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The Leahy-Smith America Invents Act, the most significant patent law reform effort in two generations, may have a dark side: it seems likely to decrease the patenting behavior of individual inventors, a category which occupies special significance in American innovation history. In this Article, we empirically predict the effects of the major change in the law, which shifts the patent priority rules from the United States' traditional "first-to-invent" system to the internationally predominant "first-to-file" system. While there has been some theoretical work on this topic, we use an analogous law change in Canada as a natural experiment to shed the first empirical light on the question. Our analysis uses a difference-in-difference framework to estimate the im-pact of the Canadian law change on small inventors. Using data on all patents granted by the Canadian Intellectual Property Office and the U.S. Patent and Trademark Office, we find a significant drop in the share of patents granted to individual inventors in Canada coincident with the implementation of a first-to-file system. We find no measurable changes in patent quality and perform several additional analyses to rule out alternative explanations. While the net welfare impact that can be expected from a shift to first-to-file is unclear, our results reveal that, contrary to the conventional wisdom, the March 2013 implementation of a first-to-file rule in the United States is likely to result in a reduced share of patents granted to individual inventors. [ABSTRACT FROM AUTHOR]

Forest plantations in the northeastern United States comprise a small proportion of the total forest area. Most plantations are typically softwood dominated and managed for sawlog and pulpwood production, while high-yield hardwood plantations for bioenergy feedstocks have not been as widely investigated. The objective of this study was to compare the biomass production of planted white spruce ( Picea glauca (Moench) Voss) and hybrid poplar ( Populus spp.) plantations (four clones) in monoculture, and in mixture of the two on a typical reforestation site in Maine. Three years following planting, hybrid poplar height and ground line diameter growth rates began to diverge among clones, and by 6 years, the Populus nigra × Populus maximowiczii (NM6) clone clearly outperformed three Populus deltoides × Populus nigra clones (D51, DN10 and DN70) both in pure stands and in mixtures with white spruce. In mixture, we found the yield of white spruce to decline as the yield of hybrid poplar increased. Overall, yields of white spruce monocultures were comparable to those reported in eastern Canada, while the hybrid poplar biomass yields were substantially lower than those reported from studies on abandoned agricultural lands, likely due to the harsher soil conditions at our site. The dominance of rocky and poorly drained sites (like the one tested in this study) across Maine will likely limit the feasibility of widespread hybrid poplar plantations, and thus constrains their potential use as a bioenergy feedstock. [ABSTRACT FROM AUTHOR]

It is by now a cliché to suggest that the United States Court of Appeals for the Federal Circuit has weakened the standards for obtaining patents. In this Article, we empirically assess that court's performance on the ultimate question of patentability--the requirement that a patentable invention must be "nonobvious. " Our findings suggest that the conventional wisdom may not be well grounded, at least on this measure. Nowhere is the Federal Circuit's controversial role as the locus of judicial power in the U.S. patent system more evident than in the context of the doctrine of obviousness under 35 U.S.C. § 103. The determination of whether an invention was "obvious" to "a person having ordinary skill in the art" at the time the invention was made is the foundation of patentability--and thus at the very core of the patent bargain. And the issue's status as a question of law. as well as the spare statutory language, means that the law of obviousness is entirely a creation of the courts'. In the study reported here, we systematically examined the Federal Circuit's doctrine of obviousness. Using empirical data collected from a novel data set spanning more than fifteen years of jurisprudential pronouncements, we suggest that the Federal Circuit has developed a doctrine in this area that is" relatively stable and appears reasonably predictable. Indeed, contrary to much recent commentary, these results suggest that the Federal Circuit's doctrinal tool kit--especially the much-discussed (and oft-maligned) "teaching, suggestion, or motivation" test for combinations of references--has not had a significant observable effect on the results of obviousness cases at that court. Although this study falls short of painting a complete picture of the Federal Circuit's performance with respect to patentability the view that emerges is of a modern jurisprudence of obviousness that is more stable, more consistent, and more flexible than has been heretofore understood, These results, then, should give pause to those who argue for a radical reshaping of the Federal Circuit's doctrine under 35 U.S.C. § 103. [ABSTRACT FROM AUTHOR]

The Southern torrent salamander (Rhyacotriton variegatus) was recently found not warranted for listing under the US Endangered Species Act due to lack of information regarding population fragmentation and gene flow. Found in small-order streams associated with late-successional coniferous forests of the US Pacific Northwest, threats to their persistence include disturbance related to timber harvest activities. We conducted a study of genetic diversity throughout this species' range to 1) identify major phylogenetic lineages and phylogeographic barriers and 2) elucidate regional patterns of population genetic and spatial phylogeographic structure. Cytochrome b sequence variation was examined for 189 individuals from 72 localities. We identified 3 major lineages corresponding to nonoverlapping geographic regions: a northern California clade, a central Oregon clade, and a northern Oregon clade. The Yaquina River may be a phylogeographic barrier between the northern Oregon and central Oregon clades, whereas the Smith River in northern California appears to correspond to the discontinuity between the central Oregon and northern California clades. Spatial analyses of genetic variation within regions encompassing major clades indicated that the extent of genetic structure is comparable among regions. We discuss our results in the context of conservation efforts for Southern torrent salamanders. [ABSTRACT FROM AUTHOR]

This Article delves into issues surrounding the relationship between technology and the patent law. Responding to Dan Burk and Mark Lemley's earlier article, Is Patent Law Technology-Specific?, the piece notes that the basic question posed by Burk and Lemley's article is a relatively easy question given the several doctrines that explicitly link the subject matter context of an invention to the validity and scope of related patents. This sort of technological exceptionalism (which this Article refers to as micro-exceptionalism) is both observable and easily justifiable for a legal regime directed to technology policy. In contrast, Burk and Lemley's identification of, and advocacy for, a broader sort of exceptionalism (macro-exceptionalism) is far more troublesome, implying a role for the patent judiciary in rather detailed policy judgments, for example the optimal breadth for biotechnological or software-based patents. The Article offers a variety of reasons that macro-exceptionalism is unwarranted, and indeed, notes that a primary claim of Burk and Lemley's—that the Federal Circuit has grossly missed the mark in its (purportedly) exceptionalist approach—previews the sort of problems created by pursuing technological exceptionalism in the patent law. [ABSTRACT FROM AUTHOR]

Analyzes the prosecution history estoppel, a judicially crafted principle in the U.S. Flaws of the principle limiting the enforceable scope of patents on acts occurring during the application process; Development of a theory based on ex ante effects; Benefits of the patent law for patent prosecution.

Investigates issues about how to understand the use of nuclear counterforce strategies by the United States and the Soviet Union during the Cold War. Function of the counterforce strategies model; Basic argument for the utility of counterforce strategies; United States superiority.

Investigates the operation of the First Amendment threshold test in an effort to determine the law of computer software. Separate methods of threshold analysis employed by the United States Supreme Court; Law of software as applied to threshold framework.

Presents comments on articles related to nursing in the U.S. Ranking of nursing profession; Debate over the bachelor of science in nursing requirement; Right of nurses to make moral judgments.

The patent doctrine of inequitable conduct--which allows a patent to be held unenforceable on the basis of misbehavior by the applicant during patent prosecution--has been the subject of intense criticism from the bench and bar alike. And yet to date there has been no systematic attempt to determine whether the doctrine is or is not working as theorized. This study fills that gap. We evaluate the performance of the inequitable conduct doctrine with a novel methodological approach: by empirically characterizing the differences between patents found unenforceable and several other types of patents (unlitigated, litigated, invalid, obvious, and underdisclosed), we use those differences to reveal the real-world impact of the inequitable conduct doctrine. We find that patents held unenforceable have clear hallmarks of risky prosecution behavior, such as longer pendency and fewer disclosures of prior art, as compared to all other types we studied. These results indicate that the doctrine is likely operating better than conventional wisdom would suggest. [ABSTRACT FROM AUTHOR]

In Bilski v. Kappos, the Supreme Court declined calls to categorically exclude business methods--or any technology--from the patent law. It also rejected as the sole test of subject matter eligibility the Federal Circuit's deeply-flawed machine-or-transformation test, under which no process is patentable unless it is tied to a particular machine or transforms an article to another state or thing. Subsequent developments threaten to undo that holding, however. Relying on the Court's description of the Federal Circuit test as a "useful and important clue," the U.S. Patent and Trademark Office, patent litigants, and district courts have all continued to rely on the machine-or-transformation test in the wake of Bilski: no longer as the sole rule, but as a presumptive starting point that threatens to effectively become mandatory. In this Article, we suggest a new way to understand the exclusion of abstract ideas from patentable subject matter. No class of invention is inherently too abstract for patenting. Rather, the rule against patenting abstract ideas is an effort to prevent inventors from claiming their ideas too broadly. By requiring that patent claims be limited to a specific set of practical applications of an idea, the abstract ideas doctrine both makes the scope of the resulting patent clearer and leaves room for subsequent inventors to improve upon--and patent new applications of--the same basic principle. Recasting the abstract ideas doctrine as an overclaiming test eliminates the constraints of the artificial machine-or-transformation test, as well as the pointless effort to fit inventions into permissible or impermissible categories. It also helps understand some otherwise-inexplicable distinctions in the case law. Testing for overclaiming allows courts to focus on what really matters: whether the scope of the patentee's claims are commensurate with the invention's practical, real-world contribution. This inquiry, we suggest, is the touchstone of the abstract ideas analysis, and the way out of the post-Bilski confusion. [ABSTRACT FROM AUTHOR]

Objective: This study describes the current management of patients with eating disorders (EDs) served by publicly-funded Medicaid behavioral health systems., Method: Behavioral health leaders across nine counties in California met on a quarterly basis to share experiences, challenges, and lessons in the management of EDs within publicly-funded service systems. Detailed notes were taken, and a qualitative content analysis was undertaken to identify key themes., Results: County leadership noted insufficient outpatient capacity and difficulty building capacity for ED treatment, in addition to extraordinary challenges when facilitating admission to out-of-network higher level of care programs, at significant expense. Several challenges were identified in building an internal ED workforce, including the fact that many providers weren't eager to treat EDs due to training burden, patient complexity, and high levels of clinician burnout. When a higher level of care was required due to lack of outpatient resources or patient symptom severity or complexity, leaders dedicated significant resources to identify and contract with an appropriate program and secure the necessary funds., Discussion: Our study supports the need for specialized ED treatment and case management, as well as standardized processes and centralized resources, in Medicaid-managed care. Findings also indicate the importance of protecting against clinician burnout, possibly through reduced caseload expectations, financial incentives, or increased support. Future policy change could reduce administrative burden and clinician burnout by facilitating admission to and reimbursement for higher levels of care., (© 2024 The Author(s). International Journal of Eating Disorders published by Wiley Periodicals LLC.)

Purpose: The primary objective of this study was to identify the trends in reimbursement for hand surgeons for new patient visits, outpatient consultations, and inpatient consultations from the years 2010-2018. In addition, we sought to investigate the influence of payer mix and coding level of service on physician reimbursement in these settings., Methods: The PearlDiver Patients Records Database was used to identify clinical encounters and their respective physician reimbursements for analysis within this study. This database was queried using Current Procedural Terminology codes to identify relevant clinical encounters for inclusion, filtered for the presence of valid demographic information and by physician specialty for the presence of a hand surgeon, and tracked by primary diagnoses. Cost data were then calculated and analyzed regarding the payer type and level of care., Results: In total, 156,863 patients were included in this study. The mean reimbursement for inpatient consultations, outpatient consultations, and new patient encounters increased by 92.75% ($134.85 to $259.93), 17.80% ($161.33 to $190.04), and 26.78% ($102.58 to $130.05), respectively. When normalized to 2018 dollars to adjust for inflation, the percent increases were 67.38%, 2.24%, and 10.09%, respectively. Commercial insurance reimbursed hand surgeons to a greater degree than any other payer type. Mean physician reimbursement differed depending on the level of service billed, with the level of service V reimbursing 4.41 times more than the level of service I visits for new outpatient visits, 3.66 times more for new outpatient consultations, and 3.04 times more for new inpatient consultations., Conclusions: This study helps to provide physicians, hospitals, and policymakers with objective information regarding the trends in reimbursement to hand surgeons. Although this study indicates increasing reimbursements for consultations and new patient visits to hand surgeons, the margins shrink when adjusted for inflation., Type of Study/level of Evidence: Economic Analysis IV., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The use of insects as animal feed has the potential to be a green revolution for animal agriculture as insects are a rich source of high-quality protein. Insect farming must overcome challenges such as product affordability and scalability before it can be widely incorporated as animal feed. An alternative is to harvest insect pests from the environment using mass trapping devices and use them as animal feed. For example, intensive agricultural environments generate large quantities of pestiferous insects and with the right harvest technologies, these insects can be used as a protein supplement in traditional animal daily rations. Most insect trapping devices are limited by the biomass they can collect. In that context, and with the goal of using wild collected insects as animal feed, the United States Department of Agriculture-Biomass Harvest Trap (USDA-BHT) was designed and built. The USDA-BHT is a valuable mass trapping device developed to efficiently attract, harvest, and store flying insects from naturally abundant agricultural settings. The trap offers a modular design with adjustable capabilities, and it is an inexpensive device that can easily be built with commonly available parts and tools. The USDA-BHT is also user-friendly and has customizable attractants to target various pest species., (Published by Oxford University Press on behalf of Entomological Society of America 2024.)

Background: Early in the pandemic, cruise travel exacerbated the global spread of SARS-CoV-2. We report epidemiologic and molecular findings from an investigation of a cluster of travellers with confirmed COVID-19 returning to the USA from Nile River cruises in Egypt., Methods: State health departments reported data on real-time reverse transcription-polymerase chain reaction-confirmed COVID-19 cases with a history of Nile River cruise travel during February-March 2020 to the Centers for Disease Control and Prevention (CDC). Demographic and epidemiologic data were collected through routine surveillance channels. Sequences were obtained either from state health departments or from the Global Initiative on Sharing Avian Flu Data (GISAID). We conducted descriptive analyses of epidemiologic data and explored phylogenetic relationships between sequences., Results: We identified 149 Nile River cruise travellers with confirmed COVID-19 who returned to 67 different US counties in 27 states: among those with complete data, 4.7% (6/128) died and 28.1% (38/135) were hospitalized. These individuals travelled on 20 different Nile River cruise voyages (12 unique vessels). Fifteen community transmission events were identified in four states, with 73.3% (11/15) of these occurring in Wisconsin (as the result of a more detailed contact investigation in that state). Phylogenetic analyses supported the hypothesis that travellers were most likely infected in Egypt, with most sequences in Nextstrain clade 20A 93% (87/94). We observed genetic clustering by Nile River cruise voyage and vessel., Conclusions: Nile River cruise travellers with COVID-19 introduced SARS-CoV-2 over a very large geographic range, facilitating transmission across the USA early in the pandemic. Travellers who participate in cruises, even on small river vessels as investigated in this study, are at increased risk of SARS-CoV-2 exposure. Therefore, history of river cruise travel should be considered in contact tracing and outbreak investigations., (Published by Oxford University Press on behalf of International Society of Travel Medicine 2022.)

When the COVID-19 global pandemic began, many higher education systems had to restructure their educational delivery system and transition to online learning. This posed a challenge for students in health professions education programs as it impacted their ability to participate in hands-on learning regarding patient care. As a result, the University of Cincinnati College of Nursing developed and implemented simulation-based learning experiences to allow graduate-level social worker, counselor, and psychiatric-mental health nurse practitioner students the opportunity to learn as an interdisciplinary team in a virtual format. The Opioid Use Disorder Simulation Case Study discussed in this article was developed as part of the Serving At-risk Youth Fellowship Experience Training program with the overarching aim to prepare culturally competent providers to deliver direct patient care and education around prevention and recovery services to individuals with substance use disorders., (Copyright © 2021 by the Association of American Medical Colleges.)

Scientists and policymakers need to compare the incidence of Covid-19 across territories or periods with various levels of testing. Benchmarking based on the increase in total cases or case fatality rates is one way of comparing the evolution of the pandemic across countries or territories and could inform policy decisions about strategies to control coronavirus transmission. However, comparing cases and fatality rates across regions is challenging due to heterogeneity in testing and health systems. We show two complementary ways of benchmarking across territories and in time. First, we used multivariate regressions to estimate the test-elasticity of Covid-19 case incidence. Cases grow less than proportionally with testing when assessing weekly changes or looking across states in the USA. They tend to be proportional or even more than proportional when comparing the month-to-month evolution of an average country in the pandemic. Our results were robust to various model specifications. Second, we decomposed the growth in cases into test growth and positive test ratio growth to intuitively visualize the components of case growth. We hope these results can help support evidence-based decisions by public officials and help the public discussion when comparing across territories and in time., (© 2021. The Author(s).)

Background/aim: To examine the impact of ACA and the association of socioeconomic factors on delay in initial treatment for multiple myeloma (MM)., Patients and Methods: Patients diagnosed with MM between 2004-2016 were identified in the National Cancer Database (NCDB). Time-to-initial treatment (TTI) was defined as the number of days from diagnosis to initial therapy. Patients were classified into quartiles and those belonging to the fourth quartile for TTI constituted the delayed treatment group. Study period was divided into pre-ACA and post-ACA using 2010 as the cut-off., Results: A total of 65,723 patients met the eligibility criteria. Median TTI was 13 (IQR=5-27) days. Racial-ethnic minorities were associated with delayed-TTI. Delayed treatment was more likely for Hispanics pre-ACA but not post-ACA, while non-Hispanic Blacks (NHB) were more likely to have delayed treatment both, pre- and post-ACA., Conclusion: While ACA has been shown to help mitigate healthcare disparities in certain cancer diagnoses, the study suggests that the effect is still limited among MM patients., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

An estimated 30 million passengers are transported on 272 cruise ships worldwide each year* (1). Cruise ships bring diverse populations into proximity for many days, facilitating transmission of respiratory illness (2). SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) was first identified in Wuhan, China, in December 2019 and has since spread worldwide to at least 187 countries and territories. Widespread COVID-19 transmission on cruise ships has been reported as well (3). Passengers on certain cruise ship voyages might be aged ≥65 years, which places them at greater risk for severe consequences of SARS-CoV-2 infection (4). During February-March 2020, COVID-19 outbreaks associated with three cruise ship voyages have caused more than 800 laboratory-confirmed cases among passengers and crew, including 10 deaths. Transmission occurred across multiple voyages of several ships. This report describes public health responses to COVID-19 outbreaks on these ships. COVID-19 on cruise ships poses a risk for rapid spread of disease, causing outbreaks in a vulnerable population, and aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Nursing programs have responsibility to become more holistic in admission practices, ensuring they admit applicants based on more than grades and test scores to determine the best fit for their program., Problem: One frequently cited holistic admissions barrier is incorporating qualitative measurement of applicant characteristics through interviews. Finding the best interview model is a challenge, depending on a program's intent to learn about applicants., Approach: This article describes the planning and implementation process for incorporating the Multiple Mini Interview (MMI) model into an existing holistic nursing program admission process., Outcomes: MMI model implementation resulted in more congruency in student attributes with the college vision, mission, and values and increased diversity., Conclusion: An efficient, well-organized MMI interview model was implemented, allowing achievement of overall admission goals and ensuring selected applicants demonstrate attributes aligned with college values and vision and increased diversity.

Purpose: The National Collaborative for Improving the Clinical Learning Environment offers guidance to health care leaders for engaging new clinicians in efforts to eliminate health care disparities., Summary: To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. Engaging new clinicians is a key element of any systems-based approach, as new clinicians will shape the future of health care delivery. Clinical learning environments, or the hospitals, medical centers, and ambulatory care clinics where new clinicians train, have an important role in this process. Efforts may include training in cultural humility and cultural competency, education about the organization's vulnerable populations, and continuous interprofessional experiential learning through comprehensive, systems-based QI efforts focused on eliminating health care disparities., Conclusion: By preparing and supporting new clinicians to engage in systems-based QI efforts to eliminate health care disparities, clinical learning environments are instilling skills and supporting behaviors that clinicians can build throughout their careers-and helping pave the road towards equity throughout the US health care system., (Published by Oxford University Press on behalf of the American Society of Health-System Pharmacists 2019.)

The American Board of Medical Specialties Maintenance of Certification Program (ABMS MOC) is designed to provide a comprehensive approach to physician lifelong learning, self-assessment, and quality improvement (QI) through its 4-part framework and coverage of the 6 competencies previously adopted by the ABMS and the Accreditation Council for Graduate Medical Education (ACGME). In this article, the theoretical rationale and exemplary empiric data regarding the MOC program and its individual parts are reviewed. The value of each part is considered in relation to 4 criteria about the relationship of the competencies addressed within that part to (1) patient outcomes, (2) physician performance, (3) validity of the assessment or educational methods utilized, and (4) learning or improvement potential. Overall, a sound theoretical rationale and a respectable evidence base exists to support the current structure and elements of the MOC program. However, it is incumbent on the ABMS and ABMS member boards to continue to examine their programs moving forward to assure the public and the profession that they are meeting expectations, are clinically relevant, and provide value to patients and participating physicians, and to refine and improve them as ongoing research indicates., (Copyright © 2013 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.)

Since its start, the Mammalian Gene Collection (MGC) has sought to provide at least one full-protein-coding sequence cDNA clone for every human and mouse gene with a RefSeq transcript, and at least 6200 rat genes. The MGC cloning effort initially relied on random expressed sequence tag screening of cDNA libraries. Here, we summarize our recent progress using directed RT-PCR cloning and DNA synthesis. The MGC now contains clones with the entire protein-coding sequence for 92% of human and 89% of mouse genes with curated RefSeq (NM-accession) transcripts, and for 97% of human and 96% of mouse genes with curated RefSeq transcripts that have one or more PubMed publications, in addition to clones for more than 6300 rat genes. These high-quality MGC clones and their sequences are accessible without restriction to researchers worldwide.

Iridoviruses of the genus Ranavirus are well known for causing mass mortality events of fish and amphibians with sporadic reports of infection in reptiles. This article describes five instances of Ranavirus infection in chelonians between 2003 and 2005 in Georgia, Florida, New York, and Pennsylvania, USA. Affected species included captive Burmese star tortoises (Geochelone platynota), a free-ranging gopher tortoise (Gopherus polyphemus), free-ranging eastern box turtles (Terrapene carolina carolina), and a Florida box turtle (Terrepene carolina bauri). Evidence for Ranavirus infection was also found in archived material from previously unexplained mass mortality events of eastern box turtles from Georgia in 1991 and from Texas in 1998. Consistent lesions in affected animals included necrotizing stomatitis and/or esophagitis, fibrinous and necrotizing splenitis, and multicentric fibrinoid vasculitis. Intracytoplasmic inclusion bodies were rarely observed in affected tissues. A portion of the major capsid protein (MCP) gene was sequenced from each case in 2003-2005 and found to be identical to each other and to Frog virus 3 (FV3) across 420 base pairs. Ranavirus infections were also documented in sympatric species of amphibians at two locations with infected chelonians. The fragment profiles of HindIII-digested whole genomic DNA of Ranavirus, isolated from a dead Burmese star tortoise and a southern leopard frog (Rana utricularia) found nearby, were similar. The box turtle isolate had a low molecular weight fragment that was not seen in the digestion profiles for the other isolates. These results suggest that certain amphibians and chelonians are infected with a similar virus and that different viruses exist among different chelonians. Amphibians may serve as a reservoir host for susceptible chelonians. This report also demonstrated that significant disease associated with Ranavirus infections are likely more widespread in chelonians than previously suspected.

Two decades into the age of high-cost biotechnology medications, health care organizations are challenged to provide safe, effective treatment while managing costs. In a market lacking generic biotech drugs, health care organizations have few opportunities to negotiate reduced pricing; other strategies must be devised to manage use. Kaiser Permanente leverages its integrated health care delivery system to deploy management tools for costly therapies: evidence analysis, usage measurements, and multidisciplinary planning. Evidence-based medicine and realization of value provided by new therapies will depend on data capture and outcomes measurement, tools that are crucial to Kaiser Permanente's management of biotechnologies and effective use of members' financial resources.

The primary purpose of this longitudinal correlational study was to examine relations between phonological processing abilities and emerging individual differences in math computation skills and also to investigate the source of covariation between reading and math computation skills in a random sample (n = 201). Phonological memory, rate of access to phonological codes in long-term memory, and phonological awareness were uniquely associated with growth in estimated total number of computation procedures mastered (general computation skills) from 92.5 to 134.8 months in age, although the contributions of the first two abilities were developmentally limited. Phonological processing almost completely accounted for the associations between reading and general computation skills. Evidence of bidirectional relations between general computation skills and simple arithmetic problem solving speed was found., (Copyright 2001 Academic Press.)

Rationale and Objectives: Bringing a new imaging technology to market is a complex process. Beyond conceptualization and proof of concept, obtaining U.S. Food and Drug Administration (FDA) approval for clinical use depends on the documented experimental establishment of safety and efficacy. In turn, safety and efficacy are evaluated in the context of the intended use of the technology. The purpose of this study was to examine a conceptual framework for technology development and evaluation, focusing on new breast imaging technologies as a highly visible and current case in point., Materials and Methods: The FDA views technology development in terms of a preclinical and four clinical phases of assessment. With a concept of research and development as a learning model, this phased-assessment concept of regulatory review against intended use was integrated with a five-level version of a hierarchy-of-efficacy framework for evaluating imaging technologies. Study design and analysis issues are presented in this context, as are approaches to supporting expanded clinical indications and new intended uses after a new technology is marketed., Conclusion: Breast imaging technologies may be intended for use as replacements for standard-of-care technologies, as adjuncts, or as complementary technologies. Study designs must be appropriate to establish claims of superiority or equivalence to the standard for the intended use. Screening technologies are ultimately judged on their demonstrated effectiveness in decreasing cause-specific mortality through early detection, but they may be brought to market for other uses on the basis of lesser standards of efficacy (eg, sensitivity, specificity, positive and negative predictive value, and stage of disease detected).

Clinical audits and practice profiling have become popular tools in the attempt to change physician behavior to improve quality of care. Unfortunately, the growing need for information on quality of care has often outpaced the development of standard, valid, and reliable approaches to using these tools. The studies of performance measurement published in the literature to date demonstrate varying impact on ability to improve clinical care; few are randomized controlled trials. While performance measurement has become a common practice, the science surrounding this field is still in its early stages of development; while it seems promising, it should be viewed as largely experimental.

Epidemiologic studies of temporal and geographic variation in asthma morbidity have identified asthma as an important public health concern. Knowledge gained from these studies has resulted in intense focus on this condition by agencies such as the National Institutes of Health and the World Health Organization. In this report, studies of recent asthma trends and patterns are explored. These studies show increases in US prevalence through 1994. Data on measures of morbidity show complex longitudinal patterns but are notable for large differences in emergency department services and hospitalizations by age and race. Very recent trends for US asthma mortality suggest widening of an existing racial gap. Limited comparisons are possible between these US trends and international trends but do suggest that US increases in prevalence and mortality rates may reflect world-wide patterns. Also, within the US, it is clear that geographic variation exists in asthma prevalence, morbidity, and mortality rates. Changes in certain environmental risk factors and exposures may contribute to recent trends, but little information is available relating specific risk factors to either longitudinal asthma trends, geographic variability, or high-risk populations.

Objective: To describe outcomes and identify variables associated with hospital and 1-year survival for patients admitted to an intensive care unit (ICU) with an acute exacerbation of chronic obstructive pulmonary disease (COPD)., Design: Prospective, multicenter, inception cohort study., Setting: Forty-two ICUs at 40 US hospitals., Patients: A total of 362 admissions for COPD exacerbation selected from the Acute Physiology and Chronic Health Evaluation (APACHE) III database of 17,440 ICU admissions., Measurements and Results: Hospital mortality for the 362 admissions was 24%. For the 167 patients aged 65 years or older, mortality was 30% at hospital discharge, 41% at 90 days, 47% at 180 days, and 59% at 1 year. Median survival for all patients was 224 days, and median survival for the patients who died within 1 year was 30.5 days. On multiple regression analysis, variables associated with hospital mortality included age, severity of respiratory and nonrespiratory organ system dysfunction, and hospital length of stay before ICU admission. Development of nonrespiratory organ system dysfunction was the major predictor of hospital mortality (60% of total explanatory power) and 180-day outcomes (54% of explanatory power). Respiratory physiological variables (respiratory rate, serum pH, PaCO2, PaO2, and alveolar-arterial difference in partial pressure of oxygen [PAO2-PaO2]) indicative of advanced dysfunction were more strongly associated with 180-day mortality rates (22% of explanatory power) than hospital death rates (4% of explanatory power). After controlling for severity of illness, mechanical ventilation at ICU admission was not associated with either hospital mortality or subsequent survival., Conclusions: Patients with COPD admitted to an ICU for an acute exacerbation have a substantial hospital mortality (24%). For patients aged 65 years or older, mortality doubles in 1 year from 30% to 59%. Hospital and longer-term mortality is closely associated with development of nonrespiratory organ system dysfunction; severity of the underlying respiratory function substantially influences mortality following hospital discharge. The need for mechanical ventilation at ICU admission did not influence either short- or long-term outcomes. Physicians should be aware of these relationships when making treatment decisions or evaluating new therapies.

Recent case law has protected medical students found guilty of academic misconduct from severe sanctions by emphasizing due process and contractural rights. In light of this development, proactive approaches should be considered by medical schools. Faculty or administrators who have legal backgrounds are more likely to avoid breach of contract and violation of due process and should be appointed as hearing officers in cases of alleged academic misconduct. Finally, determination of a student's mental state (as defined in the MPC) by the hearing officer is a fair and rational method of determining what sanctions should be placed on medical students found to have cheated or plagiarized.

Burnout may develop in highly productive, hard-working individuals from all walks of life. Extending working hours under stressful circumstances may produce a sense of frustration resulting in emotional exhaustion, loss of empathy for patients, and a decreased sense of personal accomplishment. The membership of the American Society of Head and Neck Surgery and the Society of Head and Neck Surgeons was surveyed by mail relative to burnout. A total of 395 head and neck surgeons responded. Mean age was 48 years. The average individual worked an average of 66 hours per week. More than 70% of work was devoted to patient care of which 30% to 50% was devoted to the management of head and neck cancer. A total of 128 (34%) individuals responded that they felt "burned out." Only 27%, however, indicated frustration with disease, whereas 67% indicated frustration by government and 58% indicated frustration by the economics of medical practice. Most respondents enjoy their work, nevertheless, the stress of extending working hours dealing with severely ill patients, and the increased need to deal with government and economic issues is of concern to the community of physicians practicing head and neck surgery. Discussion about and confrontation with these issues are appropriate to facilitate and enhance an individual's ability to continue to function productively in this environment.

A national survey was conducted to investigate malpractice litigation at United States child and adolescent psychiatry residency programs between 1981 and 1991. Fourteen percent of the directors of child and adolescent psychiatry reported at least one malpractice claim during this period. The highest percentage of lawsuits reported was in the northeast. Suicide and sexual abuse of latency age patients by other patients accounted for the most litigation. The mean monetary award was $167,000, and the largest award was $500,000 for discharge of a patient who killed his mother. There has been an increase in malpractice litigation during the past 10 years. Risk management strategies should be implemented to address areas of liability in child and adolescent psychiatry training programs.

Background: This is the first in a series of articles written to address the many medicolegal issues that impact the practice of dermatology. The topic of establishing the physician-patient relationship was chosen as the starting point since it is the cornerstone of every medical malpractice action., Methods: A format of an initial discussion of legal concepts followed by hypotheticals and a review of actual cases was chosen to enhance interactive learning. The subject matter is based on a review of medicolegal literature and actual recorded case law., Results: A physician-patient relationship may be established whether or not there is actual physical contact between the physician and patient, there is gratuitous advice, or there is an academic purpose., Conclusion: The key in determining whether a physician-patient relationship has been established is whether the patient reasonably relied upon advice given or had an expectation of treatment.

Physicians may attempt to disguise malignant melanoma in situ from insurance companies by diagnosing atypical melanocytic hyperplasia instead. This study indicates that the insurance industry is not misled by atypical melanocytic hyperplasia and treats it equivalently to malignant melanoma in situ. In addition, physicians' failure to diagnose malignant melanoma in situ may result in underestimation of the incidence of malignant melanoma and may cause inadequate initial treatment and patient follow-up.

Background: Photography has recently been introduced as an adjunct to the clinical management of patients with the dysplastic nevus syndrome (DNS)., Objective: Our purpose was to evaluate the methods used and the extent of clinical photography in dermatology residency programs in the United States., Methods: Nonmilitary accredited dermatology residency programs in the United States were surveyed (73% response rate) regarding utilization and technical aspects of clinical photography., Results: Forty-one percent of respondents used photography for the clinical management of 90% or more of patients with DNS. Twenty-four percent of respondents used photography for the clinical management of all patients with DNS. Eighty-one percent of respondents used slides, and 62% utilized total body photographs. The median number of photographs taken for a patient with DNS was 20., Conclusion: Dermatologic photography has been widely adopted for the clinical management of patients with DNS. Failure of the health insurance industry to recognize the value of this procedure may result in its underutilization.

Five senior medical students enrolled in the 4 week clinical elective in dermatologic surgery and cutaneous oncology (DSCO); two of these students also enrolled in a 4 week research elective in DSCO. During the elective(s) the students made significant improvement in the six areas of clinical diagnosis, histopathologic diagnosis, clinical management, DSCO procedures, research skills, and general information about the subspecialty. Following their elective(s), these students submitted a total of six abstracts, one letter, and seven manuscripts for presentation or publication.

An anonymous survey was conducted among 100 randomly selected fellows of the American Society for Dermatologic Surgery. Forty-one respondents provided information about their experience with percutaneous injury. Causes of injury during 6278 invasive procedures performed during a 1-month period included suture needlesticks (two injuries), injection needlestick (one), needle recapping (one), scalpel blade (one), skin hook (one), and an injury during the transport of an instrument (one). Dermatologic surgeons were more likely to injure their dominant fingers. Attitudes of dermatologic surgeons were surveyed regarding operating on patients while the physician or assistant was actively infected with human immunodeficiency virus, hepatitis B virus, herpetic whitlow, or paronychia caused by Staphylococcus aureus. Dermatologic surgeons believed that they should be allowed to operate while infected with human immunodeficiency virus (41.5%), hepatitis B virus (40%), herpetic whitlow (25%), and paronychia caused by S. aureus (20%). Few dermatologic surgeons would disclose preoperatively to patients infections present in themselves or in operating team members that were due to human immunodeficiency virus (29.4%), hepatitis B virus (27.8%), herpetic whitlow (28.6%), or paronychia caused by S. aureus (33.3%).

Data were collected from three medical centers in the USA, Poland, and Japan regarding 11 patients with advanced squamous cell carcinoma (SCC) secondary to epidermodysplasia verruciformis (EV). Analysis was conducted regarding primary tumor location, age at onset of EV, age at diagnosis of SCC, treatment of SCC, history of local tumor recurrence, presence of metastases, and age at death. Three of 11 patients developed both lymph node and visceral metastases and the mean patient age at death was 44 years (N = 6) with no patient to date living past 54 years. Mean patient survival time following metastases was 1.7 years (N = 2). Human papilloma virus typing of nine patients was performed. Current controversies regarding the treatment of patients with advanced SCC in the setting of EV are reviewed.