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OBJECTIVE: To characterize transitions to acute and residential care and identify variables associated with specific transitions among community-based persons living with dementia (PLWD). DESIGN: Retrospective cohort study using primary care electronic medical record data linked with health administrative data. SETTING: Alberta. PARTICIPANTS: Adults aged 65 years or older living in the community who had been diagnosed with dementia and who saw a Canadian Primary Care Sentinel Surveillance Network contributor between January 1, 2013, and February 28, 2015. MAIN OUTCOME MEASURES: All emergency department visits, hospitalizations, residential care (supportive living and long-term care) admissions, and deaths within a 2-year follow-up period. RESULTS: In total, 576 PLWD were identified who had a mean (SD) age of 80.4 (7.7) years; 55% were female. In 2 years, 423 (73.4%) had at least 1 transition and, of these, 111 (26.2%) had 6 or more. Emergency department visits, including multiple visits, were common (71.4% had ≥1, 12.1% had ≥4). Of those hospitalized (43.8%), nearly all were admitted from the emergency department; the average (SD) length of stay was 23.6 (35.8) days, and 32.9% had at least 1 alternate level of care day. In total, 19.3% entered residential care, most admitted from hospital. Those admitted to hospital and those admitted to residential care were older and had greater historical health system use, including home care. One-quarter of the sample did not have any transitions (or die) during follow-up; they were typically younger and had limited historical health system use. CONCLUSION: Older PLWD experienced frequent, and frequently compound, transitions that have implications for them, their family members, and the health system. There was also a large proportion without transitions suggesting that appropriate supports enable PLWD to do well in their own communities. The identification of PLWD who are at risk of or who make frequent transitions may allow for more proactive implementation of community-based supports and smoother transitions to residential care.

The measurement of the momentum distribution of positron annihilation radiation is a powerful method to detect and identify open-volume defects in crystalline solids. The Doppler broadening of the 511 keV line of the $2\gamma$ electron-positron annihilation event reflects the momentum density of annihilating pairs and local electron momenta at positron annihilation sites. It can provide information on the chemical surroundings of vacancies, such as the impurity atoms around them. Accurate methods based on first-principles calculations are crucial for interpreting measured Doppler spectra. In this work we will validate such a method based on variational quantum Monte Carlo by benchmarking results in aluminium nitride and silicon against experimental data measured from defect-free reference samples. The method directly models electron-positron correlations using variational wave functions. We achieve better agreement with experiments for our test set than conventional state-of-the-art methods. We show that normalized Doppler broadening spectra calculated with quantum Monte Carlo converge rapidly as a function of simulation cell size, and backflow transformations have only a minor effect. This makes the method robust and practical to support positron-based spectroscopies., Comment: 10 pages, 4 figures

Additional file 3: Patient flow diagram

Additional file 1: Appendix A: ICD-9 codes used to identify patients in the secondary prevention group

Importance: Although patients with chronic kidney disease (CKD) are routinely managed in primary care settings, no nationally representative study has assessed the quality of care received by these patients in Canada. Objective: To evaluate the current state of CKD management in Canadian primary care practices to identify care gaps to guide development and implementation of national quality improvement initiatives. Design, Setting, and Participants: This cross-sectional study leveraged Canadian Primary Care Sentinel Surveillance Network data from January 1, 2010, to December 31, 2015, to develop a cohort of 46 162 patients with CKD managed in primary care practices. Data analysis was performed from August 8, 2018, to July 31, 2019. Main Outcomes and Measures: The study examined the proportion of patients with CKD who met a set of 12 quality indicators in 6 domains: (1) detection and recognition of CKD, (2) testing and monitoring of kidney function, (3) use of recommended medications, (4) monitoring after initiation of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), (5) management of blood pressure, and (6) monitoring for glycemic control in those with diabetes and CKD. The study also analyzed associations of divergence from these quality indicators. Results: The cohort comprised 46 162 patients (mean [SD] age, 69.2 [14.0] years; 25 855 [56.0%] female) with stage 3 to 5 CKD. Only 4 of 12 quality indicators were met by 75% or more of the study cohort. These indicators were receipt of an outpatient serum creatinine test within 18 months after confirmation of CKD, receipt of blood pressure measurement at any time during follow-up, achieving a target blood pressure of 140/90 mm Hg or lower, and receiving a hemoglobin A1c test for monitoring diabetes during follow-up. Indicators in the domains of detection and recognition of CKD, testing and monitoring of kidney function (specifically, urine albumin to creatinine ratio testing), use of recommended medications, and appropriate monitoring after initiation of treatment with ACEIs or ARBs were not met. Only 6529 patients (18.4%) with CKD received a urine albumin test within 6 months of CKD diagnosis, and 3954 (39.4%) had a second measurement within 6 months of an abnormal baseline urine albumin level. Older age (≥85 years) and CKD stage 5 were significantly associated with not satisfying the criteria for the quality indicators across all domains. Across age categories, younger patients (aged 18-49 years) and older patients (≥75 years) were less likely to be tested for albuminuria (314 of 1689 patients aged 18-49 years [18.5%], 1983 of 11 919 patients aged 75-84 years [61.6%], and 614 of 5237 patients aged ≥85 years [11.7%] received the urine albumin to creatinine ratio test within 6 months of initial estimated glomerular filtration rate

Excitonic effects play a particularly important role in the optoelectronic behavior of two dimensional semiconductors. To facilitate the interpretation of experimental photoabsorption and photoluminescence spectra we provide (i) statistically exact diffusion quantum Monte Carlo bindingenergy data for a Mott-Wannier model of (donor/acceptor-bound) excitons, trions, and biexcitons in two-dimensional semiconductors in which charges interact via the Keldysh potential, (ii) contact pair-distribution functions to allow a perturbative description of contact interactions between charge carriers, and (iii) an analysis and classification of the different types of bright trion and biexciton that can be seen in single-layer molybdenum and tungsten dichalcogenides. We investigate the stability of biexcitons in which two charge carriers are indistinguishable, finding that they are only bound when the indistinguishable particles are several times heavier than the distinguishable ones. Donor/acceptor-bound biexcitons have similar binding energies to the experimentally measured biexciton binding energies. We predict the relative positions of all stable free and bound excitonic complexes of distinguishable charge carriers in the photoluminescence spectra of WSe2 and MoSe2.

The ability to stop ongoing movements or prevent unwanted movements is fundamental to behavioural control. This thesis addresses the neural processes underlying inhibitory control and how initiation and stop processes interact to control behaviour. We conducted four studies, employing various behavioural tasks that require humans to prepare to initiate a response with the possibility that it may have to be prevented or stopped from being initiated. In the first experiment we sought to determine whether the increase in reaction time (RT) during the performance of traditional stop-signal task was due to a decreased the amount of go-related preparatory activation. We used a startling acoustic stimulus (SAS) to determine whether the go-response could be triggered involuntarily, and investigated whether the latency of SAS responses were delayed when participants were instructed that they might have to stop their response compared to when they knew they would never stop (i.e., simple RT task). We found that the go-response was prepared in advance during the stop-signal task, but to a lesser degree as indicated by the slower SAS response latency, compared to when go trials were completed in the simple RT task. Thus, even the possibility of having to stop a response reduces the level of preparatory go-activation. The second experiment tested the hypothesis that behavioural control during a stop-signal task is determined by an independent race between go- and stop-processes. In this experiment we used a SAS to manipulate initiation and inhibition by probing the go- and stop-response prior to and after the stop-signal respectively in a stop-signal task. We found that the go-response could be triggered by the SAS even 200 ms following the stop-signal suggesting that behavioural control during a stop-signal task is not determined by an independent race between go- and stop-activations, but rather by an interaction between go-activation and stop processes. The third experiment investigated the effect of advance preparation on the ability to proactively and selectively inhibit a single limb in a bimanual response that had been cued to maybe stop. TMS was used to measure the excitability of the limb that was cued to maybe stop in comparison to the limb that was to continue with its response. In addition, a SAS was used to probe the preparatory state of the go-response in each limb. We found that increased preparatory go-activation of responses in both limbs overshadowed the neurophysiological evidence of proactive selective inhibition, while processes related to the selective stopping task appeared to suppress subcortical motor structures and the ability of the SAS to involuntarily trigger the prepared responses. The fourth experiment sought to determine the role of the right inferior frontal gyrus (rIFG) and the pre-supplementary motor area (preSMA) in the inhibition of response initiation during a go/no-go task. We temporarily deactivated rIFG or preSMA using continuous theta burst stimulation (cTBS) and examined changes in inhibition, voluntary initiation, and the ability of a SAS to involuntary trigger the initiation of the response. We found that stimulation to both cortical sites impaired participant’s ability to withhold movements during no-go trials. Notably, deactivating rIFG and preSMA did not affect voluntary initiation and did not enable the SAS to involuntarily trigger the response. These findings implicate the rIFG and the preSMA in the ability to inhibit responses during a go/no-go task, and suggests that preparation and initiation of the go-response occurs in response to the imperative stimulus, with inhibition only applied once the stimulus is identified as a no-go signal. Taken together, these studies show that i) modulation of preparatory go-activation contributes to the ability to inhibit a motor response, ii) motor response inhibition is achieved by initiation activation being prevented from reaching threshold, iii) preparatory go-activation overshadows proactive inhibition, iv) inhibitory control depends on the integrity and recruitment of top-down inhibitory control to suppress initiation activation once a no-go stimulus is identified. This research speaks to the interaction between initiation and inhibition processes and provides novel insight and evidence in support of an interactive model of inhibitory control.

Interview Guide. At each time point of the vignette (Table 1), the interviewer asked the following questions. Interviewers were permitted to ask follow-up questions for clarification. 1) What action would you take if the patient was presented to you at this stage with this history? 2) Are there any other resources you would consider at this stage? (DOCX 11 kb)

We use a combined ab initio calculations and k . p theory based approach to derive a low-energy effective Hamiltonian for monolayer MoS2 at the K point of the Brillouin zone. It captures the features which are present in first-principles calculations but not explained by the theory of Xiao et al. [Phys Rev Lett 108, 196802 (2012)], namely the trigonal warping of the valence and conduction bands, the electron-hole symmetry breaking, and the spin splitting of the conduction band. We also consider other points in the Brillouin zone which might be important for transport properties. Our findings lead to a more quantitative understanding of the properties of this material in the ballistic limit.

We use a combined ab-initio calculations and k.p theory based approach to derive a low-energy effective Hamiltonian for monolayer MoS2 at the K point of the Brillouin zone. It captures the features which are present in first-principles calculations but not explained by the theory of Xiao et al. [Phys Rev Lett 108, 196802 (2012)], namely the trigonal warping of the valence and conduction bands, the electron-hole symmetry breaking, and the spin-splitting of the conduction band. We also consider other points in the Brillouin zone which might be important for transport properties. Our findings lead to a more quantitative understanding of the properties of this material in the ballistic limit., Comment: new references and a new appendix added, presentation improved

We use a combined ab-initio calculations and k.p theory based approach to derive a low-energy effective Hamiltonian for monolayer MoS2 at the K point of the Brillouin zone. It captures the features which are present in first-principles calculations but not explained by the theory of Xiao et al. [Phys Rev Lett 108, 196802 (2012)], namely the trigonal warping of the valence and conduction bands, the electron-hole symmetry breaking, and the spin-splitting of the conduction band. We also consider other points in the Brillouin zone which might be important for transport properties. Our findings lead to a more quantitative understanding of the properties of this material in the ballistic limit., new references and a new appendix added, presentation improved

Background Asthma is the most common chronic condition in children. For many, the disease is inadequately controlled, which can burden the lives of children and their families as well as the health care system. Improved use of the best available scientific evidence by primary care practitioners could reduce the need for hospital care and improve quality of life and asthma control, thereby reducing overall costs to society and families. Objective The Primary Care Pathway for Childhood Asthma aims to improve the management of children with asthma by (1) providing primary care practitioners with an electronic guide (a clinical pathway) incorporated into the patient’s electronic medical record, and (2) providing train-the-trainer education to chronic disease management health professionals to promote the provision of asthma education in primary care. Methods The research will utilize a pragmatic cluster-controlled design, quantitative and qualitative research methodologies, and economic evaluation to assess the implementation of a pathway and education intervention in primary care. The intervention will be analyzed for effectiveness, and if the results are positive, a strategy will be developed to implement delivery to all primary care practices in Alberta. Results The research has been successfully funded and ethics approvals have been obtained. Practice recruitment began fall 2015, and we expect all study-related activities to be concluded by March 2018. Conclusions The proposed pathway and education intervention has the potential to improve pediatric asthma management in Alberta. The intervention is anticipated to result in better quality of care for equal or lesser cost. ClinicalTrial ClinicalTrials.gov NCT02481037; https://clinicaltrials.gov/ct2/show/NCT02481037 (Archived by WebCite at http://www.webcitation.org/6fPIQ02Ma).

Previous investigations comparing direct versus indirectly cued movements have consistently shown that indirectly cued movements take longer to prepare (Neely and Heath, 2010) and involve the recruitment of additional brain areas (Connolly et al., 2000). This increase in processing time has been associated with the additional cognitive transformations required of the task (Neely and Heath, 2010). In the present study we investigated whether differences between direct versus indirectly cued movements are also reflected in the time course of motor preparation. Participants performed a targeting task, moving directly to the location of a visual cue (i.e., directly cued movement) or to a location that differed by 60˚, 90˚, or 120˚ with respect to the visual cue provided (i.e., indirectly cued movements). Participants were instructed to initiate their movements concurrently with an anticipated go-signal. To examine the time course of motor preparation, a startling acoustic stimulus (SAS, 124dB) was randomly presented 150 ms, 500 ms, or 1000 ms prior to the go-signal. Results from the startle trials revealed that the time course of motor preparation was similar regardless of the angle of rotation required and hence whether it was a direct or indirectly cued trial. Specifically, motor preparation was delayed until less than 500 ms prior to movement initiation for both direct and indirectly cued movements. These findings indicate that similar motor preparation strategies are engaged for both types of cued movements, suggesting that the time to prepare a motor response may be similar regardless of whether a cognitive transformation is required.

To explore the status and processes of interprofessional work environments and the implications for interprofessional education in a sample of family medicine teaching clinics.Focus group interviews using a purposive sampling procedure.Four academic family medicine clinics in Alberta.Seven family physicians, 9 registered nurses, 5 licensed practical nurses, 2 residents, 1 psychologist, 1 informatics specialist, 1 pharmacist, 1 dietitian, 1 nurse practitioner, 1 receptionist, and 1 respiratory therapist.Assessment of clinic status and performance in relation to established principles of interprofessional work and education was explored using semistructured focus group interviews.Our data supported the D'Amour and Oandasan model of successful interprofessional collaborative practice in terms of the model's main "factors" (ie, shared goals and vision, sense of belonging, governance, and the structuring of clinical care) and their constituent "elements." It is reasonable to conclude that the extent to which these factors and elements are both present and positively oriented in academic clinic settings is an important contributory factor to the establishment of interprofessional collaborative practice in primary care. Using this model, 2 of the 4 clinics were rated as expressing substantial progress in relation to interprofessional work, while the other 2 clinics were rated as less successful on that dimension. None of the clinics was identified as having a clear and explicit focus on providing interprofessional education.The key factor in relation to the implementation of interprofessional work in primary care appears to be the existence of clear and explicit leadership in that direction. Substantial scope exists for improvement in the organization, conduct, and promotion of interprofessional education for Canadian primary care.

Quantum Monte Carlo methods provide in principle an accurate treatment of the many-body problem of the ground and excited states of condensed systems. In practice, however, uncontrolled errors such as those arising from the fixed-node and pseudopotential approximations often limit the quality of results. We show that the accuracy of quantum Monte Carlo calculations is limited by using available pseudopotentials. In particular, it is necessary to include angular momentum channels in the pseudopotential for excited angular momentum states and to choose the local channel appropriately to obtain accurate results. Variational and diffusion Monte Carlo calculations for Zn, O, and Si atoms and ions demonstrate that these issues can affect total energies by up to several eV for common pseudopotentials. Adding higher-angular momentum channels into the pseudopotential description reduces such errors drastically without a significant increase in computational cost.

To explore the challenges Canadian family physicians face in providing dementia care.Qualitative study using focus groups.Academic family practice clinics in Calgary, Alta, Ottawa, Ont, and Toronto, Ont.Eighteen family physicians.We conducted 4 qualitative focus groups of 4 to 6 family physicians whose practices we had audited in a previous study. Focus group transcripts were analyzed using the principles of thematic analysis.Five major themes related to the provision of dementia care by family physicians emerged: 1) diagnostic uncertainty; 2) the complexity of dementia; 3) time as a paradox in the provision of dementia care; 4) the importance of patients' families; 5) and familiarity with patients. Participants expressed uncertainty about diagnosing dementia and a strong need for expert verification of diagnoses owing to the complexity of dementia. Time, patients' family members, and familiarity with patients were seen as both barriers and enablers in the provision of dementia care.Family physicians face many challenges in providing dementia care. The results of this study and the views of family physicians should be considered in the development and dissemination of future dementia guidelines, as well as by specialist colleagues, policy makers, and those involved in developing continuing physician education about dementia.

To develop a typology of after-hours care (AHC) instructions and to examine physician and practice characteristics associated with each type of instruction.Cross-sectional telephone survey. Physicians' offices were called during evenings and weekends to listen to their messages regarding AHC. All messages were categorized. Thematic analysis of a subset of messages was conducted to develop a typology of AHC instructions. Logistic regression analysis was used to identify associations between physician and practice characteristics and the instructions left for patients.Family practices in the greater Toronto area.Stratified random sample of family physicians providing office-based primary care.Form of response (eg, answering machine), content of message, and physician and practice characteristics.Of 514 after-hours messages from family physicians' offices, 421 were obtained from answering machines, 58 were obtained from answering services, 23 had no answer, 2 gave pager numbers, and 10 had other responses. Message content ranged from no AHC instructions to detailed advice; 54% of messages provided a single instruction, and the rest provided a combination of instructions. Content analysis identified 815 discrete instructions or types of response that were classified into 7 categories: 302 instructed patients to go to an emergency department; 122 provided direct contact with a physician; 115 told patients to go to a clinic; 94 left no directions; 76 suggested calling a housecall service; 45 suggested calling Telehealth; and 61 suggested other things. About 22% of messages only advised attending an emergency department, and 18% gave no advice at all. Physicians who were female, had Canadian certification in family medicine, held hospital privileges, or had attended a Canadian medical school were more likely to be directly available to their patients.Important issues identified included the recommendation to use an emergency department as the sole source of AHC, practices providing no specific AHC instructions to their patients, and physicians' lack of acceptance of Telehealth. To improve AHC, new initiatives should build upon the existing system, changes should be integrated, and there should be a range of AHC options for patients and physicians.

To determine what proportion of patients with dementia seen by family physicians are assessed and managed according to the recommendations of the Canadian Consensus Conference on Dementia (CCCD).Retrospective medical record review.Outpatient services in university-affiliated family practice clinics in Calgary, Alta; Ottawa, Ont; and Toronto, Ont.One hundred sixty patients who were diagnosed with dementia between January 1, 2000, and June 1, 2004.Use of the Mini-Mental State Examination (MMSE); collateral history; physical examination maneuvers; initial laboratory tests; diagnostic imaging; caregiver identification, assessment, and referral; driving assessment; specialist referral patterns; and other recommendations of the CCCD.The average age of patients assessed was 83 years; most patients (66.3%) were female. More than half (54.1%) were diagnosed with Alzheimer disease or vascular dementia. More than 25% of patients were not given a specific diagnosis: 13.1% were labeled as "dementia," and 12.5% as "not yet diagnosed." For most patients (69.6%) a collateral history was obtained and a primary caregiver identified (79.4%). Few physicians, however, assessed caregiver stress (33.1%) or referred caregivers for support (12.5%). Most patients (80.6%) seen by their family physicians for cognitive changes underwent at least one MMSE. The average score on the first MMSE was 23.5 (of 30) points. Most physicians ordered appropriate "basic" blood tests as part of their assessment. Forty percent of patients had computed tomographic examinations within 3 months of reporting symptoms of cognitive difficulties to their family physicians. Of these, 25% met the criteria for computed tomographic scan as recommended by the guidelines. Only 36.5% were asked about driving status or safety concerns and had this inquiry documented. Of those, 15.5% were referred for driving evaluations and 12.5% were reported to the Ministry of Transportation.There is fair to good compliance with recommendations of the 1999 CCCD guidelines. There is, however, little assessment of caregiver coping and referral of caregivers for support. Similarly, there is little assessment of driver safety and referral for formal driving evaluations. Computed tomographic imaging as part of the evaluation of dementia is overused.

Personal digital assistants (PDAs) are popular with physicians: in 2003, 33% of Canadian doctors reported using them in their practices. We do not know, however, whether using a PDA changes the behaviour of practising physicians. We studied the effectiveness of a PDA software application to help family physicians diagnose angina among patients with chest pain.Prospective randomized controlled pilot trial using a cluster design.Primary care practices in the Toronto area.Eighteen family physicians belonging to the North Toronto Primary Care Research Network (Nortren) or recruited from a local hospital.We randomized physicians to receive a Palm PDA (which included the angina diagnosis software) or to continue conventional care. Physicians prospectively recorded the process of care for patients aged 30 to 75 presenting with suspected angina, over 7 months.Did the process of care for patients with suspected angina improve when their physicians had PDAs and software? The primary outcomes we looked at were frequency of cardiac stress test orders for suspected angina, and the appropriateness of referral for cardiac stress testing at presentation and for nuclear cardiology testing after cardiac stress testing. Secondary outcome was referrals to cardiologists.The software led to more overall use of cardiac stress testing (81% vs 50%). The absolute increase was 31% (P = .007, 95% confidence interval [CI] 8% to 58%). There was a trend toward more appropriate use of stress testing (48.6% with the PDA vs 28.6% control), an increase of 20% (P = .284, 95% CI -11.54% to 51.4%). There was also a trend toward more appropriate use of nuclear cardiology following cardiac stress testing (63.0% vs 45.5%), an absolute increase of 17.5% (P =.400, 95% CI -13.9% to 48.9%). Referrals to cardiologists did not increase (38.2% with the PDA vs 40.9%, P =.869).A PDA-based software application can lead to improved care for patients with suspected angina seen in family practices; this finding requires confirmation in a larger study.

Additional file 2:. Ovid MEDLINE search terms and strategy .

Additional file 1:. PRISMA-P checklist.

Additional file 1:. PRISMA-P checklist.

Additional file 2:. Ovid MEDLINE search terms and strategy .

Background Primary care initiatives face an imperative to not only reduce barriers to care for their patients but also to uniquely accommodate the complex needs of at-risk patient populations. Patient-centered multidisciplinary care team models for primary care, like the Alex Seniors Clinic, are one approach for providing comprehensive care for marginalized seniors. The purpose of this qualitative study was to explore patient perspectives on the responsiveness of the Alex Seniors Clinic to their stated health needs. Results Themes reflected participants’ perspectives on factors impacting their health needs as vulnerable seniors as well as on the measures that the Alex Seniors Clinic has taken to meet those needs. Factors impacting health included: the nature of their relationships to the physical environment in which they lived, the nature of the relationships they had to others in that environment, and independence and autonomy. Participants identified accessibility, respect and support, and advocacy as the ways in which the clinic was working to address those health needs. Conclusions While respect and support, as well as advocacy, effectively addressed some patient needs, participants felt that accessibility problems continue to be health-related barriers for clinic patients. This may be due to the fact that issues of accessibility reflect larger community and social problems. Nevertheless, it is only through engaging the patient community for input on clinic approaches that an understanding can be gained of how closely a clinic’s care goals are currently aligning with patient perspectives of the care and services they receive.