Approaches to Restoration: Assessing the Roles of Structure and Function in Saltmarsh Restoration in Light of Climate Change

The aim of this thesis is to review the current goals and methods for salt marsh restoration, to question how those goals and methods may change in light of global change, and to present a case study that offers a look at the kinds of information that can be gleaned by studying both structure and functionality in restoration

Community Paramedicine in Rural Areas: State and Local Findings and the Role of the State Flex Program (Policy Brief #35)

This study examined the evidence base for community paramedicine in rural communities, the role of community paramedics in rural healthcare delivery systems, the challenges faced by states in implementing community paramedicine programs, and the role of the state Flex programs in supporting development of community paramedicine programs. Additionally, the study provides a snapshot of community paramedicine programs currently being developed and/or implemented in rural areas. Another FMT briefing paper describes these same findings in detail. Highlights: Many rural community paramedicine programs are in pilot stages. Most community paramedics work within an expanded role rather than an expanded scope of practice, the latter requiring legislative or regulatory change. Funding and reimbursement for community paramedicine services are major challenges for the sustainability of community paramedicine programs. Data collection is vital for community paramedicine programs to be able to show value, including shared saving and patient outcomes. Collaboration at local and state levels is essential for buy-in, and partnering with the State Office of Rural Health is especially helpful in the early development and outreach efforts for rural community paramedicine programs

Exploring State Data Sources to Monitor Rural Emergency Medical Services Performance Improvement

In 1981, responsibility for overseeing emergency medical services (EMS) largely shifted to states and localities, contributing to the creation of a fragmented national picture of the state of EMS that is most evident in the resultant data collection and reporting issues that curb the availability of EMS data. These patchwork systems of care disproportionately affect rural areas, where myriad challenges – from a high reliance on a volunteer workforce to low call volumes and inadequate reimbursement – hinder performance. Previous studies by the Flex Monitoring Team (FMT) highlighted how little is known about the administrative, operational, and clinical capacity of rural EMS, which are key to investigate further before considering traditional EMS outcome measures. In this study, the FMT convened an expert panel comprised of representatives from a variety of stakeholders to highlight existing data challenges EMS face, identify data to support rural EMS performance measurement, as well as reassess the FMT’s 2017 rural-relevant EMS performance measures. Among the themes raised by the panel, experts suggested that improved engagement in oversight by state EMS agencies would increase accountability by local EMS; however, they cited a lack of staff capacity and expertise to analyze data in states, as well as disagreement between states on relevant measures. The FMT created EMS capacity measures to monitor and improve rural EMS capacity, along with the National Highway Traffic Safety Administration’s EMS Compass outcome measures to monitor performance. Potential opportunities identified by the panel to source standardized data for those measures include an assessment tool developed through the Joint Committee of Rural Emergency Care, or for the relevant data to be collected by state EMS agencies through their existing EMS service licensure process, many of which already collect some of the relevant data. Electronic patient care records, the typical source of data to calculate EMS clinical and non-clinical performance measures, can be collected and reported to states through the National EMS Information System (NEMSIS). Though not perfect, targeted efforts to improve the collection of local EMS data provides an opportunity for state EMS agencies and State Flex Programs (SFPs) to train local services in data collection, in addition to educating them on how to access and use their own data for performance improvement. This collaboration can also play a role in supporting improved health information exchange between EMS, hospitals, and other providers, which help improve the quality of pre-hospital care and assist in monitoring the quality and outcomes of care across the system of care. The importance of reliable, standardized, and timely data from local and state EMS is underscored by the recently launched Medicare Ground Ambulance Data Collection System, a Centers for Medicare and Medicaid Services study that will collect information to evaluate how ground ambulance costs relate to current payment policies. In turn, this will be used to formulate a report to Congress assessing the adequacy of Medicare ground ambulance payment rates and geographic variations in cost. As the data will be used to assess reimbursement rates across urban, rural, and super rural areas, accurate data collection and reporting is vital. The expert panel also reaffirmed the validity of FMT’s rural-relevant measures and raised questions about monitoring the measures longitudinally or developing measures to assess financial performance and sustainability. Additional work is needed to understand how to best use these measures to track rural EMS capacity over time, as well as identify the relevant financial measures

Hospitalizations for Hepatitis C in Mississippi, 2014-2018 – A Hidden Epidemic

Goal: Utilizing Mississippi’s hospital discharge data (HDD), we examined trends, demographics, comorbidities, in-hospital deaths, and hospital charges for hospitalizations with diagnoses for hepatitis C virus (HCV).Methods: We conducted a retrospective study of hospitalizations with primary or secondary HCV diagnoses. We performed descriptive and inferential statistical analyses using SAS 9.4. We compared categorical variables with chi-square tests and continuous variables with t-tests.Results: Between 2014 and 2018, patients hospitalized with an HCV diagnosis were more likely to have coexisting intravenous drug use (IDU) diagnoses compared to all other hospitalized patients (20.3% versus 3.3%, p \u3c 0.001). From 2014 to 2018, hepatitis C infections associated with IDU spiked by 53.8%, fueling the overall increase in the number of hepatitis C hospitalizations in Mississippi. Almost one-third (31.8%) of all hepatitis C stays had a severe liver condition and 48.2% had nicotine dependence. The average charges for stays with coexisting HCV and decompensated cirrhosis were $65,975.Conclusions: In Mississippi, there has been a rapid increase in HCV hospitalizations associated with IDU. In addition, HCV hospitalizations were associated with severe morbidity burden and high economic expense. These findings underscore the need for measures aimed at containing the spread of this dangerous but preventable infection

Addressing Opioid Use in Rural Communities: Examples from Critical Access Hospitals

The opioid epidemic continues to have a devastating impact in rural areas disproportionately affected by a lack of infrastructure to provide treatment for opioid use disorders (OUDs). Critical Access Hospitals (CAHs), often the hubs of local systems of care, can play an important role in addressing OUDs. Using a substance use framework developed for the Flex Monitoring Team’s earlier study of CAH substance use strategies, this brief highlights strategies adopted by CAHs to combat opioid use in their communities. It also identifies resources that State Flex Programs can use to support CAHs with this challenging population health issue

An insurance value modeling approach that captures the wider value of a novel antimicrobial to health systems, patients, and the population.

Background: Traditional health economic evaluations of antimicrobials currently underestimate their value to wider society. They can be supplemented by additional value elements including insurance value, which captures the value of an antimicrobial in preventing or mitigating impacts of adverse risk events. Despite being commonplace in other sectors, constituents of the impacts and approaches for estimating insurance value have not been investigated. Objectives: This study assessed the insurance value of a novel gram-negative antimicrobial from operational healthcare, wider population health, productivity, and informal care perspectives. Methods: A novel mixed-methods approach was used to model insurance value in the United Kingdom: (1) literature review and multidisciplinary expert workshops to identify risk events for 4 relevant scenarios: ward closures, unavoidable shortage of conventional antimicrobials, viral respiratory pandemics, and catastrophic antimicrobial resistance (AMR); (2) parameterizing mitigable costs and frequencies of risk events across perspectives and scenarios; (3) estimating insurance value through a Monte Carlo simulation model for extreme events and a dynamic disease transmission model. Results: The mean insurance value across all scenarios and perspectives over 10 years in the UK was £718 million, should AMR remain unchanged, where only £134 million related to operational healthcare costs. It would be 50%-70% higher if AMR steadily increased or if a more risk-averse view (1-in-10 year downside) of future events is taken. Discussion: The overall insurance value if AMR remains at current levels (a conservative projection), is over 5 times greater than insurance value from just the operational healthcare costs perspective, traditionally the sole perspective used in health budgeting. Insurance value was generally larger for nationwide or universal (catastrophic AMR, pandemic, and conventional antimicrobial shortages) rather than localized (ward closure) scenarios, across perspectives. Components of this insurance value match previously published estimates of operational costs and mortality impacts. Conclusions: Insurance value of novel antimicrobials can be systematically modeled and substantially augments their traditional health economic value in normal circumstances. These approaches are generalizable to similar health interventions and form a framework for health systems and governments to capture broader value in health technology assessments, improve healthcare access, and increase resilience by planning for adverse scenarios

Predicting Distribution of Aedes Aegypti and Culex Pipiens Complex, Potential Vectors of Rift Valley Fever Virus in Relation to Disease Epidemics in East Africa.

The East African region has experienced several Rift Valley fever (RVF) outbreaks since the 1930s. The objective of this study was to identify distributions of potential disease vectors in relation to disease epidemics. Understanding disease vector potential distributions is a major concern for disease transmission dynamics. DIVERSE ECOLOGICAL NICHE MODELLING TECHNIQUES HAVE BEEN DEVELOPED FOR THIS PURPOSE: we present a maximum entropy (Maxent) approach for estimating distributions of potential RVF vectors in un-sampled areas in East Africa. We modelled the distribution of two species of mosquitoes (Aedes aegypti and Culex pipiens complex) responsible for potential maintenance and amplification of the virus, respectively. Predicted distributions of environmentally suitable areas in East Africa were based on the presence-only occurrence data derived from our entomological study in Ngorongoro District in northern Tanzania. Our model predicted potential suitable areas with high success rates of 90.9% for A. aegypti and 91.6% for C. pipiens complex. Model performance was statistically significantly better than random for both species. Most suitable sites for the two vectors were predicted in central and northwestern Tanzania with previous disease epidemics. Other important risk areas include western Lake Victoria, northern parts of Lake Malawi, and the Rift Valley region of Kenya. Findings from this study show distributions of vectors had biological and epidemiological significance in relation to disease outbreak hotspots, and hence provide guidance for the selection of sampling areas for RVF vectors during inter-epidemic periods

Protection against LPS-induced cartilage inflammation and degradation provided by a biological extract of Mentha spicata

<p>Abstract</p> <p>Background</p> <p>A variety of mint [<it>Mentha spicata</it>] has been bred which over-expresses Rosmarinic acid (RA) by approximately 20-fold. RA has demonstrated significant anti-inflammatory activity <it>in vitro </it>and in small rodents; thus it was hypothesized that this plant would demonstrate significant anti-inflammatory activity <it>in vitro</it>. The objectives of this study were: a) to develop an <it>in vitro </it>extraction procedure which mimics digestion and hepatic metabolism, b) to compare anti-inflammatory properties of High-Rosmarinic-Acid <it>Mentha spicata </it>(HRAM) with wild-type control <it>M. spicata </it>(CM), and c) to quantify the relative contributions of RA and three of its hepatic metabolites [ferulic acid (FA), caffeic acid (CA), coumaric acid (CO)] to anti-inflammatory activity of HRAM.</p> <p>Methods</p> <p>HRAM and CM were incubated in simulated gastric and intestinal fluid, liver microsomes (from male rat) and NADPH. Concentrations of RA, CA, CO, and FA in simulated digest of HRAM (HRAM_sim) and CM (CM_sim) were determined (HPLC) and compared with concentrations in aqueous extracts of HRAM and CM. Cartilage explants (porcine) were cultured with LPS (0 or 3 μg/mL) and test article [HRAM_sim(0, 8, 40, 80, 240, or 400 μg/mL), or CM_sim(0, 1, 5 or 10 mg/mL), or RA (0.640 μg/mL), or CA (0.384 μg/mL), or CO (0.057 μg/mL) or FA (0.038 μg/mL)] for 96 h. Media samples were analyzed for prostaglandin E₂(PGE₂), interleukin 1β (IL-1), glycosaminoglycan (GAG), nitric oxide (NO) and cell viability (differential live-dead cell staining).</p> <p>Results</p> <p>RA concentration of HRAM_simand CM_simwas 49.3 and 0.4 μg/mL, respectively. CA, FA and CO were identified in HRAM_simbut not in aqueous extract of HRAM. HRAM_sim(≥ 8 μg/mL) inhibited LPS-induced PGE₂and NO; HRAM_sim(≥ 80 μg/mL) inhibited LPS-induced GAG release. RA inhibited LPS-induced GAG release. No anti-inflammatory or chondroprotective effects of RA metabolites on cartilage explants were identified.</p> <p>Conclusions</p> <p>Our biological extraction procedure produces a substance which is similar in composition to post-hepatic products. HRAM_simis an effective inhibitor of LPS-induced inflammation in cartilage explants, and effects are primarily independent of RA. Further research is needed to identify bioactive phytochemical(s) in HRAM_sim.</p

Tracheal adenoid cystic carcinoma masquerading asthma: A case report

BACKGROUND: Tracheal tumors are often misdiagnosed as asthma and are treated with inhaled steroids and bronchodilators without resolution. CASE PRESENTATION: Here, a patient with tracheal adenoid cystic carcinoma who had been previously diagnosed with difficult asthma was reported. The possibility of the presence of localized airway obstruction was raised when the flow-volume curve suggesting fixed airway obstruction, was obtained. CONCLUSION: The presenting case report emphasizes the fact that not all wheezes are asthma. It is critical to bear in mind that if a patient does not respond to appropriate anti-asthma therapy, localized obstructions should be ruled out before establishing the diagnosis of asthma