Improving osteoarthritis management in primary healthcare: results from a quasi-experimental study

Background To improve quality of care for patients with hip and knee osteoarthritis (OA), general practitioners (GPs) and physiotherapists (PTs) in a Norwegian municipality initiated an intervention. The intervention aimed to increase provision of core OA treatment (information, exercise, and weight control) prior to referral for surgery, rational use of imaging for assessing OA and improve communication between healthcare professionals. This study assessed the effectiveness of this intervention. Methods Forty-eight PTs and one hundred one GPs were invited to the intervention that included two interactive workshops outlining best practice and an accompanying template for PT discharge reports. Using interrupted time series research design, the study period was divided into three: pre-implementation, transition (implementation) and post-implementation. Comparing the change between pre- and post-implementation, the primary outcome was patient-reported quality of OA care measured with the OsteoArthritis Quality Indicator questionnaire. Secondary outcomes were number of PT discharge reports, information included in GP referral letters to orthopaedic surgeon, the proportion of GP referral letters indicating use of core treatment, and the use of imaging within OA assessment. Analyses involved linear mixed and logistic regression models. Results The PT workshop had 30 attendees, and 31 PTs and 33 GPs attended the multidisciplinary workshop. Two hundred eight and one hundred twenty-five patients completed the questionnaire during pre- and post-implementation, respectively. The adjusted model showed a small, statistically non-significant, increase in mean total score for quality of OA care (mean change = 4.96, 95% CI -0.18, 10.12, p:0.057), which was mainly related to items on OA core treatment. Patients had higher odds of reporting receipt of information on treatment alternatives (odds ratio (OR) 1.9, 95% CI 1.08, 3.24) and on self-management (OR 2.4, 95% CI 1.33, 4.32) in the post-implementation phase. There was a small, statistically non-significant, increase in the proportion of GP referral letters indicating prior use of core treatment modalities. There were negligible changes in the number of PT discharge reports, in the information included in the GP referral letters, and in the use of imaging for OA assessment. Conclusion This study suggests that a primary care intervention including two inter-active workshops can shift the quality of care towards best practice recommendations. Trial registration ClinicalTrials.gov: NCT02876120.publishedVersio

Jewels across the Landscape: Monitoring and Assessing the Quality of Lakes and Reservoirs in the United States

An early naturalist described lakes as “jewels” across the landscape and indeed they were…at the end of the nineteenth century. As we settled the country and began to utilize the lake resource for our needs, things changed. Additionally, our needs for water brought about the construction of impoundments from ice ponds to small stock ponds up to mainstem impoundments along our major rivers. The lake resource in the United States now includes natural lakes in our northern tier of states, unique physiographic regions such as Florida and the Sand Hills of Nebraska, and the mountainous regions, and impoundments scattered across the entire landscape. In this chapter, we will describe efforts by an unique partnership between the individual states and tribal nations of the USA and the US Environmental Protection Agency to monitor and assess these systems. These efforts go beyond single water quality (chemistry) issues and include assessments targeting the goal of the Clean Water Act, namely, restoring, maintaining, and protecting the chemical, physical, and biological integrity of the nation’s lakes and reservoirs

Wetland Assessment: Beyond the Traditional Water Quality Perspective

Use of water chemistry or water quality data as the sole indicator to determine if aquatic ecosystems meet restoration objectives or Clean Water Act criteria is not possible for wetland resources because surface water presence varies across wetland types. The 2011, National Wetland Condition Assessment (NWCA) assessed 967 sites representing 25,153,681 ha of wetland across the conterminous US. Surface water could be collected at 537 sites representing only 41% of the wetland population area and under-representing particular wetland types. These results motivated the authors to introduce the concept of aquatic resource quality, the condition of an ecosystem based on the integrated assessment of physical, chemical, and biological indicators, as the goal of monitoring and assessment of aquatic systems. The NWCA is an example of the use of aquatic resource quality. The survey successfully reported on wetland condition using a biotic indicator (the vegetation multimetric index) and the relative extent and relative risk of stressors using 10 physical, chemical, and biological indicators to report on aquatic resource quality. The NWCA demonstrated that aquatic resource quality can be consistently evaluated regardless of surface water presence. Consequently, we recommend aquatic resource quality as the goal of aquatic ecosystem monitoring and assessment

Rivers and Streams: Upgrading Monitoring of the Nation’s Freshwater Resources - Meeting the Spirit of the Clean Water Act

The goal of the Clean Water Act (CWA) is to restore and maintain the chemical, physical and biological integrity of the waters in the United States. Much of the monitoring and assessment is reasonably delegated to the States to monitor and report the condition of their water to Congress through the Environmental Protection Agency. States have historically been fully occupied in monitoring the most egregious water quality problems along with select high priority water bodies. This approach, while addressing State priorities with finite resources, does not capture the full spectrum and scope of water quality conditions within and across State boundaries. Hence, the reporting on progress in meeting the goals of the CWA has not been realized. In this chapter, we describe the partnership between EPA, the States and Tribes to remedy this information gap for rivers and streams. Filling this gap requires both improved monitoring designs to reflect conditions across all waters as well as the expansion of indicators to move beyond water chemistry to include all three elements of the CWA goal—chemical, physical and biological integrity

Attraction between DNA molecules mediated by multivalent ions

The effective force between two parallel DNA molecules is calculated as a function of their mutual separation for different valencies of counter- and salt ions and different salt concentrations. Computer simulations of the primitive model are used and the shape of the DNA molecules is accurately modelled using different geometrical shapes. We find that multivalent ions induce a significant attraction between the DNA molecules whose strength can be tuned by the averaged valency of the ions. The physical origin of the attraction is traced back either to electrostatics or to entropic contributions. For multivalent counter- and monovalent salt ions, we find a salt-induced stabilization effect: the force is first attractive but gets repulsive for increasing salt concentration. Furthermore, we show that the multivalent-ion-induced attraction does not necessarily correlate with DNA overcharging.Comment: 51 pages and 13 figure

Comment on Bachmann et al. (2013): A nonrepresentative sample cannot describe the extent of cultural eutrophication of natural lakes in the United States

In their recent paper, Bachmann et al. (2013) evaluate the extent to which natural lakes in the contiguous United States have been affected by cultural eutrophication since Europe-an settlement, using paleolimnological data collected during the 2007 National Lakes Assessment (NLA; U.S. Environ-mental Protection Agency [USEPA] 2009). The NLA sites were selected using a statistically valid sampling design that allows for the overall ecological condition of the nation’s lakes to be accurately characterized (USEPA 2009). Given the current consensus among limnologists regarding the prevalence of culturally eutrophic lakes (Finlayson and D’Cruz 2005; Carpenter et al. 2011), the conclusion of Bachmann et al. that ‘‘in the United States of America, the extent that natural lakes have been changed by cultural eutrophication does not seem to be large’’ (Bachmann et al. 2013, p. 950) is surprising. The findings of Bachmann et al. supporting this statement are not based on the entire NLA sample of natural lakes but rather on a subset of them. We demonstrate below that not only is this subset not representative of the entire population of natural lakes in the United States, but that it is biased toward lakes in regions with less anthropogenic activity and substantially lower nutrient concentrations. Consequently, we argue that the conclusions drawn by Bachmann et al. (2013) at the national scale are based upon a statistically flawed analysis

The Genome of Deep-Sea Vent Chemolithoautotroph Thiomicrospira crunogena XCL-2

Presented here is the complete genome sequence of Thiomicrospira crunogena XCL-2, representative of ubiquitous chemolithoautotrophic sulfur-oxidizing bacteria isolated from deep-sea hydrothermal vents. This gammaproteobacterium has a single chromosome (2,427,734 base pairs), and its genome illustrates many of the adaptations that have enabled it to thrive at vents globally. It has 14 methyl-accepting chemotaxis protein genes, including four that may assist in positioning it in the redoxcline. A relative abundance of coding sequences (CDSs) encoding regulatory proteins likely control the expression of genes encoding carboxysomes, multiple dissolved inorganic nitrogen and phosphate transporters, as well as a phosphonate operon, which provide this species with a variety of options for acquiring these substrates from the environment. Thiom. crunogena XCL-2 is unusual among obligate sulfur-oxidizing bacteria in relying on the Sox system for the oxidation of reduced sulfur compounds. The genome has characteristics consistent with an obligately chemolithoautotrophic lifestyle, including few transporters predicted to have organic allocrits, and Calvin-Benson-Bassham cycle CDSs scattered throughout the genome

Comparative Genomics of Plant-Associated Pseudomonas spp.: Insights into Diversity and Inheritance of Traits Involved in Multitrophic Interactions

We provide here a comparative genome analysis of ten strains within the Pseudomonas fluorescens group including seven new genomic sequences. These strains exhibit a diverse spectrum of traits involved in biological control and other multitrophic interactions with plants, microbes, and insects. Multilocus sequence analysis placed the strains in three sub-clades, which was reinforced by high levels of synteny, size of core genomes, and relatedness of orthologous genes between strains within a sub-clade. The heterogeneity of the P. fluorescens group was reflected in the large size of its pan-genome, which makes up approximately 54% of the pan-genome of the genus as a whole, and a core genome representing only 45-52% of the genome of any individual strain. We discovered genes for traits that were not known previously in the strains, including genes for the biosynthesis of the siderophores achromobactin and pseudomonine and the antibiotic 2-hexyl-5-propyl-alkylresorcinol; novel bacteriocins; type II, III, and VI secretion systems; and insect toxins. Certain gene clusters, such as those for two type III secretion systems, are present only in specific sub-clades, suggesting vertical inheritance. Almost all of the genes associated with multitrophic interactions map to genomic regions present in only a subset of the strains or unique to a specific strain. To explore the evolutionary origin of these genes, we mapped their distributions relative to the locations of mobile genetic elements and repetitive extragenic palindromic (REP) elements in each genome. The mobile genetic elements and many strain-specific genes fall into regions devoid of REP elements (i.e., REP deserts) and regions displaying atypical tri-nucleotide composition, possibly indicating relatively recent acquisition of these loci. Collectively, the results of this study highlight the enormous heterogeneity of the P. fluorescens group and the importance of the variable genome in tailoring individual strains to their specific lifestyles and functional repertoire

Comparative Genomics of Plant-Associated Pseudomonas spp.: Insights into Diversity and Inheritance of Traits Involved in Multitrophic Interactions

We provide here a comparative genome analysis of ten strains within the Pseudomonas fluorescens group including seven new genomic sequences. These strains exhibit a diverse spectrum of traits involved in biological control and other multitrophic interactions with plants, microbes, and insects. Multilocus sequence analysis placed the strains in three sub-clades, which was reinforced by high levels of synteny, size of core genomes, and relatedness of orthologous genes between strains within a sub-clade. The heterogeneity of the P. fluorescens group was reflected in the large size of its pan-genome, which makes up approximately 54% of the pan-genome of the genus as a whole, and a core genome representing only 45–52% of the genome of any individual strain. We discovered genes for traits that were not known previously in the strains, including genes for the biosynthesis of the siderophores achromobactin and pseudomonine and the antibiotic 2-hexyl-5-propyl-alkylresorcinol; novel bacteriocins; type II, III, and VI secretion systems; and insect toxins. Certain gene clusters, such as those for two type III secretion systems, are present only in specific sub-clades, suggesting vertical inheritance. Almost all of the genes associated with multitrophic interactions map to genomic regions present in only a subset of the strains or unique to a specific strain. To explore the evolutionary origin of these genes, we mapped their distributions relative to the locations of mobile genetic elements and repetitive extragenic palindromic (REP) elements in each genome. The mobile genetic elements and many strain-specific genes fall into regions devoid of REP elements (i.e., REP deserts) and regions displaying atypical tri-nucleotide composition, possibly indicating relatively recent acquisition of these loci. Collectively, the results of this study highlight the enormous heterogeneity of the P. fluorescens group and the importance of the variable genome in tailoring individual strains to their specific lifestyles and functional repertoire

The Constitution of the United States

This casebook emphasizes the text, structure, and history of the Constitution. It uses great cases for learning the major issues in constitutional law, and it gives less attention to small ripples of contemporary doctrine. It emphasizes the task of interpretation, including many examples of the interpretation of the Constitution by the political branches. And it includes features of our constitutional history that are neglected in many casebooks, such as slavery, the amendment process, and the early history of the freedom of speech. The third edition has many refinements. It also has more coverage of executive discretion, the taxing and spending powers, the Necessary and Proper Clause, incorporation, and the drafting of the Fourteenth Amendment. It is now suitable not only for a survey course, but also for a course focused on federalism, on the First Amendment, or on the Fourteenth Amendment.https://scholarship.law.nd.edu/law_books/1303/thumbnail.jp