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Background Abdominal pain is the most common chief complaint in US emergency departments (EDs) among patients over 65, who are at high risk of mortality or incident disability after the ED encounter. We sought to characterize the evaluation, management, and disposition of older adults who present to the ED with abdominal pain. Methods We performed a survey-weighted analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), comparing older adults with a chief complaint of abdominal pain to those without. Visits from 2013 to 2017 to nationally representative EDs were included. We analyzed 81,509 visits to 1211 US EDs, which projects to 531,780,629 ED visits after survey weighting. We report the diagnostic testing, evaluation, management, additional reasons for visit, and disposition of ED visits. Results Among older adults (≥65 years), 7% of ED visits were for abdominal pain. Older patients with abdominal pain had a lower probability of being triaged to the "Emergent" (ESI2) acuity on arrival (7.1% vs. 14.8%) yet were more likely to be admitted directly to the operating room than older adults without abdominal pain (3.6% vs. 0.8%), with no statistically significant differences in discharge home, death, or admission to critical care. Ultrasound or CT imaging was performed in 60% of older adults with abdominal pain. A minority (39%) of older patients with abdominal pain received an electrocardiogram (EKG). Conclusions Abdominal pain in older adults presenting to EDs is a serious condition yet is triaged to "emergent" acuity at half the rate of other conditions. Opportunities for improving diagnosis and management may exist. Further research is needed to examine whether improved recognition of abdominal pain as a syndromic presentation would improve patient outcomes.

This study investigates the ways students' disposition toward solidarity can be fostered during a community-based service-learning (CBSL) project performed remotely, not requiring direct contact or interactions with community members. Seventeen students were enrolled in an advanced Spanish grammar course section with a service-learning component and collaborated throughout the semester to translate documents from English to Spanish for three local non-profit organizations. The analysis of their end-of-semester reflection papers reveals that the high stakes of the outcome (facilitating the local Spanish-speaking population's access to essential social services) influenced students' engagement in the task, triggered by an emotional buy-in with the nonprofit organization's missions. Participation in the CBSL project fostered solidarity disposition as students considered opportunities to get involved and reflected on how they might be able to support Spanish speakers in their future jobs. The article concludes with suggested guidelines for the design of remote CBSL opportunities to nurture solidarity disposition as a primary objective.

This study examined perspectives on the ethical implications of preimplantation genetic testing (PGT) among individuals who actually (not hypothetically) used or considered using PGT. Most of the prior patient-centered research on PGT ethics used qualitative designs (9 out of the 11 articles) and focused only on single gene testing. This cross-sectional study used an anonymous online questionnaire; 15 items assessed potential ethical concerns involved in PGT decision-making, including clinical indications for PGT, the greater implications of PGT for society, and unused embryo disposition. N = 207 individuals (mean female/male age 35.7/38.9 years, 21% Hispanic or non-White) who had recently used or considered using PGT for single gene (60%) or for chromosomal testing (40%) completed the questionnaire. Most respondents supported PGT screening for disease conditions with childhood or adult onset that are untreatable (64%-85% across items); most opposed PGT for trait selection (76%-81%). Most respondents agreed that PGT aids in parental decision-making (66%-67%), although some expressed concern over potential unforeseen consequences (25%-30%). Regarding disposition of embryos without known genetic abnormalities, most respondents favored freezing indefinitely (86%) or donating to another family (69%), while for embryos with genetic abnormalities, most respondents favored donating to research (78%) or destroying them (62%). Stratification by religious affiliation revealed several differences, such as less acceptance of PGT for diseases that occur in adulthood and have no treatment options among Protestants (p = .015) and greater willingness to donate surplus embryos to research among participants without a religious affiliation (p

AIM Paediatric emergency departments (ED) nationwide experience a shared burden of boarding mental health patients. Whilst boarding, some patients have a change in disposition from hospitalization to discharge home. This phenomenon raises concern because EDs often have scarce resources for mental health patients. We sought to understand which patient and clinical factors are associated with a change in disposition outcome. METHODS A nested age-sex-race frequency-matched case-control study was conducted including paediatric patients who presented to an urban PED for mental healthcare over a 36-month period. Control patients included patients admitted to an inpatient psychiatric facility, whilst case patients were those discharged home. Descriptive statistics and multivariable logistic regression analyses were performed to compare groups. RESULTS Case patients were more likely to receive intramuscular Haloperidol (OR 2.2 [CI 1.1-4.4]) for agitation and a psychiatric consult (OR 2.3 [1.4-3.9]) whilst boarding. Case patients were also more likely to present with behavioural concerns (OR 1.8 [CI 1.1-3.1]) and have additional complexities such as medical comorbidities (OR 1.8 [CI 1.1-2.9]) or suicidal ideation/attempt (OR 2.6 [CI 1.1-6.1]). Amongst the most common themes for disposition change was improved patient status (58.8%). CONCLUSION These findings suggest that boarding mental health patients have different disposition outcomes and thus may benefit from patient-specific treatment interventions. Given that patients' statuses may change during the boarding period prompting discharge to home, more focus should be directed to developing brief evidence-based practises that may be implemented in the ED and effectively bridge the gap to outpatient mental health services.

Recent years have seen a growing research interest in the notion of directed motivational currents (DMCs) that defines highly intense motivational surges oriented to a much-desired goal of personal significance. However, the learner characteristics that induce individual-level variability in DMCs have yet to be explored. In particular, the role of personality in explaining variations in the DMC disposition remains empirically unresolved. The current study addresses this gap by looking at whether the five-factor model (FFM) personality traits help explain variations in the DMC disposition among 172 Turkish undergraduate students majoring in teaching English as a foreign language (EFL) at a state university in Turkey. Data were gathered using the 50-item version of International Personality Item Pool (IPIP) and the 12-item DMC Disposition Scale. Multiple linear regression analysis showed that personality traits significantly predicted variability in the DMC disposition, together accounting for 42% of the variance. Conscientiousness and extraversion appeared as the strongest predictors. The findings in general bring preliminary insights into the learner characteristics that underlie individual-level variability in DMCs, as well as having implications in particular for facilitating individual-level DMC practices in the context of second/foreign language (L2) learning.

Applying risk assessment and management tools to plutonium disposition is a long-standing challenge for the U.S. government. The science is complicated, which has helped push risk assessment and management tools in new creative directions. Yet, communicating effectively about increasingly complicated risk-science issues like plutonium disposition requires careful planning and speakers who can address why specific tools are selected, the past record of applying these tools, why assumptions sometimes are applied instead of reliable data, and how uncertainty is characterized. Speakers addressing risk issues must also overcome obstacles in communication arising from expert-audience differences in knowledge and legal restrictions on disclosing information. This perspective seeks to highlight and illustrate five key risk questions, about probabilistic risk assessment (PRA) and performance assessment (PA) in the context of managing plutonium defense nuclear waste: objectives, experience, gaps, transparency, and difficulty of applying and communicating using each tool. While the general public needs to be involved, some issues require a level of expertise that is typically beyond local communities and therefore an expert panel should support community access.

The present paper adopts and substantiates a superiority–inferiority hypothesis on disparagement humor generation and appreciation. Two between-subjects (identification with a character acting as victimizer or victim) experiments address disparaging humorous advertising effectiveness, providing a novel perspective on very old questions. Perceived superiority and inferiority autonomously mediate the relationship between a disparaging advertisement and perceived humorousness. Individuals with high superiority motivation (i.e., high-katagelasticists) experience increased humorousness and an improved attitude toward the brand when they identify with a character acting as victimizer in the disparaging ad. People with a motivation to avoid inferiority (i.e., high-gelotophobes) experience reduced humorousness and lower positive attitudes toward the brand when they identify with a character who is victimized in the disparaging ad. Gelotophiles are not driven by feelings of superiority or inferiority and experience increased humorousness as well as more positive brand attitudes irrespective of the ad's victimization focus.

Defensive behavior is a central aspect of social life and provides benefits to the self and others. Recent evidence reveals that infants evaluate third parties' prosocial and antisocial actions. Three experiments were carried out to assess toddlers' reactions to defensive and non-defensive events (N = 54). In two experiments, infants' looking times and manual choices provided converging evidence that 20-month-olds understand and evaluate defensive actions, by showing that they prefer the defensive puppet over the non-defensive puppet and that they reason on the bystander puppet's disposition. In the third experiment, toddlers rewarded the defensive puppet rather than the non-defensive puppet, revealing how their evaluations guided awarding behaviors of defensive actions toward the third party. The results support the developmental stability and provide evidence of a rich and well-organized prosociality that before the second year of life proves to be based on some moral principles and linked with a sophisticated psychological reasoning. The findings shed light on the claims that human capacities for the social evaluation of defensive behaviors toward third parties are rooted in evolved cooperative systems.

The purpose of this paper is to clarify the state of the disposition of building evacuation sites in Sendai, including the processes and background, whilst considering the project environment surrounding the disposition in central ministries and Sendai. The Home Ministry, which had been responsible for building evacuation during the wartime period, consistently promoted the conversion of evacuation sites into urban planning sites immediately following the end of World War II. The Ministry of Transport and the War-Damage Reconstruction Institute also planned to convert evacuation sites into urban planning sites and railway land. Therefore, in Sendai, there were plans to convert two evacuation sites into streets. However, due to differences in the project environment surrounding the disposition of evacuation sites; such as the number of evacuated houses, required expenses, regional characteristics, and differences in project characteristics; only one street was completed. Considering the influence of pre-war urban planning on building evacuation, and thus war-damage reconstruction: three streets coincided with preceding pre-war plans, and the pre-war urban planning street was taken over in a manner consistent with war-damage reconstruction through building evacuation., The Japanese version of this paper was published in Volume 84, Number 758, pages 1005-1015, https://doi.org/10.3130/aija.84.1005, of the Journal of Architecture and Planning (Transactions of AIJ). The authors have obtained permission for secondary publication of the English version in another journal from the Editor of the Journal of Architecture and Planning (Transactions of AIJ). This paper is based on the translation of the Japanese version with some slight modifications., IPHS Prizes and Awards 2022: East Asian Planning History Prize

Objective There is minimal evidence describing outcomes for emergency department (ED) patients with suspected coronavirus disease 2019 (COVID‐19) infection who are not hospitalized. The study objective was to assess 30‐day outcomes (ED revisit, admission, ICU admission, and death) for low‐risk patients discharged after ED evaluation for COVID‐19. Methods This was a retrospective cohort study of patients triaged to a COVID‐19 surge area within an urban ED and discharged between March 12 and April 6. Physicians were encouraged to discharge patients if they were well‐appearing with few comorbidities. Data were collected from review of medical records and phone follow‐up, and the analysis was descriptive. Results Of 452 patients, the median age was 38, and 61.7% had no comorbidities. Chest radiographs were performed for 50.4% of patients and showed infiltrates in 14% of those tested. Polymerase chain reaction testing was performed for 28.3% of patients during the index ED visit and was positive in 35.9% of those tested. Follow‐up was achieved for 75.4% of patients. ED revisits occurred for 13.7% of patients. The inpatient admission rate at 30 days was 4.6%, with 0.7% requiring intensive care. Median number of days between index ED evaluation and return for admission was 5 (interquartile range 3–7, range 1–17). There were no known deaths. Conclusions A minority of low‐risk patients with suspected COVID‐19 will require hospitalization after being discharged home from the ED. Outpatient management is likely safe for well‐appearing patients with normal vital signs, but patients should be instructed to return for worsening symptoms including labored breathing. Future work is warranted to develop and validate ED disposition guidelines.

Assuming that moral enhancement is morally permissible, I contend that a more careful theoretical treatment of emotion and the affective landscape is needed to advance both our understanding and the prospects of interventions aimed at moral enhancement. Using Douglas' proposal for the direct modulation of counter-moral emotions as a foil for discussion, I argue that the direct modulation of emotion fails to address underlying aspects of an agent's psychology that will give rise to a range of counter-moral motives beyond the emotion that is targeted. This is because the direct modulation of emotion does not accommodate the fact that an emotional episode or emotional disposition is part of a network of other dispositions and responses, against a backdrop of our having cares and goals, as well as other cognitive content that can mediate how we apprehend a situation. By focusing on emotion rather than on moral capacity as other critiques have done, I thus argue that direct modulation is likely to be ineffective, and, more positively, by drawing out patterns of connections across the affective landscape, we can better tease out what it is that we should really be targeting if we are to achieve robust and meaningful moral change.

Studies on students' perception of corporate social responsibility (CSR) have been growing in western scholarship. For students in African countries, such as Nigeria, there is little that is known about how and whether gender, level of study, and being enrolled in business education courses impact their perception of and disposition towards CSR. This study explores the significance of gender, academic status or level of study, and exposure to business ethics education (BEE) on Nigerian students' perception of CSR as a veritable business ethic. Specifically, the effects of these factors on students' perception of CSR are examined using analysis of variance. The results show a significant effect of exposure to BEE and gender on CSR‐sensitivity, and a mild, but significant effect of academic status. This implies that male students and female students had different perspectives on CSR issues. Students who took ethics courses and those who did not would run businesses differently. However, age and experience on campus did not influence students' perception or position on CSR. The study recommends that more behavioral models be estimated with the inclusion of more demographic and socioeconomic variables to elicit more robust results.

A moneyness‐based propensity to sell (MPS) measure, at the aggregate level, determines the propensity of option holders to exercise their winning relative to losing positions. Using data on individual stock and S&P 500 Index options, we find that the MPS measure has significant predictive power over the cross section of delta‐hedged option returns. We test the disposition effect in the options market based on a long–short strategy that exploits price distortions induced by the disposition bias. More pronounced evidence of the disposition bias is found for individual at‐the‐money call options than put options where the significance of abnormal returns remains robust across different subsamples even after we control for the portfolio option greeks and market‐based risk factors. The profitability of the long–short strategy is related to limit‐to‐arbitrage proxies suggesting that behavioral explanations help explain the positive relation between the MPS measure and delta‐hedged option returns.

Aims Single-dose pharmacokinetic (PK) studies in healthy subjects have been the design of choice for bioequivalence determination for decades. This preference has been recently extended to PK similarity studies of proposed biosimilars. However, PK similarity studies can be complicated by the effect of immunogenicity response on drug disposition. The impact is exacerbated when there is an imbalance in host-specific immunological characteristics of subjects between the test and reference groups. Such complications remain poorly understood. The purpose of this communication is to show that the impact of immunogenicity response on PK similarity determination can be critical, using adalimumab as an example. Methods Data for adalimumab concentrations and immunogenicity response over 10 weeks were obtained from 133 healthy subjects receiving a 40 mg dose of Humira® in a PK similarity study. Also, a population PK model with a mechanistic construct for delineating the interplay between adalimumab disposition and antidrug antibodies response was utilized to estimate via simulation the probability that a PK similarity study would fail in typical study settings. Results The simulations showed that the immunogenicity response can have a profound impact on the outcome of PK similarity determination. As such, the probability of failing to achieve the similarity conclusion increased to 51.9%, from 13.8% in the absence of immunogenicity response. Conclusion This study provides a model-based framework for better understanding of how a PK similarity study can be optimally designed and for interpretation of the outcome of PK similarity determination when the drug disposition is affected in the presence of immunogenicity response.

We provide a review of the assessment of suicidal emergency department patients and includes a legal and ethical perspective. Screening tools and psychiatric consultation are important adjuncts to the ED evaluation of potentially suicidal patients. Suicide risk should be assessed, and if positive, an appropriate and safe disposition should be arranged. The aim of this article is to review these assessment tools and consider ethical issues, such as patient autonomy, accountability of the emergency physician, and consultant to Emergency Medical Treatment and Labor Act (EMTALA) as well as confidentiality, privacy, and social issues.

Paclitaxel is a commonly used drug in the treatment of multiple solid tumors, including cancers of the breast, lung, and ovaries. Despite the established exposure–pharmacodynamic relationships for paclitaxel, treatment is associated with wide interindividual pharmacokinetic variability that leads to unpredictability of the agent's clinical activity and toxicity. We hypothesized that physiologically‐based modeling approaches could be employed to predict the human pharmacokinetics of paclitaxel following administration of the approved Cremophor‐based formulation (Taxol). The model was developed from tissue distribution studies performed in mice and applied to plasma concentration‐time data obtained in adult cancer patients receiving Taxol at the approved dose and schedule (175 mg/m2 by a 3‐hour intravenous infusion), taking into account interspecies differences in physiological parameters. The final model adequately captured the observed concentrations in patients and allowed prediction of paclitaxel distribution profiles in multiple target organs and can be applied to further refine the chemotherapeutic treatment with a clinically important agent.

Various criteria have been proposed for determining the reliability of noncompartmental pharmacokinetic estimates of the terminal disposition phase half-life (t1/2 ) and the extrapolated area under the curve (AUCextrap ). This simulation study assessed the performance of two frequently used reportability rules: the terminal disposition phase regression adjusted-r2 classification rule and the regression data point time span classification rule. Using simulated data, these rules were assessed in relation to the magnitude of the variability in the terminal disposition phase slope, the length of the terminal disposition phase captured in the concentration-time profile (data span), the number of data points present in the terminal disposition phase, and the type and level of variability in concentration measurement. The accuracy of estimating t1/2 was satisfactory for data spans of 1.5 and longer, given low measurement variability; and for spans of 2.5 and longer, given high measurement variability. Satisfactory accuracy in estimating AUCextrap was only achieved with low measurement variability and spans of 2.5 and longer. Neither of the classification rules improved the identification of accurate t1/2 and AUCextrap estimates. Based on the findings of this study, a strategy is proposed for determining the reportability of estimates of t1/2 and area under the curve extrapolated to infinity.

The adjusted r2 algorithm is a popular automated method for selecting the start time of the terminal disposition phase (tz ) when conducting a noncompartmental pharmacokinetic data analysis. Using simulated data, the performance of the algorithm was assessed in relation to the ratio of the slopes of the preterminal and terminal disposition phases, the point of intercept of the terminal disposition phase with the preterminal disposition phase, the length of the terminal disposition phase captured in the concentration-time profile, the number of data points present in the terminal disposition phase, and the level of variability in concentration measurement. The adjusted r2 algorithm was unable to identify tz accurately when there were more than three data points present in a profile's terminal disposition phase. The terminal disposition phase rate constant (λz ) calculated based on the value of tz selected by the algorithm had a positive bias in all simulation data conditions. Tolerable levels of bias (median bias less than 5%) were achieved under conditions of low measurement variability. When measurement variability was high, tolerable levels of bias were attained only when the terminal phase time span was 4 multiples of t1/2 or longer. A comparison of the performance of the adjusted r2 algorithm, a simple r2 algorithm, and tz selection by visual inspection was conducted using a subset of the simulation data. In the comparison, the simple r2 algorithm performed as well as the adjusted r2 algorithm and the visual inspection method outperformed both algorithms. Recommendations concerning the use of the various tz selection methods are presented.

BACKGROUND Pedagogical hope is a fundamental disposition for raising children. This attitude among fathers of children with Down syndrome (DS) plays an essential role in their children's development. This phenomenological study sought to explore fathers' lived experiences and to reflect on what it means to be a pedagogically hopeful father of a child with DS. METHODS Max van Manen's hermeneutic-phenomenological method was applied. Phenomenological interviews were held with 10 fathers of children with DS in Spain, Ecuador and Scotland. Anecdotal narratives from the transcribed interviews were analysed based on philosophical, philological and human science methods. RESULTS The four eidetic themes in the phenomenological text show how a pedagogically hopeful father (1) is realistic; (2) believes in the strengths of his child with DS; (3) trusts in his positive influence; and (4) is open to unexpected surprises. CONCLUSIONS Lived experiences of pedagogical hope reveal fathers' fundamental roles in stimulating the utmost development of their child's capabilities. Reflecting on this pedagogical attitude will undoubtedly encourage fathers, educators and health care professionals to make the most of this disposition and enhance their relationship with their children with DS.

Aims and objectives To test a hypothetical path model estimating the influence of resilience and gratitude disposition on well-being in Korean clinical nurses and to verify the mediating effects of burnout, compassion satisfaction and job satisfaction using a multi-mediation model. Background To improve the well-being of nurses, it is necessary to consider their personal and work-related characteristics comprehensively. Design A descriptive cross-sectional design was used. Methods A total of 310 clinical nurses participated in this study. A structured questionnaire was used to collect data. A path analysis using a multi-mediation model was performed using AMOS 23.0 to test the hypothetical path model. This study adhered to the STROBE guideline. Results The model's fit indices were adequate. Resilience and gratitude disposition both had significant direct effects on well-being. Resilience and gratitude disposition had significant indirect effects on well-being through the effect of burnout, compassion satisfaction and job satisfaction. Resilience, gratitude disposition, burnout, compassion satisfaction and job satisfaction explained 68.3% of the total variance of well-being. Conclusions Intervention programmes considering these factors may be useful to improve nurses' well-being. Relevance to clinical practice Nurses' well-being should be assessed along with resilience, gratitude disposition, burnout, compassion satisfaction and job satisfaction. To improve the well-being of clinical nurses, systematic and integrated intervention programmes need to be developed and applied, with consideration for a variety of factors related to well-being.

Product reuse is most profitable where manufacturers acquire used products in the best possible condition-near new and with little wear and tear. This requires consumers, however, to dispose of products that still work and may still be in use. Prior scholarship on acquiring consumer products for reuse focuses on consumer "returns"-products consumers find fault with, or bought in error. These, however, are a fraction of all products sold to consumers and available for reuse. Importantly, returns are motivated by a different set of factors, than product "disposal." We explore how psychological ownership influences consumer disposal of reusable products. Across three studies of Australian consumers, we found two psychological tendencies (attachment and frugality) increased product retention. We also found, that infrequent product use, and emotional reward, could weaken ownership and encourage disposal of products that are attractive for reuse. To our knowledge, no behavioral studies in the product acquisition literature deal with consumers before or during product disposal. We highlight a role for consumers in product acquisition, as well as contribute to the consumer psychology and mental accounting literature, and identify significant opportunity for manufacturers to leverage consumers' psychological tendencies to improve the collection of reusable products.

Different views appear in the literature on the extent of specific cytochrome P450 (CYP) involvement in methadone metabolism. The aim of this work is to leverage knowledge from drug-drug interaction (DDI) studies in new drug applications between methadone and antiviral medications to better understand methadone disposition and to inform design of future DDI studies with methadone. A database of DDI studies between all FDA-approved human immunodeficiency virus and hepatitis C virus medications and methadone was constructed. The database contains data from 29 DDI studies. Sixteen of the 29 studies had statistically significant changes in methadone area under the concentration-time curve. Methadone exposure was either decreased or unchanged when it was coadministered with weak to strong CYP3A inhibitors or a moderate CYP3A4 inducer. Methadone exposure was reduced when it was coadministered with CYP2B6 inducers. The role of other enzymes (CYP2C9, CYP2C19, and CYP2D6) cannot be fully elucidated from these studies. In conclusion, CYP2B6 plays a prominent role in methadone metabolism, although methadone exposure is not sensitive to CYP3A perturbation. In designing methadone DDI studies, (1) measuring R- and S-methadone is more informative than measuring total methadone, and (2) CYP2B6 genotyping of subjects enrolled in methadone DDI studies should be considered. Finally, there is a need for the development of predictive models to determine the influence of medications on methadone disposition.

Purpose To study the relationship between the availability and activation of emergency department-based telemedicine (teleED) and patient disposition in Critical Access Hospitals (CAHs). Methods A non randomized stepped wedge design examined 133,396 ED visits in 15 CAHs that subscribe to a single teleED provider. Data were available for at least 12 months prior to teleED implementation and at least 12 months of post-implementation. Primary analyses were conducted using multinomial logistic regression models with teleED availability (indicator of post-teleED implementation period) and activation (indicator of utilization of teleED service) predicting discharge disposition adjusting for age, sex, and clinical diagnosis. Results Patients for whom teleED was activated were more likely to be transferred [adjusted odds ratio (aOR) = 12.04; 95% confidence interval (CI), 10.97-13.21] and more likely to be admitted to the local hospital (aOR = 3.23; 95% CI, 2.84-3.67) than to be routinely discharged. This pattern was confirmed for patients presenting with chest pain, mental illness, and injury/poisoning. However, in the period following teleED implementation, patients presenting to EDs after telemedicine was available, but not necessarily utilized, were less likely to be admitted to the local hospital (aOR = 0.79; 95% CI, 0.76-0.82) than to be routinely discharged. Conclusions Telemedicine availability in CAH EDs is associated with a higher likelihood of routine discharges from the ED possibly due to changes in care associated with teleED implementation. The relationship between teleED use and disposition may be related to selection in activating teleED for cases more likely to require hospital inpatient care.

The principle of plenitude says that every material object coincides with abundantly many further objects that differ in their modal profiles. A necessarily unmanifested disposition is a disposition that necessarily does not manifest. This paper argues that if the principle of plenitude holds, then there are some necessarily unmanifested dispositions. These necessarily unmanifested dispositions will be argued to evade some objections against the cases of necessarily unmanifested dispositions put forward by Carrie Jenkins and Daniel Nolan.

OBJECTIVE: To demonstrate the potential of machine learning and capability of natural language processing (NLP) to predict disposition of patients based on triage notes in the ED. METHODS: A retrospective cohort of ED triage notes from St Vincent's Hospital (Melbourne) was used to develop a deep-learning algorithm that predicts patient disposition. Bidirectional Encoder Representations from Transformers, a recent language representation model developed by Google, was utilised for NLP. Eighty percent of the dataset was used for training the model and 20% was used to test the algorithm performance. Ktrain library, a wrapper for TensorFlow Keras, was employed to develop the model. RESULTS: The accuracy of the algorithm was 83% and the area under the curve was 0.88. Sensitivity, specificity, precision and F1-score of the algorithm were 72%, 86%, 56% and 63%, respectively. CONCLUSION: Machine learning and NLP can be together applied to the ED triage note to predict patient disposition with a high level of accuracy. The algorithm can potentially assist ED clinicians in early identification of patients requiring admission by mitigating the cognitive load, thus optimises resource allocation in EDs.

The overall survival for children with cancer in high income countries is excellent. However, there are many disparities that may negatively affect survival, which are particularly problematic in low income countries, such as nutritional status at diagnosis and throughout therapy. Nutritional status as well as concomitant foods, supplements, and medications may play a role in overall exposure and response to chemotherapy. Emerging science around the microbiome may also play a role and should be further explored as a contributor to disease progression and therapeutic response. This article highlights some of these issues and proposes additional areas of research relevant to nutritional status and pharmacology that are needed in pediatric oncology.

Objective: To assess community-acquired pneumonia severity scores from two perspectives: (i) prediction of ICU admission or mortality; and (ii) utility of low scores for prediction of discharge within 48 h, potentially indicating suitability for short-stay unit admission. Methods: Patients with community-acquired pneumonia were identified from a prospective database of emergency patients admitted with infection. Pneumonia severity index (PSI), CURB-65, CORB, CURXO, SMART-COP scores and the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) minor criteria were calculated. Diagnostic accuracy statistics (sensitivity, specificity, predictive values, likelihood ratios and area under receiver operating characteristic curves [AUROC]) were determined for both end-points. Results: Of 618 patients admitted with community-acquired pneumonia judged eligible for invasive therapies, 75 (12.1%) were admitted to ICU or deceased at 30 days, and 87 (14.1%) were discharged within 48 h. All scores effectively stratified patients into categories of risk. For prediction of severe pneumonia, SMARTCOP, CURXO and IDSA/ATS discriminated well (AUROC 0.84–0.87). SMARTCOP and CURXO showed optimal sensitivity (85% [95% confidence interval (CI) 75–92]), while specificity was highest for CORB and CURB-65 (93% and 94%, respectively). Using lowest risk categories for prediction of discharge within 48 h, only SMARTCOP and CURXO showed specificity >80%. PSI demonstrated highest positive predictive value (31% [95% CI 24–39]) and AUROC (0.74 [95% CI 0.69–0.79]). Conclusions: Community-acquired pneumonia severity scores had different strengths; SMARTCOP and CURXO were sensitive with potential to rule out severe disease, while the high specificity of CORB and CURB-65 facilitated identification of patients at high risk of requirement for ICU. Low severity scores were not useful to identify patients suitable for admission to short-stay units.

Bumetanide is a loop diuretic that is proposed to possess a beneficial effect on disorders of the central nervous system, including neonatal seizures. Therefore, prediction of unbound bumetanide concentrations in the brain is relevant from a pharmacological prospective. A physiologically-based pharmacokinetic (PBPK) model was developed for the prediction of bumetanide disposition in plasma and brain in adult and paediatric populations. A compound file was built for bumetanide integrating physicochemical data and in vitro data. Bumetanide concentration profiles were simulated in both plasma and brain using the Simcyp PBPK model. Simulations of plasma bumetanide concentrations were compared against plasma levels published in the literature. The model performance was verified with data from adult studies before predictions in the paediatric population were undertaken. The adult and paediatric intravenous models predicted pharmacokinetic factors, namely area under the concentration-time curve, maximum concentration in plasma and time to maximum plasma concentration, within two-fold of observed values. However, predictions of plasma concentrations within the neonatal intravenous model did not produce a good fit with the observed values. The PBPK approach used in this study produced reasonable predictions of plasma concentrations of bumetanide, except in the critically ill neonatal population. This PBPK model requires more information regarding metabolic intrinsic clearance and transport parameters prior to further validation of drug disposition predictions in the neonatal population. Given the lack of information surrounding certain parameters in this special population, the model is not appropriately robust to support the recommendation of a suitable dose of bumetanide for use as an adjunct antiepileptic in neonates.

OBJECTIVE The present study aims to prospectively validate the Sydney Triage to Admission Risk Tool (START) to predict ED disposition. METHODS This was a prospective validation study at two metropolitan EDs in Sydney, Australia. Consecutive triage encounters were observed by a trained researcher and START scores calculated. The primary outcome was patient disposition (discharge or inpatient admission) from the ED. Multivariable logistic regression was used to estimate area under curve of receiver operator characteristic (AUC ROC) for START scores as well as START score in combination with other variables such as frailty, general practitioner referral, overcrowding and major medical comorbidities. RESULTS There were 894 patients analysed during the study period. The START score when applied to the data had AUC ROC of 0.80 (95% CI 0.77-0.83). The inclusion of other clinical variables identified at triage did not improve the overall performance of the model with an AUC ROC of 0.81 (95% CI 0.78-0.84) in the present study. CONCLUSION The overall performance of the START tool with respect to model discrimination and accuracy has been prospectively validated. Further clinical trials are required to test the clinical effectiveness of the tool in improving patient flow and overall ED performance.

A growing literature has focused on the role children's temperament traits play in social behavior, but associations have traditionally been explored through informant report. We utilized a longitudinal, observational approach to (a) examine how children's traits related to their social behaviors when aggregated across the school year; (b) explore how traits and social behavior relate to children's age and sex; and (c) test how prior traits predicted subsequent change in solitary, reticent, and social play, above and beyond mean-level change in play behavior over the course of the year. Fifty-three children were observed in their preschool classroom, where coders rated children's traits and social behaviors over the course of one school year (N = 26,673 observations). Results found positive age-related associations for positive emotionality (PE) and social play. In addition, aggregated traits explained a significant amount of the variance for every social behavior. Prior levels of lower PE, higher negative emotionality (NE), and higher effortful control (EC) predicted more subsequent time spent in reticent play, while NE and EC approached significance as predictors of solitary play. These results emphasize the role of early disposition on mean levels and rates of change in social behavior in a classroom.

Affording a couple the right to decide what should become of their frozen embryos in the event they divorce is of the utmost importance. The right to procreate, as well as not to procreate, has been observed as a constitutionally protected right under the Fourteenth Amendment of the U.S. Constitution. The interference by the judiciary in overriding, superseding, or simply ignoring disposition contracts is severely problematic. The parties have theoretically decided the best course of action by addressing potential future complications in disposition contracts. Not enforcing disposition contracts creates a lack of trust between the in vitro fertilization (IVF) facility and the parties and between the parties themselves. Knowing the contract they are signing may be thrown out if one party changes their mind, severely undermines contractual authority in assisted reproductive technology. This Note proposes multiple psychological, legal, and medical safeguards to be implemented by IVF facilities in order to ensure the parties enter into a valid and enforceable contract.

This article describes a clinical case where an Advanced Brief Strategic Therapy Model (Gibson and Boardman, 2016; Gibson et al., 2014; Nardone and Watzlawick, 2005) was used with a woman presenting with presumed Borderline Personality Disorder (BPD). In the world of therapy, the process of change can often be hard to predict at the best of times and extremely unpredictable during the worst. It can be difficult for the curious therapist to know how and what to look for as indicators of change when the larger picture may appear to remain unchanged in a client's life. I am curious about those therapy cases which present with great difficulties attached to them and which often drain much of our energy, vim and vigour as psychotherapists with often little apparent return on the investment we make. That is, if we measure that return in terms of reported change by the client, as opposed to privileging therapeutic disposition. Practitioner points This article explores how an Advanced Brief Strategic Therapy Model was used with a client diagnosed with Borderline Personality Disorder I critique the often misunderstood idea of embodied cybernetics as an interpretation of the therapeutic process Drawing on clinical practice, I describe some of the challenges in working with a client who often dispensed with rationality and employed non-ordinary logic in her modus operandi

Context Prior studies suggest that clinicians can categorise patients in an emergency room as ‘sick’ or ‘not sick’ using rapid visual assessment. The rapid nature of these decisions suggests clinicians are relying on pattern recognition or System 1 processing; however, this has not been studied experimentally. In this study, we explore the accuracy of these decisions using patient disposition (discharge, admission to ward or admission to critical care) as an objective outcome, and collect evidence to argue for the use of System 1 processing in the ‘sick’ or ‘not sick’ decision process. Methods Fourteen practising emergency physicians reviewed 25 videos of patients presenting to the emergency room. They were asked to predict patient disposition (discharge, admission to ward or admission to critical care) and estimate whether they were ‘sick’ or ‘not sick’ using a continuous slider on a ‘sick’ scale from ‘not sick’ (0) to ‘sick’ (100). We collected decision time and asked physicians to identify how they came to the decision using a continuous slider on a ‘system processing’ scale from ‘knew immediately’ (0) to ‘deliberated intently’ (1). Results Inter-rater reliability judging ‘sick’ was computed as an intraclass correlation coefficient (ICC) of 0.54. Agreement among physicians in predicting disposition was 68% with ICC of 0.44, and accuracy at predicting disposition was 55%. Physicians made their decision in an average of 10 – 11 seconds and rated 70% of their decisions as < 0.5 on the scale from ‘knew immediately’ (0) to ‘deliberated intently’ (1). Conclusions Experienced emergency physicians are able to visually assess patients rapidly and predict disposition in a very short time, albeit with fair reliability and lower accuracy than reported previously. Subjectively, they reported that the majority of decisions were on the side of ‘knew immediately’, consistent with the application of System 1 processing.

This study investigated the disposition of coagulation factor VIII activity in 754 patients with moderate to severe hemophilia A following the administration of moroctocog alfa, a B-domain deleted recombinant factor VIII. Data analyzed included patients aged 1 day to 73 years enrolled in 13 studies conducted over a period of 20 years in 25 countries. A two-compartment population pharmacokinetic model with a baseline model described the pooled data well. Body size, age, inhibitors, race, and analytical assay were identified as significant predictors of factor VIII disposition. In addition, simulations of prophylactic dosing schedules in several pediatric cohorts showed large variability and suggest that younger patients would require higher weight-adjusted doses than adolescents to achieve target factor VIII trough activity when receiving every other day or twice weekly dosing.