Identifying the challenges and facilitators of implementing a COPD care bundle.

BACKGROUND: Care bundles have been shown to improve outcomes, reduce hospital readmissions and reduce length of hospital stay; therefore increasing the speed of uptake and delivery of care bundles should be a priority in order to deliver more timely improvements and consistent high-quality care. Previous studies have detailed the difficulties of obtaining full compliance to bundle elements but few have described the underlying reasons for this. In order to improve future implementation this paper investigates the challenges encountered by clinical teams implementing a chronic obstructive pulmonary disease (COPD) care bundle and describes actions taken to overcome these challenges. METHODS: An initial retrospective documentary analysis of data from seven clinical implementation teams was undertaken to review the challenges faced by the clinical teams. Three focus groups with healthcare professionals and managers explored solutions to these challenges developed during the project. RESULTS: Documentary analysis identified 28 challenges which directly impacted implementation of the COPD care bundle within five themes; staffing, infrastructure, process, use of improvement methodology and patient and public involvement. Focus groups revealed that the five most significant challenges for all groups were: staff too busy, staff shortages, lack of staff engagement, added workload of the bundle and patient coding issues. The participants shared facilitating factors used to overcome issues including: shifting perceptions to improve engagement, further education sessions to increase staff participation and gaining buy-in from managers through payment frameworks. CONCLUSIONS: Maximising the impact of a care bundle relies on its successful and timely implementation. Teams implementing the COPD care bundle encountered challenges that were common to all teams and sites. Understanding and learning from the challenges faced by previous endeavours and identifying the facilitators to overcoming these barriers provides an opportunity to mitigate issues that waste time and resources, and ensures that training can be tailored to the anticipated challenges

A rival for Babcock's star: the extreme 30-kG variable magnetic field in the Ap star HD 75049

The extraordinary magnetic Ap star HD 75049 has been studied with data obtained with the European Southern Observatory Very Large Telescope and 2.2-m telescopes. Direct measurements reveal that the magnetic field modulus at maximum reaches 30 kG. The star shows photometric, spectral and magnetic variability with a rotation period of 4.049 d. Variations of the mean longitudinal magnetic field can be described to first order by a centred dipole model with an inclination i= 25°, an obliquity β= 60° and a polar field Bp= 42 kG. The combination of the longitudinal and surface magnetic field measurements implies a radius of R= 1.7 R⊙, suggesting that the star is close to the zero-age main sequence. HD 75049 displays moderate overabundances of Si, Ti, Cr, Fe and large overabundances of rare earth elements. This star has the second strongest magnetic field of any main-sequence star after Babcock's star, HD 215441, which it rivals

The magnetic fields of hot subdwarf stars

Detection of magnetic fields has been reported in several sdO and sdB stars. Recent literature has cast doubts on the reliability of most of these detections. We revisit data previously published in the literature, and we present new observations to clarify the question of how common magnetic fields are in subdwarf stars. We consider a sample of about 40 hot subdwarf stars. About 30 of them have been observed with the FORS1 and FORS2 instruments of the ESO VLT. Here we present new FORS1 field measurements for 17 stars, 14 of which have never been observed for magnetic fields before. We also critically review the measurements already published in the literature, and in particular we try to explain why previous papers based on the same FORS1 data have reported contradictory results. All new and re-reduced measurements obtained with FORS1 are shown to be consistent with non-detection of magnetic fields. We explain previous spurious field detections from data obtained with FORS1 as due to a non-optimal method of wavelength calibration. Field detections in other surveys are found to be uncertain or doubtful, and certainly in need of confirmation. There is presently no strong evidence for the occurrence of a magnetic field in any sdB or sdO star, with typical longitudinal field uncertainties of the order of 2-400 G. It appears that globally simple fields of more than about 1 or 2 kG in strength occur in at most a few percent of hot subdwarfs, and may be completely absent at this strength. Further high-precision surveys, both with high-resolution spectropolarimeters and with instruments similar to FORS1 on large telescopes, would be very valuable

The question of declining sperm density revisited: an analysis of 101 studies published 1934-1996.

In 1992 Carlsen et al. reported a significant global decline in sperm density between 1938 and 1990 [Evidence for Decreasing Quality of Semen during Last 50 Years. Br Med J 305:609-613 (1992)]. We subsequently published a reanalysis of the studies included by Carlsen et al. [Swan et al. Have Sperm Densities Declined? A Reanalysis of Global Trend Data. Environ Health Perspect 105:1228-1232 (1997)]. In that analysis we found significant declines in sperm density in the United States and Europe/Australia after controlling for abstinence time, age, percent of men with proven fertility, and specimen collection method. The declines in sperm density in the United States (approximately 1.5%/year) and Europe/Australia (approximately 3%/year) were somewhat greater than the average decline reported by Carlsen et al. (approximately 1%/year). However, we found no decline in sperm density in non-Western countries, for which data were very limited. In the current study, we used similar methods to analyze an expanded set of studies. We added 47 English language studies published in 1934-1996 to those we had analyzed previously. The average decline in sperm count was virtually unchanged from that reported previously by Carlsen et al. (slope = -0.94 vs. -0.93). The slopes in the three geographic groupings were also similar to those we reported earlier. In North America, the slope was somewhat less than the slope we had found for the United States (slope = -0.80; 95% confidence interval (CI), -1.37--0.24). Similarly, the decline in Europe (slope = -2.35; CI, -3.66--1.05) was somewhat less than reported previously. As before, studies from other countries showed no trend (slope = -0.21; CI, -2.30-1.88). These results are consistent with those of Carlsen et al. and our previous results, suggesting that the reported trends are not dependent on the particular studies included by Carlsen et al. and that the observed trends previously reported for 1938-1990 are also seen in data from 1934-1996

Physicians' Attitudes Toward Complementary and Alternative Medicine and Their Knowledge of Specific Therapies: A Survey at an Academic Medical Center

The purpose of this study was to evaluate the attitudes of physicians at an academic medical center toward complementary and alternative medicine (CAM) therapies and the physicians' knowledge base regarding common CAM therapies. A link to a Web-based survey was e-mailed to 660 internists at Mayo Clinic in Rochester, MN, USA. Physicians were asked about their attitudes toward CAM in general and their knowledge regarding specific CAM therapies. The level of evidence a physician would require before incorporating such therapies into clinical care was also assessed. Of the 233 physicians responding to the survey, 76% had never referred a patient to a CAM practitioner. However, 44% stated that they would refer a patient if a CAM practitioner were available at their institution. Fifty-seven percent of physicians thought that incorporating CAM therapies would have a positive effect on patient satisfaction, and 48% believed that offering CAM would attract more patients. Most physicians agreed that some CAM therapies hold promise for the treatment of symptoms or diseases, but most of them were not comfortable in counseling their patients about most CAM treatments. Prospective, randomized controlled trials were considered the level of evidence required for most physicians to consider incorporating a CAM therapy into their practice. The results of this survey provide insight into the attitudes of physicians toward CAM at an academic medical center. This study highlights the need for educational interventions and the importance of providing physicians ready access to evidence-based information regarding CAM

The first evidence for multiple pulsation axes: a new roAp star in the Kepler field, KIC 10195926

We have discovered a new rapidly oscillating Ap star among the Kepler Mission target stars, KIC 10195926. This star shows two pulsation modes with periods that are amongst the longest known for roAp stars at 17.1 min and 18.1 min, indicating that the star is near the terminal age main sequence. The principal pulsation mode is an oblique dipole mode that shows a rotationally split frequency septuplet that provides information on the geometry of the mode. The secondary mode also appears to be a dipole mode with a rotationally split triplet, but we are able to show within the improved oblique pulsator model that these two modes cannot have the same axis of pulsation. This is the first time for any pulsating star that evidence has been found for separate pulsation axes for different modes. The two modes are separated in frequency by 55 microHz, which we model as the large separation. The star is an alpha^2 CVn spotted magnetic variable that shows a complex rotational light variation with a period of Prot = 5.68459 d. For the first time for any spotted magnetic star of the upper main sequence, we find clear evidence of light variation with a period of twice the rotation period; i.e. a subharmonic frequency of $\nu_{\rm rot}/2$. We propose that this and other subharmonics are the first observed manifestation of torsional modes in an roAp star. From high resolution spectra we determine Teff = 7400 K, log g = 3.6 and v sin i = 21 km/s. We have found a magnetic pulsation model with fundamental parameters close to these values that reproduces the rotational variations of the two obliquely pulsating modes with different pulsation axes. The star shows overabundances of the rare earth elements, but these are not as extreme as most other roAp stars. The spectrum is variable with rotation, indicating surface abundance patches.Comment: 17 pages; 16 figures; MNRA

Fast Distributed Approximation for Max-Cut

Finding a maximum cut is a fundamental task in many computational settings. Surprisingly, it has been insufficiently studied in the classic distributed settings, where vertices communicate by synchronously sending messages to their neighbors according to the underlying graph, known as the $\mathcal{LOCAL}$ or $\mathcal{CONGEST}$ models. We amend this by obtaining almost optimal algorithms for Max-Cut on a wide class of graphs in these models. In particular, for any $\epsilon > 0$, we develop randomized approximation algorithms achieving a ratio of $(1-\epsilon)$ to the optimum for Max-Cut on bipartite graphs in the $\mathcal{CONGEST}$ model, and on general graphs in the $\mathcal{LOCAL}$ model. We further present efficient deterministic algorithms, including a $1/3$-approximation for Max-Dicut in our models, thus improving the best known (randomized) ratio of $1/4$. Our algorithms make non-trivial use of the greedy approach of Buchbinder et al. (SIAM Journal on Computing, 2015) for maximizing an unconstrained (non-monotone) submodular function, which may be of independent interest

The symbiotic star CH Cygni – II. The ejecta from the 1998-2000 active phase

We present Hubble Space Telescope (HST) imaging, a Very Large Array (VLA) radio map (4.74 GHz), optical high-resolution (echelle) spectroscopy and UBV photoelectric photometry of the symbiotic star CH Cyg obtained during its 1998–2000 active phase. The HST imaging, taken during eclipse, shows the central stars are embedded in a nebula extending to 620 ± 150 au for a distance of 270 ± 66 pc. The inner nebula is strongly influenced by the onset of activity and associated outflow in 1998. The surface brightness contours of the contemporaneous radio VLA observation agree well with HST images. Photometric observations of the broad 1999 U-minimum suggest that it is due to the eclipse of the active hot component by the giant on the long-period (14.5 yr) outer orbit. We also find that the onset of the 1998 and the 1992 active periods occur at the same orbital phase of the inner binary. Spectroscopic observations reveal two types of outflow from the active star: a high-velocity (>1200 km s−1) hot star wind sporadically alternating with a more massive outflow indicated by P-Cygni-like profiles. We present evidence connecting the extended nebulosity with the high-velocity shocked outflow, and hence the activity in the central binary

Towards Addressing the Opportunities and Challenges of Web 2.0 for Health and Informatics

Objective: To provide an overview of Web 2.0 and Health 2.0, and so facilitate a widespread discussion of the nature of these concepts and their possible application within the health domain, and implications for health and biomedical informatics and for IMIA. Methods: IMIA, the International Medical Informatics Association, has established a Web 2.0 Exploratory Taskforce to bring together interested individuals from within and outside IMIA to explore the nature and potential of Web 2.0 applications. The Taskforce aims to develop background materials and sample uses of Web 2.0 applications, so as to propose specific lines of action for the IMIA Board and General Assembly. This paper provides a brief overview of Web 2.0 and related concepts, and examples of general and healthspecific Web 2.0 applications. Some examples of the issues, challenges and opportunities are introduced, to set the scene for a wider dialogue on if, how, and how best, IMIA, and the wider health and informatics communities, should use these new applications and approaches. Results and conclusions: This brief paper provides an introduction to, and overview of, the many issues involved in considering the application of Web 2.0 to health and informatics. All interested individuals and organisations are invited to use this as a starting point for engaging in wider discussion and contributing to the Taskforce and to IMIA\u27s future. Keywords IMIA, health informatics, medical informatics,IA,