Alien Registration- Cullen, Louise (Lewiston, Androscoggin County)

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The application of predictive statistical modelling in the investigation of suspected classical Myeloproliferative Neoplasms

The Myeloproliferative Neoplasms are a clinically heterogenous group of bone marrow haemopoietic disorders that result in the overproduction of myeloid blood cells. The identification of recurrent gene mutations has aided positive identification of disease in a substantial proportion of patients, however, a significant number of individuals with classical MPNs do not have a detectable aberration. The clinical and laboratory presentation of these disorders shows significant overlap with features associated with reactive conditions, which, in patients without detectable genetic mutations, can lead to ambiguity in their diagnosis. Traditionally, the decision to investigate an individual for a suspected classical MPN has been based upon thresholds in blood count parameters. In this work, current working practices have been audited to ascertain the extent to which diagnostic guidelines are adhered toe. We demonstrate that a significant proportion of referrals for the investigation of suspected classical MPNs do not meet these criteria. Furthermore, this work objectively assesses the diagnostic sensitivity and specificity of current guidelines in the identification of patients with classical MPNs. The use of predictive statistical modelling is a contemporary approach to the identification of individuals with increased likelihood of suffering from a classical MPN. In this work, several predictive modelling methods were applied to a data set of laboratory and basic demographic information taken from a series of patients investigated for suspected classical MPNs. This work shows that predictive statistical modelling can reproducibly identify those patients who are likely to have a classical MPN from those who do not. These models offer increased specificity and sensitivity compared with the use of published investigatory and diagnostic guidelines. Predictive statistical modelling also offers the ability to triage those patients who are likely to have classical MPNs prior to further investigation, resulting in potentially significant cost savings to both clinical and laboratory services

Deliberate clinical inertia: Using meta-cognition to improve decision-making

Deliberate clinical inertia is the art of doing nothing as a positive response. To be able to apply this concept, individual clinicians need to specifically focus on their clinical decision-making. The skill of solving problems and making optimal clinical decisions requires more attention in medical training and should play a more prominent part of the medical curriculum. This paper provides suggestions on how this may be achieved. Strategies to mitigate common biases are outlined, with an emphasis on reversing a 'more is better' culture towards more temperate, critical thinking. To incorporate such an approach in medical curricula and in clinical practice, institutional endorsement and support is required

"Chest Pain Typicality" in Suspected Acute Coronary Syndromes and the Impact of Clinical Experience

BACKGROUND: Physicians rely upon chest pain history to make management decisions in patients with suspected acute coronary syndromes, particularly where the diagnosis is not immediately apparent through ECG and troponin testing. OBJECTIVE: To establish the discriminatory value of 'typicality of chest pain' and the effect of clinician experience, for the prediction of acute myocardial infarction and presence of significant coronary artery disease. METHODS: Prospective single-center observational study undertaken in a U.K. General Hospital emergency department. We recruited consecutive adults with chest pain and a non-diagnostic ECG, for whom the treating physician determined delayed troponin testing was necessary. Using their own clinical judgment, physicians recorded whether the chest pain described was typical or atypical for acute coronary syndrome. Physicians were defined as "experienced" or "novice" according to postgraduate experience. Acute myocardial infarction was adjudicated using a high-sensitivity troponin (hs-cTn) assay, while coronary artery disease was adjudicated angiographically. RESULTS: Overall, 912 patients had typicality of chest pain assessed, of whom 114/912 (12.5%) had an acute myocardial infarction and 157/912 (17.2%) underwent angiography. In patients undergoing angiography, 90/157 (57.3%) had hs-cTn elevation, of whom 60 (66.7%) had significant coronary artery disease. 67/157 (42.7%) patients had angiography without hs-cTn elevation, of these 31 (46.2%) had significant coronary artery disease. For the diagnosis of acute myocardial infarction, chest pain typicality had an area under the curve (AUC) of 0.54 (95%CI 0.49-0.60). For the prediction of significant coronary artery disease with hs-cTn elevation AUC: 0.54 (0.40-0.67), and without hs-cTn elevation AUC: 0.45 (0.31-0.59). When assessed by experienced physicians, specificity for the diagnosis of acute myocardial infarction was higher at 65.8% (63.1%-68.7%) vs. 55.4% (53.9%-56.8%) for novices. CONCLUSIONS: Subjective interpretation of 'typicality of chest pain' is of limited discriminatory value in the assessment of suspected acute coronary syndromes, in the context of a non-diagnostic ECG. Greater clinical experience improves accuracy as a rule-in tool but does not improve overall discriminatory ability

Sequential burkholderia cenocepacia isolates from siblings with cystic fibrosis show increased lung cell attachment

No abstract availabl

Visualizing Food Traceability Systems: A novel system architecture for mapping material and information flow

Background: Traceability of food products, ingredients and associated operations are important requirements for improving food safety and consumer confidence. Food traceability systems (FTSs) often suffer from inefficiency in either material or information flow within an enterprise or between supply chain partners. Modelling of system architecture is a visualisation approach that allows multiple parties to collaborate in a system design process, identify its inefficiencies and propose improvements. However, there is little academic research on the ability to use a standard visualisation tool that supports collaborative design and considers both material and information flow for a given food traceability system. Scope & Approach: The aim of this research is to propose a new visualisation approach that allows supply chain operators to collaborate effectively in the design process of FTSs capable of maintaining streamlined information flow, minimising information loss, and improving supply chain performance. Key findings & Conclusion: Food traceability systems are complex, encompassing processes, material flow, information flow, techniques, infrastructure, people and control strategies. Screening of literature demonstrates that model-based system engineering (MBSE) offers a sound way for visualisation of such complex systems. However, in the food traceability literature, an MBSE-based standardised traceability system modelling approach is absent. This study makes a strong contribution to existing literature by proposing a novel, material and information flow modelling technique (MIFMT), to visualise FTS architecture. MIFMT can support common understanding and iterative implementation of effective FTSs that contextualise food supply chains at multiple levels and provides opportunity to identify points at where inefficiencies can occur so that actions can be taken to mitigate them

Vitamin D status is associated with early markers of cardiovascular disease in prepubertal children

Background: The associations of 25-hydroxyvitamin D [25(OH)D], non-high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL), and related markers of early cardiovascular disease (CVD) are unclear in prepubertal children. Objective: To investigate the association of 25(OH)D with markers of CVD. The hypothesis was that 25(OH)D would vary inversely with non-HDL-C. Subjects and methods: A prospective cross-sectional study of children (n=45; 26 males, 19 females) of mean age 8.3 ± 2.5 years to investigate the relationships between 25(OH)D and glucose, insulin, high-sensitivity C-reactive protein, and lipids. Vitamin D deficiency was defined as 25(OH)D/mL; overweight as body mass index (BMI) ≥ 85 th but \u3c95th \u3epercentile; and obesity as BMI \u3e95th percentile. Results: Twenty subjects (44.4%) had BMI30 ng/mL. Patients with 25(OH)D of/mL had significantly elevated non-HDL-C (136.08 ± 44.66 vs. 109.88 ± 28.25, p=0.025), total cholesterol (TC)/HDL ratio (3.89 ± 1.20 vs. 3.21 ± 0.83, p=0.042), and triglycerides (TG) (117.09 ± 71.27 vs. 73.39 ± 46.53, p=0.024), while those with 25(OH)D of \u3e30 ng/mL had significantly lower non-HDL-C, TC/HDL, TG, and LDL (82.40 ± 18.03 vs. 105.15 ± 28.38, p=0.006). Multivariate analysis showed significant inverse correlations between 25(OH)D and non-HDL cholesterol (β=-0.337, p=0.043), and TC/HDL ratio (β=-0.339, p=0.028), and LDL (β=-0.359, p=0.016), after adjusting for age, race, sex, BMI, and seasonality. Conclusions: Vitamin D varied inversely with non-HDL, TC/HDL, and LDL. A 25(OH)D level of 30 ng/mL is associated with optimal cardioprotection in children

Hepatic dysfunction is associated with vitamin D deficiency and poor glycemic control in diabetes mellitus

Background/Aims: The effect of the rising prevalence of nonalcoholic fatty liver disease on the 25-hydroxylation of pre-vitamin D in the liver, and consequent glycemic control in children with diabetes mellitus is not known. Our aim was to determine whether mild hepatic dysfunction was associated with impaired 25-hydroxylation of pre-vitamin D, and if this vitamin D deficiency was associated with impaired glycemic control in children and adolescents with type 1 diabetes (TIDM) and type 2 diabetes (T2DM). Methods: We analyzed simultaneously measured HbA1c, ALT, AST, and 25OHD levels and clinical parameters in 121 children and adolescents with T1DM (n=81) and T2DM (n=40). The subjects, ages 11–21 years, all had diabetes of \u3e6 months duration. Multivariate linear regression was used to analyze the associations, while comparisons between subgroups were made using two-tailed Student’s t-test. Results: Vitamin D deficiency (25OHD/mL (37.5 nmol/L) was more prevalent in T2DM patients (47.5%) compared to T1DM patients (18.5%). Subjects with T2DM had significantly elevated transaminases (AST 39.3±2.0 vs. 22.4±1.4, p Conclusions: The association of elevated ALT with vitamin D deficiency suggests that hepatic dysfunction could impair vitamin D metabolism and negatively impact glycemic control in youth with T2DM

Organizational Change Management (OCM): Preliminary position paper

This paper describes the initial steps in the development of Organizational Change Management (OCM), a new Critical Capability (CC) of the IT Capability Maturity Framework (IT-CMF). OCM consists of a maturity assessment and an accompanying Body of Knowledge to support an organization’s improvement efforts. An initial overview of the literature related to managing organizational change is described, based on a review of 30+ academic and practitioner publications. Core themes are identified and used to define an initial taxonomy for OCM. This initial structure was further refined and developed in collaboration with industry and academic experts to ensure it both reflects and supports contemporary organizational realities and best practices in organizational change management