Fluid professional boundaries: ethnographic observations of co-located chiropractors, osteopaths and physiotherapists.

BACKGROUND: Chiropractors, osteopaths and physiotherapists (COPs) can assess and manage musculoskeletal conditions with similar manual or physical therapy techniques. This overlap in scope of practice raises questions about the boundaries between the three professions. Clinical settings where they are co-located are one of several possible influences on professional boundaries and may provide insight into the nature of these boundaries and how they are managed by clinicians themselves. OBJECTIVES: To understand the nature of professional boundaries between COPs within a co-located clinical environment and describe the ways in which professional boundaries may be reinforced, weakened, or navigated in this environment. METHODS: Drawing from an interpretivist paradigm, we used ethnographic observations to observe interactions between 15 COPs across two clinics. Data were analysed using reflexive thematic analysis principles. RESULTS: We identified various physical and non-physical 'boundary objects' that influenced the nature of the professional boundaries between the COPs that participated in the study. These boundary objects overall seemed to increase the fluidity of the professional boundaries, at times simultaneously reinforcing and weakening them. The boundary objects were categorised into three themes: physical, including the clinic's floor plan, large and small objects; social, including identities and discourse; and organisational, including appointment durations and fees, remuneration policies and insurance benefits. CONCLUSIONS: Physical, social, organisational related factors made the nature of professional boundaries between COPs in these settings fluid; meaning that they were largely not rigid or fixed but rather flexible, responsive and subject to change. These findings may challenge patients, clinicians and administrators to appreciate that traditional beliefs of distinct boundaries between COPs may not be so in co-located clinical environments. Both clinical practice and future research on professional boundaries between COPs may need to further consider some of these broader factors.

Burning questions: Current practices and critical gaps in evaluating removal of per- and polyfluoroalkyl substances (PFAS) during pyrolysis treatments of biosolids.

Concerns surrounding potential health and environmental impacts of per- and polyfluoroalkyl substances (PFAS) are growing at tremendous rates because adverse health impacts are expected with trace-level exposures. Extreme measures are required to mitigate potential PFAS contamination and minimize exposures. Extensive PFAS use results in the release of diverse PFAS species from domestic, industrial, and municipal effluents to wastewater, which partition to biosolids throughout secondary treatment. Biosolids generated during municipal wastewater treatment are a major environmental source of PFAS due to prevailing disposal practices as fertilizers. Pyrolysis is emerging as a viable, scalable technology for PFAS removal from biosolids while retaining nutrients and generating renewable, raw materials for energy generation. Despite early successes of pyrolysis in PFAS removal, significant unknowns remain about PFAS and transformation product fates in pyrolysis products and emissions. Applicable PFAS sampling methods, analytical workflows, and removal assessments are currently limited to a subset of high-interest analytes and matrices. Further, analysis of exhaust gases, particulate matter, fly ashes, and other pyrolysis end-products remain largely unreported or limited due to cost and sampling limitations. This paper identifies critical knowledge gaps on the pyrolysis of biosolids that must be addressed to assess the effectiveness of PFAS removal during pyrolysis treatment.

Near-Peer Teaching in Radiology Symposia: A Success Story in Residents as Teachers.

INTRODUCTION: Peer learning and near-peer teaching have been described in many specialties, less so in Radiology. We present near-peer teaching whereby residents present a series of didactic sessions at the course outset in the form of "symposia" and perform a scholarly activity in the form of teaching. We aim to demonstrate how near-peer teaching in symposia front-loaded within an introductory radiology course can improve medical student satisfaction. METHOD: A total of 169 students were enrolled over a period of 3 years, 55 before (2017-2018) and 114 (2018-2020) after the introduction of the symposium. Anonymous course evaluations were collected from all students. In addition, 240 fourth-year medical students who also attended symposium lectures received satisfaction surveys in 2019 and 2020. RESULTS: All (169/169, 100%) students taking the course evaluated it. Overall evaluation scores rose from 8.3/10 to 9.0/10 post-symposia. Among student satisfaction surveys, 89/240 (37%) specifically commented on symposia; 91% (80/89) of those found symposia very or extremely informative. 29/71 (41%) of all residents were able to participate in the symposia, 20/29 in multiple years throughout residency, allowing them to fulfill the Accreditation Council for Graduate Medical Education interpersonal and communication skills core competencies and meet scholarly activity requirements. CONCLUSION: Near-peer teaching in the form of resident-taught interactive didactics grouped in symposia can have a positive outcome on medical student satisfaction.

Quantitation of Total PFAS Including Trifluoroacetic Acid with Fluorine Nuclear Magnetic Resonance Spectroscopy.

Fluorine nuclear magnetic resonance (19F-NMR) spectroscopy has been shown to be a powerful tool capable of quantifying the total per- and polyfluoroalkyl substances (PFAS) in a complex sample. The technique relies on the characteristic terminal -CF3 shift (-82.4 ppm) in the alkyl chain for quantification and does not introduce bias due to sample preparation or matrix effects. Traditional quantitative analytical techniques for PFAS, such as liquid chromatography-mass spectrometry (LC-MS) and combustion ion chromatography (CIC), contain inherent limitations that make total fluorine analysis challenging. Here, we report a sensitive 19F-NMR method for the analysis of total PFAS, with a limit of detection of 99.97 nM, or 50 µg/L perfluorosulfonic acid. To demonstrate the capabilities of 19F-NMR, the technique was compared to two commonly used methods for PFAS analysis: total oxidizable precursor (TOP) assay and LC-high resolution MS analysis for targeted quantification and suspect screening. In both cases, the 19F-NMR analyses detected higher total PFAS quantities than either the TOP assay (63%) or LC-MS analyses (65%), suggesting that LC-MS and TOP assays can lead to underreporting of PFAS. Importantly, the 19F-NMR detected trifluoroacetic acid at a concentration more than five times the total PFAS concentration quantified using LC-MS in the wastewater sample. Therefore, the use of 19F-NMR to quantify the total PFAS in highly complex samples can be used to complement classic TOP or LC-MS approaches for more accurate reporting of PFAS contamination in the environment.

When worlds collide: Experiences of physiotherapists, chiropractors, and osteopaths working together.

BACKGROUND: In Australia, people with musculoskeletal conditions frequently seek care from chiropractors, osteopaths, and physiotherapists. Intertwined histories, distinct philosophies and practical tensions characterise relationships between these three professions, yet little is known about contact or collaboration between individual clinicians. OBJECTIVES: To explore the experiences of osteopaths, physiotherapists and chiropractors who work together in the same clinic location and explore their attitudes towards each other. METHODS: Utilising a predominantly inductive qualitative research design, semi-structured interviews were undertaken with a total of 13 clinicians (physiotherapists [n=6], chiropractors [n=2], osteopaths [n=4], dual-qualified chiropractor and physiotherapist [n=1]) who work with at least one clinician from the other two professions. Interviews were analysed using reflexive thematic analysis. RESULTS: Data analysis produced two main themes and five sub-themes that characterised clinicians' experiences and attitudes: collaboration (collaborative practices; benefits of collaboration) and resisting tension (accepting similarities and differences to work towards shared goals; clinic culture; alignment with evidence-based practice). These findings can be understood in the context of the concepts of professional boundary-work and intergroup contact theory. CONCLUSIONS: The findings from this study suggest that physiotherapists, chiropractors and osteopaths that work together in the same clinic may collaborate while simultaneously navigating blurred professional lines. These results suggest that working together in the same clinic is a meaningful form of contact, which in turn allows for collaborative practices that may reduce intergroup tension between professions.

Spatial distribution of pesticides, organochlorine compounds, PBDEs, and metals in surface marine sediments from Cartagena Bay, Colombia.

Cartagena Bay is an estuarine system located in the Caribbean Sea (Colombia, South America), that receives fresh water from Canal del Dique, which is connected to the Magdalena River, the most important river of Colombia, with some of the most prominent Colombian cities located in its watershed, which has a high sediment yield. An analysis of persistent organic pollutants and heavy metals was carried out on marine sediments from Cartagena Bay. Cartagena Bay sediments deployed the occurrence of total levels of pesticides (thiocarbamates, bromacil, triazines, organochlorines, and organophosphorus), polybrominated diphenyl ethers (PBDEs), and polychlorinated biphenyls (PCBs), in sediments ranging from 0.83-33.67 ng/g dry-weight, 0.05-0.34 ng/g dry-weight, and 0.06-19.58 ng/g dry-weight, respectively. Their concentrations were lower than those reported in NOAA Screening Quick Reference Tables. DDTs and PCBs are banned organochlorine compounds, since, even at low levels, their presence in sediments represents a threat to aquatic organisms and, therefore, to human health through the trophic chain. Sediments showed high concentrations of strontium (50-959.6 mg/kg). All metals evaluated in the marine sediments were found in the S6 sampling point; this was near tannery and hydrocarbon industries (Pb 37.1 mg/kg, Cr 137.2 mg/kg, Cd 1.7 mg/kg, Cu 64.4 mg/kg, As 13.1 mg/kg, Sr 318.9 mg/kg); these results exceeded the accepted values of threshold effect levels (TEL) used as an indicator of their potential risk on marine life.

Occurrence and transformation of veterinary antibiotics and antibiotic resistance genes in dairy manure treated by advanced anaerobic digestion and conventional treatment methods.

Manure treatment technologies are rapidly developing to minimize eutrophication of surrounding environments and potentially decrease the introduction of antibiotics and antibiotic resistant genes (ARGs) into the environment. While laboratory and pilot-scale manure treatment systems boast promising results, antibiotic and ARG removals in full-scale systems receiving continuous manure input have not been evaluated. The effect of treatment on ARGs is similarly lacking. This study examines the occurrence and transformation of sulfonamides, tetracyclines, tetracycline degradation products, and related ARGs throughout a full-scale advanced anaerobic digester (AAD) receiving continuous manure and antibiotic input. Manure samples were collected throughout the AAD system to evaluate baseline antibiotic and ARG input (raw manure), the effect of hygenization (post-pasteurized manure) and anaerobic digestion (post-digestion manure) on antibiotic and ARG levels. Antibiotics were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and the ARGs tet(O), tet(W), sul1 and sul2 were analyzed by quantitative polymerase chain reaction (Q-PCR). Significant reductions in the concentrations of chlortetracycline, oxytetracycline, tetracycline and their degradation products were observed in manure liquids following treatment (p < 0.001), concomitant to significant increases in manure solids (p < 0.001). These results suggest sorption is the major removal route for tetracyclines during AAD. Significant decreases in the epimer-to-total residue ratios for chlortetracycline and tetracycline in manure solids further indicate degradation is desorption-limited. Moreover, sul1 and sul2 copies decreased significantly (p < 0.001) following AAD in the absence of sulfonamide antibiotics, while tetracyclines-resistant genes remained unchanged. A cross-sectional study of dairy farms utilizing natural aeration and liquid-solid separation treatments was additionally performed to compare levels of antibiotics and ARGs found in AAD with the levels in common manure management systems. The concentration of antibiotics in raw manure varied greatly between farms while minimal differences in ARGs were observed. However, significant (p < 0.01) differences in the levels of antibiotics and ARGs (except tet(W)) were observed in the effluents from the three different manure management systems.

Effect of Footwear on Dynamic Stability during Single-leg Jump Landings.

Barefoot and minimal footwear running has led to greater interest in the biomechanical effects of different types of footwear. The effect of running footwear on dynamic stability is not well understood. The purpose of this study was to compare dynamic stability and impact loading across 3 footwear conditions; barefoot, minimal footwear and standard running shoes. 25 injury free runners (21 male, 4 female) completed 5 single-leg jump landings in each footwear condition. Dynamic stability was assessed using the dynamic postural stability index and its directional components (mediolateral, anteroposterior, vertical). Peak vertical ground reaction force and vertical loadrates were also compared across footwear conditions. Dynamic stability was dependent on footwear type for all stability indices (ANOVA, p<0.05). Post-hoc tests showed dynamic stability was greater when barefoot than in running shoes for each stability index (p<0.02) and greater than minimal footwear for the anteroposterior stability index (p<0.01). Peak vertical force and average loadrates were both dependent on footwear (p≤0.05). Dynamic stability, peak vertical force, and average loadrates during single-leg jump landings appear to be affected by footwear type. The results suggest greater dynamic stability and lower impact loading when landing barefoot or in minimal footwear.

Are cardiovascular risk factors also associated with the incidence of atrial fibrillation? A systematic review and field synopsis of 23 factors in 32 population-based cohorts of 20 million participants.

Established primary prevention strategies of cardiovascular diseases are based on understanding of risk factors, but whether the same risk factors are associated with atrial fibrillation (AF) remains unclear. We conducted a systematic review and field synopsis of the associations of 23 cardiovascular risk factors and incident AF, which included 84 reports based on 28 consented and four electronic health record cohorts of 20,420,175 participants and 576,602 AF events. We identified 3-19 reports per risk factor and heterogeneity in AF definition, quality of reporting, and adjustment. We extracted relative risks (RR) and 95 % confidence intervals [CI] and visualised the number of reports with inverse (RR [CI]<1.00), or direct (RR [CI]>1.00) associations. For hypertension (13/17 reports) and obesity (19/19 reports), there were direct associations with incident AF, as there are for coronary heart disease (CHD). There were inverse associations for non-White ethnicity (5/5 reports, with RR from 0.35 to 0.84 [0.82-0.85]), total cholesterol (4/13 reports from 0.76 [0.59-0.98] to 0.94 [0.90-0.97]; 8/13 reports with non-significant inverse associations), and diastolic blood pressure (2/11 reports from 0.87 [0.78-0.96] to 0.92 [0.85-0.99]; 5/11 reports with non-significant inverse associations), and direct associations for taller height (7/10 reports from 1.03 [1.02-1.05] to 1.92 [1.38-2.67]), which are in the opposite direction of known associations with CHD. A systematic evaluation of the available evidence suggests similarities as well as important differences in the risk factors for incidence of AF as compared with other cardiovascular diseases, which has implications for the primary prevention strategies for atrial fibrillation.

Metagenomic profiling of historic Colorado Front Range flood impact on distribution of riverine antibiotic resistance genes.

Record-breaking floods in September 2013 caused massive damage to homes and infrastructure across the Colorado Front Range and heavily impacted the Cache La Poudre River watershed. Given the unique nature of this watershed as a test-bed for tracking environmental pathways of antibiotic resistance gene (ARG) dissemination, we sought to determine the impact of extreme flooding on ARG reservoirs in river water and sediment. We utilized high-throughput DNA sequencing to obtain metagenomic profiles of ARGs before and after flooding, and investigated 23 antibiotics and 14 metals as putative selective agents during post-flood recovery. With 277 ARG subtypes identified across samples, total bulk water ARGs decreased following the flood but recovered to near pre-flood abundances by ten months post-flood at both a pristine site and at a site historically heavily influenced by wastewater treatment plants and animal feeding operations. Network analysis of de novo assembled sequencing reads into 52,556 scaffolds identified ARGs likely located on mobile genetic elements, with up to 11 ARGs per plasmid-associated scaffold. Bulk water bacterial phylogeny correlated with ARG profiles while sediment phylogeny varied along the river's anthropogenic gradient. This rare flood afforded the opportunity to gain deeper insight into factors influencing the spread of ARGs in watersheds.

Challenges in the Measurement of Antibiotics and in Evaluating Their Impacts in Agroecosystems: A Critical Review.

Large quantities of antibiotics are used in agricultural production, resulting in their release to agroecosystems through numerous pathways, including land application of contaminated manure, runoff from manure-fertilized fields, and wastewater irrigation of croplands. Antibiotics and their transformation products (TPs) exhibit a wide range of physico-chemical and biological properties and thus present substantive analytical challenges. Advances in the measurement of these compounds in various environmental compartments (plants, manure, soil, sediment, and water) have uncovered a previously unrealized landscape of antibiotic residues. These advanced multiresidue methods, designed to measure sub-ng g concentrations in complex mixtures, remain limited by the inherent intricacy of the sample matrices and the difficultly in eliminating interferences that affect antibiotic detection. While efficient extraction methods combined with high sensitivity analysis by liquid chromatography/mass spectrometry can provide accurate quantification of antibiotics and their TPs, measured concentrations do not necessarily reflect their bioavailable fractions and effects in the environment. Consequently, there is a need to complement chemical analysis with biological assays that can provide information on bioavailability, biological activity, and effects of mixtures. Enzyme-linked immunosorbent assays (ELISA), often used as screening tools for antibiotic residues, may be useful for detecting the presence of structurally related antibiotic mixtures but not their effects. Other tools, including bioreporter assays, hold promise in measuring bioavailable antibiotics and could provide insights on their biological activity. Improved assessment of the ecological and human health risks associated with antibiotics in agroecosystems requires continued advances in analytical accuracy and sensitivity through improvements in sample preparation, instrumentation, and screening technologies.

Enhancing Extraction and Detection of Veterinary Antibiotics in Solid and Liquid Fractions of Manure.

Analysis of veterinary antibiotics in separated liquid and solid fractions of animal manures is vital because of wide variations in the composition of agriculturally applied manure. Differentiation of antibiotic concentrations is important between liquid and solid manures, as their sorption onto the solid fraction depends on physicochemical properties of each antibiotic and manure composition (e.g., organic content, pH) and because each fraction may be treated and reused differently. Here, an efficient and sensitive method for the analysis of 22 veterinary antibiotics in the liquid and solid fractions of manure is reported. Tetracycline (TC), macrolide, and sulfonamide antibiotics were extracted from liquid manure by liquid-liquid extraction (LLE) with methanol following acidification with acetic acid. Extraction from solids was performed by sonication with acetonitrile, methanol, and 0.1 M EDTA-McIlvaine buffer. Cleanup of extracts was achieved by solid-phase extraction with hydrophilic-lipophilic balance (HLB) cartridges or tandem amino (NH2) and HLB cartridges. Quantification of antibiotics was performed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) under wrong-way-round (WWR) ionization for sulfonamides and TCs and right-way-round ionization for macrolides. Recoveries of 58 to 94.7% and 62 to 94.3% were obtained in liquid and solid manure, respectively. Method detection limits range from 1.2 to 12 ng L and 0.5 to 7.9 µg kg dry wt. in liquids and solids, respectively. This method allows for extraction and analysis of both mobile antibiotics in liquid phase and hydrophobic antibiotics adsorbed on the solids. Without separate analysis, antibiotic concentrations may be improperly estimated by analyzing whole manure, as reported in many studies to date.

Lignin enrichment and enzyme deactivation as the root cause of enzymatic hydrolysis slowdown of steam pretreated sugarcane bagasse.

The enzymatic hydrolysis (EH) rate normally decreases during the hydrolysis, leaving unhydrolyzed material as residue. This phenomenon occurs during the hydrolysis of both cellulose (avicel) and lignocellulosic material, in nature or even pretreated. The progression of EH of steam pretreated sugarcane bagasse was associated with an initial (fast), intermediate (slower) and recalcitrant (slowest) phases, at glucan to glucose conversion yields of 61.7, 81.6 and 86%, respectively. Even though the EH of avicel as a simpler material than steam pretreated sugarcane bagasse, EH slowdown was present. The less thermo-stable endo-xylanase lost 58% of initial enzyme activity, followed by ß-glucosidase that lost 16%, culminating in FPase activity loss of 30% in the first 24hours. After 72hours of EH the total loss of FPase activity was 40% compared to the initial activity. Analysis of the solid residue from EH showed that lignin content, phenolic compounds and ash increased while glucan decreased as hydrolysis progressed. During the initial fast phase of EH, the total solid residue surface area consisted predominantly of internal surface area. Thereafter, in the intermediate and recalcitrant phases of EH, the ratio of external:internal surface area increased. The proposed fiber damage and decrease in internal surface area, probably by EH action, was visualized by scanning electron microscopy imagery. The higher lignin/glucan ratio as EH progressed and enzyme deactivation by thermo instability were the main effects observed, respectively to substrate and enzyme.

Review on the occurrence and profiles of polybrominated diphenyl ethers in the Philippines.

The environmental occurrence of polybrominated diphenyl ethers (PBDEs) has been a subject of concern for the past decade because they are persistent, bioaccumulative, and toxic. These compounds have been listed as persistent organic pollutants (POPs) by the Stockholm Convention and are expected to disperse in the global environment even after their use and production. While the occurrence of PBDEs has been well characterized in environmental and biological samples from North America, Europe, and some Asian countries (i.e. China, Japan, and Korea), there is a scarcity of available data in developing Asian countries, such as the Philippines. Examination of PBDE contamination in the Philippine environment is particularly important because regulations have only recently been implemented on the production and use of PBDEs in this country. Additionally, the Philippines receives e-waste from Western countries, which is becoming a major source of organic contaminants in the tropical Asian regions. Ultimately, the Philippines may be a hot spot for contributing to on-going global PBDE pollution due to long-range atmospheric transport. This paper presents a review of the available literature on PBDEs in both environmental and biological samples collected from the Philippines. It is also intended to provide an overview on the levels and congener profiles of PBDEs in samples from the Philippines and to compare these data with other Asian countries. New data are presented on PBDE occurrence and congener profiles in fish commonly consumed by Filipinos and in particulate matter samples collected in Metro Manila, the capital of the Philippines. Both studies contribute to the available knowledge of PBDEs in the Philippines. We aim to stress the importance of future studies in countries receiving e-wastes, such as the Philippines, and suggest what future directions might be taken to enhance the available data on the presence of PBDEs in the Philippine environment.

Dynamic modeling predicts continued bioaccumulation of polybrominated diphenyl ethers (PBDEs) in smallmouth bass (Micropterus dolomiu) post phase-out due to invasive prey and shifts in predation.

Unprecedented food chain links between benthic and pelagic organisms are often thought to disrupt traditional contaminant transport and uptake due to changes in predation and mobilization of otherwise sequestered pollutants. A bioaccumulation model for polybrominated diphenyl ethers (PBDEs) is developed to simulate increases in biotic congener loads based upon trophic transfer through diet and gill uptake for a Lake Erie food chain including two invasive species as a benthic-pelagic link. The model utilizes species-specific bioenergetic parameters in a four-level food chain including the green alga Scenedesmus quadricauda, zebra mussels (Dreissena polymorpha), round goby (Appollonia melanostoma), and the smallmouth bass (Micropterus dolomiu). The model was calibrated to current biotic concentrations and predicts an increase in contaminant load by almost 48% in the upper trophic level in two years. Validation to archival data resulted in <2% error from reported values following a two-year simulation.

Factors that predict increased catheter tip movement in left internal jugular vein implantable venous access ports upon standing.

PURPOSE: To determine the characteristics that predict catheter tip movement with positional changes in patients with left-sided, internal jugular vein (IJV) implantable venous access ports. METHODS: A retrospective review revealed 264 patients with left IJV ports placed at one academic institution from 2008 to 2013 with follow-up upright chest radiographs. Demographic information was recorded and anatomic measurements were made on both procedural fluoroscopic imaging and upright chest radiographs. Multivariate regression analysis was performed to determine which factors had statistically significant relationships with catheter tip movement distance. RESULTS: Mean catheter tip movement was 1.49 ± 1.97 cm. There was a statistically significant positive relationship between catheter tip movement distance and age (p = 0.03), body mass index (BMI) (p = 0.02), innominate vein angle (p<0.01) and dual- compared to single-lumen ports (p = 0.02). Port pocket location, venous access site and gender did not demonstrate statistical significance. CONCLUSIONS: The factors associated with increased positional catheter tip movement for left IJV ports include patient age, BMI, innominate vein angle and dual- vs single-lumen port. This information can be useful in determining initial placement position and avoiding complications associated with catheter malposition.

Defining disease phenotypes using national linked electronic health records: a case study of atrial fibrillation.

BACKGROUND: National electronic health records (EHR) are increasingly used for research but identifying disease cases is challenging due to differences in information captured between sources (e.g. primary and secondary care). Our objective was to provide a transparent, reproducible model for integrating these data using atrial fibrillation (AF), a chronic condition diagnosed and managed in multiple ways in different healthcare settings, as a case study. METHODS: Potentially relevant codes for AF screening, diagnosis, and management were identified in four coding systems: Read (primary care diagnoses and procedures), British National Formulary (BNF; primary care prescriptions), ICD-10 (secondary care diagnoses) and OPCS-4 (secondary care procedures). From these we developed a phenotype algorithm via expert review and analysis of linked EHR data from 1998 to 2010 for a cohort of 2.14 million UK patients aged ≥ 30 years. The cohort was also used to evaluate the phenotype by examining associations between incident AF and known risk factors. RESULTS: The phenotype algorithm incorporated 286 codes: 201 Read, 63 BNF, 18 ICD-10, and four OPCS-4. Incident AF diagnoses were recorded for 72,793 patients, but only 39.6% (N = 28,795) were recorded in primary care and secondary care. An additional 7,468 potential cases were inferred from data on treatment and pre-existing conditions. The proportion of cases identified from each source differed by diagnosis age; inferred diagnoses contributed a greater proportion of younger cases (≤ 60 years), while older patients (≥ 80 years) were mainly diagnosed in SC. Associations of risk factors (hypertension, myocardial infarction, heart failure) with incident AF defined using different EHR sources were comparable in magnitude to those from traditional consented cohorts. CONCLUSIONS: A single EHR source is not sufficient to identify all patients, nor will it provide a representative sample. Combining multiple data sources and integrating information on treatment and comorbid conditions can substantially improve case identification.

Facilitated Integrated Mood Management for adults with bipolar disorder.

OBJECTIVES: We describe the development of a five-session psychoeducational treatment, Facilitated Integrated Mood Management (FIMM), which contains many of the core elements of longer evidence-based psychosocial treatments for bipolar disorder. FIMM incorporated a novel mood monitoring program based on mobile phone technology. METHODS: Adult patients with bipolar I and II disorders (N = 19) received six sessions (Pilot I: n = 14) or five sessions (Pilot II: n = 5) of FIMM with pharmacotherapy. Treatment facilitators were novice counselors who were trained in a three-day workshop and supervised for six months. FIMM sessions focused on identifying early signs of recurrence, maintaining regular daily and nightly routines, rehearsing mood management strategies, maintaining adherence to medications, and education about substance abuse. Patients sent daily text messages or e-mails containing ratings of their mood and sleep, and weekly messages containing self-ratings on the Quick Inventory of Depressive Symptomatology (QIDS) and the Altman Self Rating Mania Scale (ASRM). Patients also completed a weekly mood management strategies questionnaire. RESULTS: Of the 19 patients, 17 (89.5%) completed FIMM in an average of 9.2 ± 3.4 weeks (Pilot I) and 7.6 ± 0.9 weeks (Pilot II). Patients reported stable moods on the QIDS and ASRM over a 120-day period, and on average responded to 81% of the daily message prompts and 88% of the weekly QIDS and ASRM prompts. Facilitators maintained high levels of fidelity to the FIMM manual. Patients' knowledge of mood management strategies increased significantly between the first and last weeks of treatment. CONCLUSIONS: Patients with bipolar disorder can be engaged in a short program of facilitated mood management. The effects of FIMM on the course of bipolar disorder await evaluation in randomized trials. The program may be a useful adjunct to pharmacotherapy in community centers that cannot routinely administer full courses of psychosocial treatment.

Preoperative statin treatment is associated with reduced postoperative mortality after isolated cardiac valve surgery in high-risk patients.

OBJECTIVE: The aim of the present study was to assess the influence of preoperative statin therapy on postoperative mortality in high-risk patients after isolated valve surgery. DESIGN: An observational cohort study. SETTING: A 1,200-bed university hospital. PARTICIPANTS: All consecutive patients undergoing isolated nonemergent valve surgery with cardiopulmonary bypass between November 2005 and December 2007 were included. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: During the period, 772 consecutive patients underwent nonemergent isolated valve surgery. Among them, 430 were high cardiovascular risk (defined by patients with 2 or more cardiovascular risk factors). In the high-risk cardiovascular patients, statin pretreatment was administered in 222 patients (52%). In multivariate analysis, after adjustment with a propensity score analysis, preoperative statin therapy was associated with a significant reduction of postoperative mortality in patients with high risk (odds ratio = 0.41; 95% confidence interval, 0.17-0.97; p = 0.04). Low left ventricular ejection fraction and elevated pulmonary artery pressure also were independently associated with increased postoperative mortality. By contrast, in the low-risk patient group, few patients received preoperative statin therapy (7%). CONCLUSIONS: This study suggests that preoperative statin therapy may have a potential beneficial effect on postoperative mortality after isolated cardiac valve surgery in high-risk cardiovascular patients.

Risk score to predict serious bleeding in stable outpatients with or at risk of atherothrombosis.

AIMS: To develop a risk score to quantify bleeding risk in outpatients with or at risk of atherothrombosis. METHODS AND RESULTS: We studied patients in the REACH Registry, a cohort of 68 236 patients with/at risk of atherothrombosis. The outcome of interest was serious bleeding (non-fatal haemorrhagic stroke or bleeding leading to hospitalization and transfusion) over 2 years. Risk factors for bleeding were assessed using modified regression analysis. Multiple potential scoring systems based on the least complex models were constructed. Competing scores were compared on their discriminative ability via logistic regression. The score was validated externally using the CHARISMA population. From a final cohort of 56 616 patients, 804 (1.42%, 95% confidence interval 1.32-1.52) experienced serious bleeding between baseline and 2 years. A nine-item bleeding risk score (0-23 points) was constructed (age, peripheral arterial disease, congestive heart failure, diabetes, hypertension, smoking, antiplatelets, oral anticoagulants, hypercholesterolaemia). Observed incidence of bleeding at 2 years was: 0.46% (score < or = 6); 0.95% (7-8); 1.25% (9-10); 2.76% (> or = 11). The score's discriminative performance was consistent in CHARISMA and REACH (c-statistics 0.64 and 0.68, respectively); calibration in the CHARISMA population was very good (modified Hosmer-Lemeshow c(2) = 4.74; P = 0.69). CONCLUSION: Bleeding risk increased substantially with a score >10. This score can assist clinicians in predicting the risk of serious bleeding and making decisions on antithrombotic therapy in outpatients.