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Background: Recently increased access to cannabis products in the United States has been associated with increased rates of driving after cannabis use. Although numerous studies indicate that cannabis impairs psychomotor and neurocognitive functions that can affect driving ability, the determination of cannabis-impaired driving risk is complicated by the extent to which frequent cannabis users develop tolerance to THC's subjective, cognitive, and psychomotor effects, and by the fact that there is no validated behavioral or biological marker of recent cannabis use or cannabis-related impairment. This study examined the psychomotor impairment-related effects experienced by frequent cannabis users in Colorado after naturalistic consumption of smoked cannabis, both immediately and 1 h postuse. Results were then validated in a smaller replication sample from Washington state. Methods: In the primary Colorado study, participants (n=70) used the DRUID(®) mobile app, a brief measure of psychomotor and cognitive domains that are sensitive to the effects of cannabis. First, participants used DRUID to establish a sober baseline impairment score. During a second appointment, they used DRUID at three time points: preuse, immediately after acutely using cannabis, and 1 h postuse. In the Washington replication sample, participants (n=39) used DRUID before acute cannabis consumption and then every half hour for 2.5 h. Results: In both studies, peak DRUID impairment effects were seen immediately after cannabis use, with recovery of performance at 1 h postuse. Specifically, significant quadratic effects of time emerged for both studies (Colorado study: (β=−0.935, SE=0.204, p

This chapter will consider normal development, functional adaptations at birth, and abnormal development. Liver and gallbladder anomalies are sometimes accompanied by abnormalities in other systems or seen as part of a fibrocystic syndrome/ciliopathy. In neonatal cholestasis, or liver failure, the liver may be biopsied. Biopsy rates in these settings vary between centers. Gene chip analysis can be performed on peripheral blood, for conditions with known genetic mutations, and biopsy is regarded by some as a “third-line” investigation in biliary atresia. Despite this, there will always be cases where biopsy is a key contributor to the multidisciplinary diagnosis of neonatal liver disease. An approach to the interpretation of patterns of liver disease, representing common diagnoses, in this age group, is presented in the settings of neonatal jaundice and liver failure. Trauma and iatrogenic causes of liver disease are considered. Intestinal failure-associated liver disease is an example of the pathologist’s role in the timing and appropriateness of transplantation, by staging liver disease and excluding additional diseases or systemic conditions. Examination of the explanted organ confirms disease processes, important in follow-up for potentially recurrent conditions. Finally, the fetal and neonatal liver can be the site of tumor formation. Salient features of these are described.

The aim of the Scot BC Quality OPS clinical project is to create a reliable prospective data set for evaluating real-world effectiveness and efficiency consequent to standardisation and monitoring of bladder cancer treatment (through the national Quality Performance Indicator programme) and streamlined surveillance in Scotland. Several work packages have been created, reflecting wide clinical and research collaboration.

Introduction: The purpose of this survey is to understand the extent of telehealth utilization for persons with sickle cell disease (SCD), while also determining possible barriers patients may have in accessing care and providers using this tool. . Community-Based Organizations (CBOs) in five states (California, Colorado, Oregon, Nevada, and Arizona) obtained feedback directly from patients with SCD on managing their care via telehealth during the current COVID-19 pandemic. Methods: Phone calls were made by CBOs in five states, to their specific patient database between May 11 - 29, 2020. A series of 17 questions were asked to obtain information from patients with SCD, parents of children with SCD, or caregivers of a person with SCD. All data was de-identified. CBOs that participated in data collection included the Sickle Cell Disease Foundation (California), Colorado Sickle Cell Association, Sickle Cell Anemia Foundation of Oregon, Sickled Not Broken Foundation of Nevada, and Sickle Cell Foundation of Arizona. Results: A total of 199 patients or caregivers of patients living with sickle cell disease were surveyed. Of these individuals, 121 (61%) were female and 78 (39%) were male. The most prevalent SCD hemoglobinopathy reported among patients was Hgb SS (68%) followed by Hgb SC disease at (20%). Hgb SB or other variants were surveyed at (9%), while (3%) were unknown. Participants with Hgb SS disease at (46%) were female while (22%) were male. Overall, the majority of patients fell within the age range of 18-35 (50%). Female patients were 18-35 yrs (30%), 0-17 yrs (18%) or > 36 yrs (13%). Male patients ranged from 18-35 years (20%), 0-17 yrs (12%), and 36 or older (7%). When surveying patients about their primary languages, the majority of participants spoke English (92%), while others spoke Spanish (5%), French (1%), Somali (1%), and Creole (1%). Individuals, who were not fluent in English, desired translated material to assist them in better understanding their disease and managing their care. To understand patient access to care via telehealth platforms during a global pandemic, we asked questions with the following themes: familiarity with telehealth services, the willingness or ability to access services and healthcare utilization patterns during COVID-19. Of those surveyed, 55% indicated that they have heard of or have participated in telehealth services. Importantly, 85% reported familiarity or the ability to download Zoom, and 80% reported interest in connecting with a provider via telehealth services. When asked about access to WiFi and to tools used to navigate online systems, the majority of patients indicated they had access to WiFi (95%) and would access telehealth services through any of the following devices: mobile phones (71%), computers (59%) or tablets (17%). Survey respondents also indicated they had assistance at home with accessing telehealth sessions (64%) while the remaining (46%) indicated that they would be interested in having a Community Health Worker provide them with support in getting started with telehealth services. When asking patients about health care utilization during the COVID-19 pandemic only 35% of patients indicated they went to an emergency room for care while the remaining 65% did not. Of note, 53% of those surveyed reported managing their SCD crisis at home, with 52% of all patients reporting that they reached out to SCD providers (hematologists with expertise in treating patients with sickle cell disease) for advice and care recommendations rather than risking exposure to COVID in the ER. In addition, patients indicated that they had difficulty getting prescriptions refilled or were unable to afford their medications (16%). Lastly, almost all patients indicated an interest in having access to a 24-hour hotline for SCD care (94%). Conclusion: The utilization of CBOs to provide ancillary support services is necessary to continue to understand patient needs, not only during a global crisis but after for routine health care. Our survey demonstrated that most patients have access to the technology needed to connect to their healthcare teams. However, access to a knowledgeable provider should be strengthened to ensure patient competence and comfort with self-management while utilizing telehealth resources. Finally, clinical care teams are recommended to enhance access to telehealth services and provide additional community resources to improve access to care. Figure Disclosures Fields: Imara Inc.: Consultancy. Brown:Novartis: Consultancy; Global Blood Therapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Objective Effective self-directed educational tools are invaluable. Our objective was to determine whether a self-directed, web-based oral case presentation module would improve medical students' oral case presentations compared to usual curriculum, and with similar efficacy as structured oral presentation faculty feedback sessions. Methods We conducted a pragmatic multicenter cluster randomized controlled trial among medical students rotating in pediatric clerkships at 7 US medical schools. In the clerkship's first 14 days, subjects were instructed to complete an online Computer-Assisted Learning in Pediatrics Program (CLIPP) oral case presentation module, an in-person faculty-led case presentation feedback session, or neither (control). At the clerkship's end, evaluators blinded to intervention status rated the quality of students' oral case presentations on a 10-point scale. We conducted intention-to-treat multivariable analyses clustered on clerkship block. Results Study participants included 256 CLIPP (32.5%), 263 feedback (33.3%), and 270 control (34.2%) subjects. Only 51.1% of CLIPP subjects completed the assigned presentation module, while 98.5% of feedback subjects participated in presentation feedback sessions. Compared to controls, oral presentation quality was significantly higher in the feedback group (adjusted difference in mean quality, 0.28; 95% confidence interval, 0.08, 0.49) and trended toward being significantly higher in the CLIPP group (0.19; 95% confidence interval, −0.006, 0.38). The quality of presentations in the CLIPP and feedback groups was not significantly different (−0.10; 95% confidence interval, −0.31, 0.11). Conclusions The quality of oral case presentations delivered by students randomized to complete the CLIPP module did not differ from faculty-led presentation feedback sessions and was not statistically superior to control.

This work was part of a National Institute for Health Research participatory action research and practice development study, which focused on the use of a therapeutic, robotic baby seal (PARO, for personal assistive robot) in everyday practice in a single-site dementia unit in Sussex. From the beginning of January 2017 until the end of September 2017, the cleaning and cleanliness of PARO was monitored through a service audit process that focused on the cleaning, amount of use and testing of contamination of PARO being used in everyday clinical practice with individuals and in group sessions. Its use and cleaning followed protocols developed by the study team, which incorporated hand hygiene and standard precaution policies. Its cleanliness was determined using an adenosine triphosphate (ATP) luminometer, with a benchmark of 50 relative light units (RLU). A reading of ATP below 50RLU is the level of cleanliness recommended for social areas in hospital settings. Throughout the study period, monitoring showed that all swab zones on PARO were within the benchmark of the 50RLU threshold for cleanliness. PARO has an emerging evidence base as a useful therapeutic device. However, introducing such devices into clinical practice may encounter barriers or concerns from an infection prevention and control (IPC) perspective. This study of PARO in clinical practice aims to address the IPC concerns raised and offers cleaning and testing protocols and results.

Objectives To examine how real-world evidence (RWE) is currently perceived and used in managed care environments, especially to inform pharmacy and therapeutic (P&T) committee decisions, to assess which study factors (e.g., data, design, and funding source) contribute to RWE utility in decisions, and to identify barriers to consideration of RWE studies in P&T decision making. Methods We conducted focus groups/telephone-based interviews and surveys to understand perceptions of RWE and assess awareness, quality, and relevance of two high-profile examples of published RWE studies. A purposive sample comprised 4 physicians, 15 pharmacists, and 1 researcher representing 18 US health plans and health system organizations. Results Participants reported that RWE was generally used, or useful, to inform safety monitoring, utilization management, and cost analysis, but less so to guide P&T decisions. Participants were not aware of the two sample RWE studies but considered both studies to be valuable. Relevant research questions and outcomes, transparent methods, study quality, and timely results contribute to the utility of published RWE. Perceived organizational barriers to the use of published RWE included lack of skill, training, and timely study results. Conclusions Payers recognize the value of RWE, but use of such studies to inform P&T decisions varies from organization to organization and is limited. Relevance to payers, timeliness, and transparent methods were key concerns with RWE. Participants recognized the need for continuing education on evaluating and using RWE to better understand the study methods, findings, and applicability to their organizations.

Background Exposure to life-threatening drug-drug interactions (DDIs) occurs despite the widespread use of clinical decision support. The DDI between warfarin and nonsteroidal anti-inflammatory drugs is common and potentially life-threatening. Patients can play a substantial role in preventing harm from DDIs; however, the current model for DDI decision-making is clinician centric. Objective This study aims to design and study the usability of DDInteract, a tool to support shared decision-making (SDM) between a patient and provider for the DDI between warfarin and nonsteroidal anti-inflammatory drugs. Methods We used an SDM framework and user-centered design methods to guide the design and usability of DDInteract—an SDM electronic health record app to prevent harm from clinically significant DDIs. The design involved iterative prototypes, qualitative feedback from stakeholders, and a heuristic evaluation. The usability evaluation included patients and clinicians. Patients participated in a simulated SDM discussion using clinical vignettes. Clinicians were asked to complete eight tasks using DDInteract and to assess the tool using a survey adapted from the System Usability Scale. Results The designed DDInteract prototype includes the following features: a patient-specific risk profile, dynamic risk icon array, patient education section, and treatment decision tree. A total of 4 patients and 11 clinicians participated in the usability study. After an SDM session where patients and clinicians review the tool concurrently, patients generally favored pain treatments with less risk of gastrointestinal bleeding. Clinicians successfully completed the tasks with a mean of 144 (SD 74) seconds and rated the usability of DDInteract as 4.32 (SD 0.52) of 5. Conclusions This study expands the use of SDM to DDIs. The next steps are to determine if DDInteract can improve shared decision-making quality and to implement it across health systems using interoperable technology.

Sarah-Mary Brown FWCF discusses some of the issues faced by owners and farriers

Payers are faced with making coverage and reimbursement decisions based on the best available evidence. Often these decisions apply to patient populations, provider networks, and care settings not typically studied in clinical trials. Treatment effectiveness evidence is increasingly available from electronic health records, registries, and administrative claims. However, little is known about when and what types of real-world evidence (RWE) studies inform pharmacy and therapeutic (PT) committee decisions.To evaluate evidence sources cited in PT committee monographs and therapeutic class reviews and assess the design features and quality of cited RWE studies.A convenience sample of representatives from pharmacy benefit management, health system, and health plan organizations provided recent PT monographs and therapeutic class reviews (or references from such documents). Two investigators examined and grouped references into major categories (published studies, unpublished studies, and other/unknown) and multiple subcategories (e.g., product label, clinical trials, RWE, systematic reviews). Cited comparative RWE was reviewed to assess design features (e.g., population, data source, comparators) and quality using the Good ReseArch for Comparative Effectiveness (GRACE) Checklist.Investigators evaluated 565 references cited in 27 monographs/therapeutic class reviews from 6 managed care organizations. Therapeutic class reviews mostly cited published clinical trials (35.3%, 155/439), while single-product monographs relied most on manufacturer-supplied information (42.1%, 53/126). Published RWE comprised 4.8% (21/439) of therapeutic class review references, and none (0/126) of the monograph references. Of the 21 RWE studies, 12 were comparative and assessed patient care settings and outcomes typically not included in clinical trials (community ambulatory settings [10], long-term safety [8]). RWE studies most frequently were based on registry data (6), conducted in the United States (6), and funded by the pharmaceutical industry (5). GRACE Checklist ratings suggested the data and methods of these comparative RWE studies were of high quality.RWE was infrequently cited in PT materials, even among therapeutic class reviews where RWE is more readily available. Although few PT materials cited RWE, the comparative RWE studies were generally high quality. More research is needed to understand when and what types of real-world studies can more routinely inform coverage and reimbursement decisions.This project was funded by the National Pharmaceutical Council. Hurwitz, Brown, Peters, and Malone have nothing to disclose. Graff is employed by the National Pharmaceutical Council Part of this study was presented as a poster presentation at the AMCP Managed CareSpecialty Pharmacy 2016 Annual Meeting; April 19-22, 2016; San Francisco, CA. Study concept and design were primarily contributed by Malone and Graff, along with Hurwitz and Brown. All authors participated in data collection, and data interpretation was performed by Malone, Hurwitz, and Graff, with assistance from Brown and Peters. The manuscript was written primarily by Hurwitz and Malone, along with Graff, Brown, and Peters, and revised by Malone, Brown, Peters, Hurwitz, and Graff.

Community health workers are increasingly recognized as useful for improving health care and health outcomes for a variety of chronic conditions. Community health workers can provide social support, navigation of health systems and resources, and lay counseling. Social and cultural alignment of community health workers with the population they serve is an important aspect of community health worker intervention. Although community health worker interventions have been shown to improve patient-centered outcomes in underserved communities, these interventions have not been evaluated with sickle cell disease. Evidence from other disease areas suggests that community health worker intervention also would be effective for these patients. Sickle cell disease is complex, with a range of barriers to multifaceted care needs at the individual, family/friend, clinical organization, and community levels. Care delivery is complicated by disparities in health care: access, delivery, services, and cultural mismatches between providers and families. Current practices inadequately address or provide incomplete control of symptoms, especially pain, resulting in decreased quality of life and high medical expense. The authors propose that care and care outcomes for people with sickle cell disease could be improved through community health worker case management, social support, and health system navigation. This report outlines implementation strategies in current use to test community health workers for sickle cell disease management in a variety of settings. National medical and advocacy efforts to develop the community health workforce for sickle cell disease management may enhance the progress and development of “best practices” for this area of community-based care.

In recent years, comparative effectiveness tools and methods have evolved to assist health care decision makers in identifying optimal therapies. In-person training programs on comparative effectiveness research may be helpful in understanding and applying this information.To provide a follow-up assessment of the use of comparative effectiveness research (CER) in the pharmacy and therapeutics (PT) committee decision-making process, using information collected from participants 1 year after attending a live continuing education program, in which participants were taught about CER designs and how to access available CER resources through the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care (EHC) Program.A retrospective, cross-sectional questionnaire was developed and mailed to 2 groups of individuals: CER workshop attendees and interested nonattendees (expressing an interest in attending a workshop but did not attend for unknown reasons). The questionnaire asked respondents to indicate personal and organizational use of CER in the decision-making process. Participants were asked to indicate whether their knowledge, ability, and use of CER studies increased since participating in the program. Data were analyzed using nonparametric tests to compare the responses of attendees and nonattendees, as well as overall reliability of the instrument.A total of 164 respondents completed the questionnaire (63 attendees and 101 nonattendees; overall response rate = 44%). The majority of respondents were pharmacists (n = 157, 95.7%) and were affiliated with a hospital (n = 106, 64.6%). Proportions of attendees and nonattendees differed significantly in the use of EHC research reviews/reports (45% and 28%, respectively; P = 0.02) and EHC executive summaries of research reviews/reports (48% and 29%, respectively; P = 0.01). At 1-year follow-up, the majority of attendees reported an increase ("somewhat" or "very much") in knowledge of CER (91.5%), ability to use CER (83.0%), and use of CER studies (58.7%).Health professionals attending a continuing education CER program reported higher use of EHC CER materials compared with nonattendees. Additionally, attendees reported increased use of CER in clinical decision making. A continuing education program such as this may provide an effective avenue for introducing CER methods and resources to the PT committee and clinical decision-making processes.This project was supported by grant number R18HS019220 from the Agency of Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency of Healthcare Research and Quality. Augustine has stock in Pfizer. The authors declared no other potential conflicts of interest associated with this study. Study concept and design were primarily contributed by Malone, along with Warholak, Hines, Brown, Hurwitz, and Taylor. Warholak, Hines, Brown, Hurwitz, and Taylor collected the data, assisted by Malone, Brixner, Cobaugh, and Schlaifer. Data interpretation was performed by Malone and Augustine, with assistance from the other authors. The manuscript was written primarily by Augustine, with assistance from Malone, Sun, Warholak, Hines, Brown, Hurwitz, and Taylor. Malone revised the manuscript, assisted by Warholak, Hines, Brown, Hurwitz, Taylor, Brixner, Cobaugh, and Schlaifer.

Summary Background Study abroad programmes have been shown to have significant benefits for participating healthcare students such as promoting cultural awareness and understanding of different healthcare settings, policies and practices. Healthcare students are encouraged to undertake elective or Erasmus placements overseas to enhance personal and professional development and to broaden horizons through lived cultural experience. However, there is a relatively low uptake of such opportunities amongst this student group. Objectives This systematic review aimed to explore factors that influence healthcare students' decision making around study abroad opportunities within undergraduate training programmes. Review design methods A systematic review was undertaken utilising a narrative synthesis approach. Data sources A comprehensive literature search was conducted on MEDLINE, CINAHL, EMBASE, PsycINFO, ASSIA, and ERIC databases. Key institutions were contacted for grey literature. Studies that reported on factors that influence healthcare students' decisions regarding study abroad programmes were included in the review. Results Ten studies were identified for inclusion (5 qualitative studies, 5 surveys), indicating a paucity of research in this area. Data synthesis indicates that factors that influence healthcare students' decisions to participate in study abroad programmes are similar across different geographic locations and different professional groups. Factors that support decisions to study overseas include having sufficient information about study abroad programmes, especially early in an academic programme, having an interest in other cultures/countries and having academic staff and family as positive role models who motivate them to study abroad. Key barriers are cost and language issues. Language remains a significant barrier even when generous bursaries are available, as with the Erasmus scheme, when students are not proficient with the language spoken in host countries. Students tend to prefer destinations where language is not a problem or where countries have cultural or historical connections, such as being part of the Commonwealth countries. Conclusions Promotion of study abroad opportunities needs to start early in an academic programme. It should include detailed information and provision of language support. Faculty have an important part to play as enthusiastic role models.

BACKGROUND:Rehabilitation following severe Traumatic Brain Injury (TBI) often involves the use of temporary tracheostomies. Tracheostomy weaning is influenced by physiological parameters, which are abnormal in the concomitant complication of Paroxysmal Sympathetic Hyperactivity (PSH). OBJECTIVE:To investigate the association between PSH and tracheostomy weaning in severe TBI. METHODS:This was a retrospective cohort study of consecutive patients with TBI and tracheostomy admitted to a Hyper-Acute Neurorehabilitation Unit over a 34-month period. Duration of tracheostomy wean and influencing characteristics were statistically compared between those with and without PSH. RESULTS:Fifty-one patients admitted with TBI required a tracheostomy. Of these, 10 patients were also diagnosed with PSH. The mean tracheostomy wean in the PSH group was longer compared to the non-PSH group (72.3, SD 61.0 versus 30.0 days, SD 16.2). This difference was statistically significant (p = 0.007, using Mann Whitney U test). The PSH group had more respiratory and oral secretions, but this was not statistically significant (p = 0.16 and 0.29). CONCLUSIONS:This is the first study to demonstrate that PSH is associated with prolonged tracheostomy weaning in severe TBI. Awareness of this association should enable those planning rehabilitation to set realistic goals for a patient’s tracheostomy weaning programme.

Overdoses (ODs) of prescription opioids (RxOs) have become a major public health issue in the United States. Objective: To determine the root causes of accidental prescription opioid overdoses (RxO-OD). Design/setting/participants/intervention: The authors conducted a root cause analysis using the Antecedent Target-Measurement method, interviewing three types of key informants: survivors of RxO-ODs, family members, and clinical experts. Results: Ten survivors, five family members, and three experts were interviewed. Proximal causes of RxO-ODs described by survivors and family members were recent RxO dose escalation (n = 9), polysubstance use (n = 5), and polypharmacy use (n = 3). Proximal causes were elicited by the following six antecedent causes: wanting to feel good/high (n = 9), perceived tolerance to RxO (n = 6), didn't know/believe it was dangerous (n = 5), wanting to reduce psychosocial pain (n = 5), wanting to reduce physical pain (n = 4), and wanting to avoid discomfort due to withdrawal symptoms (n = 4). RxOs involved in the OD were either prescribed by a doctor (n = 7), purchased from a dealer (n = 6), given/purchased from family/friends (n = 3), or stolen from family (n = 1). Psychosocial stressors (n = 9), chronic recurrent depression (n = 3), and chronic substance abuse/addiction (n = 4) were also distal and proximal causes of OD. Experts cited similar causes but added prescriberrelated causes (eg, inadequate training) and healthcare system and culture. Conclusions: Patients at risk for OD can be identified and ODs potentially prevented. Opportunities for intervention include routine screening of patients using RxOs for psychosocial distress and coping, flagging of high-risk patients, care pathways for high-risk patients, clinician and patient training on OD prevention, and developing abuse-deterrent formulations of RxOs .

[Figure][1] The Heart Research Follow-up Program at the University of Rochester Medical Center has an ongoing record of successfully carrying out large-scale clinical cardiovascular studies and randomized clinical trials for >35 years, and nearly all of the original executive committee

Atlases provide a framework for spatially mapping information from diverse sources into a common reference space. Specifically, brain atlases allow annotation of gene expression, cell morphology, connectivity, and activity. In larval zebrafish, advances in genetics, imaging, and computational methods now allow the collection of such information brain-wide. However, due to technical considerations, disparate datasets may use different references and may not be aligned to the same coordinate space. Two recent larval zebrafish atlases exemplify this problem: Z-Brain, containing gene expression, neural activity, and neuroanatomical segmentations, was acquired using immunohistochemical stains, while the Zebrafish Brain Browser (ZBB) was constructed from live scans of fluorescent reporters in transgenic larvae. Although different references were used, the atlases included several common transgenic patterns that provide potential “bridges” for transforming each into the other's coordinate space. We tested multiple bridging channels and registration algorithms and found that the symmetric diffeomorphic normalization algorithm improved live brain registration precision while better preserving cell morphology than B-spline-based registrations. Symmetric diffeomorphic normalization also corrected for tissue distortion introduced during fixation. Multi-reference channel optimization provided a transformation that enabled Z-Brain and ZBB to be co-aligned with precision of approximately a single cell diameter and minimal perturbation of cell and tissue morphology. Finally, we developed software to visualize brain regions in 3 dimensions, including a virtual reality neuroanatomy explorer. This study demonstrates the feasibility of integrating whole brain datasets, despite disparate reference templates and acquisition protocols, when sufficient information is present for bridging. Increased accuracy and interoperability of zebrafish digital brain atlases will facilitate neurobiological studies.

The Internet and social networking technologies have facilitated communication between groups of retrophiles or fans of the past. The article seeks to examine motivations for retrophilic action and to discuss these ideas within the present late capitalist culture. The article discusses how retrophiles seem to use the past in order to (re)construct their individual and collective identities and it examines two recent media representations that present retrophiles in discourses of consumption and acquisition.

Objective: To investigate: the accuracy of measuring relative left/right weight-bearing using two identically calibrated weighing scales; the short-term weight-bearing tendencies in a general population of 9 participants and long-term in 42 females; the effect weight-bearing inequalities on hip bone mineral density and leg lean tissue mass. Method: Participants were measured standing astride two scales. Short-term volunteers were measured 10 times on one visit, with repositioning between measurements and the long-term group were measured on three visits at 6 month intervals. Baseline bilateral hip and total body Dual X-ray Absorptiometry scans were performed on the long-term group. Results: The short-term Coefficient of Variation is 5.41% and long-term 7.01%. No significant correlations were found between hip bone density differences and weight-bearing inequalities, although a weak correlation of r = 0.31 (p = 0.047) was found for differences in leg lean tissue mass. Conclusion: Left/right weight-bearing measured using two scales is a consistent method for evaluating weight distribution through the legs. The short- and long-term weight-bearing tendencies showed a similar degree of variation. Weightbearing inequalities were not associated with any significant left/right differences in bone mineral density at the hip, but were weakly associated with left-right differences in leg muscle mass.

Fisheries and aquaculture production, imports, exports and equitability of distribution determine the supply of aquatic food to people. Aquatic food security is achieved when a food supply is sufficient, safe, sustainable, shockproof and sound: sufficient, to meet needs and preferences of people; safe, to provide nutritional benefit while posing minimal health risks; sustainable, to provide food now and for future generations; shock-proof, to provide resilience to shocks in production systems and supply chains; and sound, to meet legal and ethical standards for welfare of animals, people and environment. Here, we present an integrated assessment of these elements of the aquatic food system in the United Kingdom, a system linked to dynamic global networks of producers, processors and markets. Our assessment addresses sufficiency of supply from aquaculture, fisheries and trade; safety of supply given biological, chemical and radiation hazards; social, economic and environmental sustainability of production systems and supply chains; system resilience to social, economic and environmental shocks; welfare of fish, people and environment; and the authenticity of food. Conventionally, these aspects of the food system are not assessed collectively, so information supporting our assessment is widely dispersed. Our assessment reveals trade-offs and challenges in the food system that are easily overlooked in sectoral analyses of fisheries, aquaculture, health, medicine, human and fish welfare, safety and environment. We highlight potential benefits of an integrated, systematic and ongoing process to assess security of the aquatic food system and to predict impacts of social, economic and environmental change on food supply and demand.

Atlases provide a framework for information from diverse sources to be spatially mapped and integrated into a common reference space. In particular, brain atlases allow regional annotation of gene expression, cell morphology, connectivity and activity. In larval zebrafish, advances in genetics, imaging and computational methods have enabled the collection of large datasets providing such information on a whole-brain scale. However, datasets from different sources may not be aligned to the same spatial coordinate system, because technical considerations may necessitate use of different reference templates. Two recent brain atlases for larval zebrafish exemplify this problem. The Z-Brain atlas contains information on gene expression, neural activity and neuroanatomical segmentation acquired using immunohistochemical staining of fixed tissue. In contrast, the Zebrafish Brain Browser (ZBB) atlas was constructed from live scans of fluorescent reporter genes in transgenic larvae. Although different reference brains were used, the two atlases included several transgene patterns in common that provided potential 'bridges' for transforming each into the other’s coordinate space. We therefore tested multiple bridging channels and registration algorithms. The symmetric diffeomorphic normalization (SyN) algorithm in ANTs improved the precision of live brain registration while better preserving cell morphology than the previously used B-spline elastic registration algorithm. SyN could also be calibrated to correct for tissue distortion introduced during fixation and permeabilization. Finally, multi-reference channel optimization provided a transformation matrix that enabled Z-Brain and ZBB to be co-aligned with acceptable precision and minimal perturbation of cell and tissue morphology. This study demonstrates the feasibility of integrating whole brain datasets, despite disparate acquisition protocols and reference templates, when sufficient information is present for bridging.Anatomical abbreviationsacanterior commissureDTThalamusGTGriseum tectaleHaHabenulaHcHypothalamus caudal zoneHiHypothalamus intermediate zoneMOMedulla oblongataNXmVagus motor neuronsOBOlfactory bulbOEOlfactory epitheliumIOInferior oliveLCLocus coeruleusMNMauthner neuronMOMedulla oblongataPalPalliumpcposterior commissurePrPretectumSRSuperior rapheTegTegmentumTeOnOptic tectum neuropilTGTrigeminal ganglionTLTorus longitudinalis

Purpose Recommendations for including drug–drug interactions (DDIs) in clinical decision support (CDS) are presented. Summary A conference series was conducted to improve CDS for DDIs. A work group consisting of 20 experts in pharmacology, drug information, and CDS from academia, government agencies, health information vendors, and healthcare organizations was convened to address (1) the process to use for developing and maintaining a standard set of DDIs, (2) the information that should be included in a knowledge base of standard DDIs, (3) whether a list of contraindicated drug pairs can or should be established, and (4) how to more intelligently filter DDI alerts. We recommend a transparent, systematic, and evidence-driven process with graded recommendations by a consensus panel of experts and oversight by a national organization. We outline key DDI information needed to help guide clinician decision-making. We recommend judicious classification of DDIs as contraindicated and more research to identify methods to safely reduce repetitive and less-relevant alerts. Conclusion An expert panel with a centralized organizer or convener should be established to develop and maintain a standard set of DDIs for CDS in the United States. The process should be evidence driven, transparent, and systematic, with feedback from multiple stakeholders for continuous improvement. The scope of the expert panel’s work should be carefully managed to ensure that the process is sustainable. Support for research to improve DDI alerting in the future is also needed. Adoption of these steps may lead to consistent and clinically relevant content for interruptive DDIs, thus reducing alert fatigue and improving patient safety.

Objective To determine proof of concept for use of a network of pharmacists to evaluate the safety of medications. Design Pilot, comparative, prospective evaluation. Setting Community pharmacies and a pharmacist-staffed call center in Arizona during January through August 2006. Patients Patients filling prescriptions for ipratropium or tiotropium bromide at 1 of 55 Arizona pharmacies were encouraged to call a pharmacist-staffed call center. A total of 67 patients contacted the center and 41 participated. Intervention A network of community pharmacies and a call center were used to collect data on patients receiving one of two medications for the treatment of chronic obstructive pulmonary disease. Pharmacists in the community pharmacies recruited patients who presented with a prescription or requested a refill for one of the medications. The call center was used to collect patient data. Patients provided data on medication use, completed the chronic respiratory questionnaire (CRQ), and were encouraged to call the center to report health problems. After 30 days, patients were called to determine whether they experienced any adverse events while taking their medication and the CRQ was readministered. Main outcome measure Knowledge gained on the feasibility of the model using pharmacists to assess drug safety. Results A total of 67 (6.7%) of a possible 995 patients contacted the call center about participating in the study. Approximately one-half (n=28) of the 55 pharmacies had one or more patients contact the center about the study. A total of 41 patients met inclusion/exclusion criteria and were enrolled. Six (15%) patients reported an adverse effect, including one serious adverse event (acute glaucoma). Conclusion This study provides limited evidence that community pharmacies and a pharmacist-staffed call center can be used to assess medication safety; however, a number of issues need to be examined to determine whether the approaches can be sufficiently effective.

Purpose: To describe the self-reported vision, history of eye disease and general health of indigenous Australian participants in the National Indigenous Eye Health Survey. Methods: Using a multistage cluster sampling methodology, 30 geographic areas, stratified by remoteness, were selected to provide a representative population of indigenous Australians aged 5–15 years and 40 years and over. Before an eye examination, participants completed a questionnaire about their eye health and eye care facilities consulted, satisfaction with their vision and general health. Results: A total of 1694 indigenous children (49.2% female, mean age 9.5 ± 2.9 years) and 1189 adults (61.0% female, mean age 53.1 ± 9.7 years) participated. Three-quarters of adults (259/342) and 88.4% of children (129/146) wore the right distance glasses. Adults from remote areas were less likely to have refractive error (P = 0.002) as well as males versus females (P = 0.02). Similar results were found for children. Adults wearing appropriate distance glasses were as satisfied with their vision as people with normal vision who did not need glasses (P = 0.6). Both groups were more satisfied with their distance vision than people with poor presenting vision (P = 0.007). Self-report of cataract, diabetic retinopathy, glaucoma and age-related macular degeneration did not match with clinical findings (P

Vision impairment associated with diabetic retinopathy (DR) impacts on an individual’s functioning, psychosocial, physical and financial wellbeing. However, clinical measures of visual functioning are not able to capture the broad effects of vision impairment as experienced by the individual. For this reason, self-reported health-related quality of life (QoL) has become an important outcome measure in ophthalmic practice. While many health-related QoL questionnaires have been developed to measure this concept, few have adequate psychometric properties. This paper discusses the assessment of vision-specific QoL for patients with DR and the associations between DR and QoL. The impact of ophthalmic interventions and low-vision rehabilitation for people with DR are explored. To fully capture the effectiveness of such interventions, a valid, reliable, culturally appropriate, vision-specific instrument should be used.

Background: Device-related infections represent a significant clinical challenge. Once established, these infections prove difficult to treat with existing antibiotic regimens, compromising the health of device recipients, and usually requiring surgical intervention to resolve. Objective: The purpose of this study was to determine the efficacy of the AIGIS RX ™ antibacterial envelope (TyRx Pharma, Inc., Monmouth Junction, NJ, USA) designed to reduce device-related infections by incorporating minocycline and rifampin in a controlled release polymer. Methods: An infection was established in a rabbit model by creating bilateral subcutaneous implant pockets, into which a pacing device with or without AIGIS RX ™ was placed. The incisions were closed, and a defined dose of bacteria was infused into each implant pocket. After 7 days, devices were explanted and sampled for viable bacteria by swabbing and sonication. Results: Initial studies evaluated the ability of the AIGIS RX pouch to reduce Staphylococcus epidermidis (S. epi) infection in this model using clinical and quantitative microbial endpoints. Results demonstrate S. epi infection in all control samples, while no pathogens were recovered from samples with the AIGISRX ™ pouch. Systemic antibiotic levels were undetectable. Additional studies tested the efficacy of the AIGIS RX ™ pouch with additional bacterial strains, Staphylococcus capitis, Escherichia coli, and Acinetobacter Baumannii. In each case, the device and implant pocket with the AIGIS RX ™ pouch was free of any signs of infection. An assessment of biofilm produced by Acinetobacter demonstrated the elimination of biofilm formation on the implanted device. Conclusion: These results demonstrate that in this animal model, the AIGIS RX ™ device reduces the risk for infection of viable pathogens within implant pockets.

Aim: To examine the physical and mental health outcomes at school-age of a cohort of children who participated in a randomised clinical trial of treatments for persistent crying in infancy. Methods: Participants and parents attended for a standard physical examination and clinical mental health assessment of the children. Parents completed the Strength and Difficulties Questionnaire (SDQ), Child Health Questionnaire (CHQ), Forsyth Child Vulnerability Scale, Recent Life Events Questionnaire, RAND-36 Health Status Inventory and a study questionnaire about medical and socio-demographic characteristics. Results: Seventy-five of 127 (59%) traced infant–parent dyads participated. There were no significant differences in baseline demographic characteristics, infant crying or maternal stress between those who participated and those who declined. Mothers who participated had higher Edinburgh Postnatal Depression Scale scores. The study group had poorer mental health, as measured on the SDQ, than a community sample (26.3% vs. 9.9% abnormal cases, risk ratio 2.56 (confidence interval 1.72, 3.80)). Fifteen of 61 (24.6%) children who attended for the clinical mental health assessment met Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for a mental disorder. In the 4 weeks preceding the assessment, the child's health limited family activities more than in a community sample (CHQ-Family Activities; P

Background Health care professionals' ability to recognize potential drug-drug interactions (potential DDIs) is important in reducing the risk of potential DDIs and their adverse consequences. Until now, little is known about the determinants of prescribers' potential DDI knowledge. Objectives This study was conducted to develop interval scales to evaluate prescribers' potential DDI knowledge and perceived usefulness of various potential DDI information sources, and to examine demographic and practice factors that may be related to prescribers' knowledge of potential DDIs. Methods Data were obtained from a national mail survey of prescribers who were determined from pharmacy claims obtained from a pharmacy benefits manager to have prescribed at least 1 drug involved in a potential DDI, and a control group who had prescribed either 1 of the medications in the drug combinations of interest. The survey instrument included 14 drug-drug pairs that evaluated prescribers' ability to recognize clinically important potential DDIs and 5-point Likert scale-type questions that assessed prescribers' perceived usefulness of potential DDI information provided by various sources. The knowledge and usefulness questions were examined via Rasch dichotomous and rating scale models, respectively. Results A total of 950 completed surveys were included in the analysis (overall adjusted response rate: 7.9%). Rasch analysis of knowledge and usefulness items revealed satisfactory model-data-fit (infit mean square [MNSQ] ≦ 1.5 and outfit MNSQ ≦ 2.0) and moderate person reliability of 0.72 and 0.61, respectively. Multiple regression analysis revealed that compared with generalists, specialists had lower potential DDI knowledge test scores. In addition, poorer potential DDI knowledge was associated with a lack of clinical experience witnessing harm caused by a potential DDI. Also, the prescribers whose drug selections were affected by the risk of potential DDIs “very much” scored higher than those who reported that their prescribing was affected by the risk “a little” or “not at all.” Conclusions This study found that specialists were less likely to correctly identify interactions compared with generalists. Other important predictors of potential DDI knowledge included the experience of seeing a potential DDI-caused harm and the extent to which the risk of potential DDIs affected prescribers' drug selection.

Websites offering drug information vary in coverage and quality, and most health care consumers are poorly equipped to assess the quality of internet medication information.To establish a webliography of recommended prescription medication information websites for health care consumers and providers.Drug information websites were systematically identified based on recommendations from health professionals and text-word searches of MEDLINE and Google. The resulting sample of websites was evaluated in a 2-step process. Candidate websites were first screened using inclusion/exclusion criteria representing minimum information requirements. Websites that passed the inclusion/exclusion criteria were then rated on 16 quality criteria using a 5-point scale by 3 trained judges. Website ratings were averaged, then multiplied by the corresponding importance weight of each criterion and summed to generate a total score. Websites with the highest total scores were included in the webliography.Ten websites were selected for inclusion in the webliography. The 3 highest-scoring websites were Anthem Blue Cross and Blue Shield (http://home.anthemhealth.com/topic/drugcenter), U.S. National Library of Medicine (https://www.nlm.nih.gov/medlineplus/druginformation.html), and Healthvision (http://www.yourhealthinformation.com/library/healthguide/en-us/drugguide/default.htm).Medication information websites vary widely in quality and content. The online webliography is a valuable and easily accessed tool that can be recommended by health care professionals to patients who request referral to reliable websites.

Objective Diagram patients’ views of the causes of adverse drug events (ADEs) in ambulatory care, examine characteristics of causes reported by patients, and identify those that have been studied in the medical and social science literatures. Methods Twenty-two primary care patients were interviewed using a root cause analysis approach. Diagrams derived from interviews were consolidated and displayed online as a composite interactive causal diagram. Patient-reported causes were compared to evidence in the social science and medical literatures. Results Patients ascribed 164 causes to ADEs occurring through eight major pathways, including medication nonadherence, prescriber–patient miscommunication, patient medication error, failure to read medication label/insert, polypharmacy, patient characteristics, pharmacist–patient miscommunication, and self medication. Most frequently reported causes were intrapsychic and interpersonal in nature. Most patient-reported causes have been studied, however, several practical and motivational antecedents lack research. Conclusion Conducting root cause analysis with patients reveals multiple logically linked aspects of medication safety in community settings that merit further research and consideration in patient and prescriber education. Practice implications This causal diagram provides a broadly accessible planning tool for reducing ambulatory ADEs by showing a comprehensive picture of potential causes, identifying causal factors supported by evidence, and disclosing likely consequences of change efforts. Also, patient-centered medication safety strategies should address psychological and practical barriers patients face in their everyday lives.

Perioperative nursing typically is a small part of nursing school curricula, which makes it difficult to recruit new graduates into the perioperative field. St Luke's Episcopal Hospital, Houston, has taken a unique approach to addressing this problem by establishing a collaborative relationship with Prairie View A&M University, Houston. This collaborative relationship introduces perioperative nursing to nursing students who may never have considered the OR as an area of practice. In addition, it provides an opportunity for students to network with perioperative nurses, and it serves as a method for recruiting new graduates to St Luke's Episcopal Hospital. AORN J 76 (Nov 2002) 842–850.

To compare the speed and accuracy of the interpretations of digital mammograms by radiologists by using printed-film versus soft-copy display.After being trained in interpretation of digital mammograms, eight radiologists interpreted 63 digital mammograms, all with old studies for comparison. All studies were interpreted by all readers in soft-copy and printed-film display, with interpretations of images in the same cases at least 1 month apart. Mammograms were interpreted in cases that included six biopsy-proved cancers and 20 biopsy-proved benign lesions, 20 cases of probably benign findings in patients who underwent 6-month follow-up, and 17 cases without apparent findings. Area under the receiver operating characteristic curve (A(z)), sensitivity, and specificity were calculated for soft-copy and printed-film display.There was no significant difference in the speed of interpretation, but interpretations with soft-copy display were slightly faster. The differences in A(z), sensitivity, and specificity were not significantly different; A(z) and sensitivity were slightly better for interpretations with printed film, and specificity was slightly better for interpretations with soft copy.Interpretation with soft-copy display is likely to be useful with digital mammography and is unlikely to significantly change accuracy or speed.

BACKGROUND: It is increasingly important for decision makers, such as medical and pharmacy managers (or pharmacy & therapeutics committee members and staff), to understand the variation and diversity in treatment response as decisions shift from an individual patient perspective to optimizing care for populations of patients. OBJECTIVE: To assess the effectiveness of an instructional program on heterogeneity designed for medical and pharmacy managers. METHODS: A live educational program was offered to members of the Academy of Managed Care Pharmacy at the fall 2012 educational meeting and also to medical directors and managers attending a national payer roundtable meeting in October 2012. Participants completed a retrospective pretest-posttest assessment of their knowledge, attitudes, and selfefficacy immediately following the program. Participants were offered the opportunity to participate in a follow-up assessment 6 months later. Willing participants for the follow-up assessment were contacted via e-mail and telephone. Rasch rating scale models were used to compare pre- and postscores measuring participants’ knowledge about and attitude towards heterogeneity. RESULTS: A total of 49 individuals completed the retrospective pretestposttest assessment and agreed to be a part of the program evaluation. Fifty percent (n = 25) of participants had heard of the phrase “heterogeneity of treatment effect,” and 36 (72%) were familiar with the phrase “individualized treatment effect” prior to the live program. Participants reported a significant improvement in knowledge of heterogeneity (P < 0.01) and attitudes about heterogeneity (P < 0.01) immediately after attending the program. At the time of the educational program, participants had either never considered heterogeneity (26%) or reported not knowing (28%) whether their organizations considered it when determining basic coverage. Participants were more likely to report “sometimes” considering heterogeneity for determining necessity for individual appeals, prior authorization, tier placement for pharmaceutical therapies, and other types of medical management. At the 6-month follow-up, 21 of the 49 willing participants (43% response rate) completed the evaluation; participants continued to have a good understanding of heterogeneity, but there was no significant difference in attitudes towards heterogeneity between pre- and 6-month follow-up. CONCLUSION: A live educational program was effective in improving participants’ immediate knowledge and attitudes regarding the topic of heterogeneity. Participating managed care pharmacists and medical managers indicated that heterogeneity of treatment effect was likely to be used in determining prior authorizations and determining necessity.

Comparative effectiveness research (CER) is a helpful approach to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers about the most effective interventions.To (a) identify the factors necessary to increase the use of the Agency for Healthcare Research and Quality's (AHRQ) CER reviews in hospitals and managed care organizations; (b) assess current awareness and implementation of CER materials in these facilities and organizations; and (c) inform development of content for a workshop on CER.Pharmacy and therapeutics (PT) committee members and supportive personnel were recruited to participate in focus groups conducted at national health professional meetings. Prior to the sessions, each participant completed a prefocus group questionnaire evaluating the organization and process of the respondent's PT committee, as well as the respondent's role in the PT committee and awareness of AHRQ CER reports. Each session consisted of a focused discussion about CER and sources of evidence for PT monographs, and each participant completed a ballot to rank topics of importance for inclusion in a CER workshop for health care professionals involved in the PT process. Overarching themes were later identified using qualitative analysis of the transcripts of the focus group sessions.Thirty-nine (68%) pharmacists and 18 (32%) physicians involved in the PT process participated in 1 of 7 focus groups. Almost half of the participants had 6-15 years experience with the PT process. Participants represented health plans, hospitals, and health care systems. Two-thirds indicated they were aware of AHRQ's Effective Health Care Program's CER reviews, yet only 26% reported using the reviews in their organizations. The overarching themes reflected the need for timely and conclusive CER information; the role of the pharmacist as central to evidence synthesis for the PT process; and the need for educational programs in online formats that are designed primarily for pharmacists.Health care decision makers identified timeliness as a key factor for facilitating the use of AHRQ CER reviews and guides in hospitals and managed care organizations. To facilitate integration of CER into the decision-making process, it is imperative that key stakeholders have access to comprehensive and timely information. While the majority of participants indicated that they were aware of AHRQ CER reviews, few had used them in the PT process.

Comparative effectiveness research (CER) is a constellation of research methods designed to improve health care decision making. Educational programs that improve health care decision makers' CER knowledge and awareness may ultimately lead to more cost-effective use of health care resources.This study was conducted to evaluate changes in CER knowledge, attitudes, and ability among Pharmacy and Therapeutics (PT) Committee members and support staff after attending a tailored educational program.Physicians and pharmacists from two professional societies and the Indian Health Service who participated in the PT process were invited via email to participate in this study. Participants completed a questionnaire, designed specifically for this study, prior to and following the 4-hour live, educational program on CER to determine the impact on their related knowledge, attitudes, and ability to use CER in decision-making. Rasch analysis was used to assess validity and reliability of subsections of the questionnaire and regression analysis was used to assess programmatic impact on CER knowledge, attitude, and ability.One hundred and forty of the 199 participants completed both the pre- and post-CER session questionnaires (response rate = 70.4%). Most participants (75%) correctly answered eight of the ten knowledge items after attending the educational session. More than 60% of the respondents had a positive attitude toward CER both before and after the program. Compared to baseline (pretest), participants reported significant improvements in their perceived ability to use CER after attending the session in these areas: using CER reviews, knowledge of CER methods, identifying problems with randomized controlled trials, identifying threats to validity, understanding of evidence synthesis approaches, and evaluating the quality of CER (all P values 0.001). The questionnaire demonstrated acceptable reliability and validity evidence (limited evidence of construct under-representation and construct irrelevant variance).The CER educational program was effective in increasing participants' CER knowledge and self-perceived ability to evaluate relevant evidence. Improving knowledge and awareness of CER and its applicability is a critical first step in improving its use in health care decision making.

Objectives Many factors are suspected to influence the intrauterine device (IUD) insertion process. This study sought to examine the effects of a few key variables on IUD insertion tolerability, complications and follow-up issues. Methods A retrospective chart review was undertaken of all IUD insertions over an 11-month period at an urban Canadian women9s clinic. Linear regression analysis of 354 insertions assessed the effects of parity, age, local anaesthesia and other variables on insertion pain. Chi square (χ 2 ) and analysis of variance statistics were employed to evaluate differences in insertion complications by parity and age. A χ 2 test was performed to compare follow-up expulsion or removal rates by parity. Results Statistically significant differences were found, with nulliparous women and those who received local anaesthesia reporting more insertion pain. Age, IUD type and recent abortion status did not affect insertion pain. Nulliparous women did not experience significantly more insertion difficulty or complications, nor did they have higher rates of expulsion or removal at follow-up. Conclusions These findings suggest that the practice of providing cervical anaesthesia at IUD insertion may cause slightly more pain, without any obvious additional benefit. The difference in insertion pain by parity, although statistically significant, is small enough to be of questionable clinical importance. Overall, these findings add to the growing body of evidence for IUDs being safe and well-tolerated in nulliparous women.

The Affordable Healthcare for America Bill that was signed into law in March 2010 includes support for activities that come under the heading of ‘comparative effectiveness’ research. The bill attempts to accelerate the conversion to electronic health records by all payers and providers who participate in the healthcare payment data stream. Conversion to electronic health data collection and storage solutions will create a large amount of treatment and payment data that is increasingly standardized by health standards organizations which reduces integration issues between technologies. There are federal advisory committees at work on designing the infrastructure needed to support a National Health Information Network (NHIN) that will support the healthcare data exchange required for comparative effectiveness research. The theory behind this work is that the availability of a large portion of existing health data will make it possible for researchers to identify therapies that lead to superior patient outcomes. It is assumed that the superior therapy would become the ‘best practice’ approach to treating a particular ailment. Supporters of comparative effectiveness see this as a strategy for making the system more effective both in terms of good medicine and also in terms of decreased cost. Opponents of comparative effectiveness see it as healthcare rationing and an inappropriate injection of government into the healthcare decision making process. Supporters and opponents have identified both positive and negative consequences to comparative effectiveness and this chapter will analyze the impact and propose some ways to optimize the results of this work.

Relationships between educational preparation and employment choices were investigated in a study of the career paths of nursing graduates from three types of educational programs: a community college diploma program, a generic baccalaureate program, and a postdiploma baccalaureate program. Selected personal and work-related correlates of career paths for the three groups also were explored. All avallable graduates for the years 1984 to 1990 from the three programs (n = 1,544) were sent a self-administered questionnaire. Data were collected concerning demographic varlables, employment detalls, ongoing professional development, and level of satisfaction with nursing. Analysis of the data demonstrated clear variations in the career paths of the three groups of graduates, supporting the belief that the type of educational program does indeed have a steering effect on the subsequent career choices of these nurses.

Radio Frequency Identification (RFID) technologies are becoming ubiquitous in a variety of settings and industries. The healthcare industry has adopted the use of RFID as a means of tracking equipment, managing inventory, to locating human resources including controversial applications involving injecting chips into humans as a means of authentication. There are a variety of ethical implications to the use of this technology as well as potential health concerns that will be explored in this chapter.

(1992). A Model of Collaborative Service for Middle School Students. Preventing School Failure: Alternative Education for Children and Youth: Vol. 36, No. 3, pp. 10-15.

Background: There are limited data regarding implantable cardioverter defibrillator (ICD) therapy in postinfarction women with severe left ventricular dysfunction. The aim of this study was to evaluate the risk of cardiac events and effects of ICD therapy in women as compared to men enrolled in the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II). Methods and Results: Among 1,232 patients enrolled in MADIT II, there were 192 (16%) women and 1,040 (84%) men. When compared to men, women had an increased frequency of NYHA class ≥II (70 vs 63%; P = 0.067), hypertension (60% vs 52%; P = 0.047), diabetes (42% vs 34%; P = 0.027), and LBBB (25% vs 17%; P = 0.011), and less frequent CABG surgery (42% vs 60%; P < 0.001). The 2-year cumulative mortality in patients randomized to conventional therapy was not significantly different in women and men (30% and 20%, respectively; P = 0.19). Adjusting for relevant clinical covariates, the hazard ratios for ICD effectiveness were similar in women (0.57; 95% CI = 0.28–1.18; P = 0.132) and men (0.66; 95% CI = 0.48–0.91; P = 0.011). The risk of appropriate ICD therapy for VT/VF was lower in women than in men (hazard ratio = 0.60 for female vs male gender; 95% CI = 0.37–0.98; P = 0.039). Conclusions: MADIT II women had similar mortality and similar ICD effectiveness when compared to men. MADIT II women with ICDs had a lower risk of arrhythmic events with fewer episodes of ventricular tachycardia than men.

Given that online higher education is a competitive marketplace, this paper discusses how to ensure online student success. Within the online learning environment, the following may create the vitality of the online institution: (a) The online learning environment; (b) The role of the instructor; (c) Learning Communities; (d) Computer-mediated Communication Technologies; and (e) Policy and practice. These factors may be managed by the institution of higher education, the faculty member, or the learner; however, a commitment is needed by all stakeholders in the program.