Assessment of the capacity to consent to treatment in patients admitted to acute medical wards.

BACKGROUND: Assessment of capacity to consent to treatment is an important legal and ethical issue in daily medical practice. In this study we carefully evaluated the capacity to consent to treatment in patients admitted to an acute medical ward using an assessment by members of the medical team, the specific Silberfeld's score, the MMSE and an assessment by a senior psychiatrist. METHODS: Over a 3 month period, 195 consecutive patients of an internal medicine ward in a university hospital were included and their capacity to consent was evaluated within 72 hours of admission. RESULTS: Among the 195 patients, 38 were incapable of consenting to treatment (unconscious patients or severe cognitive impairment) and 14 were considered as incapable of consenting by the psychiatrist (prevalence of incapacity to consent of 26.7%). Agreement between the psychiatrist's evaluation and the Silberfeld questionnaire was poor (sensitivity 35.7%, specificity 91.6%). Experienced clinicians showed a higher agreement (sensitivity 57.1%, specificity 96.5%). A decision shared by residents, chief residents and nurses was the best predictor for agreement with the psychiatric assessment (sensitivity 78.6%, specificity 94.3%). CONCLUSION: Prevalence of incapacity to consent to treatment in patients admitted to an acute internal medicine ward is high. While the standardized Silberfeld questionnaire and the MMSE are not appropriate for the evaluation of the capacity to consent in this setting, an assessment by the multidisciplinary medical team concurs with the evaluation by a senior psychiatrist.

The use of uniaxial accelerometry for the assessment of physical-activity-related energy expenditure: a validation study against whole-body indirect calorimetry.

Assessing the total energy expenditure (TEE) and the levels of physical activity in free-living conditions with non-invasive techniques remains a challenge. The purpose of the present study was to investigate the accuracy of a new uniaxial accelerometer for assessing TEE and physical-activity-related energy expenditure (PAEE) over a 24 h period in a respiratory chamber, and to establish activity levels based on the accelerometry ranges corresponding to the operationally defined metabolic equivalent (MET) categories. In study 1, measurement of the 24 h energy expenditure of seventy-nine Japanese subjects (40 (SD 12) years old) was performed in a large respiratory chamber. During the measurements, the subjects wore a uniaxial accelerometer (Lifecorder; Suzuken Co. Ltd, Nagoya, Japan) on their belt. Two moderate walking exercises of 30 min each were performed on a horizontal treadmill. In study 2, ten male subjects walked at six different speeds and ran at three different speeds on a treadmill for 4 min, with the same accelerometer. O2 consumption was measured during the last minute of each stage and was expressed in MET. The measured TEE was 8447 (SD 1337) kJ/d. The accelerometer significantly underestimated TEE and PAEE (91.9 (SD 5.4) and 92.7 (SD 17.8) % chamber value respectively); however, there was a significant correlation between the two values (r 0.928 and 0.564 respectively; P<0.001). There was a strong correlation between the activity levels and the measured MET while walking (r(2) 0.93; P<0.001). Although TEE and PAEE were systematically underestimated during the 24 h period, the accelerometer assessed energy expenditure well during both the exercise period and the non-structured activities. Individual calibration factors may help to improve the accuracy of TEE estimation, but the average calibration factor for the group is probably sufficient for epidemiological research. This method is also important for assessing the diurnal profile of physical activity.

Model-based iterative reconstruction in pediatric chest CT: assessment of image quality in a prospective study of children with cystic fibrosis.

BACKGROUND: The potential effects of ionizing radiation are of particular concern in children. The model-based iterative reconstruction VEO(TM) is a technique commercialized to improve image quality and reduce noise compared with the filtered back-projection (FBP) method. OBJECTIVE: To evaluate the potential of VEO(TM) on diagnostic image quality and dose reduction in pediatric chest CT examinations. MATERIALS AND METHODS: Twenty children (mean 11.4 years) with cystic fibrosis underwent either a standard CT or a moderately reduced-dose CT plus a minimum-dose CT performed at 100 kVp. Reduced-dose CT examinations consisted of two consecutive acquisitions: one moderately reduced-dose CT with increased noise index (NI = 70) and one minimum-dose CT at CTDIvol 0.14 mGy. Standard CTs were reconstructed using the FBP method while low-dose CTs were reconstructed using FBP and VEO. Two senior radiologists evaluated diagnostic image quality independently by scoring anatomical structures using a four-point scale (1 = excellent, 2 = clear, 3 = diminished, 4 = non-diagnostic). Standard deviation (SD) and signal-to-noise ratio (SNR) were also computed. RESULTS: At moderately reduced doses, VEO images had significantly lower SD (P < 0.001) and higher SNR (P < 0.05) in comparison to filtered back-projection images. Further improvements were obtained at minimum-dose CT. The best diagnostic image quality was obtained with VEO at minimum-dose CT for the small structures (subpleural vessels and lung fissures) (P < 0.001). The potential for dose reduction was dependent on the diagnostic task because of the modification of the image texture produced by this reconstruction. CONCLUSIONS: At minimum-dose CT, VEO enables important dose reduction depending on the clinical indication and makes visible certain small structures that were not perceptible with filtered back-projection.

A design science approach to support the assessment of disruptive technology : the Swiss mobile payment case

Abstract In this thesis we present the design of a systematic integrated computer-based approach for detecting potential disruptions from an industry perspective. Following the design science paradigm, we iteratively develop several multi-actor multi-criteria artifacts dedicated to environment scanning. The contributions of this thesis are both theoretical and practical. We demonstrate the successful use of multi-criteria decision-making methods for technology foresight. Furthermore, we illustrate the design of our artifacts using build and-evaluate loops supported with a field study of the Swiss mobile payment industry. To increase the relevance of this study, we systematically interview key Swiss experts for each design iteration. As a result, our research provides a realistic picture of the current situation in the Swiss mobile payment market and reveals previously undiscovered weak signals for future trends. Finally, we suggest a generic design process for environment scanning.

Ambulatory assessment of 3D ground reaction force using plantar pressure distribution.

This study aimed to use the plantar pressure insole for estimating the three-dimensional ground reaction force (GRF) as well as the frictional torque (T(F)) during walking. Eleven subjects, six healthy and five patients with ankle disease participated in the study while wearing pressure insoles during several walking trials on a force-plate. The plantar pressure distribution was analyzed and 10 principal components of 24 regional pressure values with the stance time percentage (STP) were considered for GRF and T(F) estimation. Both linear and non-linear approximators were used for estimating the GRF and T(F) based on two learning strategies using intra-subject and inter-subjects data. The RMS error and the correlation coefficient between the approximators and the actual patterns obtained from force-plate were calculated. Our results showed better performance for non-linear approximation especially when the STP was considered as input. The least errors were observed for vertical force (4%) and anterior-posterior force (7.3%), while the medial-lateral force (11.3%) and frictional torque (14.7%) had higher errors. The result obtained for the patients showed higher error; nevertheless, when the data of the same patient were used for learning, the results were improved and in general slight differences with healthy subjects were observed. In conclusion, this study showed that ambulatory pressure insole with data normalization, an optimal choice of inputs and a well-trained nonlinear mapping function can estimate efficiently the three-dimensional ground reaction force and frictional torque in consecutive gait cycle without requiring a force-plate.

Assessment of high hydrostatic pressure and starter culture on the quality properties of low-acid fermented sausages

The addition of starter culture and high pressure processing after ripening improved the microbial quality of low-acid fermented sausages (fuet and chorizo). The use of Lactobacillus sakei CTC6626 and Staphylococcus xylosus CTC6013 as starter culture significantly reduced Enterobacteriaceae and Enterococcus levels in the finished sausages. Moreover, the addition of starter culture produced sausages of similar quality to traditional low-acid fermented sausages. Slightly lower pH values and higher cohesiveness were obtained for both fuet and chorizo with starter culture. Sensory analysis showed no differences between lots of chorizo whereas starter fuet was more acid and gummy. High pressure induced an additional reduction of Enterobacteriaceae in non-starter sausages. An increase of textural properties was observed after pressurization. No other differences were observed between non-treated and pressurized sausages.

Evaluation of clinician-operated sonography and fine-needle aspiration in the assessment of salivary gland tumours.

OBJECTIVES: To evaluate the combination of ultrasound (US) + fine-needle aspiration (FNA) in the assessment of salivary gland tumours in the hands of the otolaryngologist. DESIGN: A retrospective review of case notes was performed. SETTING: Two university teaching hospitals in Switzerland. PARTICIPANTS: One hundred and three patients with a total of 106 focal masses of the salivary glands were included. Clinician-operated US + FNA were the first line of investigation for these lesions. All patients underwent surgical excision of the lesion, which allowed for confirmation of diagnosis by histopathology in 104 lesions and by laboratory testing in two lesions. MAIN OUTCOME MEASURES: Primary--diagnostic accuracy in identifying true salivary gland neoplasms and detecting malignancy. Secondary--predicting an approximate and specific diagnosis in these tumours. RESULTS: The combination of US + FNA achieved a diagnostic accuracy of 99% in identifying and differentiating true salivary gland neoplasms from tumour-like lesions. In detecting malignancy, this combination permitted an accuracy of 98%. An approximate diagnosis was possible in 89%, and a specific diagnosis in 69% of our patients. CONCLUSIONS: Due to economic factors and a high diagnostic accuracy, the combination of US + FNA represents the investigation method of choice for most salivary gland tumours. We suggest that the otolaryngologist be employed in carrying out these procedures, as is already the rule in other medical specialties, while computed tomography and magnetic resonance imaging should be reserved to those few lesions, which cannot be delineated completely by sonography.

Systematic assessment of factors influencing preferences of crohn's disease patients in selecting an anti-tumor necrosis factor agent (CHOOSE TNF TRIAL).

BACKGROUND: Infliximab (IFX), adalimumab (ADA), and certolizumab pegol (CZP) have similar efficacy in induction and maintenance of clinical remission in Crohn's disease (CD). Given the comparable nature of these drugs, patient preferences may influence the choice of the product. We aimed to identify factors that may contribute to CD patients' decision in selecting one anti-tumor necrosis factor (TNF) agent over the others. METHODS: A prospective survey was performed among anti-TNF-naïve CD patients. Prior to completion of a questionnaire, patients were provided with a written description of the three anti-TNF agents, focusing on indications, mode of administration, side effects, and scientific evidence of efficacy and safety for each drug. RESULTS: One hundred patients (47 females, mean age 45 ± 16 years, range 19-81) with an ileal, colonic, or ileocolonic (33%, 40%, and 27%, respectively) disease location completed the questionnaire. Based on the information provided, 36% of patients preferred ADA, 28% CZP, and 25% IFX, whereas 11% were undecided. The patients' decision in selecting a specific anti-TNF drug was influenced by the following factors: ease of use (69%), time required for therapy (34%), time interval between application of the drug (31%), scientific evidence for efficacy (19%), and fear of syringes (10%). CONCLUSIONS: The majority of patients preferred anti-TNF medications that were administered by subcutaneous injection rather than by intravenous infusion. Ease of use and time required for therapy were two major factors influencing the patients' selection of a specific anti-TNF drug. Patients' individual preferences should be taken into account when prescribing anti-TNF drugs. (Inflamm Bowel Dis 2012).

Assessment of the carotid artery by MRI at 3T: a study on reproducibility

PURPOSE: To examine the reproducibility of carotid artery dimension measurements using 3T MRI. MATERIALS AND METHODS: Ten healthy volunteers underwent three scans on two occasions for assessment of total vessel wall area (TVWA), total luminal area (TLA), and minimum (MinT) and maximum (MaxT) vessel wall thickness. A double inversion-recovery (IR) fast gradient-echo (FGRE) sequence was used on a commercial 3T system. During the first visit the subjects were scanned twice. The third scan was performed at least four days later. One observer traced all scans, and a second observer retraced the first scan series. RESULTS: For TVWA an interclass correlation (ICC) of 0.994 was calculated with all three scans taken into account. The interobserver ICC was 0.984. The agreement between the scans for TLA showed an ICC of 0.982 with an interobserver ICC of 0.998. For MinT and MaxT an ICC of 0.843 and 0.935 were calculated, with interobserver ICCs of 0.860 and 0.726, respectively. CONCLUSION: With the use of a commercial 3T MR system, TVWA, TLA, and wall thickness measurements of the carotid artery can be assessed with good reproducibility.

An Assessment of Traffic Safety in Urban Deer Herd Management Zones in Iowa, 2010

Many states are striving to keep their deer population to a sustainable and controllable level while maximizing public safety. In Iowa, measures to control the deer population include annual deer hunts and special deer herd management plans in urban areas. While these plans may reduce the deer population, traffic safety in these areas has not been fully assessed. Using deer population data from the Iowa Department of Natural Resources and data on deer-vehicle crashes and deer carcass removals from the Iowa Department of Transportation, the authors examined the relationship between deer-vehicle collisions, deer density, and land use in three urban areas in Iowa that have deer management plans in place (Cedar Rapids, Dubuque, and Iowa City) over the period 2002 to 2007. First, a comparison of deer-vehicle crash counts and deer carcass removal counts was conducted at the county level. Further, the authors estimated econometric models to investigate the factors that influence the frequency and severity of deer-vehicle crashes in these zones. Overall, the number of deer carcasses removed on the primary roads in these counties was greater than the number of reported deervehicle crashes on those roads. These differences can be attributed to a number of reasons, including variability in data reporting and data collection practices. In addition, high rates of underreporting of crashes were found on major routes that carry high volumes of traffic. This study also showed that multiple factors affect deer-vehicle crashes and corresponding injury outcomes in urban management zones. The identified roadway and non-roadway factors could be useful for identifying locations on the transportation system that significantly impact deer species and safety and for determining appropriate countermeasures for mitigation. Efforts to reduce deer density adjacent to roads and developed land and to provide wider shoulders on undivided roads are recommended. Improving the consistency and accuracy of deer carcass and deer-vehicle collision data collection methods and practices is also desirable.

Ubiquitin Ligases of the N-End Rule Pathway: Assessment of Mutations in UBR1 That Cause the Johanson-Blizzard Syndrome.

Background: Johanson-Blizzard syndrome (JBS; OMIM 243800) is an autosomal recessive disorder that includes congenital exocrine pancreatic insufficiency, facial dysmorphism with the characteristic nasal wing hypoplasia, multiple malformations, and frequent mental retardation. Our previous work has shown that JBS is caused by mutations in human UBR1, which encodes one of the E3 ubiquitin ligases of the N-end rule pathway. The N-end rule relates the regulation of the in vivo half-life of a protein to the identity of its N-terminal residue. One class of degradation signals (degrons) recognized by UBR1 are destabilizing N-terminal residues of protein substrates.Methodology/Principal Findings: Most JBS-causing alterations of UBR1 are nonsense, frameshift or splice-site mutations that abolish UBR1 activity. We report here missense mutations of human UBR1 in patients with milder variants of JBS. These single-residue changes, including a previously reported missense mutation, involve positions in the RING-H2 and UBR domains of UBR1 that are conserved among eukaryotes. Taking advantage of this conservation, we constructed alleles of the yeast Saccharomyces cerevisiae UBR1 that were counterparts of missense JBS-UBR1 alleles. Among these yeast Ubr1 mutants, one of them (H160R) was inactive in yeast-based activity assays, the other one (Q1224E) had a detectable but weak activity, and the third one (V146L) exhibited a decreased but significant activity, in agreement with manifestations of JBS in the corresponding JBS patients.Conclusions/Significance: These results, made possible by modeling defects of a human ubiquitin ligase in its yeast counterpart, verified and confirmed the relevance of specific missense UBR1 alleles to JBS, and suggested that a residual activity of a missense allele is causally associated with milder variants of JBS.

Stimulus-response curve of human motor nerves: multicenter assessment of various indexes.

The value of various indexes to characterize the stimulus-response curve of human motor nerves was assessed in 40 healthy subjects recruited from four European centers of investigation (Créteil, Lausanne, Liège, Marseille). Stimulus-response curves were established by stimulating the right median and ulnar motor nerves at the wrist, with stimulus durations of 0.05 and 0.5 ms. The following parameters were studied: the threshold intensity of stimulation to obtain 10% (I 10), 50% (I 50), and 90% (I 90) of the maximal compound muscle action potential, the ratios I 10/I 50, I 90/I 50, (I 90 - I 10)/I 10, (I 90-I 50)/I 50, and (I 50 - I 10)/I 10, and the slopes of the stimulus-response curves with or without normalization to I 50. For each parameter, within-center variability and reproducibility (in a test-retest study) were assessed and between-center comparisons were made. For most of the parameters, the results varied significantly within and between the centers. Within the centers, only the ratios I 10/I 50 and I 90/I 50 were found constant and reproducible. Between the centers, the absolute intensity thresholds (I 10, I 50, I 90) and the ratio I 90/I 50 did not show significant differences at stimulus duration of 0.5 ms, whatever the stimulated nerve. The reduced variability and good reproducibility of the ratios I 10/I 50 and I 90/I 50 open perspectives in neurophysiological practice for the use of these indexes of the stimulus-response curve, a rapid and noninvasive test.

Assessment of Asphalt Interlayer Designed on Jointed Concrete, InTrans Project 13-475, 2014

Reflective cracking in hot mix asphalt (HMA) overlays has been a common cause of poor pavement performance in Iowa for many years. Reflective cracks commonly occur in HMA overlays when deteriorated portland cement concrete is paved over with HMA. This results in HMA pavement surfaces with poor ride quality and increased transportation maintenance costs. To delay the formation of cracks in HMA overlays, the Iowa Department of Transportation (Iowa DOT) has begun to implement a crack-relief interlayer mix design specification. The crack-relief interlayer is an asphalt-rich, highly flexible HMA that can resist cracking in high strain loading conditions. In this project, the field performance of an HMA overlay using a one inch interlayer was compared to a conventional HMA overlay without an interlayer. Both test sections were constructed on US 169 in Adel, Iowa as part of an Iowa DOT overlay project. The laboratory performance of the interlayer mix design was assessed for resistance to cracking from repeated strains by using the four-point bending beam apparatus. An HMA using a highly polymer modified binder was designed and shown to meet the laboratory performance test criteria. The field performance of the overlay with the interlayer exceeded the performance of the conventional overlay that did not have the interlayer. After one winter season, 29 percent less reflective cracking was measured in the pavement section with the interlayer than the pavement section without the interlayer. The level of cracking severity was also reduced by using the interlayer in the overlay.