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Introduction: The sources of racial disparity in duration of patients’ visits to emergency departments (EDs) have not been documented well enough for policymakers to distinguish patient-related factors from hospital- or area-related factors. This study explores the racial disparity in duration of routine visits to EDs at teaching and non-teaching hospitals.Methods: We performed retrospective data analyses and multivariate regression analyses to investigate the racial disparity in duration of routine ED visits at teaching and non-teaching hospitals. The Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) were used in the analyses. The data include 4.3 million routine ED visits encountered in Arizona, Massachusetts, and Utah during 2008. We computed duration for each visit by taking the difference between admission and discharge times.Results: The mean duration for a routine ED visit was 238 minutes at teaching hospitals and 175 minutes at non-teaching hospitals. There were significant variations in duration of routine ED visits across race groups at teaching and non-teaching hospitals. The risk-adjusted results show that the mean duration of routine ED visits for Black/African American and Asian patients when compared to visits for white patients was shorter by 10.0 and 3.4%, respectively, at teaching hospitals; and longer by 3.6 and 13.8%, respectively, at non-teaching hospitals. Hispanic patients, on average, experienced 8.7% longer ED stays when compared to white patients at non-teaching hospitals.Conclusion: There is significant racial disparity in the duration of routine ED visits, especially in non-teaching hospitals where non-White patients experience longer ED stays compared to white patients. The variation in duration of routine ED visits at teaching hospitals when compared to non-teaching hospitals was smaller across race groups. [West J Emerg Med. 2013;14(5):529–541.]

Introduction. Inadvertent excision of a soft tissue sarcoma during hernia surgery is a preventable clinical scenario that leads to unnecessary patient morbidity. Prior series are few, which only include male patients with little focus on prevention. The purpose of this study is to report the presenting features and outcomes of both male and female patients who underwent inadvertent inguinal sarcoma excision during hernia surgery. Methods. A retrospective analysis of a single sarcoma referral center identified 33 patients who were referred for definitive treatment. Patients were divided into three clinically relevant groups based on intraoperative diagnosis, sex, and location of the mass relative to the inguinal ligament. T-tests and Fisher’s exact tests were performed to compare continuous and categorical variables, respectively. Kaplan–Meier modeling was performed to assess sarcoma-specific survival. Results. Females were younger (47 years vs. 61 years, p=0.003) and had smaller sarcomas (6.7 cm vs. 11 cm, p=0.012) compared to males. Only two sarcomas (2/33, 6%) were 4 cm, irreducible, firm, and is growing, especially in females, consider obtaining preoperative advanced three-dimensional imaging (CT or MRI) that can differentiate a neoplasm from a hernia.

Abstract Background Understanding the long-term behavior of intracortically-recorded signals is essential for improving the performance of Brain Computer Interfaces. However, few studies have systematically investigated chronic neural recordings from an implanted microelectrode array in the human brain. Methods In this study, we show the applicability of wavelet decomposition method to extract and demonstrate the utility of long-term stable features in neural signals obtained from a microelectrode array implanted in the motor cortex of a human with tetraplegia. Wavelet decomposition was applied to the raw voltage data to generate mean wavelet power (MWP) features, which were further divided into three sub-frequency bands, low-frequency MWP (lf-MWP, 0–234 Hz), mid-frequency MWP (mf-MWP, 234 Hz–3.75 kHz) and high-frequency MWP (hf-MWP, >3.75 kHz). We analyzed these features using data collected from two experiments that were repeated over the course of about 3 years and compared their signal stability and decoding performance with the more standard threshold crossings, local field potentials (LFP), multi-unit activity (MUA) features obtained from the raw voltage recordings. Results All neural features could stably track neural information for over 3 years post-implantation and were less prone to signal degradation compared to threshold crossings. Furthermore, when used as an input to support vector machine based decoding algorithms, the mf-MWP and MUA demonstrated significantly better performance, respectively, in classifying imagined motor tasks than using the lf-MWP, hf-MWP, LFP, or threshold crossings. Conclusions Our results suggest that using MWP features in the appropriate frequency bands can provide an effective neural feature for brain computer interface intended for chronic applications. Trial registration This study was approved by the U.S. Food and Drug Administration (Investigational Device Exemption) and the Ohio State University Medical Center Institutional Review Board (Columbus, Ohio). The study conformed to institutional requirements for the conduct of human subjects and was filed on ClinicalTrials.gov (Identifier NCT01997125).

Abstract Background It is beneficial for health care institutions to monitor physician prescribing patterns to ensure that high-quality and cost-effective care is being provided to patients. However, detecting treatment patterns within an institution is challenging, given that medications and conditions are often not explicitly linked in the health record. Here we demonstrate the use of statistical methods together with data from the electronic health care record (EHR) to analyze prescribing patterns at an institution. Methods As a demonstration of our method, which is based on regression, we collect EHR data from outpatient notes and use a case/control study design to determine the medications that are associated with hypertension. We also use regression to determine which conditions are associated with a preferential use of one or more classes of hypertension agents. Finally, we compare our method to methods based on tabulation. Results Our results show that regression methods provide more reasonable and useful results than tabulation, and successfully distinguish between medications that treat hypertension and medications that do not. These methods also provide insight into in which circumstances certain drugs are preferred over others. Conclusions Our method can be used by health care institutions to monitor physician prescribing patterns and ensure the appropriateness of treatment.

Abstract Background Short-segment pedicle-screw instrumentation is frequently used to stabilize thoracolumbar burst fractures. A recognized disadvantage of this procedure is recurrent kyphosis from intervertebral disc creep into the fractured central endplate. Balloon Assisted Endplate Reduction (BAER) using Tricalcium Phosphate bone cement (TCP) enables elevation of the centrally depressed endplate. Our objective was to evaluate the bone-tissue response to TCP and to analyse whether BAER using TCP can prevent recurrent kyphosis after removal of the instrumentation. Methods Fourteen patients with traumatic thoracolumbar burst fractures were operated with BAER using TCP in combination with short-segment instrumentation. Nine months after surgery, instrumentation was removed and transpedicular biopsies were taken for histological and histochemical analysis. Roentgenograms pre- and postoperatively and at latest follow-up after removal of the instrumentation were evaluated. Results Average follow-up was 2.6 years. Analysis of the biopsies showed a variable degree of bone remodelling with incorporation of TCP into newly formed bone matrix. No extensive foreign body reactions, inflammation, granulomatous responses or tissue necrosis were observed. Wedge-angle, kyphosis-angle and both the anterior-posterior and central-posterior vertebral body height ratios improved significant postoperatively (p

Abstract Neuroprosthetics that combine a brain computer interface (BCI) with functional electrical stimulation (FES) can restore voluntary control of a patients’ own paralyzed limbs. To date, human studies have demonstrated an “all-or-none” type of control for a fixed number of pre-determined states, like hand-open and hand-closed. To be practical for everyday use, a BCI-FES system should enable smooth control of limb movements through a continuum of states and generate situationally appropriate, graded muscle contractions. Crucially, this functionality will allow users of BCI-FES neuroprosthetics to manipulate objects of different sizes and weights without dropping or crushing them. In this study, we present the first evidence that using a BCI-FES system, a human with tetraplegia can regain volitional, graded control of muscle contraction in his paralyzed limb. In addition, we show the critical ability of the system to generalize beyond training states and accurately generate wrist flexion states that are intermediate to training levels. These innovations provide the groundwork for enabling enhanced and more natural fine motor control of paralyzed limbs by BCI-FES neuroprosthetics.

During 2009–2012, wild animals were sampled in two areas within the Amazon biome of Brazil, in the states of Mato Grosso and Pará. Animal tissues and blood were molecularly tested for the presence of Piroplasmida (genera Babesia, Theileria, Cytauxzoon) or Hepatozoon DNA. Overall, 181 wild animals comprising 36 different species (2 reptiles, 5 birds, and 29 mammals) were sampled. The following Piroplasmida agents were detected: Cytauxzoon felis in one ocelot (Leopardus pardalis), Theileria cervi in two red brocket deer (Mazama americana), Theileria spp. in three nine-banded-armadillos (Dasypus novemcinctus), one agouti (Dasyprocta sp.), and four lowland pacas (Cuniculus paca), Babesia spp. in one common opossum (Didelphis marsupialis) and one white-lipped peccary (Tayassu pecari). The following Hepatozoon agents were detected: Hepatozoon sp. (possibly Hepatozoon caimani) in three spectacled caimans (Caiman crocodilus), Hepatozoon felis in an ocelot (Leopardus pardalis), and Hepatozoon spp. in one scorpion mud turtle (Kinosternon scorpioides) and one lowland paca (Cuniculus paca). Phylogenetic analyses inferred by the 18S rRNA gene partial sequences supported these results, highlighting at least five novel Piroplasmida agents, and two novel Hepatozoon agents. This study screened the presence of tick-borne protozoa in a number of wildlife species from the Amazon for the first time. Our results indicate that a variety of genetically distinct Piroplasmida and Hepatozoon organisms circulate under natural conditions in the Amazonian wildlife.

Humans and animals can learn to order a list of items without relying on explicit spatial or temporal cues. To do so, they appear to make use of transitivity, a property of all ordered sets. Here, we summarize relevant research on the transitive inference (TI) paradigm and its relationship to learning the underlying order of an arbitrary set of items. We compare six computational models of TI performance, three of which are model-free (Q-learning, Value Transfer, and REMERGE) and three of which are model-based (RL-Elo, Sequential Monte Carlo, and Betasort). Our goal is to assess the ability of these models to produce empirically observed features of TI behavior. Model-based approaches perform better under a wider range of scenarios, but no single model explains the full scope of behaviors reported in the TI literature.

En este ensayo se vuelve sobre el tradicional debate acerca de las similitudes y diferencias comparativas de los regímenes esclavistas que se desarrollaron en diferentes colonias y naciones de América desde el siglo XVI a finales del siglo XIX. Se centra en lo que actualmente sabemos acerca de la integración económica y social de estos afroamericanos en sus respectivas sociedades y economías, y hace especial referencia a las diferentes experiencias de los modelos latinoamericano y anglosajón

We examined the associations between serial cognition and personality in rhesus macaques (Macaca mulatta). Nine macaques were tested on a simultaneous chaining task to assess their cognitive abilities. They were also rated for personality traits and scored according to a previously extracted six component structure derived from free-ranging rhesus macaques. Friendliness and Openness were positively associated with good performance on three measures of accuracy on the serial learning task: Progress, Error, and Rewarded (i.e., correctly completed) Trials. Faster Reaction Times were associated with lower Friendliness and higher Confidence, as well as higher Openness when only correct responses were analyzed. We also used regularized exploratory factor analysis to extract two, three, four, five, and six factor structures, and found consistent associations between accuracy and single factors within each of these structures. Prior results on intelligence in other nonhuman primate species have focused on basic intelligence tests; this study demonstrates that more complex, abstract cognitive tasks can be used to assess intelligence and personality in nonhuman primates.

Studies have linked Accountable Care Organizations (ACOs) to improved primary care, but there is little research on how ACOs affect care in other settings. We examined whether Medicare ACOs have improved hospital quality of care, specifically focusing on preventable inpatient mortality. We used 2008-2014 Healthcare Cost and Utilization Project hospital discharge data from 34 states’ Medicare ACO and non-ACO hospitals in conjunction with data from the American Hospital Association Annual Survey and the Survey of Care Systems and Payment. We estimated discharge-level logistic regression models that measured the relationship between ACO affiliation and mortality following admissions for acute myocardial infarction, abdominal aortic aneurysm (AAA) repair, coronary artery bypass grafting, and pneumonia, controlling for patient demographic mix, hospital, and year. Our results suggest that, on average, Medicare ACO hospitals are not associated with improved mortality rates for the studied IQI conditions. Stakeholders may potentially consider providing ACOs with incentives or designing new programs for ACOs to target inpatient mortality reductions.

Individuals with tetraplegia identify restoration of hand function as a critical, unmet need to regain their independence and improve quality of life. Brain-Computer Interface (BCI)-controlled Functional Electrical Stimulation (FES) technology addresses this need by reconnecting the brain with paralyzed limbs to restore function. In this study, we quantified performance of an intuitive, cortically-controlled, transcutaneous FES system on standardized object manipulation tasks from the Grasp and Release Test (GRT). We found that a tetraplegic individual could use the system to control up to seven functional hand movements, each with >95% individual accuracy. He was able to select one movement from the possible seven movements available to him and use it to appropriately manipulate all GRT objects in real-time using naturalistic grasps. With the use of the system, the participant not only improved his GRT performance over his baseline, demonstrating an increase in number of transfers for all objects except the Block, but also significantly improved transfer times for the heaviest objects (videocassette (VHS), Can). Analysis of underlying motor cortex neural representations associated with the hand grasp states revealed an overlap or non-separability in neural activation patterns for similarly shaped objects that affected BCI-FES performance. These results suggest that motor cortex neural representations for functional grips are likely more related to hand shape and force required to hold objects, rather than to the objects themselves. These results, demonstrating multiple, naturalistic functional hand movements with the BCI-FES, constitute a further step toward translating BCI-FES technologies from research devices to clinical neuroprosthetics.

Background context Pseudarthrosis following spinal fusion remains problematic despite modern surgical and grafting techniques. In surgical spinal fusion, new bone forms via intramembranous and endochondral ossification, with endochondral ossification occurring in the hypoxic zones of the fusion bed. During bone development and fracture healing, the key cellular mediator of endochondral ossification is the hypertrophic chondrocyte given its ability to function in hypoxia and induce neovascularization and ossification. We therefore hypothesize that hypertrophic chondrocytes may be an effective bone graft alternative. Purpose Spinal fusion procedures have increased substantially; yet 5% to 35% of all spinal fusions may result in pseudoarthrosis. Pseudoarthrosis may occur because of implant failure, infection, or biological failure, among other reasons. Advances in surgical techniques and bone grafting have improved fusion; however pseudarthrosis rates remain unacceptably high. Thus, the goal of this study is to investigate hypertrophic chondrocytes as a potential biological graft alternative. Methods Using a validated murine fracture model, hypertrophic chondrocytes were harvested from fracture calluses and transplanted into the posterolateral spines of identical mice. New bone formation was assessed by X‐ray, microcomputed tomography (μCT), and in vivo fluorescent imaging. Results were compared against a standard iliac crest bone graft and a sham surgery control group. Funding for this work was provided by the Department of Orthopaedics and Rehabilitation, the OREF (Grant #16‐150), and The Caitlin Lovejoy Fund. Results Radiography, μCT, and in vivo fluorescent imaging demonstrated that hypertrophic chondrocytes promoted bone formation at rates equivalent to iliac crest autograft. Additionally, μCT analysis demonstrated similar fusion rates in a subset of mice from the iliac crest and hypertrophic chondrocyte groups. Conclusions This proof‐of‐concept study indicates that hypertrophic chondrocytes can promote bone formation comparable to iliac crest bone graft. These findings provide the foundation for future studies to investigate the potential therapeutic use of hypertrophic chondrocytes in spinal fusion.

Immediately following a fracture, a fibrin laden hematoma is formed to prevent bleeding and infection. Subsequently, the organized removal of fibrin, via the protease plasmin, is essential to permit fracture repair through angiogenesis and ossification. Yet, when plasmin activity is lost, the depletion of fibrin alone is insufficient to fully restore fracture repair, suggesting the existence of additional plasmin targets important for fracture repair. Previously, activated matrix metalloproteinase 9 (MMP-9) was demonstrated to function in fracture repair by promoting angiogenesis. Given that MMP-9 is a defined plasmin target, it was hypothesized that pro-MMP-9, following plasmin activation, promotes fracture repair. This hypothesis was tested in a fixed murine femur fracture model with serial assessment of fracture healing. Contrary to previous findings, a complete loss of MMP-9 failed to affect fracture healing and union through 28 days post injury. Therefore, these results demonstrated that MMP-9 is dispensable for timely fracture union and cartilage transition to bone in fixed femur fractures. Pro-MMP-9 is therefore not a significant target of plasmin in fracture repair and future studies assessing additional plasmin targets associated with angiogenesis are warranted.

Since the 1920 discovery of oil in Bolivia, the country has experimented with varying systems of private control, monopoly state ownership and even mixed state and private ownership/rental of petroleum and gas fields. The aim of our analysis is to explain why these varying patterns of ownership occurred over time and to describe how they affected production in this industry. The analysis suggests that nationalizations have been successful insofar as they took advantage of previous private investment which, meanwhile, underscores the success of the legislation for opening up access to attract private investment. This relative success of the different legal frameworks permits us to understand why the state has been changing from one scheme to another over time. Some partial explanations are offered in order to understand why these schemes could succeed with such regularity.Desde el descubrimiento del petróleo en Bolivia en el año 1920, el país ha experimentado con una variedad de sistemas de control privado, de propiedad monopólica estatal e incluso con la propiedad o el alquiler de campos petroleros y de gas en manos privadas. El propósito de nuestro análisis es explicar por qué se han dado estos variados modelos de propiedad y describir cómo han afectado en la producción de esta industria. El análisis sugiere que las nacionalizaciones han sido exitosas en la medida en que tomaron ventaja de una inversión privada anterior, lo cual mientras tanto resalta el éxito de la legislación de “apertura” para atraer la inversión privada. El éxito relativo de los diferentes marcos legales nos permite comprender por qué el estado ha ido cambiando de un esquema a otro con el paso del tiempo. Se ofrecen algunas explicaciones parciales para entender por qué este esquema pudo dar resultado con tanta regularidad.

Review

This study was performed in Maranhão state, a transition area two Brazilian biomes, Amazon and Cerrado. During 2011-2013, 1,560 domestic dogs were sampled for collection of serum blood samples and ticks in eight counties (3 within the Amazon and 5 within the Cerrado). A total of 959 ticks were collected on 150 dogs (9.6%). Rhipicephalus sanguineus sensu lato (s.l.) was the most abundant tick (68% of all collected specimens), followed by Amblyomma cajennense sensu lato (s.l.) (12.9%), Amblyomma parvum (9.2%), and Amblyomma ovale (5.2%). Other less abundant species (

Rocky Mountain spotted fever is endemic to the São Paulo metropolitan area, Brazil, where the etiologic agent, Rickettsia rickettsii, is transmitted to humans by adult Amblyomma aureolatum ticks. We determined the minimal feeding period required by A. aureolatum nymphs and adults to transmit R. rickettsii to guinea pigs. Unfed nymphs and unfed adult ticks had to be attached to the host for >10 hours to transmit R. rickettsii. In contrast, fed ticks needed a minimum of 10 minutes of attachment to transmit R. rickettsii to hosts. Most confirmed infections of Rocky Mountain spotted fever in humans in the São Paulo metropolitan area have been associated with contact with domestic dogs, the main host of A. aureolatum adult ticks. The typical expectation that transmission of tickborne bacteria to humans as well as to dogs requires ≥2 hours of tick attachment may discourage persons from immediately removing them and result in transmission of this lethal bacterium.

Introduction: The sources of racial disparity in duration of patients’ visits to emergency departments (EDs) have not been documented well enough for policymakers to distinguish patient-related factors from hospital- or area-related factors. This study explores the racial disparity in duration of routine visits to EDs at teaching and non-teaching hospitals.Methods: We performed retrospective data analyses and multivariate regression analyses to investigate the racial disparity in duration of routine ED visits at teaching and non-teaching hospitals. The Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) were used in the analyses. The data include 4.3 million routine ED visits encountered in Arizona, Massachusetts, and Utah during 2008. We computed duration for each visit by taking the difference between admission and discharge times.Results: The mean duration for a routine ED visit was 238 minutes at teaching hospitals and 175 minutes at non-teaching hospitals. There were significant variations in duration of routine ED visits across race groups at teaching and non-teaching hospitals. The risk-adjusted results show that the mean duration of routine ED visits for Black/African American and Asian patients when compared to visits for white patients was shorter by 10.0 and 3.4%, respectively, at teaching hospitals; and longer by 3.6 and 13.8%, respectively, at non-teaching hospitals. Hispanic patients, on average, experienced 8.7% longer ED stays when compared to white patients at non-teaching hospitals.Conclusion: There is significant racial disparity in the duration of routine ED visits, especially in non-teaching hospitals where non-White patients experience longer ED stays compared to white patients. The variation in duration of routine ED visits at teaching hospitals when compared to non-teaching hospitals was smaller across race groups. [West J Emerg Med. 2013;14(5):529–541.]

This essay reconsiders the theme of the comparative differences in slave systems in the New World. Despite the rejection, by North American scholars over the past quarter century, of any comparative differences, recent research has shown important variations in the slave regimes. These variations depended on differences in labor markets, in demographic structures and above all in attitudes towards manumission and the class of free colored persons prior to emancipation. Although all slave plantation regimes shared much in common, there were differences in the participation of slaves and free colored in nonagricultural and non-plantation occupations. This often depended on the availability of alternative white labor. Moreover in the 19th century many of the Latin American regimes increased the pace of manumission and learned to accept the free colored as a fundamental part of their free economy even while adopting racist attitudes toward them. At the same time the United States and some of the Caribbean plantation regimes slowed the pace of manumission and created severe restrictions on the social, geographic and economic space and mobility of their small free colored class. The causes and consequences of these differences are discussed in this essay.

Reports on the Community College of Baltimore County's (Maryland) service learning program for diversity education, which is unique to American community colleges. States that students and faculty members spent two weeks in Belize, establishing a summer camp program for children to develop English skills. Asserts that volunteers benefited from the experience as much as the children they helped. (CJW)

We experimentally infected Amblyomma aureolatum ticks with the bacterium Rickettsia rickettsii, the etiologic agent of Rocky Mountain spotted fever (RMSF). These ticks are a vector for RMSF in Brazil. R. rickettsii was efficiently conserved by both transstadial maintenance and vertical (transovarial) transmission to 100% of the ticks through 4 laboratory generations. However, lower reproductive performance and survival of infected females was attributed to R. rickettsii infection. Therefore, because of the high susceptibility of A. aureolatum ticks to R. rickettsii infection, the deleterious effect that the bacterium causes in these ticks may contribute to the low infection rates (

Argues that providing end users with more information does not really address their problems and, in fact, does not even identify them. Topics discussed include the growth of information technology, reasons for the decline in the number of reference librarians, roles of libraries, and the importance of information intermediaries. (MES)