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Hearing a song, listeners can often pick up the syntactical relationships among its words only with great difficulty. The musical flow washes away most of the syntax, and the musical connections from one phrase to the next or one section to the next, sometimes even from one note to the next, are what connect the words to one another and give them meanings very different from their submerged syntactically fixed meanings. This article probes the musical relationships joining the phrases in Beethoven’s Freude theme and attempts to paraphrase “joy” and “brotherhood” as their meanings are qualified by the musically determined relation of each to the other. It pays particular attention to the music that sets texts with a religious dimension, and the way their musical connections change the meaning of joy and brotherhood.

There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.

Strategies to control HIV in the absence of antiretroviral therapy are needed to cure HIV. However, such strategies will require analytical treatment interruptions (ATIs) to determine their efficacy. We investigated how U.S. stakeholders involved in HIV cure research perceive ATIs. We conducted 36 in-depth interviews with three groups of stakeholders: 12 people living with HIV, 11 clinician-researchers, and 13 policy-makers/bioethicists. Qualitative data revealed several themes. First, there was little consensus on when ATIs would be ethically warranted. Second, the most frequent perceived hypothetical motivators for participating in research on ATIs were advancing science and contributing to society. Third, risks related to viral rebound were the most prevalent concerns related to ATIs. Stakeholders suggested ways to minimize the risks of ATIs in HIV cure research. Increased cooperation between scientists and local communities may be useful for minimizing risk. Further ethics research is necessary.

Recent changes in the National Resident Matching Program resulted in an expansion from a one-phase to a two-phase process, thus prolonging the typical pharmacy residency interview cycle. In 2017, 5,752 applicants participated in the Match, with 3,831 candidates matching in Phase I.[1][1] A total of

Purpose In response to the increasing cancer burden in Kenya, this study identified barriers to patients seeking access to cancer testing and treatment and to clinicians in delivering these services. Policy recommendations based on findings are presented. Methods This qualitative study used semistructured key informant interviews. Purposive sampling was used to recruit 14 participants: seven oncology clinicians and seven support and advocacy leaders for patients with cancer. Qualitative analysis was used to identify themes. Results Seven barriers to cancer testing and treatment were identified: high cost of testing and treatment, low level of knowledge about cancer among population and clinicians, poor health-seeking behaviors among population, long distances to access diagnostic and treatment services, lack of decentralized diagnostic and treatment facilities, poor communication, and lack of better cancer policy development and implementation. Conclusion Kenyans seeking cancer services face significant barriers that result in late presentation, misdiagnosis, interrupted treatment, stigma, and fear. Four policy recommendations to improve access for patients with cancer are (1) improve health insurance for patients with cancer; (2) establish testing and treatment facilities in all counties; (3) acquire diagnosis and treatment equipment and train health personnel to screen, diagnose, and treat cancer; and (4) increase public health awareness and education about cancer to improve diagnoses and treatment. Effective cancer testing and treatment options can be developed to address cancer in a resource-constrained environment like Kenya. An in-depth look at effective interventions and policies being implemented in countries facing similar challenges would provide valuable lessons to Kenya’s health sector and policymakers.

Objective: To measure the return on investment (ROI) for a pediatric asthma pay-for-reporting intervention initiated by a Medicaid managed care plan in New York State. Design: Practice-level, randomized prospective evaluation. Setting: Twenty-five primary care practices providing care to children enrolled in the Monroe Plan for Medical Care (the Monroe Plan). Participants: Practices were randomized to either treatment (13 practices, 11 participated) or control (12 practices). Intervention: For each of its eligible members assigned to a treatment group practice, the Monroe plan paid a low monthly incentive fee to the practice. To receive the incentive, treatment group practices were required to conduct, and report to the Monroe Plan, the results of chart audits on eligible members. Chart audits were conducted by practices every 6 months. Aftereach chart audit, the Monroe Plan provided performance feedback to each practice comparing its adherence to asthma care guidelines with averages from all other treatment group practices. Control practices continued with usual care. Main Outcome Measures: Intervention implementation and operating costs and per member, per month claims costs. ROI was measured by net present value (discounted cash flow analysis). Results: The ROI to the Monroe Plan was negative, primarily due to high intervention costs and lack of reductions in spending on emergency department and hospital utilization forchildren in treatment relative to control practices. Conclusions: A pay-for-reporting, chart audit intervention is unlikely to achieve the meaningful reductions in utilization of high-cost services that would be necessary to produce a financial ROI in 2.5 years.

Claudin-low tumors are a highly aggressive breast cancer subtype with no targeted treatments and a clinically documented resistance to chemotherapy. They are significantly enriched in cancer stem cells (CSCs), which makes claudin-low tumor models particularly attractive for studying CSC behavior and developing novel approaches to minimize CSC therapy resistance. One proposed mechanism by which CSCs arise is via an epithelial-mesenchymal transition (EMT), and reversal of this process may provide a potential therapeutic approach for increasing tumor chemosensitivity. Therefore, we investigated the role of known EMT regulators, miR-200 family of microRNAs in controlling the epithelial state, stem-like properties and therapeutic response in an in vivo primary, syngeneic p53(null) claudin-low tumor model that is normally deficient in miR-200 expression. Using an inducible lentiviral approach, we expressed the miR-200c cluster in this model and found that it changed the epithelial state, and consequently, impeded CSC behavior in these mesenchymal tumors. Moreover, these state changes were accompanied by a decrease in proliferation and an increase in the differentiation status. miR-200c expression also forced a significant reorganization of tumor architecture, affecting important cellular processes involved in cell-cell contact, cell adhesion and motility. Accordingly, induced miR200c expression significantly enhanced the chemosensitivity and decreased the metastatic potential of this p53(null) claudin-low tumor model. Collectively, our data suggest that miR-200c expression in claudin-low tumors offers a potential therapeutic application to disrupt the EMT program on multiple fronts in this mesenchymal tumor subtype, by altering tumor growth, chemosensitivity and metastatic potential in vivo.

The molecular mechanisms underlying atrial fibrillation, the most common sustained cardiac arrhythmia, remain poorly understood. Genome-wide association studies uncovered a major atrial fibrillation susceptibility locus on human chromosome 4q25 in close proximity to the paired-like homeodomain transcription factor 2 (Pitx2) homeobox gene. Pitx2, a target of the left-sided Nodal signaling pathway that initiates early in development, represses the sinoatrial node program and pacemaker activity on the left side. To address the mechanisms underlying this repressive activity, we hypothesized that Pitx2 regulates microRNAs (miRs) to repress the sinoatrial node genetic program. MiRs are small noncoding RNAs that regulate gene expression posttranscriptionally. Using an integrated genomic approach, we discovered that Pitx2 positively regulates miR-17-92 and miR-106b-25. Intracardiac electrical stimulation revealed that both miR-17-92 and miR-106b-25 deficient mice exhibit pacing-induced atrial fibrillation. Furthermore electrocardiogram telemetry revealed that mice with miR-17-92 cardiac-specific inactivation develop prolonged PR intervals whereas mice with miR-17-92 cardiac-specific inactivation and miR-106b-25 heterozygosity develop sinoatrial node dysfunction. Both arrhythmias are risk factors for atrial fibrillation in humans. Importantly, miR-17-92 and miR-106b-25 directly repress genes, such as Shox2 and Tbx3, that are required for sinoatrial node development. Together, to our knowledge, these findings provide the first genetic evidence for an miR loss-of-function that increases atrial fibrillation susceptibility.

Virtually all social skills training (SST) regimens incorporate live or video modeling to effect gains in the targeted skills; there seems to be an implicit assumption that a behavioral model must be shown. The experimental literature to date has not investigated the effects of presenting video-based stimulus exemplars in the absence of video-based response models. In the present study two concurrent, yet independent, experiments evaluated the effectiveness of two SST regimens on the compliance of students with emotional and behavioral disorders. The first experiment represents the initial application of a video-based SST procedure, Discriminative Stimulus Social Skills Training (DS-SST). This intervention included multiple video-based exemplars of teacher requests within instruction designed to establish the requests as discriminative stimuli for individual responses that, collectively, were members of the response class, “compliance.” The second experiment evaluated the effectiveness of a novel, yet more traditional, SST approach on compliance. The Peer Assisted Social Skills Training (PA-SST) included peer modeling, imitation, role playing, and feedback/discussion and was included in the study as a nontechnological point of reference for DS-SST. Both experiments also evaluated the effects of treatment on on-task and talk-out behaviors. Results indicated a functional relation between DS-SST and compliance as well as on-task behaviors. The PA-SST experiment did not demonstrate a functional relation with compliance, but was associated with gains in on-task and a reduction in talk-out behaviors. A discussion is presented on the relationship between the DS-SST video-based elements and factors that promote generalization. Results also are related to the construct of stimulus control. Limitations and implications for future research are presented.

The strength-normalized fatigue endurance strength of the bulk metallic glass (BMG) Zr52.5Cu17.9Ni14.6Al10Ti5 (Vitreloy 105) has been reported to be the highest for any BMG; however, to date, there has been no explanation of why this material is so much better than other Zr-based compositions. In this study, the fatigue-crack growth behavior of Zr52.5Cu17.9Ni14.6Al10Ti5 was compared in ambient air vs dry nitrogen environment. The excellent fatigue life behavior is attributed to a relatively high fatigue threshold (ΔKTH ≈ 2 MPa√m) and a lack of sensitivity to environmental effects on fatigue-crack growth in ambient air, as compared to other Zr-based BMGs. Fatigue life experiments conducted in ambient air confirmed the excellent fatigue life properties with a 107-cycle endurance strength of ~0.24 of the ultimate tensile strength; however, it was also found that casting porosity, even in limited amounts, could reduce this endurance strength by as much as ~60 pct. Overall, the BMG Zr52.5Cu17.9Ni14.6Al10Ti5 appears to have excellent strength and fatigue properties and should be considered as a prime candidate material for future applications where good mechanical fatigue resistance is required.

Community food production in the form of home gardening, community gardening, school gar- dening, and urban farming continues to increase in popularity in many parts of the world. This interest has led to public and private investment in community food production and increased need for urban agricul- tural planning as a way to manage growth and prioritize resource allocation. Municipal planning and thoughtful institutional support for the practice will require program evaluation and greater attention to the spatial composition and configuration of this widely dispersed practice. This article explores the results of community-supported landscape socio-eco- logical research in Madison, WI (USA) to assess the spatial and social dynamics of community food production. Results indicate that community food production resources are unevenly distributed across the study area. Historic community garden placement does appear to be consistent with community priori- tization which dictates placing resources in areas with low median household income. However, home garden presence and recent community garden place- ment both occur in areas of higher than average median household income. Specific focus is placed on how an understanding of landscape placement and pattern has helped inform attempts to meet municipal and regional objectives in addressing urban food insecurity.

Abstract Several of Messiaen’s compositional techniques are designed, he says, to “eliminate temporality.” They succeed. Still, in a variety of highly original and interesting ways, the piece also sustains temporality. Joining the elimination of temporality with its opposite in each movement puts listeners onto the infinitesimal interface of the temporal and the eternal. The undoing and the redoing of temporality happen so differently in the various movements, however, that no procession from one movement to the next takes place. This absence of temporal coherence in the Quartet as a whole is an additional mode of eliminating temporality, but one that is, in Messiaen’s hands, joined to a strange and new kind of completeness. The salient characteristic of the latter is that while the completeness is authentic, and brings the satisfaction that is a quality of completions, it is radically open to further, though not necessarily surpassing, completions.

Therapeutic alliance is an established reliable predictor of successful therapy across patient populations and treatment modalities (e.g., Horvath & Symonds, 1991), including cognitive and behavioral (Waddington, 2002) and short-term dynamic (Crits-Christoph & Connolly, 1999) therapies. Benefits of a strong therapeutic alliance occur in face-to-face therapy, as well as therapies delivered over the phone or via the Internet (e.g., Cook & Doyle, 2004; Klein et al., 2009; Knaevelsrud & Maercker, 2007). Despite increasing use of various psychotherapies to improve cancer patients’ quality of life (e.g., Baik & Adams, 2011), studies of therapeutic alliance in therapies used with this population are limited (for a review, see Schnur & Montgomery, 2010). The present study evaluated the role of therapeutic alliance in telephone-administered cognitive-behavioral therapy (T-CBT) for the treatment of posttraumatic stress disorder (PTSD) symptoms in hematopoietic stem cell transplantation (HSCT) survivors. PTSD is experienced by a substantial proportion of HSCT survivors (Mosher et al., 2009), and often involves feelings of detachment from others, which may impede the ability to form a solid therapeutic alliance. The randomized trial (Duhamel et al., 2010) found that, compared to survivors in an assessment-only control group, those who completed T-CBT reported fewer illness-related PTSD symptoms, including less avoidance and fewer intrusive thoughts, as well as less general distress and fewer depressive symptoms. These benefits were maintained over a 12 month follow-up period. The present study examined the role of therapeutic alliance in these outcomes. We hypothesized that survivors who completed T-CBT would have greater decreases in PTSD symptoms, depressive symptoms, and general distress if they had high rather than low therapeutic alliance.

SummaryMicroRNAs (miRNAs) are small, noncoding RNAs that regulate gene expression posttranscriptionally. We investigated the hypothesis that bone morphogenetic protein (Bmp) signaling regulates miRNAs in cardiac progenitor cells. Bmp2 and Bmp4 regulate OFT myocardial differentiation via regulation of the miRNA-17-92 cluster. In Bmp mutant embryos, myocardial differentiation was delayed, and multiple miRNAs encoded by miRNA-17-92 were reduced. We uncovered functional miRNA-17-92 seed sequences within the 3′ UTR of cardiac progenitor genes such as Isl1 and Tbx1. In both Bmp and miRNA-17-92 mutant embryos, Isl1 and Tbx1 expression failed to be correctly downregulated. Transfection experiments indicated that miRNA-17 and miRNA-20a directly repressed Isl1 and Tbx1. Genetic interaction studies uncovered a synergistic interaction between miRNA-17-92 cluster and Bmp4, providing direct in vivo evidence for the Bmp-miRNA-17-92 regulatory pathway. Our findings indicate that Bmp signaling directly regulates a miRNA-mediated effector mechanism that downregulates cardiac progenitor genes and enhances myocardial differentiation.

SUMMARY Purpose To explore the use of disproportionality analysis of medication error data as a novel method to identify relationships that might not be obvious through traditional analyses. This approach can supplement descriptive data and target quality improvement efforts. Methods Data came from the Medication Error Quality Initiative (MEQI) individual event reporting system. Participants were North Carolina nursing homes who submitted incident reports to the Web-based MEQI data repository during the 2006 and 2007 reporting years. Data from 206 nursing homes were summarized descriptively and then disproportionality analysis was applied. Associations between medication type and possible causes at the state level were explored. A single nursing home was selected to illustrate how the method might inform quality improvement at the facility level. Disproportionality analysis of drug errors in this home was compared with benchmarking. Results Statewide, 59 drug-cause pairs met the disproportionality signal and 11 occurred in 10 or more reports. Among these, warfarin was co-reported with communication errors; esomeprazole, risperidone, and nitrofurantoin were disproportionately associated with transcription error; and oxycodone and morphine were disproportionately reported with name confusion. Facility-level analyses illustrate how descriptive frequencies and disproportionality analysis are complementary, but also identify different safety targets. Conclusions Exploratory analysis tools can help identify medication error types that occur at disproportionate rates. Candidate associations might be used to target patient safety work, although further evaluation is needed to determine the value of this information. Copyright # 2010 John Wiley & Sons, Ltd.

Background Students that enter pharmacy school have varying pre-pharmacy work experiences in a pharmacy setting. Pharmacy students often take a course that requires them to learn basic drug information on the Top 200 Drugs dispensed in the United States. Objective To examine the correlation between pre-pharmacy work experience and performance in a Top 200 Drugs course. Methods Pre-pharmacy student data were collected from a questionnaire that students completed the summer before their entrance into pharmacy school. Student grades were collected from a Top 200 Drugs course. This course is taken during the first and second semesters of the first professional year in pharmacy school. Correlation analyses were used to evaluate the relationship between pre-pharmacy work experience and course grades in a Top 200 Drugs course. Results Previous work experience is not a strong predictor of a student's grade in a Top 200 Drugs course. A significant correlation, however, was found between little or no pre-pharmacy work experience and receiving lower grades in a Top 200 Drugs course (α = 0.01, r = 0.284, t = 5.23). The lowest grades in the course were correlated to students who have little to no pre-pharmacy work experience. Conclusions The results of this study suggest that students who received the lowest final grades in the Top 200 Drugs course had little to no pre-pharmacy work experience.

Background: Medication errors are highly prevalent in long-term care facilities and are responsible for preventable injury. Repeat medication errors, or identical events occurring multiple times in the same patient, may be particularly preventable. Objectives: This study assessed the factors that contribute to repeat medication errors and the association between repeat medication errors and patient harm. Methods: In this cross-sectional analysis, medication error reports submitted by licensed nursing homes to North Carolina's Medication Error Quality Initiative-Individual Error Web-based incident reporting system were analyzed for fiscal years 2006–2008. When reporting errors, the sites were asked whether the event was identically repeated within the same patient. Repeat medication errors were defined as identical events in terms of patient characteristics, drug involved, error type, potential cause, phase of the medication care process, and personnel involved. Repeat errors were compared with nonrepeat errors. Multivariate logistic regression was used to explore whether certain patient or error characteristics were related to a higher likelihood of repeat errors, and a similar analysis was used to explore whether repeat errors were related to patient harm. Results: Of the total 15,037 errors reported by 294 unique nursing homes, 5615 (37.3%) were repeated one or more times. Among the repeat errors, the associated event within each error was repeated a mean (SD) of 10.7 (14.3) times. Wrong dosage (65.1% [3654/5615]) and wrong administration (10.2% [571/5615]) were the most frequent repeated events. In multivariate analysis, repeat errors occurred less frequently among younger residents (aged

Background Legislation enacted in the US State of North Carolina in 2003 requires all licenced nursing homes to report all medication errors. In 2007, nursing homes were encouraged to voluntarily convert from aggregate reporting to a new online system where they reported each individual error. Methods A new optional web-based reporting tool was made available to all 393 North Carolina nursing homes to submit error reports for each distinct medication error as they occurred during the year. Results A total of 5823 medication error reports were submitted by 203 sites (52%) using the new system during the reporting year, a median of 18 error reports per site. Of the 5823 error reports, 612 (10.5%) were categorised as serious. Serious errors were more likely to be caused by drugs given to the wrong patient (RR 4.39, CI 3.7 to 5.2), lab-work error (RR 2.40, CI 1.4 to 4.0), wrong product given (RR 2.22, CI 1.8 to 2.8) and medication overdoses (RR 1.49, 1.2 to 1.8). Serious errors were more likely to occur on second shift (RR 1.32, 1.1 to 1.5). Common medications that are involved in the most serious errors include warfarin (RR 2.58, CI 2.09 to 3.18) and insulin (RR 2.35, CI 1.86 to 2.97), and oxycodone combinations (RR 1.48, CI 1.07 to 2.06). Conclusions Data collected from a nursing home medication error system can provide helpful information on serious errors that can be used to focus patient safety efforts to reduce harm. This improved information will be useful in nursing homes for continuous quality improvement efforts.

Objective To gain insight into the perceived benefit of one continuous 10-week Advanced Community Pharmacy Practice Experience (ACPPE) versus two five-week ACPPEs, through qualitative focus group research. Methods Students were randomly assigned to spend either two five-week practice experiences at different community sites or one continuous 10-week rotation (at the same site) during their fourth professional year. Afterward, three student focus groups were convened to elicit responses to four questions related to: (1) optimal duration for an ACPPE, (2) description of the community care project they delivered, (3) students' perceived advantages or disadvantages of their sites, and (4) barriers to successfully completing a community care project. Results Students unanimously preferred two five-week rotations. Pharmacies with supportive staff and preceptors, ample space, pharmacy residents, or MTM programs were perceived advantages. There was a variety of community care projects developed. The most frequently reported barrier to the ACPPE project involved the preceptor's limited support of the project, unwillingness to continue the project long-term, or not communicating the purpose of the project to pharmacy staff. Other barriers included physical design of the pharmacy, both high and low prescription volume, and poor support from pharmacy management in chain pharmacies. Conclusion Improvements to ACPPE sites, including preceptor training and elimination of barriers to the development of the ACPPE project, might change student perception and thus should be implemented before replacing two shorter experiences within the 10-week rotation.

Background The introduction of limited explorations (LE) for parathyroidectomy broadened the management possibilities for hyperparathyroidism. We sought to document this evolution of change in parathyroid surgery. Study Design Members of the American Association of Endocrine Surgeons and the American College of Surgeons were sent a 49-question survey, and 256 surgeons, accounting for 46% of parathyroid operations nationwide, responded. Associations derived from questionnaire data were tested for significance using chi-square and Kruskal-Wallis methods. Results Currently, 10% of surgeons practice bilateral neck exploration, 68% practice LE, and 22% have a mixed practice. Five years ago, these percentages were, respectively, 26%, 43%, and 31%; and 10 years ago they were 74%, 11%, and 15%. Shift to LE was greatest among endocrine surgeons, high-volume surgeons, and surgeons trained by mentors who practiced LE. A focal, single-gland examination under general anesthesia and 23-hour observation are preferred by most surgeons. Half of all general surgeons, in contrast to fewer than 10% of endocrine surgeons, never monitor parathyroid hormone intraoperatively, even with LE. Dramatic differences were apparent among subsets of surgeons in operative volumes, indications for bilateral neck exploration, followup care, expertise with ultrasound and sestamibi, and perceptions of cure and complication rates. Evidence-based literature and guidance from surgical societies had the greatest influence on the decision to practice LE. Conclusions This survey formally documents the evolution of practice patterns in parathyroid surgery over the last decade. Although LE has achieved wide acceptance, surgical management of hyperparathyroidism has become increasingly disparate. This trend may highlight a need to define best-practice guidelines.

We sought to explore optimism/pessimism, knowledge of HIV, and attitudes toward HIV screening and treatment among Ghanaian pregnant women.Pregnant women in Accra, Ghana, completed a self-administered questionnaire including the Life Orientation Test-Revised (LOT-R, an optimism/pessimism measure), an HIV knowledge and screening attitudes questionnaire, the Short Form 12 (SF-12, a measure of health-related quality of life [HRQOL]), and a demographic questionnaire. Data were analyzed using t-tests, ANOVA, correlations, and the chi2 test.There were 101 participants; 28% were nulliparous. Mean age was 29.7 years, and mean week of gestation was 31.8. All women had heard of AIDS, 27.7% had been tested for HIV before this pregnancy, 46.5% had been tested during this pregnancy, and 59.4% of the sample had ever been tested for HIV. Of those not tested during this pregnancy, 64.2% were willing to be tested. Of all respondents, 89% said they would get tested if antiretroviral drugs (ARVs) were readily available and might prevent maternal-to-child transmission. Neither optimism/pessimism nor HRQOL was associated with attitudes toward HIV screening. Optimism was negatively correlated with HIV knowledge (p = .001) and was positively correlated with having never been tested before this pregnancy (p = .007).The relationship between optimism/pessimism and HIV knowledge and screening behavior is worthy of further study using larger samples and objective measures of testing beyond self-report.

Objective: To describe the implementation and evaluation of a web-based medication error reporting system. Design: Evaluation study. Setting: Long-term care. Participants: 25 nursing homes in the US state of North Carolina. Intervention: Detailed information about all medication errors occurring in a facility during a 1 year period was entered into a web-based reporting system. An evaluation survey was conducted to assess usability and the potential for the system to prevent errors. Main outcome measures: Number and specific characteristics of medication errors reported. A survey evaluating ease of use of the system and whether the participants thought it would help improve medication safety. Results: 23 (92%) sites entered 631 error reports for 2731 discrete error instances when weighted by the number of times the errors were repeated. 51 (8%) errors were classified as having a serious patient impact requiring monitoring/intervention or worse. The most common errors were dose omission (203, 32%), overdose (91, 14%), underdose (43, 7%), wrong patient (38, 6%), wrong product (38, 6%), and wrong strength (38, 6%). Errors most commonly occurred during medication administration (296, 47%) and were attributed to basic human error (402, 48%). Seven drugs were implicated in a third (175, 28%) of all errors: lorazepam, oxycodone, warfarin, furosemide, hydrocodone, insulin and fentanyl. 20 sites (86% of respondents) completed the evaluation survey and participants found the system easy to use and thought it would increase accuracy of reporting and improve patient safety. Conclusions: The web-based medication error reporting system was easy to use, with strong indications that it would be a valuable tool for preventing future errors.

Medication errors are an important problem in nursing homes, but little is known about the types of medications involved in errors in this setting. Gaining a better understanding of the types of medications commonly involved in medication errors in nursing homes would be an important step toward quality improvement.This study sought to describe the types of medication errors most frequently reported to a statewide repository by North Carolina nursing homes. We also examined whether nursing homes reporting an error involving a drug on the updated Beers list of medications considered potentially inappropriate for use in the elderly were likely to report a greater number of medication errors or more harmful medication errors compared with nursing homes that did not report such an error.Medication errors were defined as preventable events that had the potential to cause/lead to or actually caused/led to inappropriate medication use or patient harm. We analyzed summary reports of medication errors submitted to the State of North Carolina by licensed nursing homes for the 9-month period from January 1, 2004, to September 30, 2004, using a Web-based reporting system. Drugs commonly involved in medication errors were summarized for all nursing homes in the state. Errors involving medications on the updated Beers list also were identified. Nursing homes were profiled and compared according to the type of medication error and whether the error reached the patient and/or caused harm.Among the 384 licensed nursing homes included in our analysis, 9272 medication errors were reported. The specific medication involved was documented for 5986 of these errors. The medications most commonly involved in an error were lorazepam (457 errors [8%]), warfarin (349 [6%]), insulin (332 [6%]), hydrocodone and hydrocodone combinations (233 [4%]), furosemide (173 [3%]), and the fentanyl patch (150 [3%]). The medication errors disproportionately included central nervous system agents (16%) and analgesics (11%). Medications considered potentially inappropriate in the elderly were frequently involved in the reported errors (10% of all reported errors), with the greatest number of such errors associated with lorazepam (457 [8%]), alprazolam (130 [2%]), and digoxin (74 [1%]). Nursing homes reporting potentially inappropriate drugs among their 10 most common medication errors also reported a significantly greater mean number of errors compared with nursing homes that did not report such errors (26.9 vs 17.6, respectively; P0.001), as well as a significantly greater number of errors that reached the patient (6148 vs 1393; P0.001).Based on the experience in North Carolina, quality improvement efforts in nursing homes should focus on the medications commonly involved in errors and should continue to discourage or closely monitor the use of medications considered potentially inappropriate in the elderly.

Memory latency dominates the performance of many applications on modern processors, despite advances in caches and prefetching techniques. Numerous prefetching techniques, both in hardware and software, try to alleviate the memory bottleneck. One such technique, known as helper threading improves single-thread performance on a simultaneous multithreaded architecture (SMT), which shares processor resources, including caches, among logical threads. It uses otherwise idle hardware thread contexts to execute speculative threads on behalf of the main thread. Helper threading accelerates a program by exploiting a processor's multithreading capability to run assist threads. Based on the helper threading usage model, virtual multithreading (VMT), a form of switch-on-event user-level multithreading, can improve performance for real-world workloads with a wall-clock speedup of 5.0 to 38.5 percent

Individual, group, and family counseling are invariably included in bullying prevention programs and strategies. Nevertheless, if bullying is treated exclusively as a problem between bullies and victims or as a family problem, counseling efforts will have limited impact. Counseling strategies must be articulated within a systemic approach to bullying in schools. In particular, the roles that students and adults play in actively or passively reinforcing bullying behavior must be addressed through school-wide and family efforts to change the norms and climate with respect to bullying. The pertinent literature is reviewed and steps to implement a systemic prevention strategy are outlined.

We consider toy cosmological models in which a classical, homogeneous, spinor field provides a dominant or sub-dominant contribution to the energy-momentum tensor of a flat Friedmann-Robertson-Walker universe. We find that, if such a field were to exist, appropriate choices of the spinor self-interaction would generate a rich variety of behaviors, quite different from their widely studied scalar field counterparts. We first discuss solutions that incorporate a stage of cosmic inflation and estimate the primordial spectrum of density perturbations seeded during such a stage. Inflation driven by a spinor field turns out to be unappealing as it leads to a blue spectrum of perturbations and requires considerable fine-tuning of parameters. We next find that, for simple, quartic spinor self-interactions, non-singular cyclic cosmologies exist with reasonable parameter choices. These solutions might eventually be incorporated into a successful past- and future-eternal cosmological model free of singularities. In an Appendix, we discuss the classical treatment of spinors and argue that certain quantum systems might be approximated in terms of such fields., Comment: 12 two-column pages, 3 figures; uses RevTeX4

A programmable network architecture makes it possible to speed up the introduction of new protocols to support improved quality of service for wireless networks. But the size of each dynamically downloaded protocol can have an impact on network performance. The authors compare software and hardware implementations from a network-performance perspective.

North Carolina State University (NCSU) is a Research Intensive (Research I) university located in Raleigh, the state capital. A land grant institution, it currently has a faculty of 1685 and a student body of 29,637. Established in 1887 as an agricultural and engineering college, it is now a comprehensive university offering bachelor's degrees in 92 fields in nine colleges: Agriculture and Life Sciences, Design, Education, Engineering, Humanities and Social Sciences, Management, Natural Resources, Physical and Mathematical Sciences, and Textiles.

The ability of cloze tests containing frequent, every n-th word deletions to measure comprehension of macropropositions has been challenged on both theoretical and empirical grounds, calling into question the validity of such tests for assessing comprehension of much of the discourse encountered by university-level students. To evaluate the comprehension of a writer’s reasoning, it is recommended that cloze tests position gaps so as to target recognition of cohesive devices and the ability to draw inferences from other sentences. To test the validity of such a design, a large sample of scores on discourse cloze tests administered in introductory college economics is compared to scores on true–false comprehension tests designed to target recognition of connective propositions. The two distributions of scores do not differ significantly in terms of mean value, dispersion or frequency distribution, suggesting that appropriately designed cloze tests can provide a valid assessment of the reader’s integration of theoretical text. In addition, the usefulness of readability formulas based on surface characteristics of text is challenged when readability is defined in terms of the difficulty of constructing a coherent representation of theoretical text.

Liesegang rings are laminated ring-like structures occasionally found in benign cysts and abscesses. They have been confused with parasites (especially eggs), algae, calcifications, and psammoma bodies. We examined Liesegang rings from fine-needle aspiration (FNA) biopsies of a benign cyst of the breast and a complex renal cyst. Liesegang rings were best observed with Papanicolaou, hematoxylin-eosin, Masson's trichrome, acid-fast (AFB), and Gram stains, which accentuate the concentrically laminated morphology. An amorphous electron-dense core and fibrillary lucent concentric rings were seen with transmission electron microscopy with no significant energy peaks by electron probe microanalysis or distinct diffraction patterns by X-ray diffraction. This investigation indicates that Liesegang rings are composed of organic substances most likely formed by periodic precipitation from a supersaturated solution within cystic fluid. Awareness of the Liesegang phenomenon within cystic lesions will decrease the possibility of erroneous misdiagnosis as another type of pathologic process. Diagn. Cytopathol. 1998;19:116–119. © 1998 Wiley-Liss, Inc.

In the 1960s, effective techniques were developed for shunting hydrocephalus and for early closure of neural tube defects. As a result, orthopaedic surgeons were presented with the challenge of managing an emerging population of children who had myelomeningocele. Initially, the musculoskeletal problems in these children were treated with the modalities and expectations that had been learned from the treatment of poliomyelitis. However, it soon became apparent that the management of children who have myelomeningocele was not so simple. Additional factors include a decrease or loss of sensation affecting some or all parts of the lower extremities, associated congenital anomalies of the spine and lower extremities, and muscle imbalance that affects skeletal development over the entire period of growth. Furthermore, some patients who have myelomeningocele have a static encephalopathy that impairs coordination and results in the loss of strength of the lower and upper extremities29,30,45. Also, progressive neurological deterioration may occur because of tethered cord syndrome or syringomyelia2. As a result, the evaluation and treatment of musculoskeletal problems in these patients can be quite difficult. The purpose of this Instructional Course Lecture is to review the natural history of myelomeningocele as well as the types of deformity that are associated with it, the treatment options that are available, and the expected results of treatment of hip and knee problems related to myelomeningocele. Although other factors must be considered, the neurological level is the key to understanding the hip and knee deformities seen in these patients. Unless otherwise specified, a modification of the classification system described by Asher and Olson3 will be used to define the neurological level (Table I). This classification is based on muscle strength, is simple to use, and, in my experience, has been helpful in predicting gross motor function …

We evaluated the ability of L-deprenyl, a monoamine oxidase B-inhibitor (MAO-B), to preserve the viability of serum-deprived immortalized retinal precursor cells in vitro. We serum-deprived rat neural retinal ganglion cells immortalized by an incompetent retro virus. We instilled L-deprenyl in concentrations ranging from 0.01 to 100 microM. After 72 hours we performed a cell count of the L-deprenyl cultures and the control (no L-deprenyl instilled) with a hemocytometer and flow cytometry. We used transmission electron microscopy, DNA gel electrophoresis, and flow cytometry to determine the mechanism of cell death. This study showed that all five concentrations of L-deprenyl statistically increased the survival rate of immortalized retinal precursor cells at 72 hours in the serum-deprived medium (P = 0.01, ANOVA test). Ten microM and higher appeared to provide the greatest immortalized retinal precursor cell survival (12.7 x 10(-4) cells) compared to the control (5.8 x 10(-4) cells). Flow cytometry also demonstrated a higher percentage of surviving cells at 10 microM (80%) and 100 microM (76%) than with the control (58%) (P = 0.0017, chi2 test). Transmission electron microscopy, DNA electrophoresis, and flow cytometry showed that the mode of cell death was by apoptosis. This study suggests that L-deprenyl may be worthy of further investigation as a neuroprotective agent to treat chronic open-angle glaucoma.

Questions as to the bioreactivity of silicone breast implants (SBIs) have recently been intensely scrutinized, most notably by the media and legal system. Pathologists must be aware of the controversy and treat each SBI and associated tissue as a potential lawsuit. Grossly, silicone is a clear, viscous substance that may be observed either within or extruding from a silastic bag. By light microscopy, silicone is a nonstainable, nonpolarizable, refractile substance. Thicker sections, especially when viewed by non-Köhler illumination, phase-contrast, and darkfield microscopy will enhance visualization. Ultrastructurally, silicone is an electron-dense, amorphous substance often located within phagocytic vacuoles or extracellularly within the stroma. Correlating electron probe microanalysis allows for reliable identification. In most cases, a fibrous capsule surrounds the SBI, with the interface lining varying from a virtually acellular to a synovial-like lining composed of phagocytic and secretory cells. Silicone can often be identified within the fibrous capsule and also in distant tissues biopsied for suspected autoimmune disorders, such as synovium, skin, and lymph nodes, often without ultrastructural evidence of cytologic effects. This study has demonstrated that silicone accumulates at distant tissue sites due to preexisting inflammation acting as a stimulus. Thus, silicone is not a primary inducer of inflammatory disease processes. These findings are supported by various large epidemiologic studies.