Despite the danger of franchisee non-compliance as a severe impediment to overall franchise operation and performance, there is currently minimal understanding of the key factors that lead to these ...behaviors. Using a foundation of relational exchange theory, we construct and test a model that demonstrates how two distinct forms of trust, based upon perceptions of franchisor integrity and franchisor competence, are critical to explaining the roles that relational conflict and satisfaction play in influencing franchisee compliance. Implications of these findings are then demonstrated to have compelling relevance to the effective management of franchise systems.
Maintenance of long-term arteriovenous access is important in long-term care for patients with end-stage renal disease. Arteriovenous access is associated in the long term with the development of ...fistula aneurysms (FAs). This study aims to evaluate the outcomes of staged FA treatment in dialysis access arteriovenous fistulae (AVF).
A retrospective review of all patients over a 12-year period with primary autogenous AVF was undertaken at a single center. Patients undergoing elective open aneurysm repair were identified and were categorized into three groups: single FA repair (single, control group) and staged and unstaged repair of two FAs (staged and unstaged). A staged repair was a procedure in which the initial intent was to treat both aneurysms in the AVF and in which the most symptomatic aneurysm was treated first. When the incision from the first surgery had healed, the second symptomatic aneurysm in the AVF was treated. An unstaged repair was a procedure in which the initial intent was to repair both symptomatic aneurysms simultaneously. All patients had a fistulogram before the FA repair. Thirty-day outcomes, cannulation failure, line placement, reintervention, and functional dialysis (continuous hemodialysis for 3 consecutive months) were examined.
Five hundred twenty-seven patients presented with FA that met requirements for open intervention; 44% underwent single FA repair, whereas the remaining 34% and 22% underwent staged and unstaged repair of two FAs, respectively. The majority of patients were diabetic and Hispanic. Ninety-one percent of the patients required percutaneous interventions of the outflow tract (37%) and the central veins (54%). Thirty-day major adverse cardiovascular events were equivalent across all modalities. Thirty-day morbidity and early thrombosis (<18 days) were significantly higher in the unstaged group (4.3%) compared with the two other groups (1.3% and 2.1%, single and staged, respectively), which led to an increased need for a short-term tunneled catheter (8.9%) compared with the two other groups (3.4% and 4.4%, single and staged, respectively), Unstaged repair resulted in an increased incidence of secondary procedures (5.0%) compared with the two other groups (2.6% and 3.1%, single and staged, respectively). Functional dialysis at 5 years was equivalent in the single and staged groups but was significantly decreased in the unstaged group.
Open interventions are successful therapeutic modalities for FAs, but unstaged rather than staged repair of two concurrent FAs results in a higher early thrombosis, an increased secondary intervention rate, and a need for a short-term tunneled central line. Staged and single FA repairs have equivalent results. In the setting of two symptomatic FAs, staged repair is recommended.
Establishing long-term arteriovenous access is an important component in the long-term care of a patient with end-stage renal disease. The increasing frequency of obesity is reported to impact the ...access management of end-stage renal disease patients. This study aims to evaluate the outcomes of arteriovenous fistulae (AVF) in obese and nonobese patients.BACKGROUNDEstablishing long-term arteriovenous access is an important component in the long-term care of a patient with end-stage renal disease. The increasing frequency of obesity is reported to impact the access management of end-stage renal disease patients. This study aims to evaluate the outcomes of arteriovenous fistulae (AVF) in obese and nonobese patients.A retrospective review of all patients over ten years with primary autogenous AVF (radiocephalic, brachiocephalic, and brachial-basilic) was undertaken at a single center. Patients were subcategorized by body mass index into nonobese, class I, II, and III obesity. Outcomes of maturation (successful progression to hemodialysis), reintervention, functional dialysis (continuous hemodialysis for 3 consecutive months), and patency were examined.METHODSA retrospective review of all patients over ten years with primary autogenous AVF (radiocephalic, brachiocephalic, and brachial-basilic) was undertaken at a single center. Patients were subcategorized by body mass index into nonobese, class I, II, and III obesity. Outcomes of maturation (successful progression to hemodialysis), reintervention, functional dialysis (continuous hemodialysis for 3 consecutive months), and patency were examined.From January 1999 to December 2019, 2311 patients (67% female; mean age, 61 ± 15 years) underwent primary AVF placement (12% radiocephalic, 53% brachiocephalic, and 35% brachial basilic). Forty-one percent were nonobese, 29% had class I obesity, 19% had class II obesity, and 11% had class III obesity. The majority of patients were diabetic and Hispanic. The 30-day major adverse cardiovascular event rate was elevated in class II (0.20%) and class III (0.50%) obesity compared with class I obesity (0.15%) and nonobese (0.05%). The 30-day morbidity rate was higher in all classes of obesity (0.5% vs0.3% vs 0.2% vs 0.05% for class III vs class II vs class I obesity and nonobese, respectively). Early thrombosis was significantly increased in class II (9%) and class III obesity (12%) compared with class I obesity (5%) and nonobese (3%). There was a two-fold increase in procedures to effect maturation in class II (51%) and class III (74%) obesity compared with class I obesity (22%) and nonobese (34%). Secondary patency at 3 years was significantly lower in class III (62 ± 4%) and class II (79 ± 3%) compared with class I obesity (87 ± 2%) and nonobese (93 ± 4%). All classes of obesity required significantly more secondary Interventions per year compared with nonobese (3.9 vs 3.1 vs 2.5 vs 1.4 secondary interventions per year for class III vs class II vs class I obesity and nonobese, respectively).RESULTSFrom January 1999 to December 2019, 2311 patients (67% female; mean age, 61 ± 15 years) underwent primary AVF placement (12% radiocephalic, 53% brachiocephalic, and 35% brachial basilic). Forty-one percent were nonobese, 29% had class I obesity, 19% had class II obesity, and 11% had class III obesity. The majority of patients were diabetic and Hispanic. The 30-day major adverse cardiovascular event rate was elevated in class II (0.20%) and class III (0.50%) obesity compared with class I obesity (0.15%) and nonobese (0.05%). The 30-day morbidity rate was higher in all classes of obesity (0.5% vs0.3% vs 0.2% vs 0.05% for class III vs class II vs class I obesity and nonobese, respectively). Early thrombosis was significantly increased in class II (9%) and class III obesity (12%) compared with class I obesity (5%) and nonobese (3%). There was a two-fold increase in procedures to effect maturation in class II (51%) and class III (74%) obesity compared with class I obesity (22%) and nonobese (34%). Secondary patency at 3 years was significantly lower in class III (62 ± 4%) and class II (79 ± 3%) compared with class I obesity (87 ± 2%) and nonobese (93 ± 4%). All classes of obesity required significantly more secondary Interventions per year compared with nonobese (3.9 vs 3.1 vs 2.5 vs 1.4 secondary interventions per year for class III vs class II vs class I obesity and nonobese, respectively).Advancing obesity class is associated with an increased number of procedures to achieve AVF maturation and is associated with poorer patency and functionality as the category of obesity advances.CONCLUSIONSAdvancing obesity class is associated with an increased number of procedures to achieve AVF maturation and is associated with poorer patency and functionality as the category of obesity advances.
Stress and burnout due to electronic health record (EHR) technology has become a focus for burnout intervention. The aim of this study is to systematically review the relationship between EHR use and ...provider burnout.
A systematic literature search was performed on PubMed, EMBASE, PsychInfo, ACM Digital Library in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Inclusion criterion was original research investigating the association between EHR and provider burnout. Studies that did not measure the association objectively were excluded. Study quality was assessed using the Medical Education Research Study Quality Instrument. Qualitative synthesis was also performed.
Twenty-six studies met inclusion criteria. The median sample size of providers was 810 (total 20 885; 44% male; mean age 53 range, 34-56 years). Twenty-three (88%) studies were cross-sectional studies and 3 were single-arm cohort studies measuring pre- and postintervention burnout prevalence. Burnout was assessed objectively with various validated instruments. Insufficient time for documentation (odds ratio OR, 1.40-5.83), high inbox or patient call message volumes (OR, 2.06-6.17), and negative perceptions of EHR by providers (OR, 2.17-2.44) were the 3 most cited EHR-related factors associated with higher rates of provider burnout that was assessed objectively.
The included studies were mostly observational studies; thus, we were not able to determine a causal relationship. Currently, there are few studies that objectively assessed the relationship between EHR use and provider burnout. The 3 most cited EHR factors associated with burnout were confirmed and should be the focus of efforts to improve EHR-related provider burnout.
Pathologic Basis of Lumbar Radicular Pain Dower, Ashraf; Davies, Mark A.; Ghahreman, Ali
World neurosurgery,
August 2019, 2019-Aug, 2019-08-00, 20190801, Volume:
128
Journal Article
Peer reviewed
Lumbar radicular pain is one of the most commonly encountered clinical syndromes; however, its underlying mechanistic basis, and its relation to the natural history of the disease, are poorly ...understood.
We revieved the available literature to explore the pathophysiology and natural history of lumbar radicular pain.
Experimental observations have spawned distinctive, but not mutually exclusive, pathophysiologic descriptions of radicular pain. These mechanisms include mechanical compression and inflammatory processes. In most cases, a complex interplay between these mechanisms is required to sustain the pain. However, when the dorsal root ganglion is mechanically deformed, sustained discharges causing pain can be evoked, leading to pain based on a purely mechanical basis. However, in other instances, previous sensitization of the nerve root by inflammatory processes is required.
An understanding of these processes and the natural history of the syndrome is important to developing therapeutic strategies.
Endovascular aortic aneurysm repair of complex aortic aneurysms requires incorporation of side branches using specially designed aortic stent grafts with fenestrations, directional branches, or ...parallel stent grafts. These techniques have been increasingly used and reported in the literature. The purpose of this document is to clarify and to update terminology, classification systems, measurement techniques, and end point definitions that are recommended for reports dealing with endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms involving the renal and mesenteric arteries.
ChEMBL is now a well-established resource in the fields of drug discovery and medicinal chemistry research. The ChEMBL database curates and stores standardized bioactivity, molecule, target and drug ...data extracted from multiple sources, including the primary medicinal chemistry literature. Programmatic access to ChEMBL data has been improved by a recent update to the ChEMBL web services (version 2.0.x, https://www.ebi.ac.uk/chembl/api/data/docs), which exposes significantly more data from the underlying database and introduces new functionality. To complement the data-focused services, a utility service (version 1.0.x, https://www.ebi.ac.uk/chembl/api/utils/docs), which provides RESTful access to commonly used cheminformatics methods, has also been concurrently developed. The ChEMBL web services can be used together or independently to build applications and data processing workflows relevant to drug discovery and chemical biology.
Breast milk provides optimal nutrition for term and preterm infants, and the ideal way for infants to receive breast milk is through suckling at the breast. Unfortunately, this may not always be ...possible for medical or physiological reasons such as being born sick or preterm and as a result requiring supplemental feeding. Currently, there are various ways in which infants can receive supplemental feeds. Traditionally in neonatal and maternity units, bottles and nasogastric tubes have been used; however, cup feeding is becoming increasingly popular as a means of offering supplemental feeds in an attempt to improve breastfeeding rates. There is no consistency to guide the choice of method for supplemental feeding.
To determine the effects of cup feeding versus other forms of supplemental enteral feeding on weight gain and achievement of successful breastfeeding in term and preterm infants who are unable to fully breastfeed.
We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 31 January 2016), Embase (1980 to 31 January 2016), and CINAHL (1982 to 31 January 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.
Randomised or quasi-randomised controlled trials comparing cup feeding to other forms of enteral feeding for the supplementation of term and preterm infants.
Data collection and analysis was performed in accordance with the methods of Cochrane Neonatal. We used the GRADE approach to assess the quality of evidence.The review authors independently conducted quality assessments and data extraction for included trials. Outcomes reported from these studies were: weight gain; proportion not breastfeeding at hospital discharge; proportion not feeding at three months of age; proportion not feeding at six months of age; proportion not fully feeding at hospital discharge; proportion not fully breastfeeding at three months of age; proportion not fully breastfeeding at six months of age; average time per feed (minutes); length of stay; and physiological events of instability such as bradycardia, apnoea, and low oxygen saturation. For continuous variables such as weight gain, mean differences and 95% confidence intervals (CIs) were reported. For categorical outcomes such as mortality, the relative risks (RR) and 95% CIs were reported.
The experimental intervention was cup feeding and the control intervention was bottle feeding in all five studies included in this review. One study reported weight gain as g/kg/day and there was no statistically significant difference between the two groups (MD -0.60, 95% CI -3.21 to 2.01); while a second study reported weight gain in the first seven days as grams/day and also showed no statistically significant difference between the two groups (MD -0.10, 95% CI -0.36 to 0.16). There was substantial variation in results for the majority of breastfeeding outcomes, except for not breastfeeding at three months (three studies) (typical RR 0.83, 95% CI 0.71 to 0.97) which favoured cup feeding. Where there was moderate heterogeneity meta-analysis was performed: not breastfeeding at six months (two studies) (typical RR 0.83, 95% CI 0.72 to 0.95); not fully breastfeeding at hospital discharge (four studies) (typical RR 0.61, 95% CI 0.52 to 0.71).Two studies reported average time to feed which showed no difference between the two groups. Two studies assessed length of hospital stay and there was considerable variation in results and in the direction of effect. Only one study has reported gestational age at discharge, which showed no difference between the two groups (MD -0.10, 95% CI -0.54 to 0.34).
As the majority of infants in the included studies are preterm infants, no recommendations can be made for cup feeding term infants due to the lack of evidence in this population.From the studies of preterm infants, cup feeding may have some benefits for late preterm infants and on breastfeeding rates up to six months of age. Self-reported breastfeeding status and compliance to supplemental interventions may over-report exclusivity and compliance, as societal expectations of breastfeeding and not wishing to disappoint healthcare professionals may influence responses at interview and on questionnaires.The results for length of stay are mixed, with the study involving lower gestational age preterm infants finding that those fed by cup spent approximately 10 days longer in hospital, whereas the study involving preterm infants at a higher gestational age, who did not commence cup feeding until 35 weeks' gestation, did not have a longer length of stay, with both groups staying on average 26 days. This finding may have been influenced by gestational age at birth and gestational age at commencement of cup feeding, and their mothers' visits; (a large number of mothers of these late preterm infants lived regionally from the hospital and could visit at least twice per week).Compliance to the intervention of cup feeding remains a challenge. The two largest studies have both reported non-compliance, with one study analysing data by intention to treat and the other excluding those infants from the analysis. This may have influenced the findings of the trial. Non-compliance issues need consideration before further large randomised controlled trials are undertaken as this influences power of the study and therefore the statistical results. In addition larger studies with better-quality (especially blinded) outcome assessment with 100% follow-up are needed.
Chat Generative Pre-trained Transformer (ChatGPT) is an artificial intelligence (AI) tool which utilises machine learning to generate original text resembling human language. AI models have recently ...demonstrated remarkable ability at analysing and solving problems, including passing professional examinations. We investigate the performance of ChatGPT on some of the UK radiology fellowship equivalent examination questions.
ChatGPT was asked to answer questions from question banks resembling the Fellowship of the Royal College of Radiologists (FRCR) examination. The entire physics part 1 question bank (203 5-part true/false questions) was answered by the GPT-4 model and answers recorded. 240 single best answer questions (SBAs) (representing the true length of the FRCR 2A examination) were answered by both GPT-3.5 and GPT-4 models.
ChatGPT 4 answered 74.8% of part 1 true/false statements correctly. The spring 2023 passing mark of the part 1 examination was 75.5% and ChatGPT thus narrowly failed. In the 2A examination, ChatGPT 3.5 answered 50.8% SBAs correctly, while GPT-4 answered 74.2% correctly. The winter 2022 2A pass mark was 63.3% and thus GPT-4 clearly passed.
AI models such as ChatGPT are able to answer the majority of questions in an FRCR style examination. It is reasonable to assume that further developments in AI will be more likely to succeed in comprehending and solving questions related to medicine, specifically clinical radiology.
Our findings outline the unprecedented capabilities of AI, adding to the current relatively small body of literature on the subject, which in turn can play a role medical training, evaluation and practice. This can undoubtedly have implications for radiology.
Arteriovenous accesses develop aneurysms (FA) during their active use, resulting in pain, erosion, bleeding, and difficulty in cannulation. This study aims to evaluate the outcomes of open and ...endovascular management of single FA in arteriovenous fistulas (AVF).
A retrospective review of all upper extremity primary AVFs over 12 years was undertaken at a single center. Patients undergoing elective open and endovascular repair of a single FA were identified. Thirty-day outcomes, cannulation failure, line placement, re-intervention, and functional dialysis (continuous hemodialysis) for 3 consecutive months were examined.
Three hundred and seventy nine patients presented with a single FA that met the requirements for intervention: 126 (33%) underwent endovascular repair, and the remainder 253 (67%) underwent open repair. Preoperative fistulogram identified anatomically significant issues in 91% of the cases, and these were treated by balloon angioplasty: 10% within the fistula tract, 44% within the outflow tract, and 47% in the central veins. In open repair, 57% underwent plication, 35% underwent resection and re-anastomosis, and the remainder (8%) underwent interposition grafting. In endovascular repair, successful placement of a stent was achieved in all cases with 1 ± 2 (mean ± standard deviation SD) covered stents (diameter: 6 -8 mm) placed, achieving successful exclusion of the FA. The combination of early thrombosis and cannulation failures led to the greater need for a tunneled central line in endovascular repair (6.5% vs. 2.4%; endovascular versus open repair; P = 0.04). As a result, the mean time for establishing renewed access in the index AVF was significantly higher in endovascular repair (2 ± 3 vs. 2 ± 2 weeks, mean ± SD; endovascular open repair versus open repair; P = 0.001). In follow-up, there were more secondary interventions per year in the endovascular compared to open repair groups (3.1 vs. 1.4 secondary interventions per year; endovascular versus open repair; P = 0.04). Median functional dialysis durations were superior in the open repair (48 ± 6%, mean + standard error) compared to the endovascular repair at 5 years. (26 ± 7%; P = 0.03).
Open repair results in a more rapid return to access use, lower need for a tunneled central line, lower secondary re-intervention rates, and superior functional dialysis durations compared to endovascular repair. Open FA repair should be considered for symptomatic single FA repairs before endovascular FA repair.
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