Active video games as an adjunct to pulmonary rehabilitation of patients with Chronic Obstructive Pulmonary Disease: a commentary on a systematic review.

Pulmonary rehabilitation is a key evidence-based intervention to improve the outcomes of people living with Chronic Obstructive Pulmonary Disease (COPD). However, there are challenges in delivering pulmonary rehabilitation including reduced referral rates and suboptimal uptake and completion rates. Active video game interventions, when used as an adjunct, may increase the adoption of and access to pulmonary rehabilitation. This commentary summarises and critically appraises a systematic review which investigated the effectiveness of active video games as a supplementary component in the pulmonary rehabilitation of individuals suffering from chronic obstructive pulmonary disease.

Towards estimating the carbon footprint of external beam radiotherapy.

PURPOSE: The National Health Service (NHS) in the United Kingdom (UK) is aiming to be carbon net zero by 2040 to help limit the dangerous effects of climate change. Radiotherapy contributes to this with potential sources quantified here. METHOD: Activity data for 42 patients from within the breast IMRT and prostate VMAT pathways were collected. Data for 20 prostate patients was also collected from 3 other centres to enable cross centre comparison. A process-based, bottom-up approach was used to calculate the carbon footprint. Additionally, patients were split into pre-COVID and COVID groups to assess the impact of protocol changes due to the pandemic. RESULTS: The calculated carbon footprint for prostate and breast pre-COVID were 148 kgCO2e and 101 kgCO2e respectively, and 226 kgCO2e and 75 kgCO2e respectively during COVID. The energy usage by the linac during treatment for a total course of radiotherapy for prostate treatments was 2-3 kWh and about 1 kWh for breast treatments. Patient travel made up the largest proportion (70-80%) of the calculated carbon footprint, with linac idle power second with âˆ¼ 10% and PPE and SF6 leakage were both between 2 and 4%. CONCLUSION: These initial findings highlight that the biggest contributor to the external beam radiotherapy carbon footprint was patient travel, which may motivate increased used of hypofractionation. Many assumptions and boundaries have been set on the data gathered, which limit the wider application of these results. However, they provide a useful foundation for future more comprehensive life cycle assessments.

Thyroid Cancer Risk Communication in Patients with Thyroid Nodules.

The objective of this study is to evaluate thyroid cancer risk clinician-patient communication among patients receiving usual counseling and counseling enhanced by a conversation aid. A secondary analysis of clinical visit recordings and post-visit surveys obtained during a trial assessing the impact of a conversation aid for patients with thyroid nodules was conducted. We assessed how thyroid cancer risk was communicated, different risk communication strategies between groups, and predictors of accurate cancer risk perception. Fifty-nine patients were analyzed. Most were women (90%) and middle-aged (median 57 years). A verbal description of thyroid cancer risk was present most frequently (83%) and was more frequent in the conversation aid than the usual care group (100% vs. 63%, p < 0.001). A numerical description using percentages was present in 41% of visits and was more frequent in the conversation aid group (59% vs. 19%, p = 0.012). Natural frequencies (7%) and positive/negative framing (10%) were utilized less commonly. Uncertainty about risks was not discussed. No predictors of accurate risk perception were identified. Clinicians most commonly present a verbal description of thyroid cancer risk. Less commonly, natural frequencies, negative/positive framing, or uncertainty is discussed. Clinicians caring for patients with thyroid nodules should be aware of different strategies for communicating thyroid cancer risk.

Patient feedback receiving care using a shared decision making tool for thyroid nodule evaluation-an observational study.

PURPOSE: To characterize the feedback of patients with thyroid nodules receiving care using a shared decision making (SDM) tool designed to improve conversations with their clinicians related to diagnostic options (e.g. thyroid biopsy, ultrasound surveillance). METHODS: Investigators qualitatively analyzed post-encounter interviews with patients to characterize their feedback of a SDM tool used during their clinical visits. Additionally, investigators counted instances of diagnostic choice awareness and of patients' expression of a diagnostic management preference in recordings of clinical encounters of adult patients presenting for evaluation of thyroid nodules in which the SDM tool was used. RESULTS: In total, 53 patients (42 (79%) women); median age 62 years were enrolled and had consultations supported by the SDM tool. Patients were favorable about the design of the SDM tool and its ability to convey information about options and support patient-clinician interactions. Patients identified opportunities to improve the tool through adding more content and improve its use in practice through training of clinicians in its use. There was evidence of diagnostic choice awareness in 52 (98%) of these visits and patients expressed a diagnostic management preference in 40 (76%). CONCLUSION: User centered design including feedback from patients and real life observation supports the use of the SDM tool to facilitate collaboration between patients and clinicians.

Meeting our students' educational needs during a global pandemic: Creating online clinical learning experiences.

The purpose of this paper is to describe the conversion of in-person simulations into online evolving case study activities in an undergraduate nursing curriculum as a result of COVID-19 precautions. The School of Nursing at Eastern Kentucky University utilized technological resources to provide meaningful online learning activities to meet student learning outcomes. The key teaching strategies to maintain were application and synthesis of knowledge through guided reflective activities and discussion. Interactive evolving case studies were selected with critical thinking questions and video clips to promote student engagement. The curricular concepts were medication administration, prioritization of patient care, communication, patient safety, and clinical judgment. Student and faculty evaluations were overwhelmingly positive, resulting in sustained use of these teaching strategies within the curriculum.

Bounded Cost Path Planning for Underwater Vehicles Assisted by a Time-Invariant Partitioned Flow Field Model.

A bounded cost path planning method is developed for underwater vehicles assisted by a data-driven flow modeling method. The modeled flow field is partitioned as a set of cells of piece-wise constant flow speed. A flow partition algorithm and a parameter estimation algorithm are proposed to learn the flow field structure and parameters with justified convergence. A bounded cost path planning algorithm is developed taking advantage of the partitioned flow model. An extended potential search method is proposed to determine the sequence of partitions that the optimal path crosses. The optimal path within each partition is then determined by solving a constrained optimization problem. Theoretical justification is provided for the proposed extended potential search method generating the optimal solution. The path planned has the highest probability to satisfy the bounded cost constraint. The performance of the algorithms is demonstrated with experimental and simulation results, which show that the proposed method is more computationally efficient than some of the existing methods.

Evaluation of Self-efficacy and Confidence Levels Among Newly Graduated Nurses Exposed to an End-of-Life Simulation: A Comparison Study.

Self-efficacy and confidence levels among newly graduated nurses who participated in an end-of-life simulation were compared with nurses who had been practicing for no more than a year but had not participated in an end-of-life simulation. The study included a pretest-and-posttest evaluation of an end-of-life simulation intervention during a new graduate residency program among newly graduated nurses to improve self-efficacy and confidence with end-of-life care. Nurses who had been in practice for no more than a year but had not been exposed to an end-of-life simulation intervention were also surveyed. The Palliative Care Evaluation Tool Kit was adapted and used for this project. The 2 groups of nurses were compared in terms of self-efficacy and confidence levels regarding end-of-life care. An end-of-life simulation intervention was successful in improving self-efficacy and confidence levels among newly graduated nurses, in regard to views about end of life and death and dying compared with the nurses who did not receive the end-of-life simulation intervention. The results of this study have implications for both schools of nursing and hospital training programs.

Prediabetes: A Worldwide Epidemic.

Prediabetes, defined by blood glucose levels between normal and diabetic levels, is increasing rapidly worldwide. This abnormal physiologic state reflects the rapidly changing access to high-calorie food and decreasing levels of physical activity occurring worldwide, with resultant obesity and metabolic consequences. This is particularly marked in developing countries. Prediabetes poses several threats; there is increased risk of developing type 2 diabetes mellitus (T2DM), and there are risks inherent to the prediabetes state, including microvascular and macrovascular disease. Studies have helped to elucidate the underlying pathophysiology of prediabetes and to establish the potential for treating prediabetes and preventing T2DM.

Effectiveness of Disposable (Single-use) Tips for Dental Air-water Syringes.

BACKGROUND: Single-use dental syringe (SUS) tips eliminate cross-infection risks. Many dental materials are moisture sensitive; therefore bonding could be affected by remaining moisture from SUS tips. METHODS: An air-water syringe was calibrated to 50 PSI and the air pressure measured. SUS tips were then attached and pressure re-measured. Seven tips were tested; moisture content and spray pattern were investigated. Ethical approval was granted. Twenty third molar teeth were sectioned, stored in phosphate buffered saline and randomly allocated into groups with a SUS tip. They were mounted in acrylic and polished. Specimens were dried with a tip under standardised conditions, treated using a 3-step etch-prime-bond technique, then had a post bonded perpendicular to the dentine surface. The force to detach them was measured. Data were analysed using one-way analysis of variance (ANOVA) and Chi-squared tests. RESULTS: The difference in output pressure between groups proved significant (p < 0.001). Tensile force at failure was significantly different between groups (p = 0.19). CONCLUSIONS: The pressure output of the syringe and bond strength are influenced by the SUS tip.

Generics, Supergenerics and Patent Strategies--SMi's 13th Annual Meeting.

SMi's 13th Annual Meeting on Generics, Supergenerics and Patent Strategies, held in London, included topics covering new trends in the generics field, the difficulties faced by companies in entering the generics market and recent developments in IP. This conference report highlights selected presentations on generics in India, protecting pharmaceutical products in China, changes in generics law and litigation in the US and Europe, challenges for market selection and entry for generics companies, the influence of changes in the healthcare market on the generics industry, supergenerics, and biosimilars.

99mTc-NC100692--a tracer for imaging vitronectin receptors associated with angiogenesis: a preclinical investigation.

INTRODUCTION: Technetium 99m (99mTc)-NC100692 is being developed as a marker of vitronectin receptor expression. The purpose of this study was to confirm the binding affinity [dissociation constant (Kd)] of 99mTc-NC100692 for a range of integrin receptors including alphavbeta3 and alphavbeta5 as well as to establish the biodistribution and metabolic stability of 99mTc-NC100692 in Wistar rats. METHODS: The Kd of 99mTc-NC100692 for a range of human integrin receptors was established in an in vitro saturation binding assay. The biodistribution and metabolic stability of 99mTc-NC100692 in normal Wistar rats was investigated. RESULTS: The Kd of 99mTc-NC100692 to alphavbeta3 and alphavbeta5 was less than 1 nM. It was not possible to saturate the binding of 99mTc-NC10092 towards alphaIIbbeta3, alpha5beta1, alpha3beta1 or alpha1beta1, and as a result, accurate Kd values could not be determined. The biodistribution of 99mTc-NC100692 in male and female Wistar rats showed that radioactivity was rapidly excreted, predominantly into the urine, with very little background tissue retention apart from the liver and kidneys. Kidney and liver retention was reduced in the presence of excess NC100692 ligand. In vivo, there was little systemic metabolism of 99mTc-NC100692. CONCLUSIONS: 99mTc-NC100692 has a high affinity for the vitronectin receptors that are associated with angiogenesis. 99mTc-NC100692 is metabolically stable in the systemic circulation of rats with a biodistribution that is favourable for imaging purposes. This evidence suggests that 99mTc-NC100692 might be a useful marker of vitronectin receptor expression in vivo.

Evaluation of a tool to benchmark hospital antibiotic prescribing in the United Kingdom.

OBJECTIVE: To investigate whether Defined Daily Dose/Finished Consultant Episode (DDD/FCE) ratio is sensitive to changes in prescribing patterns and could be used as a prescribing indicator in hospitals. METHOD: The study comprised two phases. In phase 1 the weekly DDD/FCE ratios for two antibiotics were calculated and monitored in one acute NHS hospital before and after the implementation of prescribing guidelines, which impacted on the use of the antibiotics. In phase 2 data on the use of four antibiotics over one year was collected from fifty-eight medium to large acute hospitals in England, together with corresponding FCE data. DDD/FCE ratios for each antibiotic in each hospital were compared. MAIN OUTCOME MEASURE: Whether the DDD/FCE ratio for two antibiotics changed in one hospital following the introduction of prescribing guidelines for these antibiotics. The variability in DDD/FCE ratio for two broad spectrum antibiotics compared to two narrow spectrum antibiotics across a number of acute hospitals in England. RESULTS: In phase 1 the DDD/FCE ratios for the two antibiotics were lower post implementation of the guidelines indicating that the ratio was sensitive to changes in prescribing. In phase 2 the median DDD/FCE ratios of the two broad spectrum antibiotics from all fifty eight hospitals were much higher (0.126, and 0.265) than for the two narrow spectrum antibiotics (0.048, and 0.021), indicating higher use of the broad spectrum antibiotics. Furthermore, the variation in prescribing between the hospitals, as indicated by the inter-quartile range about the median, was greater for the two broad spectrum agents (0.201 and 0.193), than for the narrow spectrum agents (0.06, and 0.042), as was expected. CONCLUSION: The DDD/FCE ratio is sensitive to changes in prescribing and can reflect differences in the use of antibiotics between hospitals, after accounting for differences in activity. DDD/FCE ratio has the potential to be used to also account for differences in case mix between hospitals although further work is needed in this area.

The biodistribution of NC100668 and the effect of excess NC100668 on the biodistribution and kidney retention of (99m)Tc-NC100668 in the rat.

INTRODUCTION: (99m)Tc-NC100668 is being developed to aid the diagnosis of thromboemboli. The purpose of this study was to investigate if the presence of excess NC100668 interferes with the biodistribution and blood clot uptake of (99m)Tc-NC100668. The secondary aim was to investigate the causes underlying the kidney retention of (99m)Tc-NC100668. METHODS: The uptake of a (14)C-labelled analogue of NC100668, as well as (99m)Tc-NC100668, into plasma (in vitro) and blood (in vivo) clots was determined. The biodistribution of (99m)Tc-NC100668 at a range of NC100668 doses was studied in normal Wistar rats and those bearing experimentally induced deep venous thrombosis. The biodistribution of a negative control peptide and (99m)Tc-NC100668 plus L-lysine was studied in healthy male Wistar rats. RESULTS: The biodistribution as well as plasma clot uptake of [Asn-U-(14)C]NC100668 and (99m)Tc-NC100668 was similar. Apart from some reduction in kidney retention, the biodistribution and uptake of radioactivity into the blood clot were not significantly affected by the presence of up to 1000 times the clinical dose of NC100668. Kidney retention of radioactivity could be more effectively reduced by coadministration of 889 microg/kg NC100668 than 450 mg/kg L-lysine. A negative control peptide with no affinity for FXIIIa demonstrated very little kidney retention. CONCLUSIONS: The biodistribution and blood clot uptake of (99m)Tc-NC100668 and [Asn-U-(14)C]NC100668 are similar. With the exception of the kidneys, (99m)Tc-NC100668 biodistribution and blood clot uptake are unaffected by the presence of unlabelled NC100668. The kidney retention of radioactivity is probably due to transglutaminase activity and, to a lesser extent, nonspecific charge-mediated endocytosis.

An 'overwhelming illness': women's experiences of learning to live with chronic fatigue syndrome/myalgic encephalomyelitis.

The processes through which people learn to live with CFS/ME are poorly understood and have not been rigorously explored within the literature. Semi-structured interviews were conducted with eight women and analysed using interpretative phenomenological analysis. Participants initially described being 'overwhelmed' by CFS/ME. Attempts at seeking help were unsatisfactory and participants described feeling let down and disbelieved. Participants reacted to this by identifying types of 'self-help' and assertively taking more responsibility for their illness and its treatment. Acquiring social support and greater knowledge were key mediating factors in the emergence of control and acceptance. The relevance of the themes to existing research and the implications for clinical practice are considered.

Bone mineral density in adolescent females using depot medroxyprogesterone acetate.

STUDY OBJECTIVE: To examine bone mineral density (BMD) on a semi-annual basis among control subjects and adolescent females receiving depot medroxyprogesterone acetate (DMPA) injection or oral contraceptives. DESIGN: Non-randomized prospective study. SETTING: Teenage pregnancy prevention intervention clinic. PARTICIPANTS: Adolescent females who were new users of DMPA injection (N=58, age 12-21) or the oral contraceptive pill (N=71, age 11-19) and normal menstruating girls (N=19, age 15-18). INTERVENTIONS: Baseline and 6-monthly measures of lumbar vertebral BMD using dual-energy X-ray absorptiometry over a 2-year period. MAIN OUTCOME MEASURES: comparison of percent change on BMD over time between DMPA users, pill users, and normal menstruating girls. RESULTS: There was no difference on group characteristics at baseline except for the ethnicity between the controls and the DMPA group. There was a statistically significant decrease in BMD between DMPA users and controls at 6 months (-3.02% change, P=0.014) 12 months (-3.38% change, P=0.001) 18 months (-4.81% change, P<0.001) and 24 months (-6.81% change, P=0.010). There was no statistical difference between pill users and controls. CONCLUSION: There is a relationship between DMPA use and a decrease in BMD compared to normal menstruating controls that seems to persist up to 24 months.

Epinephrine use by emergency medical technicians for presumed anaphylaxis.

OBJECTIVE: The use of epinephrine for the treatment of anaphylaxis by emergency medical technicians (EMTs) has not been rigorously evaluated. The aim of this study was to determine whether first-tier EMTs use epinephrine safely and appropriately for anaphylactic reactions. METHODS: The study used a case-control design. Cases were persons treated by EMTs with epinephrine for presumed anaphylaxis from January 1, 2000, through January 31, 2003, in King County, Washington (n = 22). Controls were emergency medical services (EMS)-treated persons matched to cases by diagnosis category, patient age, fire department, and year, but who had not been administered epinephrine by EMTs (n = 44). Cases and controls were compared with regard to history, symptoms, and examination characteristics. In a second assessment, physicians blinded to treatment (case/control) status reviewed events to determine whether they would have treated the patient with epinephrine RESULTS: When cases were compared with controls, cases were more likely to report a history of anaphylaxis (27% vs. 2%), upper airway symptoms (59% vs. 18%), and shortness of breath (77% vs. 27%). Cases were also more likely to have tachypnea (32% vs. 5%), hypotension (41% vs. 9%), decreased level of consciousness (32% vs. 2%), abnormal breath sounds (46% vs. 16%), and rash (50% vs. 23%) (p < or = 0.01 for all comparisons). The physicians agreed with the EMTs' decisions regarding epinephrine use (or nonuse) in 86% (57/66) of events: 86% (19/22) in which the EMTs used epinephrine and 86% (38/44) in which the EMTs did not use epinephrine. CONCLUSION: In this EMS system, the EMTs used epinephrine for presumed anaphylaxis in a discriminating manner that typically agreed with physician review.