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Objective: To determine where the current literature stands in regard to diet/exercise interventions on cognition in overweight or obese individuals. Data Source: A rapid review was conducted of English-language studies published in Medline from January 1965 to January 2020. Study Inclusion and Exclusion Criteria: Included studies were intervention studies lasting ≥12 weeks, with participants aged ≥65 years, with a body mass index ≥25 kg/m2 Data Extraction: Data extracted included study population, duration, intervention design, outcomes, and results. Data Synthesis: Outcomes were qualitatively measured due to paucity of RTC. Results: 1845 citations were identified, 31 full-text articles were reviewed, and 5 studies were included. Studies had usual care control groups and combined exercise/diet intervention groups with 31-3,526 participants randomized to each arm. Mean age of participants was 69.2-83.4 years. Studies reporting on cognitive changes showed marginally significant positive changes in cognition, and those that reported BMI indicated potential improvements in cognition. Conclusions: The number of interventions assessing the combined effects of both diet and exercise is low. Future studies should evaluate the impact of combined effects to ascertain whether cognitive decline may be reversed in older adults with a BMI ≥25 kg/m2.

Introduction Effective weight-management interventions require frequent interactions with specialised multidisciplinary teams of medical, nutritional and behavioural experts to enact behavioural change. However, barriers that exist in rural areas, such as transportation and a lack of specialised services, can prevent patients from receiving quality care. Methods We recruited patients from the Dartmouth-Hitchcock Weight & Wellness Center into a single-arm, non-randomised study of a remotely delivered 16-week evidence-based healthy lifestyle programme. Every 4 weeks, participants completed surveys that included their willingness to pay for services like those experienced in the intervention. A two-item Willingness-to-Pay survey was administered to participants asking about their willingness to trade their face-to-face visits for videoconference visits based on commute and copay. Results Overall, those with a travel duration of 31–45 min had a greater willingness to trade in-person visits for telehealth than any other group. Participants who had a travel duration less than 15 min, 16–30 min and 46–60 min experienced a positive trend in willingness to have telehealth visits until Week 8, where there was a general negative trend in willingness to trade in-person visits for virtual. Participants believed that telemedicine was useful and helpful. Conclusions In rural areas where patients travel 30–45 min a telemedicine-delivered, intensive weight-loss intervention may be a well-received and cost-effective way for both patients and the clinical care team to connect.

Summary Background The public health crisis of obesity leads to increasing morbidity that are even more profound in certain populations such as rural adults. Live, two‐way video‐conferencing is a modality that can potentially surmount geographic barriers and staffing shortages. Methods Patients from the Dartmouth‐Hitchcock Weight and Wellness Center were recruited into a pragmatic, single‐arm, nonrandomized study of a remotely delivered 16‐week evidence‐based healthy lifestyle programme. Patients were provided hardware and appropriate software allowing for remote participation in all sessions, outside of the clinic setting. Our primary outcomes were feasibility and acceptability of the telemedicine intervention, as well as potential effectiveness on anthropometric and functional measures. Results Of 62 participants approached, we enrolled 37, of which 27 completed at least 75% of the 16‐week programme sessions (27% attrition). Mean age was 46.9 ± 11.6 years (88.9% female), with a mean body mass index of 41.3 ± 7.1 kg/m2 and mean waist circumference of 120.7 ± 16.8 cm. Mean patient participant satisfaction regarding the telemedicine approach was favourable (4.48 ± 0.58 on 1‐5 Likert scale—low to high) and 67.6/75 on standardized questionnaire. Mean weight loss at 16 weeks was 2.22 ± 3.18 kg representing a 2.1% change (P < .001), with a loss in waist circumference of 3.4% (P = .001). Fat mass and visceral fat were significantly lower at 16 weeks (2.9% and 12.5%; both P < .05), with marginal improvement in appendicular skeletal muscle mass (1.7%). In the 30‐second sit‐to‐stand test, a mean improvement of 2.46 stands (P = .005) was observed. Conclusion A telemedicine‐delivered, intensive weight loss intervention is feasible, acceptable, and potentially effective in rural adults seeking weight loss.

The SuperCam instrument suite provides the Mars 2020 rover, Perseverance, with a number of versatile remote-sensing techniques that can be used at long distance as well as within the robotic-arm workspace. These include laser-induced breakdown spectroscopy (LIBS), remote time-resolved Raman and luminescence spectroscopies, and visible and infrared (VISIR; separately referred to as VIS and IR) reflectance spectroscopy. A remote micro-imager (RMI) provides high-resolution color context imaging, and a microphone can be used as a stand-alone tool for environmental studies or to determine physical properties of rocks and soils from shock waves of laser-produced plasmas. SuperCam is built in three parts: The mast unit (MU), consisting of the laser, telescope, RMI, IR spectrometer, and associated electronics, is described in a companion paper. The on-board calibration targets are described in another companion paper. Here we describe SuperCam's body unit (BU) and testing of the integrated instrument. The BU, mounted inside the rover body, receives light from the MU via a 5.8 m optical fiber. The light is split into three wavelength bands by a demultiplexer, and is routed via fiber bundles to three optical spectrometers, two of which (UV and violet; 245-340 and 385-465 nm) are crossed Czerny-Turner reflection spectrometers, nearly identical to their counterparts on ChemCam. The third is a high-efficiency transmission spectrometer containing an optical intensifier capable of gating exposures to 100 ns or longer, with variable delay times relative to the laser pulse. This spectrometer covers 535-853 nm ( 105 - 7070 cm − 1 Raman shift relative to the 532 nm green laser beam) with 12 cm − 1 full-width at half-maximum peak resolution in the Raman fingerprint region. The BU electronics boards interface with the rover and control the instrument, returning data to the rover. Thermal systems maintain a warm temperature during cruise to Mars to avoid contamination on the optics, and cool the detectors during operations on Mars. Results obtained with the integrated instrument demonstrate its capabilities for LIBS, for which a library of 332 standards was developed. Examples of Raman and VISIR spectroscopy are shown, demonstrating clear mineral identification with both techniques. Luminescence spectra demonstrate the utility of having both spectral and temporal dimensions. Finally, RMI and microphone tests on the rover demonstrate the capabilities of these subsystems as well., Proyecto MINECO Retos de la Sociedad. Ref. ESP2017-87690-C3-1-R

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a project designed to improve the degree and quality of support for lifestyle change provided to patients with type 2 diabetes and obesity in the outpatient endocrinology clinic of a rural academic medical center.

The energy used to construct, operate and eventually demolish buildings has accounted for 40% of total energy used globally and 9% of the world’s greenhouse emissions. When examining major energy consumers such as Europe or the United States, the amounts of energy used for buildings is even higher. The use of energy-efficient technologies (EETs), such as low-energy windows and programmable thermostats, have had many positive results, including long-term energy reductions, a healthier living environment, the creation of jobs, and better quality housing. Unfortunately, there continue to be barriers to the use of EETs. While there are dozens of strategies for overcoming these barriers, many have gotten overlooked or lost. This paper provides a review of the literature that has focused on barriers to the use of EETs and strategies for overcoming these barriers. The method used for identifying relevant literature was a systematic search of scholarly publications addressing barriers and/or strategies for EET use. A theoretical framework is presented as a means of organizing the literature. The framework includes three broad groups of barriers: knowledge of EETs, access to EETs, and desire to use EETs. Strategies for overcoming the barriers are likewise organized and described.

The Hecht equation can be used to model the nonlinear degradation of charge collection efficiency (CCE) in response to radiation-induced displacement damage in both fully and partially depleted GaAs photodiodes. CCE degradation is measured for laser-generated photocurrent as a function of fluence and bias in Al0.3Ga0.7As/GaAs/Al0.25Ga0.75As p-i-n photodiodes which have been irradiated with 12 MeV C and 7.5 MeV Si ions. CCE is observed to degrade more rapidly with fluence in partially depleted photodiodes than in fully depleted photodiodes. When the intrinsic GaAs layer is fully depleted, the 2-carrier Hecht equation describes CCE degradation as photogenerated electrons and holes recombine at defect sites created by radiation damage in the depletion region. If the GaAs layer is partially depleted, CCE degradation is more appropriately modeled as the sum of the 2-carrier Hecht equation applied to electrons and holes generated within the depletion region and the 1-carrier Hecht equation applied to minority carriers that diffuse from the field-free (non-depleted) region into the depletion region. Enhanced CCE degradation is attributed to holes that recombine within the field-free region of the partially depleted intrinsic GaAs layer before they can diffuse into the depletion region.

OBJECTIVE: Adolescents are exposed to alcohol marketing through traditional advertising and through newer digital media channels. Cumulative marketing exposure across channels is of concern but has been insufficiently studied. This study explores the measurement of alcohol marketing exposure across channels and whether cumulative recalled exposure is independently associated with underage drinking. METHOD: Two hundred two New England adolescents (ages 12–17 years) were recruited from a general pediatrics clinic and completed an online survey. Recall of alcohol marketing across channels (e.g., Internet, magazines) was assessed, along with drinking behavior and relevant covariates (i.e., demographics, parental/peer drinking, smoking status, sensation seeking, Internet use, social media use, television use, and parental Internet monitoring). Confirmatory factor analysis was used to establish a latent construct of alcohol marketing exposure recall. Logistic regression tested associations between alcohol marketing recall and adolescent drinking, with covariates controlled for. RESULTS: Adolescents reported recall of alcohol marketing across all marketing channels. Alcohol marketing recall items were significantly correlated, with α = .83. The latent measurement model of alcohol marketing recall provided excellent fit to the data, χ(2)(17, n = 202) = 27.402, p = .052; root mean square error of approximation (.000–.092) = .055; Tucker–Lewis Index = .960; comparative fit index = .976; standardized root mean square residual = .037). Adjusted cross-sectional logistic regression analyses demonstrated that the latent alcohol marketing recall construct was significantly associated with underage drinking (adjusted odds ratio = 4.08, 95% CI [1.15, 14.46]) when relevant covariates were accounted for. CONCLUSIONS: The final measurement model provided support for construct validity of a novel alcohol marketing recall construct assessing cumulative cross-channel marketing exposure. Adolescent recall of alcohol marketing across channels was significantly associated with underage drinking, while associated factors such as peer/parental drinking were accounted for.

Sarcopenic obesity portends poor outcomes, yet it is under-recognized in practice. We collected baseline clinical data including data on body composition (total and segmental muscle mass and total body fat), grip strength, and 5-times sit-to-stand. We defined sarcopenia using cut-points for appendicular lean mass (ALM) and obesity using body-fat cut-points. A total of 599 clinic patients (78.5% female; mean age was 51.3 ± 14.2 years) had bioelectrical impedance analysis (BIA) data (83.8%). Mean body mass index (BMI) and waist circumference were 43.1 ± 8.9 kg/m2 and 132.3 ± 70.7 cm, respectively. All patients had elevated body fat. There were 284 (47.4%) individuals fulfilling criteria for ALM-defined sarcopenia. Sarcopenic obese persons had a lower BMI (38.2 ± 6.4 vs 47.6 ± 8.6; P 3; P = 0.009) than those without sarcopenic obesity. Grip strength was lower in those with sarcopenic obesity (25.1 ± 8.0 vs 30.5 ± 11.3 kg; P

We present a new Li source for focused ion beam applications. Based on an AuSi eutectic alloy, Li is added as an impurity to minimize effects from degradation when exposed to air. We show the source is stable over the course of an hour and spot sizes ≲ 10 nm can be achieved. The Li beam can achieve hundreds of nanometer ranges in semiconductors with minimal damage being generated along the path length. The source performance is evaluated through a high-resolution ion beam induced charge collection experiment on an Si-based detector. Further application of the source for ion beam analysis is numerically explored; the example investigated is based on probing a semiconductor heterostructure through a Rutherford backscattering experiment, where the Li beam can reveal information that is inaccessible with either low energy or high energy He projectiles used as probes.

Nad barjem je veter in moker je zrak, uši imam v tuniki, v nosu prehlad. Z neba štropotajo nalivi dežja, vojak sem na zidu, ne vem sploh, zakaj. Po sivem kaménju se plazi megla, dekle imam v Tungriji, jaz pa spim sam.

Objective Evidence suggests that adolescents are exposed to alcohol marketing in digital media. We aimed to assess recall of Internet alcohol marketing and its association with underage drinking. Methods New England adolescents age 12-17 years (N=202) were recruited from a pediatric clinic. Subjects completed an online survey assessing: 1) general simple recall of Internet alcohol marketing and 2) image-prompted recall of specific Internet alcohol marketing channels (display ads, commercials, brand websites, brand social media pages). Cross-sectional associations between recall (simple and image-prompted) and ever-drinking were each assessed in regression analysis adjusting for age, gender, race, parent education, ever-smoking, media use, sensation-seeking, peer/parent drinking, parent monitoring/responsiveness, and parent Internet monitoring. Results In this sample (Mage=14.5 years; 55% female; 89% white; high parent education), 20% reported ever-drinking and 87% recalled Internet alcohol marketing. Of the latter, 67% recalled display ads, 67% Internet commercials, 5% websites, 5% social media pages. In logistic regression, higher Internet alcohol advertising recall was independently associated with higher odds of ever-drinking for simple (AOR: 2.66 [1.04,6.83]) but not for image-prompted recall. Conclusions Despite controlling for potential confounders, simple recall of Internet alcohol marketing was significantly associated with underage drinking whereas image-prompted recall was significant only in bivariate analysis, likely due to small sample and a more limited range of specific channels assessed than those accessed by adolescents. Further longitudinal studies using image-prompted recall and capturing a broader range of internet platforms could be used to better understand adolescent engagement with alcohol marketing and guide policy and prevention efforts.

Large and increasing numbers of rural-to-urban migrants provided new challenges for tuberculosis control in large cities in China and increased the need for high quality tuberculosis care delivered by clinics in urban migrant communities. Based on a household survey in migrant communities, we selected and separated clinics into those that mainly serve migrants and those that mainly serve local residents. Using standardized patients, this study provided an objective comparison of the quality of tuberculosis care delivered by both types of clinics and examined factors related to quality care. Only 27% (95% confidence interval (CI) 14&ndash, 46) of cases were correctly managed in migrant clinics, which is significantly worse than it in local clinics (50%, 95% CI 28&ndash, 72). Clinicians with a base salary were 41 percentage points more likely to demonstrate better case management. Furthermore, clinicians with upper secondary or higher education level charged 20 RMB lower out of pocket fees than less-educated clinicians. In conclusion, the quality of tuberculosis care accessed by migrants was very poor and policies to improve the quality should be prioritized in current health reforms. Providing a base salary was a possible way to improve quality of care and increasing the education attainment of urban community clinicians might reduce the heavy barrier of medical expenses for migrants

Optimal detector / pre-amplifier combinations have been identified for the use of light ion IBIC (ion beam induced charge) to probe the physical structure of electrically active defects in damage cascades caused by heavy ion implantation. The ideal detector must have a sufficiently thin dead layer that incident ions will produce the majority of damage cascades in the depletion region of the detector rather than the dead layer. Detector and circuit noise must be low enough to detect the implantation of a single heavy ion as well as the decrease in the light ion IBIC signal caused by Shockley-Read-Hall recombination when the beam scans regions of the detector damaged by the heavy ion. The IBIC signals from three detectors irradiated with 750 keV He + ions are measured with commercial and bespoke charge sensitive pre-amplifiers to identify the combination with the lowest noise.

BACKGROUND: The average U.S. adolescent is exposed to about 2.5 hours of popular music and 8 mentions of alcohol brands every day. Alcohol brand mentions may function as advertising whether or not they are sanctioned by the alcohol industry. Our study aimed to determine associations between adolescents' involvement with music containing alcohol brand mentions and alcohol-related behaviors. METHODS: In 2010 to 2011, we conducted a random-digit-dial survey using national U.S. land line and cell phone frames. Through screening interviews, we identified 6,466 eligible households with subjects between 15 and 23 years of age, of whom 3,422 (53%) completed the telephone survey. Of these, 2,541 opted to participate in a subsequent web-based component. Independent variables included a composite score indicating owning and liking popular songs with alcohol brand mentions and correct recall of alcohol brands in songs. Outcome measures included ever having consumed a complete drink, ever bingeing, bingeing at least monthly, and having experienced problems from alcohol use. RESULTS: Among the 2,541 participants, compared with those in the lowest tertile on the receptivity scale, those in the highest tertile had higher odds of having had a complete drink (OR = 3.4; 95% CI = 2.2, 5.2) after adjusting for age, sex, race/ethnicity, socioeconomic status, sensation seeking, friend alcohol use, and parent alcohol use. Compared with those who did not identify at least 1 alcohol brand correctly, those who did had over twice the odds of having had a complete drink (OR = 2.1; 95% CI = 1.2, 3.8) after adjusting for all covariates. RESULTS were also significant for the outcome of ever bingeing, but not for bingeing at least monthly or having had problems due to drinking. CONCLUSIONS: In a national sample of U.S. adolescents and young adults, there were independent associations between involvement with popular music containing alcohol brand mentions and both having ever had a complete drink and having ever binged on alcohol. Language: en

Dr. Alice Stewart conclusively demonstrated, in 1958, that pediatric X-rays doubled the risk of childhood leukemia. Nevertheless, doctors continued X-raying mothers-to-be until 1980. Margaret Heffernan's (2011) book, Willful Blindness: Why We Ignore the Obvious at Our Peril, documents this and numerous other examples of our skill at ignoring information that points to something we don't want to know. Specifically, on the topic of climate change, Heffernan notes: “[I]n failing to confront the greatest challenge of our age – climate change – all the forces of willful blindness come together, like synchronized swimmers in a spectacular water ballet.” When it comes to corporate sustainability, we're seeing some recent efforts to get past willful blindness. In 2013, we saw examples such as Auden Schendler (co-author of this piece) and Michael Toffel's (2013) publication in Grist, Corporate Sustainability is Not Sustainable, which itself built upon Professor Robin Craig's (2012) article provocatively entitled “Climate Change Means the Death of Sustainability.” More recently, in Lima, Unilever's Paul Polman said that “.. most CEOs…know that their companies cannot prosper in a world with runaway climate change.” Perhaps, after years of corporate sustainability flag waving, it is no longer possible to ignore the fact that much of what companies classify as “sustainability” is, at best, green fluff that is fundamentally out of touch with the realities of anticipated climate change. Significantly, chief executive officers (CEOs) themselves are questioning the historic focus on corporate sustainability policies and targets. As summarized in the CEO Study on Sustainability, jointly published by the United Nations (UN) Global Compact and Accenture (2013): “Business leaders [now] believe that only with greater government intervention — at global, national and local levels — can sustainability move from sporadic incremental advances to a collective and transformative impact.”

We present experimental evidence of single-event upsets in 28 and 45 nm CMOS SRAMs produced by single energetic electrons. Upsets are observed within 10% of nominal supply voltage for devices built in the 28 nm technology node. Simulation results provide supporting evidence that upsets are produced by energetic electrons generated by incident X-rays. The observed errors are shown not to be the result of “weak bits” or photocurrents resulting from the collective energy deposition from X-rays. Experimental results are consistent with the bias sensitivity of critical charge for direct ionization effects caused by low-energy protons and muons in these technologies. Monte Carlo simulations show that the contributions of electron-induced SEU to error rates in the GEO environment depend exponentially on critical charge.

Measurements of single particle displacement damage are presented as discrete increases in reverse-biased diode leakage current, or current steps, caused by individual heavy ions in 252Cf-irradiated JFET diodes. The maximum size of measured current steps agrees with calculations obtained from the expression for Shockley-Read-Hall generation when the radiation-induced defect density is derived from Monte Carlo simulations of atomic displacements and the electric field enhancement of defect emission is taken into account. The distribution of the current steps shows good agreement with experimental data.

BACKGROUND AND OBJECTIVE: Internet alcohol marketing is not well studied despite its prevalence and potential accessibility and attractiveness to youth. The objective was to examine longitudinal associations between self-reported engagement with Internet alcohol marketing and alcohol use transitions in youth. METHODS: A US sample of 2012 youths aged 15 to 20 was surveyed in 2011. An Internet alcohol marketing receptivity score was developed, based on number of positive responses to seeing alcohol advertising on the Internet, visiting alcohol brand Web sites, being an online alcohol brand fan, and cued recall of alcohol brand home page images. We assessed the association between baseline marketing receptivity and both ever drinking and binge drinking (≥6 drinks per occasion) at 1-year follow-up with multiple logistic regression, controlling for baseline drinking status, Internet use, sociodemographics, personality characteristics, and peer or parent drinking. RESULTS: At baseline, ever-drinking and binge-drinking prevalence was 55% and 27%, respectively. Many (59%) reported seeing Internet alcohol advertising, but few reported going to an alcohol Web site (6%) or being an online fan (3%). Higher Internet use, sensation seeking, having family or peers who drank, and past alcohol use were associated with Internet alcohol marketing receptivity, and a score of 1 or 2 was independently associated with greater adjusted odds of initiating binge drinking (odds ratio 1.77; 95% confidence interval, 1.13–2.78 and odds ratio 2.15; 95% confidence interval, 1.06–4.37 respectively) but not with initiation of ever drinking. CONCLUSIONS: Although high levels of engagement with Internet alcohol marketing were uncommon, most underage youths reported seeing it, and we found a prospective association between receptivity to this type of alcohol marketing and future problem drinking, making additional research and ongoing surveillance important.

Monte Carlo simulations demonstrate that electrons in a Europa-like radiation environment produce single events capable of depositing more than 100 keV in a shielded focal plane array (FPA). Aluminum shielding slows down high energy free space electrons through collisions. Incident electrons can also generate secondary particles within shielding through electromagnetic cascades, nuclear interactions, and other mechanisms. When incident electrons and secondary particles deposit energy in FPA pixels, the result is transient increases in background noise. We compare the energy deposition integral cross sections and estimate the single event effect rate for a range of electron energies incident upon an FPA shielded with 1, 5, and 10 cm of aluminum.

Introduction Diabetes in human subjects is often associated with hypertension. The aim of this study was to examine the development of cardiac fibrosis following induction of type 1 diabetes in genetically hypertensive rats. Methods Diabetes was induced by streptozotocin (STZ) injection in 8-week-old normotensive Wistar–Kyoto (WKY) rats and spontaneously hypertensive rats (SHRs) for a duration of 16 or 24 weeks. Aged-matched, nondiabetic WKY and SHRs were used as controls. At termination of treatment, the rats were anaesthetized, hearts arrested in diastole and perfusion fixed. A comprehensive examination of cardiac fibrosis throughout the right and left ventricles was undertaken in picrosirius red-stained sections, using image analysis and by undertaking collagen type I and type III immunohistochemistry. Results Induction of diabetes in the SHRs led to a marked increase in the levels of interstitial fibrosis in the left ventricle plus septum (LV+S) at both 16 and 24 weeks duration (59% and 43% increase, respectively) and also in the right ventricle after 24 weeks duration of diabetes (35% increase compared to the nondiabetic SHR). Exacerbated perivascular fibrosis was also observed in the LV+S in the diabetic-hypertensive rats at the later time point. These effects of induction of diabetes were not observed in the normotensive strain. Conclusions/Interpretation Our findings clearly demonstrate elevations in cardiac fibrosis when type 1 diabetes is combined with hypertension. Our findings thus stress the importance of closely monitoring both blood pressure and glucose levels in type 1 diabetic patients in order to prevent myocardial collagen deposition.

Background Studies in high-income countries have found that female physicians exhibit better performance than their male counterparts. However, it is largely unclear whether these findings are influenced by case and patient mix bias. We aimed to objectively assess differences in clinical practice and treatment between female and male primary care providers in rural China. Methods In this cross-sectional study, we used standardised patients to assess provider performance in clinical practice, yielding objective performance measures free from case and patient mix bias. We included 309 primary providers who received 412 visits from standardised patients in township health centres in rural areas of three provinces in western, central, and eastern China. All providers were visited by standardised patients who were trained to consistently present three disease cases. Clinical process was graded against checklists based on national and international guidelines of recommended questions and exams to be performed. Assessment of treatment considered the appropriateness of medicine dispensed and referrals made, as well as the types and quantity of medicines dispensed. Unadjusted comparisons of the performance of male and female providers used Ordinary Least Squares (OLS) regressions controlling for disease cases. Adjusted comparisons additionally controlled for facility fixed effects and provider characteristics. We obtained ethics approval from the institutional review boards of Stanford University, USA, and Sichuan University, China. Informed consent was obtained verbally from all providers participating in the study. Consent from village and township providers was obtained as part of the facility survey approximately 5 weeks before visits. All individuals who participated as standardised patients were trained to protect themselves from any invasive tests or procedures. Findings In unadjusted comparisons, female providers completed 0·76 (95% CI 0·05–1·47) more clinical checklist items on average than male providers, representing an increase of 15% over the mean number of checklist items completed by male providers (5·04 items). Female providers were also 15 percentage points (95% CI 0–30) more likely to give appropriate treatment than male providers (38%). Although, there was no significant difference in unadjusted comparisons (43% for female providers and 41% male providers), female providers prescribed significantly fewer unnecessary or harmful medicines such as antibiotics than male providers after controlling for facility fixed effects and other provider characteristics (–21 percentage points, 95% CI −41 to −2). Interpretation This study finds that female providers prescribe fewer unnecessary or harmful treatments in primary care than male providers in rural China after controlling for potential sources of bias. No difference between female and male providers was found for other measures of clinical process quality after adjusting for observable characteristics. Funding 111 Project (Grant B16031 ), the Laboratory of Modern Teaching Technology of the Ministry of Education, Shaanxi Normal University, National Natural Science Foundation of China (Grant 71703083 ), the National Social Science Fund Youth Project (Grant 15CJL005 ), the National Natural Science Foundation of China (Grant 71703084 ), and the Knowledge for Change program at The World Bank (Grant 7172469 ).

Women's colleges in the 1970s and 1980s faced highly uncertain futures. Soaring popularity of coeducation left them with serious enrollment downturns, and challenges from proposed equal rights legislation threatened to render illegal their single-sex admissions policies. These perilous external conditions drew together the presidents of U.S. women's colleges in new ways as they sought to preserve and strengthen their individual institutions and to secure a future for women's colleges as an institutional type.

To assess health care consumers' inclination to engage in selected patient safety practices. A Fall 2006 telephone survey of 856 randomly selected adults (age, 18 years and older) in Pennsylvania. There are distinct differences in health care consumers' self-reported inclination to engage in various patient safety practices. Consumers seem to be willing to ask for explanations of things they do not understand, question unexpected procedures and unfamiliar drugs, and seek second opinions on important decisions. They seem less inclined to ask for confirmation of their identity before a procedure or to ask a health care worker if they have washed their hands. Health care consumers are inclined to engage in practices intended to promote their own safety when interacting with the health care system. The extent of their inclination to engage in these practices varies depending on which practice is studied. Participants were inclined toward practices aimed at informing themselves. They were less inclined toward practices that may be viewed as more confrontational.

The eSDO project is a UK e-Science project funded by PPARC to develop solar algorithms, visualization tools and designs for a UK data centre that can be accessed through the UK virtual observatory in preparation for the Solar Dynamic Observatory (SDO) mission in 2008. Algorithms available for use by the solar community include helioseismology applications, coronal feature recognition, and wave power analysis. Visualization tools will allow users to vary time ranges, cadence and resolution and they view streams of images data from the Atmospheric Imaging Assembly (AIA) and Helioseismic Magnetic Imager (HMI) instruments. Finally, a prototype UK data centre will demonstrate efficient UK user access to SDO data through both AstroGrid searches and integration with the global SDO data archive. (c) 2007 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

This study compared the experiences of women attending women's colleges with those of women attending coeducational institutions. Analyses of data from the National Survey of Student Engagement (NSSE) from random samples of female first-year and senior students from 26 women's colleges and 264 other four-year institutions were conducted. Women at single-sex institutions were more engaged in effective educational practices and reported higher levels of feelings of support and greater gains in college. With regard to the effect of different backgrounds on college experiences, transfer students at women's colleges were as engaged or more engaged than students who start at and graduate from the same school, and students of color tended to be less engaged than White students.

Alcohol is the most common drug among youth and a major contributor to morbidity and mortality worldwide. Billions of dollars are spent annually marketing alcohol.To examine the reach of television alcohol advertising and its effect on drinking among underage youth.Longitudinal telephone- and web-based surveys conducted in 2011 and 2013 involving 2541 US adolescents 15 to 23 years of age at baseline, with 1596 of these adolescents completing the follow-up survey. Cued recall of television advertising images for top beer and distilled spirits brands that aired nationally in 2010-2011 (n = 351). Images were digitally edited to remove branding, and the respondents were queried about 20 randomly selected images. An alcohol advertising receptivity score was derived (1 point each for having seen the ad and for liking it, and 2 points for correct brand identification). Fast-food ads that aired nationally in 2010-2011 (n = 535) were similarly queried to evaluate message specificity.Among the underage youth at baseline, we determined (1) the onset of drinking among those who never drank, (2) the onset of binge drinking among those who were never binge drinkers, and (3) the onset of hazardous drinking among those with an Alcohol Use Disorders Identification Test consumption subscore of less than 4. Multivariate regressions were used to predict each outcome, controlling for covariates (demographics, drinking among friends and parents, and sensation seeking), weighting to the US population, and using multiple imputation to address loss to follow-up.Underage participants were only slightly less likely than participants of legal drinking age to have seen alcohol ads (the mean percentage of ads seen were 23.4%, 22.7%, and 25.6%, respectively, for youth 15-17, 18-20, and 21-23 years of age; P .005). The transition to binge and hazardous drinking occurred for 29% and 18% of youth 15 to 17 years of age and for 29% and 19% of youth 18 to 20 years years of age, respectively. Among underage participants, the alcohol advertising receptivity score independently predicted the onset of drinking (adjusted odds ratio [AOR], 1.69 [95% CI, 1.17-2.44]), the onset of binge drinking (AOR, 1.38 [95% CI, 1.08-1.77]), and the onset of hazardous drinking (AOR, 1.49 [95% CI, 1.19-1.86]). Fast-food advertising receptivity was not associated with any drinking outcome.Receptivity to television alcohol advertising predicted the transition to multiple drinking outcomes. The findings are consistent with the idea that marketing self-regulation has failed to keep television alcohol advertising from reaching large numbers of underage persons and affecting their drinking patterns.

PurposeThe paper seeks to address four key Top Management Team (TMT) demographic characteristics in their relationship with firm performance: age, functional background, educational field, and team tenure. The study extends research on the TMT by explicitly introducing team performance as a new context measured in the form of International Risk Management Factor, in addition to demographic characteristic effects. International Risk Management Factor is developed based on multiple international risks trading off theory. In order to calculate that factor International Risk Management Index is introduced.Design/methodology/approachIn the paper a sample of 212 firms was used, including 4,009 executives; also four hypotheses were tested. The hypotheses were tested using multiple regression analysis.FindingsThe findings in this paper support the proposition that top management team is an appropriate unit of study, due to its impact on firm performance. The results indicate that there is a significant correlation between TMT demographic characteristics and firm performance. This study concluded that three of the proposed four TMT demographic characteristics, including age, functional background, and team tenure influence firm performance. Results validate the proposition that TMT demographic characteristics show a significant positive correlation with firm performance, particularly when the accounting measure is applied. In addition, Top Management Team performance was positively correlated to team tenure, suggesting that as team tenure progresses team performance improves.Originality/valueThe paper differs in many features from previous research. Some of the most important aspects include scope of the study, scale of the sample, complexity of the moderated variable, uniqueness of moderated variable operationalization, and innovation in calculating International Risk Management Factor. For the first time, the study focuses exclusively on Top Management Team performance. The concept, which captures complexity of all TMT characteristics, is not included in demographic characteristics of TMT.

Summary Industrial ecology (IE) has historically focused on manufacturing but could be applied more broadly, particularly to sectors of the economy not typically considered “dirty.” The guest-service sector, for example, has a significant ecological footprint, often in environmentally sensitive areas, and would benefit from an IE perspective. Colorado's Aspen Skiing Company, which hosts 1.3 million skiers annually on 5, 000 acres of skiable terrain, is integrating concepts of energy efficiency, feedback, life-cycle costing, nutrient cycling, renewable energy, ecosystem diversity, local sourcing, and human capital into operations at four ski areas and two hotels. An IE perspective offers the guest service sector a holistic view of its environmental impacts, a big-picture view that is missing from an industry where environmentalism has historically meant “recycling” or end-of-pipe pollution control. Many industrial ecology principles are directly applicable to resorts, but implementers will encounter a host of obstacles cultural, institutional, and economic that express themselves in unique ways in the guest service sector. Written using firsthand experiences from Aspen's ski slopes, restaurants, and a five-star hotel, this article explores what happens when the principles of industrial ecology are applied to the guest service sector, particularly what goes right, and what goes wrong.

Nearly every US acute care hospital reports publicly on adherence to recommended processes of care for patients hospitalized with pneumonia. However, it remains uncertain how much performance of these process measures has improved over time or whether performance is associated with superior patient outcomes.To describe trends in processes of care, mortality, and readmission for elderly patients hospitalized for pneumonia and to assess the independent associations between processes and outcomes of care.Retrospective cohort study conducted from January 1, 2006, to December 31, 2010, at 4740 US acute care hospitals. The cohort included 1 818 979 cases of pneumonia in elderly (≥65 years), Medicare fee-for-service patients who were eligible for at least 1 of 7 pneumonia inpatient processes of care tracked by the Centers for MedicareMedicaid Services (CMS).Annual performance rates for 7 pneumonia processes of care and an all-or-none composite of these measures; and 30-day, all-cause mortality and hospital readmission, adjusted for patient and hospital characteristics.Adjusted annual performance rates for all 7 CMS processes of care (expressed in percentage points per year) increased significantly from 2006 to 2010, ranging from 1.02 for antibiotic initiation within 6 hours to 5.30 for influenza vaccination (P .001). All 7 measures were performed in more than 92% of eligible cases in 2010. The all-or-none composite demonstrated the largest adjusted relative increase over time (6.87 percentage points per year; P .001) and was achieved in 87.4% of cases in 2010. Adjusted annual mortality decreased by 0.09 percentage points per year (P .001), driven primarily by decreasing mortality in the subgroup not treated in the intensive care unit (ICU) (-0.18 percentage points per year; P .001). Adjusted annual readmission rates decreased significantly by 0.25 percentage points per year (P .001). All 7 processes of care were independently associated with reduced 30-day mortality, and 5 were associated with reduced 30-day readmission.Performance of processes of care for elderly patients hospitalized for pneumonia improved substantially from 2006 to 2010. Adjusted 30-day mortality declined slightly over time primarily owing to improved survival among non-ICU patients, and all individual processes of care were independently associated with reduced mortality.

This study sought to improve mental health care for patients with head and neck cancers (HNCs) through the implementation of an evidence-based process for identifying and managing psychological distress. This process in an HNC medical oncology clinic was assessed and redesigned using quality improvement (QI) methods from November 2010 through April 2012. The redesign, starting in January 2011, involved a 2-component QI intervention: the validated NCCN Distress Thermometer and an evidence-based treatment decision algorithm. Screening processes were improved through Plan-Do-Study-Act (PDSA) cycles. Before January 2011, distress identification was based on a provider's clinical assessment. Cause-effect diagramming suggested that lack of a formalized process for distress assessment contributed to missed diagnoses. Providers were also unfamiliar with mental health resources. After implementing process changes, biweekly distress screening rates rose from 0% to 38% between January and July 2011. Furthermore, with additional PDSA cycles, these rates increased to 74% between October 2011 and April 2012. Similar to proposed benchmarks, 84% (n=47) of newly diagnosed patients (n=56) were screened. Improvement in screening was attributed to process changes and involvement of senior leadership. QI principles can be applied to the cancer setting in order to create systems of care which more reliably identify and address the needs of patients with psychological distress.

Importance Obesity affects health in children and adolescents. Television viewing is an established risk factor for obesity in youth. No prospective study has assessed whether a bedroom television confers an additional risk for obesity in youth. Objective To assess the prospective association between the presence of a bedroom television and change in body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), independent of television viewing, in a nationally representative sample of US children and adolescents. Design, Setting, and Participants We conducted a random-digit prospective telephone survey that captured children and adolescents from across the United States. Participants included 6522 boys and girls aged 10 to 14 years at baseline who were surveyed via telephone about media risk factors for obesity. Weighted regressions assessed adiposity at 2- and 4-year follow-up, controlling for television and movie viewing, video-game playing, parenting, age, sex, race or ethnicity, household income, and parental educational level. Exposure Report of having a television in the bedroom at baseline. Main Outcomes and Measures Age- and sex-adjusted BMI based on self-report and parent report of weight and height at 2- and 4-year follow-up. Results Distributions for age, sex, race or ethnicity, and socioeconomic status were similar to census estimates for the US population. Sample weighting methods accounted for higher dropout rates among ethnic minorities and those with lower socioeconomic status. Bedroom televisions were reported by 59.1% of participants at baseline, with boys, ethnic minorities, and those of lower socioeconomic status having significantly higher rates. In multivariate analyses, having a bedroom television was associated with an excess BMI of 0.57 (95% CI, 0.31-0.82) and 0.75 (0.38-1.12) at years 2 and 4, respectively, and a BMI gain of 0.24 (0.02-0.45) from years 2 to 4. Conclusions and Relevance Having a bedroom television is associated with weight gain beyond the effect of television viewing time. This association could be the result of uncaptured effects of television viewing or of disrupted sleep patterns. With the high prevalence of bedroom televisions, the effect attributable to this risk factor among US children and adolescents is excess weight of 8.7 million kg/y.

An anxious resident paged ethics at 2:00 a.m. His patient, Mr. M, a twenty-nine-year-old man with a history of multiple substance abuse, was in the hospital after cardiac arrest and lack of cerebral perfusion. Sadly, the young man probably met the criteria for brain death, but the final apnea test to confirm the diagnosis could not be done for another forty-eight to seventy-two hours because the Klonopin in his system might confound the results. The resident's concern, however, addressed a request made by the patient's mother for a sperm harvest. The patient's mother maintained that her son had said he wanted to give her grandchildren. She wished to harvest sperm from him for a future use with an as-yet-to-be-determined surrogate mother.

Purpose: To examine the effects of temperature on auditory brainstem responses (ABRs) in infants during hypothermic cardiopulmonary bypass for total circulatory arrest (TCA). The relationship between ABRs (as a surrogate measure of corebrain temperature) and body temperature as measured at several temperature monitoring sites was determined. Methods: In a prospective, observational study, ABRs were recorded non-invasively at norrnothermia and at every I or 2~ change in ear-canal temperature during cooling and rewarming in I 5 infants (ages: 2 days to 14 months) that required TCA. The ABR latencies and amplitudes and the lowest temperatures at which an ABR was identified (the threshold) were measured during both cooling and rewarming. Temperatures from four standard temperature monitoring sites were. simultaneously recorded�9 Re,sults: The latencies of ABRs increased and amplitudes decreased with cooling (P < 0.01), but rewarming reversed these effects. The ABR threshold temperature as related to each monitoring site (ear-canal, nasopharynx, esophagus and bladder) was respectively determined as 23 ___ 2.2~ 20.8 --- 1.7~ 14.6 __. 3.4~ and 21.5 --- 3.8~ during cooling and 21.8 _+ 1.6~ 22�9 _+ 2.0~ 27.6 --- 3.6~ and 23.0 --- 2.4~ during rewarming. The rewarming latencies were shorter and Qi0 latencies smaller than the corresponding cooling values (P < 0.01). Esophageal and bladder sites were more susceptible to temperature variations as compared with the ear-canal and nasopharynx. Conclusion: No temperature site reliably predicted an electrophysiological threshold. A faster latency recovery during rewarming suggests that body temperature monitoring underestimates the effects of rewarming in the core-brain. ABRs may be helpful to monitor the effects of cooling and rewarming on the core-brain during pediatric cardiopulmonary bypass. Objectif: Examiner les effets de la temperature sur les rEponses du tronc cErEbral ~ des stimuli auditifs chez des enfants pendant la circulation extracorporelle hypothermique dans le cas d'un art& circulatoire total (ACT). La relation entre les r~ponses du tronc cErEbral (en rant que mesure substitutive de la temperature c&Ebrale centrale) et la temperature du corps (mesurEe ~ diff&ents points d'enregistrement)

Background. Pediatric patients undergoing repair of congenital cardiac abnormalities have a significant risk of an adverse neurologic event. Therefore this retrospective cohort study examined the potential benefit of interventions based on intraoperative neurophysiologic monitoring in decreasing both postoperative neurologic sequelae and length of hospital stay as a cost proxy. Methods: With informed parental consent approved by the institutional review board, electroencephalography, transcranial Doppler ultrasonic measurement of middle cerebral artery blood flow velocity, and transcranial near-infrared cerebral oximetry were monitored in 250 patients. An interventional algorithm was used to detect and correct specific deficiencies in cerebral perfusion or oxygenation or to increase cerebral tolerance to ischemia or hypoxia. Results: Noteworthy changes in brain perfusion or metabolism were observed in 176 of 250 (70%) patients. Intervention that altered patient management was initially deemed appropriate in 130 of 176 (74%) patients with neurophysiologic changes. Obvious neurologic sequelae (i.e., seizure, movement, vision or speech disorder) occurred in five of 74 (7%) patients without noteworthy change, seven of 130 (6%) patients with intervention, and 12 of 46 (26%) patients without intervention (p = 0.001). Survivors' median length of stay was 6 days in the no-change and intervention groups but 9 days in the no-intervention group. In addition, the percentage of patients in the no-intervention group discharged from the hospital within 1 week (32%) was significantly less than that in either the intervention (51%, p = 0.05) or no-change (58%, p = 0.01) groups. On the basis of an estimated hospital neurologic complication cost of $1500 per day, break-even analysis justified a hospital expenditure for neurophysiologic monitoring of $2142 per case. Conclusions: Interventions based on neurophysiologic monitoring appear to decrease the incidence of postoperative neurologic sequelae and reduce the length of stay. Inasmuch as the break-even cost for neurophysiologic monitoring is more than four times the actual average charge, both patients and hospital may profit from this service. Because this study was not a truly randomized clinical trial, unintentional statistical bias may have occurred and caution is urged in interpreting the magnitude of apparent intergroup outcome differences. (J Thorac Cardiovasc Surg 1997;114:707-17)

An infant with a newly-described subtype of congenital long QT syndrome is presented, along with her perioperative management on three separate occasions. During each anaesthetic characteristic arrhythmias occurred. The available literature and rational approaches to these high risk patients are reviewed.

Objective To compare media/marketing exposures and family factors in predicting adolescent alcohol use. Design Cohort study. Setting Confidential telephone survey of adolescents in their homes. Participants Representative sample of 6522 US adolescents, aged 10–14 years at baseline and surveyed four times over 2 years. Primary outcome measure Time to alcohol onset and progression to binge drinking were assessed with two survival models. Predictors were movie alcohol exposure (MAE), ownership of alcohol-branded merchandise and characteristics of the family (parental alcohol use, home availability of alcohol and parenting). Covariates included sociodemographics, peer drinking and personality factors. Results Over the study period, the prevalence of adolescent ever use and binge drinking increased from 11% to 25% and from 4% to 13%, respectively. At baseline, the median estimated MAE from a population of 532 movies was 4.5 h and 11% owned alcohol-branded merchandise at time 2. Parental alcohol use (greater than or equal to weekly) was reported by 23% and 29% of adolescents could obtain alcohol from home. Peer drinking, MAE, alcohol-branded merchandise, age and rebelliousness were associated with both alcohol onset and progression to binge drinking. The adjusted hazard ratios for alcohol onset and binge drinking transition for high versus low MAE exposure were 2.13 (95% CI 1.76 to 2.57) and 1.63 (1.20 to 2.21), respectively, and MAE accounted for 28% and 20% of these transitions, respectively. Characteristics of the family were associated with alcohol onset but not with progression. Conclusion The results suggest that family focused interventions would have a larger impact on alcohol onset while limiting media and marketing exposure could help prevent both onset and progression., Article summary Article focus Predictors of drinking during adolescence. Particular focus on predicting onset versus binge drinking and media/marketing exposures versus family risk factors. Key messages Somewhat different risk factors exist for alcohol onset versus binge drinking. Movie alcohol, alcohol marketing, friend drinking and sensation seeking predicted both outcomes. Parent drinking, availability of alcohol at home and parenting predicted alcohol onset, not binge drinking. Strengths and limitations Strengths include longitudinal design, large sample size and analysis that accounted for attrition. Limitations include inability to generalise beyond US adolescents or beyond this age bracket.

Objective To describe ownership of alcohol-branded merchandise (ABM) and its association with attitudinal susceptibility, initiation of alcohol use, and binge drinking. Design Three-wave longitudinal study. Setting Confidential telephone survey. Participants Representative US sample of 6522 adolescents aged 10 to 14 years at baseline survey (4309 of whom were never-drinkers at 8 months); subjects were resurveyed at 16 and/or 24 months. Main Exposures Ownership of ABM (first assessed at the 8-month survey) and attitudinal susceptibility to alcohol use. Outcome Measures Initiation of alcohol use that parents did not know about and binge drinking (≥5 drinks in a row). Results Prevalence of ABM ownership ranged from 11% of adolescents (at 8 months) to 20% (at 24 months), which extrapolates to 2.1 to 3.1 million US adolescents, respectively. Clothing and headwear comprised 88% of ABM. Beer brands accounted for 75% of items; 45% of items bore the Budweiser label. Merchandise was obtained primarily from friends and/or family (71%) but was also purchased by the adolescents themselves (24%) at stores. Among never-drinkers, ABM ownership and susceptibility were reciprocally related, each significantly predicting the other during an 8-month period. In turn, we found that ABM ownership and susceptibility predicted both initiation of alcohol use and binge drinking, while controlling for a broad range of covariates. Conclusions Alcohol-branded merchandise is widely distributed among US adolescents, who obtain the items one-quarter of the time through direct purchase at retail outlets. Among never-drinkers, ABM ownership is independently associated with susceptibility to as well as with initiation of drinking and binge drinking.

Although the bulk of the data useful to the Virtual Observatory are in the public domain and have uniform, read-only access from archives, there are several important cases where appropriate access varies from user to user. We outline these cases and list the desirable feature of an access-control system to cover them. AstroGrid is building such a system and we describe its architecture: X.500 names and X.509 certificates for user identity; a Public Key Infrastructure for authentication of identity; and the Community Privilege Service for sharing authorization information.

The alcohol industry spends over $5 billion a year on marketing, much of which is accessible to children. The distribution of branded articles of clothing and other personal items is one aspect of alcohol marketing that has not been adequately studied. In this study, the prevalence of ownership of alcohol-branded merchandise (ABM) was determined in a sample of rural northern New England adolescents, and the relationship between ownership of such items and initiation of alcohol use was examined.Northern New England middle school students who had not yet initiated alcohol use were captured at baseline in a 1999 school-based survey, and ownership of an ABM item and initiation of alcohol use were determined 1 to 2 years later by telephone. The analysis controlled for demographics (gender, grade in school); characteristics of the child (school performance, sensation seeking, rebelliousness); parenting style; and peer alcohol use.Of 2406 baseline never-drinkers, 15% had initiated alcohol use and 14% owned an ABM item by follow-up. ABM items consisted primarily of articles of clothing such as t-shirts and hats. ABM ownership was associated with higher grade in school, male gender, exposure to peer drinking, having tried smoking, poorer academic performance, higher levels of sensation seeking and rebelliousness, and less-responsive and restrictive parenting styles. Owners of ABM items at follow-up had higher rates of alcohol initiation compared with non-owners (25.5% vs 13.1%, respectively, p0.001). After adjusting for the above confounders, students who owned an ABM item were significantly more likely to have initiated alcohol use compared with students who did not own one (adjusted odds ratio 1.5, 95% confidence interval, 1.1-2.0).In this northern New England adolescent sample, ownership of alcohol-branded merchandise was prevalent and exhibited an independent cross-sectional association with onset of adolescent drinking. Further studies are necessary to determine whether the relationship is causal, and whether teen use of ABM items influences peer drinking norms and behavior.

J Thorac Cardiovasc Surg Patricia B. Cerrito and Erle H. Austin, III Thomas Yeh, Jr, John Gouldman, Steve M. Auden, Vedad Seremet, Harvey L. Edmonds, Jr, during pediatric cardiopulmonary bypass Mixed venous oxygen saturation does not adequately predict cerebral perfusion http://jtcs.ctsnetjournals.org/cgi/content/full/122/1/192 the World Wide Web at: The online version of this article, along with updated information and services, is located on

The plenitude of possibility, sometimes terrifying, sometimes remaking and enabling, which the near-proximity of Yeats’s presence opened up for subsequent Irish poetry, becomes very evidently more divided, emptier, when translated into subsequent British poetry. The opportunities for identification and rejection, on political, cultural and religious grounds, offered under the multivalent name ‘Yeats’ in his native country, became in Britain both seemingly more knowable and therefore more ‘readable’ for later poets. Beyond the immediate historical and cultural context which lay behind his own revisions and indecipherabilities, the divergent values and qualities expressed in his work became, elsewhere, more readily subtractable the one from the other. ‘The infinity of a totality’, Paul de Man claims, constitutes the ‘main attraction’ of symbolic presence within Romantic and post-Romantic writing, and is founded on ‘an intimate unity’ between word and ‘actuality’ or ‘truth’, a unity obviously lessened beyond an original cultural context.

43 Background: To better address the emotional needs of cancer patients by improving mental health care in Head and Neck Cancer (HNC) Medical oncology at Norris Cotton Cancer Center, Lebanon, NH, through implementing an evidence-based process for identifying and managing psychological distress. Methods: Using quality improvement methods, mental health care in HNC Medical Oncology was evaluated and revised November 2010 through April 2012. In January 2011, a two-component intervention was put into routine care including 1) the validated National Comprehensive Cancer Network (NCCN) distress thermometer (DT) and 2) a treatment decision algorithm. A licensed nursing assistant administered the DT and providers reviewed results as part of the clinical exam. Heightened distress was defined as a score of ≥ 4. Screening processes were improved through Plan-Do-Study-Act (PDSA) cycles. Results: Prior to January 2011, identification of distress was based on provider’s clinical assessment. Of 104 patients seen between November 2010 and January 2011, 25% (26) were diagnosed with psychological problems. Cause-effect diagraming suggested that lack of a formalized process for distress assessment contributed to missed diagnoses. Providers were unfamiliar with mental health resources. As reported in Psycho-Oncology 21(Suppl. 1): 51(2012) after implementing process changes, bi-weekly distress screening rates rose from 0% to 38% between January and July 2011. With additional PDSA cycles, these rates increased to 74% between October 2011 and April 2012. Similar to proposed benchmarks, 84% (47) of newly diagnosed patients (56) were assessed for distress. Furthermore, of 138 unique patients seen, 71% (98) were screened for distress and 47% (46) of these had heightened distress. Providers addressed the needs of all those identified. Improvement was attributed to the empowerment of staff and participation of senior leadership. Barriers included a heavy reliance on the presence of trained staff. Conclusions: Quality improvement methods can be applied to the cancer setting in order to create systems of care, which more reliably identify and address distress. Teams, however, must be invested in the work and receive support from senior leadership.

Monte-Carlo radiation transport simulations are used to evaluate the implications of track structure on the response of microelectronics to energy deposition from ionizing radiation events. Results show that average track structure models cannot fully account for effects on microelectronics devices from energy deposition by δ-rays. Additionally, results indicate that δ-ray energy deposition events are capable of depositing up to 10 keV of energy within a 50 nm cube at radial distances greater than 10 μm from an ionizing particle event.