bluuebunny/crossref_metadata_2025 huggingface dataset:
Do organization-level quality management systems influence department-level quality? A cross-sectional study across 32 large hospitals in Australia
Authors: Taylor Natalie , Clay-Williams Robyn , Ting Hsuen P , Arnolda Gaston , Winata Teresa , Hogden Emily , Braithwaite Jeffrey
Published: September 2019

Objective

Little is known about the influence that hospital quality systems have on quality at department level, in Australia and elsewhere. This study assessed the relationships between organizational-level quality management systems, and the extent to which hospital-level quality management systems and department-level quality management strategies are related.

Design

A multi-level, cross-sectional, mixed-method study.

Setting and participants

As part of the Deepening our Understanding of Quality in Australia (DUQuA) project, we invited all large hospitals in Australia (~200 or more beds) which provided acute myocardial infarction (AMI), hip fracture and stroke care. The quality managers of these hospitals were the respondents for one of seven measures of hospital quality management systems and strategies. Data across the six remaining measures were collected through site visits by external surveyors assessing the participating hospitals.

Main outcome measures

Relationships were assessed between three organization-level quality management system measures: a self-report measure assessing organization-level quality activities (quality management systems index, QMSI); externally assessed organization-level compliance to procedures used to plan, monitor and improve quality of care (quality management compliance index, QMCI); and externally assessed implementation of quality systems (clinical quality implementation index, CQII). Associations were also assessed between organization-level quality management systems and department-level quality management strategies: how clinical responsibilities are assigned for a particular condition; whether department organization processes are organized to facilitate evidence-based care recommendations; compliance with selected recommendations of international agencies; and whether clinical reviews are performed systematically.

Results

Of 78 invited hospitals, 32 participated in the study. QMSI was positively associated with QMCI and CQII, but after controlling for QMSI, no relationship was found between QMCI and CQII. There appears to be a cluster of relationships between QMSI and department-level measures, but this was not consistent across all departments.

Conclusion

This is the first national study undertaken in Australia to assess relationships within and between organization-level and department-level quality management systems. These quality management system tools align with many components of accreditation standards and may be useful for hospitals in continuously monitoring and driving improvement.
Implementation and data-related challenges in the Deepening our Understanding of Quality in Australia (DUQuA) study: implications for large-scale cross-sectional research
Authors: Arnolda Gaston , Winata Teresa , Ting Hsuen P , Clay-Williams Robyn , Taylor Natalie , Tran Yvonne , Braithwaite Jeffrey
Published: September 2019

Healthcare organisations vary in the degree to which they implement quality and safety systems and strategies. Large-scale cross-sectional studies have been implemented to explore whether this variation is associated with outcomes relevant at the patient level. The Deepening our Understanding of Quality in Australia (DUQuA) study draws from earlier research of this type, to examine these issues in 32 Australian hospitals. This paper outlines the key implementation and analysis challenges faced by DUQuA. Many of the logistical difficulties of implementing DUQuA derived from compliance with the administratively complex and time-consuming Australian ethics and governance system designed principally to protect patients involved in clinical trials, rather than for low-risk health services research. The complexity of these processes is compounded by a lack of organizational capacity for multi-site health services research; research is expected to be undertaken in addition to usual work, not as part of it. These issues likely contributed to a relatively low recruitment rate for hospitals (41% of eligible hospitals). Both sets of issues need to be addressed by health services researchers, policymakers and healthcare administrators, if health services research is to flourish. Large-scale research also inevitably involves multiple measurements. The timing for applying these measures needs to be coherent, to maximise the likelihood of finding real relationships between quality and safety systems and strategies, and patient outcomes; this timing was less than ideal in DUQuA, in part due to administrative delays. Other issues that affected our study include low response rates for measures requiring recruitment of clinicians and patients, missing data and a design that necessarily included multiple statistical comparisons. We discuss how these were addressed. Successful completion of these projects relies on mutual and ongoing commitment, and two-way communication between the research team and hospital staff at all levels. This will help to ensure that enthusiasm and engagement are established and maintained.
Can benchmarking Australian hospitals for quality identify and improve high and low performers? Disseminating research findings for hospitals
Authors: Hibbert Peter , Saeed Faisal , Taylor Natalie , Clay-Williams Robyn , Winata Teresa , Clay Chrissy , Hussein Wadaha , Braithwaite Jeffrey
Published: September 2019

This paper examines the principles of benchmarking in healthcare and how benchmarking can contribute to practice improvement and improved health outcomes for patients. It uses the Deepening our Understanding of Quality in Australia (DUQuA) study published in this Supplement and DUQuA’s predecessor in Europe, the Deepening our Understanding of Quality improvement in Europe (DUQuE) study, as models. Benchmarking is where the performances of institutions or individuals are compared using agreed indicators or standards. The rationale for benchmarking is that institutions will respond positively to being identified as a low outlier or desire to be or stay as a high performer, or both, and patients will be empowered to make choices to seek care at institutions that are high performers. Benchmarking often begins with a conceptual framework that is based on a logic model. Such a framework can drive the selection of indicators to measure performance, rather than their selection being based on what is easy to measure. A Donabedian range of indicators can be chosen, including structure, process and outcomes, created around multiple domains or specialties. Indicators based on continuous variables allow organizations to understand where their performance is within a population, and their interdependencies and associations can be understood. Benchmarking should optimally target providers, in order to drive them towards improvement. The DUQuA and DUQuE studies both incorporated some of these principles into their design, thereby creating a model of how to incorporate robust benchmarking into large-scale health services research.
Trap Height Affects Catches of Bark and Woodboring Beetles (Coleoptera: Curculionidae, Cerambycidae) in Baited Multiple-Funnel Traps in Southeastern United States
Authors: Miller D R , Crowe C M , Sweeney J D
Published: September 2019

In north-central Georgia, trap height affected catches of some species of bark and woodboring beetles (Coleoptera) in traps baited with lures used in surveillance programs to detect non-native forest insects. Traps were placed within the canopy and understory of mature oak trees (Quercus spp.) with collection cups placed 18–23 m above ground level (AGL), and 0.3–0.5 m AGL, respectively. Traps were baited with ethanol to target ambrosia beetles (Curculionidae: Scolytinae) in one experiment, ethanol + syn-2,3-hexanediol + racemic 3-hydroxyhexan-2-one + racemic 3-hydroxyoctan-2-one to target hardwood woodborers (Cerambycidae) in a second experiment, and α-pinene + racemic ipsenol + racemic ipsdienol to target pine bark beetles (Curculionidae) and woodborers (Cerambycidae) in a third experiment. Canopy traps were more effective than understory traps for detecting Cnestus mutilatus (Blandford) (Curculionidae), Neoclytus scutellaris (Olivier), and Monochamus titillator (F.) (Cerambycidae). The reverse was true for Xylosandrus crassiusculus (Motschulsky), Dendroctonus terebrans (Olivier) (Curculionidae), and Neoclytus acuminatus (F.) (Cerambycidae). Catches of a third group which included Hylobius pales (Herbst), Ips grandicollis (Eichhoff) (Curculionidae), Neoclytus mucronatus (F.), and Anelaphus pumilus (Newman) (Cerambycidae) were largely unaffected by trap height. Similar patterns were noted for species of Cleridae, Scarabaeidae, Trogossitidae, and Zopheridae but not Histeridae or Tenebrionidae (Coleoptera). Catches of the bee assassin Apiomerus crassipes (F.) (Hemiptera: Reduviidae) in traps baited with the hardwood borer blend were greater in canopy traps than in understory traps.
The A to B of starch granule formation in wheat endosperm
Authors: Lloyd James R
Published: September 2019

This article comments on:

Chia T, Chirico M, King R et al. 2019. A carbohydrate-binding protein, B-granule content 1 influences starch granule-size distribution in a dose dependent manner in polyploid wheat. Journal of Experimental Botany 70, 105–115.
A new method for target selection in direct imaging programmes with COPAINS
Authors: Fontanive C , Mužić K , Bonavita M , Biller B
Published: September 2019

We present COPAINS (Code for Orbital Parametrization of Astrometrically Inferred New Systems), an innovative tool developed to identify previously undiscovered companions detectable via direct imaging, based on changes in stellar proper motions across multiple astrometric catalogues. This powerful procedure allows for dynamical predictions of the possible masses and separations of unseen companions compatible with observed astrometric trends, marginalized over unknown orbital elements. Validating our approach using well-constrained systems, we found that our tool provides a good indication of the region of the parameter space where undetected secondaries may be located. Comparing the output of the code to the measured or expected sensitivity from various imaging instruments, this in turn enables us to robustly select the most promising targets for direct imaging campaigns searching for low-mass companions. Such an informed selection method promises to reduce the null detection rates from current programmes and will significantly increase the current census of wide brown dwarfs and planetary companions to stars, which remain extremely rare in the surveys conducted so far.
The orbital content of bars: the origin of ‘non-x1-tree’, bar-supporting orbits
Authors: Patsis P A , Athanassoula E
Published: September 2019

Recently, many orbital studies in barred galaxy potentials have revealed the existence of orbits that are not trapped around x1-tree orbits, but could be potentially appropriate building blocks for bars. These findings question the uniqueness of the x1 family as the standard paradigm of orbital motion in galactic bars. The main goal of this paper is to investigate the role that such orbits could play in shaping the morphology of bars. We trace the morphological patterns appearing in the face-on and edge-on views of the non-periodic orbits presented in these studies and we show that they are introduced in the system by second type (‘deuxième genre’) bifurcations of x1. For this purpose, we use a typical 3D Ferrers bar model and follow the radial and vertical bifurcations of the x1 family considered as being mul-periodic, with mul = 2, 3, 5. The variation of the stability indices of x1 in the mul = 2, 3 cases gives us also the 4- and 6-periodic orbits, respectively. We tabulate these orbits including all information necessary to assess their role as appropriate building blocks. We discuss their stability and their extent, as well as their size and morphological evolution, as a function of energy. We conclude that even the most important of the mul-periodic orbits presented in Tables 2–5 are less appropriate building blocks for bars than the families of the x1-tree at the same energy.
Desorption of N2, CO, CH4, and CO2 from interstellar carbonaceous dust analogues
Authors: Maté B , Jimenez-Redondo M , Peláez R J , Tanarro I , Herrero V J
Published: September 2019

The interaction of volatile species with carbonaceous interstellar dust analogues is of relevance in the chemistry and physics of dense clouds in the interstellar medium. Two deposits of hydrogenated amorphous carbon (HAC), with different morphologies and aromatic versus aliphatic ratio in their structure, have been grown to model interstellar dust. The interaction of N2, CO, CH4, and CO2 with these two surfaces has been investigated using thermal programmed desorption (TPD). Desorption energy distributions were obtained by analysing TPD spectra for one monolayer coverage with the Polanyi–Wigner equation. The desorption energies found in this work for N2, CO, and CH4 are larger by 10–20 per cent than those reported in the literature for siliceous or amorphous solid water surfaces. Moreover, the experiments suggest that the interaction of the volatiles with the aromatic substructure of HAC is stronger than that with the aliphatic part. Desorption of CO2 from the HAC surfaces follows zero-order kinetics, reflecting the predominance of CO2–CO2 interactions. A model simulation of the heating of cold cloud cores shows that the volatiles considered in this work would desorb sequentially from carbonaceous dust surfaces with desorption times ranging from hundreds to tens of thousands of years, depending on the molecule and on the mass of the core.
The Genome of the Endangered Dryas Monkey Provides New Insights into the Evolutionary History of the Vervets
Authors: van der Valk Tom , Gonda Catalina M , Silegowa Henri , Almanza Sandra , Sifuentes-Romero Itzel , Hart Terese B , Hart John A , Detwiler Kate M , Guschanski Katerina
Published: September 2019

Genomic data can be a powerful tool for inferring ecology, behavior, and conservation needs of highly elusive species, particularly, when other sources of information are hard to come by. Here, we focus on the Dryas monkey (Cercopithecus dryas), an endangered primate endemic to the Congo Basin with cryptic behavior and possibly <250 remaining adult individuals. Using whole-genome sequencing data, we show that the Dryas monkey represents a sister lineage to the vervets (Chlorocebus sp.) and has diverged from them ∼1.4 Ma with additional bidirectional gene flow ∼750,000–∼500,000 years ago that has likely involved the crossing of the Congo River. Together with evidence of gene flow across the Congo River in bonobos and okapis, our results suggest that the fluvial topology of the Congo River might have been more dynamic than previously recognized. Despite the presence of several homozygous loss-of-function mutations in genes associated with sperm mobility and immunity, we find high genetic diversity and low levels of inbreeding and genetic load in the studied Dryas monkey individual. This suggests that the current population carries sufficient genetic variability for long-term survival and might be larger than currently recognized. We thus provide an example of how genomic data can directly improve our understanding of highly elusive species.
Urinary N7-(1-hydroxy-3-buten-2-yl) guanine adducts in humans: temporal stability and association with smoking
Authors: Jokipii Krueger Caitlin C , Madugundu Guru , Degner Amanda , Patel Yesha , Stram Daniel O , Church Timothy R , Tretyakova Natalia
Published: September 2019

1,3-Butadiene (BD) is a known human carcinogen found in cigarette smoke, automobile exhaust, and urban air. Workers occupationally exposed to BD in the workplace have an increased incidence of leukemia and lymphoma. BD undergoes cytochrome P450-mediated metabolic activation to 3,4-epoxy-1-butene (EB), 1,2,3,4-diepoxybutane (DEB) and 1,2-dihydroxy-3,4-epoxybutane (EBD), which form covalent adducts with DNA. We have previously reported a quantitative nanoLC/ESI+-HRMS3 method for urinary N7-(1-hydroxy-3-buten-2-yl) guanine (EB-GII) adducts as a mechanism-based biomarker of BD exposure. In the present study, the method was updated to include high throughput 96-well solid phase extraction (SPE) and employed to establish urinary EB-GII biomarker stability and association with smoking. Urinary EB-GII levels were measured bimonthly for 1 year in 19 smokers to determine whether single adduct measurement provides reliable levels of EB-GII in an individual smoker. In addition, association of EB-GII with smoking was studied in 17 individuals participating in a smoking cessation program. EB-GII levels decreased 34% upon smoking cessation, indicating that it is associated with smoking status, but may also originate from sources other than exposure to cigarette smoke.
Evidence of Partisan Agenda Fragmentation in the American Public, 1959–2015
Authors: Gruszczynski Mike
Published: September 2019

This research examines the extent to which partisan agenda fragmentation is occurring within the American public. Though numerous scholars of public opinion and political communication have warned of the deleterious effects of agenda fragmentation, to this point such fragmentation has been demonstrated only across a small number of issues over short periods of time. This research is the first to utilize both a large set of issues and a long time frame to assess the state of partisan agendas from 1959 to 2015 through the use of individual-level Gallup’s “Most Important Problem” polls. Findings show that the public agenda has fragmented on a large number of issues, in terms of both the level of and shifts in attention that partisans accord to issues of the day. Additionally, this research highlights the importance of recent increases in agenda diversity and carrying capacity to fragmentation, demonstrating that while the presence of large, obtrusive issues tends to be associated with correspondence in partisan agendas, the ordering of partisan issue agendas has decoupled substantially in recent decades.
Incidence of myocardial infarction and associated mortality varies by latitude and season: findings from a Swedish Registry Study
Authors: Harvey Nicholas C , Lorentzon Mattias , Kanis John A , McCloskey Eugene , Johansson Helena
Published: September 2019

Background

We investigated whether the incidence of death following myocardial infarction (MI) varied by season and latitude in the Swedish population.

Methods

We studied deaths following MI from January 1987 to December 2009, using the Swedish National Cause of Death Register. County of residence was used to determine latitude and population density. An extension of Poisson regression was used to study the relationship between risk of death following MI with age, latitude, time (from 1987), population density and calendar days.

Results

Over the study period, there was a secular decrease in the incidence of MI-related death. In men, MI-related death incidence increased by 1.3% [95% confidence interval (CI) = 1.1–1.5] per degree of latitude (northwards). In women, MI-related death incidence increased by 0.6% (95% CI = 0.4–0.9) per degree of latitude. There was seasonal variation in the risk of MI-related death with peak values in the late winter and a nadir in the summer months in both the north and the south of Sweden. Findings were similar with incident MI as the outcome.

Conclusions

The incidence of MI-related death varied markedly by season and latitude in Sweden, with summer months and more southerly latitude associated with lower rates than winter months and more northerly latitude.
Priscilla Wordsworth’s Pocketbook Diaries and Interfaces of Subjectivity
Authors: Eckert Lindsey
Published: September 2019

Pocketbook diaries were one of the most pervasive platforms for autobiography in Britain throughout the eighteenth and nineteenth centuries. The relative standardization of the genre’s bibliographic and textual elements encouraged users to record their lives in discrete day-by-day blocks and their finances in neat columns. As culturally ubiquitous interfaces, pocketbooks had the potential to shape the records that users wrote in them as well as, this article argues, users themselves. I draw on the case study of Priscilla Wordsworth’s pocketbooks from the early 1800s, contextualizing them alongside other largely unknown female diarists from the period. I show that, in addition to the content of diary entries, the way Wordsworth and others interact with the material and cultural expectations of their pocketbooks reveals much about pocketbooks’ affordances and their potential to influence their users. This article suggests that the interfaces that people used might affect not only their interactions with a particular interface—such as a pocketbook—but also their sense of self. Employing theories of interface design often applied to digital media, this article offers connections between old and new media and within scholarship on media studies, book history, and material culture.
Exosomes in intercellular communication and implications for osteoarthritis
Authors: Asghar Sabha , Litherland Gary J , Lockhart John C , Goodyear Carl S , Crilly Anne
Published: September 2019

Osteoarthritis (OA) is the most prevalent of the musculoskeletal conditions and represents a significant public health burden. While degeneration of articular cartilage is a key feature, it is now increasingly recognized as a complex condition affecting the whole joint, with synovial inflammation present in a significant proportion of patients. As a secretory tissue, the OA synovium is a rich source of both soluble inflammatory mediators and extracellular vesicles, including exosomes, which have been implicated in cell–cell communication. Exosome cargo has been found to include proteins, lipids and various RNA subtypes such as mRNA and miRNA, potentially capable of regulating gene expression in target cells and tissues. Profiling of exosome cargo and understanding effects on cartilage could elucidate novel regulatory mechanisms within the joint, providing insight for targeted treatment. The aim of this article is to review current literature on exosome biology, highlighting the relevance and application for OA pathogenesis.
A Comparison of Immediate and Short-Term Defensive Responses toPhytophthoraSpecies Infection in Both Susceptible and Resistant Walnut Rootstocks
Authors: Alvarado Laureano , Saa Sebastián , Cuneo Italo F. , Pedreschi Romina , Morales Javiera , Larach Alejandra , Barros Wilson , Guajardo Jeannette , Besoain Ximena
Published: September 2019

Clonal rootstocks are one alternative used by the walnut industry to control damage caused by Phytophthora species, traditionally using plants grafted on susceptible Juglans regia rootstock. Vlach, VX211, and RX1 are clonal rootstocks with a degree of resistance to Phytophthora species. The resistance to pathogens in these rootstocks depends on the resistance mechanisms activated by the presence of the pathogen and subsequent development of responses in the host. In this work, we analyzed how plants of J. regia, Vlach, VX211, and RX1 responded to inoculation with Phytophthora cinnamomi or Phytophthora citrophthora isolates obtained from diseased English walnut plants from Chilean orchards. After inoculation, plants of Vlach, VX211, and RX1 showed canopy and root damage indexes that did not differ from noninoculated control plants. In contrast, plants of J. regia, which is susceptible to P. cinnamomi and P. citrophthora, died after inoculation. Vlach, VX211, and RX1 plants inoculated with P. cinnamomi or P. citrophthora showed greater root weight and volume and greater root growth rates than their respective controls. These results suggest that short-term carbohydrate dynamics may be related to the defense mechanisms of plants; they are immediately activated after inoculation through the production of phenolic compounds, which support the further growth and development of roots in walnut clonal rootstocks. To our knowledge, this is the first study that comprehensively characterizes vegetative and radicular growth and the dynamics of sugars and phenols in response to infection with P. cinnamomi or P. citrophthora in walnut rootstocks.
A Survey of Virginia Vineyards Revealed High Incidences of Grapevine Rupestris Stem Pitting-Associated Virus, Grapevine Red Blotch Virus, and Two Mealybug Species
Authors: Jones Taylor , Nita Mizuho
Published: September 2019

We investigated the prevalence of viruses infecting grapevines in Virginia, identity of disease vectors, and potential factors affecting virus incidence. Tested viruses were grapevine leafroll-associated virus (GLRaV-1 and -4), grapevine fleck virus (GFkV), grapevine virus A (GVA), grapevine virus B (GVB), grapevine rupestris stem pitting-associated virus (GRSPaV), tomato ringspot virus (ToRSV), grapevine vein clearing virus (GVCV), grapevine red blotch virus (GRBV), and grapevine Pinot gris virus (GPGV). We documented wide distributions of GRSPaV (54%) and GRBV (24%) and common occurrences of grape (Pseudococcus maritimus) and Gill’s (Ferrisia gilli) mealybugs among vineyards. This is the first report of GLRaV-1, GLRaV-4, GVA, GVB, GRSPaV, and obscure mealybug (Pseudococcus viburni) in Virginia. We also documented significant association (P ≤ 0.05) of the presence of mealybugs and GVA and GVB. With younger vines, significantly lower incidences were found for viruses that were listed (i.e., tested for a certification) by the Foundation Planting Service’s and the National Clean Plant Network’s grape programs. On the other hand, there was a lack of the age effect on incidence of GRSPaV and GRBV, which were not listed until recently. These results suggest the importance of clean plant material and vector management for grapevine virus disease management in Virginia.
Effects of Temperature, Relative Humidity, and Plant Age on Bacterial Disease of Onion Plants
Authors: Tho Kim E. , Brisco-McCann Elizabeth , Wiriyajitsomboon Prissana , Hausbeck Mary K.
Published: September 2019

Foliar disease of onion in Michigan, caused by Pantoea agglomerans, Pantoea ananatis, or Enterobacter cowanii, has recently become a concern to producers. The objective of this study was to determine the effect of temperature, relative humidity (RH), and plant age in growth chamber and greenhouse experiments on onion plants inoculated with each pathogen. A significant level of disease resulted from each pathogen at 25 to 30°C, with strong positive associations detected using regression analysis between the area under the disease progress curve (AUDPC) and temperature. RH also significantly influenced symptom development. Foliar disease symptoms developed sooner and were more severe when RH was high (80 to 100%) but was limited at RH < 60%. Significant positive associations between RH and AUDPC, as described by linear regression, were also detected. When 6- to 14-week-old plants were inoculated with each bacterial pathogen, susceptibility increased significantly with age. These results provide insight into the epidemiology of P. agglomerans, P. ananatis, and E. cowanii bacterial pathogens of onions in Michigan and can assist in the development and timing of management strategies.
How Consistent Is Competent? Examining Variance in Psychomotor Skills Assessment
Authors: Labbé Mathilde , Young Meredith , Mascarella Marco , Husein Murad , Doyle Philip C. , Nguyen Lily H.P.
Published: September 2019

Purpose

Direct assessment of trainee performance across time is a core tenet of competency-based medical education. Unlike variability of psychomotor skills across levels of expertise, performance variability exhibited by a particular trainee across time remains unexplored. The goal of this study was to document the consistency of individual surgeons’ technical skill performance.

Method

A secondary analysis of assessment data (collected in 2010–2012, originally published in 2015) generated by a prospective cohort of participants at Montreal Children’s Hospital with differing levels of expertise was conducted in 2017. Trained raters scored blinded recordings of a myringotomy and tube insertion performed 4 times by junior and senior residents and attending surgeons over a 6-month period using a previously reported assessment tool. Descriptive exploratory analyses and univariate comparison of standard deviations (SDs) were conducted to document variability within individuals across time and across training levels.

Results

Thirty-six assessments from 9 participants were analyzed. The SD of scores for junior residents was highly variable (5.8 out of a scale of 30 compared with 1.8 for both senior residents and attendings [F(2,19) = 5.68, P < 0.05]). For a given individual, the range of scores was twice as large for junior residents than for senior residents and attendings.

Conclusions

Surgical residents may display highly variable performances across time, and individual variability appears to decrease with increasing expertise. Operative skill variability could be underrepresented in direct observation assessment; emphasis on an adequate amount of repetitive evaluations for junior residents may be needed to support judgments of competence or entrustment.
Health Care in the United States: Individual Right or Government Duty?
Authors: Holtzman Jessica N. , Schwartzstein Richard M.
Published: September 2019

The authors discuss the notion of health care as a governmental duty rather than a right of individuals. The notion of individual rights was proposed by political philosophers of the 17th and 18th centuries, who posited that people existed in a state of nature before coming together to form communities. Members of communities relinquish certain freedoms in exchange for services provided by government, including protection of the natural rights of “life, liberty, and the pursuit of happiness.” In this tradition, there are natural rights that exist before government and must be protected from government infringement. The U.S. Constitution almost exclusively enshrines negative rights, which protect natural rights from government interference. Rights belong to individuals, whereas the government has duties to provide services, such as basic education, that society deems to be important. The discussion of health care as a positive right, one requiring government to provide citizens with services, runs counter to this tradition of natural rights.

The authors propose that reframing the discussion to see universal access to health care as an obligation of government, rather than a right of individuals, will center the discussion more accurately within U.S. political tradition. This may drain the emotional charge associated with claims to “rights” from public debate and allow for productive negotiations over the extent of health care appropriate for government to provide, within the context of the other obligations that form the social contract between the citizenry and its government.
Teaching Professionalism in Postgraduate Medical Education: A Systematic Review
Authors: Berger Arielle S. , Niedra Elizabeth , Brooks Stephanie G. , Ahmed Waleed S. , Ginsburg Shiphra
Published: September 2019

Purpose

This systematic review sought to summarize published professionalism curricula in postgraduate medical education (PGME) and identify best practices for teaching professionalism.

Method

Three databases (MEDLINE, Embase, ERIC) were searched for articles published from 1980 through September 7, 2017. English-language articles were included if they (1) described an educational intervention addressing professionalism, (2) included postgraduate medical trainees, and (3) evaluated professionalism outcomes.

Results

Of 3,383 articles identified, 50 were included in the review. The majority evaluated pre- and posttests for a single group (24, 48%). Three (6%) were randomized controlled trials. The most common teaching modality was small-group discussions (28, 56%); other methods included didactics, reflection, and simulations. Half (25, 50%) used multiple modalities. The professionalism topics most commonly addressed were professional values/behavior (42, 84%) and physician well-being (23, 46%). Most studies measured self-reported outcomes (attitude and behavior change) (27, 54%). Eight (16%) evaluated observed behavior and 3 (6%) evaluated patient outcomes. Of 35 studies that evaluated statistical significance, 20 (57%) reported statistically significant positive effects. Interventions targeting improvements in knowledge were most often effective (8/12, 67%). Curriculum duration was not associated with effectiveness. The 45 quantitative studies were of moderate quality (Medical Education Research Study Quality Instrument mean score = 10.3).

Conclusions

Many published curricula addressing professionalism in PGME are effective. Significant heterogeneity in curricular design and outcomes assessed made it difficult to synthesize results to identify best practices. Future work should build upon these curricula to improve the quality and validity of professionalism teaching tools.
Airway Pressure Release Ventilation in Adult Patients With Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-Analysis*
Authors: Lim Jolene , Litton Edward
Published: September 2019

Objectives:

To evaluate the efficacy and safety of airway pressure release ventilation in critically ill adults with acute hypoxemic respiratory failure.

Data Sources:

A systematic literature search of MEDLINE via PUBMED, EMBASE, the Cochrane Library, published conference proceedings and abstracts, reference lists of eligible studies and review articles, and hand searches of relevant journals and trial registers.

Study Selection:

Eligible studies included randomized controlled trials published between years 2000 and 2018, comparing airway pressure release ventilation to any ventilation mode, in critically ill adults with acute hypoxemic respiratory failure and reporting at least one mortality outcome.

Data Extraction:

Screened citations were reviewed and extracted independently by two investigators onto a prespecified proforma.

Data Synthesis:

There were 412 patients from seven randomized controlled trials included in the qualitative and quantitative data synthesis. Airway pressure release ventilation was associated with a significant mortality benefit (relative risk, 0.67; 95% CI, 0.48–0.94; I
2 < 0.1%; p = 0.97) and improvement in day 3 Pao
2/Fio
2 ratio (weighted mean difference, 60.4; 95% CI, 10.3–110.5). There was no significant difference in requirement to initiate rescue treatments including inhaled pulmonary vasodilators, prone positioning, or extracorporeal membrane oxygenation (relative risk, 0.51; 95% CI, 0.22–1.21; I
2 = 64.7%; p = 0.04). The risk of barotrauma was only reported in three studies and did not differ between groups (relative risk, 0.39; 95% CI, 0.12–1.19; I
2 < 0.1%; p = 0.99).

Conclusions:

In adult patients requiring mechanical ventilation for acute hypoxic respiratory failure, airway pressure release ventilation is associated with a mortality benefit and improved oxygenation when compared with conventional ventilation strategies. Given the limited number of patients enrolled in the available studies, larger multicenter studies are required to validate these findings.
Prognosis and Management of Thick and Ultrathick Melanoma
Authors: Blakely Andrew M. , Cohen Joshua T. , Comissiong Danielle S. , Vezeridis Michael P. , Miner Thomas J.
Published: September 2019

Objectives:

Thick melanomas, defined as ≥4 mm in thickness, represent ~5% of new melanoma diagnoses and have been associated with poor overall survival (OS). Ultrathick melanomas, those lesions ≥8 mm in thickness, have been associated with worse survival. We sought to compare prognostic factors for thick and ultrathick melanoma.

Methods:

Retrospective analysis of a prospective database of all patients receiving an operation for melanoma, June 2005 to December 2016 was performed. Multivariate Cox proportional hazards regression analyses were performed to identify predictors of progression-free survival (PFS) and OS.

Results:

Of 95 patients with thick melanoma, 37 (39%) had ultrathick tumors (≥8 mm thick). Thick and ultrathick lesions were not significantly different on the basis of tumor location, ulceration, mitotic rate, lymphovascular invasion, or performance or positivity of sentinel node biopsy or therapeutic lymphadenectomy. Disease recurrence was identified in 38 patients overall (40%), more commonly in ultrathick disease (55% vs. 29%, P=0.008). Serum neutrophil to lymphocyte ratio (NLR) was available for 36 patients, of whom 23 (64%) had high NLR (>3.0). Decreased PFS was independently associated with ultrathick tumors (HR, 2.9; P=0.003), head/neck location (HR, 2.6; P=0.023), and positive lymph nodes (HR, 3.3; P=0.004). Decreased OS was independently associated with high NLR (HR, 5.0; P=0.042).

Conclusions:

Disease progression was higher in the ultrathick melanoma group. Thicker tumors, head/neck location, and positive lymph nodes were associated with decreased PFS. High NLR was associated with decreased OS. Ultrathick melanomas represent advanced malignancy; however, patients may derive benefit from surgical treatment to achieve locoregional control.
Multimedia Technology Used to Supplement Patient Consent for Mohs Micrographic Surgery
Authors: West Lindsey , Srivastava Divya , Goldberg Leonard H. , Nijhawan Rajiv I.
Published: September 2019

BACKGROUND

The patient consent process traditionally relies on conversations between the physician and the patient and rarely utilizes supplemental multimedia aids.

OBJECTIVE

To determine whether the addition of an educational video on Mohs micrographic surgery (MMS) can improve patient satisfaction with the consent process.

MATERIALS AND METHODS

This prospective observational quality improvement study compared the outcomes of traditional patient consent alone versus standard consent plus an educational video among patients undergoing their first MMS for a primary skin cancer. End points were patient satisfaction and preferences measured by postprocedure questionnaires.

RESULTS

The addition of a supplemental video to the consent process did not affect overall patient satisfaction, which was very high in both video and control groups. However, specific components of patient satisfaction were improved such as patient perception of the opportunity to ask questions and understand the procedure.

CONCLUSION

Multimedia aids can be effective tools in the patient consent process.
Cicatricial Ectropion Repair for Dermatologic Surgeons
Authors: Kooistra Laura J. , Scott Jeffrey F. , Bordeaux Jeremy S.
Published: September 2019

BACKGROUND

Cicatricial ectropion occurs when tension of a scar below the eye has sufficient downward pull to evert the lower eyelid. There are many surgical techniques to repair cicatricial ectropion.

OBJECTIVE

To review the published literature on the repair of cicatricial ectropion, review relevant anatomy, and review surgical considerations for patients with cicatricial ectropion from the perspective of a dermatologic surgeon.

MATERIALS AND METHODS

A search of PubMed was conducted to identify articles on cicatricial ectropion repair through December 1, 2017. Articles were individually reviewed for applicability to dermatologic surgery.

RESULTS

Forty-one articles were reviewed. Many articles report significant differences in outcomes when comparing 1 cicatricial ectropion repair technique to another; however, 1 single surgical approach has not been shown to be superior to the rest for most patients.

CONCLUSION

There is a lack of consensus among the literature about the optimal approach to repairing cicatricial ectropion. The selection of surgical technique will vary depending on several factors including the lateral or medial extent of the ectropion, the degree of scarring and tissue density of potential donor sites for a skin flap, and the severity of lid laxity.
A Study of 219Rn Outgassing and 211Pb Contamination from 223Ra In dry, Liquid, and Murine Tissue Samples
Authors: Adler Stephen , Baidoo Kwamena , Jagoda Elaine , Phelps Tim , Roy Jyoti , Seidel Jurgen , Lin Frank , Choyke Peter
Published: September 2019

Introduction: A study of 211Pb contamination caused by the outgassing of 219Rn from 223Ra in dry, liquid, and murine tissues samples has been made to help design proper handling procedures for 223Ra in preclinical biodistribution work. Materials and Methods:
211Pb activity levels were measured from 223Ra in dry, liquid, and tissue samples using aspiration and autoradiography techniques. Results: Using aspiration techniques on dry samples of 223Ra, an average 219Rn outgassing rate of 51% ± 21% was measured with one measurement reaching as high as 81%. 31% ± 4% 211Pb contamination was measured within a 4.3 cm radius of a dry 223Ra source placed inside a 10-cm-diameter petri dish where the lip of the petri dish contained the 219Rn dissemination. Without the containment of the petri dish, 219Rn can reach as far as 7.8 cm from the source with trace levels spreading further. Using aspiration techniques on liquid samples of 223Ra, outgassing rates of 219Rn were 0.9% ± 0.3%. The outgassing levels in harvested organs from a biodistribution were as high as 10.1% ± 0.4% for an intraperitoneally injected mouse and 0.204% ± 0.006% for an intravenously injected mouse. The outgassing of the intravenously injected mouse carcass was less than 0.1%. Conclusion: In dry form, the high levels of 219Rn outgassing from a 223Ra source necessitate the use of ventilated biohoods when handling or preparing dry 223Ra from source vials. The very low levels of 219Rn outgassing from 223Ra liquid sources reduces exposure to 219Rn by a factor of 50. 219Rn exposure from murine organ tissue reaches levels of 10% when handling organs from an intraperitoneal injection and less than 0.2% for an intravenous injection.
FLUORESCENCE LIFETIME IMAGING OPHTHALMOSCOPY (FLIO) PATTERNS IN CLINICALLY UNAFFECTED CHILDREN OF MACULAR TELANGIECTASIA TYPE 2 (MACTEL) PATIENTS
Authors: Sauer Lydia , Vitale Alexandra S. , Andersen Karl M. , Hart Barbara , Bernstein Paul S.
Published: September 2019

Purpose:

Macular telangiectasia Type 2 (MacTel) is an inherited retinal disease following an autosomal dominant pattern with late onset and reduced penetrance. Fluorescence lifetime imaging ophthalmoscopy (FLIO) enhances diagnosis by showing distinct changes in MacTel. This study investigates FLIO-associated changes in clinically unaffected family members.

Methods:

Eighty-one patients with MacTel (61 ± 12 years), 33 clinically healthy children under age 40 years of these MacTel patients (MacTel-C; 31 ± 6 years), 27 other family members (children over age 40 years, siblings, and parents) and 30 controls were investigated with the Heidelberg FLIO. All subjects underwent multimodal conventional imaging, including optical coherence tomography, blue-light reflectance, fluorescein angiography, and macular pigment imaging.

Results:

All 81 patients with MacTel showed typical FLIO patterns. Of the 33 investigated MacTel-C with completely normal eye examinations and conventional imaging, 12 (36%) show FLIO patterns consistent with early MacTel.

Conclusion:

Prolonged FLIO lifetimes in the parafoveal area within the short spectral channel, especially temporally, are MacTel-specific. Fluorescence lifetime imaging ophthalmoscopy detects these lifetime patterns in over one-third of clinically unaffected MacTel-C. Although further studies will be necessary to determine the specificity of FLIO, it may help diagnose MacTel before conventional imaging modalities show changes or patients experience visual disturbances. Early detection may facilitate future gene discovery studies and interventional trials.
EFFECT OF LASER PHOTOCOAGULATION ON MACULAR EDEMA ASSOCIATED WITH MACULAR HOLES
Authors: Francone Anibal , Essilfie Juliet , Sarraf David , Preti Rony C. , Monteiro Mario L. R. , Hubschman Jean-Pierre
Published: September 2019

Purpose:

To report the outcomes of laser therapy to barricade eccentric full-thickness macular hole with associated cystoid macular edema.

Methods:

We report two patients who developed an eccentric full-thickness macular hole with persistent cystoid macular edema after pars plan vitrectomy with and without internal limiting membrane peel for epiretinal membrane and the results of argon laser therapy.

Results:

Barricade argon laser therapy was applied concentric to the full-thickness macular hole. Associated cystoid macular edema was noted to resolve within 1 to 3 months of therapy in both cases.

Conclusion:

Barricade laser therapy surrounding a macular hole can lead to resolution of associated cystoid macular edema. Pathogenic mechanisms to explain this favorable outcome are discussed.
ALTERNATIVE MANAGEMENT OF CIRCUMSCRIBED CHOROIDAL HEMANGIOMA USING INTRAVITREAL METOPROLOL
Authors: Jorge Rodrigo , Chaves Leandro , Cunha Armando da Silva , Correa Zelia M.
Published: September 2019

Background/Purpose:

To describe a patient with visually symptomatic circumscribed choroidal hemangioma (CCH) treated successfully with intravitreal beta‐blocker.

Methods:

This is an interventional single case report of a 63 year‐old man with a juxtafoveal CCH and extensive subretinal fluid (SRF) unsuccessfully treated with intravitreal anti‐VEGF. Off‐label intravitreal use of metoprolol (50μg/0.05 ml) was then performed. Main outcome measures were resolution or decreased subretinal fluid on OCT, visual stability or improvement, lack of retinal/ocular toxicity.

Results:

Following 2 intravitreal injections of metoprolol (1 month apart), significant response was observed with decrease of SRF and visual improvement to 20/400 during a 9‐week follow‐up after the injections.

Conclusion:

These preliminary findings suggest that intravitreal metoprolol can be a safe alternative treatment for patients with CCH. This off‐label therapy could represent another option for patients with this condition.
Cognitive Dysfunction and Its Predictors in Adult Patients With Cancer Receiving Chemotherapy: A Cross-Sectional Correlational Study
Authors: WAZQAR Dhuha Youssef
Published: September 2019

Background:

Chemotherapy-related cognitive dysfunction, one of the most frequently reported symptoms in patients with cancer, has a negative impact on the daily lives of patients. No research has examined cognitive dysfunction and its potential predictors in adult patients with cancer receiving chemotherapy in Saudi Arabia.

Purpose:

The purpose of this study was to examine the sociodemographic, clinical, and psychological factors associated with cognitive dysfunction in adult patients with cancer receiving chemotherapy.

Methods:

A cross-sectional correlational study was carried out with a convenience sample of 100 adult patients with cancer receiving chemotherapy at a university teaching hospital in Saudi Arabia. The Montreal Cognitive Assessment, the Hospital Anxiety and Depression Scale, and sociodemographic and clinical surveys were completed by participants. Descriptive statistics and linear regression were used to analyze the data.

Results:

The data showed that the participants experienced moderate-to-severe cognitive dysfunction. Participants performed poorly in the divided attention and memory cognitive domains. Age, educational level, and depression factors were found to be significant predictors of cognitive dysfunction.

Conclusions/Implications for Practice:

Cognitive dysfunction is commonly seen in patients with cancer receiving chemotherapy. Chemotherapy, age, and psychological factors increase susceptibility to cognitive dysfunction in adult patients with cancer. Oncology nurses should be aware that patients with cancer may be extremely vulnerable to cognitive dysfunction. Furthermore, age and psychological factors must be considered when developing symptom management and supportive care intervention programs to reduce the incidence of negative cognitive outcomes in this population.