Implementation of an EMR integrated pathway for the management of malignant bowel obstruction.

813 Background: Despite published evidence based interventions for malignant bowel obstruction (MBO), implementation of a standard pathway is challenging. We hypothesized that using industrial engineering techniques and a modified dynamic sustainability framework for implementation, we can implement an electronic medical record (EMR) based pathway in the management of MBO. Methods: A workflow in the management of MBO was developed using iterative meetings from 8/2018 to 4/2019 including gateway stakeholders (surgical oncology, gynecological oncology and medical oncology), interventional stakeholders (gastroenterology, interventional radiology) and supportive stakeholders (hospital medicine, palliative care, nutrition, nursing). Industrial engineers were utilized to study human factors, and perform a method study. EMR integration was performed using EPIC systems Agile MD pathway and educational materials were created. Interventions such as early placement of gastrostomy tubes, total parenteral nutrition and medications were protocolized. Results: Since implementation, over 6 months the pathway and order set has been activated 56 times. Orders have been employed 21 times through the AgileMD pathway demonstrating a pathway drift of 62.5%. Educational materials have been accessed routinely during this time. Conclusions: Feasibility of implementing an EMR integrated MBO pathway is demonstrated with early suggestion of pathway drift. Utilizing tools of implementation science are necessary to facilitate widespread adoption of evidence based interventions in the management of patients with MBO.

Evolution of Eye Reduction and Loss in Trilobites and Some Related Fossil Arthropods

The fossil record of arthropod compound eyes reflects different modes and occasions of eye reduction and blindness. In the best-studied fossil examples, the trilobites [trilobites: extinct arthropods, dominant during the Palaeozoic], which have an excellent geological record, eyes are primary structures, and in all known genera which lack them, eye-loss is always secondary. Once the eyes were lost, they never were never re-established. The most striking examples occur in the Upper Devonian, when two unrelated major groups of trilobites, with different kinds of eyes, underwent eye reduction and even total loss of the eyes over the same time period, undoubtedly due to long-term environmental change. One reason is that a mud blanket spread over a vast area, there was no firm substrate, and many trilobites became small and many became endobenthic, reducing or losing their eyes in the process. Toxic environmental conditions may also have had an effect. Certain coeval forms remained, however, which still possess perfectly good compound eyes. Either they found vacant refuges where they could survive, or alternatively their visual systems were elaborate enough to adapt to the changing conditions. Another inducement for evolving small, reduced compound eyes is to become a tiny organism oneself, with simply not enough space to establish a regular and functional compound eye, and in such minaturised eyes special adaptations for capturing enough photons are necessary. Thus very small compound eyes often establish wide acceptance angles of their ommatidia, collecting light over large angular ranges of space and it is beneficial to have a wide rhabdom provided that it is short, has a wide lens diameter, and perhaps even possess highly sensitive receptor cells. We find such a miniaturised system in the first recorded planktonic trilobite. Another kind of reduction of a compound eye, or parts of it, also occurs, if selective pressure claims for a high specialisation of eyes that results in several facets fusing into a single functional unit. This probably can be found in phacopid trilobites, ~400 million years old. Here the enlarged aperture of a resulting large lens may allow vision under dim light conditions such as at greater depth. The fossil record gives relatively little evidence about parasites, which often have reduced eyes. Agnostida are blind relatives of trilobites which lived during the Cambrian and Ordovician. An early suggestion was that some of these were parasitic, but this was never commonly adopted. Finally penstastomids (Crustacea), worm-like parasitic organisms, already have been blind from the Cambrian (~487Ma).

An easily missed cause for low GCS in a Scottish Intensive Care Unit

A case report of a 36-year-old patient who presented with seizures, a large thyroid and decreased consciousness level requiring admission to the intensive care unit, where the final diagnosis had a prevalence of 2.1/100,000 and a female to male ratio of 4:1. The final diagnosis was suggested early by a focussed internet search. This is unusual because as clinicians we often tell the general public to ignore an internet search. The early suggestion demonstrated that in the right hands the use of internet searches can help us make more informed decisions and aid patient management when combined with traditional investigative medical practice. However, the lesson with this case is that there are many unusual and rare causes of presentations to critical care units and as clinicians we should keep an open mind and wide differential diagnosis so as not to miss the rarer reasons for these presentations.

Schimpfen und Fluchen im Luwischen

Zusammenfassung The Cuneiform Luwian verb arraḫḫani(ya)- attested in both Luwian and Hittite context is interpreted here as ‘to curse’ following an early suggestion of Meriggi, which has been forgotten in current Luwian scholarship. A new etymology is proposed. The connection of the verb with the PIE root *reh₂(y)- ‘schreien, brüllen’ (LIV²: 501) makes possible the reconstruction of a neuter menstem *reh₂-mn̥, which lost the bilabial nasal by sound change and was derived with the reflex of denominative *-ye/o- in Luwian. Initial *r- is avoided by means of a prothetic vowel (*r- > *er- > *ér- > arr-).

The impact of date palm fruits and their component polyphenols, on gut microbial ecology, bacterial metabolites and colon cancer cell proliferation

The fruit of the date palm (Phoenix dactyliferaL.) is a rich source of dietary fibre and polyphenols. We have investigated gut bacterial changes induced by the whole date fruit extract (digested date extract; DDE) and its polyphenol-rich extract (date polyphenol extract; DPE) using faecal, pH-controlled, mixed batch cultures mimicking the distal part of the human large intestine, and utilising an array of microbial group-specific 16S rRNA oligonucleotide probes. Fluorescence microscopic enumeration indicated that there was a significant increase in the growth of bifidobacteria in response to both treatments, whilst whole dates also increased bacteroides at 24 h and the total bacterial counts at later fermentation time points when compared with DPE alone. Bacterial metabolism of whole date fruit led to the production of SCFA, with acetate significantly increasing following bacterial incubation with DDE. In addition, the production of flavonoid aglycones (myricetin, luteolin, quercetin and apigenin) and the anthocyanidin petunidin in less than 1 h was also observed. Lastly, the potential of DDE, DPE and metabolites to inhibit Caco-2 cell growth was investigated, indicating that both were capable of potentially acting as antiproliferative agentsin vitro, following a 48 h exposure. This potential to inhibit growth was reduced following fermentation. Together these data suggest that consumption of date fruits may enhance colon health by increasing beneficial bacterial growth and inhibiting the proliferation of colon cancer cells. This is an early suggestion that date intake by humans may aid in the maintenance of bowel health and even the reduction of colorectal cancer development.

Integrating Psychotherapy with Obstetrics and Gynaecology

As a specialist Obstetrics and Gynaecology I then became a specialist also in psychotherapy, including: psychodynamic therapy, group therapy, hypnotherapy, and body-therapy. In the last nineteen years I have been working to integrate the medical and psychotherapeutic approach, including attention to psychosocial factors. After some years, I found our German rate of premature birth to be 7%. This amazed me because prematurity very rarely occurred in my patients, which was down to about 1%. In France they did some surveys and studies. By informing the mothers how to live, and reducing smoking and drugs, they reduced their prematurity rate to about half, but still much above my rate of 1%. I have described my method in articles. This is vital work, because serious prematurity is responsible for most damage and death amongst the children. A mother's complaint may be an early suggestion of danger. We then check it with the regular obstetric assessments. Even before birth symptoms can indicate a problem, such as premature labour, much as postnatal problems while breast feeding are indicated by symptoms. And before birth, as well as after birth stress and emotional problems can be the cause for serious somatic illness. It is really an effect of one relationship on the other. The way a woman relates to her child depends on her feeling of security among all who support her. All her relationships are important: how she grew up with her parents; her work; her other children. Further problems that experience of psychotherapy can help to reduce are: exceeding the estimated date of delivery; pre-eclampsia; HELLP-syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets). The lectures we offer on the subject are also relevant to psychotherapeutic understanding and in guiding to treatment.

“The Success of Gentleness”: Homosocial Desire and the Homosexual Personality in the Novels of William Godwin

This article explores William Godwin’s work in his novels to expose ways in which traditional conceptions of masculinity foster aggression and rivalry between men. For Godwin, the destructiveness of such interactions profoundly threatened the potential he saw for the perfectibility of human nature and social relationships. From his early novel Imogen to the deeply psychological Caleb Williams, Fleetwood, and Mandeville, Godwin frequently illustrates the injurious potential of homosocial and homoerotic desire. In many of these instances, such desire is depicted through the use of subtle allusions to classical conceptions of friendship. In the case of Cloudesley, Godwin carries this project further, developing a persona in the hero Julian, whose gentle, feminized personality works to soften the more traditionally masculine and destructive men around him. As a new conception of the male personality, Julian exemplifies Godwin’s argument that “disinterested affection” is the only means towards a more perfect global society. In Godwin’s career as a novelist, therefore, we see an early suggestion that social progress demands a redefinition of traditional conceptions of gender.

Diapiric origin of the Chessel-Noville Hills of the Rhone Valley interpreted from georadar mapping

In an attempt to understand the origin of the enigmatic Chessel-Noville hills in the Rhone River plain of western Switzerland, we have recorded two and three-dimensional ground-penetrating radar (georadar) data and drilled six shallow boreholes. Cross-sections and maps of horizons extracted from the georadar data reveal normal fault zones under the hill flanks and minor grabens and domes below the hill crests. Comparable graben-like structures with normal step faults converging with depth are observed at a nearby outcrop. Fine sand and silt within some of the exposed faults may have been dragged into the fault planes or injected as clastic dikes under high pore pressures. A silt unit encountered in two of the boreholes correlates with a strong georadar reflection. Although angular calcareous boulders are scattered across the surface, the early suggestion that the hills are remnants of a large historic rockfall is not compatible with the subsurface lithologies and structures. Neither is the frequently referenced hypothesis that they are moraines. Moreover, the absence of significant thrust faulting and lack of strong structural trends in the georadar data and at outcrops are inconsistent with the more recent interpretation of the hills as glaciotectonic ridges. Instead, our results indicate that the hills and their internal structures represent vertically uplifted and deformed fluvio-deltaic sediments. Diapirism offers a plausible explanation for the observed uplift and deformation. Saturated fine-grained sediments underlying the former Rhone Delta may have been compacted and overpressured during burial by pro-grading deltaic sands and thickening sequences of fluvial sands and gravels. Under these conditions, mud diapirs may develop. Actual diapiric uplift and deformation may have been triggered by a large historic earthquake (e. g., Tauredunum event of 563 A.D.) that would have induced additional over-pressurization, liquefaction and upward mobilization of the fine-grained sediments. Such an earthquake may also have triggered the rockfall responsible for the scattered calcareous boulders.

White Dwarf Pulsations

It has been known for a long time that white dwarfs are pulsationally unstable if nuclear burning takes place in their envelopes. Perturbation of energy generation rate promotes pulsational instability and this effect is frequently referred to as ε-mechanism. In recent years, with the advent of high-speed photometry, many rapidly varying white dwarfs have been discovered. However, periods of variability were found to be significantly longer than the periods of radial pulsations which were the only type of oscillations considered before the discovery. Furthermore, the case of ε-mechanism as being responsible for the observed variability has never been made strong for any of the observed objects.Variable white dwarfs are found among: Io single DA-type objects in the effective temperature range 10000-15000K; 2o members of close, usually but not always, cataclysmic binary systems. Although, following an early suggestion by Warner and Robinson (1972), the excitation of nonradial oscillation is postulated in both cases, the two types represent very different physical situations and they will be discussed here separately.

Asperisporium caricae. [Descriptions of Fungi and Bacteria].

A description is provided for Asperisporium caricae. Information is included on the disease caused by the organism, its transmission, geographical distribution, and hosts. HOSTS: Carica papaya. DISEASE: Black spot, blight or 'rust' of papaw (Carica papaya). Water-soaked spots on mature leaves become necrotic, usually circular and up to 4 mm diam., the dark conidia! masses being conspicuous on the under surface. Abundant spotting causes defoliation and over 50% leaf fall can occur. Similar spots form on the fruit; they cause shallow lesions and no decay. Young leaves are not attacked. GEOGRAPHICAL DISTRIBUTION: Restricted to Central and S. America, West Indies and USA (Florida, Texas) (CMI Map 488, ed. 1, 1972). TRANSMISSION: Presumably air dispersed but no experimental work has been reported and there is no confirmation of an early suggestion of seed transmission (4: 682).