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Many institutions are attempting to implement patient-reported outcome (PRO) measures. Because PROs often change clinical workflows significantly for patients and providers, implementation choices can have major impact. While various implementation guides exist, a stepwise list of decision points covering the full implementation process and drawing explicitly on a sociotechnical conceptual framework does not exist.
To facilitate real-world implementation of PROs in electronic health records (EHRs) for use in clinical practice, members of the EHR Access to Seamless Integration of Patient-Reported Outcomes Measurement Information System (PROMIS) Consortium developed structured PRO implementation planning tools. Each institution pilot tested the tools. Joint meetings led to the identification of critical sociotechnical success factors.
Three tools were developed and tested: (1) a PRO Planning Guide summarizes the empirical knowledge and guidance about PRO implementation in routine clinical care; (2) a Decision Log allows decision tracking; and (3) an Implementation Plan Template simplifies creation of a sharable implementation plan. Seven lessons learned during implementation underscore the iterative nature of planning and the importance of the clinician champion, as well as the need to understand aims, manage implementation barriers, minimize disruption, provide ample discussion time, and continuously engage key stakeholders.
Highly structured planning tools, informed by a sociotechnical perspective, enabled the construction of clear, clinic-specific plans. By developing and testing three reusable tools (freely available for immediate use), our project addressed the need for consolidated guidance and created new materials for PRO implementation planning. We identified seven important lessons that, while common to technology implementation, are especially critical in PRO implementation.
The forests of the north-east USA were once home to the wolf Canis lupus, a species that played an important role in the ecology of this region. However, wolves were eradicated from the region more than a century ago, altering the species composition of the landscape and driving cascading changes in this ecosystem. Outdoor recreation is a major component of the economy of this region, and outdoor recreationists, including the hunting community, have a strong influence over decision-making related to policies on natural resources. Given their powerful position, hunters are important stakeholders whose views need to be taken into account when designing policies related to wildlife, in particular in relation to a controversial species such as the wolf. In this study, through expert interviews and an online survey, we gained a deeper understanding of the attitudes of hunters towards wolves, and how these attitudes could affect any future reintroduction programme or natural movement of wolves into the state. We found that the majority of hunters hold a suite of negative attitudes towards wolves, their role in the landscape and their potential impact on the region. However, for hunters who were able to recognize the ecological roles of wolves, these negative attitudes were mostly reversed.
Scientific discovery, especially at the boundaries of human observational capacity, is an extended, incremental and sometimes controversy-laden process; but practicing researchers' published statements do not always portray it as such. If extraterrestrial life (ETL) exists, and if we find it, the process of observation, interpretation, understanding and confirmation may take decades. Though it is, thus, likely that scientific consensus will accrue around an ETL interpretation in a gradual and subtle process, the general public and even practicing scientists often discuss ETL discovery as though it will be rapid and dramatic. To illustrate this phenomenon, this review analyses a convenience sample of astronomers', astrobiologists' and astrosociologists' statements and assumptions in scholarly and general-audience media regarding a prospective discovery of ETL. Of 30 surveyed scholarly studies and 37 surveyed general-audience pieces, 24 scholarly and scientists' perspectives in 32 general-audience pieces do not acknowledge the extended nature of scientific discovery; and only three and four, respectively, do so explicitly. These results suggest that ETL researchers' statements could often portray an inaccurate or at least atypical vision of scientific progress in their own studies and to general-audience media outlets.
We present the case of a 17-year-old boy with a cardiac venous malformation. This case highlights the diagnostic challenges of such tumours and demonstrates the potential efficacy of a watch-and-wait management approach.
A common property regime was established at the founding of the Maya site of Actuncan, Belize, in the Terminal Preclassic period (175 BC–AD 300), which governed access to land until the Terminal Classic period (AD 780–1000). This interpretation is based on urban settlement patterns documented through household excavation and remote-sensing programs. Excavations of all visible patio-focused groups in the urban core provided data to reconstruct residential histories, and a 60,621 m2 gradiometer survey resulted in a magnetic gradient map that was used to document buried constructions. Twenty ground-truth testpits correlated types of magnetic signatures to buried patio-focused groups and smaller constructions, including walled plots in agricultural field systems that were later exposed more fully through large-scale excavations. Combined, these methods provided data to reconstruct four correlates of land tenure systems: (1) the spatial proximity of residential units to land and resources, (2) diachronic changes in community settlement patterns, (3) land subdivision and improvements, and (4) public goods. Spatial analyses documented that houselots did not cluster through time, but instead became gradually improved, lending evidence to suggest the transgenerational inheritance of property rights in the Late and Terminal Classic periods.
OBJECTIVES/SPECIFIC AIMS: Objectives and goals of this study will be to: (1) compare fecal microbiota and fecal organic acids in irritable bowel syndrome (IBS) patients and controls and (2) investigate the association between colonic transit and fecal microbiota in IBS patients and controls. METHODS/STUDY POPULATION: We propose an investigation of fecal organic acids, colonic transit and fecal microbiota in 36 IBS patients and 18 healthy controls. The target population will be adults ages 18–65 years meeting Rome IV criteria for IBS (both diarrhea- and constipation-predominant, IBS-D and IBS-C) and asymptomatic controls. Exclusion criteria are: (a) history of microscopic colitis, inflammatory bowel disease, celiac disease, visceral cancer, chronic infectious disease, immunodeficiency, uncontrolled thyroid disease, liver disease, or elevated AST/ALT>2.0× the upper limit of normal, (b) prior radiation therapy of the abdomen or abdominal surgeries with the exception of appendectomy or cholecystectomy >6 months before study initiation, (c) ingestion of prescription, over the counter, or herbal medications affecting gastrointestinal transit or study interpretation within 6 months of study initiation for controls or within 2 days before study initiation for IBS patients, (d) pregnant females, (e) antibiotic usage within 3 months before study participation, (f) prebiotic or probiotic usage within the 2 weeks before study initiation, (g) tobacco users. Primary outcomes will be fecal bile acid excretion and profile, short-chain fatty acid excretion and profile, colonic transit, and fecal microbiota. Secondary outcomes will be stool characteristics based on responses to validated bowel diaries. Stool samples will be collected from participants during the last 2 days of a 4-day 100 g fat diet and split into 3 samples for fecal microbiota, SCFA, and bile acid analysis and frozen. Frozen aliquots will be shipped to the Metabolite Profiling Facility at Purdue University and the Mayo Clinic Department of Laboratory Medicine and Pathology for SCFA and bile acid measurements, respectively. Analysis of fecal microbiota will be performed in the research laboratory of Dr David Nelson in collaboration with bioinformatics expertise affiliated with the Nelson lab. Colonic transit time will be measured with the previously validated method using radio-opaque markers. Generalized linear models will be used as the analysis framework for comparing study endpoints among groups. RESULTS/ANTICIPATED RESULTS: This study seeks to examine the innovative concept that specific microbial signatures are associated with increased fecal excretion of organic acids to provide unique insights on a potential mechanistic link between altered intraluminal organic acids and fecal microbiota. DISCUSSION/SIGNIFICANCE OF IMPACT: Results may lead to development of targets for novel therapies and diagnostic biomarkers for IBS, emphasizing the role of the fecal metabolome.
The purpose of this study was to investigate the 10-year impact of Hurricane Katrina on the incidence of acute myocardial infarction (AMI) along with contributing risk factors and any alteration in chronobiology of AMI.
A single-center, retrospective, comparison study of AMI incidence was performed at Tulane University Health Sciences Center from 2 years before Hurricane Katrina to 10 years after Hurricane Katrina. A 6-year, pre-Katrina and 10-year, post-Katrina cohort were also compared according to pre-specified demographic, clinical, and chronobiological data.
AMI incidence increased from 0.7% (150/21,079) to 2.8% (2,341/84,751) post-Katrina (P<0.001). The post-Katrina cohort had higher rates of coronary artery disease (36.4% vs. 47.9%, P=0.01), diabetes mellitus (31.3% vs. 39.9%, P=0.04), hyperlipidemia (45.4% vs. 59.3%, P=0.005), smoking (34.4% vs. 53.8%, P<0.001), drug abuse (10.2% vs. 15.4%, P=0.02), psychiatric illness (6.7% vs. 14.9%, P<0.001), medication non-adherence (7.3% vs. 15.3%, P<0.001), and lack of employment (7.2% vs. 16.4%, P<0.001). The post-Katrina group had increased rates of AMI during nights (29.8% vs. 47.8%, P<0.001) and weekends (16.1% vs. 29.1%, P<0.001).
Even 10 years after the storm, Hurricane Katrina continues to be associated with increased incidence of AMI, higher prevalence of traditional cardiovascular and psychosocial risk factors, and an altered chronobiology of AMI toward nights and weekends. (Disaster Med Public Health Preparedness. 2019;13:217–222)
The genetic component of Cannabis Use Disorder may overlap with influences acting more generally on early stages of cannabis use. This paper aims to determine the extent to which genetic influences on the development of cannabis abuse/dependence are correlated with those acting on the opportunity to use cannabis and frequency of use.
A cross-sectional study of 3303 Australian twins, measuring age of onset of cannabis use opportunity, lifetime frequency of cannabis use, and lifetime DSM-IV cannabis abuse/dependence. A trivariate Cholesky decomposition estimated additive genetic (A), shared environment (C) and unique environment (E) contributions to the opportunity to use cannabis, the frequency of cannabis use, cannabis abuse/dependence, and the extent of overlap between genetic and environmental factors associated with each phenotype.
Variance components estimates were A = 0.64 [95% confidence interval (CI) 0.58–0.70] and E = 0.36 (95% CI 0.29–0.42) for age of opportunity to use cannabis, A = 0.74 (95% CI 0.66–0.80) and E = 0.26 (95% CI 0.20–0.34) for cannabis use frequency, and A = 0.78 (95% CI 0.65–0.88) and E = 0.22 (95% CI 0.12–0.35) for cannabis abuse/dependence. Opportunity shares 45% of genetic influences with the frequency of use, and only 17% of additive genetic influences are unique to abuse/dependence from those acting on opportunity and frequency.
There are significant genetic contributions to lifetime cannabis abuse/dependence, but a large proportion of this overlaps with influences acting on opportunity and frequency of use. Individuals without drug use opportunity are uninformative, and studies of drug use disorders must incorporate individual exposure to accurately identify aetiology.
While our fascination with understanding the past is sufficient to warrant an increased focus on synthesis, solutions to important problems facing modern society require understandings based on data that only archaeology can provide. Yet, even as we use public monies to collect ever-greater amounts of data, modes of research that can stimulate emergent understandings of human behavior have lagged behind. Consequently, a substantial amount of archaeological inference remains at the level of the individual project. We can more effectively leverage these data and advance our understandings of the past in ways that contribute to solutions to contemporary problems if we adapt the model pioneered by the National Center for Ecological Analysis and Synthesis to foster synthetic collaborative research in archaeology. We propose the creation of the Coalition for Archaeological Synthesis coordinated through a U.S.-based National Center for Archaeological Synthesis. The coalition will be composed of established public and private organizations that provide essential scholarly, cultural heritage, computational, educational, and public engagement infrastructure. The center would seek and administer funding to support collaborative analysis and synthesis projects executed through coalition partners. This innovative structure will enable the discipline to address key challenges facing society through evidentially based, collaborative synthetic research.
An adolescent male with a recent history of streptococcal pharyngitis presented with severe substernal chest pain, troponin leak, and ST-segment elevation, which are suggestive of acute inferolateral myocardial infarction. The coronary angiogram was normal. The patient was subsequently diagnosed with non-rheumatic streptococcal myocarditis. He was treated with amoxicillin and had excellent recovery. Non-rheumatic streptococcal myocarditis is an important mimic of acute myocardial infarction in young adults.
Whether monozygotic (MZ) and dizygotic (DZ) twins differ from each other in a variety of phenotypes is important for genetic twin modeling and for inferences made from twin studies in general. We analyzed whether there were differences in individual, maternal and paternal education between MZ and DZ twins in a large pooled dataset. Information was gathered on individual education for 218,362 adult twins from 27 twin cohorts (53% females; 39% MZ twins), and on maternal and paternal education for 147,315 and 143,056 twins respectively, from 28 twin cohorts (52% females; 38% MZ twins). Together, we had information on individual or parental education from 42 twin cohorts representing 19 countries. The original education classifications were transformed to education years and analyzed using linear regression models. Overall, MZ males had 0.26 (95% CI [0.21, 0.31]) years and MZ females 0.17 (95% CI [0.12, 0.21]) years longer education than DZ twins. The zygosity difference became smaller in more recent birth cohorts for both males and females. Parental education was somewhat longer for fathers of DZ twins in cohorts born in 1990–1999 (0.16 years, 95% CI [0.08, 0.25]) and 2000 or later (0.11 years, 95% CI [0.00, 0.22]), compared with fathers of MZ twins. The results show that the years of both individual and parental education are largely similar in MZ and DZ twins. We suggest that the socio-economic differences between MZ and DZ twins are so small that inferences based upon genetic modeling of twin data are not affected.
OBJECTIVES/SPECIFIC AIMS: Recent data suggest that fecal microbiota and intraluminal organic acids may play an important role in irritable bowel syndrome (IBS) pathogenesis through effects on intestinal secretion and motility. Understanding their contribution will be critical in developing diagnostic and treatment strategies. Objectives and goals of this study will be to: (1) compare fecal microbiota and fecal organic acids in IBS patients and controls and (2) investigate the association between colonic transit and fecal microbiota in IBS patients and controls. METHODS/STUDY POPULATION: We propose a prospective investigation of fecal organic acids, colonic transit and fecal microbiota in 36 IBS patients and 18 healthy controls. The target population will be adults ages 18–65 years meeting Rome IV criteria for IBS (both diarrhea predominant and constipation-predominant, IBS-D, and IBS-C) and asymptomatic controls. Exclusion criteria are: (a) history of microscopic colitis, inflammatory bowel disease, celiac disease, cancer, chronic infectious disease, immunodeficiency, uncontrolled thyroid disease, liver disease, or elevated AST/ALT>2.0x the upper limit of normal, (b) prior radiation therapy of the abdomen or abdominal surgeries with the exception of appendectomy or cholecystectomy>6 months before study initiation, (c) ingestion of prescription, over the counter, or herbal medications affecting gastrointestinal transit or study interpretation within 6 months of study initiation for controls or within 2 days before study initiation for IBS patients, (d) pregnant females, (e) antibiotic usage within 3 months prior to study participation, (f) prebiotic or probiotic usage within the 2 weeks prior to study initiation, (g) tobacco users. Primary outcomes will be fecal bile acid excretion and profile, short-chain fatty acid (SCFA) excretion and profile, colonic transit, and fecal microbiota. Secondary outcomes will be stool characteristics based on responses to validated bowel diaries. Stool samples will be collected from participants during the last 2 days of a 4-day 100-g fat diet and split into 3 samples for fecal microbiota, SCFA, and bile acid analysis and frozen. Frozen aliquots will be shipped to the Metabolite Profiling Facility at Purdue University and the Mayo Clinic Department of Laboratory Medicine and Pathology for SCFA and bile acid measurements, respectively. Analysis of fecal microbiota will be performed in the research laboratory of Dr. David Nelson in collaboration with bioinformatics expertise affiliated with the Nelson lab. Colonic transit time will be measured with the previously validated method using radio-opaque markers. Generalized linear models will be used as the analysis framework for comparing study endpoints among groups. RESULTS/ANTICIPATED RESULTS: This study seeks to examine the innovative concept that specific microbial signatures are associated with increased fecal excretion of organic acids to provide unique insights on a potential mechanistic link between altered intraluminal organic acids and fecal microbiota. DISCUSSION/SIGNIFICANCE OF IMPACT: Results may lead to development of targets for novel therapies and diagnostic biomarkers for IBS, emphasizing the role of the fecal metabolome.
The purpose of this study was to quantify the effect of multidrug-resistant (MDR) gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) on mortality following infection, regardless of patient location.
We conducted a retrospective cohort study of patients with an inpatient admission in the US Department of Veterans Affairs (VA) system between October 1, 2007, and November 30, 2010. We constructed multivariate log-binomial regressions to assess the impact of a positive culture on mortality in the 30- and 90-day periods following the first positive culture, using a propensity-score–matched subsample.
Patients identified with positive cultures due to MDR Acinetobacter (n=218), MDR Pseudomonas aeruginosa (n=1,026), and MDR Enterobacteriaceae (n=3,498) were propensity-score matched to 14,591 patients without positive cultures due to these organisms. In addition, 3,471 patients with positive cultures due to MRSA were propensity-score matched to 12,499 patients without positive MRSA cultures. Multidrug-resistant gram-negative bacteria were associated with a significantly elevated risk of mortality both for invasive (RR, 2.32; 95% CI, 1.85–2.92) and noninvasive cultures (RR, 1.33; 95% CI, 1.22–1.44) during the 30-day period. Similarly, patients with MRSA HAIs (RR, 2.77; 95% CI, 2.39–3.21) and colonizations (RR, 1.32; 95% CI, 1.22–1.50) had an increased risk of death at 30 days.
We found that HAIs due to gram-negative bacteria and MRSA conferred significantly elevated 30- and 90-day risks of mortality. This finding held true both for invasive cultures, which are likely to be true infections, and noninvasive infections, which are possibly colonizations.
A macrofloral assemblage dominated by elements of the Euramerican dryland biome is described from the Brazil Formation in Clay County, Indiana (Illinois Basin). Fossils were recovered from a thin heterolithic unit between a shallow-marine bed and the paleosol beneath the Minshall Coal, a Middle Pennsylvanian succession deposited near the Atokan-Desmoinesian and Bolsovian-Asturian boundaries. Sedimentological indicators imply accumulation under a seasonal climate, including interbedded siltstone and sandstone deposited during flashfloods, intraclasts eroded from local sources, and charcoal produced by wildfires. The macrofloral assemblage is consistent with a dryland setting, being dominated by large, coriaceous gymnosperm leaves with mesic to xeric traits, including Cordaites spp. indet., Lesleya sp. indet., and Taeniopteris sp. cf. T. multinervia. Sphenopsids and ferns typical of the wetland biome are rare. In contrast, the microfloral assemblage is dominated by fern spores, with lesser lycopsid spores and cordaitalean pollen. The succession indicates that the dryland biome predominated during late regression, prior to the onset of perhumid conditions that resulted in peat accumulation at late lowstand. However, the abundance of palynomorphs from wetland vegetation implies gradual fragmentation of the prevailing dryland flora and replacement by the wetland biome in the transition to glacial maximum. The taphonomic and paleobiogeographic context confirms that floras adapted to seasonal moisture deficit periodically dispersed into tropical lowlands, rather than being transported from ‘extrabasinal’ or ‘upland’ environments. The precocious occurrence of Taeniopteris, more typical of Late Pennsylvanian and Permian floras, may be the earliest record of the fossil-genus, and exemplifies the association of derived plant taxa with dryland habitats. The predominance of broad-leaved gymnosperms with mesic to xeric characters suggests that dryland communities contained more slow-growing and long-lived plants than contemporaneous wetland floras.
Taxonomic analysis is provided for a Middle Pennsylvanian macrofloral assemblage collected from clastic wetland deposits in Clay County, Indiana, on the eastern margin of the Illinois Basin. Adpressed plant fossils were recovered from four distinct beds in the lowermost Staunton Formation, positioned above the Minshall Coal (uppermost Brazil Formation), part of a succession deposited near the Atokan-Desmoinesian boundary. The assemblage of 22 fossil-taxa is dominated by pteridosperms (including Neuropteris flexuosa, Macroneuropteris scheuchzeri, Alethopteris densinervosa, Neuropteris ovata, Eusphenopteris neuropteroides, and Neuropteris missouriensis) with lesser cordaitaleans (Cordaites spp. indet.) and sphenopsids (particularly Sphenophyllum cuneifolium). Lycopsids are uncommon, and ferns are rare. In contrast, the microfloral assemblage from the Minshall Coal and overlying clastic units is dominated by lycopsid and tree fern spores. Comparisons with established biozonation schemes yield different ages depending on the regional biostratigraphic framework used: (1) latest Bolsovian (Radiizonates difformis Biozone, American microfloras); (2) latest Bolsovian or earliest Asturian (‘Neuropteris’ rarinervis Biozone, Appalachian Basin macrofloras); or (3) earliest Asturian (Linopteris obliqua Biozone, European macrofloras). The placement and correlation of the Bolsovian-Asturian and Atokan-Desmoinesian boundaries, which have traditionally been equated by palynology, are evaluated in the context of this discordance. Several revised stratigraphic scenarios are proposed for this interval in the Illinois Basin, which is being increasingly recognized as a time of significant environmental change throughout Euramerica. Homotaxial comparisons with European macrofloral assemblages indicate that, of the 18 biological taxa recorded, between 14 and 17 (78–94%) also are common in coeval wetland deposits in Europe. The similarities exemplify the spatial conservatism and low diversity of wetland plant communities over vast areas of tropical Euramerica, a manifestation of the intrinsically stressful conditions that characterize such habitats, and indicates that neither the Laurentian Shield nor the Appalachian-Variscan Mountains were an insurmountable barrier to plant dispersal during the Middle Pennsylvanian.