Effect of a Clinical Evidence Technology on Patient Skin Disease Outcomes in Primary Care: A Cluster-Randomized Controlled Trial

Objective: Providers’ use of clinical evidence technologies (CETs) improves their diagnosis and treatment decisions. Despite these benefits, few studies have evaluated the impact of CETs on patient outcomes. Investigators evaluated the effect of one CET, VisualDx, on skin problem outcomes in primary care. Methods: The cluster-randomized controlled pragmatic trial was set in outpatient clinics at an academic medical center in the Northeast. Participants were Primary Care Providers (PCPs) and adult patients seen for skin problems. The intervention was VisualDx as used by PCPs. Outcomes were patient-reported time from index clinic visit to problem resolution, and the number of follow-up visits to any provider for the same problem. PCPs assigned to intervention agreed to use VisualDx as their primary evidence source for skin problems. Control group PCPs agreed not to use VisualDx. Investigators collected outcome data from patients by phone at 30 day intervals. Cox proportional hazards models assessed time to resolution. Wilcoxon-rank sum tests and logistic regression compared return appointments. Results: Thirty-two PCPs and 433 patients participated. In proportional hazards modelling adjusted for provider clusters, the days from index visit to skin problem resolution were similar in both groups (HR 0.92; CI 0.70, 1.21 P= 0.54). Patient follow-up appointments did not differ significantly between groups (OR 1.26 95% CI 0.94, 1.70 P =0.29). Conclusion: This pragmatic trial tested the effectiveness of VisualDx on patient reported skin disease outcomes in a generalizable clinical setting. There was no difference in skin problem resolution or number of follow-up visits when PCPs used VisualDx

Assisting Elders with Dementia in Residential Settings through Music Therapy: A Literature Review

Dementia is one of the most prevalent diagnoses for elders causing strain and debilitation of their social, mental, physical, emotional, behavioral and psychological faculties. Due to the nature of this condition, treatments for dementia have been structured to aid and improve the well-being and quality of life for those afflicted. Some of the goals that assisted-living services establish include reducing anxiety, increasing levels of comfort, improving mood, memory care and bettering verbal processing. Music therapy has been an intervention that assists with establishing these goals and implementing strategies resulting in short-term and long-term effects for those receiving treatment for dementia. This paper explored how the literature based on music therapy for elders with dementia has been defined and evolved over time and what could be done to explore more social aspects of the work within an assisted-living setting on many levels (i.e. peer to peer, client to therapist, client to assisted living staff). The literature detailed the results from studies that have explored short-term and long-term effects of music therapy and the varying theoretical approaches developed and implemented. Additionally, the literature presented describe how music therapy treatments are introduced to programs seeking out non-pharmacological measures to treat elders with dementia. In so doing, music therapy is presented as assisting elders to be individually empowered through use and acknowledgement of their personal narratives as well as socially empowered through efforts of clients working and interacting with one another in the same setting along with staff and caregivers who work to improve their lives

Positron emission tomography imaging agents with gallium-68 : bifunctional chelators and multimodality

Positron emission tomography (PET) as a nuclear medicine technique offers very high sensitivity compared with other imaging modalities. PET is often combined with computed tomography (CT) to offer structural information. Incorporation of a positron emitting metal radioisotope such as 68Ga requires a bifunctional chelator (BFC) to form a stable complex in vivo and for covalent bond formation (conjugation) with a targeting moiety. In this work, the routinely used macrocyclic BFC DOTA has been modified to replace an acetate arm with a benzimidazole unit to give an alternative BFC structure. It does not affect coordination number, has a secondary amine for bioconjugation and is a chromophore, therefore increasing the number of potential applications beyond DOTA to include optical properties (fluorescence and lanthanide luminescence sensitisation). Four benzimidazole DO3A derivatives have been synthesised and radiolabelled with 68Ga in comparable radiochemical yields to the structurally similar DOTA. Reaction conditions of ca. 5 minutes at room temperature are shorter and milder than those required for DOTA, which can cause degradation of conjugated biomolecules.Magnetic resonance imaging (MRI) can replace CT as the structural partner in clinical PET imaging and has many advantages including the potential for use of MRI contrast agents. PET/MRI is an emerging field and there is scope for the development of multimodal imaging constructs combining a PET radioisotope with a MRI contrast agent. In this work, super-paramagnetic iron oxide nanoparticles (SPIONs) as T2 MRI contrast agents have been functionalised with a range of macrocyclic derivatives and radiolabelled with 68Ga in near quantitative yields to form PET/MRI multi-modal imaging agents which have been shown to be stable to EDTA competition and in serum over four hours. Modification of the surface of the SPIONs was shown to have no detrimental effect to their clinical applicability by size variation (aggregation).The use of the chelators synthesised in the work for other applications is also of interest, with preliminary studies carried out towards the development of 86Y and 90Y agents for PET and radioimmunotherapy respectively. Benzimidazole DO3A, along with the corresponding yttrium(III) and europium(III) complexes were studied by potentiometric titration, luminescent lifetime measurements and variable temperature NMR to fully characterise the coordination sphere and gain insight into their physicochemical characteristics

Measurement of ultra-thin film fracture by nano-indentation: a numerical study

As the individual layers of interconnect structures decrease in size, it becomes increasingly difficult to determine the fracture toughness, and hence the reliability, of these layers. After a layer is thinner than ~500nm, it becomes difficult to determine the fracture toughness directly with traditional methods. Using nano-indentation, it is possible to extract the cohesive and adhesive fracture energies of these films without elaborate experimental setups. There are, however, several issues with this approach. Nano-indentation creates cracks both within the film (the cohesive cracks) and between the film and the substrate (the adhesive cracks) as well as significant plastic deformation of the film and substrate. Using SIMULA Abaqus Standard, a commercial finite element analysis tool, 2D and 3D models were created to examine the deformation characteristics associated with the nano-indentation process. The models either have pre-existing stationary cracks, or simulated by cohesive zone surfaces to account for crack nucleation and growth. The 2D model is axi-symmetric and only accounts for the adhesive crack. It is used primarily as a test the cohesive zone model and to begin to determine experimental testing limits. The 3D model is a one sixth slice of the area indented. Both cohesive and adhesive cracks are modeled and the interaction between the two cracks is investigated. While there are many parameters controlling the crack initiation and propagation process, several trends were identified. The domain of practical testing should be between one and three film thickness, so as to avoid the confluence of the indenter plastic process zone on the propagating crack front. When excursion on the load-indentation depth happens, the fracture energy is about 20% of the associated work done by the indenter (or the area under the excursion segment). The FEM simulation showed the general role of film thickness, toughness and modulus on the initiation and propagation of both cohesive and adhesive cracks. Though, there remains to be many other geometric attributes of the thin film fracture process that requires additional investigations

Master of Arts

thesisIn this work, I deal with the question of how one ought to live and raise children in the context; of environmental catastrophe. I tell several stories about my experiences as a Peace Corps volunteer in The Republic of Kiribati and about the process of becoming a father. I find that while disasters like climate change are too far advanced for human beings to avoid some very disturbing consequences, we can, through storytelling, deal with those losses by making sure they are not forgotten. I conclude that personal stories about fear, loss, tragedy and hope are part of the process of healing wounds inflicted by tragedy and that it is imperative that these stories be passed on to younger generations lest they lose their capacity for empathy

Language Style Matching in Older Couples and Marital Satisfaction

Research on marital communication has focused on nonverbal behaviors (e.g., affect), leaving specific word use relatively unexplored. Recent work, however, suggests that similarity in function words (e.g., articles) may be associated with relational functioning in younger couples. We explored if this language style matching (LSM) also occurred in more established relationships and whether it was related to marital satisfaction within a sample of 64 older adult married couples. Using a dyadic, two-wave, observational research design, our results suggest that LSM is highly prevalent in older couples’ conversations across three different tasks (reminiscence, problem solving, and health support). Only LSM during reminiscence, however, was related to wives’ concurrent marital satisfaction. We considered implications for future research and for potential clinical interventions targeting language and communication in older adults

Barriers and Facilitators to Use of a Clinical Evidence Technology for Management of Skin Problems in Primary Care: Insights from Mixed Methods

Background: A previous cluster-randomized controlled trial tested the effectiveness of a clinical evidence technology (CET), VisualDx, for skin problems seen by Primary Care Providers (PCPs). Based on patient report, there was no effect on time to problem resolution or return appointments. Objective: To explain, from the provider perspective, why the CET did not make a difference in the clinical trial and to identify barriers and facilitators to use. Methods: Mixed methods study design. Providers from both arms completed a survey about their use of VisualDx and information-seeking during and after the trial. Active arm providers participated in interviews to explore their opinions and experiences using VisualDx. Behavioral steps of the evidence-based medicine (EBM) paradigm informed the 6 step model. Results: PCPs found VisualDx easy to use (median 3 on a 1-4 scale), but found it only somewhat useful (median 2 on a 1-4 scale). PCPs with fewer years in practice used it more often and found it easier to use. Interviews identified facilitators and barriers to using VisualDx. Facilitators included diagnostic uncertainty, positive attitude, easy access, utility for diagnosis and therapy decisions, and utility for patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulty, and retrieval of irrelevant diagnoses and images. Some PCPs reported positive impacts on patient treatment and fewer referrals; others saw no difference. PCPs found VisualDx easy to access, but some found the interface difficult to use. They found it useful and relevant at times, but also frustrating and time-consuming. They used other sources in addition to, or instead of, VisualDx. Conclusion: PCPs did not perceive VisualDx as “useful” often enough for them to use it frequently or exclusively, thereby reducing the likelihood of its making a difference in patient-level outcomes such as problem resolution and return appointments

Barriers and Facilitators to Use of a Clinical Evidence Technology in the Management of Skin Problems in Primary Care: Insights from Mixed Methods

Objective: Few studies have examined the impact of a single clinical evidence technology (CET) on provider practice or patient outcomes from the provider’s perspective. A previous cluster-randomized controlled trial with patient-reported data tested the effectiveness of a CET (i.e., VisualDx) in improving skin problem outcomes but found no significant effect. The objectives of this follow-up study were to identify barriers and facilitators to the use of the CET from the perspective of primary care providers (PCPs) and to identify reasons why the CET did not affect outcomes in the trial. Methods: Using a convergent mixed methods design, PCPs completed a post-trial survey and participated in interviews about using the CET for the management of patients’ skin problems. Data from both methods were integrated. Results: PCPs found the CET somewhat easy to use but only occasionally useful. Less experienced PCPs used the CET more frequently. Data from interviews revealed barriers and facilitators at four steps of evidence-based practice: clinical question recognition, information acquisition, appraisal of relevance, and application with patients. Facilitators included uncertainty in dermatology, intention for use, convenience of access, diagnosis and treatment support, and patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulties, presence of irrelevant information, and lack of decision impact. Conclusion: PCPs found the CET useful for diagnosis, treatment support, and patient communication. However, the barriers of interface difficulties, irrelevant search results, and preferred use of other sources limited its positive impact on patient skin problem management

Mindset Matters: Developing a Growth Mindset to Reframe Failure in Libraries

The theory of the growth mindset was first described by Stanford psychology professor Carol Dweck and is an emerging concept within the field of education. It is now also being applied to business theory. Those with a growth mindset hold the belief that intelligence can be developed, leading to a desire to learn and a tendency to embrace challenges, persist in the face of setback, see effort as a path to mastery, learn from criticism and find lessons and inspiration in other’s successes. As a result, they continually reach higher levels of achievement and a greater sense of free will. In contrast, those with a fixed mindset hold the belief that intelligence is static, leading to a desire to look smart and therefore a tendency to avoid challenges, give up easily, see effort as fruitless, ignore useful (but negative) feedback, and feel threatened by the success of others. As a result of this deterministic view, they may plateau early and not achieve their full potential. This poster highlights a successful internal professional development activity that introduced the concept of developing a growth mindset within the library. The program was created and facilitated through a collaboration between a librarian and a library administrator and used a combination of a flipped lesson plan and active learning. The application of the growth mindset in library management is new, and the presenters felt that exploring the differences between the growth and fixed mindsets would be useful to our organization, which was in a significant state of change. Our goal was to provide a useful model to our colleagues which could help them to understand that change is a process and in doing so, help them to be more understanding of each other as we learn and grow as an organization. Furthermore, the growth mindset has application to the conference theme because it provides a model that can help libraries not to be ashamed of challenges, setbacks and failures but to use them as learning opportunities. A key attribute of those who hold a growth mindset is the ability to view failure honestly and as a challenge to strive forward. By changing the way our library thinks about setbacks, we hope to encourage risk taking, open communication, and the delivery and reception of constructive criticism. The poster will help attendees to: Understand the differences between the growth and fixed mindsets Learn the benefits of developing a growth mindset Plan a simple, practical way to introduce the growth mindset to their organization