Management errors in adults with congenital heart disease: prevalence, sources, and consequences

AIMS: Improved survival has resulted in increasing numbers and complexity of adults with congenital heart disease (ACHD). International guidelines recommend specialized care but many patients are still not managed at dedicated ACHD centres. This study analysed referral sources and appropriateness of management for patients referred to our tertiary ACHD Centre over the past 3 years. METHODS AND RESULTS: We compared differences in care between patients referred from paediatric/ACHD-trained vs. general adult cardiologists, according to Adherence (A) or Non-Adherence (NA) with published guidelines. Non-Adherent cases were graded according to the severity of adverse outcome or risk of adverse outcome. Of 309 consecutively referred patients (28 ± 14 years, 51% male), 134 (43%) were from general cardiologists (19% highly complex CHD) and 115 (37%) were from paediatric cardiology or ACHD specialists (33% highly complex CHD). Sixty referrals (20%) were from other medical teams and of those, 31 had been lost to follow-up. Guideline deviations were more common in referrals from general compared to CHD-trained cardiologists (P < 0.001). Of general cardiology referrals, 49 (37%) were NA; 18 had catastrophic or major complications (n = 2, 16 respectively). In contrast, only 12 (10%) of the paediatric/ACHD referrals were NA, but none of these were catastrophic and only 3 were major. Simple, moderate, and highly complex CHD patients were at increased risk of adverse outcome when not under specialized CHD cardiology care (P = 0.04, 0.009, and 0.002, respectively). CONCLUSION: Non-adherence with guidelines was common in the ACHD population, and this frequently resulted in important adverse clinical consequences. These problems were more likely in patients who had not been receiving specialized CHD care. Configuring healthcare systems to optimize ‘whole of life’ care for this growing population is essential

Validation of a method for identifying nursing home admissions using administrative claims

<p>Abstract</p> <p>Background</p> <p>Currently there is no standard algorithm to identify whether a subject is residing in a nursing home from administrative claims. Our objective was to develop and validate an algorithm that identifies nursing home admissions at the resident-month level using the MarketScan Medicare Supplemental and Coordination of Benefit (COB) database.</p> <p>Methods</p> <p>The computer algorithms for identifying nursing home admissions were created by using provider type, place of service, and procedure codes from the 2000 – 2002 MarketScan Medicare COB database. After the algorithms were reviewed and refined, they were compared with a detailed claims review by an expert reviewer. A random sample of 150 subjects from the claims was selected and used for the validity analysis of the algorithms. Contingency table analysis, comparison of mean differences, correlations, and t-test analyses were performed. Percentage agreement, sensitivity, specificity, and Kappa statistics were analyzed.</p> <p>Results</p> <p>The computer algorithm showed strong agreement with the expert review (99.9%) for identification of the first month of nursing home residence, with high sensitivity (96.7%), specificity (100%) and a Kappa statistic of 0.97. Weighted Pearson correlation coefficient between the algorithm and the expert review was 0.97 (<it>p </it>< 0.0001).</p> <p>Conclusion</p> <p>A reliable algorithm indicating evidence of nursing home admission was developed and validated from administrative claims data. Our algorithm can be a useful tool to identify patient transitions from and to nursing homes, as well as to screen and monitor for factors associated with nursing home admission and nursing home discharge.</p

Isoprene suppression of new particle formation in a mixed deciduous forest

Production of new particles over forests is an important source of cloud condensation nuclei that can affect climate. While such particle formation events have been widely observed, their formation mechanisms over forests are poorly understood. Our observations made in a mixed deciduous forest with large isoprene emissions during the summer displayed a surprisingly rare occurrence of new particle formation (NPF). Typically, NPF events occur around noon but no NPF events were observed during the 5 weeks of measurements. The exceptions were two evening ultrafine particle events. During the day, sulfuric acid concentrations were in the 106 cm-3 range with very low preexisting aerosol particles, a favorable condition for NPF to occur even during the summer. The ratio of emitted isoprene carbon to monoterpene carbon at this site was similar to that in Amazon rainforests (ratio &gt;10), where NPF events are also very rare, compared with a ratio &lt;0.5 in Finland boreal forests, where NPF events are frequent. Our results suggest that large isoprene emissions can suppress NPF formation in forests although the underlying mechanism for the suppression is unclear. The two evening ultrafine particle events were associated with the transported anthropogenic sulfur plumes and ultrafine particles were likely formed via ion-induced nucleation. Changes in landcover and environmental conditions could modify the isoprene suppression of NPF in some forest regions resulting in a radiative forcing that could have influence on the climate. © 2011 Author(s)

Isoprene suppression of new particle formation in a mixed deciduous forest

Production of new particles over forests is an important source of cloud condensation nuclei that can affect climate. While such particle formation events have been widely observed, their formation mechanisms over forests are poorly understood. Our observations made in a mixed deciduous forest with large isoprene emissions during the summer displayed a surprisingly rare occurrence of new particle formation (NPF). Typically, NPF events occur around noon but no NPF events were observed during the 5 weeks of measurements. The exceptions were two evening ultrafine particle events. During the day, sulfuric acid concentrations were in the 106 cm-3 range with very low preexisting aerosol particles, a favorable condition for NPF to occur even during the summer. The ratio of emitted isoprene carbon to monoterpene carbon at this site was similar to that in Amazon rainforests (ratio &gt;10), where NPF events are also very rare, compared with a ratio &lt;0.5 in Finland boreal forests, where NPF events are frequent. Our results suggest that large isoprene emissions can suppress NPF formation in forests although the underlying mechanism for the suppression is unclear. The two evening ultrafine particle events were associated with the transported anthropogenic sulfur plumes and ultrafine particles were likely formed via ion-induced nucleation. Changes in landcover and environmental conditions could modify the isoprene suppression of NPF in some forest regions resulting in a radiative forcing that could have influence on the climate. © 2011 Author(s)

The use of disjunct eddy sampling methods for the determination of ecosystem level fluxes of trace gases

The concept of disjunct eddy sampling (DES) for use in measuring ecosystem-level micrometeorological fluxes is re-examined. The governing equations are discussed as well as other practical considerations and guidelines concerning this sampling method as it is applied to either the disjunct eddy covariance (DEC) or disjunct eddy accumulation (DEA) techniques. A disjunct eddy sampling system was constructed that could either be combined with relatively slow sensors (response time of 2 to 40 s) to measure fluxes using DEC, or could also be used to accumulate samples in stable reservoirs for later laboratory analysis (DEA technique). Both the DEC and DEA modes of this sampler were tested against conventional eddy covariance (EC) for fluxes of either CO2 (DEC) or isoprene (DEA). Good agreement in both modes was observed relative to the EC systems. However, the uncertainty in a single DEA flux measurement was considerable (∼40%) due to both the reduced statistical sampling and the analytical precision of the concentration difference measurements. We have also re-investigated the effects of nonzero mean vertical wind velocity on accumulation techniques as it relates to our DEA measurements. Despite the higher uncertainty, disjunct eddy sampling can provide an alternative technique to eddy covariance for determining ecosystem-level fluxes for species where fast sensors do not currently exist

Quantifying the seasonal and interannual variability of North American isoprene emissions using satellite observations of the formaldehyde column

Quantifying isoprene emissions using satellite observations of the formaldehyde (HCHO) columns is subject to errors involving the column retrieval and the assumed relationship between HCHO columns and isoprene emissions,taken here from the GEOSCHEM chemical transport model. Here we use a 6-year (1996-2001) HCHO column data set from the Global Ozone Monitoring Experiment (GOME) satellite instrument to (1) quantify these errors, (2) evaluate GOME-derived isoprene emissions with in situ flux measurements and a process-based emission inventory (Model of Emissions of Gases and Aerosols from Nature, MEGAN), and (3) investigate the factors driving the seasonal and interannual variability of North American isoprene emissions. The error in the GOME HCHO column retrieval is estimated to be 40%. We use the Master Chemical Mechanism (MCM) to quantify the time-dependent HCHO production from isoprene, α-and β-pinenes, and methylbutenol and show that only emissions of isoprene are detectable by GOME. The time-dependent HCHO yield from isoprene oxidation calculated by MCM is 20-30% larger than in GEOS-CHEM. GOME-derived isoprene fluxes track the observed seasonal variation of in situ measurements at a Michigan forest site with a -30% bias. The seasonal variation of North American isoprene emissions during 2001 inferred from GOME is similar to MEGAN, with GOME emissions typically 25% higher (lower) at the beginning (end) of the growing season. GOME and MEGAN both show a maximum over the southeastern United States, but they differ in the precise location. The observed interannual variability of this maximum is 20-30%, depending on month. The MEGAN isoprene emission dependence on surface air temperature explains 75% of the month-to-month variability in GOME-derived isoprene emissions over the southeastern United States during May-September 1996-2001. Copyright 2006 by the American Geophysical Union

In-canopy gas-phase chemistry during CABINEX 2009: Sensitivity of a 1-D canopy model to vertical mixing and isoprene chemistry

Vegetation emits large quantities of biogenic volatile organic compounds (BVOC). At remote sites, these compounds are the dominant precursors to ozone and secondary organic aerosol (SOA) production, yet current field studies show that atmospheric models have difficulty in capturing the observed HOx cycle and concentrations of BVOC oxidation products. In this manuscript, we simulate BVOC chemistry within a forest canopy using a one-dimensional canopy-chemistry model (Canopy Atmospheric CHemistry Emission model; CACHE) for a mixed deciduous forest in northern Michigan during the CABINEX 2009 campaign. We find that the base-case model, using fully-parameterized mixing and the simplified biogenic chemistry of the Regional Atmospheric Chemistry Model (RACM), underestimates daytime in-canopy vertical mixing by 50-70% and by an order of magnitude at night, leading to discrepancies in the diurnal evolution of HO x, BVOC, and BVOC oxidation products. Implementing observed micrometeorological data from above and within the canopy substantially improves the diurnal cycle of modeled BVOC, particularly at the end of the day, and also improves the observation-model agreement for some BVOC oxidation products and OH reactivity. We compare the RACM mechanism to a version that includes the Mainz isoprene mechanism (RACM-MIM) to test the model sensitivity to enhanced isoprene degradation. RACM-MIM simulates higher concentrations of both primary BVOC (isoprene and monoterpenes) and oxidation products (HCHO, MACR+MVK) compared with RACM simulations. Additionally, the revised mechanism alters the OH concentrations and increases HO 2. These changes generally improve agreement with HO x observations yet overestimate BVOC oxidation products, indicating that this isoprene mechanism does not improve the representation of local chemistry at the site. Overall, the revised mechanism yields smaller changes in BVOC and BVOC oxidation product concentrations and gradients than improving the parameterization of vertical mixing with observations, suggesting that uncertainties in vertical mixing parameterizations are an important component in understanding observed BVOC chemistry. © 2012 Author(s)