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Objective To use the electronic medical record (EMR) to optimize patient care, facilitate documentation, and support quality improvement and practice-based research, in a headache specialty clinic. Background Many physicians enter data into the EMR as unstructured free text and not as discrete data. This makes it challenging to use data for quality improvement or research initiatives. Methods We describe the process of building a customized structured clinical documentation support toolkit, specific for patients seen in a headache specialty clinic. The content was developed through frequent physician meetings to reach consensus on elements that define clinical Best Practices. Tasks were assigned to the care team and data mapped to the progress note. Results The toolkit collects hundreds of fields of discrete, standardized data. Auto scored and interpreted score tests include the Generalized Anxiety Disorder 7-item, Center for Epidemiology Studies Depression Scale, Migraine Disability Assessment questionnaire, Insomnia Sleep Index, and Migraine-Specific Quality of Life. We have developed Best Practice Advisories (BPA) and other clinical documentation support tools that alert physicians, when appropriate. As of April 1, 2018, we have used the toolkits at 4346 initial patient visits. We provide screenshots of our toolkits, details of data fields collected, and diagnoses of patients at the initial visit. Conclusions The EMR can be used to effectively structure and standardize headache clinic visits for quality improvement and practice-based research. We are sharing our proprietary toolkit with other clinics as part of the Neurology Practice-Based Research Network. These tools are also facilitating clinical research enrollment and a pragmatic trial of comparative effectiveness at the point-of-care among migraine patients.

ObjectivesTo demonstrate the feasibility of pragmatic clinical trials comparing the effectiveness of treatments using the electronic medical record (EMR) and an adaptive assignment design.MethodsWe have designed and are implementing pragmatic trials at the point-of-care using custom-designed structured clinical documentation support and clinical decision support tools within our physician’s typical EMR workflow. We are applying a subgroup based adaptive design (SUBA) that enriches treatment assignments based on baseline characteristics and prior outcomes. SUBA uses information from a randomization phase (phase 1, equal randomization, 120 patients), to adaptively assign treatments to the remaining participants (at least 300 additional patients total) based on a Bayesian hierarchical model. Enrollment in phase 1 is underway in our neurology clinical practices for 2 separate trials using this method, for migraine and mild cognitive impairment (MCI).ResultsWe are successfully collecting structured data, in the context of the providers’ clinical workflow, necessary to conduct our trials. We are currently enrolling patients in 2 point-of-care trials of non-inferior treatments. As of March 1, 2018, we have enrolled 36% of eligible patients into our migraine study and 63% of eligible patients into our MCI study. Enrollment is ongoing and validation of outcomes has begun.DiscussionThis proof of concept article demonstrates the feasibility of conducting pragmatic trials using the EMR and an adaptive design.ConclusionThe demonstration of successful pragmatic clinical trials based on a customized EMR and adaptive design is an important next step in achieving personalized medicine and provides a framework for future studies of comparative effectiveness.

Summary Background No treatment has consistently shown efficacy in slowing disability progression in patients with secondary progressive multiple sclerosis (SPMS). We assessed the effect of siponimod, a selective sphingosine 1-phosphate (S1P) receptor 1,5 modulator, on disability progression in patients with SPMS. Methods This event-driven and exposure-driven, double-blind, phase 3 trial was done at 292 hospital clinics and specialised multiple sclerosis centres in 31 countries. Using interactive response technology to assign numbers linked to treatment arms, patients (age 18–60 years) with SPMS and an Expanded Disability Status Scale score of 3·0–6·5 were randomly assigned (2:1) to once daily oral siponimod 2 mg or placebo for up to 3 years or until the occurrence of a prespecified number of confirmed disability progression (CDP) events. The primary endpoint was time to 3-month CDP. Efficacy was assessed for the full analysis set (ie, all randomly assigned and treated patients); safety was assessed for the safety set. This trial is registered with ClinicalTrials.gov, number NCT01665144. Findings 1651 patients were randomly assigned between Feb 5, 2013, and June 2, 2015 (1105 to the siponimod group, and 546 to the placebo group). One patient did not sign the consent form, and five patients did not receive study drug, all of whom were in the siponimod group. 1645 patients were included in the analyses (1099 in the siponimod group and 546 in the placebo). At baseline, the mean time since first multiple sclerosis symptoms was 16·8 years (SD 8·3), and the mean time since conversion to SPMS was 3·8 years (SD 3·5); 1055 (64%) patients had not relapsed in the previous 2 years, and 918 (56%) of 1651 needed walking assistance. 903 (82%) patients receiving siponimod and 424 (78%) patients receiving placebo completed the study. 288 (26%) of 1096 patients receiving siponimod and 173 (32%) of 545 patients receiving placebo had 3-month CDP (hazard ratio 0·79, 95% CI 0·65–0·95; relative risk reduction 21%; p=0·013). Adverse events occurred in 975 (89%) of 1099 patients receiving siponimod versus 445 (82%) of 546 patients receiving placebo; serious adverse events were reported for 197 (18%) patients in the siponimod group versus 83 (15%) patients in the placebo group. Lymphopenia, increased liver transaminase concentration, bradycardia and bradyarrhythmia at treatment initiation, macular oedema, hypertension, varicella zoster reactivation, and convulsions occurred more frequently with siponimod than with placebo. Initial dose titration mitigated cardiac first-dose effects. Frequencies of infections, malignancies, and fatalities did not differ between groups. Interpretation Siponimod reduced the risk of disability progression with a safety profile similar to that of other S1P modulators and is likely to be a useful treatment for SPMS. Funding Novartis Pharma AG.

Background and purpose Epilepsy patients are more likely to experience depressive symptoms and cognitive impairment compared to individuals in the general population. As the reasons for this are not definitively known, we sought to determine what factors correlate most strongly with cognition and a screening test for depression in epilepsy patients. Methods Our study population included 379 adult patients diagnosed with epilepsy or seizure in our neurology clinic. We collected detailed demographic and clinical data during patient visits using structured clinical documentation support tools that we have built within our commercial electronic medical records system (Epic), including a depression score (Neurological Disorders Depression Inventory for Epilepsy, NDDIE) and cognition score test measures (specifically in this study, Mini-Mental State Examination [MMSE]). Medication, age, gender, body mass index, duration of epilepsy, seizure frequency, current number of anti-epileptic medications, years of education were assessed in relation to baseline score as well as change in score from initial visit to first annual follow-up. Results Of the analyzed factors, two statistically significant associations were found after correction for multiple testing. Male gender and lower anti-seizure medication count were associated with better mood, as assessed by NDDIE score, at initial visit. Specifically, male gender was associated with a 1.3 decrease in NDDIE and for each additional anti-seizure medication, there was an associated 1.2 increase in NDDIE. Conclusions However, these factors were not associated with change in NDDIE score from initial to first annual follow-up visit. These findings, although interesting, are preliminary. Additionally, these findings were based on a homogenous (mainly Caucasian) clinic-based population and detailed information on previous medication use was lacking. Further work is needed to replicate these findings and to understand any mechanisms that may explain these associations.

Despite its unalterable march into past history, the Holocaust remains an object of fascination to contemporary novelists and filmmakers as well as to the public. Along with works that are recognized as enduring masterpieces (Lanzmann's Sboah, David Grossman's See Under: Love, Kertesz's Fatelessness), this fascination has produced dozens, if not hundreds, of films and novels that deserve to be forgotten quickly. In the wide terrain between these two extremes, one finds a small number of works that have enjoyed worldwide success even while provoking passionate critical debates: what some viewers or readers consider as an important artistic achievement, others consider as a piece of commercial marketing with no artistic merit, or maybe even as an insult to civilized values. Jonathan Littell's 2006 novel, Les Bienveillantes (The Kindly Ones), featuring a former Nazi as first-person narrator, was extolled by some extremely distinguished critics and received two major literary prizes in France before becoming an international publishing phenomenon, but it was also trashed by other, equally distinguished readers. Similarly divided opinions greeted Steven Spielberg's Schindler's List (1994), Roberto Benigni's Life Is Beautiful (1997), and most recently Quentin Tarantino's Inglourious Basterds (2009). Such contested works--we could call them crisis works or "weathervanes"--point to unresolved ethical and aesthetic issues concerning representations of the Holocaust. What can or should be shown or told in a work of art dealing with a historic event that has been called unrepresentable? Even more importantly, what can or should not be shown or told? When Schindler's List first came out, a number of commentators--foremost among them Claude Lanzmann--expressed outrage at the sequence where a group of women deported to Auschwitz are shown naked, entering a room that looks as if it could be a gas chamber. Such a representation is, according to Lanzmann, positively obscene--not to be shown. (1) By showing it, Lanzmann contended, Spielberg had committed both an artistic sin of bad taste and a grave ethical lapse, even if the room in question turned out to be an actual shower room, not a gas chamber. If the question raised by Schindler's List was "What can be shown?" then the question raised by Benigni's Life Is Beautiful was "How should it be shown?" Negative criticisms of that film emphasized its unrealistic way of depicting the concentration camp where Guido and his son are imprisoned: the camp looked too manicured, not at all like the real thing. And whoever heard of a Jewish inmate who succeeded in keeping his young child hidden for weeks or months in a Nazi concentration camp? Such criticisms focused on the criterion of historical authenticity--and once again, the issue was both ethical and aesthetic. Those who criticized this aspect of the film maintained that it is ethically reprehensible to go against historical facts in representing the Holocaust. The other, related theoretical issue concerned humor: Was humor, and the comic in general, an acceptable mode for treating this most serious subject? Those who defended Benigni's film declared not only that the artistic imagination must brook no limits, including that of factuality, but that comedy could be a powerful means of expression, even about the Holocaust. The eminent specialist of Holocaust literature Sidra Ezrahi argued that since Benigni presented the film from the start as a "fable," it should be interpreted as a comic counterfactual story, a kind of Purimspiel that presented a "meliorative" version of history and that should not be interpreted with "dead-minded literalism." Ezrahi saw in Benigni's film--as well as in several other comic representations of the Shoah, such as Radu Mihaileanu's film Train of Life (also from 1997) or Jurek Becker's novel Jakob the Liar (1969)--a continuation of the tradition of Jewish humor that one finds in the stories of Sholem Aleichem, for example. …

SummaryObjective Using the electronic medical record (EMR) to capture structured clinical data at the point of care would be a practical way to support quality improvement and practice-based research in epilepsy. Methods We describe our stepwise process for building structured clinical documentation support tools in the EMR that define best practices in epilepsy, and we describe how we incorporated these toolkits into our clinical workflow. Results These tools write notes and capture hundreds of fields of data including several score tests: Generalized Anxiety Disorder-7 items, Neurological Disorders Depression Inventory for Epilepsy, Epworth Sleepiness Scale, Quality of Life in Epilepsy–10 items, Montreal Cognitive Assessment/Short Test of Mental Status, and Medical Research Council Prognostic Index. The tools summarize brain imaging, blood laboratory, and electroencephalography results, and document neuromodulation treatments. The tools provide Best Practices Advisories and other clinical decision support when appropriate. The tools prompt enrollment in a DNA biobanking study. We have thus far enrolled 231 patients for initial visits and are starting our first annual follow-up visits and provide a brief description of our cohort. Significance We are sharing these EMR tools and captured data with other epilepsy clinics as part of a Neurology Practice Based Research Network, and are using the tools to conduct pragmatic trials using subgroup-based adaptive designs.

The role of sex steroid hormones in reproductive function in women is well established. However, in the last two decades it has been shown that receptors for estrogens, progesterone and androgens are expressed in non reproductive tissue /organs (bone, brain, cardiovascular system) playing a role in their function. Therefore, it is critical to evaluate the impact of sex steroid hormones in the pathophysiology of some diseases (osteoporosis, Alzheimer, atherosclerosis). In particular, women with primary ovarian insufficiency, polycystic ovary syndrome, endometriosis and climacteric syndrome may have more health problems and therefore an hormonal treatment may be crucial for these women.

Background Many physicians enter data into the electronic medical record (EMR) as unstructured free text and not as discrete data, making it challenging to use for quality improvement or research initiatives. Objectives The objective of this research paper was to develop and implement a structured clinical documentation support (SCDS) toolkit within the EMR to facilitate quality initiatives and practice-based research in a multiple sclerosis (MS) practice. Methods We built customized EMR toolkits to capture standardized data at office visits. Content was determined through physician consensus on necessary elements to support best practices in treating patients with demyelinating disorders. We also developed CDS tools and best practice advisories within the toolkits to alert physicians when a quality improvement opportunity exists, including enrollment into our DNA biobanking study at the point of care. Results We have used the toolkit to evaluate 541 MS patients in our clinic and begun collecting longitudinal data on patients who return for annual visits. We provide a description and example screenshots of our toolkits, and a brief description of our cohort to date. Conclusions The EMR can be effectively structured to standardize MS clinic office visits, capture data, and support quality improvement and practice-based research initiatives at the point of care.

Victims of the Holocaust have for a long time fascinated historians, psycholo gists, and novelists, as well as the general public; many victims themselves have published testimonies or autobiographical fictions, attesting to the ongo ing interest in the experience of those who suffered at the hands of the Nazis. Perpetrators' testimonies, however, are virtually nonexistent; that of Rudolf H?ss, the commandant of Auschwitz, who wrote his "memoirs" in prison before being executed, is a rare exception. Anyone curious about the actions and motivations of those who willingly participated in the Nazi project of mass murder has had to rely on historians and philosophers such as Raul Hilberg, Hannah Arendt, Christopher Browning, and Daniel Goldhagen. Fictional representations of the inner world of perpetrators (as opposed to the standard external view of Nazi villains in countless films) are also hard to find. Robert Merle's novel La mort est mon m?tier {Death Is My Trade, 1952), a fictionalized version of H?ss's autobiography, was until recently the only full-length novel narrated in the voice of a Nazi perpetrator. Jorge Luis Borges's short story "Ein Deutsches Requiem" ("A German Requiem," 1949) is the unrepentant monologue of a Nazi officer about to be executed, and George Steiner concludes his novel The Portage to San Cristobal of A. H. (1981) with a first-person self-justificatory rant by Adolf Hitler himself. David Grossman's

OBJECTIVE To compare rates of a composite outcome of mortality or major morbidity in very-preterm/very low birth weight infants between 8 members of the International Network for Evaluating Outcomes. STUDY DESIGN We included 58 004 infants born weighing

cism of her early work to the ethically engaged stance of her later essays, right up to the last one she published in her lifetime, the stinging indictment of American torture of Iraqi prisoners at Abu Ghraib. Sontag was eloquent, as well as somewhat despairing, in her diagnosis of an "increasing acceptance of brutality" and a "culture of shamelessness" in American life ("Regarding the Torture" 28-29); similarly, after September 11, 2001, she did not hesitate to denounce (in a brief essay that earned her the label of "un-American" in some quarters) the "sanctimonious, reality-concealing rhetoric spouted by American officials and media commentators" in the days follow ing the attack ("Comment"). One clear manifestation of Sontag's evolution from aestheticism to ethics, according to this view, is the contrast between an early essay like the 1965 "On Style" and the 1975 "Fascinating Fascism," both of which deal?the former almost in passing, the latter in a ma jor way?with the work of Hitler's favorite filmmaker, Leni Riefen stahl. In "On Style," Sontag emphasizes Riefenstahl's "genius as a filmmaker" and claims that the two films Riefenstahl is most famous

Contrary to what one still occasionally reads or hears, the French have not, in recent years, refused to remember the so-called "dark years" of the Vichy regime under German occupation (1940-1944). While the more shameful aspects of Vichy notably, its collaboration with the Germans in the roundup and deportation of seventy-five thousand Jews from French soil was for many years a taboo subject in public discourse as well as in the academy, that is no longer the case. Indeed, some historians have lately deplored the French "obsession" with memory of the Vichy years. Henry Rousso, in his acclaimed 1987 book The Vichy Syndrome, showed that increasingly after the mid1 970s, Vichy and its turpitudes became a focus of public attention.1 This was aided by a series of highly publicized trials for crimes against humanity, starting with the 1987 trial of Klaus Barbie, a Nazi functionary notorious for his role in the persecution of resistants and Jews in Lyon, and ending with the 1997 trial of Maurice Papon, a highly placed French bureaucrat in charge of the roundup of Jews in Bordeaux.2 It was just a few months before the opening of the Papon trial, in February 1997, that the so-called "Aubrac affair" burst into the French press, where it occupied considerable attention for over six months and beyond. Raymond and Lucie Aubrac, who enjoyed national and international fame as heroes of the Resistance, were suddenly placed under suspicion of having betrayed their comrades, and in particular the Resistance hero Jean Moulin, fifty-four years earlier. As even this onesentence summary suggests, the "Aubrac affair" raises fascinating issues about the history and memory of the Resistance in France. It also raises important issues about narrative, in particular about what I call narrative desire: on the one hand, the desire for heroic aggrandizement (or for its opposite, the toppling of heroes); on the other hand, the desire for narrative coherence and plausibility, or what in fiction is called verisimilitude.

This essay discusses the nature of literary testimony in three autobiographical works by the Buchenwald survivor Jorge Semprun, written over a period of twenty years. By tracing the variations and carefully orchestrated contradictions of a single episode recounted in all three books (Quel beau dimanche!, L’Ecriture ou la vie and Le Mort qu’il faut), the essay explores the function of repetition as well as of literary artifice in the working-through of traumatic experience. I argue that Semprun’s use of inconsistent repetition can be read as an allegory of testimony and of the failures of memory, as well as of the relation between testimony and history.

In an essay published more than forty years ago, Theodor Adorno asked: What does it mean to "work up," to "process," or-as the English translation puts it-to "come to terms with" the past? ("Was bedeutet: Aufarbeitung der Vergangenheit"). The word Aufarbeitung, Adorno wrote in 1959, had already become a highly suspect Schlagwort, or slogan, for it did not imply a "serious working through of the past, the breaking of its spell

This essay explores questions about memory and its relation to historical truth, chiefly through an examination of the “Wilkomirski case,”involving a highly acclaimed Holocaust memoir that has now been shown to be a fake. I argue that the categorical distinction between memoir and novel, while not always easy or even possible to determine, is nonetheless important;Wilkomirski's Fragments is neither an authentic memoir nor a novel but a false or deluded memoir. I discuss in contrast to this work a passage from the recent memoirs of Elie Wiesel, in which Wiesel himself revises a fragment of his acclaimed work Night. Such revision enriches both the author's and the reader's interpretations of a life-shattering experience.

Although medicalization of dementing disorders encompasses broad societal developments, such trends influence and are influenced by the context of everyday expectations and behaviors. This study provides evidence based on data from physicians in the medical community and family caregivers in the lay community that the medicalization process of Alzheimer's disease and related disorders remains incomplete. The findings suggest that physicians and families currently resolve the paradox between physician capability and family expectations by accepting the definition of Alzheimer's disease as a unique, highly variable, currently incurable illness.

Contemporary Jewish Writing in Hungary features works by twenty-four of Hungary's best writers who have written about what it means to be Jewish in post-Holocaust Eastern Europe. This volume includes work by Nobel Prize winner Imre Kertesz and other internationally known writers such as Gyorgy Konrad and Peter Nadas, but most of the authors appear here in English for the first time. This anthology features poetry, long and short stories, and excerpts from memoirs and novels by postwar writers. Some of these authors were well known in Hungary before World War II, some were children or adolescents during the war and began publishing in the 1970s, some were born to survivors in the years immediately following the war and grew up during the decades of Communist rule, while others started publishing chiefly after the fall of Communism in 1989. Unique among Eastern European countries, Hungary still has a large and visible Jewish population, many of them writers and intellectuals living in Budapest. This anthology introduces English-speaking readers to outstanding works of literature that show the wide range of responses to Jewish identity in contemporary Hungary. The editors' introduction provides a historical and critical context for these works and discusses the important role of Jews in Hungarian culture from the late nineteenth century to the present.

Le mecanisme d'appropriation autobiographique comme strategie de lecture des memoires de guerres.

Prologue - playing and modernity: pleasures of theory metapolylogue - on playing and modernity. Part 1 A double margin - woman writers and the avant-garde in France: of margins and avant-gardes the Surrealist subject women in the history of Surrealism. Part 2 Aggressions and counteraggressions - readability in avant-garde fiction: reading and rupture Robbe-Grillet, or, the readability of transgression Maurice Roche - paradigm lost and found self-reflexive afterthought. Part 3 Reading Robbe-Grillet - sadism and text in project pour une revolution a New York. Part 4 Transgression and the avant-garde - Bataille's "Histoire de l'oeil": pornography as textuality pornography as "Reality" feminist poetics and the pornographic imagination. Part 5 Love stories - women, madness, and narrative: mastery and transference - the significance of "Dora" Breton, Charcot, and the spectacle of female otherness Duras/Lucan - not knowing as entanglement. Part 6 The politics and poetics of female eroticism: equal rights, or, telling it with four-letter words celebrating difference, or, writing (and reading) otherwise dreaming beyond the number two. Part 7 Feminist intertextuality and the laugh of the mother: parody and politics parody, perversion, collage - Surrealists at play daughers playing - some feminist rewritings and the mother "The Hearing Trumpet" - Marian Leatherby and the holy grail the laugh of the mother. Part 8 Feminism and postmodernism - in lieu of an ending: une histoire bien postmoderne discourses on the postmodern and the emergence of feminist postmodernism opposition in Babel? the political status of postmodern intertextuality to market, to market - oppositional art in mass culture of cyborgs and (other) "Women" - the politics of decentered subjects.

A reader may be in" a text as a character is in a novel, but also as one is in a train of thought--both possessing and being possessed by it. This paradox suggests the ambiguities inherent in the concept of audience. In these original essays, a group of international scholars raises fundamental questions about the status--be it rhetorical, semiotic and structuralist, phenomenological, subjective and psychoanalytic, sociological and historical, or hermeneutic--of the audience in relation to a literary or artistic text.Originally published in 1980.The Princeton Legacy Library uses the latest print-on-demand technology to again make available previously out-of-print books from the distinguished backlist of Princeton University Press. These paperback editions preserve the original texts of these important books while presenting them in durable paperback editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905.

All avant-garde literature is in some sense «unreadable»—that is, unintelligible in terms of prevailing norms of intelligibility. Avant-garde fiction aggressively proclaims its transgressions of traditional narrative «logic,» and thus challenges at the same time the reader's belief in his or her sense-making ability; the reader may react to this threat by counter-attacking, dismissing the text as «unreadable.» Paradoxically, the term «readable» has a negative value in Roland Barthes's terminology, where the «readable text» is opposed to Barthes's idealized notion of the truly modern «writable text.» According to Barthes, the «writable text» refuses commentary, defies all attempt at a logical, systematic reading. This view is a romantic one. Barthes suggests that the only appropriate way to read modern texts is by adopting their fragmentariness, yielding to them in a kind of ecstasy ( jouissance ). I suggest, however, that at least two other ways of reading such texts are possible, and desirable: one way consists in the discovery of new rules of readability, which admittedly tend to lead to new codifications and a new canon (this, I argue, is what has occurred in the case of Robbe-Grillet's «transgressive» fictions); the other way consists in seeing how modern texts inscribe the question of their «unreadability» within themselves—in other words, how they thematize the opposition between readable and unreadable, unity and fragmentation, order and transgression. Maurice Roche's Compact serves as the text of reference in this latter discussion.