bluuebunny/crossref_metadata_2025 huggingface dataset:
THE ROLE OF LAW IN ADVANCE CARE PLANNING: SHOULD IT LEAD, FOLLOW, OR GET OUT OF THE WAY?
Authors: Chesterman J
Published: April 2013

Background

This paper explores the tensions that exist between clinical advance care planning initiatives and the complex amalgam of laws that govern medical treatment decision making, particularly decision making in relation to patients who do not have the capacity to consent to their own treatment.

Aim

The aims of the paper are to identify the current challenges faced by advocates of advance care planning—from both clinical and legal perspectives—and to propose reforms.

Methods

The paper considers the current legal parameters in which advance care planning operates, and also considers some recent reform initiatives in Australia, including the adoption of a national framework for advance directives, as well as key recommendations arising from recent guardianship law reviews in Queensland and Victoria.

Conclusion

In considering whether the law should lead, follow, or get out of the way, the paper concludes by suggesting that reforms are warranted that would enable it to do all three. It should lead, by ensuring the protection of vulnerable people. It should follow, by more meaningfully recognising current advance care planning initiatives and scholarship. And it should get out of the way, by reducing, and where possible eliminating, current unnecessary legal complexities.
A BROADER APPROACH TO LIMITATION OF MEDICAL TREATMENT: AUDIT OF COMPLIANCE AFTER CHANGING FROM ‘NFR’ TO ‘GOALS OF CARE’ IN AN ACUTE HOSPITAL
Authors: Thomas R , Ashby M
Published: April 2013

Background

In March 2010 ‘Not For Resuscitation’ (NFR) forms in the Royal Hobart Hospital (RHH) were replaced with a ‘Goals of Care’ (GOC) form that documents limitation of medical treatment in three categories: curative, palliative and terminal.

Aim

To assess the uptake and completion of the GOC form within the hospital, in particular, the sections of the form that were most likely to be filled out and by whom.

Method

A ‘snapshot’ of all patients in the RHH on 6 September 2012 was obtained. 283 patient files were reviewed for a GOC form and the completed forms were evaluated. Any Advanced Care Planning (or similar) was noted and compared with the GOC form completed. The results were compared with a previous audit of the NFR form.

Results

Overall 52% of patients had a GOC form completed. Medical teams showed the greatest use of the GOC form with an uptake of 84%, compared with the NFR form at 34%. The documentation of the reason for limitation was completed in 27% of the cases.

Discussion

The GOC form has been well received within the hospital and is used more extensively than the previous ‘NFR’ form.

Conclusion

The GOC form provides a documentation point for the overall treatment goals for the patient and is widely used by medical teams. Further improvements can be made with simplification of the form and education of non-medical specialties. It provides a clear medical decision-making framework for the deteriorating patient who is approaching the end of life.
ETHICAL CHALLENGES IN PROVIDING EOLC IN THE ICU
Authors: Truog R
Published: April 2013

Background

Twenty per cent of Americans die using ICU services. Efforts to improve palliative care overall must therefore involve the ICU, yet the ICU presents many difficult ethical challenges not always found in other settings.

Aim

To review the ethical challenges of providing high quality palliative care in the ICU.

Methods

Clinical experience and review of the literature

Results

Three classical philosophical distinctions continue to resonate through end-of-life care in the ICU—the distinction between killing versus allowing-to-die, the distinction between withholding versus withdrawing treatments, and the distinction between hastening death as an intended versus merely foreseen side effect of administering analgesics and sedatives.

Discussion

Using cases from my experience and the literature, each of these distinctions will be explored in terms of modern ICU care. Specifically, I will discuss the role of non-invasive mechanical ventilation, along with the withdrawal of mechanical ventilation, cardiac pacemakers, tube feedings, and oral feedings. I will discuss various approaches to providing analgesia and sedation following the withdrawal of life support, including the use of unconventional agents (eg, propofol), unconventional doses, and the debate around the use of neuromuscular blocking agents in end of life care.

Conclusion

Classical philosophical dilemmas continue to generate ethical challenges to providing high quality end-of-life care in the ICU, and careful normative analysis can help to clarify the issues involved and guide practice.
FACILITATING ACCESS TO ACP AND AD EVIDENCE IN PALLIATIVE CARE
Authors: Tieman J , Rawlings D
Published: April 2013

Background

Advance care planning (ACP) and advance directives (AD) issues are significant for health professionals providing palliative care and those affected by the need for palliative care. For change to occur, existing and emerging evidence on ACP and AD needs to be accessible. While research-based evidence is being generated at ever faster rates, better infrastructure in the management of evidence-based knowledge is needed.

Aim

To facilitate access to evidence-based resources related to ACP and AD.

Methods

CareSearch is funded by the Department of Health and Ageing to provide evidence-based information for the palliative care community. Content is created within a knowledge translation framework. This includes identifying intended users, searching and appraising relevant literature and online resources, writing and peer review of web pages, development of evidence tools including PubMed searches, and identification of relevant materials for inclusion in the CareSearch bibliographic databases.

Results

Web metrics show the website's ACP and AD materials are being used with nearly 40 000 page views in 2012. Page views by type of resource were:

Clinical Practice Pages: 10 173

For Patients and Families: 9828

RAC/GP/Nurses Hub: 12 915

Finding Evidence: 5823

Discussion

Web-based resources can increase access and reach to the evidence base for ACP and AD. While access to evidence does not necessarily change practice, it is a necessary first step.

Conclusion

The CareSearch website promotes evidence-based practice by facilitating access to the underlying evidence. Specific ACP and AD evidence resources and easy to read and download consumer information are available at http://www.caresearch.com.au
DEVELOPING MEANINGFUL OUTCOME MEASURES FOR ADVANCE CARE PLANNING IN THE CONTEXT OF END STAGE RENAL DISEASE (ESRD): GOING BEYOND RANDOMISED CLINICAL TRIALS (RCTS)
Authors: Effiong A
Published: April 2013

Background

Despite the prevalence of aggressive end-of-life care for ESRD patients, there is paucity of data from RCTs of ACP interventions for ESRD patients. This is due in part to the dearth of RCTs utilising ACP as an outcome measure. Even when RCTs are used to assess ACP as an endpoint, results are often misleading, or too location-centric.

Methods

In an ongoing Cochrane Review, we attempt to elucidate primary and secondary outcomes of ACP for ESRD patients, by evaluating not only clinical outcomes, but also outcome measures that are relevant to patients, policy drivers, and the general populace. Because such objectives are difficult to evaluate with RCTs, the inclusion of observational studies is most meaningful. Therefore, a systematic review that will include non-RCTs as well as RCTs will be conducted. Contextual factors such as quality of life, social determinants of health, and cultural values, which influence prognoses will be examined. Specific domains will be applied to grade the strength of the evidence.

Results

Preliminary data extracted from these studies indicate that ACP is beneficial to the ESRD patient and may lower the likelihood of intractable conflicts between relevant parties. Furthermore, the inclusion of non-RCTs points to a more robust and logistically feasible analysis.

Discussion

This study will add to the evidence base and will highlight the importance of ACP in ESRD. It will also lay out the rationale for conducting systematic reviews of non-RCTs, in order to adequately capture the concerns of patients, their caregivers, policy makers, and gatekeepers.
FIFTY SHADES OF DYING: THE CHALLENGE OF ADVANCE CARE PLANNING ACROSS THE SPECTRUM OF DISEASE TRAJECTORIES IN ADVANCED HEART FAILURE
Authors: Beattie J M , Flynn T N , Davidson P M
Published: April 2013

Background

Chronic progressive heart failure due to left ventricular systolic dysfunction (LVSD) affects a burgeoning proportion of the multi-morbid ageing population. Those living and dying with LVSD decline along a roller coaster disease trajectory unique to each individual and prognostication is difficult. Patient preferences may be unexplored or undermined by widely espoused, guideline driven protocols, incorporating a technological imperative in the use of life-sustaining implantable electronic devices and cardiac surgical interventions.

Aim

To avoid possible barriers to patient choice along the dynamic course of LVSD and foster advance care planning (ACP) to better ensure patient-centred care at the end of life.

Methods

We shall describe factors potentially confounding patient choice across four domains—those linked to the disease, the patient, the clinician and to service provision. Overarching elements of risk include:

the individuality of each patient's clinical course

the intrinsic unpredictability of LVSD

a lack of acknowledgment of mortality risk by both patients and healthcare professionals.

the requirement for both active therapy and palliative care

recognition of transitions when goals of care require review

Discussion

A lack of appreciation of the significance of LVSD and overrated perceptions about treatment option benefits may influence patient choice. Inconsistent study results also refute the common assumption that LVSD patients would trade-off burdensome longevity for a shorter, better quality life. Patient education and the use of discrete choice modelling may provide objectivity, promote consensus development, and facilitate ACP with appropriate treatment decisions towards the end of life.
INTERPRETING NOT JUST THE WORDS BUT THE MEANING INTENDED IN END OF LIFE AND ORGAN DONATION DISCUSSIONS WITH CULTURALLY AND LINGUISTICALLY DIVERSE (CALD) FAMILIES
Authors: Dowling M
Published: April 2013

Background

In all end of life and organ donation family conversations specific training of medical and nursing staff is considered essential. Interpreters are asked to deliver the healthcare professional's very challenging and often emotive discussions to grieving families without any specific training, or even awareness of the orientation of these conversations.

Aim

Interpreters involved in end of life and organ donation situations need to feel supported in their role, to be familiar with the terms and concepts associated with end of life and organ donation, to have some understanding of the organ donation process and to have considered their own attitudes to, and assumptions about end of life and organ donation.

Methods

This DVD highlights the multiple conversations on end of life and organ donation that occur in the emergency department and in the intensive care unit (breaking bad news to families, futility of treatment and withdrawal of care, the very personal lifestyle questionnaire, the organ donation consent process). A number of CALD actors portray families participating in these conversations.

Results

Segments of difficult and sensitive conversations are highlighted eliciting a range of family responses. Experienced interpreters provide tips on the successful and effective utilisation of the interpreter when conducting face to face conversations and conversations through the Skype medium.

Discussion

Information on end of life and organ donation processes is provided in a logical and contextual format

Conclusion

This DVD is a suitable educational tool for all people involved in end of life and organ donation situations—interpreters, pastoral care services, social work, nursing and medical staff.
HOW CAN WE DELIVER GOOD PALLIATIVE CARE EFFICIENTLY?
Authors: Yates Prof Patsy
Published: April 2013

The changing patterns of disease and growth in demand for palliative care services will necessitate new approaches to service provision at end of life. As demand and expectations for good palliative care increases, resources will need to be allocated efficiently while maintaining high-quality and effective outcomes. To achieve this, reforms will be needed at multiple levels. Service delivery models and interventions will be needed that ensure end of life services are organised and supplied based on population need rather than local interest. Robust methods for measuring consumer and carer experience and outcomes of end of life care will also be required to enable tracking of performance over time to inform local and national improvements. Such reforms will depend on sustained efforts to build and enhance the capacity of all relevant sectors in health and human services to provide quality palliative care, as well as efforts to develop the community’s capacity to participate effectively in decisions about end of life care.
ADVANCE CARE PLANNING, A STEP-BY-STEP GUIDE FOR HEALTH CARE PROFESSIONALS ASSISTING PATIENTS WITH CHRONIC CONDITIONS TO PLAN FOR CARE TOWARDS END OF LIFE
Authors: Greeve K , Bloomer S , Chellew-Hawley M , Clarnette R , Fortnum D , Garton-Smith J , Harney M , Ibrahim J , Kendall P , Koay A , Moody H , Porter S , Scarff Z , Trevaskis G , Yuen K , Walker H
Published: April 2013

Background

Advance Care Planning encourages people to think about, and discuss their preferred about future health care. Many patients rely on their health professionals to initiate ACP discussions, however most health professionals lack the skills required for such discussions.

Aim

To improve uptake of ACP amongst healthcare professionals in WA Health.

Methods

An ACP Chronic Disease Reference Group was established to provide leadership of the project. Interviews were conducted with reference group members to identify the barriers to ACP and identify patient groups who would benefit. A literature search was undertaken to identify prognostic indicators and issues relevant to target patient groups. These outputs were assessed against a multidisciplinary panel of stakeholders and the ACP reference group.

Results

Chronic heart failure, chronic lung disease, renal disease and neurodegenerative conditions were identified as priorities for additional ACP resources. Specific and general prognostic indicators were identified which could act as triggers for initiating ACP conversations. Medical and lifestyle considerations relevant to specific conditions were identified and discussion prompts provided. Finally, guidance regarding documentation and dissemination of the outputs of these discussions was considered.

Discussion

A guide on its own as a resource will not drive a culture change within health. A model of ACP, consistent with national and international literature, and acknowledging the barriers to ACP is required.

Conclusion

To address issues in communication and education, an ACP model which assists in the identification of patients who may benefit from ACP and issues relevant to those with chronic diseases has been developed.
ESTIMATING THE IMPACT OF ADVANCE CARE PLANNING ON HOSPITAL ADMISSIONS, OCCUPIED BED DAYS, AND ACUTE CARE SAVINGS
Authors: Hunt R W , Jones L , Owen L , Seal M
Published: April 2013

Background

Apart from the ethical imperatives and improved client outcomes in support of advance care planning, a compelling argument for health care administrators is the containment of escalating health care costs in ageing communities. Advance care planning activity has repeatedly been shown to reduce hospital admissions.1–3In particular, care toward the end of life is expensive, and advance care planning reduces the use of invasive and expensive hospital treatments during terminal illness.

Aim

To estimate the impact of advance care planning activity on the number of hospital admissions, occupied bed days, and hospital costs in Adelaide, South Australia.

Methods

We apply the results of previous research on the impact of advance care planning,1–3to the number of advance care plans made following implementation of the Respecting Patient Choices (RPC) Program in community and hospital settings in Adelaide, to estimate the number of saved hospital admissions, occupied bed days, and costs.

Results

Data records began in 2005 during The Queen Elizabeth Hospital RPC pilot. Data collection from community settings began in 2008, and then from other public hospitals in the Central and Northern Adelaide metropolitan area from 2010. A total of 2604 advance care plans were made and the estimated Occupied Bed Days saved was 23 957. The number of admissions to hospitals from the 42 Nursing Homes engaged in advance care planning was estimated to be reduced by 840 over the last 2–3 years.

Discussion

Several assumptions are used in applying previous research to calculate the estimated hospital savings. The estimates suggest significant savings, which should be of interest to health administrators. Costs and savings will be detailed in the presentation. Further investment and evaluation of the impact of advance care planning is clearly warranted.

Conclusion

A relative small investment in advance care planning has the potential to reap considerable savings in hospital use, particularly at the end of life.
SUCCESS IN ADVANCE CARE PLANNING: THE CHANGING GOAL POST?
Authors: Knight K
Published: April 2013

Background

Since its inception advance care planning (ACP) has generated passionate advocates and severe critics. In 2004 a Hastings Center Report publication claimed that the living will has failed, yet we gather at the 4th international conference of ACP suggesting that the idea is thriving. How can such adverse positions coexist?

Aim

This paper aims to clarify ideas of success in ACP in order to make sense of the disagreements.

Method

Literature review and critical reflection

Results

ACP is promoted in pursuit of a combination of utilitarian, libertarian and/or compassionate aims and notions of ACP success vary considerably. In the empirical literature success either refers to successful programme implementation, the achievement of an ideological good for a patient or both. A historical evolution of types of success criteria is evident and ambitions as to what constitute adequate markers of success are diverse.

Discussion

As a complex multidisciplinary field ACP provides a fertile ground for partial successes and failures. A particular problem is that addressing shortcomings in one area can often only be achieved by reducing ambitions in others, leading to a dynamic shifting of ACP goals. Criticisms from one discipline are evaded through discipline specific research design or via different discipline specific goals and ambitions.

Conclusion

Whether ACP is seen as successful depends on how many and which goals ACP is meant to address at once. Although modern ACP has made many practical advances, it has done so at significant cost elsewhere and certain criticisms remain relevant.
COMMUNICATING MY VALUES, MY WISHES: ADVANCE CARE PLANNING IN COMMUNITY PALLIATIVE CARE
Authors: Tatlow K
Published: April 2013

Background and Aim

All people have the right to receive high-quality care; to be offered Advance Care Planning (ACP) opportunities and to have a dignified death in line with their spiritual and psychosocial wishes.

With the recent dissemination of the National Framework for Advance Care Directives, it was timely that Eastern Palliative Care Association Incorporated (EPC) strengthen its ACP approach and develop a clearer process for it within its service.

Method

A reference group was conducted that emphasised the need to produce something relevant to the needs of community palliative care clients. Staff expressed the desire for a ‘kit’ of resources that could be utilised according to client need.

Following extensive research and consultation with other services, a Resource Kit was designed.

Results

The Kit contains a staff guide; information brochure; conversation tools; legal forms and Statement of Wishes form.

The conversation tools include the Coda Alliance ‘GoWish cards’ and EPC's ‘My Values, My Wishes prompt booklet’. These tools can be a less intrusive way of facilitating sensitive conversations.

The Statement of Wishes form was designed to ensure clients' psychosocial and spiritual needs are included at the onset.

Discussion and Conclusion

EPC's ACP Resource Kit is a unique and innovative step forward in facilitating ACP with palliative clients, by incorporating aspects of care that are most important to them. A recent staff evaluation after 6 months in use, indicated that the kit ‘opened doors’ in assisting client's to reflect on and communicate things that they previously were unable to do.
ADVANCE CARE PLANNING FOR PATIENTS WITH HEART FAILURE IN A MULTIETHNIC SOUTH EAST ASIAN COHORT
Authors: Sim D K L , Tan S H , Tan B C , Neo C L , Wong G
Published: April 2013

Background

Limited data in our multi-ethnic South East Asian society on the feasibility of advance care planning (ACP) where different cultures have disparate beliefs with regards to death.

Aim

A pilot study for the feasibility of basic ACP for patients with mild heart failure.

Methods

Patients were recruited from a heart failure clinic over a 4 month period if they are in New York Heart Association class I/II with no readmission in preceding 6 months.

Results

Of 58 patients, 83% had formal ACP while 17% declined to participate. Mean age was 57 years with predominance of male (72%). Ethnic distribution followed the national demographic (84% Chinese, 9% Indian, 7% Malay). The participation rate among the different ethnic groups were 86% for Chinese, 100% for Indians and 25% for Malay. For the participants, 90% had more than one ACP session with a mean duration of 60 min per session, and 17% had completed the ACP forms upon enrolment of the last patient. Significant challenges faced were low awareness of ACP among patients and caregivers as well as need for coordination across multiple disciplines.

Discussion

There is a high acceptance of ACP among patients with mild heart failure. But there is a disparity in the attitudes of different ethnic groups towards ACP where Malay are less willing to discuss it compared to Chinese and Indian.

Conclusion

Our study highlights the feasibility of implementing ACP in South East Asian patients with heart failure, and the need for further research on the observed impact of ethnicity.
IMPLEMENTATION OF THE LIVERPOOL CARE PATHWAY IN THE ACUTE SETTING IMPROVED END OF LIFE CARE
Authors: Fullerton S , Bhagat Sandeep
Published: April 2013

Background

The care of dying patients and families represents an important aspect of health service provision. 1500 patients a year die in Eastern Health beds, only 40% of whom are seen by the hospital based palliative care consultation team (HBPCCT). There is room to improve the quality of care offered to dying patients and families outside a specialist palliative care setting.

The Liverpool Care Pathway (LCP) is an integrated, evidence-based, multidisciplinary document representing the ‘Gold Standard’ in quality end-of-life-care provision.

Aim

To implement and evaluate the LCP in acute wards in EH.

Methods

Wards with the highest numbers of deaths were identified.

After consultation, the LCP was implemented.

Surveys of staff were carried out before and after implementation.

Results

More than 200 patients and families have been cared for on the LCP. Some patients were discharged back to residential care and some to palliative care beds.

Only 9% of the 88 surveyed staff who had used the LCP felt that it had not helped improve the care of dying patients and families in EH, and 6% of staff felt that the LCP had not helped staff in caring for dying patients.

Conclusions

Staff feel that the introduction of the LCP improved end of life care at EH.

Use of LCP did not prevent transfer from acute beds to specialist palliative care beds.
TBC
Authors: Clifton Di
Published: April 2013

No abstract
NORMALISING ACP IN THE COMMUNITY
Authors: Hammes B , Briggs Linda A
Published: April 2013

Background

Advance care planning is the process of coming to a greater understanding of future medical decisions; personally reflecting on those decisions; discussing the options and plans with others who are close; and creating a clear plan of action. This is a process that needs to be part not only of the health care system, but also of the community life.

Aim

To explore the way that the process of advance care planning can become part of family and community life.

Discussion

While advance care planning is often focused on medical treatment decisions, for example, resuscitation, in reality such planning is more about values and goals of individuals. As such, it has as much to do with fundamental beliefs, obligations; relationships; and values as it does about information regarding a treatment. It is coming to a fuller and timely understanding of these aspects of an individual's life that the goals of medical care and the treatment decisions get shaped. In this regard advance care planning is a human activity that involves relationships and activities like religion and culture. Such conversations belong as much in the community as they do in the hospital. This broader approach, however, is not well understood by the larger community nor is it fully trusted. To have a highly successful advance care planning approach requires the engagement of a wide variety of organisations and institutions from the community. This presentation will explore effective methods of such engagement and consider how it improves outcomes.
Comparison of chest compressions in the standing position beside a bed at knee level and the kneeling position: a non-randomised, single-blind, cross-over trial
Authors: Oh Je Hyeok , Kim Chan Woong , Kim Sung Eun , Lee Sang Jin , Lee Dong Hoon
Published: April 2013

Background

When rescuers perform cardiopulmonary resuscitation (CPR) from a standing position, the height at which chest compressions are carried out is raised.

Objective

To determine whether chest compressions delivered on a bed adjusted to rescuer's knee height are as effective as those delivered on the floor.

Materials and methods

A total of 20 fourth-year medical students participated in the study. The students performed chest compressions for 2 min each on a manikin lying on the floor (test 1) and on a manikin lying on a bed (test 2). The average compression rate (ACR) and the average compression depth (ACD) were compared between the two tests.

Results

The ACR was not significantly different between tests 1 and 2 (120.1 to 132.9  vs 115.7 to 131.2 numbers/min, 95% CI, p=0.324). The ACD was also not significantly different between tests 1 and 2 (51.2 to 56.6 vs 49.4 to 55.7 mm, 95% CI, p=0.058).

Conclusions

The results suggest that there may be no significant differences in compression rate and depth between CPR performed on manikins placed on the floor and those placed at a rescuer's knee height.
Four-wheeled walker related injuries in older adults in the Netherlands
Authors: van Riel K M M , Hartholt K A , Panneman M J M , Patka P , van Beeck E F , van der Cammen T J M
Published: April 2013

Background

With ageing populations worldwide, mobility devices are used more than ever. In the current literature there is no consensus whether the available mobility devices safely improve the mobility of their users. Also, evidence is lacking concerning the risks and types of injuries sustained while using a four-wheeled walker.

Objective

To assess injury risks and injury patterns in older adults (≥65 years) who presented at Emergency Departments (ED) in the Netherlands with an injury due to using a four-wheeled walker.

Design and setting

In this study, the Dutch Injury Surveillance System was used to obtain a national representative sample of annual ED visits in the Netherlands in the adult population (≥65 years) sustaining an injury while using a four-wheeled walker. The numbers of four-wheeled walker users in the Netherlands were obtained from the national insurance board. The numbers of ED visits were divided by the numbers of four-wheeled walker users to calculate age- and sex-specific injury risks.

Results

Annually 1869 older adults visited an ED after sustaining an injury while using a four-wheeled walker. Falls were the main cause of injury (96%). The injury risk was 3.1 per 100 users of four-wheeled walkers. Women (3.5 per 100 users) had a higher risk than men (2.0 per 100 users). Injury risk was the highest in women aged 85 years and older (6.2 per 100 users). The majority of injuries were fractures (60%) with hip fracture (25%) being the most common injury. Nearly half of all four-wheeled walker related injuries required hospitalisation, mostly due to hip fractures. Healthcare costs per injury were approximately €12 000.

Conclusions

This study presents evidence that older adults experiencing a fall while using a four-wheeled walker are at high risk to suffer severe injuries.
MULTI-OPTIONS BIDDING STRATEGY IN DISTRIBUTED ENVIRONMENT
Authors: LING LIUYI , YANG ZHENG , PU XUJIN , QIN JIN , DU SHAOFU
Published: April 2013

When a Make-To-Order (MTO) enterprise receives a bidding invitation from a customer, he does not know the demand is price-sensitive or time-sensitive. In order to increase the possibility of winning this contingent order, the enterprise tenders his bid with two options characterized with price and delivery time. One is for time-sensitive demand, and it ensures that the products will be delivered as soon as possible. The other is for price-sensitive demand, and it ensures that the products will be produced at the lowest cost. The enterprise is comprised of several plants that jointly produce custom products and each plant's decision is made in a distributed way. Hence, the enterprise has to coordinate the production plans of these plants to generate the two options. Since Analytical Target Cascading (ATC) can solve multi-level hierarchical distributed problem and its convergence is proven, it is adopted to coordinate the plants' planning. This paper proposes a unique bidding option generating process in which an extended ATC model is utilized to produce time-sensitive and price-sensitive options by adjusting the coefficient of delivery tardiness. The numerical study in this paper demonstrates (1) the extended ATC model works effectively; (2) ATC with augmented Lagrangian relaxation (AL-ATC) is more effective in producing solutions than ATC with quadratic penalty function (QP-ATC); (3) ATC is an effective coordination tool by comparing the solutions made by ATC and All-In-One (AIO).
Cerebellar motor learning: are environment dynamics more important than error size?
Authors: Gibo Tricia L. , Criscimagna-Hemminger Sarah E. , Okamura Allison M. , Bastian Amy J.
Published: April 2013

Cerebellar damage impairs the control of complex dynamics during reaching movements. It also impairs learning of predictable dynamic perturbations through an error-based process. Prior work suggests that there are distinct neural mechanisms involved in error-based learning that depend on the size of error experienced. This is based, in part, on the observation that people with cerebellar degeneration may have an intact ability to learn from small errors. Here we studied the relative effect of specific dynamic perturbations and error size on motor learning of a reaching movement in patients with cerebellar damage. We also studied generalization of learning within different coordinate systems (hand vs. joint space). Contrary to our expectation, we found that error size did not alter cerebellar patients' ability to learn the force field. Instead, the direction of the force field affected patients' ability to learn, regardless of whether the force perturbations were introduced gradually (small error) or abruptly (large error). Patients performed best in fields that helped them compensate for movement dynamics associated with reaching. However, they showed much more limited generalization patterns than control subjects, indicating that patients rely on a different learning mechanism. We suggest that patients typically use a compensatory strategy to counteract movement dynamics. They may learn to relax this compensatory strategy when the external perturbation is favorable to counteracting their movement dynamics, and improve reaching performance. Altogether, these findings show that dynamics affect learning in cerebellar patients more than error size.
Inhibition to retinal rod bipolar cells is regulated by light levels
Authors: Eggers Erika D. , Mazade Reece E. , Klein Justin S.
Published: April 2013

The retina responds to a wide range of light stimuli by adaptation of retinal signaling to background light intensity and the use of two different photoreceptors: rods that sense dim light and cones that sense bright light. Rods signal to rod bipolar cells that receive significant inhibition from amacrine cells in the dark, especially from a rod bipolar cell-activated GABAergic amacrine cell. This inhibition modulates the output of rod bipolar cells onto downstream neurons. However, it was not clear how the inhibition of rod bipolar cells changes when rod signaling is limited by an adapting background light and cone signaling becomes dominant. We found that both light-evoked and spontaneous rod bipolar cell inhibition significantly decrease with light adaptation. This suggests a global decrease in the activity of amacrine cells that provide input to rod bipolar cells with light adaptation. However, inhibition to rod bipolar cells is also limited by GABAergic connections between amacrine cells, which decrease GABAergic input to rod bipolar cells. When we removed this serial inhibition, the light-evoked inhibition to rod bipolar cells remained after light adaptation. These results suggest that decreased inhibition to rod bipolar cells after light adaptation is due to decreased rod pathway activity as well as an active increase in inhibition between amacrine cells. Together these serve to limit rod bipolar cell inhibition after light adaptation, when the rod pathway is inactive and modulation of the signal is not required. This suggests an efficiency mechanism in the retina to limit unnecessary signaling.
Left Ventricular Flow Analysis: Recent Advances in Numerical Methods and Applications in Cardiac Ultrasound
Authors: Borazjani Iman , Westerdale John , McMahon Eileen M. , Rajaraman Prathish K. , Heys Jeffrey J. , Belohlavek Marek
Published: April 2013

The left ventricle (LV) pumps oxygenated blood from the lungs to the rest of the body through systemic circulation. The efficiency of such a pumping function is dependent on blood flow within the LV chamber. It is therefore crucial to accurately characterize LV hemodynamics. Improved understanding of LV hemodynamics is expected to provide important clinical diagnostic and prognostic information. We review the recent advances in numerical and experimental methods for characterizing LV flows and focus on analysis of intraventricular flow fields by echocardiographic particle image velocimetry (echo-PIV), due to its potential for broad and practical utility. Future research directions to advance patient-specific LV simulations include development of methods capable of resolving heart valves, higher temporal resolution, automated generation of three-dimensional (3D) geometry, and incorporating actual flow measurements into the numerical solution of the 3D cardiovascular fluid dynamics.
Trichorhinophalangeal Syndrome Type I: A Patient with Two Novel and Different Mutations in the TRPS1 Gene
Authors: Dias Catarina , Isidoro Lara , Santos Mafalda , Santos Helena , Marques Jorge Sales
Published: April 2013

Background. Trichorhinophalangeal syndrome (TRPS) is an autosomal dominant skeletal dysplasia caused by defects involving the TRPS1 gene. Three types (TRPSs I, II, and III) have been described, exhibiting the common triad of hair, craniofacial, and skeletal abnormalities. TRPS II includes the additional characteristics of mental retardation and multiple exostoses.Case Report. We describe a sporadic case of TRPS type I in a child with two novel nonsense pathogenic mutations in the TRPS1 gene, both in heterozygosity—c.1198C>T (p. Gln400X) and c.2086C>T (p.Arg696X). None of these mutations were found in her parents. Clinical presentation included typical hair and facial features, as well as slight skeletal abnormalities.Discussion. There is a wide variability in clinical expression of TRPS I. Manifestations of the disease can be subtle, yet skeletal anomalies imply that TRPS I is more than an esthetic problem. Clinical and genetic diagnosis allows adequate followup and timely therapeutic procedures. When a single mutation was sufficient for the onset of the disease, our patient presented two different ones.
Comparison of INNO-LIPA and TRUGENE Assays for Genotyping and Drug-Resistance Mutations in Chronic Hepatitis B Virus Infection
Authors: Basaras Miren , Arrese Elisabete , Blanco Sonia , Arroyo L. Sara , Ruiz Pablo , Cisterna Ramón
Published: April 2013

Objective: Hepatitis B virus (HBV) genotyping and detection of resistance to drugs have become essential in epidemiological and clinical diagnosis. Our main objective was to determine the prevalence of HBV genotypes and drug-resistance mutations in chronic asymptomatic carriers and chronic HBV sufferers comparing 2 detection assays. Methods: Serum samples from 28 chronic HBV patients and 22 chronic asymptomatic carriers were analyzed. For HBV genotyping, the INNO-LIPA and TRUGENE™ HBV genotyping kits were evaluated. For drug-resistance mutations, INNO-LIPA DR v2 and INNO-LIPA DR v3 prototype and the TRUGENE™ HBV genotyping kit were evaluated. Results: In HBV genotyping, concordant results were 98% and both assays were able to detect more than one genotype. Different genotypes were detected, the most prevalent being D (46%) and A (26%). In relation to drug-resistance mutations, the sensitivity of the line probe assay was lower than TRUGENE because INNO-LIPA could not detect two mutations (S202G and V214A). Conclusions: Both assays are easy and suitable for detecting HBV genotype and drug-resistance mutations and for routine laboratory use. However, TRUGENE presented better sensitivity in both analyses and it is possible to conduct both on the same sample. This assay is also able to detect primary and secondary mutations.
Association between Water Intake, Chronic Kidney Disease, and Cardiovascular Disease: A Cross-Sectional Analysis of NHANES Data
Authors: Sontrop Jessica M. , Dixon Stephanie N. , Garg Amit X. , Buendia-Jimenez Inmaculada , Dohein Oriane , Huang Shih-Han S. , Clark William F.
Published: April 2013

Background: Evidence from animal and human studies suggests a protective effect of higher water intake on kidney function and cardiovascular disease (CVD). Here the associations between water intake, chronic kidney disease (CKD) and CVD were examined in the general population. Methods: We conducted a cross-sectional analysis of the 2005-2006 National Health and Nutrition Examination Survey. Non-pregnant adults with an estimated glomerular filtration rate (eGFR) ≥30 ml/min/1.73 m2 who were not taking diuretics were included. Total water intake from foods and beverages was categorized as low (<2.0 l/day), moderate (2.0-4.3 l/day) and high (>4.3 l/day). We examined associations between low total water intake and CKD (eGFR 30-60 ml/min/1.73 m2) and self-reported CVD. Results: Of 3,427 adults (mean age 46 (range 20-84); mean eGFR 95 ml/min/1.73 m2 (range 30-161)), 13% had CKD and 18% had CVD. CKD was higher among those with the lowest (<2.0 l/day) vs. highest total water intake (>4.3 l/day) (adjusted odds ratio (OR) 2.52; 95% confidence interval (CI) 0.91-6.96). When stratified by intake of (1) plain water and (2) other beverages, CKD was associated with low intake of plain water: adjusted OR 2.36 (95% CI 1.10-5.06), but not other beverages: adjusted OR 0.87 (95% CI 0.30-2.50). There was no association between low water intake and CVD (adjusted OR 0.76; 95% CI 0.37-1.59). Conclusions: Our results provide additional evidence suggesting a potentially protective effect of higher total water intake, particularly plain water, on the kidney.
Yankee Ingenuity in the South: James Burton and Confederate Ordnance Production
Authors: Collins Steven G.
Published: April 2013

This article examines the role of James Burton in the diffusion of military technology in the mid-19th century. Burton worked as the Master Armorer at the Harpers Ferry Armory, as a contractor in the Connecticut Valley, and as an engineer at the Enfield Armory. At each location he incorporated the latest ideas of the American System of Manufacturing. Not only did he transmit new ideas, he visited, studied, and learned from his international peers. When the American Civil War began, he joined the Confederate Ordnance Department and helped the South continue a long and destructive war. The new technological ideas—bred out of necessity of war—continued to help shape the creation of a New South. After the war, Burton influenced weapons manufacturing in Russia, Italy, Turkey, and Egypt. The ideas that Burton helped implement is a case study of international technological diffusion.
Transcriptional basis of the acclimation to high environmental temperature at the olfactory receptor organs of Drosophila melanogaster
Authors: Riveron Jacob , Boto Tamara , Alcorta Esther
Published: April 2013

Background

Environmental temperature directly affects the concentrations of chemicals in the gas phase. Therefore, if the olfactory system does not physiologically adapt to environmental conditions, it may provide inadequate information about the distance to or direction of odor sources. Previous reports have shown at the behavioral level that temperature induces changes in olfactory sensitivity inDrosophila melanogaster. These changes are initiated in the main olfactory receptor organs, the antennae. In this work, we attempted to identify the particular genes responsible for olfactory adaptation to increasing temperatures in these organs based on current knowledge of the molecular basis of olfactory reception.

Results

Whole-genome transcriptional responses to transitory temperature shifts from 21-30°C were analyzed in the third antennal segments ofDrosophila. More than 53% of the genome was expressed in these organs; this percentage increased slightly (55%) after heat treatment. However, the expression levels increased for 26%, decreased for 21% and remained constant for 53% of the expressed genes. Analysis of the changes produced in 389 genes related to heat response and olfactory reception, according to the current functional annotations of theDrosophilagene set, showed significant differences in 95 of these genes, which are involved in the heat response (23), perireceptor events in olfaction (50), olfactory and gustatory receptors (18) and G-proteins and transduction cascades (4).

Conclusions

Gene expression was altered in response to environmental heat in the antennae ofDrosophilaby increasing or decreasing expression. Different acclimation patterns emerged for reception through the basiconic, trichoid and coeloconic sensilla. Changes in genes with a central role in olfactory reception, such asorco, may account for part of the acclimation reported at the behavioral level.
Screening cluster A and cluster B personality disorders in Chinese high school students
Authors: Wang Yuping , Zhu Xiongzhao , Cai Lin , Wang Qin , Wang Mengcheng , Yi Jinyao , Yao Shuqiao
Published: April 2013

Background

Personality disorders (PDs) during adolescence may, in addition to increasing risk for violent behaviors and suicide, also increase risk for elevated PD traits in adulthood. The aim of this study was to explore the prevalence of Cluster A and Cluster B PD traits and their relationships to demographic variables in Chinese high school students.

Methods

A cohort of 3,552 students from eight high schools completed the Personality Diagnostic Questionnaire-4+ (PDQ-4+) and MacArthur Scale of Subjective Social Status-youth version (SSSy) questionnaires.

Results

Boys scored higher than girls on the paranoid, schizotypal, antisocial, and narcissistic PDs. Freshmen and sophomores scored higher than juniors on schizoid, borderline, and antisocial PDs. Children in single-child families scored higher than nonsingletons on the paranoid and antisocial PDs. Students from single-parent households scored higher than students from double-parent households on the schizotypal and antisocial PDs, and students with remarried parents scored higher than students from double-parent households on the borderline and antisocial PDs. Students who had low perception of social status in the society ladder scored higher than those with a high perceived status on the schizoid and borderline PDs, but scored lower on the histrionic PD; students with a low subjective social status in the school community ladder scored higher scores than those with a high perceived status on the paranoid, schizoid, borderline, and antisocial PDs, but scored lower on the histrionic PD.

Conclusions

Gender, grade, family structure, and subjective social status may affect the development of PDs. Longitudinal studies and studies of the full scope of PDs are needed to fully elucidate the impact of demographic variables on PD prevalence rates in adolescence and adulthood.
Safety and efficacy of duloxetine treatment in older and younger patients with osteoarthritis knee pain: a post hoc, subgroup analysis of two randomized, placebo-controlled trials
Authors: Micca Joseph L , Ruff Dustin , Ahl Jonna , Wohlreich Madelaine M
Published: April 2013

Background

Osteoarthritis (OA) knee pain is common in older patients and contributes to decreased quality of life. Older patients are generally at higher risk of adverse drug reactions due to age-related changes in physiology that affect drug disposition, metabolism, and response. These analyses examined efficacy and safety outcomes of older (≥65 years) versus younger patients from clinical trials of duloxetine in the management of OA knee pain.

Methods

This is a post hoc analysis of two 13-week studies, in which patients were randomized to duloxetine 60 mg/day or placebo. Both studies allowed potential dose changes after 7 weeks of dosing, with Study I re-randomizing duloxetine treated patients to either stay on 60 mg/day or increase to 120 mg/day; while Study II more closely mimicked clinical practice by escalating only non-responding patients to 120 mg/day. For all analyses patients were subgrouped by age: older (≥65 years) and younger (40–64 years). Overall efficacy and safety age-group comparisons of duloxetine versus placebo were performed using pooled data from both studies with all duloxetine dose levels combined. Safety analyses included discontinuation rates, treatment-emergent adverse events, and serious adverse events. To evaluate the effects of increasing the dose in non-responding patients, only Study II data were evaluated. Treatment arms were defined post hoc as placebo, duloxetine 60 mg/day, and duloxetine 60/120 mg/day.

Results

At study end, patients in each age group who were treated with duloxetine versus placebo had significantly greater improvement in pain (both, p<.05), and there was no significant effect of age on treatment (p=.72). Increasing the dose to 120 mg in non-responding patients was not found to have a significant advantage. Among treatment-emergent adverse events with duloxetine treatment, only dizziness had a significantly differential treatment effect (p=.02) with greater incidence over placebo in younger patients (6.6% versus 0.6%, p=.02), but not in older patients (1.0% versus 3.2%, p=.29).

Conclusions

Duloxetine was efficacious and generally well tolerated for management of symptomatic knee OA in both older and younger patients, but increasing the dose to 120 mg in non-responding patients did not provide additional benefit.