of this force was to produce a position paper on this topic by investigating the association of chronic kidney disease and venous thromboembolism in cancer patients, focusing particularly on the anticoagulant management of patients presenting these three comorbidities. The use of low-molecular-weight heparins, vitamin K agonists and oral direct anticoagulants in cancer patients with chronic kidney disease was reviewed.

Sudden unexpected death of an individual with epilepsy (SUDEP) can pose a challenge to death investigators, as most deaths are unwitnessed and the individual is commonly found dead in bed. Anatomic findings (e.g., tongue/lip bite) are commonly absent and of varying specificity, limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus, it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden, unexpected death in a person with epilepsy is encountered.

The National Association of Medical Examiners commissioned an ad hoc committee to provide recommendations for the investigation, examination, and reporting of deaths in custody. Deaths in custody, whether occuring in jail/prison or during an altercation with law enforcement, is a complex issue and requires the forensic pathologist to be knowledgable and deliberative about his/her diagnosis. This paper provides recommendations for the forensic pathologist as it relates to 1) categorization of deaths in custody, 2) critical information required during investigation, 3) enhanced autopsy procedures, 4) guidance on death certification, 5) parameters for statistical reporting, and 6) release of information to the public. A uniform approach by medical examiners and coroners to the investigation and evaluation of deaths in custody is critical. The establishment of recommendations has the potential to ensure consistency and reliability to the definition, investigation, and certification of these cases. Such uniformity and consistency will instill confidence in the independence of the medical examiner/forensic pathologist/coroner by the criminal justice system, public health system, and community at large.

Brachiocephalic arteriovenous fistulas (AVF) makeup approximately one third of prevalent dialysis vascular accesses. The most common cause of malfunction with this access is cephalic arch stenosis (CAS). The accepted requirement for treatment of a venous stenosis lesion is ⩾50% stenosis associated with hemodynamically abnormalities. However, the correlation between percentage stenosis and a clinically significant decrease in access blood flow (Qa) is low. The critical parameter is the absolute minimal luminal diameter (MLD) of the lesion. This is the parameter that exerts the key restrictive effect on Qa and results in hemodynamic and functional implications for the access. CAS is the result of low wall shear stress (WSS) resulting from the effects of increased blood flow and the unique anatomical configuration of the CAS. Decrease in WSS has a linear relationship to increased blood flow velocity and neointimal hyperplasia exhibits an inverse relationship with WSS. The result is a stenotic lesion. The presence of downstream venous stenosis causes an inflow-outflow mismatch resulting in increased pressure within the access. Qa in this situation may be decreased, increased, or within a normal range. Over time, the increased intraluminal pressure can result in marked aneurysmal changes within the AVF, difficulties with cannulation and the dialysis treatment, and ultimately, increasing risk of access thrombosis. Complete characterization of the lesion both hemodynamically and anatomically should be the first step in developing a strategy for management. This requires both access flow measurement and angiographic imaging. Patients with CAS present a relatively broad spectrum as relates to both of these parameters. These data should be used to determine whether primary treatment of CAS should be directed toward the anatomical lesion (small MLD and low Qa) or the pathophysiology (large MLD and high Qa).

Objective: To determine whether patients with stroke receiving rehabilitation for upper limb deficits using smart technology (video and reminder functions) demonstrate greater adherence to prescribed home exercise programmes and better functional outcomes when compared with traditional paper-based exercise prescription. Design: Randomized controlled trial comparing upper limb home exercise programmes supported by video and automated reminders on smart technology, with standard paper-based home exercise programmes. Setting: A community rehabilitation programme within a large metropolitan health service. Subjects: Patients with stroke with upper limb deficits, referred for outpatient rehabilitation. Interventions: Participants were randomly assigned to the control (paper-based home exercise programme) or intervention group (home exercise programme filmed on an electronic tablet, with an automated reminder). Both groups completed their prescribed home exercise programme for four weeks. Main measures: The primary outcome was adherence using a self-reported log book. Secondary outcomes were change in upper limb function and patient satisfaction. Results: A total of 62 participants were allocated to the intervention ( n = 30) and control groups ( n = 32). There were no differences between the groups for measures of adherence (mean difference 2%, 95% CI −12 to 17) or change in the Wolf Motor Function Test log transformed time (mean difference 0.02 seconds, 95% CI −0.1 to 0.1). There were no between-group differences in how participants found instructions ( p = 0.452), whether they remembered to do their exercises ( p = 0.485), or whether they enjoyed doing their exercises ( p = 0.864). Conclusions: The use of smart technology was not superior to standard paper-based home exercise programmes for patients recovering from stroke. This trial design was registered prospectively with the Australian and New Zealand Clinical Trials Register, ID: ACTRN 12613000786796. http://www.anzctr.org.au/trialSearch.aspx

Purpose: This work aimed to identify and analyze the most frequently cited articles in retinal detachment (RD). Methods: Institute for Scientific Information’s Web of Science index (Thomas Scientific) was used to identify the top 100 most cited articles on RD between 1900 and 2019. Data from the top 100 most cited articles that met inclusion criteria were analyzed based on title, citation frequency, authorship, institution, journal, year of publication, and country of origin. Results: The top 100 articles in RD were cited 88 to 480 times. Steven K. Fisher was the most cited individual, with the University of California system being the most cited organization. Sixty-four percent of the top 100 articles originated from the United States and were published in the American Journal of Ophthalmology, Ophthalmology, and Archives of Ophthalmology at frequencies of 36%, 24%, and 11%, respectively. The top funding agencies included the US Department of Health and Human Services, the National Institutes of Health, and the National Eye Institute at 29%, 28%, and 27%, respectively. The top-cited article, which assessed the role of the retinal pigment epithelium by histologic and electron microscopic analysis of RDs in eyes of owl monkeys, was by Machemer and Laqua in the American Journal of Ophthalmology. Conclusions: This bibliometric analysis provides researchers and clinicians with a detailed overview of the most cited manuscripts in RD. Such analyses may guide researchers and funding agencies on important research areas in the field.

The anesthesia community has openly debated if the care of transplant patients was generalist or specialist care ever since the publication of an opinion paper in 1999 recommended subspecialty training in the field of liver transplantation anesthesia. In the past decade, liver transplant anesthesia has become more complex with a sicker patient population and evolving evidence-based practices. Transplant training is currently not required for accreditation or certification in anesthesiology, and not all anesthesia residency programs are associated with transplant centers. Yet there is evidence that patient outcome is affected by the experience of the anesthesiologist with liver transplants as part of a multidisciplinary care team. Requests for a formal review of the inequities in training opportunities and requirements led the Society for the Advancement for Transplant Anesthesia (SATA) to begin the task of developing post-graduate fellowship training recommendations. In this article, members of the SATA Working Group on Transplant Anesthesia Education present their reasoning for specialized education and conclusions about which pathways can better prepare trainees to care for complex transplant patients.

Around the world, school staff are increasingly expressing concern about nonsuicidal self-injury (NSSI) and how best to address this behavior in the school setting. However, there is a notable lack of informed guidance for schools, and clear inconsistencies in the practices school staff adopt. In this position paper we draw on our collective research and clinical expertise to provide best-practice guidelines for addressing NSSI in school settings. We outline the importance of a school protocol, and the key features all school protocols should contain. We also focus on how schools can minimize contagion of NSSI within their school environment. We believe these guidelines will be an important starting point for schools interested in developing an evidence-based approach to addressing NSSI.

Background: GlucoTab, an electronic diabetes management system (eDMS), supports healthcare professionals (HCPs) in inpatient blood glucose (BG) management at point-of-care and was implemented for the first time under routine conditions in a regional hospital to replace the paper insulin chart. Method: To investigate quality of the eDMS for inpatients with type 2 diabetes mellitus a monocentric retrospective before-after evaluation was conducted. We compared documentation possibilities by assessing a blank paper chart vs the eDMS user interface. Further quality aspects were compared by assessing filled-in paper charts ( n = 106) vs filled-in eDMS documentation ( n = 241). HCPs ( n = 59) were interviewed regarding eDMS satisfaction. Results: The eDMS represented an improvement of documentation possibilities by offering a more structured and comprehensive user interface compared to the blank paper chart. The number of good diabetes days averaged to a median value of four days in both groups (paper chart: 4.38 [0-7] vs eDMS: 4.38 [0-7] days). Median daily BG was 170 (117-297) mg/dL vs 168 (86-286) mg/dL and median fasting BG was 152 (95-285) mg/dL vs 145 (69-333) mg/dL, and 0.1% vs 0.4% BG values Conclusions: The eDMS completely replaced the paper chart, showed comparable glycemic control, was positively accepted by HCPs, and is suitable for inpatient diabetes management.

This initial study used an equivalent-groups design to evaluate differences in story comprehension scores between children with autism spectrum disorder (ASD) and their neurotypical (NT) peers using paper and iPad® storybooks. Fifteen children with ASD of ages 4–6 and 15 NT peers matched for receptive vocabulary age and gender met inclusion criteria. Across two individualized testing sessions, participants answered language abstraction questions about three formats of Pete the Cat stories (paper, iPad adult read, and iPad with the read-to-me feature activated) during shared storybook reading. When examining the entire group of participants, all children performed better with either type of iPad storybook compared to the paper book. The current study indicates storybooks on the iPad function in similar ways for NT children and children with ASD. Further, this research shows promise for using the iPad with young children during shared storybook reading. Directions for future research and implications for special education personnel are provided.

Summary Letter writing was used as a qualitative research strategy to access the narratives of individuals living in rural poverty. Undergraduate social work students in a freshman seminar course were paired with participants of a local agency to engage in a letter writing exchange about life experiences. Community members who volunteered to participate in the letter-writing exchange were identified via their participation in services offered by a local, community-based agency that is situated in a rural community. In the fall of 2018, a sample of 20 community members and 28 students participated in two rounds of letter exchange. Findings The letter-writing exchange was an effective way to collect data. The content of the letters enhanced students’ understanding of the daily experiences of individuals living in rural poverty. Data collected demonstrated that social isolation remains a central concern among poor, rural residents. Letter writing supported a sense of personal connection between students and community members; these social connections may have attenuated the pain of social isolation that many community members experience. Applications Narrative inquiry and the use of letter writing as a research methodology allowed us access to greater understanding about the lived experience of rural poverty. People living in rural poverty experience a layered isolation that keeps them separate from resources and each other. Letter writing provided connection and rich data that enhanced our understanding of this community.

Background: In recognition of the ongoing discussion on euthanasia and physician-assisted suicide, the Board of Directors of the European Association for Palliative Care commissioned this white paper from the palliative care perspective. Aim: This white paper aims to provide an ethical framework for palliative care professionals on euthanasia and physician-assisted suicide. It also aims to provide an overview on the available evidence as well as a discourse of ethical principles related to these issues. Design: Starting from a 2003 European Association for Palliative Care position paper, 21 statements were drafted and submitted to a five-round Delphi process Participants: A panel with 17 experts commented on the paper in round 1. Board members of national palliative care or hospice associations that are collective members of European Association for Palliative Care were invited to an online survey in rounds 2 and 3. The expert panel and the European Association for Palliative Care board members participated in rounds 4 and 5. This final version was adopted as an official position paper of the European Association for Palliative Care in April 2015. Results: Main topics of the white paper are concepts and definitions of palliative care, its values and philosophy, euthanasia and physician-assisted suicide, key issues on the patient and the organizational level. The consensus process confirmed the 2003 European Association for Palliative Care white paper and its position on the relationship between palliative care and euthanasia and physician-assisted suicide. Conclusion: The European Association for Palliative Care feels that it is important to contribute to informed public debates on these issues. Complete consensus seems to be unachievable due to incompatible normative frameworks that clash.

The Canadian Association of Radiologists Incidental Findings Working Group consists of both academic subspecialty and general radiologists and is tasked with adapting and expanding upon the American College of Radiology incidental findings white papers to more closely apply to Canadian practice patterns, particularly more comprehensively dealing with the role of ultrasound and pursuing more cost-effective approaches to the workup of incidental findings without compromising patient care. Presented here are the 2020 Canadian guidelines for the management of hepatobiliary incidental findings. Topics covered include initial assessment of hepatic steatosis and cirrhosis, the workup of incidental liver masses identified on ultrasound and computed tomography (with algorithms presented), incidental gallbladder findings (wall thickening, calcification, and polyps), and management of incidental biliary dilatation.

Multiple sclerosis is a complex, autoimmune-mediated disease of the central nervous system characterized by inflammatory demyelination and axonal/neuronal damage. The approval of various disease-modifying therapies and our increased understanding of disease mechanisms and evolution in recent years have significantly changed the prognosis and course of the disease. This update of the Multiple Sclerosis Therapy Consensus Group treatment recommendation focuses on the most important recommendations for disease-modifying therapies of multiple sclerosis in 2021. Our recommendations are based on current scientific evidence and apply to those medications approved in wide parts of Europe, particularly German-speaking countries (Germany, Austria, and Switzerland). in press, CA extern

End-stage kidney disease patients who are candidates for surgical arteriovenous fistula creation commonly experience obstacles to a functional surgical arteriovenous fistula, including protracted wait time for creation, poor maturation, and surgical arteriovenous fistula dysfunction that can result in significant patient morbidity. The recent approval of two endovascular devices designed to create a percutaneous arteriovenous fistula enables arteriovenous fistula creation to be placed in the hands of interventionalists, thereby increasing the number of arteriovenous fistula providers, reducing wait times, and allowing the patient to avoid surgery. Moreover, current studies demonstrate that patients with percutaneous arteriovenous fistula experience improved time to arteriovenous fistula maturation. Yet, in order to realize the potential advantages of percutaneous arteriovenous fistula creation within our hemodialysis patient population, it is critical to select appropriate patients, ensure adequate patient and dialysis unit education, and provide sufficient instruction in percutaneous arteriovenous fistula cannulation and monitoring. In this White Paper by the American Society of Diagnostic and Interventional Nephrology, experts in interventional nephrology, surgery, and interventional radiology convened and provide recommendations on the aforementioned elements that are fundamental to a functional percutaneous arteriovenous fistula.

Background Plaque psoriasis (PsO) is a chronic inflammatory disease that often presents at peak reproductive age in women of child-bearing potential (WOCBP). With the emergence of biologic therapies to treat PsO, guidance on disease management in WOCBP is needed to inform treatment decisions before, during, and after pregnancy. Objectives To develop a practical, up-to-date consensus document, based on available evidence and expert opinion where evidence was lacking, in order to guide both Canadian and international clinicians treating PsO in WOCBP. Methods A panel of 9 Canadian dermatologists with extensive clinical experience managing PsO reviewed the relevant literature from the past 25 years in 3 key domains: overview of PsO in WOCBP and clinical considerations, treatment considerations, and postpartum considerations. The structured literature search focused on WOCBP treated with TNF-alpha inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab), IL-23 inhibitors (guselkumab, risankizumab, tildrakizumab), IL-12/23 inhibitors (ustekinumab), and IL-17 inhibitors (brodalumab, ixekizumab, secukinumab). This literature review, along with clinical expertise and opinion, was used to develop concise and clinically relevant consensus statements to guide practical management of PsO in WOCBP. Experts voted on the statements using a modified Delphi process and prespecified agreement cut-off of 75%. Results and implications After review, discussion, and voting on 19 draft consensus statements at an in-person meeting and remotely, 12 consensus statements were approved by the expert panel. The statements presented here will guide healthcare providers in practical disease management using biologic therapies for the treatment of PsO in WOCBP.

Background: Outcome measurement plays an increasing role in improving the quality, effectiveness, efficiency and availability of palliative care. Aim: To provide expert recommendations on outcome measurement in palliative care in clinical practice and research. Methods: Developed by a European Association for Palliative Care Task Force, based on literature searches, international expert workshop, development of outcome measurement guidance and international online survey. A subgroup drafted a first version and circulated it twice to the task force. The preliminary final version was circulated to wider expert panel and 28 international experts across 20 European Association for Palliative Care member associations and the European Association for Palliative Care Board of Directors and revised according to their feedback. The final version was approved by the European Association for Palliative Care Board for adoption as an official European Association for Palliative Care position paper. Results: In all, 12 recommendations are proposed covering key parameters of measures, adequate measures for the task, introduction of outcome measurement into practice, and national and international outcome comparisons and benchmarking. Compared to other recommendations, the White Paper covers similar aspects but focuses more on outcome measurement in clinical care and the wider policy impact of implementing outcome measurement in clinical palliative care. Patient-reported outcome measure feedback improves awareness of unmet need and allows professionals to act to address patients’ needs. However, barriers and facilitators have been identified when implementing outcome measurement in clinical care that should be addressed. Conclusion: The White Paper recommends the introduction of outcome measurement into practice and outcomes that allow for national and international comparisons. Outcome measurement is key to understanding different models of care across countries and, ultimately, patient outcome having controlled for differing patients characteristics.

Diffuse reflectance ultraviolet-visible-near-infrared (UV-Vis-NIR) spectroscopy is applied as a means of differentiating various types of writing, office, and photocopy papers (collected from stationery shops in India) on the basis of reflectance and absorbance spectra that otherwise seem to be almost alike in different illumination conditions. In order to minimize bias, spectra from both sides of paper were obtained. In addition, three spectra from three different locations (from one side) were recorded covering the upper, middle, and bottom portions of the paper sample, and the mean average reflectivity of both the sides was calculated. A significant difference was observed in mean average reflectivity of Side A and Side B of the paper using Student's pair t-test. Three different approaches were used for discrimination: (1) qualitative features of the whole set of samples, (2) principal component analysis, and (3) a combination of both approaches. On the basis of the first approach, i.e., qualitative features, 96.49% discriminating power (DP) was observed, which shows highly significant results with the UV-Vis-NIR technique. In the second approach the discriminating power is further enhanced by incorporating the principal component analysis (PCA) statistical method, where this method describes each UV-Vis spectrum in a group through numerical loading values connected to the first few principal components. All components described 100% variance of the samples, but only the first three PCs are good enough to explain the variance (PC1 = 51.64%, PC2 = 47.52%, and PC3 = 0.54%) of the samples; i.e., the first three PCs described 99.70% of the data, whereas in the third approach, the four samples, C, G, K, and N, out of a total 19 samples, which were not differentiated using qualitative features (approach no. 1), were therefore subjected to PCA. The first two PCs described 99.37% of the spectral features. The discrimination was achieved by using a loading plot between PC1 and PC2. It is therefore concluded that maximum discrimination of writing, office, and photocopy paper could be achieved on the basis of the second approach. Hence, the present inexpensive analytical method can be appropriate for application to routine questioned document examination work in forensic laboratories because it provides nondestructive, quantitative, reliable, and repeatable results.

Healthcare’s environmental sustainability is increasingly an area of research and advocacy focus. The Australian and New Zealand College of Anaesthetists (ANZCA) has produced a professional document, PS64, Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice, and a background paper, PS64 BP. The purpose of the statement is to affirm ANZCA’s commitment to environmental sustainability and support anaesthetists in promoting environmentally sustainable work practices. This article presents the main features of PS64 and its background paper, and the associated supporting evidence. The healthcare sector is highly interconnected with activities that emit pollution to air, water and soils, considerably adding to humanity’s collective ecological footprint. As anaesthetists, we are uniquely high-carbon doctors due to our work anaesthetising with greenhouse gases (particularly desflurane and nitrous oxide) and our exposure and contribution to large amounts of resource and energy use and waste generation in operating theatres. Discussion is made of the improving research base of anaesthetic life-cycle assessments—that is, cradle-to-grave studies of how much energy, water and so on a product or process requires throughout its entire life. Thereafter, reducing, reusing and recycling as well as water use are examined. Ongoing research efforts within environmentally sustainable anaesthesia are highlighted. Environmentally sustainable anaesthesia requires scholarship, health advocacy, leadership, communication and collaboration. The focus is placed on practical initiatives within PS64 and the background paper that can be achieved by all anaesthetists striving towards more sustainable healthcare practices that reduce waste, reap financial benefits and improve health.

The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group ( P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.

The ability to critically read a research paper is a skill that all postgraduate students and academicians require because the findings of a study must be interpreted in the context of its strengths and limitations. This article summarizes a recent study on continuation vs. discontinuation of antidepressants during pregnancy; preterm birth and low-birth weight were the outcomes of interest. The strengths and limitations of the study are considered, as are the best and worst case scenarios related to antidepressant use during pregnancy. It is hoped that this exercise will increase the reader's awareness of statistical and methodological issues that emerge when a study is critically examined.

The National Association of Medical Examiners convened a panel to create a position paper for recommendations for the investigation of infant deaths due to inflicted head trauma. The correct certification of both the cause and manner of death is dependent upon an evaluation of all available data including information derived from the investigation, scene, postmortem examination, and ancillary studies. This paper provides recommendations for the forensic pathologist on what constitutes the dataset to be produced during the postmortem examination of infants who have died of, or have apparently died of, inflicted head trauma. Specifically, this paper describes 1) procedures, 2) ancillary laboratory tests, and 3) forms of documentation that are important in the investigation of these deaths. The evaluation and documentation of such infant deaths involves the production of a detail oriented and thoroughly documented examination that is independently reviewable to support the multitude of inquiries that may follow from the public and the criminal justice system.

Peer review has been the principal way of evaluating scientific articles, ensuring that publications meet standards of methodology, integrity, and ethics. Occasionally, however, reviews are suboptimal, especially those by inexperienced reviewers. Therefore, this article offers suggestions on how to review a scientific article. Some of the most important suggestions include submitting the review in a timely fashion without undue delay, not breeching confidentiality, focusing mainly on the methodology, following specific format, and avoiding embarrassing comments to the authors.

As part of an advanced doctoral course on representing qualitative research, the authors used collage to represent either who they were as researcher or the research they were conducting. The authors, comprised of the course professor and seven doctoral students, read about collage as inquiry and research representation and then participated reflexively in a course lecture on the background of collage, a collage creation activity, a gallery walk, written and oral reflection on each other’s collages, a research poster presentation at a campus research event, and a final reflection of the entire process. As the process unfolded the authors represented the experience in the form of a collective collage poem, and a methodological and pedagogical article. Elements of this article include a review of collage as an art and research inquiry form, an overview of the pedagogical experiences, and the authors’ experiences shared in the form of brief vignettes and collage images.

In nonclinical safety studies for new drug development, healthy animals have been commonly used. However, in some cases, the use of animal models of human disease is considered to be more favorable in evaluating risks in patients. To elucidate the current status of the use of animal models for nonclinical safety assessment, an internal questionnaire from the Japan Pharmaceutical Manufacturers Association and surveys (questionnaire period: August 27 to September 30, 2015) of both common technical documents and review reports of approved drugs (approval period: May 1999 to May 2017) disclosed by the Pharmaceutical and Medical Devices Agency were conducted. Although there were some concerns and limitations raised, the survey results revealed that animal models have been used in nonclinical safety assessment on a case-by-case basis and that nonclinical safety studies using animal models were included in the data packages of several approved drugs in Japan. The survey results also revealed that nonclinical safety studies using animal models have become more frequent in the past few years. In almost all cases, useful information, such as signs of toxicity under disease conditions and mechanisms of toxic change, was obtained from the results of nonclinical studies using animal models. Note: This is an opinion article submitted to the Toxicologic Pathology Forum. It represents the views of the author(s). It does not constitute an official position of the Society of Toxicologic Pathology, British Society of Toxicological Pathology, or European Society of Toxicologic Pathology, and the views expressed might not reflect the best practices recommended by these Societies. This article should not be construed to represent the policies, positions, or opinions of their respective organizations, employers, or regulatory agencies.

Dangerous abbreviations on the Institute for Safe Medication Practices Canada's "Do Not Use" list have resulted in medication errors leading to harm. Data comparing rates of use of dangerous abbreviations in paper and electronic medication orders are limited.To compare rates of use of dangerous abbreviations from the "Do Not Use" list, in paper and electronic medication orders. Secondary objectives include determining the proportion of patients at risk for medication errors due to dangerous abbreviations and the most commonly used dangerous abbreviations.One-day cross-sectional audits of medication orders were conducted at a 6-site hospital network in Toronto, Canada, between December 2013 and January 2014. Proportions of paper and electronic medication orders containing dangerous abbreviation(s) were compared using a χOverall, 255 patient charts were reviewed. The proportions of paper and electronic medication orders containing dangerous abbreviation(s) were 172/714 (24.1%) and 9/2207 (0.4%), respectively ( P0.001). Almost one-third of patients had medication order(s) containing dangerous abbreviation(s). The proportions of patients with at least 1 medication order during the audit period containing dangerous abbreviation(s) for patients with paper only, electronic only, or a hybrid of paper and electronic medication orders were 50.5%, 5%, and 47.2%, respectively. Those most commonly used were "D/C", drug name abbreviations, "OD," "cc," and "U."Electronic medication orders have significantly lower rates of dangerous abbreviation use compared to paper medication orders.

Introduction Treatment of pediatric malignancies is becoming progressively more complex, implying the adoption of multimodal therapies. A reliable, long-lasting venous access represents one of the critical requirements for the success of those treatments. Recent technical innovations—such as minimally invasive procedures for placement, new devices and novel materials—have rapidly spread for clinical use in adult patients, but are still not consistently used in the pediatric population. Methods The Supportive Therapy Working Group of Italian Association of Hematology and Oncology (AIEOP) reviewed medical literature focusing on new aspects of central venous access devices (VADs) in pediatric patients affected by oncohematological diseases. Results Appropriate recommendations for clinical use in these patients have been discussed and formulated. Conclusions The importance of the correct choice, management and use of VADs in pediatric oncohematological patients is a necessary prerequisite for an adequate standard of care, also considering the increased chances of cure and the longer life expectancy of those patients with modern therapies.

Objective Forensic pathologists play a vital role in the justice system in matters concerning questions of death. Science as applied in the justice system should be objective and neutral. Since the goals of medical examiners and coroners are to determine the cause and manner of death for certification and public health functions (goals different and distinct from the missions of law enforcement agencies), it is important that medicolegal death investigation be independent. Accurate investigation, examination, reporting, and testimony by forensic pathologists are important to determine the cause and manner of death of individuals who die under sudden, unexpected, or violent circumstances. These cases can become the focus of political or legal pressure by individuals or offices seeking to influence the pathologist's findings. This pressure, even if seemingly unsuccessful in an individual case, can introduce error, bias, and corruption into the medicolegal investigation process. This paper reinforces the principle that medical examiners, coroners and forensic pathologists should be allowed to perform medicolegal investigations free of these influences. Participants The ad hoc Committee on Medical Examiner Independence of the National Association of Medical Examiners (NAME), a self-selected volunteer committee, developed this position paper. The findings are based on surveys of the NAME membership regarding members’ experience with, and reaction to, outside influence. Evidence Surveys of NAME members revealed that medical examiner independence was important to most members. Over 70% of survey respondents had been subjected to pressures to influence their findings, and many had suffered negative consequences for resisting those influences. In a separate study, over 30% of respondents indicated that fear of litigation affected their diagnostic decision-making. In 2009, the National Research Council of the National Academies published recommendations to strengthen the forensic sciences; they specifically recommended that medical examiner and coroner offices should be independent from law enforcement agencies and prosecutors’ offices. Consensus Process This position paper represents the consensus of the ad hoc Committee on Medical Examiner Independence, submitted to the Executive Committee and Board of Directors of NAME, and subject to comment and review by the membership. Conclusions It is the position of NAME that forensic pathologists working in or for medical examiner or coroner offices or as private consultants should be permitted to objectively pursue and report the facts and their opinions of those cases which they are investigating independent of political influences from other agencies within their respective jurisdictions and independent of the threat of litigation.

The purpose of this study was to assess whether a computerized battery of neuropsychological tests could produce similar results as the conventional forms. Comparisons on 77 volunteer undergraduates were carried out with two neuropsychological tests: Line Orientation Test and Enhanced Cued Recall Test. Firstly, students were assigned randomly across the test medium (paper-and-pencil versus computerized). Secondly, the groups were given the same test in the other medium after a 30-day interval between tests. Results showed that the Enhanced Cued Recall Test–Computer-based did not correlate with the Enhanced Cued Recall Test-Paper-and-pencil results. Line Orientation Test–Computer-based scores, on the other hand, did correlate significantly with the Line Orientation Test–Paper-and-pencil version. In both tests, scores were higher on paper-and-pencil tests compared to computer-based tests. Total score difference between modalities was statistically significant for both Enhanced Cued Recall Tests and for the Line Orientation Test. In both computer-based tests, it took less time for participants to complete the tests.

iPad® and paper versions of a receptive vocabulary assessment were administered to 4- to 6-year olds with a diagnosis of autism spectrum disorder (ASD). No differences were found between scores on the two assessments. Standardized testing for children with ASD can be challenging; however, testing using the iPad® may offer a different avenue as it provides visual input that appears to be motivating. Findings suggest iPad® assessments offer an efficient format for itinerant speech-language pathologists (SLPs) and SLPs providing telepractice when creating individualized evaluation plans.

The Scientific and Regulatory Policy Committee of the Society of Toxicologic Pathology (STP) appointed a working group to address risk assessment for increases in alveolar macrophages following inhalation of pharmaceutical materials. This position paper provides recommendations for inhalation study–specific terminology and interpretation based on literature and information from marketed inhaled drugs. Based on a weight-of-the-evidence approach, and with appropriate consideration of the physical and pharmacological characteristics of the compound, uncomplicated increases in the size or number of alveolar macrophages in nonclinical species are interpreted as nonadverse.

Sudden unexpected death is typically diagnosed in infants, children, teenagers, and young adults following completion of an autopsy that fails to identify a cause of death or when autopsy suggests a potentially genetic cause of death in an individual less than 40, such as cardiomyopathy or aneurysm. Such deaths may be a result of genetic abnormalities that are unable to be diagnosed by gross or microscopic inspection, but may be detectable by molecular studies. Unfortunately, the ability to perform postmortem genetic testing is frequently hindered by lack of an appropriate specimen following completion of an autopsy. This paper provides recommendations developed by the National Association of Medical Examiners with the assistance of genetic counselors. The recommendations establish procedures to facilitate postmortem genetic testing and DNA banking by health care professionals assisting families who have experienced sudden death in young relatives by clarifying proper sample acquisition and storage. Additionally, recommendations for discussion with surviving family members and test planning are provided. The objective of these recommendations is to ensure that postmortem samples suitable for DNA banking are retained, allowing at risk family members improved detection of potentially treatable genetic diseases.

Purpose. Using the Problem Oriented Screening Instrument for Teenagers (POSIT), the effect of mode of administration on (1) students' willingness to disclose sensitive information and (2) response rates was investigated. Design. A2 × 2 unequal N factorial analysis of variance (ANOVA) design was employed. Mode of administration (paper-and-pencil vs. Web-based) was crossed with grade level (middle vs. high school). Setting. The study was conducted in two middle and two high schools. Subjects. A total of 628 middle and high school students completed the survey. Measures. The POSIT is a self-report measure with 139 yes/no items that identifies stressors in 10 functional areas (e.g., Substance Use). Analysis. An unequal N 2 (mode) × 2 (grade level) factorial ANOVA was employed. Results. No statistically significant differences were found for self-reported risk across modes of administration. Students completing the Web-based version of the survey were four times more likely to skip an item. Conclusions. Effect of Mode on Reporting of Sensitive Information—Students completed the Web-based surveys in computer labs with other students. The intent of the Web-based survey was to increase perceived privacy but the environment likely negated any effect. Effect of Mode on Response Rates—The higher response rate for the paper-and-pencil survey was the opposite of what was expected and revealed that students were more likely to skip sensitive items on the Web survey. (Am J Health Promot 2011;25[5]:349-352.)

AIMS This study compared data quality and response rates for the Alcohol Use Disorders Identification Test (AUDIT) in a web-based versus in a paper-and-pencil format survey. SETTING Subjects were randomised to one of two parallel samples, one web-based and the other paper-based. Data were collected during 2009. Results The web-based format yielded a lower response rate compared to the paper version (26.2% vs. 53.6%), internal consistency was quite similar (0.82 vs. 0.77), while the mean AUDIT scores were higher in the web-based format for both men and women. Conclusions Future studies should focus on methods for combining different administration methods in order to maximize response rates.

Background: Paper printers have been used to document radiological findings in some hospitals. It is critical to establish whether paper printers can achieve the same efficacy and quality as dry laser printers for full-field digital mammography (FFDM). Purpose: To compare the image quality and detection rate of dry laser printers and paper printers for FFDM. Material and Methods: Fifty-five cases (25 with single clustered microcalcifications and 30 controls) were selected by a radiologist not participating in the image review. All images were printed on film and paper by one experienced mammography technologist using the processing algorithm routinely used for our mammograms. Two radiologists evaluated hard copies from dry laser printers and paper printers for image quality and detectability of clustered microcalcifications. For the image quality comparisons, agreement between the reviewers was evaluated by means of kappa statistics. The significance of differences between both of the printers was determined using Wilcoxon's signed-rank test. The detection rate of two printing systems was evaluated using receiver operating characteristic (ROC) analysis. Results: From 110 scores (55 patients, two readers) per printer system, the following quality results were achieved for dry laser printer images: 70 (63.6%) were rated as good and 40 (36.4%) as moderate. By contrast, for the paper printer images, 25 scores (22.7%) were rated as good and 85 (77.3%) as moderate. Therefore, the image quality of the dry laser printer was superior to that achieved by the paper printer ( P=0.00). The average area-under-the-curve (Az) values for the dry laser printer and the paper printer were 0.991 and 0.805, respectively. The difference was 0.186. Results of ROC analysis showed significant difference in observer performance between the dry laser printer and paper printer ( P=0.0015). Conclusion: The performance of dry laser printers is superior to that of paper printers. Paper printers should not be used in FFDM.

The authors examined whether paper-and-pencil and Web surveys administered in the school setting yield equivalent risk behavior prevalence estimates. Data were from a methods study conducted by the Centers for Disease Control and Prevention (CDC) in spring 2008. Intact classes of 9th- or 10th-grade students were assigned randomly to complete a survey via paper-and-pencil or Web. Data from 5,227 students were analyzed using logistic regression to identify associations of mode with reporting of 74 risk behaviors. Mode was associated with reporting of only 7 of the 74 risk behaviors. Results indicate prevalence estimates from paper-and-pencil and Web school-based surveys are generally equivalent.

This article reviews the regulatory guidelines that provide for the inclusion of recovery groups in toxicology studies, presents the challenges in the design and interpretation of nonclinical recovery studies, and summarizes the best practices for the role of an anatomic pathologist regarding toxicology studies with recovery groups. Evaluating the potential recovery of histopathologic findings induced by a biopharmaceutical requires the active participation of one or more anatomic pathologists. Their expertise is critical in risk assessment regarding the potential for recovery as well as providing scientific guidance in the design and evaluation of studies with recovery groups.