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Hospitalized patients often are readmitted soon after discharge, with many hospitalizations being potentially preventable. The authors evaluated a mobile health intervention designed to improve post-hospitalization support for older adults with common chronic conditions. All participants enrolled with an informal caregiver or "CarePartner" (CP). Intervention patients received automated assessment and behavior change calls. CPs received automated, structured feedback following each assessment. Clinicians received alerts about serious problems identified during patient calls. Controls had a 65% greater risk of hospitalization within 90 days post discharge than intervention patients (P = .041). For every 6.8 enrollees, the intervention prevented 1 rehospitalization or emergency department encounter. The intervention improved physical functioning at 90 days (P = .012). The intervention also improved medication adherence and indicators of the quality of communication with CPs (all P < .01). Automated telephone patient monitoring and self-care advice with feedback to primary care teams and CPs reduces readmission rates over 90 days.

Problem University of Washington Medicine (UW Medicine), an academic health system in Washington State, was at the epicenter of the first outbreak of the COVID-19 pandemic in the United States. The extent of emergency activation needed to adequately respond to this global pandemic was not immediately known, as the evolving situation differed significantly from any past disaster response preparations in that there was potential for exponential growth of infection, unproven mitigation strategies, serious risk to health care workers, and inadequate supply chains for critical equipment. Approach The rapid transition of the UW Medicine system to account for projected COVID-19 and usual patient care, while balancing patient and staff safety and conservation of resources, represents an example of an adaptive disaster response. Key Insights Although our organization's ability to meet the needs of the public was uncertain, we planned and implemented changes to space, supply management, and staffing plans to meet the influx of patients across our clinical entities. The surge management plan called for specific actions to be implemented based on the level of activity. This article describes the approach taken by UW Medicine as we braced for the storm.

On January 19, 2020, the first case of a patient with coronavirus disease 2019 (COVID-19) in the United States was reported in Washington State. On February 29, 2020, a patient infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) passed away in a hospital in Seattle-King County, the first reported COVID-19-related death in the United States. That same day, a skilled nursing and rehabilitation facility in the county reported that several of its residents tested positive for SARS-CoV-2 and that many staff had symptoms compatible with COVID-19. The University of Washington Medicine health system (UW Medicine), which is based in Seattle-King County and provides quaternary care for the region, was one of several health care organizations called upon to address this growing crisis. What ensued was a series of swiftly enacted decisions and activities at UW Medicine, in partnership with local, state, and national public health agencies, to respond to the COVID-19 pandemic. Tapping into the multipronged mission areas of academic medicine, UW Medicine worked to support the community, innovate in science and clinical practice; lead policy and practice guideline development; and adopt changes as the crisis unfolded. In doing so, health system leaders had to balance their commitments to students, residents and fellows, researchers, faculty, staff, and hospital and health center entities, while ensuring that patients continued to receive cutting-edge, high-quality, safe care. In this Invited Commentary, the authors highlight the work and challenges UW Medicine has faced in responding to the global COVID-19 pandemic.

Background Reliable, timely-onset, oral treatments with an acceptable safety profile for patients with hyperkalemia are needed. We examined the efficacy and safety of sodium zirconium cyclosilicate (SZC; formerly ZS-9) treatment for ≤ 48 h in patients with baseline serum potassium level ≥ 5.5 mmol/L. Methods Data were pooled from two phase 3 studies (ZS-003 and HARMONIZE) among patients receiving SZC 10 g three times daily. Outcomes included mean and absolute change from baseline, median time to potassium level ≤ 5.5 and ≤ 5.0 mmol/L, and proportion achieving potassium level ≤ 5.5 and ≤ 5.0 mmol/L at 4, 24, and 48 h. Outcomes were stratified by baseline potassium. Safety outcomes were evaluated. Results At baseline, 125 of 170 patients (73.5%) had potassium level 5.5– 6.5 mmol/L. Regardless of baseline potassium, mean potassium decreased at 1 h post-initial dose. By 4 and 48 h, 37.5% and 85.0% of patients achieved potassium level ≤ 5.0 mmol/L, respectively. Median (95% confidence interval) times to potassium level ≤ 5.5 and ≤ 5.0 mmol/L were 2.0 (1.1–2.0) and 21.6 (4.1–22.4) h, respectively. Fifteen patients (8.8%) experienced adverse events; none were serious. Conclusions SZC 10 g three times daily achieved serum potassium reduction and normokalemia, with a favorable safety profile. Trial registration ClinicalTrials.gov identifiers: ZS-003: NCT01737697 and HARMONIZE: NCT02088073.

Understanding the speciation of divalent mercury (Hg(II)) in aquatic systems containing dissolved organic matter (DOM) and sulfide is necessary to predict the conversion of Hg(II) to bioavailable methylmercury. We used X-ray absorption spectroscopy to characterize the structural order of mercury in Hg(II)-DOM-sulfide systems for a range of sulfide concentration (1-100 μM), DOM aromaticity (specific ultraviolet absorbance (SUVA254)), and Hg(II)-DOM and Hg(II)-DOM-sulfide equilibration times (4-142 h). In all systems, Hg(II) was present as structurally disordered nanocolloidal metacinnabar (β-HgS). β-HgS nanocolloids were significantly smaller or less ordered at lower sulfide concentration, as indicated by under-coordination of Hg(II) in β-HgS. The size or structural order of β-HgS nanocolloids increased with increasing sulfide abundance and decreased with increasing SUVA254 of the DOM. The Hg(II)-DOM or Hg(II)-DOM-sulfide equilibration times did not significantly influence the extent of structural order in nanocolloidal β-HgS. Geochemical factors that control the structural order of nanocolloidal β-HgS, which are expected to influence nanocolloid surface reactivity and solubility, should be considered in the context of mercury bioavailability.

Background: Reliable, timely-onset, oral treatments with an acceptable safety profile for patients with hyperkalemia are needed. We examined the efficacy and safety of sodium zirconium cyclosilicate (SZC; formerly ZS-9) treatment for ≤48 hours in patients with baseline serum potassium level ≥5.5 mmol/L. Methods: Data were pooled from two phase 3 studies (ZS-003 and HARMONIZE) among patients receiving SZC 10 g three times daily. Outcomes included mean and absolute change from baseline, median time to potassium level ≤5.5 and ≤5.0 mmol/L, and proportion achieving potassium level ≤5.5 and ≤5.0 mmol/L at 4, 24, and 48 hours. Outcomes were stratified by baseline potassium. Safety outcomes were evaluated. Results: At baseline, 125 of 170 patients (73.5%) had potassium level 5.5–6.5 mmol/L. Regardless of baseline potassium, mean potassium decreased at 1-hour post-initial dose. By 4 and 48 hours, 37.5% and 85.0% of patients achieved potassium level ≤5.0 mmol/L, respectively. Median (95% confidence interval) times to potassium level ≤5.5 and ≤5.0 mmol/L were 2.0 (1.1–2.0) and 21.6 (4.1–22.4) hours, respectively. Fifteen patients (8.8%) experienced adverse events; none were serious. Conclusions: SZC 10 g three times daily achieved serum potassium reduction and normokalemia, with a favorable safety profile. ClinicalTrials.gov identifiers: NCT01737697 and NCT02088073

Introduction Patients with chronic illness often require ongoing support postdischarge. This study evaluated a simple-to-use, mobile health-based program designed to improve postdischarge follow-up via (1) tailored communication to patients using automated calls, (2) structured feedback to informal caregivers, and (3) automated alerts to clinicians about urgent problems. Methods A total of 283 patients with common medical diagnoses, including chronic obstructive pulmonary disease, coronary artery disease, pneumonia, and diabetes, were recruited from a university hospital, a community hospital, and a US Department of Veterans Affairs hospital. All patients identified an informal caregiver or "care partner" (CP) to participate in their postdischarge support. Patient-CP dyads were randomized to the intervention or usual care. Intervention patients received weekly automated assessment and behavior change calls. CPs received structured e-mail feedback. Outpatient clinicians received fax alerts about serious problems. Primary outcomes were 30-day readmission rate and the combined outcome of readmission/emergency department (ED) use. Information about postdischarge outpatient visits, rehospitalizations, and ED encounters was obtained from medical records. Results Overall, 11.4% of intervention patients and 17.9% of controls were rehospitalized within 30 days postdischarge (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.31–1.11; p = 0.102). Compared to intervention patients with other illnesses, those with pulmonary diagnoses generated the most clinical alerts (p = 0.004). Pulmonary patients in the intervention group showed significantly reduced 30-day risk of rehospitalization relative to controls (HR: 0.31; 95% CI: 0.11–0.87; p = 0.026). Conclusion The CP intervention did not improve 30-day readmission rates overall, although post hoc analyses suggested that it may be promising among patients with pulmonary diagnoses.

Physical and chemical weathering of arsenic-enriched mine wastes can lead to the mobilization and dispersal of contaminated sediments into surrounding (residential) areas. Additionally, seasonal effects during dry and rainy seasons affect contaminant bioaccessibility in ways that may significantly influence risk estimates of chronic arsenic exposure for residents living near mining sites. Rainwater-transported sediments from the Red Hill Mercury Mine in Tustin, California were collected monthly over a period of 25 months and the ingestible size fraction (≤250 μm) analyzed for bulk arsenic concentration (239 ± 149 mg/kg, n = 32, 114 to 678 mg/kg), assessed for arsenic bioaccessibility (11.2 ± 6.3%, n = 32, 2.7 to 24.9%), and compared with realtime rainfall data. Arsenic bioaccessibility was highly variable and strongly negatively correlated with cumulative rainfall over the preceding 40 days (r2 = 0.51, P

OBJECTIVES Patient safety event (PSE) reporting is a critical element for healthcare organizations that are striving for continuous quality improvement. Although resident physicians routinely provide the majority of direct patient care, the level of their participation in PSE reporting historically has been low. In addition, as part of the Accreditation Council for Graduate Medical Education's Next Accreditation System, the Clinical Learning Environment Review site visit assesses residents' engagement in PSE reporting at each accredited academic institution. The objective of this study was to understand the common barriers to PSE reporting and design an intervention to increase the number of PSE reports by resident physicians. METHODS We surveyed 304 residents and fellows to assess attitudes toward the PSE reporting system and identify barriers to submitting online PSE reports. Based on this analysis of barriers, we piloted interventions with the internal medicine residency program and measured their effect on resident PSE reporting. RESULTS Of the survey respondents, 58% had never submitted a PSE report. The most commonly identified barriers were too much time required to submit a report (38% of all respondents), lack of education on how or what to report (37%), lack of feedback or change after reporting (19%), and concern for repercussions or lack of anonymity (13%). Based on this analysis of barriers, we piloted interventions with the internal medicine residency program to educate residents about PSE reporting through a reminder message in their orientation e-mail, informational slides at the end of conferences that described what and how to report, a pocket card with reporting instructions, and leadership encouragement during walk rounds by chief medical residents and the program director. Compared with the 10 weeks before the start of the intervention, the number of PSE reports submitted by internal medicine residents more than doubled, from 16 to 37 reports (P < 0.01). This increase in resident PSE reporting was sustained for 20 weeks despite the interventions lasting only 8 weeks. CONCLUSIONS A resident-driven intervention that fostered a culture of encouragement for PSE reporting through leadership support and targeted education increased the number of PSE reports submitted by internal medicine residents at our health system. Hospitals and health systems should seek to understand the common barriers to PSE reporting from this important group of direct patient care providers and administer structured educational programs to encourage their participation.

Background:Many experts believe that hospitals with more frequent readmissions provide lower-quality care, but little is known about how the preventability of readmissions might change over the postdischarge time frame. Objective:To determine whether readmissions within 7 days of discharge differ from those between 8 and 30 days after discharge with respect to preventability. Design:Prospective cohort study. Setting:10 academic medical centers in the United States. Patients:822 adults readmitted to a general medicine service. Measurements:For each readmission, 2 site-specific physician adjudicators used a structured survey instrument to determine whether it was preventable and measured other characteristics. Results:Overall, 36.2% of early readmissions versus 23.0% of late readmissions were preventable (median risk difference, 13.0 percentage points [interquartile range, 5.5 to 26.4 percentage points]). Hospitals were identified as better locations for preventing early readmissions (47.2% vs. 25.5%; median risk difference, 22.8 percentage points [interquartile range, 17.9 to 31.8 percentage points]), whereas outpatient clinics (15.2% vs. 6.6%; median risk difference, 10.0 percentage points [interquartile range, 4.6 to 12.2 percentage points]) and home (19.4% vs. 14.0%; median risk difference, 5.6 percentage points [interquartile range, -6.1 to 17.1 percentage points]) were better for preventing late readmissions. Limitation:Physician adjudicators were not blinded to readmission timing, community hospitals were not included in the study, and readmissions to nonstudy hospitals were not included in the results. Conclusion:Early readmissions were more likely to be preventable and amenable to hospital-based interventions. Late readmissions were less likely to be preventable and were more amenable to ambulatory and home-based interventions. Primary Funding Source:Association of American Medical Colleges.

The capacity of nanosized particles to adsorb and sequester dissolved metals can be significantly impacted by the mechanism and extent of aggregation the particles have undergone, which in turn can affect the long-term fate and transport of potentially toxic metals in natural aqueous systems. Suspensions of monodisperse nanoscale iron oxyhydroxides were synthesized and subjected to increased pH (pH 8.0, 10.0) or ionic strength (0.1, 1.0 M NaNO 3 ) conditions to induce various states of aggregation prior to conducting macroscopic adsorption/desorption experiments with dissolved Cu(II) or Zn(II). The metal adsorption and retention capacities of the nanoparticle aggregates were compared to one another and to non-aggregated control nanoparticles, while the mode(s) of metal sorption to the nanoparticle surfaces were characterized by extended X-ray absorption fine structure (EXAFS) spectroscopy analysis. With increasing aggregation by both pH and ionic strength, the proportion of introduced zinc adsorbed to the iron oxyhydroxide nanoparticles progressively decreased from 45% on the monodispersed control particles to as low as 16% on the aggregates, while the proportion of introduced zinc retained upon desorption (obtained by lowering the suspension pH) increased from 7% on the control particles to as much as 17% on the aggregated particles. Copper exhibited a subtler trend of only slightly declining uptake (from 43% to 36%) and retention (from 35% to 30%) with increasing aggregation state. EXAFS analysis was consistent with the macroscopic results, showing relatively little change in Cu speciation between samples analyzed before and after the desorption step but significant increases in Zn–Fe interatomic distances and coordination numbers after desorption. This suggests the presence of both strongly- and weakly-bound zinc ions; the latter are likely affiliated with less stable, more distorted surface sorption sites and are thus more readily desorbed, resulting in the retention of zinc that is bound to more stable, less-distorted sorption sites. For both metals, inner-sphere bidentate sorption appears to dominate the sorption process to the nanoparticle aggregates, with potential structural incorporation into the aggregates themselves.

The aggregation and growth of nanosized particles can greatly impact their capacity to sorb and retain dissolved metals, thus affecting metal fate and transport in contaminated systems. Aqueous suspensions of synthesized nanoscale iron oxyhydroxides were exposed to dissolved Zn(II) or Cu(II) and aged at room temperature (∼20 °C), 50 °C, and 75 °C for timeframes ranging from 0 to 96 h before sorbed metal ions were desorbed by lowering the suspension pH. Atomic absorption spectroscopic analysis of supernatants both before and after the desorption step determined how temperature and time affect macroscopic metal uptake and retention capacities. Extended X-ray absorption fine structure (EXAFS) spectroscopy analysis described the local binding environment of the sorbed/retained metals on the solid phase. With increasing aging temperature and time, the initial ∼5-nm oblong nanoparticles formed dense aggregates, lost reactive surface area, and retained progressively larger fractions of the initially-introduced Zn(II) and Cu(II) following the desorption step, with the copper species inhibiting the oriented aggregation of the nanoparticles into nanorods. Based on EXAFS analysis, the speciation of the sorbed metal species evolves with increasing time and temperature from surface-sorbed metal ions, which readily desorb and return to solution, to more strongly-bound, structurally-incorporated metal ions. These retained metals appear to associate intimately with the nanoparticle aggregates by substituting for iron in the nanoparticle lattice or by binding within nanoparticle aggregate pore spaces.

Gold and silver mining conducted throughout the state of California has left an environmental legacy of exposed mine wastes containing elevated levels of toxic metals and metalloids including arsenic (As), a known carcinogen. These mine tailings, particularly the fine-grained size fractions, are susceptible to weathering and windborne transport, significantly increasing the spatial extent of contamination in topsoils and potential exposure of humans to toxic metal(loid)s. Depth-based field sampling of soils surrounding several abandoned mines in the Mojave Desert (Southern CA) have identified an exponential decline in As soil enrichment with both depth and increasing distance from tailings piles to the east, consistent with prevailing west-to-east wind directions. In vitro extraction studies using a phagolysosomal simulant fluid (PSF), mimicking the inhalation of the most finely sieved size fraction of selected samples (⩽20 μm), indicate that initial solid As concentration is the strongest indicator in predicting the concentration of As released in the lung. When extraction data are incorporated into exposure risk assessment calculations, the majority of samples investigated exceed both cancer risk thresholds and non-cancer-related minimal risk levels (MRLs) based on long-term chronic exposure to airborne mine tailings dusts. This suggests that long-term residents of communities located close to these abandoned mine sites, especially those who reside downwind (i.e. east) of mine tailings piles, face possible health effects due to the inhalation of fine-grained mine tailings mobilized through aeolian processes.

The landscape of hospital-based care has shifted to place greater emphasis on improving quality and delivering value. In response, hospitals and healthcare organizations must reassess their strategies to improve care delivery in their facilities and beyond. Although these institutional goals may be defined at the executive level, implementation takes place at local sites of care. To lead these efforts, hospitals need to appoint effective leaders at the frontlines. Hospitalists are well poised to take on the role of the local clinical care improvement leader based on their experiences as direct frontline caregivers and their integral roles in hospital-wide quality and safety initiatives. A unit-based leadership model consisting of a medical director paired with a nurse manager has been implemented in several hospitals to function as an effector arm in response to the changing landscape of inpatient care. We provide an overview of this new model of leadership and describe the experiences of 6 hospitals that have implemented it.

Synchrotron-based X-ray absorption spectroscopy (XAS) is an in situ , minimally-destructive, element-specific, molecular-scale structural probe that has been employed to study the chemical forms (species) of arsenic (As) in solid and aqueous phases (including rocks, soils, sediment, synthetic compounds, and numerous types of biota including humans) for more than 20 years. Although several excellent reviews of As geochemistry and As speciation in the environment have been published previously (including recent contributions in this volume), the explosion of As-XAS studies over the past decade (especially studies employing microfocused X-ray beams) warrants this new review of the literature and of data analysis methods. This review has two main sections. The first is a presentation of methods for sample preparation and for the collection, processing and analysis of As-XAS spectra. Since several more comprehensive reviews of the X-ray absorption theory and data collection methodology exist, this section is brief and focused specifically on As. The second section is a critical review of the As-XAS literature, arranged by sample type and accompanied by summary tables (collected as appendices at the end of the chapter). One of the most important aims of this review is to clarify the different types of analysis that are performed on As-XAS spectra, and to describe the benefits, drawbacks, and limitations of each. Arsenic XAS spectra are analyzed to obtain one or more of the following types of information (in increasing order of sophistication): 1. Identification of oxidation state (+ quantification of relative abundance, if multiple oxidation states are present) 2. Selection of the appropriate number and type of model compound As-XAS spectra to use in speciation fits (see 3); 3. Quantification of the relative abundance of species in a multi-species sample; 4. Identification of the molecular-scale (~ 4–7 A) attributes of the predominant (one or two) As species. The type of As-XAS spectral …

BACKGROUND Patient-centered care has been identified as 1 of the 6 aims for the 21st century healthcare system. The notepad is a simple tool for reminders and personal interactions. We introduced Dear Doctor (DD) notes, a bedside notepad designed to prompt patient questions and improve patient satisfaction. OBJECTIVE To provide DD notes as a bedside tool to facilitate patient communication and improve patient encounters with physicians in the hospital. DESIGN This is a single-center, cross-sectional survey. METHODS Over a 3-month period (July 2009–September 2009), all hospitalized patients in the intervention group (1 general medicine and 1 cardiology unit) at a large academic medical center received a DD notepad, a pen, and instructions on its use. We surveyed patients who received the DD notes on the intervention group (n = 440) and compared their responses to those from a matched control group (1 general medicine and 1 cardiology unit, n = 224). RESULTS Of the 440 patients surveyed in the intervention group, 78% (n = 343) received the notepads in their rooms and 47% (n = 207) used them. Of the 343 patients who received the DD notepads, 65% (n = 223) reported that they took notes related to their hospital stay compared to only 22% of 224 patients (n = 50) in the control group (P < 0.001). The 207 patients using the DD notes had their questions more often answered by their physicians as measured on a 5-point Likert scale, compared to the control group (4.63 vs 4.45; P < 0.001). However, overall rating of communication did not differ between intervention and control groups in an intention-to-treat analysis (4.55 vs 4.55, P = 0.89). All patients who used the DD notepads responded on the survey that communication with their physicians was enhanced to at least some degree. CONCLUSIONS Utilizing a bedside notepad improved patients' satisfaction with physician communication. A simple, low-cost, patient-centered tool such as the DD notes may enhance a patient's overall experience with their providers and the hospital. Journal of Hospital Medicine 2013;8:553–558. © 2013 Society of Hospital Medicine

During mineralization, the hard outer magnetite-containing shell of the radular teeth of Cryptochiton stelleri undergoes four distinct stages of structural and phase transformations: (i) the formation of a crystalline α -chitin organic matrix that forms the structural framework of the non-mineralized teeth, (ii) the templated synthesis of ferrihydrite crystal aggregates along these organic fi bers, (iii) subsequent solid state phase transformation from ferrihydrite to magnetite, and (iv) progressive magnetite crystal growth to form continuous parallel rods within the mature teeth. The underlying α -chitin organic matrix appears to infl uence magnetite crystal aggregate density and the diameter and curvature of the resulting rods, both of which likely play critical roles in determining the local mechanical properties of the mature radular teeth.

Background:Background: Patients are vulnerable to issues that emerge after discharge from the hospital, and this susceptibility is compounded as patients attempt to navigate complex healthcare organizations. Post-discharge clinic appointments may provide the opportunity to mitigate risks posed to patients during this vulnerable time. Abstract: Objective:Objective: Our aim was to determine whether actively engaging patients in scheduling post-discharge appointments before leaving the hospital affects the rate of patients seeing an ambulatory care physician. Abstract: Methods:Methods: This was a prospective cohort pilot study from May to July 2007 with a historical convenience control from 2003. The setting was an inpatient academic tertiary care referral center in the US. Study participants had been discharged from a general medicine hospitalist service during the study time period. Patients, or their designated caregivers, were contacted in hospital rooms to schedule a post-discharge appointment before discharge. The primary outcome was rate of attendance at post-discharge appointments, determined a priori. Abstract: Results:Results: Eighty-three patients with 115 scheduled appointments in the intervention group were compared with 306 patients with 398 appointments in the historical control group. The attendance rate was 59.5% in the control group versus 78.3% in the study group (p < 0.0001). Patients received 1.3 discharge appointments per discharge in both the historical and study group. In a limited evaluation, the study group had a trend towards a lower return rate to the emergency department within 3 days of discharge (1.2% vs 3.8%, nonsignificant), and a lower readmission rate within 14 days of discharge (10.8% vs 11.8%, nonsignificant). Abstract: Conclusion:Conclusion: Our patient-centered process for helping patients arrange their post-discharge appointments before discharge improved the attendance rate at those appointments.

The mining and processing of metal-bearing ores has resulted in contamination issues where waste materials from abandoned mines remain in piles of untreated and unconsolidated material, posing the potential for waterborne and airborne transport of toxic elements. This study presents a systematic method of particle size separation, mass distribution, and bulk chemical analysis for mine tailings and adjacent background soil samples from the Rand historic mining district, California, in order to assess particle size distribution and related trends in metal(loid) concentration as a function of particle size. Mine tailings produced through stamp milling and leaching processes were found to have both a narrower and finer particle size distribution than background samples, with significant fractions of particles available in a size range (⩽250 μm) that could be incidentally ingested. In both tailings and background samples, the majority of trace metal(loid)s display an inverse relationship between concentration and particle size, resulting in higher proportions of As, Cr, Cu, Pb and Zn in finer-sized fractions which are more susceptible to both water- and wind-borne transport as well as ingestion and/or inhalation. Established regulatory screening levels for such elements may, therefore, significantly underestimate potential exposure risk if relying solely on bulk sample concentrations to guide remediation decisions. Correlations in elemental concentration trends (such as between As and Fe) indicate relationships between elements that may be relevant to their chemical speciation.

Objectives: To better define the role of the medical students in the event of a disaster requiring a surge response in healthcare systems.Setting: The University of Michigan Medical School and Health System, where staffing plans for a pandemic flu were actively taking place.Subjects: All medical students at the University of Michigan.Interventions: The authors surveyed medical students to evaluate how they felt they could contribute during a pandemic flu.Results: Of the students who completed the survey, 88 percent of the respondents felt that students should formally be incorporated into the health system’s staffing plan during a pandemic. This survey further identified the specific patient care tasks that students felt comfortable performing, which may be of value to medical school and hospital administration that are considering inclusion of medical students into their pandemic planning.Conclusions: There should be formal inclusion of medical students into health systems’ staffing plans in the case of pandemic flu, as they are valuable first responders who are both willing and able to participate in the pandemic response.

Patient safety (PS) and quality improvement (QI) are among the highest priorities for all health systems. Resident physicians are often at the front lines of providing care for patients. In many instances, however, QI and PS initiatives exclude trainees. By aligning the goals of the health system with those of the residency program to engage residents in QI and PS projects, there is a unique opportunity to fulfill both a corporate and educational mission to improve patient care. Here, the authors briefly describe one residency program's educational curriculum to provide foundational knowledge in QI and PS to all its trainees and highlight a resident team-based project that applied principles of lean thinking to evaluate the process of responding to an in-hospital cardiopulmonary arrest. This approach provided residents with a practical experience but also presented an opportunity for trainees to align with the health system's approach to improving quality and safety.

Adsorption at the mineral-water interface is an important process governing metal ion concentration and mobility in aqueous systems. Ferric iron oxyhydroxide nanoparticles possess a large capacity for the adsorption of heavy metals but quantification of metal uptake and sequestration is challenging due to the tendency of natural nanoparticles to aggregate in natural waters. We studied the effects of aggregation via pH, ionic strength, drying, and freezing on the uptake and release of copper from ferrihydrite nanoparticles employing small-angle X-ray scattering (SAXS) studies of aggregate morphology, macroscopic Cu(II) sorption and desorption batch experiments, and extended X-ray absorption fine structure (EXAFS) spectroscopic studies of copper sorption geometries. Results show that the mechanism of aggregation has a large effect upon aggregate morphology and consequently on the net sorption/retention of ions from solution. While aggregation reduces the total amount of copper that can be adsorbed, it also may introduce physical constraints to desorption and/or increased proportions of higher strength binding sites that lead to greater retention, and hence more effective sequestration, of metal ion contaminants.

Recent concerns about an influenza pandemic have highlighted the need to plan for offsite Alternate Care Centers (ACCs). The likelihood of a successful response to patient surges will depend on the local health systems' ability to prepare well in advance of an influenza pandemic. Our health system has worked closely with our state's medical biodefense network to plan the establishment of an ACC for an influenza pandemic. As hospitalists have expanded their roles in their local health systems, they are poised to play a major role in planning for the next influenza pandemic. Hospitalists should work with their health system's administration in developing an ACC plan. Journal of Hospital Medicine 2009;4:546–549. © 2009 Society of Hospital Medicine.

Purpose Patients with bone and brain metastases are among the most symptomatic nonemergency patients treated by radiation oncologists. Treatment should begin as soon as possible after the request is generated. We tested the hypothesis that the operational improvement method based on lean thinking could help streamline the treatment of our patients referred for bone and brain metastases. Methods University of Michigan Health System has adopted lean thinking as a consistent approach to quality and process improvement. We applied the principles and tools of lean thinking, especially value as defined by the customer, value stream mapping processes, and one piece flow, to improve the process of delivering care to patients referred for bone or brain metastases. Results and Conclusion The initial evaluation of the process revealed that it was rather chaotic and highly variable. Implementation of the lean thinking principles permitted us to improve the process by cutting the number of individual steps to begin treatment from 27 to 16 and minimize variability by applying standardization. After an initial learning period, the percentage of new patients with brain or bone metastases receiving consultation, simulation, and treatment within the same day rose from 43% to nearly 95%. By implementing the ideas of lean thinking, we improved the delivery of clinical care for our patients with bone or brain metastases. We believe these principles can be applied to much of the care administered throughout our and other health care delivery areas.

The transition out of the hospital is a vulnerable time for patients, relying heavily on communication and coordination of resources across care settings. Understanding the perspectives of inpatient and outpatient physicians regarding factors contributing to readmission and potential preventive strategies is crucial in designing appropriately targeted readmission prevention efforts. To examine and compare inpatient and outpatient physician opinions regarding reasons for readmission and interventions that might have prevented readmission. Cross-sectional multicenter study. We identified patients readmitted to general medicine services within 30 days of discharge at 12 US academic medical centers, and surveyed the primary care physician (PCP), discharging physician from the index admission, and admitting physician from the readmission regarding their endorsement of pre-specified factors contributing to the readmission and potential preventive strategies. We calculated kappa statistics to gauge agreement between physician dyads (PCP-discharging physician, PCP-admitting physician, and admitting-discharging physician). We evaluated 993 readmission events, which generated responses from 356 PCPs (36 % of readmissions), 675 discharging physicians (68 % of readmissions), and 737 admitting physicians (74 % of readmissions). The most commonly endorsed contributing factors by both PCPs and inpatient physicians related to patient understanding and ability to self-manage. The most commonly endorsed preventive strategies involved providing patients with enhanced post-discharge instructions and/or support. Although PCPs and inpatient physicians endorsed contributing factors and potential preventive strategies with similar frequencies, agreement among the three physicians on the specific factors and/or strategies that applied to individual readmission events was poor (maximum kappa 0.30). Differing opinions among physicians on factors contributing to individual readmissions highlights the importance of communication between inpatient and outpatient providers at discharge to share their different perspectives, and suggests that multi-faceted, broadly applied interventions may be more successful than those that rely on individual providers choosing specific services based on perceived risk factors.

Leucine-rich repeat kinase 2 (LRRK2) is the single most common genetic cause of both familial and sporadic Parkinson's disease (PD), both of which share pathogenetic and neurologic similarities with human immunodeficiency virus 1 (HIV-1)-associated neurocognitive disorders (HAND). Pathologic LRRK2 activity may also contribute to neuroinflammation, because microglia lacking LRRK2 exposed to proinflammatory stimuli have attenuated responses. Because microglial activation is a hallmark of HIV-1 neuropathology, we have investigated the role of LRRK2 activation usingin vitroandin vivomodels of HAND. We hypothesize that LRRK2 is a key modulator of microglial inflammatory responses, which play a pathogenic role in both HAND and PD, and that these responses may cause or exacerbate neuronal damage in these diseases. The HIV-1 Tat protein is a potent neurotoxin produced during HAND that induces activation of primary microglia in culture and long-lasting neuroinflammation and neurotoxicity when injected into the CNS of mice. We found that LRRK2 inhibition attenuates Tat-induced pS935–LRRK2 expression, proinflammatory cytokine and chemokine expression, and phosphorylated p38 and Jun N-terminal kinase signaling in primary microglia. In our murine model, cortical Tat injection in LRRK2 knock-out (KO) mice results in significantly diminished neuronal damage, as assessed by microtubule-associated protein 2 (MAP2), class III β-tubulin TUJ1, synapsin-1, VGluT, and cleaved caspase-3 immunostaining. Furthermore, Tat-injected LRRK2 KO animals have decreased infiltration of peripheral neutrophils, and the morphology of microglia from these mice were similar to that of vehicle-injected controls. We conclude that pathologic activation of LRRK2 regulates a significant component of the neuroinflammation associated with HAND.

Nanoparticulate goethite, akaganeite, hematite, ferrihydrite and schwertmannite are important constituents of soils, sediments and mine drainage outflows. These minerals have high sorption capacities for metal and anionic contaminants such as arsenic, chromium, lead, mercury and selenium. Contaminant sequestration is accomplished mainly by surface complexation, but aggregation of particles may encapsulate sorbed surface species into the multigrain interior interfaces, with significant consequences for contaminant dispersal or remediation processes. Particularly for particle sizes on the order of 1–10 nm, the sorption capacity and surface molecular structure also may differ in important ways from bulk material. We review the factors affecting geochemical reactivity of these nanophases, focusing on the ways they may remove toxins from the environment, and include recent results of studies on nanogoethite growth, aggregation and sorption processes.

The study of mercury sorption products in model systems using appropriate in situ molecular-scale probes can provide detailed information on the modes of sorption at mineral/water interfaces. Such studies are essential for assessing the influence of sorption processes on the transport of Hg in contaminated natural systems. Macroscopic uptake of Hg(II) on goethite ( α -FeOOH), γ -alumina ( γ -Al 2 O 3 ), and bayerite ( β -Al(OH) 3 ) as a function of pH has been combined with Hg L III -edge EXAFS spectroscopy, FTIR spectroscopy, and bond valence analysis of possible sorption products to provide this type of information. Macroscopic uptake measurements show that Hg(II) sorbs strongly to fine-grained powders of synthetic goethite (Hg sorption density Γ =0.39–0.42 μmol/m 2 ) and bayerite ( Γ =0.39–0.44 μmol/m 2 ), while sorbing more weakly to γ -alumina ( Γ =0.04–0.13 μmol/m 2 ). EXAFS spectroscopy on the sorption samples shows that the dominant mode of Hg sorption on these phases is as monodentate and bidentate inner-sphere complexes. The mode of Hg(II) sorption to goethite was similar over the pH range 4.3–7.4, as were those of Hg(II) sorption to bayerite over the pH range 5.1–7.9. Conversion of the γ -Al 2 O 3 sorbent to a bayerite-like phase in addition to the apparent reduction of Hg(II) to Hg(I), possibly by photoreduction during EXAFS data collection, resulted in enhanced Hg uptake from pH 5.2–7.8 and changes in the modes of sorption that correlate with the formation of the bayerite-like phase. Bond valence calculations are consistent with the sorption modes proposed from EXAFS analysis. EXAFS analysis of Hg(II) sorption products on a natural Fe oxyhydroxide precipitate and Al/Si-bearing flocculent material showed sorption products and modes of surface attachment similar to those for the model substrates, indicating that the model substrates are useful surrogates for the natural sediments.

The speciation of Hg is a critical determinant of its mobility, reactivity, and potential bioavailability in mine-impacted regions. Furthermore, Hg speciation in these complex natural systems is influenced by a number of physical, geological, and anthropogenic variables. In order to investigate the degree to which several of these variables may affect Hg speciation, extended X-ray absorption fine structure (EXAFS) spectroscopy was used to determine the Hg phases and relative proportions of these phases present in Hg-bearing wastes from selected mine-impacted regions in California and Nevada. The geological origin of Hg ore has a significant effect on Hg speciation in mine wastes. Specifically, samples collected from hot-spring Hg deposits were found to contain soluble Hg-chloride phases, while such phases were largely absent in samples from silica-carbonate Hg deposits; in both deposit types, however, Hg-sulfides in the form of cinnabar (HgS, hex.) and metacinnabar (HgS, cub.) dominate. Calcined wastes in which Hg ore was crushed and roasted in excess of 600 °C, contain high proportions of metacinnabar while the main Hg-containing phase in unroasted waste rock samples from the same mines is cinnabar. The calcining process is thought to promote the reconstructive phase transformation of cinnabar to metacinnabar, which typically occurs at 345 °C. The total Hg concentration in calcines is strongly correlated with particle size, with increases of nearly an order of magnitude in total Hg concentration between the 500–2000 μm and III -EXAFS analysis of samples from Au mining regions, where elemental Hg(0) was introduced to aid in the Au recovery process, identified the presence of Hg-sulfides and schuetteite (Hg 3 O 2 SO 4 ), which may have formed as a result of long-term Hg(0) burial in reducing high-sulfide sediments.

Determining the chemical speciation of mercury in contaminated mining and industrial environments is essential for predicting its solubility, transport behavior, and potential bioavailability as well as for designing effective remediation strategies. In this study, two techniques for determining Hg speciation--X-ray absorption fine structure (XAFS) spectroscopy and sequential chemical extractions (SCE)--are independently applied to a set of samples with Hg concentrations ranging from 132 to 7539 mg/kg to determine if the two techniques provide comparable Hg speciation results. Generally, the proportions of insoluble HgS (cinnabar, metacinnabar) and HgSe identified by XAFS correlate well with the proportion of Hg removed in the aqua regia extraction demonstrated to remove HgS and HgSe. Statistically significant (>10%) differences are observed however in samples containing more soluble Hg-containing phases (HgCl2, HgO, Hg3S2O4). Such differences may be related to matrix, particle size, or crystallinity effects, which could affect the apparent solubility of Hg phases present. In more highly concentrated samples, microscopy techniques can help characterize the Hg-bearing species in complex multiphase natural samples.

Three methods, pyrolytic and chemical extractions (PCE), extended X-ray adsorption fine structure spectroscopy (EXAFS) and solid-phase-Hg-thermo-desorption (SPTD) were applied to determine mercury speciation in amended substrates and mine waste samples. Although these three methods determine Hg speciation by fundamentally different processes, comparison of the results are useful for validation of the three methods. PCE uses pyrolysis and weak leaches to determine relative percentages of volatile, ‘soluble’ and residual Hg in substrate. The results are operationally defined and specific species cannot be determined with this method. EXAFS is a nondestructive method which uses high energy synchrotron-sourced X-ray radiation to identify specific species based on scattering patterns. Least squares data analysis is done to link patterns to a database of model compounds. This method is most useful for identification of specific species, given that they are included in the model database. Identification of Hg 0 is difficult using EXAFS. SPTD identifies Hg species by incremental heating and comparison of thermal release patterns to a database of compounds. SPTD allows the identification of a more limited number of specific species than EXAFS, but is the best of the three methods for the identification of Hg 0 . Overlapping release patterns make the identification of species, such as HgS and some forms of matrix-bound Hg, difficult. Results of PCE analyses indicate that volatile and leachable forms of Hg in mine waste are low relative to the total Hg concentration. This was supported by EXAFS and SPTD analysis which identified HgS as the primary component of mine waste. In contrast, analysis of tailings from mills that utilized Hg to amalgamate Au and Ag from ores yielded conflicting results. The results of this study illustrate the importance of using multiple analytical methods for the evaluation of Hg in the substrate.

Incident radiation has been reported to facilitate mercury release from soils. In this study the influence of light on mercury emissions from substrates amended with pure synthetic mercury species, and from naturally and anthropogenically mercury-enriched substrates were investigated using laboratory experiments and in situ flux measurements. Light-enhanced emissions were found to occur from substrates amended with HgS, and from elemental mercury (Hg 0 ) and HgCl2 amended iron oxide and organic containing substrates. The magnitude of light-enhanced emissions for natural substrates ranged from 1.5 to 116 times that occurring in the dark at the same substrate temperature. Substrates containing corderoite, metacinnabar and ‘‘matrix bound mercury’’ (that bound to organic or inorganic phases) exhibited a higher degree of light-enhanced emissions relative to that containing predominantly cinnabar. Calculated activation energies for both laboratory and field data indicate that photo-reduction is a process associated with the light-enhanced emissions. Activation energies, derived using in situ mercury fluxes and soil temperatures, indicated that photo-reduction was a dominant process facilitating release of Hg from substrates with sunrise. Activation energies, calculated using daytime data, were less than those calculated for sunrise. This is hypothesized to be due to a pool of Hg 0 being developed with photo-reduction at first light that is released as soil temperatures and convective heat transfer increase during the day. This study demonstrated that light energy is the more dominant process controlling mercury emissions from naturally enriched substrates than soil temperature. r 2002 Elsevier Science Ltd. All rights reserved.

Background Iron oxyhydroxides are commonly found in natural aqueous systems as nanoscale particles, where they can act as effective sorbents for dissolved metals due to their natural surface reactivity, small size and high surface area. These properties make nanoscale iron oxyhydroxides a relevant option for the remediation of water supplies contaminated with dissolved metals. However, natural geochemical processes, such as changes in ionic strength, pH, and temperature, can cause these particles to aggregate, thus affecting their sorption capabilities and remediation potential. Other environmental parameters such as increasing salinity may also impact metal retention, e.g. when particles are transported from freshwater to seawater. Results After using synthetic iron oxyhydroxide nanoparticles and nanoparticle aggregates in batch Zn(II) adsorption experiments, the addition of increasing concentrations of chloride (from 0.1 M to 0.6 M) appears to initially reduce Zn(II) retention, likely due to the desorption of outer-sphere zinc surface complexes and subsequent formation of aqueous Zn-Cl complexes, before then promoting Zn(II) retention, possibly through the formation of ternary surface complexes (supported by EXAFS spectroscopy) which stabilize zinc on the surface of the nanoparticles/aggregates. In batch Cu(II) adsorption experiments, Cu(II) retention reaches a maximum at 0.4 M chloride. Copper-chloride surface complexes are not indicated by EXAFS spectroscopy, but there is an increase in the formation of stable aqueous copper-chloride complexes as chloride concentration rises (with CuCl+ becoming dominant in solution at ~0.5 M chloride) that would potentially inhibit further sorption or encourage desorption. Instead, the presence of bidentate edge-sharing and monodentate corner-sharing complexes is supported by EXAFS spectroscopy. Increasing chloride concentration has more of an impact on zinc retention than the mechanism of nanoparticle aggregation, whereas aggregation condition is a stronger determinant of copper retention. Conclusions Based on these model uptake/retention studies, iron oxyhydroxide nanoparticles show potential as a strategy to remediate zinc-contaminated waters that migrate towards the ocean. Copper retention, in contrast, appears to be optimized at an intermediate salinity consistent with brackish water, and therefore may release considerable fractions of retained copper at higher (e.g. seawater) salinity levels.

Mining of mercury deposits located in the California Coast Range has resulted in the release of mercury to the local environment and water supplies. The solubility, transport, and potential bioavailability of mercury are controlled by its chemical speciation, which can be directly determined for samples with total mercury concentrations greater than 100 mg kg(-1) (ppm) using X-ray absorption spectroscopy (XAS). This technique has the additional benefits of being non-destructive to the sample, element-specific, relatively sensitive at low concentrations, and requiring minimal sample preparation. In this study, Hg L(III)-edge extended X-ray absorption fine structure (EXAFS) spectra were collected for several mercury mine tailings (calcines) in the California Coast Range. Total mercury concentrations of samples analyzed ranged from 230 to 1060 ppm. Speciation data (mercury phases present and relative abundances) were obtained by comparing the spectra from heterogeneous, roasted (calcined) mine tailings samples with a spectral database of mercury minerals and sorbed mercury complexes. Speciation analyses were also conducted on known mixtures of pure mercury minerals in order to assess the quantitative accuracy of the technique. While some calcine samples were found to consist exclusively of mercuric sulfide, others contain additional, more soluble mercury phases, indicating a greater potential for the release of mercury into solution. Also, a correlation was observed between samples from hot-spring mercury deposits, in which chloride levels are elevated, and the presence of mercury-chloride species as detected by the speciation analysis. The speciation results demonstrate the ability of XAS to identify multiple mercury phases in a heterogeneous sample, with a quantitative accuracy of +/-25% for the mercury-containing phases considered. Use of this technique, in conjunction with standard microanalytical techniques such as X-ray diffraction and electron probe microanalysis, is beneficial in the prioritization and remediation of mercury-contaminated mine sites.