Transfer Patient Imaging: A Novel Peer Feedback Program Beyond Institutional Boundaries.

BACKGROUND: At our level 1 trauma center, we overread cross-sectional scans on all transferred patients, initially reported by community radiologists (CR). We designed a unique peer feedback learning model to address discrepancies encountered with outside overreads with the goal of practice improvement on the part of the CRs. Although there is ample literature on internal peer review and peer learning programs, no publications address errors committed by peers outside institutional boundaries. In this paper we describe our model and report a survey analyzing the perception of the program by the CRs. MATERIALS AND METHODS: Outside CT and MR exams and reports of patients transferred to our level 1 trauma center were imported into PACS and prospectively overread by specialist trauma radiologists. Our report contained a summary of the outside findings as well as our findings. In the case of a significant discrepancy, a paper copy of our final report was sent by US mail to the originating CR. When the program had been active for 18 months, an invitation to participate in a survey was sent to all radiologists who had been sent reports. RESULTS: Eight thousand three hundred forty patients were transferred, of which 4331 (52%) had 9175 exams with outside reports (8666 CT scans and 509 MRI). One hundred seventy six final report letters containing significant discrepancies were sent to 139 individual radiologists. These 139 radiologists also later received our survey letter. Thirty-eight (27%) responses were received. Thirty-two respondents (84%) recalled receiving the report and reviewed the exam in question. Twenty-eight of them (85%) agreed with the overread and 30 (88%) believed that our feedback program should be continued. CONCLUSION: We have designed a novel peer feedback learning model to address discrepancies in outside overreads which is administratively simple and well received by the CRs getting feedback. Those CR who responded to the survey rated the experience favorably and wanted the practice continued, although the overall response rate did not allow statistical analysis. Also, institutions trying to design similar or new peer learning models can benefit from our experience.

Transfer patient imaging: discordances between community and subspecialist emergency radiologists.

PURPOSE: To determine the rate and nature of significant discordances between community and subspecialist emergency radiologists' interpretations of cross-sectional exams performed on patients transferred to our trauma center. METHODS: Outside hospital CT and MRI exams performed on transfer trauma patients are routinely overread by subspecialist emergency radiologists, specifying either concordance or discordance with the interpretation by the community radiologist. We evaluated the discordant reports for clinical significance, defined as an additional finding or difference in interpretation which was likely to affect patient management. The total rate of significant discordances, rate by modality, rate by body region, and rate per patient transferred were calculated. The most common errors were identified, and the distribution of errors among individual community radiologists was examined. RESULTS: 9175 exams were reviewed. Significant discordances were encountered in 4.1% of exams: 3.9% for CT and 6.7% for MRI; 5.1% for head and neck exams, 3.3% for spine, 3.8% for torso, and 2.9% for extremities. The discordance rate per patient transferred was 7.7%. The most common discordances involved missing injuries to the cranio-cervical junction, missing or misinterpreting vascular injuries in the neck, and incompletely characterizing facial fractures. Discordances were evenly spread among 220 community radiologists. CONCLUSION: There is frequent discordance between community and emergency radiologists' interpretations of CT and MRI exams, leading to a change in transferred patient management. Thus, trauma center radiologists provide added value overreading these patients' exams. It is difficult to predict which patients or exams will contain discordances, justifying routine overreading of all such exams.

Education and employment outcomes in clients of the Nurse-Family Partnership.

OBJECTIVES: Nurse-Family Partnership (NFP) is an evidence-based home visitation program designed for low-income, first-time mothers to support pregnancy, child development, and maternal self-sufficiency. This study examined educational and employment outcomes among NFP clients compared to a reference sample. DESIGN: Entropy balancing and a difference-in-difference design were used to compare the two samples of women from 2007 to 2016. SAMPLE: There were 127,427 women in the NFP sample, and 787 women in the reference cohort. MEASUREMENTS: Educational outcomes included high school completion and employment outcomes consisted of employment status. RESULTS: Across a one-year interval, NFP mothers with less than a high school diploma or general education diploma (GED) at baseline showed a 9.5 percentage point increase in diploma or GED attainment compared to the reference mothers [95% CI: 0.015-0.180]. Similarly, mothers enrolled in NFP who were not employed at baseline showed a 7.8 percentage point increase in employment compared to the reference mothers [95% CI: 0.003-0.150]. CONCLUSIONS: The findings in this study show positive results for NFP mothers attaining high school completion and employment compared to mothers in the reference group. Such findings are of importance with regard to progression toward economic self-sufficiency and corresponding reduction of health disparities.

Evidence of Selection for Fungicide Resistance in Zymoseptoria tritici Populations on Wheat in Western Oregon.

Plant pathogens pose a major challenge to maintaining food security in many parts of the world. Where major plant pathogens are fungal, fungicide resistance can often thwart regional control efforts. Zymoseptoria tritici, causal agent of Septoria tritici blotch, is a major fungal pathogen of wheat that has evolved resistance to chemical control products in four fungicide classes in Europe. Compared with Europe, however, fungicide use has been less and studies of fungicide resistance have been infrequent in North American Z. tritici populations. Here, we confirm first reports of Z. tritici fungicide resistance evolution in western Oregon through analysis of the effects of spray applications of propiconazole and an azoxystrobin + propiconazole mixture during a single growing season. Frequencies of strobilurin-resistant isolates, quantified as proportions of G143A mutants, were significantly higher in azoxystrobin-sprayed plots compared with plots with no azoxystrobin treatment at two different locations and were significantly higher in plots of a moderately resistant cultivar than in plots of a susceptible cultivar. Thus, it appears that western Oregon Z. tritici populations have the potential to evolve levels of strobilurin resistance similar to those observed in Europe. Although the concentration of propiconazole required to reduce pathogen growth by 50% values were numerically greater for isolates collected from plots receiving propiconazole than in control plots, this effect was not significant (P > 0.05).

Second Life™: a novel simulation platform for the training of surgical residents.

A virtual world is a three-dimensional, computer-generated, simulated environment. Human users create "avatars," or virtual projections of themselves, in order to explore this virtual environment and interact with the objects and structures inside it. Second Life™ is one such virtual world accessible freely via the internet, which has been used to construct a virtual hospital complete with reception areas, changing rooms, offices, and hospital wards. Early pioneering studies have demonstrated the advantages of using virtual worlds in the education of surgical residents in a number of ways, from introductions to the clinical environment, initial patient assessment, and managing adverse outcomes, to gaining informed consent, hospital-wide training, and medical device development.

Potential role of transient receptor potential channel M5 in sensing putative pheromones in mouse olfactory sensory neurons.

Based on pharmacological studies of chemosensory transduction in transient receptor potential channel M5 (TRPM5) knockout mice it was hypothesized that this channel is involved in transduction for a subset of putative pheromones in mouse olfactory sensory neurons (OSNs). Yet, in the same study an electroolfactogram (EOG) in the mouse olfactory epithelium showed no significant difference in the responses to pheromones (and odors) between wild type and TRPM5 knockout mice. Here we show that the number of OSNs expressing TRPM5 is increased by unilateral naris occlusion. Importantly, EOG experiments show that mice lacking TRPM5 show a decreased response in the occluded epithelia to putative pheromones as opposed to wild type mice that show no change upon unilateral naris occlusion. This evidence indicates that under decreased olfactory sensory input TRPM5 plays a role in mediating putative pheromone transduction. Furthermore, we demonstrate that cyclic nucleotide gated channel A2 knockout (CNGA2-KO) mice that show substantially decreased or absent responses to odors and pheromones also have elevated levels of TRPM5 compared to wild type mice. Taken together, our evidence suggests that TRPM5 plays a role in mediating transduction for putative pheromones under conditions of reduced chemosensory input.

Spring Wheat Tolerance and Resistance to Heterodera avenae in the Pacific Northwest.

The cereal cyst nematode Heterodera avenae reduces wheat yields in the Pacific Northwest. Previous evaluations of cultivar resistance had been in controlled environments. Cultivar tolerance had not been evaluated. Seven spring wheat trials were conducted in naturally infested fields in three states over 2 years. A split-plot design was used for all trials. Five trials evaluated both tolerance and resistance in 1.8-by-9-m plots treated or not treated with nematicides. Two trials evaluated resistance in 1-m head rows where each wheat entry was paired with an adjacent row of a susceptible cultivar. Cultivars with the Cre1 resistance gene ('Ouyen' and 'Chara') reduced the postharvest density of H. avenae under field conditions, confirming Cre1 parents as useful for germplasm development. Ouyen was resistant but it was also intolerant, producing significantly lower grain yield in controls than in plots treated with nematicides. Susceptible cultivars varied in tolerance. Undefined resistance was identified in one commercial cultivar ('WB-Rockland) and four breeding lines (UC1711, SO900163, SY-B041418, and SY-97621-05). This research was the first systematic field demonstration of potential benefits to be derived through development and deployment of cultivars with resistance plus tolerance to cereal cyst nematode in North America.

Optimizing the statistical estimation of the parameters of the Farquhar-von Caemmerer-Berry model of photosynthesis.

The model of Farquhar, von Caemmerer and Berry is the standard in relating photosynthetic carbon assimilation and concentration of intercellular CO(2). The techniques used in collecting the data from which its parameters are estimated have been the object of extensive optimization, but the statistical aspects of estimation have not received the same attention. The model segments assimilation into three regions, each modeled by a distinct function. Three parameters of the model, namely the maximum rate of Rubisco carboxylation (V(c max)), the rate of electron transport (J), and nonphotorespiratory CO(2) evolution (R(d)), are customarily estimated from gas exchange data through separate fitting of the component functions corresponding to the first two segments. This disjunct approach is problematic in requiring preliminary arbitrary subsetting of data into sets believed to correspond to each region. It is shown how multiple segments can be estimated simultaneously, using the entire data set, without predetermination of transitions by the investigator. Investigation of the number of parameters that can be estimated in the two-segment model suggests that, under some conditions, it is possible to estimate four or even five parameters, but that only V(c max), J, and R(d), have good statistical properties. Practical difficulties and their solutions are reviewed, and software programs are provided.