The potential of virtual triage AI to improve early detection, care acuity alignment, and emergent care referral of life-threatening conditions.

Objective: To evaluate the extent to which patient-users reporting symptoms of five severe/acute conditions requiring emergency care to an AI-based virtual triage (VT) engine had no intention to get such care, and whose acuity perception was misaligned or decoupled from actual risk of life-threatening symptoms. Methods: A dataset of 3,022,882 VT interviews conducted over 16 months was evaluated to quantify and describe patient-users reporting symptoms of five potentially life-threatening conditions whose pre-triage healthcare intention was other than seeking urgent care, including myocardial infarction, stroke, asthma exacerbation, pneumonia, and pulmonary embolism. Results: Healthcare intent data was obtained for 12,101 VT patient-user interviews. Across all five conditions a weighted mean of 38.5% of individuals whose VT indicated a condition requiring emergency care had no pre-triage intent to consult a physician. Furthermore, 61.5% intending to possibly consult a physician had no intent to seek emergency medical care. After adjustment for 13% VT safety over-triage/referral to ED, a weighted mean of 33.5% of patient-users had no intent to seek professional care, and 53.5% had no intent to seek emergency care. Conclusion: AI-based VT may offer a vehicle for early detection and care acuity alignment of severe evolving pathology by engaging patients who believe their symptoms are not serious, and for accelerating care referral and delivery for life-threatening conditions where patient misunderstanding of risk, or indecision, causes care delay. A next step will be clinical confirmation that when decoupling of patient care intent from emergent care need occurs, VT can influence patient behavior to accelerate care engagement and/or emergency care dispatch and treatment to improve clinical outcomes.

A comparison of self and proxy quality of life ratings for people with dementia and their carers: a European prospective cohort study.

Objectives: To identify correlates of self-rated and proxy-rated quality of life (QoL) in people with dementia on (i) a dementia-specific and (ii) a capability-wellbeing QoL measure at baseline and 12-month follow-up, and to consider such factors in the context of QoL intervention development.Method: Prospective clinical and demographic data were collected from 451 community-dwelling dyads (mild-moderate dementia) across eight European countries. QoL was measured using the QOL-AD and the ICECAP-O. Multivariate modelling identified correlates of self- and proxy-rated QoL at baseline and at 12-month follow-up.Results: Carer's proxy-ratings of QoL were significantly lower than self-ratings at all time-points for both measures. Proxy-ratings declined over time, but self-ratings remained stable. Baseline predictors of greater self-rated QoL were education, and greater functional ability and relationship quality. Greater proxy-rated QoL was associated with education and greater functional ability, relationship quality, carer social support and carer QoL, lower carer anxiety/depression and less severe neuropsychiatric symptoms in people with dementia. At follow-up, greater self-rated QoL was predicted by greater functional ability, relationship quality, carer social support and having a spousal carer. Greater proxy-rated QoL at follow-up was associated with the same factors as at baseline; however, the dyad living together was an additional predictive factor.Conclusion: Both proxy-ratings and self-ratings of QoL should be interpreted with caution and in the context of each individual caregiving relationship. Different functional, psychosocial, relational and contextual factors influence self- and proxy-ratings, and both sets of factors should be considered in the context of QoL intervention development for the dyad.

Access to community care for people with dementia and their informal carers : Case vignettes for a European comparison of structures and common pathways to formal care.

BACKGROUND: People with dementia and their informal carers often do not receive appropriate professional support or it is not received at the right time. OBJECTIVES: Description and comparison of common pathways to formal community dementia care in eight European countries as a part of the transnational Actifcare project. MATERIALS AND METHODS: The German team was responsible for creating an individual case scenario as a starting point. The research teams in Ireland, Italy, the Netherlands, Norway, Portugal, Sweden, and the United Kingdom were then asked to describe a common pathway to formal dementia care by writing their own vignette using the provided individual case scenario. RESULTS: A transnational qualitative content analysis was used to identify the following categories as being the most important: involved professionals, dementia-specific and team-based approaches, proactive roles, and financial aspects. General practitioners (GPs) are described as being the most important profession supporting the access to formal care in all the involved countries. In some countries other professionals take over responsibility for the access procedure. Dementia-specific approaches are rarely part of standard care; team-based approaches have differing significances in each of the countries. Informal carers are mainly proactive in seeking formal care. The Nordic countries demonstrate how financial support enhances access to the professional system. CONCLUSION: Enhanced cooperation between GPs and other professions might optimize access to formal dementia care. Team-based approaches focusing on dementia care should be developed further. Informal carers should be supported and relieved in their role. Financial barriers remain which should be further investigated and reduced.

Cancer and quackery.

The Internal Medicine Journal published an article by two senior oncologists who were contesting the supposed miracle cure of a cancer survivor. This paper draws on the history of medicine to explore the conflict between biomedicine and alternative therapies. I suggest that the Internal Medicine Journal article, written about an episode that occurred more than 30 years ago, can best be explained by some oncologists' discomfort with losing their authority to dictate patient choices. I propose a compromise that rejects paternalism but accepts the possibility of worse patient outcomes.

A comparison of autoimmune liver disease in juvenile and adult populations with systemic lupus erythematosus-a retrospective review of cases.

OBJECTIVE: To compare the prevalence and type of autoimmune liver disease in adult and juvenile patients with systemic lupus erythematosus (SLE) in a large UK cohort. METHODS: A retrospective analysis was performed of patients attending the adult and juvenile lupus clinics at University College Hospital and Great Ormond Street Hospital, respectively, between January 1978 and December 2004. Patients with autoimmune liver disease were identified by searching an existing database (adults) and by case note review (juveniles). Histological diagnosis and autoantibody profile was noted and the time that had elapsed in months between the two diagnoses calculated. RESULTS: Of 377 adult patients and 92 juvenile patients, 5 and 9 respectively, had histologically confirmed autoimmune liver disease. This corresponds to a statistically significant (P < 0.001) greater prevalence in juvenile onset patients of 9.8% compared with 1.3% in adult patients. The juvenile patients were all positive for smooth muscle antibody and had histological changes consistent with autoimmune hepatitis. The adult patients had a variable antibody profile and one patient had histological changes consistent with primary biliary cirrhosis. In all of the juvenile patients, but notably in none of the adult patients, the liver disease predated the diagnosis of SLE (P < 0.001). CONCLUSIONS: Our study confirms that autoimmune liver disease occurs infrequently in adult lupus patients but should be considered in a patient with persistent liver enzyme abnormalities. However, in our study there is a significantly higher prevalence in juvenile lupus patients. This association is previously unreported.

Biomimetic evolutionary analysis: testing the adaptive value of vertebrate tail stiffness in autonomous swimming robots.

For early vertebrates, a long-standing hypothesis is that vertebrae evolved as a locomotor adaptation, stiffening the body axis and enhancing swimming performance. While supported by biomechanical data, this hypothesis has not been tested using an evolutionary approach. We did so by extending biomimetic evolutionary analysis (BEA), which builds physical simulations of extinct systems, to include use of autonomous robots as proxies of early vertebrates competing in a forage navigation task. Modeled after free-swimming larvae of sea squirts (Chordata, Urochordata), three robotic tadpoles (;Tadros'), each with a propulsive tail bearing a biomimetic notochord of variable spring stiffness, k (N m(-1)), searched for, oriented to, and orbited in two dimensions around a light source. Within each of ten generations, we selected for increased swimming speed, U (m s(-1)) and decreased time to the light source, t (s), average distance from the source, R (m) and wobble maneuvering, W (rad s(-2)). In software simulation, we coded two quantitative trait loci (QTL) that determine k: bending modulus, E (Nm(-2)) and length, L (m). Both QTL were mutated during replication, independently assorted during meiosis and, as haploid gametes, entered into the gene pool in proportion to parental fitness. After random mating created three new diploid genotypes, we fabricated three new offspring tails. In the presence of both selection and chance events (mutation, genetic drift), the phenotypic means of this small population evolved. The classic hypothesis was supported in that k was positively correlated (r(2)=0.40) with navigational prowess, NP, the dimensionless ratio of U to the product of R, t and W. However, the plausible adaptive scenario, even in this simplified system, is more complex, since the remaining variance in NP was correlated with the residuals of R and U taken with respect to k, suggesting that changes in k alone are insufficient to explain the evolution of NP.

Nurses' evaluations of sources of information about HIV and AIDS.

Reviews of the literature indicate that nurses feel ill-informed about HIV/AIDS and that poor knowledge is associated with anxiety and negative attitudes towards infected patients and their care. Although some studies have sought to identify the sources of HIV/AIDS information available to nurses, few have attempted to understand how nurses evaluate such sources. In this study in 1992, 15 sources of HIV/AIDS information were identified during group discussions with nursing staff and nurse tutors. 277 nursing staff evaluated each of the sources in terms of perceived frequency (how often the source is used) and six items chosen to assess the usability and usefulness of each source (e.g. how informative the source is, how easy it is to understand). The results indicate that in-service training, basic training and professional colleagues are the sources evaluated most highly while posters and advertisements, television and radio and popular newspapers are the most frequently used sources of information. Trades unions' journals and pamphlets are the least frequently used sources of information and receive only modest evaluations. 20% of respondents report never having received any training regarding HIV and AIDS. Implications for the future provision of HIV/AIDS information and directions for further research are discussed.

A measure of knowledge and confidence in relation to HIV and AIDS: reliability and validity.

Knowledge of HIV and AIDS is widely seen as an important determinant of anxiety about such infection in health care workers. However, existing measures of this knowledge suffer from a number of methodological problems and few demonstrate adequate reliability and validity. This paper documents the development of a new measure detailing its reliability and validity. Knowledge, and also confidence in knowledge, were assessed across seven domains of relevant information (e.g. epidemiology, personal risk, symptomatology) in one non-expert group (non-medical undergraduate psychologist) and in three groups with greater expertise (nursing students and third year and final year medical students). The measure was shown to be reliable and to discriminate between the four groups in a manner consistent with the level of education received by each group and in terms of both the scale scores for the seven domains and the individual items. In general, final year medical students were shown to be more knowledgeable, and more confident in their knowledge, than the other groups. The non-medical undergraduates showed the lowest level of knowledge. In general, the groups appeared under-confident in their knowledge about HIV/AIDS. This was interpreted in terms of members of these groups exhibiting caution and the perceived fluctuating nature of the HIV knowledge base. Implications for the training of health care workers in relation to HIV/AIDS are discussed.

Unusual presentation of malaria as a leukaemoid reaction. A case report.

In a 4-year-old black patient with Plasmodium falciparum malaria the diagnosis was established by observing plentiful gametocytes in the peripheral blood, although ring forms were very scanty. The blood picture was that of a leukaemoid reaction with severe anaemia, high total leucocyte count and thrombocytosis. Treatment with chloroquine and primaquine, together with packed red cell transfusions, was successful in eliminating both the malaria parasites and the leukaemoid blood picture. The rarity of malaria presenting as a leukaemoid blood picture is discussed.

Asbestos exposures in Massachusetts public schools.

A Massachusetts legislative commission was established to investigate the potential health hazards associated with the use of sprayed-on asbestos in public school buildings. All schools built, renovated, or added onto from 1946 to 1973 were surveyed. Sprayed-on materials from the public areas of these schools were analyzed for asbestos content. Air samples were collected from 173 schools positively identified for asbestos. Most of the air sampling results were below the predetermined background noise level of 0.04 fibers per cc. It was concluded that it is not possible to quantify public exposures to asbestos because of the limitations of air sampling technology. A rating system was devised which generated a single number known as the Ferris Index which reflected the sprayed-on material's degree of potential health hazard. Data from five predictor variables were incorporated in this index. Although sprayed-on asbestos was present in 12 percent of the surveyed schools, only 3 percent required long-term control recommendations.

Acceleration of the rate of deamidation of GlyArgAsnArgGly and of human transferrin by addition of L-ascorbic acid.

Experiments on the model peptide, GlyArgAsnArgGly, and the protein, human transferrin, have shown that hydrolytic deamidation of these molecules is markedly accelerated by addition of physiologically significant concentrations of l-ascorbic acid. Since hydrolytic demidation has been suggested as an important timer of biological events, the effects on hydrolytic deamidation of substances that are normally present in living organisms and are subject to nutritional control are of special relevance.