Does eliminating the preoperative history and physical make a difference in low-risk cataract surgery patients? A before and after study of 30-day morbidity and mortality.

OBJECTIVE: To evaluate the safety of omitting the conventional preoperative history and physical examination (H&P) for low-risk cataract surgery patients. DESIGN: Comparison of outcomes before and after the January 1, 2015 system wide implementation of a program that eliminated the conventional preoperative H&P for low-risk patients as identified by a 12-item risk stratification questionnaire. PARTICIPANTS: Two separate groups of Winnipeg residents who had cataract surgery at the city's sole ophthalmological referral centre between July 1 and December 31, 2014 (preimplementation reference group) or between October 1, 2015 and March 31, 2016 (postimplementation intervention group). METHODS: A detailed chart review was completed for cataract surgery patients who experienced a postoperative medical event (a composite of death or hospital admission or emergency department visit, identified within administrative databases) within 30 days of surgery. Nonfatal events were captured for all 7 hospitals and urgent care centres in the city, including the ophthalmological referral centre. RESULTS: Postoperative medical events occurred in 114 of 2981 (3.82%) intervention group surgeries and 125 of 3037 (4.12%) reference group surgeries (Relative risk 0.92, 95% confidence interval 0.72 to 1.19, p = 0.6 Fisher exact test). Subgroup analyses of major medical events and medical events by affected organ system yielded no significant differences between the 2 groups. In the opinion of the physician chart reviewers, none of the events among low-risk patients in the intervention group were related to the omission of a conventional preoperative H&P. CONCLUSIONS: The risk of adverse medical events within 30 days of cataract surgery was not higher after the omission of the conventional preoperative H&P in patients screened to be low risk by a validated preoperative questionnaire.

The neural basis of humour comprehension and humour appreciation: The roles of the temporoparietal junction and superior frontal gyrus.

Psychological well-being and social acumen benefit from the recognition of humourous intent and its enjoyment. The enjoyment of humour requires recognition, but humour recognition is not necessarily accompanied by humour enjoyment. Humour recognition is crucial during social interactions, while the associated enjoyment is less critical. Few neuroimaging studies have explicitly differentiated between the neural foundations of humour comprehension and humour appreciation. Among such studies, design limitations have obscured the specification of neural correlates to humour comprehension or appreciation. We implemented a trichotomous response option to address these design limitations. Twenty-four participants rated 120 comics (90 unaltered with humourous intent and 30 caption-altered without humourous intent) as either funny jokes (FJ), not funny jokes but intended to be funny (NFJ), or not intended to be funny or non-jokes (NJ). We defined humour comprehension by NFJ minus NJ and humour appreciation by FJ minus NFJ. We measured localized blood oxygen level dependent (BOLD) neural responses with a 3T MRI scanner. We tested for BOLD responses in humour comprehension brain regions of interest (ROIs), humour appreciation ROIs, and across the whole-brain. We found significant NFJ-NJ BOLD responses in our humour comprehension ROIs and significant FJ-NFJ BOLD responses in select humour appreciation ROIs. One key finding is that comprehension accuracy levels correlated with humour-comprehension responses in the left temporo-parietal junction (TPJ). This finding represents a novel and precise neural linkage to humour comprehension. A second key finding is that the superior frontal gyrus (SFG) was uniquely associated with humour-appreciation. The SFG response suggests that complex cognitive processing underlies humour appreciation and that current models of humour appreciation be revised. Finally, our research design provides an operational distinction between humour comprehension and appreciation and a sensitive measure of individual differences in humour comprehension accuracy.

Patients' experience and satisfaction in primary care: secondary analysis using multilevel modelling.

OBJECTIVE: To explore whether responses to questions in surveys of patients that purport to assess the performance of general practices or doctors reflect differences between practices, doctors, or the patients themselves. DESIGN: Secondary analysis of data from a study of access to general practice, combining data from a survey of patients with information about practice organisation and doctors consulted, and using multilevel modelling at practice, doctor, and patient level. SETTING: Nine primary care trusts in England. PARTICIPANTS: 4573 patients who consulted 150 different doctors in 27 practices. MAIN OUTCOME MEASURES: Overall satisfaction; experience of wait for an appointment; reported access to care; satisfaction with communication skills. RESULTS: The experience based measure of wait for an appointment was more discriminating between practices (practice level accounted for 20.2% (95% confidence interval 9.1% to 31.3%) of variance) than was the overall satisfaction measure (practice level accounted for 4.6% (1.6% to 7.6%) of variance). Only 6.3% (3.8% to 8.9%) of the variance in the doctors' communication skills measure was due to differences between doctors; 92.4% (88.5% to 96.4%) of the variance occurred at the level of the patient (including differences between patients' perceptions and random variation). At least 79% of the variance on all measures occurred at the level of the patient, and patients' age, sex, ethnicity, and housing and employment status explained some of this variation. However, adjustment for patients' characteristics made very little difference to practices' scores or the ranking of individual practices. CONCLUSIONS: Analyses of surveys of patients should take account of the hierarchical nature of the data by using multilevel models. Measures related to patients' experience discriminate more effectively between practices than do measures of general satisfaction. Surveys of patients' satisfaction fail to distinguish effectively between individual doctors because most of the variation in doctors' reported performance is due to differences between patients and random error rather than differences between doctors. Although patients' reports of satisfaction and experience are systematically related to patients' characteristics such as age and sex, the effect of adjusting practices' scores for the characteristics of their patients is small.

Warfarin, head injury and bruising.

A 75-year-old woman with a history of recurrent pulmonary emboli and atrial fibrillation presented with shortness of breath. Her warfarin had been stopped 4 weeks previously after a minor fall where a head injury and extensive facial "bruising" was noted. A computed tomography pulmonary angiogram subsequently confirmed another pulmonary embolus. On examination the discolouration was still evident, but it was noted to be in a photosensitive distribution, and on further questioning it was determined that it had been present for some months before the fall. The patient had been on minocycline for acne rosacea for several years and the diagnosis of minocycline induced hyperpigmentation allowed for a more considered decision to restart warfarin.

Findings from the most recent Medical Library Association salary survey.

OBJECTIVE: The objective is to provide information on basic issues in library management identified by the Medical Library Association's (MLA's) seventh triennial salary survey. METHODS: The survey was a Web-based questionnaire. A nonrandom sample of persons was obtained by posting messages to MLA's membership and to the MEDLIB-L e-mail discussion list. Employed MLA members and nonmembers employed in medical library settings filled out a Web-based form designed using common gateway interface (CGI) programming. RESULTS: Six hundred forty-five usable responses were analyzed by the Hay Group and presented in the MLA publication, Hay Group/MLA 2001 Compensation and Benefits Survey. Results from the 2001 survey in this article focus on pay and job satisfaction. Salary survey results since 1983 were analyzed to review trends in seniority, diversity, and pay equity. CONCLUSIONS: Given the age progression of respondents from 1983 to 2001, it is clear that succession planning is a core issue for medical libraries. Although efforts to create more diversity in medical libraries in member organizations have started to yield results, pay for white respondents has increased at a higher rate than for other racial categories. The authors found that the pay-for-performance system in the organizations of approximately two-thirds of the respondents is suboptimized and that most of the reasons medical librarians cite for leaving their organization can be addressed and potentially changed by management. Results from the eighth salary survey, slated to be conducted in the fall of 2004, will further track these trends and issues.