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Background: This analysis aimed to examine the factors predictive of service utilization among patients with anxiety and/or depression. Quick and appropriate treatment for anxiety and depression can reduce disease burden and improve social functioning. Currently, less than half of the population with comorbid anxiety and depression receives the recommended treatment., Aims: This analysis aims to identify factors predictive of utilizing mental health treatment for those with anxiety and/or depression by analyzing intrinsic, patient-centered factors., Methods: This study is a cross-sectional cohort analysis using National Health Interview Survey (NHIS) 2019 data. The sample size is 7,156 adults aged 18 to 64 with family incomes ≤100% of the federal poverty level. We used multivariate logistic regression analysis to identify factors predictive of care utilization in this population. Variables of interest include scores on Patient Health Questionnaire-8 (PHQ-8) and Generalized Anxiety Disorder-7 (GAD-7), service utilization, level of social functioning, having a usual source for care, and previous mental health care utilization. Additional covariates were age, gender, race, country of origin, education, marital status, and insurance coverage., Results: Twenty-one percent of respondents reported using mental health services. Factors predictive of care utilization were older age, female gender, limited social functioning, having a usual source of care, and insurance coverage., Conclusion: There are significant barriers to receiving quick and appropriate care for anxiety and/or depression. Strategies should focus on reducing barriers for young adults, men, and the uninsured/underinsured. Strategies for integrating mental health services into primary care could increase the percentage of people with anxiety and/or depression who receive services., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The Royal Australasian College of Physicians (RACP) oversees physician training across Australia and Aotearoa New Zealand. Success in a written examination and clinical skills assessment (known as the clinical examination) at the mid-point of training is a requirement to progress from basic to advanced training. The clinical examination had evolved over many years without a review process. This paper describes the approach taken, the changes made and the evaluation undertaken as part of a formal review., Methods: A working party that included education experts and examiners experienced in the assessment of clinical skills was established. The purpose of the clinical examination and competencies being assessed were clarified and were linked to learning objectives. Significant changes to the marking and scoring approaches resulted in a more holistic approach to the assessment of candidate performance with greater transparency of standards. Evaluation over a 2-year period was undertaken before the adoption of the new approach in 2019., Results: In 2017 testing of a new marking rubric occurred during the annual examination cycle which confirmed feasibility and acceptability. The following year an extensive trial utilising the new marking rubric and a new scoring approach took place involving 1142 examiners, 880 candidates and 5280 scoresheets which led to some minor modifications to the scoring system. The final marking and scoring approaches resulted in unchanged pass rates and improved inter-rater reliability. Feedback from examiners confirmed that the new marking and scoring approaches were easier to use and enabled better feedback on performance for candidates., Conclusion: The refresh of the RACP clinical examination has resulted in an assessment that has clarity of purpose, is linked to learning objectives, has greater transparency of expected standards, has improved inter-rater reliability, is well accepted by examiners and enables feedback on examination performance to candidates., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Whiting et al.)

Editor's note: This is the 19th article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Editor's note: This is the 18th article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Colloidal nanoparticles can be coated with a conformal shell to form multifunctional nanoparticles. For instance, plasmonic, magnetic, and catalytic properties, chemical stability and biocompatibility can be mixed and matched. Here, a facile synthesis for depositing metal boride amorphous coatings on colloidal metallic nanocrystals is introduced. The synthesis is independent of core size, shape, and composition. We have found that the shell synthesis is limited to nanoparticles capped with short molecular weight and low binding energy ligands, and does not work with polyvinylpyrrolidone (PVP)-coated Ag nanoparticles or thiol-coated Au nanoparticles. Shell thickness can be as thin as 3 nm with no apparent pinholes. High pressure studies show that the coatings are highly resistant to crystallization and are strongly bonded to the crystalline core. By choosing either CoB or NiB for the coating, the composite nanoparticles can be either ferromagnetic or paramagnetic at room temperature, respectively., Competing Interests: There are no conflicts of interest to declare., (This journal is © The Royal Society of Chemistry.)

Editor's note: This is the 16th article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Editor's note: This is the 15th article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Editor's note: This is the 12th article in a series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Editor's note: This is the 11th article in a series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. The articles will be accompanied by a podcast offering more insight and context from the authors. To see all the articles in the series, go to https://links.lww.com/AJN/A204., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Editor's note: This is the 10th article in a series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. The articles will be accompanied by a podcast offering more insight and context from the authors. To see all the articles in the series, go to https://links.lww.com/AJN/A204., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: The convergence of the opioid epidemic and COVID-19 pandemic created an urgent need in our communities to combat a rising tide of "deaths of despair." Responding to the call to care for persons with a substance use disorder is a service to both community and to self. Working in addictions provides the nurse practitioner renewed opportunity to experience life and career affirming humility, resilience, and gratitude through the joys of recovery., Competing Interests: Competing interests: The author reports no conflicts of interest., (Copyright © 2022 American Association of Nurse Practitioners.)

Abstract: Editor's note: This is the ninth article in a series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. The articles will be accompanied by a podcast offering more insight and context from the authors. To see all the articles in the series, go to https://links.lww.com/AJN/A204., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Editor's note: This is the eighth article in a series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. The articles will be accompanied by a podcast offering more insight and context from the authors. To see all the articles in the series, go to https://links.lww.com/AJN/A204., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Health professions curricula are created to prepare learners to effectively address health issues affecting individ uals and their communities. Ideally, curricula emphasize the predominant biopsychosocial influences impacting the health of diverse populations. However, despite decades of investment and advances in educational research and design, we have failed to create a health professional workforce capable of equitably meeting the health care needs of the public. Particular communities, geographic regions, and patients with stigmatized diagnoses continue to be underserved, and the potential contributions of multidisciplinary health professionals and advanced practice providers continue to be unrealized within a predominantly physician-centric health care model. Genuine educational transformation requires multidimensional, iterative strategies used to meaningfully evolve traditional classroom curricula, break from the implicit and "hidden" curricula, and enrich the educational ecosystem in which all operate. This manuscript elaborates the construct and process of "educational ecosystem transformation" as a tool for the evolution of the educational ecosystem and its situated curriculum that will eventually drive the enrichment of the healthcare workforce. Drawing from traditional models of curriculum development, recent work on transforming the hidden curriculum, the clinical learning environment, and change management strategies, this new approach uses a health equity and structural competence lens to interrogate and deconstruct a learning system in order to identify opportunities to change, strengthen, and deepen a learner's experience around a specific topic. This process requires an in-depth, multidimensional assessment followed by the identification of key change targets and a stepwise, iterative plan for improvement and transformation. The topic area of substance use disorders (SUD) is used to illustrate how this complex process might be employed to improve the quality of care, realize and amplify the contributions of the entire healthcare team, stimulate interest in addiction medicine as a career, and reduce the stigma and disparities patients with SUDs often experience.

Background: Adherence to clinical practice guidelines for alcohol and drug screening, brief intervention, and referral to treatment (SBIRT) is often inadequate. Mobile apps developed as clinical translation tools could improve the delivery of high fidelity SBIRT., Methods : This study tested the effectiveness of an SBIRT mobile app conceptually aligned with the Theory of Planned Behavior (TPB) to support SBIRT delivery by health care trainees (nursing, social work, internal medicine, psychiatry, and psychology) working in clinical settings ( N  = 101). Bivariate analyses examined the rate of SBIRT delivery between trainees assigned to the experimental (app) and control (no app) study conditions; as well as the relationship between TPB-based constructs, intention to deliver SBIRT, and screening rates., Results : No significant differences were identified between the study conditions in SBIRT delivery. Significant correlations were found between intent to screen and TPB variables including attitudes/behavioral beliefs concerning substance use treatment ( r  = .49, p  = .01); confidence in clinical skills ( r  = .36, p  = .01); subjective norms ( r  = .54, p  = .01) and perceived behavioral control over appointment time constraints ( r  = .42, p  = .01). Also significant were correlations between percent of patients screened and confidence ( r  = .24, p  = .05); subjective norms ( r  = .22, p  = .05) and perceived behavioral control ( r  = .28, p  = .01)., Conclusions : The negative results of the study condition comparisons indicate the need for further investigation of strategies to optimize mobile app utilization, engagement, and effectiveness as a clinical translation tool. Findings of significant correlations between substance use screening rates and both norms and confidence support the potential value of the TPB model in explaining behavior of health care learners in SBIRT delivery.

Editor's note: This is the fourth article in a series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. The articles will be accompanied by a podcast offering more insight and context from the authors. To see all the articles in the series, go to http://links.lww.com/AJN/A204., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Editor's note: This is the third article in a series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. The articles will be accompanied by a podcast offering more insight and context from the author., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Conferences are designed for knowledge translation, but traditional conference evaluations are inadequate. We lack studies that explore alternative metrics to traditional evaluation metrics. We sought to determine how traditional evaluation metrics and Twitter metrics performed using data from a conference of the Canadian Association of Emergency Physicians (CAEP)., Methods: This study used a retrospective design to compare social media posts and tradition evaluations related to an annual specialty conference. A post ("tweet") on the social media platform Twitter was included if it associated with a session. We differentiated original and discussion tweets from retweets. We weighted the numbers of tweets and retweets to comprise a novel Twitter Discussion Index. We extracted the speaker score from the conference evaluation. We performed descriptive statistics and correlation analyses., Results: Of a total of 3,804 tweets, 2,218 (58.3%) were session-specific. Forty-eight percent (48%) of all sessions received tweets (mean = 11.7 tweets; 95% CI of 0 to 57.5; range, 0-401), with a median Twitter Discussion Index score of 8 (interquartile range, 0 to 27). In the 111 standard presentations, 85 had traditional evaluation metrics and 71 received tweets (p > 0.05), while 57 received both. Twenty (20 of 71; 28%) moderated posters and 44% (40 of 92) posters or oral abstracts received tweets without traditional evaluation metrics. We found no significant correlation between Twitter Discussion Index and traditional evaluation metrics (R = 0.087)., Conclusions: We found no correlation between traditional evaluation metrics and Twitter metrics. However, in many sessions with and without traditional evaluation metrics, audience created real-time tweets to disseminate knowledge. Future conference organizers could use Twitter metrics as a complement to traditional evaluation metrics to evaluate knowledge translation and dissemination.

Background and Purpose: Screening, brief Intervention, and referral to treatment (SBIRT) is a widely trained evidence-based strategy to identify and address alcohol and drug use problems. The purpose of this qualitative study was to explore the experience of family nurse practitioner (FNP) learners in the implementation of SBIRT and the perceived clinical utility of an SBIRT mobile app., Methods: Twenty-two FNP learners completed didactic SBIRT training and orientation to an SBIRT mobile app. At the conclusion of the study, participant focus groups explored overall SBIRT delivery (N = 19) and SBIRT mobile app utilization (N = 14). Focus group data were analyzed within a Theory of Planned Behavior framework., Results: Participants indicated that the mobile app was useful in the ongoing development of SBIRT knowledge, skill confidence, and motivation. Learners identified the clinical context as a major factor in facilitating the delivery of SBIRT overall. Participants who did not deliver SBIRT indicated that the most significant barriers to SBIRT implementation were lack of support from clinical preceptors and health systems., Conclusions: Findings suggest that a mobile app is an acceptable and feasible tool to improve the delivery of SBIRT. However, collaboration with preceptors and clinical training organizations is essential to optimize clinical translation.

Background and Purpose: In March 2017, the Environmental Protection Agency (EPA) reversed course on a proposal to ban the agricultural use of the organophosphate (OP) insecticide chlorpyrifos (CPF). The purpose of this article is to examine the evidence leading to this controversial decision and provide clinically applicable health promotion guidance for nurse practitioners on CPF exposure and risk reduction measures., Methods: Environmental Protection Agency documents on CPF regulation and corresponding research referenced within the EPA reports are reviewed. Evidence-based health promotion strategies obtained through PubMed, CINAHL, Center for Disease Control and Prevention, and National Institutes of Health sources are summarized., Conclusions: Available data suggest a potential association between CPF exposure and adverse neurodevelopmental outcomes. Particularly vulnerable populations are pregnant women, children younger than two years, and agricultural workers. There may be genetic variability in susceptibility to environmental toxins., Implications for Practice: Because of the extensive use of the OP CPF in agriculture and other community-based settings throughout the United States, nurse practitioners should be knowledgeable of the evidence regarding CPF exposure and be prepared to provide health promotion guidance to patients in clinical practice. Nurse practitioners should also consider their role in advocacy for healthy environments and the protection of vulnerable populations as it relates to agricultural insecticide exposure.

In laser spectroscopy, high photon flux can perturb the sample away from thermal equilibrium, altering its spectroscopic properties. Here, we describe an optical beam scanning apparatus that minimizes repetitive sample excitation while providing shot-to-shot sample exchange for samples such as cryostats, films, and air-tight cuvettes. In this apparatus, the beam crossing point is moved within the focal plane inside the sample by scanning both tilt angles of a flat mirror. A space-filling spiral scan pattern was designed that efficiently utilizes the sample area and mirror scanning bandwidth. Scanning beams along a spiral path is shown to increase the average number of laser shots that can be sampled before a spot on the sample cell is resampled by the laser to ∼1700 (out of the maximum possible 2500 for the sample area and laser spot size) while ensuring minimal shot-to-shot spatial overlap. Both an all-refractive version and an all-reflective version of the apparatus are demonstrated. The beam scanning apparatus does not measurably alter the time delay (less than the 0.4 fs measurement uncertainty), the laser focal spot size (less than the 2 μm measurement uncertainty), or the beam overlap (less than the 3.3% measurement uncertainty), leading to pump-probe and autocorrelation signal transients that accurately characterize the equilibrium sample.

Background: Postgraduate medical education bodies and national patient safety institutes recommend that trainees develop patient safety competencies such as those for Morbidity and Mortality (M&M) rounds, yet there exists no model for their educational delivery., Objective: We studied the effect of a single educational intervention on emergency medicine residents' aptitudes in selecting and analysing M&M rounds cases., Methods: In this before-and-after study, participants attended an 1 h educational session based on the previously described Ottawa Morbidity and Mortality Model (OM3). Residents were asked to submit a case suitable for M&M rounds both preintervention and postintervention. A novel M&M rounds case critique tool was developed based on OM3 and used to assign a numerical score to each submitted case. Our primary outcome was an increase in mean scores between phases using the case critique tool. An a priori score increase of 1 was defined as educationally significant. Data were analysed using a paired Student's t test., Results: A total of 19 residents were recruited for our pre-intervention and 15 residents for the post-intervention analysis. Mean M&M rounds case critique scores increased from 5.53 to 8.67 (p<0.01) between phases. Residents reported higher comfort with structured case selection and analysis, with an increase in five-point Likert scale means of 2.32 and 3.69 (p<0.01)., Conclusions: We found that residents were more effective at M&M rounds case selection and analysis after our focused 1 h educational intervention. Training programmes should consider an M&M rounds training model to ensure future physicians have these skills for 21st-century practice., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Introduction: Emergency medicine point-of-care ultrasonography (EM-PoCUS) is a core competency for residents in the Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada emergency medicine (EM) training programs. Although EM-PoCUS fellowships are currently offered in Canada, there is little consensus regarding what training should be included in a Canadian EM-PoCUS fellowship curriculum or how this contrasts with the training received in an EM residency.Objectives To conduct a systematic needs assessment of major stakeholders to define the essential elements necessary for a Canadian EM-PoCUS fellowship training curriculum., Methods: We carried out a national survey of experts in EM-PoCUS, EM residency program directors, and EM residents. Respondents were asked to identify competencies deemed either nonessential to EM practice, essential for general EM practice, essential for advanced EM practice, or essential for EM-PoCUS fellowship trained (‘‘expert’’) practice., Results: The response rate was 81% (351 of 435). PoCUS was deemed essential to general EM practice for basic cardiac, aortic, trauma, and procedural imaging. PoCUS was deemed essential to advanced EM practice in undifferentiated symptomatology, advanced chest pathologies, and advanced procedural applications. Expert-level PoCUS competencies were identified for administrative, pediatric, and advanced gynecologic applications. Eighty-seven percent of respondents indicated that there was a need for EM-PoCUS fellowships, with an ideal length of 6 months., Conclusion: This is the first needs assessment of major stakeholders in Canada to identify competencies for expert training in EM-PoCUS. The competencies should form the basis for EM-PoCUS fellowship programs in Canada.

Objective: Point-of-care ultrasonography (PoCUS) first appeared in the 1980s in North America, but the extent of the diffusion of its adoption is unknown. We characterized early PoCUS adoption by emergency physicians in Canada and its barriers to use using Rogers' diffusion of innovations theory., Methods: We developed a questionnaire based on a pilot study and literature review to assess past, current, and potential use of PoCUS and potential barriers to adoption. A Dillman technique for electronic surveys was used for dissemination. Using Rogers' diffusion of innovations theory, we developed and validated the Evaluation Tool for Ultrasound skills Development and Education (ETUDE). ETUDE scores allowed categorization of respondents into innovators, early adopters, majority, and nonadopters. Descriptive statistics, correlations, and χ² statistics were used to analyze the data., Results: The 296 respondents (36.4% of 814 surveyed) had a median age of 40 and were 72.5% male. Adoption scores using ETUDE revealed nonadopters (18.8%), majority (28.7%), early adopters (34.5%), and innovators (18.0%). Respondents endorsed "always" using PoCUS currently and in the future for focused assessment with sonography in trauma (FAST) (current 41.8%/future 88.4%), first trimester pregnancy (current 23.3%/future 73.7%), suspected abdominal aortic aneurysm (current 32.7%/future 92.6%), basic cardiac indications (current 30.7%/future 87.5%), and central venous catheterization (current 17.0%/future 80.3%). Several barriers to PoCUS were identified for part-time emergency physicians and those working in inner-city/urban/suburban settings., Conclusion: This is the first study to determine the state of adoption and barriers to the introduction of PoCUS in Canadian emergency medicine practice. The novel validated ETUDE instrument should be used to evaluate the uptake of PoCUS over time.

Granulocyte colony-stimulating factor is a cytokine able to stimulate both myelopoiesis and hematopoietic stem cell mobilization, which has seen it used extensively in the clinic to aid hematopoietic recovery. It acts specifically via the homodimeric granulocyte colony-stimulating factor receptor (G-CSFR), which is principally expressed on the surface of myeloid and hematopoietic progenitor cells. A number of pathogenic mutations have now been identified in CSF3R, the gene encoding G-CSFR. These fall into distinct classes, each of which is associated with a particular spectrum of myeloid disorders, including malignancy. This review details the various CSF3R mutations, their mechanisms of action, and contribution to disease, as well as discussing the clinical implications of such mutations.

Introduction: We report the first 100 patients who underwent prostate brachytherapy as monotherapy with 125I at an institution with moderate volume radical prostatectomy but low volume brachytherapy (<2 cases per month). Learning curve and quality improvement was assessed by way of achieving prescription dose targets., Materials and Methods: From May 2002 to August 2006, 100 patients underwent prostate 125I brachytherapy monotherapy via preplanned approach. Preoperative planned dose to 100% of prostate gland (D100) was 145 Gy and postoperative confirmed dose was assessed by computed tomography. The cohort was divided into quartiles and recurrence was assessed using Kaplan-Meier analysis., Results: Patient quartiles were of similar age and Gleason grade, while PSA was slightly higher in the first group. Postoperative D90 increased after the first quartile (p = < 0.0001) reaching targeted values. Kaplan-Meier survival analysis revealed that 5 year recurrence-free survivals by Phoenix definition was 96%-100% in all groups while by ASTRO definition there was a decrease in recurrence for later cases., Conclusions: At our low volume institution during the first 100 brachytherapy cases, a learning curve for radiation dosimetry was evident, which improved after 25 patients. Preplanned dose-volume parameters were adjusted, enabling the achievement of post-implant goals emphasizing the importance of continuous quality improvement. Although recurrence data is limited by sample size and moderate follow up, there was a discrepancy between the Phoenix and ASTRO definition when evaluating recurrence.

Background: To increase the market share of Californian wines in other countries, wine preferences need to be explored in potential markets. This work studied the preferences of American and Italian consumers for red wines produced in California and Italy, focusing on wines made from the same varieties in each location. Descriptive analysis and consumer preference tests were performed., Results: Americans scored each of the Californian wines significantly higher in preference than the Italian wines. In contrast, the Italian consumer preference scores for many Italian and Californian wines overlapped. By external preference mapping of the American consumer segments, the ideal flavour of one cluster was closest to the Californian Zinfandel, Merlot and Syrah, which had the 'most balanced' flavour profiles. Another cluster of Italians also preferred the Californian wines. In addition, one Italian cluster was driven by a dislike of the leather, band-aid and medicinal aromas of the Italian Merlot and Refosco., Conclusion: The results provided information that can contribute to wine marketing research necessary for successfully exporting Californian red wines to Italy and vice versa., (© 2012 Society of Chemical Industry.)

A standards-based, service-oriented architecture for clinical decision support (CDS) has the potential to significantly enhance CDS scalability and robustness. To enable such a CDS architecture, the Health Level 7 CDS Work Group reviewed the literature, hosted multi-stakeholder discussions, and consulted domain experts to identify and prioritize the services and capabilities required from clinical information systems (CISs) to enable service-oriented CDS. In addition, relevant available standards were identified. Through this process, ten CIS services and eight CIS capabilities were identified as being important for enabling scalable, service-oriented CDS. In particular, through a survey of 46 domain experts, five services and capabilities were identified as being especially critical: 1) the use of standard information models and terminologies; 2) the ability to leverage a Decision Support Service (DSS); 3) support for a clinical data query service; 4) support for an event subscription and notification service; and 5) support for a user communication service.

Context: Adolescence is a pivotal developmental period for the establishment of positive health and health practices. However, developmentally propelled risk behaviors coinciding with barriers to health services may increase the propensity for untoward health outcomes in adolescence. In addition, the sociocultural context of the rural environment can present challenges to the health of adolescents. Limited data on rural adolescent health, particularly among population subgroups, hinder the ability to adequately advocate for adolescent health prevention services., Methods: A secondary analysis of the 2005 California Health Interview Survey Adolescent questionnaire was conducted. Selected survey items corresponding to the Healthy Youth 2010 objectives were analyzed for 663 adolescents aged 12-17 residing in rural regions of California. Adolescent subgroup analysis included race/ethnicity, age, and poverty level., Findings: Adolescent health issues of particular concern in this study include sexual health, substance use, mental health, and risk factors for obesity. Predictably, risk behaviors increase with the age of the adolescent. Minority and poor youth demonstrate the greatest vulnerability to untoward health outcomes., Conclusion: Significant risk behaviors and health concerns exist among the rural adolescent population, particularly among poor and minority youth, arguing for the creation and preservation of prevention services for youth in the rural community. Future research using alternative sampling methodologies may be necessary to adequately represent the higher-risk adolescent in the rural community. More data are needed on vulnerable adolescent populations in the rural community in order to adequately advocate for prevention services., (© 2010 National Rural Health Association.)

Femtosecond transient grating experiments are used to investigate electronic structures and transport mechanisms in dye-sensitized nanocrystalline TiO(2) films. This study examines two molecular sensitizers spanning the weak (a phosphonated Ruthenium complex) and strong (catechol) molecule-TiO(2) coupling regimes. It is shown that strong molecule-TiO(2) interactions give rise to photoinduced vibrational coherences at the interface between species. We suggest that the amplitudes of these coherences reflect the molecule-TiO(2) coupling strength and signify the delocalization of excited state wavefunctions., (© 2011 American Institute of Physics)

Purpose: The Royal College of Physicians and Surgeons of Canada undertook a review of its Clinician Investigator Program (CIP), 13 years after launching the program in response to shortages in clinical investigators. The primary study goals were to determine the outcomes, impact, strengths and weaknesses of CIP., Methods: Focus groups and telephone interviews with current and past program directors (PD) and a detailed survey of current and former trainees were conducted. Thirteen PD and 45% of current and former trainees from 10 CIP participated., Results: Since 1995, 12 CIP have been accredited and 553 residents have enrolled in CIP, with 194 completing CIP and residency training by 2008. PD recognized CIP as an excellent program that produces highly qualified clinical investigators; important for faculty renewal. Both trainees and PD identified the need to improve CIP funding. Most (84%) CIP trainees did not have prior graduate degrees. Most alumni had completed Masters (58%) or Doctoral (39%) programs during CIP and published on their CIP research (97%). Among alumni who completed CIP and residency, many obtained an academic appointment with protected time for research, with 39% receiving an external career award. Many (60%) alumni reported no drawbacks to CIP and recognized the added values included Royal College recognition, structured training, pursuit of graduate studies, integration of clinical/research training and enhanced mentorship., Conclusion: Since the progam's inception, the number of CIP in Canada has grown. CIP are recognized as important mechanisms for integrating clinical and research training during residency to produce highly qualified clinician investigators.

With the present review, we intend to highlight the importance of considering the age- and development-dependent occurrence of comorbidity in ADHD and to outline distinct trajectories of symptom progression with possible impact on course and outcome of ADHD. The review will focus on introducing the concepts of "developmental epidemiology" and "developmental comorbidity". Psychiatric and non-psychiatric age-dependent comorbidity can be seen in the majority of children, adolescents and adults with ADHD, resulting in a severe impairment of everyday life with considerable functional and psychosocial problems. Concerning the temporal order of occurrence, psychiatric conditions may be present before the appearance of first definite ADHD symptoms ("pre-comorbidity", such as temperament factors, sleep disturbance, autism spectrum disorders and atopic eczema). They may coincide with the time when ADHD symptoms reach a clinically significant level ("simultaneous comorbidity": enuresis, encopresis, developmental dyslexia). The majority of comorbidity, however, appears after the onset of ADHD in the course of disease ("post-comorbidity": tic disorder, depression and suicidality, anxiety disorders, obsessive compulsive disorder, bipolar disorder, conduct and substance use disorders, obesity and personality disorders). The aetio-pathophysiology of ADHD and its comorbid disorders and also the nature of comorbidity itself being highly heterogeneous, we additionally discuss possible models of comorbidity. In the future, longitudinal data on distinct patterns of symptom and comorbidity progression would help to refine disease classification systems, strengthen the power of future genetic studies and finally allow for more specific treatment strategies.

Objective: Emergency medicine is an evolving discipline in Canadian medical schools. Little has been published regarding student preferences for emergency medicine training during the clerkship phase of MD programs. We assessed medical students' perceptions of a newly developed emergency medicine clerkship rotation involving multiple learning modalities. The evaluation process included assessment of the rotation's instructional elements and overall educational value., Methods: The first cohort of medical students to complete this new emergency medicine clerkship was invited to answer a questionnaire just before graduation. Students rated their preferences for components of the rotation using paired comparisons. Open ended questions explored students' satisfaction with the emergency medicine clerkship as well as perceptions of the rotation's impact on career development., Results: Of the 94 students in the first clerkship cohort, 81 (86%) responded to the survey. Students found the emergency medicine clerkship highly valuable, citing the broad range of cases seen, close supervision, and opportunities to develop clinical assessment, decision making and procedural skills. Students' curricular preferences were for advanced cardiac life support (ACLS) (26.4%), clinical shifts (20.6%), supervised clinical shifts (17.8%), procedural skills laboratories (14.8%), tutorials (10.8%) and preceptor assisted learning sessions (9.8%)., Conclusion: This new emergency medicine clerkship program incorporated multiple learning methods within a 4-week rotation and was highly rated by students. Although clinical shifts and ACLS were generally preferred activities, students had varying individual preferences for specific learning activities. Multiple learning methods allowed all students to benefit from the rotation. This study makes a compelling case for including an emergency medicine rotation with multiple learning modalities as a core element of clerkship at every medical school.

Background: Despite widespread endorsement for administrative training during residency, teaching and learning in this area remains intermittent and limited in most programmes., Aim: To inform the development of a Manager Train-the-Trainer program for faculty, the Royal College of Physicians and Surgeons of Canada undertook a survey of perceived Manager training needs among postgraduate trainees., Methods: A representative sample of Canadian specialty residents received a web-based questionnaire in 2009 assessing their perceived deficiencies in 13 Manager knowledge and 11 Manager skill domains, as determined by gap scores (GSs). GSs were defined as the difference between residents' perceived current and desired level of knowledge or skill in selected Manager domains. Residents' educational preferences for furthering their Manager knowledge and skills were also elicited., Results: Among the 549 residents who were emailed the survey, 199 (36.2%) responded. Residents reported significant gaps in most knowledge and skills domains examined. Residents' preferred educational methods for learning Manager knowledge and skills included workshops, web-based formats and interactive small groups., Conclusion: The results of this national survey, highlighting significant perceived gaps in multiple Manager knowledge and skills domains, may inform the development of Manager curricula and faculty development activities to address deficiencies in training in this important area.

In-depth interviews were conducted in 2007 with 175 undergraduate students (94 males, 81 females, 13 non-Caucasian) at a large, public southeastern research university located in an urban area in the United States. Our primary goal was to identify how these students conceive of Attention Deficit Hyperactivity Disorder (ADHD) stimulants and their illegal use. We discovered that these students frame stimulant use as both physically harmless and morally acceptable. Specifically, these students justify their drug use through the use of four recurring prostimulant arguments: 1) comparison-and-contrast, 2) all-things-in-moderation, 3) self-medicating, and 4) minimization arguments. We discuss limitations to the study and conclude by suggesting five strategies for prevention researchers that would directly target these four arguments.

Objective: To survey program directors of family medicine-emergency medicine (CCFP[EM]) training programs regarding current and future emergency medicine ultrasonography (EMUS) training., Design: A Web-based survey using a modified Dillman method. Two academic emergency physicians reviewed the validity and reliability of the survey., Setting: Canada., Participants: Program directors of all 17 Canadian CCFP(EM) residency training programs in 2006., Main Outcome Measures: Characteristics of EMUS training currently offered and program directors' perceptions of needs for future EMUS training., Results: The survey, performed in 2006, had a response rate of 100% (17/17), although not all respondents answered all questions. At the time of the study, 82.4% of respondents' programs used EMUS. Although all program directors recommended that residents attend introductory EMUS courses, only 71.4% (10/14) of programs offered such courses; 60.0% (9/15) of those were mandatory. In one-third of the programs, more than 75% of the attending staff used EMUS. A total of 76.5% of program directors thought that introductory courses in EMUS should be mandatory; 62.5% (10/16) believed that residents were able to acquire sufficient experience to use EMUS independently to make practice decisions before completion of their residency; and 88.2% believed that EMUS should be a part of the scope of practice for emergency medicine physicians. Only 58.8% believed that there should be questions about EMUS on the CCFP(EM) Certification examination. Open responses indicated that funding, resources, and standardization were issues that needed to be addressed., Conclusion: Formal EMUS training for CCFP(EM) programs is being introduced in Canada. Quality assurance needs to be strengthened. Most program directors thought that an introductory course in EMUS should be mandatory. Fewer directors, however, believed EMUS should be on the CCFP(EM) Certification examination until further funding, resources, and standardization of EMUS programs were in place.

Objective: Insertion of central venous catheters (CVCs) is an essential competency for emergency physicians. Ultrasound-guided (USG) insertion of CVCs has been shown to be safer than the traditional landmark technique. There is no clear consensus on effective methods for training physicians in USG insertion of CVCs. We developed and evaluated a novel educational training program in the USG technique for insertion of CVCs., Methods: Sixteen emergency medicine residents volunteered for a pre- and postprogram evaluation study, which was approved by our research ethics board. After their previous experience was determined, each participant was videotaped inserting a USG CVC in the right internal jugular vein on models. Participants then reviewed a Web-based instructional module and had a practical session. Participants were again videotaped inserting a USG CVC. The primary outcome was the change in score before and after the training program, using an expert-validated performance evaluation tool used to review the videotaped performances in a blinded fashion. Participants also completed a questionnaire to measure their satisfaction with the training program and any change in their perceived competence., Results: Participants ranged from residency year 1 to 5. Thirteen of 16 (81%) had never attempted USG insertion of a CVC. Participants reported that the models were realistic. Performance scores (12/19 to 13.2/19) and global ratings assessments (3.5/7 to 5.5/7) improved significantly (p < 0.01; the effect size, Cohen d = 1.12 before and 1.28 after) after the instruction. There was good interrater reliability between evaluators of the videotaped performances regarding performance scores (r = 0.68) and global rating scores (r = 0.75). All participants felt their confidence and technical skills were improved (p < 0.01) and all felt satisfied with the training program., Conclusion: This brief innovative multimethod training program was effective in enhancing emergency medicine resident competence in USG insertion of CVCs.

Introduction: Focused assessment with sonography for trauma (FAST) is an important modality in the initial assessment of trauma patients. Information regarding the current status, availability, as well as educational and training processes in the use of FAST is limited. The purpose of this study was to survey Canadian general surgery residency program directors regarding FAST., Methods: A Web-based survey was developed to assess the availability and use of FAST, education and training, as well as the role of FAST in general surgery residency training programs across Canada. Two experts reviewed the survey for validity and reliability. The survey was then pilot tested by 2 general surgeons., Results: The survey response rate was 75.0% (12/16). FAST was available at all the institutions that responded. FAST was used 100% of the time in the initial assessment of the trauma patient. In all, 75.0% (9/12) respondents have no formal residency training in FAST, 91.7% (11/12) of respondents agreed or strongly agreed that training in FAST should be included in the residency curriculum, and 66.7% (8/12) of respondents perceive that general surgery residents are not competent in the use of FAST., Conclusions: Overall, Canadian general surgery program directors do not feel that surgical residents are competent in the use of FAST. Current training is limited, and program directors believe that training and education in FAST should be included in the postgraduate education curriculum.

Some patients are unable to participate in a good, mutually cooperative relationship with their primary care doctors. They may have long-standing psychosocial difficulties exacerbated by chronic, painful, or life-threatening illnesses. Some may have somatic symptoms that they define as evidence only of an identified illness but which are reflections of psychic misery with roots in their thoughts, feelings, and relationships. This article describes a Workshop approach to teaching those patients' physicians how to make diagnostic use of their own "gut reactions" to understand the common dynamics of the doctor- patient relationship; to understand the psychological aspects of various physical symptoms; and manage challenging patients to optimize their quality of life, cost-effectiveness of treatment and minimize physician "burnout."

Purpose: Determine the degree of interfraction prostate motion and its components measured by using daily megavoltage (MV) cone beam computed tomography (CBCT) imaging., Methods and Materials: A total of 984 daily MV CBCT images from 24 patients undergoing definitive intensity-modulated radiotherapy for localized prostate cancer were analyzed retrospectively. Pretreatment couch shifts, based on physician registration of MV CBCT to planning CT data sets, were used as a measure of daily interfraction motion. Off-line bony registration was performed to separate bony misalignment from internal organ motion. Interobserver and intraobserver variation studies were performed on 20 MV CBCT images., Results: Mean interfraction prostate motion was 6.7 mm, with the greatest single-axis deviation in the anterior-posterior (AP) direction. The largest positional inaccuracy was accounted for by systematic deviations in bony misalignment, whereas random deviations occurred from bony misalignment and internal prostate motion. In the aggregate, AP motion did not correlate with days elapsed since beginning therapy or on average with rectal size at treatment planning. Interobserver variation was greatest in the AP direction, decreased in experienced observers, and further decreased in intraobserver studies. Mean interfraction motion during the first 6 days of therapy, when used as a subsequent offset, reduced acceptable AP planning target volume margins by 50%., Conclusion: The MV CBCT is a practical direct method of daily localization that shows significant interfraction motion with respect to conventional three-dimensional conformal and intensity-modulated radiotherapy margins, similar to that measured in other modalities.

Context: Although concern has been raised about the value of clinical evaluation reports for discriminating among trainees, there have been few efforts to formalise the dimensions and qualities that distinguish effective versus less useful styles of form completion., Methods: Using brainstorming and a modified Delphi technique, a focus group determined the key features of high-quality completed evaluation reports. These features were used to create a rating scale to evaluate the quality of completed reports. The scale was pilot-tested locally; the results were psychometrically analysed and used to modify the scale. The scale was then tested on a national level. Psychometric analysis and final modification of the scale were completed., Results: Sixteen features of high-quality reports were identified and used to develop a rating scale: the Completed Clinical Evaluation Report Rating (CCERR). The reliability of the scale after a national field test with 55 raters assessing 18 in-training evaluation reports (ITERs) was 0.82. Further revisions were made; the final version of the CCERR contains nine items rated on a 5-point scale. With this version, the mean ratings of three groups of 'gold-standard' ITERs (previously judged to be of high, average and poor quality) differed significantly (P < 0.05)., Discussion: The CCERR is a validated scale that can be used to help train supervisors to complete and assess the quality of evaluation reports.

The U.S. Veterans Health Administration (VHA) provides care to some 5.2 million patients spread across the continental United States, Alaska, Hawaii, Puerto Rico, and the Philippines. Sites of care include 157 medical centers, nearly 900 outpatient clinics, long-term facilities, and home care. Over the last 10 years, major changes in the nature of VHA healthcare have imposed a requirement for longitudinal electronic health records and integration of those records across the enterprise at the point of care. VHA has now evolved through three generations of applications that support such integration. This paper reports on the VHA experience, points out lessons learned, and outlines future directions for electronic health record integration in VHA.

This article describes a qualitative descriptive exploratory study carried out in Hospital de Clinicas de Porto Alegre, RS, Brazil, in 2005, in which the perception of nurses on the Nursing Diagnosis (ND) introduced in the institution, was analyzed. Data were collected using semi-structured interviews with ten nurses working in different units, and were analyzed by the Minayo method, taking into account ethical aspects. Two categories were identified in the ND: positive aspects, and aspects needing improved, each with its subcategories. It was concluded that ND was beneficial to nurses; however, there are still doubts and criticism on this subject.

Objective: To compare out-of-box performance of three commercially available continuous speech recognition software packages: IBM ViaVoice 98 with General Medicine Vocabulary; Dragon Systems NaturallySpeaking Medical Suite, version 3.0; and L&H Voice Xpress for Medicine, General Medicine Edition, version 1.2., Design: Twelve physicians completed minimal training with each software package and then dictated a medical progress note and discharge summary drawn from actual records., Measurements: Errors in recognition of medical vocabulary, medical abbreviations, and general English vocabulary were compared across packages using a rigorous, standardized approach to scoring., Results: The IBM software was found to have the lowest mean error rate for vocabulary recognition (7.0 to 9.1 percent) followed by the L&H software (13.4 to 15.1 percent) and then Dragon software (14.1 to 15.2 percent). The IBM software was found to perform better than both the Dragon and the L&H software in the recognition of general English vocabulary and medical abbreviations., Conclusion: This study is one of a few attempts at a robust evaluation of the performance of continuous speech recognition software. Results of this study suggest that with minimal training, the IBM software outperforms the other products in the domain of general medicine; however, results may vary with domain. Additional training is likely to improve the out-of-box performance of all three products. Although the IBM software was found to have the lowest overall error rate, successive generations of speech recognition software are likely to surpass the accuracy rates found in this investigation.