Mixed-reality technology for clinical communication: objective assessment of the HoloLens 2 as a clinical communication device in a simulated on-call scenario.

OBJECTIVE: Specialty on-call clinicians cover large areas and complex workloads. This study aimed to assess clinical communication using the mixed-reality HoloLens 2 device within a simulated on-call scenario. METHOD: This study was structured as a randomised, within-participant, controlled study. Thirty ENT trainees used either the HoloLens 2 or a traditional telephone to communicate a clinical case to a consultant. The quality of the clinical communication was scored objectively and subjectively. RESULTS: Clinical communication using the HoloLens 2 scored statistically higher than telephone (n = 30) (11.9 of 15 vs 10.2 of 15; p = 0.001). Subjectively, consultants judged more communication episodes to be inadequate when using the telephone (7 of 30) versus the HoloLens 2 (0 of 30) (p = 0.01). Qualitative feedback indicates that the HoloLens 2 was easy to use and would add value during an on-call scenario with remote consultant supervision. CONCLUSION: This study demonstrated the benefit that mixed-reality devices, such as the HoloLens 2 can bring to clinical communication through increasing the accuracy of communication and confidence of the users.

An impact of agronomic practices of sustainable rice-wheat crop intensification on food security, economic adaptability, and environmental mitigation across eastern Indo-Gangetic Plains.

In the eastern Indo-Gangetic Plains (EIGP), conventional rice-wheat system has led to a decline in productivity, input-use efficiency, and profitability. To address these, a four-year field study was conducted to evaluate the performance of tillage and crop establishment (TCE) methods in rice-wheat-greengram rotation. The treatments included: 1) random puddled transplanted rice (RPTR) - conventional-till broadcast wheat (BCW) - zero-till greengram (ZTG); 2) line PTR (LPTR) - conventional-till drill sown wheat (CTW) - ZTG; 3) machine transplanted rice in puddled soil (CTMTR) - zero tillage wheat (ZTW) - ZTG; 4) machine transplanted rice in zero-till wet soil (ZTMTR) - ZTW - ZTG; 5) system of rice intensification (SRI) - system of wheat intensification (SWI) - ZTG; 6) direct-seeded rice (DSR) - ZTW - ZTG; and 7) zero-till DSR - ZTW - ZTG. During the initial two years, conventional rice system (PTR) recorded a 16.2 % higher rice grain yield than DSR system. Whereas in the fourth year, the rice yields under DSR and PTR were comparable. As compared to SRI/SWI, the average wheat yield in ZT system was significantly high, whereas in rice, SRI/SWI system was comparable with CT system. ZTW after non-puddled rice was at par to CTW after PTR. The ZT wheat produced 4.6 % more yield than CT system. DSR production system consumed 6.8 % less water compared to transplanted system. On the system basis, 10.8 % higher net returns were recorded with CA-based system compared to conventional system. The system energy productivity under CA-based production system was 14-36 % higher than PTR-based systems. CA-based system also led to 8-10 % lower global warming potential (GWP) than conventional methods. The current study indicated that as compared to conventional system, a significant gain in productivity, profitability and energy-use efficiency, and reduction in the environmental mitigation are possible with emerging alternative TCE methods. Long-term expansion and further refinement of these technologies in local areas need to be explored for the second green revolution.

Monte Carlo skin dose simulation in intraoperative radiotherapy of breast cancer using spherical applicators.

The relatively new treatment modality electronic intraoperative radiotherapy (IORT) is gaining popularity, irradiation being obtained within a surgically produced cavity being delivered via a low-energy x-ray source and spherical applicators, primarily for early stage breast cancer. Due to the spatially dramatic dose-rate fall off with radial distance from the source and effects related to changes in the beam quality of the low keV photon spectra, dosimetric account of the Intrabeam system is rather complex. Skin dose monitoring in IORT is important due to the high dose prescription per treatment fraction. In this study, modeling of the x-ray source and related applicators were performed using the Monte Carlo N-Particle transport code. The dosimetric characteristics of the model were validated against measured data obtained using an ionization chamber and EBT3 film as dosimeters. By using a simulated breast phantom, absorbed doses to the skin for different combinations of applicator size (1.5-5 cm) and treatment depth (0.5-3 cm) were calculated. Simulation results showed overdosing of the skin (>30% of prescribed dose) at a treatment depth of 0.5 cm using applicator sizes larger than 1.5 cm. Skin doses were significantly increased with applicator size, insofar as delivering 12 Gy (60% of the prescribed dose) to skin for the largest sized applicator (5 cm diameter) and treatment depth of 0.5 cm. It is concluded that the recommended 0.5-1 cm distance between the skin and applicator surface does not guarantee skin safety and skin dose is generally more significant in cases with the larger applicators. HIGHLIGHTS: • Intrabeam x-ray source and spherical applicators were simulated and skin dose was calculated. • Skin dose for constant skin to applicator distance strongly depends on applicator size. • Use of larger applicators generally results in higher skin dose. • The recommended 0.5-1 cm skin to applicator distance does not guarantee skin safety.

Biopsy of the posterior interosseous nerve: a low morbidity method for assessment of peripheral nerve disorders.

AIMS: The sural nerve is the commonest peripheral nerve biopsied to help in the diagnosis of peripheral neuropathy of unknown cause. However, associated complications limit its use. The aim was, as an alternative, to asses biopsy of the terminal branch of the posterior interosseous nerve (PIN) in the forearm. METHODS: PIN pathology was morphometrically quantified in 10 male patients with Type 2 diabetes and compared with six PIN biopsy specimens taken post mortem from male cadavers with no history of neuropathy or trauma. RESULTS: The PIN biopsy procedure provides a long (approximately 3 cm) mono- or bifascicular nerve biopsy with generous epineurial tissue and adjacent vessels. Our results show a significantly lower myelinated fibre density in subjects with diabetes [5782 (3332-9060)/mm(2)] compared with autopsy control material [9256 (6593-12,935)/mm(2), P < 0.007]. No postoperative discomfort or complications were encountered. CONCLUSIONS: A reduction in myelinated fibre density has previously been shown to be a clinically meaningful measure of neuropathy in diabetic patients. We demonstrate similar findings using the PIN biopsy. The PIN biopsy procedure fulfils the criteria for nerve biopsy and was well tolerated by the patients. It may be a possible alternative to sural nerve biopsy to allow for diagnosis of neuropathy.

Cost effectiveness of duloxetine in the treatment of diabetic peripheral neuropathic pain in the UK.

OBJECTIVE: The objective of this analysis was to evaluate the cost-effectiveness of duloxetine when considered as an additional treatment option for UK-based patients suffering from diabetic peripheral neuropathic pain. RESEARCH DESIGN AND METHODS: A decision-analytic model was used to represent the sequential management of patients with diabetic peripheral neuropathic pain. The standard UK treatment strategy was defined as first-line tricyclic antidepressants (amitriptyline), second-line anticonvulsants (gabapentin) and lastly an opioid-related treatment. The cost-effectiveness of duloxetine was evaluated as an additional first, second, third or fourth-line therapy over a 6-month treatment period for a cohort of 1000 patients. Treatment response was modelled based on changes from baseline pain severity using a standard 11-point pain scale (0-10); full response (>or= 50% change), partial response (30-49%) and no response (< 30%). The model was populated with efficacy and discontinuation data using indirect comparisons of treatment efficacy based on relative effects to a common placebo comparator. RESULTS: The second-line use of duloxetine resulted in cost savings of pound 77,071 for every 1000 treated patients, with an additional 29 patients achieving a full pain response when compared to standard UK treatment. Additional quality-adjusted life years (QALYs) were achieved at 1.88 QALYs per 1000 patients. CONCLUSIONS: This UK-based economic model suggests that second-line use of duloxetine is a beneficial and cost-effective treatment strategy for diabetic peripheral neuropathic pain.

Improving seizure control in dogs with refractory epilepsy using gabapentin as an adjunctive agent.

OBJECTIVE: To assess whether there is a change in seizure activity in dogs with refractory epilepsy that are receiving appropriate doses of phenobarbitone and/or potassium bromide, when gabapentin is added to the therapeutic regimen. DESIGN: A prospective study of 17 dogs with a refractory seizure disorder, 16 of which have idiopathic epilepsy. PROCEDURE: Patients were stabilised using phenobarbitone and/or potassium bromide to produce tolerable therapeutic serum concentrations and dosed additionally with gabapentin at 35 to 50 mg/kg/d (divided twice or three times daily) for 4 months. Owners recorded seizure activity and side effects during this period in a standardised diary. Patients underwent monthly physical examinations and venepuncture to assess selected serum biochemical analytes, as well as phenobarbitone and bromide concentrations. Patients were further monitored for long-term response to adjunctive gabapentin therapy. RESULTS: There was no significant decrease in the number of seizures over the study period for the entire cohort, however three dogs stopped seizuring completely. There was a significant increase in the number of patients who showed an increase in the interictal period (P > 0.001). Serum alkaline phosphatase activity and triglyceride concentrations were elevated at baseline. There were no significant changes in biochemical analytes during the course of the study period. Side effects observed initially on addition of gabapentin included sedation and hind limb ataxia. The former resolved spontaneously after a few days; the latter after a slight reduction in bromide dose. Long-term, a further two patients became seizure free and ten patients remained on gabapentin indefinitely. No long-term side effects have become apparent. CONCLUSION: Addition of gabapentin to phenobarbitone and/or potassium bromide increased the interictal period and shortened the post-seizure recovery in some canine epileptics. In some dogs, seizures were prevented completely, while in others there was an increase in interictal period. The short-half life of gabapentin has advantages for seizure control, however its present high cost may prohibit therapy in large dogs.

Prescription pattern of benzodiazepines for inpatients at a tertiary care university hospital in Pakistan.

OBJECTIVE: To determine the point prevalence of benzodiazepine prescriptions for inpatients at a tertiary care university hospital in Pakistan and to correlate it with prescription patterns of various specialties, indications and demographic variables of the patients. METHODS: This 24-hours point prevalence study was done at The Aga Khan University Hospital, Karachi. By convenient random sampling, 208 inpatients were interviewed. Patients' files were also studied to record the drugs administered. Data was entered into questionnaires and analyzed by SPSS 10.0. RESULTS: The point prevalence of the benzodiazepines was 21.2%. It was higher among males than females and among surgical than non-surgical patients. Midazolam was the most commonly used benzodiazepine, followed by Alprazolam and Lorazepam. Pre-anesthesia and psychiatric symptoms were the two most common indications. Oral route was used in 84% patients for drug administration and mean Valium equivalent dosage was 4.86 mg/day. Mean length of prescription was 3 days. Longer duration of hospitalization was a significant predictor of the requirement of benzodiazepine prescription (p-value = 0.020). CONCLUSION: Prescription pattern of benzodiazepines at a tertiary care university hospital is similar to that reported in the developed countries through monitoring at various levels by physicians, clinical pharmacist and nursing staff. Data regarding the prescription pattern of benzodiazepines is scarce, and it needs to be expanded to formulate clear guidelines regarding their prescription.

Small fiber neuropathy in diabetes: clinical consequence and assessment.

Recent findings have shed new light on the role of peripheral nerves in the skin and have established a modern concept of cutaneous neurobiology. There is bidirectional rather than unidirectional (conveying information from the periphery) signaling between central and peripheral nerves and the endocrine and immune systems. This interaction is mediated principally by cutaneous small nerve fibers and will influence a variety of physiologic and pathophysiologic functions central to wound healing, which include cellular development, growth, differentiation, immunity, vasoregulation, and leukocyte recruitment. Thus, disease of the small fibers in diabetic patients is frequent and may have a considerable impact on the predisposition and subsequent wound-healing response to foot ulceration. The authors review the basic pathophysiology, clinical consequences, and current methods to evaluate somatic and autonomic nerve fiber dysfunction and damage.

Assessment of the CASP4 fold recognition category.

We present the assessment of the CASP4 fold recognition category. The tasks we had to execute include the splitting of multidomain targets into single domains, the classification of target domains in terms of prediction categories, the numerical evaluation of predictions, the mapping of numerical scores to quality indices, the ranking of predictors, the selection of top-performing groups, and the analysis and critical discussion of the state of the art in this field. The 125 fold recognition groups were assessed by a total score that summarizes their performance over all targets and a quality score reflecting the average quality of the submitted models. Most of the top-performing groups achieved respectable results on both scores simultaneously. Several groups submitted models that were much closer to the respective target structures than any of the known folds in the Protein Data Bank. The CASP4 assessment included the automated servers of the parallel CAFASP experiment. For the total score, the highest rank achieved by a fully automated server is 12. Two thirds of the predictors have rather low scores.

What do adolescent girls experience when they visit family practitioners?

OBJECTIVE: To describe the experiences of 12- to 17-year-old girls when they visit general or family practitioners and to gain some understanding of how they relate to these caregivers. DESIGN: Qualitative analysis of the oral narratives of eight adolescent girls. SETTING: After-school community drop-in centre for youth in downtown Toronto. PARTICIPANTS: Eight adolescent girls between the ages of 12 and 17 years attending the drop-in centre. MAIN OUTCOME FINDINGS: Five themes emerged: adolescent girls feel more comfortable with female physicians, they feel uncomfortable during physical examinations, they would like doctors to explain medical issues, they would like doctors to be more like friends, and they want to be treated as teenagers by their doctors. CONCLUSIONS: This study was unique in its use of personal interviews with adolescent girls to understand the experiences they have had with family physicians. The themes indicated how family physicians could improve therapeutic relationships between themselves and their female adolescent patients.

Cryptococcosis in cats: clinical and mycological assessment of 29 cases and evaluation of treatment using orally administered fluconazole.

Twenty-nine cats with naturally occurring cryptococcosis were evaluated prior to commencing oral fluconazole therapy (25-100 mg every 12 h). Affected cats ranged from 2 to 15 years-of-age. Male cats (19; 66%) and Siamese cats (5; 21%) appeared to be over-represented in comparison to the hospital's cat population. Mycotic rhinitis was observed in 24 (83%) of the cases, although nasal cavity involvement was subtle in four animals. Disease of the skin and subcutaneous tissues was present in 15 cases (52%) and amongst these the nasal plane (seven cats) and bridge of the nose (seven cats) were most commonly involved. Primary infection of the central nervous system was not encountered, although one cat developed meningoencephalitis and optic neuritis as a sequel to longstanding nasal cavity disease. Antibodies against the feline immunodeficiency virus (FIV) were detected in eight cats (28%), and these cats tended to have advanced and/or disseminated disease. There was a tendency for cats to develop cryptococcosis during the Australian summer. Organisms were cultured from 27 cases. Cryptococcus neoformans var. neoformans was isolated from 21 cats, while C. neoformans var. gattii was identified in the remaining six. The response to oral fluconazole was excellent in this series, which included many cats with advanced, longstanding or disseminated disease. The fungal infection resolved in all but one advanced case which died after only 4 days of therapy. A dose of 50 mg per cat, given every 12 h, produced a consistently good response without side effects. Lower doses were effective in some cases, while 100 mg every 12 h was required to control the infection in one cat. Serum fluconazole levels obtained during chronic dosing (50 +/- 18 mg l-1, mean +/- SD; 50 mg per cat every 12 h) were highly variable (range 15-80 mg l-1). Concurrent FIV infection did not impart an unfavourable prognosis, although affected cats often required prolonged courses of therapy.

Who gets what? Utilization of health services in Indonesia.

An evaluation of health service utilization patterns was carried out in five rural districts and a number of urban areas in Indonesia. The study was part of a larger effort to develop economically-related information about the health care services. Utilization levels were then related to such selected population variables as distance from health facilities, insurance status and income. The annual contact rate, curative plus preventive, with all public sector facilities was found to be 0.8 per capita. The geographic catchment areas of the facilities were also found to be very limited. The insured population (civil servants and their families) used services about four times more frequently, on average, than did the rest of the population. In one provincial study, the top 9 per cent of income earners made up one-third of all hospital inpatients, one-half of all hospital outpatients, and one-quarter of all health centre visitors. The implications of these results for equity and efficiency are discussed.

Food: a priority for consumer protection in Asia and the Pacific Region.

Food is mankind's most basic need. A recent global survey revealed that the single most important problem in the world--in developed and developing countries alike--was the high cost of living, and of food, its major component. In a world where many are starving, undernourished, malnourished or suffering from deficiency diseases, the problems of food quality and safety must be given special attention. Many developed countries have already made food a priority and created effective systems of consumer protection for food. But a number of developing countries are still struggling with the best way to control food problems. This paper will deal primarily with food and consumer protection problems in Asia and the Pacific region, but the solutions offered are universal.