Search

ObjectivesTo compare the severity of illness and outcomes among children admitted to a children's hospital PICU from referring emergency departments with and without access to a pediatric critical care telemedicine program.DesignRetrospective cohort study.SettingTertiary academic children's hospital PICU.PatientsPediatric patients admitted directly to the PICU from referring emergency departments between 2010 and 2014.InterventionsNone.MeasurementsDemographic factors, severity of illness, and clinical outcomes among children receiving care in emergency departments with and without access to pediatric telemedicine, as well as a subcohort of children admitted from emergency departments before and after the implementation of telemedicine.Main resultsFive hundred eighty-two patients from 15 emergency departments with telemedicine and 524 patients from 60 emergency departments without telemedicine were transferred and admitted to the PICU. Children admitted from emergency departments using telemedicine were younger (5.6 vs 6.9 yr; p< 0.001) and less sick (Pediatric Risk of Mortality III score, 3.2 vs 4.0; p < 0.05) at admission to the PICU compared with children admitted from emergency departments without telemedicine. Among transfers from emergency departments that established telemedicine programs during the study period, children arrived significantly less sick (mean Pediatric Risk of Mortality III scores, 1.2 units lower; p = 0.03) after the implementation of telemedicine (n = 43) than before the implementation of telemedicine (n = 95). The observed-to-expected mortality ratios of posttelemedicine, pretelemedicine, and no-telemedicine cohorts were 0.81 (95% CI, 0.53-1.09), 1.07 (95% CI, 0.53-1.60), and 1.02 (95% CI, 0.71-1.33), respectively.ConclusionsThe implementation of a telemedicine program designed to assist in the care of seriously ill children receiving care in referring emergency departments was associated with lower illness severity at admission to the PICU. This study contributes to the body of evidence that pediatric critical care telemedicine programs assist referring emergency departments in the care of critically ill children and could result in improved clinical outcomes.

As telehealth plays an even greater role in global health care delivery, it will be increasingly important to develop a strong evidence base of successful, innovative telehealth solutions that can lead to scalable and sustainable telehealth programs. This paper has two aims: (1) to describe the challenges of promoting telehealth implementation to advance adoption and (2) to present a global research agenda for personalized telehealth within chronic disease management. Using evidence from the United States and the European Union, this paper provides a global overview of the current state of telehealth services and benefits, presents fundamental principles that must be addressed to advance the status quo, and provides a framework for current and future research initiatives within telehealth for personalized care, treatment, and prevention. A broad, multinational research agenda can provide a uniform framework for identifying and rapidly replicating best practices, while concurrently fostering global collaboration in the development and rigorous testing of new and emerging telehealth technologies. In this paper, the members of the Transatlantic Telehealth Research Network offer a 12-point research agenda for future telehealth applications within chronic disease management.

BackgroundThe etiology of cognitive impairment in heart failure (HF) is controversial and likely multifactorial. Physicians may hesitate to prescribe evidence-based HF medication because of concerns related to potential negative changes in cognition among a population that is already frequently impaired. We conducted a study to determine if prescription of evidence-based HF medications (specifically, β-blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blocking agents, diuretics, and aldosterone inhibitors) was associated with cognition in a large HF sample.MethodsA total of 612 patients completed baseline data collection for the Rural Education to Improve Outcomes in Heart Failure clinical trial, including information about medications. Global cognition was evaluated using the Mini-Cog.ResultsThe sample mean (SD) age was 66 (13) years, 58% were men, and 89% were white. Global cognitive impairment was identified in 206 (34%) of the 612 patients. Prescription of evidence-based HF medications was not related to global cognitive impairment in this sample. This relationship was maintained even after adjusting for potential confounders (eg, age, education, and comorbid burden).ConclusionPrescription of evidence-based HF medications is not related to low scores on a measure of global cognitive function in rural patients with HF.

In 2015, Canada’s national security law landscape received some long-overdue attention in the form of Bill C-51, the Anti-Terrorism Act. It was the culmination of a series of smaller initiatives that had brought attention to national security law in Canada, but also a direct response to two terrorist attacks that left two Canadians dead in October 2014. Bill C-51 did indeed reinvigorate discussions around national security law in Canada, but it became a lightning rod for criticism. Bill C-59, An Act Respecting National Security Matters 2017 was not passed until June 2019, but it was nevertheless a direct response to Bill C-51 and the criticisms it faced. Yet for the most part, Bill C-59 amended but did not repeal the important new powers, or even the most controversial ones, found in Bill C-51. Instead, Bill C-59 can be seen, in part, as a technical-legal bill that largely entrenched the powers first conceived of in Bill C-51 by putting them on firmer constitutional footing. But Bill C-59 was also much more than a series of legal/constitutional improvements: its legislative scope went much further afield from the Bill C-51 regime, amending the authorities of agencies – such as the Communications Security Establishment – that had been untouched by Bill C-51, while also greatly expanding national security oversight and review through the creation of important new bodies. The purpose of this paper is to compare these two important pieces of national security legislation with a view to explaining what these legislation reforms did, why the reforms were undertaken, and to identify the relative strengths and weaknesses of the most controversial of the reforms under each bill. The idea is to explain where Canada stands today, in the wake of this massive legislative overhaul. By identifying what has already been addressed, we can identify next steps and, in particular, where the focus of future legislative reforms in national security should be. Three recommendations flow from this conclusion. First, national security legislation must be reformed with greater consistency than in the past. Second, as an immediate priority, Canada must address its “intelligence-to-evidence” problem; that is, the system by which it converts – or fails to convert – raw intelligence into the sort of evidence usable by courts of law. Third, enforcement of Canada’s national security laws must now take priority, in particular by prosecuting returning foreign fighters and far-right extremists where their activities meet the threshold of a terrorism offence, as well as terrorist financing, to a greater degree than Canada has seen to date

Photocurrent control in nanoscale systems offers opportunities for nanoelectronic devices and ultrafast imaging applications. Here, the authors show by means of angle-resolved two-dimensional velocity mapping that angular photoemission distributions can be controlled by varying the polarization and frequency of the laser.

Hidradenitis suppurativa (HS) is a chronic, often debilitating, skin condition that historically does not respond well to treatment. Although there is no cure for HS, symptoms can be managed if the appropriate diagnosis is made. HS most commonly develops in postpubertal women and manifests as painful, deep-seated, inflamed lesions, including nodules, sinus tracts, and abscesses. HS flares are marked by increased pain and suppuration at varying intervals and can occur in women before menstruation. HS is commonly misdiagnosed; physicians might mistake a lesion for an infection, abscess, or sexually transmitted infection. Incision and drainage of these lesions often leads to recurrence. Given that management of this chronic disease is often difficult, we sought to outline current diagnosis and management strategies for HS. Keywords: Hidradenitis suppurativa, Treatment in women and pregnancy

rnithosuchidae is one of the most enigmatic clades of Triassic pseudosuchians. The group is composed by three carnivorous species that were excavated from Upper Triassic beds of Scotland and Argentina. We describe the first ornithosuchid from the Upper Triassic sediments of Brazil and explore its phylogenetic affinities and implications for the evolution of the group. Dynamosuchus collisensis gen. et sp. nov. was found as the sister taxon of the Argentinean form Venaticosuchus rusconii. These relationships reject a potential endemic radiation of ornithosuchids from the Ischigualasto-Villa Unión Basin and would better support multiple diversification events. Our findings with ornithosuchids is consistent with the pattern reported for proterochampsid and erpetosuchid archosauriforms from Ischigualasto-Villa Unión and the Paraná basins. In addition, the presence of an ornithosuchid in the Late Triassic of Brazil suggests that ornithosuchids were more widespread than previously thought in the southern hemisphere. The new ornithosuchid further demonstrates a faunistic link between the Argentinean and Brazilian basins during the Carnian. Finally, the discovery of the new species provides the first clue of a putative necrophagous vertebrate from the oldest dinosaur-bearing beds and expands our knowledge regarding the trophic structure of the Late Triassic of Brazil.

The Manda Beds of southwest Tanzania have yielded key insights into the early evolutionary radiation of archosaurian reptiles. Many key archosaur specimens were collected from the Manda Beds in the 1930s and 1960s, but until recently, few of these had been formally published. Here, we describe an archosaur specimen collected in 1963 which has previously been referred to informally as Pallisteria angustimentum. We recognize this specimen as the type of a new taxon, Mambawakale ruhuhu gen. et sp. nov. The holotype and only known specimen of M. ruhuhu comprises a partial skull of large size (greater than 75 cm inferred length), lower jaws and fragments of the postcranium, including three anterior cervical vertebrae and a nearly complete left manus. Mambawakale ruhuhu is characterized by several cranial autapomorphies that allow it to be distinguished with confidence from all other Manda Beds archosaurs, with the possible exception of Stagonosuchus nyassicus for which comparisons are highly constrained due to very limited overlapping material. Phylogenetic analysis suggests that M. ruhuhu is an early diverging pseudosuchian, but more precise resolution is hampered by missing data. Mambawakale ruhuhu is one of the largest known pseudosuchians recovered to date from the Middle Triassic.

Abstract Objectives Studies have found that prolonged boarding time for intensive care unit (ICU) patients in the emergency department (ED) is associated with higher in‐hospital mortality. However, these studies introduced selection bias by excluding patients with ICU admission orders who were downgraded and never arrived in the ICU. Consequently, they may overestimate mortality in prolonged ED boarders. Methods This was a retrospective cohort study at a single center covering the period from August 14, 2015 to August 13, 2019. Adult ED patients with medical ICU admission orders and at least 6 hours of subsequent critical care in either the ED or the ICU were included. Patients were classified as having either prolonged (>6 hours) or non‐prolonged (≤6 hours) ED boarding. Downgraded patients were identified, and mortality was compared, both including and excluding downgraded patients. Results Of 1862 patients, 612 (32.9%) had prolonged boarding; at 6 hours after ICU admission order entry, they were still in the ED. The remaining 1250 (67.1%) had non‐prolonged boarding; at 6 hours after the ICU admission order entry, they were already in the ICU. In‐hospital mortality in the non‐prolonged boarding group was 18.9%. In the prolonged boarding group, 296 (48.4%) patients were downgraded in the ED and never arrived in the ICU. Including these ED downgrades, the mortality in the prolonged boarding group was 13.4% (risk difference ‐5.5%, 95% confidence interval [CI] ‐8.9% to ‐2.0%, P = 0.0031). When we excluded downgrades, the mortality in the prolonged boarding group increased to 17.4% (risk difference ‐1.5%, 95% CI ‐6.2% to 3.2%, P = 0.5720). The lower mortality in the prolonged group was attributable to lower severity of illness (mean emergency critical care SOFA [eccSOFA] difference: ‐0.8, 95% CI ‐1.1 to ‐0.4, P

This pilot randomised controlled trial aims to assess the feasibility and acceptability of a 12-week home-based telehealth exercise and behavioural intervention delivered in socioeconomically deprived patients with peripheral artery disease (PAD). The study will also determine the preliminary effectiveness of the intervention for improving clinical and health outcomes. Sixty patients with PAD who meet the inclusion criteria will be recruited from outpatient clinic at the Freeman Hospital, United Kingdom. The intervention group will undergo telehealth behaviour intervention performed 3 times per week over 3 months. This program will comprise a home-based exercise (twice a week) and an individual lifestyle program (once per week). The control group will receive general health recommendations and advice to perform unsupervised walking training. The primary outcome will be feasibility and acceptability outcomes. The secondary outcomes will be objective and subjective function capacity, quality of life, dietary quality, physical activity levels, sleep pattern, alcohol and tobacco use, mental wellbeing, and patients' activation. This pilot study will provide preliminary evidence of the feasibility, acceptability and effectiveness of home-based telehealth exercise and behavioural intervention delivered in socioeconomically deprived patients with PAD. In addition, the variance of the key health outcomes of this pilot study will be used to inform the sample size calculation for a future fully powered, multicentre randomized clinical trial.

For farmers to adopt and maintain sustainable farming practices, they must have the resources and network to succeed with this work and must realize a positive impact on their business model. As a food system is ultimately made up of the people, organizations, and institutions that grow, move, buy and sell food, we must understand who is at the center of this network, who is well-connected, and who is peripheral. Within a particular regional food system in a highly productive southeastern U.S. state, the network of local producers interested in sustainable production, including environmental and economic components, seems to be growing. However, it is unclear who benefits from this system and whether this system is growing in a way that encourages and enhances the benefits for sustainable agriculture. Existing evidence for the network size and its vulnerabilities has been anecdotal, from Extension agents and their contacts with individual producers, rather than based on systematic research. We used social network analysis to understand the status of the system and its constituents. Connections between producers appear to be weak overall with potential fragmentation, suggesting a fragility that could easily derail efforts to increase sustainable production in the region.

In Australia, telehealth is not new, with several telehealth specialist services being available for those living in rural and remote communities. However, prior to the COVID-19 pandemic, telehealth was not routinely available for primary care or urban specialist appointments. There has been an increased focus in the use of telehealth within primary care, and particularly general practice, but overall, there has been limited research to date to guide telehealth best-practice based on consumer experiences and preferences within these settings. We aimed to capture the consumer experience of telehealth during the COVID-19 pandemic, through a novel Kitchen Table Discussion (KTD) method. This increases access to a broader community consumer cohort, with consumer hosts leading discussions in a safe environment. The KTDs were conducted in May 2021, with 10 community members each hosting a group of up to 10 participants. A total of 90 participants took part from across Australia, with the majority living in major cities, although a significant proportion lived in inner and outer regional areas of Australia, or had experience living in rural, regional or remote areas. Seventy percent of participants reported using telehealth in the past. Data were analysed sequentially using thematic analysis and identified key themes: modality, convenience, access, wait time, existing relationship, communication, connectivity, cost, and privacy. Overall, the future of telehealth looks hopeful from the perspective of the consumer, but significant improvements are required to improve consumer engagement and experience. It is evident that 'one size does not fit all', with results suggesting consumers value the availability of telehealth and having choice and flexibility to use telehealth when appropriate, but do not want to see telehealth replacing face-to-face delivery. Participants tended to agree that telehealth was not a preferred method when physical examination was required but would suit certain points of the patient journey.

Background: Knowledge about rare diseases is often lacking due to the low prevalence of each disease. A challenge to increasing knowledge about rare diseases is the plethora of data silos being generated, which create barriers to information sharing, collaboration and coordination between researchers. The inability to share and reuse research data contributes to inefficient data collection, increased patient burden and possibly decelerates the path to better treatments. A unique, universal identifier would have the ability to link the same patient across research datasets and eliminate data silos. Methods: We present CRID (clinical research ID), a unique, universal, patient-generated identifier that can be used to facilitate collaborative rare disease clinical research. The identifier consists of 8 random alphanumeric characters, and can uniquely identify a patient. The CRID website [https://TheCRID.org] is available in multiple languages to support patients globally, and is installed on a secure, cloud-based server platform. All patient data are encrypted in-transit, at rest and within the application. We field-tested the CRID identifier across 6 rare disease research studies to demonstrate its ability to connect a patient across multiple research studies. Results: The CRID website allows a patient to create their unique identifier quickly and share it with researchers easily. Field tested across multiple disease research studies, this identifier has helped to reduce the burden on the patient by reusing their documents and transposing form data from the patient's original study into subsequent studies. Conclusion: A unique, universal, patient-generated identifier can be used to facilitate collaborative rare disease clinical research. With patients’ data connected using the CRID identifier and shared across study protocols, better insights can be gained into how a disease develops that is not possible with inaccessible data silos.

Prior to the COVID-19 pandemic, we demonstrated the efficacy of a novel Cognitive Behavioural Therapy programme for the treatment of Non-Rapid Eye Movement Parasomnias (CBT-NREMP) in reducing NREM parasomnia events, insomnia and associated mood severities. Given the increased prevalence and worsening of sleep and affective disorders during the pandemic, we examined the sustainability of CBT-NREMP following the U.K.’s longest COVID-19 lockdown (6 January 2021–19 July 2021) by repeating the investigations via a mail survey in the same 46 patient cohort, of which 12 responded. The survey included validated clinical questionnaires relating to NREM parasomnia (Paris Arousal Disorder Severity Scale), insomnia (Insomnia Severity Index) and anxiety and depression (Hospital Anxiety and Depression Scale). Patients also completed a targeted questionnaire (i.e., Impact of COVID-19 Lockdown Questionnaire, ICLQ) to assess the impact of COVID-19 lockdown on NREM parasomnia severity, mental health, general well-being and lifestyle. Clinical measures of NREM parasomnia, insomnia, anxiety and depression remained stable, with no significant changes demonstrated in questionnaire scores by comparison to the previous investigatory period prior to the COVID-19 pandemic: p (ISI) = 1.0; p (HADS) = 0.816; p (PADSS) = 0.194. These findings support the longitudinal effectiveness of CBT-NREMP for up to three years following the clinical intervention, and despite of the COVID-19 pandemic.

Red to red-orange spheres in the vascular canals of fossil bone thin sections have been repeatedly reported using light microscopy. Some of these have been interpreted as the fossilized remains of blood cells or, alternatively, pyrite framboids. Here, we assess claims of blood cell preservation within bones of the therizinosauroid theropod Beipiaosaurus inexpectus from the Jehol Lagerstätte. Using Raman spectroscopy, Energy Dispersive X-ray Spectrometry, and Time of Flight Secondary Ion Mass Spectroscopy, we found evidence of high taphonomic alteration of the bone. We also found that the vascular canals in the bone, once purported to contain fossil red blood cell, are filled with a mix of clay minerals and carbonaceous compounds. The spheres could not be analyzed in isolation, but we did not find any evidence of pyrite or heme compounds in the vessels, surrounding bone, or matrix. However, we did observe similar spheres under light microscopy in petrified wood found in proximity to the dinosaur. Consequently, we conclude that the red spheres are most likely diagenetic structures replicated by the clay minerals present throughout the vascular canals.

Unweighted Pair Group Method with Arithmetic Mean (UPGMA) is one of the most popular distance-based methods to reconstruct an equidistant phylogenetic tree from a distance matrix computed from an alignment of sequences. Since we use equidistant trees as gene trees for phylogenomic analyses under the multi-species coalescent model and since an input distance matrix computed from an alignment of each gene in a genome is estimated via the maximum likelihood estimators, it is important to conduct a robust analysis on UPGMA. Stochastic safety radius, introduced by Steel and Gascuel, provides a lower bound for the probability that a phylogenetic tree reconstruction method returns the true tree topology from a given distance matrix. In this article, we compute the stochastic safety radius of UPGMA for a phylogenetic tree with n leaves. Computational experiments show an improved gap between empirical probabilities estimated from random samples and the true tree topology from UPGMA, increasing confidence in phylogenic results.

ObjectivesDepression is an independent predictor of adverse outcomes in patients with heart failure (HF). However, the effect of changes in cognitive-affective and somatic symptoms on mortality of HF patients is not known. The purpose of this study was to examine whether changes in cognitive-affective and somatic depressive symptoms over time were associated with mortality in HF.MethodsIn this secondary analysis of data from the Rural Education to Improve Outcomes in Heart Failure clinical trial, we analyzed data from 457 HF patients (39% female, mean [standard deviation] age = 65.6 [12.8] years) who survived at least 1 year and repeated the Patient Health Questionnaire at 1 year. Cognitive-affective and somatic depression scores were calculated, respectively, based on published Patient Health Questionnaire factor models. Using Cox proportional hazards regression analyses, we evaluated the effect of changes in cognitive-affective and somatic symptoms from baseline to 1 year on cardiac and all-cause deaths.ResultsControlling for baseline depression scores and other patient characteristics, the change in somatic symptoms was associated with increased risk of cardiac death during the subsequent 1-year period (hazard ratio = 1.24, 95% confidence interval = 1.07-1.44, p = .005), but the change in cognitive-affective symptoms was not (hazard ratio = 0.94, 95% confidence interval = 0.81-1.08, p = .38). Similar results were found for all-cause mortality.ConclusionsWorsening somatic depressive symptoms, not cognitive-affective symptoms, are independently associated with increased mortality of HF patients. The findings suggest that routine and ongoing assessment of somatic depressive symptoms in HF patients may help clinicians identify patients at increased risk for adverse outcomes.Trial registrationClinicalTrials.gov NCT00415545.

BackgroundPatients hospitalized with heart failure are often readmitted. Health literacy may play a substantial role in the high rate of readmissions. The purpose of this study was to examine the association of health literacy with the composite end point of heart failure readmission rates and all-cause mortality in patients with heart failure living in rural areas.Methods and resultsRural adults (n = 575), hospitalized for heart failure within the past 6 months, completed the Short Test of Functional Health Literacy in Adults (STOFHLA) to measure health literacy and were followed for ≥2 years. The percentage of patients with the end point of heart failure readmission or all-cause death was different (P = .001) among the 3 STOFHLA score levels. Unadjusted analysis revealed that patients with inadequate and marginal health literacy were 1.94 (95% confidence interval [CI] 1.43-2.63; P < .001) times, and 1.91 (95% CI 1.36-2.67; P < .001) times, respectively, more likely to experience the outcome. After adjustment for covariates, health literacy remained a predictor of outcomes. Of the other covariates, worse functional class, higher comorbidity burden, and higher depression score predicted worse outcomes.ConclusionsInadequate or marginal health literacy is a risk factor for heart failure rehospitalization or all-cause mortality among rural patients with heart failure.

BackgroundComprehensive economic evaluations have not been conducted on telemedicine consultations to children in rural emergency departments (EDs).ObjectiveWe conducted an economic evaluation to estimate the cost, effectiveness, and return on investment (ROI) of telemedicine consultations provided to health care providers of acutely ill and injured children in rural EDs compared with telephone consultations from a health care payer prospective.MethodsWe built a decision model with parameters from primary programmatic data, national data, and the literature. We performed a base-case cost-effectiveness analysis (CEA), a probabilistic CEA with Monte Carlo simulation, and ROI estimation when CEA suggested cost-saving. The CEA was based on program effectiveness, derived from transfer decisions following telemedicine and telephone consultations.ResultsThe average cost for a telemedicine consultation was $3641 per child/ED/year in 2013 US dollars. Telemedicine consultations resulted in 31% fewer patient transfers compared with telephone consultations and a cost reduction of $4662 per child/ED/year. Our probabilistic CEA demonstrated telemedicine consultations were less costly than telephone consultations in 57% of simulation iterations. The ROI was calculated to be 1.28 ($4662/$3641) from the base-case analysis and estimated to be 1.96 from the probabilistic analysis, suggesting a $1.96 return for each dollar invested in telemedicine. Treating 10 acutely ill and injured children at each rural ED with telemedicine resulted in an annual cost-savings of $46,620 per ED.LimitationsTelephone and telemedicine consultations were not randomly assigned, potentially resulting in biased results.ConclusionsFrom a health care payer perspective, telemedicine consultations to health care providers of acutely ill and injured children presenting to rural EDs are cost-saving (base-case and more than half of Monte Carlo simulation iterations) or cost-effective compared with telephone consultations.

ObjectivesTo compare the appropriateness of hospital admission in eight rural emergency departments among a cohort of acutely ill and injured children who receive telemedicine consultations from pediatric critical care physicians to a cohort of similar children who receive telephone consultations from the same group of physicians.DesignRetrospective cohort study between January 2003 and May 2012.SettingEight rural emergency departments in Northern California.PatientsAcutely ill and injured children triaged to the highest-level triage category who received either telemedicine or telephone consultations.InterventionsTelemedicine and telephone consultations.Measurements and main resultsWe compared the overall and stratified observed-to-expected hospital admission ratios between telemedicine and telephone cohorts by calculating the risk of admission using the second generation of Pediatric Risk of Admission score and the Revised Pediatric Emergency Assessment Tool. A total of 138 charts were reviewed; 74 children received telemedicine consultations and 64 received telephone consultations. The telemedicine cohort had fewer hospital admissions compared with the telephone cohort (59.5% vs 87.5%; p < 0.05). Although the telemedicine cohort had lower observed-to-expected admission ratios than the telephone cohort, these differences were not statistically different (Pediatric Risk of Admission II, 2.36 vs 2.58; Revised Pediatric Emergency Assessment Tool, 2.34 vs 2.57). This result did not change when the cohorts were stratified into low (below median) and high (above median) risk of admission cohorts, using either Pediatric Risk of Admission II (low risk, 18.25 vs 22.81; high risk, 1.40 vs 1.54) or Revised Pediatric Emergency Assessment Tool (low risk, 5.35 vs 5.94; high risk, 1.51 vs 1.81).ConclusionsAlthough the overall admission rate among patients receiving telemedicine consultations was lower than that among patients receiving telephone consultations, there were no statistically significant differences between the observed-to-expected admission ratios using Pediatric Risk of Admission II and Revised Pediatric Emergency Assessment Tool. Our findings may be reassuring in the context of previous research, suggesting that telemedicine specialty consultations can aid in the delivery of more appropriate, safer, and higher quality of care.

ABSTRACT The use of molecular-based diagnostic testing, such as the Luminex Verigene system, to rapidly identify the most common bacterial isolates from blood cultures is an important tool that reduces the duration of inappropriate antibiotics and decreases mortality. However, 5 to 15% of microorganisms recovered from blood culture are unable to be identified by the Verigene Gram-negative (BC-GN) or Gram-positive (BC-GP) assays. In this retrospective, observational study, we evaluate the identities and antimicrobial susceptibility patterns of 229 isolates that were not identified by either the Verigene BC-GN or BC-GP assay. The results presented here suggest that important, clinically relevant information about antimicrobial susceptibility patterns can still be inferred even when isolates are not identified by Verigene. We also examined changes in antibiotic use for patients with “unidentified” Verigene results at our institution and found that this subgroup represents an opportunity to optimize empirical antibiotic therapy. IMPORTANCE Rapid diagnostic testing to identify bloodstream pathogens has arisen as an important tool both to ensure adequate antimicrobial therapy is given early and to aid in antimicrobial stewardship by allowing for more rapid deescalation of inappropriate antimicrobial therapy. However, there is a paucity of data regarding the significance of isolates that are not able to be identified by rapid diagnostic testing. In this study, we report the identification to the species level and antimicrobial susceptibilities among isolates that were not identified by one such rapid diagnostic platform, the Verigene system. This study provides important insight into how a strong understanding of the strengths and limitations of a given rapid diagnostic platform, coupled with insight into local antibiotic susceptibility patterns, can allow for more nuanced and thoughtful empirical antibiotic selection.

Investments in preschool programs for children from disadvantaged backgrounds have historically been supported by research showing that these programs help children build school readiness skills and narrow the income-achievement gap. However, results from recent studies of the links between preschool participation and increases in school readiness skills are more mixed. Significant variation in regular preschool attendance and the availability of high-quality early learning environments could help explain mixed findings on preschool effectiveness. Using data from a preschool expansion demonstration project, we explored associations between children's attendance rates, classroom quality, and neighborhood poverty and children's fall to spring gains in a set of important school readiness skills in executive functioning. Children (N = 197) lived in neighborhoods where 26% of households (range = 0 - 92%) lived below the poverty line and attended 48 classrooms in public and private settings. Attendance rates, including chronic absenteeism, were significantly associated with children's gains in executive functioning skills, but only when children attended high-quality classrooms. Results suggest that efforts to increase attendance rates may benefit children's executive functioning skills among children living in higher poverty neighborhoods the most when communities also invest in increasing preschool classroom quality.

Exceptionally preserved fossils retain soft tissues and often the biomolecules that were present in an animal during its life. The majority of terrestrial vertebrate fossils are not traditionally considered exceptionally preserved, with fossils falling on a spectrum ranging from very well-preserved to poorly preserved when considering completeness, morphology and the presence of microstructures. Within this variability of anatomical preservation, high-quality macro-scale preservation (e.g., articulated skeletons) may not be reflected in molecular-scale preservation (i.e., biomolecules). Excavation of the Hayden Quarry (HQ; Chinle Formation, Ghost Ranch, NM, USA) has resulted in the recovery of thousands of fossilized vertebrate specimens. This has contributed greatly to our knowledge of early dinosaur evolution and paleoenvironmental conditions during the Late Triassic Period (~212 Ma). The number of specimens, completeness of skeletons and fidelity of osteohistological microstructures preserved in the bone all demonstrate the remarkable quality of the fossils preserved at this locality. Because the Hayden Quarry is an excellent example of good preservation in a fluvial environment, we have tested different fossil types (i.e., bone, tooth, coprolite) to examine the molecular preservation and overall taphonomy of the HQ to determine how different scales of preservation vary within a single locality. We used multiple high-resolution mass spectrometry techniques (TOF-SIMS, GC-MS, FT-ICR MS) to compare the fossils to unaltered bone from extant vertebrates, experimentally matured bone, and younger dinosaurian skeletal material from other fluvial environments. FT-ICR MS provides detailed molecular information about complex mixtures, and TOF-SIMS has high elemental spatial sensitivity. Using these techniques, we did not find convincing evidence of a molecular signal that can be confidently interpreted as endogenous, indicating that very good macro- and microscale preservation are not necessarily good predictors of molecular preservation.

Quantum state-resolved spectroscopy was recently achieved for C_{60} molecules when cooled by buffer gas collisions and probed with a midinfrared frequency comb. This rovibrational quantum state resolution for the largest molecule on record is facilitated by the remarkable symmetry and rigidity of C_{60}, which also present new opportunities and challenges to explore energy transfer between quantum states in this many-atom system. Here we combine state-specific optical pumping, buffer gas collisions, and ultrasensitive intracavity nonlinear spectroscopy to initiate and probe the rotation-vibration energy transfer and relaxation. This approach provides the first detailed characterization of C_{60} collisional energy transfer for a variety of collision partners, and determines the rotational and vibrational inelastic collision cross sections. These results compare well with our theoretical modeling of the collisions, and establish a route towards quantum state control of a new class of unprecedentedly large molecules.

Monitoring visitor use in parks and protected areas (PPAs) provides essential information for managers of PPAs to evaluate aspects of the visitor experience and balance the ecological disturbance that use creates. Traditional methods for quantifying visitation and spatial use of PPAs are resource intensive and thus are conducted infrequently or at cost-effective intervals which may fail to capture the dynamic nature of modern visitor use trends. This paper provides an addition to a growing literature using mobile-device data to quantify visitation and spatial density of use of urban-proximate PPAs in Orange County, California, USA using the analysis platform Streetlight, Inc. The results of our analysis compared favorably with well-established automatic trail counting and GPS-based monitoring methods, and illustrate several advantages of mobile device data to inform the management of PPAs. Mobile device data provide reliable estimates of visitation and spatial density of use and can augment and compliment existing social and resource monitoring for PPA management and planning.

There is a high incidence of upper respiratory viral infections in the human population, with infection severity being unique to each individual. Upper respiratory viruses have been associated previously with secondary bacterial infection, however, several cross-sectional studies analyzed in the literature indicate that an inverse relationship can also occur. Pathobiont abundance and/or bacterial dysbiosis can impair epithelial integrity and predispose an individual to viral infection. In this review we describe common commensal microorganisms that have the capacity to reduce the abundance of pathobionts and maintain bacterial symbiosis in the upper respiratory tract and discuss the potential and limitations of localized probiotic formulations of commensal bacteria to reduce the incidence and severity of viral infections.

Abstract Forest ecosystem resilience is of considerable interest worldwide, particularly given the climate crisis, biodiversity loss, and recent instances of zoonotic diseases linked to deforestation and forest loss. Novel, digital‐based technologies are also increasingly ubiquitous. We provide a more comprehensive understanding of how these new technologies are being used for forest management in different sectors and contexts, and discuss potential implications and future research needs for forestry researchers, managers, and policymakers. We carried out a literature database search and scoping review to collect peer‐reviewed articles from 2010 to 2020, and developed a forest‐technology classification to identify hardware and/or software technologies and techniques, methodology used, forest management application(s), spatial and temporal context, subsequent challenges and limitations, and opportunities. A qualitative analysis revealed a strong emphasis on remote sensing‐based innovations for forest monitoring, planning, and management, where machine‐learning techniques also play an important role in data collection, processing, and analysis. Data fusion approaches are also becoming more common, enabled by open‐source data sets and data sharing practices. More emerging technologies and applications include virtual/augmented environments for understanding human‐nature relationships and behavior patterns, automated workflows for forestry operations, and urban green infrastructure mapping and ecosystem services assessments via social media and mobile tracking applications. The continued adoption of digital‐based tools will likely bring about new research questions about forest ecosystems as dynamic social, ecological, and technological landscapes, and future work should more closely examine how forestry researchers, managers, and stakeholders can anticipate and adapt to both environmental and technological uncertainty change in a forest‐ecosystem context.

Background: Following the success of Cognitive Behavioral Therapy (CBT) for insomnia, there has been a growing recognition that similar treatment approaches might be equally beneficial for other major sleep disorders, including non-rapid eye movement (NREM) parasomnias. We have developed a novel, group-based, CBT-program for NREM parasomnias (CBT-NREMP), with the primary aim of reducing NREM parasomnia severity with relatively few treatment sessions.Methods: We investigated the effectiveness of CBT-NREMP in 46 retrospectively-identified patients, who completed five outpatient therapy sessions. The outcomes pre- and post- CBT-NREMP treatment on clinical measures of insomnia (Insomnia Severity Index), NREM parasomnias (Paris Arousal Disorders Severity Scale) and anxiety and depression (Hospital Anxiety and Depression Scale), were retrospectively collected and analyzed. In order to investigate the temporal stability of CBT-NREMP, we also assessed a subgroup of 8 patients during the 3 to 6 months follow-up period.Results: CBT-NREMP led to a reduction in clinical measures of NREM parasomnia, insomnia, and anxiety and depression severities [pre- vs. post-CBT-NREMP scores: P (Insomnia Severity Index) = 0.000054; P (Paris Arousal Disorders Severity Scale) = 0.00032; P (Hospital Anxiety and Depression Scale) = 0.037]. Improvements in clinical measures of NREM parasomnia and insomnia severities were similarly recorded for a subgroup of eight patients at follow-up, demonstrating that patients continued to improve post CBT-NREMP.Conclusion: Our findings suggest that group CBT-NREMP intervention is a safe, effective and promising treatment for NREM parasomnia, especially when precipitating and perpetuating factors are behaviorally and psychologically driven. Future randomized controlled trials are now required to robustly confirm these findings.

The current wellness crisis among graduate students calls on institutions of higher education to act and advocate for student thriving. While existing research on human thriving provides insight into how this experience of positive functioning can be understood across the lifespan, what it means to thrive within graduate programs—and by extension, how to support students in their ability to thrive within these programs—remains understudied. To address this gap in the literature, this study examined how graduate students describe and understand thriving within their programs of study. We thematically and quantitatively analyzed 2,287 Canadian graduate students survey responses to the question “How would you describe a student who is thriving in your program.” Findings indicate that graduate students conceptualize thriving as a complex and multi-dimensional construct involving both academic and non-academic components. The six overarching themes of achieving, engaging, connecting, balancing, enjoying, and being provide foundation for further exploration and insight into the ways that universities and post-secondary institutions can support students’ positive functioning.

Genetic pathways regulating hematopoietic lineage commitment at critical stages of development remain incompletely characterized. To better delineate genetic sources of variability regulating cellular speciation during steady-state hematopoiesis, we applied a factorial single-cell latent variable model (f-scLVM) to decompose single-cell transcriptome heterogeneity into interpretable biological factors (refined pathway annotations or gene sets without annotation) dynamically regulating cell fate. Hematopoietic single cell transcriptomic raw sequencing data extracted from 1,920 hematopoietic stem and progenitor cells (HSPCs) derived from 12-week-old female mice were used for data analysis and model development. These single cell RNA sequencing data were subsequently analyzed using the factorial single-cell latent variable model (f-scLVM), with their heterogeneity decomposed into interpretable biological factors. The top biological factors underlying the basal hematopoiesis were subsequently identified for the aggregate, and lineage-restricted (myeloid, megakaryocyte, erythroid) progenitor cells. For a subset of factors, data were independently verified experimentally in a companion research paper [1]. These data facilitate the identification of novel subpopulations and adjust gene sets to discover new marker genes and hidden confounding factors driving basal hematopoiesis.

Abstract This is the protocol for a Campbell review. The review aims to systematically collect, appraise, map and synthesise the evidence from systematic reviews on the differential gender impacts of social protection programmes in Low‐ and Middle‐Income Countries (LMICs). Therefore, it will answer the following questions: (1) What is known from systematic reviews on the gender‐differentiated impacts of social protection programmes in LMICs? (2) What is known from systematic reviews about the factors that determine these gender‐differentiated impacts? (3) What is known from existing systematic reviews about design and implementation features of social protection programmes and their association with gender outcomes?

The purpose of this paper is to examine traditional organizational structures and leadership styles in Canada, to assess their responsiveness to a changing educational, social and political context, and to propose an alternative approach. We argue that the educational enterprise would benefit from distancing itself from these traditional models, and moving towards embracing a transformational style of leadership based on a restorative justice model. This paradigm would include a holistic, inclusive, integral approach from which educational leaders and their constituents could bring about change both within learning communities and the larger social order by challenging existing patriarchal constructs and practices.