MidHudson Regional Hospital

A special-purpose load unit is proposed as part of a processor design. The unit prefetches data from the cache by predicting the address of the data fetch in advance. This prefetch allows the cache access to take place early, in an otherwise unused cache cycle, eliminating one cycle from the load instruction. The prediction also allows the cache to prefetch data if they are not already in the cache. The cache-miss handling can be overlapped with other instruction execution. It is shown, using trace-driven simulations, that the proposed mechanism, when incorporated in a design, may contribute to a significant increase in processor performance. The paper also compares different prediction methods and describes a hardware implementation for the load unit.

The decreased sexual desire screener is a brief diagnostic instrument for generalized acquired hypoactive sexual desire disorder in women. During the screening visit of 2 clinical trials, the authors assessed sensitivity of the decreased sexual desire screener in premenopausal women presenting with decreased sexual desire. The authors compared diagnoses of generalized acquired hypoactive sexual desire disorder made by clinicians who were not trained or specialized in the diagnosis of female sexual dysfunction using the decreased sexual desire screener with diagnoses made by expert clinicians after an extensive diagnostic interview. The sensitivity of the decreased sexual desire screener was 0.946 in a North American trial and 0.960 in a European trial.

OBJECTIVE: To survey employee competence assessment practices in departments of pathology and laboratory medicine and provide suggestions for improvement. DESIGN: A 3-part study consisting of a questionnaire about current competence assessment practices, an evaluation of compliance with stated competence assessment practices using personnel records of 30 employees, and a written appraisal of competence of 5 specimen-processing staff members per institution. SETTING: A total of 522 institutions participating in the College of American Pathologists 1996 Q-Probes program. MAIN OUTCOME MEASURES: Institutional competence assessment practices, compliance of each institution with their own practices, and determination of competence of specimen-processing personnel. RESULTS: Of the participating institutions, 89.8% had a written competence plan and 98.1% reported reviewing employee competence at least yearly. General competence was reviewed by direct observations (87.5%), review of test or quality control results (77.4%), review of instrument preventive maintenance (60.0%), written testing (52.2%), and/or other methods (20.8%). In 8.6% of institutions, employees who failed competence assessment were not allowed to continue their usual work. On review of records of 14 029 employees for adherence to the laboratory's general competence plan, adherence was 89.7% for direct observations, 85.8% for review of quality control and test results, 78.0% for review of instrument records, and 74.0% for written testing. Employee failure rate ranged from 0.9% to 6.4%, depending on the competence evaluated. Adherence to an institution's plan was 90.4% for new employees, 93.1% for computer skills, 95.8% for laboratory safety, and 92.1% for continuing education. When a written competence assessment was given to 2853 specimen-processing staff members, 90.0% responded satisfactorily. CONCLUSIONS: Opportunities for improvement in employee competence assessment are numerous, and we provide several specific suggestions.

OBJECTIVE: The objective of this study was to evaluate tourniquet use in the Hartford prehospital setting during a 34-month period after the Hartford Consensus was published, which encouraged increasing tourniquet use in light of military research. DESIGN: This was a retrospective review of patients with bleeding from a serious extremity injury to determine appropriateness of tourniquet use or omission. SETTING: Level II trauma center between April 2014 and January 2017. PARTICIPANTS: Eighty-four patients met inclusion criteria and were stratified based on tourniquet use during prehospital care. MAIN OUTCOME MEASURES: Five of the 84 patients received a tourniquet. All five of those tourniquets (100 percent of the group, 6.0 percent of the population) were not indicated and deemed inappropriate. Three of the 84 patients did not receive a tourniquet when one was indicated (3.8 percent of the group, 3.6 percent of the population) and these omissions were also deemed inappropriate. Total error rate was 9.5 percent (8/84). RESULTS: There was a significant association between Mangled Extremity Severity Score (MESS) and likelihood of requiring a tourniquet (p = 0.0013) but not between MESS and likelihood of receiving a tourniquet (p = 0.1055). There was also a significant association between wrongly placed tourniquets and the type of providers who placed them [first responders, p = 0.0029; Emergency Medicine Technicians (EMTs), p = 0.0001]. CONCLUSIONS: Tourniquets are being used inappropriately in the Hartford prehospital setting. Misuse is associated with both EMTs and first responders, highlighting the need for better training and more consistent protocols.

INTRODUCTION: Lewy body dementia (LBD) is common, yet under-recognized and under-researched. To plan studies with the highest impact, engagement of the community personally affected by these conditions is essential. METHODS: A web-based survey of people living with LBD and current and former caregivers of people with LBD queried research priorities through forced ranking and exploration of burden of LBD symptoms. Specific caregiving needs in LBD and perceptions of research participation were also investigated. RESULTS: Between April 7, 2021 and July 1, 2021, 984 responses were recorded. Top research priorities included disease-modifying therapies and improved disease detection and staging. People with LBD were interested in pathophysiology and more bothered by motor symptoms; caregivers were interested in risk factors and symptomatic therapies and more bothered by neuropsychiatric symptoms. Few available LBD treatments and resources were rated as helpful, and many valuable services were never received. Previous participation in LBD research was infrequent, but interest was high. DISCUSSION: People with LBD and caregivers highlighted the need for research across all aspects of LBD, from pathophysiology and disease modification to prognosis, education, symptomatic treatments, and caregiver support. Funders should increase support for all aspects of LBD research to target the many needs identified by individuals and families living with LBD.

Objective To determine the effect of a Best Practice Advisory (BPA) on the ordering and administration of contraindicated dopamine blocking agents (DBA) to hospitalized patients with Parkinson’s disease (PD) and related disorders. Background Patients with PD are more likely to require hospitalization and are at increased risk of complications. Administration of contraindicated DBA contributes to worsened outcomes in this patient population. Electronic medical record (EMR) warnings (also referred to as BPA) have been proposed as a way to prevent the administration of contraindicated medications. Methods A BPA was launched in January 2020 within the University of Rochester EMR system, which alerts the provider when a contraindicated DBA is ordered in hospitalized patients with PD and related disorders. Patients with PD and related disorders hospitalized at two hospitals affiliated to the University of Rochester during a time period before ( t1 : 1/1/2019–1/1/2020) and after ( t2 : 1/8/2020–1/8/2021) the implementation of the BPA were included in this study. Epic SliderDicer was used to collect the data from the University of Rochester EMR. The number of patients who had contraindicated DBA orders and administrations in both time periods, and the number of patients who had the BPA triggered during t2 were obtained. We compared the results before and after the implementation of the BPA. Results 306 patients with PD and related disorders were hospitalized during t1 and 273 during t2 . There was significantly less percentage of patients who had contraindicated DBA orders (41.5% in t1 vs. 17.6% in t2 ) and patients who had contraindicated DBA administrations (16% in t1 vs. 8.8% in t2 ) during t2 ( p < 0.05 for both comparisons). There was no significant difference between the percentage of patients who had contraindicated DBA orders in t1 and patients with attempted orders (BPA triggered) in t2 ( p = 0.27). Conclusion The results of this study increase the evidence of the potential benefit of EMR warnings for the optimization of inpatient medication management in patients with PD and related disorders. In particular, our results suggest that EMR warnings help reduce the administration of contraindicated medications, which is a known contributing factor for hospital complications in this patient population.

BACKGROUND: More than 20 million children in the United States lack access to primary health care. PRACTICE LEARNING: Research shows that students with regular access to physical and mental health services have fewer absences, are more social, less likely to participate in risky behaviors, have improved focus and higher test scores. IMPLICATION FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: School-based health centers (SBHCs) can be an important, valuable and viable health care delivery option to meet the full-range of primary health care needs of students where they spend the majority of their wake hours, ie, in school. Children in rural and other underserved communities, as well as those underinsured, non-insured, economically challenged, underserved, and the most vulnerable among us are especially at risk. CONCLUSIONS: This paper discusses the history, value, and importance of SBHCs from myriad perspectives, including physical and emotional wellbeing, academic and social success, and the promotion of a positive transition to adulthood. In addition, the authors' experiences that resulted in building the first SBHC in the Mid-Hudson Valley Region of New York State are shared. These experiences form the foundation for creating an important roadmap for individuals and school leaders that are interested in bringing a SBHC to their school and district.

Technology has had a dramatic impact on how diseases are diagnosed and treated. Although cut, sew, and tie remain the staples of surgical craft, new technical skills are required. While there is no replacement for live operative experience, training outside the operating room offers structured educational opportunities and stress modulation. A stepwise program for acquiring new technical skills required in robotic surgery involves three modules: ergonomic, psychomotor, and procedural. This is a prospective, educational research protocol aiming at evaluating the responsiveness of general surgery residents in Robotic-Assisted Surgery Training (RAST). Responsiveness is defined as change in performance over time. Performance is measured by the following content-valid metrics for each module. Module 1 proficiency in ergonomics includes: cart deploy, boom control, cart driving, camera port docking, targeting anatomy, flex joint, clearance joint and port nozzle adjusting, and routine and emergent undocking. Module 2 proficiency in psychomotor skills includes tissue handling, accuracy error, knot quality, and operating time. Module 3 proficiency in procedural skills prevents deviations from standardized sequential procedural steps in order to test length of specimen resection, angle for transection, vessel stump length post ligation, distance of anastomosis from critical landmarks, and proximal and distal resection margins. Resident responsiveness over time will be assessed comparing the results of baseline testing with final testing. Educational interventions will include viewing one instructional video prior to module commencement, response to module-specific multiple-choice questions, and individual weekly training sessions with a robotic instructor in the operating room. Residents will progress through modules upon successful final testing and will evaluate the educational environment with the Dundee Ready Educational Environment Measure (DREEM) inventory. The RAST program protocol outlined herein is an educational challenge with the primary endpoint to provide evidence that formal instruction has an impact on proficiency and safety in executing robotic skills.

With the advent of significant new features in APL, for example APL2, attention to and an understanding of the fundamental principles and concepts of APL is especially important. This expository paper is aimed primarily at the APL educator, present or future, and the person seriously pursuing a more in-depth mastery of the language. The paper states some of the underlying concepts and principles of the language and why they are important. Within the presentation several techniques which the author has found successful in conveying these concepts are stated. Finally, the fact that APL2 permits another new and different approach to problem solving is discussed and illustrated.

Abstract Takotsubo cardiomyopathy (TTC), commonly known as “broken heart syndrome” or “stress cardiomyopathy,” is characterized by transient left ventricular (LV) systolic dysfunction, usually in the absence of significant obstructive coronary artery stenosis. The pathophysiology of TTC remains elusive; however, the three most common plausible mechanisms include catecholamine surge causing myocardial stunning, multivessel coronary spasm, and microvascular dysfunction. Although initially thought to be a benign, reversible, and transient disorder, newer research data demonstrate that TTC may sometimes have severe short-term complications and some long-term residual effects. Several risk factors have been associated with the outcomes of TTC. In this review, we aim to provide a comprehensive review of the prognostication of TTC in the context of different clinical variables presented in multiple research studies. Various clinical factors, including the types of TTC triggers, the patient’s sex, the presence of cardiogenic shock, atrial arrhythmias, LV tract obstruction, and the presence of certain other clinical comorbidities may significantly impact patient outcomes in TTC patients. A thorough understanding of these factors helps clinicians to better prognosticate the outcome of their patients. Furthermore, early institution of aggressive treatment interventions in the presence of these risk factors may improve the subsequent clinical course.

With the advent of significant new features in APL, for example APL2, attention to and an understanding of the fundamental principles and concepts of APL is especially important. This expository paper is aimed primarily at the APL educator, present or future, and the person seriously pursuing a more in-depth mastery of the language. The paper states some of the underlying concepts and principles of the language and why they are important. Within the presentation several techniques which the author has found successful in conveying these concepts are stated. Finally, the fact that APL2 permits another new and different approach to problem solving is discussed and illustrated.

KANAAR, A. C. and M. W. HECHT. Marathon swim training in a 74-yr-old man: personal experiences. Med. Sci. Sports Exerc., Vol. 24, No. 4, pp. 490–494. This is a special individual case study of the extraordinary efforts of a 74-yr-old man training for a marathon swim. The observations were carried out under field conditions. These are unique observations that are unlikely to be repeated.

INTRODUCTION: Spine surgeons are embracing advanced biologic technologies in an attempt to help millions of people achieve a better outcome in spine surgery. These new technologies may be complicated to understand, partly because the contribution of different types of cells has not been definitively identified. This paper describes the characteristics of the stem cells used in spine surgery, including their actions and possible complications. The description necessitates an overview of all studies to date on the use of stem cells in spine surgery, as well as other cells used in cellular therapy. MATERIALS AND METHODS: The paper summarizes the results of major studies to date on the use of stem cells in spine surgery. Cells were harvested from the posterior superior iliac spine, vertebral bodies in surgery, fat tissue, or from the posterior spine of cadavers. RESULTS: This paper reports on three studies involving 37 patients treated with stem cells for regenerative spine surgery, 14 studies involving 533 patients treated with stem cells in spinal fusion surgery, and one study in which stem cells were used for the treatment of anterior cervical discectomy and fusion. DISCUSSION: Indications, techniques, and calibration of results were different in each study. Results are available for cellular augmentation of demineralized bone sponges, OsteoSponge® (Bacterin, Belgrade, Montana) and concentrated bone marrow (Terumo BCT®, Lakewood, CO); cancellous allograft bone and BMA; mineralized collagen and BMA; Osteocel® Plus (OC+) (Nuvasive®, San Diego, California); b-Tricalcium phosphate (b-TCP) (SYNTHES® Dento, West Chester, Pennsylvania; a silicate-substituted calcium phosphate (Si-CaP) with bone marrow aspirate (BMA), and HEALOS® graft carrier (DePuy Synthes, West Chester, Pennsylvania) with bone marrow aspirate. CONCLUSION: Stem cell augmentation of spinal fusion surgery is equivalent to the gold standard for iliac crest bone graft in posterolateral fusion models. There is evidence of safety and feasibility in the injectable treatment of DDD with autologous BMC that indicates a favorable outcome of mesenchymal cell concentration on discogenic pain reduction. The use of adult stem cells is an innovation that promises fewer complications and improved function in patients who are demographically suitable for stem cell therapy.

BACKGROUND: Minor phenomena, including illusions, feeling of presence, and passage hallucinations, are common in Parkinson's disease (PD) and may be a risk factor for the development of psychosis (hallucinations and delusions). OBJECTIVES: The objective of this study was to determine the 3-year cumulative probability of developing psychosis among individuals with PD minor phenomena. METHODS: We conducted a 3-year, prospective, observational study of individuals with PD minor phenomena with biannual study visits. The presence of psychosis was ascertained using the Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) Part I Hallucinations and Psychosis item and the enhanced Scale for the Assessment of Positive Symptoms in PD (eSAPS-PD). The primary outcome variable was the time from baseline to the development of psychosis. Proportional hazards regression models were applied to examine potential risk factors for the development of psychosis. RESULTS: We enrolled 38 individuals with PD minor phenomena and included 34 in the primary analysis (47% female with mean standard deviation [SD]), with age 70.3 (7.9) years and mean (SD) time from PD diagnosis 7.5 (5.9) years). Twenty-four (71%) of the 34 developed psychosis during follow-up. None of the examined demographic or clinical variables were associated with the time to development of psychosis. CONCLUSIONS: Over a 3-year period, there was a high cumulative probability of psychosis among individuals with PD minor phenomena in this single-center prospective study.

The results are presented of a study on two blanket design concepts for application in a Commercial Tokamak Hybrid Reactor (CTHR). Both blankets operate on the U-Pu cycle and are designed to achieve tritium self-sufficiency while maximizing the fissile fuel production within thermal and mechanical design constraints. The two blanket concepts that were evaluated were: (1) a UC fueled, stainless steel clad and structure, helium cooled blanket; and (2) a UO/sub 2/ fueled, zircaloy clad, stainless steel structure, boiling water cooled blanket. Two different tritium breeding media, Li/sub 2/O and LiH, were evaluated for use in both blanket concepts. The use of lead as a neutron multiplier or reflector and graphite as a reflector was also considered for both blankets.

Minimally invasive surgery has rapidly evolved from the once novel laparoscopic approach to advanced robotic surgery. In the past few decades alone, robotic systems have gone from systems which were significantly limited to full-fledged platforms featuring 3D vision, articulated instruments, integrated ultrasound and fluorescence capabilities, and even the latest wireless connectivity, as is now standard. In this review, we aimed to summarize features of currently commercialized and utilized robotic surgical systems as well as currently unfolding platforms. The pros and cons of different robotic surgical systems were discussed. In addition, we discussed the future perspectives of robotic platforms used in general surgery. In this regard, we emphasized that the market, once dominated by Intuitive Surgical Inc., has become occupied by several worthy competitors with new technological giants such as Google. Eventually, the question facing hospital systems will not be of whether or not to invest in robotic surgery, but instead of how they will strike balance between price, features, and availability when choosing robots from the growing market to best equip their surgeons.

Global disparities in stroke care, particularly in acute interventions like mechanical thrombectomy (MT), remain profound, with the Mechanical Thombectomy Global Access for Stroke study reporting a median global MT access of just 2.79%. Furthermore, the low- and middle-income countries (LMICs) have been recognized to be disproportionately burdened in this regard as compared with high-income countries. These observed inequities in stroke care impact not only clinical outcomes but also economic productivity and social systems. Recent advancements, such as TeleStroke networks, Mobile Stroke Units, and artificial intelligence-powered tools, have the potential to bridge these gaps. The Mechanical Thrombectomy Access Score (MTAS) offers a novel standardized approach to quantifying barriers to MT access and guiding targeted interventions to mitigate such obstacles. This review explores how MTAS enables the integration of these advancements into global stroke care systems, addressing inequities and optimizing outcomes. Emphasizing the importance of measuring access to manage inequities, we propose strategies to refine and validate MTAS while advocating for systemic investments to enhance global stroke care.

The make-up of communities has been changing at an increased rate, especially the demographic make-up. For libraries the ability to recognize and respond to these changes is crucial. Rather than waiting for a full scale community assessment, techniques such as focus groups, targeted surveys and partnerships can be used to maintain a library's ability to adequately respond to community needs and tailored to work with multicultural populations.

Tracheobronchopathia osteochondroplastica (TPO) is a rare, benign condition characterized by the presence of submucosal cartilaginous and osseous nodules protruding into the anterior and lateral walls of the tracheobronchial lumen, sparing the posterior membranous wall. These nodules are incidentally discovered on imaging and bronchoscopy performed for unrelated respiratory symptoms. The exact etiopathogenesis is unclear, with various hypotheses proposed. The most widely accepted one is that chronic inflammation leads to cartilaginous and osseous metaplasia of the tracheobronchial submucosa. TPO is rare, with the prevalence further underestimated due to the incidental nature of the diagnosis. Clinically, patients may be asymptomatic or can have nonspecific symptoms such as chronic cough, dyspnea, and recurrent respiratory infections. Suspicion of the diagnosis arises upon incidental identification of nodules in the tracheobronchial lumen. Diagnosis is established through bronchoscopic visualization of characteristic nodular lesions sparing the posterior wall and can be confirmed by histopathologic examination showing submucosal cartilage formation and ossification. Management is generally conservative, focusing on symptomatic relief and treatment of infections. Severe cases with significant airway obstruction may warrant advanced bronchoscopic procedures or surgical interventions. Despite its benign nature, TPO can mimic other serious tracheal diseases. Awareness of this condition is essential for accurate diagnosis and appropriate management. We present a case of a 65-year-old asymptomatic chronic smoker who was found to have tracheal nodules on thoracic imaging. Bronchoscopic evaluation was consistent with TPO, with histopathology reaffirming the diagnosis.

The Queen's Company, based in New York, is one of the most important all-women's companies in America. It was founded in 2000 by Rebecca Patterson as an answer to the many experiments in all-male p...