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Aims To determine the first manifestation of cardiovascular or kidney disease (CVKD) and associated resource use in type 2 diabetes mellitus (T2DM) patients during seven years of follow-up. Methods Observational-retrospective secondary data study using medical records of patients aged ≥18 years with T2DM and without prior CVKD between 2013 and 2019. The index date was 01/01/2013 (fixed date). The manifestation of CVKD was defined by the first diagnosis of heart-failure (HF), chronic-kidney disease (CKD), myocardial-infarction (MI), stroke or peripheral-artery disease (PAD). The main variables were baseline characteristics, manifestation of CVKD, mortality, resource use and costs. Descriptive analyses and Cox model were applied to the data. Results 26,542 patients were selected (mean age: 66.6 years, women: 47.8%, mean duration of T2DM: 17.1 years). 18.7% (N = 4974) developed a first CVKD manifestation during the seven years [distribution: HF (22.4%), CKD (36.6%), MI (14.5%), stroke (15.3%) and PAD (11.3%)]. Overall mortality was 8.3% (N = 2214). The mortality risk of the group that developed HF or CKD as the first manifestation compared to the CVKD-free cohort was higher [HR: 2.5 (95% CI: 1.8–3.4) and 1.8 (95% CI: 1.4–2.3)], respectively. The cumulative costs per patient of HF (€50,942.80) and CKD (€48,979.20) were higher than MI (€47,343.20) and stroke (€47,070.30) and similar to PAD (€51,240.00) vs. €13,098.90 in patients who did not develop CVKD, p Conclusions In T2DM patients, HF and CKD were the first most common manifestations and had higher mortality and re-hospitalisation rates. HF and CKD were associated with the highest resource use and costs for the Spanish National-Health-System.

Objectives Chronic hepatitis C (CHC) infection affects more than 70 million people worldwide and imposes considerable health and economic burdens on patients and society. This study estimated 2 understudied components of the economic burden, patient out-of-pocket (OOP) costs and time costs, in patients with CHC in a tertiary hospital clinic setting and a community clinic setting. Methods This was a multicenter, cross-sectional study with hospital-based (n = 174) and community-based (n = 101) cohorts. We used a standardized instrument to collect healthcare resource use, time, and OOP costs. OOP costs included patient-borne costs for medical services, nonprescription drugs, and nonmedical expenses related to healthcare visits. Patient and caregiver time costs were estimated using an hourly wage value derived from patient-reported employment income and, where missing, derived from the Canadian census. Sensitivity analysis explored alternative methods of valuing time. Costs were reported in 2020 Canadian dollars. Results The mean 3-month OOP cost was $55 (95% confidence interval [CI] $21-$89) and $299 (95% CI $170-$427) for the community and hospital cohorts, respectively. The mean 3-month patient time cost was $743 (95% CI $485-$1002) (community) and $465 (95% CI $248-$682) (hospital). The mean 3-month caregiver time cost was $31 (95% CI $0-$63) (community) and $277 (95% CI $174-$380) (hospital). Patients with decompensated cirrhosis bore the highest costs. Conclusions OOP costs and patient and caregiver time costs represent a considerable economic burden to patient with CHC, equivalent to 14% and 21% of the reported total 3-month income for the hospital-based and community-based cohorts, respectively.

Author(s): Seo, Young-Ji; Sareh, Sohail; Hadaya, Joseph; Sanaiha, Yas; Ziaeian, Boback; Shemin, Richard J; Benharash, Peyman | Abstract: BackgroundLack of consensus remains about factors that may be associated with high resource use (HRU) in adult cardiac surgical patients. This study aimed to identify patient-related, hospital, and perioperative characteristics associated with HRU admissions involving elective cardiac operations.MethodsData from the National Inpatient Sample was used to identify patients who underwent coronary artery bypass graft, valve replacement, and valve repair operations between 2005 and 2016. Admissions with HRU were defined as those in the highest decile for total hospital costs. Multivariable regressions were used to identify factors associated with HRU.ResultsAn estimated 1,750,253 hospitalizations coded for elective cardiac operations. The median hospitalization cost was $34,700 (interquartile range, $26,800- to $47,100), with the HRU (Nn= 175,025) cutoff at $66,029. Although HRU patients comprised 10% of admissions, they accounted for 25% of cumulative costs. On multivariable regression, patient-related characteristics predictive of HRU included female sex, older age, higher comorbidity burden, non-White race, and highest income quartile. Hospital factors associated with HRU were low-volume hospitals for both coronary artery bypass graft and valvular operations. Among postoperative outcomes, mortality, infectious complications, extracorporeal membrane oxygenation use, and hospitalization for more than 8 days were associated with greater odds of HRU.ConclusionsIn this nationwide study of elective cardiac surgical patients, several important patient-related and hospital factors, including patients' race, comorbidities, postoperative infectious complications, and low hospital operative volume were identified as predictors of HRU. These highly predictive factors may be used for benchmarking purposes and improvement in surgical planning.

Objectives To understand the social and individual effects of the disease and make decisions on the allocation of health resources, it is necessary to understand the economic burden of coronavirus disease (COVID-19); however, there are limited data in this field. This study aimed to estimate diagnostic and therapeutic costs of patients with a diagnosis of or suspected of COVID-19 disease admitted to hospitals in northeast Iran. Methods This descriptive and analytical research was conducted as a retrospective study using the data collected from 2980 patients admitted to 30 hospitals from February to April 2020 in Iran. For data collection, an appropriate data capture tool was designed to record detailed resource use. A multivariate regression analysis was performed to examine the association between the treatment costs and sociodemographic, disease severity, and underlying diseases. Data were analyzed using Excel 2017 (Microsoft, Redmond, WA) and SPSS version 21 software (SPSS Inc., Chicago, IL). Results The inpatient costs per patient were Int$416, of which 74% were paid by social health insurance systems, 19% by the government, and 7% by the patients. The largest cost components were hoteling (37%) and medicine (36%). The 4 subscales of age, sex, underlying disease, and severity predicted 48.6% of the cost variance. Conclusion Understanding the economic consequences of diseases can help policymakers to make plans to reduce out-of-pocket payments and make plans for funding. Since COVID-19 is a newly emerging disease and there is no definitive cure for the disease, the discovery of an effective medicine may alter medical costs and reduce the hospital length of stay, therefore significantly reducing treatment costs.

BACKGROUND: Trisomy 21 (T21) patients often have elevated pulmonary vascular resistance, which may result in suboptimal cavopulmonary connection (CPC) following Glenn or Fontan operations. The purpose of this study was to assess in a nationwide, multi-institution cohort of CPC patients the impact of T21 on patient morbidity, mortality, and resource utilization. METHODS: A total of 23,271 CPC pediatric patients (2004 – 2019) at 50 U.S. hospitals were evaluated using the Pediatric Health Information System (PHIS) database. Univariable and multivariable regression analyses were used to assess risk-adjusted associations between Down syndrome and other risk factors and postoperative measures of morbidity, mortality, lengths of stay (LOS) and cost of hospitalization. RESULTS: The overall prevalence of T21 among Glenn and Fontan patients was 1.5% (199/13,268) and 0.8% (78/1,003), respectively. Among both CPC cohorts, T21 status significantly increased unadjusted mortality, hospital lengths of stay and total costs of hospitalization compared to non-T21 CPC patients (all P < 0.001). T21 patients also incurred a higher incidence of prolonged mechanical ventilation compared to non-T21 patient in both Glenn and Fontan patients (P < 0.001). Multivariable regression analysis further estimated that T21 patients are associated with a 5.5-fold increase in mortality (P < 0.001) compared to non-T21 patients. Lastly, T21 patients had increased long-term mortality compared to their peers. CONCLUSIONS: Trisomy 21 significantly increases risk-adjusted morbidity, inpatient mortality, long-term mortality and resource utilization following cavopulmonary connections. Further investigation is needed to clarify modifiable patient-level and center-specific risk factors to improve outcomes for T21 patients.

Highlights • An RT process simulation model aided managers with resource planning decisions. • Several scenarios could easily be evaluated without affecting the clinical work. • Starting vacation periods for preparations prior to treatment was most beneficial., Purpose Radiotherapy (RT) resources need to be used wisely to balance workload and patient throughput. There are no known strategies on how to plan resource use around longer vacation periods to avoid patient waiting times. We created a simulation model over the RT workflow to evaluate different scenarios for this purpose. Materials and Methods The simulation model mimics a large modern RT department in Sweden. It was based on real data on patient referral patterns and resource use extracted from clinical systems (3666 treatment courses). Workshops with managers and staff were held to investigate nine different scenarios for the summer vacation period including one scenario to validate the model. Different capacity reductions, vacation period lengths and timing of the vacation periods between the preparatory part of the RT workflow and the treatment part were evaluated. Results For an eight-week period, resource utilization was predicted to be high both before and after the vacation period regardless of timing. However, more patients would be waiting with completed preparations with simultaneous vacation periods than when the preparatory part started one-two weeks prior to the treatment part. With shorter vacation periods, treatment would require overtime during the vacation period with higher levels of patients waiting compared to an eight-week scenario. Conclusions Our proposed strategy aided managers to identify a preferred scenario for the summer vacation period with the preparatory part starting one-two weeks prior to the treatment part for an eight-week vacation period. This can help other RT departments to plan for similar situations.

Frailty has been widely recognized as a predictor of postoperative outcomes. Given the paucity of standardized frailty measurements in thoracic procedures, this study aimed to determine the impact of coding-based frailty on clinical outcomes and resource use after anatomic lung resection.All adults undergoing elective, anatomic lung resections (segmentectomy, lobectomy, pneumonectomy) from 2005 to 2014 were identified using the National Inpatient Sample. Patients were categorized as either frail or nonfrail on the basis of the presence of any frailty-defining diagnoses defined by the Johns Hopkins Adjusted Clinical Groups. Multivariable models were used to assess the independent association of frailty with in-hospital mortality, nonhome discharge, complications, duration of stay, and costs.Of an estimated 366,357 hospitalizations for elective lung resection during the study period, 4.4% were in frail patients. Patients who underwent pneumonectomy or were treated at low-volume hospitals were more commonly frail. Relative to nonfrail patients, frailty was associated with increased unadjusted mortality (9.1% vs 1.7%; P.001) and nonhome discharge (44.7% vs 10.5%; P.001). Frail patients had 3.47 increased adjusted odds of mortality across resection types (95% confidence interval, 2.94 to 4.09). Frailty conferred the greatest increase in mortality, complications, and resource use after pneumonectomy relative to lobectomy or segmentectomy, although significant differences were evident for all 3 operations.Frailty exhibits a strong association with inferior clinical outcomes and increased resource use after elective lung resection, particularly pneumonectomy. This readily available tool may improve preoperative risk assessment and allow for better selection of treatment modalities for frail patients with pulmonary disorders.

Purpose To describe the proportion of children with an index hospitalization in 2014 who had established long-term invasive ventilator dependence (LTVD), and determine regional variation in hospital length of stay, charges, and readmissions. Design and methods Multicenter, longitudinal, retrospective cohort study using a recently established algorithm to identify children with LTVD from the Pediatric Health Information System database with an index hospitalization at least once during 2014, excluding normal newborn care or chemotherapy, and the subset with established LTVD. Hospitals were grouped by geographic regions. Analysis included descriptive statistics and multi-variable mixed modeling for length of stay, charges, and readmissions. Results Of the 615,883 unique children discharged from 45 children's hospitals in 2014, 2235 (0.4%) had established LTVD. Of these, 342 (15%) were hospitalized in the Northeast, 677 (30%) Midwest, 733 (32%) South and 481 (22%) West. Most had at least two complex chronic conditions (97%) and used a medical device for at least two body systems (71%). No statistically significant regional variation was found for length of stay, charges, or readmissions after adjustment for child demographics, admission type, disposition, primary diagnosis, ICU stay, and number of chronic conditions. Conclusions This study characterized the population of children with LTVD hospitalized in 2014. No regional variation was found for length of stay, charges, or readmissions. Practice implications Children with established LTVD make up a small subset of all children admitted to children's hospitals however, they require substantial, costly, multifaceted care as most have additional complex chronic conditions and require multiple medical devices.

This paper explores conceptualisations of households in sustainability transitions. Existing literature in the field has only engaged with households in a limited and fragmented way, despite the role of households in resource use, shaping social innovation and as a target of environmental policies. The paper asks: how are households conceptualised in sustainability transitions and how could this be further developed in future research? The paper uses systematic review to explore how the literature currently engages with households. We find two overarching approaches to households: a closed-box approach and an open-box approach. The closed-box approach engages households as a fixed unit of analysis, without attention to internal dynamics and how these may interact with system-level changes, whereas the open-box approach unpacks the household as a dynamic social unit and material setting in the context of multiple scales and other social units. Both approaches are further discussed in terms of how they engage with households as users, sites and sources. Based on the analysis, the paper proposes a comprehensive definition of households in transition studies, and identifies four areas for future research in sustainability transitions: households' and householders’ agency; unpacking household dynamics; household innovation across scales and socio-technical systems; and households in policy and governance.

Truncus arteriosus is a congenital heart defect with high resource use, cost, and mortality. Value assessment (outcome relative to cost) can improve quality of care and decrease cost. This study hypothesized that truncus arteriosus repair at a high-volume center would result in better outcomes at lower cost (higher value) compared with a low-volume center.This study retrospectively analyzed a multicenter cohort of neonates undergoing truncus arteriosus repair (2004 to 2015) by using the Pediatric Health Information Systems database. Multivariate quantile, logistic, and negative binomial regression models were used to evaluate total hospital cost, in-hospital mortality, ventilation days, intensive care unit length of stay (LOS), hospital LOS, and days of inotropic agent use by center volume (high-volume3/year) and age at repair while adjusting for sex, ethnicity, race, genetic abnormality, prematurity, low birth weight, concurrent interrupted arch repair, and truncal valve repair.Of 1024 neonates with truncus arteriosus, 495 (48%) were treated at high-volume centers. Costs at the 75th percentile were lower at high-volume vs low-volume centers by $28,456 (P = .02) at all ages at repair. Patients at high-volume centers had lower median postoperative ventilation days (5 days vs 6 days; P.001), intensive care unit LOS (13 days vs 19 days; P.001), hospital LOS (23 days vs 28 days; P = .02), and inotropic agent use (3 days vs 4 days; P = .004). In-hospital mortality did not differ by center volume.In neonates undergoing truncus arteriosus repair, costs are lower and outcomes are better at high-volume centers, thus resulting in higher value at all ages of repair. Value-based interventions should be considered to improve outcomes and decrease cost in truncus arteriosus care.

Invasive species often possess a suite of behaviours that increase their likelihood of establishing populations in novel environments. These suites often include combinations of high motility, exploration, aggression, boldness or plasticity in resource use. In Australia, invasive house geckos, Hemidactylus frenatus, have continued to expand their range since the 1960s, spreading from predominantly human-disturbed areas to peri-urban regions. Here, we used open-field tests to investigate whether invasive house geckos showed greater exploratory activity and boldness than native Australian house geckos, Gehyra dubia. We expected that, like many other successful invasive species, invasive house geckos would be bolder and show greater exploratory activity than native house geckos. Consistent with our expectations, invasive house geckos showed significantly higher levels of exploratory activity, travelling on average 1.6 times further than native house geckos. However, none of our boldness tests indicated that invasive house geckos were bolder than native house geckos. In addition, we found no influence of sex on exploratory activity or boldness in either species. While invasive house geckos were not bolder than native house geckos, their increased exploratory activity may have contributed to their successful expansion into the natural environments surrounding urbanized areas.

The surveillance strategy for patients taking low dose cabergoline for hyperprolactinaemia is controversial. As more evidence has emerged that the risks of cardiac valvulopathy in this population of patients are low, fewer and fewer endocrinologists adhere strictly to the original medicines and healthcare products agency MHRA guidance of "at least" annual echocardiography. Strict adherence to this guidance would be costly in monetary terms (£5.76 million/year in the UK) and also in resource use (90,000 extra echocardiograms/year). This article reviews the proposed pathophysiological mechanism underlying the phenomenon of dopamine agonist valvulopathy, the characteristic echocardiographic changes seen, summarises the published literature on the incidence of valvulopathy with low dose cabergoline and examines the previous and current evidence-based screening guidelines.

International audience; Massive animal farming for meat production poses major problems in terms of resource use, environmental impact, and biodiversity. Furthermore, excessive meat consumption has been associated with multiple deleterious health consequences. However, more and better-designed randomized trials are needed to increase the level of evidence on the health impacts of meat. Novel meat alternatives, such as plant- and cell-based meat, are much less impactful to the environment and might replace traditional animal meat in the future, but, despite promising early data, the health consequences of these novel products need further study. This manuscript focuses on the health impacts of meat over 3 main sections: 1) overview of the evidence highlighting the association of meat consumption with health; 2) novel alternatives to meat, including plant-based and cell-based alternatives; and 3) examine the rationale for randomized studies to evaluate the effects of the novel meat alternatives compared with the standard animal meat.

The aim of this study was to compare the occurrence of postoperative complications in patients undergoing elective open abdominal surgery and receiving intraoperative goal-directed hemodynamic therapy or restrictive normovolemic therapy.A total of 401 patients were randomized in the goal-directed hemodynamic therapy or restrictive normovolemic therapy groups. A cardiac output monitor was used in all goal-directed hemodynamic therapy patients and was left at the discretion of anesthetists in charge of patients in the restrictive normovolemic therapy group. The primary outcome was a composite morbidity endpoint (30-day mortality and complications grade 2-4 according to Dindo-Clavien classification). Secondary outcomes were the hospital duration of stay, the incidence of pulmonary, cardiovascular, and renal complications up to 30 days after surgery, and midterm survival.Intraoperatively, the goal-directed hemodynamic therapy group received higher intravenous fluid volumes (mean of 10.8 mL/kg/h and standard deviation of 4.0) compared with the restrictive normovolemic therapy group (mean of 7.2 mL/kg/h and standard deviation of 2.0; P.001). On the first postoperative day, similar fluid volumes were infused in the 2 groups. The primary outcome occurred in 57.7% of goal-directed hemodynamic therapy and 53.0% of restrictive normovolemic therapy (relative risk, 1.09 [95% confidence interval, 0.91-1.30]), and there was no significant difference between groups for any secondary outcomes.Among patients undergoing major open abdominal surgery, the goal-directed hemodynamic therapy and the restrictive normovolemic therapy were associated with similar incidence of moderate-to-severe postoperative complications and hospital resource use.

The aim of this study was to determine the impact of preoperative pulmonary risk factors (PRFS) on surgical outcomes after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2016 to 2018. All pediatric patients with AIS undergoing PSF were identified. Patients were then categorized by whether they had recorded baseline PRF or no-PRF. Patient demographics, comorbidities, intraoperative variables, complications, length of stay, discharge disposition, and readmission rate were assessed.A total of 4929 patients were identified, of whom 280 (5.7%) had baseline PRF. Compared with the no-PRF cohort, the PRF cohort had higher rates of complications (PRF, 4.3% vs. no-PRF, 2.2%; P = 0.03) and longer hospital stays (PRF, 4.6 ± 4.3 days vs. no-PRF, 3.8 ± 2.3 days; P0.001), yet, discharge disposition was similar between cohorts (P = 0.70). Rates of 30-day unplanned readmission were significantly higher in the PRF cohort (PRF, 6.3% vs. no-PRF, 2.7%; P = 0.009), yet, days to readmission (P = 0.76) and rates of 30-day reoperation (P = 0.16) were similar between cohorts. On multivariate analysis, PRF was found to be a significant independent risk factor for longer hospital stays (risk ratio, 0.74; 95% confidence interval, 0.44-1.04; P0.001) but not postoperative complication or 30-day unplanned readmission.Our study showed that PRF may be a risk factor for slightly longer hospital stays without higher rates of complication or unplanned readmission for patients with AIS undergoing PSF and thus should not preclude surgical management.

Presenting to the fracture clinic carries economic, social and societal consequences. The virtual fracture clinic (VFC) has proven to be a safe, patient-focused, cost-effective means of delivering trauma care, whilst reducing unnecessary clinic attendances. Within our institution, a Satellite VFC was established, so as to accommodate an offsite referring emergency department. The VFC database was accessed to identify the first 500 patients who were referred to the Satellite VFC. The decision made for each patient, the rate of returns to the clinic, and the rate of referrals requiring surgical intervention, following discussion at the VFC, ,were identified. A cost analysis and cost comparison was carried out between the Satellite VFC and the traditional "face to face" fracture clinic. There were 500 patients referred to the Satellite VFC within the study period. Of such patients, 288 (58%) were discharged directly following review at the Satellite VFC, 141 patients (28%) were referred to physiotherapy, 50 (10%) were redirected to the trauma clinic, 11 (2%) were sent directly to hand therapy, and 10 (2%) were sent to the ED review clinic. Patients who returned to the fracture clinic accounted for 3.8% of all referrals, and 0.2% of all referrals necessitated surgical intervention. This pilot initiative saved the Dublin Midlands Hospital Group over €50,000. The Satellite VFC is the first of its kind in the literature. Rural communities worldwide would benefit from remote orthopaedic management of suitable fracture patterns. The true value of the Satellite VFC process comes from its use of robust patient care pathways, rationalising resource use and minimising patient travel, whilst demonstrating reliable outcomes and promoting safety.

Few data are available on the temporal patterns of health resource utilization (HRU) and expenditures around paroxysmal supraventricular tachycardia (PSVT) diagnosis. This study assessed the longitudinal trends in HRU and expenditures in the 3 years preceding and subsequent to PSVT diagnosis.Adult patients (age 18-65 years) with newly diagnosed PSVT were identified using administrative claims from the IBM MarketScan Research Database between January 1, 2008 and December 31, 2016 and propensity-score matched (1:1) with non-PSVT controls.Among the 12,305 PSVT patients compared with matched controls, PSVT was associated with statistically significant higher annual rates of emergency department visits, physician office visits, inpatient hospitalizations, and diagnostic testing. HRU increased in the years preceding PSVT diagnosis, reaching its peak in the year following PSVT diagnosis. Over the 6-year follow-up period, PSVT was associated with higher mean annual per patient expenditures ($12,665) compared to matched controls ($6,004; P.001). Upon diagnosis of PSVT, the mean expenditures per PSVT patient doubled from $11,714 in the year immediately preceding index diagnosis to $23,335 in the first postdiagnosis year. Inpatient services, diagnostic testing, and ablation procedures were the principle drivers of higher mean expenditures in the first year post-PSVT diagnosis versus the year prior to PSVT diagnosis.PSVT presents a substantial economic burden to health care systems. The annual expenditure per PSVT patient is within the range previously reported for atrial fibrillation. The increased HRU and expenditures in the year following diagnosis, which do not return to baseline, suggest a potential gap in non-interventional, long-term PSVT management.

Northeast China (NEC) is one of the major maize production areas in China. Agro-climatic resources have obviously changed, which will seriously affect crop growth and development in this region. It is important to investigate the contribution of climate change adaptation measures to the yield and resource use efficiency to improve our understanding of how we can effectively ensure high yield and high efficiency in the future. In this study, we divided the study area into five accumulated temperature zones (ATZs) based on growing degree days (GDD). Based on the meteorological data, maize data (from agro-meteorological stations) and the validated APSIM-Maize Model, we first investigated the spatial distributions and temporal trends of maize potential yield of actual planted cultivars, and revealed the radiation use efficiency (RUE) and heat resource use efficiency (HUE) from 1981 to 2017. Then according to the potential growing seasons and actual growing seasons, we identified the utilization percentages of radiation (PR) resource and heat resource (PH) for each ATZ under potential production from 1981 to 2017. Finally, we quantified the contributions of cultivar changings to yield, PR and PH of maize. The results showed that during the past 37 years, the estimated mean potential yield of actual planted cultivars was 13 649 kg ha–1, ranged from 11 205 to 15 257 kg ha–1, and increased by 140 kg ha–1 per decade. For potential production, the mean values of RUE and HUE for the actual planted maize cultivars were 1.22 g MJ–1 and 8.58 kg (°C d)–1 ha–1. RUE showed an increasing tendency, while HUE showed a decreasing tendency. The lengths of the potential growing season and actual growing season were 158 and 123 d, and increased by 2 and 1 d per decade. PR and PH under potential production were 82 and 86%, respectively and showed a decreasing tendency during the past 37 years. This indicates that actual planted cultivars failed to make full use of climate resources. However, results from the adaptation assessments indicate that, adoption of cultivars with growing season increased by 2–11 d among ATZs caused increase in yield, PR and PH of 0.6–1.7%, 1.1–7.6% and 1.5–8.9%, respectively. Therefore, introduction of cultivars with longer growing season can effectively increase the radiation and heat utilization percentages and potential yield.

Objective The association between neighborhood environments and health outcomes has long been recognized, but the importance of environmental factors is less well examined in osteoarthritis (OA). We aimed to give an overview of the literature examining the role of neighborhood built environments in the context of OA self-management. Material and Methods A literature search between 2000 and 2019 was performed using a scoping methodology. Literature examining the influence of neighborhood built environments on health and other outcomes in people with OA, mixed or unspecified arthritis were screened by two independent reviewers. Seven domains were pre-determined based on the World Health Organization European Healthy Cities Framework. Sub-domains and themes were synthesized from the literature. Results We included 27 studies across seven pre-determined domains, 23 sub-domains. We identified 6 key outcomes of physical activity, quality of life, community participation, resource use, psychological health, and other physical health. The majority of studies emphasized the importance of neighborhood built environment on supporting OA self-management, particularly for facilitating physical activity. The impacts on other outcomes were also considered important but were less well studied, especially access to healthy food. Conclusions This review highlights the potential of better using the built environment to support OA management to address many different outcomes. Understanding the impacts of different environments is the first step, and designing new and novel ways to utilize neighborhoods is needed. Implementing strategies and public policies at a neighborhood level may be a more viable way to curb further increases in the OA epidemic than addressing individual factors alone.

Objective The suggested high costs of endovascular aneurysm repair (EVAR) hamper the choice of insurance companies and financial regulators for EVAR as the primary option for elective abdominal aortic aneurysm (AAA) repair. However, arguments used in this debate are impeded by time related aspects such as effect modification and the introduction of confounding by indication, and by asymmetric evaluation of outcomes. Therefore, a re-evaluation minimising the impact of these interferences was considered. Methods A comparative analysis was performed evaluating a period of exclusive open repair (OR; 1998–2000) and a period of established EVAR (2010–2012). Data from four hospitals in The Netherlands were collected to estimate resource use. Actual costs were estimated by benchmark cost prices and a literature review. Costs are reported at 2019 prices. A break even approach, defining the costs for an endovascular device at which cost equivalence for EVAR and OR is achieved, was applied to cope with the large variation in endovascular device costs. Results One hundred and eighty-six patients who underwent elective AAA repair between 1998 and 2000 (OR period) and 195 patients between 2010 and 2012 (EVAR period) were compared. Cost equivalence for OR and EVAR was reached at a break even price for an endovascular device of €13 190. The main cost difference reflected the longer duration of hospital stay (ward and Intensive Care Unit) of OR (€11 644). Re-intervention rates were similar for OR (24.2%) and EVAR (24.6%) (p = .92). Conclusion Cost equivalence for EVAR and OR occurs at a device cost of €13 000 for EVAR. Hence, for most routine repairs, EVAR is not costlier than OR until at least the five year follow up.

Interhospital transfer is a common clinical practice that has been associated with poor patient outcomes in small series. We aimed to evaluate the impact of transfer status on cardiac surgery patients in a national cohort.Patients undergoing nonelective coronary artery bypass grafting, valve replacement or repair, or a combination were identified using the 2010 to 2017 Nationwide Readmissions Database. Patients were stratified by transfer status and outcomes were evaluated using adjusted multivariable linear and logistic models.Of an estimated 1,023,315 patients, 170,319 (16.6%) were transfers. Transfer was independently associated with increased complications, index hospitalization duration of stay, costs, early (30 day), and intermediate (31-90 day) readmission. Among transferred patients, transfer to a high-volume center predicted reduced odds of mortality (adjusted odds ratio: 0.64, P.001). Additionally, transfers were less likely to be readmitted back to the index hospital (80.7% vs 44.9%, P.001).Transfer status is a significant independent predictor of increased complications, length of stay, cost, and readmission among nonelective cardiac surgery patients. Notably, transfer to higher volume facilities appears to increase odds of survival. Our findings are important when considering the risks involved in the management of transferred patients.

Objectives The objective of this review was to identify outcomes reported in adolescent major depressive disorder trials and quantify outcome heterogeneity. Study Design and Setting Three databases were searched to identify trials evaluating therapies for major depressive disorder in adolescents published from 2008 to 2017. Identified outcomes were thematically grouped and mapped into predefined outcome core areas (physiological/clinical, life impact, resource use, adverse events, and death). Outcome heterogeneity was quantified using descriptive analyses. Results Of 2,686 articles yielded from the search, 42 articles describing 32 trials were included. A total of 434 outcomes measured using 118 different outcome measurement instruments were grouped into 86 unique outcome terms. Most outcome terms mapped to the physiological/clinical core area (62%), followed by the life impact (27%). Nearly half (45%) were reported in only a single trial each. Of 18 primary outcomes reported, 13 (72%) were each only reported in a single trial. “Depressive symptom severity”, reported in 30 trials (94%), was measured using 19 different outcome measurement instruments. Conclusion Heterogeneity exists in the outcomes and outcome measurement instruments used in adolescent depression trials. To enable reproducibility, comparison, and synthesis of trial results, a standard set of agreed-on outcomes and methods of measurement is needed.

Background Surgical education is changing, with residents having less time to learn more procedures. We aim to explore how residents prepare for the operating room and what factors impact their preparation. Methods A qualitative study was conducted using conventional content analysis. General surgery residents at one institution were invited to participate in semi-structured interviews. Each interview was recorded, transcribed verbatim, and then inductively examined to generate themes. Results Fourteen residents elected to participate. Six themes were identified: (1) All participants similarly defined preparation, (2) Residents learned through trial and error and co-residents, (3) Factors impacting preparation were time, attendings, autonomy, case complexity, and difficulty finding resources, (4) Resource use varied, (5) PGY level impacted preparation and, (6) Optimal resources were high yield. Conclusion Although surgical residents similarly defined operating room preparation, they use a variety of different resources to achieve this, which is often difficult and time consuming.

BACKGROUND Blood eosinophil counts correlate with exacerbations, but there is a lack of consensus on a clinically relevant definition of eosinophil count elevation. OBJECTIVE To analyze health care resource use among patients with elevated blood eosinophil counts defined at 150 cells/μL or greater and 300 cells/μL or greater. METHODS Data on patients who received a diagnosis of asthma between 2007 and 2016 were extracted from EMRClaims + database. Patients were defined as having elevated eosinophil counts if any test result during 3 months before follow-up found blood eosinophil count of 150 cells/μL or more or 300 cells/μL or more. Hospitalizations, emergency department visits, outpatient visits, and associated costs were compared. With logistic regression, likelihood of hospitalization was assessed in the presence of eosinophil elevation. RESULTS Among 3687 patients who met the study criteria, 1152 received a test within 3 months before the follow-up period, of whom 644 (56%) had elevated eosinophil counts of 150 cells/μL or greater and 322 (29%) had eosinophil counts of 300 cells/μL or greater. Overall, the mean (SD) number of hospitalizations for patients with elevated eosinophil counts vs the comparator was significantly greater (0.29 [0.92] vs 0.17 [0.57], P < .001 at ≥150 cells/μL and 0.30 [0.95] vs 0.18 [0.61] at ≥300 cells/μL, P = .001). The total mean cost was significantly greater for patients with elevated eosinophil counts (at ≥150 cells/μL: $10,262 vs $7149, P < .001 and at ≥300 cells/μL: $9966 vs $7468, P = .003). CONCLUSION Patients with asthma incurred greater health care resource use when their blood eosinophil counts were elevated at 150 cells/μL or greater and 300 cells/μL or greater as measured within 3 months of follow-up.

Idiopathic pulmonary fibrosis (IPF) is a rare and serious condition that is associated with high health-care resource use. The goal of this study was to estimate hospital-related resource use and costs by using a national, prospective registry of patients who were diagnosed with IPF or who had their diagnosis confirmed at the enrolling center in the past 6 months in the United States.Participants enrolled between June 5, 2014, and April 12, 2016, in the ongoing Idiopathic Pulmonary Fibrosis Prospective Outcomes Registry were included (N = 300). Time to first hospitalization was analyzed by using Kaplan-Meier methods. Annualized costs were estimated for hospitalizations, ICU admissions, and ED visits.At enrollment, most participants were male (75%), white (95%), commercially insured (64%), smokers (68%), had an FVC between 50% and 80% predicted (66%), and received antifibrotic drugs (55%). During the first 12 months of follow-up, participants averaged 0.11 ED visit, 0.42 hospitalization, 0.08 ICU admission, 2.18 hospital days, and 0.45 ICU day. Probability of hospitalization was 18% and 30% at 6 and 12 months, respectively, and was highest for those with FVC 50% predicted/diffusing lung capacity for carbon monoxide 30% predicted. Mean annual costs (95% CI) for ICU admission and inpatient care were $10,098 ($4,732-$16,662) and $13,975 ($8,482-$20,918), respectively, per patient.IPF is associated with a substantial economic burden incurred by patients requiring hospital care. Future research in IPF should focus on improving clinical outcomes while reducing cost of care in hospitals.ClinicalTrials.gov; No.: NCT01915511; URL: www.clinicaltrials.gov.

Territoriality is central to animal behaviourists' understanding of many facets of animal behaviour, including resource acquisition, space use behaviour, communication and mating systems. However, the term itself, how it is conceptualized and defined, has long been nebulous and contentious. Here, we ask whether juxtaposing debates about territoriality from animal behaviour with parallel discussions of territoriality from the social sciences can offer a historically and sociologically informed path out of the conceptual gridlock in which animal territoriality has been located for decades. We delineate two key problems with territoriality identified in the animal behaviour literature: First, that it focuses on how animals are expected to behave rather than how they actually behave and, second, that it assumes rather than demonstrates the function of, and specific relationships among, individuals. We then link these problems to social scientists' theorizations of the difference between property and access: whereas property is focused on how people are expected to behave under juridical–legal rules governing resource use, access focuses on a wide array of means by which people actually access resources. We thus argue that longstanding problems with animal territoriality have arisen due to implicitly embedded notions of property and ownership. Our juxtaposition raises two further problems with territoriality: first, it unwarrantedly serves to attribute authority to individuals described as territory ‘owners’ and casts others (‘intruders’, ‘sneakers’) as transgressors and, second, conceiving of ownership is unfeasible in animal societies lacking the particular juridical–legal institutions that establish and enforce property rights. Instead, we advocate for an access-based approach that will obviate these problems. Ultimately, we argue that the theory of access, as developed in social science literatures on spatial and relational resource use, will allow for a fuller and more nuanced understanding of variation in animal behaviour than that afforded by current dominant notions of territoriality.

Emerging nurse leaders are not adequately prepared to handle the pervasive health care problems and threats related to the changing environment. Nurse educators prepare nurses for an extensive variety of roles and responsibilities necessary to meet the health care needs of society. The Penn State College of Nursing implemented several initiatives to support environmental sustainability within the college and nursing education. The inclusion of environmental sustainability in nursing education is foundational if students are to become informed members and emerging leaders of a broader health care team, advocates for conscientious and ethical resource use, and contributors to improved patient outcomes.

Nowadays, industrial companies embrace the cutting-edge artificial intelligence (AI) techniques to achieve smart manufacturing over the entire organization. However, effective data collection and annotation still remain as a big challenge in many manufacturing scenarios. Transfer learning, serving as a breakthrough of learning sharing knowledge and extracting latent features from scarce data, has attracted much attention. Transfer learning in literature mainly focuses on the definitions and mechanisms of interpretation while lacking a systematic implementation scheme for manufacturing. To fulfill this gap and facilitate industrial resource use efficiency, this paper attempts to systematize strategies of transfer learning in today’s smart manufacturing in a step-by-step manner. Twenty representative transfer learning works are investigated from the perspectives of manufacturing activities along the engineering product lifecycle. Meanwhile, the potential availability of industrial dataset is also briefly introduced. It is hoped this research can provide a clear guide for both academics and industrial practitioners to design appropriate learning approaches according to their own industrial scenarios.

Information on paroxysmal supraventricular tachycardia (PSVT) patient characteristics and the associated economic burden of the disease is limited. Therefore, we sought to characterize newly diagnosed PSVT patients and quantify their healthcare resource use and expenditures. We used enrollment, demographic, and claims data from IBM MarketScan Research Database and Medicare Limited Data Set (LDS) to identify patients newly diagnosed with PSVT (ICD-9: 427.0; ICD-10: I47.1) from 10/1/2012 to 9/30/2016. Patients were required to be observable 1-year before and after index diagnosis. Patients were stratified by age (

Objectives Resource use and cost (RUC) evidence is one of the factors that can be considered when formulating recommendations in clinical practice guidelines (CPGs). However, it is unclear how CPG developers incorporate this information. The purpose of this study was to identify available guidance from guideline organizations on how to incorporate RUC in CPGs. Study Design and Setting This is a methodological survey. We searched MEDLINE, the G-I-N library, the Cochrane Methodology Register, and gray literature from inception to 2017. We included the most recent version of guidance documents. We excluded those that only reported methodology for adapting, endorsing, or updating CPGs, and documents reporting methods followed in the development of one or more specific CPGs. Results We included 77 documents from 67 organizations. Fifty-nine organizations (88.1%) include information regarding RUC during the CPG development process. Fifty-five (82.1%) organizations report taking RUC into account when developing recommendations: 44 (65.7%) do this explicitly, 5 (7.5%) implicitly, and 6 (9.0%) explicitly as optional. Twelve of the 44 organizations that explicitly consider RUC (27.3%) provide guidance to identify, assess and use the RUC evidence when developing recommendations. Twenty-three consider RUC when moving from the evidence to recommendations (52.3%). Seventeen of the 44 (38.6%) recommend making qualitative judgments about whether the desirable effects of interventions were worth the associated costs. Conclusion More explicit guidance is needed alongside tools to help CPGs developers incorporate RUC evidence when formulating recommendations. Our results may be of use for guideline developers to improve this guidance.

Objective To estimate the direct ophthalmic health care resource use in patients with geographic atrophy (GA) secondary to age-related macular degeneration (AMD). Design Retrospective analysis of anonymized data derived from electronic medical records acquired at 10 clinical sites in the United Kingdom. Participants Patients aged ≥50 years with ≥1 eye with a clinical record of GA or, for comparison, bilateral early/intermediate AMD. Four subgroups were identified: GA in both eyes (GA : GA); GA in 1 eye, choroidal neovascularization (CNV) in the fellow eye (GA : CNV); GA in 1 eye with early or intermediate AMD in the fellow eye (GA : E); and early/intermediate AMD in both eyes (E : E). Methods Electronic medical records were analyzed to derive the median number of visits over the first 2 years following diagnosis of GA or early/intermediate AMD. Clinical tests recorded at visits were used to calculate estimated costs (payer perspective) of monitoring. Analyses were restricted to patients with an initial diagnosis on or after January 1, 2011 to represent present day monitoring and costs associated with AMD. Main Outcome Measures Median number of visits and estimated monitoring costs per patient (in £) over the first 2 years among patients with ≥2 years of follow-up and in the individual subgroups. Intravitreal treatment costs in the GA : CNV group were excluded. Results For all 3 GA subgroups (n = 1080), the median number of visits over the first 2 years was 5 and monitoring costs were £460.80 per patient. The GA : CNV subgroup (n = 355) had the highest number of visits (median, 15), with a cost of £1581, compared with the GA : E subgroup (n = 283; median 4 visits; cost ∼£369) and the GA : GA subgroup (n = 442; median 3 visits; cost ∼£277). Ophthalmic tests were conducted most frequently in the GA : CNV subgroup. Visits and costs in the E : E subgroup (n = 6079) were lower. Conclusions Resource use in patients with GA varies considerably and is strongly influenced by the concomitant presence of CNV and lack of monitoring strategies for GA.

Background Motor neurone disease (MND) places a significant burden on patients, their carers, and healthcare systems. Objectives To estimate health utilities and costs of MND within the UK setting. Methods Patients with MND, recruited via 22 regional clinics, completed a postal questionnaire of a cost and quality-of-life survey. Health outcome assessment included the EuroQoL (EQ)-5D-5L, EQ-5D-visual analogue scale, Amyotrophic Lateral Sclerosis Utility Index, and the Amyotrophic Lateral Sclerosis Functional Rating Scale–Revised. Clinical staging was based on the Kings and Milano-Torino (MiToS) systems. The questionnaire asked about patients’ use of primary, secondary, and community care services in the previous 3 months. Variability in total costs was examined using regression models. Results 595 patients were included in the health utility analysis, of whom 584 patients also completed a resource use questionnaire. Mean health utility decreased and costs increased between consecutive Kings stages, from 0.76 (95% CI 0.71-0.80) and £1096 (£757-£1240) in Kings stage 1, to 0.50 (0.45-0.54) and £3311 (£2666-£4151) in stage 4, respectively. The changes by MiToS stages were from 0.71 (0.69-0.73) and £1115 (£937-£1130) in MiToS stage 0, to 0.25 (0.07-0.42) and £2899 (£2190-£3840) in stage 2. Kings stages 3 and 4 and MiToS stages 1 and 2, respectively, were significant in explaining variability in total costs. Conclusions The impact of MND on health utilities and costs differs by disease severity. The data provided here can be used in cost-effectiveness analyses and to inform decision-making regarding healthcare provision for people with MND.

Plant diversity exerts significant effects on ecosystem functioning. However, it remains unclear that whether the ecological consequences of genotypic diversity of the dominant species is similar to that of species diversity. In this study, diversity effects on biomass of 12 companion species and 12 genotypes of the dominant species (Stipa grandis) in the Inner Mongolia Steppe of China were examined by two independent diversity experiments. In order to explain the diversity effects, seven plant functional traits for each species or each genotype of S. grandis per mixture treatment were measured and their Rao’s quadratic entropy (FDQ) was estimated. There was significantly positive net species diversity effect on aboveground biomass, which was mainly contributed by complementarity effect; however, net diversity effects were not significant in genotypic diversity experiment. The FDQ among S. grandis genotypes was significantly lower than that among the companion species, and the relatively lower FDQ would increase niche overlap and limit complementarity effect among genotypes. Neither species diversity nor genotypic diversity of S. grandis showed significant influences on belowground biomass, suggesting the non-consistent results of diversity effect between belowground and aboveground systems. The present finding highlighted the species diversity effects on biomass, the role of FDQ on explaining complementarity effect by niche overlap or resource use efficient.

Background A prolonged activated partial thromboplastin time (APTT) of unknown cause is one of the most frequent reasons why outpatients are referred for hemostasis consultation. Nevertheless, very few data are available on the relative contribution of individual causes of this common clinical scenario. Here, we present a systematic evaluation of all causes of APTT prolongation in a consecutive population of outpatients referred for specialized hemostasis consultation during a 14‐year period. Methods All cases referred to an academic specialized hemostasis outpatient unit due to APTT prolongation of unknown etiology whose prolonged APTT was confirmed in the first visit were included in the study. Data were obtained from the electronic medical records. Results Among 187 consecutive patients, the most frequent causes were antiphospholipid antibodies in 22.6%, contact pathway factor deficiencies in 17.4%, other coagulation factor deficiencies in 11.6%, and vitamin K deficiency/liver disease in 11.6%. A definite cause was not identified in 22.1% of patients. Presence of antiphospholipid antibodies, and absence of bleeding symptoms were both associated with significantly longer APTT values compared to other categories/clinical scenarios. The investigation of each case required a mean of 18.2 additional tests per patient, with estimated costs ranging from US$191.60 to US$1055.60. Conclusions Our results describe the main causes of APTT prolongation in outpatients, as well as estimates of resource use required to investigate this condition, thus providing evidence supporting the importance of measures to minimize the indiscriminate use of this assay.

Introduction and objectives Potentially inappropriate prescription (PIP) is common in elderly people. It has become a global public health problem due to its association with adverse drug effects (ADE), increased morbidity and mortality, emergency care visits and resource use. The main aim of this study was to determine whether the use of a notification program of PIP in elderly patients admitted in the hospital led to a reduction of their prescription. Method A quasi-experimental before–after study was conducted. PIP were identified by using Beers (2012 update) and STOPP-START criteria (2008 version). An individualized report on PPI was prepared and the effect of this intervention was evaluated. Results 174 patients were included who presented 284 PIP. 54% (153) of the recommendations were accepted. Barthel index was the only variable that proved to contribute to the presence of PIP modifications. The patients whose PIP drugs were modified were significantly more dependent (p = .005), presented cognitive impairment (p = .001) and were more institutionalized (p = .039) than those without any modifications. There were fewer readmissions, emergency care visits and mortality within six months after intervention comparing patients with and without PIP modifications, but without significant differences. 32 ADE were detected, 29 related with PIP drugs. Adverse events were significantly associated with PIP drugs, versus other medications (p Conclusions Review of medication in elderly patients, along with the use of tools that help in the identification of dangerous drugs, entail a reduction of inadequate prescription and significantly contribute to the continuous improvement of chronic medication in elders.

The circular economy has emerged as an important approach in addressing how society can use its resources more efficiently. Theoretical advancements in the circular economy have yielded benefits for both practice and policymaking. However, if the eco-efficiency of resource use is to be improved, then certain challenges that face the circular economy must be resolved. One of these challenges concerns the rebound effect. By investigating resource flow with a circular (rather than linear) system, as well as within a producer-producer (rather than producer-consumer) type of relationship, we identify a rebound effect that we term ‘symbiotic rebound’. We differentiate it from other forms of rebound effect on the basis of its main driver: Opportunity costs drive a higher than expected use of resources in a circular economy, rather than the usual driver of ‘demand’, as found in other types of rebound. In identifying, describing, and illustrating a symbiotic rebound effect, we make two contributions: first to the rebound literature, and second to theory development on the circular economy.

Real capital investments are important for a transition to a more sustainable economy and for the continuous process of creative destruction and economic development. At the same time investments h ...

Use of intensive care unit (ICU) resources in the USA far outpaces that of other countries. This increased use is not accompanied by superior clinical outcomes and is at times discordant with patient desires. This Series paper seeks to identify major drivers of ICU resource use in the USA, and to offer steps towards better aligning ICU resource use with clinical needs and patient preferences. After considering several factors, such as organisational, ethical, and economic factors, we suggest that there are four intersecting drivers of irresponsible use of ICU resources in the USA: first, excess ICU bed capacity and a scarcity of data to understand which patients that truly benefit from ICU compared with ward care; second, clinicians misinterpreting the goals and means of patient autonomy; third, an extreme fear of rationing by the general public; and fourth, fee-for-service driven use of advanced medical technologies and procedures that beget ICU expansion.

Objective Attention is drawn to the potential of global warming to influence the health and wellbeing of the human race. There is increasing public and governmental pressure on healthcare organisations to mitigate and adapt to the climate changes that are occurring. The science of anaesthetic agents such as nitrous oxide and the halogenated anaesthetic agents such as greenhouse gases and ozone-depleting agents is discussed and quantified. Additional environmental impacts of healthcare systems are explored. The role of noninhalational anaesthetic pharmaceuticals is discussed, including the environmental life-cycle analyses of their manufacture, transport, disposal and use. The significant role of anaesthetists in recycling and waste management, resource use (particularly plastics, water and energy) and engagement in sustainability are discussed. Finally, future directions for sustainability in veterinary anaesthesia are proposed. Conclusions Veterinary anaesthetists have a considerable opportunity to drive sustainability within their organisations through modification of their practice, research and education. The principles of sustainability may help veterinary anaesthetists to mitigate and adapt to our environmental crisis. Due to their particular impact as greenhouse gases, anaesthetic agents should be used conservatively with the lowest safe fresh gas flow possible. Technologies for reprocessing anaesthetic agents are described.

Despite general agreement on the importance of adjusting each life cycle assessment (LCA) to its goal, the methodological choices in previously published LCAs on wastewater and sludge management systems are surprisingly similar, even when the information sought in the studies most likely differ. We argue that the potential of LCA may not currently be fully utilised, partly due to particular methodological challenges arising in both attributional and consequential LCAs for this type of systems. By developing the theory for handling of allocation problems in attributional LCAs, and by elaborating on the different possible foreseeable consequences in consequential LCA, we aim to facilitate both attributional and consequential LCAs, and to show the importance of such choices for a specific wastewater and sludge management system. We introduce and apply a distinction between physically and legally joint processes as basis for the allocation of resource use and emissions in attributional LCA, and suggest that, when the joint process is not driven by commercial interests, allocation factors could be identified and quantified through stakeholder priorities. In consequential LCAs, the substitution depends on the subjective view on what consequences are foreseeable, for example based on short- or long-term considerations. All of these modelling aspects can, as our case study illustrates, affect the LCA results.

Current environmental problems of the two Large Marine Ecosystems (LMEs) in Far Eastern Russia, the Sea of Okhotsk LME and the West Bering Sea LME, were analyzed. The overall strategic problem for the sustainable regional development is the resource use conflicts and the resolution of these conflicts for long-term nature management purposes. This problem occurs due to registered hydrocarbon deposits on the shelf of the Sea of Okhotsk LME, as well as ore raw materials on the coast of Kamchatka, and possible damage to the renewable fish resources of the West Bering Sea LME during the exploration and production of mineral resources. Peculiar environmental issues are a) irrational use of bioresources, b) pollution of river and coastal water, and c) increase of industrial and domestic waste, including marine litter. The problem of industrial and domestic pollution is closely related with prevailing use of mineral resources. The total anthropogenic load on the Sea of Okhotsk LME is higher than on the West Bering Sea LME.

Efficient and effective wildland fire response requires interregional coordination of suppression resources. We developed a mathematical model to examine how scarce resources are shared. Best-fit models describe regional resource allocation according to driving risk factors. By regressing a linear system of ordinary differential equations with GIS-data for demand predictors like suppression resource use, ongoing fire activity, fire weather metrics, accessibility, and population density onto pre-smoothed Resource Ordering Status System (ROSS) wildfire personnel and equipment requests, we fit a national scale model. We report statistical properties of the best-fit parameters and indicate how these findings might be interpreted for personnel and equipment sharing by examining test cases for national, central/southern Rockies, and California interregional sharing. Abrupt switching behavior across medium and high alert levels was found in test cases for national, central/southern Rockies, and California interregional sharing.

Given the substantial resource use and emissions generated from the building sector, China is seeking a more sustainable and greener mode of building construction. To grasp the characteristics of the embodied energy use of the building sector across provinces in China, a multidimensional framework is developed to examine the spatial and sectoral distributions through the whole supply chain using a multiregional input-output (MRIO) analysis and structural path analysis (SPA) as the underlying methods. The results show that from a regional perspective, Liaoning, Shandong, and Guangdong are identified as top contributors, while from a sectoral perspective, the manufacture of nonmetallic mineral products, smelting and pressing of metals, and transportation, storage, posts, and telecommunications are the largest energy suppliers. The upstream examination indicates that self-digestion is an obvious and dominant energy use behavior for most regions, while the relative importance of sectoral suppliers changes regularly with the increase in upstream stages. The energy capture that occurred in the cross-regional energy transfers indicates that Zhejiang and Hebei are the national leading net importer and net exporter of energy use in China's building sector, respectively.

Maize is the most important staple crop in Mexico and is cultivated under varied agro-climatic and socio-economic conditions. The aim of this study is to estimate energy use, cumulative exergy consumption (CExC), and greenhouse gas (GHG) emissions of different maize production systems as proxies to compare their resource use and environmental performance. Based on average values, per-hectare energy use, energy intensity (EI), energy output-input ratio (ER), and net energy (NE) are in the range of 2.3–40.2 GJ ha−1, 1.8–8.5 MJ kg−1, 1.7–12.0, and 16.3–73.1 GJ ha−1, respectively. Per-hectare CExC, exergy intensity (ExI), exergy output-input ratio (ExR), and net exergy (NEx) are in the range of 2.5–52.1 GJ ha−1, 1.9–10.7 MJ kg−1, 1.6–14.1, and 19.6–86.8 GJ ha−1, respectively. Per-hectare GHG emissions, GHG intensity (GHGI), and GHG per unit energy input (GHGEi) are in the range of 152.9–3475.8 kg CO2e ha−1, 116.5–601.9 kg CO2e Mg−1, and 63.1–117.2 kg CO2e GJ−1, respectively. Low-input rain-fed production systems perform better in EI, ER, ExI, ExR, GHGI, and GHGEi though, they also show the lowest NE and NEx due to poor yields. High-input surface irrigated production systems have the highest NE and NEx coupled with medium values of EI, ExI, and GHGI due to high productivity.

Background Patients with severe aortic stenosis (AS) have repeat hospitalizations for multiple conditions. Objectives The purpose of this study was to assess the effect of transcatheter aortic valve replacement (TAVR) on hospitalizations in severe AS. Methods Using data from the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) registry with linkage to Medicare claims, the authors examined rates of all-cause, cardiovascular, and noncardiovascular hospitalizations and hospital days, as well as inpatient costs in the year pre-TAVR and post-TAVR. Multivariable modeling was used to determine rate ratios of post-TAVR versus pre-TAVR hospitalizations and costs. Results Among 15,324 patients at 328 sites with Medicare linkage undergoing TAVR, the median age was 84 years, the median Society of Thoracic Surgeons Predicted Risk of Mortality score was 7.0, and 61.1% patients underwent TAVR via transfemoral access. Post-TAVR, heart failure hospitalization rates and hospitalized days were reduced compared with pre-TAVR (rate ratio: 0.87 and 0.95 respectively; p Conclusions Patients had lower costs and fewer heart failure hospitalizations but more all-cause, noncardiovascular, and bleeding hospitalizations post-TAVR. Reduction in hospitalizations varied by specific patient subgroups, and thus, payors and providers seeking to reduce resource use may consider strategies designed to improve processes of care among patients with increased resource utilization post-TAVR as compared with pre-TAVR.

Objective To apply time-driven activity-based costing (TDABC) methodology to determine emergency medicine physician documentation costs with and without scribes. Methods This was a prospective observation cohort study in a large academic emergency department. Two research assistants with experience in physician–scribe interactions and ED workflow shadowed attending physicians for a total of 64 hours in the adult emergency department. A tablet-based time recorded was used to obtain estimates for physician documentation time on both control (no scribe) and intervention (scribe) shifts. Results Control shifts yielded approximately 3 hours of documentation time per 8 hours of clinical time (2 hours during the shift, 1 hour following the shift). When paired with a scribe, attending physician documentation decreased to 1 hour and 45 minutes during a shift and 15 minutes of postshift documentation. The physician cost estimate for documentation without and with a scribe is 644 and 488 dollars, respectively. Conclusions When one looks at the time saved by the provider, scribes appear to be a financially sound decision. TDABC methodology demonstrated that scribes afford a cost-effective solution to ED clinical documentation and serves as a tool to develop an accurate costing system, based on actual resources and processes, and allowed for understanding of resource use at a more granular level.

Breeding green varieties that have high yield potential and require less resource input is the ideal way to cope with the challenges that human is facing with respect to food security and environmental pollution. However, few studies have focused on how high yield and high resource use efficiency is coordinated in rice (Oryza sativa L.). Here three varieties with different sink size, namely Yongyou4949 (YY4949) with large sink size, Yangliangyou6 (YLY6) with medium sink size, and Huanghuazhan (HHZ) with small sink size, were used in field and pot experiments in 2015–2017. The objective was to examine how enlarged sink size coordinate high yield and high nitrogen (N) use efficiency (NUE). It was found that YY4949 produced a grain yield of 9.60-11.79 t ha−1 in 2015–2017, which was higher than that of YLY6 by 0.3-1.75 t ha−1, and that of HHZ by 1.3-2.18 t ha−1. N use efficiency for grain production (NUEg) of YY4949 reached 47.7-58.3 kg kg−1 depending on the weather condition, which was 5.3–12.8% higher than that of YLY6 and 15.8–20.7% higher than that of HHZ. The concomitantly higher grain yield and NUEg of YY4949 were due to: (1) higher efficiency of spikelet production in respect of dry matter, N, accumulated temperature and radiation; (2) higher biomass production and N accumulation after flowering; (3) higher RUE after flowering due to the better canopy structure. In conclusion, rice breeding in the future should continue to enlarge the sink size especially through the improvement in production efficiency of sink size, while simultaneously increase the post-heading biomass production capacity.

Although food production is a main driver of environmental pressure and resource use globally, food delivers critical nutrition to humans. In life cycle assessment (LCA) of foods, the dominant functional unit is mass, despite the ISO requirement that the LCA unit should reflect the actual function. Studies have used various dietary quality scores in environmental assessments of foods, but the consideration of the dietary context is largely missing. The main function, i.e., nutrient supply, is complex since the nutritional value of a food item depends on its dietary context. Moreover, overall nutritional value is a combination of multiple nutrients. The aim was to combine scientific knowledge from the fields of nutrition and LCA to generate a basis for further research. The long-term aim was to help develop methods to support sustainability-based planning and decision making by food chain stakeholders. The proposed functional unit expresses the nutrient content of individual foods in relation to the nutritional supply of the complete diet, to create a single score reflecting the nutrient quality in a given dietary context. The nutrient quality index developed was evaluated by analyzing how relationships in global warming potential (GWP) between single products differed when using as functional unit either the mass of the food product, a nutrient quality index not considering the dietary context (the Nutrient Rich Foods Index 9.3, NRF9.3) and the new dietary dependent nutrient quality index (NQI) proposed. Two dietary scenarios were explored, an average Swedish diet and a typical unhealthy diet. The products considered were: bread, apples, tomatoes, milk, hard cheese, spread and chicken fillets. The results, calculated using bread as the reference, indicated that in both dietary contexts apples, tomatoes, and hard cheese had lower NQIadjusted GWPs compared to when GWPs were calculated using mass as the functional unit. Milk's NQI-adjusted and mass-calculated GWPs differed little, while the chicken fillet GWPs were the same in the unhealthy diet and performed better in the average diet. The NRF9.3-adjusted GWPs differed from the NQI-adjusted ones for all analysed foods. The main conclusions were: 1) considering nutritional value in the LCA of foods improves our understanding of how the environmental impacts and nutritional functions of food are related; 2) the environmental performance of different products varies with dietary context; and 3) application of the NQI could help industry, authorities, and consumers improve products and diets.