A systematic review of acquisition and mastery of skills taught using the Picture Exchange Communication System.

The Picture Exchange Communication System (PECS) is a popular augmentative and alternative communication intervention for individuals with developmental disabilities that includes six, sequential phases of instruction. We systematically reviewed published and unpublished single-case PECS studies for details about the percentage of participants mastering PECS phases, how long it took participants to master PECS phases (in trials to mastery), and what constituted mastery of PECS phases. We found most participants mastered only the first two phases of PECS, and Phases I, II, and IV showed the slowest and widest variability in trials to mastery. Moreover, participants who were taught the third PECS phase learned to select from an average array of three symbols, which may limit the range of messages they can communicate. We discuss our findings in light of a few important limitations and provide directions for future researchers along with recommendations for professionals who might consider PECS.

Hospital admission as a deprescribing triage point for patients discharged to Residential Aged Care Facilities.

BACKGROUND: Deprescribing may benefit older frail patients experiencing polypharmacy. We investigated the scope for deprescribing in acutely hospitalised patients and the long-term implications of continuation of medications that could potentially be deprescribed. METHODS: Acutely hospitalised patients (n = 170) discharged to Residential Aged Care Facilities, ≥75 years and receiving ≥5 regular medications were assessed during admission to determine eligibility for deprescribing of key drug classes, along with the actual incidence of deprescribing. The impact of continuation of nominated drug classes (anticoagulants, antidiabetics, antiplatelets, antipsychotics, benzodiazepines, proton pump inhibitors (PPIs), statins) on a combined endpoint (death/readmission) was determined. RESULTS: Hyperpolypharmacy (>10 regular medications) was common (49.4%) at admission. Varying rates of deprescribing occurred during hospitalisation for the nominated drug classes (8-53%), with considerable potential for further deprescribing (34-90%). PPI use was prevalent (56%) and 89.5% of these had no clear indication. Of the drug classes studied, only continued PPI use at discharge was associated with increased mortality/readmission at 1 year (hazard ratio 1.54, 95% confidence interval (1.06-2.26), P = 0.025), driven largely by readmission. CONCLUSION: There is considerable scope for acute hospitalisation to act as a triage point for deprescribing in older patients. PPIs in particular appeared overprescribed in this susceptible patient group, and this was associated with earlier readmission. Polypharmacy in older hospitalised patients should be targeted for possible deprescribing during hospitalisation, especially PPIs.

Flood resilience, amenity and biodiversity benefits of an historic urban pond.

The main pond within the historic Royal Botanic Garden Edinburgh is an important component of urban blue-green infrastructure. This paper reports on flood resilience provided by the pond (simulated using the CityCAT hydrodynamic model), its water residence times (obtained using the Shetran hydrological model), and the ecology and biodiversity (vascular plants, bryophytes, aquatic invertebrates, phyto- and zooplankton, birds) of the pond and the adjacent area. The results show that the pond improves the flood resilience with at least a 27% reduction in the peak discharge during a 1 h, one in 100-year event. The area represents a biodiversity hot spot with a range of native taxa occurring among introduced plant species. The plankton community is dominated by diatoms, reflecting elevated levels of turbulence and a relatively short residence time, with an average value of 10 days. Analysis of macroinvertebrate community indicates a potential for water quality improvement. The results are discussed in relation to multiple societal benefits related to flood resilience, recreation, education, water quality, amenity and biodiversity value. The conclusions may prove particularly valuable for introducing practical measures in the water catchment, preventing waterlogging of the soil and ensuring an uninterrupted supply of public services. This article is part of the theme issue 'Urban flood resilience'.

The Role of Problem-Based Learning in Preparing Medical Students to Work As Community Service-Oriented Primary Care Physicians: A Systematic Literature Review.

The number of primary care physicians in the United States is dwindling rapidly, and osteopathic medical schools are embracing the challenge of leading students toward a career in primary care to meet this need. In recent years, the Problem-Based Learning (PBL) curriculum in medical education has emerged as a patient-centered, social-justice-focused methodology. The unique format of PBL centered around patient cases allows learning through community-based medicine, promoting medical graduates' entry into primary care. Through exploring the literature on this topic, the research question posed for this review is as follows: How have the skills gained in PBL been effectively preparing medical students to become community service-oriented primary care physicians, and how can we qualitatively and quantitatively assess a learner's preparedness to engage in primary care work? The variables studied were board licensing examination scores, clinical competence, and interpersonal skills, all of which emerged as common ways to assess learners' preparedness to work in primary care. The methodology of this literature review was organized using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart to describe how articles were selected and synthesized to evaluate the variables. The results revealed the variables to be consistent strengths of PBL students, particularly clinical competence, and interpersonal skills, both of which are key in working in primary care and any clinical specialty. Since early in its implementation, literature has demonstrated the tendencies of PBL students to be interested in and later work in primary care, though little follow-up has been done recently. The question of why this phenomenon exists was largely answered by our literature review. In conclusion, through our analysis of the existing literature, the authors demonstrated that the PBL curriculum helps foster students' desire to serve patients. Limitations of the literature included small sample sizes, heterogeneous analysis methods, limited inclusion of qualitative assessment of student progress, and limited existing data on the prevalence of PBL in medical schools, as well as the entrance of PBL graduates into primary care careers.

A Systematic Review of Linguistic and Verbal Behavior Outcomes of Pivotal Response Treatment.

Pivotal Response Treatment (PRT) is a popular intervention for improving targeted and untargeted communication skills for learners with autism. We systematically reviewed communication outcomes reported in experimental research to determine linguistic forms and verbal behavior functions associated with PRT. We found most researchers aggregated results or did not report sufficient detail to determine linguistic forms and/or verbal behavior functions. Generalization of communication skills to untargeted people, settings, materials, and/or activities was evident. However, only one study clearly indicated untargeted linguistic forms emerged following PRT, and no researchers described results that indicated improved generalized and collateral verbal behavior functions. We suggest PRT researchers more clearly define and report primary, generalized, and collateral communication-specific outcomes in order to advance research and practice.

Potential drug-drug interactions with direct oral anticoagulants in elderly hospitalized patients.

BACKGROUND: To determine the prevalence and nature of potential drug-drug interactions (DDIs) with direct oral anticoagulants (DOACs) in elderly hospitalized patients. METHODS: This was a retrospective observational study. Inclusion criteria were: aged over 65 years; taking apixaban, rivaroxaban or dabigatran; and admitted to the Repatriation General Hospital between April 2014 and July 2015. A list of clinically relevant 'perpetrator' drugs was compiled from product information, the Australian Medicines Handbook, the Australian National Prescribing Service resources, and local health network guidelines. The prevalence and nature of potential DDIs with DOACs was determined by comparing inpatient drug charts with the list of perpetrator drugs. RESULTS: There were 122 patients in the study with a mean age of 82 years. Most patients had nonvalvular atrial fibrillation and were taking DOACs to prevent thrombotic stroke (83%). Overall, 45 patients (37%) had a total of 54 potential DDIs. Thirty-five patients had potential pharmacodynamic DDIs with antidepressants, nonsteroidal anti-inflammatory drugs and antiplatelets (35/122, 29%). Nineteen patients had potential pharmacokinetic DDIs (19/122, 16%). Of these, 68% (13/19) were taking drugs that increase DOAC plasma concentrations (amiodarone, erythromycin, diltiazem or verapamil) and 32% (6/19) were taking drugs that decrease DOAC plasma concentrations (carbamazepine, primidone or phenytoin). There were no cases of patients taking contraindicated interacting drugs. DISCUSSION: Potential DDIs with DOACs in elderly hospital inpatients are relatively common, particularly interactions that may increase the risk of bleeding. The risk-benefit ratio of DOACs in elderly patients on polypharmacy should always be carefully considered.

An annotated bibliography of articles in the Journal of Speech and Language Pathology-Applied Behavior Analysis.

The open-source Journal of Speech and Language Pathology-Applied Behavior Analysis (JSLP-ABA) was published online from 2006 to 2010. We present an annotated bibliography of 80 articles published in the now-defunct journal with the aim of representing its scholarly content to readers of The Analysis of Verbal Behavior. We hope this effort will stimulate discussion, research, and treatment applications with respect to disorders of speech, language, hearing, swallowing, and voice and that collaborative efforts may be fostered between the two professions represented by JSLP-ABA: speech-language pathology and applied behavior analysis.

Chronic hypoxemia in late gestation decreases cardiomyocyte number but does not change expression of hypoxia-responsive genes.

BACKGROUND: Placental insufficiency is the leading cause of intrauterine growth restriction in the developed world and results in chronic hypoxemia in the fetus. Oxygen is essential for fetal heart development, but a hypoxemic environment in utero can permanently alter development of cardiomyocytes. The present study aimed to investigate the effect of placental restriction and chronic hypoxemia on total number of cardiomyocytes, cardiomyocyte apoptosis, total length of coronary capillaries, and expression of genes regulated by hypoxia. METHODS AND RESULTS: We induced experimental placental restriction from conception, which resulted in fetal growth restriction and chronic hypoxemia. Fetal hearts in the placental restriction group had fewer cardiomyocytes, but interestingly, there was no difference in the percentage of apoptotic cardiomyocytes; the abundance of the transcription factor that mediates hypoxia-induced apoptosis, p53; or expression of apoptotic genes Bax and Bcl2. Likewise, there was no difference in the abundance of autophagy regulator beclin 1 or expression of autophagic genes BECN1, BNIP3, LAMP1, and MAP1LC3B. Furthermore, fetuses exposed to normoxemia (control) or chronic hypoxemia (placental restriction) had similar mRNA expression of a suite of hypoxia-inducible factor target genes, which are essential for angiogenesis (VEGF, Flt1, Ang1, Ang2, and Tie2), vasodilation (iNOS and Adm), and glycolysis (GLUT1 and GLUT3). In addition, there was no change in the expression of PKC-ε, a cardioprotective gene with transcription regulated by hypoxia in a manner independent of hypoxia-inducible factors. There was an increased capillary length density but no difference in the total length of capillaries in the hearts of the chronically hypoxemic fetuses. CONCLUSION: The lack of upregulation of hypoxia target genes in response to chronic hypoxemia in the fetal heart in late gestation may be due to a decrease in the number of cardiomyocytes (decreased oxygen demand) and the maintenance of the total length of capillaries. Consequently, these adaptive responses in the fetal heart may maintain a normal oxygen tension within the cardiomyocyte of the chronically hypoxemic fetus in late gestation.