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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.
Remote delivery of evidence-based psychological therapies via video conference has become particularly relevant following the COVID-19 pandemic, and is likely to be an on-going method of treatment delivery post-COVID. Remotely delivered therapy could be of particular benefit for people with social anxiety disorder (SAD), who tend to avoid or delay seeking face-to-face therapy, often due to anxiety about travelling to appointments and meeting mental health professionals in person. Individual cognitive therapy for SAD (CT-SAD), based on the Clark and Wells (1995) model, is a highly effective treatment that is recommended as a first-line intervention in NICE guidance (NICE, 2013). All of the key features of face-to-face CT-SAD (including video feedback, attention training, behavioural experiments and memory-focused techniques) can be adapted for remote delivery. In this paper, we provide guidance for clinicians on how to deliver CT-SAD remotely, and suggest novel ways for therapists and patients to overcome the challenges of carrying out a range of behavioural experiments during remote treatment delivery.
Key learning aims
(1) To learn how to deliver all of the core interventions of CT-SAD remotely.
(2) To learn novel ways of carrying out behavioural experiments remotely when some in-person social situations might not be possible.
Hydrilla is an invasive aquatic plant that has rapidly spread through many inland water bodies across the globe by outcompeting native aquatic plants. The negative impacts of hydrilla invasion have become a concern for water resource management authorities, power companies, and environmental scientists. The early detection of hydrilla infestation is very important to reduce the costs associated with control and removal efforts of this invasive species. Therefore, in this study, we aimed to develop a tool for rapid, frequent, and large-scale monitoring and predicting spatial extent of hydrilla habitat. This was achieved by integrating in situ and Landsat 8 Operational Land Imager satellite data for Lake J. Strom Thurmond, the largest US Army Corps of Engineers lake east of the Mississippi River, located on the border of Georgia and South Carolina border. The predictive model for presence of hydrilla incorporated radiometric and physical measurements, including remote-sensing reflectance, Secchi disk depth (SDD), light-attenuation coefficient (Kd), maximum depth of colonization (Zc), and percentage of light available through the water column (PLW). The model-predicted ideal habitat for hydrilla featured high SDD, Zc, and PLW values, low values of Kd. Monthly analyses based on satellite images showed that hydrilla starts growing in April, reaches peak coverage around October, begins retreating in the following months, and disappears in February. Analysis of physical and meteorological factors (i.e., water temperature, surface runoff, net inflow, precipitation) revealed that these parameters are closely associated with hydrilla extent. Management agencies can use these results not only to plan removal efforts but also to evaluate and adapt their current mitigation efforts.
Tidal flexure in ice shelf grounding zones has been used extensively in the past to determine grounding line position and ice properties. Although the rheology of ice is viscoelastic at tidal loading frequencies, most modelling studies have assumed some form of linear elastic beam approximation to match observed flexure profiles. Here we use density, radar and DInSAR measurements in combination with full-Stokes viscoelastic modelling to investigate a range of additional controls on the flexure of the Southern McMurdo Ice Shelf. We find that inclusion of observed basal crevasses and density dependent ice stiffness can greatly alter the flexure profile and yet fitting a simple elastic beam model to that profile will still produce an excellent fit. Estimates of the effective Young's modulus derived by fitting flexure profiles are shown to vary by over 200% depending on whether these factors are included, even when the local thickness is well constrained. Conversely, estimates of the grounding line position are relatively insensitive to these considerations for the case of a steep bed slope in our study region. By fitting tidal amplitudes only, and ignoring phase information, elastic beam theory can provide a good fit to observations in a wide variety of situations. This should, however, not be taken as an indication that the underlying rheological assumptions are correct.
Orthopedic devices improve the quality of life of millions of people, and show up on radiographs and cross-sectional imaging studies daily. This text will familiarise radiologists with the indications, applications, potential complications, and radiologic evaluation of many medical devices. The book offers a complete discussion of fracture fixation, joint arthroplasty, and orthopedic apparatus of the neck and spine, including the cervical, thoracic, and lumbar spine. It also provides detailed overviews of devices used for common dental disease, covers the general principles applicable to complications of orthopedic devices, foreign body ingestions, insertions and injuries, and details quality assurance issues concerning the manufacture and distribution of devices. Featuring a large gallery of apparatus for reference, an extensive glossary of terms and a list of manufacturers, Radiologic Guide to Orthopedic Devices is an essential resource for radiologists, orthopedists and emergency medicine physicians. Regular updates to the topics covered will be available on http://www.medapparatus.com.
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. . .