Electronic communication between providers of primary and secondary care.

OBJECTIVE--To study the effects of the introduction of electronic data interchange between primary and secondary care providers on speed of communication, efficiency of data handling, and satisfaction of general practitioners with communication. DESIGN--Comparison of traditional paper based communication for laboratory reports and admission-discharge reports between hospital and general practitioners and electronic data interchange. SETTING--Twenty-seven general practitioners whose offices were equipped with a practice information system and two general hospitals. OUTCOME MEASURES--Paper based communication was evaluated by questionnaire responses from and interviews with care providers; electronic communication was evaluated by measuring time intervals between generation and delivery of messages and by assessing doctors'' satisfaction with electronic data interchange by questionnaire. RESULTS--Via paper mail admission-discharge reports took a median of 2-4 days, and laboratory reports 2 days, to reach general practitioners. With electronic data interchange almost all admission-discharge reports were available to general practitioners within one hour of generation. When samples were analysed on the day of collection (as was the case for 174/542 samples in one hospital and 443/854 in the other) the laboratory reports were also available to the general practitioner the same day via electronic data interchange. Fifteen general practitioners (of the 24 who returned the questionnaire) reported that the use of electronic admission-discharge reports provided more accurate and complete information about the care delivered to their patients. Ten general practitioners reported that electronic laboratory reports lessened the work of processing the data. CONCLUSION--Electronic communication between primary and secondary care providers is a feasible option for improving communication.     

Methods for a public health response to birth defects clusters

Few resources are available to guide public health officials in investigations of reported birth defects clusters. The majority of published resources focus on the investigation of cancer and infectious disease clusters and do not address clinical and epidemiologic concerns specific to birth defects research. This document aims to address these concerns, discuss the needs of the affected community, and provide suggestions for the development of a standardized protocol to be used as a guide in the investigation of birth defects clusters. We suggest that health departments and birth defects registries that may receive reports of birth defects clusters establish a protocol for responding that includes the following steps: develop a proactive plan for future birth defects cluster reports (step I), receive report of a birth defects cluster (step II), verify diagnoses and complete case ascertainment (step III), compare the observed rate to a reference rate (step IV), ascertain exposures among cases from available records (step V), interview case mothers (step VI), initiate further epidemiologic study-selection of controls (step VII), and communicate results to the community (step VIII). Specific criteria for continuing or terminating an investigation should be established before receiving cluster reports. The recommendations in this report should be carefully considered to ensure that the specific needs of the region, agency and affected community are met.     

Recommendations for lipid testing and reporting by Australian pathology laboratories

The importance of measuring blood lipids in determining the absolute risk of a cardiovascular event is now well established. In Australia, the National Heart Foundation of Australia and the Cardiac Society of Asutralia and New Zealand (NHFA/CSANZ) have done much to educate doctors. In recent years the recommendations of the NHFA/CSANZ have been based on values for Low-density lipoprotein (LDL-C) as well as High-density lipoprotein cholesterol (HDL-C) and Triglyceride (TG). This change has been reflected in requests to pathology laboratories. However the interpretation of these results may be difficult and the NHFA guidelines outline desirable values for patients at high risk only. There are no formal recommendations for reference intervals or interpretive comments. With the availability of expert systems, some pathology laboratories are now in a better position to provide specific comments to assist with the interpretation of test results.An ad hoc committee of private and public chemical pathologists met to draft recommendations for lipid testing and reporting by Australian pathology providers, on the basis of current guidelines and their own expertise. Provisions in the current Medicare Benefits Schedule (MBS) for lipid testing were reviewed, and the indications for lipid testing, recommended tests, the logistics of managing specimens, methods of analysis and availability of specialised tests have been documented. Recommendations are made on the provision of desirable values for lipid tests. Suggestions are provided on interpretive comments which could accompany reports of lipid test results, including categorisation of the likely associated lipoprotein abnormalities, their causes, contribution to risk for cardiovascular disease (CVD) and targets for treatment. Current and future approaches to the assessment of risk for CVD are discussed.     

Does medio-lateral motion occur in the normal knee? An in-vitro study in passive motion

Medio-lateral translation during knee flexion continues to raise controversy. Small population sizes, small joint flexion ranges, less-reliable measurement techniques and disparate experimental conditions led to inconsistent reports in the past. To study this subject with more accurate and reliable measurements, we carried out femur and tibia tracking in 22 intact cadaver knees during passive joint motion using a state-of-the-art surgical navigation system. Trackers with active light-emitting diodes were fixed onto the femur and tibia, and an instrumented pointer was used to digitize a number of anatomical landmarks. International recommendations were adopted for anatomical-based reference frame definitions and joint kinematic analysis. For the first time, knee joint translations were reported in both the femoral and tibial reference frames, and over a flexion/extension arc as large as 140°. During flexion, in the femoral reference frame, the center of the tibial plateau moved 4.8 ± 2.8mm medially when averaged over the specimens. In the tibial frame, the knee center moved 13.3 ± 5.7 mm laterally. The relative femoral-to-tibial medio-lateral translation was, on average over the specimens, nearly 20% of the width of the tibial plateau, and can be as large as 35%. Medio-lateral translation occurs in the natural normal knee joint.     

Personal computer-based visualization of molecular models by available ray-tracing software

Developed primarily for the graphic arts, ray-tracing algorithms offer a high level of flexibility with reference to photorealistic and surrealistic image rendering. The utility of these programs is further enhanced by portability (i.e., compatibility with a number of operating systems), accessibility through various sources, and low cost. This report documents, through the use of existing software, the application of these ray-tracing attributes to molecular graphics on a desktop computer. This application is especially pertinent in view of rapid speed enhancements in personal computers (PCs), which have enabled molecular modeling and dynamics on these systems. In this regard, ray tracing on a PC provides enhanced capabilities for molecular graphics rendering that are potentially equivalent to those achieved by workstations.     

Caregiving as a Cultural System: Conceptions of Filial Obligation and Parental Dependency in Urban America

Verbal reports were elicited from 70 caregivers rendering care to impaired parents. Despite great empirical variety in the caregiving context, caregivers showed a striking commonality of interpretation with respect to attitudes about parental dependency and the obligation to care for a parent. In fact, ideas about dependency and obligation covary in predictable ways. Content analysis of the verbal reports and additional ethnographic data show that the association of these two sets of ideas represents shared knowledge in a culture of caregiving. Ideas about dependency and obligation "go together," even for caregivers whose situations vary radically. While a minority of caregivers deviate from this consensus, they do not represent an alternative culture, but rather cases where the history of parent-child relations leads them to interpret dependency and obligation more variably.     

2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients: Executive summary

Guidelines for the implantation of cardiac implantable electronic devices (CIEDs) have evolved since publication of the initial ACC/AHA pacemaker guidelines in 1984 [1]. CIEDs have evolved to include novel forms of cardiac pacing, the development of implantable cardioverter defibrillators (ICDs) and the introduction of devices for long term monitoring of heart rhythm and other physiologic parameters. In view of the increasing complexity of both devices and patients, practice guidelines, by necessity, have become increasingly specific. In 2018, the ACC/AHA/HRS published Guidelines on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay [2], which were specific recommendations for patients >18 years of age. This age-specific threshold was established in view of the differing indications for CIEDs in young patients as well as size-specific technology factors. Therefore, the following document was developed to update and further delineate indications for the use and management of CIEDs in pediatric patients, defined as ≤21 years of age, with recognition that there is often overlap in the care of patents between 18 and 21 years of age.This document is an abbreviated expert consensus statement (ECS) intended to focus primarily on the indications for CIEDs in the setting of specific disease/diagnostic categories. This document will also provide guidance regarding the management of lead systems and follow-up evaluation for pediatric patients with CIEDs. The recommendations are presented in an abbreviated modular format, with each section including the complete table of recommendations along with a brief synopsis of supportive text and select references to provide some context for the recommendations. This document is not intended to provide an exhaustive discussion of the basis for each of the recommendations, which are further addressed in the comprehensive PACES-CIED document [3], with further data easily accessible in electronic searches or textbooks.     

Volume-rendering representations of ab initio electron densities

Many molecular properties are three-dimensional scalar fields, making the representation of their values throughout the molecular volume a four-dimensional problem. Volume rendering offers a means of graphically displaying the value of a property throughout a volume. In this paper we present the result of an interface of the ab initio electronic structure program, GAUSSIAN 85, and the interactive volume-rendering program, VOXEL-VIEW PLUS, and its initial application: the representation of electron densities for acetylene and difluoroacetylene, and transition structures for the corresponding vinylidene isomerizations.     

Differences in Functional Outcomes for Adult Patients with Prosthodontically-Treated and -Untreated Shortened Dental Arches: A Systematic Review

This review examined differences in functional outcomes and patient satisfaction when shortened dental arches are left untreated compared to their restoration to complete arch lengths with different prosthodontic interventions.

Methods

A protocol was developed according to the criteria for a systematic review. All relevant databases were searched to identify appropriate clinical trials regardless of language or publication status. Predetermined eligibility criteria were applied, trial quality assessed and data extracted for each study. Relevant outcomes assessed were: functioning ability, patient satisfaction and harmful effects on oral structures.

Results

Searches yielded 101 articles: 81 from electronic databases and 20 from reference lists of retrieved articles (PEARLing searches). Sixty-nine citations were assessed for eligibility after removing 32 duplicate records. After reading titles and abstracts, a total of 41 records were excluded and the full-texts of the remaining 28 records were read. Only 21 records were included for the SR because 7 records were excluded after reading the full-text reports. These 21 records report the outcomes of four randomized controlled trials (RCTs) and one non-randomized clinical trial (CT) which were pre-specified and used for this review. No on-going studies were found and no eligible studies were excluded for failure to report the reviewer’s pre-specified outcomes. Outcomes were reported in the retrieved 21 articles. A narrative explanation of the pre-specified outcomes is reported for the 3 comparison groups (which were based on the different interventions used for the individual clinical trials). The shortened dental arch as a treatment option is encouraging in terms of functioning, patient satisfaction and cost-effectiveness. By using only high quality studies it was expected that the results would be more reliable when making conclusions and recommendations, but some of the included studies had to be downgraded due to methodological errors.     

Chipping away at the old block

With growing concern that women are still failing to progress in scientific careers, many countries are trying to address the problem. The British government has just received a hard-hitting report with recommendations for swift action to tackle the problems. Nigel Williams reports.     

Laboratory reporting of urine protein and albumin

Communication between pathology laboratories and clients involves more than just a result. There may be advice on recommended specimen type as well as the units and reference intervals used to report results. Between-laboratory variability in these factors has the potential to cause unnecessary confusion and even to lead to variation in interpretation for samples sent to different laboratories. A survey of Australian and New Zealand laboratories covering sample recommendations, specimens received, units and reference intervals for urine albumin and urine protein was conducted through the Royal College of Pathologists of Australasia Quality Assurance Program (RCPA QAP). The results confirm earlier findings of wide between-laboratory variability in all these factors. It is proposed that only recommendations developed by relevant professional societies and adopted by all laboratories can lead to reduction in this variability.     

A low-cost, portable generic biotoxicity assay for environmental monitoring applications

Fish chromatophores have been shown to be promising biosensors for the detection of hostile agents in the environment. However, state-of-art methods for such applications are still based on extensive use of data/signal processing, in conjunction with need for a skilled human observer to carry out the detection. As a result, conventional methods are complex, costly and cumbersome rendering them useless for field applications requiring low-cost portable solutions capable of fast detection. A new technique is proposed based on the popular scheme of observing the aggregation response in chromatophores for detection of toxicity, and a solution using optical detection and electronic processing is outlined. This scheme has the advantage of being low in cost while providing simple, fast and reliable detection.     

Evolutionary Medicine and the Medical School Curriculum: Meeting Students Along Their Paths to Medical School

Over the past several years, numerous reports that have been independently prepared by prestigious organizations in the U.S. have agreed that new approaches to improve teaching and learning of biology at both the pre-college and undergraduate levels are important and timely. Their recommendations, which are based on emerging research about human learning and cognition, are in agreement that evolution is an organizing principle and foundation of modern biology and should be presented as such. This paper provides an overview of the conclusions and recommendations from those reports and proposes that helping students learn evolution through the lens of human examples that are part of the emerging field of evolutionary medicine could help biology educators improve the teaching of evolution, and biology more generally, by asking students to address biological problems that are inherently interesting and motivating.     

Current Controlled Trials: an opportunity to help improve the quality of clinical research

Some problems with the quality of controlled clinical trials can be addressed by following these procedures: registering all trials at inception; using systematic reviews to inform the design of new studies; posting and obtaining feedback on preprints; reporting all well conducted trials, regardless of their results; reducing biased and inefficient assessment of reports submitted for publication; publishing sufficiently detailed reports; linking trial reports to relevant external information; providing readier access to reports; and reviewing and amending reports after initial publication. The launch of a new range of electronic journals by Current Controlled Trials offers an opportunity to contribute to progress in these ways.     

Development and pilot testing of a model to translate risk assessment data for Great Lakes Native American communities using mobile technology

The Chippewa Ottowa Resource Authority monitors fish contaminants in Anishinaabe (Great Lake Native American) tribal fisheries. A software program (app) was programmed to translate and operationalize these data for the first time in an interactive, personalized, and culturally tailored format. This article reports the process for creation, and preliminary community reception, of interactive fish consumption advisory using software that can be accessed via mobile phones and/or the internet. Response data to previous advisories guided the app presentation and aesthetics. The app “Gigiigoo'inaan’ [Our Fish] presents personalized recommendations based on back-end calculated reference doses as well as a novel risk/benefit quantification originally presented by Ginsberg et al. (Human Ecol Risk Assess, Vol. 21, 2015, pp. 810–39) and Ginsberg and Toal (Environ Health Perspect, Vol. 117, 2009, pp. 267–75) to characterize nutritional benefits. The partnering organization, Inter-Tribal Council of Michigan recruited focus groups to pilot test the app for usability, influence on dietary behavior, and cultural appropriateness. The general concept of the app and the presentation of the data were deemed culturally acceptable and pleasing to the participants. The results suggest that risk-benefit data is valuable to end-users but meal frequency recommendations, typically based on federal guidelines, should also be clearly communicated. How these guidelines are selected and presented will likely impact the reception and adoption of consumption advice.     

Clinical interpretation and recommendations for patients with a variant of uncertain significance in BRCA1 or BRCA2: a survey of genetic counseling practice

The intent of this study was to document current practices in breast cancer genetic counseling and identify areas of variability for patients with a variant of uncertain significance (VUS) in the BRCA1 or BRCA2 gene. Registered members of the National Society of Genetic Counselors (NSGC) Cancer Special Interest Group (SIG) were sent an invitation via electronic mail to participate in an online questionnaire. The questionnaire was divided into three sections: clinical experience, clinical meaning, and risk perceptions and clinical recommendations for clinical situations involving a VUS. Fifty-seven of the eligible members responded. During the pre-test counseling session for a BRCA risk assessment patient, the vast majority of counselors (80.7%) mention VUS as a possible test result. Nearly half, 49.1%, report having given such a result to their patients at least one to four times. However, only 63.2% felt as though their patients understood the meaning of a VUS result. When asked to conclude the implication of a VUS and make medical management recommendations, the responses were varied. Nevertheless, a good proportion of counselors expressed the importance of testing other family members to help clarify the proband's risk and aid in medical management issues. Although the recent recommendations by the American College of Medical Genetics suggest standards for the interpretation of sequence variations, they do not provide guidelines for making clinical recommendations based on these variations. The results of this study reveal significant diversity in the personal interpretation of a VUS result, leading to various clinical recommendations, and suggest a need for clinical management recommendations as well.     

Devitalization of Transgenic Seed That Preserves DNA and Protein Integrity

Agricultural biotechnology companies have been asked to provide intact transgenic seed to regulatory agencies as reference materials for evaluating transgene and protein detection methods (PCR and immunoassay). Due to intellectual-property and product-stewardship considerations, submission of devitalized seed prior to regulatory approval is preferable in any given country. Commonly used devitalization procedures, such as heating or autoclaving, degrade the protein and/or DNA rendering the seed unfit as a reference material for these tests. A novel method for devitalizing seed was developed that involves hydration, freezing in liquid nitrogen, and lyophilization. The devitalization method described here was found to preserve the transgenic DNA and protein in cotton (Gossypium hirsutum) and maize (Zea mays) seed allowing its use as a reference material for evaluating detection methods.     

A precise and non-destructive method to calculate the surface area in living scleractinian corals using X-ray computed tomography and 3D modeling

The surface area of corals represents a major reference parameter for the standardization of flux rates, for coral growth investigations, and for investigations of coral metabolism. The methods currently used to determine the surface area of corals are rather approximate approaches lacking accuracy, or are invasive and often destructive methods that are inapplicable for experiments involving living corals. This study introduces a novel precise and non-destructive technique to quantify surface area in living coral colonies by applying computed tomography (CT) and subsequent 3D reconstruction. Living coral colonies of different taxa were scanned by conventional medical CT either in air or in sea water. Resulting data volumes were processed by 3D modeling software providing realistic 3D coral skeleton surface reconstructions, thus enabling surface area measurements. Comparisons of CT datasets obtained from calibration bodies and coral colonies proved the accuracy of the surface area determination. Surface area quantifications derived from two different surface rendering techniques applied for scanning living coral colonies showed congruent results (mean deviation ranging from 1.32 to 2.03%). The validity of surface area measurement was verified by repeated measurements of the same coral colonies by three test persons. No significant differences between all test persons in all coral genera and in both surface rendering techniques were found (independent sample t-test: all n.s.). Data analysis of a single coral colony required approximately 15 to 30 min for a trained user using the isosurface technique regardless of the complexity and growth form of the latter, rendering the method presented in this study as a time-saving and accurate method to quantify surface areas in both living coral colonies and bare coral skeletons. Communicated by Biology Editor Dr Michael Lesser     

International clinical recommendations on scar management

Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence-based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicone gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practices and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.