Direct laser writing of volumetric gradient index lenses and waveguides.

Direct laser writing (DLW) has been shown to render 3D polymeric optical components, including lenses, beam expanders, and mirrors, with submicrometer precision. However, these printed structures are limited to the refractive index and dispersive properties of the photopolymer. Here, we present the subsurface controllable refractive index via beam exposure (SCRIBE) method, a lithographic approach that enables the tuning of the refractive index over a range of greater than 0.3 by performing DLW inside photoresist-filled nanoporous silicon and silica scaffolds. Adjusting the laser exposure during printing enables 3D submicron control of the polymer infilling and thus the refractive index and chromatic dispersion. Combining SCRIBE's unprecedented index range and 3D writing accuracy has realized the world's smallest (15 µm diameter) spherical Luneburg lens operating at visible wavelengths. SCRIBE's ability to tune the chromatic dispersion alongside the refractive index was leveraged to render achromatic doublets in a single printing step, eliminating the need for multiple photoresins and writing sequences. SCRIBE also has the potential to form multicomponent optics by cascading optical elements within a scaffold. As a demonstration, stacked focusing structures that generate photonic nanojets were fabricated inside porous silicon. Finally, an all-pass ring resonator was coupled to a subsurface 3D waveguide. The measured quality factor of 4600 at 1550 nm suggests the possibility of compact photonic systems with optical interconnects that traverse multiple planes. SCRIBE is uniquely suited for constructing such photonic integrated circuits due to its ability to integrate multiple optical components, including lenses and waveguides, without additional printed supports.

Code Critical: Improving Care Delivery for Critically Ill Patients in the Emergency Department.

PROBLEM: Although certain critically ill patients in emergency departments-such as those experiencing trauma, stroke, and myocardial infarction-often receive care through coordinated team responses, resource allocation and care delivery can vary widely for other high-acuity patients. The absence of a well-defined response process for these patients may result in delays in care, suboptimal outcomes, and staff dissatisfaction. The purpose of this quality improvement project was to develop, implement, and evaluate an ED-specific alert team response for critically ill medical adult and pediatric patients not meeting criteria for other medical alerts. METHODS: Lean (Lean Enterprise Institute, Boston, MA) principles and processes were used to develop, implement, and evaluate an ED-specific response team and process for critically ill medical patients. Approximately 300 emergency nurses, providers, technicians, unit secretaries/nursing assistants, and ancillary team members were trained on the code critical process. Turnaround and throughput data was collected during the first 12 weeks of code critical activations (n = 153) and compared with historical controls (n = 168). RESULTS: After implementing the code critical process, the door-to-provider time decreased by 62%, door to laboratory draw by 76%, door-to-diagnostic imaging by 46%, and door-to-admission by 19%. A year later, data comparison demonstrated sustained improvement in all measures. DISCUSSION: Emergency nurses and providers see the value of coordinated team response in the delivery of patient care. Team responses to critical medical alerts can improve care delivery substantially and sustainably.

Improving the quality of primary care for adults with intellectual and developmental disabilities: Value of the periodic health examination.

OBJECTIVE: To implement a Health Check protocol for patients with intellectual and developmental disabilities (IDD) and assess outcomes. DESIGN: Retrospective chart review and staff survey. SETTING: Two Ontario family health teams. PARTICIPANTS: Of 276 patients with IDD identified, 139 received the Health Check (Health Check group). A convenience sample (N = 147) of clinical staff participated in the survey. MAIN OUTCOME MEASURES: The protocol included patient identification, invitation, and modified health examination. Chart review assessed completion of 8 preventive maneuvers, and clinical staff were surveyed on their comfort, knowledge, and skills in care of patients with IDD. Logistic regression analyses were used to compare outcomes for the Health Check and non-Health Check groups, adjusted for practice site. RESULTS: Documentation of blood pressure, weight, body mass index, and influenza vaccination was significantly higher (P < .001) in the Health Check group, exceeding 70% of patients. Screening rates were higher for mammograms (63% vs 54%), fecal occult blood testing (39% vs 23%), and diabetes testing (80% vs 61%), but not significantly so, and they were similar to general population rates. Papanicolaou test rates were low for both groups (34% vs 32%). Staff comfort and skills were rated significantly higher (P < .05) for those who performed the Health Check. Still, fewer than half thought they had the necessary skills and resources to care for patients with IDD. CONCLUSION: Performing the Health Check was associated with improved preventive care and staff experience. Wider implementation and evaluation is needed, along with protocol adjustments to provide more support to staff for this work.

Evaluating the Implementation of Health Checks for Adults With Intellectual and Developmental Disabilities in Primary Care: The Importance of Organizational Context.

Compared to other adults, those with intellectual and developmental disabilities have more health issues, yet are less likely to receive preventative care. One strategy that has shown success in increasing prevention activities and early detection of illness is the periodic comprehensive health assessment (the health check). Effectively moving evidence into practice is a complex process that often receives inadequate attention. This qualitative study evaluates the implementation of the health check at two primary-care clinics in Ontario, Canada, and the influence of the clinic context on implementation decisions. Each clinic implemented the same core components; however, due to contextual differences, some components were operationalized differently. Adapting to the setting context is important to ensuring successful and sustainable implementation.

Diving Into Blunt Aortic Injury: A Case Review.

Although many advances in trauma care have occurred, traumatic aortic injuries remain a leading cause of death in trauma patients. For those who survive long enough to receive treatment, rapid identification of injuries, surgical intervention, and definitive care are critical. Assessment findings and diagnostic imaging are both necessary to rapidly identify aortic injury and select the proper intervention. Surgical options are now available that, for the appropriate patient with aortic injury, can eliminate the need for invasive surgery, decrease complications, and decrease recovery time.

Would continuous feedback of patient's clinical outcomes to practitioners improve NHS psychological therapy services? Critical analysis and assessment of quality of existing studies.

PURPOSE: Continuous outcome monitoring studies have been conducted by one group of researchers in the United States, mainly in university counselling clinics. We completed a systematic review of continuous outcome monitoring and feedback during psychological therapy and assessed the quality and methodological rigour of existing studies to examine if the findings might be applicable to psychological therapy settings in the United Kingdom. METHODS: An electronic database literature search was carried out on studies on or after 1990 to June 2013 using strict research criteria. Independent ratings of the quality of existing studies were undertaken. RESULTS: Ten studies with original data met inclusion criteria and two meta-analyses. Feedback improves outcomes for clients who are at risk of treatment failure but effect sizes diminish with more severe psychiatric populations. No study has followed up patients to assess maintenance of gains. Study quality is highly variable. Few studies included diagnostic information and details of randomization. Clinical Support Tools are thought to be helpful but how these were used was not described. CONCLUSIONS: Although research in continuous monitoring and feedback of clinical outcomes shows promising results in counselling settings, study quality, and methodological issues set limitations on the generalizability of the findings. PRACTITIONER POINTS: Feedback improves the outcome of therapy for young people with mild problems for those who are at risk of not improving with therapy. Feedback improves outcomes for those with more severe mental health problems but with reduced effect sizes. We do not know if improved outcomes are sustained. The generalizability of the findings may be limited.

Mental health services for individuals with high functioning autism spectrum disorder.

Adolescents and adults with an autism spectrum disorder (ASD) who do not have an intellectual impairment or disability (ID), described here as individuals with high-functioning autism spectrum disorder (HFASD), represent a complex and underserved psychiatric population. While there is an emerging literature on the mental health needs of children with ASD with normal intelligence, we know less about these issues in adults. Of the few studies of adolescents and adults with HFASD completed to date, findings suggest that they face a multitude of cooccurring psychiatric (e.g., anxiety, depression), psychosocial, and functional issues, all of which occur in addition to their ASD symptomatology. Despite this, traditional mental health services and supports are falling short of meeting the needs of these adults. This review highlights the service needs and the corresponding gaps in care for this population. It also provides an overview of the literature on psychiatric risk factors, identifies areas requiring further study, and makes recommendations for how existing mental health services could include adults with HFASD.

Teratogenic risk and contraceptive counselling in psychiatric practice: analysis of anticonvulsant therapy.

BACKGROUND: Anticonvulsants have been used to manage psychiatric conditions for over 50 years. It is recognised that some, particularly valproate, carbamazepine and lamotrigine, are human teratogens, while others including topiramate require further investigation. We aimed to appraise the documentation of this risk by psychiatrists and review discussion around contraceptive issues. METHODS: A retrospective review of prescribing patterns of four anticonvulsants (valproate, carbamazepine, lamotrigine and topiramate) in women of child bearing age was undertaken. Documented evidence of discussion surrounding teratogenicity and contraceptive issues was sought. RESULTS: Valproate was most commonly prescribed (n=67). Evidence of teratogenic risk counselling at medication initiation was sub-optimal--40% of individuals prescribed carbamazepine and 22% of valproate. Documentation surrounding contraceptive issues was also low- 17% of individuals prescribed carbamazepine and 13% of valproate. CONCLUSION: We found both low rates of teratogenic risk counselling and low rates of contraception advice in our cohort. Given the high rates of unplanned pregnancies combined with the relatively high risk of major congenital malformations, it is essential that a detailed appraisal of the risks and benefits associated with anticonvulsant medication occurs and is documented within patients' psychiatric notes.

Development and initial psychometric properties of the Computer Assisted Maltreatment Inventory (CAMI): a comprehensive self-report measure of child maltreatment history.

OBJECTIVES: The present study reports on the development and initial psychometric properties of the Computer Assisted Maltreatment Inventory (CAMI), a web-based self-report measure of child maltreatment history, including sexual and physical abuse, exposure to interparental violence, psychological abuse, and neglect. METHODS: The CAMI was administered to a geographically diverse sample of college students (N=1398). For validation purposes, participants also completed a widely used measure of maltreatment (Childhood Trauma Questionnaire) as well as measures of social desirability. To examine test-retest reliability, a subset of participants (n=283) completed the CAMI a second time 2-4 weeks after the initial administration. RESULTS: Short-term test-retest reliability of the CAMI subscales was good to strong, as was internal consistency on applicable scales. Criterion-related validity of the CAMI's composite abuse severity scores was supported through predicted discriminative correlations with subscales of the CTQ. The CAMI subscales showed comparable or weaker associations with measures of social desirability than did the CTQ. Although both measures were more strongly associated with a need for approval than other aspects of social desirability, these correlations were still rather low in magnitude and in a range typical of many clinical measures. CONCLUSIONS: The present findings as well as the rich descriptive data and flexibility offered by computer administration suggest that the CAMI is a promising instrument for the comprehensive assessment of maltreatment history from adults.

Nonoffending parent expectations of sexually abused children: predictive factors and influence on children's recovery.

This study examined the influence of parental expectations on the functioning of sexually abused children. Participants included 67 sexually abused youth and 63 of their nonoffending primary caregivers. Parental expectations about how sexual abuse will impact children were predictive of parents' ratings of children's behavior at pretreatment, while parental expectations of children's overall future functioning were not predictive of parents' ratings of children's behavior. Parental expectations about how sexual abuse will impact their children and about their children's overall future functioning were not predictive of parents' ratings of children's behavior at posttreatment. Results highlight the influential role the sexual abuse label has in shaping parental expectations about children's functioning. Recommendations for research and intervention are discussed.