Creating Safety in the Testing Process in Primary Care Offices

Background: The testing process in primary care is complex, and it varies from one office to another. We sought to understand how family medicine offices create safety in this process. Methods: Using observations, interviews, and surveys, we collected data at four family medicine offices. We searched the interview and observation notes for stories of safety, error prevention, and recovery and coded them to a model of resilient engineering properties, work system components, and testing process steps. Results: We found only six examples of practices that were systematically creating safety in the testing process via organizational resilience. The most common resilience properties were top-level commitment and a learning culture applied to work system components of people and their tasks. Offices predominantly depended on individuals to double-check, remember, and work around ongoing problems. Conclusions: While family medicine offices overwhelming depend on individuals to work around testing process problems, important properties of office-wide safety practices included a top-level commitment and a learning culture

Equivalent titanium dioxide nanoparticle deposition by intratracheal instillation and whole body inhalation: the effect of dose rate on acute respiratory tract inflammation

BACKGROUND: The increased production of nanomaterials has caused a corresponding increase in concern about human exposures in consumer and occupational settings. Studies in rodents have evaluated dose–response relationships following respiratory tract (RT) delivery of nanoparticles (NPs) in order to identify potential hazards. However, these studies often use bolus methods that deliver NPs at high dose rates that do not reflect real world exposures and do not measure the actual deposited dose of NPs. We hypothesize that the delivered dose rate is a key determinant of the inflammatory response in the RT when the deposited dose is constant. METHODS: F-344 rats were exposed to the same deposited doses of titanium dioxide (TiO(2)) NPs by single or repeated high dose rate intratracheal instillation or low dose rate whole body aerosol inhalation. Controls were exposed to saline or filtered air. Bronchoalveolar lavage fluid (BALF) neutrophils, biochemical parameters and inflammatory mediator release were quantified 4, 8, and 24 hr and 7 days after exposure. RESULTS: Although the initial lung burdens of TiO(2) were the same between the two methods, instillation resulted in greater short term retention than inhalation. There was a statistically significant increase in BALF neutrophils at 4, 8 and 24 hr after the single high dose TiO(2) instillation compared to saline controls and to TiO(2) inhalation, whereas TiO(2) inhalation resulted in a modest, yet significant, increase in BALF neutrophils 24 hr after exposure. The acute inflammatory response following instillation was driven primarily by monocyte chemoattractant protein-1 and macrophage inflammatory protein-2, mainly within the lung. Increases in heme oxygenase-1 in the lung were also higher following instillation than inhalation. TiO(2) inhalation resulted in few time dependent changes in the inflammatory mediator release. The single low dose and repeated exposure scenarios had similar BALF cellular and mediator response trends, although the responses for single exposures were more robust. CONCLUSIONS: High dose rate NP delivery elicits significantly greater inflammation compared to low dose rate delivery. Although high dose rate methods can be used for quantitative ranking of NP hazards, these data caution against their use for quantitative risk assessment

Through An Equity Lens: Illuminating The Relationships Among Social Inequities, Stigma And Discrimination, And Patient Experiences of Emergency Health Care

People who experience the greatest social inequities often have poor experiences in emergency departments (EDs) so that they are deterred from seeking care, leave without care complete, receive inadequate care, and/or return repeatedly for unre- solved problems. However, efforts to measure and monitor experiences of care rarely capture the experiences of people facing the greatest inequities, experiences of discrimination, or relationships among these variables. This analysis examined how patients’ experiences, including self-reported ratings of care, experiences of discrimination, and repeat visits vary with social and economic circumstances. Every consecutive person presenting to three diverse EDs was invited if/when they were able to consent; 2424 provided demographic and contact information; and 1692 (70%) completed the survey. Latent class analysis (LCA) using sociodemographic variables: age, gender, financial strain, employment, housing stability, English as first language, born in Canada, and Indigenous identity, indicated a six-class solution. Classes differed significantly on having regular access to primary care, reasons for the visit, and acuity. Classes also differed on self-reported discrimination every day and during their ED visit, ratings of ED care, and number of ED visits within the past six months. ED care can be improved through attention to how intersecting forms of structural disadvantage and inequities affect patient experiences

Open Access

Equivalent titanium dioxide nanoparticle deposition by intratracheal instillation and whole body inhalation: the effect of dose rate on acute respiratory tract inflammatio

Experiential education and outreach based on nearshore monitoring of the Elwha River restoration project

Nearshore monitoring of benthic habitats and the coastal environment following the Elwha River Restoration project has engaged students and citizens with coastal science and management issues. In the post-dam-removal period, the lessons learned will continue to be disseminated via a UW undergraduate course and an interactive digital map, both designed to engage students and communities in restoration science. The research-focused course developed at the UW Friday Harbor Labs has allowed us to engage diverse undergraduate students (and graduate teaching assistants) in the research process. The course integrates interdisciplinary lectures and workshops on data analysis and laboratory methods, with the research process; from proposal to oceanographic data collection to analysis to publication. The course provides opportunities for student creativity and leadership. Outcome tracking indicates that these undergraduate (and post-bac) students are generally attending graduate school at a high rate, and launching careers in education, coastal management, and other STEM fields. To engage a broader segment of the community and to support decision-making about large-scale coastal restoration projects, we have developed an interactive digital map that will be available on-line, and will also be piloted as a physical interpretive display at the Feiro Marine Life Center in Port Angeles, WA. The interactive digital map is designed to effectively tell the story of the Elwha restoration in the coastal environment through the compilation and display of multiple data sets, some of which have never before been publicly available. Ultimately, the result of long-term monitoring of the Elwha nearshore system will provide a better understanding of the effects of restoration activities, such as dam removal on benthic habitats, and this knowledge will be passed to future managers and citizens through educational and outreach activities that captivate and inspire a broad audience

Changes in Kelp and Other Seaweeds Following Elwha Dam Removal

Kelps are ecologically important seaweeds that dominated the nearshore vegetation community prior to dam removal on the Elwha River. Dam removal is expected to trigger a shift from kelps to vegetation types that are characteristic of soft-sediment communities through restoring natural sediment supply. This study is investigating how nearshore vegetation responds to restoration of the natural sediment regime, both initially when large amounts of sediment entrained in the reservoirs are released and over longer time periods. We assessed vegetation at multiple spatial scales using three approaches. First, we measured floating kelp canopy area using aerial photography. Second, we assessed the abundance of understory kelp and seagrasses with towed videography along 50 km of shoreline. Third, scuba divers recorded density of kelp species and other seaweeds along 10 km of shoreline bracketing the river mouth. Results show profound changes in vegetation and a strong gradient in magnitude of impact related to distance from the river mouth. Floating kelp canopy area decreased 74% in the Elwha Drift Cell in the first year following project initiation (year 1), with lower magnitude losses throughout the Strait of Juan de Fuca. Area of prostrate kelps decreased by 45% (400 ha) and of stipitate kelps by 30% (130 ha) in the Elwha Drift Cell in year 1. Mean kelp density near the river mouth decreased 77% in year 1 and 95% in year 2. While all 10 kelp species declined, annuals were more impacted than perennials. In contrast to the general decline, juveniles of several kelp species appeared in late August of year 2, a substantial delay compared to typical spring timing of juvenile growth. What caused the large kelp losses and apparent delay of juvenile growth? Likely candidates include light reduction from the river plume and scour, burial or settlement inhibition from deposition. These candidates will be explored using physical data from the multidisciplinary research effort

Behavioral profiling of multiple pairs of rats selectively bred for high and low alcohol intake using the MCSF test

Genetic aspects of alcoholism have been modeled using rats selectively bred for extremes of alcohol preference and voluntary alcohol intake. These lines show similar alcohol drinking phenotypes but have different genetic and environmental backgrounds and may therefore display diverse behavioral traits as seen in human alcoholics. The multivariate concentric square field™ (MCSF) test is designed to provoke exploration and behaviors associated with risk assessment, risk taking and shelter seeking in a novel environment. The aim was to use the MCSF to characterize behavioral profiles in rat lines from selective breeding programs in the United States (P/NP, HAD1/LAD1, HAD2/LAD2), Italy (sP/sNP) and Finland (AA/ANA). The open field and elevated plus maze tests were used as reference tests. There were substantial differences within some of the pairs of selectively bred rat lines as well as between all alcohol-preferring rats. The most pronounced differences within the pairs of lines were between AA and ANA rats and between sP and sNP rats followed by intermediate differences between P and NP rats and minor differences comparing HAD and LAD rats. Among all preferring lines, P, HAD1 and HAD2 rats shared similar behavioral profiles, while AA and sP rats were quite different from each other and the others. No single trait appeared to form a common 'pathway' associated with a high alcohol drinking phenotype among all of the alcohol-preferring lines of rats. The marked behavioral differences found in the different alcohol-preferring lines may mimic the heterogeneity observed among human alcoholic subtypes