Comparing Emergency Department Resident and Patient Perspectives on Costs in Emergency Care

Objectives: Costs of care are increasingly important in healthcare policy and, more recently, clinical care in the Emergency Department (ED). We compare ED resident and patient perceptions surrounding the costs of emergency care, compliance, communication, and education. Methods: We conducted a mixed methods study using surveys and qualitative interviews in a single, urban academic ED. The first study population was a convenience sample of adult patients (\u3e17 years of age), and the second was ED residents training at the same institution. Participants answered open- and closed-ended questions on costs, cost-related compliance, and communication. Residents answered additional questions on residency education on costs of care. Closed-ended data were tabulated and described using standard statistics while open-ended responses were analyzed using grounded theory. Results: Thirty ED patients and 24 ED residents participated in the study. Both ED patients and residents felt neutral regarding the importance of cost discussions and generally did not have knowledge of medical costs. Patients were comfortable discussing costs while residents were less comfortable. Additionally, some patients had cost concerns restricting compliance with treatment. Limitations to discussing costs included lack of time and perceived irrelevance. Generally, ED residents took costs into consideration during clinical decision-making, most commonly because of a feeling of personal responsibility to control healthcare costs. Nearly all ED residents agreed they had too little education regarding costs, and the most common suggestion for enhancing education was inclusion of price lists. Conclusions: There were several notable differences in patient and resident perspectives on cost discussions in the ED in this sample. While patients do not see cost discussions to be important, they are generally comfortable discussing costs yet do not report having sufficient knowledge on what care costs. ED residents think costs are important, but are less comfortable discussing them, primarily because they lack education on medical costs

Cryostratigraphy, sedimentology, and the late Quaternary evolution of the Zackenberg River delta, northeast Greenland

The Zackenberg River delta is located in northeast Greenland (74°30′ N, 20°30′ E) at the outlet of the Zackenberg fjord valley. The fjord-valley fill consists of a series of terraced deltaic deposits (ca. 2 km2) formed during relative sea-level (RSL) fall. We investigated the deposits using sedimentological and cryostratigraphic techniques together with optically stimulated luminescence (OSL) dating. We identify four facies associations in sections (4 to 22 m in height) exposed along the modern Zackenberg River and coast. Facies associations relate to (I) overriding glaciers, (II) retreating glaciers and quiescent glaciomarine conditions, (III) delta progradation in a fjord valley, and (IV) fluvial activity and niveo-aeolian processes. Pore, layered, and suspended cryofacies are identified in two 20 m deep ice-bonded sediment cores. The cryofacies distribution, together with low overall ground-ice content, indicates that permafrost is predominately epigenetic in these deposits. Fourteen OSL ages constrain the deposition of the cored deposits to between approximately 13 and 11 ka, immediately following deglaciation. The timing of permafrost aggradation was closely related to delta progradation and began following the subaerial exposure of the delta plain (ca. 11 ka). Our results reveal information concerning the interplay between deglaciation, RSL change, sedimentation, permafrost aggradation, and the timing of these events. These findings have implications for the timing and mode of permafrost aggradation in other fjord valleys in northeast Greenland

Cryostratigraphy, sedimentology, and the late Quaternary evolution of the Zackenberg River delta, northeast Greenland

The Zackenberg River delta is located in northeast Greenland (74°30′ N, 20°30′ E) at the outlet of the Zackenberg fjord valley. The fjord-valley fill consists of a series of terraced deltaic deposits (ca. 2 km2) formed during relative sea-level (RSL) fall. We investigated the deposits using sedimentological and cryostratigraphic techniques together with optically stimulated luminescence (OSL) dating. We identify four facies associations in sections (4 to 22 m in height) exposed along the modern Zackenberg River and coast. Facies associations relate to (I) overriding glaciers, (II) retreating glaciers and quiescent glaciomarine conditions, (III) delta progradation in a fjord valley, and (IV) fluvial activity and niveo-aeolian processes. Pore, layered, and suspended cryofacies are identified in two 20 m deep ice-bonded sediment cores. The cryofacies distribution, together with low overall ground-ice content, indicates that permafrost is predominately epigenetic in these deposits. Fourteen OSL ages constrain the deposition of the cored deposits to between approximately 13 and 11 ka, immediately following deglaciation. The timing of permafrost aggradation was closely related to delta progradation and began following the subaerial exposure of the delta plain (ca. 11 ka). Our results reveal information concerning the interplay between deglaciation, RSL change, sedimentation, permafrost aggradation, and the timing of these events. These findings have implications for the timing and mode of permafrost aggradation in other fjord valleys in northeast Greenland

Use of endogenous signal sequences for transient production and efficient secretion by moss (Physcomitrella patens) cells

BACKGROUND: Efficient targeting to appropriate cell organelles is one of the bottlenecks for the production of recombinant proteins in plant systems. A common practice is to use the native secretory signal peptide of the heterologous protein to be produced. Though general features of secretion signals are conserved between plants and animals, the broad sequence variability among signal peptides suggests differing efficiency of signal peptide recognition. RESULTS: Aiming to improve secretion in moss bioreactors, we quantitatively compared the efficiency of two human signal peptides and six signals from recently isolated moss (Physcomitrella patens) proteins. We therefore used fusions of the different signals to heterologous reporter sequences for transient transfection of moss cells and measured the extra- and intracellular accumulation of the recombinant proteins rhVEGF and GST, respectively. Our data demonstrates an up to fivefold higher secretion efficiency with endogenous moss signals compared to the two utilised human signal peptides. CONCLUSION: From the distribution of extra- and intracellular recombinant proteins, we suggest translational inhibition during the signal recognition particle-cycle (SRP-cycle) as the most probable of several possible explanations for the decreased extracellular accumulation with the human signals. In this work, we report on the supremacy of moss secretion signals over the utilised heterologous ones within the moss-bioreactor system. Though the molecular details of this effect remain to be elucidated, our results will contribute to the improvement of molecular farming systems

BAMBI Is Expressed in Endothelial Cells and Is Regulated by Lysosomal/Autolysosomal Degradation

BACKGROUND: BAMBI (BMP and Activin Membrane Bound Inhibitor) is considered to influence TGFβ and Wnt signaling, and thereby fibrosis. Surprisingly data on cell type-specific expression of BAMBI are not available. We therefore examined the localization, gene regulation, and protein turnover of BAMBI in kidneys. METHODOLOGY/PRINCIPAL FINDINGS: By immunofluorescence microscopy and by mRNA expression, BAMBI is restricted to endothelial cells of the glomerular and some peritubular capillaries and of arteries and veins in both murine and human kidneys. TGFβ upregulated mRNA of BAMBI in murine glomerular endothelial cells (mGEC). LPS did not downregulate mRNA for BAMBI in mGEC or in HUVECs. BAMBI mRNA had a half-life of only 60 minutes and was stabilized by cycloheximide, indicating post-transcriptional regulation due to AU-rich elements, which we identified in the 3' untranslated sequence of both the human and murine BAMBI gene. BAMBI protein turnover was studied in HUVECs with BAMBI overexpression using a lentiviral system. Serum starvation as an inducer of autophagy caused marked BAMBI degradation, which could be totally prevented by inhibition of lysosomal and autolysosomal degradation with bafilomycin, and partially by inhibition of autophagy with 3-methyladenine, but not by proteasomal inhibitors. Rapamycin activates autophagy by inhibiting TOR, and resulted in BAMBI protein degradation. Both serum starvation and rapamycin increased the conversion of the autophagy marker LC3 from LC3-I to LC3-II and also enhanced co-staining for BAMBI and LC3 in autolysosomal vesicles. CONCLUSIONS/SIGNIFICANCE: 1. BAMBI localizes to endothelial cells in the kidney and to HUVECs. 2. BAMBI mRNA is regulated by post-transcriptional mechanisms. 3. BAMBI protein is regulated by lysosomal and autolysosomal degradation. The endothelial localization and the quick turnover of BAMBI may indicate novel, yet to be defined functions of this modulator for TGFβ and Wnt protein actions in the renal vascular endothelium in health and disease

Barriers and enablers experienced by health care workers in swabbing for COVID-19 in Papua New Guinea: A multi-methods cross-sectional study.

OBJECTIVE: We aimed to identify the barriers and enablers that Health Care Workers (HCWs) in Papua New Guinea experienced in swabbing for COVID-19. METHODS: We conducted a cross-sectional multi-methods study: a qualitative scoping exercise and a telephone survey. The target population was COVID-19-trained HCWs from all provinces of Papua New Guinea. A descriptive analysis of survey responses was conducted alongside a rapid qualitative analysis of interviews and open-ended survey questions. RESULTS: Four thematic areas were identified: human resources, logistics, HCW attitudes and community attitudes. The survey response rate was 70.3% (407/579). Commonly reported barriers to COVID-19 swabbing were insufficient staff trained (74.0%, n = 301), inadequate staffing in general (64.9%, n = 264), insufficient supply of personal protective equipment (60.9%, n = 248) and no cold chain to store swabs (57.5%, n = 234). Commonly reported enablers to swabbing were community awareness and risk communication (80.8%, n = 329), consistent and sufficient supplies of personal protective equipment (67.8%, n = 276), increased surge workforce (63.9%, n = 260) and having a fridge to store swabs (59.7%, n = 243). CONCLUSIONS: A comprehensive community and HCW engagement strategy combined with innovations to improve the supply chain are needed to increase COVID-19 swabbing in Papua New Guinea to reach national testing targets. Investments in increasing numbers of frontline workforce, consistent supplies of PPE, swabs, transport medium, cold boxes and ability to make ice packs, in addtion to establishing regular tranport of specimens from the facility to the testing site will strengthen the supply chain. Innovations are needed to address these issues

Combining transcranial direct current stimulation with group cognitive behavioral therapy developed to treat rumination: a clinical pilot study

BackgroundAs part of repetitive negative thinking (RNT), rumination is a maladaptive cognitive response style to stress or negative mood which can increase the risk of depression and may prohibit complete recovery. Cognitive behavioral therapy (CBT) and transcranial direct current stimulation (tDCS) both proved to be effective in decreasing rumination. However, the combined effects of tDCS and CBT interventions on rumination have not yet been explored. The first aim of this pilot study is to investigate whether the combination of tDCS and CBT has an accumulating positive effect on modulating state rumination. The second aim is to assess the feasibility and safety profile of the proposed combined approach.MethodSeventeen adults aged 32–60 years, suffering from RNT, were referred by their primary care professional to participate in an 8-week group intervention for RNT (“Drop It”) comprising 8 sessions of CBT. Before each CBT session, patients underwent one double-blinded prefrontal active (2 mA for 20 min) or sham tDCS (anode over F3, cathode over the right supraorbital region) combined with an internal cognitive attention task focused on individual RNT, i.e., online tDCS priming. During each session, the Brief State Rumination Inventory was used to assess state rumination.ResultsA mixed effects model analysis revealed no significant differences between the stimulation conditions, weekly sessions, or their interaction in terms of state rumination scores.ConclusionOverall, the combination of online tDCS priming followed by group CBT was found to be safe and feasible. On the other hand, no significant additional effects of this combined approach on state rumination were established. Although our pilot study may have been too small to find significant clinical effects, future larger RCT studies on combined tDCS-CBT treatment protocols may reevaluate the selection of internal cognitive attention tasks and more objective neurophysiological measurements, consider the optimal timing of the combination (concurrently or sequentially), or may add additional tDCS sessions when following CBT