Competency to Stand Trial on Trial

This Article considers the legal standards for the determination of competency to stand trial, and whether those standards are understood and applied by psychiatrists and psychologists in the forensic evaluations they perform and in the judgments they make–judgments that are routinely accepted by trial courts as their own judgments. The Article traces the historical development of the competency construct and the development of two competency standards. One standard, used today in eight states that contain 25% of the population of the United States, requires that the defendant be able to assist counsel in the conduct of a defense “in a rational manner.” The second, adopted by the Supreme Court in Dusky v. United States, 362 U.S. 402 (1960) as the Court’s interpretation of the federal competency statute, requires that the defendant have an ability to consult with counsel with a reasonable degree of “rational understanding.” The “rational manner” standard seemingly focuses on the defendant’s behavior; the “rational understanding” standard seemingly focuses on the defendant’s thinking. The Article reports on a survey we conducted of 273 forensic psychiatrists and psychologists who were asked to read two case study vignettes and assess the competency of each criminal defendant using the “rational manner” standard, the “rational understanding” standard, and the federal statutory standard that merely requires that the defendant be able to “assist properly” in his or her defense. In one vignette, the defendant’s thinking was irrational but his behavior was rational. In the other, the defendant’s thinking was rational, but her behavior was irrational. In responding to both vignettes, more than three-fourths of all respondents either found the defendant competent under all three standards or incompetent under all three standards. Surprisingly, in answering the first vignette, the respondents divided almost equally in deciding whether the defendant was competent. The Article analyzes the results of the study and concludes with specific proposals to improve competency to stand trial assessments. Fairness to the defendant requires that the competency standard be clearly defined and applied by those who assess and determine competency

q-Deformed de Sitter/Conformal Field Theory Correspondence

Unitary principal series representations of the conformal group appear in the dS/CFT correspondence. These are infinite dimensional irreducible representations, without highest weights. In earlier work of Guijosa and the author it was shown for the case of two-dimensional de Sitter, there was a natural q-deformation of the conformal group, with q a root of unity, where the unitary principal series representations become finite-dimensional cyclic unitary representations. Formulating a version of the dS/CFT correspondence using these representations can lead to a description with a finite-dimensional Hilbert space and unitary evolution. In the present work, we generalize to the case of quantum-deformed three-dimensional de Sitter spacetime and compute the entanglement entropy of a quantum field across the cosmological horizon.Comment: 18 pages, 2 figures, revtex, (v2 reference added

An Assessment of Dialysis Provider's Attitudes towards Timing of Dialysis Initiation in Canada

Background: Physicians' perceptions and opinions may influence when to initiate dialysis. Objective: To examine providers' perspectives and opinions regarding the timing of dialysis initiation. Design: Online survey. Setting: Community and academic dialysis practices in Canada. Participants: A nationally-representative sample of dialysis providers. Measurements and Methods: Dialysis providers opinions assessing reasons to initiate dialysis at low or high eGFR. Responses were obtained using a 9-point Likert scale. Early dialysis was defined as initiation of dialysis in an individual with an eGFR greater than or equal to 10.5 ml/min/m 2 . A detailed survey was emailed to all members of the Canadian Society of Nephrology (CSN) in February 2013. The survey was designed and pre-tested to evaluate duration and ease of administration. Results: One hundred and forty one (25% response rate) physicians participated in the survey. The majority were from urban, academic centres and practiced in regionally administered renal programs. Very few respondents had a formal policy regarding the timing of dialysis initiation or formally reviewed new dialysis starts (N = 4, 3.1%). The majority of respondents were either neutral or disagreed that late compared to early dialysis initiation improved outcomes (85–88%), had a negative impact on quality of life (89%), worsened AVF or PD use (84–90%), led to sicker patients (83%) or was cost effective (61%). Fifty-seven percent of respondents felt uremic symptoms occurred earlier in patients with advancing age or co-morbid illness. Half (51.8%) of the respondents felt there was an absolute eGFR at which they would initiate dialysis in an asymptomatic patient. The majority of respondents would initiate dialysis for classic indications for dialysis, such as volume overload (90.1%) and cachexia (83.7%) however a significant number chose other factors that may lead them to early dialysis initiation including avoiding an emergency (28.4%), patient preference (21.3%) and non-compliance (8.5%). Limitations: 25% response rate. Conclusions: Although the majority of nephrologists in Canada who responded followed evidence-based practice regarding the timing of dialysis initiation, knowledge gaps and areas of clinical uncertainty exist. The implementation and evaluation of formal policies and knowledge translation activities may limit potentially unnecessary early dialysis initiation

PT-symmetric models in curved manifolds

We consider the Laplace-Beltrami operator in tubular neighbourhoods of curves on two-dimensional Riemannian manifolds, subject to non-Hermitian parity and time preserving boundary conditions. We are interested in the interplay between the geometry and spectrum. After introducing a suitable Hilbert space framework in the general situation, which enables us to realize the Laplace-Beltrami operator as an m-sectorial operator, we focus on solvable models defined on manifolds of constant curvature. In some situations, notably for non-Hermitian Robin-type boundary conditions, we are able to prove either the reality of the spectrum or the existence of complex conjugate pairs of eigenvalues, and establish similarity of the non-Hermitian m-sectorial operators to normal or self-adjoint operators. The study is illustrated by numerical computations.Comment: 37 pages, PDFLaTeX with 11 figure

Financial Incentives for Transcatheter Aortic Valve Implantation in Ontario, Canada: A Cost-Utility Analysis

Background Transcatheter aortic valve implantation (TAVI) is a minimally invasive therapy for patients with severe aortic stenosis, which has become standard of care. The objective of this study was to determine the maximum cost-effective investment in TAVI care that should be made at a health system level to meet quality indicator goals. Methods and Results We performed a cost-utility analysis using probabilistic patient-level simulation of TAVI care from the Ontario, Canada, Ministry of Health perspective. Costs and health utilities were accrued over a 2-year time horizon. We created 4 hypothetical strategies that represented TAVI care meeting =1 quality indicator targets, (1) reduced wait times, (2) reduced hospital length of stay, (3) reduced pacemaker use, and (4) combined strategy, and compared these with current TAVI care. Per-person costs, quality-adjusted life years, and clinical outcomes were estimated by the model. Using these, incremental net monetary benefits were calculated for each strategy at different cost-effectiveness thresholds between $0 and$100 000 per quality-adjusted life year. Clinical improvements over the current practice were estimated with all comparator strategies. In Ontario, achieving quality indicator benchmarks could avoid ˜26 wait-list deaths and 200 wait-list hospitalizations annually. Compared with current TAVI care, the incremental net monetary benefit for this strategy varied from $10 765 (±$8721) and $17 221 (±$8977). This would translate to an annual investment of between ˜$14 to ˜$22 million by the Ontario Ministry of Health to incentivize these performance measures being cost-effective. Conclusions This study has quantified the modest annual investment required and substantial clinical benefit of meeting improvement goals in TAVI care

Statistical entropy of three-dimensional q-deformed Kerr-de Sitter space

A quantum deformation of three-dimensional de Sitter space was proposed in hep-th/0407188. We use this to calculate the entropy of Kerr-de Sitter space, using a canonical ensemble, and find agreement with the semiclassical result.Comment: 11 pages, revtex, (v2, reference added

Development of Risk Prediction Equations for Incident Chronic Kidney Disease

IMPORTANCE Early identification of individuals at elevated risk of developing chronic kidney disease (CKD) could improve clinical care through enhanced surveillance and better management of underlying health conditions.OBJECTIVE To develop assessment tools to identify individuals at increased risk of CKD, defined by reduced estimated glomerular filtration rate (eGFR).DESIGN, SETTING, AND PARTICIPANTS Individual-level data analysis of 34 multinational cohorts from the CKD Prognosis Consortium including 5 222 711 individuals from 28 countries. Data were collected from April 1970 through January 2017. A 2-stage analysis was performed, with each study first analyzed individually and summarized overall using a weighted average. Because clinical variables were often differentially available by diabetes status, models were developed separately for participants with diabetes and without diabetes. Discrimination and calibration were also tested in 9 external cohorts (n = 2 253 540).EXPOSURES Demographic and clinical factors.MAIN OUTCOMES AND MEASURES Incident eGFR of less than 60 mL/min/1.73 m(2).RESULTS Among 4 441 084 participants without diabetes (mean age, 54 years, 38% women), 660 856 incident cases (14.9%) of reduced eGFR occurred during a mean follow-up of 4.2 years. Of 781 627 participants with diabetes (mean age, 62 years, 13% women), 313 646 incident cases (40%) occurred during a mean follow-up of 3.9 years. Equations for the 5-year risk of reduced eGFR included age, sex, race/ethnicity, eGFR, history of cardiovascular disease, ever smoker, hypertension, body mass index, and albuminuria concentration. For participants with diabetes, the models also included diabetes medications, hemoglobin A(1c), and the interaction between the 2. The risk equations had a median C statistic for the 5-year predicted probability of 0.845 (interquartile range [IQR], 0.789-0.890) in the cohorts without diabetes and 0.801 (IQR, 0.750-0.819) in the cohorts with diabetes. Calibration analysis showed that 9 of 13 study populations (69%) had a slope of observed to predicted risk between 0.80 and 1.25. Discrimination was similar in 18 study populations in 9 external validation cohorts; calibration showed that 16 of 18 (89%) had a slope of observed to predicted risk between 0.80 and 1.25.CONCLUSIONS AND RELEVANCE Equations for predicting risk of incident chronic kidney disease developed from more than 5 million individuals from 34 multinational cohorts demonstrated high discrimination and variable calibration in diverse populations. Further study is needed to determine whether use of these equations to identify individuals at risk of developing chronic kidney disease will improve clinical care and patient outcomes.</p

The kidney failure risk equation:evaluation of novel input variables including eGFR estimated using the CKD-EPI 2021 equation in 59 cohorts

SIGNIFICANCE STATEMENT: The kidney failure risk equation (KFRE) uses age, sex, GFR, and urine albumin-to-creatinine ratio (ACR) to predict 2- and 5-year risk of kidney failure in populations with eGFR <60 ml/min per 1.73 m 2 . However, the CKD-EPI 2021 creatinine equation for eGFR is now recommended for use but has not been fully tested in the context of KFRE. In 59 cohorts comprising 312,424 patients with CKD, the authors assessed the predictive performance and calibration associated with the use of the CKD-EPI 2021 equation and whether additional variables and accounting for the competing risk of death improves the KFRE's performance. The KFRE generally performed well using the CKD-EPI 2021 eGFR in populations with eGFR <45 ml/min per 1.73 m 2 and was not improved by adding the 2-year prior eGFR slope and cardiovascular comorbidities. BACKGROUND: The kidney failure risk equation (KFRE) uses age, sex, GFR, and urine albumin-to-creatinine ratio (ACR) to predict kidney failure risk in people with GFR <60 ml/min per 1.73 m 2 . METHODS: Using 59 cohorts with 312,424 patients with CKD, we tested several modifications to the KFRE for their potential to improve the KFRE: using the CKD-EPI 2021 creatinine equation for eGFR, substituting 1-year average ACR for single-measure ACR and 1-year average eGFR in participants with high eGFR variability, and adding 2-year prior eGFR slope and cardiovascular comorbidities. We also assessed calibration of the KFRE in subgroups of eGFR and age before and after accounting for the competing risk of death. RESULTS: The KFRE remained accurate and well calibrated overall using the CKD-EPI 2021 eGFR equation. The other modifications did not improve KFRE performance. In subgroups of eGFR 45-59 ml/min per 1.73 m 2 and in older adults using the 5-year time horizon, the KFRE demonstrated systematic underprediction and overprediction, respectively. We developed and tested a new model with a spline term in eGFR and incorporating the competing risk of mortality, resulting in more accurate calibration in those specific subgroups but not overall. CONCLUSIONS: The original KFRE is generally accurate for eGFR <45 ml/min per 1.73 m 2 when using the CKD-EPI 2021 equation. Incorporating competing risk methodology and splines for eGFR may improve calibration in low-risk settings with longer time horizons. Including historical averages, eGFR slopes, or a competing risk design did not meaningfully alter KFRE performance in most circumstances

Conversion of Urine Protein-Creatinine Ratio or Urine Dipstick Protein to Urine Albumin-Creatinine Ratio for Use in Chronic Kidney Disease Screening and Prognosis : An Individual Participant–Based Meta-analysis

Financial Support: The CKD-PC Data Coordinating Center is funded in part by a program grant from the U.S. National Kidney Foundation and the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK100446). Various sources have supported enrollment and data collection, including laboratory measurements and follow-up, in the collaborating cohorts of the CKD-PC. These funding sources include government agencies, such as national institutes of health and medical research councils, as well as the foundations and industry sponsors listed in Supplemental Appendix 3 (available at Annals.org).Peer reviewedPostprin