Review of: Erin Dominique Williams & Leo van der Reis, Health Care at the Abyss: Managed Care vs. The Goals of Medicine (1997)

Review of the book: Erin Dominique Williams & Leo van der Reis, Health Care at the Abyss: Managed Care vs. The Goals of Medicine (William S. Hein 1997). About the authors, acknowledgments, figures, index, preface, references, table of abbreviations. ISBN 1-57588-201-9 [242 pp. Paper.

Telehealth and Physical Therapy Clinical Decision Making in a Patient with a Falcine Meningioma

Telehealth utilizes information technologies and communication networks to deliver healthcare and education with lower costs and improved access, quality, and efficiency of healthcare services.  This report describes the application of telehealth for medical screening, clinical decision making, and medical referral in a physical therapy practice. The patient described was a 50-year old man who contacted his physical therapist via telephone for a chief complaint of worsening left sided numbness and tingling that began insidiously 2 days prior.  Further questioning revealed that the patient also complained of left ankle weakness, and slight unsteadiness with walking. He had not been feeling well and had been experiencing increasing bouts of unexplained fatigue over the previous two months that were now interfering with his work and recreational activities. The patient was evaluated by his physician the next day.  Magnetic resonance imaging of the brain revealed a large (4 cm) falcine meningioma in the right parietal region.  The patient was immediately referred to a neurosurgeon and underwent a craniotomy and tumor resection ten days later and subsequent gamma knife radiosurgery of the residual tumor bed two months after craniotomy and tumor resection.  Follow-up imaging one year later revealed no evidence of recurrence or residual tumor.  This patient case underscores the importance of recognizing signs and symptoms of serious disease, and how referral following telehealth via telephone can inform diagnosis

Preparation of an Electrophilic 3-Methylindole Derivative: Difficulties in Forming a Stable, Suitable Material for the Preparation of Tryptophan

In an attempt to prepare stereoselectively beta-deuterated tryptophan, N-protected indole-3-methanol compounds were prepared with model studies being done on undeuterated material. Conversion of these compounds to electrophilic species proved exceptionally difficult and resulted in very low yields or recovered starting material only. A summary of the current results utilizing N-tosyl indole-3-methanol will be presented as well as efforts using N-Boc indole-3-methanol

Diagnosis of Internal Carotid Artery Stenosis in a Patient Referred to a Physiotherapist for Dizziness

PURPOSE: The purpose of this report is to describe the diagnostic focus of the clinical decision-making process for a patient referred to a physiotherapist for treatment of persistent dizziness, who was subsequently diagnosed with severe stenosis of the internal carotid arteries. CASE DESCRIPTION: The patient was a 79-year-old man who was referred to a physiotherapist by his primary care physician for the treatment of persistent intermittent dizziness. The patient’s dizziness began 6 months prior insidiously; it was worsening over time and now interfered with activities of daily living. The patient denied cervical pain or headaches, numbness or tingling in his extremities, difficulty maintaining balance with walking, unsteadiness, muscle weakness, dysphagia, drop attacks, diplopia or dysarthria. At the physiotherapist’s initial evaluation, cervical range of motion was moderately restricted in all motions and his dizziness was elicited with changes in head position. The patient’s neurological examination was unremarkable. Due to positional complaints of dizziness, a Dix–Hallpike test was used to screen for benign paroxysmal positional vertigo, which was positive for symptoms reproduction; however, no nystagmus was noted. The patient also became diaphoretic and exhibited significant discoloration of his face during the test. OUTCOMES: Due to concern over vascular compromise, carotid duplex ultrasonography and magnetic resonance angiography were completed and revealed near complete occlusion of the left internal carotid artery at its origin. The patient subsequently underwent a left internal carotid endarterectomy with resolution of symptoms and a return to all activities of daily living. DISCUSSION: Carotid artery stenosis, although frequently asymptomatic until severe, may manifest as complaints of dizziness that mimic peripheral vestibular dysfunction. Appropriate and prudent screening and referral is necessary if clinical symptoms suggestive of vascular compromise are present

Menu Planning and Grocery Shopping for People Living with Psychiatric Disabilities

Introduction: •The HowardCenter in Burlington, Vermont is designed to empower and improve the lives of individuals with mental illness throughout Chittenden County. •People living with chronic psychiatric disabilities have higher mortality rates and earlier onset of medical illness. It has been observed that many of the risk factors for chronic conditions revolve around nutrition, implying a chance to intervene. •Understanding the various ways people with psychiatric disabilities eat, buy, cook, and value a healthy diet is fundamental for the Howard Center to address increased mortality in this population. •Our goal is to identify barriers and develop a resource to improve nutrition in this population.https://scholarworks.uvm.edu/comphp_gallery/1054/thumbnail.jp

NuSTAR Observations of the Magnetar 1E 2259+586

We report on new broad band spectral and temporal observations of the magnetar 1E 2259+586, which is located in the supernova remnant CTB 109. Our data were obtained simultaneously with the Nuclear Spectroscopic Telescope Array (NuSTAR) and Swift, and cover the energy range from 0.5-79 keV. We present pulse profiles in various energy bands and compare them to previous RXTE results. The NuSTAR data show pulsations above 20 keV for the first time and we report evidence that one of the pulses in the double-peaked pulse profile shifts position with energy. The pulsed fraction of the magnetar is shown to increase strongly with energy. Our spectral analysis reveals that the soft X-ray spectrum is well characterized by an absorbed double-blackbody or blackbody plus power-law model in agreement with previous reports. Our new hard X-ray data, however, suggests that an additional component, such as a power-law, is needed to describe the NuSTAR and Swift spectrum. We also fit the data with the recently developed coronal outflow model by Beloborodov for hard X-ray emission from magnetars. The outflow from a ring on the magnetar surface is statistically preferred over outflow from a polar cap.Comment: 37 pages, 9 figures, corresponding author, [email protected]

First test results from a high-resolution CdZnTe pixel detector with VLSI readout

We are developing a CdZnTe pixel detector with a custom low- noise analog VLSI readout for use in the High-Energy Focusing Telescope balloon experiment, as well as for future space astronomy applications. The goal of the program is to achieve good energy resolution (< 1 keV FWHM at 60 keV) and low threshold in a sensor with approximately 500 micrometers pixels. We have fabricated several prototype detector assemblies with 2 mm thick, 680 by 650 micrometers pitch CdZnTe pixel sensors indium bump bonded a VLSI readout chip developed at Caltech. Each readout circuit in the 8 X 8 prototype is matched to the detector pixel size, and contains a preamplifier, shaping amplifiers, and a peak stretcher/discriminator. In the first 8 X 8 prototype, we have demonstrated the low-noise preamplifier by routing the output signals off-chip for shaping and pulse-height analysis. Pulse height spectra obtained using a ^(241)Am source, collimated to illuminate a single pixel, show excellent energy resolution of 1.1 keV FWHM for the 60 keV line at room temperature. Line profiles are approximately Gaussian and dominated by electronic noise, however a small low energy tail is evident for the 60 keV line. We obtained slightly improved resolution of 0.9 keV FWHM at 60 keV by cooling the detector to 5 degree(s)C, near the expected balloon- flight operating temperature. Pulse height spectra obtained with the collimated source positioned between pixels show the effect of signal sharing for events occurring near the boundary. We are able to model the observed spectra using a Monte-Carlo simulation that includes the effects of photon interaction, charge transport and diffusion, pixel and collimator geometry, and electronic noise. By using the model to simulate the detector response to uncollimated radiation (including the effect of finite trigger threshold for reconstruction of the total energy of multi-pixel events), we find the energy resolution to be degraded by only 10% for full-face illumination, compared to the collimated case. The small value of the degradation is due directly to the low readout noise and amplifier threshold

Challenges of Population-based Measurement of Suicide Prevention Activities Across Multiple Health Systems

Suicide is a preventable public health problem. Zero Suicide (ZS) is a suicide prevention framework currently being evaluated by Mental Health Research Network investigators embedded in six Health Care Systems Research Network (HCSRN) member health systems implementing ZS. This paper describes ongoing collaboration to develop population-based process improvement metrics for use in, and comparison across, these and other health systems. Robust process improvement metrics are sorely needed by the hundreds of health systems across the country preparing to implement their own best practices in suicide care. Here we articulate three examples of challenges in using health system data to assess suicide prevention activities, each in ascending order of complexity: 1) Mapping and reconciling different versions of suicide risk assessment instruments across health systems; 2) Deciding what should count as adequate suicide prevention follow-up care and how to count it in different health systems with different care processes; and 3) Trying to determine whether a safety planning discussion took place between a clinician and a patient, and if so, what actually happened. To develop broadly applicable metrics, we have advocated for standardization of care processes and their documentation, encouraged standardized screening tools and urged they be recorded as discrete electronic health record (EHR) variables, and engaged with our clinical partners and health system data architects to identify all relevant care processes and the ways they are recorded in the EHR so we are not systematically missing important data. Serving as embedded research partners in our local ZS implementation teams has facilitated this work

The Nuclear Spectroscopic Telescope Array (NuSTAR)

The Nuclear Spectroscopic Telescope Array (NuSTAR) is a NASA Small Explorer mission that will carry the first focusing hard X-ray (5 -- 80 keV) telescope to orbit. NuSTAR will offer a factor 50 -- 100 sensitivity improvement compared to previous collimated or coded mask imagers that have operated in this energy band. In addition, NuSTAR provides sub-arcminute imaging with good spectral resolution over a 12-arcminute field of view. After launch, NuSTAR will carry out a two-year primary science mission that focuses on four key programs: studying the evolution of massive black holes through surveys carried out in fields with excellent multiwavelength coverage, understanding the population of compact objects and the nature of the massive black hole in the center of the Milky Way, constraining explosion dynamics and nucleosynthesis in supernovae, and probing the nature of particle acceleration in relativistic jets in active galactic nuclei. A number of additional observations will be included in the primary mission, and a guest observer program will be proposed for an extended mission to expand the range of scientific targets. The payload consists of two co-aligned depth-graded multilayer coated grazing incidence optics focused onto solid state CdZnTe pixel detectors. To be launched in early 2012 on a Pegasus rocket into a low-inclination Earth orbit. Data will be publicly available at GSFC's High Energy Astrophysics Science Archive Research Center (HEASARC) following validation at the science operations center located at Caltech.Comment: 9 pages, 5 figures, to appear in Proceedings of the SPIE, Space Telescopes and Instrumentation 2010: Ultraviolet to Gamma Ra

NuSTAR Spectroscopy of Multi-Component X-ray Reflection from NGC 1068

We report on observations of NGC1068 with NuSTAR, which provide the best constraints to date on its $>10$~keV spectral shape. We find no strong variability over the past two decades, consistent with its Compton-thick AGN classification. The combined NuSTAR, Chandra, XMM-Newton, and Swift-BAT spectral dataset offers new insights into the complex reflected emission. The critical combination of the high signal-to-noise NuSTAR data and a spatial decomposition with Chandra allow us to break several model degeneracies and greatly aid physical interpretation. When modeled as a monolithic (i.e., a single N_H) reflector, none of the common Compton-reflection models are able to match the neutral fluorescence lines and broad spectral shape of the Compton reflection. A multi-component reflector with three distinct column densities (e.g., N_H~1.5e23, 5e24, and 1e25 cm^{-2}) provides a more reasonable fit to the spectral lines and Compton hump, with near-solar Fe abundances. In this model, the higher N_H components provide the bulk of the Compton hump flux while the lower N_H component produces much of the line emission, effectively decoupling two key features of Compton reflection. We note that ~30% of the neutral Fe Kalpha line flux arises from >2" (~140 pc), implying that a significant fraction of the <10 keV reflected component arises from regions well outside of a parsec-scale torus. These results likely have ramifications for the interpretation of poorer signal-to-noise observations and/or more distant objects [Abridged].Comment: Submitted to ApJ; 23 pages (ApJ format); 11 figures and 3 tables; Comments welcomed