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When a physician decides on a treatment and its schedule for a specific patient, information gained from prior patients and experience in the past is taken into account. A more objective way to make such treatment decisions based on actual data would be useful to the clinician. Although there are many mathematical models proposed for various diseases, so far there is no mathematical method that accomplishes optimization of the treatment schedule using the information gained from past patients or “rapid learning” technology. In an attempt to use this approach, we integrate the information gained from patients previously treated with intermittent androgen suppression (IAS) with that from a current patient by first fitting the time courses of clinical data observed from the previously treated patients, then constructing the prior information of the parameter values of the mathematical model, and finally, maximizing the posterior probability for the parameters of the current patient using the prior information. Although we used data from prostate cancer patients, the proposed method is general, and thus can be applied to other diseases once an appropriate mathematical model is established for that disease.

We investigate whether, and to what extent, Nozick’s entitlement theory and Rawls’s theory of justice as fairness can normatively ground affirmative action policies. Our findings are that, whereas the Nozickean project offers no guidance for large-scale redress, the Rawlsian position supports affirmative action as redress, but only in its softer forms. Therefore, if one accepts the assumptions of equal liberty and fairness upon which Rawls’s theory is based, one is left with two alternatives: either to reject Rawls’s theory because it fails to support quota systems, or to accept Rawls’s theory and reject quota systems as a legitimate form of redress. We argue for the latter option.

This study was designed to address the issue of whether there is a general processor for the perception of emotion or whether there are separate processors. We examined the relationships among three channels of emotional communication in 100 healthy right-handed adult males and females. The channels were facial, prosodic/intonational, and lexical/verbal; both identification and discrimination tasks of emotional perception were utilised. Statistical analyses controlled for nonemotional perceptual factors and subject characteristics (i.e. demographic and general cognitive). For identification, multiple significant correlations were found among the channels. For discrimination, fewer correlations were significant. Overall, these results provide support for the notion of a general processor for emotional perceptual identification in normal adult subjects.

Judge Robert B. Patterson found that the unofficial Harry Potter Lexicon written by Steve Vander Ark and published by RDR Books infringed the copyright in the seven Harry Potter novels and two companion works (Fantastic Beasts and Where to Find Them and Quidditch Through the Ages) and that the defence of fair use did not apply.

Background Care of patients with diabetes often occurs in the context of other chronic illness. Competing disease priorities and competing patient-physician priorities present challenges in the provision of care for the complex patient. Guideline implementation interventions to date do not acknowledge these intricacies of clinical practice. As a result, patients and providers are left overwhelmed and paralyzed by the sheer volume of recommendations and tasks. An individualized approach to the patient with diabetes and multiple comorbid conditions using shared decision-making (SDM) and goal setting has been advocated as a patient-centred approach that may facilitate prioritization of treatment options. Furthermore, incorporating interprofessional integration into practice may overcome barriers to implementation. However, these strategies have not been taken up extensively in clinical practice. Objectives To systematically develop and test an interprofessional SDM and goal-setting toolkit for patients with diabetes and other chronic diseases, following the Knowledge to Action framework. Methods 1. Feasibility study: Individual interviews with primary care physicians, nurses, dietitians, pharmacists, and patients with diabetes will be conducted, exploring their experiences with shared decision-making and priority-setting, including facilitators and barriers, the relevance of a decision aid and toolkit for priority-setting, and how best to integrate it into practice. 2. Toolkit development: Based on this data, an evidence-based multi-component SDM toolkit will be developed. The toolkit will be reviewed by content experts (primary care, endocrinology, geriatricians, nurses, dietitians, pharmacists, patients) for accuracy and comprehensiveness. 3. Heuristic evaluation: A human factors engineer will review the toolkit and identify, list and categorize usability issues by severity. 4. Usability testing: This will be done using cognitive task analysis. 5. Iterative refinement: Throughout the development process, the toolkit will be refined through several iterative cycles of feedback and redesign. Discussion Interprofessional shared decision-making regarding priority-setting with the use of a decision aid toolkit may help prioritize care of individuals with multiple comorbid conditions. Adhering to principles of user-centered design, we will develop and refine a toolkit to assess the feasibility of this approach.

Background Melanoma incidence is growing and more people require follow-up to detect recurrent melanoma quickly. Those detecting their own recurrent melanoma appear to have the best prognosis, so total skin self examination (TSSE) is advocated, but practice is suboptimal. A digital intervention to support TSSE has potential but it is not clear which patient groups could benefit most. The aim of this study was to explore cutaneous melanoma recurrence patterns between 1991 and 2012 in Northeast Scotland. The objectives were to: determine how recurrent melanomas were detected during the period; explore factors potentially predictive of mode of recurrence detection; identify groups least likely to detect their own recurrent melanoma and with most potential to benefit from digital TSSE support. Methods Pathology records were used to identify those with a potential recurrent melanoma of any type (local, regional and distant). Following screening of potential cases available secondary care-held records were subsequently scrutinised. Data was collected on demographics and clinical characteristics of the initial and recurrent melanoma. Data were handled in Microsoft Excel and transported into SPSS 20.0 for statistical analysis. Factors predicting detection at interval or scheduled follow-up were explored using univariate techniques, with potentially influential factors combined in a multivariate binary logistic model to adjust for confounding. Results 149 potential recurrences were identified from the pathology database held at Aberdeen Royal Infirmary. Reliable data could be obtained on 94 cases of recurrent melanoma of all types. 30 recurrences (31.9%) were found by doctors at follow-up, and 64 (68.1%) in the interval between visits, usually by the patient themselves. Melanoma recurrences of all types occurring within one-year were significantly more likely to be found at follow-up visits, and this remained so following adjustment for other factors that could be used to target digital TSSE support. Conclusions A digital intervention should be offered to all newly diagnosed patients. This group could benefit most from optimal TSSE practice.

Wireless technology in healthcare has been associated with communication-related improvements in workflow; however, there are barriers to adoption. This study examined predictors of use of wireless communication devices (WCDs) in environments with unique needs (i.e., intensive care unit [ICU]). Nurses were recruited in the ICU to complete a paper questionnaire to assess their willingness to use WCDs. The Theory of Planned Behaviour was used to assess attitudes, subjective norms, perceived control, and behavioral intent. Responses included Likert scale scores and open-ended questions. Data were collected before and following the implementation of WCDs in ICU. The combined effects of attitudes, perceived control and subjective norms on behavioral intent were tested using the general linear model. The narrative data were analyzed using a thematic analysis approach. Attitudes and subjective norms were predictors of behavioral intent to use WCDs preimplementation but not postimplementation. Differences in the factors affecting intent to use WCDs between the ICU and the surgical unit may be related to the unique nature of the critical care environment, and to the lack of a comprehensive preimplementation strategy. A study examining predictors of use on a general inpatient unit where a comprehensive implementation strategy was not employed would provide insight into whether these findings are related to the implementation strategy or the unique nature of the critical care environment. Improved understanding of the function and application of innovative technology at the point of care, and attention to the process of implementation may improve adoption of this potentially beneficial device.

Within his cultural environment, as a physician, Herbert J. Hall (1870-1923) incorporated the Arts and Crafts movement ideology with medicine. He studied neurasthenia and the rest cure, which was the current treatment. He envisioned a better way and opened a sanatorium that incorporated work cure theories and employed craftsmen as guides. With success, Hall expanded, trained apprentices, and made occupational therapy equipment and kits for hospitals and asylums. He also published textbooks and essays and articles in scientific journals. Although the occupational therapy field has recognized some of his innovative ideas, the information presented here is a comprehensive review of his contributions that may not be recorded elsewhere.

Tumor-initiating cells (TICs) often survive therapy and give rise to second-line tumors. We tested the plausibility of sphere cultures as models of TICs. Microarray data and microRNA data analysis confirmed the validity of spheres as models of TICs for breast and prostate cancer as well as mesothelioma cell lines. Microarray data analysis revealed the Trp pathway as the only pathway upregulated significantly in all types of studied TICs, with increased levels of indoleamine-2,3-dioxygenase-1 (IDO1), the rate-limiting enzyme of Trp metabolism along the kynurenine pathway. All types of TICs also expressed higher levels of the Trp uptake system consisting of CD98 and LAT1 with functional consequences. IDO1 expression was regulated via both transcriptional and posttranscriptional mechanisms, depending on the cancer type. Serial transplantation of TICs in mice resulted in gradually increased IDO1. Mitocans, represented by α-tocopheryl succinate and mitochondrially targeted vitamin E succinate (MitoVES), suppressed IDO1 in TICs. MitoVES suppressed IDO1 in TICs with functional mitochondrial complex II, involving transcriptional and posttranscriptional mechanisms. IDO1 increase and its suppression by VE analogues were replicated in TICs from primary human glioblastomas. Our work indicates that IDO1 is increased in TICs and that mitocans suppress the protein.

Wholesale contracts are a prudent business option for smaller cities and rural systems that desire to maintain local control while addressing quality requirements and cost limitations. These contracts benefit both sellers (who gain a larger customer base over which to spread costs) and buyers (who gain a product that meets state and federal standards while holding down local costs). As part of a larger strategic planning process, the Kansas City, Mo., Water Services Department undertook an extensive telephone survey of water providers to assess their use of and interest in wholesale contracts. The survey indicated that buy-sell arrangements were common; wholesale contracts must be reached through a long-term, mutually acceptable business relationship; and regular statements of support by leaders reassure uncertain potential wholesale customers.

Because rodents behave cryptically and often have large home ranges, the role of social defence in determining their spatial dispersion in grassland remains an enigma. Individual dispersion and access to resources could be determined mainly by the aggressive exclusion of intruders from large territories by residents, or by the scattered distribution of resources and avoidance of dominant competitors occupying preferred sites. The ways in which predictions from these two hypotheses correspond to intra-sexual competitive behaviour within unfamiliar dyads of the mouseMus spretus, recently captured from two grassland populations, were examined. A series of tests in enclosures examined (1) exploration by intruders given a choice between a resident’s soiled sites versus clean sites, or between resident-soiled sites versus sites bearing their own odour, in the absence of the resident; (2) the response of an intruder on meeting either the resident or another mouse, in an adjacent clean tunnel; and (3) the response of a resident to an intruder compared with mice meeting in a clean enclosure. In both sexes, dyads quickly established dominance relationships through brief attacks and chases, and static defensive postures, rather than persistent pursuit and flight. Intruders were strongly attracted to a resident’s nest and subsequently were more aggressive towards the resident than towards an opponent from an unfamiliar enclosure. There was less differentiation in competitive behaviour and more mutual fighting between residents and intruders than between mice in clean enclosures, with relative body weight being the most important factor determining competitive behaviour. The results were thus more consistent with competition for dominance over suitable sites than investment in fierce aggression to drive competitors away.

This paper describes a project incorporating writing-to- learn activities into an introductory finance class. Such activities use writing informally as a vehicle to promote student learning. Examination of the students' brief papers showed that students became less likely to skip theory and go to canned formulas and that they took more responsibil ity for their work. For instructors, the project was beneficial because it enabled them to tailor class presentations more precisely to students' actual comprehension of course material.

Schools cannot ignore social media for any longer, says Susan Hall – but vigilance is the watchword.

families. 11 The Scottish Government’s publication Living and Dying Well: A national action plan for palliative and end-of-life care in Scotland states that Community Health Partnerships and palliative care networks should encourage GP practices to make full use of the upgraded IT systems available to support patients to die at home should that be appropriate. This should include GPs using upgraded IT system to record patients’ palliative care needs, plan review dates and assist multidisciplinary team meetings and sharing summary information with OOH services and NHS 24 (equivalent to NHS Direct in England). 11 Electronic Palliative Care Summaries (ePCSs) have been developed to utilize the upgraded IT systems to improve on the existing basic Emergency Care Summary, and it allows electronic rather than fax transmission to NHS24 of details of palliative care patients. The ePCS is an electronic template embedded within existing primary care electronic patient record systems. The ePCS template collects detailed information on a patient’s current diagnosis, their medical history, their current medication, their wishes with respect to the management of their illness and information on their wishes regarding resuscitation. It is designed to be paper free with patient information being uploaded in the practice by GPs and nurses onto their practice software system initially. Subsequently, any changes to the information can be made manually, or in the case of medications, the update is automatic, and GPs receive on-screen prompts to review the information at regular intervals. 12,13 The ePCS allows, with patient/carer consent, automatic twice-daily updates of information from computerized GP records to a central store, from where they will be made available to OOH services, NHS 24, acute receiving units, accident and emergency (A&E) departments and shortly to the Scottish Ambulance Service. 12,13 This allows vital structured information on vulnerable patients to be available both in routine surgery time and OOH. The aspirations underpinning the ePCS are consistent with the 2010 Health care Quality Strategy for Scotland that seeks to support clear collaboration and communication between patients, carers and health professionals and to promote continuity of care and clinical excellence: 14 similar initiatives for palliative care

In contrast, during the same period, under-5 mortality has fallen by more than 60% in other middle-income countries such as Brazil and Mexico. Beyond mortality, we know little about care of chronic disease (other than infections) in children, management of disabled children (including epilepsy), child abuse, adolescent problems, or transition from children’s to adult services in South Africa. Those reaching the health services often represent only the tip of the iceberg of childhood morbidity. All but invisible are problems of children and young people, 3 such as sexual and physical violence, mental health problems, and adolescent pregnancy, drugs, crime and suicide. The country’s political and economic history underlies much of this ill-health. 4 South Africa is among the world’s most unequal societies, with a Gini coefficient of 0.666 in 2008. In the health sector, human resource numbers and skills have not grown in proportion with the population or increasing burden of disease. Between 1997 and 2006, the number of specialists in the public sector declined by 25% while non-specialist medical practitioners increased by only 8.4%. 5 The shortage of doctors is aggravated by maldistribution between private and public sectors and urban and rural areas, and public sector doctors concentrated in large city hospitals are often not easily accessible to residents of townships and informal settlements. South African medical graduates are out of step with South Africa’s health needs. A review of South African health sciences faculties found that students spent only 3 - 25% of clinical curriculum time in community or rural settings, that rural supervision was inadequate, and that there was no formal assessment of clinical practice in rural or under-served areas. 6

PURPOSE: To explore experiences and support needs of people with colorectal cancer, with a focus on identifying opportunities for primary care interventions. METHODS: We conducted a new qualitative analysis of an existing dataset, comprising semi-structured interview transcripts from 39 people with colorectal cancer from across the UK, interviewed in 2001-2002 for www.healthtalkonline.org . Then, we conducted semi-structured interviews with 30 people with colorectal cancer from North East Scotland and Glasgow in 2009 and analysed these new data to explore themes and challenge hypotheses that emerged from the Healthtalkonline data. RESULTS: Formal sources of support, including that from primary care, were valued by those who received them, but provision was described as sporadic both in 2002 and in 2009. However, more of the 2009 participants gave descriptions of specialist nurse and community nurse involvement, and telephone contact from general practitioners, which were welcomed. Improvements in meeting information needs, particularly on the issues of diet and sex, were identified by 2009. A recurring issue reported by patients was the distress experienced by their own friends and family; some patients found themselves having to provide, rather than receive, emotional support at this difficult time. CONCLUSIONS: There have been improvements in support for people with colorectal cancer since 2002, with more specialist and community nurse involvement, and telephone contact from general practitioners, but provision remains piecemeal. Patients would benefit if their families received support, and primary care may be in a good position to provide this. A proactive approach from general practitioners in the post-discharge period is valued.

The number of people surviving cancer for extended periods is increasing. Consequently, due to workload and quality issues, there is considerable interest in alternatives to traditional secondary care-led cancer follow-up.To explore the views of potential recipients of shared follow-up of cancer. To conduct a modelling exercise for shared follow-up and to explore the opinions and experiences of both the patients and GPs involved.Semi-structured audio-taped telephone or face-to-face interviews were conducted with 18 patients with a range of cancers currently attending for structured follow-up in secondary care. Six GPs and five patients (four with melanoma and one with stable metastatic colorectal cancer) took part in a shared follow-up modelling exercise. During the modelling exercise, the GPs attended 4 review meetings, which included brief training seminars, and at the conclusion 10 individuals took part in semi-structured audio-taped telephone or face-to-face interviews.Many rural patients, and some urban patients, would appreciate follow-up being available nearer to home with the associated benefits of time saved and easier parking and continuity of care. Patients have concerns related to the level of extra training received by the GP and loss of contact with their consultant. GPs have concerns about gaining and maintaining the clinical skills needed to conduct follow-up, especially if the numbers of patients seen are small. They also have concerns about lack of support from other GPs, and some administrative and organizational issues.Many patients would be willing to have GPs share their cancer follow-up with the caveat that they had received extra training and were appropriately supported by secondary care specialists. Patients attending shared care clinics appreciated a local service and longer appointment times. GPs stress the importance of maintaining their own clinical skills and reliable clinical and administrative support from secondary care.

Aspirin should not be used in children except for specific therapeutic reasons. We report on a severely ill infant who had ingested aspirin contained in a traditional medicine and review 21 other patients with pre-admission non-therapeutic salicylate exposure.We reviewed laboratory, clinical and poisons unit records to determine how many children were admitted to our hospital over an 18-month period with evidence of salicylate ingestion not prescribed for therapeutic reasons. We determined the source of the salicylate, elapsed time between ingestion and laboratory assay, morbidity and mortality and final diagnosis.Twenty-one children meeting our criteria, including 9 under 6 months of age, were admitted during this period. The most prevalent source of salicylate was over-the-counter (OTC) aspirin, but some had reportedly only been given traditional medicines. Nineteen were seriously ill, 4 died and 3 had severe brain injury. Two, initially diagnosed with Reye's syndrome, probably had inherited metabolic disorders. Only 2 patients had salicylate levels that at the time of measurement are normally considered toxic; however, the literature suggests that lower levels may exacerbate illness severity in young children.We found inappropriate use of OTC aspirin in children that requires explanation. There may be policy implications for the content and presentation of patient information; the incorporation of pharmaceuticals in traditional medicines merits further study. Salicylate toxicity should be considered in children with unexplained metabolic acidosis out of keeping with the severity of their acute illness.

Background: People with colorectal cancer have impaired quality of life (QoL). We investigated what factors were most highly associated with it.Methods: Four hundred and ninety-six people with colorectal cancer completed questionnaires about QoL, functioning, symptoms, co-morbidity, cognitions and personal and social factors. Disease, treatment and co-morbidity data were abstracted from case notes. Multiple linear regression identified modifiable and unmodifiable factors independently predictive of global quality of life (EORTC-QLQ-C30).Results: Of unmodifiable factors, female sex (PConclusion: Most factors affecting QoL are modifiable, especially symptoms (fatigue, anorexia, dyspnoea) and depression. Beliefs about illness are also important. Unmodifiable factors, including metastatic (or unstaged) disease at diagnosis, have less impact. There appears to be potential for interventions to improve QoL in patients with colorectal cancer.

Wireless technology in healthcare has been associated with communication-related improvements in workflow; however, there are barriers to adoption. The purpose of this study was to assess perceptions and attitudes of staff toward the use of a wireless communication device (Vocera, Vocera Communications, Inc., San Jose, CA) and to compare communication patterns before and after implementation. A pretest-posttest quasi-experimental design and the Theory of Planned Behavior were used. Attitudes, subjective norms, and perceived control explained 25% of the variation in behavioral intent before and 45% of the variation in behavioral intent after Vocera implementation. The time for key communication activities was reduced by 25% overall. On average, each nurse engaged in these activities 16.2 times a day before Vocera and 11.6 times a day with Vocera. This study provides evidence that introduction of novel communication technology must account for user attitudes before implementation. Vocera improved "hand-off" communication, was perceived to be of benefit, and has the potential to improve patient safety and work environments. This may also translate to reduction in healthcare resources.

Introduction: To investigate the feasibility of improving asthma management – in particular, the implementation of individualised asthmaaction plans (AAPs) for poorly-controlled adult asthma patients – by providing training in asthma-focused clinical and communicationskills for practice nurses who deliver asthma clinics.Methods: A pragmatic, cluster randomised trial with an intervention (an interactive seminar) delivered at practice level (n=13 practices;6=intervention, 7=control). The impact of the intervention was assessed against patient outcomes: routinely available asthma outcomemeasures (β2-agonist prescription rate and number of oral steroid courses) for asthma patients identified as being poorly-controlled frompractice records; and questionnaire data – Mini Asthma Quality of Life Questionnaire (AQLQ) and the Asthma Control Questionnaire(ACQ) – from a subset of consenting patients. Data was collected at baseline and at 6-month follow-up.Analysis: Routine data was analysed for 629 patients. 236 (37%) of these patients consented to provide questionnaire data at baseline,with 75% returning questionnaires at follow-up. After adjustment for baseline and practice, there was a significant difference at follow-up between intervention and control practices on the Mini AQLQ only (p=0.03). Estimates for subsequent sample sizes to inform futuretrials of asthma training were identified. Conclusion: Training designed to support practice nurses in implementing individualised AAPs impacted on one patient outcome only.This disappointing outcome may have been due to many different factors such as outcome measure limitations, data collection problems,and underestimating the complexity of supporting practice nurses in behaviour change.© 2007 General Practice Airways Group. All rights reserved.JA Cleland