Resuming hip and knee arthroplasty after COVID-19: ethical implications for wellbeing, safety and the economy

Reinstating elective hip and knee arthroplasty services presents significant challenges. We need to be honest about the scale of the obstacles ahead and realise that the health challenges and economic consequences of the COVID-19 pandemic are potentially devastating. We must also prepare to make difficult ethical decisions about restarting elective hip and knee arthroplasty. These decisions should be based on the existing evidence-base, reliable data, the recommendations of experts, and regional circumstance

Depressive symptoms and emotion regulation strategies in children with and without developmental language disorder: a longitudinal study

BACKGROUND: Depressive symptoms are common in children with developmental language disorder (DLD). However, risk and protective factors contributing to these problems are currently underspecified. AIMS: The current longitudinal study examined the role of emotion-regulation (ER) strategies in the severity of depressive symptoms in children with and without DLD, taking into account the severity of communication problems of children with DLD. METHODS & PROCEDURES: We followed clinically referred children with DLD (n = 114, 49% girls) and without DLD (n = 214, 58% girls) between the ages of 8 and 16 years across an 18-month period. Participants completed self-report questionnaires at three time points. Parents of children with DLD reported on their child's communication problems. OUTCOMES & RESULTS: Multilevel analyses confirmed higher levels of depressive symptoms in youngsters with DLD compared with peers without DLD, with a decrease across time in the DLD group. In both groups, higher levels of approach and increasing avoidant strategies aimed at distraction or trivializing a problem explained lower depressive symptoms, whereas more worry and externalizing strategies contributed to more depressive symptoms. Within the DLD group, semantic language problems were associated with higher depressive symptoms. However, this relation was mediated by the tendency to worry or use externalizing strategies. CONCLUSIONS & IMPLICATIONS: Results suggest that interventions for children with DLD should focus on enhancing their adaptive ER strategies to help them cope with daily stressors just as in the general population

Decreasing Corn Particle Size Increases Metabolizable Energy When Fed to Gestating Sows

Previous research has demonstrated that reducing the particle size of corn improved metabolizable energy (ME) utilization in many phases of swine production. One phase that has had limited research thus far is the gestating phase for sows. The objectives of this paper were to determine the effects of corn particle size on the digestibility of gross energy (GE), and determine the digestible energy (DE) and ME in gestating sow diets. A total of 27 sows during the second phase of gestation (d 40 to 74) were chosen and fed a common diet with corn ground to 1 of 3 target average particle sizes (geometric mean diameter; dgw) of 400, 800, or 1200 μm. Corn was ground using a 3 high roller mill (RMS model 924). Titanium dioxide (0.25%) was included in the diet as an indigestible marker for index digestibility calculations. Sows were fed experimental diets for 7 d to allow for diet adaptation before a 2-d collection period. At the beginning of the collection period, sows were fitted with a urinary catheter and urine was collected in buckets containing 20 mL of sulfuric acid. Fecal grab samples were also collected from each sow during the collection period. Subsamples were taken, mixed, analyzed for GE, and titanium levels to determine digestibility of gross energy and to calculate DE and ME. The ME of corn was calculated by subtracting the ME of soybean meal (1,494 kcal/lb) and soybean oil (3,889 kcal/lb) from diet ME, utilizing the NRC 2012 values for those ingredients. Apparent total tract digestibility (ATTD) of GE and calculated DE, ME, and corn ME content increased (linear, P \u3c 0.001) as corn particle size was reduced from 1200 to 400 μm. The ME of the diet (88.5% DM) increased by 81 kcal/lb as the dgw was reduced from 1,200 to 400 μm. The calculated corn ME (88.5% DM) also increased by 103 kcal/lb as the dgw was reduced from 1,200 to 400 μm. Utilizing a linear regression model and the analyzed corn particle size data herein, it was determined that for every 100 μm reduction in corn dgw from 1,372 to 404 μm, the ME value of corn is increased by 10.7 kcal/lb

Decreasing Corn Particle Size Increases Metabolizable Energy When Fed to Gestating Sows

Previous research has demonstrated that reducing the particle size of corn improved metabolizable energy (ME) utilization in many phases of swine production. One phase that has had limited research thus far is the gestating phase for sows. The objectives of this paper were to determine the effects of corn particle size on the digestibility of gross energy (GE), and determine the digestible energy (DE) and ME in gestating sow diets. A total of 27 sows during the second phase of gestation (d 40 to 74) were chosen and fed a common diet with corn ground to 1 of 3 target average particle sizes (geometric mean diameter; dgw) of 400, 800, or 1200 μm. Corn was ground using a 3 high roller mill (RMS model 924). Titanium dioxide (0.25%) was included in the diet as an indigestible marker for index digestibility calculations. Sows were fed experimental diets for 7 d to allow for diet adaptation before a 2-d collection period. At the beginning of the collection period, sows were fitted with a urinary catheter and urine was collected in buckets containing 20 mL of sulfuric acid. Fecal grab samples were also collected from each sow during the collection period. Subsamples were taken, mixed, analyzed for GE, and titanium levels to determine digestibility of gross energy and to calculate DE and ME. The ME of corn was calculated by subtracting the ME of soybean meal (1,494 kcal/lb) and soybean oil (3,889 kcal/lb) from diet ME, utilizing the NRC 2012 values for those ingredients. Apparent total tract digestibility (ATTD) of GE and calculated DE, ME, and corn ME content increased (linear, P \u3c 0.001) as corn particle size was reduced from 1200 to 400 μm. The ME of the diet (88.5% DM) increased by 81 kcal/lb as the dgw was reduced from 1,200 to 400 μm. The calculated corn ME (88.5% DM) also increased by 103 kcal/lb as the dgw was reduced from 1,200 to 400 μm. Utilizing a linear regression model and the analyzed corn particle size data herein, it was determined that for every 100 μm reduction in corn dgw from 1,372 to 404 μm, the ME value of corn is increased by 10.7 kcal/lb

Baseline chest computed tomography as standard of care in high-risk hematology patients

Baseline chest computed tomography (BCT) in high-risk hematology patients allows for the early diagnosis of invasive pulmonary aspergillosis (IPA). The distribution of BCT implementation in hematology departments and impact on outcome is unknown. A web-based questionnaire was designed. International scientific bodies were invited. The estimated numbers of annually treated hematology patients, chest imaging timepoints and techniques, IPA rates, and follow-up imaging were assessed. In total, 142 physicians from 43 countries participated. The specialties included infectious diseases (n = 69; 49%), hematology (n = 68; 48%), and others (n = 41; 29%). BCT was performed in 57% (n = 54) of 92 hospitals. Upon the diagnosis of malignancy or admission, 48% and 24% performed BCT, respectively, and X-ray was performed in 48% and 69%, respectively. BCT was more often used in hematopoietic cell transplantation and in relapsed acute leukemia. European centers performed BCT in 59% and non-European centers in 53%. Median estimated IPA rate was 8% and did not differ between BCT (9%; IQR 5-15%) and non-BCT centers (7%; IQR 5-10%) (p = 0.69). Follow-up computed tomography (CT) for IPA was performed in 98% (n = 90) of centers. In high-risk hematology patients, baseline CT is becoming a standard-of-care. Chest X-ray, while inferior, is still widely used. Randomized, controlled trials are needed to investigate the impact of BCT on patient outcome

The Impact of Duty Hours on Resident Self Reports of Errors

BACKGROUND: Resident duty hour limitations aim, in part, to reduce medical errors. Residents’ perceptions of the impact of duty hours on errors are unknown. OBJECTIVE: To determine residents’ self-reported contributing factors, frequency, and impact of hours worked on suboptimal care practices and medical errors. DESIGN: Cross-sectional survey. SUBJECTS: 164 Internal Medicine Residents at the University of California, San Francisco. MEASUREMENTS AND RESULTS: Residents were asked to report the frequency and contributing factors of suboptimal care practices and medical errors, and how duty hours impacted these practices and aspects of resident work-life. One hundred twenty-five residents (76%) responded. The most common suboptimal care practices were working while impaired by fatigue and forgetting to transmit information during sign-out. In multivariable models, residents who felt overwhelmed with work (p = 0.02) and who reported spending >50% of their time in nonphysician tasks (p = 0.002) were more likely to report suboptimal care practices. Residents reported work-stress (a composite of fatigue, excessive workload, distractions, stress, and inadequate time) as the most frequent contributing factor to medical errors. In multivariable models, only engaging in suboptimal practices was associated with self-report of higher risk for medical errors (p < 0.001); working more than 80 hours per week was not associated with suboptimal care or errors. CONCLUSION: Our findings suggest that administrative load and work stressors are more closely associated with resident reports of medical errors than the number of hours work. Efforts to reduce resident duty hours may also need to address the nature of residents’ work to reduce errors

Communication in the Third Dimension: Song Perch Height of Rivals Affects Singing Response in Nightingales

Many animals use long-range signals to compete over mates and resources. Optimal transmission can be achieved by choosing efficient signals, or by choosing adequate signalling perches and song posts. High signalling perches benefit sound transmission and reception, but may be more risky due to exposure to airborne predators. Perch height could thus reflect male quality, with individuals signalling at higher perches appearing as more threatening to rivals. Using playbacks on nightingales (Luscinia megarhynchos), we simulated rivals singing at the same height as residents, or singing three metres higher. Surprisingly, residents increased song output stronger, and, varying with future pairing success, overlapped more songs of the playback when rivals were singing at the same height than when they were singing higher. Other than expected, rivals singing at the same height may thus be experienced as more threatening than rivals singing at higher perches. Our study provides new evidence that territorial animals integrate information on signalling height and thus on vertical cues in their assessment of rivals

Exploring the perspectives and preferences for HTA across German healthcare stakeholders using a multi-criteria assessment of a pulmonary heart sensor as a case study

Background Health technology assessment and healthcare decision-making are based on multiple criteria and evidence, and heterogeneous opinions of participating stakeholders. Multi-criteria decision analysis (MCDA) offers a potential framework to systematize this process and take different perspectives into account. The objectives of this study were to explore perspectives and preferences across German stakeholders when appraising healthcare interventions, using multi-criteria assessment of a heart pulmonary sensor as a case study. Methods An online survey of 100 German healthcare stakeholders was conducted using a comprehensive MCDA framework (EVIDEM V2.2). Participants were asked to provide i) relative weights for each criterion of the framework; ii) performance scores for a health pulmonary sensor, based on available data synthesized for each criterion; and iii) qualitative feedback on the consideration of contextual criteria. Normalized weights and scores were combined using a linear model to calculate a value estimate across different stakeholders. Differences across types of stakeholders were explored. Results The survey was completed by 54 participants. The most important criteria were efficacy, patient reported outcomes, disease severity, safety, and quality of evidence (relative weight >0.075 each). Compared to all participants, policymakers gave more weight to budget impact and quality of evidence. The quantitative appraisal of a pulmonary heart sensor revealed differences in scoring performance of this intervention at the criteria level between stakeholder groups. The highest value estimate of the sensor reached 0.68 (on a scale of 0 to 1, 1 representing maximum value) for industry representatives and the lowest value of 0.40 was reported for policymakers, compared to 0.48 for all participants. Participants indicated that most qualitative criteria should be considered and their impact on the quantitative appraisal was captured transparently. Conclusions The study identified important variations in perspectives across German stakeholders when appraising a healthcare intervention and revealed that MCDA can demonstrate the value of a specified technology for all participating stakeholders. Better understanding of these differences at the criteria level, in particular between policymakers and industry representatives, is important to focus innovation aligned with patient health and healthcare system values and constraints

Golden Rule of Forecasting: Be Conservative

This article proposes a unifying theory, or the Golden Rule, or forecasting. The Golden Rule of Forecasting is to be conservative. A conservative forecast is consistent with cumulative knowledge about the present and the past. To be conservative, forecasters must seek out and use all knowledge relevant to the problem, including knowledge of methods validated for the situation. Twenty-eight guidelines are logically deduced from the Golden Rule. A review of evidence identified 105 papers with experimental comparisons; 102 support the guidelines. Ignoring a single guideline increased forecast error by more than two-fifths on average. Ignoring the Golden Rule is likely to harm accuracy most when the situation is uncertain and complex, and when bias is likely. Non-experts who use the Golden Rule can identify dubious forecasts quickly and inexpensively. To date, ignorance of research findings, bias, sophisticated statistical procedures, and the proliferation of big data, have led forecasters to violate the Golden Rule. As a result, despite major advances in evidence-based forecasting methods, forecasting practice in many fields has failed to improve over the past half-century