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There is a lack of knowledge of the arthropod communities in both wild hazelnut and cultivated hybrid hazelnut ecosystems in the Midwestern United States. Our goal was to characterize the composition of these arthropod communities in hazelnut plantings. We surveyed six experimental plantings of hazelnuts in Wisconsin and two in Minnesota during growing seasons, from May 2017 to August 2021. We used four methods to survey the arthropod community of these plantings: ad libitum survey of specimen observations and collection, dissection of hazelnut buds and nuts, cone traps placed on the ground, and beat sheet sampling of plants. We registered 116 different morphospecies of five classes and 83 families. Arthropods with known feeding habits were grouped into four guilds: 59 herbivores, 36 carnivores (predators, parasites, and parasitoids), 4 decomposers (detritivores and scavengers), and 4 omnivores. While we registered 12 herbivorous species that could potentially cause damage to hazelnuts, we directly observed nine of them feeding upon or damaging plant parts: Phytoptus avellanae s.l. Nalepa (Eriophyoidea: Phytoptidae), Curculio obtusus Blanchard and Strophosoma melanogrammum Förster (Coleoptera: Curculionidae), Popillia japonica Newman (Coleoptera: Scarabeidae), Parthenolecanium sp. (Hemiptera: Coccidae), Euschistus servus euschistoides Say (Hemiptera: Pentatomidae), aphids (Hemiptera: Aphididae), Acleris sp., and Choristoneura rosaceana Harris (Lepidoptera: Tortricidae). We also registered eight species of parasites or parasitoids that could offer biocontrol services in the cropping system. These findings provide a foundation for future targeted studies on potential pests and beneficial arthropods, as well as ecological interactions within the hybrid hazelnut ecosystem in the Midwest.

Pulmonary aspergillosis has been reported at high rates in patients with coronavirus disease 2019 (COVID-19) and is associated with high morbidity and mortality. We retrospectively assessed all patients admitted to an intensive care unit during the early COVID-19 surge (3/17/20–5/10/20) at our medical center in the midwestern USA for the presence of COVID-19-associated pulmonary aspergillosis (CAPA). Patients were not routinely screened for CAPA; diagnostic work-up for fungal infections was pursued when clinically indicated. Among 256 patients admitted to the ICU with severe COVID-19, 188 (73%) were intubated and 62 (24%) ultimately expired within 30 days of admission to the ICU. Only three patients (1%) were found to have CAPA; diagnosis was made by tracheal aspirate cultures in two cases and by bronchoalveolar lavage fluid Aspergillus galactomannan in one case. None of the patients who developed CAPA had classic risk factors for invasive fungal infection. The occurrence of CAPA was much lower than that reported at other centers, likely reflecting the local epidemiology.

The midwestern United States is a highly productive agricultural region, and extended crop-free periods in winter/spring can result in nitrogen (N) and phosphorus (P) losses to waterways that degrade downstream water quality. Planting winter cover crops can improve soil health while reducing nutrient leaching from farm fields during the fallow period. In this study, we used linear mixed effects models and multivariate statistics to determine the effect of cover crops on soil nutrients by comparing fields with cover crops (n = 9) versus those without (n = 6) in two Indiana agricultural watersheds: the Shatto Ditch Watershed, which had >60% of croppable acres in winter cover crops, and the Kirkpatrick Ditch Watershed, which had ∼20%. We found that cover crops decreased soil nitrate-N by >50% and that the magnitude of reduction was related to the amount of cover crop biomass. In contrast, cover crops had variable effects on water extractable P and Mehlich III soil test P. Finally, cover crop biomass significantly increased soil N mineralization and nitrification rates, demonstrating that cover crops have the potential to supply bioavailable N to cash crop after termination. Our study showed that widespread implementation of winter cover crops holds considerable promise for reducing nutrient loss and improving soil health. The degree to which these results are generalizable across other systems depends on factors such as climate, soil characteristics, and past and current agronomic practices.

A lack of targeted perioperative academic preparation may have led to not enough nursing graduates entering and staying in the perioperative field. This deficit and a large portion of the workforce approaching retirement age have contributed to a perioperative nursing shortage. In collaboration with an associated medical center, a college of nursing in the midwestern United States offered and evaluated a redesigned perioperative elective for student nurses. After implementation, interviews and focus groups were used to determine the effect on the student nurses' confidence, their progression through orientation after graduating and being hired into the perioperative department, and the perioperative department's retention rates. Recently graduated nurses with perioperative educational experience have a better understanding of the role of a perioperative nurse. Increasing prelicensure student exposure to the perioperative clinical environment is associated with positive outcomes for the department, organization, nurses, and patients. Similar results in other specialties may be possible.

Background Kidney disease has historically been the primary source of early mortality in adults with tuberous sclerosis complex (TSC). Kidney imaging surveillance promotes early detection of lesions requiring intervention. We describe kidney imaging frequency in relationship to patient-level characteristics for commercially insured patients with TSC in the United States. Methods This retrospective observational study used 2003 to 2016 enrollment and claims data from a de-identified fully insured commercial health insurer. Patients with TSC less than 65 years were included. The patient-level kidney imaging rate was calculated as the number of kidney imaging procedures divided by length of continuous enrollment. A multiple linear regression model was used to determine the relationship between imaging rate and progression of TSC-associated kidney disease, number of specialists seen, and nephrologist care. Results At least half of the 70 patients with TSC included in the study were aged 16 years or younger. Over a follow-up period of up to 14 years, the median kidney imaging rate was 0.13 procedures per year with 43% (N = 30) of patients lacking evidence of kidney imaging during the observation period. Imaging frequency increased with progression of TSC-associated kidney disease, more specialists, and nephrologist care (P Conclusions A substantial percentage of patients with TSC in the United States are at risk for delayed detection of kidney manifestations due to infrequent kidney imaging surveillance. Multispecialty care, including neurologists, may positively affect kidney surveillance rates.

To identify risk factors associated with severe COVID-19 infection in a defined Midwestern US population overall and within different age groups.We used the Rochester Epidemiology Project research infrastructure to identify persons residing in a defined 27-county Midwestern region who had positive results on polymerase chain reaction tests for COVID-19 between March 1, 2020, and September 30, 2020 (N=9928). Age, sex, race, ethnicity, body mass index, smoking status, and 44 chronic disease categories were considered as possible risk factors for severe infection. Severe infection was defined as hospitalization or death caused by COVID-19. Associations between risk factors and severe infection were estimated using Cox proportional hazard models overall and within 3 age groups (0 to 44, 45 to 64, and 65+ years).Overall, 474 (4.8%) persons developed severe COVID-19 infection. Older age, male sex, non-White race, Hispanic ethnicity, obesity, and a higher number of chronic conditions were associated with increased risk of severe infection. After adjustment, 36 chronic disease categories were significantly associated with severe infection. The risk of severe infection varied significantly across age groups. In particular, persons 0 to 44 years of age with cancer, chronic neurologic disorders, hematologic disorders, ischemic heart disease, and other endocrine disorders had a greater than 3-fold increased risk of severe infection compared with persons of the same age without those conditions. Associations were attenuated in older age groups.Older persons are more likely to experience severe infections; however, severe cases occur in younger persons as well. Our data provide insight regarding younger persons at especially high risk of severe COVID-19 infection.

STUDY OBJECTIVES: Cultural sleep practices and COVID-19 mitigation strategies vary worldwide. The sleep of infants and toddlers during the COVID-19 pandemic in the United States is understudied. METHODS: Caregivers of children aged $150,000: β = –0.19; P = .01), and lack of room-sharing (β = –0.09; P = .05). Parental frustration with sleep increased with age (all P

Objectives Increased exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a result of having an essential job is compounded by factors such as age, race, and ethnicity. We used a cross-sectional study design to describe disparities in the seroprevalence of SARS-CoV-2 immunoglobulin G (IgG) test results by demographic characteristics and clinical roles among a cohort of health care workers employed by the largest Midwestern health care system in the United States. Methods We collected 16 233 SARS-CoV-2 IgG serum samples from June 8 through July 10, 2020, from a convenience sample of Illinois- and Wisconsin-based adult health care workers. The research team, in collaboration with ACL Laboratories, used a SARS-CoV-2 IgG assay to detect the presence of SARS-CoV-2 IgG antibodies. Study data included SARS-CoV-2 IgG assay results and demographic characteristics of workers (age, sex, race, ethnicity, clinical role, zip code). We generated crude and adjusted odds ratios (ORs) to describe disparities in seroprevalence distribution among demographic and social factors. Results Of 16 233 IgG serum samples tested, 622 (3.8%) test results were positive for SARS-CoV-2. We found significant disparities in SARS-CoV-2 positivity by age, race, ethnicity, and clinical role. Participants aged 32-82 had lower adjusted ORs (aORs) of positive IgG than participants aged 18-31 (aOR range, 0.54-0.66). Odds of positivity were higher among Black (aOR = 3.86), Asian (aOR = 1.42), and mixed-race (aOR = 1.99) workers than among White workers; among Hispanic workers (aOR = 1.80) than among non-Hispanic workers; and among coronavirus disease 2019 (COVID-19) clinical workers (aOR = 1.86) than among nonclinical workers. Conclusions Public health efforts should focus on increasing COVID-19 safety messaging, testing, vaccination, and other prevention efforts for people who are young, non-White, Hispanic, and working in COVID-19–clinical units.

Objective The aims of this study were to explore nurses' fatigue levels and sleep measures during two 12-hour consecutive day shifts and examine the relationships between nurses' fatigue levels within shifts and their previous-night sleep characteristics. Background Monitoring changes in fatigue and sleep is important to enable effective fatigue management. Methods This was a descriptive, repeated-measures study. Data were collected using surveys and actigraphy 4 times during each consecutive shift (7:00 am-7:30 pm). Results General fatigue levels started trending up 4 hours after the start of work; highest levels were reported at 7:30 pm. Fatigue levels accumulated across consecutive shifts. Subjective sleep quality was higher the night before the 2nd shift than the night before the 1st shift. Nurses' poor sleep the night before a shift was related to increased fatigue levels during the next shift. Conclusion It is important to consider when fatigue management interventions will be most effective and to consider previous-night's sleep when monitoring fatigue.

Protective factors facilitate success on community supervision, but relatively little is known about correctional clients who are highly compliant particularly in the federal system. Drawing on a near population of federal clients on supervised release in the Midwestern United States, the current study examined variables associated with compliant supervision status. One day on supervision contributed to a 1% reduction in the logged odds of supervision compliance. Clients with no drug history had 793% increased odds, clients with sustained remission had 620% increased odds, and clients with early remission had 458% increased odds of compliant supervision status relative to clients actively using drugs. Among the federal Post Conviction Risk Assessment (PCRA) indices, only PCRA Criminal History was significant as clients with less extensive criminal history were more likely to be compliant supervision clients. A one-unit change in PCRA Criminal History status was associated with 25% reduced odds of supervision compliance. Total conditions were inversely associated with compliant supervision status with each additional condition associated with a 19% reduced likelihood of compliant supervision status. None of the demographic variables was significantly associated with compliant supervision status. Implications of the findings for the protective factor paradigm in corrections are discussed.

BACKGROUND Low back pain (LBP) is increasing in the pediatric population. Advanced imaging, such as computed tomography and magnetic resonance imaging, performed for LBP imposes significant costs with little benefit. We investigated annual trends and demographic and geographic variation in spinal imaging for first-time pediatric presenters with LBP in primary care clinics. METHODS We queried a private administrative claims database for patients presenting with LBP who underwent plain radiography, computed tomography, and magnetic resonance imaging from 2011 to 2017. We used a Cochrane Armitage test of trend to determine significant annual variation in diagnostic imaging utilization during the study period. The χ2 test was used to determine demographic and geographic variation. RESULTS The study included 67,423 patients with mean age 15.2 ± 3 years. There was no significant change in radiography (34.8% in 2011 vs. 35.5% in 2017, P = 0.795) or computed tomography (1.6% in 2011 vs. 1.1% in 2017, P = 0.073), but there was a significant increase in magnetic resonance imaging (3.3% in 2011 vs. 4.5% in 2017, P = 0.017). Overall, there was no significant change in total imaging use (P = 0.895). Boys had higher rates of imaging compared with girls (40.2% vs. 35.6%, P < 0.001). Imaging rates significantly varied between regions across the United States (P < 0.001). The Midwest had the highest imaging rates (41%), while the Northeast had the lowest rates (31%). CONCLUSIONS There was significant demographic and geographic variation but no significant annual change in total diagnostic spinal imaging for pediatric patients with LBP between 2011 and 2017, with rates of advanced imaging remaining relatively low.

Background Food pantries have the potential to improve the quality of clients’ diets. Objective This study evaluated the relationship between the quality of the mix of foods in pantry inventories and client food bags (separately), as assessed by the Healthy Eating Index-2010 (HEI-2010), with client diet quality and how these relationships varied by food security status. Design This cross-sectional, secondary analysis used baseline data from the Voices for Food intervention study (Clinical Trial Registry: NCT03566095 ). A demographic questionnaire, the US Household Food Security Survey Module, and up to three 24-hour dietary recalls on nonconsecutive days, including weekdays and weekends, were collected. Foods available in pantry inventories and distributed in client food bags were recorded at one time point during baseline data collection. Participants and setting A convenience sample of adult food pantry clients (N = 575) from 24 rural, food pantries in the US Midwest was recruited from August to November 2014. Main outcome measures Pantry inventories, client food bags, and client diets were scored using the HEI-2010. Main outcomes were client HEI-2010 scores. Statistical analyses performed Linear regression models estimated associations between HEI-2010 total and component scores for pantry inventories and client food bags (in separate models) and the corresponding scores for client dietary intake. The interaction of client food security status, and potential pantry- and client-level confounders, was considered. Results Client food bag HEI-2010 scores were positively associated with client diet scores for total vegetables, greens and beans, and total fruit components, whereas pantry inventory HEI-2010 scores were negatively associated with client diet scores for total fruit, total protein foods, and seafood and plant proteins components. Client food bag whole-grains scores were more strongly associated with very low food secure compared with food secure client diet scores (all P values Conclusions The quality of client food bags, but not of pantry inventories, was positively associated with client diet quality in a rural sample in the US Midwest.

A growing demand for perioperative nurses, insufficient interest in the perioperative nursing specialty, and nurse retirements have resulted in a perioperative nursing workforce shortage. Undergraduate nursing students' limited exposure to perioperative content, along with facility hiring practices that exclude recently graduated nurses, further contribute to this shortage. To address these concerns, a large health care system in the midwestern United States partnered with a college of nursing to institute a perioperative preceptorship for baccalaureate nursing students during their final semester. After completing the preceptorship, students reported increased understanding of perioperative nursing roles and responsibilities, time management, and patient safety skills; ability to work effectively as a part of an interdisciplinary team; and independence in the perioperative setting. Future study is needed to examine rates of matriculation among program graduates into perioperative nursing positions and the program's effect on the length of orientation for recently graduated nurses and nurse retention.

Objective The present study investigated the bidirectional associations of adolescent peer experiences and sleep/wake problems during early adolescence. Design The study used a two-wave longitudinal design. Setting Participants were recruited from a small urban community in the Midwestern United States. Participants At T1, participants included 100 adolescents (53% boys; mean age = 11.05 years, SD = 0.33) and their mothers (96% biological), and 78 teachers (62% female). At T2, 89 adolescents and their mothers returned; 76 teachers participated. The racial/ethnic composition of the sample of adolescents and mothers included 57%–63% European American and 43%–37% racial/ethnic minorities (e.g., African American, Hispanic/Latino). Measurements At both waves, adolescents reported on their sleep quality (sleep/wake problems). Adolescent-, mother-, and teacher-reported peer victimization were composited at each wave, and a composite for positive peer relationships included adolescent-reported friendship quality; adolescent-, mother-, and teacher-reported friends’ prosociality; and mother- and teacher-reported peer acceptance. Results Findings from cross-lagged panel models revealed some support for reciprocal associations such that T1 positive peer relationships predicted fewer T2 sleep problems and T1 sleep problems predicted less positive peer relationships at T2. However, only T1 sleep problems predicted more peer victimization at T2, controlling for T1 peer victimization, with the effect driven by adolescent-reported peer victimization. Conclusions Findings provide new insight for prevention and intervention efforts regarding the potential protective function of positive peer relationships in reducing sleep problems, as well as the need to address sleep problems as a means to promote more positive peer relationships and less peer victimization over time.

Many workers experience ebbs and flows of workload in concert with busy seasons, changing project demands, and changes to the way tasks are completed. The present study examined how anticipating workload changes influences emotional strain resulting from current workload. We extend conservation of resources theory (Hobfoll, 1989) by hypothesizing that anticipated changes in workload may be viewed as a future opportunity to recover from current workload (in the case of anticipated workload decrease) or as a threat of loss of resources (in the case of anticipated workload increase), and that anticipated changes in workload would moderate the current workload-emotional strain relationship. Using a sample of employees engaged in project-based work, we found that anticipation of a workload increase exacerbated the current workload-emotional strain relationship and anticipation of a workload decrease buffered this relationship. The results suggest that stressor-strain relations may be influenced by anticipated change in stressor conditions. In other words, employees are more likely to tolerate stressful circumstances if they see the proverbial "light at the end of the tunnel." Implications for occupational stress research and practice are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Excessive daytime sleepiness (EDS) is the most common symptom of sleep-disorders. Although high levels of EDS have been reported among firefighters, there is a limited understanding on EDS in firefighters. A cross-sectional survey was conducted in full-time firefighters (

Salon gatherings featuring conversations about current themes in a profession are evolving with time and practice to meet the needs of modern nurses and their clinical partners. Nursing clinical educators at a Midwestern pediatric hospital system offered a nursing salon experience as a new component of education days to provide an opportunity for clinical staff to engage in content and conversations about practice in a setting away from direct patient care. The objective of the nursing salons was to engage in professional reflection. Staff members of a professional development center and a department of quality and safety collaborated to provide this experience for over 500 nurses, clinical support associates, and leaders, to enhance clinical education days.

BACKGROUND The Whole School, Whole Community, Whole Child (WSCC) model is an evidence‐based comprehensive framework to address health in schools. WSCC model use improves health and educational outcomes, but implementation remains a challenge. METHODS Working with 6 schools in 2 districts in the Midwest, we used a mixed‐methods approach to determine the people, systems, and messages needed to activate WSCC implementation. We report on social network analysis and message testing findings and research translation to develop the Healthy Schools Toolkit. RESULTS Social networks for both districts included more than 150 individuals. Both demonstrated network densities less than half of the desirable threshold, with evidence of clustering by role and minimal cross‐school relationships, posing challenges for WSCC implementation. Across stakeholder groups, messages that emphasize empathy, teamwork, and action were well‐received, especially when shared by trusted individuals through communication channels that align with stakeholder needs. CONCLUSIONS The Healthy Schools Toolkit provides an example of a translational product that helps to bridge research with practice. With features that highlight 6 design principles, the toolkit provides complementary activities that schools and districts can use as they plan for integration of the WSCC model.

The epidemiology of macrolide resistance inMycoplasma(Mycoplasmoides)pneumoniaein the United States is incompletely described. Using a PCR assay targeting common mutations associated with macrolide resistance inM. pneumoniae(23S rRNA gene, A2063G/A2064G), the frequency of macrolide resistance was estimated to be 10% based on analysis of 114 samples tested from January 2014 to September 2021 at Mayo Clinic Laboratories.

Cases of anomalous morphologies in the blacklegged tick, Ixodes scapularis, have been reported in both field-collected and human-biting specimen in the Northeastern and Midwestern United States, complicating the identification of this medically important tick species. We herein describe four cases of morphological anomalies in I. scapularis females exhibiting nanism and abnormally small genital apertures. We also report a female I. scapularis displaying slight asymmetry in the lower abdomen oriented toward the right side and an abnormal anal groove completely enclosing the anus. The identity of each specimen was confirmed using taxonomic keys, high resolution light and scanning electron microscopy imaging, and DNA sequencing of the 18S rRNA gene. All specimens described in this study were found parasitizing human hosts and were submitted to the Connecticut Agricultural Experiment Station-Tick Testing Laboratory in 2021 for species identification and pathogen screening. Here, we also discuss recent reports of teratological abnormalities in I. scapularis as well as likely causes for such deformities and potential implications.

Recent changes in rendering availability for chemically-euthanized animals have created a need to explore composting as an equine mortality management method. The objectives of this study were to evaluate equine mortality composting in the Upper Midwest during fall and spring, document sodium pentobarbital concentrations throughout the process, and determine nutrient content of finished compost. During each season, four horses were euthanized by intravenous administration of sodium pentobarbital. Carcasses were positioned at the center of a woodchip and shavings base and covered with a 2:1 mixture of horse stall waste and cattle feedlot waste. Data loggers were placed at 46- and 91cm depths to record pile temperatures every 8 hours. At turning (44-50 days) and trial conclusion (181-216 days), compost piles were sampled for sodium pentobarbital and nutrient composition. Piles contained large bones after 6 months of composting. Sodium pentobarbital remained detectable at trial conclusion (0.002-1.49 mg kg

Despite evidence of superior outcomes for rectal cancer at high-volume, multidisciplinary cancer centers, many patients undergo surgery in low-volume hospitals.This study aimed to examine considerations of former patients with rectal cancer when selecting their surgeon and to evaluate which considerations were associated with surgery at high-volume hospitals.In this retrospective cohort study, patients were surveyed about what they considered when selecting a cancer surgeon.Study data were obtained via survey and the statewide Iowa Cancer Registry.All eligible individuals diagnosed with invasive stages II/III rectal cancer from 2013 to 2017 identified through the registry were invited to participate.The primary outcomes were the characteristics of the hospital where they received surgery (ie, National Cancer Institute designation, Commission on Cancer accreditation, and rectal cancer surgery volume).Among respondents, 318 of 417 (76%) completed surveys. Sixty-nine percent of patients selected their surgeon based on their physician's referral/recommendation, 20% based on surgeon/hospital reputation, and 11% based on personal connections to the surgeon. Participants who chose their surgeon based on reputation had significantly higher odds of surgery at National Cancer Institute-designated (OR 7.5; 95% CI, 3.8-15.0) or high-volume (OR 2.6; 95% CI, 1.2-5.7) hospitals than those who relied on referral.This study took place in a Midwestern state with a predominantly white population, which limited our ability to evaluate racial/ethnic associations.Most patients with rectal cancer relied on referrals in selecting their surgeon, and those who did were less likely to receive surgery at a National Cancer Institute-designated or high-volume hospitals compared to those who considered reputation. Future research is needed to determine the impact of these decision factors on clinical outcomes, patient satisfaction, and quality of life. In addition, patients should be aware that relying on physician referral may not result in treatment from the most experienced or comprehensive care setting in their area. See Video Abstract at http://links.lww.com/DCR/B897.REMISIONES Y CONSIDERACIONES PARA LA TOMA DE DECISIONES RELACIONADAS CON LA SELECCIÓN DE UN CIRUJANO PARA EL TRATAMIENTO DEL CÁNCER DE RECTO EN EL MEDIO OESTE DE LOS ESTADOS UNIDOSANTECEDENTES:A pesar de la evidencia de resultados superiores para el tratamiento del cáncer de recto en centros oncológicos de gran volumen y multidisciplinarios, muchos pacientes se someten a cirugía en hospitales de bajo volumen.OBJETIVOS:Examinar las consideraciones de los antiguos pacientes con cáncer de recto al momento de seleccionar a su cirujano y evaluar qué consideraciones se asociaron con la cirugía en hospitales de gran volumen.DISEÑO:Encuestamos a los pacientes sobre qué aspectos consideraron al elegir un cirujano oncológico para completar este estudio de cohorte retrospectivo.AJUSTE:Los datos del estudio se obtuvieron mediante una encuesta y el Registro de Cáncer del estado de Iowa.PACIENTES:Se invitó a participar a todas las personas elegibles diagnosticadas con cáncer de recto invasivo en estadios II/III entre 2013 y 2017 identificadas a través del registro.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados principales fueron las características del hospital donde fue realizada la cirugía (es decir, designación del Instituto Nacional del Cáncer, acreditación de la Comisión de Cáncer y volumen de cirugía del cáncer de recto).RESULTADOS:Hubo 318 de 417 (76%) encuestas completadas. El sesenta y nueve por ciento seleccionó a su cirujano en función de la referencia / recomendación de su médico, el 20% por la reputación del cirujano/hospital, y el 11% por sus conexiones personales con el cirujano. Los participantes que eligieron a su cirujano en función a la reputación tuvieron probabilidades significativamente más altas de cirugía en el Instituto Nacional del Cáncer designado (OR = 7,5, IC del 95%: 3,8-15,0) o en hospitales de alto volumen (OR = 2,6, IC del 95%: 1,2-5,7) que aquellos que dependían de la derivación.LIMITACIONES:Este estudio se llevó a cabo en un estado del medio oeste con una población predominantemente blanca, lo que limitó nuestra capacidad para evaluar las asociaciones raciales/étnicas.CONCLUSIONES:La mayoría de los pacientes con cáncer de recto dependían de las derivaciones para seleccionar a su cirujano, y los que lo hacían tenían menos probabilidades de recibir cirugía en un hospital designado por el Instituto Nacional del Cáncer o en hospitales de gran volumen en comparación con los que consideraban la reputación. Se necesitan investigaciones a futuro para determinar el impacto de estos factores de decisión en los resultados clínicos, la satisfacción del paciente y la calidad de vida. Además, los pacientes deben ser conscientes de que depender de la remisión de un médico puede no resultar en el tratamiento más experimentado o integral en su área. Consulte Video Resumen en http://links.lww.com/DCR/B897. (Traducción-Dr Osvaldo Gauto).

Purpose The objective of this study is to identify how predisposing characteristics, enabling factors, and health needs are jointly and individually associated with epidemiological patterns of outpatient healthcare utilization for patients who already interact and engage with a large healthcare system. Methods We retrospectively analyzed electronic medical record data from 1,423,166 outpatient clinic visits from 474,674 patients in a large healthcare system from June 2018-March 2019. We evaluated patients who exclusively visited rural clinics versus patients who exclusively visited urban clinics using Chi-square tests and the generalized estimating equation Poisson regression methodology. The outcome was healthcare use defined by the number of outpatient visits to clinics within the healthcare system and independent variables included age, gender, race, ethnicity, smoking status, health status, and rural or urban clinic location. Supplementary analyses were conducted observing healthcare use patterns within rural and urban clinics separately and within primary care and specialty clinics separately. Findings Patients in rural clinics vs. urban clinics had worse health status [χ2 = 935.1, df = 3, p Conclusions Within the large healthcare system, patients in rural clinics had lower outpatient healthcare utilization compared to their urban counterparts despite having potentially elevated health needs reflected by a higher number of unique health diagnoses documented in their electronic health records after adjusting for multiple factors. This work can inform future studies exploring the roots and ramifications of rural-urban healthcare utilization differences and rural healthcare disparities.

BACKGROUND Hypoglycemia can be a common occurrence in hospitalized patients, both those with and without diabetes. Hypoglycemia poses significant risks to hospitalized patients, including increased mortality. OBJECTIVES This was a retrospective pre-post study of hypoglycemic patients in an academic medical center of an intervention to improve timely staff nurse adherence to a hypoglycemia protocol. The number of mild and severe hypoglycemia events pre- and postintervention, timeliness of adherence to the hypoglycemia protocol, the number of treatment interventions, and time to return patients to euglycemia were analyzed. METHODS Data from hospitalizations of patients who experienced hypoglycemia (

Introduction: Current research in the areas of liver transplant and cognitive function has primarily examined cognitive changes from pre- to 1-year posttransplant, resulting in an insufficient understanding of cognitive trajectory beyond early periods of transplant and its impact on self-management. This study aimed (1) to describe global and domain-specific cognitive function in liver transplant recipients who survived more than 6 months after transplant and (2) to describe patient and clinical characteristics of recipients with impaired global and/or domain-specific cognitive function. Further, this study explored the potential relationships between cognitive function and self-management by examining differences in cognitive function by levels of self-management. Design: This secondary data analysis included 107 adult liver transplant recipients, who had a functioning transplant for at least 6 months. Data of cognitive function, demographic and clinical characteristics, and self-management were extracted for this study. T tests, Mann-Whitney tests, and Kruskal-Wallis tests were used to examine differences in cognitive function by variables. Results: More than half of the recipients had global cognitive impairment. Significant differences were found in global and domain-specific cognitive function. Older, male, married, or deceased donor recipients had lower cognitive test scores than younger, female, single, or living donor recipients. There were no significant differences in global and domain-specific cognitive function by time since transplant and levels of self-management. Discussion: Future longitudinal studies should examine the long-term trajectory of cognitive function posttransplant. Other factors such as caregivers’ participation in self-management should be accounted for in future studies when examining the relationship between cognitive function and self-management.

Background: Cardiovascular disease is the leading cause of death in kidney transplant recipients. Physical activity after transplant is the most modifiable nonpharmacological factor for improving cardiovascular outcomes. Few studies have tested walking interventions to enhance daily steps and health outcomes in older kidney recipients. Methods: Using a pilot feasibility randomized clinical trial design, we tested the feasibility and efficacy of a 6-month SystemCHANGE™ (Change Habits by Applying New Goals and Experience) + Activity Tracker intervention for recruitment, retention, daily steps, and health outcomes (blood pressure, heart rate, body mass index, waist circumference, and physical function). The SystemCHANGE™ + Activity Tracker intervention taught participants to use a multicomponent intervention that connects person-centered systems solutions combined with visual feedback from a mobile activity tracker to achieve daily step goals. Results: Fifty-three participants (mean age 65 years, 66% male, and 57% white) participated with 27 in the intervention and 26 in the control group. The study protocol was feasible to deliver with high adherence to the protocol in both groups. The intervention group increased daily steps at 3 months (mean difference, 608; standard error = 283, P = .03) compared to the control group. The secondary outcome of heart rate decreased for the intervention group (baseline [mean] 74.4+ 10.8 [standard deviation, SD;] vs 6 months [mean] 67.6+ 11.3 [SD]; P = .002) compared to the control group (baseline [mean] 70.67+ 10.4 [SD]; vs 6 months [mean] 70.2 + 11.1 [SD]; P = .83). Conclusions: SystemCHANGE™ + Activity Tracker intervention appears to be feasible and efficacious for increasing daily steps in older kidney recipients.

Observations of volatile organic compounds (VOCs) from a surface sampling network and simulation results from the EMAC (ECHAM5/MESSy for Atmospheric Chemistry) model were analyzed to assess the impact of increased emissions of VOCs and nitrogen oxides from U.S. oil and natural gas (O&NG) sources on air quality. In the first step, the VOC observations were used to optimize the magnitude and distribution of atmospheric ethane and higher-alkane VOC emissions in the model inventory for the base year 2009. Observation-based increases of the emissions of VOCs and NOx stemming from U.S. oil and natural gas (O&NG) sources during 2009–2014 were then added to the model, and a set of sensitivity runs was conducted for assessing the influence of the increased emissions on summer surface ozone levels. For the year 2014, the added O&NG emissions are predicted to affect surface ozone across a large geographical scale in the United States. These emissions are responsible for an increased number of days when the averaged 8-h ozone values exceed 70 ppb, with the highest sensitivity being in the central and midwestern United States, where most of the O&NG growth has occurred. These findings demonstrate that O&NG emissions significantly affect the air quality across most of the United States, can regionally offset reductions of ozone precursor emissions made in other sectors, and can have a determining influence on a region’s ability to meet National Ambient Air Quality Standard (NAAQS) obligations for ozone.