Genetic Diversity and Population Parameters of Sea Otters, \u3cem\u3eEnhydra lutris\u3c/em\u3e, before Fur Trade Extirpation from 1741–1911

All existing sea otter, Enhydra lutris, populations have suffered at least one historic population bottleneck stemming from the fur trade extirpations of the eighteenth and nineteenth centuries. We examined genetic variation, gene flow, and population structure at five microsatellite loci in samples from five pre-fur trade populations throughout the sea otter’s historical range: California, Oregon, Washington, Alaska, and Russia. We then compared those values to genetic diversity and population structure found within five modern sea otter populations throughout their current range: California, Prince William Sound, Amchitka Island, Southeast Alaska and Washington. We found twice the genetic diversity in the pre-fur trade populations when compared to modern sea otters, a level of diversity that was similar to levels that are found in other mammal populations that have not experienced population bottlenecks. Even with the significant loss in genetic diversity modern sea otters have retained historical structure. There was greater gene flow before extirpation than that found among modern sea otter populations but the difference was not statistically significant. The most dramatic effect of pre fur trade population extirpation was the loss of genetic diversity. For long term conservation of these populations increasing gene flow and the maintenance of remnant genetic diversity should be encouraged

Smells like school spirit: The organizational factors affecting targeted student and teacher outcomes

Teacher burnout and stress have been studied at length in the education literature, but industrial-organizational psychologists may have a fresh perspective to offer in regard to understanding and solving the problems that negatively impact the public education system. This study aims to identify the root causes underlying the constructs of stress and burnout through the examination of working conditions that impact teacher absenteeism, turnover, and health outcomes. Additionally, this study will analyze the various predictors of student outcomes, including yearly test scores, absenteeism, and disciplinary referral rates. We will begin by conducting focus groups of teachers from laboratory schools and comparable public schools to gather qualitative data to inform our hypotheses. In the next phase, we will create a tailored survey that thoroughly assesses the working conditions that we hypothesize to be connected to our outcome variables. This survey will be dispersed to teachers state-wide, and from the results, we hope to create a comprehensive model that connects various environmental conditions to student and teacher outcomes and propose interventions

Who Opens Alerts to Physicians? (And Who Doesn’t?)

Background: Electronic medical records (EMR) provide opportunities to implement systems of information flow, such as alerts to providers. Methods: Within a group practice with an EMR, we conducted a trial of automated alerts to the in-baskets of primary care physicians and staff when patients were discharged from hospital to home. We generated alerts for new medications or monitoring needs. Staff received alerts to schedule office visits. Using EMR “digital crumbs”, we tracked when alerts were viewed. We analyzed the impact of physician age, gender, department, and employment status (full-time, part-time) as well as patient conditions (age, gender, comorbidity, and number of office visits in the previous year) on timely opening. Results: Of 763 alerts to physicians, 616 (81%) were opened within one day. Characteristics associated with timely opening were age \u3c 50 (OR 1.7, 95% CI 1.1, 2.6) and full-time employment (OR 2.9, 95% CI 1.6, 5.2). Of 1928 alerts to staff, 1173 (61%) were opened within one day. Staff of male physicians were more likely to open the alerts within one day (OR 1.8, 95% CI 1.4, 2.4) as were working for the Family Medicine department (OR 1.9, 95% CI 1.3, 2.6) or a sub-specialty department (OR 16.6, 95% CI 2.3, 122.3). Staff of full-time physicians were less likely to open alerts (OR 0.64, 95% CI 0.47, 0.87). Adjusting for patient characteristics had no impact on results. Conclusion: Special efforts may be required to reach physicians working part-time and older physicians. Characteristics related to staff opening of alerts are specific to this group practice, but the high level of variability across physician types and departments is likely to be an issue in many settings. Design of a system directed at reaching staff quickly may require in-depth assessment of work flow and communication patterns in clinical department

Need for Aeromedical Evacuation High-Level Containment Transport Guidelines

Circumstances exist that call for the aeromedical evacuation high-level containment transport (AE-HLCT) of patients with highly hazardous communicable diseases. A small number of organizations maintain AE-HLCT capabilities, and little is publicly available regarding the practices. The time is ripe for the development of standards and consensus guidelines involving AE-HLCT

Genetic Diversity and Population Parameters of Sea Otters, Enhydra lutris, before Fur Trade Extirpation from 1741–1911

All existing sea otter, Enhydra lutris, populations have suffered at least one historic population bottleneck stemming from the fur trade extirpations of the eighteenth and nineteenth centuries. We examined genetic variation, gene flow, and population structure at five microsatellite loci in samples from five pre-fur trade populations throughout the sea otter's historical range: California, Oregon, Washington, Alaska, and Russia. We then compared those values to genetic diversity and population structure found within five modern sea otter populations throughout their current range: California, Prince William Sound, Amchitka Island, Southeast Alaska and Washington. We found twice the genetic diversity in the pre-fur trade populations when compared to modern sea otters, a level of diversity that was similar to levels that are found in other mammal populations that have not experienced population bottlenecks. Even with the significant loss in genetic diversity modern sea otters have retained historical structure. There was greater gene flow before extirpation than that found among modern sea otter populations but the difference was not statistically significant. The most dramatic effect of pre fur trade population extirpation was the loss of genetic diversity. For long term conservation of these populations increasing gene flow and the maintenance of remnant genetic diversity should be encouraged

Patient Adherence to Laboratory Tests to Monitor Medication Therapy: A Mixed-Methods Study

Background Little is known about the contribution of patient behavior to incomplete laboratory monitoring and the reasons for patient non-completion of ordered laboratory tests remain unclear. Objective To describe factors, including patient-reported reasons, associated with non-completion of ordered laboratory tests. Design Mixed-methods study including a quantitative assessment of the frequency of patient adherence to ordered monitoring tests combined with qualitative, semi-structured, patient interviews. Participants Quantitative assessment included patients 18 years or older from a large multispecialty group practice prescribed a medication requiring monitoring. Qualitative interviews included a subset of adherent and non-adherent patients prescribed a cardiovascular, anti-convulsant, or thyroid replacement medication. Main Measures Proportion of recommended monitoring tests for each medication not completed, factors associated with patient non-adherence, and patient-reported reasons for non-adherence. Results Of 27,802 patients who were prescribed one of 34 medications, patient non-completion of ordered tests varied (range: 0% to 29%, by drug-test pair). Factors associated with higher odds of test non-completion included younger patient age (\u3c 40 years vs. ≥80 years, adjusted odds ratio [AOR] 1.52, 95% confidence interval [95% CI] 1.27-1.83), lower medication burden (1 medication vs. more than 1 drug, AOR for non-completion 1.26, 95% CI 1.15-1.37), and lower visit frequency (0-5 visits/year vs. ≥19 visits/year, AOR 1.41, 95% CI 1.25 to 1.59). Drug-test pairs with black box warning status were associated with greater odds of non-completion compared to drugs included only in the PDR (AOR 1.91, 95% CI 1.66-2.19). Qualitative interviews, with 16 non-adherent and 7 adherent patients, identified forgetting as the main cause of non-adherence. Conclusions Patient non-adherence contributed to missed opportunities to monitor medications and was associated with younger patient age and lower medication burden and black box warning status. Interventions to improve laboratory monitoring should target patients as well as physicians

Intervention to Reduce Adverse Outcomes among Older Adults Discharged from Skilled Nursing Facilities to Home

Background: Older adults may be at risk for adverse outcomes after discharge from skilled nursing facilities (SNF), but little research has focused on this transition. Objective: To assess the impact of an alert system on the rates of adverse outcomes among older adults discharged from SNFs to home. Methods: Within a multispecialty group practice, we tracked 30-day re-hospitalizations after SNF discharges during an intervention that provided discharge alerts to primary care physicians. We compared them to discharges from the pre-intervention period matched on age, gender and SNF. For the first 100 intervention discharges and their matches, we performed chart reviews to identify adverse drug events (ADEs). Multivariate analyses controlled for age, gender and intervention status. Results: We matched 313 intervention SNF discharges to 313 previous discharges. There was a slight reduction in the rate of 30-day re-hospitalization (30% vs. 31%) adjusted. Within the ADE study, 30% of the discharges during the intervention period and 30% of matched discharges had ADEs within 45 days. Among the 83 ADEs identified, 28% were deemed preventable; 69% resulted in symptom duration more than one day; 69% occurred within the first 14 days after discharge. This was a highly vulnerable population: mean age 82.5 (standard deviation (SD) 6.7); mean number of prescribed medications 11.9 (SD 8); 17% had Charlson Comorbidity Scores of ≥4. Common clinical conditions included myocardial infarction (24%), heart failure (22%), COPD (23%), and major depression (28%). Patients with scores of ≥4 were more likely to experience an ADE than those with lower scores (adjusted OR 2.5 (CI 1.2, 5.5), RD 0.21). Conclusion: Simply providing alerts when these vulnerable patients are discharged from SNFs is not sufficient to lower rates of adverse outcomes. Further research is required to track trajectories and identify additional points for interventions

Reducing Rehospitalizations through Automated Alerts to Primary Care Providers and Staff When Older Patients are Discharged from the Hospital: A Randomized Trial

Background: Inadequate continuity of care places older patients at very high risk during transitions from the hospital to ambulatory setting. Methods: We conducted a randomized controlled trial of an HIT-based transitional care intervention in patients aged 65 and older discharged from hospital to home. All patients were senior plan members of a Massachusetts-based health plan, and cared for by a multispecialty medical group using the EpicCare Ambulatory Medical Record. In addition to notifying providers about the patient’s recent transition, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and laboratory monitoring of high-risk medications, and reminded the primary care provider’s support staff to schedule a post-hospitalization office visit. Randomization occurred at the time of hospital discharge during a one-year intervention period beginning in August 2010. Alerts were automatically delivered to the provider and staff in-basket within the EMR. The primary outcomes were: 1) having an outpatient office visit with the primary care provider within 30 days following discharge; and 2) having a rehospitalization within 30 days following discharge. Results: The study included 3667 discharges of which 1877 discharges were randomly assigned to the intervention arm. Forty-nine percent of discharges in the intervention arm were followed by office visits with the primary care provider within 30 days, compared to 51% in the comparison arm (RR 0.96, 95% CI 0.90, 1.03). Eighteen percent of discharges in the intervention arm were followed by a rehospitalization within 30 days compared to 20% in the comparison arm (RR 0.92, 95% CI 0.80, 1.05). Conclusions: This HIT-based intervention was not effective in increasing the percentage of hospital discharges of older patients that were followed by timely office visits to primary care providers or reducing the percentage with rehospitalization

Adverse Drug Events Post-Hospital Discharge in Older Patients: Types, Severity, and Involvement of Beers Criteria Medications

Objective: To characterize adverse drug events (ADEs) occurring within the high-risk 45-day period post-hospitalization in older adults. Design: Clinical pharmacists reviewed the ambulatory records of 1000 consecutive discharges. Setting: A large multispecialty group practice closely aligned with a Massachusetts-based health plan. Participants: Hospitalized patients aged 65 years and older who were discharged to home. Measurements: Possible drug-related incidents occurring during the 45-day period post-hospitalization were identified and presented to a pair of physician-reviewers who classified incidents as to whether an ADE was present, whether the event was preventable, and the severity of the event. Medications implicated in ADEs were further characterized according to their inclusion in the 2012 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Results: At least one ADE was identified during the 45-day period in 18.7% (187) of the 1000 discharges. Of the 242 ADEs identified, 35% (n=84) were deemed preventable, of which 32% (n=27) were characterized as serious, and 5% (n=4) as life threatening. Over half of all ADEs occurred within the first 14 days post-hospitalization. The percentage of ADEs in which Beers Criteria medications were implicated was 16.5% (n=40). Beers Criteria medications with both a high quality of evidence and strong strength of recommendation were implicated in 6.6% (n=16) of the ADEs. Conclusion: ADEs are common and often preventable among older adults following hospital discharge, underscoring the need to address medication safety during this high-risk period in this vulnerable population. Beers Criteria medications played a small role in these events suggesting that efforts to improve the quality and safety of medication use during this critical transition period must extend beyond a singular focus on Beers criteria medications