Assessing the Burden of Unnecessary Central Venous Catheters in Patients on Medical-Surgical Floors

Project goals: Our project goals are to: a) assess the burden of unnecessary PICCs and other non-tunneled central lines on med-surg units at TJUH and b) understand the underlying reasons behind the problem. In the first phase of our project we conducted an audit of med-surg unit PICCs and other non-tunneled central lines with the goal of obtaining a rough estimate of the number of line days that are unnecessary. SMART AIM By December 31, 2017, the TJUH medical-surgical floors will reduce the number of unnecessary PICC lines by 30%.https://jdc.jefferson.edu/patientsafetyposters/1024/thumbnail.jp

Differing Attitudes Between Psychiatrists and Primary Care Providers at the Interface

Abstract Objective: Market forces caused by managed care are shaping practice styles for both psychiatrists and primary care physicians. This study offers a sample of the attitudes of both groups of practitioners highlighting the differences. Method: Forty-two psy chiatrists and primary care physicians (POP) completed surveys. The responses of each group were compared using chi square analyses. Results: Psychiatrists and POPs differed significantly on their: 1) degree of comfort in the other's traditional service domain -with POPs more comfortable dealing with their patients'psychiatric problems than psychiatrists were dealing with their patients' medi cal problems, 2) perceived barriers to effective communicationpsychiatrists acknowledge their own time constraints while POPs blame their colleagues unavailability (actually an agreement that psychiatrists' availability is a limiting factor), 3) projected areas of interface in the future-with psychiatrists prioritizing collaboration on health maintenance while POPs valued collaboration on prevention and referral as equally significant. Conclusions: Conflict between needs and expectations found in this pilot study, if shown in larger studies to be representative, will impact the success of changes in practice patterns encouraged by emerging managed care initia tives. These findings suggest that the discordant expectations between psychiatrists and POPs about the interface of their prac tices deserve further study. Recent changes in the healthcare delivery system have focused attention on the changing practice patterns between psychiatry and primary care, with some crossing-over into each other's service domain. -Though external forces may ultimately dictate the roles of the generalist and specialist, attitudes about the scope of practice among active practitioners and existing patterns of interaction between the groups will certainly impact the success of such mandates. Primary care's current role in mental health care delivery has been characterized as de facto responsibility for 50% of the nation's mentally ill population. Unfortunately the literature docu ments an inadequate record for appropriate diagnosis and treatment of mental disorders such as major depression. 3 Concerning their interaction with psychiatrists. PCPs have complained about psychiatrist's unavailability and unsatisfactory feedback on refer rals.

The androgen receptor drives the sex-specific expression of vascular cell adhesion molecule-1 in endothelial cells but not lipid metabolism genes in monocyte-derived macrophages

Background: Anecdotal evidence suggests that male sex hormones are proatherogenic. We hypothesized that the male sex hormone receptor, the androgen receptor (AR), acts as a molecular switch in sex-specific inflammatory signaling in vascular cells. Materials and methods: AR expression in human umbilical vein endothelial cells (HUVECs), human monocyte-derived macrophages (MDMs) or HeLa cells was modulated by transfection with AR siRNA or human AR cDNA expression vector. Activity and expression levels were measured by luciferase reporter assays, Western blotting or real-time PCR analysis. Results: AR knockdown reduced expression of vascular cell adhesion molecule-1 (VCAM-1) in genetically male HUVECs. Conversely, AR upregulation in genetically female HUVECs induced VCAM-1 expression and increased dihydrotestos-terone-stimulated monocyte adhesion. Co-transfection of an AR expression vector with VCAM-1 or NF-kB-reporter vectors into phenotypically female, AR-negative HeLa cells confirmed AR regulation of VCAM-1 expression as well as AR activation of NF-kB. AR upregulation was not sufficient to increase ICAM-1 levels in female HUVECs or lipoprotein metabolism gene expression in female MDMs, despite AR knockdown limiting expression in their male counterparts. Conclusions: AR acts as a molecular switch to induce VCAM-1 expression. Low AR levels in female HUVECs limit NF-kB/VCAM-1 induction and monocyte adhesion and could contribute to the gender bias in cardiovascular disease. Unidentified factors in female cells limit induction of other proatherogenic genes not primarily regulated by NF-kB. © 2010, by Walter de Gruyter Berlin New York. All rights reserved

A Forecasting Model to Predict the Demand of Roses in an Ecuadorian Small Business Under Uncertain Scenarios

[EN] Ecuador is worldwide considered as one of the main natural flower producers and exporters ¿being roses the most salient ones. Such a fact has naturally led the emergence of small and medium sized companies devoted to the production of quality roses in the Ecuadorian highlands, which intrinsically entails resource usage optimization. One of the first steps towards optimizing the use of resources is to forecast demand, since it enables a fair perspective of the future, in such a manner that the in-advance raw materials supply can be previewed against eventualities, resources usage can be properly planned, as well as the misuse can be avoided. Within this approach, the problem of forecasting the supply of roses was solved into two phases: the first phase consists of the macro-forecast of the total amount to be exported by the Ecuadorian flower sector by the year 2020, using multi-layer neural networks. In the second phase, the monthly demand for the main rose varieties offered by the study company was micro-forecasted by testing seven models. In addition, a Bayesian network model is designed, which takes into consideration macroeconomic aspects, the level of employability in Ecuador and weather-related aspects. This Bayesian network provided satisfactory results without the need for a large amount of historical data and at a low-computational cost.Authors of this publication acknowledge the contribution of the Project 691249, RUC-APS ¿Enhancing and implementing Knowledge based ICT solutions within high Risk and Uncertain Conditions for Agriculture Production Systems¿ (www.ruc-aps.eu), funded by the European Union under their funding scheme H2020-MSCA-RISE-2015. In addition, the authors are greatly grateful by the support given by the SDAS Research Group (www.sdas-group.com)Herrera-Granda, ID.; Lorente-Leyva, LL.; Peluffo-Ordóñez, DH.; Alemany Díaz, MDM. (2021). A Forecasting Model to Predict the Demand of Roses in an Ecuadorian Small Business Under Uncertain Scenarios. Lecture Notes in Computer Science. 12566:245-258. https://doi.org/10.1007/978-3-030-64580-9_21S24525812566Asociación de Productores y Exportadores de Flores: Inicio – Expoflores. https://expoflores.com/Palacios, J., Rosero, D.: Análisis de las condiciones climáticas registradas en el Ecuador continental en el año 2013 y su impacto en el sector agrícola. Estud. e Investig. meteorológicas. Ina. Inst. Nac. Meteorol. e Hidrol. Ecuador, 28, p. (2014)Hidalgo-Proaño, M.: Variabilidad climática interanual sobre el Ecuador asociada a ENOS. CienciAmérica 6, 42–47 (2017)Ritchie, J.W., Abawi, G.Y., Dutta, S.C., Harris, T.R., Bange, M.: Risk management strategies using seasonal climate forecasting in irrigated cotton production: a tale of stochastic dominance. Aust. J. Agric. Resour. 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Syst. 106, 33–45 (2012). https://doi.org/10.1016/j.agsy.2011.10.005Scott, S.L., Varian, H.R.: Predicting the present with bayesian structural time series. Available SSRN 2304426 (2013)Prudhomme, C., Shaffrey, L., Woollings, T., Jackson, C., Fowler, H., Anderson, B.: IMPETUS: Improving predictions of drought for user decision-making. International Conference on Drought: Research and Science-Policy Interfacing, 2015. pp. 273–278. CRC Press/Balkema, Centre for Ecology and Hydrology, Wallingford, Oxfordshire, United Kingdom (2015)Wiles, P., Enke, D.: A hybrid neuro-fuzzy model to forecast the Soybean complex. International Annual Conference of the American Society for Engineering Management 2015, ASEM 2015. pp. 1–5. American Society for Engineering Management, Missouri University of Science and Technology, Engineering Management and Systems Engineering Department, United States (2015)Hansen, B.G., Li, Y.: An analysis of past world market prices of feed and milk and predictions for the future. Agribusiness 33, 175–193 (2017). https://doi.org/10.1002/agr.21474Johnson, M.D., Hsieh, W.W., Cannon, A.J., Davidson, A., Bedard, F.: Crop yield forecasting on the Canadian Prairies by remotely sensed vegetation indices and machine learning methods. Agric. For. Meteorol. 218, 74–84 (2016). https://doi.org/10.1016/j.agrformet.2015.11.003Chen, J., Yang, J., Zhao, J., Xu, F., Shen, Z., Zhang, L.: Energy demand forecasting of the greenhouses using nonlinear models based on model optimized prediction method. Neurocomputing 174, 1087–1100 (2016). https://doi.org/10.1016/j.neucom.2015.09.105Fodor, N., et al.: Integrating plant science and crop modeling: assessment of the impact of climate change on soybean and maize production. Plant Cell Physiol. 58, 1833–1847 (2017). https://doi.org/10.1093/pcp/pcx141Chapman, R., et al.: Using Bayesian networks to predict future yield functions with data from commercial oil palm plantations: a proof of concept analysis. Comput. Electron. Agric. 151, 338–348 (2018). https://doi.org/10.1016/j.compag.2018.06.006Lara-Estrada, L., Rasche, L., Sucar, L.E., Schneider, U.A.: Inferring Missing Climate Data for Agricultural Planning Using Bayesian Networks. LAND. 7 (2018). https://doi.org/10.3390/land7010004Abdelaal, H.S.A., Thilmany, D.: Grains production prospects and long run food security in Egypt. Sustain. 11 (2019). https://doi.org/10.3390/su11164457Kusunose, Y., Ma, L., Van Sanford, D.: User responses to imperfect forecasts: findings from an experiment with Kentucky wheat farmers. Weather. Clim. Soc. 11, 791–808 (2019). https://doi.org/10.1175/wcas-d-18-0135.1Kadigi, I.L., et al.: Forecasting yields, prices and net returns for main cereal crops in Tanzania as probability distributions: a multivariate empirical (MVE) approach. Agric. Syst. 180 (2020). https://doi.org/10.1016/j.agsy.2019.102693McGrath, G., Rao, P.S.C., Mellander, P.-E., Kennedy, I., Rose, M., van Zwieten, L.: Real-time forecasting of pesticide concentrations in soil. Sci. Total Environ. 663, 709–717 (2019). https://doi.org/10.1016/j.scitotenv.2019.01.401Yang, B., Xie, L.: Bayesian network modelling for “direct farm” mode based agricultural supply chain risk. Ekoloji 28, 2361–2368 (2019)Zaporozhtseva, L.A., Sabetova, T. V, Yu Fedulova, I.: Assessment of the uncertainty factors in computer modelling of an agricultural company operation. International Conference on Information Technologies in Business and Industries, ITBI 2019. Institute of Physics Publishing, Voronezh State Agrarian University, Michurina Str. 30, Voronezh, 394087, Russian Federation (2019)Box, G.E.P., Jenkins, G.M., Reinsel, G.C., Ljung, G.M.: Time series analysis: forecasting and control. Wiley (2015)Hanke, J., Wichern, D.: Business forecast. 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ABSTRACT. Objective. Bone scintigraphy has been advocated as a useful diagnostic tool for patients with suspected osteonecrosis or in screening for multifocal disease. We evaluated the sensitivity of bone scanning relative to magnetic resonance imaging (MRI) in the diagnosis of osteonecrosis. Methods. Forty-eight patients presented with suspected osteonecrosis of the shoulder, hip, knee, or ankle. All patients underwent simultaneous (< 3 months apart) bone scans and MRI studies as part of diagnostic investigations. Histological confirmation of osteonecrosis was obtained for all suspected lesions. The diagnostic result for each imaging modality was then assessed and compared. Results. All 163 (100%) histologically confirmed lesions were identified by MRI, while only 91 lesions (56%) were identified by bone scan. There was complete congruency of bone scans with MR images in only 38% of patients (18/48). Bone scanning identified 72% of lesions (47/65) in oligofocal patients (≤ 2 joints involved) compared with 45% of the lesions (44/98) in multifocal patients (≥ 3 joints involved). Sensitivity of lesions was highest for the knee and hip and lower for the shoulder and ankle. Larger and later-stage lesions had a higher bone scan sensitivity. Conclusion. Our results demonstrated the low sensitivity of bone scintigraphy for diagnosing symptomatic osteonecrosis. It is least sensitive for early-stage lesions where it might be most useful to diagnose the disease. Our study also confirms that this test is less sensitive for joints other than the hip and is also not useful as a screening tool. Our study does not support the use of bone scans as a diagnostic or screening tool for osteonecrosis

Assessing fitness-to-practice of overseas-trained health practitioners by Australian registration & accreditation bodies

Assessment of fitness-to-practice of health professionals trained overseas and who wish to practice in Australia is undertaken by a range of organisations. These organisations conduct assessments using a range of methods. However there is very little published about how these organisations conduct their assessments. The purpose of the current paper is to investigate the methods of assessment used by these organisations and the issues associated with conducting these assessments

Human Uterine Wall Tension Trajectories and the Onset of Parturition

Uterine wall tension is thought to be an important determinant of the onset of labor in pregnant women. We characterize human uterine wall tension using ultrasound from the second trimester of pregnancy until parturition and compare preterm, term and twin pregnancies. A total of 320 pregnant women were followed from first antenatal visit to delivery during the period 2000–2004 at the John Hunter Hospital, NSW, Australia. The uterine wall thickness, length, anterior-posterior diameter and transverse diameter were determined by serial ultrasounds. Subjects were divided into three groups: women with singleton pregnancies and spontaneous labor onset, either preterm or term and women with twin pregnancies. Intrauterine pressure results from the literature were combined with our data to form trajectories for uterine wall thickness, volume and tension for each woman using the prolate ellipsoid method and the groups were compared at 20, 25 and 30 weeks gestation. Uterine wall tension followed an exponential curve, with results increasing throughout pregnancy with the site of maximum tension on the anterior wall. For those delivering preterm, uterine wall thickness was increased compared with term. For twin pregnancies intrauterine volume was increased compared to singletons (), but wall thickness was not. There was no evidence for increased tension in those delivering preterm or those with twin gestations. These data are not consistent with a role for high uterine wall tension as a causal factor in preterm spontaneous labor in singleton or twin gestations. It seems likely that hormonal differences in multiple gestations are responsible for increased rates of preterm birth in this group rather than increased tension

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

SummaryBackground The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. Methods We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). Findings Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. Interpretation Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. Funding Bill & Melinda Gates Foundation

High-levels of acquired drug resistance in adult patients failing first-line antiretroviral therapy in a rural HIV treatment programme in KwaZulu-Natal, South Africa.

OBJECTIVE: To determine the frequency and patterns of acquired antiretroviral drug resistance in a rural primary health care programme in South Africa. DESIGN: Cross-sectional study nested within HIV treatment programme. METHODS: Adult (≥ 18 years) HIV-infected individuals initially treated with a first-line stavudine- or zidovudine-based antiretroviral therapy (ART) regimen and with evidence of virological failure (one viral load >1000 copies/ml) were enrolled from 17 rural primary health care clinics. Genotypic resistance testing was performed using the in-house SATuRN/Life Technologies system. Sequences were analysed and genotypic susceptibility scores (GSS) for standard second-line regimens were calculated using the Stanford HIVDB 6.0.5 algorithms. RESULTS: A total of 222 adults were successfully genotyped for HIV drug resistance between December 2010 and March 2012. The most common regimens at time of genotype were stavudine, lamivudine and efavirenz (51%); and stavudine, lamivudine and nevirapine (24%). Median duration of ART was 42 months (interquartile range (IQR) 32-53) and median duration of antiretroviral failure was 27 months (IQR 17-40). One hundred and ninety one (86%) had at least one drug resistance mutation. For 34 individuals (15%), the GSS for the standard second-line regimen was <2, suggesting a significantly compromised regimen. In univariate analysis, individuals with a prior nucleoside reverse-transcriptase inhibitor (NRTI) substitution were more likely to have a GSS <2 than those on the same NRTIs throughout (odds ratio (OR) 5.70, 95% confidence interval (CI) 2.60-12.49). CONCLUSIONS: There are high levels of drug resistance in adults with failure of first-line antiretroviral therapy in this rural primary health care programme. Standard second-line regimens could potentially have had reduced efficacy in about one in seven adults involved