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Coastal ecosystems are ecologically and commercially valuable, productive habitats that are experiencing escalating compromises of their structural and functional integrity. The Clean Water Act (USC 1972) requires identification of impaired water bodies and determination of the causes of impairment. Classification simplifies these determinations, because estuaries within a class are more likely to respond similarly to particular stressors. We reviewed existing classification systems for their applicability to grouping coastal marine and Great Lakes water bodies based on their responses to aquatic stressors, including nutrients, toxic substances, suspended sediments, habitat alteration, and combinations of stressors. Classification research historically addressed terrestrial and freshwater habitats rather than coastal habitats. Few efforts focused on stressor response, although many well-researched classification frameworks provide information pertinent to stressor response. Early coastal classifications relied on physical and hydrological properties, including geomorphology, general circulation patterns, and salinity. More recent classifications sort ecosystems into a few broad types and may integrate physical and biological factors. Among current efforts are those designed for conservation of sensitive habitats based on ecological processes that support patterns of biological diversity. Physical factors, including freshwater inflow, residence time, and flushing rates, affect sensitivity to stressors. Biological factors, such as primary production, grazing rates, and mineral cycling, also need to be considered in classification. We evaluate each existing classification system with respect to objectives, defining factors, extent of spatial and temporal applicability, existing sources of data, and relevance to aquatic stressors. We also consider classification methods in a genetic sense and discuss their strengths and weaknesses for our purposes. Although few existing classifications are based on responses to stressors, many well-researched paradigms provide important information for improving our capabilities for classification as an investigative and predictive management tool. [ABSTRACT FROM AUTHOR]

Background: Lung cancer is a major health problem throughout the world. It is the leading cause of cancer-related death in men and women in the USA, with a 5-year survival rate of only 14%. It has been hypothesized that variables such as physical and social functioning, cancer-related symptomatology, comorbid conditions, cell type, and treatment are valid predictors of the psychological response to a diagnosis of lung cancer. Methods: As part of a larger longitudinal study, 211 patients, 65 years of age or older, with an incident diagnosis of lung cancer, were recruited from 23 sites within a midwestern state. Repeated measures analysis of variance techniques were used to analyse how age, gender, comorbid conditions, stage of disease, cell type, as well as the time-dependent variables symptoms, physical functioning, social functioning, and treatment predict depressive symptomatology at four assessments over the first year following diagnosis. Results: Social functioning (p <0.0001), symptoms severity (p <0.0001) and radiation treatment (p =0.017) were significant predictors of depressive symptomatology, with more symptoms and more restricted social functioning generally corresponding to higher levels of depressive symptomatology. Patients who had not received radiation treatment were more depressed than those who had received treatment at least 40 days prior to the interview. Conclusions: At a clinical level of patient care, these findings mandate early identification of psychosocial difficulties experienced, an individualized symptom management plan and the application of other interventions, such as information giving, reassurance and referral to other resources. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Documentation is essential for communicating care between credentialed nutrition and dietetics practitioners and other health care providers. A validated tool that can evaluate quality documentation of the Nutrition Care Process (NCP) encounter, including progress on outcomes is lacking. The aim of the NCP Quality Evaluation and Standardization Tool (QUEST) validation study is to revise an existing NCP audit tool and evaluate it when used within US Veterans Affairs in all clinical care settings. Six registered dietitian nutritionists revised an existing NCP audit tool. The revised tool (NCP-QUEST) was analyzed for clarity, relevance, and reliability. Eighty-five documentation notes (44 initial, 41 reassessment) were received from eight volunteer Veterans Affairs sites. Five of six registered dietitian nutritionists participated in the interrater reliability testing blinded to each other's ratings; and two registered dietitian nutritionists participated in intrarater reliability reviewing the same notes 6 weeks later blinded to the original ratings. Results showed moderate levels of agreement in interrater reliability (Krippendorff's α = .62 for all items, .66 for total score, and .52 for quality category rating). Intrarater reliability was excellent for all items (α = .86 to .87 for all items; .91 to .94 for total score and.74 to .89 for quality category rating). The NCP-QUEST has high content validity (Content Validity Index = 0.78 for item level, and 0.9 for scale level) after two cycles of content validity review. The tool can facilitate critical thinking, improved linking of NCP chains, and is a necessary foundation for quality data collection and outcomes management. The NCP-QUEST tool can improve accuracy and confidence in charting., (Copyright © 2022 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Introduction: As educators seek to improve medical student well-being, it is essential to understand the interplay between distress and important outcomes. Performance on Step 1 of the United States Medical Licensing Examination has played a significant role in selection for postgraduate residency positions in the United States and consequently has been a source of great stress for medical students. The purpose of this study was to examine whether student well-being correlates with performance on a high stakes licensing examination., Methods: Between 2014 and 2016, three sequential cohorts of medical students at the University of Michigan Medical School completed the Medical Student Well-Being Index (MSWBI) at the end of their 2nd-year curriculum, shortly before taking Step 1. Associations between well-being and Step 1 scores were investigated while adjusting for MCAT scores and cumulative second-year course scores., Results: In total, 354 students were included in the analysis (68.1% of potential responders). On bivariate analysis, poor student well-being (0 = low distress [high well-being], 7 = high distress [poor well-being]) was associated with lower Step 1 examination scores (slope = -2.10, P < .01), and well-being accounted for 5% of overall Step 1 score variability (R 2  = .05). However, after adjustment for MCAT scores and cumulative GPA (full model R 2  = .51), the relationship between well-being and Step 1 score was no longer significant (slope = -0.70, P-value = .06)., Conclusions: When controlling for metrics of academic performance, student well-being prior to taking Step 1 was not associated with how well students performed on Step 1 for the study sample., (© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Background: Access to specialty health care in the Veterans Affairs (VA) system continues to be problematic. Given the potential temporal and fiscal benefits of telehealth, the Madison VA developed a virtual consultation (VC) mechanism to expedite diagnostic and therapeutic interventions for Veterans with incidentally discovered pulmonary nodules. Materials and., Methods: VC, a remote encounter between referring provider and thoracic surgeon for incidentally discovered pulmonary nodules, was implemented at the Madison VA between 2009 and 2011. Time from request to completion of consultation, hospital cost, and travel costs were determined for 157 veterans. These endpoints were then compared with in-person consultations over a concurrent 6-mo period., Results: For the entire study cohort, the mean time to completion of VC was 3.2 d (SD ± 4.4 d). For the 6-mo period of first VC availability, the mean time to VC completion versus in-person consultation was 2.8 d (SD ± 2.8 d) and 20.5 d (SD ± 15.6 d), respectively (p < 0.05). Following initial VC, 84 (53%) veterans were scheduled for virtual follow-up alone; no veteran required an additional office visit before further diagnostic or therapeutic intervention. VA hospital cost was $228 per in-person consultation versus $120 per episode for VC - a 47.4% decrease. The average distance form veteran home to center was 86 miles, with an average travel reimbursement of $112 per in-person consultation, versus no travel cost associated with VC., Conclusions: VC for incidentally discovered pulmonary nodules significantly decreases time to consultation completion, hospital cost, and veteran travel cost. These data suggest that a significant opportunity exists for expansion of telehealth into additional practice settings within the VA system., (© Association of Military Surgeons of the United States 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

This article examines alcohol use disorders in the context of work and disability. The authors investigated the problem from a disability perspective and how to determine if alcohol use is functionally impairing the worker and requires workplace disability. Key identifiers for impairment are addressed, including evaluation of treatment intensity, comorbidities,and functional declines. Return to work issues include how an occupational health nurse/nurse case manager can assist employees in planning and managing a successful return to work, because return to work is a key component of reintegration after treatment for an alcohol use disorder.

U.S. Army flight medics performed a process improvement initiative of 15 blood product transfusions on select Category A (Urgent) helicopter evacuation casualties meeting approved clinical indications for transfusion. These transfusions were initiated from point of injury locations aboard MEDEVAC aircraft originating from one of two locations in southern Afghanistan. All flight medics executing the transfusions were qualified through a standardized and approved program of instruction, which included day and night skills validation, and a 90% or higher written examination score. There was no adverse reaction or out-of-standard blood product temperature despite hazardous conditions and elevated cabin temperatures. All casualties within a 10-minute flight time who met clinical indications were transfused. Utilization of a standard operating procedure with strict handling and administration parameters, a rigorous training and qualification program, an elaborate cold chain system, and redundant documentation of blood product units ensured that flight medic initiated transfusions were safe and effective. Research study is needed to refine the indications for prehospital blood transfusion and to determine the effect on outcomes in severely injured trauma patients., (Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.)

The Equal Employment Opportunity Commission (EEOC), which recently took the position that employer health plans are required, in many instances, to cover prescription contraceptives, has issued guidelines to assist employers in complying with the law prohibiting discrimination on the basis of sex and pregnancy. Employers should review these guidelines carefully in relation to their health care plans.

Social cognitive theory posits that behavior can be changed by observing others perform or describe performance of behaviors. This framework was applied to understanding health behavior change associated with workplace health and safety training. Questionnaires were developed and administered to 426 workers at a United Automobile Worker's Union health and safety training program. Participants received training from one of three trainers: (1) local union discussion leaders (LUDLs), (2) professional staff trainers, or (3) LUDLs with professional staff trainers. Data were collected in three phases: before, after, and three months post-training. Findings show that subjects trained by LUDLs identify most closely with their instructors, whereas subjects trained by staff trainers identify least closely with them. In addition, workers trained by LUDLs reported changing behavior as a result of training more often than workers trained by others.

Purpose: To determine the 15-year outcome for women with ductal carcinoma in situ (DCIS, intraductal carcinoma) of the breast treated with breast-conserving surgery followed by definitive breast irradiation., Patients and Methods: An analysis was performed of 270 intraductal breast carcinomas in 268 women from 10 institutions in Europe and the United States. In all patients, breast-conserving surgery included complete gross excision of the primary tumor followed by definitive breast irradiation. When performed, pathologic axillary lymph node staging was node-negative (n=86). The median follow-up time was 10.3 years (range, 0.9 to 26.8)., Results: The 15-year actuarial overall survival rate was 87%, and the 15-year actuarial cause-specific survival rate was 96%. The 15-year actuarial rate of freedom from distant metastases was 96%. There were 45 local recurrences in the treated breast, and the 15-year actuarial rate of local failure was 19%. The median time to local failure was 5.2 years (range, 1.4 to 16.8). A number of clinical and pathologic parameters were evaluated for correlation with local failure, and none were predictive for local failure (all P > or = .15)., Conclusion: The results from the present study demonstrate high rates of overall survival, cause-specific survival, and freedom from distant metastases following the treatment of DCIS of the breast using breast-conserving surgery and definitive breast irradiation. These results support the use of breast-conserving surgery and definitive breast irradiation for the treatment of DCIS of the breast.

A dedicated microcomputer system has been developed to provide voice control over a wide variety of motorized devices. Employing a 8051 microprocessor with 16 kilobytes of ROM and 16 kilobytes of non-volatile RAM, the system potentially realizes an OEM cost of under $100. Other features include: a simplified user interface, a failsafe stop and voice programmable capabilities. This system has the potential to bring voice control into the marketplace in a wide variety of applications. Currently, the system has been adapted to surgical microscopes and is used in controlling several types of hospital beds.