The unruptured intracranial aneurysm treatment score: a multidisciplinary consensus.

OBJECTIVE We endeavored to develop an unruptured intracranial aneurysm (UIA) treatment score (UIATS) model that includes and quantifies key factors involved in clinical decision-making in the management of UIAs and to assess agreement for this model among specialists in UIA management and research. METHODS An international multidisciplinary (neurosurgery, neuroradiology, neurology, clinical epidemiology) group of 69 specialists was convened to develop and validate the UIATS model using a Delphi consensus. For internal (39 panel members involved in identification of relevant features) and external validation (30 independent external reviewers), 30 selected UIA cases were used to analyze agreement with UIATS management recommendations based on a 5-point Likert scale (5 indicating strong agreement). Interrater agreement (IRA) was assessed with standardized coefficients of dispersion (vr*) (vr* = 0 indicating excellent agreement and vr* = 1 indicating poor agreement). RESULTS The UIATS accounts for 29 key factors in UIA management. Agreement with UIATS (mean Likert scores) was 4.2 (95% confidence interval [CI] 4.1-4.3) per reviewer for both reviewer cohorts; agreement per case was 4.3 (95% CI 4.1-4.4) for panel members and 4.5 (95% CI 4.3-4.6) for external reviewers (p = 0.017). Mean Likert scores were 4.2 (95% CI 4.1-4.3) for interventional reviewers (n = 56) and 4.1 (95% CI 3.9-4.4) for noninterventional reviewers (n = 12) (p = 0.290). Overall IRA (vr*) for both cohorts was 0.026 (95% CI 0.019-0.033). CONCLUSIONS This novel UIA decision guidance study captures an excellent consensus among highly informed individuals on UIA management, irrespective of their underlying specialty. Clinicians can use the UIATS as a comprehensive mechanism for indicating how a large group of specialists might manage an individual patient with a UIA.

The Process of Starting a Business

Many students are inspired to start their own business venture after taking some courses in school or simply just taking an idea and turning it into a business. The beginning process is usually most difficult in terms of establishing a functioning business, getting the right connections, and avoiding discouragement to follow through with the business. That is why many businesses fall into the categories of starting, failing along the process, or failing to get started. There is a lot to be learned from the process of starting a business venture. In addressing this issue, some of the questions this research study aims to explore and study are how people go about their new venture efforts? Second, what steps they undertake? Third, from whom do they get information? And fourth, how do they use that information? This study will seek a variety of insights that can help answer these questions and improve our understanding of why some businesses fail, succeed, or never get started.

THE EQUILIBRIUM CONSTANT FOR THE GLYCINE SYNTHASE REACTION (ONE-CARBON, METABOLISM, FOLATE)

The equilibrium constant (K(,c)) under physiological conditions (38(DEGREES)C, 0.25 M ionic strength (I), pH 7.0) for the glycine synthase (GS) reaction (E C 2.1.2.1.0) (Equation 1) has been determined. (UNFORMATTED TABLE FOLLOWS)^ 5,10-CH(,2)-H(,4)Folate NADH NH (,4)+ CO(,2) ^ K(,c) = Eq. 1^ H(,4)Folate NAD('+) GLY ^(TABLE ENDS)^ The enzymatic instability of the GS enzyme complex itself has made it necessary to determine the overall K(,c) from the product of constants for the partial reactions of GS determined separately under the same conditions. The partial reactions are the H(,4)Folate-formaldehyde (CH(,2)(OH)(,2)) condensation reaction (Reaction 1) the K(,c) for which has been reported by this laboratory (3.0 x 10('4)), the lipoate (LipS(,2)) dehydrogenase reaction (LipDH) (Reaction 2) and the Gly-Lip^ decarboxylase reaction (Reaction 3) forming reduced lipoate (Lip(SH)(,2)), NH(,4)('+), CO(,2) and CH(,2)(OH)(,2.) (UNFORMATTED TABLE FOLLOWS)(,)^ H(,4)Fote + CH(,2)(OH)(,2) 5,10-CH(,2)-H(,4)Folate (1)^ Lip(SH)(,2) + NAD('+) LipS(,2) + NADH + H('+) (2)^ H('+) + Gly + LipS(,2) Lip(SH)(,2) + NH(,4)('+) CO(,2) + CH(,2)(OH)(,2) (3)^(TABLE ENDS)^ In this work the K(,c) for Reactions 2 and 3 are reported.^ The K(,c)' for the LipDH reaction described by other authors was reported with unexplainable conclusions regarding the pH depend- ence for the reaction. These conclusions would imply otherwise unexpected acid dissociation constants for reduced and oxidized lipoate. The pK(,a)',s for these compounds have been determined to resolve discrepancy. The conclusions are as follows: (1) The K(,c) for the LipDH reaction is 2.08 x 10('-8); (2) The pK(,a)',s for Lip(SH)(,2) are 4.77(-COOH), 9.91(-SH), 11.59(-SH); for LipS(,2) the carboxyl pK(,a)' is 4.77; (3) Contrary to previous literature, the log K(,c)' for the LipDH reaction is a linear function of the pH, a conclusion supported by the values for the dissociation constants.^ The K(,c) for Reaction 3 is the product of constants for Reactions 4-7. (UNFORMATTED TABLE FOLLOWS)^ LipSHSCH(,2)OH + H(,2)O Lip(SH)(,2) + CH(,2)(OH)(,2) (4)^ H(,2)O + LipSHSCH(,2)NH(,3)('+) LipSHSCH(,2)OH + NH(,4)('+) (5)^ LipSHSCH(,2)NH(,2) + H('+) LipSHSCH(,2)NH(,3)('+) (6)^ Gly + LipS(,2) LipSHSCH(,2)NH(,2) + CO(,2) (7)^(TABLE ENDS)^ Reactions 4-6 are non-enzymatic reactions whose constants were determined spectrophotometrically. Reaction 7 was catalyzed by the partially purified P-protein of GS with equilibrium approached from both directions. The value for K(,c) for this reaction is 8.15 x 10('-3). The combined K(,c) for Reactions 4-7 or Reaction 3 is 2.4 M.^ The overall K(,c) for the GS reaction determined by combination of values for Reactions 1-3 is 1.56 x 10('-3). ^

The effect of triage team on time-in-department in a pediatric emergency department

Objective. To determine whether the use of a triage team would reduce the average time-in-department in a pediatric emergency department by 25%.^ Methods. A triage team consisting of a physician, a nurse, and a nurse's assistant initiated work-ups and saw patients who required minimal lab work-up and were likely to be discharged. Study days were randomized. Our inclusion criteria were all children seen in the emergency center between 6p and 2a Monday-Friday. Our exclusion criteria included resuscitations, inpatient-inpatient transfers, left without being seen, leaving against medical advice, any child seen outside of 6p-2am Monday-Friday and on the weekends. A Pearson-Chi square was used for comparison of the two groups for heterogeneity. For the time-in-department analysis, we performed a 2 sided t-test with a set alpha of 0.05 using Mann Whitney U looking for differences in time-in-department based on acuity level, disposition, and acuity level stratified by disposition. ^ Results. Among urgent and non-urgent patients, we found a statistically significant decrease in time-in-department in a pediatric emergency department. Urgent patients had a time-in-department that was 51 minutes shorter than patients seen on non-triage team days (p=0.007), which represents a 14% decrease in time-in-department. Non-urgent patients seen on triage team days had a time-in-department that was 24 minutes shorter than non-urgent patients seen on non-triage team days (p=0.009). From the disposition perspective, discharged patients seen on triage team days had a shorter time-in-department of 28 minutes as compared to those seen on non-triage team days (p=0.012). ^ Conclusion. Overall, there was a trend towards decreased time-in-department of 19 minutes (5.9% decrease) during triage team times. There was a statistically significant decrease in the time-in-department among urgent patients of 51 minutes (13.9% decrease) and among discharged patients of 28 minutes (8.4% decrease). Urgent care patients make up nearly a quarter of the emergency patient population and decreasing their time-in-department would likely make a significant impact on overall emergency flow.^

Factors that affect non-adherence to first line antiretroviral medications among HIV infected children and adolescents in Botswana

The aims of the study were to determine the prevalence of and factors that affect non-adherence to first line antiretroviral (ARV) medications among HIV infected children and adolescents in Botswana. The study used secondary data from Botswana-Baylor Children's Clinical Center of Excellence for the period of June 2008 to February 10th, 2010. The study design was cross-sectional and case-comparison between non-adherent and adherent participants was used to examine the effects of socio-demographic and medication factors on non-adherence to ARV medications. A case was defined as non-adherent child with adherence level < 95% based on pill count and measurement of liquid formulations. The comparison group consisted of children with adherence levels ≥95%.^ A total of 842 participants met the eligibility criteria for determination of the prevalence of non-adherence and 338 participants (169 cases and 169 individuals) were used in the analysis to estimate the effects of factors on non-adherence. ^ Univariate and multivariable logistic regression were used to estimate the association between non-adherence (outcome) and socio-demographic and medication factors (exposures). The prevalence of non-adherence for participants on first line ARV medications was 20.0% (169/842).^ Increase in age (OR (95% CI): 1.10 (1.04–1.17) p = 0.001) was associated with nonadherence, while increase in number of caregivers (OR (95% CI): 0.72 (0.56–0.93) p = 0.01) and increase in number of monthly visits (OR (95% CI): 0.92 (0.86–0.99) p = 0.02), were associated with good adherence in both the unadjusted and the adjusted models. For the categorical variables, having more than two caregivers (OR (95% CI): 0.66 (0.28–0.84), p = 0.002) was associated with good adherence even in the adjusted model. ^ Conclusion. The prevalence of non-adherence to antiretroviral medicines among the study population was estimated to be 20.0%. In previous studies, adherence levels of ≥ 95% have been associated with better clinical outcomes and suppression of virus to prevent development of resistance. Older age, fewer numbers of caregivers and fewer monthly visits were associated with non-adherence. Strategies to improve and sustain adherence especially among older children are needed. The role of caregivers and social support should be investigated further.^

Social network size and perceived network sufficiency as predictors of perceived health status

This study focused on the relationship between social network size (number of friends and relatives), perceived sufficiency of the network and self-rated health utilizing data from the National Survey of Personal Health Practices and Consequences, 1979. For men neither perceived sufficiency nor number of relatives were associated with self-rated health status. The number of friends was positively associated with health status. For women perceived network sufficiency was positively and significantly related to health status, independent of network size. The number of friends and relatives was not associated with self-rated health status. The sociodemographic variables accounted for most of the explained variance in health status for both males and females. Social networks may hold different meanings for women and men, and may require qualitative as well as quantitative analysis. There may have been insufficient variance in the major variables to produce meaningful results. ^

A low-latitude Upper Pleistocene oxygen isotope stack

Below oxygen isotope stage 16, the orbitally derived time-scale developed by Shackleton et al. (1990) from ODP site 677 in the equatorial Pacific differs significantly from previous ones (e.g. Kominz and Pisias, 1979 doi:10.1126/science.204.4389.171; Morley and Hays, 1981 doi:10.1016/0012-821X(81)90034-0, Imbrie et al. 1984), yielding estimated ages for the last Earth magnetic reversals that are 5-7% older than the K/Ar values (Mankinen and Dalrymple, 1979 doi:10.1029/JB084iB02p00615; Berggren et al., 1985; Harland and Armstrong, 1989) but are in good agreement with recent Ar/Ar dating (Baksi et al., 1991; 1992 doi:10.1126/science.256.5055.356; Spell and McDougall, 1992 doi:10.1029/92GL01125). These results suggest that in the lower Brunhes and upper Matuyama chronozones most deep-sea climatic records retrieved so far apparently missed or misinterpreted several oscillations predicted by the astronomical theory of climate. To test this hypothesis, we studied a high-resolution oxygen isotope record from giant piston core MD900963 (Maldives area, tropical Indian Ocean) in which precession-related oscillations in delta18O are particularly well expressed, owing to the superimposition of a local salinity signal on the global ice volume signal (Rostek et al., 1993 doi:10.1038/364319a0). Three additional precession-related cycles are observed in oxygen isotope stages 17 and 18 of core MD900963, compared to the SPECMAP composite curves (Imbrie et al., 1984; Prell et al., 1986 doi:10.1029/PA001i002p00137), and stage 21 clearly presents three precession oscillations, as predicted by Shackleton et al. (1990). The precession peaks found in the delta18O record from core MD900963 are in excellent agreement with climatic oscillations predicted by the astronomical theory of climate. Our delta18O record therefore permits the development of an accurate astronomical time-scale. Based on our age model, the Brunhes-Matuyama reversal is dated at 775 +/- 10 ka, in good agreement with the age estimate of 780 ka obtained by Shackleton et al. (1990) and recent radiochronological Ar/Ar datings on lavas (Baksi et al., 1991; 1992; Spell and McDougall, 1992). We developed a new low-latitude, Upper Pleistocene delta18O reference record by stacking and tuning the delta18O records from core MD900963 and site 677 to orbital forcing functions.

El hermetismo del mito de Adonis en la literatura británica

Si bien el termino Adonai o su variante Adonis en la mitología Griega remiten tanto a la divinidad Bíblica como a la mitología antigua e inclusive a los tratados filosóficos de Aristóteles o Spinoza, es curioso que el concepto haya sido personificado y alegorizado con tanta frecuencia en la literatura Anglófona, inclusive en textos cuya interpretación tradicional ha sido de carácter secular. La forma fragmentada en la que la crítica ha entendido el concepto Adonai en obras clásicas de escritores como Shakespeare, Spenser, Milton, Blake, Coleridge, Shelley, Bulwer, Joyce, T. S. Eliot, entre otros se convierte en el desencadenante de debates no solo literarios sino también filosóficos y religiosos como por ejemplo los desatados por la aparición de El Código Da Vinci (en su formato de novela y de película), en el que el concepto Adonai es recreado desde una perspectiva esotérica que invita a reconsiderar la concepción del mismo en los clásicos escritos siglos antes. Si el contacto que tuvieron Shelley, Shakespeare, Milton, Spenser, Bulwer, Blake y Joyce con la doctrina hermética les proporcionó el sustento simbólico y el imaginario alquímico de sus obras, entonces se puede afirmar que sus obras pueden condensar de manera alegórica el conocimiento que ellos tenían de las ciencias ocultas. Si el mito de Adonis alegóricamente recrea, de acuerdo al hermetismo, la caída sexual de Adonis, y a través de él la caída de la humanidad, entonces las obras analizadas aludirían a la debilidad carnal del ser humano. Si se puede descubrir una esencia arquetípica de Adonis en las obras estudiadas y asimismo detectarse un paralelismo en las ideas planteadas por la película norteamericana The Da Vinci Code, entonces es posible identificar analogías y relaciones entre los intereses artísticos e ideológicos presentes en ambas culturas.

“Dishonourable disobedience” – Why refusal to treat in reproductive healthcare is not conscientious objection

In medicine, the vast majority of conscientious objection (CO) is exercised within the reproductive healthcare field – particularly for abortion and contraception. Current laws and practices in various countries around CO in reproductive healthcare show that it is unworkable and frequently abused, with harmful impacts on women's healthcare and rights. CO in medicine is supposedly analogous to CO in the military, but in fact the two have little in common. This paper argues that CO in reproductive health is not actually Conscientious Objection, but Dishonourable Disobedience (DD) to laws and ethical codes. Healthcare professionals who exercise CO are using their position of trust and authority to impose their personal beliefs on patients, who are completely dependent on them for essential healthcare. Health systems and institutions that prohibit staff from providing abortion or contraception services are being discriminatory by systematically denying healthcare services to a vulnerable population and disregarding conscience rights for abortion providers. CO in reproductive healthcare should be dealt with like any other failure to perform one's professional duty, through enforcement and disciplinary measures. Counteracting institutional CO may require governmental or even international intervention.

Plutonium and americium concentrations in sea water and in sinking particles

Vertical fluxes of 239+240Pu and 241Am and temporal changes in their inventories in the northwestern Mediterranean Sea have been examined through high-resolution water column sampling coupled with direct measurements of the vertical flux of particle-bound transuranics using time-series sediment traps. Water column profiles of both radionuclides showed well-defined sub-surface maxima (2391240Pu between 100-400 m; 241Am at 100-200 m and 800 m), the depths of which are a result of the different biogeochemical scavenging behavior of the two radionuclides. Comparison of deep water column (0-2,000 m) transuranic inventories with those derived from earlier measurements demonstrate that the total 2391240Pu inventory had not substantially changed between 1976-1990 whereas 241Am had decreased by approximately 24%. Enhanced scavenging of 241Am and a resultant, more rapid removal from the water column relative to 239+240Pu was also supported by the observation of elevated Am/Pu activity ratios in sinking particles collected in sediment traps at depth. Direct measurements of the downward flux of particulate 239+240Pu and 241Am compared with transuranic removal rates derived from observed total water column inventory differences over time, show that particles sinking out of deep waters (1,000-2,000 m) could account for 26-72% of the computed total annual 239+240Pu loss and virtually all of the 241Am removal from the water column. Upper water column (0-200 m) residence times based on direct flux measurements ranged from 20-30 yr for 239+240Pu and 5-10 yr for 241Am. The observation that 241Am/239+240Pu activity ratios in unfiltered Mediterranean seawater are six times lower than those in the north Pacific suggests the existence of a specific mechanism for enhanced scavenging and removal of 241Am from the generally oligotrophic waters of the open Mediterranean. It is proposed that atmospheric inputs of aluminosilicate particles transported by Saharan dust events which frequently occur in the Mediterranean region could enhance the geochemical scavenging and resultant removal of 241Am to the sediments.

Spectral reflectance library of selected biotic and abiotic coral reef features in Glovers Reef, Belize

Underwater spectral reflectance was measured for selected biotic and abiotic coral reef features of Glovers Reef, Belize from March 6 - 10, 2005. Spectral reflectance's of 63 different benthic types were obtained in-situ. An Ocean Optics USB2000 spectrometer was deployed in an custom made underwater housing with a 0.5 m fiber-optic probe mounted next to an artificial light source. Spectral readings were collected with the probe (bear fibre) about 5 cm from the target to ensure that the target would fill the field of view of the fiber optic (FOV diameter ~4.4 cm), as well as to reduce the attenuating effect of the intermediate water (Roelfsema et al., 2006). Spectral readings included for one target included: 1 reading of the covered spectral fibre to correct for instrument noise, 1 reading of spectralon panel mounted on divers wrist to measure incident ambient light, and 8 readings of the target. Spectral reflectance was calculated for each target by first subtracting the instrument noise reading from each other reading. The corrected target readings were then divided by the corrected spectralon reading resulting in spectral reflectance of each target reading. An average target spectral reflectance was calculated by averaging the eight individual spectral reflectance's of the target. If an individual target spectral reflectance was visual considered an outlier, it was not included in the average spectral reflectance calculation. See Roelfsema at al. (2006) for additional info on the methodology of underwater spectra collection.