Diagnosis isn\u27t enough: Understanding the connections between high health care utilization, chronic conditions and disabilities among U.S. working age adults

Background Under the ACA, new programs are being developed to enhance care coordination and reduce health care costs among people with chronic conditions, disabilities, and high utilization of health care. However, the relationships between these groups are not well understood. Objectives Our aims were to (1) identify high utilizers of health care in the U.S. working age (18–64) population, (2) examine the overlap between this group and people with chronic conditions and/or disabilities, (3) identify predictors of high service use or cost among these subpopulations, and (4) recommend approaches for stratification of individuals with high health care utilization. Methods Using pooled national data from the Medical Expenditure Panel Survey (2006–2008), we created indices to identify elevated or high utilization and cost groups. We performed descriptive analyses, bivariate comparisons and multivariate analyses to examine the relations between these populations and individuals with chronic conditions and/or disabilities. Results While the large majority of persons with high use/cost had chronic conditions, the minority of persons with chronic conditions had high health care utilization. However, among persons with chronic conditions, disability was a significant predictor of high utilization. Annual expenditures were significantly elevated among people with disabilities, particularly when activities of daily living were limited. Conclusions We conclude that medical diagnosis alone is insufficient for the development of eligibility criteria for, or the evaluation of, programs intended to better the delivery or coordination of services for high utilizers of health care services. New approaches are needed to assess functional limitations and identify ongoing needs for services and supports

Atomic Force Microscopic Measurement of a Used Cylinder Liner for Prediction of Boundary Friction

Accurate simulation performs a crucial role in the design and development of new modern internal combustion engines. In the case of piston rings, simulations are used to effectively predict generated friction and power loss of proposed designs. These are consequences of viscous shear of a thin lubricant film, likewise boundary friction caused by direct interaction of piston rings with the cylinder liner/bore surface. The most commonly used model for determining boundary friction is that of Greenwood and Tripp. The model requires the pressure coefficient of boundary shear strength of asperities from the softer of the contacting surfaces as an input. This parameter needs to be measured. The paper describes the process of measurement using an Atomic Force Microscope (AFM), both for a dry surface and that wetted by the presence of a lubricant layer. For realistic results, the investigated specimen is a used, tested engine cylinder liner where boundary active lubricant additives are bonded to its surface as well as combustion products. This approach is as opposed to the previously reported works using new flat surfaces with base oil or partially formulated lubricants and has not been previously reported in the literature. The results show that for used cylinder liners, the measured boundary shear strength of asperities varies according to location along the stroke. Results are reported for the top dead centre, mid-stroke and bottom dead centre locations. The measurements are subsequently used with two-dimensional Reynolds solution for a top compression ring-liner contact, where it is found that accurate localised predictions of generated friction and power loss can be made instead of the usual average value approach reported in the literature

Influence of Different Levels of Lipoic Acid Synthase Gene Expression on Diabetic Nephropathy

Oxidative stress is implicated in the pathogenesis of diabetic nephropathy (DN) but outcomes of many clinical trials are controversial. To define the role of antioxidants in kidney protection during the development of diabetic nephropathy, we have generated a novel genetic antioxidant mouse model with over- or under-expression of lipoic acid synthase gene (Lias). These models have been mated with Ins2Akita/+ mice, a type I diabetic mouse model. We compare the major pathologic changes and oxidative stress status in two new strains of the mice with controls. Our results show that Ins2Akita/+ mice with under-expressed Lias gene, exhibit higher oxidative stress and more severe DN features (albuminuria, glomerular basement membrane thickening and mesangial matrix expansion). In contrast, Ins2Akita/+ mice with highly-expressed Lias gene display lower oxidative stress and less DN pathologic changes. Our study demonstrates that strengthening endogenous antioxidant capacity could be an effective strategy for prevention and treatment of DN

Toward assessing farm-based anaerobic digestate public health risks : comparative investigation with slurry, effect of pasteurization treatments, and use of miniature bioreactors as proxies for pathogen spiking trials

Manure and slurry may contain a range of bacterial, viral, and parasitic pathogens and land application of these organic fertilizers typically occurs without prior treatment. In-situ treatment through farm-based anaerobic digestion (AD) of such organic fertilizers co-digested with food-production wastes is multi-beneficial due to energy recovery, increased farm incomes and noxious gas reduction. Before risk assessment can be carried out at field scale an investigation of the fate of relevant target pathogens during the actual AD process must be undertaken, requiring the development of practical test systems for evaluation of pathogen survival. The present study examines miniature (50 mL) and laboratory (10 L) scale AD systems. Treatments included slurry co-digested with fats, oils, and grease (FOG) under typical operating and pasteurization conditions used in farm-based AD, in batch-fed miniature and laboratory mesophilic (37°C) continuously stirred tank reactors. Biogas production, pH, chemical oxygen demand, volatile solids, and ammonia concentration were measured throughout the trial, as were fecal indicator bacteria (FIB) i.e., total coliforms, Escherichia coli, and Enterococcus species. The miniature and laboratory bioreactors performed similarly in terms of physicochemical parameters and FIB die-off. In the absence of pasteurization, after 28 days, enterococci numbers were below the <1,000 cfu g−1 threshold required for land application, while E. coli was no longer detectable in the digestate. For comparison, FIB survival in slurry was examined and after 60 days of storage, none of the FIB tested was <1,000 cfu g−1, suggesting that slurry would not be considered safe for land application if FIB thresholds required for AD digestate were to be applied. Taken together we demonstrate that (i) miniature-scale bioreactors are valid proxies of farm-based AD to carry out targeted pathogen survival studies and (ii) in situ AD treatment of slurry prior to land application reduces the level of FIB, independently of pasteurization, which in turn might be indicative of a decreased potential pathogen load to the environment and associated public health risks

Enabling Digital First: A Case Study of Sight-Impaired Users in Wales

The aim of this research is to provide a detailed examination of visually impaired community’s access to and usage of digital technology, focusing on the effectiveness of training in reducing digital skill gaps and current challenges associated with accessibility of devices, software and applications. In partnership with RNIB, we run three focus groups between 14–22 May 2018 as part of a research project based at Swansea University, funded by the Challenging Human Environments and Research Impact for a Sustainable and Healthy Digital Economy Centre (CHERISH-DE). By conducting empirical research with sight-impaired users, we aim to provide a first-hand account of the user experience to inform digital inclusivity policy. Specifically, we will firstly assess support networks provided to sight-impaired users - in particular, local support group and Welsh Government funded projects including digital communities in this report. In addition, we will investigate barriers faced by sight impaired users to the full use of accessible features across devices, software and applications. Finally, through experimental interactions with Amazon Alexa and Google Duplex, we aim to develop consumer-led recommendations to improve inclusive technology.Our research reveals the importance of digital trainings in disseminating knowledge, implementing changes, triggering bottom-up approach of peer learning and self-learning. For the future, support towards setting up devices and training on online security and data protection are crucial in involving and protecting vulnerable users. In a highly competitive market, the tech industry and service industry tend to focus on the most active and affluent users. While sensory impaired users are overlooked in this market-driven and technology-oriented approach, accessibility features are often treated as add-ons to ‘fix’ any potential problems if needs must, resulting in incompatibility in operating systems, web browsers, mobile devices, and platforms. Based on the analysis of our focus group data, we put forward recommendations on four key topics: web/app accessibility; better integration and standardisation; more user participation in technology development; and continuous support and training towards the sight impaired community. In additional to recommending better standardisation through adherence to, development and refinement of appropriate design guidelines and best practice, we also encourage a bottom-up approach for web and app accessibility guidelines. Involving users into the process of technology design and development would assure the technology capacity is tailored around the need of the user. Ultimately, inclusive design is to improve the quality of life for everyone, whatever their ability

Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT

Background: Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased. Objective: To compare clinical and cost-effectiveness of surgical fixation with cast treatment and early fixation of those that fail to unite for scaphoid waist fractures in adults. Design: Multicentre, pragmatic, open-label, parallel two-arm randomised controlled trial with an economic evaluation and nested qualitative study. Setting: Orthopaedic departments of 31 hospitals in England and Wales recruited from July 2013 with final follow-up in September 2017. Participants: Adults (aged ≥ 16 years), presenting within two weeks of injury with a clear bicortical fracture of the scaphoid waist on plain radiographs. Interventions: Early surgical fixation using CE marked headless compression screws. Below elbow cast immobilisation for six to ten weeks, and urgent fixation of confirmed non-union. Main outcome measures: The primary outcome and end-point was the Patient Rated Wrist Evaluation (PRWE) total score at 52 weeks, with a clinically relevant difference of six points. Secondary outcomes included PRWE pain and function subscales, Short Form 12-item questionnaire (SF-12), bone union, range of movement, grip strength, complications and return to work. Results: The mean age of 439 participants was 33 years, 363 were male (83%) and 269 had an undisplaced fracture (61%). The primary analysis was on 408 participants providing valid PRWE outcome data for at least one post-randomisation time-point (surgery n=203 of 219; cast n=205 of 220). There was no clinically relevant difference in the total PRWE at 52 weeks: cast group mean 14.0 [95% confidence interval (CI) 11.3 to 16.6] and surgery group mean 11.9 (95% CI 9.2 to 14.5); adjusted mean difference of -2.1 in favour of surgery (95% CI -5.8 to 1.6, p=0.27). Non-union rate was low (surgery group n=1; cast group n=4). Eight participants in the surgery group had 11 re-operations, and one participant in the cast group required a re-operation for non-union. The base-case economic analysis at 52 weeks found the cost of surgery was £1,295 more per patient (95% CI £1,084 to £1,504) than cast treatment. The base-case analysis of a lifetime extrapolated model confirmed that the cast treatment pathway was the most cost-effective option. The nested qualitative study identified patients desire to have a “sense of recovering” which surgeons should address at the outset. Limitation: There were 17 participants who had initial cast treatment and surgery for confirmed non-union, 14 within six months from randomisation and three after six months. Three of four participants in the cast group, who had a non-union at 52 weeks, were not offered surgery. Conclusions: Adult patients with an undisplaced or minimally displaced scaphoid waist fracture should have cast immobilisation and suspected non-unions immediately confirmed and urgently fixed. Future work: Patients will be followed-up at five years to investigate the effect of partial union, degenerative arthritis, malunion and screw problems on their quality of life

Global modeling of aerosol nucleation with a semi-explicit chemical mechanism for highly oxygenated organic molecules (HOMs)

Abstract. New particle formation (NPF) involving organic compounds has been identified as an important process affecting aerosol particle number concentrations in the global atmosphere. Laboratory studies have shown that highly oxygenated organic molecules (HOMs) can make a substantial contribution to NPF, but there is a lack of global model studies of NPF with detailed HOM chemistry. Here, we incorporate a state-of-the-art biogenic HOM chemistry scheme with 96 chemical reactions to a global chemistry–climate model and quantify the contribution to global aerosols through HOM-driven NPF. The updated model captures the frequency of NPF events observed at continental surface sites (normalized mean bias changes from −96 % to −15 %) and shows reasonable agreement with measured rates of NPF and sub-20 nm particle growth. Sensitivity simulations show that compared to turning off the organic nucleation rate, turning off organic initial growth results in a more substantial decrease in aerosol number concentrations. Globally, organics contribute around 45 % of the annual mean vertically integrated nucleation rate (at 1.7 nm) and 25 % of the vertically averaged growth rate. The inclusion of HOM-related processes leads to a 39 % increase in the global annual mean aerosol number burden and a 33 % increase in cloud condensation nuclei (CCN) burden at 0.5 % supersaturation compared to a simulation with only inorganic nucleation. Our work predicts a greater contribution of organic nucleation to NPF than previous studies due to the semi-explicit HOM mechanism and an updated inorganic NPF scheme. The large contribution of biogenic HOMs to NPF on a global scale could make aerosol sensitive to changes in biogenic emissions

Bacterial Filtration Using Carbon Nanotube/Antibiotic Buckypaper Membranes

The preparation of free-standing carbon nanotube “buckypaper” (BP) membranes consisting of either single-walled carbon nanotubes (SWNTs) or multi-walled carbon nanotubes (MWNTs), and the antibiotic ciprofloxacin (cipro), is reported. The electrical, mechanical and morphological properties of these membranes have been characterised and are compared to those of the corresponding buckypaper membranes containing the surfactant Triton X-100 (Trix). Analysis of scanning electron microscopic images of the surfaces of SWNT/cipro and SWNT/Trix (Trix  =  Triton X-100) buckypapers revealed that the diameter of their surface pores was significantly smaller than that of the corresponding materials prepared using MWNTs. Similarly, the average internal pore diameter of both SWNT buckypapers was found to be smaller than that of their MWNT counterparts, after analysis of binding isotherms derived from nitrogen adsorption/desorption measurements performed on the materials. All four buckypaper membranes examined were found to be >99% effective for removing Escherichia coli (E. coli) from aqueous suspensions. However, buckypapers containing ciprofloxacin outperformed their counterparts containing the surfactant. Both MWNT buckypapers were more effective at preventing passage of E. coli than their analogues containing SWNTs, while fluorescence microscopic examination of stained membrane surfaces demonstrated that buckypapers composed of SWNTs had greater bactericidal properties