Pediatric emergency department physicians' perceptions of virtual mental health assessments for urgent needs.

PURPOSE: Pressures related to the COVID-19 pandemic have created the need to develop innovative ways to deliver mental health care, especially for urgent needs. After the launch of a pediatric Emergency Department (ED) Virtual Care service, we aimed to evaluate pediatric ED physicians' experiences with the use of ED virtual care for mental health assessments. METHODS: This mixed-methods study was conducted at a pediatric academic health center in Ontario, Canada. Pediatric ED physicians who conducted ED virtual mental health assessments from May to December 2020 were eligible. Participants completed a 22-question novel survey and were invited to participate in a focus group. Descriptive and thematic analyses were used to analyze the data. RESULTS: Twenty-nine physicians provided mental health services through the ED virtual care platform. Twenty-five physicians (86% response rate) completed the survey and 3 (10%) participated in a focus group. While many agreed that virtual care benefits patients (67%), key barriers identified included time constraints, lack of mental health clinician support, and uncertainty around the pediatric ED physicians' role in these types of assessments. Despite these barriers, physicians recognized the potential benefit of the ED virtual care service for mental health assessments and were largely amenable to improving this process should mental health support be available. CONCLUSIONS: While many physicians agreed that there is a potential benefit of the ED virtual care platform for urgent mental health assessments, time constraints and lack of confidence in providing satisfactory virtual mental health care with minimal mental health support limited its acceptability. These findings can inform the future implementation of mental health services using an innovative virtual ED platform.

RéSUMé: OBJECTIF: Les pressions liées à la pandémie de COVID-19 ont créé le besoin de développer des moyens innovants pour fournir des soins de santé mentale, en particulier pour les besoins urgents. Après le lancement d'un service de soins virtuels aux urgences pédiatriques, nous avons cherché à évaluer les expériences des médecins des urgences pédiatriques avec l'utilisation des soins virtuels aux urgences pour les évaluations de la santé mentale. MéTHODOLOGIE: Cette étude à méthodes mixtes a été menée dans un centre universitaire de santé pédiatrique en Ontario, au Canada. Les médecins pédiatriques qui ont effectué des évaluations virtuelles de la santé mentale aux urgences de mai à décembre 2020 étaient admissibles. Les participants ont rempli une enquête inédite de 22 questions et ont été invités à participer à un groupe de discussion. Des analyses descriptives et thématiques ont été utilisées pour analyser les données. RéSULTATS: Vingt-neuf médecins ont fourni des services de santé mentale par le biais de la plateforme de soins virtuels des urgences. Vingt-cinq médecins (taux de réponse de 86 %) ont répondu au sondage et trois (10 %) ont participé à un groupe de discussion. Si beaucoup s'accordent à dire que les soins virtuels sont bénéfiques pour les patients (67 %), les principaux obstacles identifiés sont les contraintes de temps, le manque de soutien des cliniciens en santé mentale et l'incertitude quant au rôle des urgentistes pédiatriques dans ces types d'évaluations. Malgré ces obstacles, les médecins ont reconnu l'avantage potentiel du service de soins virtuels de l'urgence pour les évaluations de la santé mentale et étaient largement disposés à améliorer ce processus si un soutien en santé mentale était disponible. CONCLUSIONS: Bien que de nombreux médecins s'accordent à dire que la plateforme de soins virtuels des urgences présente un avantage potentiel pour les évaluations urgentes de la santé mentale, les contraintes de temps et le manque de confiance dans la prestation de soins de santé mentale virtuels satisfaisants avec un soutien minimal en matière de santé mentale ont limité son acceptabilité. Ces résultats peuvent éclairer la mise en œuvre future des services de santé mentale à l'aide d'une plateforme virtuelle d'urgence innovante.

From pressure in the pipeline to accelerating ascension: a survey to understand professional experiences of and opportunities for Canadian women in the healthcare sector.

BACKGROUND: Much has been written about the state and persistent lack of progress regarding gender equity and the commonly referenced phenomenon of a 'leaking pipeline'. This framing focuses attention on the symptom of women leaving the workforce, rather than the well-documented contributing factors of hindered recognition, advancement, and financial opportunities. While attention shifts to identifying strategies and practices to address gender inequities, there is limited insight into the professional experiences of Canadian women, specifically in the female-dominated healthcare sector. METHODS: We conducted a survey of 420 women working across a range of roles within healthcare. Frequencies and descriptive statistics were calculated for each measure as appropriate. For each respondent, two composite Unconscious Bias (UCB) scores were created using a meaningful grouping approach. RESULTS: Our survey results highlight three key areas of focus to move from knowledge to action, including (1) identifying the resources, structural factors, and professional network elements that will enable a collective shift towards gender equity; (2) providing women with access to formal and informal opportunities to develop the strategic relational skills required for advancement; and (3) restructuring social environments to be more inclusive. Specifically, women identified that self-advocacy, confidence building, and negotiation skills were most important to support development and leadership advancement. CONCLUSIONS: These insights provide systems and organizations with practical actions they can take to support women in the health workforce amid a time of considerable workforce pressure.

Implementing routine communication about costs of cancer treatment: perspectives of providers, patients, and caregivers.

OBJECTIVES: Rising costs in oncology care often impact patients and families directly, making communication about costs and financial impacts of treatment crucial. Cost expenditures could offer opportunities for estimation and prediction, affording personalized conversations about financial impact. We sought to explore providers', patients', and caregivers' preferences towards implementing communication about cost, including when, how, and by whom such information might be provided. METHODS: We conducted semi-structured phone interviews with a diverse population including 12 oncology providers, 12 patients, and 8 patient caregivers (N = 32). The constant comparative method was used to identify mutually agreed upon themes. RESULTS: Participant groups differed in their concerns surrounding cost communication, namely whether they want to receive this information and how such information might impact provider and patient treatment decisions. All participants agreed that oncology providers should not be leading cost conversations. Patients and caregivers identified social workers or financial advisors as most equipped to communicate about cost. Participants emphasized timely cost conversations, ideally around the time of diagnosis. Participants favored various metrics of financial impact beyond overall costs of care including disability, days lost from work, and out-of-pocket expenses. CONCLUSION: Cost transparency should be incorporated into usual care; however, there are several challenges to making cost conversations a part of everyday practice. Patients and family members need resources related to cost to aid in decision-making and those delivering cost information should have competency in oncology, financial advisement, and patient-centered care.

Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer.

BACKGROUND: Robust data on patient-reported outcome measures comparing treatments for clinically localized prostate cancer are lacking. We investigated the effects of active monitoring, radical prostatectomy, and radical radiotherapy with hormones on patient-reported outcomes. METHODS: We compared patient-reported outcomes among 1643 men in the Prostate Testing for Cancer and Treatment (ProtecT) trial who completed questionnaires before diagnosis, at 6 and 12 months after randomization, and annually thereafter. Patients completed validated measures that assessed urinary, bowel, and sexual function and specific effects on quality of life, anxiety and depression, and general health. Cancer-related quality of life was assessed at 5 years. Complete 6-year data were analyzed according to the intention-to-treat principle. RESULTS: The rate of questionnaire completion during follow-up was higher than 85% for most measures. Of the three treatments, prostatectomy had the greatest negative effect on sexual function and urinary continence, and although there was some recovery, these outcomes remained worse in the prostatectomy group than in the other groups throughout the trial. The negative effect of radiotherapy on sexual function was greatest at 6 months, but sexual function then recovered somewhat and was stable thereafter; radiotherapy had little effect on urinary continence. Sexual and urinary function declined gradually in the active-monitoring group. Bowel function was worse in the radiotherapy group at 6 months than in the other groups but then recovered somewhat, except for the increasing frequency of bloody stools; bowel function was unchanged in the other groups. Urinary voiding and nocturia were worse in the radiotherapy group at 6 months but then mostly recovered and were similar to the other groups after 12 months. Effects on quality of life mirrored the reported changes in function. No significant differences were observed among the groups in measures of anxiety, depression, or general health-related or cancer-related quality of life. CONCLUSIONS: In this analysis of patient-reported outcomes after treatment for localized prostate cancer, patterns of severity, recovery, and decline in urinary, bowel, and sexual function and associated quality of life differed among the three groups. (Funded by the U.K. National Institute for Health Research Health Technology Assessment Program; ProtecT Current Controlled Trials number, ISRCTN20141297 ; ClinicalTrials.gov number, NCT02044172 .).

An assessment of the effect of contact time on cadmium phytoavailability in a pasture soil.

The length of time cadmium (Cd) is in contact with the soil has been recognised as a factor affecting phytoavailability, but the extent of this process is currently poorly understood. This study used isotopic dilution techniques (E and L values) to determine the effect of contact time on Cd phytoavailability from soil collected from a long-term phosphorus (P) fertiliser trial. Cadmium phytoavailability was determined in soil that was last fertilised with soluble Cd from P fertiliser 17 years prior to sampling (residual plots) and soil that received annual applications of P fertiliser until sampling (continuous plots). It was found that both E values and L values increased with P fertiliser (viz Cd) inputs and were significantly related to each other (r 2 = 0.82 P < 0.005). There was however no significant difference (P < 0.05) in the percentage of total Cd that was phytoavailable calculated using E values (E%) between the continuous (mean 51 %) and the residual plots (mean 51 %). There was also no significant difference (P < 0.05) in the percentage of total soil Cd that was phytoavailable calculated using L values (L%) between the continuous (mean 77 %) and residual plots (mean 87 %). These results suggest that despite Cd being in contact with the soil for 17 years, there was no difference in the size of the phytoavailable Cd pool compared to recent Cd inputs. This study should be repeated for other soil types and factored into any analysis for the long-term implications of ongoing Cd accumulation in soil on future landuse.

Optical projection tomography permits efficient assessment of infarct volume in the murine heart postmyocardial infarction.

The extent of infarct injury is a key determinant of structural and functional remodeling following myocardial infarction (MI). Infarct volume in experimental models of MI can be determined accurately by in vivo magnetic resonance imaging (MRI), but this is costly and not widely available. Experimental studies therefore commonly assess injury by histological analysis of sections sampled from the infarcted heart, an approach that is labor intensive, can be subjective, and does not fully assess the extent of injury. The present study aimed to assess the suitability of optical projection tomography (OPT) for identification of injured myocardium and for accurate and efficient assessment of infarct volume. Intact, perfusion-fixed, optically cleared hearts, collected from mice 7 days after induction of MI by coronary artery occlusion, were scanned by a tomograph for autofluorescence emission after UV excitation, generating >400 transaxial sections for reconstruction. Differential autofluorescence permitted discrimination between viable and injured myocardium and highlighted the heterogeneity within the infarct zone. Two-dimensional infarct areas derived from OPT imaging and Masson's trichrome staining of slices from the same heart were highly correlated (r(2) = 0.99, P < 0.0001). Infarct volume derived from reconstructed OPT sections correlated with volume derived from in vivo late gadolinium enhancement MRI (r(2) = 0.7608, P < 0.005). Tissue processing for OPT did not compromise subsequent immunohistochemical detection of endothelial cell and inflammatory cell markers. OPT is thus a nondestructive, efficient, and accurate approach for routine in vitro assessment of murine myocardial infarct volume.

Dipeptidyl-peptidase-4 inhibitors and pancreatic cancer: a cohort study.

AIM: To compare pancreatic cancer incidence and diagnostic evaluation among patients initiating dipeptidyl-peptidase-4 (DPP-4) inhibitor treatment with those initiating sulfonylureas (SU) and thiazolidinediones (TZD). METHODS: Medicare claims data were examined in a new-user active-comparator cohort study. Patients >65 years with no prescriptions for DPP-4 inhibitors, SU or TZD at baseline were included if they had at least two claims for the same drug within 180 days. Using an as-treated approach and propensity score-adjusted Cox models, we estimated the hazard ratios (HRs) and 95% confidence intervals (CIs) for pancreatic cancer. Diagnostic evaluations were compared using risk ratios. RESULTS: In the DPP-4 inhibitor versus SU comparison, there were 18 179 patients who initiated treatment with DPP-4 inhibitors, of whom 26 developed pancreatic cancer (interquartile range follow-up 5-18 months). In the DPP-4 inhibitor versus TZD comparison there were 29 366 people initiating DPP-4 inhibitor treatment and 52 of these developed pancreatic cancer. The risk of pancreatic cancer with DPP-4 inhibitor treatment was lower relative to SU treatment (HR: 0.6, CI: 0.4-0.9) and similar to TZD treatment (HR: 1.0, 95% CI: 0.7-1.4). After the first 6 months of follow-up were excluded to reduce the potential for reverse causality, the results were not altered. The probability of diagnostic evaluation after commencing DPP-4 inhibitor treatment (79.3%) was similar to that for TZD (74.1%, risk ratio 1.06, 95% CI: 1.05-1.07) and SU (74.6%) (risk ratio 1.06, 95% CI: 1.05-1.07). The probability of diagnostic evaluation before the index date (date of initiating treatment) was ∼80% for all cohorts. CONCLUSION: Although the present study was limited by sample size and the observed duration of treatment in the USA, our well-controlled population-based study suggests there is no higher short-term pancreatic cancer risk with DPP-4 inhibitor treatment relative to SU or TZD treatment.

Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial.

BACKGROUND/OBJECTIVES: Invasive procedures such as surgery cause immunosuppression, leading to increased risk of complications, infections and extended hospital stay. Emerging research around immune-enhancing nutrition supplements and their ability to reduce postoperative complications and reduce treatment costs is promising. This randomised controlled trial aims to examine the effect of preoperative immunonutrition supplementation on length of hospital stay (LOS), complications and treatment costs in both well-nourished and malnourished gastrointestinal surgery patients. SUBJECTS/METHODS: Ninety-five patients undergoing elective upper and lower gastrointestinal surgery were recruited. The treatment group (n=46) received a commercial immuno-enhancing supplement 5 days preoperatively. The control group (n=49) received no supplements. The primary outcome measure was LOS, and secondary outcome measures included complications and cost. RESULTS: A nonsignificant trend towards a shorter LOS within the treatment group was observed (7.1 ± 4.1 compared with 8.8 ± 6.5 days; P=0.11). For malnourished patients, this trend was greater with hospital stay reduced by 4 days (8.3 ± 3.5 vs 12.3 ± 9.5 days; P=0.21). Complications and unplanned intensive care admission rates were very low in both the groups. The average admission cost was reduced by AUD1576 in the treatment group compared with the control group (P=0.37). CONCLUSIONS: Preoperative immunonutrition therapy in gastrointestinal surgery has the potential to reduce the LOS and cost, with greater treatment benefit seen in malnourished patients; however, there is a need for additional research with greater patient numbers.

Use of colour duplex ultrasound as a first line surveillance tool following EVAR is associated with a reduction in cost without compromising accuracy.

INTRODUCTION: CT scanning remains the postoperative surveillance imaging modality of choice following EVAR. Concerns regarding cost, exposure to ionising radiation and intravenous contrast have led to a search for a less expensive, equally efficacious and safer method of monitoring EVAR patients after endograft deployment. This study evaluated the cost saving obtained if CDUS was employed as a first line surveillance tool following EVAR, as well as comparing the two entities in terms of efficacy. PATIENTS & METHODS: Postoperative surveillance CTs and CDUS scans in the 145 patients who have undergone EVAR from 1st June 2003 to 1st July 2010 were compared for the detection of endoleak and determination of residual sac size. RESULTS: Adopting a protocol where CDUS was employed as the first line surveillance tool following EVAR would result in a reduction in the number of postoperative CTs required in 2010 from 235 to 36. Based on 2010 costings, this would equate to an estimated reduction in expenditure from €117,500 to €34,915 a saving of €82,585. CDUS had a sensitivity of 100% and a specificity of 85% in the detection of endoleaks compared to CT. The positive predictive value was 28% and negative predictive value 100%. The Pearson Coefficient correlation of 0.96 indicates a large degree of correlation between CDUS and CT when measuring residual aneurysm size following EVAR. CONCLUSION: CDUS can replace CT as the first line surveillance tool following EVAR. This is associated with a significant reduction in the cost of surveillance without any loss of imaging accuracy.

Health needs assessment in a male prison in England.

OBJECTIVES: To assess the health needs of prisoners in a male category B prison in Bristol, England, to identify areas for improving health in the prison. STUDY DESIGN: Cross-sectional and qualitative. METHODS: Analysis of prisoners' self-reported health needs at reception and at a secondary health screen; prisoners' access to primary care, inpatients, mental health, sexual health and substance misuse services; and prescribed medications. Random selection of prisoners for interviews. Focus groups and interviews with staff and stakeholders. RESULTS: 18 prisoners were interviewed (29% of those randomly selected), five focus groups were held with staff and stakeholders involved in health care provision in the prison and four interviews were held with staff and stakeholders. The areas of greatest health needs were identified as dental care, mental health and substance misuse. Prisoners and staff generally reported good access to most health care staff, provision of prescribed medication, bloodborne virus vaccination and treatment of substance misuse. Twenty nine recommendations were identified with five high-priority areas for improvement including an urgent review of dental services; stronger joint commissioning arrangements for health and social care; installing an integrated IT system; prevention of disease and health promotion; better use of the voluntary sector. A detailed action plan was developed to address all the recommendations and this has formed the basis of a programme of ongoing quality improvement work which is monitored by the Prison Partnership Board. Progress has been made against all key areas. CONCLUSIONS: The mixed methodology which involved analysis of health data and talking to a wide group of stakeholders, including prisoners, helped triangulate the data. The process of undertaking the health needs assessment shifted the focus from 'health care' to 'health'. This has facilitated a significant reframing of the concepts of 'health' and 'health need' with ongoing work now focused on the prison as a whole system, not merely on the provision of health care within the prison. Many improvements have already been made in response to the assessment.

Quality defects in market beef and dairy cows and bulls sold through livestock auction markets in the Western United States: II. Relative effects on selling price.

Relative effects of Beef Quality Assurance (BQA)-related defects in market beef and dairy cows and bulls on selling price at auction was evaluated during 2008. The presence and severity of 23 BQA-related traits were determined during sales in Idaho, California, and Utah. Overall, 18,949 unique lots consisting of 23,479 animals were assessed during 125 dairy sales and 79 beef sales. Mean sale price ± SD (per 45.5 kg) for market beef cows, beef bulls, dairy cows, and dairy bulls was $45.15 ± 9.42, $56.30 ± 9.21, $42.23 ± 12.26, and $55.10 ± 9.07, respectively. When combined, all recorded traits explained 36% of the variation in selling price in beef cows, 35% in beef bulls, 61% in dairy cows, and 56% in dairy bulls. Premiums and discounts were determined in comparison with a "par" or "base" animal. Compared with a base BCS 5 beef cow (on a 9-point beef scale), BCS 1 to 4 cows were discounted (P < 0.0001), whereas premiums (P < 0.05) were estimated for BCS 6 to 8. Compared with a base BCS 3.0 dairy cow (on a 5-point dairy scale), more body condition resulted in a premium (P ≤ 0.001), whereas a less-than-desirable BCS of 2.0 or 2.5 was discounted (P < 0.0001). Emaciated or near-emaciated cows (beef BCS 1 or 2; dairy BCS 1.0 or 1.5) were discounted (P < 0.0001). Compared with base cows weighing 545 to 635 kg, lighter BW beef cows were discounted (P < 0.0001), whereas heavier beef cows received (P < 0.05) a premium. Compared with a base dairy cow weighing 636 to 727 kg, lighter BW cows were discounted (P < 0.0001), whereas heavier cows (727 to 909 kg) received a premium (P < 0.01). Beef and dairy cows with any evidence of lameness were discounted (P < 0.0001). Presence of ocular neoplasia in the precancerous stage discounted (P = 0.05) beef cows and discounted (P < 0.01) dairy cows, whereas at the cancerous stage, it discounted (P < 0.0001) all cows. Hide color influenced (P < 0.0001) selling price in beef cattle but had no effect (P = 0.17) in dairy cows. Animals that were visibly sick were discounted (P < 0.0001). Results suggest that improving BCS and BW, which producers can do at the farm or ranch level, positively affects sale price. Furthermore, animals that are visibly sick or have a defect associated with a possible antibiotic risk will be discounted. Ultimately, animals with minor quality defects should be sold in a timely manner before the defect advances and the discount increases.

Survey of quality defects in market beef and dairy cows and bulls sold through livestock auction markets in the Western United States: I. Incidence rates.

A survey was conducted to quantify incidence of Beef Quality Assurance (BQA)-related defects in market beef and dairy cows and bulls selling at auction during 2 seasons in 2008. Twenty-three BQA-related traits were evaluated by 9 trained personnel during sales at 10 livestock auction markets in Idaho (n = 5; beef and dairy), California, (n = 4; dairy only), and Utah (n = 1; beef and dairy). Overall, 18,949 unique lots (8,213 beef cows, 1,036 beef bulls, 9,177 dairy cows, and 523 dairy bulls,) consisting of 23,479 animals (9,299 beef cows, 1,091 beef bulls, 12,429 dairy cows, and 660 dairy bulls) were evaluated during 125 sales (64 spring, 61 fall) for dairy and 79 sales (40 spring, 39 fall) for beef. The majority of market beef cows and bulls (60.9 and 71.3%, respectively) were predominantly black-hided, and the Holstein hide pattern was observed in 95.4 and 93.6% of market dairy cows and bulls, respectively. Market cattle weighed 548 ± 103.6 kg (beef cows), 751 ± 176.1 kg (beef bulls), 658 ± 129.7 kg (dairy cows), and 731 ± 150.8 kg (dairy bulls). Most beef cows (79.6%) weighed 455 to 726 kg, and most beef bulls (73.8%) weighed 545 to 954 kg, respectively. Among market beef cattle, 16.0% of cows and 14.5% of bulls weighed less than 455 and 545 kg, respectively, and 63.7% of dairy cows and 81.5% of dairy bulls weighed 545 to 817 kg or 545 to 954 kg, respectively. However, 19.5% of dairy cows and 13.1% of dairy bulls weighed less than 545 kg. Mean BCS for beef cattle (9-point scale) was 4.7 ± 1.2 (cows) and 5.3 ± 0.9 (bulls), and for dairy cattle (5-point scale) was 2.6 ± 0.8 (cows) and 2.9 ± 0.6 (bulls). Some 16.5% of beef cows and 4.1% of beef bulls had a BCS of 1 to 3, whereas 34.8% of dairy cows and 10.4% of dairy bulls had a BCS of 2 or less. Emaciation (beef BCS = 1, dairy BCS = 1.0) or near-emaciation (beef BCS = 2, dairy BCS = 1.5) was observed in 13.3% of dairy cows and 3.9% of beef cows. Among beef cattle, 15.1% of cows and 15.4% of bulls were considered lame. In contrast, 44.7% of dairy cows and 26.1% of dairy bulls were lame. Ocular neoplasia (cancer eye) was observed in only 0.6% of beef cows, 0.3% of beef bulls, 0.3% of dairy cows, and 0.0% of dairy bulls. However, among animals with ocular neoplasia, it was cancerous in 34.4% of beef bulls, 48.0% of dairy cows, and 73.3% of beef cows. In conclusion, numerous quality defects are present in market beef and dairy cattle selling at auction in the Western United States, which could influence their value at auction.

Cardiac risk assessment before the use of stimulant medications in children and youth: A joint position statement by the Canadian Paediatric Society, the Canadian Cardiovascular Society, and the Canadian Academy of Child and Adolescent Psychiatry.

Regulatory decisions and scientific statements regarding the management of attention-deficit hyperactivity disorder (ADHD) raise questions about the safety of medications and the appropriate pretreatment evaluation to determine suitability for treatment with medication. This is particularly true in the setting of known structural or functional heart disease. The present paper reviews the available data, including peer-reviewed literature, data from the United States Food and Drug Administration Web site on reported adverse reactions in children using stimulant medication, and Health Canada data on the same problem. A consensus-based guideline on appropriate assessment is provided, based on input from members of the Canadian Paediatric Society, the Canadian Cardiovascular Society and the Canadian Academy of Child and Adolescent Psychiatry, with specific expertise and knowledge in the areas of both ADHD and pediatric cardiology. The present statement advocates a thorough history and physical examination before starting stimulant medications, with an emphasis on the identification of risk factors for sudden death, but does not routinely recommend electrocardiographic screening or cardiac subspecialist consultation unless indicated by history or physical examination findings. A checklist for identifying children who are potentially at risk of sudden death (independent of ADHD or medications used to treat it) is provided. Although recommendations are based on the best evidence currently available, the committee further agrees that more research on this subject is necessary to optimize the approach to this common clinical scenario.

Cardiac risk assessment before the use of stimulant medications in children and youth.

Regulatory decisions and scientific statements regarding the management of attention-deficit hyperactivity disorder (ADHD) raise questions about the safety of medications and the appropriate pretreatment evaluation to determine suitability for treatment with medication. This is particularly true in the setting of known structural or functional heart disease. The present paper reviews the available data, including peer-reviewed literature, data from the United States Food and Drug Administration Web site on reported adverse reactions in children using stimulant medication, and Health Canada data on the same problem. A consensus-based guideline on appropriate assessment is provided, based on input from members of the Canadian Paediatric Society, the Canadian Cardiovascular Society and the Canadian Academy of Child and Adolescent Psychiatry, with specific expertise and knowledge in the areas of both ADHD and paediatric cardiology. The present statement advocates a thorough history and physical examination before starting stimulant medications, with an emphasis on the identification of risk factors for sudden death, but does not routinely recommend electrocardiographic screening or cardiac sub-specialist consultation unless indicated by history or physical examination findings. A checklist for identifying children who are potentially at risk of sudden death (independent of ADHD or medications used to treat it) is provided. Although recommendations are based on the best evidence currently available, the committee further agrees that more research on this subject is necessary to optimize the approach to this common clinical scenario.

Magnetic resonance imaging assessment of a sinus lift operation using reoxidised cellulose (Surgicel) as graft material.

Various materials have been used for bone grafts in the sinus lift operation, to increase the vertical bone height in the maxilla before the placement of dental implants in the atrophic maxilla. In this case history, Surgicel (oxidised regenerated cellulose) was used as a graft material for one patient, allowing successful delayed implant placement within new and existing bone. The sinus region was examined three months after grafting with Surgicel using magnetic resonance imaging (MRI). The MR images showed that material of similar MR signal to bone had formed within the graft. MRI allowed us to gain tomographic information of the region without exposure of the patient to ionising radiation. The formation of bone within the Surgicel matrix was confirmed at implant placement. This poses interesting questions as to the physiology of bone formation within non-particulate graft material, warranting further investigation.

Monte Carlo studies of model Langmuir monolayers.

This paper examines some of the basic properties of a model Langmuir monolayer, consisting of surfactant molecules deposited onto a water subphase. The surfactants are modeled as rigid rods composed of a head and tail segment of diameters sigma(hh) and sigma(tt), respectively. The tails consist of n(t) approximately 4-7 effective monomers representing methylene groups. These rigid rods interact via site-site Lennard-Jones potentials with different interaction parameters for the tail-tail, head-tail, and head-head interactions. In a previous paper, we studied the ground-state properties of this system using a Landau approach. In the present paper, Monte Carlo simulations were performed in the canonical ensemble to elucidate the finite-temperature behavior of this system. Simulation techniques, incorporating a system of dynamic filters, allow us to decrease CPU time with negligible statistical error. This paper focuses on several of the key parameters, such as density, head-tail diameter mismatch, and chain length, responsible for driving transitions from uniformly tilted to untilted phases and between different tilt-ordered phases. Upon varying the density of the system, with sigma(hh)=sigma(tt), we observe a transition from a tilted (NNN)-condensed phase to an untilted-liquid phase and, upon comparison with recent experiments with fatty acid-alcohol and fatty acid-ester mixtures [M. C. Shih, M. K. Durbin, A. Malik, P. Zschack, and P. Dutta, J. Chem. Phys. 101, 9132 (1994); E. Teer, C. M. Knobler, C. Lautz, S. Wurlitzer, J. Kildae, and T. M. Fischer, J. Chem. Phys. 106, 1913 (1997)], we identify this as the L'(2)/Ov-L1 phase boundary. By varying the head-tail diameter ratio, we observe a decrease in T(c) with increasing mismatch. However, as the chain length was increased we observed that the transition temperatures increased and differences in T(c) due to head-tail diameter mismatch were diminished. In most of the present research, the water was treated as a hard surface, whereby the surfactants are only allowed to move within the plane of this surface. However, we have also utilized a more realistic model for the surfactant-water interactions, developed by Karaborni and Toxvaerd, in order to examine the role which the coupled effects of head group size and head group-subphase interactions plays in determining tilt ordering and on the stability of the monolayer. It is found that increasing the head diameter results in a widening of the air-water interface and an associated destruction of orientational order. Furthermore, the onset of capillary waves at lower temperatures for larger head diameters implies that the L2-L1 phase boundary for acids and acetates should move to lower temperatures relative to the L'(2)/Ov-L1 phase boundary for alcohols and esters. This feature has yet to be seen in experimental studies.

Visual field loss after stroke: confrontation and perimetry in the assessment of recovery.

The purpose of this study was to examine the recovery of visual field deficits after first-ever stroke and to determine the accuracy of standard clinical assessment using oculokinetic perimetry. Of 148 patients with a hemisphere stroke and a normal conscious level, 75 (50.6%) were found to have a visual field deficit by clinical examination. Only 19 (11 women) stroke patients with visual field deficits were able to complete a perimetric examination within 1 week of their stroke. They were followed-up for a period of 12 weeks with serial clinical and perimetric examinations every 4 weeks. Clinical assessment of the patient failed to note further recovery after 4 weeks. By using oculokinetic perimetry, 8 (42.1%) patients recovered central vision but had a persistent peripheral field loss; maximal recovery of central vision was noted in the first 4 weeks. By using oculokinetic perimetry as the gold standard, the sensitivity of clinical assessment of visual field deficits was 94.4% on admission. The sensitivity fell to 55.5% during follow-up because of the clinicians' inability to detect central recovery by confrontation. The small numbers recruited show the difficult in recruiting acute stroke patients in measurements of recovery.