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Objectives The 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines provided clinicians with pragmatic treatment recommendations for bipolar disorder (BD). While these guidelines included commentary on how mixed features may direct treatment selection, specific recommendations were not provided- a critical gap which the current update aims to address. Method Overview of research regarding mixed presentations in BD, with treatment recommendations developed using a modified CANMAT/ISBD rating methodology. Limitations are discussed, including the dearth of high-quality data and reliance on expert opinion. Results No agents met threshold for first line treatment of DSM-5 manic or depressive episodes with mixed features. For mania + mixed features second line treatment options include asenapine, cariprazine, divalproex, and aripiprazole. In depression + mixed features, cariprazine and lurasidone are recommended as second line options. For DSM-IV defined mixed episodes, with a longer history of research, asenapine and aripiprazole are first line, and olanzapine (monotherapy or combination), carbamazepine, and divalproex are second line. Research on maintenance treatments following a DSM-5 mixed presentation is extremely limited, with third-line recommendations based on expert opinion. For maintenance treatment following a DSM-IV mixed episode, quetiapine (monotherapy or combination) is first line, and lithium and olanzapine identified as second line options. Conclusion The CANMAT and ISBD groups hope these guidelines provide valuable support for clinicians providing care to patients experiencing mixed presentations, as well as further influence investment in research to improve diagnosis and treatment of this common and complex clinical state.

Aim To investigate the role stressors, and how coping strategies cultivated nurse managers' resilience in rural workplaces. Background A stressful workplace can impair the mental and physical health of nurse managers leading to poor performance. Building and sustaining manager resilience in complex and stressful practice environments is necessary to attract and maintain competent and skilled managers. Method In this qualitative exploratory inquiry, a purposive sampling method was used to recruit 16 nurse managers in rural western Canada. Results Coping strategies fostered manager's resilience that made their work meaningful, and included putting out fires, psychologically reframing a situation, serving others and receiving support. Conclusions Managers brought expertise, knowledge and skill to make their work meaningful and central to ongoing health service delivery in these rural communities. Nurse manager resilience can be strengthened by using evidence-based strategies in an increasingly complex health care environment. Implications for nursing management Managers need to be supported and encouraged to develop awareness of their own protective factors as they cope with challenging situations. Building resilience through formal education, social support and meaningful recognition is an important focus for nurse leaders in establishing a healthy work environment and maintaining a stable nursing workforce.

Purpose In this exploratory study, the effect of postprocedural flushing with crystalloids after oxaliplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC) on platinum concentrations in peritoneal tissue, blood, and drain fluid was studied. Interpatient variability in oxaliplatin pharmacokinetics and the relation between platinum concentration in peritoneal fluid and platinum exposure in tissue and blood was explored. Methods Ten patients with peritoneal carcinomatosis of colorectal origin were treated with HIPEC including postprocedural flushing, followed by ten patients without flushing afterwards. Tissue, peritoneal fluid, blood, and drain fluid samples were collected for measurement of total and ultrafiltered platinum concentrations. Results Peritoneal tissue concentration and systemic ultrafiltered platinum exposure showed large inter individual variability, ranging from 65 to 1640 µg/g dry weight and 10.5 to 28.0 µg*h/ml, respectively. No effect of flushing was found on geometric mean platinum concentration in peritoneal tissue (348 vs. 356 µg/g dry weight), blood (14.8 vs. 18.1 µg*h/ml), or drain fluid (day 1: 7.6 vs. 7.7 µg/ml; day 2: 1.7 vs. 1.9 µg/ml). The platinum concentration in peritoneal fluid at the start of HIPEC differed twofold between patients and was positively correlated with systemic exposure (p = .04) and peak plasma concentration (p = .04). Conclusion In this exploratory study, no effect was found for postprocedural flushing on platinum concentrations in peritoneal tissue, blood, or drain fluid. BSA-based HIPEC procedure leads to large interpatient variability in platinum exposure in all compartments. The study was registered at ClinicalTrials.gov on 7 December 2017 under registration number NCT03364907.

Contains fulltext : 218875.pdf (Publisher’s version ) (Open Access) Myxofibrosarcoma(MFS) is the most common soft tissue sarcoma(STS) in elderly patients. Surgical resection remains the main treatment modality but tumor borders can be difficult to delineate with conventional clinical methods. Incomplete resections are a common problem and local recurrence remains a clinical issue. A technique that has shown great potential in improving surgical treatment of solid tumors is tumor targeted imaging and image-guided surgery with near-infrared fluorescence. To facilitate this technique, it is essential to identify a biomarker that is highly and homogenously expressed on tumor cells, while being absent on healthy non-malignant tissue. The purpose of this study was to identify suitable molecular targets for tumor-targeted imaging of myxofibrosarcoma. Ten potential molecular targets for tumor targeted imaging were investigated with immunohistochemical analysis in myxofibrosarcoma tissue (n = 34). Results were quantified according to the immunoreactive score(IRS). Moderate expression rates were found for uPAR, PDGFRa and EMA/MUC1. High expression rates of VEGF and TEM1 were seen. Strong expression was most common for TEM1 (88.2%). These results confirms that TEM1 is a suitable target for tumor-targeted imaging of myxofibrosarcoma. Keywords Image-guided surgery; Immunohistochemistry; Molecular imaging; Myxofibrosarcoma; Soft tissue sarcoma; Tumor endothelial marker 1(TEM1), Vascular endothelial growth factor (VEGF).

OBJECTIVES While clinical guidelines exist for the management of bipolar disorder (BD), there are significant challenges to their widespread dissemination and implementation in clinical practice. The Canadian Network of Mood and Anxiety Treatment Improving Patient Care and Outcomes in the Treatment of Bipolar Disorder (C-IMPACT BD) web-based application was developed for use at the point-of-care to improve adherence to guidelines for evidence-based pharmacological management of BD. METHODS C-IMPACT BD uses a point-of-care practice assessment which, via adaptive questioning of patient-specific information, text/video descriptions of the guidelines, and pop-up prompts delivers personalized, evidence-based treatment recommendations for patients with BD. In order to inform quality improvement of the newly developed tool, a sample of Canadian physicians were invited to use the application and record its influence on their prescribing behavior. RESULTS Of 375 patients with bipolar I (BD-I) or bipolar II (BD-II) disorder for whom a point-of-care practice assessment was completed, a change in therapy was considered for 225 (60.0%). Prior to completing the assessment, 59.6% of these patients were receiving first-line therapy recommended for their phase of illness. Following the assessment, the overall number of patients for whom a first-line recommended therapy was being considered increased significantly to 76.9% (p = 0.0001). CONCLUSIONS Outcomes suggest that the C-IMPACT BD web-based application has the potential to improve physician adherence to clinical treatment guidelines. Formal research investigations are warranted to explore the impact of this tool on physician prescribing behavior and patient outcomes.

Introduction: Neoadjuvant chemotherapy (CT) for locally advanced colon cancer (LACC) could potentially lead to tumor shrinkage, eradication of micrometastases, and prevention of tumor cell shedding during surgery. This retrospective study investigates the surgical and oncological outcomes of preoperative CT for LACC. Methods: Using the Netherlands Cancer Registry, data of patients with stage II or III colon cancer, diagnosed between 2008 and 2016 was collected. A propensity score matching (PSM; 1:2) was performed and compared patients with clinical tumor (cT) 4 colon cancer who were treated with neoadjuvant CT to patients with cT4 colon cancer treated with adjuvant CT (Fig. 1). Results: A total of 192 patients treated with neoadjuvant CT were compared to 1,954 patients that received adjuvant CT. After PSM, 149 patients in the neoadjuvant group were compared to 298 patients in the control group. No significant differences were found in baseline characteristics after PSM. After neoadjuvant CT, a significant response was observed in 13 (9%) patients with 5 (4%) patients showing a complete response. Complete resection margins (R0) were achieved in 77% in the neoadjuvant group versus 86% in the adjuvant treated group (p = 0.037). Significantly less tumor positive lymph nodes were found in the neoadjuvant group (median 0 vs. 2, p < 0.001). Major complication rates and 5-year overall survival did not differ between both groups (67–65%, p = 0.87). Conclusion: Neoadjuvant CT seems safe and feasible with similar long-term survival compared to patients who are treated with adjuvant CT.

Psychiatric nurses often experience associative stigma. Associative stigma may impact psychiatric nurses' views of their professional identity which ultimately impacts the health care of individuals experiencing mental health concerns. Very little research has been conducted on associative stigma in the western Prairie Provinces, including Manitoba. The authors conducted a secondary analysis on the results of an explanatory sequential mixed methods research study to determine if psychiatric nurses in Manitoba are influenced by associative stigma. Three themes were identified through this analysis, specifically: (1) the perception that RPNs are not "Real" Nurses; (2) lack of recognition of specialized training; and (3) working with a stigmatized population. Associative stigma was intertwined in all of the participants' narratives indicating a need to dismantle associative stigma. Strategies to enhance the public perception of psychiatric nursing and decrease associative stigma within the profession are described.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

Purpose: Intraoperative image guidance may aid in clinical decision-making during surgical treatment of colorectal cancer. We developed the dual-labeled carcinoembryonic antigen–targeting tracer, [111In]In-DTPA-SGM-101, for pre- and intraoperative imaging of colorectal cancer. Subsequently, we investigated the tracer in preclinical biodistribution and multimodal image-guided surgery studies, and assessed the clinical feasibility on patient-derived colorectal cancer samples, paving the way for rapid clinical translation. Experimental Design: SGM-101 was conjugated with p-isothiocyanatobenzyl–diethylenetriaminepentaacetic acid (DTPA) and labeled with Indium-111 (111In). The biodistribution of 3, 10, 30, and 100 μg [111In]In-DTPA-SGM-101 was assessed in a dose escalation study in BALB/c nude mice with subcutaneous LS174T human colonic tumors, followed by a study to determine the optimal timepoint for imaging. Mice with intraperitoneal LS174T tumors underwent micro-SPECT/CT imaging and fluorescence image–guided resection. In a final translational experiment, we incubated freshly resected human tumor specimens with the tracer and assessed the tumor-to-adjacent tissue ratio of both signals. Results: The optimal protein dose of [111In]In-DTPA-SGM-101 was 30 μg (tumor-to-blood ratio, 5.8 ± 1.1) and the optimal timepoint for imaging was 72 hours after injection (tumor-to-blood ratio, 5.1 ± 1.0). In mice with intraperitoneal tumors, [111In]In-DTPA-SGM-101 enabled preoperative SPECT/CT imaging and fluorescence image–guided resection. After incubation of human tumor samples, overall fluorescence and radiosignal intensities were higher in tumor areas compared with adjacent nontumor tissue (P < 0.001). Conclusions: [111In]In-DTPA-SGM-101 showed specific accumulation in colorectal tumors, and enabled micro-SPECT/CT imaging and fluorescence image–guided tumor resection. Thus, [111In]In-DTPA-SGM-101 could be a valuable tool for preoperative SPECT/CT imaging and intraoperative radio-guided localization and fluorescence image–guided resection of colorectal cancer.

Background The HOPE-BD was a naturalistic study established to follow individuals in Canada seeking treatment for bipolar disorder (BD). The study aimed to examine the course of BD and describe how clinical and sociodemographic factors are associated with outcomes. Methods Individuals with BD had their clinical data recorded at enrolment and were naturalistically treated. Participant were followed for up to four years, and visits occurred at least once every three months. We investigated the longitudinal outcomes with logistic, Cox, and quantile regressions. Results Among the 354 participants, 57.3% had BD type I. Depression as first episode, younger ages at onset and older ages of the first professional help predicted longer delays in correct diagnosis. Among the symptomatic patients at baseline, the median time to remission was 10.9 months. Comorbid alcohol use disorder and the severity of baseline depressive symptoms predicted longer times to remission. Among the euthymic participants, the median time to recurrence was 14.5 months. History of anxiety disorder and younger ages at onset predicted shorter times to recurrence. Baseline depression scores predicted recurrence in euthymic patients. Limitations We did not investigate the predictors of each polarity. Our findings may not apply to individuals followed in non-specialised outpatient services. Conclusion Our study reinforces the necessity of early diagnosis and interventions, as well as the importance of treating depressive symptoms and comorbidities.

Background Prescribers at a 400-bed metropolitan teaching hospital applied for approval to prescribe restricted antimicrobials using Guidance DS® (GDS), an electronic antimicrobial approval system (EAAS). The implementation of Cerner Millennium® (CM), a computerised physician order entry system (CPOE), necessitated a new but cumbersome workflow for prescribers. This prompted an evaluation of the value of a stand-alone EAAS, which has no interface with a CPOE, for antimicrobial stewardship. Aim This study compares the performance of an EAAS and CPOE, used alone and in combination, for surveillance of restricted antimicrobials and compliance with antimicrobial restriction policy. Method General medical and surgical patients prescribed restricted antimicrobials over three defined periods were retrospectively recruited; period one (P1) used GDS plus National Inpatient Medication Chart, period two (P2), GDS plus CM, and period three (P3), CM alone. For each period, 100 medical and 100 surgical restricted antimicrobial orders were collected. Data collection included prescribing date, indication, approvals obtained, and time to approval. Surveillance rate and compliance was compared. Results The introduction of CM improved surveillance from 10.5% (P1) to 65% (P2) and 100% (P3) via a CM reporting module (p < 0.0001). Compliance improved from 6% (P1), to 55% (P2) and 76% (P3) (p < 0.0001). Documentation of a clear/complete indication improved from 10% (P1) to 56.5% (P2) and 76.5% (P3) (p < 0.0001). Approvals obtained within 24 h of prescribing improved from 61.9% (P1), to 96.9% (P2), and 100% (P3). Conclusion Cerner Millennium®, with customisation, optimises surveillance and significantly improves compliance with policy, negating the need for a stand-alone EAAS.

Objective: Previous studies reported decreased N-acetyl aspartate and increased Glx (the sum of glutamate plus glutamine) in bipolar disorder. Since these studies included patients at different stages of illness, it is unknown whether these changes have a causal role or a consequence of multiple episodes and treatments. The studies in early-stage bipolar disorder patients have the potential to provide answers to these issues. Therefore, we evaluated N-acetyl aspartate and Glx levels in hippocampi of first-episode bipolar disorder patients and health subjects at baseline and at 12 months, and examined the impact of episode recurrence on these measures. Method: We used single-voxel proton magnetic resonance spectroscopy to compare the hippocampal neurometabolites ( N-acetyl aspartate and Glx) levels between 41 patients with bipolar disorder following recovery from their first-manic episode and 27 matched healthy subjects at recruitment and 12 months later. We also compared N-acetyl aspartate and Glx levels between patients who had a recurrence of a mood episode and those who did not. Results: There was no main effect of either group (diagnosis) or time for hippocampal N-acetyl aspartate and Glx levels in bipolar disorder patients and healthy subjects. We also did not find any group-by-time interaction for the levels of these metabolites. There were also no differences in N-acetyl aspartate and Glx between patients who experienced a recurrence of a mood episode and those who did not over 12-month follow-up. Conclusion: Our data suggest that N-acetyl aspartate and Glx levels are not altered in early stage bipolar disorder. Further, these data suggest that episode recurrence in early stages does not have a significant impact on the levels of these metabolites. These may suggest that there may be an early window for intervention to potentially arrest neuroprogression of the disease.

Objective To illustrate ways in which clinical decision support systems (CDSSs) malfunction and identify patterns of such malfunctions.Materials and Methods We identified and investigated several CDSS malfunctions at Brigham and Women’s Hospital and present them as a case series. We also conducted a preliminary survey of Chief Medical Information Officers to assess the frequency of such malfunctions.Results We identified four CDSS malfunctions at Brigham and Women’s Hospital: (1) an alert for monitoring thyroid function in patients receiving amiodarone stopped working when an internal identifier for amiodarone was changed in another system; (2) an alert for lead screening for children stopped working when the rule was inadvertently edited; (3) a software upgrade of the electronic health record software caused numerous spurious alerts to fire; and (4) a malfunction in an external drug classification system caused an alert to inappropriately suggest antiplatelet drugs, such as aspirin, for patients already taking one. We found that 93% of the Chief Medical Information Officers who responded to our survey had experienced at least one CDSS malfunction, and two-thirds experienced malfunctions at least annually.Discussion CDSS malfunctions are widespread and often persist for long periods. The failure of alerts to fire is particularly difficult to detect. A range of causes, including changes in codes and fields, software upgrades, inadvertent disabling or editing of rules, and malfunctions of external systems commonly contribute to CDSS malfunctions, and current approaches for preventing and detecting such malfunctions are inadequate.Conclusion CDSS malfunctions occur commonly and often go undetected. Better methods are needed to prevent and detect these malfunctions.

Bipolar I disorder (BD) is associated with increased inflammation, which is believed to be central to disease etiology and progression. However, BD patients also have high rates of obesity, itself an inflammatory condition, and the relative contributions of mood illness and obesity to inflammation are unknown. Moreover, the impact of inflammation on clinical illness course has not been well studied. The objectives of this analysis were therefore: (1) to determine if inflammation in BD is mood illness-related or secondary to elevated body mass index (BMI), and (2) to investigate the impact of inflammation on prospectively-ascertained relapse into depression and mania. We measured the serum levels of 7 inflammatory cytokines (TNF-α, γ-interferon, monocyte chemoattractant protein-1 [MCP-1], IL-1α, IL-2, IL-6, and IL-8) and 2 anti-inflammatory cytokines (IL-4 and IL-10) in 52 early-stage BD patients and 22 healthy subjects. In patients, a multivariate multiple regression model that controlled for psychotropic medications found that higher BMI, but not recent (past-6-month) mood episodes, predicted greater inflammatory cytokines (p=.05). Healthy subjects also had a BMI-related increase in inflammatory cytokines (p

TPS4119 Background: Successful treatment of patients with colorectal peritoneal carcinomatosis highly depends on complete surgical tumor resection of all tumor. Oncological outcomes can potentially be improved by intraoperative imaging using a tumor-targeting antibody conjugated to a fluorophore and a radiotracer. This enables preoperative radionuclide imaging, real-time intraoperative fluorescence imaging and gamma detection. In this study we investigate the feasibility, accuracy and safety of CEA-targeted preoperative SPECT/CT and intraoperative fluorescence imaging in patients with colorectal PC. Methods: In this phase I/II single arm protein dose escalation study patients with peritoneal metastases of colorectal origin who are scheduled for cytoreductive surgery and HIPEC will receive an intravenous injection of the CEA-targeting tracer 111In-DOTA-labetuzumab-IRDye800CW. The first 15 patients will receive a single dose of 2,10 or 50 mg 6 to 7 days prior to surgery. Four to five days after injection SPECT/CT imaging of the thorax and abdomen is performed to determine intra-abdominal tumor load and detect extra-abdominal metatases. At day 6/7 after injection, standard cytoreductive surgical resection extended with real-time near-infrared fluorescence imaging and radio guidance is performed. After surgery, the peritoneal cavity will be re-examined for residual disease with fluorescence imaging. Resected specimens are analyzed microscopically, immunohistochemically (CEA and H&E) and by gamma counting. Blood samples are drawn for farmacokinetics and safety analysis at 180 minutes, 4 days, 6 days and 3 weeks after tracer injection. In the phase II dose expansion cohort, 14 more patients will receive the optimal dose as determined in the phase I trial. The primary objectives of the trial are to assess the safety, feasibility and accuracy of preoperative SPECT/CT and intraoperative fluorescence imaging after administration of 111In- labetuzumab-IRDye800CW in patients with peritoneal carcinomatosis of colorectal origin who will undergo cytoreductive surgery and HIPEC. The secondary objectives are to assess whether additional malignant lesions can be visualized by fluorescence imaging after cytoreductive surgery, to assess the intensity of fluorescence in malignant and non-malignant tissue, to assess the correlation between localization of the dual-labeled antibody and CEA expression in tumor and healthy tissue and to determine blood concentrations of the dual labelled antibody at several time points in patients. Clinical trial information: NCT03699332 .

The revised Technology Curriculum for years 1 - 13 now includes two Digital Technologies areas: ‘computational thinking for Digital Technologies’ and ‘designing and developing digital outcomes’. By 2020, all schools are expected to address these curriculum additions. This article outlines some of the background stated purposes for introducing this curriculum addition. I also examine some of the challenges including teacher readiness and resourcing, professional development and some resources to accompany the changes. The article also discusses how curriculum integration, including the use of authentic contexts, and the use of ‘unplugged’ resources might alleviate some potential challenges.

Light Spectrum Glazes has been granted a patent for the novel process of expanding and completing the spectral light array emitted by LED bulbs with transparent colors filters. Non-luminescent, low-cost, stable, and highly durable color filters are used to expand the jagged LED spectral emission into a full, true white light array. Transparent colors are applied in combination with existing manufacturing technologies as a final color-tuning step in bulb design. The quantity of emitted light that can be color filtered is adjustable from 1p to 100p of emitted light, creating a custom balance of light quantity with light quality. This invention recognizes that: (1) approximately 1/3 of people do not have trichromatic vision, (2) a robust white light spectrum of light is necessary to avoid metameric failure, and (3) "better light" quality is often as important or more important than "brighter light" quantity in the consumer marketplace.

We analyze residential architecture and domestic artifacts as expressions of wealth, prestige, and social class at three Aztec-period settlements in Morelos, Mexico: Capilco, Cuexcomate, and Yautepec. House size, as expressed in both floor area and construction volume, shows a strongly bimodal distribution that we interpret as marking elite and commoner residences. We test this interpretation with two artifactual indices of household wealth. One is designed to maximize the elite-commoner distinction in each setting, but is not directly comparable among contexts. The other is a simpler generic wealth index that can be compared among sites and across time. We also consider variability within the commoner class in house size and artifact inventories. While some degree of variation is present, the extent of variation is minor in comparison to the level of elite-commoner differences.

Adenomyoepithelioma (AME) is a biphasic neoplasm of epithelial and myoepithelial cells. It is most commonly found in the breast, although rare cases have been reported from the lung, salivary glands, and skin. There are 5 well-documented cases of cutaneous AME in the literature. We report a new case of cutaneous AME. Our case was commingled with apocrine hidrocystoma. This is the first report of cutaneous AME in a male patient and the first to describe SOX10 immunostaining in cutaneous AME. We review the literature on cutaneous AME and note the greater than chance colocalization with other adnexal tumors. We speculate that AME may represent localized overgrowth of myoepithelial cells within a pre-existent sweat gland tumor. Histopathologists should be aware of the potential of SOX10-positive myoepithelial neoplasms to mimic nodular melanocytic proliferations.

Background Our health service is introducing an electronic medication management system (eMMs). Obtaining baseline data on the work patterns of pharmacists will allow assessment of the impact of the eMMs on pharmacists' work patterns. Aim To quantify the time clinical pharmacists spend on various activities over their working day prior to the implementation of an eMMs. Method During this continuous observational time-and-motion study (23 November to 17 December 2009), clinical pharmacists assigned to general medical and surgical wards were shadowed by two independent observers over their entire working days. A customised Access application was used to log times and calculate average times spent on each activity. Other data collected included time from admission to interview and opportunities for medication chart review. Results 9 pharmacists were observed for 265.3 hours over 30 separate pharmacist observation days. Clinical activities (56% of total time) included professional communication (20%), medication chart review (9.6%), medication history interview (9.5%), clinical review (9.1%), providing information to patients/carers (5.5%), ascertaining discharge drugs required (1.6%), and obtaining drug information (0.5%). Non-clinical activities (44% of total time) included social activities/breaks (13%), meetings (6.9%), ordering/distribution (6.6%), discharge dispensing (6.3%), walking between wards/pharmacy (5.2%), looking for something (3.1%), and other activities (2.8%). On an average day, each pharmacist reviewed 21 of a possible 38 medication charts (55%), spent 20 minutes on clinical interventions and completed 4.5 medication history interviews. Average time from admission to interview was 67 hours. 18% of pharmacists' time was taken up with discharge/transfer of patients. Most patients 130/141 (93%) at discharge did not require further medication history clarification. Conclusion This study provides baseline data for comparison of the impact of the eMMs on pharmacist workflow.

Although associations between antipsychotic use and neuropsychological impairment in bipolar I disorder have been observed, there is a lack of studies comparing the effects of specific agents used in this population. We compared performance between patients receiving maintenance treatment with mood stabilizer monotherapy (n=15), adjunctive risperidone (n=15) or quetiapine (n=17), and a group of demographically matched healthy controls (n=28) on tests of executive function (working memory, set shifting, and inhibition) and verbal learning. Despite having a similar clinical profile, patients being treated with risperidone showed significantly impaired working memory, set-shifting, and verbal learning (P0.05) compared with those either on mood stabilizer monotherapy or adjunctive quetiapine. Although randomized controlled trials are required to confirm the cognitive side effects of medications prescribed for maintenance treatment of bipolar I disorder, preliminary results indicate that addition of risperidone to a mood stabilizer has a negative impact on executive function and verbal learning, an effect not shared with quetiapine.

Twenty criteria are used to analyze sixteen national action plans that focus on women, peace, and security. United Nations Security Council Resolution 1325, a base for the national plans, highlights the terrible consequences of violent conflict on women and girls as well as the important role of women in all peacebuilding processes. Suggestions are made for those developing or revising plans and include addressing the relevant points from four UN Security Council resolutions (1325, 1820, 1888, and 1889); specifying all processes and timelines; and including civil society participation in all phases of a plan's development; implementation, and assessment.

There are many reasons to develop closer links between research and teaching. To do this, we argue the need to move beyond university rhetoric that fractures the engagement of teaching with research and instead focus on the development of what is necessary to bring these two core academic activities closer together. Opening with a review of the current literature on research‐led teaching, the paper then highlights the various debates about whether or not the divide between research and teaching can be broached. We then explore a number of often contradictory myths that we argue universities subscribe to in their efforts to bring teaching and research together as they simultaneously create structures to separate them. The paper seeks to better ‘marry’ research and teaching activities in higher education settings, concluding with a set of principles that could be used by university leaders to guide the implementation of research‐led teaching.

Research on social stigma and disadvantage has flourished in the past two decades. The authors highlight the theoretical and methodological advancements that have been made, such as how experience sampling procedures and neuroscience have shed light on processes associated with social stigma. Finally, the authors discuss policy implications of historical and contemporary research on social stigma and disadvantage, as well as address ideas for future research that may be useful in creating policies and programs that promote social equality.

In this paper we argue that living in university accommodation is a possible means of improving the security of international students. Our argument is supported by a qualitative case study of a single Hall of Residence on Monash University's Clayton campus. Data were collected primarily from interviews with three groups of participants – six international students currently living in that Hall of Residence, three international students who used to live in the Halls of Residence, and three College Heads. The primary finding of this study was that international students living in university accommodation felt very physically secure and experienced a reduced threat level to their social security. It is intended that our findings will assist universities and government in improving the security of international students studying in Australia, thus contributing to a more sustainable Australian education export industry.

Aim: To describe the implementation of pharmacist-initiated e-script transcription service (PETS) in a teaching hospital; to validate the service through process indicators; and to explore the views of stakeholders. Method: Following an initial trial, PETS was implemented in 7 medical and surgical units at Frankston Hospital. Data were collected on activities and discharge prescription errors. Stakeholders' satisfaction was measured using a Likert scale based survey and group interviews. Transcripts of group interviews were analysed by informal word-based techniques, noting words or synonyms used repeatedly to discover themes. Results: During the implementation phase (8 to 29 February 2008), a daily average of 15 prescriptions (112 items) were prepared by the PETS pharmacist, i.e 30 to 60% of weekday discharge prescriptions. The discharge prescription error/ amendment rate was 0.06 per patient. 163 respondents (92%) were satisfied or very satisfied with PETS. As a result of 3 group interviews of 10 doctors, 10 nurses and 10 pharmacists, several areas for enhancement were identified and implemented. Conclusion: PETS has transitioned from trial to mainstream service, facilitating the discharge process and improving continuity of care.

Aim: To evaluate a pharmacist-initiated e-script transcription service for discharged patients. Method: A sequential prospective study of 2 groups of 40 eligible medical patients recruited from the neurology and respiratory wards. Pre-implementation of the service, baseline data were collected from 40 consecutive medical patients. After the new service was implemented and allowing for a 2 week run-in period, data were collected from a further 40 consecutive medical patients. The outcome indicators were the time taken to discharge patients and the number of prescribing errors. Results: The pharmacist-initiated e-script transcription service was successfully implemented. The discharge process was faster with the time taken from decision to discharge to actual discharge decreased by 34% (p = 0.02). The time spent by dispensing pharmacists in clarifying and amending discharge prescriptions decreased from 9.5 to 1.5 minutes per patient. The time spent by doctors in preparing discharge prescriptions fell from 15 to 2 minutes per patient. There were also fewer prescribing errors – number of errors decreased from 0.83 to 0.1 per patient (p = 0.0005) and from 0.0962 to 0.0137 per item (p = 0.011). Conclusion: Combining a prescribing role with the medication safety elements of electronic prescribing and medication reconciliation has resulted in significant improvements in the quality, accuracy and timeliness of discharge prescriptions. The centralised discharge transcription service is transferable to a wide variety of health settings. The principles of workforce substitution and process change is important as the health system struggles to meet ever increasing demands. J Pharm Pract Res 2009; 39: 39-42.

This article provides background information about special education and mediation and offers some points to consider for those interested in starting, improving or analyzing a special education mediation process. This article is based on the author's experience as a mediator as well as on site visits, interviews and a review of the relevant literature. The author concludes that mediation can be a very effective method for settling special education disputes and/or improving relationships but that the process can be affected by outside factors such as politics, finances and/or the system.

Purpose: This paper describes a process for the identification of genes that can report on the aggressiveness of prostate tumors and thereby add to the information provided by current pathologic analysis. Materials and Methods: Expression profiling data from over 100 laser capture microdissection derived samples from nonneoplastic epithelium; Gleason patterns 3, 4, and 5 and node metastasis prostate cancer were used to identify genes at abnormally high levels in only some tumors. These variably overexpressed genes were stratified by their association with aggressive phenotypes and were subsequently filtered to exclude genes with redundant expression patterns. Selected genes were validated in a case-control study in which cases (systemic progression within 5 years) and controls (no systemic progression at 7 years of follow-up) were matched for all clinical and pathologic criteria from time of prostatectomy (n = 175). Both cases and controls, therefore, could have nodal invasion or seminal vesicle involvement at the time of initial treatment. Results: A number of candidate variably overexpressed genes selected for their association with aggressive prostate cancer phenotype were evaluated in the case control study. The most prominent candidates were SSTR1 and genes related to proliferation, including TOP2A. Conclusions: The process described here identified genes that add information not available from current clinical measures and can improve the prognosis of prostate cancer.

In this chapter, we review clinical decision support systems (CDSS) at Brigham and Women’s Hospital (BWH), including design, implementation, and evaluation. BWH has over 40 years active experience in the development of clinical information systems. Here we focus specifically on BWH’s work in assessing the impact of CDSS in critical areas of patient safety, quality, and cost outcomes, and offer generalizable lessons for current and future applications of CDSS. CDSS examined include both inpatient and outpatient systems, medication related, laboratory and radiology decision support as well as documentation-related CDSS, clinical reminders, and patient-centric applications. Also included are descriptions of studies on the impact on the user and cost-effectiveness of CDSS.

The aim of this paper is to evaluate the impact of internationalisation on academic work within a department of management in a large Australian university. It has been argued elsewhere that internationalisation strategies have transformed the nature and demands of academic work through the massification and commodification of educational curricula. Drawing on one of our university's projects to develop and deliver internationalised common curricula to students in Asia, South Africa and Australia we contend that internationalisation strategies have contributed to what we identify as the “Taylorisation” of teaching and learning. Frederick Taylor's principles of scientific management, exemplified by the growing trend towards standardisation of delivery and curricula, are readily identified in the pedagogical processes and expected academic practice in higher education. This paper draws on the work of others who highlight the complexity of internationalisation issues in the development and delivery of curric...

The aim of this study was to demonstrate that telehomecare linking homebound patients with their home health-care nurses over the plain old telephone system (POTS) provides high-quality, clinically useful, and patient satisfactory interactions. Congestive heart failure, chronic obstructive pulmonary disease, and chronic wound-care patients receiving skilled home nursing care were randomized into control (standard home health care, HHC) and two intervention (standard care plus video conferencing/Internet access; the above plus physiological monitoring) groups. Virtual visits (VVs), consisting of two-way audio and video interactions between the central site HHC nurse and the subject at home, were compared for technical quality and clinical usefulness by the HHC nurses who performed the VVs. Subject perception of telehomecare and satisfaction with their HHC were assessed over the course of the project. There were a total of 567 virtual and 1,057 actual visits conducted for the 53 subjects completing the study. The technical quality of VVs were rated at 94.7%. They were considered to be as useful as actual visits in 90.7% of cases. Subject telehomecare perception increased after experiencing the process. All subjects were satisfied with their HHC; satisfaction increased with an increasing level of telehomecare intervention. Subjects receiving physiological monitoring and video conferencing/Internet access in addition to standard care were most satisfied with their care. VVs can be conducted over POTS. Patients can use telehomecare with moderate levels of training. These programs can provide timely and quality home health nursing care with VVs augmenting traditional home visits.

Approaches to integrated service learning are detailed for three courses—Organizational Theory, Land Use and Environmental Dispute Resolution, and Mediation Skills. The focus of this paper is on the process of integration rather than the specifics of the courses. A faculty member interested in developing a service-learning component in a course is advised to (1) publicly identify the course as one that includes a service-learning experience, (2) be passionate, organized, flexible, and experienced, (3) establish an excellent relationship with a community agency, (4) be flexible about course content and schedule, (5) recognize that some students may have problems with an experience-based approach to learning, and (6) conduct periodic evaluations of all stages of the service-learning experience.

Illuminant metameric failure is frequently experienced when viewing material samples under LED generated light vs. traditional incandescent light. LED light temperatures can be improved with phosphor coatings, but long-wave red light is still generally absent in LED "warm-white" light, resulting in metameric failure of orange-to-red objects. Drawing on techniques developed for the architectural restoration of stained glass, we find that transparent, heat-resistant, permanent, pigmented coatings can be applied to any glass, aluminum or plastic surface of an LED bulb, including the phosphor plate, dome or envelope, to produce warmer visible light than in current warm-light LED bulbs. These glazes can be applied in combination with existing technologies to better tune the LED emitted light or they may be used alone. These pigmented coatings include, but are not limited to, those made by suspending inorganic materials in potassium silicates or durable transparent pigmented resins. The pigmented resin glazes may be produced in either a clear gloss vehicle or an iridescent, light diffusing transparent base. Further, a graduated density of the tinted glazes on dimmable bulbs allow the light to change color as wattage is diminished. The glazes may be applied in the manufacturing of the bulb or marketed to current bulb owners as an after-market product to better tune the thousands of LED light bulbs currently in use.

Tele HomeCare is a demonstration telemedicine project focused on the delivery of home health care to elderly homebound patients who are receiving care for either congestive heart failure, chronic obstructive pulmonary disease, or chronic wound healing. The telemedicine components of the study involve low-cost, standards-based videoconferencing and Internet access delivered over regular voice-grade telephone service and the patient’s television as well as physiological monitoring. This technology links the patient at home with a home care nurse at the home health agency. This is a randomized clinical trial with control and telemedicine intervention groups. Study design, technology details, and focus group and pilot study results are reported. Outcome measures, including quality of care, access, patient satisfaction, and cost factors, will be reported at the conclusion of the study.

Congressional enactment of Federal Rules of Evidence 413-415 changed centuries of the law which had excluded evidence by the state that the defendant had committed other bad acts and was therefore the sort of person who would be more likely to commit the act charged. The passage of Rules 413-415 opens the door to this type of character evidence in sexual assault and child molestation cases and requires trial judges to assess the probative value of this propensity evidence offered. Yet, neither these rules nor their legislative history offer much guidance in this assessment. This article offers guidance to trial judges and lawyers to assess the probative value of propensity evidence offered under these rules.

Over 880 communities have put regulations in place to reduce or eliminate tobacco use in buildings used by the public. This study examines the experience of one such community—Well City, Ohio. The nonsmoker protection efforts in Well City help us identify and discuss eight important considerations affecting policy development and implementation: (1) anticipate community opposition, (2) identify and collaborate with a support network, (3) control the community hearing process, (4) anticipate outside interests, (5) recognize the potential for legal challenges, (6) address life with legal limbo, (7) start strong, and (8) watch the mix of politics and public health. Current clean indoor air efforts seem to focus on establishing coalitions and encouraging employers to voluntarily establish tobacco-free workplaces and restaurants. These efforts certainly need to continue but as a basic part of a comprehensive program which recognizes the importance and fosters the development of strong nonsmoker protection regulations developed at the local level by health boards, county boards of supervisors, and/or city councils.

Immunosuppressive therapies that block the CD40/CD154 costimulatory pathway have proven to be uniquely effective in preclinical xenotransplant models. Given the challenges facing clinical translation of CD40/CD154 pathway blockade, we examined the efficacy and tolerability of CD40/CD154 pathway-sparing immunomodulatory strategies in a pig-to-nonhuman primate islet xenotransplant model. Rhesus macaques were rendered diabetic with streptozocin and given an intraportal infusion of ≈ 50 000 islet equivalents/kg wild-type neonatal porcine islets. Base immunosuppression for all recipients included maintenance therapy with belatacept and mycophenolate mofetil plus induction with basiliximab and LFA-1 blockade. Cohort 1 recipients (n = 3) were treated with the base regimen alone; cohort 2 recipients (n = 5) were additionally treated with tacrolimus induction and cohort 3 recipients (n = 5) were treated with alefacept in place of basiliximab, and more intense LFA-1 blockade. Three of five recipients in both cohorts 2 and 3 achieved sustained insulin-independent normoglycemia (median rejection-free survivals 60 and 111 days, respectively), compared to zero of three recipients in cohort 1. These data show that CD40/CD154 pathway-sparing regimens can promote xenoislet survival. Further optimization of these strategies is warranted to aid the clinical translation of islet xenotransplantation.

Costimulation blockade of the CD40/CD154 pathway has been effective at preventing allograft rejection in numerous transplantation models. This strategy has largely depended on mAbs directed against CD154, limiting the potential for translation due to its association with thromboembolic events. Though targeting CD40 as an alternative to CD154 has been successful at preventing allograft rejection in preclinical models, there have been no reports on the effects of CD40-specific agents in human transplant recipients. This delay in clinical translation may in part be explained by the presence of cellular depletion with many CD40-specific mAbs. As such, the optimal biologic properties of CD40-directed immunotherapy remain to be determined. In this report, we have characterized 3A8, a human CD40-specific mAb and evaluated its efficacy in a rhesus macaque model of islet cell transplantation. Despite partially agonistic properties and the inability to block CD40 binding of soluble CD154 (sCD154) in vitro, 3A8-based therapy markedly prolonged islet allograft survival without depleting B cells. Our results indicate that the allograft-protective effects of CD40-directed costimulation blockade do not require sCD154 blockade, complete antagonism or cellular depletion, and serve to support and guide the continued development of CD40-specific agents for clinical translation.

The objective of this study was to assess the relationship of the tumor protein levels of TOP2A and MIB-1 and ERG status with cancer-specific outcomes in men with high-risk prostate cancer treated by radical prostatectomy (RP). A 150-pair case-control study was designed from RP patients who developed systemic progression (SP) within 6 years of RP (cases) and men who were free of disease at least 8 years after RP (controls). The cases and controls were matched on conventional prognostic clinical parameters. TOP2A and MIB-1 levels were assessed by immunohistochemical methods, and ERG status was assessed by quantitative reverse transcription-PCR. The prognostic abilities of TOP2A and MIB-1 were significantly better in ERG(−) patients, and TOP2A was superior to MIB-1. In receiver operating characteristic analysis, the TOP2A and MIB-1 scores exhibited AUCs of 0.81 and 0.78 for ERG(−) patients, versus 0.67 and 0.68 for ERG(+) patients, respectively. Clinical parameters attained an AUC of 0.65 in ERG(−) patients and 0.54 in ERG(+) patients. When both markers were incorporated into a model for ERG(−) patients, the AUC increased to 0.83, with TOP2A showing a stronger association with SP than MIB-1. The time to SP was significantly associated with TOP2A; higher 5-year SP rates were observed in patients with higher TOP2A protein levels. In addition, although patient numbers are small, the response to adjuvant androgen deprivation therapy is associated with ERG status, showing more significant treatment effect in ERG(+) patients. Cancer Res; 70(22); 8994–9002. ©2010 AACR.

Thirty patients with chemotherapy-induced anemia were treated with recombinant human erythropoietin for 4 weeks. In this dose-escalation study, cohorts of five to eight patients were treated per dose level. The doses of erythropoietin were 25, 50, 100, 200, or 300 IU/kg/d given intravenously for 5 days each week. Of 30 patients, 15 (50%) had a greater than 10% increase of their hemoglobin (Hb) values and were considered responders. At the two highest dose levels, 11 of 13 patients (85%) responded. In the 15 responding patients, the mean Hb level increased by 1.7 g/dL from baseline compared with an average decrease of 1.5 g/dL in the previous cycles of chemotherapy without erythropoietin administration. Recombinant human erythropoietin is effective in ameliorating chemotherapy-induced anemia when administered in adequate doses.

This paper proposes a descriptive model illustrating the path of adult problem solving and thinking that leads to reentry, retention, and eventual completion of a college degree. Each stage of the model represents a unique decision point at which action may or may not be taken to achieve the goal of college degree completion. Variables depicting the outcome of each decision point are identified. Intrinsic and extrinsic facilitators and inhibitors to degree completion, theories of motivation, and persistence are explored. The educational program options available to adult learners in the 1990s, the types of choices adults make in the process of reentering higher education, and relevant extant theory contribute to the proposed model. A discussion of implication for policy development that would encourage adult reentry and degree completion is included.

Publisher Summary This chapter evaluates a prototype of a new daylighting system for use in the offices. It consists of a special retro-reflecting solar blind and a dedicated reflector at the ceiling, and fluorescent lighting fixtures equipped with a daylight responsive dimming system. The light technical and thermal behavior is evaluated by comparison of a test office with a reference office. Several parameters are also measured—namely, the illuminance, the temperatures, the solar irradiation, the lighting power, and the heating power. It is noted that the thermal evaluation is performed during the weekend, with both the offices closed and electrically heated up to the same temperature. It can be thus concluded that the system brings more uniform light at the workstations in the office. The daylighting system has a similar thermal performance as a white horizontal solar blind.