Communication practices in physician decision-making for an unstable critically ill patient with end-stage cancer.

BACKGROUND: Shared decision-making has become the standard of care for most medical treatments. However, little is known about physician communication practices in the decision making for unstable critically ill patients with known end-stage disease. OBJECTIVE: To describe communication practices of physicians making treatment decisions for unstable critically ill patients with end-stage cancer, using the framework of shared decision-making. DESIGN: Analysis of audiotaped encounters between physicians and a standardized patient, in a high-fidelity simulation scenario, to identify best practice communication behaviors. The simulation depicted a 78-year-old man with metastatic gastric cancer, life-threatening hypoxia, and stable preferences to avoid intensive care unit (ICU) admission and intubation. Blinded coders assessed the encounters for verbal communication behaviors associated with handling emotions and discussion of end-of-life goals. We calculated a score for skill at handling emotions (0-6) and at discussing end of life goals (0-16). SUBJECTS: Twenty-seven hospital-based physicians. RESULTS: Independent variables included physician demographics and communication behaviors. We used treatment decisions (ICU admission and initiation of palliation) as a proxy for accurate identification of patient preferences. Eight physicians admitted the patient to the ICU, and 16 initiated palliation. Physicians varied, but on average demonstrated low skill at handling emotions (mean, 0.7) and moderate skill at discussing end-of-life goals (mean, 7.4). We found that skill at discussing end-of-life goals was associated with initiation of palliation (p = 0.04). CONCLUSIONS: It is possible to analyze the decision making of physicians managing unstable critically ill patients with end-stage cancer using the framework of shared decision-making.

Physical controls on the seasonal migration of the North Pacific transition zone chlorophyll front

The large seasonal migration of the transition zone chlorophyll front (TZCF) is of interest because a number of marine fauna, both commercial and endangered, appear to track it. Herein we examine the physical dynamics driving this seasonal migration of the TZCF. Vertical processes, traditionally viewed as controlling the dynamical supply of nutrients to surface waters, prove insufficient to explain seasonal variations in nutrient supply to the transition zone. Instead, we find that the horizontal Ekman transport of nutrients from higher latitudes drives the TZCF's southward migration. The estimated horizontal transport of nitrate supports up to 40% of new primary productivity in the region annually and nearly all of new primary productivity in the winter. The significance of horizontal advection to the North Pacific transition zone supports revising the paradigm that nutrients are supplied to surface waters from below. © 2010 by the American Geophysical Union.

Comparative effectiveness studies to improve clinical outcomes in end stage renal disease: the DEcIDE patient outcomes in end stage renal disease study.

BACKGROUND: Evidence is lacking to inform providers' and patients' decisions about many common treatment strategies for patients with end stage renal disease (ESRD). METHODS/DESIGN: The DEcIDE Patient Outcomes in ESRD Study is funded by the United States (US) Agency for Health Care Research and Quality to study the comparative effectiveness of: 1) antihypertensive therapies, 2) early versus later initiation of dialysis, and 3) intravenous iron therapies on clinical outcomes in patients with ESRD. Ongoing studies utilize four existing, nationally representative cohorts of patients with ESRD, including (1) the Choices for Healthy Outcomes in Caring for ESRD study (1041 incident dialysis patients recruited from October 1995 to June 1999 with complete outcome ascertainment through 2009), (2) the Dialysis Clinic Inc (45,124 incident dialysis patients initiating and receiving their care from 2003-2010 with complete outcome ascertainment through 2010), (3) the United States Renal Data System (333,308 incident dialysis patients from 2006-2009 with complete outcome ascertainment through 2010), and (4) the Cleveland Clinic Foundation Chronic Kidney Disease Registry (53,399 patients with chronic kidney disease with outcome ascertainment from 2005 through 2009). We ascertain patient reported outcomes (i.e., health-related quality of life), morbidity, and mortality using clinical and administrative data, and data obtained from national death indices. We use advanced statistical methods (e.g., propensity scoring and marginal structural modeling) to account for potential biases of our study designs. All data are de-identified for analyses. The conduct of studies and dissemination of findings are guided by input from Stakeholders in the ESRD community. DISCUSSION: The DEcIDE Patient Outcomes in ESRD Study will provide needed evidence regarding the effectiveness of common treatments employed for dialysis patients. Carefully planned dissemination strategies to the ESRD community will enhance studies' impact on clinical care and patients' outcomes.

The End(s) of the End of Poverty

This dissertation explores the emergence of Millennium Development and the promise to end poverty by 2015. After exploring the global scale phenomena, the project turns to the implementation of the "end of poverty" in the model Millennium Village of Sauri, Kenya.

Overview of FEED, the feeding experiments end-user database.

The Feeding Experiments End-user Database (FEED) is a research tool developed by the Mammalian Feeding Working Group at the National Evolutionary Synthesis Center that permits synthetic, evolutionary analyses of the physiology of mammalian feeding. The tasks of the Working Group are to compile physiologic data sets into a uniform digital format stored at a central source, develop a standardized terminology for describing and organizing the data, and carry out a set of novel analyses using FEED. FEED contains raw physiologic data linked to extensive metadata. It serves as an archive for a large number of existing data sets and a repository for future data sets. The metadata are stored as text and images that describe experimental protocols, research subjects, and anatomical information. The metadata incorporate controlled vocabularies to allow consistent use of the terms used to describe and organize the physiologic data. The planned analyses address long-standing questions concerning the phylogenetic distribution of phenotypes involving muscle anatomy and feeding physiology among mammals, the presence and nature of motor pattern conservation in the mammalian feeding muscles, and the extent to which suckling constrains the evolution of feeding behavior in adult mammals. We expect FEED to be a growing digital archive that will facilitate new research into understanding the evolution of feeding anatomy.

Estimating the flow rate capacity of an overturned rail carriage end exit in the presence of smoke

While incidents requiring the rapid egress of passengers from trains are infrequent, perhaps the most challenging scenario for passengers involves the evacuation from an overturned carriage subjected to fire. In this paper we attempt to estimate the flow rate capacity of an overturned rail carriage end exit. This was achieved through two full-scale evacuation experiments, in one of which the participants were subjected to non-toxic smoke. The experiments were conducted as part of a pilot study into evacuation from rail carriages. In reviewing the experimental results, it should be noted that only a single run of each trial was undertaken with a limited — though varied — population. As a result it is not possible to test the statistical significance of the evacuation times quoted and so the results should be treated as indicative rather than definitive. The carriage used in the experiments was a standard class Mark IID which, while an old carriage design, shares many features with those carriages commonly found on the British rail network. In the evacuation involving smoke, the carriage end exit was found to achieve an average flow rate capacity of approximately 5.0 persons/min. The average flow rate capacity of the exit without smoke was found to be approximately 9.2 persons/min. It was noted that the presence of smoke tended to reduce significantly the exit flow rate. Due to the nature of the experimental conditions, these flow rates are considered optimistic. Finally, the authors make several recommendations for improving survivability in rail accidents. Copyright © 2000 John Wiley & Sons, Ltd.

Numerical algorithms for modelling electrodeposition: Tracking the deposition front under forced convection from megasonic agitation

Electrodeposition is a widely used technique for the fabrication of high aspect ratio microstructures. In recent years, much research has been focused within this area aiming to understand the physics behind the filling of high aspect ratio vias and trenches on substrates and in particular how they can be made without the formation of voids in the deposited material. This paper reports on the fundamental work towards the advancement of numerical algorithms that can predict the electrodeposition process in micron scaled features. Two different numerical approaches have been developed, which capture the motion of the deposition interface and 2-D simulations are presented for both methods under two deposition regimes: those where surface kinetics is governed by Ohm’s law and the Butler–Volmer equation, respectively. In the last part of this paper the modelling of acoustic forces and their subsequent impact on the deposition profile through convection is examined.

Arrears end

Considers the proposed pre-action protocol for mortgage arrears aimed at residential lenders and intended to restrict their ability to seek possession. Includes responses to the Civil Justice Council's consultation, which ended in May 2008, with particular emphasis on the objections of the Council of Mortgage Lenders. [From Legal Journals Index]

South East London Palliative and End of Life Care Education and Training Strategy: Meeting the Education and Training Needs of the Health & Social Care Workforce Involved in the Care of Patients and Carers at the End of Life.

EXECUTIVE SUMMARY Aims 1. The aims of this strategy are • to ensure that a full range of education and training related to the adult end of life care pathway is available across South East London to meet the needs of our health and social care workforce • to enable those responsible for end of life care education and training commissioning to procure comprehensively from a full range of education providers in a systematic and strategic manner. Background 2. The work that underpins this strategy was begun by the South East London Cancer Network via its Palliative and End of Life Care Coordinating Group and then developed by way of the Marie Curie Delivering Choice Programme’s Education and Training work stream.

Position and structure of the subtropical/Azores front region from combined Lagrangian and remote sensing (IR/altimeter/SeaWIFS) measurements

The position and structure of the North Atlantic Subtropical Front is studied using Lagrangian flow tracks and remote sensing (AVHRR imagery: TOPEX/POSEIDON altimetry: SeaWiFS) in a broad region ( similar to 31 degree to similar to 36 degree N) of marked gradient of dynamic height (Azores Current) that extends from the Mid-Atlantic Ridge (MAR), near similar to 40 degree W, to the Eastern Boundary ( similar to 10 degree W). Drogued Argos buoy and ALACE tracks are superposed on infrared satellite images in the Subtropical Front region. Cold (cyclonic) structures, called storms, and warm (anticyclonic) structures of 100-300 km in size can be found on the south side of the Subtropical Front outcrop, which has a temperature contrast of about 1 degree C that can be followed for similar to 2500 km near 35 degree N. Warmer water adjacent to the outcrop is flowing eastward (Azores Current) but some warm water is returned westward about 300 km to the south (southern Counterflow). Estimates of horizontal diffusion in a Storm (D=2.2t10 super(2) m super(2) s super(-1)) and in the Subtropical Front region near 200 m depth (D sub(x)=1.3t10 super(4) m super(2) s super(-1), D sub(y)=2.6t10 super(3) m super(2) s super(-1)) are made from the Lagrangian tracks. Altimeter and in situ measurements show that Storms track westwards. Storms are separated by about 510 km and move westward at 2.7 km d super(-1). Remote sensing reveals that some initial structures start evolving as far east as 23 degree W but are more organized near 29 degree W and therefore Storms are about 1 year old when they reach the MAR (having travelled a distance of 1000 km). Structure and seasonality in SeaWiFS data in the region is examined.