Abstract The cancer care system is increasingly complex, marked by multiple hand-offs between primary care and specialty providers, inadequate communication among providers, and lack of clarity about ...a “medical home” (the ideal accountable care provider) for cancer patients. Patients and families often cite such difficulties as information deficits, uncoordinated care, and insufficient psychosocial support. This article presents a review of the challenges of delivering well coordinated, patient-centered cancer care in a complex modern healthcare system. An examination is made of the potential role of information technology (IT) advances to help both providers and patients. Using the published literature as background, a review is provided of selected work that is underway to improve communication, coordination, and quality of care. Also discussed are additional challenges and opportunities to advancing understanding of how patient data, provider and patient involvement, and informatics innovations can support high-quality cancer care.
The nature and cause of deep earthquakes remain enduring unknowns in the field of seismology. We present new models of thermal structures of subducted slabs traced to mantle transition zone depths ...that permit a detailed comparison between slab pressure/temperature (P/T) paths and hydrated/carbonated mineral phase relations. We find a remarkable correlation between slabs capable of transporting water to transition zone depths in dense hydrous magnesium silicates with slabs that produce seismicity below ∼300‐km depth, primarily between 500 and 700 km. This depth range also coincides with the P/T conditions at which oceanic crustal lithologies in cold slabs are predicted to intersect the carbonate‐bearing basalt solidus to produce carbonatitic melts. Both forms of fluid evolution are well represented by sublithospheric diamonds whose inclusions record the existence of melts, fluids, or supercritical liquids derived from hydrated or carbonate‐bearing slabs at depths (∼300–700 km) generally coincident with deep‐focus earthquakes. We propose that the hydrous and carbonated fluids released from subducted slabs at these depths lead to fluid‐triggered seismicity, fluid migration, diamond precipitation, and inclusion crystallization. Deep focus earthquake hypocenters could track the general region of deep fluid release, migration, and diamond formation in the mantle. The thermal modeling of slabs in the mantle and the correlation between sublithospheric diamonds, deep focus earthquakes, and slabs at depth demonstrate a deep subduction pathway to the mantle transition zone for carbon and volatiles that bypasses shallower decarbonation and dehydration processes.
Plain Language Summary
Earthquakes occurring below ∼300 km, especially in the mantle transition zone are some of the strongest events experienced on Earth. Deep earthquakes, whose nature and cause are poorly known, occur with regularity and are a deep and prominent result of plate tectonics. We model the paths of subducting slabs to relate pressure‐temperature conditions to the experimentally determined mineralogies of the slab crust and mantle. We present a synthesis of mantle minerals included in diamonds derived from same depths as the deep earthquakes to show that fluids exist there. We show that decarbonization/melting reactions in the slab crust and dehydration reactions in the slab mantle can provide fluids to the earthquake generation regions, suggesting that fluids cause or are related to deep earthquakes.
Key Points
Mineral inclusions in sublithospheric diamonds are evidence for mobile fluids in the mantle transition zone
Thermal modeling shows that carbonated crust and hydrated mantle in cold slabs can produce fluids at the depths of deep‐focus earthquakes
Fluids should be considered as significant contributors to the genesis of deep earthquakes
Britain relied upon secret intelligence operations to rule Mandatory Palestine.Statecraft by Stealthsheds light on a time in history when the murky triad of intelligence, policy, and security ...supported colonial governance. It emphasizes the role of the Anglo-Zionist partnership, which began during World War I and ended in 1939, when Britain imposed severe limits on Jewish immigration and settlement in Palestine.
Steven Wagner argues that although the British devoted considerable attention to intelligence gathering and analysis, they never managed to solve the basic contradiction of their rule: a dual commitment to democratic self-government and to the Jewish national home through immigration and settlement. As he deftly shows, Britain's experiment in Palestine shed all pretense of civic order during the Palestinian revolt of 1936-41, when the police authority collapsed and was replaced by a security state, created by army staff intelligence. That shift, Wagner concludes, was rooted in Britain's desire to foster closer ties with Saudi Arabia just before the start of World War II, and thus ended its support of Zionist policy.
Statecraft by Stealthtakes us behind the scenes of British rule, illuminating the success of the Zionist movement and the failure of the Palestinians to achieve independence. Wagner focuses on four key issues to stake his claim: an examination of the "intelligence state" (per Martin Thomas's classic,Empires of Intelligence), the Arab revolt, the role of the Mufti of Jerusalem, and the origins and consequences of Britain's decision to end its support of Zionism.
Wagner crafts a superb story of espionage and clandestine policy-making, showing how the British pitted individual communities against each other at particular times, and why.
Skinfold calipers: which instrument to use? Cintra-Andrade, Joaquim H.; Ripka, Wagner L.; Heymsfield, Steven B.
Journal of nutritional science (Cambridge),
07/2023, Volume:
12
Journal Article
Peer reviewed
Open access
The considerable amount of original and generic types of skinfold calipers available is a source of systematic measurement error. This study is a brief report that critically examines the original ...and illustrated structural configuration of the three main types of skinfold calipers. For more than half a century, the Harpenden®, Lange® and Slim Guide® skinfolds calipers have been widely used in clinical and research settings. It is well established that the physical, mechanical and functional specificity of each type of skinfold caliper makes its interchangeable use impossible. Our report suggests that commercially available technical specifications are insufficient to judiciously choose a skinfold caliper. The area of the jaws, the coefficient of spring and the static and dynamic downward pressure of each type of skinfold caliper must be determined in the metrological laboratory and added to the technical user manual. Choosing a type of skinfold caliper for regular use, without conflict of commercial interest, requires a critical understanding of the physical, mechanical and functional characteristics that configure it. Therefore, a new downward static calibration test and the first eligibility flowchart for a skinfold caliper have been proposed. Finally, the information gathered in this report may be useful for manufacturers of anthropometric instruments and health professionals who use the skinfold technique as a tool for diagnosis and nutritional control.
We report characteristics of soybean genetic diversity and structure from the resequencing of 481 diverse soybean accessions, comprising 52 wild (Glycine soja) selections and 429 cultivated (Glycine ...max) varieties (landraces and elites). This data was used to identify 7.8 million SNPs, to predict SNP effects relative to genic regions, and to identify the genetic structure, relationships, and linkage disequilibrium. We found evidence of distinct, mostly independent selection of lineages by particular geographic location. Among cultivated varieties, we identified numerous highly conserved regions, suggesting selection during domestication. Comparisons of these accessions against the whole U.S. germplasm genotyped with the SoySNP50K iSelect BeadChip revealed that over 95% of the re-sequenced accessions have a high similarity to their SoySNP50K counterparts. Probable errors in seed source or genotype tracking were also identified in approximately 5% of the accessions.
Context: The gastrointestinal peptide hormone, peptide YY3–36 (PYY3–36), is implicated to be a postprandial satiety factor.
Objective: The aim of this study is to assess the safety, tolerability, and ...efficacy of intranasal PYY3–36 to induce weight loss in obese patients.
Design: The study was designed as a randomized, 2-wk, single-blind placebo run-in followed by a 12-wk double-blind, placebo-controlled treatment period.
Setting: The study was set within a private and institutional practice.
Patients: A total of 133 obese patients (body mass index, 30–43 kg/m2; age, 18–65 yr) participated in the study.
Intervention: Placebo or 200- or 600-μg PYY3–36 was administered as an intranasal spray 20 min before breakfast, lunch, and dinner in conjunction with a hypocaloric diet and exercise.
Main Outcome Measure: Body weight was the main outcome measure.
Results: The number of patients completing 12 wk on the drug was 38 of 43 (88%), 31 of 44 (70%), and 12 of 46 (26%) for placebo, 200 μg three times a day (t.i.d.) and 600 μg t.i.d., respectively. In the 600 μg t.i.d. group, 27 of 46 (59%) patients discontinued due to nausea and vomiting. Among all randomized patients who took at least one drug dose and had a postbaseline measurement, the mean body weight change from baseline was −2.8, −3.7, and −1.4 kg for placebo, 200 and 600 μg, respectively. The least squares mean difference (95% confidence interval) between placebo and 200 μg was −0.9 (−2.6, 0.7) kg (P = 0.251). A difference of 2.11 kg was sought. No meaningful inference can be drawn from the few patients who completed the study on 600 μg.
Conclusions: Intranasal PYY3–36 as administered at these intervention doses and preprandial timing is not efficacious in inducing weight loss in obese patients after 12 wk of treatment.
Anecdotes and limited evidence suggest that a significant percentage of cancer patients encounter troublesome problems in the course of their care.
The authors collected data about barriers to and ...facilitators of high-quality cancer care and innovative solutions to improve quality from three sources: focus groups with patients, family members of cancer patients and providers; site visits to cancer care providers and organisations in three American communities; and expert interviews.
The authors' respondents consistently described a similar list of problems facing the individual with a suspicion or diagnosis of cancer and his/her family: delays in and lack of coordination of care, patient information gaps and passivity, inadequate attention to emotional and social problems, and difficulty accessing services because of inadequate insurance, limited financial resources or rural residence. The fragmentation and uncertain accountability of cancer care contribute to these issues. Respondents recommended linking patients with a care navigator or manager, using computer technology to better inform and support patients and connect providers, and reforming provider reimbursement to encourage more patient-centred care.
Cancer patients and their families have urgent needs for information and support especially early in their course. To meet these needs, early cancer care must be better organised, integrated, and patient centred. The Institute of Medicine's Model for the Delivery of Psychosocial Services appears to provide a relevant guide to delivering cancer care that better meets patient and family needs.
The Institute of Medicine (IOM) report Crossing the Quality Chasm proposed 6 aims for high-quality healthcare: effective, safe, timely, efficient, equitable, and patient-centered, and emphasized care ...coordination. Through interviews with nationally recognized experts in healthcare quality, perspectives on barriers and facilitators to achieving these aims for cancer patients were elicited.
In all, 23 peer-nominated experts with diverse backgrounds in policy, healthcare, patient advocacy, and research were individually interviewed. They were asked about barriers and facilitators to achieving high-quality cancer care, and information technology or other innovations that might improve the quality of cancer diagnosis, treatment, and surveillance. Interviews were tape-recorded and transcribed. Two analysts independently reviewed and coded each transcript using ethnographic software to elucidate key themes.
The major perceived barrier to providing high-quality cancer care was unnecessary variation in cancer care because of lack of standardization or adherence to guidelines during diagnosis, treatment, and surveillance. Additional barriers included insufficient teamwork and communication among multidisciplinary care teams, lack of patient awareness and empowerment, diagnostic delays during provider transitions, and excessive reimbursement for treatment. Experts suggested improving cancer patients' experiences by standardizing care, adhering to guidelines, and using "patient navigators" and an interoperable electronic medical record accessible to patients and providers at multiple facilities.
Some of these solutions have been developed and tested, whereas others have not. It is hoped that these suggestions provide impetus for new research, accelerating progress toward achieving the IOM's vision for high-quality cancer care.
Cannabinoid 1 receptor (CB1R) inverse agonists are emerging as a potential obesity therapy. However, the physiological mechanisms by which these agents modulate human energy balance are incompletely ...elucidated. Here, we describe a comprehensive clinical research study of taranabant, a structurally novel acyclic CB1R inverse agonist. Positron emission tomography imaging using the selective CB1R tracer
18FMK-9470 confirmed central nervous system receptor occupancy levels (∼10%–40%) associated with energy balance/weight-loss effects in animals. In a 12-week weight-loss study, taranabant induced statistically significant weight loss compared to placebo in obese subjects over the entire range of evaluated doses (0.5, 2, 4, and 6 mg once per day) (p < 0.001). Taranabant treatment was associated with dose-related increased incidence of clinical adverse events, including mild to moderate gastrointestinal and psychiatric effects. Mechanism-of-action studies suggest that engagement of the CB1R by taranabant leads to weight loss by reducing food intake and increasing energy expenditure and fat oxidation.
To date, few data on paediatric COVID-19 have been published, and most reports originate from China. This study aimed to capture key data on children and adolescents with severe acute respiratory ...syndrome coronavirus 2 (SARS-CoV-2) infection across Europe to inform physicians and health-care service planning during the ongoing pandemic.
This multicentre cohort study involved 82 participating health-care institutions across 25 European countries, using a well established research network-the Paediatric Tuberculosis Network European Trials Group (ptbnet)-that mainly comprises paediatric infectious diseases specialists and paediatric pulmonologists. We included all individuals aged 18 years or younger with confirmed SARS-CoV-2 infection, detected at any anatomical site by RT-PCR, between April 1 and April 24, 2020, during the initial peak of the European COVID-19 pandemic. We explored factors associated with need for intensive care unit (ICU) admission and initiation of drug treatment for COVID-19 using univariable analysis, and applied multivariable logistic regression with backwards stepwise analysis to further explore those factors significantly associated with ICU admission.
582 individuals with PCR-confirmed SARS-CoV-2 infection were included, with a median age of 5·0 years (IQR 0·5-12·0) and a sex ratio of 1·15 males per female. 145 (25%) had pre-existing medical conditions. 363 (62%) individuals were admitted to hospital. 48 (8%) individuals required ICU admission, 25 (4%) mechanical ventilation (median duration 7 days, IQR 2-11, range 1-34), 19 (3%) inotropic support, and one (<1%) extracorporeal membrane oxygenation. Significant risk factors for requiring ICU admission in multivariable analyses were being younger than 1 month (odds ratio 5·06, 95% CI 1·72-14·87; p=0·0035), male sex (2·12, 1·06-4·21; p=0·033), pre-existing medical conditions (3·27, 1·67-6·42; p=0·0015), and presence of lower respiratory tract infection signs or symptoms at presentation (10·46, 5·16-21·23; p<0·0001). The most frequently used drug with antiviral activity was hydroxychloroquine (40 7% patients), followed by remdesivir (17 3% patients), lopinavir-ritonavir (six 1% patients), and oseltamivir (three 1% patients). Immunomodulatory medication used included corticosteroids (22 4% patients), intravenous immunoglobulin (seven 1% patients), tocilizumab (four 1% patients), anakinra (three 1% patients), and siltuximab (one <1% patient). Four children died (case-fatality rate 0·69%, 95% CI 0·20-1·82); at study end, the remaining 578 were alive and only 25 (4%) were still symptomatic or requiring respiratory support.
COVID-19 is generally a mild disease in children, including infants. However, a small proportion develop severe disease requiring ICU admission and prolonged ventilation, although fatal outcome is overall rare. The data also reflect the current uncertainties regarding specific treatment options, highlighting that additional data on antiviral and immunomodulatory drugs are urgently needed.
ptbnet is supported by Deutsche Gesellschaft für Internationale Zusammenarbeit.
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