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A series of Ru(III)–NHC complexes, identified as [RuIII(PyNHCR)(Cl)3(H2O)] (1a–c), have been prepared, starting from RuCl3·3H2O following a base-free route. The Lewis acidic Ru(III) centre operates via a halide-assisted, electrophilic C–H activation for carbene generation. The best results were obtained with azolium salts having the I− anion, while ligand precursors with Cl−, BF4−, and PF6− gave no complex formation and those with Br− gave a product with mixed halides. The structurally simple, air and moisture-stable complexes represent rare examples of paramagnetic Ru(III)–NHC complexes. Furthermore, these benchtop stable Ru(III)–NHC complexes were shown to be excellent metal precursors for the synthesis of new [RuII(PyNHCR)(Cl)2(PPh3)2] (2a–c) and [RuII(PyNHCR)(CNCMe)I]PF6 (3a–c) complexes. All the complexes have been characterised using spectroscopic methods, and the structures of 1a, 1b, 2c, and 3a have been determined using the single-crystal X-ray diffraction technique. This work allows easy access to new Ru–NHC complexes for the study of new properties and novel applications. [ABSTRACT FROM AUTHOR]

The study analyses the possible responses to cyber-attacks through cyberspace deterrence. The inundated cyber-attacks have prompted major powers to establish cyber deterrence. However, in the absence of a model of punishment, as it is empirically found in the nuclear domain, the efficacy of cyber deterrence is limited. The model of punishment against cyber-attacks is based on the traditional nuclear deterrence model, which is either deterrence by denial or deterrence by punishment. Cyber deterrence may not be a replica of traditional deterrence and give similar response measures in a cyber-attack. The assured retaliation in cyber requires an explanation of response measures that do not cause collateral damage. The paper concludes that cyber aggressors escaped retaliation due to the lack of attribution and not being punished due to limited retaliatory measures. [ABSTRACT FROM AUTHOR]

Background: There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care.Methods: We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review.Results: Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently.Conclusions: This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care. [ABSTRACT FROM AUTHOR]

Objective: To determine the utility of EEG and its association with both normal and abnormal results among patients presenting in a private psychiatric facility Materials and Methods: A total of 15950 patients were seen from June 2013 to June 2016 in a private psychiatric facility in Peshawar and about 1714 patients who underwent EEG investigation for diagnosis and on demand with no prior or current medical history were included in the study using a cross sectional study design. The data was collected in a standardized manner, recorded in a private clinic's database and evaluated on the basis of international classification of diseases (ICD-10) and international classification of headache disorders (ICHD-III). Results: A total of 1714 patients were identified who had gone through EEG either to confirm their diagnosis or to satisfy patients on their demand regarding the diagnosis. The participants comprised of majority of females (F=1143, 66.6%) and males almost half of the females (M=571, 33.3%) with majority of age ranges between eighteen to thirty years. Electroencephalograms done for assistance in diagnosis was associated with abnormal results while Electroencephalograms done on demand was associated with normal results. Conclusion: This study determined the incremental value of electroencephalogram in order "to increase the probability of correct diagnosis" among people with psychiatric conditions by showing more abnormal results. [ABSTRACT FROM AUTHOR]

Objective: To compare the mean onset time of motor and sensory block of Isobaric Ropivacaine and Hyperbaric Bupivacaine for elective caesarean sections at Tertiary Care Hospital, Karachi. Methods: A double blinded Randomized control trial study carried out over the period of six months, from August 2016 to January 2017 using non probability consecutive sampling technique. A total of 128 pregnant women planned for LSCS under spinal anesthesia were enrolled in this study. Patients were randomly divided into two groups (Group B and Group R) receiving equipotent doses of spinal anaesthetic drugs. In group B, spinal anaesthesia were given to 64 patients with intrathecal injection of 3ml of 0.5% (5mg/ml) Hyperbaric Bupivacaine and in group R, 64 patients received spinal anaesthesia using 3ml of 0.5% (5mg/ml) Isobaric Ropivacaine. Motor block was evaluated by using Modified Bromage scale score and a score of >2 is consider as optimal motor nerve block. Sensory block was evaluated by using 25G needle pinprick method along the mid clavicular line bilaterally and sensory block (loss of sensation to pain) at T6 level is consider as optimal sensory nerve block. At 10 minutes, Final outcome for each group B and R will be labelled in term of mean time of achievement of motor and sensory block and two dermatomal sensory segment regression. Results: Out of 128 patients, 64 patients receiving spinal anaesthesia using Hyperbaric Bupivacaine the mean duration to achieve sensory nerve block at T6 Level is found to be faster as compare to Isobaric Ropivacaine while the mean onset time of motor nerve block was also considerably significant in between the two groups (p=0.049). The Regression time of maximum sensory block from two dermatomal skin level is also found to be earlier in Isobaric Ropivacaine as compare to patients receiving spinal anaesthesia with Hyperbaric Bupivacaine (130.34 ± 15.26 vs 146.41 ± 12.81; p-value=0.0005). These regional anaesthetic properties of Isobaric Ropivacaine makes it a safer regional anaesthetic agent as Hyperbaric Bupivacaine. Conclusion: Spinal anaesthesia using intrathecal Ropivacaine for elective caesarean sections is an effective and optimal drug of choice. Two Dermatomal Sensory Regression was also found to be earlier in Isobaric Ropivacaine thus ropivacaine provides surgically effective anaesthesia of shorter duration and early sensory onset without compromising neonatal outcome and maternal hemodynamics. [ABSTRACT FROM AUTHOR]

• DFT study of the mechanism for the electrophilic C H activation during the base-free synthesis of Ru(III)-NHC complexes is reported. • A comparison of the three halide ions on the electrophilic C H activation is discussed. • The effect of contact ion pairs and halide coordination to metal are explored. • A concerted metalation deprotonation (CMD) mechanism for ion pair route was found. • Higher activation barrier for Cl- ions are due to more stabilization of intermediates. The effect of contact ion pairs and comparison of the three halide ions on the electrophilic C H activation during the base-free synthesis of Ru(III)-NHC complexes [RuIII(PyNHCR)(Cl) 3 (H 2 O)] (1a ; R = Me, and 1b ; R = iPr) have been investigated. DFT modelling of two pathways for the formation of Ru(III)-NHC complexes, viz. halide coordination pathway and ion-pair pathway, reveals the effect of halide ions during electrophilic C H activation for the generation of carbene. The ion-pair path is preferred for azolium salts with Cl− and I −, whereas with Br−, the reaction follows the halide coordination route leading to the mixed halide complex. The synthetic route follows concerted-metalation-deprotonation (CMD) mechanism for ion pair pathway. The higher activation barrier for the reaction with Cl− ions can be explained in terms of greater stabilization of the intermediates, compared to the transition states, due to halide coordination or hydrogen bonding with Cl− ions. Furthermore, the successful synthesis of 1b from the reaction of RuCl 3 ·3H 2 O and the corresponding imidazolium salt precursor with Cl− in dioxane at 100 °C validates the conclusions of the DFT studies. [Display omitted] [ABSTRACT FROM AUTHOR]

Health care organizations are leveraging machine-learning techniques, such as artificial neural networks (ANN), to improve delivery of care at a reduced cost. Applications of ANN to diagnosis are well-known; however, ANN are increasingly used to inform health care management decisions. We provide a seminal review of the applications of ANN to health care organizational decision-making. We screened 3,397 articles from six databases with coverage of Health Administration, Computer Science and Business Administration. We extracted study characteristics, aim, methodology and context (including level of analysis) from 80 articles meeting inclusion criteria. Articles were published from 1997–2018 and originated from 24 countries, with a plurality of papers (26 articles) published by authors from the United States. Types of ANN used included ANN (36 articles), feed-forward networks (25 articles), or hybrid models (23 articles); reported accuracy varied from 50% to 100%. The majority of ANN informed decision-making at the micro level (61 articles), between patients and health care providers. Fewer ANN were deployed for intra-organizational (meso- level, 29 articles) and system, policy or inter-organizational (macro- level, 10 articles) decision-making. Our review identifies key characteristics and drivers for market uptake of ANN for health care organizational decision-making to guide further adoption of this technique. [ABSTRACT FROM AUTHOR]

Introduction: Canada's health systems remain fragmented, an issue further exacerbated by the COVID-19 pandemic. Evidence-informed system transformation towards better integrated care can ensure our health systems and policies are oriented towards achieving the Quadruple Aim and health equity. The Canadian Institutes of Health Research - Institute of Health Services and Policy Research (CIHR-IHSPR) is developing a large-scale research funding initiative Transforming Health with Integrated Care (THINC) to address challenges with implementation, evaluation, and scale of evidence-informed integrated care policies and interventions. This study reports on the process and outcomes of an evidence-informed, community-engaged approach to designing the THINC research funding initiative. Aims and Methods: We aimed to meaningfully engage with patients, providers, researchers, and decision-makers from the health services and policy research community. Participants were identified from the literature, Institute's network, and referrals. We conducted a retrospective analysis of relevant funded research, an environmental scan (2011-2021), and a series of engagements (June - November 2021): semi-structured interviews (n=14), a workshop at the 1st North American Conference on Integrated Care, and three focus groups (n=~8-10 participants per group) among prioritized population groups. Descriptive (quantitative) and thematic (qualitative) analyses were used to identify themes essential for successful integrated care, research investment priorities, and funding design elements. Key Findings: Preliminary findings suggest several elements essential to integrating care, however with a critical need for a better understanding of how to implement and adapt promising interventions and policies for equitable uptake across diverse contexts. Stakeholder engagements identified a common interest in prioritizing research and assessment of impact within integrated care and the need for community-based and community-led solutions. Patients identified the need for patient-led research and strategies for meaningful engagement; providers expressed the need for improving access, data infrastructure and team-based care models for better integration of care; and distinct priorities, needs and challenges were identified among rural and remote communities. There was common agreement across key informants and focus groups about the importance of partnerships among researchers, practitioners, decision-makers and patients/communities. Conclusions: Transformative integrated care remains a priority for patients, providers, researchers, and decision-makers alike to achieve the Quadruple Aim and health equity for all Canadians. Future research investments are needed to support equitable scale and spread of interventions and policies with the greatest potential for transformative impact. Implications for applicability/transferability, sustainability, and limitations: By co-creating and mobilizing knowledge related to the development of this large, pan-Canadian research initiative, we as a federal research funding agency contribute towards learning health systems. Challenges with developing a large strategic research initiative within a short time frame included limited time and resources. [ABSTRACT FROM AUTHOR]

Workshop - Background: With the launch of CIHR-IHSPR's 2021-2026 strategic plan, IHSPR is developing a new research initiative that addresses challenges at the macro- (e.g. policy, funding) and meso-levels (e.g. governance, technology) of integrated care, with outcomes centered on health equity and the Quadruple Aim. Workshop - Aims and Objectives Using a partnered and consultative approach, the workshop aims to inform and invite participants to engage in improving a shared understanding of macro/meso-level innovations in systems organization, governance, and funding that are working towards integrated care that is transformative for Canadians. Specifically, workshop objectives are to advance a common understanding of (i) what transformative integrated care means, (ii) which building blocks are essential for successful integration, (iii) where and how evidence can bring the most value, and (iv) examples of successful integrated care and the resulting impacts of integration. Workshop - Target audience: The workshop will be of interest to professionals (researchers, policy and decision-makers, health care providers, and research funders) who are interested in better integrated care as well as patient/caregiver and community members to learn about and share perspectives regarding transformative integrated care. Workshop - Format: Our approach includes a combination of a presentation led by the chair, introductions, and an active Q&A period between panelists and participants moderated by the chair and facilitators. We estimate a 40-minute discussion with panelists using leading questions and at least 20-minutes for an open dialogue with the audience. Panelists and participants will be invited to reflect on case examples of successful integration, building blocks essential to integrated care, challenges in integrating care, and mechanisms for continuous and wider patient/community engagement. Participants will be invited to vote on specific topics and results will be reported back in real-time. Workshop - Key Learnings/Take away: Participants will gain insights regarding enablers and barriers to the successful integration of care, approaches to meaningful patient/caregiver engagement in evidence-informed transformative integrated care, and inform the development of a pan-Canadian research initiative in integrated care. [ABSTRACT FROM AUTHOR]

Background: Despite research demonstrating the potential effectiveness of Telehomecare for people with Chronic Obstructive Pulmonary Disease and Heart Failure, broad-scale comprehensive evaluations are lacking. This article discusses the qualitative component of a mixed-method program evaluation of Telehomecare in Ontario, Canada. The objective of the qualitative component was to explore the multi-level factors and processes which facilitate or impede the implementation and adoption of the program across three regions where it was first implemented.Methods: The study employs a multi-level framework as a conceptual guide to explore the facilitators and barriers to Telehomecare implementation and adoption across five levels: technology, patients, providers, organizations, and structures. In-depth semi-structured interviews and ethnographic observations with program stakeholders, as well as a Telehomecare document review were used to elicit key themes. Study participants (n = 89) included patients and/or informal caregivers (n = 39), health care providers (n = 23), technicians (n = 2), administrators (n = 12), and decision makers (n = 13) across three different Local Health Integration Networks in Ontario.Results: Key facilitators to Telehomecare implementation and adoption at each level of the multi-level framework included: user-friendliness of Telehomecare technology, patient motivation to participate in the program, support for Telehomecare providers, the integration of Telehomecare into broader health service provision, and comprehensive program evaluation. Key barriers included: access-related issues to using the technology, patient language (if not English or French), Telehomecare provider time limitations, gaps in health care provision for patients, and structural barriers to patient participation related to geography and social location.Conclusions: Though Telehomecare has the potential to positively impact patient lives and strengthen models of health care provision, a number of key challenges remain. As such, further implementation and expansion of Telehomecare must involve continuous assessments of what is working and not working with all stakeholders. Increased dialogue, evaluation, and knowledge translation within and across regions to understand the contextual factors influencing Telehomecare implementation and adoption is required. This can inform decision-making that better reflects and addresses the needs of all program stakeholders. [ABSTRACT FROM AUTHOR]

Abstract: The mononuclear Schiff base complexes of the type, [ML(CH3OH)2] [M=Co(II), Ni(II), Cu(II) and Zn(II)] have been synthesized by template condensation of l-leucine and glyoxal. The complexes have been characterized on the basis of the results of the elemental analysis, molar conductance, magnetic susceptibility measurements and spectroscopic studies viz, FT-IR, Mass, 1H NMR and 13C NMR spectra. The UV–vis and magnetic moment data revealed an octahedral geometry around Co(II), Ni(II) ion with distortion around Cu(II) ion complex confirmed by EPR data. The conductivity data show a non-electrolytic nature of the complexes. Absorption and fluorescence spectroscopic studies support that all the complexes exhibit a significant binding to calf thymus DNA. [Copyright &y& Elsevier]

Background The objective of this study was to investigate the changes in blood pressure among patients enrolled in the Telehomecare programme in Ontario, Canada. Methods This observational study utilised a prospective longitudinal cohort design, including patients with heart failure and chronic obstructive pulmonary disease enrolled in the Ontario Telehomecare programme from July 2012 to July 2015. The outcome of interest was change in mean (biweekly) systolic and diastolic blood pressure levels over a six-month period. Patient data were extracted from the Ontario Telemedicine Network database, and analysed using generalised linear mixed model procedures. Results Overall, we analysed data for 3513 patients. Patients were on average 74.1 ± 11.4 years of age; almost half were men, 62% had heart failure, 55% chronic obstructive pulmonary disease and 29% diabetes. At baseline, the mean systolic and diastolic blood pressure levels were 130.4 ± 19.1 mmHg and 72.2 ± 12.5 mmHg for the total sample. At six months, the adjusted reduction in systolic and diastolic blood pressure values were 4.0 mmHg (95% confidence interval: -4.5 to -3.5) and 2.7 mmHg (95% confidence interval: -3.1 to -2.4), respectively. In a subgroup of 1220 patients with uncontrolled blood pressure at baseline (systolic/diastolic blood pressure of 150.7 ± 10.2 mmHg/80.2 ± 13.5 mmHg) the adjusted reduction in systolic blood pressure was 12.5 mmHg (95% confidence interval: -13.4 to -11.6) and in diastolic blood pressure was 7.1 mmHg (95% confidence interval: -7.8 to -6.5) over the six-month period. Conclusions Blood pressure levels were significantly reduced in patients enrolled in the Telehomecare programme, with changes being more pronounced in patients with uncontrolled blood pressure. The sustainability of decreased blood pressure on other clinical outcomes needs further evaluation. [ABSTRACT FROM AUTHOR]

Objective: To compare early post-operative pain in mesh fixation versus without fixation in open Lichtenstein hernioplasty. Material and Methods: All patients meeting the inclusion criteria and presenting with inguinal hernia were admitted from out-patient department (OPD) in Surgical unit, District Headquarter (DHQ) Hospital, Abbottabad from period February 2019 till October 2021. The patients were randomized into two groups of 40 patients each and were managed with Lichtenstein repair followed by either suture fixation for mesh or non-fixation of Mesh. Standard protocols set by the department were followed. Results: There was statistically significant difference between the two groups in terms of postoperative pain (p <0.001). Independent samples t-test was used to compare the VAS score in two groups and the results were found to be statistically significant (p <0.001). Conclusion: There was statistically significant difference in occurrence of post-operative pain in fixed versus non-fixed mesh. [ABSTRACT FROM AUTHOR]

Background: Choosing Wisely (CW) is an international movement comprised of campaigns in more than 20 countries to reduce low-value care (LVC). De-implementation, the reduction or removal of a healthcare practice that offers little to no benefit or causes harm, is an emerging field of research. Little is known about the factors which (i) sustain LVC; and (ii) the magnitude of the problem of LVC. In addition, little is known about the processes of de-implementation, and if and how these processes differ from implementation endeavours. The objective of this study was to explicate the myriad factors which impact the processes and outcomes of de-implementation initiatives that are designed to address national Choosing Wisely campaign recommendations.Methods: Semi-structured interviews were conducted with individuals implementing Choosing Wisely Canada recommendations in healthcare settings in four provinces. The interview guide was developed using concepts from the literature and the Implementation Process Model (IPM) as a framework. All interviews were conducted virtually, recorded, and transcribed verbatim. Data were analysed using thematic analysis.Findings: Seventeen Choosing Wisely team members were interviewed. Participants identified numerous provider factors, most notably habit, which sustain LVC. Contrary to reporting in recent studies, the majority of LVC in the sample was not 'patient facing'; therefore, patients were not a significant driver for the LVC, nor a barrier to reducing it. Participants detailed aspects of the magnitude of the problems of LVC, providing insight into the complexities and nuances of harm, resources and prevalence. Harm from potential or common infections, reactions, or overtreatment was viewed as the most significant types of harm. Unique factors influencing the processes of de-implementation reported were: influence of Choosing Wisely campaigns, availability of data, lack of targets and hard-coded interventions.Conclusions: This study explicates factors ranging from those which impact the maintenance of LVC to factors that impact the success of de-implementation interventions intended to reduce them. The findings draw attention to the significance of unintentional factors, highlight the importance of understanding the impact of harm and resources to reduce LVC and illuminate the overstated impact of patients in de-implementation literature. These findings illustrate the complexities of de-implementation. [ABSTRACT FROM AUTHOR]

Introduction: Trauma to the elbow is an ordinary source of joint stiff ness that might require surgical release. Release of the stiff elbow can be done by open or arthroscopic approach. Th ere is no high-level evidence for the best surgical treatment modality for post-traumatic elbow stiff ness. Objective: Objective of this study is to assess the percentage improvement in range of motion aft er surgical release for management of patients of post-traumatic stiff elbows. Material and Methods: Th is Quasi experimental study was done at Ghurki Trust Teaching Hospital, Lahore from January 2018 to December 2018. Total 95-patients fulfi lling the selection criteria were included in this study from Orthopedic Ward of Department of Orthopedic and Spine Surgery, Ghurki Trust Hospital, Lahore. An informed consent was obtained. Demographic profi le was obtained. Th en ROM at baseline was noted. Th en all patients underwent surgical release under general anesthesia by a single surgical team. Bone resection procedure was used to release the stiff ness. Patients were followed-up in OPD aft er 4-weeks, 12-weeks and then 24-weeks. Th en aft er 24-weeks, ROM was noted and percentage improvement was calculated. Results: In this study percentage improvement in ROM aft er surgical release for management of patients of post-traumatic stiff elbows was 59.83%±8.39. Minimum and maximum percentage of improvement in ROM was 43% and 74.14% respectively. However age, gender, duration of disease and body mass index of patients was not signifi cantly associated with percentage improvement in ROM aft er surgical release. Conclusion: In this study patients undergoing surgical treatment of post traumatic stiff ness of the elbow had good percentage improvement in ROM. Th is shows the eff ectiveness of surgical release in post-traumatic stiff elbows. However age, gender, duration of disease and body mass index did not establish any signifi cant changes in the prognosis regarding release of the elbow stiff ness. [ABSTRACT FROM AUTHOR]