scholarly journals LO70: Functional & cognitive decline in older delirious adults after an emergency department visit

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S33
Author(s):  
M. Giroux ◽  
M. Sirois ◽  
A. Nadeau ◽  
V. Boucher ◽  
P. Carmichael ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cognitive Decline ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Cognitive Status ◽  
Cognitive Outcomes ◽  
Negative Consequences ◽  
Significant Difference ◽  
The Impact

Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.

Functional and cognitive decline in older delirious adults after an emergency department visit

2020 ◽  
Author(s):  
Marianne Giroux ◽  
Marcel Émond ◽  
Alexandra Nadeau ◽  
Valérie Boucher ◽  
Pierre-Hugues Carmichael ◽  
...  
Keyword(s):  
Emergency Department ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Cognitive Status ◽  
Confusion Assessment ◽  
Lower Baseline ◽  
A Minor ◽  
The Impact ◽  
Minor Improvement

Abstract Background the aim of this study was to evaluate the impact of emergency department (ED) stay-associated delirium on older patient’s functional and cognitive status at 60 days post ED visit. Methods this study was part of the multi-centre prospective cohort INDEED study. This project took place between March 2015 and July 2016 in five participating EDs across the province of Quebec. Independent non-delirious patients aged ≥65, with an ED stay ≥8 hours, were monitored for delirium until 24 hours post ward admission. A 60-day follow-up phone assessment was conducted. Participants were screened for delirium using the Confusion Assessment Method. Functional and cognitive statuses were assessed at baseline and at the 60-day follow-up using OARS and TICS-m. Results a total of 608 patients were recruited, 393 of which completed the 60-day follow-up. The Confusion Assessment Method was positive in 69 patients (11.8%) during ED stay or within the first 24 hours following ward admission. At 60 days, delirium patients experienced an adjusted loss of −2.9/28 [95%CI: −3.9, −2.0] points on the OARS scale compared to non-delirious patients who lost −1.6 [95%CI: −1.9, −1.3] (P = 0.006). A significant adjusted difference in cognitive function was also noted at 60 days, as TICS-m scores in delirious patients decreased by −1.6 [95%CI: −3.5, 0.2] compared to non-delirious patients, who showed a minor improvement of 0.5 [95%CI: −0.1, 1.1] (P = 0.03). Conclusion seniors who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients, and they will experience a more significant decline at 60 days post ED visit.

scholarly journals LO023: Association between ED-induced delirium and cognitive & functional decline in seniors

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S38-S38
Author(s):  
M. Giroux ◽  
M. Émond ◽  
M. Sirois ◽  
V. Boucher ◽  
R. Daoust ◽  
...  
Keyword(s):  
Cognitive Decline ◽  
Functional Decline ◽  
Hospital Setting ◽  
Clinical Importance ◽  
Assessment Method ◽  
Cognitive Status ◽  
Medical Complication ◽  
Impact Measurement ◽  
Significant Difference

Introduction: Delirium is a common medical complication among seniors in hospital setting. In the emergency department (ED), its prevalence varies between 7 & 14%. Delirium is associated with increased mortality & longer hospital stay. This condition is also associated with functional & cognitive decline in hospitalized seniors and higher risk of institutionalization up to 2 years after their discharge. However, no data is currently available for ED patients. The aim of this study was to evaluate the association between ED-induced delirium and functional & cognitive decline in seniors at 60 days. Methods: This study is part of the Incidence and Impact measurement of Delirium Induced by ED-Stay (INDEED) study, an ongoing multicenter prospective cohort study in 5 Quebec EDs. Patients were recruited after 8 hours in the ED and followed up to 24h after admission. A 60-day follow-up phone assessment was also conducted. Delirium was measured by the validated Confusion Assessment Method & the Delirium Index. Functional status was measured by the validated OARS. Cognitive status was measured using the validated TICS-M. Functional and cognitive decline were obtained by comparing the baseline and 60-days follow-up scores. Results: 380 seniors were recruited and 280 had 60-day follow-up data available. ED-induced delirium was 8.4% of seniors. There was a difference in mean functional decline among seniors with and without ED-induced delirium 2.95(1.23-4.67) vs 1.55(1.20-1.91, pwlicoxon= 0.05] Proportion of seniors showing a decline ≥2 points on the OARS was significantly higher In those with ED-induced delirium (65,0 % vs 40.18 %, p=0.03). Seniors with ED-induced delirium also showed a significant decline in mean TICS scores [3.31 (0,82-5.84) vs -0.01((-.071-0.75)), pwlicoxon =0.009]. There was no significant difference in the proportions of seniors showing a decline ≥ 3 OARS points between those with or without delirium (p=0.06). Conclusion: ED-induced delirium seems to be associated with poor functional and cognitive outcomes in older patients 60 days after discharge from the hospital. Further studies are required to confirm clinical importance ED-induced delirium delayed complication.

scholarly journals Cognitive function and type of physical activity: results from the FRéLE longitudinal study

2019 ◽  
Vol 29 (Supplement_4) ◽  
Author(s):  
C Dupré ◽  
D Hupin ◽  
C Goumou ◽  
F Béland ◽  
F Roche ◽  
...  
Keyword(s):  
Physical Activity ◽  
Longitudinal Study ◽  
Cognitive Decline ◽  
Cognitive Disorders ◽  
Cognitive Status ◽  
Professional Activity ◽  
Domestic Activity ◽  
Different Types ◽  
The Impact

Abstract Background Previous cohorts have been notably criticized for not studying the different type of physical activity and not investigating household activities. The objective of this work was to analyse the relation between physical activity and cognitive decline in older people living in community. Impact of type of physical activity on the results has been realised. Methods The study used data from the longitudinal and observational study , FrèLE (FRagility: Longitudinal Study of Expressions). The collected data included: socio-demographic variables, lifestyle, and health status (frailty, comorbidities, cognitive status, depression). Cognitive decline was assessed by using: MMSE (Mini-Mental State Examination)and MoCA (Montreal Cognitive Assessment). Physical activity was assessed by the PASE (Physical Activity Scale for the Elderly). This tool is structured in three sections: the leisure activity, the domestic activity and the professional activity. Logistic regressions and proportional hazards regression models (Cox) were used to estimate the risk of cognitive disorders. Results At baseline, the prevalence of cognitive disorders was 6.9% according to MMSE. In total, 1326 participants without cognitive disorders were included in the analysis. The mean age was 77.4 years, and 52.1% of the participants were women. After a 2 years long follow-up, we found cognitive disorders on 92 participants (6.9%). Physical activity at baseline is lower in older adults for whom cognitive decline was observed after two years of follow-up. Subclass analyses showed that leisure and domestic activities were associated to cognitive decline, but not professional activities. Conclusions Analysis showed a relationship between cognitive disorders and type of physical activity. The current study will be completed by the MoCA for mild cognitive impairment. These findings compared to other ongoing studies will contribute to the debate on the beneficial effects of physical activity on cognition. Key messages The work allowed us to analyze the link between the different types of physical activity and mild to severe cognitive disorders. The aim is to put in place preventive policies of aging. The work allowed us to see the effect of the different types of physical activity and the impact of the statistical method on the results.

Evaluation of Early Versus Late Postdischarge Medication Reconciliation on Readmission Rates and Emergency Department Visits

2017 ◽  
Vol 31 (3) ◽  
pp. 279-283 ◽  
Author(s):  
Tina Joseph ◽  
Rebecca A. Barros ◽  
Elise Kim ◽  
Bupendra Shah
Keyword(s):  
Emergency Department ◽  
Clinical Pharmacist ◽  
Medication Reconciliation ◽  
Emergency Department Visits ◽  
Optimal Timing ◽  
Significant Difference ◽  
The Impact ◽  
Late Group ◽  
Hospital Use

Background: The current literature speculates ideal postdischarge follow-up focusing on transitions from hospital to home can range anywhere between 48 hours and 2 weeks. However, there is a lack of evidence regarding the optimal timing of follow-up visit to prevent readmissions. Objective: The purpose of this study is to evaluate the impact of early (<48 hours) versus late (48 hours-14 days) postdischarge medication reconciliation on readmissions and emergency department (ED) use. Methods: In this retrospective study, data for patients who had a clinic visit with a primary care provider (PCP), clinical pharmacist, or both for postdischarge medication reconciliation were reviewed. Primary outcome included hospital use rate at 30 days. Secondary outcomes included hospital use rate at 90 days and hospital use rate with a postdischarge PCP follow-up visit, clinical pharmacist, or both at 30 days. Results: One hundred sixty patients were included in the analysis: 31 early group patients and 129 late group patients. There was no significant difference on hospital use at 30 days in patients who received early or late groups (32.3% vs 21.8%, P = .947). There was also no significant difference on hospital use at 90 days in patients in early versus late group (51.6% vs 50.3%, P = .842). The type of provider (PCP vs pharmacists) conducting postdischarge medication reconciliation did not show significance on hospital use at 30 days (19.9% vs 21.4%, P = .731). Conclusion: Results from this study suggest patients can be seen up to 14 days postdischarge for medication reconciliation with no significant difference on hospital use.

scholarly journals MP30: Validation of the 4AT questionnaire in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S75
Author(s):  
A. Gagné ◽  
P. Voyer ◽  
V. Boucher ◽  
M. Pelletier ◽  
E. Gouin ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cognitive Impairment ◽  
Telephone Interview ◽  
Rapid Assessment ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Cognitive Status ◽  
French Version ◽  
Elderly Inpatients ◽  
Patients At Risk

Introduction: Delirium is a very prevalent cognitive impairment in elderly inpatients, but it often goes undetected, especially in the emergency department (ED). The tools currently available to screen or diagnose patients at risk of delirium are very time-consuming and are impossible to systematically perform in the ED environment. For this reason, short tests are necessary to screen for delirium in this fast-paced setting. The objective of this study was to evaluate the performance of the French version of the Rapid Assessment Test for Delirium (4AT) for the detection of delirium and cognitive impairment in older patients. The 4AT takes less than 2 minutes to administer, which is a great advantage on the others tests. Methods: The study was conducted in four emergency departments across the province of Québec. Participants were independent or semi-independent patients aged 65 and older, admitted to hospital and who had an 8-hour exposure to the ED. The Telephone Interview for Cognitive Status (TICS) was administered at the initial interview and the Confusion Assessment Method (CAM) as well as the 4AT were administered to patients twice a day during their ED or hospital stay. The 4AT’s sensitivity and specificity were compared to that of the CAM (for delirium), and to that of the TICS (for cognitive impairment). Results: 324 patients were included in the study, with a mean age of 76 years old. Among the recruited participants, 21 (6.5%) had a prevalent delirium according to the CAM, and 30 (10.2%) had an incident delirium. According to the 4AT, 48 patients (14.9%) had cognitive impairment and 81 (25.2%) had a prevalent delirium. According to the TICS, 87 patients (29.2%) have cognitive impairment. The 4AT has a sensitivity of 68,4% (IC 95% : 47,5-89,3) and a specificity of 73.2% (IC 95% : 67,8-78,7) for delirium, and a sensitivity of 50% (IC 95% : 35,9-64,1) and a specificity of 87,0% (IC 95% : 81,2-92) for cognitive impairment. Conclusion: The French Version of the 4AT could be a fast and reliable screening tool for delirium and cognitive impairment in ED. Further research is necessary for its validation in the ED.

scholarly journals DELIRIUM SEVERITY AND COGNITIVE OUTCOMES

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S921-S921
Author(s):  
Sarah A Welch ◽  
E Wesley Ely ◽  
Jin H Han
Keyword(s):  
Severity Of Illness ◽  
The Elderly ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Cognitive Outcomes ◽  
Illness Cognition ◽  
Point Increase ◽  
Comorbidity Burden ◽  
Factor Interactions ◽  
The Impact

Abstract Delirium is heterogeneous and can vary by severity. The impact of its severity is unclear. This prospective cohort study enrolled emergency department (ED) patients who were &gt; 65 years old and admitted to the hospital. Delirium severity was determined by the Confusion Assessment Method for the Intensive Care Unit Severity (CAM-ICU-S) Scale measured at enrollment. This scale ranges from 0 (no symptoms) to 7 (most severe). Premorbid and 6-month cognition were determined using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which ranges from 1 to 5 (severe cognitive impairment). Multiple linear regression was performed to determine if delirium severity was associated with 6-month function and cognition adjusted for pre-illness IQCODE, baseline functional status, comorbidity burden, severity of illness, and central nervous system diagnosis. Two-factor interactions were incorporated to determine if pre-illness cognition modified the relationship between delirium severity as measured by the CAM-ICU-S and 6-month cognition. A total of 228 older patients were enrolled in the ED and of these, 105 were delirious. Median (interquartile range) CAM-ICU-S scores was 2 (0, 5). In patients with intact pre-illness cognition, a point increase in the CAM-ICU-S significantly increased the 6-month IQCODE by 0.06 (95%CI: 0.01 to 0.12) points. In patients with impaired pre-illness cognition, there was no significant association between the CAM-ICU-S and 6-month IQCODE. Thus delirium severity is associated with poorer 6-month cognition, but this association is more prominent in those with intact pre-illness cognition.

scholarly journals Association of education with occurrence of delirium in patients from an emergency department

2016 ◽  
Vol 10 (3) ◽  
pp. 198-203
Author(s):  
Simone Sieben da Mota ◽  
Vera Beatriz Delgado ◽  
Artur Francisco Schumacher-Schuh ◽  
Marcia Lorena Fagundes Chaves
Keyword(s):  
Emergency Department ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Cognitive Status ◽  
Logistic Regression Models ◽  
Educational Backgrounds ◽  
Charlson Comorbidity Score ◽  
History Of ◽  
Lower Education ◽  
State Examination

ABSTRACT Background: Delirium is a neuropsychiatric syndrome with multiple etiological factors. Evaluation of delirium in different settings, especially the Emergency Department (ED) pertaining to different regions of the world with patients from different cultural and educational backgrounds is needed. Objective: To determine the prevalence of delirium and its association with education in an ED in Brazil during a 6-month period. Methods: Patients aged >18 years were randomly selected from ED admissions. The instruments Confusion Assessment Method (CAM) scale, Mini-Mental State Examination (MMSE), Wechsler Logical Memory (WLM) and Charlson comorbidity score were applied to evaluate delirium, cognitive status, and comorbidities. Results: The prevalence of delirium was10.7%. Delirium patients had significantly lower education, MMSE and WLM (immediate and delayed) scores, with 97.4% presenting episodic memory impairment. Patients with delirium had more history of neurological disorders. Three logistic regression models evaluating the association of variables with delirium were developed. Age and MMSE were retained in the first model, WLM scores in the second, and education in the third. Conclusion: To the best of our knowledge, this is the first study estimating the prevalence of delirium in a Brazilian ED. Lower education was associated with the occurrence of delirium.

scholarly journals 288. Follow-Up Blood Cultures in Gram-Negative Bacteremia: How Do They Impact Outcomes

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S144-S144
Author(s):  
Azza Elamin ◽  
Faisal Khan ◽  
Ali Abunayla ◽  
Rajasekhar Jagarlamudi ◽  
aditee Dash
Keyword(s):  
Clinical Outcomes ◽  
Antibiotic Treatment ◽  
Readmission Rate ◽  
Blood Cultures ◽  
Categorical Variables ◽  
Gram Negative ◽  
Number Of Patients ◽  
Significant Difference ◽  
The Impact

Abstract Background As opposed to Staphylococcus. aureus bacteremia, there are no guidelines to recommend repeating blood cultures in Gram-negative bacilli bacteremia (GNB). Several studies have questioned the utility of follow-up blood cultures (FUBCs) in GNB, but the impact of this practice on clinical outcomes is not fully understood. Our aim was to study the practice of obtaining FUBCs in GNB at our institution and to assess it’s impact on clinical outcomes. Methods We conducted a retrospective, single-center study of adult patients, ≥ 18 years of age admitted with GNB between January 2017 and December 2018. We aimed to compare clinical outcomes in those with and without FUBCs. Data collected included demographics, comorbidities, presumed source of bacteremia and need for intensive care unit (ICU) admission. Presence of fever, hypotension /shock and white blood cell (WBC) count on the day of FUBC was recorded. The primary objective was to compare 30-day mortality between the two groups. Secondary objectives were to compare differences in 30-day readmission rate, hospital length of stay (LOS) and duration of antibiotic treatment. Mean and standard deviation were used for continuous variables, frequency and proportion were used for categorical variables. P-value &lt; 0.05 was defined as statistically significant. Results 482 patients were included, and of these, 321 (67%) had FUBCs. 96% of FUBCs were negative and 2.8% had persistent bacteremia. There was no significant difference in 30-day mortality between those with and without FUBCs (2.9% and 2.7% respectively), or in 30-day readmission rate (21.4% and 23.4% respectively). In patients with FUBCs compared to those without FUBCs, hospital LOS was longer (7 days vs 5 days, P &lt; 0.001), and mean duration of antibiotic treatment was longer (14 days vs 11 days, P &lt; 0.001). A higher number of patients with FUBCs needed ICU care compared to those without FUBCs (41.4% and 25.5% respectively, P &lt; 0.001) Microbiology of index blood culture in those with and without FUBCs Outcomes in those with and without FUBCs FUBCs characteristics Conclusion Obtaining FUBCs in GNB had no impact on 30-day mortality or 30-day readmission rate. It was associated with longer LOS and antibiotic duration. Our findings suggest that FUBCs in GNB are low yield and may not be recommended in all patients. Prospective studies are needed to further examine the utility of this practice in GNB. Disclosures All Authors: No reported disclosures

Relation between cognitive disorders and type of physical activity: Results of the FréLE cohort

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
C Dupré ◽  
N Barth ◽  
A El Moutawakkil ◽  
F Béland ◽  
F Roche ◽  
...  
Keyword(s):  
Physical Activity ◽  
Cognitive Decline ◽  
Proportional Hazards ◽  
Cognitive Disorders ◽  
The Elderly ◽  
Cognitive Status ◽  
Global Test ◽  
Professional Activities ◽  
Beneficial Effects ◽  
The Impact

Abstract Background Few previous cohorts have studied the different type of physical activities and the degree of cognitive decline. The objective of this work was to analyze the leisure, domestic and professional activities with mild and moderate cognitive disorders in older people living in community. Methods The study used data from the longitudinal and observational study, FrèLE (FRagility: Longitudinal Study of Expressions). The collected data included: socio-demographic variables, lifestyle, and health status (frailty, comorbidities, cognitive status, depression). Cognitive decline was assessed by using: MMSE (Mini-Mental State Examination) and MoCA (Montreal Cognitive Assessment). MoCA was used with two cut-offs (26 and 17) so as to define mild and moderate cognitive disorders Physical activity was assessed by the PASE (Physical Activity Scale for the Elderly), structured in three sections: leisure, domestic and professional activities. Spline and proportional hazards regression models (Cox) were used to estimate the risk of cognitive disorders. Results At baseline, 1623 participants were included and the prevalence of cognitive disorders was 6.9% (MMSE) and 7.2% (MoCA), mild cognitive disorders was 71.3%. The mean age was 77 years, and 52% of the participants were women. After a 2 years long follow-up, we found 6.9% (MMSE) and 6% (MoCA) cognitive disorders on participants. Analyses showed that domestic activities were associated to cognitive decline (HR = 0.52 [0.28-0.94] for MMSE and HR = 0.48 [0.28-0.80] for MoCA). No association were found with leisure and professional activities, and no spline were significant with mild cognitive disorders. Conclusions Analysis showed a relationship between cognitive disorders and type of physical activity, thanks to the use of specific questionnaire of elderly and two global test of cognition. These findings will contribute to the debate on the beneficial effects of physical activity on cognition. Key messages This work allowed to compare two test of cognition and their link with physical activity. It contributes to the debate on the beneficial effects of physical activity on cognition. The work allowed us to see the effect of the different types of physical activity and the impact of the statistical method on the results.

scholarly journals Cognitive decline in patients with prostate cancer: study protocol of a prospective cohort, NEON-PC

BMJ Open ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. e043844
Author(s):  
Natalia Araujo ◽  
Samantha Morais ◽  
Ana Rute Costa ◽  
Raquel Braga ◽  
Ana Filipa Carneiro ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Cognitive Decline ◽  
Cognitive Performance ◽  
Androgen Deprivation Therapy ◽  
Survival Rates ◽  
Cardiovascular Complications ◽  
Androgen Deprivation ◽  
High Survival ◽  
The Impact

IntroductionProstate cancer is the most prevalent oncological disease among men in industrialised countries. Despite the high survival rates, treatments are often associated with adverse effects, including metabolic and cardiovascular complications, sexual dysfunction and, to a lesser extent, cognitive decline. This study was primarily designed to evaluate the trajectories of cognitive performance in patients with prostate cancer, and to quantify the impact of the disease and its treatments on the occurrence of cognitive decline.MethodsParticipants will be recruited from two main hospitals providing care to approximately half of the patients with prostate cancer in Northern Portugal (Portuguese Institute of Oncology of Porto and São João Hospital Centre), and will comprise a cohort of recently diagnosed patients with prostate cancer proposed for different treatment plans, including: (1) radical prostatectomy; (2) brachytherapy and/or radiotherapy; (3) radiotherapy in combination with androgen deprivation therapy and (4) androgen deprivation therapy (with or without chemotherapy). Recruitment began in February 2018 and is expected to continue until the first semester of 2021. Follow-up evaluations will be conducted at 1, 3, 5, 7 and 10 years. Sociodemographic, behavioural and clinical characteristics, anxiety and depression, health literacy, health status, quality of life, and sleep quality will be assessed. Blood pressure and anthropometrics will be measured, and a fasting blood sample will be collected. Participants’ cognitive performance will be evaluated before treatments and throughout follow-up (Montreal Cognitive Assessment and Cube Test as well as Brain on Track for remote monitoring). All participants suspected of cognitive impairment will undergo neuropsychological tests and clinical observation by a neurologist.Ethics and disseminationThe study was approved by the Ethics Committee of the hospitals involved. All participants will provide written informed consent, and study procedures will be developed to ensure data protection and confidentiality. Results will be disseminated through publication in peer-reviewed journals and presentation in scientific meetings.

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