THE HIGH COST OF LOW VALUE CARE

The main focus of this study is bridging the evidence gap between frontline decision-making in health care and the actual evidence, with the hope of reducing unnecessary diagnostic testing and treatments. From our work in pulmonary embolism (PE) and over ordering of computed tomography pulmonary angiography, we integrated the highly validated Wells\u27 criteria into the electronic health record at two of our major academic tertiary hospitals. The Wells\u27 clinical decision support tool triggered for patients being evaluated for PE and therefore determined a patients\u27 pretest probability for having a PE. There were 12,759 patient visits representing 11,836 patients, 51% had no D-dimer, 41% had a negative D-dimer, and 9% had a positive D-dimer. Our study gave us an opportunity to determine which patients were very low probabilities for PE, with no need for further testing

Healthcare provider perceptions of clinical prediction rules

Objectives: To examine internal medicine and emergency medicine healthcare provider perceptions of usefulness of specific clinical prediction rules. Setting: The study took place in two academic medical centres. A web-based survey was distributed and completed by participants between 1 January and 31 May 2013. Participants: Medical doctors, doctors of osteopathy or nurse practitioners employed in the internal medicine or emergency medicine departments at either institution. Primary and secondary outcome measures: The primary outcome was to identify the clinical prediction rules perceived as most useful by healthcare providers specialising in internal medicine and emergency medicine. Secondary outcomes included comparing usefulness scores of specific clinical prediction rules based on provider specialty, and evaluating associations between usefulness scores and perceived characteristics of these clinical prediction rules. Results: Of the 401 healthcare providers asked to participate, a total of 263 (66%), completed the survey. The CHADS2 score was chosen by most internal medicine providers (72%), and Pulmonary Embolism Rule-Out Criteria (PERC) score by most emergency medicine providers (45%), as one of the top three most useful from a list of 24 clinical prediction rules. Emergency medicine providers rated their top three significantly more positively, compared with internal medicine providers, as having a better fit into their workflow (p=0.004),helping more with decision-making (p= 0.037), better fitting into their thought process when diagnosing patients (p= 0.001) and overall, on a 10-point scale, more useful (p= 0.009). For all providers, the perceived qualities of useful at point of care, helps with decision making, saves time diagnosing, fits into thought process, and should be the standard of clinical care correlated highly (\u3e= 0.65) with overall 10-point usefulness scores. Conclusions: Healthcare providers describe clear preferences for certain clinical prediction rules, based on medical specialty

Predictors of Overtesting in Pulmonary Embolism Diagnosis

© 2019 Background: The benefits of computed tomography pulmonary angiography (CTPA) for pulmonary embolism (PE) diagnosis must be weighed against its risks, radiation-induced malignancy, and contrast-induced nephropathy. Appropriate use of CTPA can be assessed by monitoring yield, the percentage of tests positive for PE. We identify factors that are associated low CTPA yield, which may predict overtesting. Methods: This was a retrospective cohort study of six emergency departments between June 2014 and February 2017. The electronic health record was queried for CTPAs ordered for adult patients in the emergency department. We assessed the following patient factors: age, gender, body mass index, number of comorbidities, race, and ethnicity, provider factors: type (resident, fellow, attending, physician assistant) and environment factors: test time of day, season of visit, and crowdedness of the department. Results: A total of 14,782 CTPAs were reviewed, of which 1366 were found to be positive for PE, resulting in an overall CTPA yield of 9.24%. Provider type was not associated with a difference in yield. Testing was less likely to be positive in younger patients, females, those with lower body mass indexes and those identifying as Asian or Hispanic. Testing was also less likely to be positive when ordered during the overnight shift and during the winter and spring seasons. Conclusion: Our study identified several patient and environmental factors associated with low CTPA yield suggesting potential targets for overtesting. Targeting education and clinical decision support to assist providers in these circumstances may meaningfully improve yields

Generalised gravitational burst generation with Generative Adversarial Networks

We introduce the use of conditional generative adversarial networks forgeneralised gravitational wave burst generation in the time domain.Generativeadversarial networks are generative machine learning models that produce new databased on the features of the training data set. We condition the network on fiveclasses of time-series signals that are often used to characterise gravitational waveburst searches: sine-Gaussian, ringdown, white noise burst, Gaussian pulse and binaryblack hole merger. We show that the model can replicate the features of these standardsignal classes and, in addition, produce generalised burst signals through interpolationand class mixing. We also present an example application where a convolutional neuralnetwork classifier is trained on burst signals generated by our conditional generativeadversarial network. We show that a convolutional neural network classifier trainedonly on the standard five signal classes has a poorer detection efficiency than aconvolutional neural network classifier trained on a population of generalised burstsignals drawn from the combined signal class space

22q11.2 deletion syndrome

22q11.2 deletion syndrome (22q11.2DS) is the most common chromosomal microdeletion disorder, estimated to result mainly from de novo non-homologous meiotic recombination events occurring in approximately 1 in every 1,000 fetuses. The first description in the English language of the constellation of findings now known to be due to this chromosomal difference was made in the 1960s in children with DiGeorge syndrome, who presented with the clinical triad of immunodeficiency, hypoparathyroidism and congenital heart disease. The syndrome is now known to have a heterogeneous presentation that includes multiple additional congenital anomalies and later-onset conditions, such as palatal, gastrointestinal and renal abnormalities, autoimmune disease, variable cognitive delays, behavioural phenotypes and psychiatric illness - all far extending the original description of DiGeorge syndrome. Management requires a multidisciplinary approach involving paediatrics, general medicine, surgery, psychiatry, psychology, interventional therapies (physical, occupational, speech, language and behavioural) and genetic counselling. Although common, lack of recognition of the condition and/or lack of familiarity with genetic testing methods, together with the wide variability of clinical presentation, delays diagnosis. Early diagnosis, preferably prenatally or neonatally, could improve outcomes, thus stressing the importance of universal screening. Equally important, 22q11.2DS has become a model for understanding rare and frequent congenital anomalies, medical conditions, psychiatric and developmental disorders, and may provide a platform to better understand these disorders while affording opportunities for translational strategies across the lifespan for both patients with 22q11.2DS and those with these associated features in the general population

Magnetic Relaxation And Intrinsic Pinning In A Single Crystal Of Bi2sr2cacu2ox

Magnetic-relaxation experiments were performed on Bi2Sr2CaCu2Ox single crystals with the direction of the field parallel to the ab plane. Based on the relaxation data, we have obtained relationships between the activation energy U and the current density j by an approach we developed previously. We found that the activation energy has a logarithmic dependence on j in a wide regime of driving force. It has been reported that CuO2 planes in high-Tc superconductors can act as strong intrinsic pinning centers and that the relation U∼U0ln(jc/j) may describe such a pinning mechanism. Our experimental results have shown good agreement with such a physical model of intrinsic flux pinning. © 1993 The American Physical Society.4795414541

Planar Anchoring Strength And Pitch Measurements In Achiral And Chiral Chromonic Liquid Crystals Using 90-Degree Twist Cells

Chromonic liquid crystals are formed by molecules that spontaneously assemble into anisotropic structures in water. The ordering unit is therefore a molecular assembly instead of a molecule as in thermotropic liquid crystals. Although it has been known for a long time that certain dyes, drugs, and nucleic acids form chromonic liquid crystals, only recently has enough knowledge been gained on how to control their alignment so that studies of their fundamental liquid crystal properties can be performed. In this article, a simple method for producing planar alignment of the nematic phase in chromonic liquid crystals is described, and this in turn is used to create twisted nematic structures of both achiral and chiral chromonic liquid crystals. The optics of 90-degree twist cells allows the anchoring strength to be measured in achiral systems, which for this alignment technique is quite weak, about 3 x 10(-7) J/m2 for both disodium cromoglycate and Sunset Yellow FCF. The addition of a chiral amino acid to the system causes the chiral nematic phase to form, and similar optical measurements in 90-degree twist cells produce a measurement of the intrinsic pitch of the chiral nematic phase. From these measurements, the helical twisting power for L-alanine is found to be (1.1 +/- 0.4) x 10(-2) mu m(-1) wt%(-1) for 15 wt% disodium cromoglycate