Vascular injury from an arterial closure device

onographic examinations are commonly used to assess groin access sites for complications after endovascular procedures. Along with a rise in the number of endovascular procedures, there has also been increased use of percutaneous arterial closure devices, which facilitate immediate hemostasis and earlier patient mobilization.1,2 Here we report the sonographic appearance of an injury related to the deployment of an arterial closure device

Measuring agreement between decision support reminders: the cloud vs. the local expert

Background: A cloud-based clinical decision support system (CDSS) was implemented to remotely provide evidence-based guideline reminders in support of preventative health. Following implementation, we measured the agreement between preventive care reminders generated by an existing, local CDSS and the new, cloud-based CDSS operating on the same patient visit data. Methods: Electronic health record data for the same set of patients seen in primary care were sent to both the cloud-based web service and local CDSS. The clinical reminders returned by both services were captured for analysis. Cohen’s Kappa coefficient was calculated to compare the two sets of reminders. Kappa statistics were further adjusted for prevalence and bias due to the potential effects of bias in the CDS logic and prevalence in the relative small sample of patients. Results: The cloud-based CDSS generated 965 clinical reminders for 405 patient visits over 3 months. The local CDSS returned 889 reminders for the same patient visit data. When adjusted for prevalence and bias, observed agreement varied by reminder from 0.33 (95% CI 0.24 – 0.42) to 0.99 (95% CI 0.97 – 1.00) and demonstrated almost perfect agreement for 7 of the 11 reminders. Conclusions: Preventive care reminders delivered by two disparate CDS systems show substantial agreement. Subtle differences in rule logic and terminology mapping appear to account for much of the discordance. Cloud-based CDSS therefore show promise, opening the door for future development and implementation in support of health care providers with limited resources for knowledge management of complex logic and rules

Sex-Biased Gene Flow Among Elk in the Greater Yellowstone Ecosystem

We quantified patterns of population genetic structure to help understand gene flow among elk populations across the Greater Yellowstone Ecosystem. We sequenced 596 base pairs of the mitochondrial control region of 380 elk from eight populations. Analysis revealed high mitochondrial DNA variation within populations, averaging 13.0 haplotypes with high mean gene diversity (0.85). The genetic differentiation among populations for mitochondrial DNA was relatively high (FST = 0.161; P = 0.001) compared to genetic differentiation for nuclear microsatellite data (FST = 0.002; P = 0.332), which suggested relatively low female gene flow among populations. The estimated ratio of male to female gene flow (mm/mf = 46) was among the highest we have seen reported for large mammals. Genetic distance (for mitochondrial DNA pairwise FST) was not significantly correlated with geographic (Euclidean) distance between populations (Mantel’s r = 0.274, P = 0.168). Large mitochondrial DNA genetic distances (e.g., FST . 0.2) between some of the geographically closest populations (,65 km) suggested behavioral factors and/or landscape features might shape female gene flow patterns. Given the strong sex-biased gene flow, future research and conservation efforts should consider the sexes separately when modeling corridors of gene flow or predicting spread of maternally transmitted diseases. The growing availability of genetic data to compare male vs. female gene flow provides many exciting opportunities to explore the magnitude, causes, and implications of sex-biased gene flow likely to occur in many species

Using a Service Oriented Architecture Approach to Clinical Decision Support: Performance Results from Two CDS Consortium Demonstrations

The Clinical Decision Support Consortium has completed two demonstration trials involving a web service for the execution of clinical decision support (CDS) rules in one or more electronic health record (EHR) systems. The initial trial ran in a local EHR at Partners HealthCare. A second EHR site, associated with Wishard Memorial Hospital, Indianapolis, IN, was added in the second trial. Data were gathered during each 6 month period and analyzed to assess performance, reliability, and response time in the form of means and standard deviations for all technical components of the service, including assembling and preparation of input data. The mean service call time for each period was just over 2 seconds. In this paper we report on the findings and analysis to date while describing the areas for further analysis and optimization as we continue to expand our use of a Services Oriented Architecture approach for CDS across multiple institutions

Aggressive Behavior as a Function of Trait Anxiety, Anger and Sex

The relationship between trait anxiety and physical aggression was investigated. Two additional variables, sex and anger level of the Ss were considered. It was hypothesized that males would express more aggression than females and that angered Ss would be more aggressive than nonangered Ss. No hypotheses were made concerning the relationship between trait anxiety and physical aggression. Seventy-two undergraduates at the University of North Dakota were selected as Ss. A 3x2x2 factorial design was used with three levels of anxiety and two categories of anger and sex. Six Ss were assigned to each treatment condition. Trait anxiety was defined by scores on the Manifest Anxiety Scale (Taylor, 1953), and Ss were divided into low, medium, and high anxiety groups. Ss were led to believe they were participating with another student (the male confederate) in a learning experiment. In the first stage of the study half of the Ss were angered by the confederate who administered several shocks to them in evaluation of a task they had completed. Half of the Ss were not angered. Following the anger manipulation, Ss indicated their subjective feelings of anger on a Self Report Mood Scale. In the second stage Ss were instructed to teach their partner (the confederate) a concept using electric shock as punishment. The dependent variable was the mean shock Intensity ostensibly administered to the confederate on each of 31 shock trials. Angered Ss did not respond more aggressively, on the whole, than nonangered Ss, but they did report feeling significantly more angry. Males were significantly more aggressive than females on the first shock trial. Sex differences were not obtained, however, for shock trials 1-5 or for shock trials 1-31. Trait anxiety, as measured by the MAS, was not shown to be related to the overt expression of physical aggression

Effect of Dilute Polymer Solutions on External Boundary Layers

The paper reports an experimental study of the flow of homogeneous aqueous polyacrylamide MRL 402 solution over a thin flat plate. Extensive velocity profile data were obtained, using both cylindrical and conical hot-file probes, and used to obtain local skin friction profiles. Direct drag measurements were made over a period of time for concentrations of 0, 25, 50 and 75 wppm and indicated that there was no appreciable degradation of the polymer. Extensive turbulence intensity data were obtained which were contradictory but indicated that the conical type probe is better than the cylindrical type for turbulence measurements and that the turbulence intensity reduced as the fluid progressed along the surface. Results indicate that the form drag is reduced but that the viscous drag is not reduced unless an onset friction velocity is exceeded, which was found to be 0.074 ft/sec for the polymer used

Truth is Stranger Than It Used to Be: Biblical Faith in a Postmodern Age

Voted one of Christianity Today's 1996 Books of the Year! The carnivalesque, pluralistic culture in which we live can be seen as a consequence of the breakdown of modernity (which touted itself as the "greatest show on earth"), combined with a recognition of the socially constructed character of reality. Since the old construction has been discredited and is in a process of decomposition, the season is open on the construction of new realities which are produced with the speed and ease of temporary circus tents being raised. Far from witnessing the erosion or even eclipse of religious belief that the Enlightenment so confidently predicted, the eclipse of the Enlightenment has resulted in a veritable smorgasbord of religions and worldviews for our consumption. So Richard Middleton and Brian Walsh colorfully describe our postmodern setting. In this book they survey postmodern culture and philosophy, offering lucid explanations of such difficult theories as deconstruction. They are sympathetic to the postmodern critique, yet believe that a gospel stripped of its modernist trappings speaks a radical word of hope and transformation to our chaotic culture. The book for those who wonder what postmodernism is and how biblical Christians might best respond. Endorsement (from the back cover): “In Truth Is Stranger Than It Used to Be, Middleton and Walsh lead us into the postmodern crisis with skill and sensitivity, and with the mobilization of a comprehensive reading program. But this is not simply one more review. The book makes a suggestive theological response to the crisis, exploring the claims of biblical faith in a shrewd way. It will be a most helpful resource for those who care about our common future and who are willing to think honestly, informed by faith. I anticipate the book will be widely used, to our common benefit.” Walter Brueggemann, author of Texts Under Negotiation: The Bible and Postmodern Imaginatio

A patient safety toolkit for family practices

Objectives: Major gaps remain in our understanding of primary care patient safety. We describe a toolkit for measuring patient safety in family practices. Methods: Six tools were used in 46 practices. These tools were: NHS Education for Scotland Trigger Tool, NHS Education for Scotland Medicines Reconciliation Tool, Primary Care Safequest, Prescribing Safety Indicators, PREOS-PC, and Concise Safe Systems Checklist. Results: PC-Safequest showed that most practices had a well-developed safety climate. However, the Trigger Tool revealed that a quarter of events identified were associated with moderate or substantial harm, with a third originating in primary care and avoidable. Although medicines reconciliation was undertaken within 2 days in >70% of cases, necessary discussions with a patient/carer did not always occur. The prescribing safety indicators identified 1,435 instances of potentially hazardous prescribing or lack of recommended monitoring (from 92,649 patients). The Concise Safe Systems Checklist found that 25% of staff thought their practice provided inadequate follow-up for vulnerable patients discharged from hospital and inadequate monitoring of non-collection of prescriptions. Most patients had a positive perception of the safety of their practice although 45% identified at least one safety problem in the past year. Conclusions: Patient safety is complex and multidimensional. The Patient Safety Toolkit is easy to use and hosted on a single platform with a collection of tools generating practical and actionable information. It enables family practices to identify safety deficits that they can review and change procedures to improve their patient safety across a key sets of patient safety issues

Lessons Learned from Implementing Service-Oriented Clinical Decision Support at Four Sites: A Qualitative Study

Objective To identify challenges, lessons learned and best practices for service-oriented clinical decision support, based on the results of the Clinical Decision Support Consortium, a multi-site study which developed, implemented and evaluated clinical decision support services in a diverse range of electronic health records. Methods Ethnographic investigation using the rapid assessment process, a procedure for agile qualitative data collection and analysis, including clinical observation, system demonstrations and analysis and 91 interviews. Results We identified challenges and lessons learned in eight dimensions: (1) hardware and software computing infrastructure, (2) clinical content, (3) human-computer interface, (4) people, (5) workflow and communication, (6) internal organizational policies, procedures, environment and culture, (7) external rules, regulations, and pressures and (8) system measurement and monitoring. Key challenges included performance issues (particularly related to data retrieval), differences in terminologies used across sites, workflow variability and the need for a legal framework. Discussion Based on the challenges and lessons learned, we identified eight best practices for developers and implementers of service-oriented clinical decision support: (1) optimize performance, or make asynchronous calls, (2) be liberal in what you accept (particularly for terminology), (3) foster clinical transparency, (4) develop a legal framework, (5) support a flexible front-end, (6) dedicate human resources, (7) support peer-to-peer communication, (8) improve standards. Conclusion The Clinical Decision Support Consortium successfully developed a clinical decision support service and implemented it in four different electronic health records and four diverse clinical sites; however, the process was arduous. The lessons identified by the Consortium may be useful for other developers and implementers of clinical decision support services

Optimal metabolic pathway activation

This paper deals with temporal enzyme distribution in the activation of biochemical pathways. Pathway activation arises when production of a certain biomolecule is required due to changing environmental conditions. Under the premise that biological systems have been optimized through evolutionary processes, a biologically meaningful optimal control problem is posed. In this setup, the enzyme concentrations are assumed to be time dependent and constrained by a limited overall enzyme production capacity, while the optimization criterion accounts for both time and resource usage. Using geometric arguments we establish the bang-bang nature of the solution and reveal that each reaction must be sequentially activated in the same order as they appear in the pathway. The results hold for a broad range of enzyme dynamics which includes, but is not limited to, Mass Action, Michaelis-Menten and Hill Equation kinetics.Comment: 14 pages, 3 figures. Paper to be presented at the 17th IFAC World Congress, Seoul, Korea, July 200