Intravascular migration of contraceptive implants: two more cases

Cases: In addition to previously published case reports, further cases of intravascular migration of contraceptive implants have been identified from an information request to two national adverse reaction spontaneous reporting systems. We report on two new cases of insertion into the venous system with subsequent embolism to a pulmonary artery. Conclusion: Incorporating barium sulfate into the implant has facilitated diagnosis of these very rare adverse events with the initial diagnosis of embolism to the pulmonary arterial tree made by chest X-ray. Removal of an implant from a segmental branch of a pulmonary artery is technically challenging and not without risks. Unsuccessful removal appears to be preceded by a delay in diagnosis leading to endothelialization of the implant in the pulmonary arterial wall. Implications: Subdermal placement of contraceptive implants over the anterior surface of the biceps rather than in the sulcus between them biceps and triceps may negate this rare but reported risk

Transport between edge states in multilayer integer quantum Hall systems: exact treatment of Coulomb interactions and disorder

A set of stacked two-dimensional electron systems in a perpendicular magnetic field exhibits a three-dimensional version of the quantum Hall effect if interlayer tunneling is not too strong. When such a sample is in a quantum Hall plateau, the edge states of each layer combine to form a chiral metal at the sample surface. We study the interplay of interactions and disorder in transport properties of the chiral metal, in the regime of weak interlayer tunneling. Our starting point is a system without interlayer tunneling, in which the only excitations are harmonic collective modes: surface magnetoplasmons. Using bosonization and working perturbatively in the interlayer tunneling amplitude, we express transport properties in terms of the spectrum for these collective modes, treating electron-electron interactions and impurity scattering exactly. We calculte the conductivity as a function of temperature, finding that it increases with increasing temperature as observed in recent experiments. We also calculate the autocorrelation function of mesoscopic conductance fluctuations induced by changes in a magnetic field component perpendicular to the sample surface, and its dependence on temperature. We show that conductance fluctuations are characterised by a dephasing length that varies inversely with temperature.Comment: 13 pages, 10 figures, minor changes made for publicatio

Do female association preferences predict the likelihood of reproduction?

Sexual selection acting on male traits through female mate choice is commonly inferred from female association preferences in dichotomous mate choice experiments. However, there are surprisingly few empirical demonstrations that such association preferences predict the likelihood of females reproducing with a particular male. This information is essential to confirm association preferences as good predictors of mate choice. We used green swordtails (<i>Xiphophorus helleri</i>) to test whether association preferences predict the likelihood of a female reproducing with a male. Females were tested for a preference for long- or short-sworded males in a standard dichotomous choice experiment and then allowed free access to either their preferred or non-preferred male. If females subsequently failed to produce fry, they were provided a second unfamiliar male with similar sword length to the first male. Females were more likely to reproduce with preferred than non-preferred males, but for those that reproduced, neither the status (preferred/non-preferred) nor the sword length (long/short) of the male had an effect on brood size or relative investment in growth by the female. There was no overall preference based on sword length in this study, but male sword length did affect likelihood of reproduction, with females more likely to reproduce with long- than short-sworded males (independent of preference for such males in earlier choice tests). These results suggest that female association preferences are good indicators of female mate choice but that ornament characteristics of the male are also important

Measurement component technology. Volume 3: Cryogenic temperature measurement and high temperature strain gage technology

For abstract, see N74-27185

Two Mental Models of integrated Care For advanced Liver Disease: Qualitative Study of Multidisciplinary Health Professionals

OBJECTIVES: The purpose of this paper is to present two divergent mental models of integrated advanced liver disease (AdvLD) care among 26 providers who treat patients with AdvLD. SETTING: 3 geographically dispersed United States Veterans Health Administration health systems. PARTICIPANTS: 26 professionals (20 women and 6 men) participated, including 9 (34.6%) gastroenterology, hepatology, and transplant physicians, 2 (7.7%) physician assistants, 7 (27%) nurses and nurse practitioners, 3 (11.5%) social workers and psychologists, 4 (15.4%) palliative care providers and 1 (3.8%) pharmacist. MAIN OUTCOME MEASURES: We conducted qualitative in-depth interviews of providers caring for patients with AdvLD. We used framework analysis to identify two divergent mental models of integrated AdvLD care. These models vary in timing of initiating various constituents of care, philosophy of integration, and supports and resources needed to achieve each model. RESULTS: Clinicians described integrated care as an approach that incorporates elements of curative care, symptom and supportive care, advance care planning and end-of-life services from a multidisciplinary team. Analysis revealed two mental models that varied in how and when these constituents are delivered. One mental model involves sequential transitions between constituents of care, and the second mental model involves synchronous application of the various constituents. Participants described elements of teamwork and coordination supports necessary to achieve integrated AdvLD care. Many discussed the importance of having a multidisciplinary team integrating supportive care, symptom management and palliative care with liver disease care. CONCLUSIONS: Health professionals agree on the constituents of integrated AdvLD care but describe two competing mental models of how these constituents are integrated. Health systems can promote integrated care by assembling multidisciplinary teams, and providing teamwork and coordination supports, and training that facilitates patient-centred AdvLD care

Population-Based Pragmatic Trial of Advance Care Planning in Primary Care in the University of California Health System.

Introduction: Varying intensity of advance care planning (ACP) interventions at the population level has not been compared among seriously ill patients in primary care. This project will implement, test, and disseminate real-world scalable ACP interventions among primary care clinics across three University of California Health systems. The three ACP interventions are (1) distribution of an advance directive (AD) with targeted ACP messaging, (2) the AD, messaging, plus prompting patients to engage with the Prepare For Your Care website (PREPARE), and (3) the AD, messaging, PREPARE, plus Care Coordinator engagement with patients and clinicians. Methods: We will identify a population cohort of seriously ill primary care patients and implement the ACP interventions using electronic health record (EHR) patient portals and postal mailings. Forty-five clinics across the three health systems will be cluster randomized to one of the three ACP interventions. The primary outcome for the population cohort is AD or Physician Orders for Life-Sustaining Treatment documentation in the EHR. A subset of the population cohort will be surveyed to assess patient-centered outcomes, including care consistent with goals at baseline, 12 months, and 24 months. Caregivers will be interviewed if patients are unable to be surveyed or die. ACP documentation, goal concordant care, and among decedents, health care utilization will be compared among intervention arms. Study Implementation: Challenges and Contributions: The project is guided by a Study Advisory Group and Community Advisory Groups at each site to ensure rigorous patient-centered methods and consistency of implementation. Intervention fidelity will be evaluated using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. Challenges to implementation of this three-site health system trial and to intervention fidelity stem from site/clinic/system cultures, increasing attention to end-of-life care from payers and regulators, and growing pressures by health systems to implement ACP interventions. Stakeholder engagement is required to ensure consistent interventions across sites

Multicolour interphase cytogenetics: 24 chromosome probes, 6 colours, 4 layers

From the late 1980s onwards, the use of DNA probes to visualise sequences on individual chromosomes (fluorescent in-situ hybridisation - FISH) revolutionised the study of cytogenetics. Following single colour experiments, more fluorochromes were added, culminating in a 24 colour assay that could distinguish all human chromosomes. Interphase cytogenetics (the detection of chromosome copy number in interphase nuclei) soon followed, however 24 colour experiments are hampered for this application as mixing fluorochromes to produce secondary colours produces images that are not easily distinguishable from overlapping signals. This study reports the development and use of a novel protocol, new fast hybridising FISH probes, and a bespoke image capture system for the assessment of chromosome copy number in interphase nuclei. The multicolour probe sets can be used individually or in sequential hybridisation layers to assess ploidy of all 24 human chromosomes in the same nucleus. Applications of this technique are in the investigation of chromosome copy number and the assessment of nuclear organisation for a range of different cell types including human sperm, cancer cells and preimplantation embryos