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Background: Patients presenting to the Emergency Department (ED) may be subjected to unnecessary bloodwork. This leads to excessive work for front-line nurses, physicians and laboratory staff, contributing to increased ED length of stay (LOS), patient discomfort, and health care costs. Aim Statement: By January 1, 2020, we will reduce the number of targeted blood tests (AST, GGT, aPTT and CK) by 40% in the Mount Sinai ED, as measured by the percent per 1000 ED visits of AST to ALT, GGT to ALT, aPTT to INR and CK to troponin. Measures & Design: This was a prospective time series quality improvement study. Using the Model for Improvement, we engaged front-line ED staff, as well as stakeholders from Consultant, Laboratory and Information Services. Data was analyzed using run chart rules. Intervention: a) Removed rarely used tests from electronic nursing order sets b) Uncoupled order panels c) Developed six presentation-based medical directives with appropriate blood testing. d) Staff education Family of measures Outcomes: percent of targeted uncoupled test per 1000 ED visits for each of AST to ALT, GGT to ALT, aPTT to INR, and CK to troponin; Total number of blood tests ordered per 1000 ED visits Process: number of “separate and hold” tubes; number of blood tubes used in the ED; proportion of staff attending education Balancing: volume of blood drawn; LOS Evaluation/Results: Outcome: Estimated relative reduction in proportion of all uncoupled tests per 1000 ED visits by: • 33% AST/ALT • 52% GGT/ALT • 50% CK/troponin •18% aPTT/INR Total number of lab tests per 1000 ED visits decreased by 7.7% (5742 to 5331). Evidence of special cause variation on all outcomes. Process measures: 1. 100% reduction in weekly “Separate and Hold” tubes (56 to 0). 2. Monthly total of blood tubes used in the ED decreased by 2.8% (11620 to 11300) 3. Attendance pending. Balancing measures: Monthly average volume of blood drawn decreased by 1.4L(2%) from 50.4L to 49.0L; LOS pending Discussion/Impact: A multi-pronged intervention resulted in a decrease in blood testing in the ED. We achieved the sub-aim of reducing targeted blood tests and are on track to achieve the overall aim of total lab reduction in the ED by April 2020. Final interventions to be implemented in the coming months include changes to the ED paper record and replacement of the paper add-on order process with an electronic ordering tool. Complete data will be available by April 2020. This intervention is scalable and has the potential to reduce costs and preventable harm to patients.
The INTERMED method was created to identify patients with multiple care risks, needs and negative health outcomes, in order to assess their biopsychosocial complexity as a first step towards integrated care. Until now, it was based on a face-to-face interview (IM-CAG). Several studies in the last decades have confirmed its face-validity and reliability. A self-assessment version was derived (IM-SA) providing a complementary tool for clinical and research applications.
Preliminary evaluation of IM-SA's predictive validity, in comparison to IM-CAG's.
29 outpatients with liver disorders referred to the consultation-liaison psychiatry service of the Modena University Hospital underwent the protocol of evaluation, including: IM-SA, IM-CAG, CIRS, HADS, SF-36, EuroQol. Clinical and socio-demographic data were also collected for all patients.
Both INTERMED instruments, IM-CAG and IM-SA, were able to identify complex patients (with a total score higher than 21/60) and showed similar correlations to the other measurements (with a mean difference between correlations of 24%). Discrepancies were also suggested by preliminary data, particularly related to the prognostic assessment (“vulnerability”).
Preliminary results suggest that IM-SA is able to predict complexity of health care needs. the IM-SA Study, an European multicentric project supported by the INTERMED Foundation and including different clinical populations, will provide stronger evidence about generalizability of data.
Carbonate glasses can be formed routinely in the system K2CO3–MgCO3. The enthalpy of formation for one such 0.55K2CO3–0.45MgCO3 glass was determined at 298 K to be 115.00 ± 1.21 kJ/mol by drop solution calorimetry in molten sodium molybdate (3Na2O·MoO3) at 975 K. The corresponding heat of formation from oxides at 298 K was −261.12 ± 3.02 kJ/mol. This ternary glass is shown to be slightly metastable with respect to binary crystalline components (K2CO3 and MgCO3) and may be further stabilized by entropy terms arising from cation disorder and carbonate group distortions. This high degree of disorder is confirmed by 13C MAS NMR measurement of the average chemical shift tensor values, which show asymmetry of the carbonate anion to be significantly larger than previously reported values. Molecular dynamics simulations show that the structure of this carbonate glass reflects the strong interaction between the oxygen atoms in distorted carbonate anions and potassium cations.
Introduction: Active substance use and unstable housing are both associated with increased emergency department (ED) utilization. This study examined ED health care costs among a cohort of substance using and/or homeless adults following an index ED visit, relative to a control ED population. Methods: Consecutive patients presenting to an inner-city ED between August 2010 and November 2011 who reported unstable housing and/or who had a chief presenting complaint related to acute or chronic substance use were evaluated. Controls were enrolled in a 1:4 ratio. Participants’ health care utilization was tracked via electronic medical record for six months after the index ED visit. Costing data across all EDs in the region was obtained from Alberta Health Services and calculated to include physician billing and the cost of an ED visit excluding investigations. The cost impact of ED utilization was estimated by multiplying the derived ED cost per visit by the median number of visits with interquartile ranges (IQR) for each group during follow up. Proportions were compared using non-parametric tests. Results: From 4679 patients screened, 209 patients were enrolled (41 controls, 46 substance using, 91 unstably housed, 31 both unstably housed and substance using (UHS)). Median costs (IQR) per group over the six-month period were $0 ($0-$345.42) for control, $345.42 ($0-$1139.89) for substance using, $345.42 ($0-$1381.68) for unstably housed and $1381.68 ($690.84-$4248.67) for unstably housed and substance using patients (p<0.05). Conclusion: The intensity of excess ED costs was greatest in patients who were both unstably housed and presenting with a chief complaint related to substance use. This group had a significantly larger impact on health care expenditure relative to ED users who were not unstably housed or who presented with a substance use related complaint. Further research into how care or connection to community resources in the ED can reduce these costs is warranted.
In the article above there is a spelling mistake in the Figure 3 legend. Largge should be Large. The correct Figure 3 legend is shown below:-
Figure 3 Biomass values of herbivorous fish functional groups – browsers, grazers and detritivores, and scrapers and small excavators – for each island. Large excavators and bioeroders were not observed, and thus are not included in the graph.
Page 5, right column in the ‘Ecological perspective and management implications section’, in the second paragraph the third sentence should read . . .One potential management tool that considers these needs and limitations is the installation of composting toilets, after due consideration of local cultural sensitivities. . .
Small-island coral reef ecosystems are usually closely coupled to the activities of human inhabitants. Ahus Island (Papua New Guinea) is an isolated Pacific island with a rapidly growing population, heavy reliance on marine resources and limited infrastructure. We hypothesized that untreated sewage was driving distinct benthic assemblages around Ahus and neighbouring uninhabited Onetah. At sites with varying proximities to beach toilets, fore-reef herbivorous fish biomass and benthic composition were measured alongside reef-flat sedimentary oxygen consumption (SOC); a high SOC rate reflects high organic input into coastal waters, thus serving as a potential indicator of sewage input. Fish biomass was low (17.1–20.1 g m–2), but consistent between sites. However, cyanobacteria dominated the fore-reef closest to toilets (62 ± 3%) with highest reef-flat SOC, whereas hard corals dominated furthest away (63 ± 1%), where SOC was lowest. To our knowledge, this is the first study that used SOC to detect local differences in sewage pollution. The results indicate that whilst corals can maintain their dominance on overfished reefs, additional sewage stress may drive pronounced benthic shifts, highlighting the urgency to improve small-island waste management.
Introduction: Substance use and unstable housing are associated with heavy use of the Emergency Department (ED). This study examined the impact of substance use and unstable housing on the probability of future ED use. Methods: Case-control study of patients presenting to an urban ED. Patients were eligible if they were unstably housed for the past 30 days, and/or if their chief complaint was related to substance use. Following written informed consent, patients completed a baseline survey and health care use was tracked via electronic medical records for the next six months. Controls were enrolled in a 1:4 ratio. More than 2 ED visits during the follow-up was pre-specified as a measure of excess ED use. Descriptive analyses included proportions and medians with interquartile ranges (IQR). Binomial logistic regression models were used to estimate the impact of housing status, high-risk alcohol use (AUDIT) and drug use (DUDIT), and combinations of these factors on subsequent acute care system contacts (ED visits + admissions). We controlled for age, gender, comorbidities at baseline, and baseline presenting acuity. Results: 41 controls, 46 substance using, 91 unstably housed, and 31 both unstably housed and substance using patients were enrolled (n = 209). Median ED visits during follow up were 0 (IQR: 0-1.0) for controls, 1.0 (IQR: 0-3.3) for substance using, 1.0 (IQR: 0-4.0) for unstably housed and 4 (IQR: 2-12.3) for unstably housed and substance using patients. The median acute care system contacts over the same period was 1.0 (IQR 0-2.0) for controls, 1.0 (IQR: 0-4.0) for substance using, 1.0 (IQR: 0-5.0) for unstably housed and 4.5 (IQR: 2.8-14.3) for unstably housed and substance using patients. Being unstably housed was the factor most strongly associated with having > 2 ED visits (b=3.288, p<0.005) followed by high-risk alcohol and drug use (b=2.149, p<0.08); high risk alcohol use alone was not significantly associated with ED visits (b=1.939, p<0.1). The number of comorbidities present at baseline was a small but statistically significant additional risk factor (b=0.478, p<0.05). The model correctly predicted 70.1% of patients’ ED utilization status. Conclusion: Unstable housing is a substantial risk factor for ED use; high-risk alcohol and drug use, and comorbidities at baseline increased this risk. The intensity of excess ED use was greatest in patients who were unstably housed and substance using.
Many studies have used retrospective reports to assess the long-term consequences of early life stress. However, current individual characteristics and experiences may bias the recall of these reports. In particular, depressed mood may increase the likelihood of recall of negative experiences. The aim of the study was to assess whether specific factors are associated with consistency in the reporting of childhood adverse experiences.
The sample comprised 7466 adults from Canada's National Population Health Survey who had reported on seven childhood adverse experiences in 1994/1995 and 2006/2007. Logistic regression was used to explore differences between those who consistently reported adverse experiences and those whose reports were inconsistent.
Among those retrospectively reporting on childhood traumatic experiences in 1994/1995 and 2006/2007, 39% were inconsistent in their reports of these experiences. The development of depression, increasing levels of psychological distress, as well as increasing work and chronic stress were associated with an increasing likelihood of reporting a childhood adverse experience in 2006/2007 that had not been previously reported. Increases in mastery were associated with reduced likelihood of new reporting of a childhood adverse experience in 2006/2007. The development of depression and increases in chronic stress and psychological distress were also associated with reduced likelihood of ‘forgetting’ a previously reported event.
Concurrent mental health factors may influence the reporting of traumatic childhood experiences. Studies that use retrospective reporting to estimate associations between childhood adversity and adult outcomes associated with mental health may be biased.
Accumulating evidence links childhood adversity to negative health outcomes in adulthood. However, most of the available evidence is retrospective and subject to recall bias. Published reports have sometimes focused on specific childhood exposures (e.g. abuse) and/or specific outcomes (e.g. major depression). Other studies have linked childhood adversity to a large and diverse number of adult risk factors and health outcomes such as cardiovascular disease. To advance this literature, we undertook a broad examination of data from two linked surveys. The goal was to avoid retrospective distortion and to provide a descriptive overview of patterns of association.
A baseline interview for the Canadian National Longitudinal Study of Children and Youth collected information about childhood adversities affecting children aged 0–11 in 1994. The sampling procedures employed in a subsequent study called the National Population Health Survey (NPHS) made it possible to link n = 1977 of these respondents to follow-up data collected later when respondents were between the ages of 14 and 27. Outcomes included major depressive episodes (MDE), some risk factors and educational attainment. Cross-tabulations were used to examine these associations and adjusted estimates were made using the regression models. As the NPHS was a longitudinal study with multiple interviews, for most analyses generalized estimating equations (GEE) were used. As there were multiple exposures and outcomes, a statistical procedure to control the false discovery rate (Benjamini–Hochberg) was employed.
Childhood adversities were consistently associated with a cluster of potentially related outcomes: MDE, psychotropic medication use and smoking. These outcomes may be related to one another since psychotropic medications are used in the treatment of major depression, and smoking is strongly associated with major depression. However, no consistent associations were observed for other outcomes examined: physical inactivity, excessive alcohol consumption, binge drinking or educational attainment.
The conditions found to be the most strongly associated with childhood adversities were a cluster of outcomes that potentially share pathophysiological connections. Although prior literature has suggested that a very large number of adult outcomes, including physical inactivity and alcohol-related outcomes follow childhood adversity, this analysis suggests a degree of specificity with outcomes potentially related to depression. Some of the other reported adverse outcomes (e.g. those related to alcohol use, physical inactivity or more distal outcomes such as obesity and cardiovascular disease) may emerge later in life and in some cases may be secondary to depression, psychotropic medication use and smoking.
Monoclinic Cu2SnS3 was made by solution based processing of the precursor metals after which the samples are annealed in a sulphur environment. XRD and Raman spectra shows that the monoclinic phase was synthesised. One sample was further etched in KCN and HCl to remove possible secondary phases. Transmission spectra show that the material has two optical transitions and in conjunction with reflection data absorption spectra were calculated. The two optical transitions are determined to be 0.91 and 0.98 for the unetched sample and 0.90 and 0.95 eV for the etched sample. The values of the optical transitions are within the error the same and thus etching does not affect the values of these optical transitions. Photoluminescence spectra map show only one luminescence peak with a maximum at 0.95 eV, which is consistent with the values found by absorption spectra. This in combination with the Raman spectra and XRD indicates that the sample contains only one polymorph of Cu2SnS3, which is monoclinic. Therefore the two optical transitions are intrinsic to monoclinic Cu2SnS3.
Considerable evidence now links childhood adversity to a variety of adult health problems. Unfortunately, almost all of these studies have relied upon retrospective assessment of childhood events, creating a vulnerability to bias. In this study, we sought to examine three associations using data sources that allowed for both prospective and retrospective assessment of childhood events.
Methods. A 1994 national survey of children between the ages of 0 and 11 collected data from a ‘person most knowledgeable’ (usually the mother) about a child. It was possible to link data for n = 1977 of these respondents to data collected from the same people in a subsequent adult study. The latter survey included retrospective reports of childhood adversity. We examined three adult health outcomes in relation to prospectively and retrospectively assessed childhood adversity: major depressive episodes, excessive alcohol consumption and painful conditions.
Results. A strong association between childhood adversities (as assessed by both retrospective and prospective methods) and major depression was identified although the association with retrospective assessment was stronger. Weaker associations were found for painful conditions, but these did not depend on the method of assessment. Associations were not found for excessive alcohol consumption irrespective of the method of assessment.
These findings help to allay concerns that associations between childhood adversities and health outcomes during adulthood are merely artefacts of recall bias. In this study, retrospective and prospective assessment strategies produced similar results.
The Chauvet-Pont d'Arc Cave is one of the most important sites for the study of the earliest manifestations and development of prehistoric art at the beginning of the Upper Paleolithic. Different dating techniques have been performed thus far (AMS 14C, U/Th TIMS, 36Cl dating) to model the chronological framework of this decorated cave. The cave yielded several large charcoal fragments, which enabled the opportunity for obtaining multiple dates; thus, a First Radiocarbon Intercomparison Program (FIP) was initiated in 2004 using three charcoal pieces. The FIP demonstrated that those cross-dated samples belonged to a time period associated with the first human occupation. One of the statistical interests of an intercomparison program is to reduce the uncertainty on the sample age; thus, to further assess the accuracy of the chronological framework, the Second Intercomparison Program (SIP) involving 10 international 14C laboratories was carried out on two pieces of charcoal found inside two hearth structures of the Galerie des Mégacéros. Each laboratory used its own pretreatment and AMS facilities. In total, 21 and 22 measurements were performed, respectively, which yielded consistent results averaging ∼32 ka BP. Two strategies have currently been developed to identify statistical outliers and to deal with them; both lead to quasi-identical calibrated combined densities. Finally, the new results were compared with those of the FIP, leading to the important conclusion that five different samples from at least three different hearth structures give really tightened temporal densities, associated with one short human occupation in the Galerie des Mégacéros.
Outcome of moderate to severe traumatic brain injury (TBI) includes impaired emotion regulation. Emotion regulation has been associated with amygdala and rostral anterior cingulate (rACC). However, functional connectivity between the two structures after injury has not been reported. A preliminary examination of functional connectivity of rACC and right amygdala was conducted in adolescents 2 to 3 years after moderate to severe TBI and in typically developing (TD) control adolescents, with the hypothesis that the TBI adolescents would demonstrate altered functional connectivity in the two regions. Functional connectivity was determined by correlating fluctuations in the blood oxygen level dependent (BOLD) signal of the rACC and right amygdala with that of other brain regions. In the TBI adolescents, the rACC was found to be significantly less functionally connected to medial prefrontal cortices and to right temporal regions near the amygdala (height threshold T = 2.5, cluster level p < .05, FDR corrected), while the right amygdala showed a trend in reduced functional connectivity with the rACC (height threshold T = 2.5, cluster level p = .06, FDR corrected). Data suggest disrupted functional connectivity in emotion regulation regions. Limitations include small sample sizes. Studies with larger sample sizes are necessary to characterize the persistent neural damage resulting from moderate to severe TBI during development. (JINS, 2013, 19, 1–14)
To test the vascular depression hypothesis in the general population, we analyzed the association between current depression, medical history of depression, cognitive and somatic depressive symptom dimensions and measures of atherosclerosis [intima–media thickness (IMT) and carotid plaques].
We included a representative sample of 5000 participants from the Gutenberg Health Study (GHS). Depression was assessed by the nine-item Patient Health Questionnaire (PHQ-9), and IMT and carotid plaques were measured at both common carotid arteries using an edge detection system. Regression analyses were performed separately for participants with and without cardiovascular disease, adjusting for medical history, cardiovascular risk factors and psychotropic medication.
Contrary to hypotheses, we found no increased IMT for somatic symptoms of depression; the same was true for depression and cognitive symptoms in the fully adjusted model. Only a moderate relationship between medical history of depression and the presence of atherosclerotic plaques was maintained after correction.
The relationship between depression and atherosclerosis may be more complex than previously assumed. Although the vascular depression hypothesis was not supported, our results support the hypothesis that lasting depression leads to arteriosclerosis.
Integrated Multi-Trophic Aquaculture takes advantage of the mutualism between some detritivorous fish and phytoplankton. The fish recycle nutrients by consuming live (and dead) algae and provide the inorganic carbon to fuel the growth of live algae. In the meanwhile, algae purify the water and generate the oxygen required by fishes. Such mechanism stabilizes the functioning of an artificially recycling ecosystem, as exemplified by combining the euryhaline tilapia Sarotherodon melanotheron heudelotii and the unicellular alga Chlorella sp. Feed addition in this ecosystem results in faster fish growth but also in an increase in phytoplankton biomass, which must be limited. In the prototype described here, the algal population control is exerted by herbivorous zooplankton growing in a separate pond connected in parallel to the fish–algae ecosystem. The zooplankton production is then consumed by tilapia, particularly by the fry and juveniles, when water is returned to the main circuit. Chlorella sp. and Brachionus plicatilis are two planktonic species that have spontaneously colonized the brackish water of the prototype, which was set-up in Senegal along the Atlantic Ocean shoreline. In our system, water was entirely recycled and only evaporation was compensated (1.5% volume/day). Sediment, which accumulated in the zooplankton pond, was the only trophic cul-de-sac. The system was temporarily destabilized following an accidental rotifer invasion in the main circuit. This caused Chlorella disappearance and replacement by opportunist algae, not consumed by Brachionus. Following the entire consumption of the Brachionus population by tilapias, Chlorella predominated again. Our artificial ecosystem combining S. m. heudelotii, Chlorella and B. plicatilis thus appeared to be resilient. This farming system was operated over one year with a fish productivity of 1.85 kg/m2 per year during the cold season (January to April).
How much is a home worth? Who wants to live in it? Who can live in it? What kind of land uses are nearby? What kind of services does the home receive? Underlying the answers to those questions for any given piece of real property lie hundreds of private decisions by individuals. These individuals occupy many roles: buyer, seller, lender, tax assessor, landlord, tenant, real estate professional, land use planner, investor, landowner, and more.
In the era of de jure segregation, the relationships of these individuals’ decisions to spatial colorlines were obvious: American homes and neighborhoods were ordered according to express racial rules. Blacks can live here, whites there. Amenities, services, and other land privileges flowed to white neighborhoods. Between the 1940s and 1970s, however, fair housing advocates worked to dismantle de jure segregation in American housing. Express references to race in maintaining spatial colorlines were widely erased from law and public discourse. Indeed, scholars have noted a “positive shift in ‘fundamental norms with regard to race.’” Yet colorlines continue to exist in access to housing, land values, exposure to subprime lending, the siting of amenities and disamenities, and private investment. What explains this persistence? What explains the contradiction between a world of laws that make no mention of race and a world of segregation and neighborhood disadvantage on the ground? Lawyers and scholars of many disciplines have searched for answers to these questions for years.