Short waits, happy patients and expert care, moving basic musculoskeletal care from the emergency department to a physiotherapist-led diversion pathway.

OBJECTIVE: Patients with musculoskeletal conditions (MSKCs) are highly prevalent in ED. This project explores the impact of the pilot phase of a 'diversion pathway', which directed patients with MSKCs from the ED waiting room to an outpatient clinic led by advanced-scope physiotherapists. METHODS: A prospective intervention study comparing care outcomes between patients in the 'diversion pathway' with usual ED care. The characteristics of patients considered eligible and non-eligible are described. RESULTS: Between May and December 2022, 1099 patients were diverted. For diverted patients, mean length of stay (LOS) in ED was reduced by 110 (95% confidence interval [CI]: 99-120) min and 4 h rule compliance improved by 19.3% compared to usual ED care. There were fewer patients who 'did not wait' (DNW) with the diversion pathway. The diverted group was young (median age 22 years and 41% paediatric), mostly low urgency, self-referred and arrived by private transport with minor limb trauma. The diversion pathway triage process appropriately identified 182 patients ineligible for diversion. 96.7% of patients reported satisfaction with care received from the diversion pathway. There was no change in ED representation rates for diverted patients. CONCLUSIONS: A new pathway resulted in reduced LOS, reduced DNW, high patient satisfaction and more people being discharged within 4 h for diverted patients compared to usual ED care. The pathway increased ED capacity, improved key ED performance metrics and safely expedited care delivery for patients.

Validity and feasibility of the american college of surgeons colectomy composite outcome quality measure.

OBJECTIVE: To develop a reliable, robust, parsimonious, risk-adjusted 30-day composite colectomy outcome measure. BACKGROUND: A fundamental aspect in the pursuit of high-quality care is the development of valid and reliable performance measures in surgery. Colon resection is associated with appreciable morbidity and mortality and therefore is an ideal quality improvement target. METHODS: From 2010 American College of Surgeons National Surgical Quality Improvement Program data, patients were identified who underwent colon resection for any indication. A composite outcome of death or any serious morbidity within 30 days of the index operation was established. A 6-predictor, parsimonious model was developed and compared with a more complex model with more variables. National caseload requirements were calculated on the basis of increasing reliability thresholds. RESULTS: From 255 hospitals, 22,346 patients were accrued who underwent a colon resection in 2010, most commonly for neoplasm (46.7%). A mortality or serious morbidity event occurred in 4461 patients (20.0%). At the hospital level, the median composite event rate was 20.7% (interquartile range: 15.8%-26.3%). The parsimonious model performed similarly to the full model (Akaike information criterion: 19,411 vs 18,988), and hospital-level performance comparisons were highly correlated (R = 0.97). At a reliability threshold of 0.4, 56 annual colon resections would be required and achievable at an estimated 42% of US and 69% of American College of Surgeons National Surgical Quality Improvement Program hospitals. This 42% of US hospitals performed approximately 84% of all colon resections in the country in 2008. CONCLUSIONS: It is feasible to design a measure with a composite outcome of death or serious morbidity after colon surgery that has a low burden for data collection, has substantial clinical importance, and has acceptable reliability.

Eliminating errors in vital signs documentation.

This study compared two methods of documenting vital signs: a traditional method where staff wrote vital signs on paper then keyed into an electronic medical record and a wireless system that downloaded vital signs directly into an electronic medical record. The study design was pretest and posttest. Sixty-four sets of vital signs were evaluated prior to the implementation of a wireless download system and 66 sets of vital signs were evaluated after. To compare the error rates for the two methods, χ tests were used, and t tests were used to compare the elapsed time. Questionnaires relating to the clinicians' experiences were analyzed qualitatively. The paper vital signs recording had an error rate of 18.75% and the wireless system has an error rate of 0% (P < .001). The mean (SD) elapsed time from when the vital signs were taken until they were available in the electronic medical record was 38.53 (32.87) minutes for the paper method and 5.06 (6.59) minutes for the wireless method (P < .001). The electronic vital signs documentation system resulted in significantly fewer errors and shorter elapsed time when compared with the paper system.

'I thought they would do it on the spot': why do people with non-traumatic musculoskeletal pain present to emergency departments?

Objective To investigate the reasons patients with non-traumatic musculoskeletal pain (NTMSP) present to an emergency department (ED), their experience of care and perceptions about managing their condition in the future. Methods A qualitative study using semi-structured interviews with patients with NTMSP presenting to a suburban ED. A purposive sampling strategy included participants with different pain characteristics, demographics and psychological factors. Results Eleven patients with NTMSP who presented to an ED were interviewed, reaching saturation of major themes. Seven reasons for ED presentation were identified: (1) desire for pain relief, (2) inability to access other healthcare, (3) expecting comprehensive care at the ED, (4) fear of serious pathology/outcome, (5) influence of a third party, (6) desire/expecting radiological imaging for diagnosis and (7) desire for 'ED specific' interventions. Participants were influenced by a unique combination of these reasons. Some expectations were underpinned by misconceptions about health services and care. While most participants were satisfied with their ED care, they would prefer to self-manage and seek care elsewhere in the future. Conclusions The reasons for ED presentation in patients with NTMSP are varied and often influenced by misconceptions about ED care. Most participants reported that, in future, they were satisfied to access care elsewhere. Clinicians should assess patient expectations so misconceptions about ED care can be addressed.

Using a LISTSERV™ to develop a community of practice in end-of-life, hospice, and palliative care social work.

An e-mail discussion group (SW-PALL-EOL) connects the growing number of social workers interested in palliative and end-of-life care. The article discusses the concept of a technology supported "Community of Practice." Using content analysis, the article shows empirically how this electronic discussion group has contributed to the growth and expansion of a Community of Practice dedicated to improving palliative and end-of-life care among social workers. Examples are provided of the topics posted by subscribers and the guidance provided by the group's facilitators. Comments indicate satisfaction with the electronic discussion group.

Is Neck Posture Subgroup in Late Adolescence a Risk Factor for Persistent Neck Pain in Young Adults? A Prospective Study.

OBJECTIVE: The purpose of this study was to determine whether sagittal neck sitting posture subgroup membership in late adolescence was a risk factor for persistent neck pain (PNP) in young adults. METHODS: There were 686 participants enrolled in the Raine Study at the 17- and 22-year follow-ups. At 17 years of age, posture was measured by photographs, and 4 subgroups of sitting neck posture were determined by cluster analysis. Height and weight were measured, and exercise frequency, depression, and PNP were assessed by questionnaire. At 22 years of age, participants answered questions about neck pain and occupation type. Logistic regression examined if neck posture subgroups at 17 years of age were a risk factor for PNP at 22 years of age, taking into account other factors. RESULTS: Female sex (odds ratio [OR] = 1.75, 95% CI = 1.16-2.65) and PNP at 17 years of age (OR = 3.78, 95% CI = 2.57-5.57) were associated with PNP at 22 years of age. In females, neck posture subgroup at 17 years of age was a risk factor for PNP at 22 years of age. Compared with the upright subgroup, both the slumped thorax/forward head subgroup groups and the intermediate subgroup had decreased odds for PNP at 22 years of age (OR = 0.24, 95% CI = 0.08-0.76; OR = 0.38, 95% CI = 0.15-0.99, respectively). No association was found in males. CONCLUSION: After taking into account PNP at 17 years, sitting neck posture at 17 was not a risk factor for PNP at 22 years of age in males, whereas in females, more relaxed postures (slumped thorax/forward head and Intermediate postures) were protective of neck pain compared with upright posture. IMPACT: Females in late adolescence who sat in slumped thorax/forward head or intermediate posture rather than upright sitting posture had a lower risk of PNP as a young adult. The practice of generic public health messages to sit up straight to prevent neck pain needs rethinking.

Evaluation of the Humoral Response to Adeno-Associated Virus-Based Gene Therapy Modalities Using Total Antibody Assays.

The number of viral vector-based gene therapies (GTx) continues to grow with two products (Zolgensma® and Luxturna®) approved in the USA as of March 2021. To date, the most commonly used vectors are adeno-associated virus-based (AAV). The pre-existing humoral immunity against AAV (anti-AAV antibodies) has been well described and is expected as a consequence of prior AAV exposure. Anti-AAV antibodies may present an immune barrier to successful AAV transduction and hence negatively impact clinical efficacy and may also result in adverse events (AEs) due to the formation of large immune complexes. Patients may be screened for the presence of anti-AAV antibodies, including neutralizing (NAb) and total binding antibodies (TAb) prior to treatment with the GTx. Recommendations for the development and validation of anti-AAV NAb detection methods have been presented elsewhere. This manuscript covers considerations related to anti-AAV TAb-detecting protocols, including the advantages of the use of TAb methods, selection of assay controls and reagents, and parameters critical to monitoring assay performance. This manuscript was authored by a group of scientists involved in GTx development representing eleven organizations. It is our intent to provide recommendations and guidance to industry sponsors, academic laboratories, and regulatory agencies working on AAV-based GTx viral vector modalities with the goal of achieving a more consistent approach to anti-AAV TAb assessment. Graphical abstract.

Effect of postdischarge morbidity and mortality on comparisons of hospital surgical quality.

BACKGROUND: Hospitals increasingly rely on surgical quality assessment programs that require considerable resources to capture outcomes after hospital discharge. However, it is unclear whether capturing postdischarge complications and deaths is important. Our objectives were (1) to determine the frequency of postdischarge complications and deaths and (2) to determine whether hospital rankings change with inclusion of postdischarge outcomes. METHODS: From 181 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program, 329,951 patients were identified (2006-2007). Mortality and 19 complications within 30 days of the index operation were categorized as occurring before or after discharge. Risk-adjusted hospital rankings were compared based on whether only predischarge (inpatient) versus both pre- and postdischarge (inpatient and outpatient within 30 days of operation) morbidity and mortality were included. RESULTS: Postdischarge complications accounted for 32.9% of all complications. Certain complications occurred frequently after discharge: surgical site infections (66.0%), urinary tract infections (39.4%), pulmonary embolisms (42.2%), and deep venous thromboses (34.5%). Of all patients experiencing complications, 39.7% had only postdischarge complications. Of 5827 postoperative deaths, 23.6% occurred after discharge. Hospital quality rankings changed when postdischarge outcomes were excluded versus included for morbidity (median hospital rank change: 16 ranks; interquartile range, 7-36) and mortality (median hospital rank change: 14 ranks; interquartile range, 6-29), and there was disagreement in outlier status designations depending on whether postdischarge events were included (morbidity: kappa = 0.546; mortality: kappa = 0.507). CONCLUSIONS: A substantial proportion of postoperative complications and deaths occur after hospital discharge. Inclusion of postdischarge events considerably affects hospital quality rankings and outlier status designations. Quality improvement programs and research that do not consider postdischarge outcomes may offer incomplete information to hospitals, payers, providers, and patients.

Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach.

The history and development of the NSQIP, from its inception in the Veterans Administration Health System to its implementation within the private sector sponsored by the ACS, documents the growth of a program that has substantially improved the quality of surgical care and has had a considerable influence on the culture of quality improvement in the profession. The success of the ACS NSQIP is the result of providing hospitals with rigorous, clinical data, networking opportunities, and resources to improve their risk-adjusted outcomes. In this manner, the ACS NSQIP challenges its hospitals and health care providers to continually improve the care they provide. In addition to reducing the complications and mortality experienced by patients after surgical procedures, hospitals that participate in the ACS NSQIP have seen the financial rewards of their quality improvement efforts. Continued growth of the ACS NSQIP will facilitate achievement of the primary goal surrounding the current health care reform debate: efficient, high-quality care.

Effect of subjective preoperative variables on risk-adjusted assessment of hospital morbidity and mortality.

OBJECTIVE: To examine the influence of American Society of Anesthesiologists Physical Status Classification (ASA) and preoperative Functional Health Status (FHS) variables on risk-adjusted estimates of surgical quality and to assess whether classifications are inflated at some hospitals. BACKGROUND: ASA and FHS are influential in risk-adjusted comparisons of surgical quality. However, because ASA and FHS are subjective they can be inflated, making patients appear more ill than they actually are, and crediting hospitals for a sicker patient population. METHODS: We identified 28,751 colorectal surgery patients at 170 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program (ACS NSQIP) during 2006 to 2007. Logistic regression models were developed for morbidity and mortality with and without inclusion of ASA and FHS. Hospital quality rankings from the different models were compared. RESULTS: Morbidity and mortality rates were 24.3% and 3.9%, respectively. Percents of patients in ASA classes I through V were 3.3%, 46.4%, 41.5%,8.3%, and 0.7% and that were independent or partially or totally dependent were 89.2%, 7.2%, and 3.6%, respectively. Models that included ASA and FHS exhibited slightly better fit (Hosmer-Lemshow statistic) and discrimination(c-statistic) than models without both these variables, though magnitudes of differences were consistent with chance. There was inconsistent evidence for improper assignment of ASA and FHS. CONCLUSIONS: The small improvements in model quality when both ASA and FHS are present versus absent, suggest that they make a unique contribution to assessing severity of preoperative risk. With little indication that these subjective variables are subject to an important level of institutional bias, it is appropriate that they be used to assess risk-adjusted surgical quality. Periodic monitoring for inappropriate inflation of ASA status is warranted.

Variability in length of stay after colorectal surgery: assessment of 182 hospitals in the national surgical quality improvement program.

BACKGROUND: Length of postoperative stay (LOS) has gained increasing attention as a potential indicator of surgical efficiency. Our objective was to examine the feasibility of assessing LOS at 182 hospitals to identify institutions with outlying performance. METHODS: Patients were identified who underwent colorectal surgery at 182 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program (ACS NSQIP) from 2006 to 2007. Regression models for extended LOS (greater than the 75th percentile) were developed to identify hospitals whose ratios of observed to expected events (O/E) were significantly better (low outlier) or worse (high outlier) than expected after adjustment for case mix. To evaluate strategies for evaluating LOS that would be minimally influenced by the occurrence of complications, separate models were developed for patients categorized either by (1) the nonoccurrence or occurrence of any postoperative complication or (2) tercile of preoperative morbidity risk. RESULTS: The 23,098 patients selected for this study were partitioned into groups without complications (0% complications), with complications (100%) or into terciles of preoperative morbidity risk (with 22.4%, 38.7%, and 60.0% of patients having complications, respectively). In general, the greater the complication rate the longer the LOS and the fewer the number of statistical outliers that were identified. CONCLUSIONS: ACS NSQIP data can provide individual hospitals with riskadjusted LOS measures that can be used to identify outlying performance and motivate quality improvement efforts.

Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals.

BACKGROUND/OBJECTIVE: The National Surgical Quality Improvement Program (NSQIP) has demonstrated quality improvement in the VA and pilot study of 14 academic institutions. The objective was to show that American College of Surgeons (ACS)-NSQIP helps all enrolled hospitals. METHODS: ACS-NSQIP data was used to evaluate improvement in hospitals longitudinally over 3 years (2005-2007). Improvement was defined as reduction in risk-adjusted "Observed/Expected" (O/E) ratios between periods with risk adjustment held constant. Multivariable logistic regression-based adjustment was performed and included indicators for procedure groups. Additionally, morbidity counts were modeled using a negative binomial model, to estimate the number of avoided complications. RESULTS: Multiple perspectives reflected improvement over time. In the analysis of 118 hospitals (2006-2007), 66% of hospitals improved risk-adjusted mortality (mean O/E improvement: 0.174; P < 0.05) and 82% improved risk adjusted complication rates (mean improvement: 0.114; P < 0.05). Correlations between starting O/E and improvement (0.834 for mortality, 0.652 for morbidity), as well as relative risk, revealed that initially worse-performing hospitals had more likelihood of improvement. Nonetheless, well-performing hospitals also improved. Modeling morbidity counts, 183 hospitals (2007), avoided ~9598 potential complications: ~52/hospital. Due to sampling this may represent only 1 of 5 to 1of 10 of the true total. Improvement reflected aggregate performance across all types of hospitals (academic/community, urban/rural). Changes in patient risk over time had important contributions to the effect. CONCLUSIONS: ACS-NSQIP indicates that surgical outcomes improve across all participating hospitals in the private sector. Improvement is reflected for both poor- and well-performing facilities. NSQIP hospitals appear to be avoiding substantial numbers of complications- improving care, and reducing costs. Changes in risk over time merit further study.

Description of the larva of Catadromus lacordairei Boisduval, 1835 (Coleoptera: Carabidae), a threatened carabid, from Tasmania, Australia.

The carabid beetle genus Catadromus MacLeay (Coleoptera: Carabidae) is endemic to the Australasian region. Of the five currently recognised species, only one, C. lacordairei Boisduval, 1835 occurs in Tasmania, Australia, where it is listed as a threatened species on the Tasmanian Threatened Species Protection Act 1995. In the present paper, we describe and illustrate the larva of C. lacordairei, providing the first detailed larval description of a member of this genus.

Evaluation of an online learning academy of peer specialists.

OBJECTIVE: This report describes the instructional design and development process, learner feedback, and factors associated with course completion in the Academy of Peer Services (APS), an online educational platform for partial fulfillment of peer specialist state certification. METHOD: From January 2014 to August 2017, 4,064 individuals in the APS completed online courses and provided demographic information and course evaluation feedback. This report analyzed the relationship between demographic data (work role, experience with online training, level of education) and posttest performance. Course evaluation data on quality, perceived difficulty, and learner satisfaction were also analyzed. RESULTS: Overall, participants passed posttests 70.6% of the time. The effect size of work role was very small, η2 = .006. Level of education attainment was associated with differences on posttest scores, F(5, 3903) = 20.22, p < 001, but the effect size was, again, very modest, η2 = .025. Previous experience with online learning slightly influenced posttest scores, F(2, 4053) = 3.95, p < .02, η2 = .002. The great majority of students (88.2%) agreed or strongly agreed that the content was relevant to their everyday work. Similarly, 89% agreed or strongly agreed that the content contained practical tools, which they intend to use in their work. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The feedback collected from more than 4000 learners suggests that the application of instructional design principles and techniques succeeded in translating the practical knowledge of peer-provided services to an easily accessible web-based platform for persons of varying education and life experiences. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Non-traumatic musculoskeletal pain in Western Australian hospital emergency departments: A clinical audit of the prevalence, management practices and evidence-to-practice gaps.

OBJECTIVES: Musculoskeletal pain (MSP) conditions are a leading cause of morbidity worldwide and a common reason for ED presentation. Little is currently known about non-traumatic MSP (NTMSP) presenting to EDs. The present study described the prevalence and management practices of NTMSP in EDs. METHODS: The design was a retrospective clinical audit in two hospital EDs in Western Australia covering 3 months beginning 1 January 2016. We defined NTMSP as pain of musculoskeletal origin occurring in the absence of external force or excessive physical loading. The outcomes measured included: patient, condition and hospital-episode characteristics, as well as management practices. Management practices were compared to recommended care derived from guideline recommendations. These included: assessment for red flags and psychosocial risk factors, appropriate use of diagnostic imaging, provision of patient education, administration and prescription of analgesic medication, and assessment of risk factors for opioid-related harm. RESULTS: Eight hundred and eighty-eight patients were included in the present study. NTMSP accounted for 3.0% of all ED presentations. According to clinician documentation, red flag and psychosocial assessments were recorded in 73.3 and 10.5% of patients. Forty-one percent of patients were referred for imaging, of which 39.7% were inconsistent with guideline recommendations. Education was recorded 52.0% of the time. At least one opioid medication was administered to 55.3% of patients and there was no documented assessment of risk factors for opioid-related harm. CONCLUSIONS: NTMSP is a relatively common reason for ED presentation. Documented management practices are discordant with guideline recommendations. Strategies to improve the concordance between management and guideline recommendations are needed.

Transplantation of umbilical-cord blood in babies with infantile Krabbe's disease.

BACKGROUND: Infantile Krabbe's disease produces progressive neurologic deterioration and death in early childhood. We hypothesized that transplantation of umbilical-cord blood from unrelated donors before the development of symptoms would favorably alter the natural history of the disease among newborns in whom the disease was diagnosed because of a family history. We compared the outcomes among these newborns with the outcomes among infants who underwent transplantation after the development of symptoms and with the outcomes in an untreated cohort of affected children. METHODS: Eleven asymptomatic newborns (age range, 12 to 44 days) and 14 symptomatic infants (age range, 142 to 352 days) with infantile Krabbe's disease underwent transplantation of umbilical-cord blood from unrelated donors after myeloablative chemotherapy. Engraftment, survival, and neurodevelopmental function were evaluated longitudinally for four months to six years. RESULTS: The rates of donor-cell engraftment and survival were 100 percent and 100 percent, respectively, among the asymptomatic newborns (median follow-up, 3.0 years) and 100 percent and 43 percent, respectively, among the symptomatic infants (median follow-up, 3.4 years). Surviving patients showed durable engraftment of donor-derived hematopoietic cells with restoration of normal blood galactocerebrosidase levels. Infants who underwent transplantation before the development of symptoms showed progressive central myelination and continued gains in developmental skills, and most had age-appropriate cognitive function and receptive language skills, but a few had mild-to-moderate delays in expressive language and mild-to-severe delays in gross motor function. Children who underwent transplantation after the onset of symptoms had minimal neurologic improvement. CONCLUSIONS: Transplantation of umbilical-cord blood from unrelated donors in newborns with infantile Krabbe's disease favorably altered the natural history of the disease. Transplantation in babies after symptoms had developed did not result in substantive neurologic improvement.

CYP2C75-involved autoinduction of metabolism in rhesus monkeys of methyl 3-chloro-3'-fluoro-4'-{(1R)-1-[({1-[(trifluoroacetyl)amino]cyclopropyl}carbonyl)amino]ethyl}-1,1'-biphenyl-2-carboxylate (MK-0686), a bradykinin B1 receptor antagonist.

After oral treatment (once daily) for 4 weeks with the potent bradykinin B(1) receptor antagonist methyl 3-chloro-3'-fluoro-4'-{(1R)-1-[({1-[(trifluoroacetyl)amino]cyclopropyl}carbonyl)-amino]ethyl}-1,1'-biphenyl-2-carboxylate (MK-0686), rhesus monkeys (Macaca mulatta) exhibited significantly reduced systemic exposure of the compound in a dose-dependent manner, suggesting an occurrence of autoinduction of MK-0686 metabolism. This possibility is supported by two observations. 1) MK-0686 was primarily eliminated via biotransformation in rhesus monkeys, with oxidation on the chlorophenyl ring as one of the major metabolic pathways. This reaction led to appreciable formation of a dihydrodiol (M11) and a hydroxyl (M13) product in rhesus liver microsomes supplemented with NADPH. 2) The formation rate of these two metabolites determined in liver microsomes from MK-0686-treated groups was > or = 2-fold greater than the value for a control group. Studies with recombinant rhesus P450s and monoclonal antibodies against human P450 enzymes suggested that CYP2C75 played an important role in the formation of M11 and M13. The induction of this enzyme by MK-0686 was further confirmed by a concentration-dependent increase of its mRNA in rhesus hepatocytes, and, more convincingly, the enhanced CYP2C proteins and catalytic activities toward CYP2C75 probe substrates in liver microsomes from MK-0686-treated animals. Furthermore, a good correlation was observed between the rates of M11 and M13 formation and hydroxylase activities toward probe substrates determined in a panel of liver microsomal preparations from control and MK-0686-treated animals. Therefore, MK-0686, both a substrate and inducer for CYP2C75, caused autoinduction of its own metabolism in rhesus monkeys by increasing the expression of this enzyme.

Stromatolites on the rise in peat-bound karstic wetlands.

Stromatolites are the oldest evidence for life on Earth, but modern living examples are rare and predominantly occur in shallow marine or (hyper-) saline lacustrine environments, subject to exotic physico-chemical conditions. Here we report the discovery of living freshwater stromatolites in cool-temperate karstic wetlands in the Giblin River catchment of the UNESCO-listed Tasmanian Wilderness World Heritage Area, Australia. These stromatolites colonize the slopes of karstic spring mounds which create mildly alkaline (pH of 7.0-7.9) enclaves within an otherwise uniformly acidic organosol terrain. The freshwater emerging from the springs is Ca-HCO3 dominated and water temperatures show no evidence of geothermal heating. Using 16 S rRNA gene clone library analysis we revealed that the bacterial community is dominated by Cyanobacteria, Alphaproteobacteria and an unusually high proportion of Chloroflexi, followed by Armatimonadetes and Planctomycetes, and is therefore unique compared to other living examples. Macroinvertebrates are sparse and snails in particular are disadvantaged by the development of debilitating accumulations of carbonate on their shells, corroborating evidence that stromatolites flourish under conditions where predation by metazoans is suppressed. Our findings constitute a novel habitat for stromatolites because cool-temperate freshwater wetlands are not a conventional stromatolite niche, suggesting that stromatolites may be more common than previously thought.

Relative contributions of surgeons and decision support systems.

Evidence-based medicine came into focus in 1992 when scholars recognized the need for valid information required for optimal patient care. Because of the increasing volume and uncertain quality of new knowledge, traditional sources of information such as books and journals failed to meet the needs of busy practitioners.Evidence-based medicine promoted strategies for identifying and appraising relevant information and making it readily available. Surgeons face unique challenges in the recognition and application of best evidence. Evidence-based surgery requires careful appraisal of the existing evidence, expanding the pool of level 1 evidence,and improving the availability of best evidence. Ultimately, the organization of systems will incorporate best evidence into the processes of care and will document the outcomes of care.