Acute post-disaster medical needs of patients with diabetes: emergency department use in New York City by diabetic adults after Hurricane Sandy.

OBJECTIVE: To evaluate the acute impact of disasters on diabetic patients, we performed a geospatial analysis of emergency department (ED) use by New York City diabetic adults in the week after Hurricane Sandy. RESEARCH DESIGN AND METHODS: Using an all-payer claims database, we retrospectively analyzed the demographics, insurance status, and medical comorbidities of post-disaster ED patients with diabetes who lived in the most geographically vulnerable areas. We compared the patterns of ED use among diabetic adults in the first week after Hurricane Sandy\u27s landfall to utilization before the disaster in 2012. RESULTS: In the highest level evacuation zone in New York City, postdisaster increases in ED visits for a primary or secondary diagnosis of diabetes were attributable to a significantly higher proportion of Medicare patients. Emergency visits for a primary diagnosis of diabetes had an increased frequency of certain comorbidities, including hypertension, recent procedure, and chronic skin ulcers. Patients with a history of diabetes visited EDs in increased numbers after Hurricane Sandy for a primary diagnosis of myocardial infarction, prescription refills, drug dependence, dialysis, among other conditions. CONCLUSIONS: We found that diabetic adults aged 65 years and older are especially at risk for requiring postdisaster emergency care compared to other vulnerable populations. Our findings also suggest that there is a need to support diabetic adults particularly in the week after a disaster by ensuring access to medications, aftercare for patients who had a recent procedure, and optimize their cardiovascular health to reduce the risk of heart attacks

In the Interests of clients or commerce? Legal aid, supply, demand, and 'ethical indeterminacy' in criminal defence work

As a professional, a lawyer's first duty is to serve the client's best interests, before simple monetary gain. In criminal defence work, this duty has been questioned in the debate about the causes of growth in legal aid spending: is it driven by lawyers (suppliers) inducing unnecessary demand for their services or are they merely responding to increased demand? Research reported here found clear evidence of a change in the handling of cases in response to new payment structures, though in ways unexpected by the policy's proponents. The paper develops the concept of 'ethical indeterminacy' as a way of understanding how defence lawyers seek to reconcile the interests of commerce and clients. Ethical indeterminacy suggests that where different courses of action could each be said to benefit the client, the lawyer will tend to advise the client to decide in the lawyer's own interests. Ethical indeterminacy is mediated by a range of competing conceptions of 'quality' and 'need'. The paper goes on to question the very distinction between 'supply' and 'demand' in the provision of legal services

Age and Chemostratigraphy of the Finlayson Lake District, Yukon: Implications for Volcanogenic Massive Sulfide (VMS) Mineralization and Tectonics along the Western Laurentian Continental Margin

AbstractThe Yukon-Tanana terrane in the Finlayson Lake district, Yukon, represents one of the first arc–back-arc systems that formed adjacent to the Laurentian continental margin in the mid-Paleozoic. Back-arc rocks contain many large and high-grade volcanogenic massive sulfide (VMS) deposits. This study integrates U-Pb zircon geochronology, lithogeochemistry, and Hf-Nd isotopes to establish precise controls on tectonomagmatic activity adjacent to the western Laurentian margin in the Late Devonian to Early Mississippian. High-precision chemical abrasion- (CA-) ID-TIMS U-Pb zircon geochronology defines coeval arc (ca. 363.1 to 348 Ma) and back-arc (ca. 363.3 to 355.0 Ma) magmatism in the Finlayson Lake district that intruded continental crust of Laurentian affinity (e.g., Snowcap assemblage). Mafic and felsic rocks display geochemical and isotopic characteristics that are consistent with being formed from mixtures of depleted asthenosphere and enriched lithospheric mantle sources. These melts variably entrained Laurentian continental crust via high-temperature crustal melting due to basaltic underplating. The high-temperature back-arc felsic magmatism occurs at specific time periods coinciding with VMS deposits and supports previous genetic models for VMS mineralization that suggest elevated heat flow and hydrothermal circulation were due to regional-scale rift-related magmatism rather than from local subvolcanic intrusions. The short timescales and transient nature of tectonomagmatic events in the Finlayson Lake district suggest that rapid and complex subduction initiation of oceanic and continental crust fragments facilitated coeval compression, extension, and magmatism in the arc and back-arc regions. We thus reevaluate the presently accepted tectonostratigraphic framework of the Finlayson Lake district and suggest revised interpretations that shed light on VMS depositional environments and a possible broader association with the ca. 358 Ma Antler Orogeny. Results of this study have implications for incipient tectonics, magmatism, and mineralization along the western Laurentian continental margin and other orogenic belts globally

Traumatic injury in the United States: In-patient epidemiology 2000–2011

Background Trauma is a leading cause of death and disability in the United States (US). This analysis describes trends and annual changes in in-hospital trauma morbidity and mortality; evaluates changes in age and gender specific outcomes, diagnoses, causes of injury, injury severity and surgical procedures performed; and examines the role of teaching hospitals and Level 1 trauma centres in the care of severely injured patients. Methods We conducted a retrospective descriptive and analytic epidemiologic study of an inpatient database representing 20,659,684 traumatic injury discharges from US hospitals between 2000 and 2011. The main outcomes and measures were survey-adjusted counts, proportions, means, standard errors, and 95% confidence intervals. We plotted time series of yearly data with overlying loess smoothing, created tables of proportions of common injuries and surgical procedures, and conducted survey-adjusted logistic regression analysis for the effect of year on the odds of in-hospital death with control variables for age, gender, weekday vs. weekend admission, trauma-centre status, teaching-hospital status, injury severity and Charlson index score. Results The mean age of a person discharged from a US hospital with a trauma diagnosis increased from 54.08 (s.e. = 0.71) in 2000 to 59.58 (s.e. = 0.79) in 2011. Persons age 45–64 were the only age group to experience increasing rates of hospital discharges for trauma. The proportion of trauma discharges with a Charlson Comorbidity Index score greater than or equal to 3 nearly tripled from 0.048 (s.e. = 0.0015) of all traumatic injury discharges in 2000 to 0.139 (s.e. = 0.005) in 2011. The proportion of patients with traumatic injury classified as severe increased from 22% of all trauma discharges in 2000 (95% CI 21, 24) to 28% in 2011 (95% CI 26, 30). Level 1 trauma centres accounted for approximately 3.3% of hospitals. The proportion of severely injured trauma discharges from Level 1 trauma centres was 39.4% (95% CI 36.8, 42.1). Falls, followed by motor-vehicle crashes, were the most common causes of all injuries. The total cost of trauma-related inpatient care between 2001 and 2011 in the US was $240.7 billion (95$12.0 billion (95% CI 10.5, 13.4) in 2001 to 29.1 billion (95% CI 25.2, 32.9) in 2011. Conclusions Trauma, which has traditionally been viewed as a predicament of the young, is increasingly a disease of the old. The strain of managing the progressively complex and costly care associated with this shift rests with a small number of trauma centres. Optimal care of injured patients requires a reappraisal of the resources required to effectively provide it given a mounting burden

Synergistic effects of leucine and resveratrol on insulin sensitivity and fat metabolism in adipocytes and mice

Background Sirtuins are important regulators of glucose and fat metabolism, and sirtuin activation has been proposed as a therapeutic target for insulin resistance and diabetes. We have shown leucine to increase mitochondrial biogenesis and fat oxidation via Sirt1 dependent pathways. Resveratrol is a widely recognized activator of Sirt; however, the biologically-effective high concentrations used in cell and animal studies are generally impractical or difficult to achieve in humans. Accordingly, we sought to determine whether leucine would exhibit synergy with low levels of resveratrol on sirtuin-dependent outcomes in adipocytes and in diet-induced obese (DIO) mice. Methods 3T3-L1 mouse adipocytes were treated with Leucine (0.5 mM), β-hydroxy-β-methyl butyrate (HMB) (5 μM) or Resveratrol (200 nM) alone or in combination. In addition, diet-induced obese mice were treated for 6-weeks with low (2 g/kg diet) or high (10 g/kg diet) dose HMB, Leucine (24 g/kg diet; 200% of normal level) or low (12.5 mg/kg diet) or high (225 mg/kg diet) dose resveratrol, alone or as combination with leucine-resveratrol or HMB-resveratrol. Results Fatty acid oxidation, AMPK, Sirt1 and Sirt3 activity in 3T3-L1 adipocytes and in muscle cells, were significantly increased by the combinations compared to the individual treatments. Similarly, 6-week feeding of low-dose resveratrol combined with either leucine or its metabolite HMB to DIO mice increased adipose Sirt1 activity, muscle glucose and palmitate uptake (measured via PET/CT), insulin sensitivity (HOMAIR), improved inflammatory stress biomarkers (CRP, IL-6, MCP-1, adiponectin) and reduced adiposity comparable to the effects of high dose resveratrol, while low-dose resveratrol exerted no independent effect. Conclusion These data demonstrate that either leucine or its metabolite HMB may be combined with a low concentration of resveratrol to exert synergistic effects on Sirt1-dependent outcomes; this may result in more practical dosing of resveratrol in the management of obesity, insulin-resistance and diabetes

Dynamic Critical Behavior of an Extended Reptation Dynamics for Self-Avoiding Walks

We consider lattice self-avoiding walks and discuss the dynamic critical behavior of two dynamics that use local and bilocal moves and generalize the usual reptation dynamics. We determine the integrated and exponential autocorrelation times for several observables, perform a dynamic finite-size scaling study of the autocorrelation functions, and compute the associated dynamic critical exponents $z$. For the variables that describe the size of the walks, in the absence of interactions we find $z \approx 2.2$ in two dimensions and $z\approx 2.1$ in three dimensions. At the $\theta$-point in two dimensions we have $z\approx 2.3$.Comment: laTeX2e, 32 pages, 11 eps figure

Mechanism of benefit of combination thrombolytic therapy for acute myocardial infarction: A quantitative angiographic and hematologic study

AbstractObjectives. The goal of this study was to lend insight into the mechanisms responsible for the beneficial effects of combination thrombolytic therapy.Background. Combination thrombolytic therapy for acute myocardial infarction bas been associated with less reocclusion and fewer in-hospital clinical events than has monotherapy.Methods. Infarct-related quantitative coronary dimensions and hemostatic protein levels were evaluated in 287 patients with acute myocardial infarction during the early (90-min) and convalescent (7-day) phases after administration of recombinant tissue-type plasminogen activator (rt-PA), urokinase or combination rt-PA and urokinase.Results. Minimal lumen diameter was similar in the 90-min and 7-day phases after treatment with rt-PA, urokinase and combination rt-PA and urokinase (0.72 ± 0.45 mm, 0.62 ± 0.53 mm and 0.75 ± 0.58 mm, respectively, at 90 min, p = 0.16; and 1.05 ± 0.56 mm, 1.12 ± 0.72 mm and 0.94 ± 0.54 mm, respectively, at 7 days, p = 0.22). In-hospital clinical event and reocclusion rates were less frequent in patients receiving combination therapy than in those receiving monotherapy (25% vs. 38% and 32% for rt-PA and urokinase, respectively, p = 0.084; and 3% vs. 13% and 9% for rt-PA and urokinase, respectively, p = 0.03), but these events were unrelated to early or late coronary dimensions. Patients receiving combination therapy or urokinase monotherapy had significantly higher peak fibrin degradation products (1,307 ± 860 and 1,285 ± 898 μg/ml vs. 435 ± 717 μg/ml, respectively, p < 0.0001) and lower nadir fibrinogen levels (0.85 ± 1.00 and 0.75 ± 0.53 g/liter vs. 1.90 ± 0.86 g/liter, respectively, p < 0.0001) than did those receiving rt-PA monotherapy. Peak fibrinogen degradation products indirectly correlated (p = 0.004) and baseline (p = 0.026) and nadir (p = 0.089) fibrinogen levels directly correlated with reocclusion.Conclusions. Lower in-hospital clinical event and reocclusion rates observed with combination thrombolytic therapy may relate to systemic hematologic factors rather than to the residual lumen obstruction after thrombolysis

Managing for ocean biodiversity to sustain marine ecosystem services

Managing a complex ecosystem to balance delivery of all of its services is at the heart of ecosystem-based management. But how can this balance be accomplished amidst the conflicting demands of stakeholders, managers, and policy makers? In marine ecosystems, several common ecological mechanisms link biodiversity to ecosystem functioning and to a complex of essential services. As a result, the effects of preserving diversity can be broadly beneficial to a wide spectrum of important ecosystem processes and services, including fisheries, water quality, recreation, and shoreline protection. A management system that conserves diversity will help to accrue more “ecoservice capital” for human use and will maintain a hedge against unanticipated ecosystem changes from natural or anthropogenic causes. Although maintenance of biodiversity cannot be the only goal for ecosystem-based management, it could provide a common currency for evaluating the impacts of different human activities on ecosystem functioning and can act as a critical indicator of ecosystem status