Self-perceived role and knowledge of community pharmacists in organ donation.

BACKGROUND: Although a majority of North Americans is in favor of organ donation, registration remains challenging. Community pharmacists are highly accessible frontline health care professionals that could contribute to a new common registration donation consent system. AIM: The objective of the study was to assess self-perceived professional role and organ donation knowledge of community pharmacists in Quebec. METHOD: We designed a telephone interview survey using a three round modified Delphi process. Following questionnaires testing, we randomly sampled 329 community pharmacists in Quebec. Following administration, we validated the questionnaire by conducting an exploratory factorial analysis using principal component followed by a varimax rotation and rearranging domains and items accordingly. RESULTS: A total of 443 pharmacists were contacted, 329 provided answers to the self-perception role and 216 of them completed the knowledge questionnaire. Overall, community pharmacists of Quebec had a positive view on organ donation and demonstrated interest in acquiring knowledge. Respondents have identified lack of time and high pharmacy attendance as non-limiting barriers to implementing the intervention. The average score on the knowledge questionnaire was 61.2%. CONCLUSION: With the implementation of an appropriate education program to address this knowledge gap, we believe that community pharmacists could be key players in registered organ donation consent.

SIBAT-A Computerized Assessment Tool for Suicide Ideation and Behavior: Development and Psychometric Properties.

Objective: Most assessments of suicidal ideation and behavior (SIB) are limited by reliance on a single assessor, typically a clinician or patient, with scant detail on patient-related drivers of SIB and inability to detect rapid change in SIB. Furthermore, many techniques do not include a semistructured interview, increasing rater variability. The Suicide Ideation and Behavior Assessment Tool (SIBAT) addresses these limitations. Design: More than 30 experts in scale development, statistics, and clinical management of suicidal patients collaborated over a greater than four-year period to develop the SIBAT. Input for content and validity was received from patients, clinicians, and regulatory authorities in the United States (US) and Europe. Psychometric properties of the SIBAT were evaluated in validation studies. Results: The SIBAT is organized into eight independent patient- or clinician-rated modules with branching logic and scoring algorithms, which necessitates computerization. Patient-reported information is first captured in Modules 1 to 5. Thereafter, an experienced clinician reviews the patient's report, conducts a semistructured interview (Module 6), and assesses the patient's suicide risk (Module 7) and optimal antisuicide management (Module 8). Input from cognitive interviews of diverse adult, adolescent, and clinician participants was incorporated into the final version of the SIBAT. Psychometric testing demonstrated good inter-rater reliability (intraclass coefficient range: 0.68-0.82), intra-rater reliability (weighted-kappa range: 0.64-0.76), and concurrent validity with other instruments for assessing SIB. Conclusion: Patient- and clinician-based assessments and the psychometric studies summarized in this report support the validity and reliability of the SIBAT for capturing critical information related to assessment of SIB in adolescents and adults at risk for suicide.

Pupil Light Reflex for the Assessment of Analgesia in Critically Ill Sedated Patients With Traumatic Brain Injury: A Preliminary Study.

ABSTRACT: BACKGROUND: Analgesia monitoring is essential to preserve comfort in critically ill sedated patients with traumatic brain injury (TBI). Although pupil dilation (PD) and pain behaviors can be used to assess analgesia, these indicators require application of noxious stimulations for elicitation. Recently, the pupillary light reflex (PLR) has emerged as a nonnoxious parameter that may be used to predict analgesia requirements in non-brain-injured patients. Here, we explored whether PLR can be used for the purpose of analgesia monitoring in critically ill sedated TBI patients. METHODS: Fifteen mechanically ventilated TBI patients (11 men; 54 ± 20 years) under continuous analgesia and sedation infusions were assessed at predefined time within 72 hours of intensive care unit admission. Data collection was performed using video-pupillometry and the Behavioral Pain Scale. At each assessment, pupil size and PLR at rest were recorded followed immediately by the documentation of PD and pain behaviors elicited by a calibrated noxious stimulus. Blood concentrations of analgesics/sedatives were monitored. RESULTS: One hundred three assessments were completed. PLR resulted in an average decrease of 19% in pupil diameter, and PD resulted in an average increase of 10% in pupil diameter. Variations in PLR and PD were more pronounced in subjects who showed a Behavioral Pain Scale score greater than 3 (a recognized sign of subanalgesia) compared with those with no behavioral reaction. Multiple regression analyses suggest a significant overlap between fluctuations in pupillary reflexes and blood levels of fentanyl, not propofol. CONCLUSION: In our sample, percentages of variation in PLR and PD were found to be directly representative of TBI patients' fentanyl blood concentration. Considering information about blood drug concentration is generally not available at bedside, PLR could be used as a proxy to assess analgesia requirements before a nociceptive procedure in critically ill sedated TBI patients who are vulnerable to stress.

Determinants of pain assessment documentation in intensive care units.

PURPOSE: The underassessment of pain is a major barrier to effective pain management, and the lack of pain assessment documentation has been associated with negative patient outcomes. This study aimed to 1) describe the contextual factors related to pain assessment and management in five Québec intensive care units (ICUs); 2) describe their pain assessment documentation practices; and 3) identify sociodemographic and clinical determinants related to pain assessment documentation. METHODS: A descriptive-correlational retrospective design was used. Sociodemographic data (i.e., age, sex), clinical data (i.e., diagnosis, mechanical ventilation, level of consciousness, severity of illness, opioids, sedatives), and pain assessments were extracted from 345 medical charts of ICU admissions from five teaching hospitals between 2017 and 2019. Descriptive statistics and multiple linear regression were performed. RESULTS: All sites reported using the 0-10 numeric rating scale, but the implementation of a behavioural pain scale was variable across sites. A median of three documented pain assessments were performed per 24 hr, which is below the minimal recommendation of eight to 12 pain assessments per 24 hr. Overall, pain assessment was present in 70% of charts, but only 20% of opioid doses were followed by documented pain reassessment within one hour post-administration. Higher level of consciousness (ß = 0.37), using only breakthrough doses (ß = 0.24), and lower opioid doses (ß = -0.21) were significant determinants of pain assessment documentation (adjusted R2 = 0.25). CONCLUSION: Pain assessment documentation is suboptimal in ICUs, especially for patients unable to self-report or those receiving higher opioid doses. Study findings highlight the need to implement tools to optimize pain assessment and documentation.

RéSUMé: OBJECTIF: La sous-évaluation de la douleur constitue un obstacle majeur à une gestion efficace de la douleur, et le manque de documentation de l'évaluation de la douleur a été associé à des conséquences défavorables pour les patients. Cette étude visait à : 1) décrire les facteurs contextuels liés à l'évaluation et à la gestion de la douleur dans cinq unités de soins intensifs (USI) du Québec; 2) décrire leurs pratiques de documentation de l'évaluation de la douleur; et 3) identifier les déterminants sociodémographiques et cliniques liés à la documentation de l'évaluation de la douleur. MéTHODE: Un devis de recherche rétrospectif descriptif-corrélationnel a été utilisé. Les données sociodémographiques (c.-à-d. l'âge, le sexe), les données cliniques (c.-à-d. le diagnostic, la ventilation mécanique, le niveau de conscience, la gravité de la maladie, les opioïdes, les sédatifs) et les évaluations de la douleur ont été extraites de 345 dossiers médicaux avec admissions à l'USI de cinq hôpitaux universitaires entre 2017 et 2019. Des statistiques descriptives et une régression linéaire multiple ont été effectuées. RéSULTATS: Tous les sites ont déclaré utiliser l'échelle d'évaluation numérique de 0 à 10, mais l'implantation d'une échelle de douleur comportementale variait d'un site à un autre. Une médiane de trois évaluations de douleur étaient documentées par 24 heures, ce qui est inférieur à la recommandation minimale de huit à 12 évaluations de douleur par 24 heures. Dans l'ensemble, l'évaluation de la douleur était présente dans 70 % des dossiers, mais seulement 20 % des doses d'opioïdes étaient suivies d'une réévaluation documentée de la douleur dans l'heure suivant leur'administration. Un niveau de conscience plus élevé (ß = 0,37), l'utilisation exclusive d'entredoses d'opioïdes pour les percées de douleur (ß = 0,24) et des doses d'opioïdes plus faibles (ß = -0,21) ont constitué les déterminants significatifs dans la documentation de l'évaluation de la douleur (R2 ajusté = 0,25). CONCLUSION: La documentation de l'évaluation de la douleur est sous-optimale dans les USI, en particulier pour les patients incapables de s'exprimer ou ceux qui reçoivent des doses plus élevées d'opioïdes. Les résultats de cette étude soulignent l'importance d'implanter des outils pour optimiser l'évaluation et la documentation de la douleur.

Synthesis and Assessment of Novel Probes for Imaging Tau Pathology in Transgenic Mouse and Rat Models.

Aggregated tau protein is a core pathology present in several neurodegenerative diseases. Therefore, the development and application of positron emission tomography (PET) imaging radiotracers that selectively bind to aggregated tau in fibril form is of importance in furthering the understanding of these disorders. While radiotracers used in human PET studies offer invaluable insight, radiotracers that are also capable of visualizing tau fibrils in animal models are important tools for translational research into these diseases. Herein, we report the synthesis and characterization of a novel library of compounds based on the phenyl/pyridinylbutadienylbenzothiazoles/benzothiazolium (PBB3) backbone developed for this application. From this library, we selected the compound LM229, which binds to recombinant tau fibrils with high affinity (Kd = 3.6 nM) and detects with high specificity (a) pathological 4R tau aggregates in living cultured neurons and mouse brain sections from transgenic human P301S tau mice, (b) truncated human 151-351 3R (SHR24) and 4R (SHR72) tau aggregates in transgenic rat brain sections, and (c) tau neurofibrillary tangles in brain sections from Alzheimer's disease (3R/4R tau) and progressive supranuclear palsy (4R tau). With LM229 also shown to cross the blood-brain barrier in vivo and its effective radiolabeling with the radioisotope carbon-11, we have established a novel platform for PET translational studies using rodent transgenic tau models.

Suicide Ideation and Behavior Assessment Tool (SIBAT): Evaluation of Intra- and Inter-Rater Reliability, Validity, and Mapping to Columbia Classification Algorithm of Suicide Assessment.

The psychometric properties of the Suicide Ideation and Behavior Assessment Tool (SIBAT) were evaluated in 130 participants with varying levels of suicidality. Inter- and intra-rater reliability were assessed for clinician-rated outcomes, including the revised Clinical Global Impressions (CGI) of severity of suicidality (CGI-SS-r). Concurrent validity of patient-reported modules with Patient-reported Outcomes Measurement Information System (PROMIS) depression scale and Sheehan-Suicidality Tracking Scale Clinically Meaningful Change Measure (S-STS CMCM), and concordance between Columbia Classification Algorithm of Suicide Assessment (C-CASA) mappings for SIBAT, S-STS CMCM and Columbia-Suicide Severity Rating Scale (C-SSRS) were assessed. 52/130 participants (mean [SD] age: 38.3 [17.77] years) consented for multiple interviews (C-CASA mappings: n=52; rater-reliability: n=25/52). SIBAT demonstrated good intra-rater reliability (weighted-kappa range:0.64-0.76; CGI-SS-r, 0.75) and adequate inter-rater reliability (ICC range:0.68-0.82; CGI-SS-r, 0.81). There were strong correlations between PROMIS depression scores and SIBAT Module 5 ratings (Spearman correlations, r=0.64-0.74) and moderate correlations (r=0.29-0.72) between S-STS CMCM and SIBAT Modules 2, 3 and 5 ratings. Moderate agreement was noted between SIBAT C-CASA mappings and corresponding mappings from S-STS CMCM (weighted kappa: 0.54) and C-SSRS (weighted kappa: 0.56). Thus, the SIBAT provided valid assessment of suicidal ideation and behavior that could be reliably rated and adequately mapped to the C-CASA.

It Takes a Village : Contending With Drug Shortages During Disasters.

Critical drug shortages have been widely documented during the coronavirus disease 2019 (COVID-19) pandemic, particularly for IV sedatives used to facilitate mechanical ventilation. Surges in volume of patients requiring mechanical ventilation coupled with prolonged ventilator days and the high sedative dosing requirements observed quickly led to the depletion of "just-in-time" inventories typically maintained by institutions. This manuscript describes drug shortages in the context of global, manufacturing, regional and institutional perspectives in times of a worldwide crisis such as a pandemic. We describe etiologic factors that lead to drug shortages including issues related to supply (eg, manufacturing difficulties, supply chain breakdowns) and variables that influence demand (eg, volatile prescribing practices, anecdotal or low-level data, hoarding). In addition, we describe methods to mitigate drug shortages as well as conservation strategies for sedatives, analgesics and neuromuscular blockers that could readily be applied at the bedside. The COVID-19 pandemic has accentuated the need for a coordinated, multi-pronged approach to optimize medication availability as individual or unilateral efforts are unlikely to be successful.

Validation of the Withdrawal Assessment Tool-1 in Adult Intensive Care Patients.

BACKGROUND: The Withdrawal Assessment Tool-1 (WAT-1) has been validated for assessing iatrogenic withdrawal syndrome in critically ill children receiving mechanical ventilation, but little is known about this syndrome in critically ill adults. OBJECTIVE: To evaluate the validity and reliability of the WAT-1 in critically ill adults. METHODS: A prospective, observational, open-cohort pilot study of critically ill adults receiving mechanical ventilation and regular administration of opioids for at least 72 hours. Patients were assessed for withdrawal twice daily on weekdays and once daily on weekends using the WAT-1 after an opioid weaning episode. The presence of iatrogenic withdrawal syndrome was evaluated once daily using modified Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria. All evaluations were blinded and performed independently. The criterion validity of the WAT-1 and the interrater reliability for WAT-1 and DSM-5 evaluations were determined. RESULTS: During 8 months, 52 adults (median age, 51.5 years) were enrolled. Eight patients (15%) had at least 1 positive assessment during their intensive care unit stay using the DSM-5, compared with 19 patients (37%) using the WAT-1. The overall sensitivity of the WAT-1 was 50%, and its specificity was 65.9%. Agreement between WAT-1 and DSM-5 assessments was poor (κ = 0.102). The interrater reliability for the WAT-1 was 89.1% and for the DSM-5 was 90.1%. CONCLUSION: Despite showing reliability, the WAT-1 is not a valid tool for assessing the presence of iatrogenic withdrawal syndrome in adults.

Development of Quality Indicators to Assess Oral Anticoagulant Management in Community Pharmacies for Patients with Atrial Fibrillation.

BACKGROUND: Few studies have evaluated the quality of oral anticoagulant management by community pharmacists. There is no complete set of quality indicators available for this purpose. OBJECTIVE: To develop a set of specific quality indicators to assess oral anticoagulant management by community pharmacists for patients with atrial fibrillation (AF). METHODS: Quality indicators were developed in 3 phases. In phase 1, potential quality indicators were generated based on clinical guidelines and a literature review. In phase 2, a modified RAND appropriateness method involving 2 rounds was implemented with 9 experts, who judged the appropriateness of quality indicators generated in phase 1 based on the extent to which they were accurate, based on evidence, relevant, representative of best practices, and measurable in community pharmacies. Phase 3 consisted of a feasibility assessment in 5 community pharmacies on 2 patients each. RESULTS: The final set included 38 quality indicators grouped into 6 categories: documentation (n = 29), risk assessment (n = 3), clinical control (n = 1), clinical follow-up (n = 15), choice of therapy (n = 11), and interaction management (n = 8). The quality indicators referred to process of care (n = 34), clinical outcomes (n = 2), or structure of care (n = 2). There were 24 quality indicators related to vitamin K antagonists (VKAs), and 17 were related to direct oral anticoagulants (DOACs). To assess quality indicators, a questionnaire was developed for completion by community pharmacists for each patient, which included 17 questions about VKA patients and 12 questions about DOAC patients. CONCLUSIONS: A first set of quality indicators is now available to assess the quality of oral anticoagulant management by community pharmacists for patients with AF. DISCLOSURES: This research was supported by the Réseau Québécois de recherche sur le médicament (RQRM); the Blueprint for Pharmacy in collaboration with Pfizer Canada; and the Cercle du Doyen of the Faculty of Pharmacy, University of Montreal. The study sponsors were not involved in the study design, data collection, data interpretation, the writing of the article, or the decision to submit the report for publication. Chartrand received a scholarship from the Fonds de Recherche du Québec en Santé (FRQ-S), the Réseau Québécois de recherche sur l'usage des médicaments with Pfizer, and the Faculty of Pharmacy, University of Montreal. Guénette holds a Junior-1 Clinician Researcher Award from the FRQ-S in partnership with the Société québécoise d'hypertension artérielle. Williamson holds a Junior-1 Career Award from the FRQ-S. Côté reported being a medical speaker for Bayer, Boehringer Ingelheim Canada, and Pfizer Canada. The other authors reported no conflicts of interest. Study concept and design were contributed by Lalonde, Chartrand, and Martin. Chartrand, Martin, and Lalonde collected the data, along with Brouillette, Côté, Huot, Landry, Martineau, Perreault, Williamson, and White-Guay. Data interpretation was performed by Chartrand, Gagnon, and Lalonde, along with Guénette and Martin. The manuscript was primarily written by Chartrand, along with Guénette and Lalonde, and revised by Chartrand, Guénette, and Lalonde, along with the other authors. A portion of this study's results was presented at the 4th RQRM Annual Meeting on September 22-23, 2014, in Orford, Quebec, Canada, in the form of an abstract, which was published in the Journal of Population Therapeutics and Clinical Pharmacology, 2014;21(2):e312.

Iatrogenic Opioid Withdrawal in Critically Ill Patients: A Review of Assessment Tools and Management.

OBJECTIVE: To (1) provide an overview of the epidemiology, clinical presentation, and risk factors of iatrogenic opioid withdrawal in critically ill patients and (2) conduct a literature review of assessment and management of iatrogenic opioid withdrawal in critically ill patients. DATA SOURCES: We searched MEDLINE (1946-June 2017), EMBASE (1974-June 2017), and CINAHL (1982-June 2017) with the terms opioid withdrawal, opioid, opiate, critical care, critically ill, assessment tool, scale, taper, weaning, and management. Reference list of identified literature was searched for additional references as well as www.clinicaltrials.gov . STUDY SELECTION AND DATA EXTRACTION: We restricted articles to those in English and dealing with humans. DATA SYNTHESIS: We identified 2 validated pediatric critically ill opioid withdrawal assessment tools: (1) Withdrawal Assessment Tool-Version 1 (WAT-1) and (2) Sophia Observation Withdrawal Symptoms Scale (SOS). Neither tool differentiated between opioid and benzodiazepine withdrawal. WAT-1 was evaluated in critically ill adults but not found to be valid. No other adult tool was identified. For management, we identified 5 randomized controlled trials, 2 prospective studies, and 2 systematic reviews. Most studies were small and only 2 studies utilized a validated assessment tool. Enteral methadone, α-2 agonists, and protocolized weaning were studied. CONCLUSION: We identified 2 validated assessment tools for pediatric intensive care unit patients; no valid tool for adults. Management strategies tested in small trials included methadone, α-2 agonists, and protocolized sedation/weaning. We challenge researchers to create validated tools assessing specifically for opioid withdrawal in critically ill children and adults to direct management.

Inter-rater Reliability Assessment of ASPECT-R: (A Study Pragmatic-Explanatory Characterization Tool-Rating).

OBJECTIVE: The increasing importance of real-world data for clinical and policy decision making is driving a need for close attention to the pragmatic versus explanatory features of trial designs. ASPECT-R (A Study Pragmatic-Explanatory Characterization Tool-Rating) is an instrument informed by the PRECIS tool, which was developed to assist researchers in designing trials that are more pragmatic or explanatory. ASPECT-R refined the PRECIS domains and includes a detailed anchored rating system. This analysis established the inter-rater reliability of ASPECT-R. DESIGN: Nine raters (identified from a convenience sample of persons knowledgeable about psychiatry clinical research/study design) received ASPECT-R training materials and 12 study publications. Selected studies assessed antipsychotic treatment in schizophrenia, were published in peer-reviewed journals, and represented a range of studies across a pragmatic-explanatory continuum as determined by authors (CB/LA). After completing training, raters reviewed the 12 studies and rated the study domains using ASPECT-R. Intraclass correlation coefficients were estimated for total and domain scores. Qualitative ratings then were assigned to describe the inter-rater reliability. RESULTS: ASPECT-R scores for the 12 studies were completed by seven raters. The ASPECT-R total score intraclass correlation coefficient was 0.87, corresponding to an excellent inter-rater reliability. Domain intraclass correlation coefficients ranged from 0.85 to 0.31, corresponding to excellent to poor inter-rater reliability. CONCLUSION: The inter-rater reliability of the ASPECT-R total score was excellent, with excellent to good inter-rater reliability for most domains. The fair to poor inter-rater reliability for two domains may reflect a need for improved domain definition, anchoring, or training materials. ASPECT-R can be used to help understand the pragmaticexplanatory nature of completed or planned trials.

Regional distribution of selective neuronal loss and microglial activation across the MCA territory after transient focal ischemia: quantitative versus semiquantitative systematic immunohistochemical assessment.

Histopathologic assessment in transient middle cerebral artery occlusion (MCAo) rodent models generally lacks comprehensiveness and exposes to interobserver bias. Here we compared a novel quantitative assessment of regional infarction, selective neuronal loss (SNL) and microglial activation (MA) across the MCA territory to a previously published semiquantitative visual protocol. NeuN and OX42 immunohistochemistry was applied after either 15 or 45 minutes distal MCAo to maximize SNL and infarction, respectively. Survival times varied from 28 to 60 days to cover potential biases such as delayed tissue shrinkage. Damage was assessed using a template of 44 cytoarchitectonic regions of interest (ROIs) mapped onto a subset of digitized coronal sections spanning the MCA territory. For each ROI were obtained a semiquantitative visually determined index of histopathologic changes (method 1), and lpsilateral/contralesional ratios of remaining neurons and activated microglia cell counts (method 2). There was excellent agreement between the two methods for 28-day survival for both MCAo durations, whereas method 2 more sensitively detected subtle SNL and MA at 45 days and 60 days after 15-minute MCAo. Thus the visual method is accurate for usual degrees of ischemic damage, but absolute cell quantification is superior to detect subtle changes and should therefore be preferred in brief MCAo models, although requires optimal staining quality.

Abuse, not financial incentive, predicts non-credible cognitive performance in patients with psychogenic non-epileptic seizures.

Participants with psychogenic non-epileptic seizures (PNES) who fail symptom validity testing (SVT) perform worse on neuropsychological testing than those who do not, consistent with results found in participants with different clinical presentations (e.g., mild traumatic brain injury). However, little is known about how variables typically associated with SVT failure in other populations (e.g., the presence of financial incentives, exaggerated report of psychopathology) correlate with SVT failure in participants with PNES. Likewise the relationship between SVT failure and reported abuse, one of the most frequently described demographic characteristics of the PNES population, has not been examined. We found that failure on the Word Memory Test (WMT) in 91 participants with PNES was strongly associated with reported abuse but, contrary to expectations, was not associated with the presence of financial incentives or severity of reported psychopathology. These results indicate that the factors driving WMT failure may differ significantly in participants with PNES in ways that are potentially clinically relevant.

Epidemiology and management of atrial fibrillation in medical and noncardiac surgical adult intensive care unit patients.

PURPOSE: The aim of the study was to describe the epidemiology and management of atrial fibrillation (AF) in noncardiac surgery critically ill patients in a retrospective, observational study at 3 mixed medical-surgical, university-affiliated intensive care units (ICUs). METHODS: Consecutive patients admitted during a 1-year period with any documentation of AF during ICU stay were identified. Demographic data, risk factors, interventions, and outcomes were collected from the medical record. RESULTS: A total of 3081 patients were admitted during the 1-year study period in which 348 consecutive patients (10.5%) had documented AF. Atrial fibrillation was of new onset in 139 patients (4.5%) and preexisting in 186 patients (6.0%). Hemodynamic instability developed in 37% and 10% of patients with new-onset AF and patients with preexisting AF, respectively. Most (73%) patients with new-onset AF had at least 1 modifiable risk factor. Pharmacologic rhythm conversion was attempted in 76% and 26% of patients with new-onset AF and patients with preexisting AF, respectively. Although initially successful in 87% of new-onset cases, 42% reverted back to AF. Electrical conversion was successful in 7 (27%) of 26 and 0 (0%) of 5 of patients with new-onset AF and patients with preexisting AF, respectively. In total, 18% and 62% of patients with new-onset AF and patients with preexisting AF, respectively, who survived to ICU discharge left the ICU in AF. CONCLUSIONS: Atrial fibrillation is common but transient in most ICU patients. Electrical cardioversion is often unsuccessful, and pharmacologic rhythm conversion is often only transiently effective. Modifiable risk factors are common among these patients. Future studies are needed to address the management of AF in the ICU.

Adaptive management of the Great Barrier Reef: a globally significant demonstration of the benefits of networks of marine reserves.

The Great Barrier Reef (GBR) provides a globally significant demonstration of the effectiveness of large-scale networks of marine reserves in contributing to integrated, adaptive management. Comprehensive review of available evidence shows major, rapid benefits of no-take areas for targeted fish and sharks, in both reef and nonreef habitats, with potential benefits for fisheries as well as biodiversity conservation. Large, mobile species like sharks benefit less than smaller, site-attached fish. Critically, reserves also appear to benefit overall ecosystem health and resilience: outbreaks of coral-eating, crown-of-thorns starfish appear less frequent on no-take reefs, which consequently have higher abundance of coral, the very foundation of reef ecosystems. Effective marine reserves require regular review of compliance: fish abundances in no-entry zones suggest that even no-take zones may be significantly depleted due to poaching. Spatial analyses comparing zoning with seabed biodiversity or dugong distributions illustrate significant benefits from application of best-practice conservation principles in data-poor situations. Increases in the marine reserve network in 2004 affected fishers, but preliminary economic analysis suggests considerable net benefits, in terms of protecting environmental and tourism values. Relative to the revenue generated by reef tourism, current expenditure on protection is minor. Recent implementation of an Outlook Report provides regular, formal review of environmental condition and management and links to policy responses, key aspects of adaptive management. Given the major threat posed by climate change, the expanded network of marine reserves provides a critical and cost-effective contribution to enhancing the resilience of the Great Barrier Reef.

Prevention of type 2 diabetes: risk status, clinic, and community.

Although the idea of preventing type 2 diabetes has been articulated since the discovery of insulin, only in the past decade have clinical trials demonstrated that diabetes can be prevented or delayed. These trials found lifestyle intervention reduces diabetes incidence by over 50% and is more efficacious than metformin. Evidence from prevention trials comes from persons with "pre-diabetes" in which blood glucose levels are elevated but not yet in the diabetes range. In normoglycemic persons, lifestyle or drug intervention has little impact on diabetes incidence. Prevention programs are often conducted outside the clinical sector where participants' glycemic status is usually unknown; these programs may include many normoglycemic participants, which greatly reduces cost-effectiveness. An economically sustainable system for diabetes prevention will require effective partnerships among the clinical sector, community-based lifestyle programs, and third-party payers to ensure that limited resources for diabetes prevention are focused on persons at high risk of diabetes.

Frequency of abnormal scores on the Neuropsychological Assessment Battery Screening Module (S-NAB) in a mixed neurological sample.

The Neuropsychological Assessment Battery (NAB; Stern & White, 2003; White & Stern, 2003) is a comprehensive, modular battery of tests comprised of the following six modules: (a) Screening, (b) Attention, (c) Language, (d) Memory, (e) Spatial, and (f) Executive Functions. The Screening Module is an abbreviated version of the full NAB. The purpose of this descriptive study was to present index and primary test score information for the Screening Module in a mixed sample of patients with known neurological conditions. Participants were 37 outpatients with clear evidence of neurological damage or disease. Performance decrements were found on the Attention Index, most notably on the Numbers and Letters tests. Decrements were also found on the Executive Functions Index, most notably on the Word Generation test. Somewhat surprisingly, patients performed well across most of the individual test scores. This mixed clinical sample showed less neuropsychological compromise than the clinical samples presented in the NAB manual.

Agreement between self-reports and medical records was only fair in a cross-sectional study of performance of annual eye examinations among adults with diabetes in managed care.

BACKGROUND: Despite consensus about the importance of measuring quality of diabetes care and the widespread use of self-reports and medical records to assess quality, little is known about the degree of agreement between these data sources. OBJECTIVES: To evaluate agreement between self-reported and medical record data on annual eye examinations and to identify factors associated with agreement. RESEARCH DESIGN AND SUBJECTS: Data from interviews and medical records were available for 8409 adults with diabetes who participated in the baseline round of the Translating Research Into Action for Diabetes (TRIAD) Study. MEASURES: Agreement between self-reports and medical records was evaluated as concordance and Cohen's kappa coefficient. RESULTS: Self-reports indicated a higher performance of annual dilated eye examinations than did medical records (75.9% vs. 38.8%). Concordance between the data sources was 57.9%. Agreement was only fair (kappa coefficient = 0.25; 95% confidence interval, 0.23-0.26). Nearly two-thirds (64.6%) of discordance was due to lack of evidence in the medical record to support self-reported performance of the procedure. After adjustment, agreement was most strongly related to health plan (chi = 977.9, df = 9; P < 0.0001), and remained significantly better for 3 of the 10 health plans (P < 0.00001) and for persons younger than 45 years of age (P = 0.00002). CONCLUSIONS: The low level of agreement between self-report and medical records suggests that many providers of diabetes care do not have easily available accurate information on the eye examination status of their patients.

Effect of BMI on lifetime risk for diabetes in the U.S.

OBJECTIVE: At birth, the lifetime risk of developing diabetes is one in three, but lifetime risks across BMI categories are unknown. We estimated BMI-specific lifetime diabetes risk in the U.S. for age-, sex-, and ethnicity-specific subgroups. RESEARCH DESIGN AND METHODS: National Health Interview Survey data (n = 780,694, 1997-2004) were used to estimate age-, race-, sex-, and BMI-specific prevalence and incidence of diabetes in 2004. U.S. Census Bureau age-, race-, and sex-specific population and mortality rate estimates for 2004 were combined with two previous studies of mortality to estimate diabetes- and BMI-specific mortality rates. These estimates were used in a Markov model to project lifetime risk of diagnosed diabetes by baseline age, race, sex, and BMI. RESULTS: Lifetime diabetes risk at 18 years of age increased from 7.6 to 70.3% between underweight and very obese men and from 12.2 to 74.4% for women. The lifetime risk difference was lower at older ages. At 65 years of age, compared with normal-weight male subjects, lifetime risk differences (percent) increased from 3.7 to 23.9 percentage points between overweight and very obese men and from 8.7 to 26.7 percentage points for women. The impact of BMI on diabetes duration also decreased with age. CONCLUSIONS: Overweight and especially obesity, particularly at younger ages, substantially increases lifetime risk of diagnosed diabetes, while their impact on diabetes risk, life expectancy, and diabetes duration diminishes with age.