STOPP/START Criteria and Their Role as a Clinical Tool in Routine Practice

Screening Tool of Older Persons’ Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria was first published in 2008, primarily as an alternative set of explicit criteria for potentially inappropriate medications (PIMs) to Beers criteria.

Superlattice structures in twisted bilayers of folded graphene

The electronic properties of bilayer graphene strongly depend on relative orientation of the two atomic lattices. Whereas Bernal-stacked graphene is most commonly studied, a rotational mismatch between layers opens up a whole new field of rich physics, especially at small interlayer twist. Here we report on magnetotransport measurements on twisted graphene bilayers, prepared by folding of single layers. These reveal a strong dependence on the twist angle, which can be estimated by means of sample geometry. At small rotation, superlattices with a wavelength in the order of 10 nm arise and are observed by friction atomic force microscopy. Magnetotransport measurements in this small-angle regime show the formation of satellite Landau fans. These are attributed to additional Dirac singularities in the band structure and discussed with respect to the wide range of interlayer coupling models.

Examining barriers to internationalisation created by diverse systems and structures in vocational education and training

In a global society, all educational sectors need to recognise internationalism as a core, foundational principle. Whilst most educational sectors are taking up that challenge, vocational education and training (VET) is still being pulled towards the national agenda in terms of its structures and systems, and the policies driving it, disadvantaging those who graduate from VET, those who teach in it, and the businesses and countries that connect with it. This paper poses questions about the future of internationalisation in the sector. It examines whether there is a way to create a VET system that meets its primary point of value, to produce skilled workers for the local labour market, while still benefitting those graduates by providing international skills and knowledge, gained from VET institutions that are international in their outlook. The paper examines some of the key barriers created by systems and structures in VET to internationalisation and suggests that the efforts which have been made to address the problem have had limited success. It suggests that only a model which gives freedom to those with a direct vested interest, students, teachers, trainers and employers, to pursue international co-operation and liaison will have the opportunity to succeed. (DIPF/Orig.)

A Replacement Technique to Maximize Task Reuse in Reconfigurable Systems

Dynamically reconfigurable hardware is a promising technology that combines in the same device both the high performance and the flexibility that many recent applications demand. However, one of its main drawbacks is the reconfiguration overhead, which involves important delays in the task execution, usually in the order of hundreds of milliseconds, as well as high energy consumption. One of the most powerful ways to tackle this problem is configuration reuse, since reusing a task does not involve any reconfiguration overhead. In this paper we propose a configuration replacement policy for reconfigurable systems that maximizes task reuse in highly dynamic environments. We have integrated this policy in an external taskgraph execution manager that applies task prefetch by loading and executing the tasks as soon as possible (ASAP). However, we have also modified this ASAP technique in order to make the replacements more flexible, by taking into account the mobility of the tasks and delaying some of the reconfigurations. In addition, this replacement policy is a hybrid design-time/run-time approach, which performs the bulk of the computations at design time in order to save run-time computations. Our results illustrate that the proposed strategy outperforms other state-ofthe-art replacement policies in terms of reuse rates and achieves near-optimal reconfiguration overhead reductions. In addition, by performing the bulk of the computations at design time, we reduce the execution time of the replacement technique by 10 times with respect to an equivalent purely run-time one.

Safety and risk factors for difficult endoscopist-directed ERCP sedation in daily practice: a hospital-based case-control study

Background: There are limited data concerning endoscopist-directed endoscopic retrograde cholangiopancreatography deep sedation. The aim of this study was to establish the safety and risk factors for difficult sedation in daily practice. Patients and methods: Hospital-based, frequency matched case-control study. All patients were identified from a database of 1,008 patients between 2014 and 2015. The cases were those with difficult sedations. This concept was defined based on the combination of the receipt of high-doses of midazolam or propofol, poor tolerance, use of reversal agents or sedation-related adverse events. The presence of different factors was evaluated to determine whether they predicted difficult sedation. Results: One-hundred and eighty-nine patients (63 cases, 126 controls) were included. Cases were classified in terms of high-dose requirements (n = 35, 55.56%), sedation-related adverse events (n = 14, 22.22%), the use of reversal agents (n = 13, 20.63%) and agitation/discomfort (n = 8, 12.7%). Concerning adverse events, the total rate was 1.39%, including clinically relevant hypoxemia (n = 11), severe hypotension (n = 2) and paradoxical reactions to midazolam (n = 1). The rate of hypoxemia was higher in patients under propofol combined with midazolam than in patients with propofol alone (2.56% vs. 0.8%, p < 0.001). Alcohol consumption (OR: 2.674 [CI 95%: 1.098-6.515], p = 0.030), opioid consumption (OR: 2.713 [CI 95%: 1.096-6.716], p = 0.031) and the consumption of other psychoactive drugs (OR: 2.015 [CI 95%: 1.017-3.991], p = 0.045) were confirmed to be independent risk factors for difficult sedation. Conclusions: Endoscopist-directed deep sedation during endoscopic retrograde cholangiopancreatography is safe. The presence of certain factors should be assessed before the procedure to identify patients who are high-risk for difficult sedation.

Implementation of an enhanced planar processing protocol in clinical practice

Introdução: A cintigrafia óssea é um dos exames mais frequentes em Medicina Nuclear. Esta modalidade de imagem médica requere um balanço apropriado entre a qualidade de imagem e a dose de radiação, ou seja, as imagens obtidas devem conter o número mínimo de contagem necessárias, para que apresentem qualidade considerada suficiente para fins diagnósticos. Objetivo: Este estudo tem como principal objetivo, a aplicação do software Enhanced Planar Processing (EPP), nos exames de cintigrafia óssea em doentes com carcinoma da mama e próstata que apresentam metástases ósseas. Desta forma, pretende-se avaliar a performance do algoritmo EPP na prática clínica em termos de qualidade e confiança diagnóstica quando o tempo de aquisição é reduzido em 50%. Material e Métodos: Esta investigação teve lugar no departamento de Radiologia e Medicina Nuclear do Radboud University Nijmegen Medical Centre. Cinquenta e um doentes com suspeita de metástases ósseas foram administrados com 500MBq de metilenodifosfonato marcado com tecnécio-99m. Cada doente foi submetido a duas aquisições de imagem, sendo que na primeira foi seguido o protocolo standard do departamento (scan speed=8 cm/min) e na segunda, o tempo de aquisição foi reduzido para metade (scan speed=16 cm/min). As imagens adquiridas com o segundo protocolo foram processadas com o algoritmo EPP. Todas as imagens foram submetidas a uma avaliação objetiva e subjetiva. Relativamente à análise subjetiva, três médicos especialistas em Medicina Nuclear avaliaram as imagens em termos da detetabilidade das lesões, qualidade de imagem, aceitabilidade diagnóstica, localização das lesões e confiança diagnóstica. No que respeita à avaliação objetiva, foram selecionadas duas regiões de interesse, uma localizada no terço médio do fémur e outra localizada nos tecidos moles adjacentes, de modo a obter os valores de relação sinal-ruído, relação contraste-ruído e coeficiente de variação. Resultados: Os resultados obtidos evidenciam que as imagens processadas com o software EPP oferecem aos médicos suficiente informação diagnóstica na deteção de metástases, uma vez que não foram encontradas diferenças estatisticamente significativas (p>0.05). Para além disso, a concordância entre os observadores, comparando essas imagens e as imagens adquiridas com o protocolo standard foi de 95% (k=0.88). Por outro lado, no que respeita à qualidade de imagem, foram encontradas diferenças estatisticamente significativas quando se compararam as modalidades de imagem entre si (p≤0.05). Relativamente à aceitabilidade diagnóstica, não foram encontradas diferenças estatisticamente significativas entre as imagens adquiridas com o protocolo standard e as imagens processadas com o EPP software (p>0.05), verificando-se uma concordância entre os observadores de 70.6%. Todavia, foram encontradas diferenças estatisticamente significativas entre as imagens adquiridas com o protocolo standard e as imagens adquiridas com o segundo protocolo e não processadas com o software EPP (p≤0.05). Para além disso, não foram encontradas diferenças estatisticamente significativas (p>0.05) em termos de relação sinal-ruído, relação contraste-ruído e coeficiente de variação entre as imagens adquiridas com o protocolo standard e as imagens processadas com o EPP. Conclusão: Com os resultados obtidos através deste estudo, é possível concluir que o algoritmo EPP, desenvolvido pela Siemens, oferece a possibilidade de reduzir o tempo de aquisição em 50%, mantendo ao mesmo tempo uma qualidade de imagem considerada suficiente para fins de diagnóstico. A utilização desta tecnologia, para além de aumentar a satisfação por parte dos doentes, é bastante vantajosa no que respeita ao workflow do departamento.

Mesh Adaption for Tracking Vortex Structures in OVERTURNS Simulation of the S-76 Rotor in Hover

The constant need to improve helicopter performance requires the optimization of existing and future rotor designs. A crucial indicator of rotor capability is hover performance, which depends on the near-body flow as well as the structure and strength of the tip vortices formed at the trailing edge of the blades. Computational Fluid Dynamics (CFD) solvers must balance computational expenses with preservation of the flow, and to limit computational expenses the mesh is often coarsened in the outer regions of the computational domain. This can lead to degradation of the vortex structures which compose the rotor wake. The current work conducts three-dimensional simulations using OVERTURNS, a three-dimensional structured grid solver that models the flow field using the Reynolds-Averaged Navier-Stokes equations. The S-76 rotor in hover was chosen as the test case for evaluating the OVERTURNS solver, focusing on methods to better preserve the rotor wake. Using the hover condition, various computational domains, spatial schemes, and boundary conditions were tested. Furthermore, a mesh adaption routine was implemented, allowing for the increased refinement of the mesh in areas of turbulent flow without the need to add points to the mesh. The adapted mesh was employed to conduct a sweep of collective pitch angles, comparing the resolved wake and integrated forces to existing computational and experimental results. The integrated thrust values saw very close agreement across all tested pitch angles, while the power was slightly over predicted, resulting in under prediction of the Figure of Merit. Meanwhile, the tip vortices have been preserved for multiple blade passages, indicating an improvement in vortex preservation when compared with previous work. Finally, further results from a single collective pitch case were presented to provide a more complete picture of the solver results.

Initial experience with golimumab in clinical practice for ulcerative colitis

Background: Golimumab is a TNF-blocking agent indicated as a second-line therapy in ulcerative colitis. Purpose: To research the effectiveness and safety of golimumab in patients with ulcerative colitis in clinical practice. Methods: Retrospective study of the effectiveness and safety of golimumab in patients with ulcerative colitis. All patients received golimumab 200 mg subcutaneously at week 0, and golimumab 100 mg subcutaneously at week 2. After the induction treatment, each patient received 50 mg sc. every 4 weeks in patients with body weight less than 80 kg, and 100 mg every 4 weeks in patients with body weight greater than or equal to 80 kg. Results: Study of a group of 23 ulcerative colitis patients, 7 of whom were naive to any anti-TNF therapy, and 16 patients who had previously been treated with an anti-TNF agent other than golimumab (non-naive patients). The average treatment time with golimumab was 14.3 weeks. Globally, withdrawal of corticosteroids was observed in 74% of cases. Clinical response was observed in 85.5% of patients who had not received biological treatment previously, and in patients who had previously received biological treatment the response rate was 75%. Conclusions: In this short study, golimumab seems to be an alternative treatment in naive and non-naive anti-TNF ulcerative colitis patients. It is also a safe therapy, given that there were no adverse effects in the patients studied.

Perceptions of ad hoc supervision encounters in general practice training: a qualitative interview-based study

BACKGROUND: Ad hoc supervision encounters occur between general practitioner (GP) supervisors and general practice registrars outside scheduled teaching sessions. Anecdotally reported as important learning opportunities, these encounters are rarely explored in the literature. OBJECTIVE: This study examined supervisors', registrars' and practice managers' perceptions of ad hoc supervisory encounters. METHODS: Semi-structured interviews were conducted with purposively sampled supervisors, registrars and practice managers from regional general practice settings. Data were analysed using template analysis. RESULTS: Fifteen respondents participated in the interviews. Their perceptions of ad hoc encounters were reported under the categories of immediacy, safety, education, professional identity and supervisor stress. DISCUSSION: Ad hoc encounters in general practice registrar training are highly valued for supporting patient safety and registrar education. The encounters serve a range of practical purposes for supervisors, registrars and practices, and warrant further exploration on how to optimise their benefits within general practice.

A cluster randomised controlled trial of vascular risk factor management in general practice

Objective: To evaluate the impact of a lifestyle intervention in Australian general practice to reduce the risk of vascular disease.

Design, setting and participants: Stratified cluster randomised controlled trial among 30 general practices in New South Wales from July 2008 to January 2010. Patients aged 40–64 years were invited to participate. The subgroup who were 40–55 years of age were included only if they had either hypertension or dyslipidaemia.

Intervention: A general practice-based health-check with brief lifestyle counselling and referral of high-risk patients to a program consisting of one to two individual visits with an exercise physiologist or dietitian, and six group sessions.

Main outcome measures: Outcomes at baseline, 6 and 12 months included the behavioural and physiological risk factors for vascular disease — self-reported diet and physical activity, and measured weight, body mass index, waist circumference, blood lipid and blood sugar levels, and blood pressure.

Results: Of the 3128 patients who were invited, 958 patients (30.6%) responded and 814 were eligible to participate. Of these, 699 commenced the study, and 655 remained in the study at 12 months. Physical activity levels increased to a greater extent in the intervention group than the control group at 6 and 12 months (P = 0.005). There were no other changes in behavioural or physiological outcomes or in estimated absolute risk of cardiovascular disease at 12 months. Of the 384 enrolled in the intervention group, 117 patients (30.5%) attended the minimum number of group program sessions and lost more weight (mean weight loss, 1.06 kg) than those who did not attend the minimum number of sessions (mean weight gain, 0.73 kg).

Conclusion: While patients who received counselling by their general practitioner increased self-reported physical activity, only those who attended the group sessions sustained an improvement in weight. However, more research is needed to determine whether group programs offer significant benefits over individual counselling in general practice.

Case formulation in forensic practice: challenges and opportunities

Purpose – The purpose of this paper is to provide an overview of current practice in forensic case formulation, describing different approaches and discussing some of the practical and ethical issues that routinely arise. The paper further identifies areas where future practice and research might be strengthened.

Design/methodology/approach – There is only a very small literature to draw upon in reviewing this topic. Therefore a narrative literature review was undertaken, synthesising findings from published, peer-reviewed studies, and papers that addressed case formulation in psychological practice.

Findings – Despite case formation being considered by many to be a core competency of evidence-based forensic practice, it is not currently possible to describe a typical forensic case formulation or advocate for a particular approach to practice.

Practical implications – A number of practical and ethical issues routinely arise in the process of conducting a forensic case formulation. Ultimately, the absence of a consistent approach can lead to lead to poor clinical decision-making and the delivery of inadequate or inappropriate intervention.

Originality/value – This is one of the few discussions of case formulation that have been prepared for forensic practitioners. It is likely to be of interest to readers of the journal given the importance of the formulation process in contemporary forensic practice.

Principles of knowledge organization: analysis and structures in the networked environment

Knowledge organization in the networked environment is guided by standards. Standards in knowledge organization are built on principles. For example, NISO Z39.19-1993 Guide to the Construction of Monolingual Thesauri (now undergoing revision) and NISO Z39.85- 2001 Dublin Core Metadata Element Set are two standards used in many implementations. Both of these standards were crafted with knowledge organization principles in mind. Therefore it is standards work guided by knowledge organization principles which can affect design of information services and technologies. This poster outlines five threads of thought that inform knowledge organization principles in the networked environment. An understanding of each of these five threads informs system evaluation. The evaluation of knowledge organization systems should be tightly linked to a rigorous understanding of the principles of construction. Thus some foundational evaluation questions grow from an understanding of stan dard s and pr inciples: on what pr inciples is this know ledge organization system built? How well does this implementation meet the ideal conceptualization of those principles? How does this tool compare to others built on the same principles?

A Convenient Verisimilitude or Oppressive Internalization? Characterizing the Ethical Arguments surrounding Hierarchical Structures in Knowledge Organization Systems

This paper considers the ethical concerns that surface around hierarchy as structure in knowledge organization systems. In order to do this, I consider the relationship between semantics and structure and argue for a separation of the two in design and critique of knowledge organization systems. The paper closes with an argument that agency and intention, as ethical concerns in knowledge organization, lead us to argue for a neutral stance on hierarchy.