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Examine feasibility and construct validity of Pictorial fit frail scale (PFFS) for the first time in older surgical patients.The PFFS uses visual images to measure health state in 14 domains and has been previously validated in outpatient geriatric clinics.Patients ≥65 year-old who were evaluated in a multidisciplinary thoracic surgery clinic from November 2020 to May 2021 were prospectively included. Patients completed an in-person PFFS and Vulnerable Elders Survey (VES-13) during their visit, and a frailty index was calculated from the PFFS (PFFStrans). A geriatrician performed a comprehensive geriatric assessment (CGA) either in-person or virtually, from which a Frailty Index (FI-CGA) and FRAIL scale were obtained. To assess the validity of the PFFS in this population, the Spearman's rank correlations (rspearman) between PFFStrans and VES-13, FI-CGA, FRAIL were calculated.All 49 patients invited to participate agreed, of which 46/49 (94%) completed the PFFS so a score could be calculated. The majority of patients (59%) underwent an in-person CGA and the reminder (41%) a virtual CGA. The cohort was mainly female (59.0%), with a median age of 77 (range: 67-90). The median PFFStrans was 0.27 (IQR 0.12-0.34), PFFS was 11 (IQR 5-14) and 0.24 (IQR 0.13-0.32) for FI-CGA. We observed a strong correlation between the PFFStrans and FI-CGA (rspearman = 0.81, p0.001) and a moderate correlation between PFFStrans and VES-13 and FRAIL score (rspearman 0.68 and 0.64 respectively, p0.001).PFFS had good feasibility and construct validity among older surgical patients when compared to previously validated frailty measurements.

To investigate perioperative outcomes of esophagectomies by age groups. Retrospective analysis of esophageal cancer patients undergoing esophagectomy from 2005 to 2020 at a single academic institution. Baseline characteristics and outcomes were analyzed by 3 age groups:70, 70-79, and ≥80 years-old. Sub-analysis was done for 2 time periods: 2005-2012 and 2013-2020. Of 1135 patients, 789 patients were70, 294 were 70-79, and 52 were ≥80 years-old. Tumor characteristics, and operative technique were similar, except positive longitudinal margins rates (all3%) (P = 0.008). Older adults experienced increased complications (53.6% vs 69.7% vs 65.4% respectively; P0.001) attributable to grade II complications (41.4% vs 62.2% vs 63.5% respectively; P0.001). Hospital length of stay (LOS) and rehabilitation requirements were higher in older adults (both P0.05). 30-day readmissions, reoperation, and 30-day mortality rates (all2%) showed no association with age group. Overall complications, LOS, discharge disposition and re-operative rates improved from 2005 to 2012 to 2013-2020 for all (P0.05). Increasing age was an independent risk factor for cardiovascular complications (OR 1.7, 95% CI 1.23-2.46 for ages 70-79 and OR 2.7, 95% CI 1.37-5.10 for ages ≥80 ), inpatient rehabilitation (OR 3.3, 95% CI 2.26-5.05 for ages 70-79 and OR 12.1 95% CI 5.83-25.04 for ages ≥80), and prolonged LOS (OR 1.64 95% CI 1.16-2.31 for ages 70-79 and OR 3.6 95% CI 1.71-7.67 for ≥80. After adjusting for time period, older age remained associated with complications (P0.05). Highly selected older adults at a large volume esophagectomy center can undergoesophagectomy with increased minor complication and rehabilitation needs.

Important trade-offs of risks versus benefits of surgery need to be discussed with older adults, in particular nonagenarians who are candidates for surgery. Data that examine specific outcomes of surgical interventions in this age group are sparse. We aimed to evaluate the clinical presentation and postoperative outcomes of nonagenarians undergoing surgery.A retrospective cohort study of consecutive patients 90 years of age and older who underwent surgery between 2014 and 2018 in general surgical ward of a large-volume academic center. Subgroups were designed according to type of surgery (elective versus emergency surgery) and diagnosis (oncology versus non-oncology). Preoperative assessments included Malnutrition Universal Screening Tool, Norton Scale, Morse Scale, Katz, and Lawton-Brody indices.A total of 198 nonagenarians underwent surgery, of which 38% were elective and 62% were emergency surgery. Median follow-up was 26 months. More patients in the elective group compared with the emergency group had oncology diagnoses (42.1% and 14.7%, respectively, P.001), resided preoperatively at home (93.4% and 77.9%, respectively, P = .003), and were functionally independent (71.1% and 41.8%, respectively, P = .0005). Postoperative 30-day mortality frequency was 6.6% in the elective group and 39.3% in the emergency group (P.001). Two-year survival frequency of non-oncology group was 72.7% in elective surgeries and 40.6% in emergency surgeries (P.001). Two-year survival frequency of oncology group was 37% in elective surgeries and 27.8% in emergency surgeries (P = .12).Elective surgery in adults aged 90 and above can be safely performed with acceptable 2-year outcomes. Emergency surgery for oncology diagnoses carries dismal outcomes, so palliative approaches should be considered.

BACKGROUND: Patterns of overall and disease-free survival after esophagectomy for esophageal cancer in older adults have not been carefully studied. METHODS: Retrospective analysis of all patients with esophageal cancer undergoing esophagectomy from 2005 to 2020 at our institution was performed. Differences in outcomes were stratified by age groups, < 75 and ≥ 75 years old, and two time periods, 2005–2012 and 2013–2020. RESULTS: A total of 1135 patients were included: 979 (86.3%) patients were < 75 (86.3%), and 156 (13.7%) were ≥ 75 years old. Younger patients had fewer comorbidities, better nutritional status, and were more likely to receive neoadjuvant and adjuvant therapy (all p < 0.05). However, tumor stage and operative approach were similar, except for increased performance of the McKeown technique in younger patients (p = 0.02). Perioperatively, younger patients experienced fewer overall and grade II complications (both p < 0.05). They had better overall survival (log-rank p-value < 0.001) and median survival, 62.2 vs. 21.5 months (p < 0.05). When stratified by pathologic stage, survival was similar for yp0 and pathologic stage II disease (both log-rank p-value > 0.05). Multivariable Cox models showed older age (≥ 75 years old) had increased hazard for reduced overall survival (HR 2.04 95% CI 1.5–2.8; p < 0.001) but not disease-free survival (HR 1.1 95% CI 0.78–1.6; p = 0.54). Over time, baseline characteristics remained largely similar, while stage became more advanced with a rise in neoadjuvant use and increased performance of minimally invasive esophagectomy (all p < 0.05). While overall complication rates improved (p < 0.05), overall and recurrence-free survival did not. Overall survival was better in younger patients during both time periods (both log-rank p < 0.05). CONCLUSIONS: Despite similar disease-free survival rates, long-term survival was decreased in older adults as compared to younger patients. This may be related to unmeasured factors including frailty, long-term complications after surgery, and competing causes of death. However, our results suggest that survival is similar in those with complete pathologic responses.

We assessed frailty, measured by a comprehensive geriatric assessment-based frailty index (FI-CGA), and its association with postoperative outcomes among older thoracic surgical patients.Patients aged ≥65 years evaluated in the geriatric-thoracic clinic between June 2016 through May 2020 who underwent lung surgery were included. Frailty was defined as FI-CGA 0.2, and "occult frailty", a level not often recognized by surgical teams, as 0.2 FI-CGA 0.4. A qualitative analysis of geriatric interventions was performed.Seventy-three patients were included, of which 45 (62%) were nonfrail and 28 (38%) were frail. "Occult frailty" was present in 23/28 (82%). Sixty-one (84%) had lung malignancy. Geriatric interventions included delirium management, geriatric-specific pain and bowel regimens, and frailty optimization. More sublobar resections versus lobectomies (61% vs. 25%) were performed among frail patients. Frailty was not significantly associated with overall complications (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 0.88-6.44; p = 0.087), major complications (OR: 2.33; 95% CI: 0.48-12.69; p = 0.293), discharge disposition (OR: 2.8; 95% CI: 0.71-11.95; p = 0.141), or longer hospital stay (1.3 more days; p = 0.18).Frailty and "occult frailty" are prevalent in patients undergoing lung surgery. However, with integrated geriatric management, these patients can safely undergo surgery.

Geographic and socioeconomic factors impact patient treatment choices for certain cancers. Whether they impact treatment in older adults with lung cancer is unknown. We investigated geographic differences in treatment for stage I non-small-cell lung cancer (NSCLC) in older adults in the United States.Using the Surveillance, Epidemiology and End Results Database 18th submission, a cohort of stage I NSCLC patients ≥60-years-old was created. Treatment differences (surgery or radiation alone) by geographic location and socioeconomic factors were analyzed.Forty-three thousand three hundred and eighty-seven stage I NSCLC patients were analyzed. Demographics and socioeconomic factors varied across all 13 states (p 0.001). Surgery was the most common treatment in all states (range 58.6% in AK to 86.5% in CT) (all p 0.001). Our multivariable analysis found older individuals had higher odds of getting radiation as compared to surgery (odds ratio [OR]: 1.22 for 65-69 years-old to OR: 8.95 for 85+ years-old; p 0.001). Multiple states (LA, HI, IA, MI, WA, NM) were associated with increased odds of radiation use (vs. surgery alone) (all p 0.05). People with lower education level (OR: 0.98) and median income (OR: 0.99) and non-Black race (OR: 0.52 for "other" to OR: 0.68 for "White" race with respect to Black race) were associated with lower odds of radiation (p 0.05).Our study identified treatment differences for stage I NSCLC patients in the United States related to demographics, socioeconomic factors, and geographic location.

Background/Aims: The novel coronavirus SARS-CoV-2 has caused a pandemic threatening millions of people worldwide. This study aimed to describe clinical characteristics, outcomes, and risk factors of SARS-CoV-2-positive, asymptomatic, frail older adults. Methods: A retrospective cohort study was conducted in 6 designated COVID-19 units, in skilled nursing homes. Subjects were severely frail older adults, positive for SARS-CoV-2, and asymptomatic at the time of their admission in these units. Residents’ characteristics and symptoms were obtained via electronic medical records. The primary outcome was a composite of death or hospitalization by day 40. We looked at time to the primary outcome and used Cox regression for a multivariate analysis. Results: During March–November 2020, 849 residents met inclusion criteria. Median age was 84 years. Most were completely dependent for basic activities of daily living and showed cognitive impairment. Six hundred forty-one (75.5%) residents were discharged after considered cured from COVID-19, 125 (14.7%) were hospitalized, and 82 (9.7%) died in the facilities. In survival analysis, 35% reached the primary outcome of death or hospitalization by day 40. Age (hazard ratio [HR] 1.23; 95% confidence interval [CI] 1.1–1.4), male gender (HR 1.41; 95% CI: 1.1–1.88), and COPD (HR 1.8; 95% CI: 1.23–2.67) were significant risk factors. Conclusions: In this large cohort, we report care and prognosis of asymptomatic older adults with major functional or cognitive impairments during the COVID-19 pandemic. Most presymptomatic patients do not develop severe infection, and age stays a predominant risk factor, even in the frailest older adults.

Population divergence and gene flow are key processes in evolution and ecology. Model-based analysis of genome-wide datasets allows discrimination between alternative scenarios for these processes even in non-model taxa. We used two complementary approaches (one based on the blockwise site frequency spectrum (bSFS), the second on the Pairwise Sequentially Markovian Coalescent (PSMC)) to infer the divergence history of a fig wasp,Pleistodontes nigriventris. Pleistodontes nigriventrisand its fig tree mutualistFicus watkinsianaare restricted to rain forest patches along the eastern coast of Australia, and are separated into northern and southern populations by two dry forest corridors (the Burdekin and St. Lawrence Gaps). We generated whole genome sequence data for two haploid males per population and used the bSFS approach to infer the timing of divergence between northern and southern populations ofP. nigriventris,and to discriminate between alternative isolation with migration (IM) and instantaneous admixture (ADM) models of post divergence gene flow.Pleistodontes nigriventrishas low genetic diversity (π = 0.0008), to our knowledge one of the lowest estimates reported for a sexually reproducing arthropod. We find strongest support for an ADM model in which the two populations divergedca. 196kya in the late Pleistocene, with almost 25% of northern lineages introduced from the south during an admixture eventca.57kya. This divergence history is highly concordant with individual population demographies inferred from each pair of haploid males using PSMC. Our analysis illustrates the inferences possible with genome-level data for small population samples of tiny, non-model organisms and adds to a growing body of knowledge on the population structure of Australian rain forest taxa.

Advanced understanding of the molecular pathways of oncologic diseases has shifted therapeutic treatment development to focus on mechanism of actions targeting specific genomic alterations. These precision medicines are indicated for patient subsets defined by these specific mutations as determined by diagnostic devices approved by the Food and Drug Administration (FDA). The Intended Use section within the companion diagnostic (CDx) labeling has historically specified the therapeutic products for which they have been clinically validated. In April 2020, the FDA reiterated their position that therapeutic class labeling may be used, if appropriate, instead of named products. Labels for FDA approved in vitro CDxs were reviewed to evaluate the implementation of therapeutic class labeling. A total of 47 devices have been approved as of 2 January 2022, of which 3 labels were found to contain therapeutic class labeling: two devices targeting EGFR mutations for the treatment of non-small cell lung cancer (NSCLC), and one targeting BRAF V600E and BRAF/MEK inhibitor combinations for melanoma. Two devices received therapeutic class labeling upon initial approval, while the third implemented the language though a label revision. A total of 25 different indications were identified across the 47 CDx devices, of which 9 (34.6%) were associated with more than 1 CDx device. Implementation of therapeutic class labeling has been slow following the release of the FDA’s April 2020 guidance; however, the potential to incorporate such language into existing and newly approved CDx labels exists. Precedence and manufacturer experience are expected to drive an increase in therapeutic class labeling.

Photographs taken by Gertrude Bell during her 1909 and 1911 archaeological trips to Mesopotamia provide not only a valuable record of sites, monuments, and landscapes that have suffered near or complete destruction over the past one hundred years, they also provide insight into the mindset, aims, and agendas Bell held when she produced these images. Her photographs taken at two sites in particular, Assur and Ukhaidir, highlight some of her attitudes and motivations at the time. On the one hand, in the case of Assur, the photos reflect her admiration for her European archaeological colleagues' skill at excavation and concede their claim to the ancient city's glorious past. On the other hand, the photographs highlight her efforts to showcase her own archaeological knowledge. Many also reflect a sympathetic stance towards the people of modern Mesopotamia, acknowledging their vital presence and often regarding them as the inheritors of the country's rich ancient legacy.

OBJECTIVES: Walking is older adults’ second most preferred mode of transport and preferred recreational activity. This leads to greater exposure to traffic, increasing their risk of pedestrian-vehicle crashes, with older adults being more likely to die as a pedestrian when compared to other modes of transport. However, less focus has been placed on this particularly vulnerable group. This review summarises issues associated with older adult pedestrian and motorised mobility scooters (MMS) safety and interventions that have been conducted. METHODS: A literature search was undertaken from Pub Med, MUARC publications, Curtin University Library Catalogue and Google Scholar. Keywords included older pedestrians, older adult road injury, mobility scooter injury, and injury prevention. Publications from 2000 onwards were used, unless an earlier publication had significant relevance and worth. CONCLUSION: Maintaining older adults’ mobility and independence during a time of decreasing physical and mental capacity is a priority. Walking provides a key mode of transport that needs to be given higher priority within the road environment by policy makers, transport planners and drivers. Therefore governments need to consider appropriate and comprehensive urban planning and road safety policies that accommodate ‘active ageing’ to provide pedestrians and MMS users with environments that facilitate active living and safe transport. In addition there is a need for community programs that raise awareness about safe road crossing for this growing vulnerable age group.

Purpose The purpose of this study was to assess the maximal dose area product (DAP) of radiation received by women during hip arthroscopy; we used computer modeling to determine the theoretical risk to a fetus. Methods We studied 116 female patients of childbearing age who underwent hip arthroscopy. We retrospectively collected data from the procedure, hip pathologic process, and dose of irradiation in milligray. We calculated the theoretical dose of radiation to the fetus and the risk of childhood hereditary disease and cancer. Results Labral tear (52%) was the most common indication for hip arthroscopy, with labral resection the most common procedure undertaken. The maximal DAP to the patient was 9.52 mGy, and the maximal DAP was estimated to be 2.99 mGy to the fetus. The risk of hereditary disease and childhood cancer for the fetus was calculated to be 1 in 14,000 and 1 in 11,000, respectively. Conclusions Fluoroscopy used in hip arthroscopy generates a maximal theoretical dose of 2.99 mGy to the fetus, which places the procedure in the low-risk category. Level of Evidence Level IV, therapeutic case series.

Letters sent from the German scholar Ernst Herzfeld to Gertrude Bell between 1909 and 1912 provide valuable information about the scholarship of these remarkable characters as they explored issues pertaining to the development of early Islamic art and architecture in Mesopotamia. Through a spirited and often fractious exchange of ideas about a range of artistic and architectural topics that included vaulting techniques, the design of early mosques and palace forms, one can track the impact each had upon the other's scholarship, and the degree to which their respective views shaped one another's conclusions about important Islamic period sites such as Samarra and Ukhaidir.

Prophylaxis for hospitalized venous-thromboembolic events (VTEs) is frequently underutilized, in part due to lack of a simple risk assessment model (RAM).To compare patient selection and administration of VTE prophylaxis according to the American College of Chest Physicians (ACCP) 2008 guidelines versus the newer 2012 guidelines, and assess the feasibility of developing simpler local RAMs.We conducted a prospective assessment of VTE risk among 300 unselected consecutive patients admitted to a medical hospital ward, using the 2008 and 2012 ACCP guidelines. The frequency and relative weight of each risk factor in the 2012 ACCP guidelines were used to develop a local VTE RAM.VTE prophylaxis was indicated by the 2008 and 2012 ACCP guidelines in 40% and 42% of the cohort respectively, and was administered in 28% and 26% of eligible patients, respectively. Contraindication to VTE prophylaxis was found in 29% of patients according to both guidelines. In comparison to the 2008 guidelines, sensitivity and specificity of the 2012 guidelines were 96% and 88%, respectively. A local RAM based on the following concise score, comprising age, malignancy and immobility, correctly identified 99% of at-risk patients based on the 2012 guidelines, with a sensitivity and specificity of 98% and 95%, respectively.Both guidelines performed to a similar degree and were poorly implemented in daily practice. A simplified RAM accurately identified the vast majority of these eligible patients. The development of local RAMs is feasible and may result in higher utilization rates.

Gilles de la Tourette syndrome is a complex neuropsychiatric disorder with a strong genetic basis. We identified a male patient with Tourette syndrome-like tics and an apparently balanced de novo translocation [46,XY,t(2;7)(p24.2;q31)]. Further analysis using array comparative genomic hybridisation (CGH) revealed a cryptic deletion at 7q31.1-7q31.2. Breakpoints disrupting this region have been reported in one isolated and one familial case of Tourette syndrome. In our case, IMMP2L, a gene coding for a human homologue of the yeast inner mitochondrial membrane peptidase subunit 2, was disrupted by the breakpoint on 7q31.1, with deletion of exons 1-3 of the gene. The IMMP2L gene has previously been proposed as a candidate gene for Tourette syndrome, and our case provides further evidence of its possible role in the pathogenesis. The deleted region (7q31.1-7q31.2) of 7.2 Mb of genomic DNA also encompasses numerous genes, including FOXP2, associated with verbal dyspraxia, and the CFTR gene.

Adenovirus (Ad) is an efficient and safe vector for CNS gene delivery since it infects non-replicating neurons and does not cause insertional mutagenesis of host cell genomes. However, the promiscuous Ad CAR receptor targets cells non-specifically and activates a host immune response. Using Ad5 containing an expression cassette encoding the gene for green fluorescent protein, gfp, regulated by the neuron specific promoter synapsin-1 and the woodchuck post-transcriptional regulatory element (WPRE), we demonstrate efficient, prolonged and promoter-restricted gfp expression in neurons of mixed primary adult rat dorsal root ganglion (DRG) and retinal cell cultures. We also demonstrate restricted gfp expression in DRG neurons after direct injections of Ad5 containing the synapsin-1(gfp)/WPRE construct into L4 DRG in vivo, while Ad5 CMV(gfp) transfected both DRG glia and neurons. Moreover, since the effective titres of delivered Ad5 are reduced with this neuron specific promoter/WPRE expression cassette, the viral immune challenge should be attenuated when used in vivo.

Background The best treatment for dorsally displaced distal radius fracture is still debated. The aim of our study is to use the patient rated wrist evaluation (PRWE) and Euroqol functional outcome scores to look at patients’ function for a minimum of 1 year from the fracture. This is our pilot study to inform a multinational randomized controlled trial (RCT).

Epidemiologic studies of sleep disturbances and mood disorders that may provide more valid estimates of associations between these two conditions than clinical samples due to differential use of health care services. Increasing uniformity of questionnaires to assess sleep disturbances has decreased the variance in estimates of insomnia and hypersomnia within community samples. Women are more likely to report insomnia than men in every age group. There appear to be no clear racial or ethnic differences in rates of insomnia or hypersomnia. Several community-based studies have found that sleep disturbances are powerful risk factors for the development of new episodes of major depression in the following year. Individuals who report insomnia or poor quality sleep may be at higher risk for depression throughout their lifetime. Epidemiologic studies will be useful for developing the long-term perspective on the natural history of sleep disturbances and mood disorders and the consequences of treatment.

Objective To examine whether competing demands explain the appearance of inadequate primary care depression treatment observed at a single visit. Design A cross-sectional patient survey. Participants and setting Two hundred forty patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices, representing 77.4% of the depressed patients identified through 2-stage screening of more than 11,000 primary care attenders. Main outcome measures In patients with elevated depressive symptoms, discussing depression as a possible diagnosis in untreated patients, and changing depression management in treated patients. Results Physicians and patients discussed depression in 46 (47.9%) of 96 untreated patients; physicians changed depression treatment recommendations in 87 (60.4%) of 144 treated patients with current symptoms. Chronic physical comorbidity decreased the odds that physicians and untreated patients discussed depression as a possible diagnosis (odds ratio = 0.66, P = .01). New problems decreased the odds that treatment recommendations would be changed in treated patients who remained depressed (odds ratio = 0.39, P = .05). Physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients reported antidepressant medication was acceptable (odds ratio = 4.57, P = .01) and less likely to discuss depression if patients reported specialty care counseling was acceptable (odds ratio = 0.33, P = .05). Conclusions The attention depression gets during a given medical visit is less associated with the severity of the patient's depressive symptoms than with the number or recency of other problems the patient has. If competing demands provide ongoing barriers to depression treatment, interventions will be needed to assure that patients with chronic physical problems receive high-quality mental health care in the primary care setting.

The Johns Hopkins Precursors Study, a long-term prospective study, was used to study the relation between self-reported sleep disturbances and subsequent clinical depression and psychiatric distress. A total of 1,053 men provided information on sleep habits during medical school at The Johns Hopkins University (classes of 1948-1964) and have been followed since graduation. During a median follow-up period of 34 years (range 1-45), 101 men developed clinical depression (cumulative incidence at 40 years, 12.2%), including 13 suicides. In Cox proportional hazards analysis adjusted for age at graduation, class year, parental history of clinical depression, coffee drinking, and measures of temperament, the relative risk of clinical depression was greater in those who reported insomnia in medical school (relative risk (RR) 2.0, 95% confidence interval (CI) 1.2-3.3) compared with those who did not and greater in those with difficulty sleeping under stress in medical school (RR 1.8, 95% CI 1.2-2.7) compared with those who did not report difficulty. There were weaker associations for those who reported poor quality of sleep (RR 1.6, 95% CI 0.9-2.9) and sleep duration of 7 hours or less (RR 1.5, 95% CI 0.9-2.3) with development of clinical depression. Similar associations were observed between reports of sleep disturbances in medical school and psychiatric distress assessed in 1988 by the General Health Questionnaire. These findings suggest that insomnia in young men is indicative of a greater risk for subsequent clinical depression and psychiatric distress that persists for at least 30 years.

OBJECTIVES: This study examined the relationship of self-reported physical activity with subsequent depression and psychiatric distress. METHODS: Physical activity was assessed in medical school and midlife in 973 physicians as part of a prospective observational study. Outcome measures were the incidence of self-reported clinical depression and psychiatric distress on the General Health Questionnaire. RESULTS: The risk of depression was similar for nonexercisers and exercisers. No relationship was observed between physical activity level and subsequent psychiatric distress. CONCLUSIONS: This study found no evidence that exercise reduces risk for depression or psychiatric distress.

Delegation isn't just about telling someone what to do and expecting them to get on with it! It is a two-way process which, if managed well, can help to build teams, improve efficiency in the workplace and help with staff retention through motivation. In every situation, veterinary surgeons and RVNs must ensure that tasks are delegated only to those who have the appropriate competence to handle them. When delegating, who is responsible and accountable for the task carried out? How can the RVN know that tasks will be carried out competently and without compromising patient care? How is successful delegation achieved?

Objective To describe barriers to the successful use of the 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines. Methods We conducted 3 focus groups to understand barriers to the use of 4 recommendations within the NHLBI guidelines (prescription of inhaled corticosteroids, recommendation of daily peak flowmeter use, smoking cessation screening and counseling, and allergen exposure counseling). Participants Twenty-one pediatricians and 1 nurse practitioner, who each followed an average of 47 patients with asthma, participated. Six participants (27%) had a faculty or adjunct appointment at a medical school. Nineteen (90%) of the 21 pediatricians were board certified. Results We identified 171 comments about barriers to adherence. Type of recommendation and physician year of graduation from medical school were related to which barrier was prominent. For corticosteroid prescription, senior physicians mentioned lack of agreement, whereas younger physicians described lack of confidence in dosing or recognizing contraindications. For peak flowmeter use, senior physicians emphasized lack of training. Only senior physicians described the inertia of previous practice as a barrier. All groups mentioned time limitations. Conclusions Efforts to improve adherence to asthma guidelines should consider the range of barriers that pediatricians face, such as lack of awareness, familiarity, or agreement, and external barriers owing to environmental, guideline, or patient factors. In addition, this study documents barriers not previously considered, such as lack of self-efficacy, lack of outcome expectancy, and inertia of previous practice, that prevent adherence. Because type of recommendation and physician demographics are related to which barriers are prominent, interventions to improve NHLBI guideline adherence should be tailored to these factors.

Background Several studies have found that depression is an independent predictor of poor outcome after the onset of clinical coronary artery disease. There are few data concerning depression as a risk factor for the development of coronary artery disease. Objective To determine if clinical depression is an independent risk factor for incident coronary artery disease. Patients and Methods The Johns Hopkins Precursors Study is a prospective, observational study of 1190 male medical students who were enrolled between 1948 and 1964 and who continued to be followed up. In medical school and through the follow-up period, information was collected on family history, health behaviors, and clinical depression. Cardiovascular disease end points have been assessed with reviews of annual questionnaires, National Death Index searches, medical records, death certificates, and autopsy reports. Results The cumulative incidence of clinical depression in the medical students at 40 years of follow-up was 12%. Men who developed clinical depression drank more coffee than those who did not but did not differ in terms of baseline blood pressure, serum cholesterol levels, smoking status, physical activity, obesity, or family history of coronary artery disease. In multivariate analysis, the men who reported clinical depression were at significantly greater risk for subsequent coronary heart disease (relative risk [RR], 2.12; 95% confidence interval [CI], 1.24-3.63) and myocardial infarction (RR, 2.12; 95% CI, 1.11-4.06). The increased risk associated with clinical depression was present even for myocardial infarctions occurring 10 years after the onset of the first depressive episode (RR, 2.1; 95% CI, 1.1-4.0). Conclusion Clinical depression appears to be an independent risk factor for incident coronary artery disease for several decades after the onset of the clinical depression.