Are Mandates the Answer? Improving Palliative Care and Pain Management in Vermont

Background: The Vermont legislature (bill H.435, Sec. 19) has tasked the Vermont Board of Medical Practice (VBMP) with making a formal recommendation on improving Vermont health professionals’ knowledge and practice of Palliative Care and Pain Management (PC/PM). In collaboration with the VBMP, our group set out to answer the following questions: • How confident/competent are VT physicians in the practice of PC/PM? • What are the barriers to achieving optimal patient care in PC/PM? • Do VT physicians believe mandatory CME would improve the overall quality of care in PC/PM? • What are the best methods of providing Continuing Medical Education (CME)?https://scholarworks.uvm.edu/comphp_gallery/1040/thumbnail.jp

Climate, people and faunal succession on Java, Indonesia: evidence from Song Gupuh

Song Gupuh, a partially collapsed cave in the Gunung Sewu Limestones of East Java, Indonesia, contains over 16 m of deposits with a faunal sequence spanning some 70 ka. Major changes in the range of animals represented show the impact of climate change and humans. The Terminal Pleistocene and Early Holocene was a period of maximum biodiversity. Human use of Song Gupuh and other cave sites in the region also intensified significantly from ca. 12 ka, together with a new focus on exploitation of small-bodied species (macaque monkeys and molluscs), the first evidence for import of resources from the coast, and use of bone and shell tools. Human activity, especially after the onset of the Neolithic around 2.6 ka, subsequently contributed to a progressive loss of many species from the area, including tapir, elephant, Malayan bear, rhino and tiger, and this extinction process is continuing. We conclude by discussing the biogeographical significance of Song Gupuh in the context of other sites in Java (e.g. Punung, Wajak) and further afield (e.g. Liang Bua)

Age and context of the oldest known hominin fossils from Flores

Recent excavations at the early Middle Pleistocene site of Mata Menge in the So\u27a Basin of central Flores, Indonesia, have yielded hominin fossils1 attributed to a population ancestral to Late Pleistocene Homo floresiensis2. Here we describe the age and context of the Mata Menge hominin specimens and associated archaeological findings. The fluvial sandstone layer from which the in situ fossils were excavated in 2014 was deposited in a small valley stream around 700 thousand years ago, as indicated by 40Ar/39Ar and fission track dates on stratigraphically bracketing volcanic ash and pyroclastic density current deposits, in combination with coupled uranium-series and electron spin resonance dating of fossil teeth. Palaeoenvironmental data indicate a relatively dry climate in the So\u27a Basin during the early Middle Pleistocene, while various lines of evidence suggest the hominins inhabited a savannah-like open grassland habitat with a wetland component. The hominin fossils occur alongside the remains of an insular fauna and a simple stone technology that is markedly similar to that associated with Late Pleistocene H. floresiensis

Revised age for Mojokerto 1, an early Homo erectus cranium from East Java, Indonesia

Dates of around 1.8 Ma have been claimed for a hominin cranial vault excavated near Mojokerto City in East Java, Indonesia. Such an early date for presumed Homo erectus in East Asia would require a major revision of the general model for timing of initial hominin dispersal \u27Out of Africa\u27. Instead, our field study and redating of two pumice horizons at the site indicate that the age of the Mojokerto cranial vault is less than 1.49 Ma. Furthermore, we argue that a basic understanding of site and regional depositional processes is fundamental for assessing the significance of any radiometric date

Dragon\u27s Paradise Lost: Palaeobiogeography, Evolution and Extinction of the Largest-Ever Terrestrial Lizards (Varanidae)

Background The largest living lizard species, Varanus komodoensis Ouwens 1912, is vulnerable to extinction, being restricted to a few isolated islands in eastern Indonesia, between Java and Australia, where it is the dominant terrestrial carnivore. Understanding how large-bodied varanids responded to past environmental change underpins long-term management of V. komodoensis populations. Methodology/Principal Findings We reconstruct the palaeobiogeography of Neogene giant varanids and identify a new (unnamed) species from the island of Timor. Our data reject the long-held perception that V. komodoensis became a giant because of insular evolution or as a specialist hunter of pygmy Stegodon. Phyletic giantism, coupled with a westward dispersal from mainland Australia, provides the most parsimonious explanation for the palaeodistribution of V. komodoensis and the newly identified species of giant varanid from Timor. Pliocene giant varanid fossils from Australia are morphologically referable to V. komodoensis suggesting an ultimate origin for V. komodoensis on mainland Australia (\u3e3.8 million years ago). Varanus komodoensis body size has remained stable over the last 900,000 years (ka) on Flores, a time marked by major faunal turnovers, extinction of the island\u27s megafauna, the arrival of early hominids by 880 ka, co-existence with Homo floresiensis, and the arrival of modern humans by 10 ka. Within the last 2000 years their populations have contracted severely. Conclusions/Significance Giant varanids were once a ubiquitous part of Subcontinental Eurasian and Australasian faunas during the Neogene. Extinction played a pivotal role in the reduction of their ranges and diversity throughout the late Quaternary, leaving only V. komodoensis as an isolated long-term survivor. The events over the last two millennia now threaten its future survival

Obesity Predicts Lower Risk of Wound Complications following Open Reduction and Internal Fixation of Ankle Fractures

Category: Trauma Introduction/Purpose: Ankle fractures are among the most common injuries treated by Orthopaedic Surgeons. Complications following surgical treatment of ankle fractures have been well described, however less is known about the risk factors for postoperative wound complications specifically. The purpose of the present study was to evaluate the incidence of wound complications following open reduction and internal fixation of ankle fractures in obese and non-obese patients. Methods: We retrospectively identified 127 consecutive patients who underwent open reduction and internal fixation for an isolated, closed ankle fracture from 2008-2012. The age, sex, height, weight, diabetes status, and tobacco use of each patient were recorded. Time from injury to surgical fixation, use of external fixation, presence of initial dislocation, energy of mechanism, and injury pattern were also recorded. Patients’ records were reviewed to identify any postoperative wound complications. Complications were categorized as major or minor based on need for subsequent surgical intervention. Complication rates were compared between groups using the chi square test, and significant results were followed up with calculation of odds ratios and 95% confidence intervals using multivariate logistic regression. Results: The overall rate of wound complication was 18.9% (24/127), consisting of 6 major and 18 minor complications. The rate of wound complication of any type was significantly lower in obese patients at 11.7% (7/60) compared to 25.4% (17/67) in non- obese patients (P = 0.049). Obesity was associated with a significantly lower risk of developing a wound complication (OR 0.267, 95% CI 0.087 - 0.822), even when controlling for age, sex, diabetes status, tobacco use, surgical delay, external fixation, and injury pattern. No other covariates were associated with an increased risk of a wound infection. Conclusion: In the present study obese patients were less likely than non-obese patients to have a postoperative wound complication following internal fixation of an ankle fracture. Obesity may be protective against wound complications following surgical treatment of ankle fractures given the additional soft-tissue overlying the ankle

The Liang Bua faunal remains: a 95 k.yr. sequence from Flores, East Indonesia

Excavations at Liang Bua, a limestone cave on the island of Flores, East Indonesia, have yielded a well-dated archaeological and faunal sequence spanning the last 95 k.yr., major climatic fluctuations, and two human species – H. floresiensis from 95 to 17 k.yr. 1, and modern humans from 11 k.yr. to the present. The faunal assemblage comprises well-preserved mammal, bird, reptile and mollusc remains, including examples of island gigantism in small mammals and the dwarfing of large taxa. Together with evidence from Early-Middle Pleistocene sites in the Soa Basin, it confirms the long-term isolation, impoverishment, and phylogenetic continuity of the Flores faunal community. The accumulation of Stegodon and Komodo dragon remains at the site in the Pleistocene is attributed to Homo floresiensis, while predatory birds, including an extinct species of owl, were largely responsible for the accumulation of the small vertebrates. The disappearance from the sequence of the two large-bodied, endemic mammals, Stegodon florensis insularis and Homo floresiensis, was associated with a volcanic eruption at 17 ka and precedes the earliest evidence for modern humans, who initiated use of mollusc and shell working, and began to introduce a range of exotic animals to the island. Faunal introductions during the Holocene included the Sulawesi warty pig (Sus celebensis) at about 7 ka, followed by the Eurasian pig (Sus scrofa), Long-tailed macaque, Javanese porcupine, and Masked palm civet at about 4 ka, and cattle, deer, and horse - possibly by the Portuguese within historic times. The Holocene sequence at the site also documents local faunal extinctions - a result of accelerating human population growth, habitat loss, and over-exploitation

Archaeology and Age of a New Hominin from Flores in Eastern Indonesia

Excavations at Liang Bua, a large limestone cave on the island of Flores in eastern Indonesia, have yielded evidence for a population of tiny hominins, sufficiently distinct anatomically to be assigned to a new species, Homo floresiensis1. The finds comprise the cranial and some post-cranial remains of one individual, as well as a premolar from another individual in older deposits. Here we describe their context, implications and the remaining archaeological uncertainties. Dating by radiocarbon (14C), luminescence, uranium-series and electron spin resonance (ESR) methods indicates that H. floresiensis existed from before 38,000 years ago (kyr) until at least 18 kyr. Associated deposits contain stone artefacts and animal remains, including Komodo dragon and an endemic, dwarfed species of Stegodon. H. floresiensis originated from an early dispersal of Homo erectus (including specimens referred to as Homo ergaster and Homo georgicus)1 that reached Flores, and then survived on this island refuge until relatively recently. It overlapped significantly in time with Homo sapiens in the region2,3, but we do not know if or how the two species interacted

Archaeology and age of a new hominin from Flores, in eastern Indonesia

Excavations at Liang Bua, a large limestone cave on the island of Flores in eastern Indonesia, have yielded evidence for a population of tiny hominins, sufficiently distinct anatomically to be assigned to a new species, Homo floresiensis1. The finds comprise the cranial and some post-cranial remains of one individual, as well as a premolar from another individual in older deposits. Here we describe their context, implications and the remaining archaeological uncertainties. Dating by radiocarbon (14C), luminescence, uranium-series and electron spin resonance (ESR) methods indicates that H. floresiensis existed from before 38,000 years ago (kyr) until at least 18 kyr. Associated deposits contain stone artefacts and animal remains, including Komodo dragon and an endemic, dwarfed species of Stegodon. H. floresiensis originated from an early dispersal of Homo erectus (including specimens referred to as Homo ergaster and Homo georgicus)1 that reached Flores, and then survived on this island refuge until relatively recently. It overlapped significantly in time with Homo sapiens in the region2, 3, but we do not know if or how the two species interacted