Disseminated thymoma in pleural fluid: An unusual case.

Thymic epithelial tumours show characteristic cytological features on fine-needle aspiration cytology, however the cytological features of thymoma in fluid cytology are not well described. We present the case of a 77 year-old-woman with known pleural dissemination of type B2/B3 thymoma presenting with shortness of breath and orthopnoea due to a pleural effusion. Cytological evaluation of the pleural fluid showed cellular smears composed of numerous small lymphocytes with small numbers of admixed mesothelial cells. There was no epithelial component. On immunohistochemical (IHC) staining the lymphocytes were T cells which were positive for CD3. CD1a and terminal deoxynucleotide transferase (TdT) were also positive, consistent with immature lymphocytes of thymic origin. Despite the lack of an epithelial component, this case was diagnosed as suspicious for recurrent/ metastatic thymoma. This is only the second published case of thymoma identified on pleural fluid cytology, and to our knowledge the first case describing thymoma in pleural fluid with no epithelial component, a potential pitfall with the more common differential diagnosis of a reactive lymphocytic effusion.

Evaluation of the Fast Prior Authorization Technology Highway.

BACKGROUND: Prior authorization (PA) is a utilization management tool used by health plans and pharmacy benefit managers where the payer requires additional documentation from health care providers before authorization of payment for a medication or procedure. PA processes are hypothesized to be more efficient if electronic transmission is utilized instead of manual submission. OBJECTIVE: To evaluate the impact of electronic PA (ePA) on approval rate and time to decision and to assess health care provider perception of using ePA. METHODS: America's Health Insurance Plans selected 2 technology companies, Availity and Surescripts, and used an independent research organization (Research Triangle Institute [RTI]) to conduct a provider survey and analyze over 40,000 PA transactions from participating health plans. RTI examined processing time, provider experience, and other measures for PAs both before and after provider implementation of ePA. RESULTS: Providers used these tools for roughly 62% of PAs in the 6 months after implementation. The median time from PA request to decision fell from 18.7 hours to 5.7 hours. Providers using ePA reported observing some benefits relative to the number of phone calls and faxes required after ePA implementation. CONCLUSION: The primary benefit of ePA implementation was reduced time to decision. Additional benefits may occur with greater adoption since 38% of PAs were still manual after implementation of ePA.

Body mass index and in-hospital postoperative complications following primary total hip arthroplasty.

BACKGROUND: The influence of obesity measured in terms of body mass index (BMI) on the complication rates following total hip arthroplasty (THA) is a matter of debate. METHODS: This retrospective study conducted at a tertiary referral centre at Brisbane, Australia, examines the association between BMI and in-hospital postoperative complications, length of operating time and duration of hospital stay in 964 patients, who underwent THA from 2006 to 2010. RESULTS: Amongst patients undergoing primary THA, when compared to the normal weight patients, those with BMI between 25 kg/m2 and 29.9 kg/m2 (overweight) and those with BMI between 35 kg/m2 and 39.9 kg/m2 (obese class II) had lower odds of perioperative complications (odds ratio [OR]: 0.62 (95% confidence intervals [CI], 0.43-0.92, p = 0.016) and OR: 0.60 (95% CI, 0.36- 0.99, p = 0.047 respectively). Patients with BMI less than or equal to 40 kg/m2 were also associated with significantly lower odds of cardiac complications ( p = 0.02). With unadjusted regression analysis, it was noted that those with BMI ≥40 kg/m2 had the highest odds of developing infectious complications (OR 2.68, 95% CI, 1.08-6.65, p < 0.05). As the BMI increased, there was a statistically significant increase in length of operating time ( p < 0.001). CONCLUSION: There is a significant impact of BMI on the occurrence of perioperative complications following THA. Compared to normal weight category, the overweight and obese class II patients had a lower likelihood of developing overall, especially cardiac complications. Length of operating time increases along with an increase in BMI.

Transforming the future of health together: The Learning Health Systems Consensus Action Plan.

The Learning Health Community is an emergent global multistakeholder grassroots incipient movement bonded together by a set of consensus Core Values Underlying a National-Scale Person-Centered Continuous Learning Health System developed at the 2012 Learning Health System (LHS) Summit. The Learning Health Community's Second LHS Summit was convened on December 8 to 9, 2016 building upon LHS efforts taking shape in order to achieve consensus on actions that, if taken, will advance LHSs and the LHS vision from what remain appealing concepts to a working reality for improving the health of individuals and populations globally. An iterative half-year collaborative revision process following the Second LHS Summit led to the development of the Learning Health Systems Consensus Action Plan.

Factors That Influence Women to Disclose Sexual Assault History to Health Care Providers.

OBJECTIVE: To examine women's experiences with sexual assault screening by health care professionals and identify factors that influence women to disclose their sexual assault history to providers. DESIGN: Cross-sectional descriptive survey with correlational analysis. SETTING: On-line survey distributed nationally. PARTICIPANTS: One hundred forty-three women. METHODS: Participants were recruited through social media; the authors e-mailed organizations across the nation and asked them to share links to a Facebook page connected to the survey. Descriptive statistics, Spearman's rho, and contingency tables were calculated, and qualitative content analysis was performed by thematic analysis. RESULTS: Most (n = 103, 72.5%) participants reported that they felt comfortable with being asked about sexual assault, but only 41 (28.7%) participants were screened for sexual assault by health care professionals. Positive attitude and increased comfort level with screening were associated with increased intention to disclose past assault (p < .05). A total of 113 (82.5%) women reported intentions to disclose sexual assault to a provider if asked, whereas only 35 (24.6%) women would voluntarily disclose. Women identified prevention of medical and physical consequences as main facilitators to disclosure, and provider attitude and demeanor as the main barriers. Sixty-nine (48.9%) participants were victims of sexual assault. Women with a history of sexual assault were no more likely than women not victimized to have been screened for sexual assault. CONCLUSION: Study findings suggest that women are often not screened for sexual assault despite being receptive to inquiry. Health care professionals often do not identify those who have been sexually assaulted because they do not ask. Thus, many victims do not receive needed sexual assault resources and support.

Recommendations for fluoride limits in drinking water based on estimated daily fluoride intake in the Upper East Region, Ghana.

Both dental and skeletal fluorosis caused by high fluoride intake are serious public health concerns around the world. Fluorosis is particularly pronounced in developing countries where elevated concentrations of naturally occurring fluoride are present in the drinking water, which is the primary route of exposure. The World Health Organization recommended limit of fluoride in drinking water is 1.5 mg F(-) L(-1), which is also the upper limit for fluoride in drinking water for several other countries such as Canada, China, India, Australia, and the European Union. In the United States the enforceable limit is much higher at 4 mg F(-) L(-1), which is intended to prevent severe skeletal fluorosis but does not protect against dental fluorosis. Many countries, including the United States, also have notably lower unenforced recommended limits to protect against dental fluorosis. One consideration in determining the optimum fluoride concentration in drinking water is daily water intake, which can be high in hot climates such as in northern Ghana. The results of this study show that average water intake is about two times higher in Ghana than in more temperate climates and, as a result, the fluoride intake is higher. The results also indicate that to protect the Ghanaian population against dental fluorosis, the maximum concentration of fluoride in drinking water for children under 6-8 years should be 0.6 mg F(-) L(-1) (and lower in the first two years of life), and the limit for older children and adults should be 1.0 mg F(-) L(-1). However, when considering that water treatment is not cost-free, the most widely recommended limit of 1.5 mg F(-) L(-1) - which is currently the limit in Ghana--may be appropriate for older children and adults since they are not vulnerable to dental fluorosis once the tooth enamel is formed.

E-Prescribing collaboration in Massachusetts: early experiences from regional prescribing projects.

Massachusetts payers and providers have encouraged clinician usage of e-Prescribing technology to improve patient safety, enhance office practice efficiencies, and reduce medical costs. This report describes three early pilot e-Prescribing projects as case studies. These projects identified the e-Prescribing needs of clinicians, illustrated key issues that made implementation difficult, and clarified the impact of various types of functionality. The authors identified ten key barriers: (1) previous negative technology experiences, (2) initial and long-term cost, (3) lost productivity, (4) competing priorities, (5) change management issues, (6) interoperability limitations, (7) information technology (IT) requirements, (8) standards limitations, (9) waiting for an "all-in-one solution," and (10) confusion about competing product offerings including hospital/Integrated Delivery System (IDN)-sponsored projects. In Massachusetts, regional projects have helped to address these barriers, and e-Prescribing activities are accelerating rapidly within the state.

Persistence of seeds from crops of conventional and herbicide tolerant oilseed rape (Brassica napus).

A series of rotation experiments at five sites over four years has explored the environmental and agronomic implications of growing herbicide tolerant oilseed rape and sugar beet. This paper reports on the population dynamics of volunteer rape (Brassica napus). The experiments compared four winter oilseed rape (WOSR) cultivars: a conventional cultivar (Apex) and three developmental cultivars either genetically modified (GM) to be tolerant to glyphosate or glufosinate, or conventionally bred to be tolerant to herbicides of the imidazolinone group. Seed losses at harvest averaged 3575 seeds m(-2) but ranged from less than 2000 up to more than 10000 seeds m(-2). There was a rapid decline in seed numbers during the first few months after harvest, resulting in a mean loss of seeds of 60%. In subsequent seasons, the seedbank declined much more slowly at four of the five sites (ca 20% per year) and the models predicted 95% seed loss after approximately 9 years. Seed decline was much faster at the fifth site. There were no clear differences between the four cultivars in either the numbers of seeds shed at harvest or in their subsequent persistence. The importance of the persistence of GM rape seeds, in the context of the coexistence of GM and non-GM crops and the role of good management practices that minimize seed persistence, are discussed.

Flow-injection analysis with fluorescence detection for the determination of trace levels of ammonium in seawater.

A method using flow-injection, gas-diffusion, derivatisation and then fluorescent detection has been established for ammonium ion determination in seawater. The fluorescent derivative formed by reacting ortho-phthaldialdehyde (OPA) and sulfite with ammonia gives high sensitivity while removing potential interferences. This is required to measure the low concentrations of ammonium often seen in the open ocean. The experimental conditions (flow-rate, reagent concentrations, membrane configurations, etc.) were manipulated to improve performance. For a sample throughput of 30 samples h(-1), the limit of detection was 7 nM, the coefficient of variation was 5.7% at 800 nM, and the calibration curve was linear to at least 4 micromol L(-1). Interferences were minimised by a gaseous diffusion step. Volatile small molecular-weight amines as interferents were discriminated against by this method. They neither passed through the membrane as efficiently as ammonia, nor reacted as readily with OPA when sulfite was the reductant. Contamination by ammonia from laboratory and shipboard sources complicates application of the method to natural waters, especially measurement of low concentrations (<100 nM) in open-ocean waters. Steps to overcome contamination are described in detail. Some results are presented for ammonium determination in Southern Ocean and Huon Estuary (Tasmania) waters.

Herbicidal action of 2-hydroxy-3-alkyl-1,4-naphthoquinones.

The main mode of herbicidal activity of 2-hydroxy-3-alkyl-1,4-naphthoquinones is shown to be inhibition of photosystem II (PSII). The herbicidal and in vitro activities have been measured and correlated with their (Log)octanol/water partition coefficients (Log Ko/w). The length of the 3-n-alkyl substituent for optimal activity differed between herbicidal and in vitro activity. The maximum in vitro activity was given by the nonyl to dodecyl homologues (Log Ko/w between 6.54 and 8.12), whereas herbicidal activity peaked with the n-hexyl compound (Log Ko/w = 4.95). The effect of chain branching was also investigated using isomeric pentyl analogues substituted at position 3. All exhibited similar levels of in vitro activities but herbicidal activities differed, albeit moderately, with the exception of one analogue that was much less phytotoxic. Other modes of action were also investigated using two representative compounds. They did not show any activity on photosystem I or mitochondrial complex I, or generate toxic oxygen radicals by redox cycling reactions. Only moderate activity was found against mitochondrial complex III from plants, in contrast to much higher corresponding activity using an insect enzyme.