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The use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest has grown rapidly over the previous decade. Considerations for the implementation and management of extracorporeal cardiopulmonary resuscitation are presented for the perioperative physician. [ABSTRACT FROM AUTHOR]

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients. [ABSTRACT FROM AUTHOR]

Background: Nursing home (NH) residents' vulnerability to COVID‐19 underscores the importance of infection preventionists (IPs) within NHs. Our study aimed to determine whether training and credentialing of NH IPs were associated with resident COVID‐19 deaths. Methods: This retrospective observational study utilized data from the Centers for Disease Control and Prevention's National Healthcare Safety Network NH COVID‐19 Module and USAFacts, from May 2020 to February 2021, linked to a 2018 national NH survey. We categorized IP personnel training and credentialing into four groups: (1) LPN without training; (2) RN/advanced clinician without training; (3) LPN with training; and (4) RN/advanced clinician with training. Multivariable linear regression models of facility‐level weekly deaths per 1000 residents as a function of facility characteristics, and county‐level COVID‐19 burden (i.e., weekly cases or deaths per 10,000 population) were estimated. Results: Our study included 857 NHs (weighted n = 14,840) across 489 counties and 50 states. Most NHs had over 100 beds, were for profit, part of chain organizations, and located in urban areas. Approximately 53% of NH IPs had infection control training and 82% were RNs/advanced clinicians. Compared with NHs employing IPs who were LPNs without training, NHs employing IPs who were RNs/advanced clinicians without training had lower weekly COVID‐19 death rates (−1.04 deaths per 1000 residents; 95% CI −1.90, −0.18), and NHs employing IPs who were LPNs with training had lower COVID‐19 death rates (−1.09 deaths per 1000 residents; 95% CI −2.07, −0.11) in adjusted models. Conclusions: NHs with LPN IPs without training in infection control had higher death rates than NHs with LPN IPs with training in infection control, or NHs with RN/advanced clinicians in the IP role, regardless of IP training. IP training of RN/advanced clinician IPs was not associated with death rates. These findings suggest that efforts to standardize and improve IP training may be warranted. [ABSTRACT FROM AUTHOR]

Introduction: Blacks are more likely to live in poverty and be uninsured, and are less likely to undergo revascularization after am acute myocardial infarction compared to whites. The objective of this study was to determine whether Medicaid expansion was associated with a reduction in revascularization disparities in patients admitted with an acute myocardial infarction. Methods: Retrospective analysis study using data (2010–2018) from hospitals participating in the University Health Systems Consortium, now renamed the Vizient Clinical Database. Comparative interrupted time series analysis was used to compare changes in the use of revascularization therapies (PCI and CABG) in white versus non-Hispanic black patients hospitalized with either ST-segment elevation (STEMI) or non-ST-segment elevation acute myocardial infarctions (NSTEMI) after Medicaid expansion. Results: The analytic cohort included 68,610 STEMI and 127,378 NSTEMI patients. The percentage point decrease in the uninsured rate for STEMIs and NSTEMIs was greater for blacks in expansion states compared to whites in expansion states. For patients with STEMIs, differences in black versus white revascularization rates decreased by 2.09 percentage points per year (95% CI, 0.29–3.88, P = 0.023) in expansion versus non-expansion states after adjusting for patient and hospital characteristics. Black patients hospitalized with STEMI in non-expansion states experienced a 7.24 percentage point increase in revascularization rate in 2014 (95% CI, 2.83–11.7, P < 0.001) but did not experience significant annual percentage point increases in the rate of revascularization in subsequent years (1.52; 95% CI, -0.51–3.55, P = 0.14) compared to whites in non-expansion states. Medicaid expansion was not associated with changes in the revascularization rate for either blacks or whites hospitalized with NSTEMIs. Conclusion: Medicaid expansion was associated with greater reductions in the number of uninsured blacks compared to uninsured whites. Medicaid expansion was not associated, however, with a reduction in revascularization disparities between black and white patients admitted with acute myocardial infarctions. [ABSTRACT FROM AUTHOR]

The Centers for Medicare and Medicaid Services (CMS) uses hierarchical modeling to stabilize its hospital quality star ratings by shrinking the performance of low-volume hospitals toward the performance of average hospitals. Responding to criticism that the methodology may distort the performance of low-volume hospitals, a CMS expert panel recommended that the agency consider using "shrinkage targets" to more accurately classify hospital quality performance. To test the "shrinkage targets" approach, we created two parallel sets of performance measures. We found that there was moderate-to-substantial agreement between the standard CMS approach and the approach based on shrinkage targets in hospital star ratings for all but the lowest-volume hospitals. These findings suggest that the standard CMS risk-adjustment methodology does not distort the star ratings of hospitals as long as case volumes exceed the current cutoff (twenty-five cases) used by CMS for public reporting. [ABSTRACT FROM AUTHOR]

Background: The number of pregnancy-related deaths and severe maternal complications continues to rise in the United States, and the quality of obstetrical care across U.S. hospitals is uneven. Providing hospitals with performance feedback may help reduce the rates of severe complications in mothers and their newborns. The aim of this study was to develop a risk-adjusted composite measure of severe maternal morbidity and severe newborn morbidity based on administrative and birth certificate data.Methods: This study was conducted using linked administrative data and birth certificate data from California. Hierarchical logistic regression prediction models for severe maternal morbidity and severe newborn morbidity were developed using 2011 data and validated using 2012 data. The composite metric was calculated using the geometric mean of the risk-standardized rates of severe maternal morbidity and severe newborn morbidity.Results: The study was based on 883,121 obstetric deliveries in 2011 and 2012. The rates of severe maternal morbidity and severe newborn morbidity were 1.53% and 3.67%, respectively. Both the severe maternal morbidity model and the severe newborn models exhibited acceptable levels of discrimination and calibration. Hospital risk-adjusted rates of severe maternal morbidity were poorly correlated with hospital rates of severe newborn morbidity (intraclass correlation coefficient, 0.016). Hospital rankings based on the composite measure exhibited moderate levels of agreement with hospital rankings based either on the maternal measure or the newborn measure (κ statistic 0.49 and 0.60, respectively.) However, 10% of hospitals classified as average using the composite measure had below-average maternal outcomes, and 20% of hospitals classified as average using the composite measure had below-average newborn outcomes.Conclusions: Maternal and newborn outcomes should be jointly reported because hospital rates of maternal morbidity and newborn morbidity are poorly correlated. This can be done using a childbirth composite measure alongside separate measures of maternal and newborn outcomes. [ABSTRACT FROM AUTHOR]

BackgroundObjectiveMethodsResultsConclusionsPhysical activity (PA) provides physical and psychosocial benefits for people with cystic fibrosis (pwCF). However, practice levels remain below recommendations and strategies for promoting PA in specialist centers need to be better identified. The socio-ecological model of health emphasizes the central role of policies and environment in influencing individuals’ health behaviors. This model provides a basis for understanding how health professionals perceive the promotion of PA in their centers.The aim of this study was to explore intervention components of PA promotion in specialized CF centers in France that are “experienced” in PA promotion, to identify elements that can be transferable to other centers.A descriptive qualitative study was conducted with 16 healthcare professionals and pwCF. Semi-structured interviews were conducted and analyzed using inductive and deductive methods classically used in psychology.Five themes were extracted: the action and its context, the partnerships established around this action to promote physical activity, the evaluation of the action, its reproducibility, and the changes induced by COVID-19.Some factors emerged as essential for promoting PA among pwCF, notably the dialogue between the health professionals and patients, the presence of adapted PA instructors, and the involvement of partners. [ABSTRACT FROM AUTHOR]

We have performed H2(D2) diffraction experiments on a Pd(110) surface using two different high-sensitivity set-ups. We have found that, although the total reflectivity of Pd(110) is comparable to that observed in other reactive systems, the corresponding H2(D2) diffraction patterns are quite different: no diffraction peak, including the specular one, is observed on Pd(110). This unexpected result is the consequence of dynamic trapping. Such interpretation is supported by classical dynamics calculations based on accurate ab initio potential energy surfaces. [ABSTRACT FROM AUTHOR]

We study the dipolar coupling of gold nanoparticles arranged in regular two-dimensional arrays by extinction micro-spectroscopy. When the interparticle spacing approaches the plasmon resonance wavelength of the individual particles, an additional band of very narrow width emerges in the extinction spectrum. By systematically changing the particles dielectric environment, the particles shape, the grating constant and angle of incidence, we show how this band associated to a grating induced-resonance can be influenced in strength and spectral position. The spectral position can be qualitatively understood by considering the conditions for grazing grating orders whereas the strength can be related to the strength of dipolar scattering from the individual particles. [ABSTRACT FROM AUTHOR]

Visible and near infrared extinction spectra of gold nanorod regular arrays exhibit several bands assigned to high multipolar order plasmon resonances. These up to ninth order multipolar resonances generate surface enhanced Raman scattering spectra with typically 5×104 enhancement which is of similar magnitude as those obtained for dipolar excitations.© 2005 American Institute of Physics. [ABSTRACT FROM AUTHOR]

This study compared monetary penalties and rewards among safety net vs non–safety net hospitals under Medicare's Comprehensive Care for Joint Replacement (CJR) model, a bundled payment plan for hip and knee replacements intended to incentivize health care quality and savings, in 2016 and 2017. [ABSTRACT FROM AUTHOR]

The Comprehensive Care for Joint Replacement (CJR) model introduced in 2016 aims to improve the quality and costs of care for Medicare beneficiaries undergoing hip and knee replacements. However, there are concerns that the safety-net hospitals that care for the greatest number of vulnerable patients may perform poorly in CJR. In this study we used Medicare's CJR data to evaluate the performance of 792 hospitals mandated to participate in the first year of CJR. We found that in comparison to non-safety-net hospitals, 42 percent fewer safety-net hospitals qualified for rewards based on their quality and spending performance (33 percent of safety-net hospitals qualified, compared to 57 percent of non-safety-net hospitals), and safety-net hospitals' rewards per episode were 39 percent smaller ($456 compared to $743). Continuation of this performance trend could place safety-net hospitals at increased risk of penalties in future years. Medicare and hospital strategies such as those that reward high-quality care for vulnerable patients could enable safety-net hospitals to compete effectively in CJR. [ABSTRACT FROM AUTHOR]

Objective: To determine whether Medicare's Nonpayment Program was associated with decline in venous thromboembolism (VTE) following hip and knee replacements; and whether the decline was greater among hospitals at risk of larger financial losses from the Program.Data Sources: State Inpatient Database for New York (NY) from 2005 to 2013.Study Design: The primary outcome was an occurrence of VTE. Medicare Utilization Ratio (MUR), which is the proportion of inpatient days in a hospital that is financed by Medicare, represented a hospital's financial sensitivity. We used hierarchical logistic regressions with difference-in-differences estimation to study the Program effects.Principal Findings: A total of 98,729 hip replacement and 111,361 knee replacement stays were identified. For hip replacement, the Program was associated with significant reduction (Range: 44% to 53%) in VTE incidence among hospitals in MUR quartiles 2 to 4. For knee replacement, the Program was associated with significant reduction (47%) in VTE incidence only among quartile 2 hospitals.Conclusion: Implementation of the Program was associated with a reduction in VTE, especially for hip replacements, in higher MUR hospitals. Payment reforms such as Medicare's Nonpayment Program that withhold payments for complications are effective and should be continued. [ABSTRACT FROM AUTHOR]

What We Already Know About This Topic: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The 2014 American College of Cardiology Perioperative Guideline recommends risk stratifying patients scheduled to undergo noncardiac surgery using either: (1) the Revised Cardiac Index; (2) the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator; or (3) the Myocardial Infarction or Cardiac Arrest calculator. The aim of this study is to determine how often these three risk-prediction tools agree on the classification of patients as low risk (less than 1%) of major adverse cardiac event.Methods: This is a retrospective observational study using a sample of 10,000 patient records. The risk of cardiac complications was calculated for the Revised Cardiac Index and the Myocardial Infarction or Cardiac Arrest models using published coefficients, and for the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator using the publicly available website. The authors used the intraclass correlation coefficient and kappa analysis to quantify the degree of agreement between these three risk-prediction tools.Results: There is good agreement between the American College of Surgeons National Surgical Quality Improvement Program and Myocardial Infarction or Cardiac Arrest estimates of major adverse cardiac events (intraclass correlation coefficient = 0.68, 95% CI: 0.66 to 0.70), while only poor agreement between (1) American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator and the Revised Cardiac Index (intraclass correlation coefficient = 0.37; 95% CI: 0.34 to 0.40), and (2) Myocardial Infarction or Cardiac Arrest and Revised Cardiac Index (intraclass correlation coefficient = 0.26; 95% CI: 0.23 to 0.30). The three prediction models disagreed 29% of the time on which patients were low risk.Conclusions: There is wide variability in the predicted risk of cardiac complications using different risk-prediction tools. Including more than one prediction tool in clinical guidelines could lead to differences in decision-making for some patients depending on which risk calculator is used. [ABSTRACT FROM AUTHOR]

Abstract: Recent developments in structural modeling techniques have dramatically increased the capability to incorporate fold‐related data into the modeling workflow. However, these techniques are lacking a mathematical framework for properly addressing structural uncertainties. Previous studies investigating structural uncertainties have focused on the sensitivity of the interpolator to perturbing the input data. These approaches do not incorporate conceptual uncertainty about the geological structures and interpolation process to the overall uncertainty estimate. In this work, we frame structural modeling as an inverse problem and use a Bayesian framework to reconcile structural parameters and data uncertainties. Bayesian inference is applied for determining the posterior probability distribution of fold parameters given a set of structural observations and prior distributions based on general geological knowledge and regional observations. This approach allows for an inversion of structural geology data, where each realization can differ in the structural description of the fold geometries, instead of finding only a single best fit solution. We show that analyzing the variability between the resulting models highlights uncertainties associated with the geometry of regional structures. These areas can be used to target where additional data would be most beneficial for improving the model quality and efficiently reducing structural uncertainty. [ABSTRACT FROM AUTHOR]

A master equation approach is used for investigating energy transfer and trapping in two-dimensional disordered systems, where the traps are statistical pairs of pigment molecules closer than a critical distance Rc. Fluorescence decay curves are calculated over a range of concentrations as a function of Rc and the Förster transfer radius R0. The concentration dependence of the lifetimes is compared to the fluorescence self-quenching data that Chauvet et al. obtained from real-time measurements in monolayers of chlorophyll a and dioleylphosphatidylcholine (DOL). This dependence is found to be close to second order and for a choice of Rc =10 Å the experimental data are fit if R0=78±2 Å. This value is in close agreement with those found in the literature from depolarization measurements. [ABSTRACT FROM AUTHOR]

Gravity inversions have contributed greatly to our knowledge of the interior of planetary bodies and the processes that shaped them. However, previous global gravity inversion methods neglect the inference of mantle density anomalies when using techniques to decrease the non‐uniqueness of the inversion. In this work, we present a novel global gravity inversion algorithm, named THeBOOGIe, suited to inferring global‐scale density anomalies within the crust and mantle of planetary bodies. The algorithm embraces the nonuniqueness inherent in gravity inversions by not prescribing at the outset a density interface or depth range of interest. Instead, the method combines a Bayesian approach with a flexible incorporation of prior geological or geophysical information to infer density anomalies at any depth. A validation test using synthetic lunar‐like gravity data shows that THeBOOGIe can constrain the lateral location of crustal density anomalies but tends to overestimate their thicknesses. Importantly, THeBOOGIe can detect deep mantle density anomalies and quantify the level of confidence in the inferred density models. Our results show that THeBOOGIe can provide complementary information to one‐dimensional seismic models of the interior of the terrestrial planets and the Moon by constraining density anomalies that are not spherically symmetric. Additionally, THeBOOGIe is specially suited to constraining the interior of partially differentiated bodies where these large‐scale density anomalies are more likely to exist. Finally, thanks to the flexible use of priors, THeBOOGIe is an essential tool to understand the interior of planetary bodies lacking additional constraints. Plain Language Summary: Gravity data is often the main constraint on the structure of planetary interiors. However, inferring the density structure of a body from gravity data is inherently non‐unique, due to the tradeoff between density anomaly and distance in the definition of gravity anomalies. Traditional methods circumvent this problem by specifying a priori the source of gravity anomalies to crustal thickness variations while neglecting deeper anomalies. We present here an alternative approach where density anomalies are defined over finite‐size objects and the inversion is conducted within a Bayesian framework. Our algorithm, named THeBOOGIe, is able to recover the location of density anomalies in the mantle of the Moon, although the inferred shallow crustal anomalies are spread over a larger depth range than the actual object producing the gravity anomaly. Our approach provides important complementary information about the interior of planetary bodies than the one provided by traditional inversion methods. Key Points: A novel Bayesian gravity inversion method constrains 3‐D global‐scale density anomalies and provides uncertainty on the resulting modelOur algorithm recovers deep mantle anomalies adequately but dilutes shallow crustal density anomalies over a larger depth rangeOur Bayesian framework is especially suited for inverting the gravity field of planetary bodies that lack additional geophysical constraints [ABSTRACT FROM AUTHOR]

Background: Readmission penalties are central to the Centers for Medicare and Medicaid Services (CMS) efforts to improve patient outcomes and reduce health care spending. However, many clinicians believe that readmission metrics may unfairly penalize low-mortality hospitals because mortality and readmission are competing risks. The objective of this study is to compare hospital ranking based on a composite outcome of death or readmission versus readmission alone.Methods: We performed a retrospective observational study of 344,565 admissions for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumoniae (PNEU) using population-based data from the New York State Inpatient Database (NY SID) between 2011 and 2013. Hierarchical logistic regression modeling was used to estimate separate risk-adjustment models for the (1) composite outcome (in-hospital death or readmission within 7-days), and (2) 7-day readmission. Hospital rankings based on the composite measure and the readmission measure were compared using the intraclass correlation coefficient and kappa analysis.Results: Using data from all AMI, CHF, and PNEU admissions, there was substantial agreement between hospital adjusted odds ratio (AOR) based on the composite outcome versus the readmission outcome (intraclass correlation coefficient [ICC] 0.67; 95% CI: 0.56, 0.75). For patients admitted with AMI, there was moderate agreement (ICC 0.53; 95% CI: 0.41, 0.62); for CHF, substantial agreement (ICC 0.72; 95% CI: 0.66, 0.78); and for PNEU, substantial agreement (ICC 0.71; 95% CI: 0.61, 0.78). There was moderate agreement when the composite and readmission metrics were used to classify hospitals as high, average, and low-performance hospitals (κ = 0.54, SE = 0.050). For patients admitted with AMI, there was slight agreement (κ = 0.14, SE = 0.037) between the two metrics.Conclusions: Hospital performance on readmissions is significantly different from hospital performance on a composite metric based on readmissions and mortality. CMS and policy makers should consider re-assessing the use of readmission metrics for measuring hospital performance. [ABSTRACT FROM AUTHOR]

Background: The validity of basing healthcare reimbursement policy on pay-for-performance is grounded in the accuracy of performance measurement.Methods: Monte Carlo simulation was used to examine the accuracy of performance profiling as a function of statistical methodology, case volume, and the extent to which hospital or physician performance deviates from the average.Results: There is extensive variation in the true-positive rate and false discovery rate as a function of model specification, hospital quality, and hospital case volume. Hierarchical and nonhierarchical modeling are both highly accurate at very high case volumes for very low-quality hospitals. At equivalent case volumes and hospital effect sizes, the true-positive rate is higher for nonhierarchical modeling than for hierarchical modeling, but the false discovery rate is generally much lower for hierarchical modeling than for nonhierarchical modeling. At low hospital case volumes (200) that are typical for many procedures, and for hospitals with twice the rate of death or major complications for patients undergoing isolated coronary artery bypass graft surgery at the average hospital, hierarchical modeling missed 90.6% of low-quality hospitals, whereas nonhierarchical modeling missed 65.3%. However, at low case volumes, 38.9% of hospitals classified as low-quality outliers using nonhierarchical modeling were actually average quality, compared to 5.3% using hierarchical modeling.Conclusions: Nonhierarchical modeling frequently misclassified average-quality hospitals as low quality. Hierarchical modeling commonly misclassified low-quality hospitals as average. Assuming that the consequences of misclassifying an average-quality hospital as low quality outweigh the consequences of misclassifying a low-quality hospital as average, hierarchical modeling may be the better choice for quality measurement. [ABSTRACT FROM AUTHOR]

Click here to view the Original article by Dr. Wästerlid et al. [ABSTRACT FROM AUTHOR]

Background: Individual berries in a grape (Vitis vinifera L.) cluster enter the ripening phase at different times leading to an asynchronous cluster in terms of ripening. The factors causing this variable ripening initiation among berries are not known. Because the influence via hormonal communication of the seed on fruit set and growth is well known across fruit species, differences in berry seed content and resultant quantitative or qualitative differences in the hormone signals to the pericarp likely influence the relative timing of ripening initiation among berries of the cluster. Results: At the time of the initiation of cluster ripening (véraison), underripe green berries have higher seed content compared to the riper berries and there is a negative correlation between the seed weight-to-berry weight ratio (SB) and the sugar level in berries of a cluster. Auxin levels in seeds relative to the pericarp tissues are two to 12 times higher at pre-ripening stages. The pericarp of berries with high-SB had higher auxin and lower abscisic acid (ABA) levels compared to those with low-SB from two weeks before véraison. In the prevéraison cluster, the expression of auxin-response factor genes was significantly higher in the pericarp of high-SB berries and remained higher until véraison compared to low-SB berries. The expression level of auxin-biosynthetic genes in the pericarp was the same between both berry groups based upon similar expression activity of YUC genes that are rate-limiting factors in auxin biosynthesis. On the other hand, in low-SB berries, the expression of ABA-biosynthetic and ABA-inducible NCED and MYB genes was higher even two weeks before véraison. Conclusions: Differences in the relative seed content among berries plays a major role in the timing of ripening initiation. Towards the end of berry maturation phase, low and high levels of auxin are observed in the pericarp of low- and high-SB berries, respectively. This results in higher auxin-signaling activity that lasts longer in the pericarp of high-SB berries. In contrast, in low-SB berries, concomitant with an earlier decrease of auxin level, the features of ripening initiation, such as increases in ABA and sugar accumulation begin earlier. [ABSTRACT FROM AUTHOR]

Of the approximately four million women who give birth each year in the United States, nearly 13 percent experience one or more major complications. But the extent to which the rates of major obstetrical complications vary across hospitals in the United States is unknown. We used multivariable logistic regression models to examine the variation in obstetrical complication outcomes across US hospitals among a large, nationally representative sample of more than 750,000 obstetrical deliveries in 2010. We found that 22.55 percent of patients delivering vaginally at low-performing hospitals experienced major complications, compared to 10.42 percent of similar patients delivering vaginally at high-performing hospitals. Hospitals were classified as having low, average, or high performance based on a calculation of the relative risk that a patient would experience a major complication. Patients undergoing a cesarean delivery at low-performing hospitals had nearly five times the rate of major complications that patients undergoing a cesarean delivery at high-performing hospitals had (20.93 percent compared to 4.37 percent). Our finding that the rate of major obstetrical complications varies markedly across US hospitals should prompt clinicians and policy makers to develop comprehensive quality metrics for obstetrical care and focus on improving obstetrical outcomes. [ABSTRACT FROM AUTHOR]

Silica-coated gold nanorods functionalized with grafted fluorescent and photochromic derivatives were synthesized and characterized. Spectroscopic investigations demonstrated that cross-coupled interactions between plasmonic, photochromic, and fluorescence properties play a major role in such nanosystems, depending on the thickness of the silica spacer, leading to multi-signal photoswitchability. [ABSTRACT FROM AUTHOR]

Background Although there is significant variability in the rate of blood transfusion in surgical patients, the role of surgical skill as a determinant of blood use is unknown. Study Design and Methods We examined the association between surgery resident participation and intraoperative blood transfusion, and 30-day mortality and complications, among 381,036 patients undergoing noncardiac surgery, adjusting for patient factors and procedure complexity. Results Compared to attending surgeons working without a resident, cases in which the attendings worked with either Postgraduate Year ( PGY) 3 to 4 resident or a PGY5 to 8 resident had a 56% (adjusted odds ratio [ AOR], 1.56; 95% confidence interval [ CI, 1.48-1.64) or a 78% ( AOR, 1.78; 95% CI, 1.70-1.87) higher odds of receiving a blood transfusion, respectively. Involvement of surgical interns or junior residents ( PGY1-2), whose role in the operative procedure is assumed to be limited, was associated with a 27% higher odds of receiving a blood transfusion ( AOR, 1.27; 95% CI, 1.18-1.37). Overall, resident involvement was not associated with increased risk of 30-day mortality ( AOR, 0.97; 95% CI, 0.91-1.04), but was associated with a slightly increased risk of complications ( AOR, 1.13; 95% CI, 1.10-1.16). Conclusion Senior surgery resident participation in noncardiac surgery is associated with between a 56% to 78% higher risk of receiving a blood transfusion intraoperatively compared to attending surgeons working without a resident. Assuming that senior surgical trainees are performing critical parts of the operative procedure and are less skilled than attending surgeons, the findings from this exploratory study suggest that intraoperative blood transfusion may serve as an indirect measure of surgical technical quality. [ABSTRACT FROM AUTHOR]

BACKGROUND: Most studies examining the prognostic value of preoperative coagulation testing are too small to examine the predictive value of routine preoperative coagulation testing in patients having noncardiac surgery. METHODS: Using data from the American College of Surgeons National Surgical Quality Improvement database, the authors performed a retrospective observational study on 316,644 patients having noncardiac surgery who did not have clinical indications for preoperative coagulation testing. The authors used multivariable logistic regression analysis to explore the association between platelet count abnormalities and red cell transfusion, mortality, and major complications. RESULTS: Thrombocytopenia or thrombocytosis occurred in 1 in 14 patients without clinical indications for preoperative platelet testing. Patients with mild thrombocytopenia (101,000-150,000 ul), moderate-to-severe thrombocytopenia (<100,000 ul), and thrombocytosis (>=450,000 ul) were significantly more likely to be transfused (7.3%, 11.8%, 8.9%, 3.1%) and had significantly higher 30-day mortality rates (1.5%, 2.6%, 0.9%, 0.5%) compared with patients with a normal platelet count. In the multivariable analyses, mild thrombocytopenia (adjusted odds ratio [AOR], 1.28; 95% CI, 1.18-1.39) and moderate-to-severe thrombocytopenia (AOR, 1.76; 95% CI, 1.49-2.08), and thrombocytosis (AOR, 1.44; 95% CI, 1.30-1.60) were associated with increased risk of blood transfusion. Mild thrombocytopenia (AOR, 1.31; 95% CI, 1.11-1.56) and moderate-to-severe thrombocytopenia (AOR, 1.93; 95% CI, 1.43-2.61) were also associated with increased risk of 30-day mortality, whereas thrombocytosis was not (AOR, 0.94; 95% CI, 0.72-1.22). CONCLUSION: Platelet count abnormalities found in the course of routine preoperative screening are associated with a higher risk of blood transfusion and death. [ABSTRACT FROM AUTHOR]

Objective To determine whether outcome disparities between black and white trauma patients have decreased over the last 10 years. Data Source Pennsylvania Trauma Outcome Study. Study Design We performed an observational cohort study on 191,887 patients admitted to 28 Level 1 and Level II trauma centers. The main outcomes of interest were (1) death, (2) death or major complication, and (3) failure-to-rescue. Hospitals were categorized according to the proportion of black patients. Multivariate regression models were used to estimate trends in racial disparities and to assess whether the source of racial disparities was within or between hospitals. Principal Findings Trauma patients admitted to hospitals with high concentrations of blacks (>20 percent) had a 45 percent higher odds of death (adj OR: 1.45, 95 percent CI: 1.09-1.92) and a 73 percent higher odds of death or major complication (adj OR: 1.73, 95 percent CI: 1.42-2.11) compared with patients admitted to hospitals treating low proportions of blacks. Blacks and whites admitted to the same hospitals had no difference in mortality (adj OR: 1.05, 95 percent CI: 0.87, 1.27) or death or major complications (adj OR: 1.01; 95 percent CI: 0.90, 1.13). The odds of overall mortality, and death or major complications have been reduced by 32 percent (adj OR: 0.68; 95 percent CI: 0.54-0.86) and 28 percent (adj OR: 0.72; 95 percent CI: 0.60-0.85) between 2000 and 2009, respectively. Racial disparities did not change over 10 years. Conclusion Despite the overall improvement in outcomes, the gap in quality of care between black and white trauma patients in Pennsylvania has not narrowed over the last 10 years. Racial disparities in trauma are due to the fact that black patients are more likely to be treated in lower quality hospitals compared with whites. [ABSTRACT FROM AUTHOR]

Objective Older persons with coronary heart disease have reduced access to appropriate medical and surgical services if they are also mentally ill. This study determined whether difference exists in access to hospitals that provide on-site invasive cardiac procedures among a national cohort of Medicare acute myocardial infarction ( AMI) patients with and without comorbid mental illness, and its implications for subsequent procedure use. Methods Retrospective analyses of Medicare claims for initial AMI admissions between January and September 2007. Hospital service availability was obtained from annual survey data. Logistic regression estimated the associations of mental illness with admission to hospitals with any invasive cardiac services (diagnostic catheterization, coronary angioplasty, or bypass surgery) and post-admission care patterns and outcomes. Results Eighty-two percent of mentally ill AMI patients ( n = 28,888) versus 87 percent of other AMI patients ( n = 73,895) were initially admitted to hospitals with invasive cardiac facilities [adjusted odds ratio ( OR) = 0.81, p < .001]. Admission to such hospitals was associated with overall higher rate of procedure use within 90 days of admission and improved 30-days readmission and mortality rates. However, irrespective of on-site service availability of the admitting hospital, mentally ill patients were one half as likely to receive invasive procedures (adjusted OR approximately 0.5, p < .001). Conclusions Among Medicare patients with AMI, those with comorbid mental illness were less likely to be admitted to hospitals with on-site invasive cardiac services. Mental illness was associated with reduced cardiac procedure use within each type of admitting hospitals (with on-site invasive cardiac services or not). [ABSTRACT FROM AUTHOR]

BACKGROUND: Benchmarking performance across hospitals requires proper adjustment for differences in baseline patient and procedural risk. Recently, a Risk Stratification Index was developed from Medicare data, which used all diagnosis and procedure codes associated with each stay, but did not distinguish present-on-admission (POA) diagnoses from hospital-acquired diagnoses. We sought to (1) develop and validate a risk index for in-hospital mortality using only POA diagnoses, principal procedures, and secondary procedures occurring before the date of the principal procedure (POARisk) and (2) compare hospital performance metrics obtained using the POARisk model with those obtained using a similarly derived model which ignored the timing of diagnoses and procedures (AllCodeRisk). METHODS: We used the 2004-2009 California State Inpatient Database to develop, calibrate, and prospectively test our models (n = 24 million). Elastic net logistic regression was used to estimate the two risk indices. Agreement in hospital performance under the two respective risk models was assessed by comparing observed-to-expected mortality ratios; acceptable agreement was predefined as the AllCodeRisk-based observed-to-expected ratio within ± 20% of the POARisk-based observed-to-expected ratio for more than 95% of hospitals. RESULTS: After recalibration, goodness of fit (i.e., model calibration) within the 2009 data was excellent for both models. C-statistics were 0.958 and 0.981, respectively, for the POARisk and AllCodeRisk models. The AllCodeRisk-based observed-to-expected ratio was within ± 20% of the POARisk-based observed-to-expected ratio for 89% of hospitals, which was slightly lower than the predefined limit of agreement. CONCLUSION: Consideration of POA coding meaningfully improved hospital performance measurement. The POARisk model should be used for risk adjustment when POA data are available. [ABSTRACT FROM AUTHOR]

Abstract: Background: Malaria remains one of the most important illnesses in sub-Saharan Africa. In Benin, it constitutes a major public health preoccupation particularly for children and pregnant women. Until now, population still mostly relies on herbal medicine for malaria healing. Hence this study was carried out to document the medicinal plants used in the plateau of Allada in Benin and to assess local knowledge on traditional medicine in the management of malaria and related symptoms. Materials and methods: Data were collected from 53 informants composed of 23 traditional healers and 30 medicinal plants sellers using a structured questionnaire. Results: A total of 82 plants species belonging to 78 genera in 43 plant families were recorded as antimalarial in the study area. The families of Rubiaceae and Caesalpiniaceae were the most represented with seven species each. High informant consensus factor (ICF) was recorded in the treatment of malaria (ICF=0.90). High fidelity level (FL=100%) was also recorded for 45.67% of the species used as antimalarial. Dichapetalum madagascariense was the species of high relative frequency of citation (RFC=0.81). The dominant plant parts used in the preparation of remedies were leaves (68%). The decoction (79%) was the main mode of preparation, while oral route (92%) was the principal route of remedies administration. Conclusion: This study provides plant species used in the plateau of Allada for malaria and related symptoms treatment. We hope that this study could be important for the conservation of traditional knowledge on the antimalarial plants and the improvement of malaria management. However, several plant species used as antimalarial by the traditional medicine practitioners in the study area need to be screened in order to identify the species having antiplasmodial activity. [ABSTRACT FROM AUTHOR]

Abstract: Background: Malaria remains one of the most important illnesses in sub-Saharan Africa. In Benin, it constitutes a major public health preoccupation particularly for children and pregnant women. Until now, population still mostly relies on herbal medicine for malaria healing. Hence this study was carried out to document the medicinal plants used in the plateau of Allada in Benin and to assess local knowledge on traditional medicine in the management of malaria and related symptoms. Materials and methods: Data were collected from 53 informants composed of 23 traditional healers and 30 medicinal plants sellers using a structured questionnaire. Results: A total of 82 plants species belonging to 78 genera in 43 plant families were recorded as antimalarial in the study area. The families of Rubiaceae and Caesalpiniaceae were the most represented with seven species each. High informant consensus factor (ICF) was recorded in the treatment of malaria (ICF=0.90). High fidelity level (FL=100%) was also recorded for 45.67% of the species used as antimalarial. Dichapetalum madagascariense was the species of high relative frequency of citation (RFC=0.81). The dominant plant parts used in the preparation of remedies were leaves (68%). The decoction (79%) was the main mode of preparation, while oral route (92%) was the principal route of remedies administration. Conclusion: This study provides plant species used in the plateau of Allada for malaria and related symptoms treatment. We hope that this study could be important for the conservation of traditional knowledge on the antimalarial plants and the improvement of malaria management. However, several plant species used as antimalarial by the traditional medicine practitioners in the study area need to be screened in order to identify the species having antiplasmodial activity. [Copyright &y& Elsevier]

Background: Within organized trauma systems, both Level I and Level II trauma centers are expected to have the resources to treat patients with major multisystem trauma. The evidence supporting separate designations for Level I and Level II trauma centers is inconclusive. The objective of this study was to compare mortality and complications for injured patients admitted to Level I and Level II trauma centers. Study Design: Using data from the Pennsylvania Trauma Outcomes Study registry, we performed a retrospective observational study of 208,866 patients admitted to 28 Level I and Level II trauma centers between 2000 and 2009. Regression modeling was used to estimate the association between patient outcomes and trauma center designation, after controlling for injury severity, mechanism of injury, transfer status, and physiology. Results: Patients admitted to Level I trauma centers had a 15% lower odds of mortality (adjusted odds ratio [adj OR] 0.85; 95% CI 0.72 to 0.99) and a 35% increased odds of complications (adj OR 1.37; 95% CI 1.04 to 1.79). The survival benefit associated with admission to Level I centers was strongest in patients with very severe injuries (Injury Severity Score [ISS] ≥ 25; adj OR 0.78; 95% CI 0.64 to 0.95). Less severely injured patients with an ISS < 9 (adj OR 0.91; 95% CI 0.64 to 1.30) and with an ISS between 9 and 15 (adj OR 0.98; 95% CI 0.81 to 1.18) had similar risks of mortality in Level I and Level II trauma centers. Conclusions: Severely injured patients admitted to Level I trauma centers have a lower risk of mortality compared with patients admitted to Level II centers. These findings support the continuation of a 2-tiered designation system for trauma. [ABSTRACT FROM AUTHOR]

We experimentally demonstrate that atomic orbital parity mix interferences can be temporally controlled on an attosecond time scale. Electron wave packets are formed by ionizing argon gas with a comb of odd and even high-order harmonics, in the presence of a weak infrared field. Consequently, a mix of energy-degenerate even and odd parity states is fed in the continuum by one- and two-photon transitions. These interfere, leading to an asymmetric electron emission along the polarization vector. The direction of the emission can be controlled by varying the time delay between the comb and infrared field pulses. We show that such asymmetric emission provides information on the relative phase of consecutive odd and even order harmonics in the attosecond pulse train. [ABSTRACT FROM AUTHOR]

We have investigated the spectral splitting of high harmonics generated in a semi-infinite gas cell. By performing an EUV-IR cross-correlation experiment, we are able to use the phase behaviour of the different sub-peaks of each harmonic to identify them with different electronic trajectories. Both microscopic and macroscopic analyses of the spectra effects are made. The identification of a particular trajectory with a particular component of the splitting on the basis of a single-atom model is found to be incorrect, while the full macroscopic treatment is in agreement with the experiment. [ABSTRACT FROM AUTHOR]

Aims: The purpose of the present study was too explore the role of interatrial dyssynchrony in heart failure with preserved ejection fraction (HFPEF). Methods and Results: For the case study we selected seven patients with severe HFPEF, with interatrial block on electrocardiogram (ECG), and a delayed and interrupted A wave on mitral Doppler. Echocardiographic left atrial (LA) volumes/functions, mitral E/A and E/e' ratios, mitral A wave duration/deceleration time, and interatrial mechanical delays (IAMDs) at tissue Doppler, were studied. We performed right heart catheterization, and an electrophysiological study (EPS) for the measurement of interatrial conduction delay (IACD) and left atrioventricular interval (LAVI). Mean IAMD was 106 ms. All the patients exhibited a restrictive mitral Doppler pattern, high E/A and E/e' ratios, and short A wave duration/deceleration time. Left atrial volume was increased, with severely depressed functions. Right heart catheterization showed severe post-capillary pulmonary hypertension. The EPS showed an IACD of 170 ± 20 ms, with a short LAVI. Left atrial pacing through the coronary sinus reduced the IACD to 25 ± 15 ms. In the pilot study, 29 patients with HFPEF were compared with 27 age-matched control patients. HFPEF patients had longer P waves, shorter A waves, and a longer IAMD than the controls. Prevalence of severe IAMD >60 ms was 59% in HFPEF and 0% in controls. In the HFPEF group, patients with an IAMD >60 ms had significantly shorter A waves and higher E/e' ratio. Conclusion: Some HFPEF patients present with IACD, delayed LA systole, shortened LA emptying, decreased LA compliance, and increased filling pressures. Whether the condition of these patients could be improved by atrial resynchronization deserves further investigation. [ABSTRACT FROM AUTHOR]

Background: The enormous fiscal pressures facing trauma centers may lead trauma centers to reduce nurse staffing and to make increased use of less expensive and less skilled personnel. The impact of nurse staffing and skill mix on trauma outcomes has not been previously reported. The goal of this study was to examine whether nurse staffing levels and nursing skill mix are associated with trauma patient outcomes. Methods: We used data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to perform a cross-sectional study of 70,142 patients admitted to 77 Level I and Level II centers. Logistic regression models were used to examine the association between nurse staffing measures and (1) mortality, (2) healthcare associated infections (HAI), and (3) failure-to-rescue. We controlled for patient risk factors (age, gender, injury severity, mechanism of injury, comorbidities) and hospital structural characteristics (trauma center status - Level I versus Level II, hospital size, ownership, teaching status, technology level, and geographic region). Results: A 1% increase in the ratio of licensed practical nurse (LPN) to total nursing time was associated with a 4% increase in the odds of mortality (adj OR 1.04; 95% CI: 1.02-1.06; p = 0.001) and a 6% increase in the odds of sepsis (adj OR 1.06: 1.03-1.10; p < 0.001). Hospitals in the highest quartile of LPN staffing had 3 excess deaths (95% CI: 1.2, 5.1) and 5 more episodes of sepsis (95% CI: 2.3, 7.6) per 1000 patients compared to hospitals in the lower quartile of LPN staffing. Conclusions: Higher hospital LPN staffing levels are independently associated with slightly higher rates of mortality and sepsis in trauma patients admitted to Level I or Level II trauma centers. [ABSTRACT FROM AUTHOR]

Background: In addition to plant species biology and ecology, understanding the folk knowledge systems related to the use of plant species and how this knowledge system influences the conservation of plant species is an important issue in the implementation of sustainable strategies of biodiversity conservation programs. This study aimed at providing information on the use and local knowledge variation on Chrysophyllum albidum G. Don a multipurpose tree species widely used in southern Benin. Methods: Data was collected through 210 structured interviews. Informants were randomly selected from tenvillages. The fidelity level and use value of different plant parts of C. albidum were estimated. The variation in ethnobotanical knowledge was assessed by comparing the use value between ethnic, gender and age groups. In order to assess the use pattern of the different plant parts in folk medicine, a correspondence analysis was carried out on the frequency citation of plant parts. Results: Four categories of use (food, medicine, firewood and timber) were recorded for C. albidum. With respect to the different plant parts, the fleshy pulp of the African star apple fruit showed high consensus degree as food among the informants. Fifteen diseases were reported to be treated by the different parts of C. albidum in the region. Correspondence analysis revealed the specificity of each part in disease treatment. There was no significant difference among ethnic groups regarding the ethno-botanical use value of C. albidum. However, significant difference existed between genders and among age groups regarding the knowledge of the medical properties of this species.Conclusions: C. albidum is well integrated in the traditional agroforestry system of the southern Benin. Despite its multipurpose character, this species remains underutilized in the region. Considering the current threat of habitat degradation, action is needed in order to ensure the long term survival of the species and local communities' livelihoods. [ABSTRACT FROM AUTHOR]

Objectives. We examined racial disparities in rehospitalization rates among a cohort of non-Hispanic White and Black Medicare beneficiaries admitted to skilled nursing facilities for postacute care. Methods. We analyzed the 2008 national Nursing Home Minimum Data Set, augmented with other databases. We used multivariable logistic regression to estimate overall racial disparities in rehospitalization rates within 30 days and 90 days of nursing facility admission and the extent to which the disparities were explained by patient, facility, market, and state factors. Stratified analyses identified persistent disparities within patient subgroups, facility types, and states. Results. The 30-day rehospitalization rates were 14.3% for White patients (n = 865993) and 18.6% for Black patients (n = 94651); the 90-day rehospitalization rates were 22.1% and 29.5%, respectively. Both patient and admitting facility characteristics accounted for a considerable portion of overall racial disparities, but disparities persisted after multivariable adjustments overall and in patient subgroups. Conclusions. We found persistent racial disparities in rehospitalization among the nation's skilled nursing facility patients receiving postacute care. Targeted efforts are needed to remove these disparities. [ABSTRACT FROM AUTHOR]

The article discusses a study on the relationship of intraoperative blood transfusion with morbidity and mortality in patients undergoing noncardiac surgery. The study subjects included 10,100 patients undergoing orthopedic, vascular, and general surgery. Results revealed that an increased risk of mortality is associated with intraoperative blood transfusion. There are several types of complications that patients receiving intraoperative transfusion may experience including thromboembolic, septic wound, and pulmonary complications.

The article presents a study which examines the effect of modified metabolic syndrome on perioperative outcomes. For the study, researchers used data from 310,208 individuals in the Americal College of Surgeons National Surgical Quality Improvement Program database. Key findings revealed that individuals with the modified metabolic syndrome who are very obese had a 2-fold increased risk of dying. Researchers concluded that individuals with the modified metabolic syndromes subjected to noncardiac surgery have the higher risk of complications.

Volcanic gaps are segments of subduction zones that lack the volcanic activity usually found at these convergent margins. They are regions where the necessary conditions to produce melt may appear favourable, but where volcanoes are surprisingly absent from the surface. In this study, we present a new model that can explain the occurrence of such volcanic gaps. It is based on seismic imaging and geodynamic modelling of the Denali volcanic gap, a ∼400-km-wide region at the eastern end of the Alaska-Aleutian subduction zone. Here, the thick crust of the Pacific Plate and Yakutat terrane subduct at shallow angle beneath North America. A high-resolution seismic profile clearly images the subducting crust undergoing progressive dehydration between 50 and 120 km depth, and a negative subhorizontal velocity contrast at 60 km depth in the overlying mantle wedge. We interpret this 60 km discontinuity as marking the top of a layer of partial melt that pools at the base of the overriding plate. In steady-state subduction models, melt accumulates at the apex of a vaulted mantle wedge, the ‘pinch zone’, from where it may break through the overlying lithosphere to the surface. Beneath the Denali volcanic gap, the pinch zone is absent (or greatly reduced) because shallow subduction of the Yakutat terrane progressively cools the system, and causes the slab to advance and replace the hot core of the mantle wedge. This regime can be seen as the opposite of subduction roll-back. It prevents the formation of a pinch zone, reduces the length of the melting column and causes melt to pool at the base of the overriding plate, thus inhibiting magma generation and extraction. [ABSTRACT FROM AUTHOR]

The action research methodology used in this article is referred to as 'intervention research'. In specific terms, it is called the Socio-Economic Approach to Management (SEAM). The SEAM approach is both participatory and collaborative. It is a pragmatic oriented action research methodology and it belongs to the French action research tradition with roots in the UK and the work of Tavistock Institute. The action research project described in this study was carried out in a company in the security sector in France. The findings of the study indicate that a pragmatic oriented action research methodology such as SEAM may enhance the quality of human resource management and capabilities, and thus increase the value of human capital. The article also discusses the measurement of human capital and the factors which contribute to the sustainable development of human capital through time. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this study was to analyze the prevalence of claw toes and its correlation to other lower limb disorders as well as the global functional recovery in a population of hemiplegic patients 1year post-stroke. Patients and methods: This prospective study included 39 stroke patients hospitalized in the Physical Medicine and Rehabilitation (PM&R) department of a hospital between September2000 and September2001. The evaluation looked for incidence of claw toes during the first year post-stroke and whether there was a potential link to triceps surae spasticity, motor impairment of the leg and patients’ functional abilities (Barthel Index, postural assessment scale for stroke patients [PASS], functional ambulation classification [FAC]). Results: We conducted a total of 64 evaluations (one to four by patient). In 18 out of 39 (46%) patients, we found an occurrence of claw toes. In 15 out of 18 (83%) patients, who regained average functional capacities, its onset took place before the end of the third month post-stroke (Barthel: 30–70, PASS: 15–33, FAC: 3–4) and it was significantly linked to equinus and/or varus foot (p <0.0001). Conclusion: The occurrence of claw toes in hemiplegic patients is common and happens early on post-stroke. Equinus and/or varus foot and average functional capacities were associated to claw toes. Despite the few studies devoted to this affection in stroke patients, this condition must be diagnosed early and taken into account to improve the patient''s rehabilitation care. [Copyright &y& Elsevier]