Reduction in T LCO and survival in a clinical population.

BACKGROUND: How best to express the level of transfer factor of the lung for carbon monoxide (T LCO) has not been properly explored. METHODS: We used the most recent clinical data from 13 829 patients (54% male; 10% non-European ancestry; median age 60.5 years, range 20-97 years; median survival 3.5 years, range 0-20 years) to determine how best to express T LCO function in terms of its relationship to survival. RESULTS: The proportion of subjects of non-European ancestry with Global Lung Function Initiative (GLI) T LCO z-scores above predicted was reduced, but was significantly increased between -1.5 and -3.5, suggesting the need for ethnicity-appropriate equations. Applying GLI forced vital capacity (FVC) ethnicity methodology to GLI T LCO z-scores removed this ethnic bias and was used for all subsequent analysis. T LCO z-scores using the GLI equations were compared with Miller's USA equations with median T LCO z-scores being -1.43 and -1.50 for GLI and Miller equations, respectively (interquartile range -2.8 to -0.3 and -2.4 to -0.7, respectively). GLI T LCO z-scores gave the best Cox regression model for predicting survival. A previously proposed six-tier grading system for level of lung function did not show much separation in survival risk in the less-severe grades. A new four-tier grading based on z-scores of -1.645, -3 and -5 showed better separation of risk with hazard ratio for all-cause mortality of 2.0, 3.4 and 6.6 with increasing severity. CONCLUSION: Applying GLI FVC ethnicity methodology to GLI T LCO predictions to remove ethnic bias together with a new four-tier z-score grading best relates T LCO function to survival.

End of life: Expert care and support, not physician-hastened death.

In legal physician-hastened death, a physician prescribes medication with the primary intent of causing the death of a willing terminally ill patient. This practice differs radically from palliative sedation, intended to relieve a patient's suffering rather than cause a patient's death. In this position paper, we argue that the practice of physician-hastened death is contrary to the interests of patients, their families, and the sound ethical practice of medicine. Therefore, the American Academy of Neurology should advise its members against this practice, as it had done until 2018.

Advocacy for International Family Planning: What Terminology Works?

Advocating for international family planning while avoiding miscommunications with politically and religiously conservative policy makers and the public requires care and clarity with language. We find that terms such as "international family planning" are well received when the meaning is clearly explained, such as "enabling couples to determine the number and timing of pregnancies, including the voluntary use of methods for preventing pregnancy - not including abortion - harmonious with their beliefs and values". Family planning also helps reduce abortions - a powerful message for conservative policy makers and the public. We concur with Dyer et al. (2016) that the messenger is important; we find that many of the most effective advocates are religious leaders and faith-based health providers from the Global South. They know and validate the importance of family planning for improving family health and reducing abortions in their communities. "Healthy timing and spacing of pregnancy" is positive language for policy makers, especially when describing the health impact for women and children. Universal access to contraceptive services is emerging as vital for family health and also to help achieve the Sustainable Development Goals (UN 2015). Language on international family planning will evolve, and clarity of meaning will be foundational for effective advocacy.

The role of the coordination defect (CD) in the structures of anion-deficient, fluorite-related compounds.

The various superstructure phases that occur with the anion-deficient compositions of binary oxides MO(2-x) with the fluorite structure as parent are explored here in terms of the original 'coordination defect' (or CD) concept in which each vacant oxygen site, □, is 'coordinated' by six O atoms thereby creating the octahedral 'structure-determining' entity [M(3.5)□O(6)]. It emerges that the structure and composition of each anion-deficient (polymorph) phase can be described in terms of crystallographic `motifs' which comprise sets of parallel coplanar polygons based on ½<210>(F) and ½<111>(F) CD linkages.

Using computer-based monitoring and intervention to prevent harmful combinations of antiretroviral drugs in the New York State AIDS Drug Assistance Program.

BACKGROUND: Despite the growing number of HIV-infected people and the acknowledged complexity of HIV therapy, there are no standard safeguards in the outpatient setting against dangerous antiretroviral (ARV) therapy combinations in the publicly financed arena. METHODS: Using quarterly pharmacy claims data from the New York State AIDS Drug Assistance Program, a three-phase approach was developed: The extent of contraindicated ARV combinations was ascertained; prescriber alerts were developed; and, finally, the reimbursement of contraindicated ARV combinations was blocked at pharmacy. ARV dosages, the number of ARV medications in a regimen, clinical adequacy of the regimen, medication claim denials, clinician adjudication, and subsequent clinician prescribing patterns were analyzed. RESULTS: For the 27-month study period (October 1, 2006-December 31, 2009), 112,383 ARV regimens involving 396,303 ARV medications for 25,463 unique recipients were individually analyzed. A total of 1,089 interventions occurred; denials and interventions increased per quarter from a baseline of 129 to 217 by the study's end. All contraindicated combinations referred for adjudication during the study were upheld. More than 88.3% (range, 87.1% to 89.9%) of regimens per quarter were consistent with effective ARV as promulgated by current guidelines. The targeted dissemination of ARV drug interaction safety alerts to previous prescribers of contraindicated combinations during the first year of the review curtailed the practice by 77.3%. CONCLUSION: A systems-level intervention can be used on a state level to reduce ARV contraindicated medication errors in the outpatient setting through a coordinated approach of prescriber clinical education and electronic pharmacy and billing systems and provides an effective safety and quality monitoring model.

Me, myself, and I: the rise of the modern self.

Moderated by Robert Hanna (University of Colorado), historians Gerald Izenberg (Washington University, St. Louis) and Jerrold Seigel (New York University), philosopher Raymond Martin (University of Maryland and Union College), and sociologist Norbert Wiley (University of Illinois) trace the evolution of the meaning of self from antiquity to the present and consider how the self described by classical philosophers matches the reality of what we know about ourselves from human experience and research.

Compounds with a 'stuffed' anti-bixbyite-type structure, analysed in terms of the Zintl-Klemm and coordination-defect concepts.

The bixbyite structure (Mn(2)O(3)) (Ia3) is often described as a distorted face-centered cubic (f.c.c.) array of Mn atoms, with O atoms occupying 3/4 of the tetrahedral holes. The empty M(4) tetrahedra are centred at 16c. In anti-bixbyite structures (Mg(3)N(2)), cation vacancies are centred in empty N(4) tetrahedra. If 16 hypothetical atoms were located at this site they would form the structure of gamma-Si. This means that anti-bixbyite structures are ideally prepared to accommodate Si(Ge) atoms at these holes. Several compounds (Li(3)AlN(2) and Li(3)ScN(2)) fully satisfy this expectation. They are really anti-bixbyites 'stuffed' with Al(Sc). The presence of these atoms in 16c is illuminated in the light of the extended Zintl-Klemm concept (EZKC) [Vegas & García-Baonza (2007). Acta Cryst. B63, 339-345], from which a compound would be the result of 'multiple resonance' pseudo-structures, emerging from electron transfers between any species pair (like or unlike atoms, cations or anions). The coordination-defect (CD) concept [Bevan & Martin (2008). J. Solid State Chem. 181, 2250-2259] is also consistent with the EZKC description of the pseudo-structures. A more profound insight into crystal structures is gained if one is not restricted to the contemplation of classical anions and cations in their conventional oxidation states.

Utilization of rehabilitation therapies by nursing home residents with MS at admission.

OBJECTIVE: To identify factors associated with the utilization of physical and occupational therapies by nursing home residents with multiple sclerosis (MS) at admission to the facility. DESIGN: The study analyzed 27,264 admission assessments for residents with MS recorded in the national Minimum Data Set (MDS) between June, 1998 and June, 2003. A multiple linear regression model was employed to analyze the MDS data. The total number of minutes of physical and occupational therapies provided are the dependent variables. Independent variables are demographic characteristics, payment source, behavioral symptoms, and a range of health-related characteristics. RESULTS: The use of physical and occupational therapies by residents with MS at admission to the nursing facility was significantly associated with payment source, controlling for other independent variables. CONCLUSIONS: When reimbursement is available these therapies are more likely to be prescribed or requested. Since provision of these rehabilitative services diminishes disability and handicap, expanded Medicaid coverage may reduce long term health care costs and also improve the quality of life.

Racial analyses of longer-stay nursing home residents with multiple sclerosis.

OBJECTIVES: Compare profiles of African Americans with multiple sclerosis (MS) to White residents with MS one year after admission to a nursing facility. METHODS: We used all admission assessments recorded in the national Minimum Data Set (MDS) from 1999 to 2001 as well as all MDS annual assessments recorded from 2000 to 2002. We matched admission assessments with first annual assessment for 3632 White residents with MS and 461 African-American residents with MS. RESULTS: African Americans with MS were admitted at a significantly younger age and with more aid to daily living (ADL) dependence and cognitive dysfunction than Whites with MS one year after admission. Despite significantly poorer physical performance, cognitive function, and more medical comorbidities, African Americans with MS did not receive significantly more therapies or medications than White residents with MS after one year in the facility. CONCLUSIONS: Basic differences in MS expression and progression in African Americans appear to have to do with both genetic and environmental factors. Further study will help to clarify the reasons for these differences.

Nursing home residents with multiple sclerosis and dementia compared to other multiple sclerosis residents.

Cognitive impairment may be a significant symptom in multiple sclerosis (MS), affecting about one half of MS patients in study samples similar to the general MS population. An interesting question is what role dementia, of any aetiology, plays in the cognitive ability of people with MS. The objective of this research is to learn more about nursing home residents with MS and dementia, identifying how they differ from other residents with MS. We developed profiles of MS residents with dementia using the Minimum Data Set and compared these profiles to other residents with MS. Nursing home residents with MS and dementia are admitted to nursing facilities at an older age and seem less likely to have physical impairments but more mood and behaviour problems than other MS residents at admission. A cortical variant of MS may be more prevalent than previously suspected and may be a factor responsible leading to nursing home admission in this subgroup of patients. Further clinical analysis of this subgroup would be necessary to support this contention.

Nursing home residents with multiple sclerosis: comparisons of African American residents to white residents at admission.

This research profiles African American residents with multiple sclerosis (MS) at admission to the nursing facility and compares them to profiles of white residents with MS using the Minimum Data Set (MDS). We analysed MDS admission assessments for 1367 African Americans with MS and 9294 whites with MS. African American residents with MS were significantly younger at admission than white residents with MS, with almost one half of these African Americans 50 years or younger compared to only one quarter of these whites. African American residents with MS were significantly more physically disabled and cognitively impaired at admission than white residents with MS. Although there were significant racial differences in disability, there were no significant racial differences among these MS residents in the use of various therapies provided by qualified therapists. These observed racial differences among MS residents in disease manifestations, severity, progression and disability are due to multiple variables and point out the need for more research. By combining discoveries from genetics, immunology, epidemiology and virology we can gain a better understanding of the complex pathophysiology of MS and develop more effective treatments and preventive measures. Our findings also indicate potential racial disparities in the use of MS-related care, illustrating that a greater outreach effort may be needed to evaluate and treat African Americans with MS.

Analyses of nursing home residents with multiple sclerosis at admission and one year after admission.

This research compares profiles of residents with multiple sclerosis (MS) at admission to the nursing facility with profiles of these same residents one year later using the Minimum Data Set (MDS) to determine how their health and care received changed after one year in the facility. We matched MDS admission assessments with their first annual assessment for 1309 residents with MS. These residents with MS demonstrated deterioration in cognitive performance, communication skills, motor performance and bladder/bowel continence after one year in the facility. However, the proportion of residents with urinary tract infections and the proportion of residents with pressure ulcers declined after one year. A significantly larger proportion of these MS residents had a diagnosis of depression one year after admission, with significantly increased use of antipsychotic and antidepressant medications but little and declining use of psychological therapy after one year in the facility. In addition, there was a significant decline after one year in the use of physical, occupational, and speech therapies. These longer stay residents with MS may benefit from support services directed toward mental health and increased use of physical, occupational and psychological therapies provided in the nursing facility.

Missed and mismanaged injuries of the spinal cord.

OBJECTIVE: The purpose of this study was to determine the incidence of missed and mismanaged injuries of the spinal cord, to identify factors contributing to a failure to recognize such injuries, and to assess the consequences of such failures. METHODS: Missed and mismanaged injuries were defined using previously validated statements. All medical records and radiographs of patients with acute traumatic spinal cord injury admitted to the Regional Spinal Cord Injury Unit in Sheffield, United Kingdom, over a period of 10 years from 1989 were evaluated. Patients with no neurologic deficits were excluded from the study. RESULTS: Of the 569 patients, the diagnosis of spinal cord injury was missed in 52 instances (9.1%). The patients were mismanaged in 34 instances, and the treatment offered to 30 was considered negligent. In 26 of 52 (50%), mismanagement resulted in neurologic deterioration. The study identified several factors that contributed to a failure to recognize a spinal cord injury. These include ambience and circumstances surrounding the injury, inadequate neurologic assessment, associated injuries, and radiographic errors. CONCLUSION: Despite a greater awareness of the potential for spinal injury after road traffic accidents, failure to recognize a spinal cord injury in the acute care setting appears to be increasing. Injuries are seldom missed because of an isolated cause, but rather because of a combination of several factors. Increased vigilance on the part of the primary care physicians and careful documentation may reduce allegations of medical negligence.